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16188
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Discharge summary
|
report
|
Admission Date: [**2155-4-20**] Discharge Date: [**2155-4-25**]
Date of Birth: [**2107-10-19**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain, shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old
female with a history of hypertension, ITP status post
splenectomy, and a history of supraventricular tachycardia
for which she underwent an electrophysiologic study at [**Hospital1 1444**] [**2155-1-8**]. Her study
demonstrated duel pathway physiology and a diseased
His-Purkinje system. No supraventricular tachycardia or
ventricular tachycardia could be induced, however, and no
intervention could be initially undertaken. The patient had
a near syncopal event on the telemetry floor the next day in
the setting in which her heart rate decreased from 120 to 60.
The patient had an echocardiogram at that time, which
disclosed severe left ventricular dysfunction. Cardiac MRI
confirmed markedly depressed left ventricular function, but
failed to show any scarring/infarction, therefore the patient
was thought to have not ischemic cardiomyopathy. Given her
near syncope and cardiomyopathy the decision was made to
place a DDD pacemaker. Some difficulty was encountered in
placing the RV lead, per EP report. The patient did well
postoperatively, however, and had no complications until
today at 2:30 p.m. when she awoke from a nap with sharp chest
pain that radiated to her right shoulder. The patient also
experienced shortness of breath. She went to an outside
hospital where initially concern was for a pulmonary embolus.
The patient underwent CT scan, which demonstrated a large
pericardial effusion. During her time there she developed
progressively distended neck veins and hemodynamic
instability with systolic blood pressure 60 to 90. The
patient was transported urgently to [**Hospital1 190**] for further management.
ALLERGIES: Aspirin and Percocet.
CURRENT MEDICATIONS:
1. Lisinopril 2.5 mg po q.d.
2. Atenolol 50 mg po b.i.d.
PAST MEDICAL HISTORY: As above. ITP status post
splenectomy, hypertension, history of supraventricular
tachycardia status post EP study [**2155-1-8**] with diseased
His-Purkinje system. The patient is status post placement of
DDD pacemaker. Nonischemic cardiomyopathy. Echocardiogram
[**2155-1-8**] disclosed EF of 25%, severe global left
ventricular hypokinesis, no pericardial effusion. Glaucoma,
L4-L5 ruptured disc.
SOCIAL HISTORY: Negative for tobacco, alcohol and drugs.
The patient lives in [**Location 86**] with her daughter and boyfriend.
She has three children.
FAMILY HISTORY: [**Name (NI) **] sister and father have glaucoma.
Mother died at the age of 35 of an aneurysm and had a history
of hypertension. Father died of myocardial infarction at age
67.
PHYSICAL EXAMINATION: General, alert, patient acutely
distressed. Temperature 97.5. Blood pressure 115/93. Heart
rate 107. Respiratory rate 24. O2 sat 100% on room air.
HEENT mucous membranes are moist. Oropharynx is clear. Neck
supple. Markedly distended neck veins. Heart, distant heart
sounds. Lungs clear to auscultation bilaterally. Abdomen
soft, nondistended, nontender, positive bowel sounds.
Extremities without clubbing, cyanosis or edema.
LABORATORY DATA: White blood cell count of 21, hematocrit
33.3. Differential showed 92.5% neutrophils, 5.2%
lymphocytes. Chemistries were within normal limits with a
BUN and creatinine of 13 and 0.7. INR 1.4. Initial CK at
outside hospital 56, MB less then 0.5, troponin less then
0.05. Serum tox screen negative. Urine tox screen negative.
Electrocardiogram sinus tachycardia at 111 beats per minute,
normal PR intervals, prolonged QTC, normal axis, left
ventricular hypertrophy, left bundle branch block, T wave
inversions in 2, 3 and AVF, V5 and V6, poor R wave
progression. Left bundle branch block is old. Chest x-ray
slight cardiomegaly. No pneumothorax. Echocardiogram
preliminary read disclosed pericardial effusion greater then
2 cm, left ventricular ejection fraction 25%, total RARV
collapse.
IMPRESSION: The patient is a 47 year-old female who presents
with acute cardiac tamponade. The patient is taken
emergently to catheterization laboratory for a
pericardiocentesis.
HOSPITAL COURSE: Initial right heart catheterization
revealed elevated right heart filling pressures with
equalization of pressures across the [**Doctor Last Name 1754**]. The RA mean
pressure was 14 mmHg with an RVEDP and a pulmonary capillary
wedge pressure of 15 mmHg. Initial arterial pressure
measured revealed an aortic pressure of 118/72/89 mmHg. The
cardiac output on a Dopamine drip at 2 micrograms per
kilogram per minute was preserved at 7.4 meters per minute.
A pericardial drain was placed through the subxiphoid
approach. Initially pericardial pressure was found to be 15
mmHg, 350 cc of frankly blood fluid was removed with a
subsequent decrease in the mean RA pressure to 8 mmHg, a
decrease in the mean pericardial pressure to 3 mmHg and a
rise in the arterial blood pressure to 165/84/114 mmHg.
A follow up echocardiogram performed in the catheterization
laboratory demonstrated complete resolution of the
pericardial effusions. The patient was also noted to have a
left ventricular ejection fraction of 35%.
The patient underwent interrogation of pacemaker. Left
bundle branch block pattern was elicited. Analysis suggested
that the V lead was still present in the RV. The patient's
CT scans from the outside hospital were reviewed. There was
no definitive evidence of RV perforation by the V lead.
The following day the patient underwent repeat CT scan of the
chest with cardiac gaiting. There was no definitive evidence
of pacer wire perforation. Further analysis of the
echocardiogram done in the Emergency Department on [**4-19**],
however, suggested that the tip of the pacing wire in the
right ventricle appeared possibly through the RV free wall.
Therefore it was decided that the patient would go to the EP
laboratory for lead revision under fluoroscopic guidance. On
[**4-21**] the patient underwent this procedure without
complications.
Pericardial fluid was sent to the laboratory for cytology and
culture. Cytology was negative for malignant cells.
Cultures were unrevealing. Serum [**Doctor First Name **] was negative. TSH was
within normal limits.
On [**4-23**] the pericardial drain was discontinued without
difficulties. Echocardiogram did not show evidence of
recurrent pericardial effusion.
The patient was noted to have drop in hematocrit from low 30s
to 23. The etiology of hematocrit drop was unclear, since
echocardiogram did not demonstrate accumulation of
pericardial fluid. The patient was administered 3 units of
packed red blood cells.
The patient was transferred to the floor on [**2155-4-23**].
Echocardiogram on [**2155-4-25**] disclosed trivial
physiologic pericardial effusion. Compared with prior study
of [**4-24**] there has been no significant change.
It was decided that the patient was stable for discharge on
[**4-25**]. The patient will follow up in the Device Clinic on
[**4-28**].
DISCHARGE CONDITION: Good.
DISCHARGE INSTRUCTIONS: The patient is instructed to return
to the Emergency Department should she experience recurrent
chest pain or shortness of breath.
DISCHARGE FOLLOW UP:
1. The patient will follow up in the Device Clinic on [**4-28**] at 2:00 p.m. She will see Dr. [**Last Name (STitle) 284**] on [**4-28**] at
2:30 p.m.
2. The patient will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**6-5**] at 2:30 p.m. Dr. [**Last Name (STitle) **] will be the patient's new
primary care physician.
3. The patient will undergo an ETT perfusion study as an
outpatient for further evaluation of her cardiomyopathy.
DISCHARGE MEDICATIONS:
1. Lisinopril 5 mg po q.d.
2. Atenolol 37.5 mg po q.d.
DISCHARGE DIAGNOSES:
1. Pericardial tamponade.
2. Successful drainage of 350 cc bloody pericardial fluid.
3. Pacemaker lead revision.
4. Nonischemic cardiomyopathy.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 18632**]
MEDQUIST36
D: [**2155-4-25**] 09:05
T: [**2155-4-29**] 14:10
JOB#: [**Job Number 46213**]
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28,365
| 129,055
|
31707
|
Discharge summary
|
report
|
Admission Date: [**2187-11-7**] Discharge Date: [**2187-11-7**]
Date of Birth: [**2140-8-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
# Hypotension
# Hypothermia
# Alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M found intoxicated behind [**Location (un) 86**] Public Library, was
combative with police and EMS. Brought into ED for evaluation.
.
ED course:
# VS: T 97.4, HR 87, BP 108/67, SaO2 97% RA, FS 169.
# Meds: Haloperidol 5 mg IM x 1, lorazepam 2mg IM x 2, diazepam
10 mg IV x 1
# Clinical course: BP 77/40 at 2000hrs, which responded to 3L
NS. At 0000hrs, T 94.3, received bear hugger with good effect.
# Studies:
--CXR unremarkable
--FAST negative
--EKG V-paced
--CE negative x 2.
# MICU admit given hypotension and hypothermia.
.
On arrival to MICU, pt was sleeping but awoken easily and was
cooperative. Pt does not remember how he arrived at the library.
.
ROS:
(+) Feeling well. States that this was the first time he had
alcohol in months. Previously hospitalized for alcohol
withdrawal, usually at the VA. Denies hx of DTs or seizures.
(-) HA, chest pain, shortness of breath, N/V, abd pain, changes
in bowel habits, falls
Past Medical History:
--CV
# HTN
# Hypercholesterolemia
# V-pacer for bradycardia (?sick sinus)
.
--Endo
# DM2
.
--GU
# BPH
.
--Psych
# Depression
# Alcohol abuse
Social History:
# Personal: Homeless, living in a veterans' shelter.
# Alcohol: Denies abuse. Unable to quantify the amount he
drinks.
# Recreational drugs: Denies
# Tobacco: ~1 PPD for unknown number of years. Quit [**2175**].
Family History:
# Father: Unknown
# Mother: [**Name (NI) **] cancer
Physical Exam:
VS: T 96.2 (orally), BP 91/62, HR 75 (V-paced), RR 16, SaO2 98%
RA
Gen: NAD
HEENT: PERRLA, EOMI, mild exopthalmos present, no scleral
icterus, MMM
Neck: No LAD
Lungs: CTAB
Card: RRR, no murmurs appreciated
Abd: BS+, soft, NTND, no fluid wave, no HSM
Ext: DP 2+ BLE, no edema
Skin: No jaundice
Neuro: A&Ox3
Pertinent Results:
Notable labs:
.
[**2187-11-6**] 06:44PM ETHANOL-293*
[**2187-11-6**] 06:44PM WBC-5.6 RBC-4.12* HGB-13.5* HCT-37.8* MCV-92
MCH-32.7* MCHC-35.7* RDW-14.3
[**2187-11-6**] 07:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2187-11-6**] 10:57PM LACTATE-2.2*
.
Notable studies:
.
# CHEST (PA & LAT) [**2187-11-6**] 7:30 PM
IMPRESSION:
1. Mild cardiomegaly with predominant enlargement of left
ventricle.
2. No acute cardiopulmonary process.
Brief Hospital Course:
47M h/o alcohol intoxication, found down by police. Hypotensive
in ED; after administration of 3L NS, found hypothermic,
transferred to MICU for closer monitoring. Toxicology screen
positive for alcohol only.
.
# Hypotension: SBP into the 70s in the ED, but responded to SBP
90s after 4L NS SBP. Initially, hypotension presumed [**3-9**]
benzodiazepine and haldol received in the ED. R/o for
hypovolemia, infection/sepsis, cardiac dysfunction. CE were
negative x3, no EKG changes noted, blood and urine cx were
pending. Pt afebrile and responded well to boluses, remaining
normotensive in the MICU.
.
# Hypothermia: Pt found to have oral temperature of 94 in the ED
after receiving room-temperature fluids, and responded to
warming blankets. DDx included exposure (patient was found
down), infection/sepsis, and hypothyroidism, but likely due to
IVF administration. Pt afebrile and had normal temperature
while in the MICU. TSH 1.4. UA negative for infection. Blood
and urine cx pending on discharge.
.
# Alcohol intoxication/withdrawal: Per [**Name (NI) **], pt was appropriate
and conversive throughout his stay, although sleepy after
receiveing meds. No findings on neuro exam; head CT not
currently indicated. Pt denied history of DTs or seizures,
however, had been hospitalized for withdrawal in the past.
Denied h/o liver disease, and liver enzymes were WNL. Per pt,
this episode was a binge and had been sober for months prior.
Pt did not need any diazepam doses under the CIWA scale. Pt
received thiamine, folic acid, and MVI, and a social work
consult to assist with resolving alcohol abuse.
.
# DM2: Pt discharged on home regimen of rosiglitazone, after
this was originally held on admit.
.
# HTN: Beta blocker and ACE inhibitor initially held given
hypotension in the ED. BP normalized, and discharged on home
regimen of metoprolol and lisinopril.
.
# Depression: Pt stated that binging not an issue but did not
wish to discuss what prompted binge. No SI/HI. Continued on
home regimen of antidepressant.
.
# Hypercholesterolemia: Liver enzymes normal, continued on home
regimen of simvastatin.
.
# BPH: Continued on home regimen of terazosin.
# Anemia: Mild, likely multifactorial given DM2, alcohol, likely
poor nutritional intake and IVF hydration. Referred to
outpatient management.
.
# Full code
Medications on Admission:
Rosiglitazone 4mg daily
Magnesium oxide 420mg TID
Lisinopril 5mg daily
Simvastatin 20mg QHS
Terazosin 2mg HS
ASA EC 325mg daily
Metoprolol 12.5mg [**Hospital1 **]
Metformin 850mg TID
Trazodone 100mg HS
Paroxetine 60mg QAM
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Paroxetine HCl 40 mg Tablet Sig: 1.5 Tablets PO QAM.
5. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Magnesium Oxide 420 mg Tablet Sig: Four [**Age over 90 **]y (420)
mg PO TID (3 times a day).
7. traZODONE 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Terazosin 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 12.5 mg PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
.
# Alcohol intoxication
# Hypotension
# Hypothermia after administration of IV fluids
.
Secondary diagnosis
.
# Benign prostatic hypertrophy
# Diabetes mellitus type 2
# Hypertension
# Depression
# Alcohol abuse
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the intensive care unit because you
developed a very low blood pressure and a very low body
temperature in the Emergency Department, where you were taken
after you were found to be drunk after an alcohol binge.
.
Based on your physical exam, we do not believe that you are
actively withdrawing from alcohol now. However, it is important
to continue your treatment for alcohol abuse. We have made
several appointments for you. Please go to these appointments.
.
We have not given you any new medications. Please continue
taking your original medications.
.
If you have any symptoms that you are worried about, call your
primary care provider and go immediately to the emergency room.
Followup Instructions:
We have made an appointment for you to see your Nurse
Practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7460**] NP, who works with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]:
.
Wednesday, [**11-8**] at 9:30 am, [**Street Address(2) 74481**], 2F, [**Location (un) 86**]
MA.
.
If you cannot make this appointment, please call tel.
[**Telephone/Fax (1) 9075**] (fax [**Telephone/Fax (1) 10615**]).
.
You also have an appointment with the [**Location (un) **] VA substance abuse
rehabilitation program on [**11-21**], at 9:30 am, tel.
[**Telephone/Fax (1) 74482**].
.
Please also follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], case manager for the [**Location (un) 4368**] Shelter for Homeless Veterans, tel. [**Telephone/Fax (1) 74483**].
.
Please also follow-up with your psychiatrist Dr. [**Last Name (STitle) 14223**] at the
VA, tel. [**Telephone/Fax (1) 74484**].
|
[
"E939.4",
"600.00",
"311",
"250.00",
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"E939.2",
"V45.01",
"285.9",
"427.89",
"305.02",
"780.99",
"272.0",
"401.9",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6197, 6203
|
2613, 4944
|
331, 338
|
6478, 6487
|
2105, 2590
|
7243, 8199
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5216, 6174
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6224, 6457
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4970, 5193
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6511, 7220
|
1779, 2086
|
241, 293
|
366, 1301
|
1323, 1465
|
1481, 1695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,706
| 170,380
|
24017
|
Discharge summary
|
report
|
Admission Date: [**2119-4-12**] Discharge Date: [**2119-4-12**]
Date of Birth: [**2090-1-21**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Prozac / Dopamine
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
vomiting blood
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 29 yo M with h/o of bipolar disorder, anxiety, and
depression who presented from [**Hospital1 **] inpatient psych facility for
vomiting blood. On EMS arrival to [**Hospital1 **], pt was reportedly
covered in blood-tinged vomit. Pt unable to say how much blood
there was but states that he vomited blood a few times today. Pt
states he has a history of bleeding ulcers and an abdominal
hernia that has been there for 17 months. Pt is currently at
[**Hospital1 **] for HI/SI. Pt states he wants to "kill everyone in the
world". Pt is unable to give much history, has rambling speech,
is a poor historian [**12-29**] psych history. Pt does have significant
h/o EtOH abuse but no known varices. No EGD or colonoscopy
reports are in our system.
.
In the ED, initial VS were: T 96.5 HR 100 BP 107/65 RR 18 O2
sat 98% RA. Labs were remarkable for Hct 39, nl plts, nl coags.
LFTs and lipase were unremarkable. Serum tox was negative.
CXR was negative for any acute process. NG lavage was performed
which showed areas of bright red/pink blood, but also with
intermittent clear fluid returned. Tube was left in place.
Rectal exam was guiaic negative.
Pt was started on protonix bolus and gtt. 18G x 2 PIV were
placed. Pt was type and crossed x 2U. Pt rec'd 800cc NS. Pt
was given Morphine for pain, Zofran for nausea. He was also
given Atomoxetine. GI was consulted who plan to see him in AM.
On transfer, VS were Pulse: 88, RR: 14, BP: 135/72, Rhythm: nsr,
O2Sat: 99, Pain: 5.
.
On arrival to the MICU, pt is agitated. States "they were mean"
and "tried to cut my throat", referring to physicians at [**Hospital1 **].
States he had an anxiety attack. Was having nausea and vomiting
for the last 3 days (vomited 40x in last 3 days), and about 5 of
those times, there was blood. Unable to quantify the amount.
Denies fevers, diarrhea, bloody or dark stools. Endorses
chronic "pain everywhere", incl around umbilicus where he has a
hernia. Endorses chronic dizziness, esp in mornings, denies
fainting spells. Endorses SI, denies HI. Denies hallucinations.
Past Medical History:
Depression
Anxiety
Bipolar disorder
Umbilical hernia
Asthma
Right foot fracture
ADD
Social History:
has been at [**Hospital1 **] for the last 5 days, prior to that was "on the
streets" for about week, prior to that, was at [**Hospital1 **] for a 5
week program. has grandmother, brother, father and mother in
[**Name (NI) 86**] area. also, a good friend [**Name (NI) **] [**Name (NI) 36542**]. smokes 2 PPD
on average, up to 5 PPD, drinks about 12 beers per day and 1
pint of hard liquor daily (no h/o withdrawal or DTs), admits to
daily marijuana, h/o cocaine use (about 1x/month). also, admits
to occasional heroine.
Family History:
mother and father with alcoholism
Physical Exam:
admission exam
Vitals: T: 97.8 BP: 132/93 P: 88 R: 16 O2: 98% RA
General: alert, oriented, appears agitated
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, NGT
in place
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse wheezes throughout, no accesory muscle use
Abdomen: soft, obese, non-distended, largely non-tender but does
have ttp in abd hernia (4 cm area around umbilicus,
nonreducible), bowel sounds present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, mild
edema bilat
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, no asterixis
Skin: papular lesions on bilat legs
.
Pertinent Results:
admission labs:
[**2119-4-12**] 02:50AM BLOOD WBC-4.7 RBC-4.54* Hgb-12.2* Hct-39.2*
MCV-86 MCH-27.0 MCHC-31.2 RDW-16.4* Plt Ct-242
[**2119-4-12**] 02:50AM BLOOD Neuts-47.8* Lymphs-39.6 Monos-5.3
Eos-6.4* Baso-0.9
[**2119-4-12**] 02:50AM BLOOD PT-11.0 PTT-38.4* INR(PT)-1.0
[**2119-4-12**] 02:50AM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-140
K-3.3 Cl-102 HCO3-27 AnGap-14
[**2119-4-12**] 02:50AM BLOOD ALT-55* AST-40 AlkPhos-85 TotBili-0.1
[**2119-4-12**] 02:50AM BLOOD Albumin-4.5
[**2119-4-12**] 02:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
imaging
FINDINGS: Nasogastric tube courses into the stomach and out of
view. The
lungs are clear without focal consolidation, pleural effusion or
pneumothorax.
The heart is normal in size with normal cardiomediastinal
silhouette. No free intraperitoneal air is identified.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
This is a 29 yo M with h/o of bipolar disorder, anxiety, and
depression now admitted for UGIB.
.
# UGIB: Patient reported vomitting blood prior to admission. NG
lavage in the ED showed red/pink blood that GI and the ICU team
thought was due to NG trauma or other benign process. The
patient remained hemodynamically stable with stable hematocrits
throughout his stay in the ED and the ICU. Furthermore, he had
no further episodes of hemetemisis during admission. He was
initially started on a protonix gtt in the ED which was changed
to protonix IV BID while in house. GI was consulted and felt
that the patient was currently stabile and no urgent EGD was
indicated at this time. However, nonurgent endoscopy is
indicated and out-patient coordination for this procedure should
be arranged with the patient and his out-patient care providers.
Of course, the patient should avoid NSAIDS and ETOH and was
advised to do so until an out-patient EGD can be performed.
.
# Psych issues with SI/HI: He presented with intermittent
agitation and symptoms of depression. The patient was evaluated
by psychiatry who felt it is unclear if he has underlying
primary psychiatric or mood disorder, but certainly meets
criteria for antisocial personality disorder. While patient was
hospitalized, he was given lyrica, carbamazepime, ziprasidone,
Chlorpromazine x 1, and ativan x 1. He was also treated with
zyprexa 10 mg IM twice for agitation and aggressive behavior,
including threatening comments and one episode in which he
physically struck a staff member. During his hospitalization he
had a 1:1 sitter and security. Patient did not require
restraints. He did intermittently endorse SI and HI, and
Psychiatry felt it appropriate that he return to [**Hospital1 1680**] House
for on-going, in-patient psychiatric care.
.
# EtoH abuse: Patient's last drink was more than 5 days prior to
admission and therefore it was determined that CIWA was not
indicated at this time. Patient was given folate, thiamine, MVI.
.
# Asthma/bronchitis: Patient was continued on flovent,
ipratropium, albuterol nebs and montelukast. His bactrim was
discontinued.
.
# Back/leg pain: Patient was continued on methocarbamol and
lyrica. His gabapentin was stopped.
.
transitional issues:
- patient will need outpatient endoscopy
- patient's psychiatric medications may need further adjustments
- if/when he is re-hospitalized, staff should be very careful
given his history of violent behavior, including physically
striking a staff member during this hospitalization.
Medications on Admission:
per [**Hospital1 **] paperwork:
Ambien 10mg qhs
Methocarbamol 750mg q6h prn
Pseudoephedrine q6h prn
Thorazine 50mg QID prn
Gabapentin 300mg QID
Atomoxetine 40mg qam
Geodone 40mg [**Hospital1 **]
Vistaril 50mg x1 on [**4-11**]
Carbamazepine 400mg TID
Diazepam 5mg qhs
Fluticasone-Salmeterol 500-50mcg 1 puff [**Hospital1 **]
Montelukast 10mg daily
Bactrim DS [**Hospital1 **] (for bronchitis until [**4-17**])
Lamotrigine 25mg qhs
Lyrica 300mg [**Hospital1 **]
Ipratropium-Albuterol 18-103mcg 2 puffs QID
Discharge Medications:
1. pregabalin 75 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
2. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
3. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
4. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. atomoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
10. ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours) as needed for pain.
12. chlorpromazine 25 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed for agitation.
13. 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:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Primary: upper GI bleed
Secondary: Anti-social personality disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for episodes of blood in
vomit. While in the hospital we monitored your blood pressure
and levels of red blood cells, and found that you did not have a
significant bleed by the time of discharge. You will likely
require an upper endoscopy in the future on a non-emergent
basis.
Please make the following changes to your medications:
Please START taking omeprazole 20 mg po daily
Please STOP taking gabapentin.
Please STOP taking all NSAIDS (ibuprofen, advil, aleeve) as this
can irritate your stomach.
Please STOP drinking excessive amounts of alcohol, as this is
damaging your stomach and your liver.
Please take the rest of your medications as prescribed
Followup Instructions:
You should establish care with a primary care doctor. If you
would like to have one at [**Hospital1 18**] please call [**Telephone/Fax (1) 61129**]-9600.
After you establish primary care, you should schedule an upper
endoscopy to evaluate your gastrointestinal tract.
Completed by:[**2119-4-26**]
|
[
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"724.5",
"729.5",
"530.7",
"553.1",
"477.9",
"304.10",
"314.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9114, 9195
|
4847, 7078
|
301, 307
|
9307, 9307
|
3919, 3919
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9858, 10184
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247, 263
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335, 2408
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3935, 4824
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9322, 9433
|
2430, 2516
|
2532, 3056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,237
| 181,911
|
41757
|
Discharge summary
|
report
|
Admission Date: [**2128-8-8**] Discharge Date: [**2128-9-18**]
Date of Birth: [**2073-7-2**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
acute hepatitis
Major Surgical or Invasive Procedure:
liver biospy
EGD
colonoscopy
TEE
intracranial bolt placement
History of Present Illness:
55 yo F who is being transferred from [**Hospital3 3583**] for work
up and management of acute hepatitis. Patient had not been
feeling well for the past 2-3 weeks w/ symptoms of nausea, poor
PO intake, weight gain and bilateral leg edema. These symptoms
resolved 2 days PTA. On the day of admission she was not feeling
well and had a pre-syncopal episode. She presented to JH on [**8-5**]
and found to have AST 1090, ALT 1073, Tbili 11.4, INR 1.85 and
alk phos 230. RUQ U/S revealed no abnl. GI (Dr. [**First Name (STitle) 10733**] was
consulted and recommended CT abd that was concerning for portal
vein thrombosis w/ possible ischemic changes of the right
hepatic lobe. CT was repeated and this could not localize
thrombosis w/i the portal system. Hypercoag lab tests and
pending, hep screening (-) and autoimmune test pending. Iron lvl
202, [**Last Name (un) **] 18,678 and TIBC 193. LFT's were trending down by the
time of transfer.
.
Of note, patient drinks 2 glasses of wine/day and has been
eating a lot of cooked clams. Denies APAP use, herbal
supplements or teas, history of transfusions or eating wild
mushrooms. Used ibuprofen x2 in the past 2 weeks.
.
On the floor, she is feeling well and w/o complaints.
Past Medical History:
None.
Past Surgical History:
ORIF L ankle (fracture from skiing injury) with plates and
screws in place [**1-/2128**], open cholecystectomy [**46**] years ago.
Social History:
Lives in [**Location 38**] and summers in [**Location (un) **]. Drinks 2 glasses
wine/day, 8 yr pk/hx but quit >30 yrs ago. Denies IVDU.
Family History:
Mother: ? viral hepatitis
Aunt: jaundice when young
Aunt: dies of ? liver issues
Father: NHL
Physical Exam:
ADMISSION EXAM
VS: 97.7 117/67 104 20 99%RA
GENERAL: Well-appearing female in NAD, comfortable, appropriate.
HEENT: EOMI, sclerae icteric, MMM.
NECK: Supple.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, 2+ edema b/l, 2+ peripheral pulses.
SKIN: Mildly icteric
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, no asterixis.
DISCHARGE EXAM
Pertinent Results:
[**2128-8-8**] 11:25PM BLOOD WBC-5.7 RBC-3.89* Hgb-13.2 Hct-38.9
MCV-100* MCH-33.9* MCHC-33.9 RDW-15.1 Plt Ct-92*
[**2128-8-8**] 11:25PM BLOOD Neuts-61.7 Lymphs-27.6 Monos-7.7 Eos-2.5
Baso-0.4
[**2128-8-8**] 11:25PM BLOOD PT-23.9* PTT-43.1* INR(PT)-2.2*
[**2128-8-8**] 11:25PM BLOOD Glucose-69* UreaN-6 Creat-0.8 Na-139
K-4.1 Cl-106 HCO3-23 AnGap-14
[**2128-8-8**] 11:25PM BLOOD ALT-934* AST-773* LD(LDH)-401*
AlkPhos-238* TotBili-13.6*
[**2128-8-8**] 11:25PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.8 Mg-1.9
Iron-207*
[**2128-8-8**] 11:25PM BLOOD calTIBC-202* Ferritn-[**Numeric Identifier **]* TRF-155*
other work up
[**2128-8-16**] 05:20PM BLOOD IgM HBc-NEGATIVE
[**2128-8-10**] 05:40AM BLOOD IgM HAV-NEGATIVE
[**2128-8-8**] 11:25PM BLOOD HBsAg-POSITIVE* HBsAb-NEGATIVE
HBcAb-POSITIVE* HAV Ab-POSITIVE
[**2128-8-14**] 06:25AM BLOOD AMA-NEGATIVE
[**2128-8-8**] 11:25PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2128-8-14**] 06:25AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2128-8-14**] 06:25AM BLOOD CEA-3.6 AFP-5.7
[**2128-8-8**] 11:25PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2128-8-14**] 06:25AM BLOOD IgG-1365 IgA-473* IgM-75
[**2128-8-10**] 05:40AM BLOOD IgG-1143
[**2128-8-14**] 06:25AM BLOOD HIV Ab-NEGATIVE
[**2128-8-8**] 11:25PM BLOOD HCV Ab-NEGATIVE
[**2128-8-14**] 06:25AM BLOOD Triglyc-61 HDL-20 CHOL/HD-5.5 LDLcalc-77
[**2128-8-23**] 11:10AM BLOOD Triglyc-94
Heptatitis B surface Ag positive, Hepatitis core IgG positive,
Hepatitis core IgM negative, Hep B viral load undetectable.
hep D - negative
hep E - negative
LKM - negative
RPR undetectable
EBV positive
CMV positive
varicella positive
Hep B viral negative
toxo pending
HSV 1 IgG positive
ceruloplasmin - 23
CA19-9 - 41
vitamin D - 15
H. pylori postiive
CEA 3.6
AFP 5.7
LCMV - negative
Leptospira - neg
Anaplasma - neg
hep D Ab - neg
direct coombs negative
MICRO:
blood cx positive with MSSA
urine cx positive with >100,000 E.coli sensitive to cipro
PATH
Liver, transjugular needle biopsy [**2128-8-12**]
1. Minute fragmented biopsy consisting of proliferating bile
ducts and hepatic parenchyma with massive necrosis and collapse
(reticulin stain evaluated).
2 No viable hepatocytes are seen.
3. No immunoreactivity is seen for HSV and CMV; satisfactory
controls evaluated.
4. Trichrome stain is of limited value because of the extensive
collapse and degree of fibrosis cannot be evaluated.
5. Iron stain shows mild iron deposition.
[**8-16**] COLONOSCOPY
A. Transverse colon polypectomy:
Adenoma.
B. Splenic flexure polypectomy:
Sessile serrated adenoma.
C. Descending colon polypectomy #1:
Fragments of sessile serrated adenoma.
D. Descending colon polypectomy #2:
Fragments of sessile serrated adenoma.
E. Rectal polypectomy:
Hyperplastic polyp.
IMAGING:
RUQ ultrasound [**2128-8-9**]:
Heterogeneous liver compatible with acute hepatitis with trace
ascites along its right lobe and patent arterial and venous
vasculature.
CTA abdomen [**2128-8-13**]:
1. Heterogeneous enhancement of the liver parenchyma on multiple
phases of imaging, findings consistent with acute hepatitis. No
definite discrete mass.
2. Minimal perihepatic ascites.
3. Replaced right hepatic artery originating from the SMA.
Otherwise, normal conventional arterial and venous anatomy.
4. Resolution of previously seen pancreatitis.
CXR [**2128-8-13**]:
The lung volumes are normal. Borderline size of the cardiac
silhouette with mild tortuosity of the thoracic aorta. No
pleural effusions. No lung nodules or masses. No evidence of
pulmonary edema. Normal hilar and mediastinal contours.
COLONOSCOPY [**2128-8-16**]:
Polyp in the distal transverse colon (polypectomy)
Polyp in the splenic flexure (polypectomy)
Polyp in the proximal descending colon (polypectomy)
Polyps in the mid-descending colon (polypectomy)
Polyp in the rectum (polypectomy)
Grade 1 internal hemorrhoids
No evidence of diverticulum, masses or angiodysplasia
Otherwise normal colonoscopy to cecum
EGD [**2128-8-16**]:
Erosion in the lower third of the esophagus
No evidence of varices or Barretts
Mosaic appearance in the stomach body and fundus compatible with
portal gastropathy
No evidence of varices, ulcers or active bleeding
Erosions in the first part of the duodenum and second part of
the duodenum
No evidence of ulcers or active bleeding
Otherwise normal EGD to third part of the duodenum
PFTS [**2128-8-17**]:
Mechanics: The FVC and FEV1 are normal. The FEV1/FVC ratio is
elevated.
Flow-Volume Loop: Very mild expiratory coving.
Lung Volumes: The TLC, RV and RV/TLC ratio are normal. The FRC
is mildly reduced.
DLCO: The Diffusing Capacity corrected for hemoglobin is
normal.
Impression:
The study results are within normal limits.
TTE [**2128-8-17**]:
The left atrium is normal in size. The left ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
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 stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
TEE [**2128-8-19**]:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve.No vegetations
[**Last Name (un) **] on the tricuspid velve. There is no pericardial effusion.
No evidence for valvular mass or vegetations.
CT head [**2128-8-30**]:
No hemorrhage, edema, mass effect, or evidence for acute
vascular territorial infarction is present. There is no shift of
normally midline structures and [**Doctor Last Name 352**]-white matter
differentiation appears well preserved. The size and
configuration of ventricles appears normal and there is no shift
of normally midline structures. Osseous structures appear
normal. The visualized sinuses appear well aerated.
Liver duplex US [**2128-8-30**]:
1. Diffusely heterogeneous and echogenic shrunken liver
2. Patent portal and hepatic veins without evidence of thrombus.
3. Slight increase in small volume of perihepatic ascites.
CT head [**2128-9-1**]:
Through a right frontal approach an ICP catheter has been
positioned with its tip that appears to be within a right
frontal sulcus and does not appear to enter parenchyma. No
hemorrhage is present. The size, configuration of the ventricles
appears normal. There is no shift of normally midline
structures. No acute intracranial infarction is present. There
is partial opacification of bilateral ethmoid air cells.
Remaining paranasal sinuses appear normal.
CT head [**2128-9-6**]:
The ventricles are slightly smaller compared to [**2128-9-1**], with maximal frontal dimension of 13 mm from previously 16
mm. The sulci and Sylvian fissures of both cerebral hemispheres
are slightly more effaced compared to [**2128-8-30**]. There
is no evidence of acute territorial infarction.
CT head [**2128-9-7**]:
No change since [**2128-9-6**]. No new hemorrhage or edema.
CTA head [**2128-9-9**]:
No evidence of cerebral edema, territorial infarction, or
hydrocephalus.
24-hour EEG [**2128-9-15**]:
C/w encephalopathy. No evidence of seizure activity.
CT head [**2128-9-15**]:
1. No acute intracranial hemorrhage or mass effect. Removal of
an intracranial pressure monitor. Assessment for early cerebral
edema can be limited on CT and cannot be completely excluded.
2. Increased fluid within the paranasal sinuses, middle ear
cavities, and mastoid air cells.
MR head [**2128-9-16**]:
Aside from a linear tract in the right frontal lobe from the
recently removed intracranial pressure monitor, no focal MRI
abnormalities within the brain. Diffuse mucosal thickening and
fluid in the paranasal sinuses and mastoids.
Liver US [**2128-9-16**]:
1. Patent hepatic vasculature. Patent main portal vein with
hepatopetal flow.
2. Small volume ascites, appears decreased compared to prior
study.
3. Probable right pleural effusion.
CXR [**2128-9-17**]:
Lines and tubes remain in place in standard position.
Cardiomegaly is stable. There is markedly worsening severe
pulmonary edema. There is no evident pneumothorax.
Brief Hospital Course:
55 yo F with no significant past medical history who presents
from OSH for further evaluation with elevated LFTs and concern
for acute hepatitis.
The following summarizes her hospital course while admitted to
the hepatology service [**2128-8-8**]--[**2128-8-29**].
.
#. Hepatitis: Patient initially presented from OSH for further
evaluation and treatment after found to have elevated AST and
ALT into the 1000. She had an extensive workup to evaluate the
cause of the acute process however most tests were negative
(please review results section). However, patient was found to
have hepatitis surface Ag positive and core IgG positive with
negative viral load for hepatitis B making her a chronic
carrier. She had a liver biopsy showing massive necrosis. She
underwent evaluation for liver transplantation and was
successfully listed. Transplant surgery followed as well.
Patient was started on entecavir for hepatitis B. During her
hospital course her tbili, INR continued to trend up. She
developed a MELD > 40. At that time she started to develop some
mental slowing and asterixis. Lactulose was started. A dophoff
was also placed to help optimize nutritional status prior to
surgery.
.
#. staph aureus bacteremia - Pt was found to have 5/8 bottles
positive for MSSA. Likely source is from skin infection on R.
wrist. Infectious disease was consulted. TTE and TEE negative
for vegetations. Patient was initially started on nafcillin 2 g
IV q6 hrs. This was changed to cefzolin after 3 days given
development of AIN. Blood cultures remained negative since [**8-17**].
A PICC line was placed on 16.
.
# anemia - Patient had no evidence of acute blood loss. Drop in
HCT likely secondary to hemolysis. Direct coombs negative.
Patient was periodically transfused to maintain HCT > 25.
.
# DIC: likely from infection vs. liver failure vs. medication
related. fibrinogen was followed. Patient was given cryoglobulin
for fibrinogen < 100.
.
# [**Last Name (un) **] - Patient developed [**Last Name (un) **] soon after starting nafcillin.
Diuretics were stopped. Likely [**1-7**] to AIN from nafcillin
although hepatorenal may be contributing. Active urine sediment
with WBC casts c/w AIN. Antibiotics were changed from nafcillin
to cefzolin and AIN resolved. Cr then started to bump again.
Urine lytes c/w prerenal etiology (given lack of po intake) vs
hepatorenal. Patient did not respond to NS bolus or albumin.
On [**2128-8-30**], the patient became markedly encephalopathic and
was transferred to the surgical ICU under the care of the
transplant surgery service. The following summarizes the
remainder of her hospital course:
CT head on [**2128-8-30**] showed no intracranial abnormality. Liver
ultrasound was unrevealing. She underwent infectious work-up and
was started on broad-spectrum antibiotics empirically.
Hematology evaluated her anemia and found her to be in DIC
secondary to liver failure. On [**2128-8-31**], she was intubated for
waxing and [**Doctor Last Name 688**] mental status. Her coagulopathy was reversed
with transfusions and an intracranial bolt was placed the
following day for ICP monitoring. While the bolt was in place,
her coagulopathy was corrected with transfusions of FFP,
platelets, and cryoglobulin as needed to maintain an INR <2.0,
Plts >75, Hct >25 and Fibrinogen >100. ICP was maintained below
20 with sedation, hypertonic saline, mannitol, hyperventilation,
paralysis, and hypothermia, though she had intermittent
increases of ICPs to >25. Norepinephrine gtt was used to
maintain CPP >60.
On [**2128-9-6**], CVVH was started for acute renal failure, likely
hepatorenal syndrome. A suitable liver became available and she
was brought to the operating room. However, ICPs increased to
>40 and could not be lowered with medication. Therefore, she
was brought back to the SICU and the transplantation operation
was cancelled.
Supportive care was continued while awaiting liver
transplantation. On [**2128-9-10**], a multidisciplinary family
meeting concluded in the decision to continue this course.
ICPs stabilized <20 spontaneously without sedation, hypertonic
saline, mannitol, hyperventilation, paralysis, and hypothermia.
On [**2128-9-15**], the intracranial bolt was removed. At this time,
neurological exam remained poor, as at the most she grimaced to
painful stimuli. CT head, MR head, and EEG showed no acute
intracranial abnormality, aside from hepatic encephalopathy, to
explain her poor mentation. On [**2128-9-16**], she became febrile,
and her WBC count increased abruptly, raising concern of
infection. Suspicion for infection was high, although
surveillance cultures up to this time had shown no significant
evidence of infection. Antibiotics were changed from
vanc/cefep/flagyl/fluc/entecavir to
vanc/[**Last Name (un) 2830**]/flagyl/mica/entecavir.
On [**2128-9-17**], she became hypotensive, requiring the maximum
dose of norepinephrine gtt. She developed ARDS with severe
pulmonary edema with worsening respiratory status. She
developed hypoglycemia, necessitating the need for a continuous
D10 gtt.
At this point, she was deemed to have a poor prognosis overall
and not in a state of health amenable to liver transplantation.
A multidisciplinary family meeting concluded in the decision to
render her DNR. Decision was made to not withdraw care at this
time but to slowly de-escalate care. The CVVH was discontinued
per the family request.
Ms. [**Known lastname 90708**] remained on maximal levophed gtt requirement
throughout the evening of [**9-17**]. Despite the pressor, her SBP
remained in the 70s. At approximately 12:30 AM, [**9-18**], her
oxygen saturation gradually declined. After a brief period of
tachycardia to the 180s, she became bradycardic and asystolic
within minutes.
She was pronounced expired at 12:47 AM.
Medications on Admission:
ASA 81 mg, Calcium, MVI, Glucosamine/chondroitin.
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver failure
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2128-9-18**]
|
[
"V49.83",
"599.0",
"V64.1",
"999.31",
"041.86",
"V15.51",
"V49.86",
"E930.0",
"790.01",
"070.20",
"235.2",
"572.3",
"V15.82",
"790.7",
"E879.8",
"041.49",
"518.4",
"535.60",
"348.5",
"286.9",
"305.00",
"518.82",
"584.8",
"780.09",
"276.4",
"041.11",
"286.6",
"530.19",
"V66.7",
"570",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.72",
"48.36",
"38.93",
"39.95",
"45.42",
"50.11",
"01.10",
"96.04",
"88.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17132, 17141
|
11184, 13801
|
294, 356
|
17198, 17207
|
2553, 11161
|
17259, 17293
|
1957, 2052
|
17104, 17109
|
17162, 17177
|
17030, 17081
|
13819, 17004
|
17231, 17236
|
1655, 1787
|
2067, 2534
|
239, 256
|
384, 1603
|
1625, 1632
|
1803, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,356
| 137,859
|
23097
|
Discharge summary
|
report
|
Admission Date: [**2144-5-28**] Discharge Date: [**2144-5-31**]
Date of Birth: [**2073-7-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lasix / Zaroxolyn
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
This is a 70 year old female well known to this sevice, who
presents with increasing shortness of breath secondary to her
GERD, which is severe and long standing. She also had some
chest pain associated with this episode. She was a direct admit
from home. She was recently discharged from this service.
Past Medical History:
GERD s/p Laparoscopic Nissen fundoplication [**4-15**] with revision
[**10-15**] for symptom recurrence
tracheobronchomalacia s/p tracheobronchoplasty [**1-16**]
type 2 diabetes mellitus, insulin dependent
CHF
HTN
COPD
IBS
osteoarthritis
cecal AVM
h/o rheumatic [**Month/Year (2) **] in childhood
Social History:
The patient is widowed and she used to work as a medical
secretary. She drinks alcohol occasionally and socially. She is
not a current smoker. She stopped smoking 7 years ago and she
smoked for almost 40 years 1.5 - 2 packs a day and she denies
any history of any asbestos exposure.
Family History:
CAD in grandparents, but no lung disease; negative for
esophageal cancers.
Physical Exam:
AF, 154/78 110 30 96%2L
In respatory distress
tachycardic, no m/r/g
Abd: benign
Resp: upper airway wheezing, with decreased breath sounds
Pertinent Results:
[**2144-5-28**] 12:45PM PT-11.5 PTT-19.8* INR(PT)-1.0
[**2144-5-28**] 12:45PM WBC-7.3 RBC-4.52 HGB-14.0# HCT-38.3 MCV-85
MCH-31.0 MCHC-36.6* RDW-13.1
[**2144-5-28**] 12:45PM PLT COUNT-326#
[**2144-5-28**] 12:45PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.5
[**2144-5-28**] 12:45PM GLUCOSE-144* UREA N-24* CREAT-1.2* SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2144-5-28**] 12:45PM CK(CPK)-80
[**2144-5-28**] 03:19PM TYPE-ART TEMP-37.2 PO2-106* PCO2-39 PH-7.46*
TOTAL CO2-29 BASE XS-3 INTUBATED-NOT INTUBA
Brief Hospital Course:
The patient was directed admitted to Dr.[**Name (NI) 1816**] service from
home. On admission, she was underwent bronchoscopy in
conjuncition with the IP service, who also knows her. Due to
marked cord edema, she was transferred to the CSRU and was
maintatined on Heliox and CPAP mask. After her first night, she
was doing much better and was able to be weaned off her
heliox/mask. GI was consulted who adjusted her antiacid
therapy, which seemed to help. She will undergo futher work up
as an outpaient. She was tranferred to the floor once more
stable. On HD4 her breathing was much better and she was
dischared home on her modifed regimen, to recieve more extensive
outpatient workup.
Medications on Admission:
Allopurinol
pantoprozole, torsemide, aldactone, lipitor, asa, nortriptiline,
metocloparmined, hyoscyamine, insulin, lantonoprost,
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours.
Disp:*1 inhaler* Refills:*2*
11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation every four (4) hours.
Disp:*1 inhaler* Refills:*2*
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p tracheobronchoplasty [**1-16**], s/p lap nissen x2 ([**Doctor Last Name **]),
DM2, CHF (ef 55%), LVH, HTN, COPD, IBS, OA, rheumatic [**Doctor Last Name **] as
child.
vocal cord spasm-tx'd w/ racemic epinephrine and heliox
Discharge Condition:
good
Discharge Instructions:
Take all of your anti-acid medications as prescribed, below you
can find all of your appointments for your upcoming studies. If
you experience increasing shortness of breath, you should call
Dr.[**Name (NI) 1816**] office
Followup Instructions:
Call Speech and Swallow for appt [**2144-6-2**]- [**Telephone/Fax (1) 3731**].Provider:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 17075**] Date/Time:[**2144-6-9**] 10:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2144-6-9**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**0-0-**] Date/Time:[**2144-6-16**]
10:30
Completed by:[**2144-5-31**]
|
[
"401.9",
"250.00",
"715.90",
"530.81",
"496",
"786.59",
"786.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"31.42",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4276, 4282
|
2112, 2807
|
311, 326
|
4552, 4559
|
1550, 2089
|
4830, 5300
|
1298, 1374
|
2987, 4253
|
4303, 4531
|
2833, 2964
|
4583, 4807
|
1389, 1531
|
252, 273
|
354, 661
|
683, 981
|
997, 1282
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,763
| 164,312
|
13118
|
Discharge summary
|
report
|
Admission Date: [**2127-1-19**] Discharge Date: [**2127-1-31**]
Date of Birth: [**2062-9-2**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides) / Ativan / Ceftriaxone
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
difficulty breathing, stridor
Major Surgical or Invasive Procedure:
Tracheostomy
Lumbar puncture
History of Present Illness:
This is a 64 year old man with complicated neurological and
medical history below, who is followed by [**First Name3 (LF) **]. [**Last Name (STitle) 7994**] and
[**Name5 (PTitle) **]
as an outpatient, who presents with several days of worsening
inspiratory and expiratory stridor, and shortness of breath.
According to the patient and his wife, he has felt slightly
short
of breath since he left the hospital this past summer. He has
also had a hoarse, "raspy" voice. His wife thinks his breathing
and voice have been worse over the past few months. Several
days
ago, the breathing was worse than ever, and he had to take many
breaths in the middle of sentences; the stridor is loud and
comes/goes during the day. He snores loudly at night. In the
early hours of the morning, he felt like he couldn't breathe if
he turned to one side while lying down; his chest felt tight;
his
wife called EMS and he was brought to [**Hospital **] hospital, where a CT
showed a 1.3 cm extrathoracic mass occluding 50% of the airway.
He was transferred to [**Hospital1 **] for further w/u, and went to the OR for
rigid bronchoscopy and tracheoscopy which was apparently
negative. Prior to the procedure, he had been ordered for
Decadron, Heliox, and Racemic epi. Following the procedure, as
no mass was seen, meds were stopped. ENT has been consulted as
well. The patient says he has had shortness of breath for
months, which he feels is worse with conversation and actually
improves when he is exercising and not trying to talk. However,
he notices no change from beginning to building up exercise.
Past Medical History:
- HTN
- Hypercholesterolemia
- CAD s/p MI [**2114**] s/p angioplasty, had stents [**2119**]
- Kidney stones removed [**2120**]
Social History:
Lives with wife, retired corrections officer; tob [**3-23**] ppd x
25yrs, no etoh, no drugs. Has seen chiropractor for back, neck
in past, though no hx injuries to either.
Family History:
Niece died of lupus, uncle had cancer (unknown type, elderly),
father d. brain hemorrhage (elderly). No other strokes, sz,
neuro d/o incl MS, MG, no blood/clotting d/o, and no other
autoimmune d/o.
Physical Exam:
Examination:
T 97.6 HR 77 BP 143/72 RR 11-24 (currently slightly
tachypneic), 100%RA
General appearance: tachypneic, loud stidor, has to catch breath
frequently when talking
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits, though there is both inspiratory and
expiratory stridor, heard on ausculation of trachea bilaterally
and transmitted to lower lung fields bilaterally. No palpable
masses.
Heart: regular rate and rhythm, no murmurs
Lungs: transmitted upper airway sounds
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Mental Status: The patient is alert and attentive, +DOW
backwards, normal registration/recall. Good knowledge for
current
events. Language is intact with no errors. There is no apraxia
or
agnosia.
Cranial Nerves: The visual fields are full. The optic discs are
difficult to visualize - cataracts bilat. Eye movements are
significant for inability to completely bury sclera on R eye lat
gaze, but o/w normal and no diplopia; no nystagmus. Pupils
react
equally to light, both directly and consensually. Sensation on
the face is intact to light touch, pin prick. Facial movements
are normal and symmetrical. Hearing is intact to finger rub. The
palate is weaker on the right than the left, and the tongue may
also be slightly weak when pushing against the right cheek,
though it protrudes midline - no fasciculations. Voice is
hoarse, more so than when I saw him in [**8-25**]. He can count from
100 to 89 before taking another breath.
Motor System: Elevated tone in the legs bilaterally, normal in
the arms. With the exception of weakness of R EDB, the power is
normal in all 4 limbs, including shoulder abductors, and
extensors and flexors of the arms, wrists, fingers, hips, knees,
feet and toes. There is no tremor, drift, or abnormal
movements.
Reflexes: The tendon reflexes are present, symmetric in upper
ext, brisk at knees with 2 beats clonus at each ankle; both toes
are upgoing.
Sensory: Sensation is intact to pin prick, light touch,
vibration
sense, and position sense in all extremities and trunk.
Coordination: There is no ataxia. Slow foot tapping compared to
finger tapping bilat; nl f->n
Gait: could not be assessed - for ENT eval shortly
Pertinent Results:
[**2127-1-30**] 06:25AM BLOOD WBC-4.4 RBC-3.79* Hgb-11.7* Hct-33.7*
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.0 Plt Ct-202
[**2127-1-19**] 10:50AM BLOOD Neuts-85.1* Lymphs-12.1* Monos-2.5
Eos-0.2 Baso-0.2
[**2127-1-30**] 06:25AM BLOOD Plt Ct-202
[**2127-1-23**] 03:02AM BLOOD ESR-14
[**2127-1-30**] 06:25AM BLOOD Glucose-100 UreaN-5* Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-29 AnGap-11
[**2127-1-30**] 06:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
[**2127-1-26**] 07:20AM BLOOD ANCA-NEGATIVE
[**2127-1-26**] 07:20AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2127-1-23**] 03:02AM BLOOD CRP-2.4
[**2127-1-21**] 07:52PM BLOOD CRP-1.6
[**2127-1-25**] 06:10AM BLOOD IgA-175
[**2127-1-26**] 07:20AM BLOOD GQ1B IGG ANTIBODIES-PND
[**2127-1-26**] 07:20AM BLOOD SM/RNP ANTIBODIES (WITHOUT [**Doctor First Name **])-Test
[**2127-1-26**] 07:20AM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
[**2127-1-26**] 07:20AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-Test
[**2127-1-25**] 08:26AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-Test
Brief Hospital Course:
Neurology: Patient admitted to SICU and later transferred to
Neurology Service for presentation of concern of has new R
palate weakness and possibly some R tongue weakness, urinary
hesitancy, and fixed stridor. These finding were in addition to
more chronic findings of inability to fully abduct right eye,
spastic lower extremities. The etiology of Mr. [**Known lastname 39979**]
findings were investigated. It was thought that his presentation
of symptoms were localized to the brain stem and perhaps a
combination of pseudobulbar signs and lower motor neuron signs.
He underwent work up including MRI of the head (normal) and C
spine (cervical spondolysis. Serum labs for antiGq1b Ab pending,
smAb/ SmIRNP Ab neg, SSA Ab pos, SSB ab neg, ACE level WNL.
Lumbar puncture showed 26 wbc (5% polys 80%lymphs),109 rbc,
protein 35, glucose 80. CSF studies showed no oligoclonal bands,
Anti-[**Doctor Last Name **] Ab and Whipple's PCR, EBV PCR all neg. Tb CSF PCR is
pending. Full paraneoplastic antibody panel will have to be sent
as outpatient because of insurance issues. Cytology also sent on
CSF and no malignant cells seen. Patient received Imipenem,
Vancomycin and Acyclovir until CSF cx and HSV PCY were negative.
Patient was treated with 5 day course of IVIG without
significant improvement in symptoms from presentation. He had a
repeat indirect laryngoscopy by ENT which showed no significant
change in vocal cord movement. This study will have to be as
outpatient in the near future per ENT recs. His lower leg
spasticity improved with home dose of Baclofen and Valium. He
worked with PT and was able to ambulate with walker. He was
recommended to be discharged to inpatient rehabilitation
facility for further care by PT.
Respiratory: ENT was consulted to evaluate stridor. On
fiberoptic laryngoscopy neither vocalcord opens completely,
implying bilateral weakness. Rigid broncoscopy by IR was nml
with no signs of tracheal lesions/masses. He passed a swallow
study with preserved gag and cough. Based on the concern of
stridor, the patient was initially kept in ICU and received
tracheostomy on [**2127-1-24**] without complications. He was again
evaluated post-op by speech and swallow service who reaffirmed
his ability to swallow and provided Passey-Muir valve so patient
could have a trach plug when not eating/talking.
Urology: Patient evalauted by Urology for concern of weeks of
urinary retention. He demonstrated with two unsuccessful
voiding trials significant obstruction vs detrusor dysfunction.
The differential includes BPH or other neurogenic causes
(medication, infection, anesthesia, anatomic unlikely).
Urodynamic studies were recommended but not performed on this
hospitilization and patient will need to follow up with urology
as outpatient. He had a Foley placed and told to continue
Avodart.
FEN/GI: Patient tolerated po diet and cleared to eat po diet by
Speech and swallow service.
ID: Patient is MRSA cx positive and was on MRSA precautions
during his stay in the hospital.
Medications on Admission:
Meds:
1. ECASA
2. Lopressor
3. Klonopin
4. Baclofen 15/15/15/20
5. Valium 2.5 mg po bid
6. Avodart
7. Vitamin E
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
3. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Vitamin E 100 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
Discharge Disposition:
Extended Care
Facility:
Cape and [**Hospital **] Rehab
Discharge Diagnosis:
Presumed paraneoplastic brainstem disease
Discharge Condition:
Stable-unable to completly bury right [**Doctor First Name 2281**] on abduction, right
palate does not raise symmetrically with left, slow tongue
movements, stridor, raspy voice, spastic lower extremities with
clonus and bialt upgoing toes.
Discharge Instructions:
Take medications as instructed. Please Call Dr. [**Last Name (STitle) 7994**] if any
new symptoms arise.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/REUBENS Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2127-2-21**] 4:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2127-2-27**] 9:45
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
|
[
"781.0",
"401.9",
"237.5",
"323.41",
"721.0",
"V45.82",
"272.0",
"136.9",
"478.30",
"788.20",
"V13.01",
"786.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"31.1",
"33.23",
"31.42",
"96.6",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
10017, 10074
|
6010, 9027
|
334, 364
|
10160, 10403
|
4915, 5987
|
10556, 10998
|
2345, 2546
|
9190, 9994
|
10095, 10139
|
9053, 9167
|
10427, 10533
|
2561, 3226
|
265, 296
|
392, 1987
|
3441, 4896
|
3241, 3424
|
2009, 2138
|
2154, 2329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,019
| 149,238
|
9641
|
Discharge summary
|
report
|
Admission Date: [**2155-10-17**] Discharge Date: [**2155-10-21**]
Date of Birth: [**2090-5-16**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
65 M with h/o diverticulosis, rectal bleeding in [**Last Name (LF) 205**], [**First Name3 (LF) 216**],
Septemeber of [**2155**], hypertension, subdural hematoma, who was
transferred from [**Hospital1 882**] hosptial with 1 day history of BRBPR.
Pt reports feeling in his USOH until approximately 5 pm when he
had a BM accompanied by bright red blood per rectum and clots.
Then he had similar episode twice more and went to [**Last Name (un) 883**].
There he had two further episodes. No ab pain, no N/V, no fever,
no chills, no recurrent diarrhea prior to [**10-16**] onset. Denies
any tarry black stools prior to the first episode. At [**Last Name (un) 883**],
gastric lavage was negative with Hct 36.7 at 11 30 pm. Hct 28 4
at 3 am. Given 1 unit PRBCs and sent to [**Hospital1 18**]. Had screening
colonoscopy on [**2-4**] noted to have diverticulosis. First episode
of bleedign was in [**2155-7-3**] when blood drooped out like urine.
Then had similar episodes as noted above. Was to see Dr [**First Name (STitle) 26390**] at
[**Hospital1 112**] but on divert. Denies other symptoms such as chest pain and
SOB.
Past Medical History:
1. HTN
2. Diverticulosis
3. Rectal bleeding
4. OD blindness, idiopathic since [**71**] s
5. Sat night palsy/compressive radial nerve palsy
6. Subdural hemmorhage in [**2147**]
7. De quervains disease-left
8. Headache
Social History:
lives alone, +EtOH, drugs; can go 1 wk w/o drinking, carpenter,
semiretired, no tobacco, children in 30's
Family History:
No colon cancer, mother-HTN, brother HTN
Physical Exam:
Temp 97 9
BP 126/71
Pulse 72
Resp 16
O2 sat 100% o2 sat 2 LNC
Gen - Alert, no acute distress; lying flat in bed, odor of
melena in room
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist; aniceteric
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, minimally tender diffusely, nondistended, with
normoactive bowel sounds, no guarding, no mass
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**2-13**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
EKG: NSR nl axis rate 72 nl intervals and chamber size, TWI III,
TWF II, avf, V6
Brief Hospital Course:
For his bright red blood per rectum/GI bleed, the patient was
monitored in the ICU and kept NPO. Serial crtis were drawn. IV
protonix q12 was given. For his low hematacrit, 2u of PRBC's
were given. Both surgery and GI were consulted. A tagged RBC
scan was performed which was negative. His hematocrit was stable
throughout the remaineder of his stay in the ICU. On Monday,
[**10-20**], a colonoscopy was performed and diverticuli were
noted, but there was no further evidence of acute bleed.
For his history of alcohol abuse, the patient was kept on a CIWA
scale. He did not require ativan.
Access was with two large bore IV's.
Code was full.
Medications on Admission:
Hctz 25 qd
Lisinopril 40qd
Viagra PRN
Discharge Medications:
Hctz 25 qd
Lisinopril 40qd
Viagra PRN
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticuli
2. Hypertension
Discharge Condition:
Pt was discharged in good condition without any evidence of
bleeding.
Discharge Instructions:
If you have fever/chills, shortness of breath, vomiting blood,
or blood per rectum, please call your PCP or come to the
Emergency room.
You may re-start your home blood pressure medications.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 32630**] Call to schedule
appointment for post-discharge followup in [**1-3**] weeks.
|
[
"562.12",
"727.04",
"455.0",
"285.1",
"305.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
3583, 3589
|
2778, 3433
|
326, 340
|
3664, 3735
|
2673, 2755
|
3976, 4174
|
1862, 1904
|
3521, 3560
|
3610, 3643
|
3459, 3498
|
3759, 3953
|
1919, 2654
|
271, 288
|
368, 1483
|
1505, 1723
|
1739, 1846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,854
| 117,539
|
12388
|
Discharge summary
|
report
|
Admission Date: [**2129-10-17**] Discharge Date: [**2129-10-21**]
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
intubation [**2129-10-19**]
extubation [**2129-10-21**]
History of Present Illness:
[**Age over 90 **] year old woman admitted for MS changes on [**10-17**]. In the
[**Hospital1 18**] ED she was found to have a infiltrate on CXR and dirty UA
therefore started on levofloxacin and flagyl. Lactate was 1.0.
She was given levoquin, flagyl and kayexalate for her high
potassium (5.7). Also in the ED, SW spoke with the [**Hospital1 9168**] who went
into the patient's home who reported that home showed evidence
of hoarding with hallways and stairs filled with boxes of food.
[**Hospital1 9168**] reports that there was no trash or dirt among the items and
that the home was clean. Pt lives with her daughter who was home
at the time of [**Name (NI) 9168**] visit.
Daughter, [**Name (NI) 714**], reports that she is the pts primary
caretaker in the home with the only assistnce being 5 hours of
PCA through Family Services and ETHOS, and once a week visits
from her sister who lives in [**Name (NI) 3307**]. She states that she
started to increase her mothers Haldol and tylenol and codeine
as of Friday in order to help her sleep at approximately 3 times
her baseline doses. Has held her Lasix and Glyburide. Pt had
decreased PO intake at home. Daughter has been in contact with
ETHOS and with the patient's PCP, [**Name10 (NameIs) 1023**] came to house this morning
in reponse to an email from daughter. Daughter states very
clearly that she is having a hard time caring for her mother at
home, and is interested in pursuing placement for her mother
from the hospital. Daughter is also concerned about $300 copay
required by insurance if pt is admitted. SW provided support to
daughter and discussed anticipated course of care if pt is
hospitalized. Daughter is aware that keeping pt at home is no
longer working and is willing to explore options for placement.
Daughther is expressing indicators of caregiver burnout and is
aware of this and actively seeking help and support from
available services.
.
Past Medical History:
CHF
HTN
Hypothyroid
NIDDM
s/p surgery for diverticulitis
s/p CCY
s/p Appy
Multi-infart dementia
'heart murmur'
Social History:
lives with daughter at home ([**Name (NI) 714**] [**Name (NI) 4223**] [**Telephone/Fax (1) 38562**]).
No tobacco or alcohol.
Family History:
Non-contributory
Physical Exam:
PE
T 94 BP 115/58 HR 65 RR 22 92% 4L O2sats
Gen: Awake, NAD
HEENT: PERRL, EOMI, clear OP, anicteric, mmm
Neck: No LAD, JVD
Lungs: Decr BS RLL, no wheezes, crackles, rhonchi
Heart: RRR no m/r/g
Abd: Soft, NT, ND +BS
Ext: 1+ edema in ankles, trace edema in legs bilat (diffuse
below knee), 2+ DP/PT
Neuro: A&O times 2 (not time), no focal deficits, CN II-XII
intact
Pertinent Results:
[**2129-10-17**] 08:14PM URINE HOURS-RANDOM UREA N-826 CREAT-155
SODIUM-30
[**2129-10-17**] 08:14PM URINE OSMOLAL-576
[**2129-10-17**] 08:00PM GLUCOSE-113* UREA N-37* CREAT-1.6*
SODIUM-132* POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-28 ANION
GAP-14
[**2129-10-17**] 08:00PM OSMOLAL-281
[**2129-10-17**] 08:00PM PT-31.4* PTT-47.5* INR(PT)-7.4
[**2129-10-17**] 01:50PM LACTATE-1.0
[**2129-10-17**] 01:30PM GLUCOSE-98 UREA N-35* CREAT-1.3* SODIUM-131*
POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-28 ANION GAP-17
[**2129-10-17**] 01:30PM CK(CPK)-156*
[**2129-10-17**] 01:30PM CK-MB-9 cTropnT-<0.01
[**2129-10-17**] 01:30PM NEUTS-88.0* BANDS-0 LYMPHS-5.9* MONOS-4.5
EOS-1.5 BASOS-0.1
[**2129-10-17**] 01:30PM WBC-10.4 RBC-3.89* HGB-11.4* HCT-32.8* MCV-84
MCH-29.2 MCHC-34.6 RDW-13.9
[**2129-10-17**] 01:30PM PLT COUNT-164
[**2129-10-17**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2129-10-17**] 12:30PM URINE RBC-0-2 WBC-[**4-29**]* BACTERIA-MOD
YEAST-NONE EPI-0
.
[**10-17**] CXR IMPRESSION: AP chest compared to [**2128-9-16**]:
There is extensive multifocal consolidation in the lungs, most
marked in the right apex but also in the right and left lower
lung zones most consistent with multifocal pneumonia. Small
left pleural effusion is new. Moderate
cardiomegaly is chronic. Findings were discussed with Dr.
[**Last Name (STitle) 6633**] by
telephone at the time of dictation.
.
[**10-17**] CT head IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Evidence of age-related atrophic changes.
3. Findings suggestive of bilateral chronic small vessel
ischemic infarcts in
the cerebral white matter, as well as lacunar infarcts.
4. Right maxillary sinus disease.
.
[**10-18**] CT head IMPRESSION: No evidence of intracranial
hemorrhage or other acute abnormality. Please see the prior
report for findings consistent with chronic bilateral infarcts
and right maxillary sinus disease. No significant change since
the prior day.
.
[**10-19**] CXR IMPRESSION: New pulmonary edema, worsening multifocal
pneumonia, enlarging bilateral effusions
.
[**10-20**] CXR IMPRESSION: AP chest compared to [**10-17**] and
30th: Moderately severe pulmonary edema has improved slightly
since [**10-19**] at 10:02 p.m., but multifocal pneumonia is
unchanged. There is a component of atelectasis in the right
upper lobe where simple pneumonia was demonstrated on [**10-17**] and the same is probably true in the left upper lobe.
Moderate cardiomegaly is stable and a moderate-sized left
pleural effusion which developed since [**10-17**] is stable
subsequently. ET tube is in standard placement, nasogastric
tube passes below the diaphragm and out of view. Tip of the
left jugular line projects over the left brachiocephalic vein.
No pneumothorax.
Brief Hospital Course:
Assessment [**Age over 90 **] year old woman admitted for MS changes with U/A
consistent with UTI and CXR consistent with multifocal PNA.
.
## Pneumonia. As per CXR on admission, patient had extensive
multifocal consolidation in the lungs. She was started on
Flagyl and Levoquin for atypical and community aquired PNA
coverage. The patient had intermittent fevers throughout the
hospital course. We repeated CXRs daily and her PNA progressed
despite antibiotic coverage, and she was switched to
Vancomycin/Zosyn on [**10-19**]. Ongoing discussion with her daughter
involved goals of care and whether or not to intubate if that
became necessary. On the morning of [**10-19**], she became short of
breath with desaturations into the 70s and was transferred to
the MICU, initially for non-invasive ventilation. Patient's ABG
was notable for respiratory acidosis 7.29/78/71 repeat
7.21/78/71 on 4L face mask. Repeat CXR showed persistent
multilobar PNA with new LUL infiltrate, no overt evidence of
CHF. Patient received nebulizer treatment, Lasix, and
antibiotics were switched to Zosyn, Flagyl, and Vancomycin.
Daughter (HCP) was made aware of the situation by housetaff and
confirmed DNR/DNI status. Later on the day of transfer to the
ICU, the patient had increasing respiratory distress while on
non-invasive ventilation, and her daughter requested that she be
intubated. Anesthesia was called, and she was intubated without
complications. The patient's code status at that time remained
DNR (no CPR or shocks, pressors were acceptable). Over the next
1-2 days she became more hypotensive and displayed septic
physiology, ultimately requiring pressors to maintain her blood
pressure. On [**10-21**] the patietn's daughter and family made the
decision to withdraw care. Morphine was given for comfort, the
patient was extubated, and all other medications were stopped.
The patient died on [**2129-10-21**] at 9:55pm.
.
## UTI. UA had 6-10 WBCs and Pos nitrite and mod bacteria on
admission. Her Urine culture eventually grew pansensitive
e.coli. She was originally placed on Levoquin for UTI. Urine
was negative for Legionella on HD #3.
.
## Hyperkalemia/Hyponatremia. Patient was thought to be
dehydrated on admission given poor PO intake at home. SIADH was
also a possible etiology of hyponatremia. She was given
kayexalate in ED. We free water restricted her to 1.5L and used
NS for volume expansion. Nutrition was consulted. Urine
electrolytes were not revealing for SIADH.
.
## Coagulopathy. INR was probably high due to Warfarin so this
was held upon admission and INR was followed daily. INR
reversed with Vit K and FFP. LFTs were also slightly elevated
at that time and trended down.
.
## MS Changes. As noted above, this was probably multifactorial
with PNA (and resulting hypoxia and hypercarbia), UTI and poor
nutrition contributing. In addition, Tylenol with Codeine at 3x
baseline dose probably contributed. Narcotics, benadryl, and
other sedating meds were held.
.
## CHF/Afib. On admission there was moderate volume overload on
exam and CXR. Lasix was given prn to keep I/O even to negative.
Coumadin was held as above.
.
## Anemia. At baseline HCT (32) on admission. Patient received
1U PRBCs [**10-21**] for anemia and low UOP.
.
## CKD- Baseline creatinine 1.2-1.5. Steadily trended up during
hospital course. We renally dosed meds (Cr Clearance <30) and
avoided nephrotoxic meds.
.
## DM. Stable BS on admission was increasingly labile
throughout admission. Pt was covered by SSI.
.
## Hypothyroid. Continued synthroid at outpatient dose.
Medications on Admission:
Metoprolol 50 TID
Lisinopril 2.5 Daily
Amiodarone 200 Daily
Gylburide 1.25 [**Hospital1 **]
Levothyroxine 125 mcg Daily
Lasix 20 Daily
Haldol 0.5 qhs increased to tid on Fri
Warfarin 2.5 QIW
T&C #3 tid
Timolol OU
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
hypercarbic and hypoxemic respiratory failure secondary to
multifocal pneumonia
E. coli urinary tract infection
Secondary Diagnoses:
congestive heart failure
hypertension
Hypothyroidism
type II diabetes
Multi-infart dementia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"585.9",
"424.0",
"437.0",
"250.00",
"244.9",
"584.9",
"486",
"401.9",
"276.1",
"428.0",
"427.31",
"290.40",
"599.0",
"518.81",
"038.9",
"276.7",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.71",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9670, 9679
|
5785, 9378
|
245, 302
|
9966, 9975
|
2964, 5762
|
10027, 10159
|
2545, 2564
|
9642, 9647
|
9700, 9831
|
9404, 9619
|
9999, 10004
|
2579, 2945
|
9852, 9945
|
184, 207
|
330, 2252
|
2274, 2386
|
2402, 2529
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,515
| 196,595
|
2700+2701
|
Discharge summary
|
report+report
|
Admission Date: [**2137-7-11**] Discharge Date: [**2137-7-17**]
Date of Birth: [**2074-6-12**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 63-year-old
male who is status post CABG times two (LIMA/LAD, SVG/PDA) in
[**2119**]. He has had an exertional angina times six months plus
ETT. Echocardiogram in [**5-7**]: LVEF 35%, moderately dilated
aortic root and ascending aorta, trace AI, 1+ MR, mild AS.
He was admitted for cardiac catheterization on [**2137-6-20**] which
revealed 60% left main, three vessel CAD, patent LIMA
graft/LAD, 90% occluded SVG, patent left subclavian artery
stent, pulmonary hypertension, left ventricular end-diastolic
pressure 40. The patient was referred for a re-do CABG. The
patient is status post off pump CABG times one, SVG/OM. The
patient's comorbidities include CAD, CABG times two in [**2119**],
status post left subclavian artery stent in [**2133**], basilar
artery stenosis, PVD, status post left popliteal-peroneal
bypass graft, status post left carotid endarterectomy,
arthritis, status post left TAHR, status post right TKR,
hypercholesterolemia, ventral hernia, inguinal hernia, status
post inguinal hernia repair, history of tobacco (25 pack
year, quit in [**2110**]), plus ETOH.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg q.d.
2. Coumadin for basilar artery stenosis, last dose [**2137-6-15**].
3. Lisinopril 10 mg q.d.
4. Allopurinol 100 mg b.i.d.
5. Inderal 40 mg q.d.
6. Niacin 1,500 mg b.i.d.
7. Lipitor 40 mg q.d.
LABORATORY/RADIOLOGIC DATA: Preoperative EKG showed ST
depressions in the inferior leads, normal sinus rhythm, and
no acute ischemic changes.
Chest x-ray showed no acute disease.
Chest CT showed extensive calcification of the aorta and
coronary arteries.
Carotid duplex showed a less than 40% stenosis on the left
and 60-69% stenosis on the right.
Laboratories were significant for an INR of 1.2. CBC: White
count 13, hematocrit 40.3, platelets 217,000. Chemistries
included a sodium of 136, potassium 3.8, chloride 97,
bicarbonate 25, BUN 21, creatinine 0.8, glucose 105. LFTs
were within normal limits.
PHYSICAL EXAMINATION ON ADMISSION: The patient was
neurologically grossly intact without carotid bruits, but a
murmur was noted that radiates bilaterally. The lungs were
clear to auscultation. Heart: Regular rate and rhythm, S1,
S2, III/VI systolic ejection murmur loudest at the aortic
area. Abdomen: Obese, soft, nontender, plus a ventral
hernia. Extremities: Multiple areas of healed venostasis
ulcers. DP pulses were palpated bilaterally, [**12-6**]+ edema
bilaterally.
HOSPITAL COURSE: The patient is status post off-pump CABG
times one (SVG/OM) on [**2137-7-11**]. Please see the operative
note. The patient's pericardium was left open. An A-line
with Swan-Ganz catheter were in place. A ventricular and
ground wire were placed and two left pleural tubes were in
place. The patient was transferred to the CSRU with a mean
arterial pressure of 63, CVP 7, PAD 15, [**Doctor First Name 1052**] 25, and normal
sinus rhythm at a rate of 71 on Neo-Synephrine and propofol
drip.
On postoperative day number one, the patient was extubated
overnight. The vital signs were stable. The patient was
afebrile, in normal sinus rhythm with a blood pressure of
105/47 and a rate of 87. The patient had 5,898 in, 1,320 of
urine and 640 out of the chest tube. The patient's
laboratory values were within normal limits. Neo drip was
off. The patient was on a dopamine and insulin drip with a
Dilaudid PCA for pain, Kefzol and Plavix. The plan was to
continue the current medications, wean the dopamine, begin
diuresing with Lasix.
On postoperative day number two, the patient was stable with
stable vital signs on Lopressor 12.5 b.i.d., Lasix, Zantac,
Plavix, and aspirin.
On postoperative day number three, the patient had no acute
events overnight. The T. Maximum was 101.2. The heart rate
was 78, in sinus rhythm, and a blood pressure of 126/52,
saturating at 95% on room air with 360 in, 2,430 out. A
white count of 11.5, crit 28.8, platelets 171,000. The
electrolytes were within normal limits, repleted p.r.n. The
patient was on Inderal 40 b.i.d., Lasix 20 b.i.d., Lipitor 40
q.d., Allopurinol 100 b.i.d. The patient's examination was
within normal limits. Chest x-ray was checked. The patient
was pancultured and started on Levaquin prophylactically for
temperature and sputum of a brownish color.
On postoperative day number four, there were no events
overnight. The patient's vital signs were stable. The
physical examination was unremarkable. The patient was
continued on Levaquin and cardiac medications, adequate
diuresis, and was transferred to the floor in a stable
condition. Mostly the [**Hospital 228**] hospital course was
unremarkable. The patient was continued on Levaquin, sputum
cultures growing moderate oropharyngeal flora, sparse
gram-negative rods. The urine culture was growing less than
10,000 organisms with blood cultures still pending.
On postoperative day number six, the patient was discharged
with a normal white count of 9.1, hematocrit 24.7, platelets
208,000. The patient was seen by Dr. ....................
and was instructed to follow-up with him in [**Month (only) **] for a
cardiac catheterization after healing of groin staples.
CONDITION ON DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DIAGNOSIS:
1. Unstable angina.
2. Three vessel coronary artery disease.
3. Left main disease.
4. Decreased ejection fraction.
5. Status post off-pump coronary artery bypass graft times
one (SVG/OM).
DISPOSITION: The patient was discharged home with
services/VNA.
DISCHARGE INSTRUCTIONS: Keep wounds clean and dry. No
bathing or swimming, no heavy lifting (10 pound weight
limit), no driving.
FOLLOW-UP: The patient was asked to follow-up with Dr. [**Last Name (STitle) 1537**]
in four weeks and Dr. .................... for PTCA in two to
three weeks.
DISCHARGE MEDICATIONS:
1. Lasix 20 p.o. q.d. times two weeks.
2. Potassium chloride 20 p.o. q.d. times two weeks.
3. Aspirin 325 mg p.o. q.d.
4. Percocet 5 one to two tablets q. four to six hours p.r.n.
pain.
5. Plavix 75 mg p.o. q.d.
6. Atorvostatin 40 mg p.o. q.d.
7. Propanolol 40 mg p.o. b.i.d.
8. Allopurinol 100 mg p.o. b.i.d.
9. Niacin 1,500 mg p.o. b.i.d.
10. Ascorbic acid 500 p.o. b.i.d.
11. Ferrous sulfate 325 mg p.o. q.d.
12. Isosorbide mononitrate 30 mg p.o. q.d.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 13441**]
MEDQUIST36
D: [**2137-7-17**] 12:39
T: [**2137-7-17**] 12:52
JOB#: [**Job Number 13442**]
Admission Date: [**2137-7-11**] Discharge Date: [**2137-7-17**]
Date of Birth: [**2074-6-12**] Sex: M
Service:
ADDENDUM TO DISCHARGE MEDICATIONS: Levaquin 500 mg p.o. q.
day x 2 days for completion of a seven-day course.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3365**]
MEDQUIST36
D: [**2137-7-17**] 12:41
T: [**2137-7-17**] 13:06
JOB#: [**Job Number 13443**]
|
[
"272.0",
"411.1",
"424.0",
"414.01",
"414.02",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6917, 7276
|
5425, 5685
|
2630, 5330
|
5710, 5979
|
1291, 2149
|
2164, 2612
|
5355, 5404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,477
| 117,521
|
45285+45309
|
Discharge summary
|
report+report
|
Admission Date: [**2184-10-22**] Discharge Date: [**2184-10-30**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 81 year old woman
with a history of cerebrovascular accident, hypertension,
diabetes mellitus, and end-stage renal disease who presented
to the Emergency Room at 5 a.m. on [**10-22**] complaining of
worsening right sided weakness. The weakness has been
present for a while but had been worsening for about two
weeks. She has some baseline right-sided weakness from her
cerebrovascular accident five to seven years ago and requires
either a wheelchair or a assistance with ambulation. The
initial neurological evaluation in the Emergency Department
revealed the patient alert and oriented times three with
fluent speech, mind, cranial nerves intact, positive tremor
of the whole body, right leg two to three out of five
strength, intact sensory system, bilateral plantar reflexes
upward. A CT scan of the head was negative for bleed.
Vital signs on admission to the Emergency Department were
significant for a blood pressure of 248/97. She was started
on Nitroglycerin with a small decrease in blood pressure. At
MRI she would not tolerate the test and on removal she had
full-body rigoring. She said she felt that she had to gather
her bearings and was miserable, but remained afebrile.
On return to the Emergency Department, she stopped shaking,
face contorted and stopped moving. Question of whether she
stopped breathing. The patient was rapidly intubated for
airway protection and given ativan 2 mg, Vecuronium 1 mg,
succinylcholine 100, calcium and D50. Post-intubation
arterial blood gas was 7.33/40/159. The patient was
transferred to the Medical Intensive Care Unit with blood
pressure at 66/42. The blood pressure continued to be
extraordinarily low.
PAST MEDICAL HISTORY:
1. Left sided cerebrovascular accident.
2. Diabetes mellitus type 2.
3. Hypertension.
4. End-stage renal disease with hemodialysis on Monday,
Wednesday and Friday.
5. Scoliosis.
6. Legally blind, both eyes.
MEDICATIONS PRIOR TO ARRIVAL TO THE HOSPITAL:
1. Levoxyl 150 q. day.
2. Norvasc 10 q. day.
3. Celebrex 100 q. day.
4. Roxicet twice a day.
5. Nephrocaps.
6. Remegel 800 three times a day Monday and Wednesday only.
7. Aspirin 81 once a day.
8. Tylenol 325 at bedtime.
9. Ultram 50 twice a day.
10. Colace 100 twice a day.
11. Timoptic 0.5% twice a day.
12. Lactulose 30 q. day.
SOCIAL HISTORY: She lives alone with her nephew in a
building. She has no spouse and no children, but has the
support from extended family. Does not smoke; does not drink
alcohol.
PHYSICAL EXAMINATION: Vital signs 96.9 F., blood pressure
ranged from 66 to 224 over 24 to 169; heart rate 73;
respiratory rate was 16. At the time of examination, the
patient was sedated and unresponsive. In general, the
patient was intubated and sedated. The Head, Eyes, Ears,
Nose and Throat revealed pupils equal, round and reactive to
light and accommodation. Extraocular muscles were not able
to be assessed. Lungs were clear to auscultation, no rales
or rhonchi. Cardiac had regular rate and rhythm, II/VI
systolic murmur. Abdomen was soft, nontender, nondistended.
Extremities were warm with no edema. Distal pulses were not
palpable in the lower extremities. Neurologic examination
showed her moving all four limbs.
LABORATORY: White blood cell count 5.11, hematocrit 45.2,
platelets 168. Sodium 168, potassium 3.6, chloride 101,
bicarbonate 22, glucose 164, lactate was 5.7.
Chest x-ray in the Emergency Department post intubation
revealed nothing consistent with congestive heart failure.
CT scan examination revealed no acute abnormalities.
An EEG examination showed no changes consistent with recent
event.
HOSPITAL COURSE: Respiratory status included extubation on
Saturday, [**2184-10-23**], with no subsequent difficulties. Her
hypertension was managed initially with nitrates and was
changed to a regimen to include Norvasc 5 mg, Atenolol 25 mg,
and Lisinopril 5 mg once a day. This resulted in a reduction
of her blood pressure to approximately 110/70, at which point
the Norvasc was discontinued. The Atenolol was continued at
25 mg once a day and the Lisinopril was changed to 2.5 mg per
day, which seems to be an acceptable regimen producing a
blood pressure of 130/80.
Her mental status has been disoriented and confused
throughout most of the hospital stay with periods of
improvement followed by a return to the baseline of
confusion. She has said that the date is [**2105**], her location
was at home. There does not seem to be any correlation
between mental status and blood pressure.
Neurologic examination in follow-up did not provide any
follow-up any organic cause for her confusion.
Her renal issues were followed with hemodialysis for
end-stage renal disease followed by Dr. [**First Name (STitle) 805**] on Monday,
Wednesday and Friday. There were no issues.
Her disposition for hospital discharge resulted in
discussions with the family, Case Management, physicians and
Physical Therapy. It was felt by the hospital staff that
given that the patient is unable to follow commands, assist
with her care and is incontinent, that home care would not be
appropriate at this time and transfer to a rehabilitation
facility would be her best option.
This discussion went on for some time with the family, at the
end of which the family agreed at discharge to a
rehabilitation facility such as [**Hospital1 **] would be
appropriate.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. End-stage renal disease.
3. Diabetes mellitus.
4. Changes in mental status due to delirium overlaid on top
of ongoing dementia.
DISCHARGE STATUS: Fair given that the patient is unable to
follow commands or participate in her own care.
DISCHARGE MEDICATIONS:
1. Lisinopril 2.5 mg q. day p.o.
2. Atenolol 25 mg p.o. q. day.
3. Regular insulin sliding scale.
4. Bisacodyl 10 mg p.r. h.s. p.r.n.
5. Docusate 100 mg p.o. twice a day.
6. Levothyroxine 150 micrograms p.o. q. day.
7. Heparin 5000 units subcutaneously q. 12 hours.
8. Remegel 800 p.o. three times a day, Monday and Wednesday
only.
9. Aspirin 81 mg q. day.
10. Artificial Tears, one to two drops o.u. twice a day.
11. Atenolol 0.5% ophthalmic solution, one drop o.u. twice a
day.
12. Dorzolamide 2% ophthalmic solution, one drop o.u. three
times a day.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4987**]
Dictated By:[**Last Name (NamePattern1) 96751**]
D: [**2184-10-29**] 18:05
T: [**2184-10-29**] 19:20
JOB#: [**Job Number **]
Admission Date: [**2184-10-22**] Discharge Date: [**2184-10-31**]
Service:
ADDENDUM: Ms. [**Known lastname **] hospital course continued along the
same lines as in the prior dictation. Her mental status
continued to wax and wane. At her times of maximum
alertness, she was able to hold a conversation regarding her
care and her disposition, whereas at other times she spoke of
people who weren't in the room. The only change to her
medications since previous dictation is that her atenolol was
discontinued due to a heart rate of 46. She continues to be
on Lisinopril 2.5 mg once daily with adequate blood pressure
control.
After discussion with Neurology, it was also felt that she
would benefit from a Neurobehavioral assessment at her
rehabilitation facility.
DR.[**First Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 11-719
Dictated By:[**Last Name (NamePattern1) 96786**]
MEDQUIST36
D: [**2184-10-31**] 21:48
T: [**2184-11-1**] 00:13
JOB#: [**Job Number 23174**]
|
[
"707.0",
"403.91",
"583.81",
"250.40",
"437.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5541, 5804
|
5827, 7737
|
3786, 5520
|
2653, 3767
|
134, 1821
|
1843, 2444
|
2462, 2629
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,869
| 181,000
|
28784
|
Discharge summary
|
report
|
Admission Date: [**2188-3-27**] Discharge Date: [**2188-5-8**]
Date of Birth: [**2137-9-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
ERCP
Exploratory Laparotomy
Revision Roux Limb
Entero-enterostomy x 2
Repair of Abdominal Wall, Wound Dehiscence
PICC line
VAC
History of Present Illness:
Mr. [**Known lastname 57203**] is a 50 yo male with metastatic cholangiocarcinoma who
p/w fever and elevated bilirubin level. Last week he reports
that he had a temp to 102.3 and again last night to ~101. He
tells us he had a temperature last Wed of 102.4 along with a
sinus headache with no other associated symptoms. He took
Tylenol and felt better the next day. He did not call with the
temperature. He reports that last night "I felt hot all over."
He has had recurrent episodes of dry heaves which he attributes
to the chemotherapy. He has had alternating constipation and
diarrhea recently. He denies any abdominal pain.
Past Medical History:
PAST MEDICAL HISTORY:
1. Laminectomy secondary to ruptured disc in [**2173**]
2. Chronic low back pain
.
ONCOLOGIC HISTORY:
He was in his usual state of health until [**10/2186**] when he
experienced the onset of headache with associated diarrhea,
chalky-white stools, sinus tenderness, nausea, and dark urine.
Ultrasound followed by CT scan showed a soft tissue mass at the
confluence of biliary duct. ERCP and MRCP showed dilation of the
intrahepatic bile duct, which extended from the common hepatic
duct to the bifurcation. This presentation was felt to be most
consistent with cholangiocarcinoma. Mr. [**Known lastname 57203**] was then
transferred to [**Hospital3 14659**] where he underwent en bloc right
hepatectomy, cholecystectomy, resection of extrahepatic bile
ducts, regional lymph node dissection and Roux-en-Y hepatic
jejunostomy. Postoperatively, he recovered well. Pathology
revealed no positive lymph nodes, 10 were sampled. The tumor
measured 2.4 x 2.3 x 2.0 cm and was grade [**12-30**] cholangiocarcinoma
with extension to the liver and periductal structures including
the source of the gallbladder. The procedure was uncomplicated
with the exception of a bilateral chylous pleural effusion. His
postoperative CA [**99**]-9 decreased to 120, however, by [**4-/2187**] it
had increased to 812 and by [**Month (only) 216**] it was 15,999. He had
multiple PET/CT scans, which showed stable appearance of
pulmonary nodules that were not FDG avid. However, his most
recent PET scan showed findings that were consistent with
metastatic cholangiocarcinoma and local site recurrence in the
surgical bed. In light of disease recurrence in this young
patient, it was decided to proceed with treatment and he was
started on a clinical trial 05-349 and received bevacizumab,
gemcitabine, and oxaliplatin. To date, he has received 8 full
cycles. His interval CT scan after cycle #4 showed evidence of
stable disease that was confirmed by a follow up CT scan one
month later. His CA [**99**]-9 was last 6964 on [**2188-3-13**].
Social History:
The patient grew up in [**State 2690**]. He has been in the Marine Corps x
25 years and is currently at the Naval War College in [**Location (un) 7188**],
RI. He is married. He has 3 children, 2 children that are
teenagers and one daughter with a grandchild.
He is a lifelong nonsmoker and nondrinker.
Family History:
He has an elder sister and a younger brother both who are in
excellent health. Both his parents are alive; however, his mom
has had myocardial infarction and is obese. His paternal
grandfather died of a myocardial infarction. His
paternal grandmother died of myocardial infarction. His
maternal grandfather of died of MI and his maternal grandmother
is still alive with [**Name (NI) 2481**] disease and is currently age 86.
Physical Exam:
GENERAL: No apparent distress. Karnofsky performance status
equals 90. ECOG performance status equals 1.
Vital Signs: Blood Pressure: 138/98, Heart Rate: 76, Weight:
177.4 Lbs, BMI: 25.5 kg/m2, Temperature: 97.2, Resp. Rate: 16,
O2 Saturation%: 98.
LYMPHATICS: No epitrochlear, occipital, submandibular, axillary
or supraclavicular [**Doctor First Name **].
HEENT: Normocephalic, atraumatic. No icterus, no tonsillar
erythema or exudate. Sclerae are clear.
NECK: Supple. No lymphadenopathy, no JVD, no thyromegaly.
CHEST: Moving air comfortably. Clear to auscultation
bilaterally. Decreased breath sounds, right base. No wheezes,
rhonchi, or rales.
CARDIOVASCULAR: S1, S2, normal intensity. No murmurs, rubs, or
gallops.
ABDOMEN: Positive bowel sounds, soft, nontender, nondistended,
no palpable masses. Well-healed midline scar from umbilicus to
epigastrium. Mild tenderness to palpation along the scar. No
RUQ tenderness No splenomegaly
EXTREMITIES: Warm, well perfused. No lower extremity edema, no
calf tenderness.
Pertinent Results:
CT C/A/P [**2188-3-27**]: 1. Afferent loop syndrome with dilatation of
the afferent loop up to 4.4 cm until a transition point at the
Roux-en-Y anastomosis. This obstruction may be due to
stricture/inflammation at the anastomotic site or adhesions from
prior surgery.
2. Stable appearance to multiple post-surgical changes
including ill-defined soft tissue in the surgical bed and
nodularity along the mid anterior abdominal wall.
3. Perirectal soft tissue prominence most likely due to lack of
distention. To better evaluate this lesion, recommend contrast
on future CT torso, with water or barium, to fully distend the
rectal vault.
4. Stable small right pleural effusion and right lower lobe
soft tissue
lesion.
.
[**2188-4-5**] 04:13AM BLOOD WBC-11.5* RBC-3.41* Hgb-11.2* Hct-34.1*
MCV-100* MCH-32.9* MCHC-32.8 RDW-17.7* Plt Ct-470*
[**2188-4-7**] 06:00AM BLOOD Glucose-103 UreaN-6 Creat-0.4* Na-133
K-4.1 Cl-102 HCO3-26 AnGap-9
[**2188-4-1**] 05:40AM BLOOD ALT-100* AST-83* AlkPhos-735*
TotBili-2.8*
[**2188-4-5**] 04:13AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
Test Result Reference
Range/Units
CA [**99**]-9 4216 H 0-37 SEE NOTE
.
ABDOMEN (SUPINE & ERECT) [**2188-4-30**] 10:42 AM
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p entero-enterostomy X 2 and s/p wound
exploration and re-closure with retention sutures
SUPINE AND ERECT ABDOMEN: No abnormally dilated loops of bowel
are seen and gas is noted throughout much of the colon with gas
and stool in the rectum. Multiple nonspecific small bowel air
fluid levels are identified on the decubitus view. There is no
evidence of free air. Surrounding osseous structures are
unremarkable.
IMPRESSION: Multiple small bowel air fluid levels may suggest
ileus without evidence of obstruction.
[**2188-5-3**] 08:07AM BLOOD WBC-11.0# RBC-2.61*# Hgb-8.1*# Hct-26.2*
MCV-100*# MCH-31.1 MCHC-31.0 RDW-17.7* Plt Ct-578*
[**2188-5-3**] 05:31AM BLOOD WBC-7.2 RBC-1.94*# Hgb-6.1*# Hct-21.2*
MCV-109*# MCH-31.2 MCHC-28.6*# RDW-18.1* Plt Ct-436
[**2188-5-7**] 05:01AM BLOOD Glucose-117* UreaN-15 Creat-0.4* Na-134
K-4.0 Cl-105 HCO3-25 AnGap-8
[**2188-5-6**] 12:54AM BLOOD Glucose-105 UreaN-13 Creat-0.3* Na-134
K-3.9 Cl-103 HCO3-25 AnGap-10
[**2188-4-27**] 01:00AM BLOOD ALT-49* AST-60* LD(LDH)-177 AlkPhos-388*
TotBili-0.7
[**2188-4-26**] 03:18AM BLOOD ALT-44* AST-66* AlkPhos-390* TotBili-0.7
[**2188-4-23**] 02:07AM BLOOD Lipase-55
[**2188-4-20**] 03:50AM BLOOD Lipase-31
[**2188-5-7**] 05:01AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9
[**2188-4-14**] 05:00AM BLOOD calTIBC-137* Ferritn-371 TRF-105*
[**2188-5-5**] 04:43AM BLOOD Triglyc-97
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2188-4-17**] 3:39 PM
IMPRESSION:
1. No evidence of pulmonary embolism.
2. New, widespread multifocal dense ground-glass opacities,
predominantly within the right lung. While this appearance could
be consistent with asymmetric pulmonary edema, no secondary sign
of volume overload is seen. Infectious processes should be
considered, including bacterial pneumomonia as well as
opportunistic pathogens such as PCP, [**Name10 (NameIs) **] this patient receiving
chemotherapy.
3. Unchanged appearance of the anterior abdominal wall, with
abnormalities related to previous wound dehiscence, and
continued evidence of small foci of air, fluid, and abnormally
enhancing tissue, which may represent inflammatory change or,
possibly, metastatic seeding of incision tract.
4. Diffuse anasarca, ascites, and small right pleural effusion.
.
CT ABDOMEN W/CONTRAST [**2188-4-11**] 12:47 PM
IMPRESSION:
1. No clear evidence of adhesion of bowel to anterior abdominal
wall, as clinically questioned. Cannot confirm that the anterior
peritoneal wall is intact in this patient with history of wound
dehiscence and subsequent repair.
2. Interval resolution of previous small-bowel obstruction.
3. Anasarca, ascites, and massive scrotal edema.
4. Moderate right pleural effusion with interval increase in
size.
.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 69548**],[**Known firstname 396**] LORRY [**2137-9-10**] 50 Male [**Numeric Identifier 69549**]
[**Numeric Identifier 69550**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/mtd
SPECIMEN SUBMITTED: ABDOMINAL WALL FASCIA.
Procedure date Tissue received Report Date Diagnosed
by
[**2188-4-4**] [**2188-4-5**] [**2188-4-9**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
DIAGNOSIS:
Abdominal wall fascia:
Well-differentiated invasive adenocarcinoma; .
.
Brief Hospital Course:
A/P: Mr. [**Known lastname 57203**] is a 50 yo male with metastatic
cholangiocarcinoma who presents with fevers and elevated
bilirubin
.
1) Hyperbilirubinemia: Concerning for biliary obstruction due
to stricture vs. tumor progression. Fevers and elevated WBC
(11.5 today, up for ~5 previously) raises concern for ascending
cholangitis; will start Zosyn empirically.
-f/u abd CT (RUQ unlikely useful d/t anatomy)
-contact GI/ERCP for possible stent placement
-blood cultures x 2
.
2) Metastatic cholangiocarcinoma: He is currently enrolled in
Phase II trial of Gemcitabine, Oxaliplatin in combination with
Bevacizumab, protocol #05-349. This is cycle 9 Day 1.
- Hold further chemotherapy until acute illness resolved
- Anti-emetics PRN
.
3) Pain control: Continue his current regimen of Oxycontin 30 mg
qAM. Will discontinue PRN vicodin given the acetaminophen
component in the setting of elevated transaminases.
.
4) HTN: Continue Norvasc.
.
5) Prophylaxis: Continue PPI per home regimen. Ambulation as
DVT prophylaxis.
.
6) FEN: Regular diet. NPO after midnight.
.
7) Code status: Full code.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
He was admitted to surgery after an ERCP in which they were
unable to relieve obstruction with stent placement. He went to
the OR on [**3-31**] with a diagnosis of:
1. Cholangiocarcinoma.
2. Obstructed Roux-en-Y limb causing cholangitis.
3. Obstruction from Roux limb from metastatic cancer.
NAME OF OPERATION:
1. Exploratory laparotomy.
2. Revision of Roux-en-Y anastomosis with 2
enteroenterostomies.
Pain:He had a PCA and epidural for pain control and was having
much pain. Toradol was added and he seemed better. After getting
his pain under control, he was doing quite well and able to get
up and ambulate.
After the take back to the OR, he continued to use his PCA for
pain control. Pain control continued to be an issue and it took
some time to wean him from his PCA. Motrin 800mg q6h was also
added. We consulted Chronic Pain and we added Tizantidine 4 tid
and then transitioned him to PO Dilaudid.
GI/ABD: He was NPO with IVF. His abdomen was intact and dry
initially.
His Post-operative course was complicated by a wound dehiscence
requiring a return to the OR for abdominal wound repair. On
Friday evening, he began gushing salmon colored fluid from his
drain and required take back to the OR on [**4-5**] for wound
exploration and re-closure with retention sutures.
His abdomen was C/D/I with retention sutures in place. The edges
were well approximated. He was allowed sips of clears. We
advanced his diet slowly and he was tolerating rgeulat food on
POD [**7-30**].
His drain was D/C on POD [**7-30**]. He continued to drain from the
drain site and an ostomy appliance was attached.
His staple line was intact, with a minimal amount of spotty
drainage at the midpoint.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
On the early morning of [**2188-4-16**], he had acute desaturation, was
found to be hypoxic with a O2 sat in the 60%'s and HR of 140.
and a fever to 102. His Abd wound explored at bedside,
salmon-colored fluid draining.
His Pathology of Abdominal wall fascia: Well-diffn invasive
adenocarcinoma.
He was transferred to the the ICU and was placed on a 100%
non-rebreather facemask.
His WBC was 37K, His HCT fell to 22.7, he was hyponatremic with
Na 132, BUN 23, Cr 1.3, and cTrop rose to .11, and he was
oliguric.
He was not looking good and we discussed code status with the
patient and his wife given his metastatic cancer and abitlity to
recover from this event. The patient and family wanted us to do
everything possible.
He did recover somewhat the next day and began to make urine. He
receive PRBC for his blood loss anemia. He was still requiring
O2 by facemask. The wound was held together with retention
sutures and several staples were removed and the site was packed
with gauze. His abdomen was likely not going to heal with the
widespread cancer in his abdomen.
We were able to obtain a CT on [**4-17**], once his Cr had recovered,
to assess for a PE. He was intubated for the CT. He remained
intubated for several days.
Pneumonia: The CT showed no evidence of a PE, but he likely
aspirated and developed multifocal pneumonia: RUL, RML, LUL.
Centrilobular ground glass appearance suggestive of atypical
infection.
Remained intubated for many days with fever. On [**4-24**]
extubated. Now weaned to 4L N/C. Has received 9 days (approx) of
Vanco/[**Last Name (un) **]/Fluc.
Fluc was stopped after 9 days Cont. Vanco/[**Last Name (un) **] to complete [**9-7**]
days.
Micro:
[**4-16**] Abd wound: coag neg staph - sparse; ANAEROBIC: BACTEROIDES
FRAGILIS - mod, beta lact positive
5/26,[**4-21**] Sput: sparse yeast
[**4-24**]: Extubated, 6
[**4-18**]: Bronched; hypotension responsive to fluid boluses (x2)
[**4-20**]: tube feeds started, JP fluid replaced 1/2 cc:cc
[**4-23**]: TF w/ 1.5g protein, 30 kcal/kg; TPN stopped
[**4-24**] Extubated
[**4-25**] : passed speech and swallow
He remained in the ICU for several days and made it out to the
floor on [**2188-4-27**].
Once on the floor, he continued to do well. He was eating and
drinking and PT worked with him to ambulate. He was
deconditioned after his prolonged ICU stay. He was motivated to
rehab and get OOB.
.
Pain Management: Palative care was consulted for help with pain
manageent. He was being treated with Fentanyl patch, Dilaudid,
Tizanidine, Neurontin.
.
GI: On [**4-30**], HD 35, he was more distended, yet still reporting
+flatus. He was made NPO and started on IVF. A KUB was ordered
and showed air fluid levels suggestive of an ileus. He received
a suppository for a post-op Ileus. He was kept NPO for 2 days
and then restarted on a diet. He had slightly less distension
and reported +BM and +flatus. He was only tolerating small
amounts of food and contiued to need antiemetics. He was started
on TPN and this was then cycled.
.
A wound VAC was placed on his abdomen and was helping to keep
him dry. He will require VAC change q2d. His retension sutures
remained in place. There was skin breakdown around each
retension suture. He was having some fluid drainage near the
inferior portion of the wound.
He continued to have near 2 liters of clear, ascitic fluid
draining from the wound.
VAC changes required Aquacell dressing under each retention
suture, Adaptic dressing covering each retention suture, Adaptic
dressing within the opening against the fascia, stoma adhesive
around the inferior midline site and around the drain site in
the LLQ. Then black sponge to the three sites mentioned above.
The skin around the retention sutures was breaking down and
macerated.
Hyponatremia: He required salt tabs for hyponatremia.
Hypovolemia: He was requiring Albumin for low vascular volume
and for his ascities.
Edema: He had +[**12-29**] lower extremity edema and excessive scrotal
swelling.
Medications on Admission:
OxyContin 30 mg PO qAM
Vicodin [**11-27**] pills every 4 hours as needed for pain
Ativan .5 mg take every 4-6 hours PRN nausea
Compazine 10 mg take every 6-8 hours PRN nausea
Zofran 8 mg twice a day as necessary PRN nausea
Protonix 40 mg every day
Norvasc 10 mg every day
Emend 125 mg Day 1 of chemo, Day 2 80 mg ,Day 3 80 mg
Decadron 8 mg twice a day starting Day 2 after chemo to Day 5
Discharge Medications:
1. Dilaudid-5 1 mg/mL Liquid [**Month/Day (2) **]: 20-25 mg PO q2-3 hours as
needed for pain.
Disp:*1500 mL* Refills:*0*
2. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Tizanidine 2 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (2) **]:
One (1) Adhesive Patch, Medicated Topical HS (at bedtime): Apply
to Intact Skin.
On for 12 hours, then off for 12 hours.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
6. Mirtazapine 15 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever. Tablet(s)
8. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) mL PO Q8H
(every 8 hours).
Disp:*qs mL* Refills:*2*
12. Sodium Chloride 1 g Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Prochlorperazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
14. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
15. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
16. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: Two (2) Transdermal
Q72H (every 72 hours).
Disp:*30 * Refills:*2*
17. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Gas.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
19. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1)
Injection Q6H (every 6 hours).
Disp:*120 * Refills:*2*
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two
(2) ML Intravenous DAILY (Daily) as needed: After TPN and when
Hep locking.
Disp:*90 ML(s)* Refills:*0*
21. Sodium Chloride 0.9 % 0.9 % Syringe [**Last Name (STitle) **]: Ten (10) mL
Injection four times a day: Before and After meds and TPN.
Disp:*300 * Refills:*2*
22. Outpatient Lab Work
Weekly Chem 10, CBC.
23. PICC
PICC line care per protocol
Discharge Disposition:
Home With Service
Facility:
VNS of RI
Discharge Diagnosis:
Obstructed Roux Limb
Wound Dehiscence
Metastatic cholangioCA
hypoxia/tachycardia.
Lower BAck Pain
Aspiration Pneumonia
R pleural effusion
Malnutrition
Post-op Ileus
Discharge Condition:
Poor
Incision with VAC
Tolerating minimal PO diet
TPN
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 vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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 not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please take any new meds as ordered.
.
Continue to ambulate several times per day.
.
Continue with VAC change twice/week.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-27**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Provider: [**First Name11 (Name Pattern1) 14497**] [**Last Name (NamePattern1) 25880**], MD Phone:[**Telephone/Fax (1) 22**]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 3241**]
Completed by:[**2188-5-8**]
|
[
"998.32",
"155.1",
"280.0",
"507.0",
"997.4",
"560.1",
"198.2",
"518.5",
"401.9",
"263.9",
"197.7",
"197.0",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.93",
"38.93",
"99.15",
"96.6",
"51.10",
"96.72",
"54.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
20412, 20452
|
9774, 16762
|
319, 448
|
20661, 20717
|
5009, 6273
|
21807, 22292
|
3511, 3941
|
17200, 20389
|
6310, 9751
|
20473, 20640
|
16788, 17177
|
20741, 21784
|
3956, 4990
|
273, 281
|
476, 1108
|
1152, 3172
|
3188, 3495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,592
| 155,163
|
22468
|
Discharge summary
|
report
|
Admission Date: [**2139-8-30**] Discharge Date: [**2139-9-8**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
1) chest pain
2) right pleural effusion
Major Surgical or Invasive Procedure:
thoracentesis [**2139-8-31**]
History of Present Illness:
This is a [**Age over 90 **] year old man with past medical history that
includes diabetes mellitus 2, paroxysmal atrial fibrillation
(not on anticoagulation), coronary artery disease s/p multiple
caths, congestive heart failure with an ejection fraction of
35%, chronic renal insufficiency and hypothyroidism who presents
from an outside hospital after having acute chest pain yesterday
night (@12am). Patient reports going out to dinner with his son
and at around midnight yesterday began feeling intermittent dull
pain in his chest that was associated with shortness of breath
and pain radiating to his right shoulder. He denied any
associated back pain, nausea, diaphoresis or worsening of the
pain with inspiration. No fever or chills or diarrhea. Patient
does note a chronic nonproductive cough. The following morning
his son took him to an outside hospital for care.
.
At the outside hospital, patient was found to have a tropinin I
of 2.5 and on chest x-ray, a right lower lobe infiltrate. He
was subsequently given aspirin, lopressor and one dose of
levaquin. His urinalysis was negative for a urinary tract
infection.
.
In transit to [**Hospital1 18**], patient had runs of NSVT which resolved
without intervention. On arrival in the emergency room, patient
was pain free and his electrocardiogram showed lateral ST
depression, inferior T wave inversions and possibly a left
anterior fascicular block. Cardiology was consulted as to
whether to start IV heparin and recommended thorough workup of
patient's history of GI bleed and anemia. Of note, patient was
guaic positive and had a hematocrit of 31 (his baseline).
Cardiology did recommend chronic anticoagulation for this
patient with his multiple risk factors and paroxysmal atrial
fibrillation after above workup. Repeat chest x-ray showed
right pleural effusion, antibiotic was held since dose was given
at outside hospital in order for it to be possibly tap before
next dose tomorrow.
Past Medical History:
1) DM2, dx'd 25 years, numbness R hand and feet bilat, denies
any renal dz
2) CAD, s/p MI's most recent [**10-13**], denied cath at that time
3) CHF, Echo([**2138-10-24**])EF 35%, LV syst dysfcn, mild AS, mild-mod
MR
4) diabetic Right 5th metatarsal, +MRSA wound culture s/p
debridement and resection ([**2139-2-23**])
5) HTN
6) colon CA s/p partial bowel resection
7) glaucoma
8) disc surgery
9) CRI, baseline Cr 1.4
10) Anemia
11) hyopothyroidism
Social History:
Mr. [**Known lastname 656**] lives in Senior housing. He walks with a cane at
baseline. One son lives in [**Name (NI) 86**]. He denies any history of
alcohol, tobacco, or drug use.
Family History:
Father had diabetes. no known cardiac history in family.
Physical Exam:
Afebrile 96.5 127/75 96 16 100%2L
Very hard of hearing, elderly male. Very well-functioning. NAD.
Neck supple with no JVD
RRR, 3/6 SEM at apex, radiating across chest
decreased breath sounds in right base, otherwise clear to
auscultation
Abd soft, NT, ND +BS
Extr warm, with R plantar scar. 2+ pulses bilaterally.
nontender, nonedematous
Neuro AOx3, no focal deficits, motor grossly intact throughout
Pertinent Results:
In the ED:
[**2139-8-30**] 03:25PM BLOOD WBC-7.7 RBC-3.42* Hgb-9.9* Hct-31.2*
MCV-91 MCH-29.1 MCHC-31.9 RDW-12.2 Plt Ct-150
[**2139-8-30**] 03:25PM BLOOD Neuts-74.3* Lymphs-19.2 Monos-5.0 Eos-1.2
Baso-0.2
[**2139-8-30**] 03:25PM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1
[**2139-8-30**] 03:25PM BLOOD Glucose-148* UreaN-36* Creat-1.4* Na-140
K-5.8* Cl-108 HCO3-24 AnGap-14
[**2139-8-30**] 03:25PM BLOOD ALT-11 AST-21 CK(CPK)-73 AlkPhos-118*
Amylase-37 TotBili-0.2
[**2139-8-30**] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2139-8-30**] 03:25PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.9 Mg-2.1
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2139-8-30**] 4:51 PM
CHEST (PA & LAT)
Reason: Please evaluate for infiltrate, effusion, pulmonary
edema
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with chest pain
REASON FOR THIS EXAMINATION:
Please evaluate for infiltrate, effusion, pulmonary edema
INDICATION: Chest pain.
COMPARISON: [**2138-10-1**].
CHEST, PA AND LATERAL: There has been interval development of a
moderate sized right-sided pleural effusion with reactive
atelectasis. There upper zone redistribution of the pulmonary
vasculature. There is likely a small left- sided pleural
effusion also. There is no pneumothorax. The aorta is unfolded
with wall calcifications. Degenerative change is seen within the
thoracic spine.
IMPRESSION:
1. Mild left ventricular heart failure.
2. Moderate right-sided pleural effusion with likely reactive
atelectasis, although pneumonia cannot be excluded.
.
On the floor:
.
[**2139-8-30**] 03:25PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2139-8-31**] 01:40AM BLOOD CK-MB-NotDone cTropnT-0.44*
[**2139-8-31**] 07:00AM BLOOD CK-MB-NotDone cTropnT-0.53*
[**2139-8-31**] 09:38PM BLOOD cTropnT-0.49*
[**2139-9-1**] 06:10AM BLOOD cTropnT-0.50*
[**2139-9-1**] 03:15PM BLOOD cTropnT-0.52*
[**2139-8-31**] 08:10AM PLEURAL WBC-145* RBC-66* Polys-10* Lymphs-73*
Monos-0 Meso-6* Macro-11*
[**2139-8-31**] 08:10AM PLEURAL TotProt-3.9 Glucose-165 LD(LDH)-75
Amylase-40 Albumin-1.9
.
[**2139-8-31**] 8:10 am PLEURAL FLUID
GRAM STAIN (Final [**2139-8-31**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
FUNGAL CULTURE (Pending):
ACID FAST SMEAR (Final [**2139-9-1**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2139-8-31**] 4:44 PM
Reason: assess for PTX
REASON FOR THIS EXAMINATION:
assess for PTX
HISTORY: Right thoracentesis.
Since examination one day previous the large right pleural
effusion has been partially removed but there has developed a
large right PTX estimated at 50% with ipsilateral diaphragmatic
flattening and probable contralateral mediastinal shift. The
heart is normal in size without vascular congestion. Residual
effusion is seen on the right and there is blunting of the left
CP angle with probable effusion. A small bore short catheter
overlies the right lower thorax and may be within the pleural
space. No left PTX.
IMPRESSION: Interval development right probable tension
hydropneumothoax post-thoracentesis.
.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2139-9-1**] 8:09 AM
Reason: please eval progression of pneumothorax
REASON FOR THIS EXAMINATION:
please eval progression of pneumothorax
HISTORY: PTX, post-thoracentesis.
PA and lateral chest shows a large right hydropneumothorax which
is probably under tension with depressed right hemidiaphragm and
equivocal contralateral mediastinal shift. The overall
appearances are little changed from exam earlier on the same day
as well as exam on previous day ([**2139-8-31**]). The PTX has
equivocally diminished in size, but this may reflect slight
differences in positioning. Appearances suggest underlying
chronic lung disease.
.
.
Brief Hospital Course:
This is a [**Age over 90 **] year old man with past medical history that
includes diabetes mellitus 2, paroxysmal atrial fibrillation
(not on anticoagulation), coronary artery disease s/p multiple
caths, congestive heart failure with an ejection fraction of
35%, chronic renal insufficiency and hypothyroidism who presents
from an outside hospital after having acute chest pain and also
found ot have right pleural effusion on CXR.
.
Patient had a thoracentesis performed [**2139-8-31**] which drained free
flowing 2.3L of serous fluid with negative gram stain,
consistent with an exudative process by protein ratio only.
Post-procedure CXR showed a question of RLL pneumothorax versus
trapped lung, however, the patient was sat'ing 100% on room air
and denied shortness of breath. He was put on high flow oxygen
by nasal cannula. Interventional pulmonary (who did the
procedure) was notifited, and cardiothoracic surgery was
consulted overnight as to the necessity for a chest tube.
Cardiothoracics recommended serial chest x-rays every four hours
overnight which were largely unchanged and chest tube was
deferred since the patient was clinically stable. Patient
received another portable chest x-ray the evening [**2139-9-1**] which
showed reaccumulation of the right pleural fluid. Per
interventional pulmonary, likely a trapped lung.
.
Morning of [**2139-9-2**] around 11am, patient became paraphrasic which
lasted approx 1 hour. Neuro exam was otherwise nonfocal.
Vitals were stable 124/68 60 18 95RA FS 286 and EKG unchanged.
Denied chest pain, difficulty breathing or abd pain. Patient
was placed in the supine position and his symptoms resolved.
Head CT was negative for ICH bleed or lesion. Per neurology
consultation, patient was placed on gentle IVF (@75cc/hr) and
his metoprolol was reduced from 37.5mg to 25mg PO BID. The next
day he developed afib and was started on heparin and amiodarone
for rate control. He became hypotensive w/ amiodarone and
received 2L NS bolus along with a unit of PRBC. Shortly after
this, he became acutely agitated and SOB. His CXR was c/w
pulmonary edema and he was transferred to the CCU team for
management of his afib/pulmonary edema as well as for an
increasing level of nursing care.
.
After his transfer to the CCU, the patient continued to be
agitated requiring a sitter. He self-d/c his foley and urology
was consulted to replace it and control his urethral bleeding.
He was given haldol prn w/ good effect. Neurology was concerned
that he may have had a stroke and recommended a MRI to further
evaluate this possibility. They also suggested that his SBP be
kept above 120 to facilitate blood flow to the brain. CT scan
was wnl but MRI was deferred due to agitation. He spiked a
temperature in the CCU and again became acutely hypotensive in
the setting of afib. He was pan Cx and started on empiric abx.
He did not respond to fluid boluses x3 and was started on
levophed to maintain his SBP > 120 and an amiodarone drip to
control his afib. He responded to amiodarone and converted to
NSR and his BP was maintained on levophed.
.
However, he continued to have episodes of Afib and had an
increasing pressor requirement. He had worsening respiratory
status, hypotension, and acidemia which eventually caused him to
succomb. He was prononced dead at 3:34 PM on [**2139-9-8**], due to
cardiac arrest.
Medications on Admission:
1) synthroid 225mcg PO QD
2) toprol XL 50mg PO QD
3) glipizide 5mg PO QD
4) ferrous sulfate 1 tab QD
5) sennakot
6) colace 100mg PO BID
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Deceased due to Cardiac arrest
Coronary Artery Disease
Congestive Heart Failure
Diabetes Mellitus
Pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2139-11-6**]
|
[
"E878.8",
"250.00",
"512.1",
"038.9",
"276.7",
"511.9",
"244.9",
"414.01",
"995.94",
"396.2",
"410.71",
"434.91",
"427.31",
"518.81",
"412",
"398.91"
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icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10961, 10976
|
7376, 10746
|
259, 290
|
11127, 11137
|
3466, 4203
|
11190, 11225
|
2970, 3029
|
10932, 10938
|
4240, 4288
|
10997, 11106
|
10772, 10909
|
11161, 11167
|
3044, 3447
|
5892, 5991
|
180, 221
|
6819, 7353
|
318, 2282
|
5722, 5863
|
2304, 2755
|
2771, 2954
|
5672, 5686
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,287
| 110,063
|
47009
|
Discharge summary
|
report
|
Admission Date: [**2107-5-4**] Discharge Date: [**2107-5-9**]
Date of Birth: [**2056-5-8**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
female with a history of hypertension, ulcerative colitis who
over the past six months has had a complaint of chest pain,
shortness of breath, dyspnea on exertion. She had an
echocardiogram done in [**Month (only) 404**] which was significant for 3+
mitral regurgitation, 2+ aortic regurgitation and mild aortic
stenosis. The mitral valve area was 1.7 cm square. A
cardiac catheterization was performed which was normal and
was significant for an ejection fraction of 50%. She
presents to [**Hospital6 256**] for mitral
valve replacement surgery.
PAST MEDICAL HISTORY:
1. Ulcerative colitis
2. Hypertension
3. Asthma
4. Anemia
5. Hypercholesterolemia
PAST SURGICAL HISTORY:
1. Status post hysterectomy
2. Status post appendectomy
3. Status post dilatation and curettage
ADMISSION MEDICATIONS:
1. Proventil 2 puffs prn
2. Serevent 2 puffs [**Hospital1 **]
3. Flovent 2 puffs [**Hospital1 **]
4. Asacol 3 tablets po tid
5. Captopril 25 mg po bid
6. Uniphyl 1 qd
7. Claritin 10 mg po qd
ALLERGIES: PREDNISONE LEADS TO HEADACHE, NAUSEA AND VOMITING
AND FLOXIN HAS A SKIN SENSITIVITY.
PHYSICAL EXAM:
GENERAL: On admission, the patient is a middle aged woman,
obese, who is in no acute distress.
VITAL SIGNS: Temperature 99??????, heart rate 84, blood pressure
128/77, respiratory rate 14, O2 saturation 97.
LUNGS: Clear to percussion and auscultation.
CARDIAC: Normal S1, but increased S2. No gallop was
audible. A [**3-16**] near holosystolic murmur at the apex and
lower left sternal border. A faint 1/6 systolic ejection
murmur at the base, no diastolic murmur, no rub.
ABDOMEN: Soft, nontender without organomegaly. Bowel sounds
were normal.
EXTREMITIES: No edema of the extremities. No cyanosis.
NEUROLOGIC: She is alert and oriented x3.
IMAGING: Electrocardiogram showed normal sinus rhythm within
normal limits.
HOSPITAL COURSE: On the day of admission, the patient went
to the Operating Room and underwent mitral valve replacement
with a 31 mm Carbomedics valve. She tolerated the procedure
well, went to the PACU. Overnight, she remained
hemodynamically stable. She had an AAI in place at a rate of
60. Her nitroglycerin was weaned with blood pressures of 90
to 110/50s to 60s. The patient, early on postoperative day
#1, had a complaint of nausea related to Percocet. It was
changed to Dilaudid with good effect. She was found stable
and was transferred to the floor on postoperative day #1 of
the remainder of recovery. She remained afebrile and
hemodynamically stable. On postoperative day #2, the Foley
was discontinued and the pacing wires were discontinued. She
was out of bed and ambulating. She was evaluated by physical
therapy and she is currently at a level 5 activity. On
postoperative day #3, the chest tube was discontinued without
any incidents. During her postoperative course, she was
started on her Coumadin anticoagulation. Her INRs responded
appropriately and on discharge is at 2.6. The patient was
ambulating without assistance, has been tolerating a regular
diet. Wound has remained clean, dry and intact. The patient
is now ready for discharge to home. She will follow up with
Dr. [**Last Name (STitle) **] in the office in approximately one month.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg po qd x2 days
2. [**Doctor First Name **] 60 mg po bid
3. Uniphyl 600 mg po qd
4. Protonix 40 mg po qd
5. Flovent metered dose inhaler 110 mcg 2 puffs q 12 hours
6. Serevent metered dose inhaler 2 puffs q 12 hours
7. Albuterol metered dose inhaler 2 puffs q4h prn
8. Lopressor 25 mg po bid
9. Dilaudid 2 mg po q4h prn
10. Colace 100 mg po bid
DISCHARGE CONDITION: Stable. The patient will go home with
VNA for wound checks qd and PT/PTT trial starting on
Wednesday [**2107-5-11**]. The results will be sent to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 54268**] for dressing and cleaning appropriately.
The patient will follow up with Dr. [**Last Name (STitle) **] in approximately
four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2107-5-9**] 13:15
T: [**2107-5-10**] 09:23
JOB#: [**Job Number **]
|
[
"V10.83",
"401.9",
"E935.2",
"787.02",
"V12.79",
"493.90",
"396.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3880, 4534
|
3488, 3858
|
2100, 3465
|
1036, 1333
|
913, 1013
|
1348, 2082
|
158, 170
|
199, 780
|
802, 890
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,795
| 190,789
|
48328+48329
|
Discharge summary
|
report+report
|
Admission Date: [**2110-4-22**] Discharge Date: [**2110-5-5**]
Date of Birth: [**2031-7-18**] Sex: F
Service: Cardiac surgery
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 78 year-old female
with known aortic stenosis and coronary artery disease who
had several episodes of congestive heart failure, most
recently admitted to [**Hospital1 69**] at
the end of [**Month (only) 958**]. Patient underwent cardiac catheterization
which showed an aortic valve area of 1.25 cm sq, peak
gradient of 57 ejection fraction of 66 percent, 40 percent
left main disease, 80 percent LAD disease, 60 percent RCA
disease, 70 percent PDA disease. Echocardiogram showed 1 to
2+ mitral regurgitation, moderate aortic stenosis, 3+
tricuspid regurgitation and moderate pulmonary hypertension.
Patient was referred to Dr. [**Last Name (Prefixes) **] for aortic valve
replacement and coronary artery bypass grafting.
PAST MEDICAL HISTORY: 1) Aortic stenosis. 2) Coronary
artery disease. 3) Non-insulin dependent diabetes mellitus.
4) History of right breast carcinoma. 5) Hypertension. 6)
Hypercholesterolemia. 7) Osteoarthritis. 8) Congestive
heart failure. 9) Chronic obstructive pulmonary disease.
10) Obesity. 11) Skin cancer. 12) Right internal carotid
artery 60 to 69 stenosis.
PAST SURGICAL HISTORY: 1) Status post right mastectomy for
breast cancer in [**2101**]. 2) Left cataract surgery.
PREOPERATIVE MEDICATIONS:
1. Lasix 40 mg p.o. q day.
2. Lopressor 50 mg p.o. b.i.d.
3. Amlodipine 5 mg p.o. q day.
4. Glyburide 7.5 mg p.o. q A.M. and 5 mg p.o. q P.M.
5. Lipitor 40 mg p.o. q day.
6. Enteric coated aspirin 325 mg p.o. q day.
7. Ipratropium inhaler 2 puffs q.i.d.
ALLERGIES: Patient is allergic to sulfa which gives her a
rash.
[**Last Name (STitle) 2708**]was admitted to [**Hospital1 69**]
on [**4-22**] and was taken to the operating room by Dr. [**Last Name (Prefixes) 411**] for an aortic valve replacement with a 19 mm [**Last Name (un) 3843**]
[**Doctor Last Name **] Magnum pericardial valve and a coronary artery bypass
graft times one with LIMA to LAD. Please see operative note
for further details. Cardiopulmonary bypass time was 145
minutes. Crossclamp time was 120 minutes. Patient was
transported to the Intensive Care Unit in stable condition.
On the first postoperative evening the patient was noticed by
the nurse to not be moving the left upper extremity and
shortly thereafter the patient had a witnessed generalized
tonic clonic seizure. Neurology was consulted. Patient went
for an emergent CT scan which was negative for intracranial
bleed. Patient was loaded with Dilantin and patient was
started on Neo-Synephrine which was titrated for a systolic
blood pressure 130 to 140. Patient had another generalized
tonic clonic seizure the morning of postoperative day number
one for which she was given Ativan and more Dilantin.
Patient remained intubated due to her unstable neurologic
status. Patient was paced to maintain adequate cardiac
output. By neurologic examination by postoperative day
number two patient was opening eyes to stimuli and was
nodding her head to questions, spontaneously moving right
side, right upper and right lower extremity, withdrawing her
left leg to painful stimuli and no movement of her left upper
extremity. The patient's pacing wires were removed on
postoperative day number two and patient underwent an MRI of
the head. The MRI showed significant white matter
abnormality suggestive of edema accompanied by sulcal
narrowing and gyral fullness in the right frontal lobe as
well as seizure activity. Neurology felt that this was
suspicious for an old cerebrovascular accident and not
indicative of a new ischemic event. Patient continued on
Neo-Synephrine to maintain adequate blood pressure.
On postoperative day number two the patient developed rapid
atrial fibrillation, was placed on amiodarone infusion. On
postoperative day number three patient was weaned and
extubated from the mechanical ventilation without difficulty.
Patient was transfused one unit of packed red blood cells.
The patient was started on diuretics and low dose Lopressor
for rate control of the atrial fibrillation. By
postoperative day number four patient was started on a
heparin drip due to the atrial fibrillation which was cleared
by neurology. They felt there was no contraindication to
heparinization. Patient continued to have left sided
weakness, left lower extremity more so than left upper
extremity. On postoperative day number seven it was noted
that the patient had an area of warmth, erythema in the right
antecubital fossa at the site of a previous intravenous
thought to be due to a thrombophlebitis. Patient was started
on Kefzol and warm packs with subsequent improvement. On
postoperative day number eight cardiology consultation was
obtained for management of the atrial fibrillation and
potential cardioversion. Patient was sedated by
anesthesiology on postoperative day number eight and was
cardioverted from atrial fibrillation to sinus bradycardia
with significant improvement in the patient's blood pressure.
However, patient continued to require Neo-Synephrine to
maintain systolic blood pressure greater than 115 which was
the recommendation of the neurology team. As patient was
being started on Coumadin due to the atrial fibrillation
discussion was had with neurology team for the interaction of
Coumadin, amiodarone and Dilantin and it was decided to
transition patient from Dilantin to Keppra which was done
over the next couple of days and the Dilantin was
discontinued. Patient continued on Kefzol, had a normal
white blood cell count and by postoperative day number 11
patient had been weaned off her Neo-Synephrine with adequate
systolic blood pressure and patient was transferred from the
Intensive Care Unit to the regular part of the hospital.
Patient continued to receive Coumadin. She remained in sinus
rhythm. Patient was working with physical therapy and was
only able to ambulate approximately 150 feet and it was
determined that patient would benefit from a stay at short
term rehabilitation.
CONDITION AT DISCHARGE: Maximum temperature 99.2, pulse 74
and sinus rhythm, blood pressure 118/60, respiratory rate 20,
room air oxygen saturation 96 percent. Patient's weight on
[**5-5**] is 78.3. Preoperatively patient weight 82 kilograms.
Neurologically patient is awake, alert and oriented times
three. Patient has equal grip strength bilateral upper
extremities. Patient's left lower extremity hip flexion and
extension strength is 4 out of 5 and on the right it is 5 out
of 5. Patient's plantar and dorsiflexion is 4 out of 5 on
the left and on the right is 5 out of 5. Patient has had no
further postoperative seizures. Heart was regular rate and
rhythm without rub or murmur. Breath sounds are clear
bilaterally. Abdomen is obese, positive bowel sounds, soft,
nontender, nondistended. Patient is tolerating a regular
diet and having normal bowel movements. Sternal incision is
clean and dry. Steri-Strips are intact. Sternum is stapled.
There is no erythema or drainage. Bilateral lower
extremities have trace to 1+ pitting edema. Patient's right
antecubital fossa is no longer erythematous.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. q day times one month.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Lasix 20 mg p.o. q day.
4. Potassium chloride 20 mEq p.o. q day.
5. Colace 100 mg p.o. b.i.d.
6. Zantac 150 mg p.o. b.i.d.
7. Enteric coated aspirin 81 mg p.o. q day.
8. Glyburide 5 mg p.o. b.i.d.
9. Keppra 1,000 mg p.o. b.i.d.
10. Atorvastatin 40 mg p.o. q day.
11. Combivent MDI 1 to 2 puffs q 4 hours p.r.n.
12. Coumadin. Patient's dose should be adjusted based on
daily PT/INR for a goal INR of 2.0 to 2.5.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis.
2. Coronary artery disease.
3. Congestive heart failure.
4. Status post coronary artery bypass graft with 19 mm
[**Last Name (un) 3843**] [**Doctor Last Name **] Magnum pericardial valve and LIMA to LAD.
5. Postoperative seizures/
6. Left lower extremity weakness.
7. Carotid artery stenosis.
8. Status post right mastectomy for breast carcinoma.
9. Postoperative atrial fibrillation.
10. Status post DC cardioversion.
[**Last Name (STitle) 2708**]is to be discharged to rehabilitation in stable
condition. Patient should follow up with Dr. [**Last Name (STitle) 101802**] in
two weeks. Patient should follow up with Dr. [**Last Name (STitle) **] in two
weeks. She should follow up with Dr. [**Last Name (Prefixes) **] in one
month. She should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one
month. She should follow up with Dr. [**Last Name (STitle) **] in one to two
months.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2110-5-5**] 10:47
T: [**2110-5-5**] 10:49
JOB#: [**Job Number 101803**]
Admission Date: [**2110-4-22**] Discharge Date: [**2110-5-5**]
Date of Birth: [**2031-7-18**] Sex: F
Service: Cardiac surgery
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 78 year-old female
with known aortic stenosis and coronary artery disease who
had several episodes of congestive heart failure, most
recently admitted to [**Hospital1 69**] at
the end of [**Month (only) 958**]. Patient underwent cardiac catheterization
which showed an aortic valve area of 1.25 cm sq, peak
gradient of 57 ejection fraction of 66 percent, 40 percent
left main disease, 80 percent LAD disease, 60 percent RCA
disease, 70 percent PDA disease. Echocardiogram showed 1 to
2+ mitral regurgitation, moderate aortic stenosis, 3+
tricuspid regurgitation and moderate pulmonary hypertension.
Patient was referred to Dr. [**Last Name (Prefixes) **] for aortic valve
replacement and coronary artery bypass grafting.
PAST MEDICAL HISTORY: 1) Aortic stenosis. 2) Coronary
artery disease. 3) Non-insulin dependent diabetes mellitus.
4) History of right breast carcinoma. 5) Hypertension. 6)
Hypercholesterolemia. 7) Osteoarthritis. 8) Congestive
heart failure. 9) Chronic obstructive pulmonary disease.
10) Obesity. 11) Skin cancer. 12) Right internal carotid
artery 60 to 69 stenosis.
PAST SURGICAL HISTORY: 1) Status post right mastectomy for
breast cancer in [**2101**]. 2) Left cataract surgery.
PREOPERATIVE MEDICATIONS:
1. Lasix 40 mg p.o. q day.
2. Lopressor 50 mg p.o. b.i.d.
3. Amlodipine 5 mg p.o. q day.
4. Glyburide 7.5 mg p.o. q A.M. and 5 mg p.o. q P.M.
5. Lipitor 40 mg p.o. q day.
6. Enteric coated aspirin 325 mg p.o. q day.
7. Ipratropium inhaler 2 puffs q.i.d.
ALLERGIES: Patient is allergic to sulfa which gives her a
rash.
[**Last Name (STitle) 2708**]was admitted to [**Hospital1 69**]
on [**4-22**] and was taken to the operating room by Dr. [**Last Name (Prefixes) 411**] for an aortic valve replacement with a 19 mm [**Last Name (un) 3843**]
[**Doctor Last Name **] Magnum pericardial valve and a coronary artery bypass
graft times one with LIMA to LAD. Please see operative note
for further details. Cardiopulmonary bypass time was 145
minutes. Crossclamp time was 120 minutes. Patient was
transported to the Intensive Care Unit in stable condition.
On the first postoperative evening the patient was noticed by
the nurse to not be moving the left upper extremity and
shortly thereafter the patient had a witnessed generalized
tonic clonic seizure. Neurology was consulted. Patient went
for an emergent CT scan which was negative for intracranial
bleed. Patient was loaded with Dilantin and patient was
started on Neo-Synephrine which was titrated for a systolic
blood pressure 130 to 140. Patient had another generalized
tonic clonic seizure the morning of postoperative day number
one for which she was given Ativan and more Dilantin.
Patient remained intubated due to her unstable neurologic
status. Patient was paced to maintain adequate cardiac
output. By neurologic examination by postoperative day
number two patient was opening eyes to stimuli and was
nodding her head to questions, spontaneously moving right
side, right upper and right lower extremity, withdrawing her
left leg to painful stimuli and no movement of her left upper
extremity. The patient's pacing wires were removed on
postoperative day number two and patient underwent an MRI of
the head. The MRI showed significant white matter
abnormality suggestive of edema accompanied by sulcal
narrowing and gyral fullness in the right frontal lobe as
well as seizure activity. Neurology felt that this was
suspicious for an old cerebrovascular accident and not
indicative of a new ischemic event. Patient continued on
Neo-Synephrine to maintain adequate blood pressure.
On postoperative day number two the patient developed rapid
atrial fibrillation, was placed on amiodarone infusion. On
postoperative day number three patient was weaned and
extubated from the mechanical ventilation without difficulty.
Patient was transfused one unit of packed red blood cells.
The patient was started on diuretics and low dose Lopressor
for rate control of the atrial fibrillation. By
postoperative day number four patient was started on a
heparin drip due to the atrial fibrillation which was cleared
by neurology. They felt there was no contraindication to
heparinization. Patient continued to have left sided
weakness, left lower extremity more so than left upper
extremity. On postoperative day number seven it was noted
that the patient had an area of warmth, erythema in the right
antecubital fossa at the site of a previous intravenous
thought to be due to a thrombophlebitis. Patient was started
on Kefzol and warm packs with subsequent improvement. On
postoperative day number eight cardiology consultation was
obtained for management of the atrial fibrillation and
potential cardioversion. Patient was sedated by
anesthesiology on postoperative day number eight and was
cardioverted from atrial fibrillation to sinus bradycardia
with significant improvement in the patient's blood pressure.
However, patient continued to require Neo-Synephrine to
maintain systolic blood pressure greater than 115 which was
the recommendation of the neurology team. As patient was
being started on Coumadin due to the atrial fibrillation
discussion was had with neurology team for the interaction of
Coumadin, amiodarone and Dilantin and it was decided to
transition patient from Dilantin to Keppra which was done
over the next couple of days and the Dilantin was
discontinued. Patient continued on Kefzol, had a normal
white blood cell count and by postoperative day number 11
patient had been weaned off her Neo-Synephrine with adequate
systolic blood pressure and patient was transferred from the
Intensive Care Unit to the regular part of the hospital.
Patient continued to receive Coumadin. She remained in sinus
rhythm. Patient was working with physical therapy and was
only able to ambulate approximately 150 feet and it was
determined that patient would benefit from a stay at short
term rehabilitation.
CONDITION AT DISCHARGE: Maximum temperature 99.2, pulse 74
and sinus rhythm, blood pressure 118/60, respiratory rate 20,
room air oxygen saturation 96 percent. Patient's weight on
[**5-5**] is 78.3. Preoperatively patient weight 82 kilograms.
Neurologically patient is awake, alert and oriented times
three. Patient has equal grip strength bilateral upper
extremities. Patient's left lower extremity hip flexion and
extension strength is 4 out of 5 and on the right it is 5 out
of 5. Patient's plantar and dorsiflexion is 4 out of 5 on
the left and on the right is 5 out of 5. Patient has had no
further postoperative seizures. Heart was regular rate and
rhythm without rub or murmur. Breath sounds are clear
bilaterally. Abdomen is obese, positive bowel sounds, soft,
nontender, nondistended. Patient is tolerating a regular
diet and having normal bowel movements. Sternal incision is
clean and dry. Steri-Strips are intact. Sternum is stapled.
There is no erythema or drainage. Bilateral lower
extremities have trace to 1+ pitting edema. Patient's right
antecubital fossa is no longer erythematous.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. q day times one month.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Lasix 20 mg p.o. q day.
4. Potassium chloride 20 mEq p.o. q day.
5. Colace 100 mg p.o. b.i.d.
6. Zantac 150 mg p.o. b.i.d.
7. Enteric coated aspirin 81 mg p.o. q day.
8. Glyburide 5 mg p.o. b.i.d.
9. Keppra 1,000 mg p.o. b.i.d.
10. Atorvastatin 40 mg p.o. q day.
11. Combivent MDI 1 to 2 puffs q 4 hours p.r.n.
12. Coumadin. Patient's dose should be adjusted based on
daily PT/INR for a goal INR of 2.0 to 2.5.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis.
2. Coronary artery disease.
3. Congestive heart failure.
4. Status post coronary artery bypass graft with 19 mm
[**Last Name (un) 3843**] [**Doctor Last Name **] Magnum pericardial valve and LIMA to LAD.
5. Postoperative seizures/
6. Left lower extremity weakness.
7. Carotid artery stenosis.
8. Status post right mastectomy for breast carcinoma.
9. Postoperative atrial fibrillation.
10. Status post DC cardioversion.
[**Last Name (STitle) 2708**]is to be discharged to rehabilitation in stable
condition. Patient should follow up with Dr. [**Last Name (STitle) 101802**] in
two weeks. Patient should follow up with Dr. [**Last Name (STitle) **] in two
weeks. She should follow up with Dr. [**Last Name (Prefixes) **] in one
month. She should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one
month. She should follow up with Dr. [**Last Name (STitle) **] in one to two
months.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2110-5-5**] 10:47
T: [**2110-5-5**] 10:49
JOB#: [**Job Number 101804**]
|
[
"E878.2",
"780.39",
"996.62",
"414.01",
"424.1",
"997.1",
"428.0",
"997.99",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"93.90",
"39.61",
"99.04",
"88.72",
"35.21",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
16338, 16848
|
16869, 18091
|
10381, 10474
|
10500, 15207
|
15222, 16315
|
10002, 10357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,807
| 151,364
|
619
|
Discharge summary
|
report
|
Admission Date: [**2189-4-13**] Discharge Date: [**2189-4-27**]
Date of Birth: [**2119-2-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived / Simvastatin
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
SOB, increasing lower extremity edema
Major Surgical or Invasive Procedure:
IVC filter placement [**4-17**]
10U prbc transfusion
Midline placement [**2189-4-27**]
History of Present Illness:
70 year old female with h/o RA previously on humera and mtx who
was discharged on [**2189-4-11**] when she presented with R shoulder
pain. Her joint was tapped and it demonstrated an inflammatory
joint fluid c/w with RA and negative for septic arthritis. She
was discharged on ibuprofen prn. Upon return home 3 days prior
to presentation she felt very well but one day later noticed the
gradual onset of dyspnea on exertion. She also had episodes of
chest twinges overnight which resolved within minutes. + lower
extremity edema. While in the hospital she was ambulatory. She
went to [**Country 4754**] over [**Holiday **] and returned on [**2-20**]. She
has not had any long trips or travel rides since then. At home
she climbed 13 steps twice a day to get to her bedroom. She last
had a mammogram one year ago and it was normal. Her last
colonoscopy was in [**2187-4-12**] and it was normal. + difficulty
swallowing solids which began a few weeks ago.
She saw her rheumatologist Dr. [**Last Name (STitle) 1839**] today who referred her to
the emergency room.
.
Past Medical History:
RA on adalimumab and MTX
HTN
Hyperlipidemia
s/p left bunionectomy/1st MT osteotomy
Atrophic vaginitis on premarin
R eye scleritis
Social History:
Originally from [**Country 4754**]. Lives in [**Location 3307**] with her husband.
Social ETOH. No tobacco. She works as [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4761**]
housecleaner 3x per week. No falls. Her huband drives otherwise
she is indpendent of IADLS and ADLS. She has a son who lives in
[**Name (NI) 108**]. She walks without a walker or cane. + Glasses. No
dentures or hearing aides. No recent falls. 1 glass/2 < once per
month. 1 pk per week tobacco but quit "many years ago."
Family History:
Mother had diverticulosis. Father had lung disease. Sister had
DM. No family h/o malignancy. First cousin with cancer of
unknown type.
Physical Exam:
Vitals: T99.2 125/80 93 18 93%RA
Pain: denies
Access: TLC R IJ site c/d/i
Gen: nad, obese female, sitting up in chair
HEENT: mmm
CV: RRR, no m appreciated, no S3, S4
Resp: CTAB, slight bibasilar crackles, no wheezing
Abd; soft, very obese, no tenderness, no ecchymosis, +BS
Ext; +anasarca, 2+ LLE edema, 1+ RLE edema, 1+ RUE edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: pleasant
Pertinent Results:
wbc 7.3->26.6->9.6
H/H 9.7/27.8 (s/p 1U [**4-21**])
(total 10U prbc, nadir HCT 20, admission HCT 31.2)
INR 1.2
Chem panel: BUN 48->18, Creat 3.2->1.5->0.7 (baseline)
BNP 576
.
UA [**4-16**] 106 wbc, 826 rbc, no bacteria, UCx negative
UA [**4-20**] 32wbc, trace LE, no bacteria, Ucx negative
UA [**4-21**] 4wbc, no LE
blood cx [**4-20**] X2 NTD
.
.
Imaging/results:
.
LENIs [**4-14**]: No evidence of lower extremity DVT.
.
LENIs [**4-21**]: IMPRESSION: Nonocclusive thrombus within the left
common femoral and left superficial femoral vein, new when
compared to prior exam. No evidence of thrombus within the right
lower extremity
.
UE dopplers (R) [**4-22**]: negative
.
CTA [**4-13**]: CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are bilateral segmental and subsegmental pulmonary emboli
involving the right upper, middle and lower lobe pulmonary
arteries, and the pulmonary arteries supplying the left upper
lobe, lingula and the left lower lobe. No saddle pulmonary
embolus is seen, and no evidence of right heart strain
.
TTE [**4-14**]: The left atrium is elongated. The estimated right
atrial pressure is 0-10mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
CT abd/pelvis [**4-15**]:
1. Moderate-size left rectus sheath hematoma with
extraperitoneal extension inferiorly along the left piriformis
muscle. Evidence of IV contrast extravasation suggesting active
bleeding. No evidence of retroperitoneal hematoma. If serial
hemacrit continues to drop, the bleeding site may be amenable to
catheter embolization by interventional radiology.
2. Large gallstone without evidence of acute cholecystitis.
.
CT a/p [**4-23**]:
1. Left retroperitoneal hematoma likely arises from the left
psoas muscle and
tracks along the left posterior pararenal fascia. There is no
evidence of
acute extravasation.
2. Left rectus sheath hematoma is similar to [**2189-4-15**].
3. Cholelithiasis without evidence of cholecystitis..
Renal US [**4-16**]: No right hydronephrosis. Pelvic hematoma.
Otherwise, extremely limited exam, did not visualize L kidney
.
CXR [**4-16**]: no pulm edema
.
CXR [**4-20**]: In comparison with the study of [**4-16**], the patient has
been a very lordotic position which most likely accounts for the
increasing prominence of the transverse diameter of the heart.
No evidence of vascular congestion or pleural effusion. Right IJ
catheter tip extends to the lower portion of the SVC, and there
is no evidence of pneumothorax.
.
CT Head [**4-26**] (prelim): No ICH or mass.
Brief Hospital Course:
70year old female with h/o RA, HTN, obesity, recent d/c [**4-10**]
after acute RA flare, presented [**4-13**] with DOE/LE edema, found to
have bilateral/multifocal PE. LENIs were negative and TTE was
unremarkable for evidence of cardiac strain. She was started on
a heparin drip on admission but subsequently developed a rectus
sheath hematoma on [**4-15**]. Given the large clot burden, she was
hemodynamically stable, and the thought that the hematoma was
likely to tamponade itself off, heparin was not initially
stopped, although the target PTT was changed to the lower end of
therapeutic (althought PTTs remained elevated up to 90s). She
eventually developed worsening bleeding (extended
retroperitoneum) with tachycardia and hypotension and dropping
HCT (nadir 20), and was tranferred to ICU. She ended up
requiring 9U prbc for the acute bleed (10U total during hospital
course). Heparin was stopped and pt underwent IVC filter
placement on [**4-17**] by IR without complications. Her HCT stabilized
and she was transferred out of ICU on [**4-18**]. She remained stable
in terms of her HCT. However, developed asymmetrical L>R
swelling and had a fever on [**4-20**]. LE dopplers checked which
showed NEW L prox DVT. Heme was consulted to help with decision
on safety of resuming anticoagulation given significant clot
burder and ongoing hypercoag that may not be protected by IVC
filter alone. CT scan was repeated on [**4-23**] which showed large L
retroperitoneal bleed (resulting in above HCT drop), but no
active bleeding. She was given an additional 1U prbc (10 total)
for HCT 23.6 though it was not believed she had ongoing
bleeding. After discussion with patient/husband regarding
risks/benefit of anticoagulation, decision was made to resume
heparin. As for her PEs, she remained hemodynamically stable and
was weaned off of O2. For her LE edema and risk of posthrombotic
complications, she was placed on TEDs and reccommeded to keep
her legs elevated. As for the cause of her hypercoagubility, No
clear precipitant: no self-reported history of immobility (last
flight [**2-20**]), no history of malignancy (up to date with
[**Last Name (un) 3907**]/pap/cscope), no personal or family history of blood clots,
no recent surgery. Only possible trigger identified was her
recent RA flare, but this was no longer an issue so did not
explain her ongoing hypercoaguable state (LLE DVT formed
in-hosp). Another concern was her longstanding use of humira,
which can be associated with secondary malignancy. Her CT c/a/p
did not mention any abnormal masses or LAD to suggest lymphoma,
and as per above she is up to date on cancer screening. She
needs outpt further w/u for malignancy and hyper coag w/u.
Hospital course also complicated by ARF, thought to be prerenal,
s/p IVFs and blood tranfusions, now back to baseline.
Her Fe studies were c/w low Fe stores, however she likely got
enough Fe load with the blood transfusions and this can be
rechecked as outpt. Her B12 was low normal and she was started
on supplementation.
Her humira and MTx were held in the acute setting but were
resumed once pt stabilized.
Her BP meds were kept the same except norvasc was not resumed
due to well controlled BP off this.
.
.
See note below for details.
# Bilateral PEs/VTE: significant clot burden on CTA but Echo w/o
RV strain. LE doppler/CT a/p w/o thrombus on [**4-14**]. As above,
taken off heparin given significant rectus sheath/RP hematoma.
underwent IVC filter [**4-17**]. Repeat dopplers [**4-20**] (feverw w/u) with
L fem DVT suggesting she continues to be hypercoaguable which is
concerning. Heme consulted to assess whether appropriate to
resume heparin. HCT stable and CT [**4-23**] with subacute hematoma
(known bleed) but no active bleeding. Weaned off O2. Heme felt
risk outweighed benefit, and pt was agreeable to resuming
heparin gtt on [**4-24**]. She was monitored over 2 days and coumadin
was started the evening of [**4-26**]. She will need to be bridged
with heparin gtt (titrate to PTT 60-80) until therapeutic on
coumadin. Discharged on heparin gtt at 1700 U/hr. Should have
twice daily PTTs given recent massive bleed. Given no clear
precipitant of VTE episode (except perhaps prior RA flare) and
clot formation while here in her left leg, she will need an
outpatient hypercoaguable work up. She also should wear TEDs for
at least 6 months to prevent post-DVT complications. Likely will
need lifelong anticoagulation. Phone number for outpatient
hematology follow up in 6 months was given in the discharge
paperwork.
.
.
# Rectus sheath and RP hematoma: spontaneous bleed while on
heparin gtt (highest PTT 97). No recent injury, trauma, or
surgery in that site. Hemodynamic unstable bleed (transferred to
ICU), heparin gtt stopped, required 9U prbc at the time. No IR
intervention, appears to have tamponaded finally. Last t/f [**4-21**]
for slowly drifting HCT. Has been stable. Repeat CT ab/pelvis
on [**4-23**] as above showing new RP bleed as of [**4-14**], which
represents the 10U bleed [**4-16**] (subacute) rather than active
bleed. Heparin gtt was restarted on [**4-23**] with close monitoring.
Pt will need close monitoring of her PTT/INR while titrating in
coumadin (twice daily PTT, daily INR). Will not resume ASA or
NSAIDs on discharge. Would transfuse for hct less than 23 and
repeat CT scan abdomen/pelvis to eval for new bleed if hct drops
to less than 22. Hct was 28 at discharge.
.
# Fever: temp spike [**4-20**]. UA/CXR unremarkable. Blood cx X2
negative (TLC and peripheral). no leukocytosis. Did have some
loose stools, but C diff negative. Another concern was for DVT
and LE dopplers confirm L prox DVT which may be cause. Low grade
temp of 100.1 on [**4-26**]. Again, no clear source other than blood
clots. Afebrile completely on night prior to and day of
discharge.
.
# Anasarca: likely [**3-16**] large IVFs and blood in ICU. CXR w/o pulm
edema though does have significant anasarca (especially L>R LE,
R>L UE edema). Albumin low at 2.5. Started nutrition
supplements.
.
# ARF: normal creat at baseline. Developed ARF in ICU, peak
creat 3.2, BUN 50s. ddx: prerenal vs hematoma resorption vs CIN
vs ATN from hypotension. Received fluids/blood, improved to
baseline of 0.6-0.7 at discharge.
.
# Nausea: CT head negative for mass, LFTs/lipase normal.
Written for zofran as needed. Vomiting/nausea noted after pt
received her MTX on [**4-24**], which is felt to be the likely
etiology of her symptoms.
.
#Acute diastolic CHF: Noted wheezing and elevated JVP on [**4-24**],
s/p 10 U PRBC in the days prior. She was given Lasix 10 mg IV
daily on [**4-20**] with resolution of wheezing and good urine
output.
.
# HTN: Resumed home dose of lisinopril 40, toprol 50, BP well
controlled. not resuming amlodipine
.
# RA: Humira and MTX held since last admission ([**4-7**]) given
concern at that time for septic shoulder joints (negative fluid
cx). Were not resumed on last discharge with plan for f/u rheum
for resuming. Rheum/Dr. [**Last Name (STitle) 1839**] does not feel there is any
contraindication as of [**4-15**], so humira and MTX were resumed on
[**4-24**] (MTX received [**4-24**], humira received [**4-25**]).
.
# Anemia, acute and chronic: see above for acute drop 2/2
hematoma. Also has h/o Fe def and B12 def (93 in [**3-23**]). Received
good Fe load with transfusion for now, f/u Fe studies in 2
months. Continued B12 supplements. Hct stable at 28 at time of
discharge.
.
# Hyperlipidemia: Continued pravastatin 20, holding asa 81
.
# NAC study: ED protocol. infusion finished [**4-15**]
.
# Access: Midline placed [**2189-4-26**]
Medications on Admission:
Confirmed medications with patient.
Amlodipine 5 mg Tablet 1 Tablet(s) by mouth once a day
Esomeprazole Magnesium [Nexium] 40 mg Capsule, Delayed
Release(E.C.)
1 Capsule(s) by mouth once a day
Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by Other Provider) [**2189-1-12**]
Ibuprofen 800 mg Tablet 1 Tablet(s) by mouth three times a day
PRN
Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth once a day
Pravastatin [Pravachol] 20 mg Tablet 1 Tablet(s) by mouth at
bedtime [**2189-1-13**]
* OTCs *
Aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth once a day
Calcium Citrate-Vitamin D3 [Citracal + D] - 2 T [**Hospital1 **].
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
9. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Methotrexate Sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
QFRI (FR).
11. Heparin Flush (10 units/ml) 1 mL IV PRN
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
15. Humira 40 mg/0.8 mL Kit Sig: 0.8 ML Subcutaneous every 2
weeks ().
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1700 (1700) units Intravenous per hour: titrate to
PTT of 60-80.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Bilateral pulmonary embolism
Severe rectus sheath and retroperitoneal hematoma s/p 10U prbc
Hypercoag state of unclear etiology
Rheumatoid arthritis
Anemia [**3-16**] chronic disease, Fe def, and acute blood loss
Discharge Condition:
STABLE
Discharge Instructions:
You were admitted with leg swelling and shortness of breath. You
were diagnosed with multiple pulmonary embolisms.
.
You were started on heparin for anticoagulation but developed a
complication of massive bleeding into your muscle and within the
abdomen for which you recieved 10 Units of blood. Your heparin
was held for several days and you underwent IVC filter for
protection from further pulmonary embolism. You developed
another Left Leg clot while here. Hematology was consulted and
after careful consideration and discussions with you, decision
was made to restart heparin.
.
You need to have your blood counts carefully monitored. You will
be followed by Hematology after discharge for further workup of
why you developed these clots.
You are started on some new medications. From your previous
list, you will not restart norvasc. You also were started on
coumadin to help thin your blood. Also your RA meds, humira and
methotrexate were held for the most part, but were restarted
prior to discharge.
.
Call your doctor or return to the ER for any worsening shortness
of breath, new leg or arm swelling, chest pain, fainting,
palpitations, fevers, lightheadedness, or any other concerning
symptoms.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] 2 weeks after discharge from
rehab
.
2. Please follow up with Dr. [**Last Name (STitle) 4762**] of hematology in 6 months
to help work up the reason why you formed all of these blood
clots. His number is ([**Telephone/Fax (1) 4763**] and you can call in 5 months
to arrange for follow up.
.
3. Please follow up with Dr. [**Last Name (STitle) 1839**] of rheumtology after your
discharge from rehab. fax [**Telephone/Fax (1) 4764**]; phone [**Telephone/Fax (1) 4759**]
|
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icd9cm
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[
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[
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,793
| 136,281
|
21169
|
Discharge summary
|
report
|
Admission Date: [**2151-4-12**] Discharge Date: [**2151-4-20**]
Date of Birth: [**2084-6-7**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
gentleman who developed substernal chest pain that radiated
across his chest with associated gastrointestinal upset and
diaphoresis for 48 hours prior to admission.
An electrocardiogram showed T wave inversions in the septal
leads with Q waves in V1 and V2. The patient was transferred
to [**Hospital1 69**] for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Status post left pneumonectomy in [**2132**] for lung cancer.
2. Hypertension.
3. Repair of deviated nasal septum.
4. Chronic obstructive pulmonary disease.
PREOPERATIVE MEDICATIONS:
1. Diovan 160 mg by mouth once per day.
2. Levobunolol nebulizer treatment four times per day.
3. Combivent meter-dosed inhaler three to four times per
day.
4. Humibid 600 mg by mouth twice per day.
5. [**Doctor First Name **] 60 mg by mouth twice per day.
6. Maxzide.
ALLERGIES: No known drug allergies.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to [**Hospital1 1444**].
The patient was taken to the Cardiac Catheterization
Laboratory where he was found to have an ejection fraction of
approximately 30%. Left ventricular end-diastolic pressure
was 18, and pulmonary artery pressures of 29/21. Coronary
angiography revealed 80% to 90% distal left main, 80% ostial
left anterior descending artery, 80% ostial left circumflex,
and diffuse plaque of the right coronary artery.
Due to the patient's severe left main stenosis an
intra-aortic balloon pump was placed, and Cardiac Surgery was
consulted for operative treatment.
As the patient had received Integrilin and Plavix, and the
patient was pain free with the intra-aortic balloon pump, the
patient was taken urgently to the operating room on [**4-13**] for
a coronary artery bypass graft times four with left internal
mammary artery to the left anterior descending artery,
saphenous vein graft to the ramus and obtuse marginal, as
well as saphenous vein graft to the distal left anterior
descending artery. Please see the Operative Note for further
details.
At the conclusion of the surgery, the patient developed some
hypokinesis of his anterior wall and required returning to
cardiopulmonary bypass with repositioning of the left
internal mammary artery graft. The patient was successfully
from cardiopulmonary bypass and transported to the Intensive
Care Unit in stable condition on epinephrine, Levophed, and
nitroglycerin drips.
The patient remained intubated overnight. The intra-aortic
balloon pump was removed on postoperative day one without
incident. The patient was weaned and extubated from the
mechanical ventilation on postoperative day one. The patient
continued on epinephrine and Levophed infusions; both of
which were weaned off on the evening on postoperative day
one. However, the patient continued to have some moderate
hypotension. The patient required Neo-Synephrine for
maintaining adequate systolic blood pressures. The patient
was started on diuretic therapy. Regarding the patient's
pneumonectomy, the patient continued to have adequate gas
exchange and responded well to pulmonary toilet. The
patient's chest tubes were removed on postoperative day three
without incident. The patient required packed red blood cell
transfusions to maintain a hematocrit of greater than 30.
On postoperative day four, the patient was started on
low-dose Lopressor which he tolerated well. The patient was
transferred from the Intensive Care Unit to the regular part
of the hospital. The patient began working with Physical
Therapy.
The patient was weaned off of oxygen; however, with
ambulation, the patient became mildly hypoxic on room air
requiring oxygen to maintain oxygen saturations in the low
90s. The patient required some additional diuresis. By
postoperative day seven, the patient was able to ambulate on
room air while maintaining oxygen saturations in the low to
middle 90s.
It was noted during the postoperative period that the patient
had mildly elevated blood glucose levels, requiring
sliding-scale insulin coverage to maintain a blood sugar of
less than 120. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Service consultation was obtained,
and it was recommended that the patient be discharged home on
low-dose Lantus insulin with blood sugar monitoring and post
discharge followup with [**Last Name (un) **].
By postoperative day seven, the patient was cleared for
discharge to home.
PHYSICAL EXAMINATION ON DISCHARGE: Temperature maximum 100,
his pulse was 90 (in sinus rhythm), his blood pressure was
135/80, his respiratory rate was 16, and his oxygen
saturation was 96% on room air. Neurologically, the patient
was alert, awake, and oriented times three; nonfocal. Heart
was regular in rate and rhythm without rubs or murmurs.
Respiratory examination revealed breath sounds were clear on
the right without wheezes or rales. Gastrointestinal
examination revealed the abdomen was obese, soft, nontender,
and nondistended. The sternal incision was clean, dry, and
intact. There was no erythema or drainage. The sternum was
stable. The left lower extremity Steri-Strips were intact
without erythema. The bilateral lower extremities had 1 to
2+ pitting edema (left greater than right). The patient's
weight on [**4-20**] was 103.5 kilograms. The patient's weight
was 98 kilograms preoperatively.
PERTINENT LABORATORY VALUES ON DISCHARGE: White blood cell
count was 9.6, his hematocrit was 35.1, and his platelet
count was 292. Sodium was 140, potassium was 3.9, chloride
was 95, bicarbonate was 34, blood urea nitrogen was 20,
creatinine was 0.9, and his blood glucose was 120.
A chest x-ray on [**4-19**] showed a small right effusion without
pneumothorax, and no infiltrate. No evidence of congestive
heart failure.
DISCHARGE DISPOSITION: The patient was to be discharged to
home.
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
2. Enteric-coated aspirin 325 mg by mouth every day.
3. Zantac 150 mg by mouth twice per day.
4. Advair Diskus ([**9-/2097**]) 2 puffs twice per day.
5. Lopressor 75 mg by mouth twice per day.
6. Lasix 40 mg by mouth twice per day (times two weeks).
7. Diovan 80 mg by mouth twice per day.
8. Potassium chloride 20 mEq by mouth twice per day (times
14 days).
9. Combivent meter-dosed inhaler 2 puffs q.4h. as needed.
10. [**Doctor First Name **] 60 mg by mouth twice per day.
11. Humibid 600 mg by mouth twice per day.
12. Lantus insulin 5 units subcutaneously in the morning.
13. Levobunolol nebulizer treatment four times per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his
pulmonologist (Dr.[**Name (NI) 56119**]) in one to two weeks.
2. The patient was instructed to follow up with his primary
care physician in one to two weeks.
3. The patient was instructed to follow up with Dr.
[**Last Name (STitle) 56120**] from the [**Hospital **] Clinic. An appointment will be
set up and the time will be mailed to the patient.
4. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in five to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2151-4-20**] 12:56
T: [**2151-4-20**] 13:03
JOB#: [**Job Number 56121**]
|
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icd9cm
|
[
[
[]
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[
"39.49",
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icd9pcs
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[
[
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5967, 6020
|
6071, 6802
|
6835, 7689
|
758, 1072
|
1101, 4613
|
6035, 6044
|
5558, 5942
|
176, 545
|
567, 732
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,586
| 131,193
|
50274
|
Discharge summary
|
report
|
Admission Date: [**2157-7-10**] Discharge Date: [**2157-7-19**]
Date of Birth: [**2083-7-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2157-7-12**] Cardiac Catheterization with Placement of IABP
[**2157-7-13**] Mitral Valve Repair utilizing a 30mm [**Doctor Last Name **]
Annuloplasty Ring
History of Present Illness:
This is a 73 year old male with remote history of mitral valve
endocarditis and known mitral regurgitation who presented with
two week history of worsening shortness of breath. Patient
reported dyspnea that was worse with laying flat and with
exertion. His shortness of breath improved with rest and most
recently with supplemental oxygen. Patient reports mild
associated cough, nonproductive. Denies fevers, chest pain,
diaphoresis, chills and rigors. Patient reports eating out a lot
during this time, including high-sodium foods. During this time,
patient had been in touch with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]; per report
from PCP, [**Name10 (NameIs) **] has had serial echocardiograms since
establishing w Dr. [**Last Name (STitle) **], which have not shown any significant
increase in end-systolic dimension of the left ventricle,
although he has been noted to have left atrial enlargement
previously. Per PCP notes, patient's symptoms would briefly
improve with daily Lasix dosing. However, on day prior to
admission symptoms overall worsened and PCP recommended patient
present to ED. Patient initially presented to OSH, had CT chest
that did not demonstrate signs of infection and was discharged.
As symptoms continued to worsen he presented to [**Hospital1 18**] for
further workup.
.
On initial presentation to ED, vital signs were 97.3 93 139/68
18 100% RA. Exam was significant for crackles and systolic
murmur. Labs were significant for WBC15.9, Hct37.4, Cr2.1 (no
prior), Trop<.01, BNP5903, Ddimer2916. EKG w L atrial
abnormality (?p-mitrale), peaked twaves in precordials w ST
changes. OSH CT scan was re-read and w/o sign of PE. CXR did not
demonstrate any acute process. Patient was given 40mg IV Lasix,
ASA 325mg and admitted to cardiology.
Past Medical History:
- History of Mitral Valve Endocarditis(following dental work)
- Mitral valve prolapse with mitral regurgitation
- Hypertension
- Psoriasis
Social History:
- Lives with wife in [**Name (NI) 1887**], MA.
- Works as Health policy professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
- Denies tobacco and illicits.
- Drinks 2-3 drinks / day.
Family History:
No family history of early cardiac/valvular disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 98.3 degrees Farenheit, BP: 110/70 mmHg supine, HR 80
bpm, RR 20 bpm, O2: 100 % on 2L. Wt 64.7kg on standing scale
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. dry mucous membranes
NECK: Supple, No LAD. JVP to earlobe. Normal carotid upstroke
without bruits. No thyromegaly.
CV: PMI laterally displaced. RRR. Soft S1 and S2. [**2-20**] SM at
apex. No RV heave
LUNGS: Tachypneic. CTAB. No wheezes, rales, or rhonchi. Patient
acutely short of breath just with sitting up.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
NEURO: A&Ox3.
Pertinent Results:
ADMISSION LABS:
[**2157-7-10**] WBC-15.9*# RBC-4.27* Hgb-13.7* Hct-37.4* Plt Ct-296
[**2157-7-10**] Neuts-70.3* Lymphs-22.6 Monos-6.1 Eos-0.3 Baso-0.8
[**2157-7-10**] Glucose-129* UreaN-50* Creat-2.1* Na-135 K-4.8 Cl-100
HCO3-21*
[**2157-7-10**] CK(CPK)-63
[**2157-7-10**] CK-MB-3 proBNP-5903*
[**2157-7-10**] cTropnT-<0.01
[**2157-7-10**] D-Dimer-2916*
[**2157-7-11**] TSH-1.4
.
[**2157-7-11**] Echocardiogram:
The left atrium is markedly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is [**4-26**]
mmHg.Mild symmetric left ventricular hypertrophy with preserved
global and regional systolic function (LVEF >55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of mitral regurgitation.] Right ventricular
chamber size is normal with moderate 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 partial posterior leaflet flail with torn
mitral chordae attached (cannot exclude vegetation if clinically
suggested). An eccentric, anteriorly directed jet of severe (4+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderat to severe pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
[**2157-7-12**] Cardiac Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographcially apparent, flow-limiting
coronary artery
disease. The LMCA, LAD, LCx, and RCA were all normal in
appearence.
2. Resting hemodynamcis revealed mildly elevated right and
severly
elevated left ventricular filling pressures, with a RVEDP of
16mmHg and
an LVEDP of 28mmHg. There was severe pulmonary hypertension,
with a
PASP of 63 mmHg. There was no transvalvular gradient to suggest
aortic
stenosis. Significantly depressed cardiac function, with an
cardiac
index of 1.6 L/min/m2.
3. Successful placement of an 8F 30cc IABP.
.
[**2157-7-13**] Intraop TEE:
PRE BYPASS 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. Left ventricular wall thicknesses are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricle
displays moderate global free wall hypokinesis. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
aortic regurgitation is at least mild to moderate in intensity.
The mitral valve leaflets are mildly thickened. There is
extensive posterior mitral leaflet flail. Torn mitral chordae
are present. Severe, anteriorly directed (4+) mitral
regurgitation is seen. An intra-aortic balloon pump is seen in
situ. Its tip is about 3 cm below the distal aortic arch. There
is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the procedure.
POST BYPASS The patient is in sinus rhythm. The intra-aortic
balloon pump is set at a 2 to 1 ratio. Initially after
separation from bypass, the right ventricle displayed continued
moderate global hypokinesis. The left ventricle displayed septal
dyskinesis likely secondary to cardiopulmonary bypass. There is
also some moderate inferior wall hypokinesis. Epinephrine
infusion was then started and right ventricular systolic
function normalized. Overall left ventricular function improved
though inferior hypokinesis and septal dyskinesis remained -
ejection fraction approximated 40-45%. The mitral valve is
status post repair. A mitral valve annuloplasty ring is in situ.
There is some redundant anterior leaflet beyond the coaptation
point but no significant mitral valvular systolic anterior
motion is noted. Mild mitral regurgitation is seen. The maximum
gradient across the mitral valve was 5 with a mean of 3 at a
cardiac output of 5 liters/minute. The maximum gradient across
the aortic valve was 19 mmHg. The tricuspid and aortic
regurgitation is unchanged from the pre-bypass period. The aorta
appears intact after decannulation.
.
[**2157-7-17**] Chest x-ray:
Status post median sternotomy with placement of mitral annular
ring. Heart remains enlarged with left ventricular prominence,
suggestive of left ventricular hypertrophy. No evidence of
pulmonary edema, although there is mild cephalization suggestive
of pulmonary venous hypertension. The lung volumes are slightly
improved, although there is residual linear opacity at both
bases, likely representing subsegmental atelectasis. Small
bilateral pleural effusions, left greater than right, are seen.
No pneumothorax. No overt pulmonary edema.
.
DISCHARGE LABS:
pending
Brief Hospital Course:
Dr. [**Known lastname **] was admitted under cardiology with congestive heart
failure secondary to mitral regurgitation and acute renal
insufficiency. His acute renal insufficiency was attributed to
recent dye load from CTA at outside hospital. Ischemia was ruled
out as cause of this event with negative cardiac enzymes and no
ECG evidence of ischemia. CTA at outside hospital preliminary
read showed no evidence of pulmonary embolism. An echocardiogram
was performed which showed a partial mitral leaflet flail, torn
mitral chordae, and an eccentric mitral regurgitation jet with
severe (4+) MR. [**Name13 (STitle) **] prior to cardiac catheteriation, patient
developed respiratory distress and became less responsive. He
required intubation and transfered to cath lab where
catheterization revealed no angiographically apparent coronary
artery disease, cardiogenic shock with elevated biventricular
filling pressures and severe pulmonary hypertension. An
intra-aortic balloon pump was subsquently placed and he was
trasferred to the ICU. Cardiac surgery was consulted for urgent
surgical intervention.
.
On [**7-13**], Dr. [**Last Name (STitle) **] performed urgent mitral valve repair.
For surgical details, please see operative note. Given inpatient
stay prior to surgery was greater than 24 hours, Vancomycin and
Cefazolin were used for perioperative antibiotic coverage. For
surgical details, please see operative note. Following surgery,
patient was brought to the CVICU for invasive monitoring. Within
24 hours, he awoke neurologically intact and was extubated
without incident. IABP was weaned and removed without
complication. He developed atrial fibrillation and was started
on Amiodarone per protocol. By postoperative day two, he
converted back to a normal sinus rhythm. He remained stable on
medical therapy and transferred to the SDU on postoperative day
three. Renal function normalized. He remained in a normal sinus
rhythm and no further episodes of atrial fibrillation were
noted. Beta blockade was advanced as tolerated while Amiodarone
was titrated accordingly. Over several days, he continued to
make clinical improvements with diuresis and was eventually
cleared for discharge to home on postoperative day five. Prior
to discharge, all followup appointments with Dr. [**Last Name (STitle) **] and
PCP/cardiologist were arranged.
Medications on Admission:
Simvastatin 40mg daily
Omeprazole 20mg [**Hospital1 **]
Lasix 40mg daily
ASA 325mg daily
Metoprolol 75mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
[**12-19**] usual dose while on amiodarone.
Disp:*30 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg for one week then 200 daily ongoing until you see Dr.
[**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 7 days.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Cardiogenic Shock, Mitral Regurgitation s/p Mitral Valve Repair
Acute renal Insufficiency
History of MV Endocarditis, Mitral Valve Prolapse
Hypertension
Postop Atrial Fibrillation
Preop Acute Respiratory Failure
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2157-7-26**] 10:30 in
the [**Hospital **] medical office building [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2157-8-10**] 1:00 in the
[**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**0-0-**] on [**8-18**] at 9:30am
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2157-7-19**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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2494, 2696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,337
| 196,425
|
47140
|
Discharge summary
|
report
|
Admission Date: [**2169-1-3**] Discharge Date: [**2169-1-9**]
Date of Birth: [**2088-2-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 80 year old woman with a history of diastolic CHF,
severe AS, h/o atrial flutter, HTN and DM presenting with 1-2
days of shortness of breath and fatigue. Patient is a very poor
historian but reports that she was in her usual state of health
until the day prior to admission when she began to feel short of
breath. Her shortness of breath was even at rest. The shortness
of breath was accompanied by a cough which was productive of
whitish sputem. No fever or chills.
.
She also reports a brief episode of non-exertional central chest
pain which possibly radiated down the arms, L>R. This episode
lasted seconds to minutes and resolved spontaneously. No nausea
or vomiting.
.
On the day of admission she presented to her PCP's office where
per report she was noted to have a blood pressure of 90/52 with
a pulse of 58 and an O2 saturation recorded as 84% on 2L. Per
report she is not on oxygen at home. She was also noted to have
increased facial edema. She was sent to the ED for further
evaluation.
.
In the ED, initial VS were 97.6 64 125/42 18 100% on 12L NRB.
Labs were notable for a sodium of 115. An EKG was noted to have
new TWI in lead III. She was given 500cc NS and started on cipro
for evidence of a UTI on her UA. VS at time of transfer 74 98/76
(mostly 90s-120s) temp 96 bp 108/38 hr 72 rr 21 sat 96/2L
On arrival to the ICU she reports feeling significantly better.
She feels less short of breath and feels that her "chest
tiredness" has resolved. She reports feeling well overall.
.
On review of systems she reports bilateral peripheral edema
which she states is no worse than her baseline. She denies any
orthopnea or PND. She reports no recent illnesses, no changes in
medications and no head trauma. She denies any fevers, chills,
night sweats, nausea, vomiting, diarrhea. No recent medication
changes. No report of seizure activity or recent falls or head
trauma.
Past Medical History:
-CHF: diastolic dysfunction, EF 55%
-CAD, s/p placement of 2 [**First Name3 (LF) **]: In [**2-7**] found to have 90% lesion
of RCA. She was evaluated by cardiothoracic surgery, and she
was felt to not be a candidate for CABG given her co-morbidities
and morbid obesity. On [**2166-9-3**] she was admitted for SOB and
subsequently had placement of 2 drug eluting stents, one for an
ostial lesion for the
right coronary and one for a distal left circumflex lesion.
-Aortic stenosis (moderate-severe): valve area 0.8cm2 on echo,
1.1cm2 on cath
-Diabetes: controlled on oral meds, last HbA1c=6.1% in [**2-7**].
-s/p ventral hernia repair
-History of cholecystitis
-Hypertension
-Obesity
-Hypercholesterolemia: Controlled on atorvastatin, lipids last
checked [**1-/2166**]: Total cholesterol 161, HDL 45, LDL 93.
-Low back pain s/p motor vehicle accident in [**2159**] with
diffuse degenerative joint disease, pain tolerable without pain
meds
-Hypothyroidism
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Was living independently in apartment below son's apartment. Was
at [**Hospital 100**] Rehab since stent placement and is currently living at
home with VNA a few times per week. Walks with a walker, no
problems bathing/dressing. Denies smoking/ETOH use. Worked at [**Hospital1 **]
for 26 years as supervisor coordinator. Son works at [**Hospital1 **] as
materials supervisor, daughter-in-law works as phlebotomist.
Family History:
Father passed away at age 67 from heart attack, mother passed at
82 from heart attack. Has one brother age 65, lives in [**Location **]
[**Country **]. Has two sisters, 83 and 80. No history of cancer in
family.
Physical Exam:
On Admission:
Vitals: afebrile, BPs 100s/50s, HR 80s, O2 sats 97/ra
GEN: Elderly somewhat ill-appearing woman in no acute distress
HEENT: EOMI, PERRLA 1mm->2mm, sclera anicteric, no epistaxis or
rhinorrhea, MMM
NECK: JVD to 2cm below angle of jaw
CARDIAC: tachy regular, III/VI SEM throughout precordium
radiating to carotids L>R
PULM: faint bibasilar crackles, no wheeze
ABD: Obese, soft, NT, ND, +BS
EXT: 2+ pitting edema bilaterally almost to knees, bilateral
erythema with mild warmth bilaterally almost to calves
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities
.
On discharge:
Afebrile/98.1 101/39 68 20 100 RA FS 161-327
Gen: Elderly obese female with fluent speech
HEENT: MMM, sclera anicteric
Neck: Supple
Cardiac: III/VI crescendo/decresendo murmur
Pulm: CTA- bilaterally
Abd: Obese, soft, NT, ND
Ext: 1+ edema with erythema below the shins.
Neuro: Alert and oriented. Moving all extremities.
Pertinent Results:
On Admission:
[**2169-1-3**] 02:00PM WBC-9.3 RBC-3.52* HGB-10.6* HCT-29.6* MCV-84#
MCH-30.2 MCHC-35.9*# RDW-15.1
[**2169-1-3**] 02:00PM PLT COUNT-289
[**2169-1-3**] 02:00PM NEUTS-82.1* LYMPHS-12.0* MONOS-5.5 EOS-0.2
BASOS-0.2
[**2169-1-3**] 02:00PM GLUCOSE-178* UREA N-60* CREAT-1.8*
SODIUM-115* POTASSIUM-3.9 CHLORIDE-65* TOTAL CO2-37* ANION
GAP-17
[**2169-1-3**] 09:09PM NA+-118*
[**2169-1-3**] 02:00PM cTropnT-0.02*
[**2169-1-3**] 02:00PM CK(CPK)-148
[**2169-1-3**] 09:00PM cTropnT-0.02*
.
[**2169-1-3**] 05:20PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2169-1-3**] 05:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2169-1-3**] 05:20PM URINE RBC-0-2 WBC-[**3-4**] BACTERIA-MANY YEAST-NONE
EPI-0-2
.
Imaging:
FINDINGS: The lateral radiograph is nearly nondiagnostic due to
respiratory
motion and body habitus. There is possible suggestion of a
pleural effusion.
The AP radiograph is suboptimal due to very low lung volumes.
There is
possible mild cephalization of pulmonary vasculature. There is
cardiomegaly.
IMPRESSION: Suboptimal evaluation, demonstrating mild vascular
cephalization and cardiomegaly, suggestive of mild congestive
heart failure
.
ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild to moderate ([**1-1**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2168-3-31**], the severity of aortic stenosis has
progressed and is now critical. The severity of aortic
regurgitation has increased.The estimated pulmonary artery
pressures are lower (but may be underestimated).
Discharge labs:
[**2169-1-9**] 07:50AM BLOOD WBC-6.1 RBC-3.36* Hgb-10.1* Hct-30.4*
MCV-91 MCH-30.1 MCHC-33.3 RDW-15.6* Plt Ct-303
[**2169-1-8**] 07:25AM BLOOD Neuts-78* Bands-0 Lymphs-11* Monos-7
Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2169-1-9**] 07:50AM BLOOD Plt Ct-303
[**2169-1-9**] 07:50AM BLOOD Glucose-206* UreaN-61* Creat-1.4* Na-140
K-4.0 Cl-98 HCO3-30 AnGap-16
[**2169-1-4**] 09:37AM BLOOD CK(CPK)-141
[**2169-1-9**] 07:50AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
Brief Hospital Course:
80 year old woman with diastolic CHF and severe AS presenting
with 2 days of increased somnolence found to have sodium of 115.
Per family started metolazone at [**Holiday **] and since then had
progressive weight gain, orthopnea and PND. There was evidence
of peripheral edema with little evidence of LVF on CXR and exam.
Na improved after diuresis. Na slowly improved and by [**1-5**] this
was 135. She had a repeat echo which showed worsening AS which
is now critical. She was diuresed with an IV furosemide with
good urine output. She was treated for a UTI with cipro and was
noted to have new hematuria on [**1-5**]. She was transitioned to IV
furosemide boluses and transferred from the ICU on [**1-5**]. She was
subsequently diuresed on the floor with PO lasix with
improvement in her renal function. The most likely etiology for
her presentation was worsening AS.
.
# Hyponatremia: There was no significant prior history of
hyponatremia and it was thought that she had hypervolemic
hyponatremia. Her somulence and fatigue was attributed to
hyponatremia. Given the relative mildness of her symptoms for
her severe degree of hyponatremia it was felt that this was
likely a chronic progression of hyponatremia. Urine and serum
studies showed serum Osm 272 uOsm 310 UNa 12. The overall
picture was consistent with ADH-driven hypo-osmolar hypervolemic
hyponatremia with perceived reduced intravascular volume in the
setting of poor forward flow due to severe aortic stenosis and
likely worsening CHF. We slowly corrected the Na aiming for max
10 meq/24 hours to reduce risk of central pontine myelinosis.
She was mildly disoriented in time and this was monitored. He
daily weight and regular electrolytes were monitored and she was
fluid restricted to 750ml/day. Na on discharge from the ICU on
[**1-5**] was 135. She was subsequently diuresed on the floor with a
serum sodium > 130's. She was mentating appropriately, and
continued to have a good UOP. She was transitioned to PO lasix
at 200 mg a day. Her optimal dry weight is 239.7 lbs (may be
slightly less)
- Please preform daily weights
- Please keep track of I/O's.
.
# Dyspnea/Hypoxemia: Sats 97% on 2L. She is on O2 at home
according to the PCP. [**Name10 (NameIs) **] has not been on O2 once she was
diuresed. Her poor O2 sat on admission was felt to be due to
worsening poor forward flow in the setting of critical AS, and
possible acute on chronic diastolic CHF given her volume status
on exam, CXR findings and BNP elevated at 5666 (although this
relatively mild). The relative low BNP suggests she only had
mild LVEDP. She was treated with a furosemide infusion and on
[**1-5**] changed to furosemide IV boluses. Her thiazide (metolazone)
was held.
.
# Chest Pain: She had a fleeting episode of non-exertional chest
pain which resolved and did not recur. ECG changes showed only a
new TWI in III, and cardiac enzymes were negative with stable
TnT. She was monitored clinically.
.
# Aortic Stenosis: By her last echo [**1-/2169**] the aortic valve area
was 0.8-1.0 and on echo [**1-4**] this revealed now critical AS valve
area <0.8. Cardiology reviewed this finding and she was
evaluated by CT surgery, who felt she was not an ideal candidate
for surgery. She will be considered for a core valve
replacement.
.
# CHF: chronic systolic. Her last EF 55%. BNP 5666 which was
similar to prior. CXR showed mild congestion, and 2+ edema with
elevated JVP. HCO3 40 which was considered to be a likely
contraction alkalosis. On ABG there was evidence of profound
metabolic alkalosis with resp compensation - pH 7.48 pCO2 57 pO2
97 HCO3 44 BaseXS 15. She was started on acetazolamide at 250mg
[**Hospital1 **] on [**1-4**]. She was fluid restricted to 750ml/day. She was
treated with an IV furosemide infusion and this was down
titrated given low BP. She was transitioned to IV furosemide
boluses on [**1-5**] with an I/O goal 1-2L negative per day. Her
weight improved and she symptomatically improved.
She symptomatically improved although on the day of discharge
from the ICU on [**1-5**] her BP was transiently in the 80s and this
improved without intervention. Her SBP while in the hospital at
[**Hospital1 18**] was in the 100's with a diastolic in the 30's -40's.
# Acute on Chronic RF: Nonoliguric. Cr 1.8 near recent baseline
although 1.2 as recently as 3/[**2168**]. Overall story most
consistent with pre-renal azotemia in the setting of poor
forward flow. This improved with continued diuresis prior to
discharge her Cr was 1.4
.
# UTI: Patient denied dysuria but +UA, afebrile. She was started
on Cipro in ED with a plan to treat for 3 days. She had new
hematuria [**1-5**] and this will need to be monitored. Urine cultures
were negative.
.
# Hematuria: INR 1.0 on [**1-4**] and this will need to be monitored.
If this continues she will need a repeat UA, which showed a
decrease in RBCs. By [**2168-1-9**] she had a UA which showed mild
inflammation and some RBC's (decreased from previous UAs) This
will be followed as an outpatient. Her HCT was stable
throughout her hospital stay.
- Please repeat UA at rehab.
.
# DMII: She was on glipizide at home and this was held in the
setting of significant illness and manage with ISS in house. Her
blood sugar was controlled on an ISS while she was admitted.
Medications on Admission:
-Amiodarone 200 mg PO/NG DAILY Hold
-Clopidogrel 75 mg PO/NG DAILY
-Omeprazole 40 mg PO DAILY
-Aspirin 81 mg PO/NG DAILY
-Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
-Atorvastatin 40 mg PO/NG DAILY
-Levothyroxine Sodium 100 mcg PO/NG DAILY
-Calcium Carbonate 500 mg PO/NG DAILY
-Multivitamins 1 TAB PO/NG DAILY
-Cyanocobalamin 100 mcg PO/NG DAILY
-Docusate Sodium 100 mg PO BID
-Senna 2 TAB PO/NG HS:PRN constipation
-Ferrous Sulfate 325 mg PO/NG DAILY
-Fluticasone Propionate 50 mcg 1 PUFF daily
-Lasix 200 mg PO daily
-Glipizide 10 mg [**Hospital1 **]
-Nitroglycerin 0.3 mg SL.
-Metolazone
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Please see attached SS. .
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. senna 8.6 mg Capsule Sig: Two (2) Capsule PO qHS.
12. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Levothroid 150 mcg Tablet Sig: One (1) Tablet PO once a day.
14. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold for SBP < 100. Please give diuretic first.
16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
17. latanoprost 0.005 % Drops Sig: One (1) dropp Ophthalmic
qHS: Please give at bedtime.
18. Calcium-Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
19. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: Please [**Name8 (MD) 138**] MD if patient has a fever T >
100.4.
20. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
21. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation twice a day.
22. Lasix 20 mg Tablet Sig: Five (5) Tablet PO once a day:
Please hold SBP < 100.
23. Medication Order
Please give patient 100 mg PO lasix if patient gains greater
than 3 lbs. Then, please [**Name8 (MD) 138**] MD to adjust diuretic dose.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis:
Hyponatremia
Secondary Diagnosis:
Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **]-
You were admitted to the hospital with a low sodium and a
worsening valvular lesion. This resulted in the accumulation of
fluid, and poor blood flow. You were given medication to help
remove fluid from your body, and your sodium level, and mental
status. You will need to go to a rehab facility to help you
with exercise tolerance, and monitor your fluid balance.
The following medications were changed:
STOPPED: Nitro, Keflex, vitmains, actos
CHANGED: lasix
- Please check Chem 7, UA on arrival to Rehab.
- Please provide daily PT.
- Please [**Name8 (MD) 138**] MD if patient becomes SOB, or more fatiuged.
Please check chem 7.
- Please get daily weights. If the patient's weight increases
- Please avoid nitro in patient with chest pain and known
critical AS. Please [**Name8 (MD) 138**] MD on call, and get ECG.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
The Rehab facility should contact the following Providers:
1) PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 608**]
2) [**Hospital1 18**] cardiologist [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] to follow up your new
diagnosis of critical AS (see appointment below).
Department: CARDIAC SERVICES
When: MONDAY [**2169-2-13**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2169-1-11**]
|
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12,450
| 136,409
|
3355
|
Discharge summary
|
report
|
Admission Date: [**2193-5-3**] Discharge Date: [**2193-5-13**]
Date of Birth: [**2129-4-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
EGD
Push enteroscopy
History of Present Illness:
The pt is a 64 year-old left handed gentleman with multiple
medical problems including PFO/complex atheroma in the
descending aorta, lymphoma s/p chemotherapy, hepatitis B,
diabetes mellitus, s/p right BKA ([**2193-2-28**]), who was at [**Hospital1 15554**] recovering from recent admission for BKA and E coli
bacteremia. He was last seen well at 6am on the day of
admission. At 6:15am he was noted to be dysarthric with right
facial and arm weakness. Code stroke called at 8:20am. Patient
arrived shortly afterwards and was seen immediately. NIHSS on
arrival to [**Hospital1 18**] was 10. Later found to have right homonymous
hemianopia, left arm drift as well. CT was negative for
hemorrhage. CTA showed what appeared to be drop off signal of
the basilar with minimal flow in bilateral PCAs. He was given
IV t-PA at 9:06am, estimated weight of 170 pounds. Bolus 7mg,
62.6 mg infusion x 1 hr. Guaiac was trace positive pre t-PA.
No change in exam after t-PA immediately. Of note, at 11am,
fluency and dysarthria are noted to be improved, as he raised
his right arm off the bed without difficulty.
Past Medical History:
1. Reactivation Hepatitis B, on entecavir
2. TEE in [**2-11**] shows complex atheroma in descending aorta. The
interatrial septum is aneurysmal. A left-to-right shunt across a
small secundum atrial septal defect was seen.
3. Central retinal artery occlusion R eye - [**10-10**] pt developed
central retinal artery occlusion likely [**1-10**] embolic event.
4. Lymphoma - lymphoplasmacytoid lymphoma; treated with
fludaribine, five cycles in [**2187**]. Since then has been seen by
Dr. [**Last Name (STitle) 410**] and has not required further therapy.
5. Insulin Dependent Diabetes - has had for many years. Treated
with humalog-lente combination 16 u AM, 22 u PM. Has had
multiple DM complications including L eye retinopathy,
gastroparesis, peripheral neuropathy complicated by several
bouts of LE cellulitis. Creatinine at baseline is 0.8-1.0
6. Low albumin - Unclear etiology, has ranged from 1.9-3.5 over
last several years. Question of possible nephrotic syndrome; may
be related to diabetes but unclear.
7. [**Name2 (NI) 167**] acoustic schwanoma - treated with gamma knife radiation
at OSH.
8. Gastritis, duodenitis
9. PVD
10. Hypertension
11. Right BKA [**2193-2-28**] due to PVD c/b e coli bacteremia and
UTI with pseudomonas
12. anemia - iron def and anemia of chronic inflammation
13. chronic malnutrition and 2 months of diarrhea, on TPN,
multiple GI ulcers, no lymphoma seen on biopsies, but still
undergoing w/u
14. B12 deficiency on IM replacement
Social History:
The pt is married, with 2 kids. Has remote history of tobacco
use (35 pack year history). Social alcohol drinker. Retired
dentist.
Family History:
Father died in [**2185**] after amputation for gangrene (unclear
origin).
Mother died [**2191**] unclear reason, had [**Name (NI) 11964**].
Physical Exam:
VITALS: 118/60, 60 NSR (at [**Hospital1 **]), BP during CT was 112's,
and after tpa was 140's. T 100.2 rectal. FS 212 by EMS. 99%
2LNC.
GEN: elderly man, anxious
SKIN: no rash
HEENT: NC/AT, anicteric sclera, dry mm
NECK: supple, no carotid bruits
CHEST: normal respiratory pattern, CTA bilat anteriorly
CV: regular rate and rhythm without murmurs (difficult to fully
appreciate right now)
ABD: softly distended, +BS, multiple bruises
EXTREM: right BKA, left edema 1+ to knee. + scrotal edema.
.
NEURO: via Russian translator
Mental status: Patient is alert, awake, mildly anxious.
Oriented to person, place - "Ho", not time (he tries to sign out
some kind of number).
Language is NONfluent with good comprehension for 2 step
commands in Russian, repitition intact (albeit he wispers the
words), + severe dysarthria for pa/ta/ka sounds.
Further mental status testing not obtained at this time, but
does not appear to neglect one side or the other, blinks
bilaterally.
He motions well with his hands when trying to communicate.
.
Cranial Nerves:
I: deferred
II: Visual fields: right homonomous hemianopsia. Fundoscopic
exam: discs flat, fundi clear, no hemorrhages or exudates.
Pupils: 2->1 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. + left beating
horizontal nystagmus in primary gaze and worse when looking to
the left. No ptosis.
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: right lower facial droop
VIII: not tested
IX, X: DYSARTHRIC labial/lingual/gutteral sounds. trouble
coughing.
[**Doctor First Name 81**]: not tested
XII: originally was off to the left, but later midline
.
Sensory: Originally he had decreased sensation on the LEFT, but
later he said it was normal bilaterally to LT and pin. Very
poor vibration testing - intact at the knees and knucles
(barely) of the hands.
.
Motor:
Diffusely wasted bulk esp distally in hands, normal tone. No
fasciculations. + right pronator drift. No adventitious
movements. Right hemiparesis - he is barely able to lift right
arm to gravity, and cannot lift right leg to gravity.
.
Strength:
Delt Tri [**Hospital1 **] FE FF IP QD Ham DF PF
RT: 3 3 3 4+ 5 2 amputated
LEFT: 4 4 4 5 5 4 5 4- 4 5
.
Reflexes: absent, upgoing toe on the left, ampuation on the
right.
.
Coordination:
+ dysmetria on finger-to-nose on the left, too weak to tell on
the right. Unable to test legs.
.
Gait: not tested
Pertinent Results:
[**2193-5-3**] 04:14PM WBC-11.0 RBC-2.87* HGB-8.5* HCT-25.5* MCV-89
MCH-29.8 MCHC-33.4 RDW-17.6*
[**2193-5-3**] 04:14PM PLT COUNT-702*
[**2193-5-3**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2193-5-3**] 09:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2193-5-3**] 08:40AM GLUCOSE-196* UREA N-44* CREAT-0.6 SODIUM-136
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-19* ANION GAP-13
[**2193-5-3**] 08:40AM CK(CPK)-26*
[**2193-5-3**] 08:40AM CK(CPK)-26*
[**2193-5-3**] 08:40AM CK-MB-NotDone cTropnT-0.04*
[**2193-5-3**] 08:40AM CK-MB-NotDone
[**2193-5-3**] 08:40AM CALCIUM-7.2* PHOSPHATE-4.8* MAGNESIUM-2.2
[**2193-5-3**] 08:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-5-3**] 08:40AM WBC-14.7* RBC-3.59* HGB-10.6* HCT-32.1*
MCV-89 MCH-29.5 MCHC-33.1 RDW-17.6*
[**2193-5-3**] 08:40AM PLT COUNT-938*#
[**2193-5-3**] 08:40AM PT-11.5 PTT-22.7 INR(PT)-1.0
.
.
Radiologic Data
CTA brain ([**2193-5-3**]):
1. Thrombosis of the distal basilar artery.
2. No definite evidence of infarct.
MRI/MRA brain ([**2193-5-3**]):
1. Acute left PICA territorial infarct involving the inferior
aspect of the left cerebellar hemisphere. No other diffusion
abnormality identified.
2. Narrowing of the left PICA at its verterbral artery take-off
that may indicate underlying plaque versus, less likely,
dissection.
3. Distal right vertebral artery irregularity and narrowing
distal to the right PICA, likely relating to underlying
atherosclerotic disease. Relatively [**Name2 (NI) 15015**] right vertebral
artery throughout its course that may be secondary to an origin
stenosis.
CXR ([**2193-5-3**]):
Lungs remain quite low with most pronounced atelectasis at the
medial lung bases. Upper lungs clear. Heart size normal. No
pleural effusion.
MRA neck ([**2193-5-4**]):
The 2D time-of-flight MRA demonstrates normal flow signal in the
carotid and vertebral arteries. The gadolinium-enhanced MRA of
the neck demonstrates irregularity of the flow signal in the
proximal right vertebral artery on the projection images. There
is also diminished flow signal intensities seen in the right
vertebral artery compared to the left side. There is narrowing
of the distal right vertebral artery as seen on the previous CTA
of [**2193-5-3**].
Brief Hospital Course:
1. Posterior circulation stroke: As discussed in the HPI, the
pt was given intravenous tPA in the ED. Basilar artery embolism
was felt to be most likely secondary to right vertebral artery
atherosclerotic disease. Early in the course of the hospital
stay, dysarthria resolved. He continued to have congruous
incomplete homonymous hemianopia on the left and mild left-sided
weakness. Repeat MRI on hospital day three demonstrated small
lesions in the distribution of the PCA bilaterally. MRA of the
neck was also performed at that time and was negative for
dissection. As he was judged to be a high risk for bleeding
from intestinal ulcers (as discussed below), the decision was
made to place the pt on anti-platelet [**Doctor Last Name 360**] as opposed to
anticoagulation. Therefore he was placed on aggrenox. In
addition, he was placed on a statin and low-dose beta blocker.
At the time of discharge, neurologic examination was notable for
left congruous incomplete homonymous hemianopia, dysmetria
(left>right), left sided weakness in an UMN pattern. He should
undergo aggressive PT upon discharge.
2. Blood loss anemia/gastrointestinal bleeding: The pt's
hematocrit dropped to 25.5 after tPA (was initially 32.1). He
was transfused with PRBCs and went to 26, transfused again and
went to 30. He had many guaiac positive stools. He was placed on
double-dose PPI. The gastroenterology service was consulted and
an EGD was performed on hospital day three. This revealed
mosaic appearance, erythema and erosion in the whole stomach;
reticular, granularity and nodularity in the whole duodenum;
ulcer in the first part of the duodenum; otherwise normal EGD to
third part of the duodenum. As no clear evidence of source of
bleeding was identified, push enteroscopy was performed on
hospital day six and revealed friability, scalloping, atrophied
villi in the jejunum (biopsy); ulcers in the proximal jejunum
and mid jejunum (biopsy); nodularity and atrophy in the whole
duodenum; mass in the distal bulb (biopsy); edematous, boggy
mucosa and erosion in the antrum and stomach body. He was judged
to be at high risk for bleeding from the ulcers identified. His
hematocrit was cycled post-push enteroscopy and remained stable
in the 26-30 range. At discharge, his hematocrit was 26.4. This
was discussed with the gastroenterology service. They
recommended to continue to follow his hematocrit upon discharge
to rehab, and noted that further work-up will be deferred to an
outpatient basis.
3. UTI: The pt was found to have a urinary tract infection as
part of a fever work-up. He was treated with a seven day course
of bactrim DS (which was completed on the day prior to
discharge).
4. FEN: The pt was maintained on daily TPN in addition to clear
liquids (due to GI bleeding, as discussed above). Of note, he
suffers from hypoalbuminemia of unknown etiology. During his
stay in the ICU, he was aggressively given IVF. As a result, he
developed ascites and scrotal edema which began to gradually
improve at the time of discharge with gentle diuresis. His diet
should be slowly advanced as tolerated after discharge.
Medications on Admission:
mirtazapine 7.5 qhs
ondansetron prn
iron 325mg po daily
metoprolol 50mg po daily
vitamin B12 1000mcg IM q month
calcium carbonate
trypsin/balsam/[**Location (un) 15555**] to LE
entecavir 0.5mg PO daily
glycerin/bisacodyl/lactulose/senna/loperamide prn
tylenol prn
trazodone 25mg po prn
RISS
ECASA 325mg po daily
plavix 75mg po daily
SC heparin 5000 u daily
Discharge Medications:
1. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: 1000mcg
Intramuscular once a month.
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
8. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: [**12-10**] Tablet PO twice a
day.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
pain/distention.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-posterior circulation infarcts
-blood loss anemia due to gastrointestinal bleed
Discharge Condition:
Stable. Neurologic examination notable for for left congruous
incomplete homonymous hemianopia, dysmetria (left>right), mild
(4+/5) left sided weakness in an UMN pattern.
Discharge Instructions:
Please continue all medications as prescribed. Please attend all
follow-up appointments. If you experience increasing weakness,
visual or speech difficulties or other concerning symptoms,
please call your primary care doctor or return to the emergency
department for evaluation.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2193-7-4**] 9:45
Please follow-up with your PCP within the next 7-10 days.
Neurology: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2193-6-19**] 3:00
Gastroenterology: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2743**] office at
[**Telephone/Fax (1) 1983**] to arrange a follow-up appointment within the next
month.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
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4357, 5767
|
3853, 4341
|
1508, 2979
|
2995, 3129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,967
| 129,972
|
42869
|
Discharge summary
|
report
|
Admission Date: [**2139-1-6**] Discharge Date: [**2139-1-9**]
Date of Birth: [**2071-9-12**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
left heart catheterization
History of Present Illness:
Ms. [**Known lastname 3321**] is a 67 year-old female with a significant
history for COPD, HTN, as well as recent abnormal stress on
[**2138-12-25**] who presented in severe respiratory distress, on BiPAP
by EMS to [**Location (un) 620**] ED. BiPAP was continued in the emergency
department. Patient was given Solu-Medrol, nebs, magnesium.
Chest x-ray obtained immediately and was initially concerning
for pneumonia therefore patient was started on Levaquin and
vancomycin. However, after comaprison with previous CXR, opacity
was thought most likely [**1-8**] CHF. Therefore she was started on a
nitro drip. EKG showed sinus tach normal axis QTC 510, no STEMI.
Patient was transferred to [**Hospital1 18**] after patient improved and came
off BiPAP. This AM she underwent cardiac cath where she was
found to have 70-80% occlusion LCx at OM bifurcation, and
proximal 30-40% LCx lesion, with no other significant stenoses.
DES was placed to LCx. On cath she was also found to have
elevated left-sided pressures (LVEDP 30), therefore will require
diuresis. However as she received 150cc IV contrast during cath,
she is now receiving 500mL NS @50cc/hr as well as Lasix 20mg IV.
.
The patient describes intermittent dyspnea on exertion, i.e.
climbing up and down the stairs or when feeling anxious. She
recalls one isolated episode of chest discomfort that occurred
at rest several weeks ago, described as a burning substernally,
lasting several minutes before resolving spontaneously. Uses
mutiple pillows at baseline.
.
Recently in the beginning of [**Month (only) 404**], the patient was
hospitalized for flash pulmonary edema at BIDN. At that time,
she was ruled out for ACS and was provided with lasix and bipap,
which greatly helped her symptoms. At that time, BP's were noted
to be in the 160-220 range. BNP was 5314. As part of her
evaluation she underwent an echo which revealed normal LV
function. Stress testing was completed where she was only able
to exercise 2.5 minutes, stopping due to dyspnea and wheezing.
Imaging revealed possible anterior ischemia. She went home on
her usual atenolol dose of 150 mg qd and with the addition of
lisinopril 10 mg qd. In retrospect, she denies having had any
exertional chest pain and dyspnea in recent months. However,
during an admission to BIDHN in [**2138-10-7**] for a pneumonia,
she reports having a similar, but less intense episode of acute
dyspnea.
.
Her risk factors for CAD include hypertension, current cigarette
smoking (50+ pack-years total), and a family history of CAD
(maternal uncle with MI in his 60's). Her LDL on [**2138-12-15**] was 62.
Her other history is notable for COPD, a pulmonary nodule,
anxiety/depression, and EtOH excess.
.
On admission to the ED, HR was 86, BP 105/81, RR 20, 97% 2 L,
temp 99. Pt did not report and CP or SOB. Trop was 0.04 and BNP
was 4501. She had an unremarkable Chem 7 and CBC. Lactate was
elevated at 4.9. Given question of RLL infiltrate, respiratory
distress, and elevated lactate, she was transferred to the MICU
for question of pneumosepsis. In the MICU, patient remained
stable. She c/o dyspnea but was not hypoxic. Nitro gtt was
started. After cath this AM, she was transferred to the CCU for
monitoring.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, Tobacco abuse, EtoH abuse
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
COPD
Recently noted pulmonary nodule (to be followed by serial
imaging)
Anxiety
Depression
Remote sinus tachycardia, briefly treated with Inderal
Appendectomy as a child
.
Social History:
-Tobacco history: 50+ pack years. Currently smoking.
-ETOH:
-Illicit drugs:
Family History:
Maternal uncle had an MI in his early 60's, another maternal
uncle had a stroke in his 70's. Father died at cancer at age 44.
Two siblings died from non cardiac causes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: see above
GENERAL: NAD, AAOx3, supine in bed
HEENT: NCAT, PERRL, EOMI, MMM
NECK: No JVD, trachea midling
HEART: RRR S1 S2 no R/M/G
LUNGS: difficult to auscultate [**1-8**] pt position. No prominent
crackles on sides.
[**Last Name (un) **]: SNTND +BS no HSM/masses
EXTREM: WWP, no C/C/E, DP/PT 2+
NEURO: CN II-XII grossly intact
Discharge:
Vitals - Tm/Tc:98.3/97.8 HR:55-60 BP:160-198/96-105 RR:18 02
sat:96-98%
In/Out:
Last 24H: 1130/1650
Last 8H: 100/700
Weight: ( )
.
Tele: SR, no VEA
.
FS: none
.
GENERAL: 67 yo F in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+. Right groin site without
ecchymosis or tenderness.
NEURO: 5/5 strength in U/L extremities. Gait WNL.
SKIN: no rash
PSYCH: A/O, appears calm
Pertinent Results:
ADMISSION LABS
[**2139-1-6**] 02:00PM BLOOD WBC-9.7 RBC-4.66 Hgb-14.9 Hct-45.3 MCV-97
MCH-32.0 MCHC-32.9 RDW-12.5 Plt Ct-219
[**2139-1-6**] 02:00PM BLOOD Neuts-95.2* Lymphs-2.8* Monos-1.4*
Eos-0.4 Baso-0.2
[**2139-1-6**] 02:00PM BLOOD Plt Ct-219
[**2139-1-7**] 02:17AM BLOOD PT-11.6 PTT-30.8 INR(PT)-1.1
[**2139-1-6**] 02:00PM BLOOD Glucose-155* UreaN-16 Creat-0.9 Na-135
K-3.8 Cl-101 HCO3-20* AnGap-18
[**2139-1-6**] 02:00PM BLOOD proBNP-4501*
[**2139-1-6**] 02:00PM BLOOD cTropnT-0.04*
[**2139-1-6**] 07:30PM BLOOD cTropnT-0.02*
[**2139-1-7**] 02:17AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
[**2139-1-6**] 04:32PM BLOOD Type-ART pO2-72* pCO2-38 pH-7.30*
calTCO2-19* Base XS--6 Comment-GREEN TOP
[**2139-1-6**] 04:56PM BLOOD Lactate-4.9*
[**2139-1-6**] 05:35PM BLOOD Lactate-4.7*
[**2139-1-6**] 07:52PM BLOOD Lactate-3.7*
.
2D-ECHOCARDIOGRAM: [**2138-12-30**] - Normal LV function. Aortic
sclerosis, mild concentric LVH, LA enlargement
.
ETT: [**2138-12-25**] - 2.5 minutes [**Doctor First Name **] protocol, 61% max PHR, stopping
due
to shortness of breath and wheezing. Nonspecific EKG changes
noted. Imaging: LVEF 78% with normal wall motion. Possible focal
mid anterior ischemia noted at low level exercise. Evidence of
increased LV filling pressure noted during exercise.
.
CARDIAC CATH ([**2139-1-7**]): 70-80% LCx occlusion at OM bifurcation.
30-40% proximal LCx occlusion. No other significant stenoses.
DES placed to LCx. Elevated left-sided pressures (LVEDP 30).
.
ECHO ([**2139-1-8**]): The left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels 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. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
67 yo F with h/o HTN, COPD, nicotine/EtOH abuse admitted with
acute dyspnea found to have pulmonary edema, now clinically
stable s/p cardiac cath with DES placed to LCx.
.
# CORONARY ARTERY DISEASE: Patient has h/o angina, HTN, and
smoking. On admission she had no EKG changes or significantly
elevated cardiac enzymes. She is now s/p cardiac cath which
showed 70-80% LCx occlusion at OM bifurcation, and 30-40%
proximal LCx occlusion. DES was placed to LCx. Patient also
found to have elevated left-sided pressures (LVEDP 30) during
cath. Patient was treated with ASA 325mg PO daily, lisinopril
30mg PO daily, atorvastatin 20mg PO daily, clopidogrel 75mg PO
daily, and metoprolol tartrate. She was initially on NTG gtt on
admission to CCU which was tapered. Patient did complain of mild
chest/neck discomfort on evening of [**1-7**], with EKG showing
diffuse TWI but negative cardiac enzymes x2. Most likely
noncardiac chest pain. She remained clinically stable and was
called out to the floor on [**1-8**]. She was discharged the next day
on [**2139-1-9**] after BP control was achieved.
.
# DYSPNEA: multifactorial etiology. Patient has pulmonary edema
and elevated BNP, with cardiac cath showing LVEDP 30. Pulmonary
edema may have occurred in the setting of hypertension and
myocardiac ischemia causing diastolic dysfunction. She does not
have any wall motion abnormalities on echo so myocardial
infarction less likely etiology. In addition, patient has
underlying COPD which may be contributing. Because she received
IV contrast in the cath lab, patient given slow IV fluids in
CCU, and was also given Lasix 20mg IV to start diuresis. She
diuresed >2L to this, and was then started on Lasix 10mg PO
daily. Pt also treated with lisinopril and metoprolol.
.
# COPD - does have poor air entry but no significant wheezes on
exam, so no need for systemic therapy. Treated with albuterol
and tiotropium nebs.
.
# Metabolic Acidosis - On admission pt had gap acidosis with pH
7.3 with lactate of 4. Acidosis has now resolved, with pH 7.42
and lactate 1.2. Possible that in the setting of flash pulmonary
edema, she had tachycardia with underlying diastolic dysfunction
and consequent low cardiac output state, resulting in lactic
acidosis; this seems to have resolved.
.
# HTN - treated with lisinopril + metoprolol. Also on NTG gtt
while in CCU. Upon transfer to the floor, BP was still elevated
to SBPs in the 170s and amlodipine was added.
.
# Depression - continued home fluoxetine and ativan PRN
.
# Alcohol abuse - did not score on CIWA.
Medications on Admission:
ASA 81 mg qd
atenolol 150 mg qd
fluoxetine 40 mg qd
lisinopril 20 mg qd
lorazepam 0.5 mg prn
tolterodine 4 mg qd
varenicline 1 mg [**Hospital1 **].
symbicort
tiotropium inh daily
Discharge Medications:
1. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
2. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**12-8**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. aspirin 81 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable
PO once a day.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. tolterodine 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
10. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation [**Hospital1 **] (2 times a day).
13. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day): Please check with Dr. [**Last Name (STitle) **] if
you should be taking this medicine with the Symbicort.
14. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
spray Nasal once a day.
15. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive heart failure
Coronary artery disease
Hypertension
Chronic obstructive pulmonary disease
Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had trouble breathing and was transferred to [**Hospital1 18**] for a
cardiac catheterization. The catheterization found one severe
blockage in your left circumflex artery and a drug eluting stent
was placed to keep the artery open. There was another less
severe blockage that was not treated but your new medicines will
help to keep it open. It is extremely important that you take a
full dose aspirin and Clopidogrel (Plavix) every day for at
least one year. Do not stop taking aspirin and plavix or miss
any doses unless Dr. [**First Name (STitle) **] says that it is OK to do so. The
shortness of breath that you experienced in the last month seems
to be because of a stiff heart that is called diastolic
congestive heart failure. This is caused by your high blood
pressure and can be prevented with the medicines you are taking.
It is very important to watch for signs of fluid retention in
your hands, feet and trouble breathing with exercise. You will
also need to weigh yourself every morning, call Dr. [**First Name (STitle) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. INCREASE the Lisinopril to 40 mg daily to lower your blood
pressure
2. START taking Amlodipine to lower your blood pressure
3. STOP taking Atenolol, take Metoprolol instead to lower your
heart rate
4. START taking clopidogrel (plavix) every day to prevent the
stent from clotting off and causing a heart attack. Continue to
take 4 baby aspirin every day with the clopidogrel for the same
reason.
5. START taking nitroglycerin as needed if you have chest pain
at home or if you become short of breath suddenly. Take one
tablet under your tongue, wait 5 minutes, then take another
tablet. Call Dr. [**First Name (STitle) **] if the nitroglycerin helps the chest pain
or trouble breathing, call 911 if you feel it is worsening.
6. START taking Atorvastatin to lower your cholesterol and
prevent the blockages in your arteries from getting worse.
7. START taking Furosemide daily to prevent fluid retention.
Followup Instructions:
Name: [**Last Name (LF) 8505**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] B
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
*It is recommended that you see your PCP within one week. Please
call Dr. [**Last Name (STitle) 92576**] office to schedule an appointment.
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Doctor Last Name 19408**] MD
Location: [**Hospital **] MEDICAL ASSOCIATES/CARDIOLOGY
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9311**]
Phone: [**Telephone/Fax (1) 8506**]
When: Monday, [**1-19**], 2:45 PM
|
[
"401.9",
"414.01",
"305.00",
"496",
"514",
"428.33",
"276.2",
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"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"37.23",
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"36.07",
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icd9pcs
|
[
[
[]
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] |
12142, 12148
|
7671, 10214
|
292, 320
|
12333, 12333
|
5257, 7648
|
14574, 15299
|
4060, 4231
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,548
| 190,941
|
7458
|
Discharge summary
|
report
|
Admission Date: [**2122-1-4**] Discharge Date: [**2122-1-13**]
Date of Birth: [**2043-5-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
NSTEMI, Pneumonia, Resp. Failure
Major Surgical or Invasive Procedure:
Intubated x 3 days
History of Present Illness:
Pt is a 78 year old widowed white male with hx of autoimmune
recurrent pleural effusions (bilat.) for which he takes daily
prednisone who presented to an OSH c/o several days of DOE with
productive cough. At OSH he was found to have CXR c/w CHF and
troponin leak with possible worsening of chronic ST depression
laterally, he was transferred here, where he was intubated and
treatment was begun for pneumonia.
Past Medical History:
Bladder and Prostate CA S/P XRT
Pagets Disease
Recurrent pleural effusions (said to be autoimmune- tx with
pred)
DM2
HTN
Dementia
Atrial fibrillation
CVA
Social History:
Father of 5, retired, widowed.
No tobacco- ex cigar smoker, quit [**2104**]
No alcohol
Family History:
N/C
Physical Exam:
Temp 99 BP 160/73 P 90-100 RR 30 97% on 50% FIO2
UOP 400cc 1st 6 hours
Gen- Mod. Resp distress, A+Ox3
Neck- No JVD
HEENT- PERRL, EOMI
CV- Irreg. Irreg. SEM ([**1-11**]) at apex
Lung- Decr. BS on R, + egophany at R base, rales at left base
Abd- Soft, NT, ND, BSNA
Ext- No C/C/E
Pertinent Results:
[**2122-1-4**] 12:50AM CK(CPK)-291*
[**2122-1-4**] 12:50AM DIGOXIN-0.7*
[**2122-1-4**] 10:09AM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-SM
[**2122-1-4**] 04:55PM CK-MB-4 cTropnT-0.96*
[**2122-1-4**] 04:55PM WBC-8.9 RBC-3.44* HGB-10.9* HCT-30.3* MCV-88
MCH-31.8 MCHC-36.1* RDW-15.4
[**2122-1-4**] 12:31PM TYPE-ART PO2-93 PCO2-32* PH-7.50* TOTAL
CO2-26 BASE XS-1
[**2122-1-4**] 12:31PM TYPE-ART PO2-93 PCO2-32* PH-7.50* TOTAL
CO2-26 BASE XS-1
.
CT CHEST:
CT CHEST W/IV CONTRAST: There are moderate bilateral pleural
effusions, right greater than left. There are no pericardial
effusions. There are coronary artery calcifications. The airways
are patent to the level of the segmental bronchi bilaterally.
There is a 1.8 x 3.0 cm cystic structure in the left lobe of the
thyroid. There is a small focus of low attenuation in the right
lobe of the thyroid gland. An ultrasound study is recommended
for further characterization of these findings.
There are small prevascular, and precarinal lymph nodes, as well
as axillary lymph nodes, none of which meet criteria for
pathologic enlargement. There is a small left hilar lymph node,
measuring up to 1.3 cm in diameter. There is a smaller right
sided hilar node as well.
There are small calcified pulmonary nodules likely representing
calcified granulomas measuring up to 5 mm in the right middle
lobe, and 2-3 mm in the lingula. There is a small peripherally
based non-calcified nodule in the right upper lobe measuring up
to 5 mm in diameter. Comparison with prior studies if available
would be useful. Otherwise, a followup study in three months is
recommended to document stability.
There are calcifications seen in the descending thoracic aorta.
The osseous structures show no suspicious lytic or blastic
lesions.
IMPRESSION
1. Bilateral pleural effusions.
2. Small nodule in the right upper lobe, for which either
follow/up studies to document stability, or else, a follow/up
study in three months is recommended.
3. Small left hilar lymph node measuring 1.3 cm in diameter.
4. Cystic bilateral thyroid lesions for which an ultrasound is
recommended for further evaluation.
.
ECHO:
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Left ventricular function.
BP (mm Hg): 125/55
HR (bpm): 59
Status: Inpatient
Date/Time: [**2122-1-5**] at 11:31
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W044-1:37
Test Location: West CCU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 900**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *3.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 36 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
Aortic Valve - Pressure Half Time: 420 ms
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave Deceleration Time: 157 msec
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
The rhythm appears to be junctional (no A wave on transmitral
Doppler).
This study was compared to the report of the prior study (tape
not available)
of [**2119-11-17**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
global LV
hypokinesis. [Intrinsic LV systolic function depressed given the
severity of
valvular regurgitation.]
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo;
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Based on [**2113**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a moderate risk (prophylaxis
recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and
echocardiographic data.
Conclusions:
The left and the right atrium are moderately dilated. There is
mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild global
left ventricular hypokinesis with more severe hypokinesis of the
basal
inferior wall. [Intrinsic left ventricular systolic function may
be more
depressed given the severity of valvular regurgitation.] The
ascending aorta
is mildly dilated. The aortic valve leaflets are moderately
thickened. There
is mild aortic valve stenosis with mild (1+) aortic
regurgitation. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no
pericardial effusion.
IMPRESSION: Mild global and regional left ventricular systolic
dysfunction.
Moderate mitral regurgitation. Mild aortic valve stenosis.
Compared with the prior study of [**11-6**], left ventricular
systolic function is
now depressed. the severity of aortic stenosis and mitral
regurgitation are
slightly worse. Mild pulmonary artery systolic hypertension is
now present.
Based on [**2113**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Brief Hospital Course:
The patient presented with SOB and cough on [**1-4**] determined to
be congestive heart failure and pneumonia with subsequent
respiratory failure requiring intubation and elevated troponin
(0.57 which trended to 0.9 before falling) found to be a NSTEMI
by EKG. CXR revealed CHF bilat. with RLL atelectasis. His
pneumonia was treated with a 5 day course of Azithromycin and a
10 day course of third generation cephalosporin which would be
complete [**2122-1-15**].
In the MICU, Tmax spiked to 102 but resp. status improved.
Creat. spiked to 1.9. Hematocrit dropped as well but rebounded
without requiring transfusion and labs were consistent with
anemia of chronic disease and possibly iron defiency - this
would require a repeat work up once stabilized. Oxygenation and
renal function improved with agressive diuresis in the MICU.
Initial SBT with the goal of extubation failed on [**1-6**] but on [**1-7**]
the pt. self extubated and tolerated 5L NC well. He remained
afebrile since then, breathing well with O2 support.
Cardiology followed pt throughout the hospital stay. Pt had an
echo which showed decreased EF to 40% from baseline >55% in
7/[**2120**]. As pt stabilized and had no chest pain cardiology team
decided to have CAD pursued by an outpatient exercise stress
test with imaging this was discussed with RN at PCP'c office and
with pt's daughter. Pt was started on Aspirin 325 mg po qd,
Toprol, Lisinopril, and high dose statin per NSTEMI protocol.
As patient had previously had a left lower lobe pneumonia per
old records, a CT of the chest was obtained to evaluated for
obstruction. No obstructing mass was found but there was a
small nodule which would require repeat CT scan in 3 months for
follow-up. In regards to the pleural effusion, per PCP fluid
had been analyzed on multiple occassions and cytology always
normal. Lasix and Prednisone were continued. No vaccinations
were given as pt was up to date on influenza and pneumococcal
vaccine.
Pt was discharged to rehab, having been afebrile, clinically
stable, and on all po medications.
Medications on Admission:
Digoxin 0.125 PO x1 Daily
Nefidipine 90mg PO x1 Daily
Allopurinol 300mg PO x1 Daily
Protonix 40mg PO x1 Daily
Lasix 40mg IV x2 Daily
ASA 325mg PO x1 Daily
Prednisone 6mg PO x1 Daily
Heparin GTT
Metoprolol 12.5mg PO x2 Daily
Trazodone PRN
Reminyl
Fosamax
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Myocardial Infarction
Congestive Heart Failure
Pneumonia
Atrial Fibrillation
Discharge Condition:
stable
Discharge Instructions:
Return to your primary care physician or emergency department if
you develop difficulty breathing or chest pain.
Followup Instructions:
Follow up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27327**] - your daughter has made an
appointment for you for later this week.
.
You will need to get another CT scan of the chest in three
months to make certain that the small nodule seen has not grown.
Completed by:[**2122-1-13**]
|
[
"V58.61",
"427.31",
"250.00",
"428.0",
"599.0",
"293.0",
"274.9",
"V58.65",
"410.71",
"518.81",
"414.8",
"280.9",
"486",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9943, 10020
|
7564, 9639
|
304, 324
|
10141, 10149
|
1382, 3592
|
10310, 10659
|
1064, 1069
|
10041, 10120
|
9665, 9920
|
10173, 10287
|
3618, 7541
|
1084, 1363
|
232, 266
|
352, 764
|
786, 943
|
959, 1048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,054
| 125,658
|
46868
|
Discharge summary
|
report
|
Admission Date: [**2190-6-29**] Discharge Date: [**2190-7-8**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
[**2190-6-29**] ultrasound guided pigtail right posterior collection
History of Present Illness:
89 year old female with extensive
medical history who presented with right flank pain since last
night. The patient reports being in her usual state of health
until yesterday around 8pm. The pain was of incidious onset,
localized to right flank and chest wall, no inciting event. It
is
now [**4-18**], non-radiating, improved with positioning, worse with
deep inspiration and cough, unrelated to food intake. The
patient
reports a cough productive of clear sputum, rhinnorhea, and sore
throat since last night. Currently with mild SOB secondary to
pain. Denies fevers, chills, nausea, hematuria, back pain,
abdominal pain. + constipation, lightheadedness.
Past Medical History:
patient unable to give history, per last discharge summary.
Frequent Falls
CAD - s/p MI [**00**] years ago
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation, no longer on antiarrhythmic or
anticoagulation
Chronic venous stasis with b/l lower extremity edema
Constipation
Hernia repair
s/p appy
Degenerative disc disease followed by ortho
Social History:
Lives in [**Location **] with husband. Previous husband died 10 [**Name2 (NI) 1686**]
ago. Has two children, both of whom live in [**State 531**], and three
grandchildren. She used to smoke a PPD for 40 [**State 1686**] stopped
roughly 20 [**State 1686**] ago after her MI. Limited alcohol use (one glass
wine/week). No other drugs.
Family History:
NC
Pertinent Results:
[**2190-7-6**] 05:26AM BLOOD WBC-20.9* RBC-2.88* Hgb-8.4* Hct-26.9*
MCV-93 MCH-29.1 MCHC-31.2 RDW-14.9 Plt Ct-758*
[**2190-7-5**] 02:04AM BLOOD WBC-19.4* RBC-2.87* Hgb-8.3* Hct-26.7*
MCV-93 MCH-29.0 MCHC-31.2 RDW-14.5 Plt Ct-712*
[**2190-6-30**] 01:13AM BLOOD WBC-35.8* RBC-3.40* Hgb-10.3* Hct-30.8*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.7 Plt Ct-634*
[**2190-6-29**] 06:21PM BLOOD WBC-48.3* RBC-3.94* Hgb-12.1 Hct-36.0
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.7 Plt Ct-821*
[**2190-6-29**] 03:46AM BLOOD WBC-36.4*# RBC-4.57 Hgb-13.7 Hct-42.8
MCV-94 MCH-29.9 MCHC-32.0 RDW-13.7 Plt Ct-790*#
[**2190-7-4**] 02:05AM BLOOD Neuts-81* Bands-1 Lymphs-8* Monos-5 Eos-3
Baso-0 Atyps-1* Metas-1* Myelos-0
[**2190-7-4**] 02:05AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2190-7-5**] 02:04AM BLOOD PT-14.0* PTT-50.2* INR(PT)-1.2*
[**2190-7-7**] 04:58AM BLOOD Glucose-78 UreaN-15 Creat-0.5 Na-140
K-4.1 Cl-106 HCO3-29 AnGap-9
[**2190-7-5**] 02:04AM BLOOD Glucose-94 UreaN-17 Creat-0.5 Na-141
K-3.8 Cl-109* HCO3-27 AnGap-9
[**2190-6-29**] 03:46AM BLOOD Glucose-98 UreaN-16 Creat-0.6 Na-140
K-3.7 Cl-105 HCO3-22 AnGap-17
[**2190-6-29**] 03:46AM BLOOD ALT-7 AST-16 CK(CPK)-18* AlkPhos-129*
TotBili-0.5
[**2190-7-7**] 04:58AM BLOOD Albumin-1.8* Calcium-7.9* Phos-2.7 Mg-2.1
[**2190-7-4**] 02:05AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0
[**2190-6-30**] 07:39AM BLOOD Albumin-2.0* Calcium-8.2* Phos-2.9 Mg-2.3
[**2190-7-5**] Chest x/ray: IMPRESSION: Stable appearances of the right
bibasilar small pleural effusions. No new consolidation. The
right-sided pigtail catheter has been withdrawn and the tip is
unfolded. No pneumothorax.
[**2190-7-1**] CT of head:IMPRESSION: No acute intracranial process,
Mild small vessel ischemic disease, Age-appropriate atrophy
[**2190-6-30**] CT of the Chest: IMPRESSION:
Decrease in size of dominant loculated component of right
pleural fluid
collection following placement of pigtail pleural catheter, and
development of small collection of air within the pleural space
consistent with the recent procedure. Otherwise little change in
the appearance of the chest since the recent study of one day
earlier except for development of small dependent left effusion.
Abdominal findings unchanged since study of one day earlier
including marked distention of the gallbladder measuring nearly
10 cm in diameter but incompletely imaged. Cholecystis cannot be
excluded although no secondary signs are identified by CT.
[**2190-6-29**] 06:21PM BLOOD Calcium-7.5* Phos-2.7 Mg-1.5*
[**2190-7-5**] 11:30AM BLOOD Osmolal-298
[**2190-6-29**] 06:21PM BLOOD TSH-3.3
[**2190-6-30**] 07:53AM BLOOD Type-ART pO2-90 pCO2-30* pH-7.43
calTCO2-21 Base XS--2
[**2190-6-30**] 06:13AM BLOOD Type-ART Temp-36.7 pO2-96 pCO2-27*
pH-7.40 calTCO2-17* Base XS--5 Intubat-NOT INTUBA
[**2190-6-30**] 03:46AM BLOOD Type-ART pO2-103 pCO2-30* pH-7.39
calTCO2-19* Base XS--5
[**2190-6-30**] 03:46AM BLOOD Glucose-80 Lactate-0.7
[**2190-6-29**] 04:57AM BLOOD Lactate-4.0*
Brief Hospital Course:
89 year old woman with extensive medical history who presented
with right flank pain, with CT showing right sided loculated
pleural effusion, likely empyema. The patient reports being in
good health without fever and with no cough until last
night, but now patient febrile to 101 with WBCs 36.4, lactate
2.1, and chest CT suggestive of an empyema. On [**2190-6-29**] admitted
to the ICU Pigtail placed right pl effussion, afib, right
subclavian central line in place. Meds Lasix amiodarone and
lopressore for Afib. ID consulted vanco and zosyn started.
Geriatrics consult for agitation-haldol given with good effect.
On [**2190-7-1**] TPA administer to her pigtail drain to help break up
loculated fluid. After respiratory treatment patient developed
left dilated pupil -Neuro consult obtained and head CT obtained
and negative. Self resolving believe related to neb treatment to
that eye.
[**2190-7-4**] Pleural fluid growing strep-vancomycin D/c'd.
Amiodarone D/c'd Patient now in NSR. [**2190-7-5**] transfered to F9
pigtail drain converted from pleural vac to bag drainage. [**7-6**]
PICC line placed for rehab w/ zosyn, Nutrition consult for alb
of 1.8 continue with ensure 3 cans per day. Pigtail secured.
D/c to rehab; Follow up appointment on [**2190-7-22**] NPO 3 hours
prior to her appointment.
Medications on Admission:
Lipitor 10 mg Tab
Calan 40 mg Tab
Lasix 20 mg Tab
Rythmol 150 mg Tab
Coumadin 1 mg Tab
Folic Acid 400 mcg Tab
Prevacid 15 mg Cap
Discharge Medications:
1. Gabapentin 100 mg Capsule [**Date Range **]: Two (2) Capsule PO Q8H (every
8 hours).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Quetiapine 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO ONCE (Once) as
needed for agitation, insomnia.
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
7. Venlafaxine 37.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
14. Insulin sliding scale
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-80 mg/dL [**12-11**] amp D50
81-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
> 320 mg/dL Notify M.D.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (2) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
16. Piperacillin-Tazobactam 2.25 g IV Q6H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
EMPYEMA
Discharge Condition:
Good
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] with any questins or concerns [**Telephone/Fax (1) 2348**].
Call with fevers greater than 101.5
call with increased cough secretions or shortness of breath.
Call if problems with her chest drain.
Flush drain with 10 cc of normal saline Q 8 hours
Antibiotics continue until follow up appointment with Dr. [**First Name (STitle) **]
Followup Instructions:
Follow up appointment is on [**2190-7-22**] [**Hospital Ward Name **] [**Hospital Ward Name **] building
on the [**Location (un) **] radiology for a CAT scan at 8:30 am. Then to
follow you need to report to the [**Location (un) **] of the same building
for your appointment with Dr. [**First Name (STitle) **] at 11:30 am. You need to be
NPO 3 hours prior to your CAT scan.
Completed by:[**2190-7-7**]
|
[
"459.81",
"458.9",
"428.0",
"412",
"414.01",
"428.22",
"510.9",
"427.31",
"486",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8194, 8266
|
4818, 6131
|
285, 356
|
8318, 8325
|
1800, 4795
|
8748, 9154
|
1777, 1781
|
6310, 8171
|
8287, 8297
|
6157, 6287
|
8349, 8725
|
228, 247
|
384, 1042
|
1064, 1410
|
1426, 1761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,674
| 178,865
|
21163
|
Discharge summary
|
report
|
Admission Date: [**2144-3-9**] Discharge Date: [**2144-3-16**]
Date of Birth: [**2076-9-2**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Heparin Agents / Levofloxacin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**3-11**] Placement of IVC filter.
History of Present Illness:
67 yo with recent history of diverticular abscess (s/p IR
drainage [**2-21**]) and HIT developed during that admission who
presented to an OSH ED with dyspnea.
On day of admission, in the OSH ED was found to have bilateral
segmental PEs and was noted to have a BP of 80/50. She was
transferred to the [**Hospital1 18**] ED and had the following vitals 99% 4L
NC, SBP 100-140. Due to her HIT allergy, she was started on
lepiridun and transferred to the [**Hospital Unit Name 153**] for initiation of
lepirudin and close monitoring. On arrival in [**Hospital Unit Name 153**], patient
comfortable with unremarkable vital signs.
Brief history of illness: Patient presented to PCP after
experiencing several days of increasing severe abdominal pain,
diagnosed with diverticulitis and diverticular abscess by CT at
[**Hospital1 **] [**Location (un) 620**]. CT guided drainage of abscess at [**Hospital1 18**] [**Location (un) 86**] [**2-21**],
transferred back to [**Location (un) 620**] for remainder of IV abx therapy
(Levo/Flagyl).
On discharge from hospital [**2-29**], patient was transitioned to po
antibiotic regimen including levo+flagyl. On [**3-1**], patient
developed an impressive morbilliform rash on her trunk, visited
primary surgeon the next day who removed flagyl antibiotic,
suspecting this was cause of drug rash, given prednisone course
+ benadryl. Since this time, maintained on levofloxacin
monotherapy.
Patient's rash improved slightly in interim [**3-1**] - present, but
did not completely disappear off Flagyl. On admission to the ER
today, patient had sudden increase of area and hue of rash,
becoming increasingly bright erythema with mild pruritis.
Patient notes that this was after receiving IV levofloxacin in
the ER.
Past Medical History:
1. gout
2. gerd
3. htn
4. s/p hip replacement
Allergies: Flagyl (rash as above), ?levofloxacin. Hx of HIT
Social History:
Lives in [**Location 620**] alone with cat, named "Pockets". She is a
retired retail banker. Nonsmoker, denies alcohol use. No
recent travel nor exposures.
Family History:
Family history significant for mother who died in 80's of MI.
Father with adult-onset diabetes.
Physical Exam:
T 96.3 P 111 BP 133/76 RR 16 O2 sat 99% on 4L NC Wt 168 lbs
Gen: Alert, pleasant, well.
HEENT: Anicteric, MMM, OP clear.
Neck: Supple, no LAD.
Heart: RRR, nl S1, S2, no extra sounds.
Lungs: CTA bilaterally.
Abd: Soft, NT, ND, drain in place in LLQ.
Ext: Trace pedal edema, 2+ distal pulses.
Skin: Blanching, morbilloform rash on central chest, back,
spreading to bilateral upper arms, upper legs.
Pertinent Results:
[**2144-3-13**] ECHO: 1. The left atrium is mildly dilated. 2. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. 3. Right ventricular chamber size and free wall motion
are normal. 4. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. 5. There is borderline
pulmonary artery systolic hypertension. 6. There is a
trivial/physiologic pericardial effusion. 7. Compared with the
findings of the prior study (images reviewed) of [**2144-3-10**], RV
function may have improved, although it is difficult to compare
to the previous suboptimal study.
.
[**2144-3-12**] IVC filter placement: 1. Successful placement of a
Gunther Tulip retrievable inferior vena cava filter in the
infrarenal position. This filter may be retrieved, if indicated,
within 2 weeks of placement. 2. The venogram demonstrated a
single patent inferior vena cava with no evidence of intracaval
thrombosis. Flow voids from the renal veins indicated patency of
the renal veins bilaterally. 3. This filter should be removed
within the next 2 weeks. If removing filter within this
timeframe is not feasible, consider repositioning of the filter
for a later removal.
.
[**2144-3-10**] Bilateral lower extremity ultrasound: Deep venous
thrombosis involving the left common femoral and popliteal
veins.
.
[**2144-3-10**] ECHO:
Suboptimal image quality. The left atrium is elongated. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function
appears normal (LVEF>55%). Right ventricular systolic function
appears depressed. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
.
[**2144-3-9**]: AP UPRIGHT CHEST PLAIN FILM: The heart size is normal.
The aortic contour appears ectatic. Remaining mediastinal
contours are unremarkable. The lungs are clear. There are no
pleural effusions.
IMPRESSION: No acute cardiopulmonary processes.
.
[**2144-3-9**] 06:11PM BLOOD WBC-8.6 RBC-4.35 Hgb-13.9 Hct-37.4 MCV-86
MCH-31.9 MCHC-37.1* RDW-15.1 Plt Ct-196
[**2144-3-9**] 06:11PM BLOOD PT-17.9* PTT-50.8* INR(PT)-1.7*
[**2144-3-9**] 06:11PM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-139
K-3.4 Cl-99 HCO3-26 AnGap-17
[**2144-3-10**] 02:21AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6
Brief Hospital Course:
67 yo with recent history of diverticular abscess (s/p
drainage), HIT who presents with pulmonary embolism. Given
history of heparin induced thrombocytopenia, started on
lepirudin - now on argatroban. Antimicrobial therapy is
complicated by appearance of drug rash.
.
1. PE: Left leg DVT seen on U/S seems like the most likely
source - likely from venous stasis due to recent immobility
following her diverticular abscess and drainage placement. TTE
showed some depressed RV function but was of poor technical
quality. Has been hemodynamically stable after getting IVF [**3-11**].
Will encourage po intake, supplement with IVF if needed.
Lepirudin switched to argatroban [**3-11**] (after placement of filter
- did not want to reinitiate lepirudin due to risk of
anaphylaxis), started coumadin evening of [**3-10**] - overlapped with
argatroban and coumadin per protocol in front of chart.
Currently therapeutic on coumadin. Filter to stay in place for
at least two weeks - will need to be repositioned if needed for
longer.
.
2. Diverticular abscess: Patient needs broad GI gram neg.
coverage. Came in on levofloxacin monotherapy, but given recent
increase in drug rash today (off flagyl), started on zosyn
([**3-9**]). Continue zosyn likely until abdominal surgery.
.
3. Rash: Unclear source although suspect drug induced - likely
flagyl but also potentially levo. Drug rash stable. Treated with
prednisone 60 x 3 days, atarax for pruritus.
.
4. HTN: Continued diovan, lasix with holding parameters.
.
5. GERD: Continue PPI.
.
6. H/o gout: Continue allopurinol.
.
7. F/E/N: Low residue diet.
.
8. PPX: PPI, argatroban/coumadin (no heparin), bowel regimen,
RISS with prednisone.
.
9. Code: Full.
Medications on Admission:
Diovan 80 mg po qd
Lasix 20 mg po qd
Allopurinol 200 mg po qd
Prevacid 20 mg po qd
Levofloxacin 500 mg po qd
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. 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.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritus.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours).
11. sodium chloride flush for peripheral IV.
Discharge Disposition:
Home With Service
Facility:
Avory Manor
Discharge Diagnosis:
1. diverticular abscess, s/p drainage.
2. bilateral pulmonary emboli.
Discharge Condition:
Good, stable.
Discharge Instructions:
Please continue to take all medications exactly as prescribed.
If you experience any chest pain, shortness of breath, or any
other concerning symptoms, call your PCP or return to the
hospital.
Followup Instructions:
Please call to schedule an appointment with Dr. [**First Name (STitle) 2819**] from
surgery - the phone number is ([**Telephone/Fax (1) 6347**]. You will need to
have an appointment in 2 weeks.
.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]
Completed by:[**2144-3-16**]
|
[
"401.9",
"415.19",
"E934.2",
"287.4",
"530.81",
"453.41",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8312, 8354
|
5543, 7249
|
304, 341
|
8468, 8484
|
2984, 5520
|
8725, 9063
|
2452, 2549
|
7409, 8289
|
8375, 8447
|
7275, 7386
|
8508, 8702
|
2564, 2965
|
257, 266
|
369, 2127
|
2149, 2259
|
2275, 2436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,134
| 112,290
|
13553
|
Discharge summary
|
report
|
Admission Date: [**2141-8-7**] Discharge Date: [**2141-8-21**]
Date of Birth: [**2094-3-19**] Sex: F
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
obesity/desire for surgical treatment
Major Surgical or Invasive Procedure:
laparascopic gastric band
emergent trachostomy
Open reduction, internal fixation of laryngeal fracture with
plate
History of Present Illness:
The patient is a 47 year old who complains of
morbid obesity. She has been on multiple supervised diets
with an 80 pound weight loss and regain. She is currently at
325 pounds with a BMI of 50 and was deemed a good candidate
by the [**Hospital1 **] Bariatric Program for surgical
weight loss. The patient was admitted for a laparascopic
gastric band procedure
Past Medical History:
laparascopic cholecystectomy
eye surgery
anxiety
obesity
hypertension
osteoarthritis
Physical Exam:
General: no apparent distress
Head and neck: neck supple, no lymphadenopathy. pupils equal
round and reactive to light
Card: regular rate and rhythm
Lungs: clear to auscultation
abdomen: obese, soft, nontender, nondistended
extremities: no clubbing cyanosis or edema
On discharge the patients abdominal exam was benign, with a
soft, nontender abdomen, and well healing laparascopic port
incision sites.
She also had a tracheostomy incision that was healing well.
Pertinent Results:
[**2141-8-9**] Upper GI with small bowel follow through:
FINDINGS: Preliminary scout film demonstrates a gastric band
around the proximal stomach, in expected location and alignment.
Clips are noted within the gallbladder fossa consistent with
prior cholecystectomy. There is no evidence of free air under
the diaphragms.
Water soluble contrast followed by thin barium was administered
to the patient in the standing position. Contrast flowed freely
from the esophagus into the gastric pouch, through the band and
into the distal stomach. There is no evidence of obstruction or
leakage. Contrast emptied from the distal stomach into the small
bowel after approximately 15 minutes.
IMPRESSION: No evidence of obstruction or leakage s/p gastric
banding.
Brief Hospital Course:
The patient had been in the operating room undergoing a surgical
procedure and had a successful laparascopic gastric band
procedure. At the end
of the surgical procedure the patient was extubated, had loss
of airway and underwent emergency tracheotomy. After the
airway was secured, the throat was examined. It was noted
that the tracheotomy was performed at a higher level than
normal, and this was moved down to the second and third
tracheal ring. ENT was called for evaluation of injury to the
larynx. Upon arrival the laryngeal injury appeared to be a
vertical incision on the left side of the thyroid cartilage,
which extended the length of the thyroid cartilage, through
the thyroid cartilage into the larynx. A laryngoscope was
passed. There was noted to be mucosal tear around the false
cord extending to the retinoid region. The subglottic region
was normal. The vocal cords appeared to be both intact
without injury. Externally the injury site was examined.
There was noted to be a second opening into the trachea
between the cricoid thyroid membranes, which appeared to be a
clean horizontal incision.
The patient had an ORIF of the tracheal injury.
Postoperatively, the patient was vented and admitted to the
intensive care unit. the patient was weaned off of the vent on
postoperative day 2 without difficulty and the patient tolerated
CPAP well. on postoperative day 3, the patient had a trach mask
trial and she was successfully weaned from the vent by
postoperative day 4. ENT continued to evaluate the patient and
requested that the patient have antibiotics including ancef and
flagyl. an NG tube remained in place. Nutrition services was
consulted for TPN initiation. She was transferred to the
surgical floor by postoperative day 4.
On post operative day 8, the patient returned to the operating
room for direct laryngoscopy and a downsizing of her trach. She
also recieved 3 doses of IV decadron and transitioned to PO
prednisone. The patient was then given a cap trial on
Postoperative day [**9-9**], which she tolerated well. At this time
the patient was also evaluated by speech and swallow and had an
upper GI (which was negative) and she was started on a stage I
diet. The trach was removed by postoperative day [**10-11**], and the
patient was breathing comfortably. She was advanced to a stage
III diet which she was tolerating well. The patient was stable
and ready for discharge to home on postoperative days 13/5, with
ENT/speech and swallow and general surgery follow up. The
patient will remain on voice rest until follow up with ENT.
Medications on Admission:
xanax prn
Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day): crush pill before administering.
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Colace 150 mg/15 mL Liquid Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*2*
4. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day.
Disp:*600 ml* Refills:*2*
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: crush pill before administering.
Disp:*3 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: crush pill before administering.
Disp:*3 Tablet(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Ten (10) ml PO Q8H (every 8 hours) for 6
doses.
Disp:*60 ml* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Obesity
status post laparascopic gastric band
Laryngeal injury
respiratory distress requiring emergent tracheostomy
status post open reduction internal fixation of larynx
Discharge Condition:
Good
Discharge Instructions:
You should continue voice rest until you follow up with Dr.
[**Last Name (STitle) **] in ENT.
Stay on Stage III until follow up. Do not self advance diet
Do not drink out of a straw. Do not chew gum
You may shower (no bathing or swimming) if no drainage from
wound
If clear drainage, cover wound with clean dressing, stop
showering
No heavy (10 pounds or heavier) for 6 weeks
If severe pain, persistent nausea, vomiting, fevers >101.5,
redness of wound, call surgeon
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2349**] in [**12-9**]
weeks.
You should have a vidoe stroboscopy before your visit and call
[**Telephone/Fax (1) 2349**] to schedule this.
You will also follow up with Speech and swallow. You should be
on voice rest until you follow up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] they will
send you to speech and swallow after they evaluate you in [**12-9**]
weeks.
You should follow up in [**Hospital 1560**] clinic [**Telephone/Fax (1) **] at 2 weeks
(Do not call surgeons office)
|
[
"518.5",
"519.09",
"278.01",
"807.5",
"E878.8",
"300.00",
"998.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.64",
"44.39",
"38.93",
"31.1",
"97.23",
"38.91",
"06.02",
"33.23",
"96.04",
"96.72",
"31.42",
"97.37",
"31.62",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5815, 5821
|
2265, 4858
|
370, 485
|
6036, 6042
|
1486, 2242
|
6559, 7143
|
4918, 5792
|
5842, 6015
|
4884, 4895
|
6066, 6536
|
1000, 1467
|
293, 332
|
513, 877
|
899, 985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,281
| 123,827
|
298
|
Discharge summary
|
report
|
Admission Date: [**2125-12-10**] Discharge Date: [**2125-12-25**]
Date of Birth: [**2052-4-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone/Acetaminophen / Morphine Sulfate
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation
PICC line placement
History of Present Illness:
Ms. [**Known lastname 2816**] is a 73 yo female with PMH significant for ILD on
[**1-27**].5L home O2, diastolic CHF, cor pulmonale, s/p liver
[**Date Range **] on immunosuppression, post-[**Date Range **]
myeloproliferative disorder s/p CHOP and rituximab who was
initially admitted to hospital after a mechanical fall for pain
control who is now being transferred to the MICU for
hypercarbic/hypoxic respiratory failure in the setting of
emesis. Patient was initially admitted to the medicine service
on [**12-10**] for a mechanical fall. She stated that prior to her
fall she was in her USOH without any change in her baseline
respiratory status or other new symptoms. She stepped on her
scale and then lost her balance and landed on her low back. She
was then brought to [**Hospital1 18**] ED. There was no head trauma or LOC by
report. Here, spine films revealed no acute fracture. She was
being treated with PT and pain control. She was not receiving
any opiates due to underlying lung disease. She did received
tylenol, ibuprofen, and lidoderm patch.
.
Yesterday evening, the patient triggered after an episode of
nausea and vomiting as well as a drop in her O2 saturation.
Changed to face mask with improvement in O2. She remained
hemodynamically stable. No CXR or ABG was performed. Changed to
40% ventimask and satting in mid-90s. At 10:30 this am, looks
ashen, cyanotic, and lethargic on 4 L of 50% venti. O2 in high
70s at that time. Sleepy but arousable. Increased O2 to 15L on
50% ventimask. Given nebs. On exam, tight air movement and
cracklie but not significantly different from baseline. Initial
gas 7.29/97/113 on 15L 50% ventimask. Last ABG in system
7.43/47/73 in 3/[**2124**]. Mental status improved with increase in
oxygenation. She was given solumedrol 100 mg IV Q8H. Reevaluated
in 1 hr, still lethargic but arousable. Repeat ABG 7.28/108/79
on 15L 50% ventimask. CXR performed on floor, showed some
diffuse fluffiness. She received 40 mg IV lasix. She continues
to have intermittent nausea and vomiting with 2-3 episodes of
emesis since yesterday evening.
.
n the MICU, she was intubated on [**12-12**] for worsening
hypercarbia. That evening she spiked a fever, went into AF vs
MAT with HRs into the 160s, and hypotension to the 80s. She did
not tolerate beta blockers at that time and was started on an
amiodarone gtt. She was also started on empiric vancomycin and
zosyn for possible aspiration pna. She received aggressive
volume resuscitation and converted to NSR the following morning.
Her amiodarone was discontinued given concern for worsening lung
and liver disease. Her beta blocker was uptitrated. Antibiotics
were briefly discontinued on [**12-14**] and restarted on [**12-15**]. She
was eventually diuresed and was able to be extubated on [**12-16**].
She was called out to the medical floor on [**12-17**].
.
While on the medical floor, she was continued on vancomycin and
zosyn for presumed aspiration pna. She had no microbiology data
to help guide therapy. She was continued on diuretics but has
run I/O even per documentation. While on floor, SBPOs 100s, HRs
80s, RR 20s, O2 90s on 3LNC.
.
On the evening of transfer, trigger called for increased work of
breathing. Upon floor evaluation, patient denied any subjective
SOB. O2 requirement the same at 90s n 3LNC and no significant
change in RR. However, at ~ MN, patient went into irregular SVT
(AF vs MAT) to 150s, T100.3, with SBPs into 90s, RR increased to
30s, and O2 sats low 90s on 4-6L. She received lopressor 5 mg IV
x 2 without significant change in her HR and decrease in SBP to
80s. CXR repeated without significant change compared to this
am. ABG showed 7.35/73/54.
Past Medical History:
# Interstitial pulmonary fibrosis
- home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)
- recently titrated off prednisone as unresponsive
# cor pulmonale
# S/p Liver [**Month/Year (2) **] [**4-26**] for cryptogenic cirrhosis
# Post-[**Month/Year (2) **] lymphoproliferative disorder s/p CHOP and
rituximab
# Type 2 DM (without peripheral neuropathy)
# HTN
# Hypothyroidism
# Diastolic dysfunction with LVEF of 65%
# Cholecystectomy.
# Appendectomy.
# h/o of atrial fibrillation
Social History:
Married, previously lived at home but recently discharged to
rehab. Denies tobacco use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Afib in sister
Physical Exam:
moon facies
buffalo hump
difficult to assess JVP
poor air movement. Diffuse crackles worst at B bases
midline hernia, reducible
NABS. Obese. S/NT
Warm. 1+ LE edema. Difficult to palpate DP pulses
myoclonic jerks in B UEs
Lethargic. Oriented x 2 to self and knows shes in the hospital
but does not know date or how long she has been in hospital. CNs
grossly intact. Motor exam limited by MS but moving all
extremities.
Pertinent Results:
[**2125-12-10**] 10:55AM PLT COUNT-258
[**2125-12-10**] 10:55AM NEUTS-80.1* LYMPHS-15.1* MONOS-3.2 EOS-1.2
BASOS-0.4
[**2125-12-10**] 10:55AM WBC-7.7 RBC-4.48 HGB-13.1 HCT-37.9 MCV-85
MCH-29.3 MCHC-34.6 RDW-15.1
[**2125-12-10**] 10:55AM CK-MB-NotDone
[**2125-12-10**] 10:55AM cTropnT-<0.01
[**2125-12-10**] 10:55AM CK(CPK)-22*
[**2125-12-10**] 10:55AM estGFR-Using this
[**2125-12-10**] 10:55AM GLUCOSE-154* UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-88* TOTAL CO2-45* ANION GAP-12
Brief Hospital Course:
73 yo female with PMH significant for ILD on home O2, diastolic
CHF, cor pulmonale, s/p liver [**Month/Day/Year **] on immunosuppression,
post-[**Month/Day/Year **] myeloproliferative disorder s/p CHOP and
rituximab who was initially admitted to hospital after a
mechanical fall for pain control who was transferred to the MICU
for hypercarbic/hypoxic respiratory failure in the setting of
emesis
# Respiratory failure: In the setting of witnessed emesis prior
to decompensation, pt treated for aspiration/hospital acquired
pneumonia. Weaned from vent and extubated on 4L NC. Called out
to floor. Developed acute respiratry distress and transferred
back to MICU. Completed course of abx for HAP/aspiration PNA,
but restarted based on evolving CXR. Eventually in setting of
renal failure pt developed worsening resp status and was placed
on CPAP. When pt became obtunded discussion with HCp - pt's
daughter it was decided to not intubate and pt passed away from
respiratory failure
.
# Tachycardic arrhythmia: Pt had sinus tachycardia to SVT on
[**12-13**] ? of A-fib vs. MAT. Had resolved when pt was transferred
back to floor from MICU. On transfer back to the MICU pt's
cardiac issues were managed with toprol.
.
# S/P Fall/Pain control: no evidence of fracture. C/o back pain
initially but pain issues were resolved on second transfer back
to ICU. Pt followed after extubation.
.
# DM: Good FSBG control while hospitalized.
.
# ILD: Pulmonary followed as inpt. Treated pt's PNA.
Alb/atrovent nebs PRN.
.
# PTLD: No known active issues during hospitalization. LFTs
were normal. Tacrolimus levels were followed.
.
# HTN: On toprol as inpt.
.
# Hypothyroidism: Continued on levothyroxine
.
# Access: PICC line was placed during hospitalization for abx
therapy.
.
# FEN: After aspiration episode, eval'd by speech and swallow.
Made NPO when transferred back to ICU b/c of respiratory
distress and concern for aspiration.
.
# Prophylaxis: Heparin SC 5000 tid, PPI, and Bactrim
.
# Code status: DNR/DNI - intially pt's status was DNR and okay
to intubate, but after discussion with pt's family decision was
made to make pt DNR/DNI.
# Pt passed away from respiratory distress after she was
dependent on non invasive ventilation, then became obtunded and
would have required intubation. After several family meetings
with her primary Pulmonologist Dr.[**Last Name (STitle) **], she was made CMO and
expired within an hour with family at bedside
Medications on Admission:
Medications on transfer:
Levothyroxine Sodium 75mcg PO
Acetaminophen 325-650 mg PO Q6H:PRN
Lidocaine 5% Patch 1 PTCH TD DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Metoprolol Tartrate 75 mg PO TID
Calcium Carbonate 1250 mg PO TID
MethylPREDNISolone Sodium Succ 100 mg IV Q8H
Docusate Sodium 100 mg PO DAILY
Omeprazole 20 mg PO DAILY
Furosemide 40 mg PO DAILY
Heparin 5000 UNIT SC TID
Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR
Insulin sliding scale
Tacrolimus 3 mg PO Q12H
Dose to be admin. at 6am and 6pm Order date: [**12-10**] @ 1603
Ipratropium Bromide MDI 2 PUFF IH QID
TraMADOL (Ultram) 50 mg PO Q4H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H
Vitamin D 50,000 UNIT PO QTUES
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
s/p Fall
Secondary:
Interstitial pulmonary fibrosis, s/p liver [**Month/Year (2) **] c/b PTLD,
Diabetes Mellitus type 2, HTN, hypothyroidism, diastolic CHF (EF
65%)
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"584.5",
"250.00",
"518.81",
"724.2",
"117.9",
"401.9",
"515",
"428.32",
"V42.7",
"428.0",
"507.0",
"E885.9",
"285.29",
"427.89",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8996, 9005
|
5817, 8266
|
347, 392
|
9224, 9234
|
5283, 5794
|
9286, 9292
|
4732, 4829
|
9026, 9203
|
8292, 8292
|
9258, 9263
|
4844, 5264
|
276, 309
|
420, 4095
|
8317, 8973
|
4117, 4609
|
4625, 4716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,538
| 188,568
|
45194
|
Discharge summary
|
report
|
Admission Date: [**2168-12-8**] Discharge Date: [**2168-12-23**]
Date of Birth: [**2097-12-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
new lung mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71F with a history of hypertension, anxiety, abnormal LFTs,
macular degeneration, GERD,fibroid uterus, urinary incontinence,
hyperlipidemia, and pancreatitis who is admitted today following
a newly diagnosed RLL lung mass. She was recently discharged
form the [**Hospital1 18**] ED on [**2168-11-10**] after presenting with 1 day of
blood-streaked sputum, mild dyspnea and wheezing in the setting
of 6 months of a non-productive cough. At that time, she denied
chest pain or syncope. A CXR at that time showed a RML
pneumonia with a new ill-defined opacity noted overlying on of
the mid-thoracic vertebral bodies. She was sent home with ten
days of levofloxacin 500mg po daily for the pneumonia. In
follow-up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], she noted no further
hemoptysis and an improvement in her mild dyspnea and wheezing.
A repeat CXR on [**11-30**] showed a persistent infiltrate/atelectasis
in the RML; it also showed a mass-like enlarged right hilum and
a new 8-mm nodular density projecting over the left lung apex.
Her PCP started her empirically on 10 days of
amoxicillin/clavulanate at this time and scheduled a chest CT.
.
The CT on [**12-7**] showed bulky mediastinal adenopathy with
collapse of the right middle bronchus, occlusion of the right
superior pulmonary vein, encasement/constriction of the right
main pulmonary artery and inferior pulmonary veins,
displacement/deformation of the left atrium, and
narrowing/invasion of the superior vena cava. It noted a 3.5 x
3cm mass in the right lower lobe, presumed to be the primary
tumor. A 7mm apical nodule was deemed consistent with a
granuloma. No pleural or pericardial effusions were seen. Both
adrenals were noted to be enlarged. The liver was noted to
likely be cirrhotic along with intraabdominal ascites. Of note,
a CXR on [**2167-9-15**] was normal.
.
Her PCP sent her to the ED for expedited workup and management.
In the ED, her vitals were T 96.9, HR 90, BP 150/90, RR 16, Sat
99% on room air. Her exam was notable for wheezes in the right
lung field. She received 40 mEq of PO KCl due to a level of 2.3
and was put on telemetry.
.
ROS: Reports one week of excessive fatigue. Reports normal
appetite and [**3-19**] lbs weight gain over past several weeks.
Reports mild increase in abdominal girth. Denies changes in
urinary or bowel habits. Denies any recent fevers, cough,
dyspnea, or wheezing over the psat 3 weeks. Reports chronic,
worsening vision loss. Denies headaches. She denies any recent
chest pain, pedal edema, exertional or rest dyspnea.
Past Medical History:
hypertension
GERD
uterine fibroids
hyperlipidemia
anxiety disorder
macular degeneration
urinary incontinence
pancreatitis in [**9-/2167**]
colonoscopy on [**2168-11-30**] showed several adenomatous polyps
normal EGD on [**2168-11-30**]
Social History:
Ms. [**Known lastname 83347**] grew up in [**Location (un) **]. She is married, has a
husband and two grown children. She has been smoking 3-4packs of
cigarettes for 53 years. She rarely drinks alcohol and has no
history of drug use.
Family History:
Ms. [**Known lastname 96582**] father died of coronary artery disease at age 69,
her mother has diabetes mellitus and hypertension. Her sister
also has hypertension.
Physical Exam:
T 96.8 BP 156/100 HR 96 RR 20 Sat 96% on 2L
Gen: mildly Cushingoid, pleasant, no acute distress
HEENT: clear OP, no icterus, EOMI, PERRL
Neck: no carotid bruits, no wheezing/stridor, no thyromegaly
Chest: faint expiratory wheezing in right middle lung field
Breasts: patient declined examination
CV: regular rate/rhythm, normal S1S2, no murmurs, no S3 or S4
heard
Abd: protuberant, soft, nontender, moderately distended,
tympanic, ?dullness to percussion in R flank
Back: no CVA tenderness
Extr: no edema, 2+ PT pulses
Neuro: A&O x3, CN 2-12 intact, [**6-17**] grip strength bilaterally,
[**6-17**] arm and shoulder flexion/extension bilaterally, [**6-17**]
hip/knee/ankle flexion/extension
Skin: ?mild hyperpigmentation, no rashes/lesions
Pertinent Results:
CT Chest ([**12-7**]): The hilar component of a 6 x 5cm, mass
involving the right hilus and middle mediastinum, obstructs the
right middle lobe bronchus, producing collapse of the RML,
significantly narrows the upper lobe bronchus and protrudes into
the bronchus intermedius, narrowing it as well. Proximally,
endobronchial tumor extends to 1 cm from the carina. The mass
occludes the right superior pulmonary vein and encases and
constricts the right main pulmonary artery and inferior
pulmonary veins. It displaces and deforms the left atrium,
obliterating adjacent fat planes; no pericardial effusion is
present. Mediastinal tumor in the right paratracheal station
from the right upper lobe bronchus to the level of the aortic
arch, up to 4.5cm in diameter, severely narrows and invades the
superior vena cava. Subcarinal adenopathy measures 3 x 4 cm. A
3.5 x 3 cm mass in the superior segment of the right lower lobe
is most likely the primary lung cancer. A 7mm left apical nodule
is most likely a granuloma. Mild emphysema is predominantly
apical. The pleural surfaces are smooth and there is no pleural
effusion. Both adrenals are enlarged, the left 6.0 x 2.6 cm,
the right 4.7 x 2.0 cm. Ascites is present and the lobulated
liver margins, irregularity and heterogeneity of the liver
suggest cirrhosis. Hypodense renal lesions are likely cortical
cysts. There are no bone lesions suspicious for malignancy.
.
CT head ([**12-8**]): No acute intracranial hemorrhage or mass
effect.
.
ECG ([**12-8**]): sinus rhythm at 101 bpm, normal axis, normal
intervals, ST depression in II, V2-V5, no Q waves, no ST
elevations
Brief Hospital Course:
Pt's chest CT was concerning for malignancy. Pt was seen by
Interventional Pulm who placed a stent in her RML bronchus
~[**12-8**] and obtained a biopsy which revealed small cell
carcrinoma. She was started on pip/taz and vanco for
post-obstructuve PNA. She continued to have hypokalemia and
hyperglycemia causing concern for an ACTH secreting
paraneoplastic syndrome. She was the transfered to the oncology
service on [**2168-12-10**] for initiation of chemotherapy. She
received 3 doses of carboplatin and etoposide on [**11-9**],
and [**12-14**].
.
Pt was transfused 2 Units of PRBC's on [**12-13**] with an increase in
her HCT from 23 to 25 (HCT 40 on admission). She was therefore
given an additional 2 Units [**12-14**]. On [**12-15**] at 6AM she was noted
to have diarrhea with blood. HCT was again 23. She was
transfused 1 Unit of PRBC's with an appropriate increase to 27.
She remained stable until the evening of [**12-15**] when she dropped
to 23. She received 2 Units and bumped to 30. Her HCT
decreased from 30 to 20 over the next 24 hrs. She is now being
transfused 2 Units. Of note on [**11-30**] she underwent an EGD
notable for mild gastritis and a C-scope notable for several
adenomatous polyps. She had a RBC scan which was unremarkable
on [**12-15**]. NG lavage clear but was without bile.
.
[**Hospital Unit Name 13533**]:
# GIB:
Pt was transferred to the [**Hospital Unit Name 153**] on [**12-17**] for repeat EGD in the
setting of GIB. At the time she denied CP/SOB/N/hematemesis/abd
pain/fever/chills. +appetite. Repeat EGD was unremarkable for
source of acute bleeding. As such, lower GI source was
suspected, given recent polypectomy on [**11-30**]. However, pt's
diarrhea contained only modest melena/red streaks. As such, GI
deferred colonoscopy on [**12-18**]. Pt is also s/p recent negative
tagged rbc scan on [**12-14**]. Hemolysis labs were obtained on [**12-18**]
which was unremarkable. Pt's WBC was <0.5 raising concern for
neutropenia, thus GI deferred colonoscopy again on [**12-19**]. Given
pt was otherwise hemodynamically stable, decision was made to
start neupogen on [**12-20**] and await WBC>=1.0 before proceeding with
colonoscopy. Pt was called out to floor on [**12-21**] as her hct had
been stable for ~24-36hrs, to await colonoscopy.
.
Pt continued to require multiple transfusions to maintain HCT >
25, suggesting ongoing bleeding, thus she remained in the ICU
and received an additional unit of PRBC on [**12-18**] and [**12-19**], in
addition to 1 bag platelets. Her atenolol was held in the
setting of GIB. CT abdomen on [**12-19**] was negative for RP bleed.
Given ongoing bleeding, and decsision to defer colonscopy, pt
underwent nuclear scan on [**2169-12-22**] which showed ?focus of
abnormal activity on RLQ. pt was then discussed with IR, with
plan for angiography +/- embolization if possible, however
tagged rbc scan was negative. pt was also evaluated by surgical
service with regard to operative management of lower GIB, with
decision to defer surgical intervention given lack of definitive
source of bleeding. On [**12-23**] decision was made to pursue
colonoscopy given ongoing active bloody stools without obvious
source of bleeding, which showed apparent several cm long region
of infiltrating tumor ~60cm from anus, c/w infiltrative folds,
with a single very large ulcer was seen in the colon at the area
of infiltrated-appearing folds at 60cm from the anus, suggestive
of either metastatic disease vs primary colon cancer.
.
.
given the above findings, family meeting was held with oncology
service, and goals of care were changed to comfort only. pt was
extubated, later that evening, and expired shortly thereafter at
4:55PM on [**2168-12-23**].
.
.
# Metastatic ACTH-secreting small cell lung CA:
Pt has mets to liver and adrenals. MRI Head negative for mets.
She is s/p [**4-15**] doses of chemo on [**12-14**]. Chemo was likley
contributing to pancytopenia. Vanco/Zosyn were started on
admission empirically for post-obstructive pneumonia, however
these were d/c'd on [**12-18**] as pt was without fever, wbc, or sputum
production. On [**12-21**] pt was noted to have fever to 100.4. Given
her neutropenia, cultures were obtained, and pt started on
cefipime/vanco (day 1 [**12-21**]). her most recent chemo was dose 3/3
of [**Doctor Last Name **]/Etoposide ([**Date range (1) **]). Rad/onc initially had plans
XRT post chemo, which were to be deferred until resolution of
GIB.
.
.
# Thrombocytopenia - was felt likely secondary to chemo and
dilution from 10+ units of PRBC's. Per GI plan was to transfuse
platelets to keep plt > 50 as this could be contributing to
ongoing active bleeding.
.
.
# Hypokalemia/Hypernatremia - most likely secondary to
ACTH-secreting SCLC (cortisol 167). Spirinolactone was
continued as pt's SBPs remained stable throughout her GIB
episode. Her potassium was aggresively repleted. Her Na
remained within normal limits once pt was encouraged to maintain
PO hydration. Pt continued to have [**Hospital1 **] lytes and active
repletion of K. She was also continued on spironalactone
(started [**12-9**]), at 50mg qdaily.
.
.
# Hyperglycemia - likely related to ACTH secretion from lung
cancer, pt was continued on RISS. In addition, she was started
on glypizide on [**12-21**] given her likelihood of continuing to have
elevated FSBS [**3-17**] ACTH secretion.
.
.
# Hypertension: BP well controlled despite holding atenolol for
active GIB. We have tolerated SBPs 150s-160s in the setting of
gi bleeding.
.
.
# ARF (baseline 1.2-1.3) thought to be prerenal azotemia; Creat
subsequently trended down to 1.0. Elevated BUN may be secondary
to hypovolemia from GI bleed. Good UOP after foley placement
(pt was incontinent x 3 [**12-17**]), and creatinine remained at
baseline throughout [**Hospital Unit Name 153**] course.
.
.
# Ascites/?cirrhosis: LFTs mildly elevated likely related to
metastatic diasese to liver, and per daughter ascites on [**12-18**]
was better than baseline obese habitus. no dullness to
percussion on exam throughout [**Hospital Unit Name 153**] course, and LFTs
unremarkable. pt was continued on spirinolactone for
hyperaldosterone state as above.
.
.
# Anxiety. Pt had episode of delirium thought to be secondary
to high dose ativan. She remained anxious on [**12-17**], but A&Ox3.
As such, low dose ativan 0.5 mg IV prn was used. On [**12-21**] AM pt
was notable agitated/irritated. She "wants to get out of the
ICU!". Did not feel this represent delirium as pt was A&Ox3 and
able to focus appropriately. Did not feel ativan was
contributing given she has been receiving this throughout
hospital course in low-dose form. No intervention was felt
necessary, and pt was subsequently intubated and sedated for
colonoscopy.
.
.
# COPD: pt continued on Albuterol/Atrovent nebs. Will hold
tiotropium while hospitalized
.
# FEN: On [**12-18**] pt advanced to clears with jello after negative
EGD. As she was awaiting colonoscopy, plan is to advance diet
to regulars until WBC > 0.5-1.0 before re-prepping. however on
[**12-22**] pt was prepped for colonoscopy and remained NPO until she
expired.
.
.
# PPX: No heparin given compromise of great vessels by tumor;
pneumoboots, IV PPI [**Hospital1 **].
.
# dispo - pt expired on [**12-23**] after goals of care changed to CMO
during family meeting.
Medications on Admission:
atenolol 50mg daily
augmentin (since [**12-1**])
celexa 20mg daily
ferrous sulfate 325mg daily
ativan 2mg qhs
nexium 40mg qhs
Discharge Medications:
none.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
colon cancer
Discharge Condition:
expired
Discharge Instructions:
none.
Followup Instructions:
none.
|
[
"284.8",
"578.9",
"285.1",
"198.89",
"496",
"197.6",
"253.6",
"401.9",
"276.8",
"300.00",
"162.8",
"197.7",
"255.0",
"362.50",
"569.82",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"38.93",
"96.04",
"96.05",
"88.47",
"96.71",
"45.13",
"99.04",
"99.25",
"99.05",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
13664, 13683
|
6076, 13458
|
330, 336
|
13739, 13748
|
4429, 6053
|
13802, 13810
|
3483, 3650
|
13634, 13641
|
13704, 13718
|
13484, 13611
|
13772, 13779
|
3665, 4410
|
277, 292
|
364, 2955
|
2977, 3215
|
3231, 3467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,473
| 111,519
|
21312
|
Discharge summary
|
report
|
Admission Date: [**2126-7-25**] Discharge Date: [**2126-8-13**]
Date of Birth: [**2057-3-8**] Sex: M
Service: LIVER TRANSPLANT SURGERY SERVICE
BRIEF CLINICAL HISTORY: The patient is a 60 year old white
man who is status post orthotopic liver transplant on [**2126-2-22**] by Dr. [**First Name (STitle) **] for hepatitis C virus and
hepatocellular carcinoma, presenting as a transfer from [**Hospital3 15516**] Hospital after 36 hour history of upper GI bleed and
melanotic stool. At [**Hospital3 **] Hospital, patient's platelet
counts were reported to be 3 with hematocrit of less than 20.
By report by the patient, he began to vomit bright red blood
approximately 36 hours prior to his presentation to [**Hospital3 **]
Hospital and 2 days prior to his presentation to the [**Hospital1 18**].
This bright red blood vomiting was quickly followed by severe
nausea and diarrhea. The patient does have a history of
grade III esophageal varices, but otherwise there is no
history of GI bleed.
The patient has been on multiple immunosuppressants since his
transplant. He was initially started on cyclosporin and
mycophenolate mofetil. At some point, the cyclosporin had
been discontinued and he was started on rapamycin. He was
continued on rapamycin for many months. However,
approximately 1 week prior to admission, he was changed to
Prograf. He has also been taking Bactrim one single-strength
pill daily since [**2126-2-26**].
Patient had been noted to have episodic thrombocytopenia
since as early as [**2125-6-26**]. Platelet level has fluctuated
between 80 and 130. Over the last 2 to 3 months, the patient
has had several hospital admissions for malaises and nausea
and vomiting. He has undergone extensive work up with
multiple cultures to test for viral and bacterial etiologies.
All of these have been negative. Most recent discharge was
[**Hospital1 18**] on [**7-20**].
Upon arrival to [**Hospital1 18**] he was transported immediately to the
surgical intensive care unit where he was found to have an
extremely low platelet count of less than 5, hematocrit of
20.5. He has required at least 6 units of blood since his
arrival and 4 units of platelets immediately upon his
arrival.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis.
2. Hepatitis C.
3. Hepatocellular carcinoma.
4. Aforementioned orthotopic liver transplant.
5. Portal hypertension.
6. Splenomegaly.
7. Esophageal varices.
8. Distant history of tuberculosis, 18 years ago.
9. Coronary artery disease status post CABG.
MEDICATIONS AT HOME:
1. Bactrim single-strength.
2. Protonix 40 mg p.o. q. day.
3. Caltrate 600 mg p.o. b.i.d.
4. Aspirin 81 mg p.o. q. day.
5. Isordil 15 mg p.o. q day.
6. Propranolol 10 mg p.o. b.i.d.
7. Pyridoxine 100 mg p.o. q. day.
8. Isoniazid 300 mg p.o. q. bedtime.
9. CellCept [**Pager number **] mg 2 b.i.d.
10. Prograf 6 mg p.o. b.i.d.
ALLERGIES: Penicillin.
LABORATORY DATA ON PRESENTATION: Laboratories on
presentation include a white count of 8.6, hematocrit of
20.5, platelets 5. Chem-7 is sodium 143, potassium 3.9,
chloride 112, CO2 23, BUN 53, creatinine 1.0, glucose 128.
AST was noted to be 26, ALT 24, alk phos 65. Total bilirubin
is 1.1.
PERTINENT EXAMINATION: On presentation, patient's vital
signs are temperature 99.9, pulse 91, blood pressure 133/47,
respiratory rate of 23, saturation 100%. In general, the
patient is alert and oriented x3. He is not in distress, but
he does appear sickly. Pupils are equal and reactive to
light bilaterally. There is no evidence of any scleral
icterus. Cranial nerves II through XII are noted to be
grossly intact. Pulmonary examination shows the lungs to be
clear to auscultation bilaterally. Cardiac examination shows
heart regular rate and rhythm with no evidence of any
murmurs, rubs, or gallops. Abdomen is soft, nontender, with
no evidence of any distention. There is a well healed
midline incision. No evidence of any distention or tympany.
Extremities are warm, well perfused.
CLINICAL COURSE: Shortly after arrival in the intensive care
unit, the patient had an internal jugular catheter to provide
central venous access placed without complication. Shortly
thereafter, consultations were requested from the
hematology/oncology service, gastroenterology service,
transplant service. Once a nasogastric tube could be placed,
it was seen that the patient continued to have bright red
blood upon lavage. On the night of admission, Dr. [**Known firstname **]
[**Last Name (NamePattern1) 131**] performed an upper GI endoscopy. This revealed a small
to medium size actively bleeding source on the lesser
curvature of the stomach. This was cauterized with
apparently excellent resolution of the bleeding. At that
time, possible etiologies for the patient's thrombocytopenia
included hemolytic urea mix syndrome, ITP, and a possibility
of graft versus host disease following liver transplant.
Care in the intensive care unit focused on re-establishing
physiologically safe levels of platelets and bringing
hematocrit back up. To that end, all immunosuppressants were
stopped on arrival. Per hematology/oncology recommendations,
patient was started on first course of IVIG. Likewise,
heparin induced thrombocyte antibodies were sent and
subsequently were returned negative. Despite several course
of IVIG, there was reportedly very little resolution or
improvement in the platelet count despite multiple
transfusion of platelets and other blood products. Platelets
very rarely extended above 20.
On hospital day 6, patient was continuing to be stable and
decision was made to move him out of intensive care unit.
Immunosuppression was restarted with Solu-Medrol 60 mg p.o.
q. day. The following day, this was supplemented with
cyclosporin 125 mg p.o. b.i.d. Although, patient's clinical
appearance continued to improve, his thrombocytopenia
persisted, staying refractory to multiple platelet
transfusions and additional courses of IVIG. On hospital day
7, the patient underwent bone marrow biopsy for assess for
graft versus host disease. At the time of this dictation,
those results were not available. On hospital day 12,
hematology/oncology was once again reconsulted and it was
felt the patient's thrombocytopenia might very well be due to
sequestration. This turned conversation to considering
splenectomy versus rituximab or splenic sequestration. After
much consideration, discussing between the various teams,
decision was made to undergo splenectomy. On [**2126-8-9**]
or hospital day 16, the patient underwent laparoscopic
splenectomy by Dr. [**First Name (STitle) **]. The procedure went well. The
patient was extubated in the operating room. He was
transported to the post-anesthesia care unit and ultimately
onto the floor that night. Total blood loss during the
procedure was minimal and the patient only required 2 units
of packed red blood cells. For the subsequent days, the
patient's clinical picture continued to improve. He
recovered from the surgery extremely well with a gradual rise
in his platelet counts.
On hospital day 20, after final evaluation by Dr. [**Last Name (STitle) **] and
the hematology/oncology service, it was deemed the patient
was an appropriate candidate for discharge. His platelets
had remained stable and his immuno regimen likewise had been
stable. The patient did have a drainage catheter still in
place. This remained in the bed of the splenectomy. In the
days prior to discharge, this had put out 300, 200, and 65 ml
a day respectively.
DISCHARGE DIAGNOSIS:
1. Idiopathic thrombocytopenic purpura.
2. Status post splenectomy, [**2126-8-9**].
3. Status post liver transplant, [**2126-2-21**].
4. Status post upper gastrointestinal bleed.
5. Status post coronary artery disease.
6. Status post hypertension.
MEDICATIONS ON DISCHARGE:
1. Pantoprazole 40 mg p.o. q. day.
2. Percocet 5/325, dispense 30, 1 to 2 tablets to be taken
every 4 to 6 hours p.o.
3. Prednisone 10 mg p.o. q. day.
4. CellCept [**Pager number **] mg p.o. b.i.d.
5. Cyclosporin 200 mg p.o. q. 12.
6. Isosorbide dinitrate 10 mg p.o. q. day.
7. Caltrate 1 tablet p.o. b.i.d.
FOLLOW UP: Patient will follow up with Dr. [**Last Name (STitle) **] in 1 to 2
weeks. He has a drainage catheter in placed. He has been
trained and VNA has been arranged for him to be able to drain
and measure this daily. He will record these outputs and
report them to Dr. [**Last Name (STitle) **] on his return.
DISPOSITION: The patient is discharged to home to the care
of his family with VNA service in place.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2126-8-13**] 17:01:42
T: [**2126-8-13**] 18:10:34
Job#: [**Job Number 56346**]
|
[
"287.3",
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"414.00",
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"V45.81",
"729.82",
"V10.07",
"289.51",
"V12.01",
"535.40",
"V11.3",
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icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"99.14",
"41.31",
"41.5",
"38.93",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
7555, 7805
|
7831, 8144
|
2547, 7534
|
8156, 8842
|
2249, 2526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,744
| 183,197
|
45426
|
Discharge summary
|
report
|
Admission Date: [**2124-11-4**] Discharge Date: [**2124-11-23**]
Service: SURGERY
Allergies:
Penicillins / Erythromycin Base / Iodine; Iodine Containing /
Demerol / Codeine / Lopressor / Morphine
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
1. Melena
2. Lightheadiness
3. Abdominal pain
Major Surgical or Invasive Procedure:
[**11-7**]:EGD and colonoscopy
[**11-14**]:Left colectomy and splenectomy
[**11-19**]:PICC line placement
Blood transfusion x 2 ([**11-4**], [**11-15**])
History of Present Illness:
This is a [**Age over 90 **] year-old female w/ h/o DM2, HTN, CAD, duodenitis,
arthritis, s/p recent admission for bronchitis who presents from
rehab c/o 4-day h/o melena, lightheadiness, and abdominal pain.
The patient reports that 4 days PTA she suddenly developed
diarrhea with production of black stool. She had six episodes of
large black stool 4 days PTA, five episodes 3 days PTA, three
episodes 1 day PTA and last BM was yesterday evening in the ED.
She states that the volume is usually large. She denies any pain
with defecation and has not noticed any bright red blood in her
stool. She denies any h/o melena or bright red blood in her
stool. She usually has 1 BM per day or every other day. She
denies epistaxis, bleeding gums, or easily bruising.
In addition, she also reports weakness and mild lightheadedness
with ambulation starting 4 days PTA. She had difficulties
walking. She usually is active and walks a lot with her cane.
She denies any headaches, fall or LOC. She has been taken her
insulin and diabetic mediation as directed and denies any change
in her diabetic diet recently.
She also c/o abdominal "ache" located in her upper right and
left abdominal quadrants, which is not affected by po intake.
She denies any N, V and reports that her appetite is fair but
she has been able to tolerate po intake without problems. She
states that she has had chronic abdominal pain in that location
and is not sure if this abdominal pain has changed from before
and if it is acute. She had a voluntary weight loss of 40lbs
over the last several months. She has not taken any weight loss
supplements. She changed her diet and walked a lot. She eats
usually fish and chicken, with vegetables, and occasionally
fruits. She denies any recent antibiotic, steroid or NSAID
intake.
The patient also reports an episode of CP - a "twinge" yesterday
morning. She states that she has had this type of CP for years
and it is unchanged from prior. At home she takes SLNG for it.
It is not related to exercise and comes on rarely. She has
occasional PND and uses two pillows to sleep. She denies any
dyspnea and is able to walk several flights of stairs without
dyspnea. She denies diaphoresis.
In the ED: VS 96.8, 76, 155/63 the patient was guaiac pos
without gross blood. A NG Lavage was negative. WBC 11.2 with
left shift, HCT 31.1, Cr 1.5, Lactate 2.9, lipase and amylase
slighly elevated. Cardiac enzyme x 1 negative. She was given 1L
of NS and 1L of D5W w/ NaHCO3 for CIN prevention. CT abd was
unremarkable except for an assymetric focus of wall thickening
in descending colon. The patient was admitted to the medicine
service for further work-up and management.
Past Medical History:
1. Hypertension
2. Type II diabetes with retinopathy and renal dysfunction
3. Coronary artery disease with a catherization in [**2116**] that
showed 40% distal RCA and diffuse OM1 disease. She had a normal
P-MIBI in [**2121-1-26**].
4. Legally blind secondary to diabetic retinopathy & anterior
ischemic optic neuropathy.
5. Arthritis, Dupuytren's
6. Status post excision of bladder tumor [**2120-2-19**]
7. Status post left TKA
8. Status post cholecystectomy
9. Status post bilateral cataract extractions
10. Status post herniorrhaphy x 3
11. Status post hysterectomy age 30
Social History:
Tobacco: h/o 3 cig/day x 1 year, quit 50 years ago
EtOH: denies, no h/o alcoholism
Illicit drugs: denies, no IVDU
She lives alone at Mission [**Doctor Last Name **] and is independent. She is
widowed, legally blind. She is a retired nursing assistant who
worked at NEBH for 20 yrs. She has 2 sons in the [**Name (NI) 86**] area and
1 son in [**Name (NI) 4565**]. She has 8 grandchildren and 5
great-grandchildren. She is currently at [**Hospital3 **]
([**Telephone/Fax (1) 7233**]).
Family History:
Mother died at age 53 of nephritis and father did at age [**Age over 90 **]. No
h/o GI bleed, colon cancer, DM, asthma, heart disease
Physical Exam:
VS: T:97.0F HR:72 regular BP:132/70 RR:18
O2Sat:97%RA
General:Appears younger than stated age, NAD, resting
comfortably in bed
Skin: No scalp, face, or neck lesions/abrasions/lacerations
HEENT: NT/AC. PERRLA, EOMi. Petechiae on lateral sides of
tongue? Oropharynx clear. No tonsillar enlargement. Tongue moves
to left and right.
Neck: No lymphadenopathy. Supple, non-tender, no JVD or carotid
bruises appreciated. Trachea midline. Thyroid gland with no
masses
Pulm: Normal excursion. CTA bilaterally. No crackles or wheezes.
CV: RRR, normal S1, S2, no S3 or S4. II/VI holosystolic ejection
murmur.
Abd: Soft, tender to palpation in right and left upper
quadrants, non-distended, +bowel sounds. No hepatomegaly, no
spleenomegaly. No CVA tenderness.
Ext: +1 pitting edema in LE bilaterally. No clubbing, jaundice
or erythema. Numbness in both feet. No DP or PT pulses
appreciated.
Neuro: A/Ox3. No abnormal findings.
Pertinent Results:
Radiology:
CT ABDOMEN ([**2124-11-4**]):
IMPRESSION:
1. Colonic diverticulosis without acute diverticulitis.
2. Focal wall thickening of descending colon of unclear etiology
however correlation with colonoscopy is recommended as indicated
to exclude a neoplastic process.
3. Atherosclerotic changes of abdominal aorta and its branches
with infrarenal ectasia without frank aneurysm. Atrophic left
kidney.
4. Previously noted enhancing bladder mass not definitively
identified today.
BILAT LOWER EXT VEINS [**2124-11-8**] 3:37 PM
IMPRESSION: No deep vein thrombosis in the lower extremities.
Transthoracic Echocardiogram, [**11-13**]:
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2124-8-4**], the
findings are similar
CHEST (PORTABLE AP) [**2124-11-16**] 11:29 PM
IMPRESSION: Bilateral pleural effusions, with a question of a
possible pulmonary infarct on the right
CT CHEST W/O CONTRAST [**2124-11-17**] 7:58 PM
Lateral right lower lung opacity reflects combination of
layering effusion and multifocal right-sided pneumonia as
described above. Given patient's age, postoperative status and
fairly dependent positioning, aspiration is favored. No wedge
shaped opacities to suggest infarct. Small-to-moderate bilateral
simple pleural effusions with adjacent compressive atelectasis.
Marked narrowing of the bronchus intermedius likley related to
focal bronchomalacia. Dilated pulmonary artery.
Endoscopy:
Colonoscopy [**11-7**]:
Polyp in the transverse colon (biopsy),Polyp in the descending
colon (biopsy), Mass in the 45cm (biopsy, injection),
Diverticulosis of the sigmoid colon and descending colon
EGD [**11-7**]: Mild erythema in the antrum and stomach body
compatible with mild gastritis, Small hiatal hernia, Submucosal
venous structure in the mid-esophagus.
Pathology:
Colon bx from colonoscopy [**11-7**]:
A) Ascending colon polyp, biopsy: Adenoma.
B) Transverse colon polyp, biopsy: Adenoma.
C) Mass at 45 cm, biopsy:Colonic mucosa with a single fragment
of neoplastic epithelium. The neoplastic fragment is scant and
is not associated with intact mucosa tissue; thus, further
interpretation is not possible. It may represent adenoma,
adenocarcinoma, or carry-over artifact.
Surgical Pathology, 11/20 L colectomy:
T3 lesion, N0 (0 of 13 nodes positive), clear margins
[**2124-11-4**] 09:50AM GLUCOSE-78 UREA N-33* CREAT-1.4* SODIUM-145
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-15
[**2124-11-4**] 09:50AM CK(CPK)-42 AMYLASE-112*
[**2124-11-4**] 09:50AM LIPASE-106*
[**2124-11-4**] 09:50AM CK-MB-NotDone cTropnT-<0.01
[**2124-11-4**] 09:50AM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-2.4
[**2124-11-4**] 09:50AM WBC-10.6 RBC-3.00* HGB-8.6* HCT-25.9* MCV-86
MCH-28.8 MCHC-33.4 RDW-15.3
[**2124-11-4**] 09:50AM PLT COUNT-373
[**2124-11-3**] 09:52PM URINE HOURS-RANDOM
[**2124-11-3**] 09:52PM URINE GR HOLD-HOLD
[**2124-11-3**] 09:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2124-11-3**] 09:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-11-3**] 07:39PM K+-4.8
[**2124-11-3**] 06:52PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2124-11-3**] 06:52PM GLUCOSE-151* LACTATE-2.9* NA+-141 K+-6.2*
CL--106
[**2124-11-3**] 06:52PM HGB-10.1* calcHCT-30
[**2124-11-3**] 05:55PM GLUCOSE-160* UREA N-43* CREAT-1.5* SODIUM-138
POTASSIUM-6.3* CHLORIDE-104 TOTAL CO2-20* ANION GAP-20
[**2124-11-3**] 05:55PM estGFR-Using this
[**2124-11-3**] 05:55PM ALT(SGPT)-13 AST(SGOT)-34 ALK PHOS-59
AMYLASE-135* TOT BILI-0.3
[**2124-11-3**] 05:55PM LIPASE-102*
[**2124-11-3**] 05:55PM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-2.6
[**2124-11-3**] 05:55PM WBC-11.2* RBC-3.49* HGB-10.1* HCT-31.1*
MCV-89 MCH-28.9 MCHC-32.5 RDW-15.1
[**2124-11-3**] 05:55PM NEUTS-86.9* BANDS-0 LYMPHS-10.3* MONOS-2.4
EOS-0.2 BASOS-0.2
[**2124-11-3**] 05:55PM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
[**2124-11-3**] 05:55PM PLT SMR-HIGH PLT COUNT-494*#
[**2124-11-4**] 09:50AM BLOOD WBC-10.6 RBC-3.00* Hgb-8.6* Hct-25.9*
MCV-86 MCH-28.8 MCHC-33.4 RDW-15.3 Plt Ct-373
[**2124-11-4**] 09:50AM BLOOD Glucose-78 UreaN-33* Creat-1.4* Na-145
K-4.1 Cl-108 HCO3-26 AnGap-15
[**2124-11-4**] 09:50AM BLOOD CK(CPK)-42 Amylase-112*
[**2124-11-4**] 09:50AM BLOOD Lipase-106*
[**2124-11-4**] 09:50AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.4
Brief Hospital Course:
[**Age over 90 **] year-old female w/ h/o DM2, HTN, CAD, recent diagnosis of
duodenitis, arthritis, s/p recent admission for bronchitis who
presented from rehab c/o 4-day h/o melena, lightheadedness, and
abdominal pain. She underwent EGD and colonoscopy on [**11-7**]
(reports above) when a L colon mass was found and biopsies
taken.
Surgical course:
The general surgery team was consulted on [**11-8**] in regards to
the mass found in the left colon on colonoscopy. It was
determined that the patient would require surgical resection of
the left colon and she was booked for surgery on [**2124-11-14**]. On
the night prior to surgery she underwent a bowel prep. During
the procedure the left colon was successfully resected in an
open procedure. The mass was located in the splenic flexure.
Her tissue in this region was noted to be quite friable and
there was injury to spleen during mibilization of the flexure.
It was decided to perform a splenectomy to avoid possible
bleeding complications. A central line and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3389**] local
anesthesia pump were placed intraoperatively. Post-operatively
she was taken to the PACU and remained there overnight for
increased monitoring giving the amount of intraoperative blood
loss and her age/comorbidities. Secondary to altered mental
status (sedation and then agitation) as well as decreased
respiratory drive and continued O2 requirement, she was
transferred from the PACU to the Trauma Surgical ICU. The
patient experienced delerium on transfer to the ICU which she
gradually recovered from over the following days, returning to
her baseline mental status. Postoperative CXR's were suggestive
of a R lung wedge infarct, which seemed unlikely. Therefore a CT
of the chest was performed to confirm this diagnosis(without
contrast given reports of prior adverse reaction), which did not
show any pulmonary infarct, but did show a RLL pneumonia. Zosyn
was started empirically for nosocomial pneumonia. On [**11-16**] the
patient was transferred to the surgical floor, however on [**11-18**]
she went into rapid a-fib with some hemodynamic instability
(mild hypotension). Diltiazem and beta-blockade was started. The
patient expericenced a 4 second pause in cardiac rhythm and
relative hypotension and so was transferred back to the ICU for
rate control by diltiazem drip and beta blockade. Over the
following days her cardiac rate improved. She was transitioned
to PO diltiazem and beta-blockers were titrated to obtain
adequate rate control. She remained in a-fib, and given the
patient's desire to avoid anticoagulation, as well as her fall
risk, it was decided by the surgical and cardiology teams not to
have the patient on anti-coagulation except aspirin. Of note,
the patient does have a history of paroxysmal AF, for which she
had refused anticoagulation previously. This issue may be
addressed by her PCP and cardiologist after discharge. The
patient regained bowel function on [**11-20**] and was able to
ambulate with assistance. She was advanced to a soft regular
diet, which she tolerated well, however required significant
encouragment to increase intake.
On [**11-23**] it was noted that the patient's acute medical and
surgical issues had been adequate dealt with and that her
primary goals of care were that of physical rehabilitation. She
was therefore discharged to [**Hospital3 2558**] for acute
rehabilitation on the afternoon of [**11-23**]. Discharge instructions
and follow up as listed above.
Splenectomy: performed during procedure of [**11-14**]. Patient was
administered spenectomy vaccines (pneumococcus, h-flu, and
meningicoccus) prior to discharge.
.
Cardiology was consulted for rapid/paroxysmal atrial
fibrillation.
.
GI was consulted on [**11-4**] for GI bleed and recommended protonix,
transfusion with goal HCT >30 and EGD and colonoscopy which were
performed [**11-7**].
.
Pre-operative course issues:
Melena:
The Patient presented with 4-day h/o melena with diarrhea,
lightheadiness and abdominal pain. This was c/w with upper GI
bleeding even though NG lavage was negatvie in. Her Hct
decreased to 25 and she received 2 units of pRBC. Her Hct was
stable throughout the hospital stay. She was not tachycardic or
hypotensive. She had a EDG done wich showed gastritis and a
submucosal lesion in the mid-esophagus. Colonoscopy revealed two
polyps and a malignant appearing mass at 45 cm. There was no
active bleeding identified. The pathology report came back as
ademoma and one specimen . Surgery was consulted who
recommeneded an operation to remove the mass. She had a CT chest
for staging and a pre-op evaluation by cardiology.
.
Lightheadedness:
The patients's lightheadiness started at the same time she
noticed melena and diarrhea. This was most likley related to her
anemia. Her lightheadedness was unchanged throughout the
pre-operative portion of her hospital stay. She had no
orthostatics.
.
Abdominal pain:
The patient's abdominal pain was in the epigastric area. There
was suspicion for pancreatitis given slightly elevated amylase
and lipase, however there was no clinical or radiographic
evidence.
.
Chest pain:
Her chest pain has been chronic and did not appear to be cardiac
in etiology. She had no DOE, no radiation to arm or jaw. Her
cardiac enzyme x 1 was negative. Stress test in [**2120**] was normal.
Her EKG was unchanged. She was on telemtry with no concerning
changes.
.
Cough:
She has a recent hospitalization end of Octover [**2123**] for
bronchitis. Her cough was improving. She was on Albuterol nebs
prn and anti-tussant prn.
.
Chronic renal insufficiency:
The patient's creatinine was 1.5 on admission, which was
baseline. Her Cr was stable at 1.4-1.5 throughout the hospital
stay.
.
Diabetes mellitus type 2:
Her Blood sugars were in the range of 80-200. She had mild
hypoglycemic symptoms after being NPO for her procedure. She
received juice and D5W. She was stable throughout her hospital
stay. She was on an Insulin sliding scale. Glyburide was held on
admission and restarted on day of discharge.
.
HTN:
Her blood pressure was controlled while holding on metoprolol
and lasartan.
Medications on Admission:
- Docusate Sodium 100 mg [**Hospital1 **] as needed for constipation.
- Aspirin 81 mg PO DAILY
- Insulin Lispro Sliding Scale
- Glyburide 2.5 mg PO DAILY
- Losartan 50 mg PO DAIKY
- Metoprolol Succinate 25 mg PO DAILY
- Fluticasone 50 mcg/Actuation Aerosol [**Hospital1 **]
- Guaifenesin PO Q6H
- Doxercalciferol 0.5 mcg PO DAILY
- Benzonatate 100 mg PO TID
- Acetaminophen 650 mg Q6H as needed.
- Pantoprazole 40 mg PO Q24H
- Menthol-Cetylpyridinium 3 mg Lozenge Q6H as needed.
- Albuterol Sulfate neb Inhalation every 6 hours.
- Prednisone taper (40mgx2d, 30mgx2d, 15mgx2d, 10mgx2d, 5mgx2d)
- started on [**2124-10-27**]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
11. Insulin Lispro 100 unit/mL Solution Sig: per flowsheet
Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis
1. Gastritis
2. Anemia
3. adenocarcinoma of the colon
4. splenectomy
Secondary diagnoses:
1. Chronic renal insufficiency
2. Diabetes mellitus type 2
3. Hypertension
Discharge Condition:
good. tolerating a soft regular diet. Pain well controlled on
oral medications.
Discharge Instructions:
-eat a soft diet while you are having difficulty with solid
foods.
Incision Care:
-Your steri-strips will fall off on their own.
-You may shower, and gently wash surgical incision.
-Avoid swimming and [**Known lastname 4997**]s until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision site.
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 vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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.
* Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
You were admitted to the hospital because you had evidence of
blood in your stool and had abdominal pain and light-headedness.
Because your blood levels were low we gave you 2 units of blood
which brought your blood levels back to your baseline. You had
an endoscopy and a colonoscopy. Based on the endoscopy you were
diagnosed with mild gastritis (inflammation in the stomach)
which was most likely the cause of your bleeding. In order to
treat your gastritis we started you on a medication called
protonix, which decreases the acid in your stomach which
decreases irritation in the stomach. In the colonoscopy a 4cm
mass was found in your colon. This mass was removed with the
left part of your colon and it showed adenocarcinoma.
.
Please take all your medications as prescribed, please go to all
your follow up appointments as scheduled.
Followup Instructions:
Dr. [**Last Name (STitle) **] (surgery), please call as soon as possible([**Telephone/Fax (1) 4336**] to make an appointment for 2-3 weeks from now.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2124-12-6**] 10:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2125-1-23**] 10:40
Opthomology: Dr. [**First Name8 (NamePattern2) 33664**] [**Name (STitle) **]. Monday, [**2124-12-11**], at 9AM.
If you have any questions, please call [**Telephone/Fax (1) 28100**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2125-3-9**] 9:30
|
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icd9cm
|
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[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,638
| 135,772
|
20941+57207
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-9-20**] Discharge Date: [**2138-10-6**]
Date of Birth: [**2060-2-6**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
LLQ abdominal pain
Major Surgical or Invasive Procedure:
sigmoid colectomy, end colostomy, hartmann pouch and splenectomy
[**9-20**]
History of Present Illness:
78 year old man presented to ED with gradual onset of sharp pain
day prior to admission. The pain was constant with occasional
exacerbation, but resolved over the course of the day. The pain
retuned on day of admission, worse after breakfast. No N/V,
small BM on day of admission, but no diarrhea, no f/c, no
dysuria. compleated 5 cycles of chemotheapy.
Past Medical History:
Non-Hodgkins lymphoma of bladder
R hyronephrosis s/p stent
HTN
Gastritis
h/o pancreatitis
repair perfed duodeal ulcer
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
98.5 119 20 146/75 98%RA
AOx3
anicteric, neck supple no mass or bruits
CTA-B
Abd-distended, soft, tender LLQ with guarding
small redusable inguinal hernia
Rectal-Nl guiac neg
Pertinent Results:
[**2138-9-20**] 12:28PM BLOOD WBC-58.1*# RBC-3.99* Hgb-12.6* Hct-38.6*
MCV-97 MCH-31.5 MCHC-32.6 RDW-16.6* Plt Ct-300
[**2138-9-20**] 03:22PM BLOOD PT-12.6 PTT-19.9* INR(PT)-1.0
[**2138-9-22**] 04:46AM BLOOD Gran Ct-[**Numeric Identifier 17135**]*
[**2138-9-20**] 12:28PM BLOOD Glucose-168* UreaN-32* Creat-1.1 Na-144
K-3.8 Cl-106 HCO3-22 AnGap-20
[**2138-9-20**] 12:28PM BLOOD ALT-36 AST-20 AlkPhos-88 Amylase-44
TotBili-1.5
[**2138-9-20**] 12:28PM BLOOD Lipase-27
[**2138-9-24**] 03:31PM BLOOD CK-MB-4 cTropnT-0.01
[**2138-9-25**] 02:45PM BLOOD CK-MB-5 cTropnT-<0.01
[**2138-9-20**] 07:27PM BLOOD Calcium-7.5* Phos-4.2# Mg-1.4*
[**2138-9-19**] 01:55PM BLOOD TSH-0.029*
[**2138-9-19**] 01:55PM BLOOD T4-11.6 Free T4-2.6*
[**2138-9-20**] 05:56PM BLOOD Type-ART pO2-222* pCO2-36 pH-7.42
calHCO3-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2138-9-20**] 05:56PM BLOOD Glucose-145* Lactate-3.2* Na-136 K-3.9
Cl-107
[**2138-9-20**] 05:56PM BLOOD freeCa-1.16
Brief Hospital Course:
Pt was admitted to the TSICU s/p ex-lap for colectomy, splectomy
and colostomy for acute abdomen/perfed diveticulitis. Pt did
well, post operatively, there was no SOB/CP/Abd pain post-op.
His granulocyte count was monitored due to his recent chemo, and
neupogen was started. Pt saw the patient, and he did well with
this. He was taking his home inhalers and was switched to
nebulizers. Enterostomal therapy also followed the patient, who
started teaching. Oncology was following, who recommended RBC
and platelets as necessary, also to continue neupogen until D/C.
Had episode of PVC and HR to 100-110. Lytes were replaced, and
the episode resolved. Pt ruled out for MI. Pt was admitted
back to SICU for AFlutter. He did well and was transferred back
to the floor. Once back to the floor he did well and was D/C'ed
on POD10
Medications on Admission:
omperazole 20mg QD
levoxyl 150mg QD
norvasc 10mg QD
allopurinol 300mgQD
ASA 81mg QD
prednisone 100 QD
albuterol/atrovent nebs
advair
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours).
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000 unit
dose Injection QMOWEFR (Monday -Wednesday-Friday).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**]
Puffs Inhalation Q4H (every 4 hours).
6. Albuterol Sulfate 0.083 % Solution Sig: [**12-13**] neb Inhalation
Q4H (every 4 hours).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
11. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) for 7 days.
12. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 4 days.
13. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours) for 4 days. gram
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Perforated Diverticultits
Discharge Condition:
good to rehab
Discharge Instructions:
Return to clinic if you experience any of the following:
Fever>101.4, increasing pain, redness, pus or other concering
signs at the operative site. Also for nausea, vomiting,
diarrhea or any other sign you think is abnormal
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in [**12-13**] weeks, please call his office
for an appointment
Completed by:[**2138-9-30**] Name: [**Known lastname 10433**],[**Known firstname **] Unit No: [**Numeric Identifier 10434**]
Admission Date: [**2138-9-20**] Discharge Date: [**2138-10-6**]
Date of Birth: [**2060-2-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4**]
Chief Complaint:
See main report
Major Surgical or Invasive Procedure:
sigmoid colectomy, end colostomy, hartmann pouch and splenectomy
[**9-20**]
History of Present Illness:
See original report
Past Medical History:
Non-Hodgkins lymphoma of bladder
R hyronephrosis s/p stent
HTN
Gastritis
h/o pancreatitis
repair perfed duodeal ulcer
Social History:
Non-contributory
Family History:
Non-contributory
Physical Exam:
See original report
Pertinent Results:
see original report
Brief Hospital Course:
This is an addendum for the hospital course from [**9-30**] to
patient expiration:
Just before discharge, the patient was found to be aspirating
and having a difficult time breating. There was an attempt at
NGT placement, but the patient had a massive episode of emesis
leading to gross aspiration. A code was called, and the patient
required emergent intubation, tracheal suctioning, and transfer
to the ICU. A discussion was held with the family regarding
possibility for recovery and the decison was made to allow a few
days to see if the patient could turn the corner. He was
aggressivly treated with IV antibiotics, mechanical ventilation
and appropriate ICU care, which is detaied in the full chart.
After meeting with the family and a lack of improvment in his
clinical condition, the decision was made to discontinue care,
he expired shortly thereafter
Medications on Admission:
see origianl report
Discharge Medications:
PT expired
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1132**] - [**Location (un) 407**]
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Last Updated by:
[**Last Name (LF) 10435**],[**Name8 (MD) **], MD on [**10-1**] @ 1010
Perforated Diverticultits
secondary diagnoses:
neutropenia necessitating neupogen
anemia necessitating transfusion
non hodgkin's lymphoma of bladder on chemotherapy
hypothyroidism
gout
right hydronephrosis
hypertension
gastritis
pancreatitis
Discharge Condition:
expired
Discharge Instructions:
None
Followup Instructions:
NOne
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**]
Completed by:[**2138-11-3**]
|
[
"790.92",
"995.92",
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icd9cm
|
[
[
[]
]
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[
"96.07",
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"46.21",
"99.04",
"99.15",
"45.75",
"38.91",
"41.5",
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] |
icd9pcs
|
[
[
[]
]
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7030, 7107
|
6058, 6925
|
5623, 5701
|
7521, 7530
|
6014, 6035
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7583, 7742
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7129, 7282
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6951, 6972
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7554, 7560
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5974, 5995
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7303, 7500
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5568, 5585
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5729, 5750
|
5772, 5891
|
5907, 5925
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,791
| 131,434
|
32786
|
Discharge summary
|
report
|
Admission Date: [**2167-4-3**] Discharge Date: [**2167-4-14**]
Date of Birth: [**2098-12-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68M with h/o CAD s/p stent in the [**2157**] in [**Country 10181**] and one episode
of PNA several years ago admitted recently with PNA treated with
PO levoflox but now re-presenting with fevers and fatigue. Per
patient he was in his USOH until Sunday when he developed severe
fatigue. He says this was how he felt with his last bout of PNA.
He had a dry cough but is not sure if he also had fevers because
he didnt have a thermometer. He was admitted here with a CAP and
treated with one dose of levofloxacin IV and then switched to PO
levofloxacin and sent home.
Over the last few days he has not felt any better and every
time the tylenol wears off he feels even worse. Mostly he has
fatigue. The cough is non-productive but it does hurt him to
cough. He denies myalgias. He had one episode of diarrhea this
morning but otherwise no GI complaints although he has not been
able to drink or eat much. Today he was feeling even worse and
he took his temperature and it was 103 so he decided to come to
the Ed.
In the ED Admission Vitals: 101.9 130 132/90 24 100% 3L.
HPI was as above in the ED and Otherwise ROS negative in ED. CXR
in ED looks like persistent RLL PNA consistent with evolving
PNA. ECG was sinus tachycardia to 126bpm. 2L NS brought HR down
to 90s. He received vanc/ctx/azithro and although he reports a
pcn allergy with hives he tolerated the ctx well.
VS on transfer were: Temp 98.4, HR 92, 109/68, RR22 96 on 2L.
(94 on RA).
.
On the floor, patient reports severe fatigue and dry cough. He
reports the one episode of "explosive" diarrhea but none since.
No other changes in bowel or bladder function. No sick contacts.
[**Name (NI) **] recent travel. Never smoker. No TB risks but never had a PPD.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied Denied nausea,
vomiting, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
(per OMR and patient)
-CAD- S/P MI with stent in [**2157**] (type of stent not known -
placed in [**Country 10181**] where he was stationed at the time)
-Hyperlipidemia
-PUD - bleeding ulcer in [**2158**] (cauterized endoscopically per pt)
-Gastric hamartoma [**2135**]
Social History:
(per OMR and confirmed with patient) Retired Army colonel and
Army pilot. Works in [**Location (un) 86**] while son
is attending college, but lives with wife in [**Name (NI) 18317**] and plans
to return there in near future. Drank up to one bottle of wine
per night up to several months ago, when he quit cold [**Country 1073**] and
has abstained ever since. Life-long non-smoker.
Family History:
( per OMR) Father deceased in his 70s - [**Name (NI) 5895**]
Mother deceased in her 70s - heart failure
One brother - schizophrenia
One sister-epilepsy
Two biological sons - both healthy
Physical Exam:
Vitals: T:96.9 P:93 BP118/83 R: 20 O2: 96 on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM,
Lungs: Wheezing in RLL and RML. left side clear but poor
inspiratory effort [**1-28**] coughing with deep breaths
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+OX3
DISCHARGE:
Pertinent Results:
[**2167-4-3**] 10:25PM LACTATE-3.2*
[**2167-4-3**] 08:14PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2167-4-3**] 08:14PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2167-4-3**] 08:14PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2167-4-3**] 08:14PM URINE AMORPH-OCC
[**2167-4-3**] 08:14PM URINE MUCOUS-RARE
[**2167-4-3**] 08:10PM GLUCOSE-197* UREA N-19 CREAT-1.3* SODIUM-130*
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-24 ANION GAP-15
[**2167-4-3**] 08:10PM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-2.6
[**2167-4-3**] 03:36PM LACTATE-2.7*
[**2167-4-3**] 03:15PM GLUCOSE-155* UREA N-21* CREAT-1.5*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-25 ANION GAP-17
[**2167-4-3**] 03:15PM CALCIUM-8.7 PHOSPHATE-1.8* MAGNESIUM-2.6
[**2167-4-3**] 03:15PM WBC-11.2*# RBC-4.89 HGB-16.4 HCT-45.1 MCV-92
MCH-33.5* MCHC-36.3* RDW-14.0
[**2167-4-3**] 03:15PM NEUTS-85.3* LYMPHS-9.2* MONOS-4.5 EOS-0.2
BASOS-0.7
[**2167-4-3**] 03:15PM PLT COUNT-105*
Micro: blood, sputum cultures . . .
Urine legionella negative
Cdiff . . .
Images:
POrtable CXR: RLL PNA
IMPRESSION:
1. Right lower lobar pneumonia with a small amount of adjacent
pleural
effusion. No large obstructing mass is seen, although
post-treatment imaging
can be considered if there is a concern for malignancy.
2. Nonspecific ground-glass opacity within the right upper lobe,
likely
reflecting mild inflammatory change.
3. Mild left atelectasis with a trace amount of pleural
effusion.
4. Small pericardial effusion.
5. Splenomegaly, incompletely imaged.
Brief Hospital Course:
# PNA: Failed PO levoquin and CURB65 score high enough to be
re-admitted. Likely had resistent bacterial PNA and needs Rx
with IV antibiotics for longer prior to switching to PO. He was
treated with Vanc/ctx/azithro and then switched to
vanc/meropenem/gent/azithro at the recommendations of ID when he
continued to have hypoxia and fevers. A CT showed no abscess or
fluid collection. He underwent bronchoscopy which revealed clear
airways but blood-tinged fluid on BAL. Blood, urine, and sputum
cultures had no growth. Urinary legionella was negative. His
antibiotics were eventually tailored to meropenem, gentamicin,
vancomycin prior to transfer out of MICU and doses increased
according to levels. His oxygenation requirements decreased and
he was transferred out of the MICU. He was treated with mucinex
and codeine as well as nebs PRN for symptom control. his final
antibiotic regimen was vanc to be continued for 5 more days,
gentamycin to be continued for two more days and ciprofloxacin
to be continued for 2 more days. He completed a course of
azithromycin as well as meropenem. PPD was negative.
# Hyponatremia: likely [**1-28**] to either the PNA or dehydration
from poor po intake. Improved with IVF. Discharge sodium 138.
# Renal Insufficiency: likely pre-renal [**1-28**] fever and
dehydration from poor po intake. Improved with IVR. Discharge
creatinine 0.8.
# Tachycardia: Likely [**1-28**] dehydration from fever and poor po
intake. Resolved with IVF.
# Diarrhea: likely [**1-28**] ADR from ABx but could be cdiff or [**1-28**]
legionella which would explain both the lung and GI findings.
Urinary legionella was negative and Cdiff negatiee as well.
Diarrhea resolved.
# CAD: Stable. ACE inhibitor and statin held in the setting of
acute illness. Restarted on time of discharge.
# GERD: Continued home nexium
# Code: confirmed full
# Emergency Contact: wife: [**Telephone/Fax (1) 76344**]
Transitions of care:
- Multiple cultures and serologies pending and will be followed
up by the infectious disease department at his follow up
appointment. They should call him within 48 horus with this
appointment and if they do not call he should call them. He was
discharged to [**Hospital **] Rehab with these instructions.
- The PICC line needs to be removed when the antibiotics are
finished.
Medications on Admission:
(per d/c summary [**2167-4-1**] and confirmed with patient)
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*90 ML(s)* Refills:*0
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO at
bedtime as needed for cough: DO NOT DRIVE while taking this
medication as it will make you sleepy.
Disp:*200 ML(s)* Refills:*0*
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 5 days.
Disp:*10 gram* Refills:*0*
8. gentamicin 40 mg/mL Solution Sig: Five Hundred (500) mg
Injection Q24H (every 24 hours) for 2 days.
Disp:*1000 mg* Refills:*0*
9. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
10. PICC REMOVAL
Please remove PICC line after course of IV antibiotics are
finished in 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**]-[**Location (un) 86**]
Discharge Diagnosis:
Community Acquired PNA
Hyponatremia
Acute renal failure [**1-28**] dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with pneumonia and
dehydration. You were given IV fluids and IV antibiotics. Your
pneumonia got better. You should continue your medications as
prescribed.
Medication Changes:
START Vancomycin for 5 more days
START: Gentamycin for 2 more days
START: Ciprofloxacin for 2 more days
START: Guaifensin with codeine QHS as needed for cough
START: Benzonatate [**Hospital1 **] as needed for cough
Followup Instructions:
You will need the PICC line removed after you are finished with
your antibiotics in 5 days. This can be done at the rehab
facility.
PCP [**Name Initial (PRE) **]: Thursday, [**4-23**] at 4:40pm
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 76345**],MD
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Infection Disease Appointment: PENDING
Phone: [**Telephone/Fax (1) 457**]
** This department is working on getting you a follow up
appointment for this hospitalization. If you havent received a
call from them within 48hours from your discharge please call
them at the above number for an appointment within 10 days from
your discharge
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
Completed by:[**2167-4-15**]
|
[
"V45.82",
"272.4",
"789.2",
"787.91",
"287.5",
"276.1",
"995.91",
"038.9",
"584.9",
"530.81",
"E930.9",
"785.0",
"412",
"482.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9594, 9663
|
5398, 7314
|
281, 288
|
9785, 9785
|
3751, 5375
|
10385, 11323
|
3005, 3194
|
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|
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3209, 3732
|
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|
234, 243
|
316, 2039
|
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|
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|
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|
2604, 2988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,564
| 161,984
|
24668
|
Discharge summary
|
report
|
Admission Date: [**2190-7-21**] Discharge Date: [**2190-8-18**]
Date of Birth: [**2124-12-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Facial and upper extremity swelling
Major Surgical or Invasive Procedure:
Insertion of Right femoral triple-lumen catheter.
Insertion of tunneled hemodialysis catheter.
Re-insertion of right femoral triple-lumen catheter.
History of Present Illness:
Briefly after review of night float admit note, this is a 65
y.o. female with h/o ESRD, DM, CHF, and osteomyelitis who was
sent to the ED from [**Hospital3 2558**] for increased facial swelling
and SOB as noted by the staff at [**Hospital3 2558**]. Upon
interviewing the patient this morning, she does not understand
why she is in the hospital. Her only complaint is a rash on her
buttocks. She has a h/o of chronic diarrhea but no N/V or
abdominal pain.
.
In the ED, she was found to have a decreased O2 Sat and started
on supplemental O2. In the ED she was found to have a systolic
pressure in the 80's and was given 500cc NS bolus. Her O2
Saturation was also 92 and she was started on 2L NC and it
improved to 97%. She was presumed to have a PNA and was given 1
dose of levofloxacin and then admitted.
.
Of note, patient had been started on a 10 week course of
nafcillin on [**2190-4-21**], per the records. She was still being
administered this course via a PICC prior to admission. The PICC
was removed during transfer from ambulance to ED.
Past Medical History:
End-stage renal disease on HD
Hypertension
C. diff Colitis [**9-9**]
s/p cholecystectomy
Appendicitis
Asthma
Fluid overload
Hypothyroidism
DM
PNA with parapneumonic effusion s/p VATS with drainage [**10-10**]
Social History:
Nursing home resident. She needs assistance with her ADL's. Next
of [**First Name8 (NamePattern2) **] [**Doctor First Name **] or [**Male First Name (un) **] [**Telephone/Fax (1) 62260**]. Lives at [**Hospital3 2558**] 4th.
At baseline, knows where she is, reads the paper a little
Family History:
Non-contributory.
Physical Exam:
Vitals: 96.9, 112/70, 93, 20, 97% on 2L
General: A&O x3, poor remote memory, NAD, without labored
breathing
HEENT: EOMI, MMM, clear oropharynx
Pulm: transmitted upper airway sounds, no accessory muscle use,
no crackles appreciated
Cor: RRR, no M/G/R
Abd: Soft, NT, ND, +BS
Ext: +2 edema in Left upper extremity with indurated,
non-erythematous skin, non-warm skin. Multiple punctate
eschars/abrasions on right knee.
Pertinent Results:
[**2190-8-1**] 06:08AM BLOOD WBC-7.4 RBC-2.61* Hgb-8.5* Hct-27.0*
MCV-104* MCH-32.5* MCHC-31.4 RDW-17.4* Plt Ct-325
[**2190-8-1**] 06:08AM BLOOD Neuts-58.6 Lymphs-25.6 Monos-11.9*
Eos-3.6 Baso-0.3
[**2190-8-1**] 11:52AM BLOOD PTT-44.7*
[**2190-8-1**] 06:08AM BLOOD Plt Ct-325
[**2190-8-1**] 06:08AM BLOOD PT-18.1* PTT-60.4* INR(PT)-1.7*
[**2190-8-1**] 06:08AM BLOOD Glucose-115* UreaN-8 Creat-2.1* Na-140
K-3.7 Cl-105 HCO3-26 AnGap-13
[**2190-8-1**] 12:04AM BLOOD Glucose-123* UreaN-8 Creat-2.0*# Na-137
K-3.5 Cl-104 HCO3-25 AnGap-12
[**2190-8-1**] 06:08AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.7
Brief Hospital Course:
This is a 65 y.o. female with h/o ESRD, DM, CHF, and MSSA
osteomyelitis who was admitted with shortness of breath and
facial swelling, presumed secondary to SVC thrombosis.
.
# Facial and upper extremity swelling due to SVC thrombosis and
upper extremity DVT . Pt. at risk w/ multiple central access
attempts (HD tunneled catheters) and a subtherapeutic INR. UE
U/S with recannulization of left IJ. When the patient lost
peripheral IV access, IR was unable to place a PICC, and so a
right femoral central line had to be placed for lone access.
When IR tried to replace a tunneled HD catheter that she had
pulled out, they found complete occlusions of left internal
jugular and occlusion at the junction of the R. IJV and R.
subclavian. Therefore, it necessitated placement of a left
FEMORAL tunnelled HD catheter. The above study also showed much
flow through tortuous collaterals, which may be suggestive of
chronic thrombosis in jugular/subclavian veins. Pt. was seen by
vascular surgery during the hospitalization and they recommended
continuing anticoagulation, follow-up as an outpatient, and a CT
venogram if her symptoms worsen. Earlier in the admission,
there was also concern for upper airway obstruction and stridor
but ENT evaluated on [**7-24**] and found no signs of extrinsic airway
compression. Her upper airway symptoms improved with 3 doses of
decadron. After all the IR procedures, the patient's warfarin
was being titrated while bridging with heparin gtt. In the
interim, she developed hypotension refractory to fluid boluses.
She was found to have an infected right femoral line, at which
point it was pulled and she was transferred to the MICU.
.
# Access: Numerous access problems were encountered during this
admission. Once she lost her peripheral IV, PICC placement was
sought at bedside and by IR, both of which failed. The reason
for this was revealed during the re-insertion of a tunneled HD
catheter, S/P extirpation of the old one. She was found to have
thrombus bilateral IJV obstruction and tortuous collateral flow,
possibly indicating chronic thrombosis. A femoral line was
placed on [**7-23**] because of inability to get access anywhere else
for her heparin gtt. Femoral line placement was complicated by
continued episodes of diarrhea, and due to development of
inflammation at line site and hypotension, this line was pulled
on [**7-31**].
.
# ESRD-HD: The patient pulled out her left tunneled HD catheter
(had pulled out her left on a previous admission). A left
femoral tunneled HD catheter was placed on [**7-26**] and she has
tolerated dialysis will through this. Patient was maintained on
calcium acetate, Epo with dialysis, and a low-potassium
low-phosphate diet while on the floor.
.
# CHF: EF 40%. Upper extremity and facial swelling more likely
due to SVC thrombosis than to heart failure. Had crackles on
exam and a BNP that was 70,000 on admission, which was quite
suggestive of CHF but somewhat difficult to interpret in the
setting of renal failure. Unable to diurese due to ESRD, so
volume reduction achieved through HD. Prior to discharge, we
were planning to restart ACE-I and BB at low dose for CHF if her
pressures were able to tolerate it. We were also careful about
giving her no more than 250cc boluses due to CHF and ESRD.
.
# ID: Patient was receiving a prolonged course of antibiotics
for MSSA osteo/discitis. Dr. [**First Name (STitle) **], her ID specialist, was
informed of her admission. We obtained ESR and CRP which were
elevated, but per ID, these were decreased from previously and
not really indicative of continuing osteomyelitis. As a result,
Abx therapy for osteomyelitis was discontinued. She was
maintained on a course of prophylactic metronidazole for a h/o
recurrent C. difficile colitis, continued diarrhea and a h/o
prolonged Abx course, although C. difficile toxins were
negative. Pt. was scheduled for a follow-up appointment with
Dr. [**First Name (STitle) **] in the [**Hospital **] clinic for her osteomyelitis.
.
# DM2: The patient was maintained on her home regimen of NPH
with an insulin sliding scale while in house.
.
# Hyperchol: Patient was maintained on her home regimen of
atorvastatin.
.
# Hypothyroid: The patient's TSH continued to be elevated at 24
on admission and fT4 was also decreased. We spoke with
endocrinology regarding an already quite high dose of
levothyroxine (225mcg). They felt that there may be a drug
interaction or physiologic process that is impairing
levothyroxine absorbtion. However, they said it would be
alright to raise the dose of levothyroxine further if needed.
It was raised to 250mcg per day. Patient will need outpatient
follow-up of her TSH in 6 weeks.
.
# PPx: PPI given for GERD. Patient was anti-coagulated with
warfarin S/P IR procedures and bridged with heparin gtt.
.
# Full Code
MICU Course -- As the team was concerned that Mrs. [**Known lastname 12303**] had an
SVC syndrome, the patient underwent an MRV, showing occlusion of
both brachiocephalic veins. This was discussed with vascular
surgery and IR, who collaborated and decided that a stenting
procedure was possible, but that it would only have a 20-30%
chance of success and that there was a significant risk of
re-occlusion by six months. It was decided that this option
would be deferred until there was definitive management of her
airway.
.
In terms of her airway, Mrs. [**Known lastname 12303**] probably has a crowded
oropharynx at baseline, and this has been significantly worsened
by her pronounced swelling from the SVC syndrome. She
frequently de-satted at night to the 70's on 4L-nc, felt to be
due to mixed apnea, both central and obstructive. In addition
to this, she was witnessed to aspirate while eating on numerous
occasions, once with total occlusion and collapse of the left
lung; she was made NPO, and multiple attempts at NGT-placement
failed. Again, her aspiration was ascribed to worsening
oropharyngeal crowding from significant edema. In discussion
with that patient and her family, as her respiratory status was
quite tenuous and the causative factors (SVC syndrome and
recurrent aspiration) were felt to probably be irreversible, the
decision was reached to have her undergo tracheostomy and PEG
tube placement.
.
Her hypotension continued to be an ongoing problem throughout
the MICU stay without a clear etiology. She was treated for
sepsis given the infected line that brought her to the MICU, the
site of which grew out multiple GNRs. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test showed a
normal response. Multiple ECG's showed no changes concerning
for ischemia. It was felt that the main cause was likely
hypovolemia, as she responded to volume challenge; the thought
was that she was significantly third-spacing fluid due to her
SVC syndrome.
.
There was no etiology found for her hypotension and she was
continued on the pressors. Finally in discussion with the HCP,
it was decided to make her [**Name (NI) 3225**]. She died on [**2190-8-18**].
Medications on Admission:
-Phoslo
-Metronidazole 250mg tid on non-HD days
-Pantoprazole 40mg daily
-Levothyroxine 225mcg daily
-Tramadol 50mg [**Hospital1 **]:prn
-NPH 7am, 4pm
-RISS
-ASA 325mg daily
-Atorvastatin 80mg daily
-Clopidogrel 75mg daily
-Warfarin 7mg daily
-Epo
inpt-
-Levothyroxine 250mcg DAILY
-Loperamide HCl 2 mg PO QID:PRN
-Metronidazole 250mg PO TID
-Acetaminophen 325-650mg PO Q4-6H:PRN
-Miconazole Vaginal 1 Appl VG HS
-Nystatin-Triamcinolone 1 Appl TP [**Hospital1 **]:PRN
-Calcium Acetate 667mg PO TID W/MEALS
-Pantoprazole 40mg PO Q24H
-Sodium Chloride Nasal [**12-7**] SPRY NU QID:PRN
-Heparin IV
-Warfarin 7.5mg PO HS
-traMADOL 50mg PO BID:PRN
Discharge Medications:
EXPIRED
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Completed by:[**2190-8-18**]
|
[
"585.6",
"038.9",
"518.81",
"376.01",
"459.2",
"276.7",
"250.40",
"996.62",
"428.0",
"453.8",
"995.92",
"707.03",
"403.91",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.6",
"33.23",
"39.95",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10988, 11058
|
3212, 10262
|
349, 499
|
11109, 11147
|
2596, 3189
|
2125, 2144
|
10956, 10965
|
11079, 11088
|
10288, 10933
|
2159, 2577
|
274, 311
|
527, 1575
|
1597, 1808
|
1824, 2109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,241
| 196,455
|
53595+53596+53597
|
Discharge summary
|
report+report+report
|
Admission Date: [**2133-4-22**] Discharge Date: [**2133-4-23**]
Date of Birth: [**2056-3-11**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old man
with a history of coronary artery disease and amyotrophic
lateral sclerosis who presents with several weeks of nausea
and vomiting as well as abdominal pain and decreased
appetite. On the night before admission, he had one episode
of hematemesis at his nursing home. His sister was notified
and he was brought to the [**Hospital1 188**] Emergency Department. The patient does report that he
recently started taking Naprosyn b.i.d. for pain.
Additionally, he started Riluzole several months ago which
can have the side effect of nausea and vomiting.
In the Emergency Department, his systolic blood pressure was
in the 80s-90s initially with a hematocrit of 22.6 down from
his baseline in the mid 30s. NG lavage was positive for
coffee ground emesis which cleared with 600 cc of saline. He
was transfused 1 unit of packed red cells and 1 liter of
normal saline with improved blood pressures.
PAST MEDICAL HISTORY: ALS, currently followed by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 110117**] of the [**Hospital3 **] Neurology
Department.
CAD, status post MI times three. Most recent catheterization
with three vessel disease, 1+ AR, and an EF of 55 percent.
BPH, status post TURP.
B12 deficiency.
Status post inguinal hernia repair.
Diverticulosis seen on colonoscopy in [**2129-10-28**].
ALLERGIES: Penicillin which causes rash and angioedema.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg.
2. Nadolol 40.
3. Lisinopril 20.
4. B12 every month.
5. Imdur 10 b.i.d.
6. Diltiazem extended release 120 q.d.
7. Riluzole 50 mg b.i.d., has been on hold for several weeks.
8. Prozac 20.
9. Multivitamin.
10. Senna.
11. Lactulose.
12. Tylenol p.r.n.
13. Naprosyn 250 b.i.d.
14. Vicodin p.r.n.
SOCIAL HISTORY: He lives at [**Location 10140**] secondary to his
ALS. He is a retired accountant. He previously smoked
cigars but quit 20 years ago and has approximately two to
three drinks per week. He has no children. His family
contact is his sister, [**Name (NI) **] [**Name (NI) 110118**], phone number [**Telephone/Fax (1) 110119**].
FAMILY HISTORY: There is a family history of colon cancer.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.3 in the
Emergency Department, heart rate 71, blood pressure 100/35,
saturating 98 percent on 2 liters 02 by nasal cannula.
General: He was awake and alert, lying comfortably in bed,
in no acute distress with an NG tube in place. Head and
neck: Notable for dry mucous membranes. Cardiovascular:
Notable for a III/VI systolic murmur at the left upper
sternal border. Lungs: Clear. Abdomen: Soft with minimal
diffuse tenderness. Extremities: Trace pedal edema.
Neurologic: He was alert and oriented times three with
normal speech but he had significantly decreased strength in
all extremities, proximal greater than distal.
LABORATORY DATA: On admission, white count 19.2, hematocrit
22.6 down from 36.9, platelets 449,000. Chemistries were
notable for a potassium of 6.1, BUN 92, creatinine 1.2. CK
33, troponin 0.08, PT 13.5, PTT 23.7, INR 1.2.
CT of the abdomen showed no abdominal aortic aneurysm, no
free fluid or free air in the abdomen and a 2 mm stone in the
left ureteropelvic junction with no hydronephrosis.
EKG revealed a sinus rhythm at 75 beats per minute with an
old left bundle branch block.
ASSESSMENT: This is a 77-year-old man with a history of CAD,
status post MI, and ALS, who presents with an upper GI bleed.
UPPER GASTROINTESTINAL BLEED: The patient was started on IV
Protonix b.i.d. in the Emergency Department. He was
transfused a total of 3 units of packed red blood cells with
good response initially in his hematocrit. EGD revealed
several duodenal ulcers that all had a clean base with no
visible vessels and no currently active bleeding. Therefore,
he should be continued on b.i.d. proton pump inhibitor for at
least the next several months followed by indefinite daily
administration of a PPI. Additionally, his aspirin and
NSAIDs were stopped and should be held indefinitely.
Finally, on admission, due to his relative hypotension, all
of his cardiac and hypertensive medicines were held and they
should be restarted gradually as his blood pressure and heart
rate tolerate.
ACUTE RENAL FAILURE: Likely secondary to intravascular
depletion and his creatinine normalized with fluid
resuscitation with IV fluids and packed red blood cells.
CORONARY ARTERY DISEASE: Aspirin has been discontinued
secondary to his GI bleeding. His beta blocker, Diltiazem,
ACE inhibitor, and nitrates were held secondary to low blood
pressures. As his blood pressures and heart rate tolerate,
he should be restarted on these medications.
ALS: This was not an active issue while the patient was in-
house and per his outpatient neurology plan, his Riluzole was
continued to be held.
DISCHARGE CONDITION: Stable and improved with a stable
hematocrit.
DISCHARGE DIAGNOSES: Anemia secondary to blood loss.
Duodenal ulcers.
Coronary artery disease.
Amyotrophic lateral sclerosis.
Acute renal failure, resolved.
DISCHARGE MEDICATIONS:
1. Protonix 40 b.i.d.
2. Aspirin and Naprosyn have been discontinued.
3. As on admission except that his Nadolol, lisinopril,
Diltiazem, and Imdur were held while he was in the
hospital due to hypotension on presentation and should be
restarted as an outpatient as his blood pressure and heart
rate tolerate.
DISCHARGE STATUS: To a nursing home.
FOLLOW UP: The patient is to follow-up with his primary care
physician in the next one to two weeks for his duodenal
ulcers and for further management of his heart disease.
Additionally, he will need to follow-up on the results of his
biopsies from the [**Last Name (un) **] with his primary care physician.
He should have his anemia checked in a few days to ensure
that it is stable.
He should follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 110117**] in
the [**Hospital 878**] Clinic as needed.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 49323**]
MEDQUIST36
D: [**2133-4-23**] 12:58:54
T: [**2133-4-23**] 14:03:56
Job#: [**Job Number **]
Admission Date: [**2133-4-22**] Discharge Date: [**2133-5-1**]
Date of Birth: [**2056-3-11**] Sex: M
Service: MED
CHIEF COMPLAINT: Nausea, vomiting, hematemesis.
HISTORY OF PRESENT ILLNESS: This is a 77 year old male with
a history of coronary artery disease, amyotrophic lateral
sclerosis, and polyneuropathy who presents with several weeks
of nausea and vomiting. The patient has recently been cared
for at [**Hospital 10140**] Nursing Home and has been taking
Naproxen sodium for pain. He complains of several weeks of
nausea and vomiting along with abdominal pain and decreased
appetite. His sister reports that his previous episodes of
vomiting produced an emesis that looked like phlegm.
However, on the day of admission she was called from the
nursing home with a report that he had blood in his emesis.
The patient was transferred to [**Hospital6 2018**] for further workup.
PAST MEDICAL HISTORY: Polyneuropathy secondary to
amyotrophic lateral sclerosis; coronary artery disease,
status post myocardial infarction; three vessel coronary
artery disease on cardiac catheterization; benign prostatic
hypertrophy, status post transurethral resection of the
prostate; B12 deficiency; colonoscopy in [**Month (only) 1096**] that showed
diverticulosis; status post inguinal hernia repair.
ALLERGIES: Penicillin causing rash.
MEDICATIONS ON ADMISSION: Aspirin 325 mg daily; Nadolol 40
mg daily; Lisinopril 20 mg daily; B12 1000 mcg q. month;
Riluzole 50 mg b.i.d.; Prozac 20 mg daily; Tylenol prn;
Vicodin prn; Naproxen sodium prn; multivitamin; Diltiazem
extended release 120 mg daily; Lactulose 5 mg q.h.s.; Isordil
10 mg b.i.d.; Senna q.h.s.
SOCIAL HISTORY: The patient lives at [**Location 10140**]. He is a
retired accountant who quit smoking 20 years ago. He has two
alcoholic beverages a week. He has no children.
FAMILY HISTORY: Positive for colon cancer.
PHYSICAL EXAMINATION: Physical examination on admission
revealed temperature 96.3, heart rate 71, blood pressure
100/35, respiratory rate 20, oxygen saturation 98 percent on
2 liters. General: Awake and alert, lying in bed in no
acute distress. Nasogastric tube in place. Head, eyes,
ears, nose and throat, pupils equal, round and reactive to
light, oropharynx clear. Mucous membranes dry.
Cardiovascular examination, regular rate and rhythm with a
III/VI systolic ejection murmur at the left sternal border.
Lungs clear to auscultation bilaterally. Abdomen soft,
minimal diffuse tenderness. Extremities, no cyanosis,
clubbing and there was trace bilateral pedal edema present.
Neurological examination, alert and oriented times three,
normal speech. Decreased strength in the lower exsanguinate.
In the upper extremities he was barely able to move his legs
and has extensive arm weakness.
LABORATORY DATA: Laboratory data on admission revealed white
blood cell count 19.2, hematocrit 22.6, platelets 449, sodium
140, potassium 4.8, BUN 92, creatinine 1.2, creatinine kinase
33, troponin 0.08, INR 1.2, PTT 23.7. Electrocardiogram,
normal sinus rhythm with left bundle branch block pattern, no
new changes compared to his previous electrocardiogram.
Computerized tomography scan of the abdomen, chest and pelvis
revealed no aortic aneurysm or periaortic hematoma, 2 mm
nonobstructing stone in the proximal left ureter without
hydronephrosis, 2.7 cm low attenuation lesion of the right
kidney which likely represents a cyst. There is no free
fluid in the pelvis.
HOSPITAL COURSE: Gastrointestinal bleed - In the Emergency
Department, the patient was found to have a hematocrit of
22.6, was hypotensive with systolic blood pressures in the
80s and 90s. His nasogastric lavage revealed hemoccult
positive coffee ground emesis. Two large bore peripheral
intravenous lines were obtained and the patient was
transfused with 1 unit of packed red blood cells and given 1
liter of normal saline at which time his systolic blood
pressure improved and he was transferred to the Intensive
Care Unit. The patient was seen by Gastroenterology and
underwent an urgent esophagogastroduodenoscopy which reveals
a small amount of coffee ground material in the fundus and a
few nonbleeding ulcers ranging in size from 9 to 11 mm in the
anterior bulb and distal bulb of the duodenum. The ulcers
were clean-based with no simple vessel. The patient received
an additional 2 units of packed red blood cells initially in
the Intensive Care Unit after which time his gastrointestinal
bleeding appeared to stabilize, and he was transferred to the
Medical Floor. On the Medical Floor he remained stable for
approximately 48 to 72 hours at which point he developed
recurrent gastrointestinal bleeding as evidenced by a large
amount of melena. Central intravenous line access was
obtained with a right subclavian triple lumen catheter. The
patient was transfused with 2 units of packed red blood cells
and transferred again to the Intensive Care Unit for
monitoring. The patient underwent a repeat upper endoscopy
while in the Intensive Care Unit which again showed
nonbleeding, clean-based, duodenal ulcers with no evidence of
coffee ground or fresh blood in the stomach or duodenum. At
this time, the patient melena had stopped and the patient
expressed a desire to have no further interventional
procedures including a colonoscopy. The patient specified
that he would accept blood transfusions if he had recurrent
melena while in the hospital, however, he wanted the goals of
his care to be shifted towards comfort. During the remainder
of his Intensive Care Unit stay, the patient hematocrit
remained stable in the high 20s and he did not require any
further blood transfusions, nor did he have any recurrent
melena.
Urosepsis - The patient developed urosepsis with Escherichia
coli in his blood and urine. He was started initially on
intravenous Levofloxacin and quickly defervesced. He will
complete a seven day course of therapy with Levofloxacin.
Amyotrophic lateral sclerosis - The patient has had
progressive poly motor neuropathy from his amyotrophic
lateral sclerosis over the past one year. He is now unable
to ambulate or use his legs to support his weight. He is
also having extensive upper extremity weakness. In addition
during his Intensive Care Unit stay, the patient was noted to
have difficulty swallowing with decreased gag reflex and a
weak cough mechanism. The patient had a bedside speech and
swallow evaluation which showed that he aspirated at all
consistencies. Given the fact that the patient has a
progressive and fatal disease and that he does not want any
further interventional procedures it was felt that the
patient's goals of comfort and plans to discharge to a
hospice facility or a nursing home with hospice benefit would
allow for him to have nectar-thickened liquids and soft
solids. He could be treated with oral antibiotics for
aspiration pneumonia if this were to develop at the nursing
home or a hospice facility. The patient was also seen in the
Intensive Care Unit by his outpatient neurologist who is in
agreement with this plan.
Code status and goals of care - The patient's code status is
do not resuscitate, do not intubate. He has also clearly
expressed his desire to not have any further invasive
procedures. Once he is discharged from [**Hospital6 649**], he has stated that he does not want further
blood transfusions. A palliative care consult was placed to
assist with the patient's disposition and to ensure that his
goals of care were adequately met. Multiple conversations
were had with the patient, the patient's sister and the
patient's nephew. His sister is [**Name (NI) **] [**Name (NI) 110120**], his nephew
is [**Name (NI) **] [**Name (NI) 110120**]. His sister can be reached at telephone
#[**Telephone/Fax (1) 110121**], his nephew can be reached at home, [**Telephone/Fax (1) 110122**] or on his cell phone [**Telephone/Fax (1) 110123**].
The remainder of the discharge summary will be dictated by
the covering intern.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2133-4-30**] 16:00:34
T: [**2133-4-30**] 17:28:48
Job#: [**Job Number **]
Admission Date: [**2133-4-22**] Discharge Date: [**2133-5-5**]
Date of Birth: [**2056-3-11**] Sex: M
Service: MED
HOSPITAL COURSE (CONTINUED): Please see the previously
dictated discharge summary dated [**5-1**] for prior hospital
course. The remainder of this discharge addendum summary
covers hospitalization from [**5-1**] through [**2133-5-5**].
The patient was called out to the floor in stable condition
with the following issues outstanding.
1. GI BLEEDING: Etiology remains unclear. [**Name2 (NI) **] refusing
further invasive procedures including colonoscopy. The
patient was maintained on po Protonix [**Hospital1 **]. Hematocrit
checks were performed qod, with transfusion threshold for
hematocrit less than 28, given coronary artery disease
history. He received 1 unit of packed red cells for a
crit of 27. Serial hematocrits afterwards were stable to
baseline low-30's. We are avoiding anticoagulation
medications with him. He will likely need to restart his
baby aspirin in about 1 month. Further evaluation would
be done by his outpatient primary care provider.
1. E. COLI SEPSIS: He remained afebrile with negative
surveillance blood cultures. He completed a 10-day course
of Levaquin.
1. ALS: He was maintained on fall and aspiration
precautions. He failed the bedside swallow exam, but per
the patient wants to eat. So, a soft diet with thickened
liquids was ordered; he tolerated it well. Activity was
out-of-bed to chair via [**Doctor Last Name 2598**] lift.
1. WOUND CARE: He continued to receive wound care for his
superficial decub ulcer. He had no evidence of infection.
1. LOW BACK PAIN: The patient had chronic low back pain with
no acute history, but he was controlled on a fentanyl
patch and prn Vicodin. He was also started on a lidocaine
patch at night with further improvement.
1. PROPHYLAXIS: He was maintained on Protonix, pneumoboots
and a bowel regimen.
1. ACCESS: The patient had right subclavian placed on [**4-28**]
in the intensive care unit, and this was discontinued on
the day of discharge.
1. PSYCH: The patient was restarted on Prozac on the day
prior to discharge. He refused Celexa.
1. HYPERTENSION: The patient was subsequently restarted on
his ACE inhibitor prior to discharge, given an elevated
blood pressure. We were not readding his other cardiac
meds, given the fact that he had a history of GI bleed.
This will likely need to be readjusted with his primary
care physician.
DISPOSITION: The patient was initially screened for hospice
with the plan for comfort measures only. After further
evaluation with the palliative care team and with the patient
and family discussion, a meeting was held and the patient
declined hospice care. He was wanting to return back to the
same nursing home, although with a higher level of skilled
nursing need. He was screened and was returned back to a
more intensive care setting to his original nursing home.
Prior to disposition via the ambulance, he refused to sign
the DNR/DNI form, at which point he reversing his DNR/DNI
status.
DISCHARGE CONDITION: Afebrile. Stable heart rate, blood
pressure. Surveillance cultures were no growth to date.
DISCHARGE MEDICATIONS:
1. Vicodin 5/500, 1-2 tabs po q 4-6 h prn pain.
2. Protonix 40 mg po bid for 2 months, and after 2 months can
decrease to qd.
3. Lisinopril 200 mg po qd.
4. Riluzole 50 mg 1 tab po bid--on hold. Please restart as
per your outpatient neurologist.
5.Fluoxetine 20 mg po qd.
1. Senna 1 tab po bid.
2. Lactulose 45 ml po at hs.
3. Lidocaine 5 percent adhesive patch 1 patch medically
topical q hs--please DC in the morning.
4. Fentanyl 25 mcg 1 patch q 72 h.
10.Colace 100 mg po bid.
DISPOSITION: The patient is being returned to his original
nursing home with increased nursing care. He will likely
need qod hematocrit checks with a transfusion threshold of
less than 27.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 12481**]
MEDQUIST36
D: [**2133-5-5**] 13:41:15
T: [**2133-5-5**] 14:50:05
Job#: [**Job Number **]
|
[
"E935.6",
"707.0",
"584.9",
"599.0",
"532.40",
"335.20",
"038.42",
"344.00",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"99.04",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17931, 18025
|
8339, 8367
|
5116, 5257
|
18048, 18996
|
7847, 8141
|
9961, 16309
|
5654, 6596
|
8390, 9943
|
6614, 6646
|
16322, 17909
|
6675, 7372
|
7395, 7820
|
8158, 8322
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,384
| 122,773
|
32319
|
Discharge summary
|
report
|
Admission Date: [**2193-12-26**] Discharge Date: [**2193-12-29**]
Date of Birth: [**2160-5-17**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
syncope & lightheadedness.
Major Surgical or Invasive Procedure:
Central line with temporary pacing wires placed.
Central line removal
Pacemaker replacement
History of Present Illness:
[**Known firstname **] [**Known lastname **]-[**Known lastname **] is a 33 yo female with a past medical
history of congenital ASD and VSD c/b complete heart block s/p
pacer at age 9 months old who presented to OSH lighheadedness
and one episode of syncope. She reports that she has been
feeling lightheaded for 2.5 weeks. The lightheadedness is not
associated with postural changes. It is unrelated to exertion.
Last night she had her first episode of syncope. She had LOC
for approximately 6 sec. It was witnessed by her sister who
caught her. She denied tonic/clonic movements, tongue biting,
confusion, bowel or bladder incontinence. She reported
palpitations but denies any associated chest pain, pressure or
shortness of breath. Her pacer was last placed 12 years ago.
She reports that she saw her cardiologist approx 2-3 months ago
for concern regarding hand numbness and was told that the pacer
was working well. At the OSH she was found to have symptomatic
pauses up to 6 seconds in duration without ventricular pacing at
those times. The most recent one occured on the ride over.
Head CT was negative at OSH. She was transferred for temporary
pacer and evaluation of her pacemaker.
.
On review of systems, Positive for rhinorrhea for 2 days.
Daughter with URI.
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems as above is notable for absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, or palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: No Diabetes, No Dyslipidemia, No
Hypertension
2. CARDIAC HISTORY:
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD: First PPM placed at age 9mo in [**2161**]. Since then she
has had 5 different pacers placed. The most recent one is a
dual-chamber [**Company 1543**] pacemaker placed in [**January 2180**] No. [**Serial Number 75526**] in
her left chest.
3. OTHER PAST MEDICAL HISTORY:
# ASD & VSD - s/p repair as an infant
# Complete heart block - pacemaker dependent since age 9 months.
Social History:
She is single. She has 2 children ages 2 & 12.
-Tobacco history: [**1-25**] PPD for 22 years. 11PY
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: Scar in left chest with device below. RRR, 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.
EXTREMITIES: No c/c/e. wwp
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
EKG: AV paced HR 60
.
TELEMETRY: Paced rhythm HR 60. Frequent long pauses.
.
2D-ECHOCARDIOGRAM: n/a
ETT: n/a
CARDIAC CATH: n/a
HEMODYNAMICS: n/a
.
CXR: pacer in left chest with leads in RV & RA & epicaridium.
no acute cp process.
.
LABORATORY DATA: (FROM OSH)
UCG neg at OSH
136 22 9
-----------------< 93
4 105 0.6
LFTs wnl
WBC 7.7
HGB 11.1
HCT 34.0
PLT 317
.
ADMISSION LABS
[**2193-12-27**] 01:01AM WBC-10.0 Hgb-11.0* Hct-33.9* Plt Ct-337
[**2193-12-27**] 01:01AM Neuts-62.0 Lymphs-26.9 Monos-5.0 Eos-5.4*
Baso-0.7
[**2193-12-27**] 01:01AM PT-12.2 PTT-29.6 INR(PT)-1.0
[**2193-12-27**] 01:01AM Glucose-107* UreaN-13 Creat-0.9 Na-140 K-3.9
Cl-107 HCO3-23 AnGap-14
[**2193-12-27**] 01:01AM Calcium-9.2 Phos-4.2 Mg-2.0
IRON LABS:
[**2193-12-28**] 05:12AM Iron-49 calTIBC-369 Ferritn-11* TRF-284
DISCHARGE LABS:
[**2193-12-29**] 05:30AM WBC-6.7 Hgb-9.4* Hct-29.3* Plt Ct-286
[**2193-12-29**] 05:30AM Neuts-50.4 Lymphs-38.1 Monos-5.0 Eos-6.0*
Baso-0.5
[**2193-12-29**] 05:30AM PT-12.5 PTT-28.6 INR(PT)-1.1
[**2193-12-29**] 05:30AM Glucose-85 UreaN-7 Creat-0.6 Na-139 K-4.2
Cl-106 HCO3-27 AnGap-10
[**2193-12-29**] 05:30AM Calcium-8.6 Phos-4.2 Mg-1.9
Brief Hospital Course:
33 yo female with congenital ASD & VSD s/p repair with complete
heart block since she was an infant who presents with syncope.
# Heart Block with pacer Malfunction: Pt has history of
complete heart block and is dependent on her pacemaker. Pt is
[**Name (NI) 1925**] paced in 60s with frequent long (6 sec) symptomatic pauses
indicating malfunctioning pacemaker. Pt had temporary pacing
wire placed on the night of admission. She had her pacemaker
replaced on [**2193-12-27**]: New RV lead ([**Company 1543**] 4076)-->left
subclavian; Generator change-->[**Company 1543**] EnRhythm; Old RV
lead-->insulation breech and conductor fracture near header.
CXR shows correct placement of the leads and no pneumothorax.
The patient was started on IV Cefazolin after the placement and
switched to PO Abx on discharge.
# CORONARIES: no history of CAD. No symptoms of CP
# PUMP: No history of CHF. Pt euvolemic on exam.
# TOB USE: advised smoking cessation. Pt provided with smoking
cessation materials.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 6 days. Tablet(s)
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
5. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain for 7 days.
Discharge Disposition:
Home
Discharge Diagnosis:
pacer malfunction
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted for evaluation of symptoms of syncope and
lightheadedness. You were found to have a malfunctioning pacer.
It was discovered that your pacer was not firing appropriately
and needed to be adjusted. During your hospitalization your
pacer was replaced so that it should work appropriately for
several years at minimum without difficulty. However, you
should continue to follow up with your cardiologist to ensure
that the pacer is working correctly.
Medications added during this hospitalization:
Percocet, Ibuprofen & Tylenol as needed for pain.
Do NOT drink alcholol or drive while taking percocet.
Colace for constipation while taking percocet.
Keflex - an antibiotic to prevent infection.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], the EP Cardiologist who
replaced your pacemaker next week. Please call ([**Telephone/Fax (1) 66291**]
to schedule an appointment for next week. He mentioned that he
would try to arrange for an appointment for you on [**1-2**]. His
office is located at [**Hospital1 **], [**Location (un) 75527**], [**Location (un) 86**], [**Numeric Identifier **]
Please make a follow up appointment with your primary care
doctor in the next 1-2 weeks as well.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
[
"996.01",
"V15.1",
"780.2",
"305.1",
"E878.1",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.76",
"38.93",
"37.87",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
6574, 6580
|
4971, 5976
|
299, 393
|
6642, 6642
|
3774, 4594
|
7524, 8168
|
2924, 3039
|
6031, 6551
|
6601, 6621
|
6002, 6008
|
6787, 7501
|
4610, 4948
|
3054, 3755
|
2313, 2619
|
233, 261
|
421, 2200
|
6656, 6763
|
2650, 2755
|
2222, 2293
|
2771, 2908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,082
| 103,227
|
24695
|
Discharge summary
|
report
|
Admission Date: [**2178-11-11**] Discharge Date: [**2178-12-3**]
Date of Birth: [**2102-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
Arterial line placement
Tracheostomy
PEG placement
History of Present Illness:
76 yo F w/ h/o emphysema initially admitted to ICU [**2178-11-11**] for
hypoxic respiratory failure due to CAP w/ mucous plugging
causing acute desat that led to urgent intubation.
Past Medical History:
emphysema
macular degeneration
EF 75-80%, mod pulm htn, 2+ TR
Social History:
Alcohol: 2 drinks/night.
Tobacco: 50 pack-years. Currently still smoking.
Drugs: Denies.
Currently retired. Lives alone without assistance. Daughters in
the area. Used to work as a secretary at a lumber mill.
Family History:
CAD father and brother 50s. Mother with cardiac history.
Physical Exam:
On initial MICU admission:
Afebrile, normotensive with normal pulse.
Gen: well appearing elderly woman sitting upright in chair,
conversing comfortably. Alert and oriented.
HEENT: Pupils reactive, irregular. + cataract over right eye.
CV: RRR. Nl S1, S2. S4 present. No murmurs or rubs.
Lungs: Diminished breath sounds throughout. Exp wheezing in
upper lobes. Prolonged expiratory phase.
Abd: Soft. NT. ND. Normoactive bowel sounds.
Ext: Warm. Trace pitting edema. Thin extremities. DP 2+ b/l.
Neuro: Moves extremities well.
Rectal: Deferred but guaiac positive at OSH.
Pertinent Results:
CT ABDOMEN W/O CONTRAST [**2178-11-17**] 5:00 PM
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with new free air seen under diaphragm. Has
been on chronic steroids.
HISTORY: Free intraperitoneal air. On chronic steroids. Evaluate
bowel after administration of gastrografin.
COMPARISON: CT of the abdomen and pelvis from [**2178-11-17**]
at 14:16.
TECHNIQUE: MDCT acquired contiguous axial images from the lung
bases to the pubic symphysis were acquired following the
administration of oral gastrografin. IV contrast had been
administered earlier for the previous CT examination. Coronal
and sagittal reconstructions were obtained.
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Again demonstrated within
the lung bases are bibasilar atelectasis and bilateral pleural
effusions, right greater than left.
There has been no significant interval change in the large
amount of free intraperitoneal air noted. Contrast is
demonstrated within the stomach and small bowel, and there is no
evidence of contrast extravasation. Within the left lower
quadrant, there is a focal segment of small bowel which
demonstrates mild bowel wall thickening, which on the prior exam
appeared to be normal. The significance of this bowel wall
thickening is uncertain, however ischemia cannot be fully
excluded. There is no evidence of pneumatosis.
The remainder of the examination is stable.
CT OF THE PELVIS WITHOUT IV CONTRAST: Pelvic loops of bowel
appear unremarkable. Again no evidence of contrast extravasation
is noted. Again noted, there is a large calcified fibroid uterus
with large bilateral adnexal cysts. There is no evidence of
pneumatosis.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in confirming the above findings.
IMPRESSION:
1. No evidence of oral contrast extravasation.
2. Focal area of bowel wall thickening involving a loop of the
mid small bowel within the left lower quadrant. Previously, this
loop of bowel appeared unremarkable on the examination from
three hours earlier. The significance of this bowel wall
thickening is unclear and it may be due to under filling of this
loop, however ischemia cannot be fully excluded.
3. Otherwise, stable appearance of the abdomen and pelvis with a
large amount of free intraperitoneal air again demonstrated.
Echo:
1. The left atrium is normal in size.
2.There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). A mid-cavitary
resting gradient is identified.
3.Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension.
6.There is no pericardial effusion.
E:A ratio: 0.50
CXR ([**11-22**]):
CHEST, SINGLE AP VIEW.
There is upper zone redistribution, without overt CHF. Again
seen is a small-to-moderate right pleural effusion with
underlying collapse and/or consolidation. This is probably
slightly larger than on the film obtained one day earlier. There
is also atelectasis at the left base, with some blunting of the
costophrenic angle, slightly improved in the interim.
CHEST (PORTABLE AP) [**2178-11-27**] 6:35 AM
PORTABLE AP CHEST: As compared to [**11-26**], moderate bilateral
pleural effusions have increased in size, allowing for
differences in patient positioning. Increasing airspace opacity
within the right mid lung could represent atelectasis, but
pneumonia have a similar appearance. Endotracheal tube and
enteric tube remain in stable position.
IMPRESSION:
1. Interval increase in size of now moderate bilateral pleural
effusions.
2. Atelectasis within the right midlung versus pneumonia.
CHEST (PORTABLE AP) [**2178-11-28**] 3:52 AM
IMPRESSION: AP chest compared to [**11-27**] and 3rd:
Left pleural effusion has resolved. No pneumothorax. Moderate
sized right pleural effusion has improved and atelectasis in the
right lower lobe decreased. Hyperinflation indicates severe
emphysema. The heart is normal size. Feeding tube passes into
the stomach and out of view while an ET tube is in standard
placement.
CHEST (PORTABLE AP) [**2178-11-30**] 3:52 AM
An endotracheal tube and feeding tube remain in place. Cardiac
and mediastinal contours are stable. There remains evidence of a
small-to- moderate right pleural effusion with adjacent
atelectasis. There may be a very minimal pleural effusion on the
left, but this is significantly smaller than on pre-
thoracentesis radiographs.
MICROBIOLOGY:
[**11-25**] urine cx, [**11-30**] urine cx: yeast
[**11-27**] sputum: MRSA (vanc-sensitive)
Brief Hospital Course:
Sputum cx grew out sparse Strep pneumo and OP flora. CXR c/w
atypical PNA. Patient tx w/ levo and then started on steroids
[**11-14**] for failure to wean from vent (tachypneic and
hypercarbic)/concern for COPD flare. She was ultimately able to
be extubated on [**11-14**] but required suction assistance w/ copious
secretions. S/p extubation, she passed a swallow eval. She was
transferred to the floor on [**11-16**] and was managed w/ a steroid
taper. Of note, on [**11-17**] CXR, patient noted to have free air
under the diaphragm. Abd CT showed large amount of free
intraperitoneal air w/ LLQ small bowel thickening - ? ischemia
but exam unremarkable w/o peritoneal signs. Surgery was
consulted but the patient remained clinically stable with benign
abdominal exam and antibx were expanded to pip/tazo. On [**11-19**]
the patient then developed acute hypercarbic and hypoxic
respiratory failure with O2 sat 59% off face mask thought [**2-25**]
combination of pneumonia, RLL collapse [**2-25**] mucous plug, and
COPD, and was transferred back to the MICU. In the MICU,
patient's respiratory status improved on BiPaP. She was then
transitioned to face mask. Her ABG improved to 7.35/64/73 at the
time of transfer to floor on [**11-20**].
.
The patient was doing well on the floor until one afternoon,
when she was found by a nurse sitting on the edge of her bed,
trying to get out of bed, disoriented, her O2 disconnected from
the wall. She c/o nausea. She was hypoxic to 57% after being
placed on 4L NC. She was then placed on 100% NRB and sats
improved to 90s. She was tachypneic to RR in high 30's and
somnolent. She was treated w/ atrovent neb and placed on Venturi
mask. Suctioning productive of moderate amount of thick white
sputum. ABGs as follows (baseline 7.44/56/92->7.23/87/71->? VBG
7.20/100/39->7.25/91/72). At the time of transfer back to MICU,
the patient oriented to self and hospital, somnolent, mildly
increased work of breathing. She initially did well on BiPAP but
had increasing work of breathing despite nebulizers and
suctioning and agreed to an elective intubation [**2178-11-25**]. A chest
CT showed large pleural effusions; the left side was tapped
(800cc of transudative fluid) and the right improved as well
with diuresis. Despite diuresis and the thoracentesis she
persistantly remained vent-dependant with copious secretions
and, after discussion with her family, agreed to a trach & PEG
on [**12-1**].
.
1. Hypercarbic respiratory failure:
- s/p Trach [**12-1**]
- Etiology potentially multifactorial but likely secondary to
underlying severe COPD with mucous plugging. S/p left chest
thoracentesis [**11-26**].
- continue nebulizer treatments, spiriva upon extubation
- continue frequent pulmonary toilet
- Influenza and pneumococcal vaccine given
- sputum: [**11-25**] sparse yeast; [**11-27**] MRSA; R midlung atelectasis
vs. pneumonia, on Vancomycin ([**11-27**]) for MRSA (suspect
tracheobronchitis rather than PNA)
- continue prednisone taper (day 2 at 15mg [**12-2**])
- OOB to chair as much as possible
- maintain on PS as tolerated; has had some apneic episodes at
night requiring MMV
.
2. ID: Fever and leukocytosis without obvious source, although
given increased secretions in an intubated patient, likely
pulmonary. completed course of Zosyn ([**Date range (1) 41492**]) for ?PNA on
admission. Prev had free air under diaphragm, followed by
surgery without any evidence ofr infection or surgical
indication. Abdominal exam remains benign with resolution of
previously visualized free air. Continue to monitor abdominal
exam and contact surgery with any change in exam. LFTs within
normal limits (consideration towards acalculous cholecystitis in
ICU patient). - patient started on Vancomycin (start [**11-27**]) for
increasing MRSA in sputum cultures and temp spike [**11-26**]. C. Diff
sent and neg x 3. Had course of cipro for UTI.
- Blood cultures pending, no growth to date
- vanco 7 day course for tracheobronchitis ([**11-27**] to [**12-3**])
- PICC placed [**11-30**]
- d/c foley [**12-2**]
.
3. HTN/CHF: Continue diltiazem, avoid beta blockers given
possibility of associated bronchial constriction
.
4. PPX: SQ Heparin, PPI, bowel regimen
.
5. FEN:
- replete lytes PRN
- PEG [**12-1**] with TF
.
6. Code: Full code (confirmed [**11-24**]; pt would not want long-term
vent but did want intubation)
.
7. Access: R PICC ([**11-30**])
- d/c foley today
.
8. Communication: patient
Son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 62302**](h) [**Telephone/Fax (1) 62303**](w)
Daughter [**Name (NI) 1439**] Cell [**Telephone/Fax (1) 62304**]
Grandson [**Name (NI) **] cell [**Telephone/Fax (1) 62305**]
Medications on Admission:
unknown eye drops
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*[**Numeric Identifier 31034**] units* Refills:*0*
2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) for 1 months.
Disp:*1200 ML(s)* Refills:*0*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
Disp:*1 bottle* Refills:*0*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day) for 1
months.
Disp:*60 Disk with Device(s)* Refills:*0*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) for 1 months.
Disp:*120 nebulizer* Refills:*0*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) for 1 months.
Disp:*180 nebulizer* Refills:*0*
11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily) for 1 months.
Disp:*30 Cap(s)* Refills:*0*
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day) for 1 months.
Disp:*6000 mg* Refills:*0*
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Pantoprazole 40 mg IV Q24H
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
Disp:*1 container* Refills:*0*
17. Vancomycin HCl 1000 mg IV Q 12H
please D/C after [**2178-12-3**] dosing
18. Morphine Sulfate 1-2 mg IV Q4H:PRN
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): [[**2178-12-2**] 15mg]
[[**2178-12-3**] 15mg]
[[**2178-12-4**] 10mg]
[[**2178-12-5**] 10mg]
[[**2178-12-6**] 10mg]
[[**2178-12-7**] 5mg]
[[**2178-12-8**] 5mg]
[[**2178-12-9**] 5mg.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Hypercarbic respiratory failure
MRSA+ sputum
emphysema
macular degeneration
Moderate pulmonary hypertension
Tricuspid regurgitation
Discharge Condition:
Stable
Discharge Instructions:
You should tell your nurse [**First Name (Titles) **] [**Last Name (Titles) **] if you have worsening
pains, fevers, chills, nausea, vomiting, shortness of breath,
chest pain, or other concerns.
It is important you take medications as directed. The physicians
at the rehabilitation center will adjust them as necessary
Followup Instructions:
Call your primary care [**Last Name (Titles) **] for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment
within 1 week after you leave the rehabilitation center.
|
[
"518.84",
"401.9",
"V58.65",
"518.1",
"491.21",
"933.1",
"305.1",
"416.8",
"481",
"428.0",
"482.41",
"276.1",
"599.0",
"V09.0",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"38.91",
"96.71",
"38.93",
"96.6",
"34.91",
"31.1",
"43.11",
"96.04",
"96.72",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13655, 13727
|
6442, 11109
|
344, 420
|
13903, 13912
|
1620, 1671
|
14280, 14471
|
957, 1015
|
11177, 13632
|
1708, 6419
|
13748, 13882
|
11135, 11154
|
13936, 14257
|
1030, 1601
|
276, 306
|
448, 630
|
652, 715
|
731, 941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,706
| 134,578
|
11056
|
Discharge summary
|
report
|
Admission Date: [**2111-3-10**] Discharge Date: [**2111-3-14**]
Date of Birth: [**2049-9-30**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 61 year old female
with diabetes mellitus, congestive heart failure, chronic
renal insufficiency, who was admitted to the Intensive Care
Unit for treatment of hyperglycemia. Over the past few days
prior to admission, the patient's fingersticks were in the
400s. In addition, she had four days of increasing shortness
of breath. She awoke on the morning of admission with severe
abdominal pain, nausea, vomiting and diarrhea. In addition,
she had an episode of chest pain associated with diaphoresis
and shortness of breath that occurred for a short period of
time and then resolved on its own. She states that she takes
her insulin as prescribed and with feedings of normal meals.
PAST MEDICAL HISTORY:
1. Diabetes mellitus for twenty-six years with history of
diabetic ketoacidosis admissions.
2. History of gastroparesis.
3. Coronary artery disease, status post coronary artery
bypass graft in [**2103**], status post cardiac catheterization in
[**2109**]. Persantine MIBI in [**2109-6-27**], showed a fixed basal
lateral wall defect.
4. Congestive heart failure with an ejection fraction of
40%, mild global hypokinesis, and basal lateral hypokinesis.
5. Hypertension.
6. Hypercholesterolemia.
7. Chronic renal insufficiency with baseline creatinine of
1.3 to 1.6. This has been increasing recently. As per
primary care physician, [**Name10 (NameIs) **] may be having worsening baseline
renal insufficiency.
8. Uterine fibroids.
9. Peripheral vascular disease, status post left CEA.
10. Status post pelvic fracture in [**2109-10-27**].
11. Recent Methicillin resistant Staphylococcus aureus
urinary tract infection [**2111-1-26**].
12. Status post cholecystectomy.
13. History of spiculated mass in right upper lobe.
14. History of pleural effusion requiring a thoracentesis in
[**2110-12-28**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg once daily.
2. Atorvastatin 10 mg once daily.
3. Hydralazine 25 mg twice a day.
4. Lantus insulin 14 q.h.s.
5. Humalog sliding scale.
6. Lasix 20 mg twice a day.
7. Lopressor 25 mg twice a day.
8. Nitroglycerin p.r.n.
9. Os-Cal with Vitamin D.
10. Home oxygen one to two liters.
11. Protonix 40 mg once daily.
12. Reglan 10 mg twice a day.
13. Sucralfate one twice a day.
14. Wellbutrin 150 mg twice a day.
15. Zestril 30 mg once daily.
SOCIAL HISTORY: The patient is divorced. She denies alcohol
use. She has two children. She has positive tobacco
history. She smoked approximately two packs per day for
about fifty years.
FAMILY HISTORY: Not obtained.
PHYSICAL EXAMINATION: Blood pressure is 218/63 which changed
to 138/43 with 5 mg of intravenous Lopressor and Hydralazine.
Temperature 95.8, pulse 62, respiratory rate 16, oxygen
saturation 100% on two liters. Examination significant for
elderly female in no acute distress with moist mucous
membranes. Heart - normal S1 and S2, with S4. Pulmonary -
decreased breath sounds at bilateral bases. Abdomen - mild
tenderness in right upper quadrant. Extremities - 1+
peripheral edema. All other organ systems examined and found
to be within normal limits.
LABORATORY DATA: White blood cell count was 7.1, hematocrit
30.2. Sodium 136, potassium 5.0, blood urea nitrogen 48,
creatinine 2.3, anion gap of 12, glucose 696. Initial
arterial blood gases showed pH 7.35, 46, 127. Alkaline
phosphatase 122, albumin 3.1, CPK 76, troponin 0.09.
Urinalysis with 500 protein, 1000 glucose, 15 ketone.
Electrocardiogram showed normal sinus rhythm at 65 beats per
minute, normal axis, left atrial enlargement. T wave
inversions inferolaterally.
Chest x-ray showed congestive heart failure, bilateral small
pleural effusions and emphysema. Abdominal ultrasound showed
no duct dilatations, no free fluid, no liver abnormality, 2.2
by 2.5 centimeter cyst in the right kidney.
HOSPITAL COURSE: This is a 61 year old female, active
tobacco user, who came to the Emergency Department with
gastrointestinal symptoms and was found to have a serum
glucose of 696, acute renal failure on top of chronic renal
insufficiency, and hypertension.
1. Hyperglycemia - The patient was initially given an
insulin bolus and started on insulin drip. She never had an
anion gap. Her insulin drip was transitioned over to
subcutaneous insulin. [**Last Name (un) **] was consulted and the patient
was maintained on Glargine and Humalog insulin sliding scale.
2. Diastolic congestive heart failure - The patient was
hydrated on admission to treat her hyperglycemia. After this
hydration, she complained of orthopnea but her oxygen
saturation measurements remained unchanged. She appeared
slightly fluid overloaded. However, because of her increased
creatinine function, she was not actively diuresed. She was
maintained on 1.5 liter fluid restriction after input and
output. Her ace inhibitor was also held because of her renal
function.
3. Acute on chronic renal failure - Initially the patient's
creatinine was 2.3 on admission and her baseline creatinine
is 1.3 to 1.6. She was initially treated with intravenous
fluids. The thought was that her baseline renal function has
been deteriorating recently. Prior to discharge, her 24 hour
urine was collected for use with her outpatient management.
The total protein was 362, sodium 47 and creatinine 58 which
gives a ratio of about 6:1 protein to creatinine. She did
not have urine eosinophils. Renal ultrasound revealed no
hydronephrosis. There was a tiny nonobstructing stones
bilaterally. Mild increase in echogenicity of the renal
parenchyma consistent with medical renal disease. Her
creatinine peaked at 3.1.
4. Hypertension - Initially, her blood pressure was elevated
in the Emergency Department and she was treated with
intravenous beta blocker and Hydralazine. During her
hospitalization, her ace inhibitor was held and she was
maintained on beta blocker, Hydralazine, and long acting
nitrates for blood pressure control. Upon discharge, she
will continue this regimen and follow-up as an outpatient for
reinstituting her ace inhibitor and for managing her blood
pressure medications.
5. Coronary artery disease - She will continue on her beta
blocker, Aspirin and statin.
6. Precautions - The patient was kept on Methicillin
resistant Staphylococcus aureus precautions because she had a
recent Methicillin resistant Staphylococcus aureus urinary
tract infection.
7. Abdominal pain - On admission, the patient complained of
abdominal pain and right upper quadrant ultrasound did not
reveal any gallbladder or liver abnormality. She had a
mildly elevated alkaline phosphatase and elevated GGT. These
abnormalities had unclear etiology. Upon discharge, she no
longer was having abdominal pain. She will be monitored as
an outpatient.
8. History of pleural effusions - Apparently during her last
hospitalization, the patient had pleural effusions that
required thoracentesis. They revealed a transudate with
negative cytology. She had mediastinal lymphadenopathy on
chest x-ray. She will need outpatient follow-up to evaluate
for possible cancer.
9. Infectious disease - The patient had two sets of negative
blood cultures drawn on admission and, in addition, she had
stool cultures sent that were negative for salmonella,
shigella, Campylobacter, Vibrio, Yersinia, E. coli,
Clostridium difficile upon admission because of her abdominal
pain. A urine culture drawn upon admission had no growth.
DISCHARGE STATUS: The patient was discharged home with
services.
CONDITION ON DISCHARGE: Tolerating p.o. diet, ambulating
with assistance, creatinine 3.1, blood urea nitrogen 67,
protein/creatinine ratio on 24 hour urine of 6.2.
DISCHARGE DIAGNOSES:
1. Hyperglycemia.
2. Type 2 diabetes mellitus.
3. Coronary artery disease.
4. Congestive heart failure.
5. Acute renal failure on chronic renal insufficiency.
6. Hypertension.
7. Hypercholesterolemia.
8. Chronic renal insufficiency.
9. History of Methicillin resistant Staphylococcus aureus
urinary tract infection.
10. Gastroparesis.
11. Spiculated mass on chest x-ray.
12. Mildly elevated liver function tests.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once daily.
2. Metoprolol 25 mg p.o. twice a day.
3. Hydralazine 25 mg q6hours.
4. Atorvastatin 10 mg p.o. once daily.
5. Vitamin D 400 units p.o. once daily.
6. Pantoprazole 40 mg p.o. once daily.
7. Reglan 10 mg p.o. four times a day.
8. Albuterol one to two puffs q6hours p.r.n.
9. Bupropion 150 mg p.o. twice a day.
10. Calcium Carbonate 500 mg p.o. twice a day.
11. Isosorbide Dinitrate 10 mg one tablet p.o. three times a
day.
12. Colace 100 mg p.o. twice a day.
13. Senna 8.6 mg p.o. twice a day.
14. Insulin Glargine 12 units q.h.s.
15. Humalog insulin sliding scale, a copy of which was given
to the patient prior to discharge.
FOLLOW-UP PLANS: The patient will follow-up with Dr.
[**Last Name (STitle) **], [**2111-3-18**], at 11:20 a.m. She will also follow-up
with the [**Hospital **] Clinic in two weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 35739**]
Dictated By:[**Last Name (NamePattern1) 17526**]
MEDQUIST36
D: [**2111-3-16**] 13:44
T: [**2111-3-17**] 20:10
JOB#: [**Job Number 35741**]
|
[
"263.9",
"250.00",
"401.9",
"511.9",
"492.8",
"593.9",
"789.00",
"428.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2722, 2737
|
7864, 8287
|
8313, 8983
|
2048, 2512
|
4028, 7677
|
2760, 4010
|
9001, 9441
|
156, 853
|
875, 2022
|
2529, 2705
|
7702, 7843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,029
| 164,464
|
11822
|
Discharge summary
|
report
|
Admission Date: [**2162-1-22**] Discharge Date: [**2162-2-3**]
Date of Birth: [**2096-9-20**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Septic gangrene of the left foot.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old white male
with coronary artery disease, status post CABG/AVR, history
of congestive heart failure, diabetes mellitus, chronic renal
insufficiency, peripheral vascular disease, status post right
femoropopliteal bypass graft, bladder carcinoma, MRSA who
developed ischemic ulcers of the left foot about two months
prior to admission. The patient had been hospitalized at the
[**Hospital1 69**] in [**2161-11-18**] on the
medical service for a supratherapeutic INR and ischemic left
foot. Arteriogram done at that time showed that the patient
had nonreconstructable disease. The patient was discharged
home and followed as an outpatient.
Three weeks prior to admission the patient developed
increasing pain in his left foot. He presented to the [**Hospital6 3622**] where x-rays showed probable osteomyelitis
with air in the soft tissues. The patient requested a
transfer to the [**Hospital1 69**] for
evaluation and treatment by Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY:
1. Coronary artery disease, myocardial infarction x 3;
CABG/AVR in [**2154**]. Positive Persantine MIBI study in [**2161-11-18**] led to a transthoracic echocardiogram showing an
ejection fraction of 40%. Cardiac catheterization on
[**2161-12-2**] showed patent grafts and no intervention was
necessary.
2. Congestive heart failure.
3. Diabetes mellitus.
4. Chronic renal insufficiency.
5. GI bleed secondary to aspirin.
6. Bladder cancer.
7. Hypercholesterolemia.
8. Nephrolithiasis.
9. Rheumatoid arthritis.
10. Supratherapeutic INR of 6 during [**2161-11-18**]
hospitalization.
11. MRSA foot culture [**2161-11-18**].
12. Rheumatoid arthritis.
13. Chronic anemia.
14. Peripheral vascular disease.
PAST SURGICAL HISTORY:
1. CABG/AVR in [**2154**].
2. Right femoropopliteal bypass graft [**2160-10-18**].
FAMILY HISTORY: A brother died of liver cancer at age 55.
Mother died of brain cancer at age 75.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] is a retired probation officer. He quit smoking
cigarettes about eight years ago after a 100-pack-year
history. He occasionally uses alcohol, no drug use.
ALLERGIES:
1. Intravenous contrast caused ATN in [**2161-11-18**].
2. Oxacillin caused a rash.
3. Iron/niacin caused a rash.
4. Percocet and Darvocet caused unknown reaction; tolerates
Dilaudid.
MEDICATIONS ON ADMISSION:
1. Coumadin 5 mg alternating with 7.5 mg q.d.
2. NPH Insulin 15 units subcutaneous q.a.m.
3. NPH Insulin 5 units subcutaneous q. supper.
4. Regular Insulin sliding scale.
5. Lopressor 25 mg p.o. b.i.d.
6. Digoxin 0.25 mg p.o. q.d.
7. Lisinopril 5 mg p.o. q.d.
8. Lasix 60 mg p.o. q.d.
9. Aspirin 81 mg p.o. q.d.
10. Protonix 40 mg p.o. q.d.
11. Folate 1 mg p.o. q.d.
12. Multivitamins 1 p.o. q.d.
PHYSICAL EXAMINATION: Vital signs showed a temperature of
97.9, pulse 86, respiratory rate 30, blood pressure 102/61,
oxygen saturation equals 100%. General: Awake, oriented
white male having difficulty finding words. Chest: Lungs
clear bilaterally. Heart: Regular rate and rhythm without
murmur. Abdomen: Soft, nontender. Extremities: Left foot
gangrenous with necrotic ulcer on the plantar surface.
ADMISSION LABORATORY STUDIES: White blood cell count 48.7,
hemoglobin 7, hematocrit 22.2, platelet count 757,000, PT
18.2, PTT 42.9, INR 2.2, sodium 137, potassium 5.6, chloride
102, CO2 22, BUN 56, creatinine 2.5, glucose 133, digoxin
2.8. Urinalysis showed 208 red blood cells, 18 white blood
cells, no epithelial cells, no bacteria, no yeast.
EKG showed normal sinus rhythm at a rate of 86. ST-T wave
changes were present. Chest x-ray on [**2161-12-27**] showed no
acute pulmonary disease.
HOSPITAL COURSE: The patient was transferred from the [**Hospital6 3622**] on [**2162-1-22**] and admitted to [**Hospital1 346**]. A CT scan without contrast was
done because of the patient's dysarthria and difficulty word
finding. Head CT showed no acute bleeding and two old
infarcts were present in the middle cerebral artery
territory.
The patient was taken emergently for a guillotine amputation
of his left foot on admission. The patient was started on
intravenous vancomycin, Zosyn, and Flagyl. Wound cultures
were sent from the operating room and grew moderate MRSA,
probable Enterococcus and moderate diphtheroids.
Postoperatively the patient was transferred to the surgical
intensive care unit. He was started on intravenous heparin
for anticoagulation for his mechanical valve. This was done
after the neurology service reviewed the patient's CT scan
and agreed that the patient did not have an acute bleed or
infarct. The patient's sepsis continued to improve, and on
[**2162-1-27**] the patient underwent completion below the knee
amputation. At the time of this dictation the patient's
incision is clean, dry and intact. He does not need any
dressing or knee immobilizer. He will continue vancomycin
and Zosyn for two more weeks. He had a PICC line placed in
his left arm on [**2162-2-2**] by interventional radiology.
The patient is awaiting placement in a [**Hospital 3058**]
rehabilitation facility. He will follow up with Dr.
[**Last Name (STitle) **] in the office for staple removal approximately one
month after surgery, that is, approximately [**2162-3-1**]. His
INR at the time of dictation is 2.0. His goal INR for his
heart valve anticoagulation is 2.5 to 3.0.
DISCHARGE MEDICATIONS:
1. Coumadin 7.5 mg p.o. alternating with 5.0 mg q.d.
2. Vancomycin 1 gram intravenous q. 18 hours to finish on
[**2162-2-15**].
3. Zosyn 2.25 mg intravenous q. 6 hours to finish on
[**2162-2-15**].
4. Digoxin 0.125 mg p.o. q.d.
5. Lopressor 25 mg p.o. b.i.d.
6. Lasix 60 mg p.o. q.d.
7. Lipitor 10 mg p.o. q.d.
8. Lisinopril 5 mg p.o. q.d.: To be restarted [**2162-2-8**].
9. NPH Insulin 15 units subcutaneous q.a.m.
10. NPH Insulin 5 units subcutaneous q. supper.
11. Regular Insulin sliding scale q.i.d.
12. Protonix 40 mg p.o. q.d.
13. Aspirin 81 mg p.o. q.d.
14. Folic acid 1 mg p.o. q.d.
15. Multivitamins 1 p.o. q.d.
16. Tylenol 1-2 tablets p.o. q. 4-6 hours p.r.n.
17. Hydromorphone 2-6 mg p.o. q. 3-4 hours p.r.n. pain.
18. Colace 100 mg p.o. b.i.d.
19. Dulcolax 10 mg p.o./p.r. q.d. p.r.n.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: [**Hospital **] rehabilitation.
DISCHARGE DIAGNOSES:
1. Septic gangrene of the left foot.
2. Guillotine amputation on [**2162-1-22**].
3. Completion below the knee amputation on [**2162-1-27**].
SECONDARY DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus osteomyelitis
of the left foot.
2. Left PICC line placed [**2162-2-2**] for intravenous antibiotics
therapy.
3. Diabetes mellitus.
4. Chronic renal insufficiency.
5. Coronary artery disease.
6. Bladder cancer.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2162-2-2**] 13:08
T: [**2162-2-2**] 13:20
JOB#: [**Job Number 37341**]
|
[
"707.15",
"440.24",
"730.07",
"038.9",
"V43.3",
"V45.81",
"518.4",
"272.0",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"84.14",
"84.15"
] |
icd9pcs
|
[
[
[]
]
] |
2067, 2149
|
6558, 6701
|
5649, 6450
|
2612, 3010
|
3940, 5626
|
1966, 2050
|
6722, 7262
|
3033, 3922
|
166, 201
|
230, 1218
|
1240, 1943
|
2166, 2586
|
6475, 6537
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,111
| 166,307
|
52217
|
Discharge summary
|
report
|
Admission Date: [**2163-2-23**] Discharge Date: [**2163-3-14**]
Date of Birth: [**2100-6-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Abdominal pain, nausea and vomiting, and decreased PO intake
Major Surgical or Invasive Procedure:
removal of peritoneal catheter
History of Present Illness:
HPI: 62 y/o man with type I diabetes, well controlled for many
years, crohn's disease, and recently diagnosed metastatic
carcinoma of presumed GI origin who is admitted to the medical
service after presenting to the emergency department when his
Visiting nurse felt him not not look well.
.
He was in good health until late [**Month (only) **] when we was admitted
to [**Hospital1 18**] [**2163-1-25**] wtih abdominal bloating. He was found to have
rapidly reacumulating ascites, peritoneal carcinomatosis, a long
circumferential mass lesion in the descending colon, multiple
liver metastasis, and bilateral pulmonary emboli. Biopsy
attempts have thus far been non-confirmatory which included
biopsy of his colonic lesion, and cytology and cell block of
ascitic fluid. A peritoneal port was placed for ascitic drainage
and he was discharged with TPN and oncology follow up on [**2162-2-9**].
He is re-admitted as above with nausea, vomitting, decreased PO
intake, relative hypotension, and [**Name2 (NI) 108028**] to thrive.
.
In the emergency department his vital signs were within normal
limits (HR 96, BP 122/67, sating 97%RA) he was given NS @
250cc/hour for a total of 250cc. He was given dilaudid 1mg IV x
2, and zofran 4mg IV x 2. An abdominal ultrasound was largely
unchanged from [**2163-2-5**], demonstrating ascites, sludge, and liver
masses. As he does not have a primary oncologist yet (has not
had an appointment with Dr. [**Last Name (STitle) **] he was admitted to medicine
with plans for oncology to consult.
.
Further review of systems is notable for marked fatigue and
malaise in associating with his pain and anti-nausea
medications.
.
Past Medical History:
PMH:
Type I diabetes since age 16
Chron's disease
Perpipheral Vascular disease s/p bipass [**2159**]
Remote tuberculosis [**2116**]
Social History:
professor of biology at [**Location (un) 270**] community college. Lives in [**Location **]
wtih his wife ( an anatomy and microbiology professer), has
three children. Non-smoker, no etoh or other drug use
.
Family History:
Non-contributory
Physical Exam:
PE:
110/67 89 18 95%RA
GEN: cachectic, chronically ill appearing.
HEENT: sceral icterus, jaundiced
CV: RRR s1, s2, no M/G/R
RESP: crackles bialterally
ABD: distended, diffusly tender to palpation
EXT: 1+ emema, posative pulses
Pertinent Results:
[**2163-2-23**] 06:10PM PT-13.1 PTT-31.8 INR(PT)-1.1
[**2163-2-23**] 06:10PM PLT COUNT-710*
[**2163-2-23**] 06:10PM NEUTS-80.7* LYMPHS-7.9* MONOS-7.8 EOS-2.7
BASOS-0.7
[**2163-2-23**] 06:10PM WBC-10.2 RBC-3.46* HGB-8.0* HCT-26.4*
MCV-76*# MCH-23.1*# MCHC-30.4* RDW-17.5*
[**2163-2-23**] 06:10PM TOT PROT-5.6* CALCIUM-8.0* PHOSPHATE-4.1
MAGNESIUM-2.2
[**2163-2-23**] 06:10PM LIPASE-11
[**2163-2-23**] 06:10PM ALT(SGPT)-41* AST(SGOT)-55* ALK PHOS-520* TOT
BILI-3.7*
[**2163-2-23**] 06:10PM GLUCOSE-203* UREA N-41* CREAT-1.1 SODIUM-139
POTASSIUM-4.9 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
[**2163-2-23**] 06:24PM GLUCOSE-197* LACTATE-1.3 NA+-143 K+-4.8
CL--114* TCO2-22
[**2163-2-23**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2163-2-23**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-4* PH-6.5
LEUK-NEG
[**2163-2-24**] 05:46AM BLOOD Albumin-1.6* Calcium-7.8* Phos-4.7*
Mg-2.2
[**2163-2-24**] 01:35PM OTHER BODY FLUID WBC-700* RBC-7150* Polys-71*
Lymphs-9* Monos-19* Mesothe-1*
.
[**2163-2-23**] 6:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2163-2-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 330PM [**2163-2-24**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2163-2-24**] 1:35 pm DIALYSIS FLUID
**FINAL REPORT [**2163-2-27**]**
GRAM STAIN (Final [**2163-2-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2163-2-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
.
CXR: Likely mild atelectasis at the right lung base and scarring
in
the upper right lung. Stable PICC line. No edema.
.
[**2-23**] Liver US: 1. Multiple liver masses correspond with known
colon cancer metastases.
2. Findings are equivocal for acute cholecystitis as there is
mild
gallbladder dilation, stones, and sludge but lack of son[**Name (NI) 493**]
[**Name (NI) **]
sign and no biliary dilation. If concern remains, consider HIDA
scan after
consult with nuclear medicine in light of the patients depressed
liver
function.
,
[**2-26**] CT abd/pelvis: 1. No evidence of bowel obstruction.
Abdominal distension likely secondary
to large volume ascites.
2. Widespread hepatic metastases and omental caking/peritoneal
carcinomatosis.
3. Anasarca. Decreased size of pleural effusions when compared
to [**2163-2-3**], moderate on the right and small on the left.
.
Brief Hospital Course:
Please note the following summary is divided into sections based
on the patients complicated hospital course.
.
[**Hospital Ward Name 517**] Course:
A+P: 62 y/o man with metastatic carcinoma of unknown primary,
though likely GI/colonic, admitted with dehydration, abd pain
and fullness.
.
# Abdominal pain, peritonitis: Admitted for abdominal pain, N/V,
decreased PO intake. PTA pt was controlling his abdominal pain
secondary to extensive abdominal tumor burden by draining
approximately 1 L of ascites via his peritoneal port everyday.
Multiple etiologies were considered for the abdominal pain,
including peritonitis secondary to peritoneal port and frequent
access. Acute cholecysitis / cholangitis was also considered
because of rising LFTs on admission and an early US equivical
for sig pesued ns of acute cholecysitis. Intestinal obstruction
was also possible given he difficulty with BMs, N/V, and known
large colon mass. Analysis of peritoneal fluid showed 700 WBC
and 71% polys, and a culture grow coag negative staph which was
also in the blood confirming peritonitis. Therefore the
peritoneal port was removed. On [**2-25**] Nr [**Known lastname **] had [**11-12**] pain
and rebound and gaurding on exam and vomiting and further
imaging was obtained. On MRCP did not show any evidence of
biliary tree obstruction. CT abd with PO contrast showed
extensive mets but no evidence of intestinal obstruction. Mr
[**Known lastname **] was treated with a Dilaudid PCA for pain control. He was
started on Vancomycin and Zosyn for peritonitis, narrowed to
vancomycin on [**2-27**]. Nausea /vomitting controled with zofran,
phenegram, zyprexa. ID was consulted for advice on whether the
GPC in blood, peritoneal fluid represents infection vs
comtamination and if the PICC line needed to be removed. They
agreed should be treated with IV vanco for 2 weeks and that the
PICC line could remain. The pt was subsequently placed back
Zosyn.
.
# Dehydration: Dehydrated on admssion [**3-7**] Poor po intake, N/V,
and ongoing third spacing from hypoalbuminemia. Getting TPN.
Holding diuretics. Received blood 1/24 in hope of increasing the
fluid keep intravasculary.
.
# Metastatic Carcinoma: no tissue diagnosis, but likely colonic.
Treatments should be considered palliative at this point given
extent of disease and poor functional status. Already has colon
stent in plan. Oncology consult was obtained. The patient and
family does not wish to persue a liver bx for tissue diagnosis.
The patient remained full code after long discussion and the
decision to start aggressive chemotherapy was possible was made.
Transfered to OMED for possible FOLFOX. The patients severe
tumor burden and rapidly accumilating ascites is a major
contributer to the abdominal pain. Palliative care consult was
obtain.
.
# ARF: Baseline Cr 1.1 peaked at 1.7. Likely secondary to
dehydration and intravascular hypovolemia. At first Cr worsened
with IVF. His diuretics were held. Urine Eos were negative and
FE urea was 41%, (<35% prerenal). However, latter the Cr
improved with IVF bolus. Foley was placed to monitor UO.
.
# ? aspiration: While getting PO contrast for CT via NG tube
vomitted NG tube up and most of contrast. Brief coughing and
desat, quickly resolved, now back on RA
.
# diabetes type I: continued on lantus and ISS, allthough
monitor for hypoglycemia in setting of imparied hepatic
function.
[**Hospital Unit Name 153**] Course:
The patient was with transferred to the [**Hospital Unit Name 153**] after sudden
tachypnea, w/o significant hypoxia (98% on 2L). Later on
developed hypotension down to 90/50 which was fluid responsive.
He also had change of mental status and was only oriented x 1.
His tachypnea was thought to be due to aspiration PNA and his
change of mental status to infection vs aspiration.
He developed worsening hypotension to the 80's unresponsive to
IVF. Dr. [**Last Name (STitle) **] met with the family and stated that chemo would
not be indicated in his current state. His family choose to
make him [**Last Name (STitle) 3225**] and antibiotics and other treatments were stopped.
He was treated with morphine prn for SOB.
Overnight his SBPs stabilized and his respiratory status
improved. By morning his mental status had cleared and he was
alert and oriented. Given his improvement he and his wife
wished to reverse his [**Name (NI) 3225**] status and revisit the issue of chemo.
He was restarted on vanc/zosyn and his other treatments.
OMED Course:
62 M with metastatic carcinoma of likely GI/colonic, transferred
to OMED for potential initiation of chemotherapy. His clinical
status been declining steadily and rapidly. Following discussion
with HCP (wife) it was decided not to pursue chemotherapy.
Patient was made comfort oriented and passed 2/9/9.
Medications on Admission:
ALLERGIES: NKDA
.
MEDICATIONS:
Glargine 7 units QPM
Lispro insulin
diazepam 5mg po Qhs prn insomnia
Lasix 40mg po Qday
Spironolactone 100mg po Qday
Lovenox 80mcg CS [**Hospital1 **]
colace
protonix
oxycodone 5-10mg prn
compazine prn
zofran prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
stage 4 cancer of GI origin
secondary bacterial peritonitis
acute renal failure
constipation
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2163-4-3**]
|
[
"250.03",
"584.9",
"995.92",
"338.3",
"038.19",
"197.6",
"555.9",
"996.69",
"V12.51",
"789.51",
"197.7",
"276.3",
"153.2",
"572.2",
"276.52",
"567.29",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.93",
"99.15",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10786, 10795
|
5671, 10460
|
376, 409
|
10932, 10941
|
2770, 3883
|
10997, 11034
|
2490, 2508
|
10754, 10763
|
10816, 10911
|
10486, 10731
|
10965, 10974
|
2523, 2751
|
3927, 5648
|
276, 338
|
437, 2094
|
2116, 2249
|
2265, 2474
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,316
| 114,630
|
34168
|
Discharge summary
|
report
|
Admission Date: [**2139-10-15**] Discharge Date: [**2139-10-21**]
Date of Birth: [**2085-2-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
tracheal stent placement
History of Present Illness:
This 54 yo woman with a history of obesity, asthma, anxiety,
kidney stones is transferred from [**Hospital3 **] after diagnosis of
MG (+ MUSK Ab) who is being admitted to the medical ICU
following respiratory decomposition after extubation following
placement of tracheal stent via elective rigid bronchoscopy.
She has had several recent decompositions from her myasthenia
over the past year, and most recently getting IVIG while
continuing on her cellcept, prednisone, amd pyridostigmine. She
has been recalcitrant to steroids in the past. She was last
admitted from [**2139-4-27**] - [**2139-5-26**] during which she had 3 tracheal
intubations (*Difficult airway/fiberscopic intubation) and
underwent plasmapheresis. She underwent trach/PEG placement on
[**2139-5-22**] by Dr. [**Last Name (STitle) **]. She was decanculated on [**2139-7-9**].
This morning, she had noted some increased tiredness and
diplopia,
She had tracheobronchomalacia on CT from the spring, and
underwent initial stent placement on [**2139-5-7**]. Y stent was
removed on [**2139-9-15**] and there was moderate granulation tissue
seen in the mainstem bronchi at that time. She was electively
admitted for Y-stent re-placement today, which occurred without
complication. She had cryotherapy to local granulation tissue.
After the extubation, the patient was noted to be hypoxic in the
PACU with O2 sats 70s-80s with mental status
change/unresponsiveness. She was on BiPap with improvement in
mental status and now weaned off to face tent.
Currently, she is complaining of severe headache mostly, which
has followed her General Anesthesia the last 3 procedures. Mild
dyspnea. She has some complaint of pain in her chest following
the stent, which she has had previously in same setting.
Past Medical History:
asthma
bronchitis
GERD
obesity
panic d/o
anxiety
s/p ccy
kidney stones
recent PNA with possible ards that improved on steroids
DMII, diet controlled
Social History:
No smoking, etoh, illicit drug use. Lives with son.
Family History:
Unknown
Physical Exam:
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL, EOM Full
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : upper airway transmitted wheezing, Diminished: at
bases)
Abdominal: Soft, Non-tender, No(t) Distended
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Not assessed, Tone:
Not assessed, UE [**3-28**] proxmially, [**4-27**] distally, LE [**4-27**] distally,
CN appear intact. No overt ptosis seen
Pertinent Results:
[**2139-10-21**] 05:05AM BLOOD WBC-9.4 RBC-5.05 Hgb-13.3 Hct-41.4 MCV-82
MCH-26.3* MCHC-32.1 RDW-14.8 Plt Ct-319
[**2139-10-15**] 08:42PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.9 Eos-0.7
Baso-0.2
[**2139-10-21**] 05:05AM BLOOD PT-12.2 PTT-22.7 INR(PT)-1.0
[**2139-10-21**] 05:05AM BLOOD Glucose-143* UreaN-9 Creat-0.7 Na-145
K-3.5 Cl-97 HCO3-41* AnGap-11
[**2139-10-21**] 05:05AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
[**2139-10-20**] 07:14AM BLOOD Type-ART pO2-123* pCO2-75* pH-7.42
calTCO2-50* Base XS-20
[**2139-10-20**] 01:13AM BLOOD Lactate-1.2
Sputum [**10-19**]: HEAVY GROWTH OROPHARYNGEAL FLORA
C. diff negative [**2139-10-16**]
CXR: [**10-20**]
FINDINGS: In comparison with the study of [**10-19**], there is little
change.
Bibasilar atelectasis without evidence of acute pneumonia.
CT-head: [**10-19**]
IMPRESSION: Study limited by motion artifact. However, no
evidence of acute intracranial hemorrhage or mass effect.
Spirometry:
SPIROMETRY Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.31 2.76 47 1.33 48 +2
FEV1 1.03 2.05 50 1.00 49 -3
MMF 0.97 2.53 39 0.78 31 -20
FEV1/FVC 79 75 106 75 101 -5
Brief Hospital Course:
Assessment and Plan
54 yo woman with [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**] on cellcept, mestinon, and
prednisone, GERD, anxiety, admitted to MICU for respiratory
distress following extubation for Y-stent replacement. DDx for
resp failure includes hypercarbia, hypoventilation from MG, or
aspiration process
# Respiratory Failure:
The patient had an elective stent replacement on [**2139-10-15**]. She
required admission to the ICU s/p procedure, however, for
hypoxia (70's-80's) and somnalnace requiring mask ventilation
thought secondary either to neuromuscular weakness (in context
of MG) causing hypoventialtion vs. obstruciton and collapse in
setting of bronch findings above.
.
In the ICU, the patient was started on BIPAP. She was given a
Z-pak for possible sinusitis and started on Tessalon Perles,
Mucinex, and Nebulized saline to aid in secretion clearance. She
was placed on an Insulin SS for her diabetes. She continued her
outpatient MG regimen of Prednisone 20mg [**Hospital1 **], Mestinone 50mg q4h
and Cellcept 1000mg PO BID. She was followed by IP s/p Y-stent
placement. She required only 1L o2 by NC. She was
tachychardicinto the 150's while in the ICU; this was thought
2dary to anxiety. A neurology consult was requested; the
neurology team noted that the patient had not taken her
Pyridostigmine since the day before the procedure. They
additionally recommended infectious work-up in case infection
was triggering an exacerbation of MG. A Trial off BIPAP was
attempted on [**10-17**] but she failed, but the team was successful
in subsequent weaning such that on the day of transfer, she
required only 3 hours Bipap and was breathing 97% on 2L NC. She
did have new complaints suggestive for possible hospital aquired
PNA, and was started on Vancomycin but not Ceft/Zosyn.
Although her pCO2 was elevated, she was clinically stable and
thought to be stable for transfer from the ICU. She was briefly
transferred to the floor and then returned to the ICU with
hypertension and respiratory distress likely secondary to flash
pulmonary edema. She was stablized overnight and returned to
the floor. The patient was continued on nebs, but still
continued to have difficulty breathing and was not at her
baseline status. The patient continued to be increasingly
anxious to go home and decided the leave AMA. The patient
understood the risks, but felt that she stable enough to return
home. The patient was setup with follow-up appointments and
will return for an outpatient bronch in approx one week.
.
#) Myasthenia [**Last Name (un) **]
- Neurology consulted for possibility of MG component to
respiratory status, however given NIFS were -80 it was thought
that her MG was under control. She was continued on her
prednisone, mestinone, and cell cept. She had one episode of
diplopia that self-resolved.
#) Tracheomalacia
s/p Y stent
# Anxiety/panic d/o: The patient had continued anxiety during
her admission. She was continued on paxil 15 mg daily.
Additionally, the patient was treated with xanax 0.125mg prn.
# DM: stable, followed FSG and covered with RISS
.
#Tachycardia: Pt had sinus tachycardia and was started on 30mg
diltiazem. The patient was stable and her sinus tachycardia was
likely secondary to anxiety. She was not continued on diltiazam
upon discharge.
.
#Diarrhea: The patient had compliants of loose stools. The
patient states that these symptoms had occured for awhile prior
to admission. She stated it was well controlled by immodium
prior to admission. It was felt that her loose stools were
likely secondary to her Mestinon and she was restarted on
immodium.
.
#FEN:
- regular diet
- replete lytes PRN.
.
#ACCESS: PIV
.
#PPx: Heparin sub-q for DVT prophylaxis, bowel regimen, ppi,
.
#CODE: FULL.
.
#COMMUNICATION: Patient, sons: [**Name (NI) **], HCP ([**Telephone/Fax (1) 78744**],
[**Doctor Last Name **] (other son) ? [**0-0-**].
Medications on Admission:
ALENDRONATE 70 mg Tablet - qSun
FLONASE - 50 mcg Spray 2 sprays daily
OMEPRAZOLE - 40 mg [**Hospital1 **]
PAROXETINE HCL [PAXIL] - 15 mg daily
POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel. [**Hospital1 **]
CALCIUM CARBONATE [CALCIUM 500] - 1 tab TID
DEXTROMETHORPHAN-GUAIFENESIN [MUCINEX DM] - 1,200 mg-60 mg Tab,
Multiphasic Release 12 hr - 1 Tab(s) by mouth twice a day
Compazine 5mg PO PRN
RISS
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed.
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
Sunday.
11. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
spary Nasal once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Hypercapneic respiratory failure
Secondary:
Bronchitis
GERD
obesity
panic d/o
anxiety
s/p ccy
kidney stones
DMII, diet controlled
tracheobronchomalacia s/p Y stent placement
Discharge Condition:
AGAINST MEDICAL ADVICE
Discharge Instructions:
YOU ARE LEAVING AGAINST MEDICAL ADVICE. The risks of leaving
were explained to you and you stated that you understood. You
were admitted to [**Hospital1 18**] for elective Y-stent replacement, but had
respiratory decompensation after the procedure. Your stay in
the ICU was complicated by continued respiratory distress,
hypertension and increased heart rate. You were stablized and
sent to the general medical floor for further management.
Please continue to take your medications as prescribed below.
Please follow-up with the appointments made below.
Please call your PCP or go to the ED if you experience worsening
shortness of breath, respiratory distress, cough, fevers,
chills, nausea, vomiting, diarrhea, chest pain or other
concerning symptoms.
Followup Instructions:
Interventional Pulm will call you regarding setting up an
outpatient bronchoscopy in 1 week. If you do not hear from them
in [**12-24**] days please call [**Telephone/Fax (1) 7769**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2139-10-29**] 11:15
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2846**]
Date/Time:[**2139-12-8**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-12-28**]
1:00
Completed by:[**2139-10-21**]
|
[
"787.91",
"784.0",
"518.81",
"278.00",
"493.90",
"519.19",
"401.9",
"300.00",
"358.00",
"427.89",
"518.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"32.01",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9803, 9861
|
4460, 8373
|
305, 331
|
10089, 10114
|
3233, 4437
|
10923, 11602
|
2382, 2391
|
8826, 9780
|
9882, 10068
|
8399, 8803
|
10138, 10900
|
2406, 3214
|
245, 267
|
359, 2124
|
2146, 2296
|
2312, 2366
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,032
| 190,953
|
45525
|
Discharge summary
|
report
|
Admission Date: [**2130-12-25**] Discharge Date: [**2131-1-2**]
Date of Birth: [**2074-11-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
Ventricular Tachycardia Ablation
History of Present Illness:
A 56 yoM with PMH medically managed inferior wall MI, anterior
wall MI s/p athrectomy in LAD, ischemic cardiomyopathy LVEF 15%
s/p BiV pacer and AICD, VT s/p ablation is transfered to [**Hospital1 18**]
from [**Hospital1 **] CCU for repeat VT ablation. Pt presented to
[**Hospital **] [**Hospital **] hospital [**12-24**] with SOB and presyncope x 2
days. He reports that he began feeling unwell and SOB [**12-23**] and
felt his AICD fire 1x, the symptoms gradually worsened and he
received another shock [**12-24**] prompting him to present to
[**Hospital1 **] where he was treated initially for heart failure with
furosemide 20mg IV and diuresed one liter. The morning of [**12-25**]
he had an episode of SVT vs VT which was self limited, a second
episode occurred and he received lopressor 5mg IV and ativan and
transfered to the CCU where he had another episode of SVT and
was treated with lidocaine 100mg bolus followed by drip at
2mg/min. He was transfered to [**Hospital1 18**] for evaluation for VT
ablation.
.
On arrival to the [**Hospital1 18**] CCU, his vitals were T:97.0 P:73
BP:108/65 RR:18 SaO2 97% 2L. Initial EKG revealed sinus rhythm
with RV paced beats at 91 BPM, and TWI in V5-V6, aside from
twave chanes EKG was similar to 5/[**2130**]. Shortly thereafter, he
had multiple runs of ventricular tachycardia lasting ~15
seconds. His pacer was interrogated which showed that the AICD
had fired twice on the day of arrival and that he had been ATP
paced out of VT multiple times throughout the day. The pacer was
changed from BiV pacing to LV then RV pacing, while on LV
pacing, multiple runs of VT occurred and fewer occurred while on
RV pacing. The pacer was left in RV pacing with a plan for VT
ablation.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Smoking: 30
pack years quit [**2111**].
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
IMI [**2111**]- medically treated
AMI [**2112**]- treated with atherectomy to proximal and mid LAD
[**2125**] DES to the LCx and OM
[**2130-6-7**] Cardiac catheterization: 90% stenosis of proximal LAD
with DES placed, 90% stenosis of Diagonal with DES placed.
.
[**2130-2-28**] Cardiac catheterization: mild left main disease. 60%
diffuse proximal LAD with 100% occlusion of the mid LAD after
the first diagonal. D1 with a 70% proximal stenosis. Left
circumflex is widely patent. RCA dominant vessel with a 100%
mid occlusion. The LAD fills via collaterals. The RCA fills via
bridging collaterals.
.
[**6-24**] Cardiac catheterization: Subtotal occlusion of the mid LAD,
occlusion of the mid RCA and an 80% mid circumflex lesion
involving the first OM branch. DES to LCx into OM1.
.
-PACING/ICD:
[**2125**] Dual chamber Guidant ICD
[**2-25**] Unsuccessful placement of LV pacing lead
[**3-1**] Upgrade to biventricular [**Company 2267**] Cognis 100 D ICD
[**3-1**] AV nodal ablation
[**1-29**] VT ablation
.
CARDIAC IMAGING:
[**2130-4-29**] Resting Thallium: large anterior, anteroapical, and
inferior scar. There was significant uptake in the anterior
lateral wall which improved on the second image consistent with
viable and hibernating myocardium.
.
[**1-/2130**]: Echocardiogram: Dialated left atrium. Right atrial
thrombus associated with pacer lead. Severely depressed LV
systolic function. [**1-21**]+ MR, aortic valve Lambl's excesences.
.
[**2127**] ECHO: LVEF 15%
[**6-/2125**] Echocardiogram: Severely dilated left ventricle. LVEF of
18%. Extensive nonviable myocardium involving the inferior wall,
mid and distal anterior and anteroseptal walls and apex.
Partial
viability in the basal anterior and anteroseptal walls.
Complete
viability in the inferior lateral wall. Moderate MR. [**Name14 (STitle) 97119**] of
47%. [**Hospital1 **]-atrial enlargement.
.
3. OTHER PAST MEDICAL HISTORY:
Moderate MR
[**Name13 (STitle) **] II-III NY Heart Association heart failure symptoms
PAF
HTN
Hyperlipidemia
[**2100**] Perforated gastric ulcer requiring surgical repair
Social History:
Retired telephone installation technician. Lives with wife, 3
living children.
-Tobacco history: 30 pack years quit [**2111**].
-ETOH: 2 beers 1-2x/week
-Illicit drugs: denies
Family History:
Mother died of a stroke in her 70's and his father died of Lung
cancer at age 47.
Physical Exam:
Admission:
GENERAL: Middle aged male appearing uncomfortable. AAOx3
HEENT: Pink conjuntiva, no oral pharyngeal erythemia, false
upper teeth, poor lower dentition.
NECK: No lymphadenopathy. Supple with JVP of 6 cm at 30 degrees.
CARDIAC: Distant heart sounds, S1, S2 RRR, no MRG. No S3.
LUNGS: Unlabored breathing, CTABL, no wheezes/ronchi/rales
ABDOMEN: Soft nontender non distended, BS normoactive. No HSM or
tenderness. No abdominial bruits.
EXTREMITIES: No edema.
SKIN: No stasis dermatitis, ulcers.
PULSES: DP 2+ BL, PT 1+BL.
.
Discharge
GENERAL: Middle aged male appearing comfortable. AAOx3
HEENT: Pink conjunctiva. No sig JVD
NECK: No lymphadenopathy.
CARDIAC: Distant heart sounds, S1, split S2 RRR, II/VI low
pitched holosystolic murmur at apex
LUNGS: Unlabored breathing, Insp crackles at L base, no
wheezes/ronchi
ABDOMEN: Soft nontender non distended, BS normoactive.
EXTREMITIES: No edema.
PULSES: DP 2+ BL, PT 1+BL.
Pertinent Results:
Admission
[**2130-12-25**] 04:54PM BLOOD WBC-7.2 RBC-4.50* Hgb-13.9* Hct-40.5
MCV-90 MCH-31.0 MCHC-34.3 RDW-13.3 Plt Ct-175
[**2130-12-25**] 04:54PM BLOOD Neuts-69.1 Lymphs-23.3 Monos-3.9 Eos-3.0
Baso-0.8
[**2130-12-25**] 04:54PM BLOOD PT-27.5* PTT-31.9 INR(PT)-2.7*
[**2130-12-25**] 04:54PM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-26 AnGap-11
[**2130-12-25**] 04:54PM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.4 Mg-2.0
[**2130-12-25**] 04:54PM BLOOD TSH-0.56
[**2130-12-25**] 04:54PM BLOOD Digoxin-0.8*
.
Discharge: .
[**2131-1-2**] 07:35AM BLOOD WBC-7.7 RBC-3.48* Hgb-10.5* Hct-31.6*
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.5 Plt Ct-195
[**2131-1-2**] 07:35AM BLOOD PT-26.2* PTT-29.5 INR(PT)-2.5*
.
Cardiac Cath [**12-27**]:Resting hemodynamics revealed mildly elevated
left sided filling pressure with mean PCWP 16 mmHg. There was
mildly elevated pulmonary arterial systolic pressure PASP
33mmHg, with a normal PVR. The cardiac index was depressed at
1.9L/min/m2.
FINAL DIAGNOSIS:
1. Mildly elevated left sided filling pressure and pulmonary
artery
pressure
2. Low cardiac output.
3. Low PVR.
.
CXR [**12-29**]: FINDINGS: No previous images. Endotracheal tube tip
lies above the clavicular level, approximately 7.5 cm from the
carina. A three-channel pacemaker-defibrillator device is in
place. Mild atelectatic changes are seen at the left base.
.
ECHO [**12-26**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 15-20 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. Right ventricular chamber
size is normal. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets are mildly
thickened (?#). There are filamentous strands on the aortic
leaflets consistent with Lambl's excresences (normal variant).
There is no aortic valve stenosis. The mitral valve leaflets are
moderately thickened. An eccentric, laterally directed jet of
severe (4+) mitral regurgitation is seen. There is no
pericardial effusion.Compared with the prior transesophageal
study (images reviewed) of [**2130-1-23**], left ventricular systolic
function is probably significantly worse although views are
suboptimal for comparison. Mitral regurgittaion is now worse.
Brief Hospital Course:
A 56 yoM with PMH CAD, inferior wall MI followed by anterior
wall MI with ischemic cardiomyopathy, and Ventricular
tachycardia admitted for evaluation of VT ablation and found to
be in VT storm.
.
# RHYTHM: Patient presented with SOB, presyncope, and recurrent
AICD firing. Interrogation of pacer revealed multiple episodes
of VT with ATP rescue consistent with VT storm. After admission,
pacer was changed from BiV pacing to RV pacing with
significantly deminished ectopy. Patient was maintained on
lidocaine drip with good control of VT. On HD1, lidocaine was
weaned and significant ectopy with VT ensued, patient remained
normotensive and complained only of palpatations. Lidocaine was
increased with improved control. Mexilitine was started and
lidocaine weaned with fair control of ectopy. On HD5, patient
went for VT ablation, which was successful. Dofetilide and
mexiletine were d/c and Quinidine gluconate 324 mg Q8H was
started [**1-1**] EKG checked [**1-2**] showed normal QTc. Patient was
discharged on quinidine with a plan for follow up with
electrophysiology.
.
# CORONARIES: Patient has significant CAD history with multiple
DES placed including to LAD, Lcx, OM and Diag. patient remained
hemodynamically stable throughout episodes of VT and suspicion
for myocardial ishcemia was low. He was continued on Clopidogrel
75 mg Daily, Aspirin 325 mg Daily, Atorvastatin 80 mg Daily. He
was on heparin drip post ablation and then restarted on
warfarin, which he will continue to take as an outpatient.
.
# PUMP: Patient has depressed LVEF, and chronic congestive heart
failure wiht systolic dysfunction. Last ECHO in [**1-/2130**] showed
severely depressed LV systolic function. He is anticoagulated
with warfarin for depressed EF and history of RA thrombus.
Continued Digoxin, Eplerenone. He had a right heart cath while
inpatient as the beginning of workup for possible heart
transplant. Right heart cath showed OCWO 16mmHg, low PVR, and a
depressed cardiac index of 1.9L/min/m2. Importantly, no
pulmonary hypertension was noted suggesting that he may be a
candidate for heart transplant. He will follow up with his
outpatient cardiologist regarding the remaining tests needed to
heart transplant.
.
# Epistaxis: On HD10 patient experienced an episode of severe
epistaxis while on heparin gtt, warfarin (INR <2), aspirin, and
plavix. ENT consult was consulted who cauterized a bleeding
vessel and packed his nose with dissolvable packing, achieving
adequate hemostasis. He was also started on clindamycin to
prevent toxic shock syndrome while nose was packed, and will
complete a 7 day course. He will follow up with ENT in [**3-23**] weeks
post-discharge.
.
# Hypertension: patient relatively hypotensive on admission with
SBP 108, and hypotensive were held. Metoprolol dose was changed
to 50mg [**Hospital1 **], eplerenone 25mg was continued and valsartan was
changed to 80mg daily.
.
# Back pain: Patient reported long standing lower back pain for
which he takes percocet as an out patient. He was treated with
oxycodone 5-10mg and given a prescription for a limited supply
of oxycodone on discharge.
.
# Depression: Continue home regimen of Citalopram 20 mg Daily.
.
# Insomnia: He was continued on home Zolpidem 10 mg Daily.
.
#CODE: FULL CODE Confirmed during this admission
.
COMM: patient, wife [**Name (NI) **] (cell) [**Telephone/Fax (1) 97120**].
Follow up: Appointments, as relayed to the patient.
Medications on Admission:
Atorvastatin 80 mg Daily
Citalopram 20 mg Daily
Clopidogrel 75 mg Daily
Digoxin 250 mcg Daily
Dofetilide 500 mcg [**Hospital1 **]
Eplerenone 25 mg Daily
Metoprolol succinate 50 mg [**Hospital1 **]
Nitroglycerin 0.4 mg Tablet, Sublingual PRN
Valsartan 160 mg Tablet Daily
Warfarin 5 mg Tue/Sat
Warfarin 7.5mg MWF Sunday
Zolpidem 10 mg Daily
Aspirin 325 mg Daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Outpatient Lab Work
Please check chem-7 and digoxin level on [**2131-1-5**] with results
to Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**0-0-**]
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for back pain.
Disp:*40 Tablet(s)* Refills:*0*
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
12. quinidine gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*2*
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes as needed for chest pain: take no
more than 2 tablets as directed.
14. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
15. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
16. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for epistaxis for 3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Chronic Systolic Congestive Heart Failure
Ischemic Cardiomyopathy
Epistaxis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to the CCU at [**Hospital1 18**] for management of your
recurrent ventricular tachycardia. You underwent VT ablation on
[**12-29**], which you tolerated well. You were also started on a new
medication for your rhythm called quinidine. You had some blood
in your stools that we think is because of hemmorrhoids. You
also had some bleeding from your nose, probably from the blood
thinners. You now have packing in the nose to prevent the
bleeding from starting again. Make sure you don't blow your nose
or lift anything more than 10 pounds for one week to allow the
nose to heal. You can use the oxymetazoline spray if the
bleeding starts but call Dr. [**Last Name (STitle) 39**] as well.
Medication changes:
1. Discontinue Dofetalide
2. Start quinidine to prevent ventricular tachycardia
3. Start Clindamycin to prevent an infection in your nose
because of the packing. You will take this for 2 more days.
4. Decrease Digoxin to 0.125mg daily ([**1-21**] pill)
5. Decrease Warfarin to 5 mg daily, please check your INR on
Friday
6. Use saline nasal spray twice daily to keep you nose moist.
7. Discontinue Percocet, take oxycodone instead for your back
pain
8. Decrease Valsartan to 80 mg, [**1-21**] pill, daily
9. Use oxymetazoline 0.05 % nasal spray if the bleeding starts
again. You should also call the ENT office at [**Telephone/Fax (1) 41**] to
discuss further treatment.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 20222**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Name: [**Last Name (LF) 20222**], [**First Name7 (NamePattern1) 3924**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART CENTER OF [**Hospital1 **]
Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 6256**]
Appointment: Monday [**1-22**] at 1:00PM
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2131-1-24**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: CARDIAC SERVICES
When: Monday [**2-19**] at 11:00am
With: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2131-1-2**]
|
[
"401.9",
"784.7",
"V45.02",
"427.1",
"414.8",
"428.22",
"V45.82",
"414.01",
"428.0",
"780.52",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
13599, 13605
|
8150, 11521
|
317, 351
|
13762, 13762
|
5634, 6613
|
15477, 16479
|
4582, 4666
|
11986, 13576
|
13626, 13741
|
11601, 11963
|
6630, 8127
|
13913, 14623
|
4681, 5615
|
2240, 4167
|
11533, 11575
|
14643, 15454
|
266, 279
|
379, 2105
|
13777, 13889
|
4198, 4370
|
2127, 2220
|
4386, 4566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,231
| 152,796
|
2582
|
Discharge summary
|
report
|
Admission Date: [**2174-11-21**] Discharge Date: [**2174-11-25**]
Date of Birth: [**2112-1-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Aspirin / E-Mycin / Sulfonamides / Latex /
Levofloxacin / Methotrexate / Codeine / Shellfish / Peanut Oil /
Corn
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Loss of upper and lower extremity function
Major Surgical or Invasive Procedure:
[**2174-11-21**]: C2-C6 posterior decompression and C3-C6 posterior
spinal fusion
History of Present Illness:
62M with idiopathic polyneuropathy s/p anterior disectomy,
fusion and grafting in early [**2165**], now with 3+ days of worsening
gait abnormalities, decreased coordination and falls. Presented
to [**Hospital1 **] after 3 falls and increased pain. At baseline, has no
bilateral lower extremity sensation but has motor function.
Bilateral proximal upper extremity weakness and positive right
Hoffmans
Past Medical History:
Idiopathic Peripheral Neuropathy
s/p sural nerve biopsy c/b chronic LE wound infection
S/P Discectomy/Fusion c/b Neck Wound Infection
UE Wounds/Cellulitis c/b 'Sepsis'
CAD/MI (Medical Rx; No PCI)
Hypertension
CRI (Baseline Cr 1.7-2.2)
Hypercholesterolemia
GERD
Cervical Spinal Stenosis
Obstructive Sleep Apnea,
Allergies/Asthma
RUL "Aspiration PNA" with Apical Scarring
Upper Extremity Tremor
Olecranon bursitis of L (x2) and R (x1) elbows
Diverticulitis
Osteoarthritis
Prinzmental??????s angina
NAFLD
Colitis
Diverticulitis
BPH
CTS
Social History:
On disability for past 5 yrs. Previously worked as an
electrical engineer. Lives in [**Location 13056**] with girlfriend. [**Name (NI) **]
EtOH. 120 pack year hx. Quit smoking over 15 years ago.
Family History:
Father died age 52 of lung cancer. Mother living with severe
vascular disease; MI at 80. Has 2 brothers, one with undefined
immunodeficiency disorder and MI at 38. Mr. [**Known lastname 13057**] has daughter
with Crohn??????s and son with [**Name2 (NI) **]. One son without medical problems.
Physical Exam:
Intact bicepts flexion bilaterally, no use of hands, no
sensation in hands, hip flexors intact bilaterally, no more
distal motor function, no sensation in legs.
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service.
Medicine was consulted for pre operative evaluation. He was
taken to the Operating Room for the above procedure on [**2174-11-21**].
Refer to the dictated operative note for further details. The
surgery was without complication and the patient was transferred
to the ICU intubated in a stable condition. TEDs/pnemoboots
were used for postoperative DVT prophylaxis. Intravenous
antibiotics were continued for 24hrs postop per standard
protocol.
Initial postop pain was controlled with IV medications. He was
weaned from the vent in the ICU and remained stable. He was
extubated on POD2. His neurologic status was stable compared to
his pre op exam. On POD2 his hemovac drain was removed and he
was started on sub Q heparin for DVT prophylaxis.
Diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet.
Foley was removed. 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. His exam at the time of discharge
was mildly improved with 3-4/5 grip and foot dorsi/plantar
flexion bilaterally, [**4-17**] hip flexion bilaterally, [**4-17**] bicepts
bilaterally, sensation to elbow level bilaterally and sensation
to hip level bilaterally.
Medications on Admission:
Vitamin E, [**Doctor First Name **]-D, Citalopram, Mobic, darvocet, Uroxatral,
MVI, Vit c, Proscar, hydrocortisone cream, isosorbide dinitrate,
nitrotabs, lopressor, neruontin, albuterol, prevacid
Discharge Medications:
1. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1)
Tablet PO DAILY (Daily).
2. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
7. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO Daily ().
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold if sbp < 100.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold if sbp < 100.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever. Tablet(s)
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
16. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
19. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for please give 20 minutes prior to PT:
please give 20 minutes prior to PT sessions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
Severe Cervical Spinal Stenosis
Discharge Condition:
stable
Discharge Instructions:
Activity: You should not lift anything greater than 10 lbs.
Cervical Collar / Neck Brace: You need to wear the brace at all
times.
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. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home medications.
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 narcotic prescriptions
(oxycontin, oxycodone, percocet) to the 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, drainage from your wound, or have any questions.
Followup Instructions:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
|
[
"721.1",
"413.9",
"414.01",
"272.0",
"788.20",
"585.9",
"493.90",
"723.0",
"412",
"530.81",
"515",
"327.23",
"403.90",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"00.94",
"02.95",
"81.02",
"77.79",
"02.94",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
5938, 6008
|
2241, 3706
|
436, 520
|
6084, 6093
|
7457, 7586
|
1743, 2041
|
3953, 5915
|
6029, 6063
|
3732, 3930
|
6117, 6250
|
2056, 2218
|
354, 398
|
6262, 7434
|
548, 952
|
974, 1511
|
1527, 1727
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,452
| 102,322
|
20774+20775
|
Discharge summary
|
report+report
|
Admission Date: [**2148-6-27**] Discharge Date: [**2148-6-27**]
Date of Birth: [**2128-1-16**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old
male status post motor vehicle collision unrestrained driver
with airbag deployment. Positive loss of consciousness;
however, GCS of 15 on scene. The patient was intubated for
airway protection due to severe midface injuries with
aspiration of blood. Hemodynamically stable, but was not
moving legs prior to intubation. The patient received Solu-
Medrol bolus in field and was started on the 23-hour steroid
protocol.
PAST MEDICAL HISTORY: None.
MEDICATIONS AS AN OUTPATIENT: None.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.1, blood
pressure 137 over palp, pulse is 68, respiratory rate is 16,
oxygen saturation is 100 percent on ventilator settings
unknown. HEENT: Right frontal positive mid face fracture
unstable, positive laceration on neck. Cervical spine C-
collar in place. No step off noted. Chest is clear to
auscultation bilaterally. Abdomen is soft and nondistended.
Pelvis stable, no rectal tone. Guaiac negative.
Extremities, positive ecchymosis, no abrasion noted. Pulses
2+ throughout. Neurological exam, pupil [**4-2**] bilaterally, not
responding to pain. Back spine, no step off or contusion
noted.
LABORATORY DATA: On admission, INR 1.3, CBC 15.6/43.5/221,
sodium 141, potassium 3.1, chloride 109, glucose of 153, and
lactate 2.9 and ABG 7.3/42/133/21/-5. Imaging on admission,
CT of the head and face is positive for nasal bone fracture
with ethmoid opacification. CT of the spine is negative. CT
of the chest, right upper lobe, right lower lobe collapse,
left first rib fracture. CT of the abdomen and pelvis are
negative. CT of the TLS showed T12 burst fracture with
retropulsed fragment, hecal sac impingement. MRI of the T-
spine confirmed T12 burst fracture with slight ligamentous
disruption, 50 percent narrowing of the spinal canal with
increased T2 signal. Note that C-spine was also included in
this study, which showed no abnormalities.
HOSPITAL COURSE: In brief, the patient was admitted to the
ICU for administration of the steroid protocol. ICU stay
significant for the placement of an IVC filter on hospital
day number 6. The patient also underwent an anterior fusion
on hospital day number 3, which necessitated six units of
blood loss. The patient was therefore transfused
accordingly. The patient returned to the OR on hospital day
number 6 for a posterior fusion of T9-L2. The patient was
extubated successfully on hospital day number 8. The patient
had some residual agitation requiring extra time in the ICU.
The patient was successfully transferred to the floor on the
hospital day number 11. Hospital floor course was
unremarkable. The patient was alert, oriented, and mental
status was appropriate throughout the remainder of the
hospital course. The patient was evaluated accordingly by
Physical and Occupational Therapy, also a Social Work
counsel. The patient's IVC filter was removed without
complications in conjunction with the Orthopedics team. The
patient was discharged to rehab in stable condition. The
patient's nasal fracture was reduced successfully by the LNF
service without complications.
DISCHARGE MEDICATIONS:
1. Albuterol one to two puffs q. 4-6h p.r.n.
2. Colace 100 mg b.i.d.
3. Lovenox 30 mg subcutaneous b.i.d.
4. Hydromorphone 2 mg p.o. q. 3-4h p.r.n.
The patient is to follow up with Dr. [**Last Name (STitle) 363**] in one week. The
patient will also follow up in the Trauma Clinic in two
weeks. The patient will also follow up with LNF surgery
after his discharge from rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 55422**], [**MD Number(1) 55423**]
Dictated By:[**Last Name (NamePattern1) 27758**]
MEDQUIST36
D: [**2148-7-8**] 11:53:06
T: [**2148-7-9**] 02:33:03
Job#: [**Job Number 55424**]
Admission Date: [**2148-6-27**] Discharge Date: [**2148-7-10**]
Date of Birth: [**2128-1-16**] Sex: M
Service: TRA
ADDENDUM:
FINAL DIAGNOSIS: Paraplegia.
Closed head injury.
Cord injury/T12 burst fracture with cord impingement.
Left first rib fracture.
Aspiration with right upper lobe, right lower lobe collapse,
status post bronchoscopy.
Stellate laceration to face and nose.
Bilateral nasal bone fracture.
SURGICAL/INVASIVE PROCEDURES: Anterior and posterior spinal
fusion, C9 to L2, done in without separate operations, [**6-29**]
and [**7-2**].
Nasal bone fracture reduction [**2148-6-28**].
Bronchoscopy [**2148-6-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 27758**]
MEDQUIST36
D: [**2148-7-10**] 07:20:05
T: [**2148-7-10**] 07:41:47
Job#: [**Job Number 55425**]
|
[
"807.01",
"518.0",
"E815.0",
"934.8",
"850.5",
"873.49",
"806.25",
"861.21",
"802.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"96.72",
"77.71",
"81.04",
"03.09",
"33.22",
"21.71",
"81.63",
"77.79",
"81.05",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
3319, 4118
|
2119, 3296
|
4136, 4901
|
708, 2101
|
165, 617
|
640, 685
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,529
| 182,956
|
31876
|
Discharge summary
|
report
|
Admission Date: [**2128-8-23**] Discharge Date: [**2128-9-2**]
Date of Birth: [**2061-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Cholangitis -> transfer for ERCP
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is a 67 yo M with h/o CAD s/p CABG [**2125**], CHF, AF on coumadin,
T2DM, obesity, ESRD on HD, who initially presented on [**8-18**] to
[**Hospital3 **] with N/V and fever/chills after HD and was found to
have cholangitis and cholelithiasis. The patient had been
experiencing intermiteent n/v for the last 2 mo following
dialysis, as well as after eating. The pt reports decreased POs
during this time. After HD on [**8-18**], the patient experienced
additional n/v with RUQ abd pain, and was taken to the OSH ED
for evaluation.
.
In the ED at OSH, his T 102.6 with BP 110/76 initially. Labs
were notable for Tbili 5.7, AP 800, [**Doctor First Name **] 213 and INR 5.8 (given
vit K). RUQ showed cholelithiasis with CBD 2.5cm. Pt
subsequently became hypotensive to the 80s sytolic and was
started on dopamine, switched to levophed, as well as empiric
Vanco/Zosyn for presumed cholangitis. He was transferred to the
ICU for further monitoring. In the ICU, a LIJ and RSC line were
placed (under sterile conditions). On [**8-19**] he underwent ERCP
showing a 10mm stone in the distal CBD. Stent was successfully
placed (spincterotomy was deferred given oozing from site and
coagulopathy for which he received 3 units FFP). Post ERCP he
developed pancreatitis (Lip >10K, [**Doctor First Name **] 2K). His [**Doctor First Name **]/Lip
subsequently trended down, and his LFTs/Tbili remained unchaged
from admission. His INR also trended down to 1.5. He underwent
HD on [**2128-8-20**]. TTE showed EF 60% with dilated RA/RV with RV
systolic dysfxn. However, given the need for further
intervention he was transferred to [**Hospital1 18**] for sphicterotomy. On
transfer, he was still on levophed at 2-3mcg/min, vanco/zosyn,
with negative cultures to date and stable VS.
.
On arrival to the [**Hospital1 18**] ICU, the patient reported feeling well.
He reported mild RUQ abd pain, but no CP, SOB, nausea. He was
awake and alert.
.
Past Medical History:
CAD, s/p MI/CABG [**2125**], no stents
Diastolic CHF with TTE [**8-23**] with EF 60%, RA/RV dilatation, RV
syst dysfxn, LVH
AFib on coumadin
Type 2 DM
Morbid obesity
ESRD on HD qMWF, has left arm fistula -> nephrologist Dr. [**Last Name (STitle) 72152**]
HTN
Hyperlipidemia
OSA not on BiPAP
COPD
patient reports hx "stroke last year that left my right eye
blind"
Social History:
The patient lives at home alone. Former truck driver. Has 80
pack yr smoking history, quit 15yrs ago. Former heavy EtOH use.
Daughter [**Name (NI) **] lives in area [**Telephone/Fax (1) 74754**]
Family History:
Non-contributory
Physical Exam:
VS T 97.4 BP 105/54 HR 62 RR 17 O2 Sat 97% 4L
Gen: Obese, jaundiced male, awake, alert, NAD
HEENT: NC/AT, EOMI, R cataract appreciated, incteric sclera, OP
clear
NECK: LIJ CVL intact, supple, no LAD, could not appreciate JVP
COR: S1S2, irregular, + S3
PULM: CTA bilat ant/lat, adequate inspiratory effort
ABD: obese, soft + RUQ tenderness, no guarding/rebound neg
[**Doctor Last Name **] sign, + BS
Skin: warm extremities, jaundiced, scattered ecchymoses
EXT: 2+ DP, no edema/c/c, no CVA tenderness, no calf tenderness
Neuro: awake, alert, moving all extremities, no gross deficits
appreciated
Pertinent Results:
Labs at OSH:
Lab: 5.7 T bili, Dbili 4.6, INR 1.7, WBC 12.1, Hct 36.7, plt
198, Na 133, K 4.8, Cl 82, HCO3 22
Troponin 0.08.
.
Admission Labs at [**Hospital1 18**]:
Chemistries:
Na 137 K 4.9 Cl 92 HCO3 21 BUN 66 Cre 8.6 Glucose 118
ALT(SGPT)-28 AST(SGOT)-57* LD(LDH)-176 ALK PHOS-312*
AMYLASE-255* TOT BILI-5.3* Lipase 168
ALBUMIN-3.3* CALCIUM-9.2 PHOSPHATE-7.9* MAGNESIUM-2.4
.
Hematology:
WBC-13.9* RBC-3.86* HGB-11.7* HCT-37.0* MCV-96 MCH-30.4
MCHC-31.8 RDW-17.3*
PLT COUNT-254
PT-16.0* PTT-31.1 INR(PT)-1.5*
.
Imaging:
RUQ US
1. Extra-hepatic biliary ductal dilatation. No calculi
visualized in the limited evaluation of the common bile duct.
2. Cholelithiasis, no evidence of acute cholecystitis.
3. Coarse liver echotexture.
.
Abd CT from OSH: dilated CBD at 2.5cm, cholelithiasis, adrena
adenoma, fatty infiltration of liver, small bowel diverticula
.
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is >20
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 60%). There is no ventricular septal defect. The
right ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
ERCP:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: A plastic stent placed in the biliary duct was
found in the major papilla. The stent was in good position and
was draining bile.
Biliary Tree: A single 10mm stone that was causing partial
obstruction was seen at the upper third of the common bile duct.
Otherwise the common bile duct, common hepatic duct were
partially filled with contrast and appeared normal. Given
suspicion of cholangitis, fully opacification of the biliary
tree was not performed.
Procedures: A plastic stent was removed.
A 8cm by 10fr Cotton-[**Doctor Last Name **] biliary stent was placed successfully
using a Oasis system stent introducer kit.
Impression: Stent in the major papilla - this was removed.
Stone in the bile duct, otherwise limited cholangiogram.
A biliary stent was inserted.
..
..
Discharge labs:
Source: Line-Left AV Fistula
135 96 42 214 AGap=21
4.0 22 7.3
Ca: 8.5 Mg: 2.0 P: 5.3 D
ALT: 15 AP: 241 Tbili: 2.1 Alb:
AST: 17 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 94
Source: Line-Left AV Fistula
CBC:
WBC:6.6 plt:144
Crit:35.1
N:81.1 L:11.7 M:4.5 E:2.3 Bas:0.4
Source: Line-Left AV Fistula
PT: 23.7 PTT: 41.5 INR: 2.4
Brief Hospital Course:
A/P: 67 M with CAD s/p CABG, Afib, DM2, ESRD on HD, with
cholangitis/cholelithiasis with gallstone in CBD, pancreatitis,
hypotension, transferred from OSH for repeat ERCP and definitive
management.
.
1) Cholelithiasis/Cholangitis: The patient presented with
fevers/chills, RUQ pain, jaundice consistent with cholangitis.
Found to have gallstone in distal CBD. He underwent stenting at
[**Hospital6 **] with good bile flow. His fevers improved as
did his LFTs. He was transferred here for repeat ERCP. He
underwent ERCP on [**8-24**]. The original stent was replaced with
larger stent but a sphincterotomy was not performed because of
the patient's coagulopathy. On presentation he was placed on
vancomycin and zosyn for empiric antibiotic coverage and prior
to leaving MICU his vancomycin was discontinued. All blood
cultures here were negative. His LFTs continued to trend down.
He will undero repeat ERCP and elective sphincterotomy as an
outpatient with Dr. [**Last Name (STitle) **] at [**Hospital3 2568**] (in several weeks vs. with
Dr. [**First Name (STitle) **] [**Name (STitle) **] here once his inflammation has improved. He
is scheduled with Dr. [**Last Name (STitle) **] here for [**10-28**] at 8AM. Will need
to be off coumadin at least 5 days in case of need of
sphincterotomy. Got 7 days of zosyn and 4 days of cipro/flagyl,
should have 3 more days of cipro/flagyl. Should have INR
checked as below as well as lft's, lipase on [**9-3**] dialysis
.
2) Pancreatitis: Amylase and Lipase elevated on admission. This
was felt to be most likely secondary to post-ERCP pancreatitis
but could also be secondary to known gallstone disease. His
triglycerides were within normal limits. His amylase and lipase
are trending down, compared to OSH values. Last lipase 94.
Diet full over last two days without nausea or abdominal pain.
Lipase with dialysis on [**9-3**] should be checked.
3) Hypotension: On presentation the patient was hypotensive to
80s systolic. At the outside hospital a central line was placed
given concern for sepsis and he was started on levophed. On
arrival here he continued to be hypotensive and levophed was
continued. Clinically, however, the patient appeared quite
well. Given the patient's severe peripheral vascular disease and
clinical appearance there was suspicion that the low blood
pressure readings were not accurate. On [**8-24**] an arterial femoral
line was placed to allow for better blood pressure measurement.
These measurements were significantly higher and the levophed
was discontinued. All blood cultures have been negative. He
underwent cortisol stim test which was normal. He had an
echocardiogram which showed a preserved LVEF but a dilated
hypocontractile right ventricle. Cardiac enzymes were
significant for a troponin of 0.3 which was stable x 3 sets. He
underwent dialysis on [**8-25**] without evidence of hypotension. His
arterial line was discontinued prior to transfer to the floor.
He continued to have sbp's by cuff of 80's to 100's throughout
stay without change in clinical status, afebrile. ON discussion
with PCP and patient, this is his baseline bp since CABG over
1.5 years ago. Given echo findings, suspect secondary to RCA
infarction at that time. Of note, also bradycardic to 50's
throughout stay, also baseline. Got albumin with dialysis on
[**9-1**] to help with hypotension during dialysis.
.
4) ESRD: Anuric at baseline. Disease likely related to diabetes
and hypertension. Currently he receives dialysis MWF per left
sided fistula. There was no acute indication for hemodialysis
on the day of arrival. He underwent dialysis on [**8-25**] and through
[**9-1**](last) He was continued on his phoslo. He will resume his
outpatient HD schedule. As noted, albumin with dialysis on [**9-1**].
[**Hospital1 18**] nephrology contact[**Name (NI) **] outpatient providers with update.
Epo continued as well here.
.
5) CAD/CABG: Patient with h/o MI in [**2125**] with CABG. Currently
CP free. Not on outpatient ASA for unclear reasons. PCP front
desk confirmed he is on Zocor 80 but have not yet restarted this
given his acute liver issues this admission. Not on a beta
blocker as he has had underlying asymptomatic bradycardia HR
50-60s throughout his stay. Outpatient lisinopril being held
given hypotension. Discharge [**Male First Name (un) **] aspirin as no clear
indications, zocor 10mg with planned titration and no beta
blocker given relative bradycardia and no lisionopril given bp
ranging 80's to 100's.
6) Diastolic CHF: TTE at OSH with EF60%. Likely diastolic
component. Repeat echo here with preserved EF but evidence.
Overall fluid overloaded without pulmonary edema. Continue
diuresis with dialysis as bp allows. No beta blocker or ace as
above. Of note, RV hypocontactile as above, likely accounting
for hypotension and bradycardia--?rca territory infarct
7) Atrial Fibrillation: Patient currently self-rate controlled
with HR in the 50s, underlying rhythm is Afib. His coumadin was
held prior to ERCP and he was placed on a heparin drip at OSH,
continued here. Heparin gtt d/c'ed [**8-25**] (does not have other hx
such as mechanical valve to warrant a bridge. His CHADS2 score
= 5, event rate per year is 4.6, so should be OK with
subtherapeutic INR for brief period) Received vit K at OSH.
Coumadin 5mg from [**Date range (1) 74755**]. None on [**9-1**] evening. iNR 2.4 on
[**9-1**], re-started 2.5mg qhs on [**9-2**] given concurrent cipro/flagyl
and poor PO. INR should be checked on [**9-3**] at dialsysi and
coumadin adjusted for goal INR 2-2.5 .
8) DM type 2: Patient with good glycemic control at OSH per
records. Given that the patient was NPO he was placed on a
sliding scale and his long acting insulin was held. With
increased PO, starting 10NPH [**Hospital1 **] and continuing humalog sliding
scale. Outpt dose was 60U NOvolin qAM and 40U NOvolin qPM.
Will need to be titrated.
.
9) COPD: Not on oxygen at home. He received nebulizers PRN with
good effect. Sounds like chronic bronchitis and emphysema.
WOuld benefit from flovent or advair as outpatient depending on
pft's, needs pft's.
10) OSA: has underlying OSA, says he doesn't use CPAP. Observed
to have brief apneic periods while asleep here.
11)BAck pain, lumbar: darvocet as outpatient continued and
dilaudid prn initiated with variable control.
Discussed with Dr. [**Last Name (STitle) 74756**] on day of discahrge. D/c summary
to be faxed to him at [**Telephone/Fax (1) 74757**]
Medications on Admission:
Coumadin
Lisinopril
PhosLo 667mg QID
Novolin 60 units qAM, 40units qPM
Ambien 10mg qHS
MVI
Darvocet 100mg q4 prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): patient needs INR check on [**9-3**].
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: dose after dialysis on dialysis
days.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qAM: normally on Novolin 60U qAM.
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qPM: Patietn usually takes 40U Novolin qPM.
8. Humalog 100 unit/mL Cartridge Sig: see attached scale units
Subcutaneous as directed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours): back pain.
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: back pain.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY (): 12 hours on
and 12 hours off to lower back.
13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) as
directed Injection ASDIR (AS DIRECTED): with dialysis.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Outpatient Lab Work
CBC, alt, ast, alkaline phosphatase, lipase, PT, PTT, INR and
chem -10 to be drawn at dialysis [**9-3**]. Result to treating
physician at [**Name9 (PRE) **] [**Name9 (PRE) 41402**]
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
1. Cholangitis
2. Choledocholithiasis with obstruction
3. Pancreatitis
Secondary:
1. CKD stage V on HD
2. Coronary Artery disease
3. Atrial Fibrillation
4. Type II DM, uncontrolled with neuropathy, nephropathy
5. Lumbar back pain
6. Neuropathy
Discharge Condition:
Stable, tolerating PO, afebrile.
Discharge Instructions:
Follow up as below. A doctor will be seeing you at Life Care
[**Location (un) 2199**]. Dr. [**Last Name (STitle) 74756**] will continue to follow you as your
primary care doctor.
If you develop fevers, chills, abdominal pain, worsening nausea,
any other concerning complaints, contact your doctor or go to
the emergency room.
All medications as prescribed. I have made multiple changes.
Followup Instructions:
Follow up with the ERCP doctors here at [**Hospital3 **] as
scheduled:Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2128-10-28**] 8:00
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2128-10-28**] 8:00
..
..
Follow up with your kidney doctor, Dr. [**Last Name (STitle) **]. You will get
dialysis at [**Hospital1 8**] as usual. Our kidney doctors [**Name5 (PTitle) **] discuss
your care with him.
FOllow up with Dr. [**Last Name (STitle) 74756**]. You should see him within the
next few weeks once you are feeling a bit better. The doctors
at [**Name5 (PTitle) 2199**] [**Name5 (PTitle) **] lcommunicate with him. His number is [**Telephone/Fax (1) 74758**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,316
| 194,502
|
1543+1544
|
Discharge summary
|
report+report
|
Admission Date: [**2102-12-18**] Discharge Date: [**2102-12-22**]
Date of Birth: [**2039-4-19**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS:
The patient is a 63-year-old male with history of Down's
syndrome sent to the [**Hospital1 69**] for
a temperature of 100.3, dark-cloudy urine, and lethargy. In
the ambulance, the patient had some apnea which resolved
after coughing. The patient had a recent admission to [**Hospital1 1444**] for aspiration pneumonia
complicated by sepsis.
In the Emergency Room the patient was started on ceftriaxone
and Flagyl and sent to the floor. On the floor, the patient
became hypotensive to a systolic blood pressure in the 70s.
The urinalysis was positive and the chest x-ray was equivocal
for a new pneumonia. The patient received 5 liters of normal
saline on the floor, and was started on Neo-Synephrine drip.
Soon after transfer to the MICU, the blood pressure improved.
The pressures greater than 120/70.
PAST MEDICAL HISTORY:
1. Down's syndrome.
2. Hypothyroidism.
3. Adrenal insufficiency secondary to use of Megace.
4. Aspiration pneumonia.
5. PEG on [**2102-8-9**].
6. Status post pacemaker for complete heart block.
7. Upper gastrointestinal bleed secondary to gastric ulcer.
8. Peripheral vascular disease.
9. Atlantoaxial subluxation.
ALLERGIES:
No known drug allergies.
MEDICATIONS ON TRANSFER:
1. SubQ heparin.
2. Albuterol and Atrovent nebs prn.
3. Clindamycin IV.
4. Levofloxacin IV.
5. Neo-Synephrine.
6. GGT.
SOCIAL HISTORY:
Nursing home resident.
PHYSICAL EXAMINATION (ON ADMISSION TO THE MICU):
Temperature equals 100.0. Pulse equals 67-89. Respiratory
rate equals 14-23. Blood pressure equals 89-136/70-93. O2
sat equals 98-99%. General appearance: The patient is awake
and alert in no acute distress. Patient is not cooperative
on examination. HEENT: Normocephalic, atraumatic. Eyes
examination not tolerated. Oropharynx clear. No jugular
venous distention. No lymphadenopathy. Supple neck. Lungs:
Coarse rhonchi diffusely. Cardiovascular: Regular, rate,
and rhythm, normal S1, S2, no murmurs appreciated. Back: No
costovertebral angle tenderness. Abdomen: Normoactive bowel
sounds, soft, nontender, nondistended. G tube in place.
Extremities: No clubbing, cyanosis, or edema. Pulses
palpable distally. Neurologic: The patient is responsive
and moves all four extremities spontaneously.
LABORATORY DATA:
White blood cells 7.9, hematocrit 34.0, platelets 392,000.
Sodium is 145, potassium 4.2, chloride 107, bicarb 34, BUN
25, creatinine 0.9, glucose 107. Urinalysis: Hazy, positive
nitrates, greater than 50 white blood cells, many bacteria.
Chest x-ray questionable right base opacity, appearing to be
present on previous studies.
SUMMARY OF HOSPITAL COURSE:
The patient is a 63-year-old male presenting from nursing
home with a urinary tract infection. Became hypotensive on
the medical floor and was then transferred to the Intensive
Care Unit for further care. Patient became septic on the
floor and in addition was markedly dehydrated. Patient
received 5 liters of normal saline while on the floor and
antibiotics with marked improvement in blood pressure. In
the past the patient had secondary adrenal insufficiency due
to use of .................... discontinued several months
ago.
The patient may have had an aspiration pneumonia secondary to
mental status changes caused by his urinary tract infection.
While in the Intensive Care Unit, the patient's urinary tract
infection was treated with ceftriaxone with the possibility
of aspiration pneumonia. Patient was started on Flagyl. In
addition Vancomycin was started because the patient had
multiple cultures in the past that were resistant to
antibiotics including methicillin-resistant Staphylococcus
aureus.
Patient remained afebrile during hospital course as well as
normal white blood cell count. When initially in the
Intensive Care Unit, the patient's pressor was changed from
Neo-Synephrine to Levophed. Levophed was eventually weaned
to off, and patient was hemodynamically stable with normal
saline fluid boluses prn. Patient eventually no longer
required any fluid boluses to maintain systolic blood
pressures in the 100s. While in the Intensive Care Unit, the
patient's secretion management improved as well with the
suctioning required every 1-2 hours with improvement to
suctioning of every 3-4 hours.
On [**2102-12-21**], the patient's antibiotics were changed.
Levofloxacin was added and ceftriaxone was discontinued for
the purposes of covering Pseudomonas which grew out in sputum
cultures. On [**2102-12-22**], a cosyntropin (ACTH) stimulation test
was performed. The results are pending. The patient had a
random cortisol baseline of 12.
On [**2102-12-22**], the patient was transferred to the medical floor
in hemodynamically stable condition. Vancomycin was
discontinued and the patient was maintained on po
levofloxacin as well as po Flagyl.
After stable condition on medical floor, the patient will be
transferred back to his nursing home.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE DIAGNOSES:
1. Urinary tract infection.
2. Pneumonia versus tracheobronchitis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2102-12-22**] 12:02
T: [**2102-12-22**] 12:05
JOB#: [**Job Number 9020**]
Admission Date: [**2102-12-18**] Discharge Date: [**2102-12-22**]
Date of Birth: [**2039-4-19**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS:
The patient is a 63-year-old male with history of Down's
syndrome sent to the [**Hospital1 69**] for
a temperature of 100.3, dark-cloudy urine, and lethargy. In
the ambulance, the patient had some apnea which resolved
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for aspiration pneumonia
complicated by sepsis.
In the Emergency Room the patient was started on ceftriaxone
and Flagyl and sent to the floor. On the floor, the patient
became hypotensive to a systolic blood pressure in the 70s.
The urinalysis was positive and the chest x-ray was equivocal
saline on the floor, and was started on Neo-Synephrine drip.
Soon after transfer to the MICU, the blood pressure improved.
The pressures greater than 120/70.
PAST MEDICAL HISTORY:
1. Down's syndrome.
2. Hypothyroidism.
3. Adrenal insufficiency secondary to use of Megace.
4. Aspiration pneumonia.
5. PEG on [**2102-8-9**].
6. Status post pacemaker for complete heart block.
7. Upper gastrointestinal bleed secondary to gastric ulcer.
8. Peripheral vascular disease.
9. Atlantoaxial subluxation.
ALLERGIES:
No known drug allergies.
MEDICATIONS ON TRANSFER:
1. SubQ heparin.
2. Albuterol and Atrovent nebs prn.
3. Clindamycin IV.
4. Levofloxacin IV.
5. Neo-Synephrine.
6. GGT.
SOCIAL HISTORY:
Nursing home resident.
PHYSICAL EXAMINATION (ON ADMISSION TO THE MICU):
Temperature equals 100.0. Pulse equals 67-89. Respiratory
rate equals 14-23. Blood pressure equals 89-136/70-93. O2
sat equals 98-99%. General appearance: The patient is awake
and alert in no acute distress. Patient is not cooperative
on examination. HEENT: Normocephalic, atraumatic. Eyes
examination not tolerated. Oropharynx clear. No jugular
venous distention. No lymphadenopathy. Supple neck. Lungs:
Coarse rhonchi diffusely. Cardiovascular: Regular, rate,
and rhythm, normal S1, S2, no murmurs appreciated. Back: No
costovertebral angle tenderness. Abdomen: Normoactive bowel
sounds, soft, nontender, nondistended. G tube in place.
Extremities: No clubbing, cyanosis, or edema. Pulses
palpable distally. Neurologic: The patient is responsive
and moves all four extremities spontaneously.
LABORATORY DATA:
White blood cells 7.9, hematocrit 34.0, platelets 392,000.
Sodium is 145, potassium 4.2, chloride 107, bicarb 34, BUN
25, creatinine 0.9, glucose 107. Urinalysis: Hazy, positive
nitrates, greater than 50 white blood cells, many bacteria.
Chest x-ray questionable right base opacity, appearing to be
present on previous studies.
SUMMARY OF HOSPITAL COURSE:
The patient is a 63-year-old male presenting from nursing
home with a urinary tract infection. Became hypotensive on
the medical floor and was then transferred to the Intensive
Care Unit for further care. Patient became septic on the
floor and in addition was markedly dehydrated. Patient
received 5 liters of normal saline while on the floor and
antibiotics with marked improvement in blood pressure. In
the past the patient had secondary adrenal insufficiency due
to use of Megace, which has been discontinued several months
ago.
The patient may have had an aspiration pneumonia secondary to
mental status changes caused by his urinary tract infection.
While in the Intensive Care Unit, the patient's urinary tract
infection was treated with ceftriaxone with the possibility
of aspiration pneumonia. Patient was started on Flagyl. In
addition Vancomycin was started because the patient had
multiple cultures in the past that were resistant to
antibiotics including methicillin-resistant Staphylococcus
aureus.
Patient remained afebrile during hospital course as well as
normal white blood cell count. When initially in the
Intensive Care Unit, the patient's pressor was changed from
Neo-Synephrine to Levophed. Levophed was eventually weaned
to off, and patient was hemodynamically stable with normal
saline fluid boluses prn. Patient eventually no longer
required any fluid boluses to maintain systolic blood
pressures in the 100s. While in the Intensive Care Unit, the
patient's secretion management improved as well with the
suctioning required every 1-2 hours with improvement to
suctioning of every 3-4 hours.
On [**2102-12-21**], the patient's antibiotics were changed.
Levofloxacin was added and ceftriaxone was discontinued for
the purposes of covering Pseudomonas which grew out in sputum
cultures. On [**2102-12-22**], a cosyntropin (ACTH) stimulation test
was performed. The results are pending. The patient had a
random cortisol baseline of 12.
On [**2102-12-22**], the patient was transferred to the medical floor
in hemodynamically stable condition. Vancomycin was
discontinued and the patient was maintained on po
levofloxacin as well as po Flagyl.
After stable condition on medical floor, the patient will be
transferred back to his nursing home.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE DIAGNOSES:
1. Urinary tract infection.
2. Pneumonia versus tracheobronchitis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2102-12-22**] 12:02
T: [**2102-12-22**] 12:05
JOB#: [**Job Number 9020**]
|
[
"038.9",
"507.0",
"758.0",
"276.5",
"599.0",
"482.1",
"244.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10567, 10909
|
8228, 10513
|
5630, 6421
|
6821, 6941
|
6443, 6796
|
6957, 8200
|
10537, 10546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,590
| 121,871
|
33614+33615+57861
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2112-6-4**] Discharge Date: [**2112-6-17**]
Date of Birth: [**2031-10-23**] Sex: F
Service: SURGERY
Allergies:
Benzodiazepines / Vancomycin / Oxycontin / Rifampin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient has had several recent admissions for chronic abdominal
pain related to cholecystitis. Patient had a percutaneous
Cholecystotomy tube placed on [**4-25**]. Now returns with a dislodged
tube.
Major Surgical or Invasive Procedure:
Status Post laparoscopic cholecystectomy.
History of Present Illness:
Patient admitted on [**2112-5-30**] with nausea and abdominal pain for
several days. Admitting diagnosis was pancreatitis, urinary
tract infection, and dehydration. Patient stabilized and sent
back to her nursing home with plans to return in 3 weeks for a
cholecystectomy.
Patient returned with a dislodged cholecystotomy tube on [**2112-6-3**].
Past Medical History:
Hypertension
Cholelithiasis,
T11-L1 osteomyelitis (s. epi, [**Female First Name (un) **]) c/b sepsis,
breast ca,
rotator calf injury R,
Past surgical history: status post Bilateral total hip
replacement THR,
status post L mastectomy,
status post L ankle repair
Social History:
Lives at [**Hospital 14468**] Nursing Home
Family History:
NC
Physical Exam:
Vital Signs: temperature 96.9, heartrate 96, respiratory rate
28, 1.5 liters nasal prongs.
NAD
Cardiovascular: tachycardia
Respiratory: clear to auscultation bilaterally.
Abdomen: large, soft, chole tube out
extremities: 4+ pitting edema/anascara
positive CSM, palpable pulses, cold exremities
Pertinent Results:
[**2112-6-3**] 06:05AM BLOOD WBC-9.9# RBC-3.08* Hgb-9.1* Hct-27.2*
MCV-88 MCH-29.6 MCHC-33.6 RDW-14.9 Plt Ct-276
[**2112-6-6**] 10:06AM BLOOD WBC-16.6* RBC-2.94* Hgb-8.5* Hct-25.8*
MCV-88 MCH-29.0 MCHC-33.1 RDW-15.0 Plt Ct-380
[**2112-6-3**] 06:05AM BLOOD Plt Ct-276
[**2112-6-6**] 02:14AM BLOOD PT-17.5* PTT-41.3* INR(PT)-1.6*
[**2112-6-6**] 10:06AM BLOOD Glucose-102 UreaN-7 Creat-0.3* Na-141
K-3.2* Cl-112* HCO3-22 AnGap-10
[**2112-6-3**] 06:05AM BLOOD Amylase-112*
[**2112-6-6**] 04:12AM BLOOD CK(CPK)-43
[**2112-6-6**] 10:06AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.0
[**2112-6-5**] 10:48AM BLOOD Glucose-93 Lactate-1.9 Na-135 K-3.6
Cl-113* calHCO3-18*
[**2112-6-5**] 01:39PM BLOOD Lactate-3.0*
[**2112-6-17**] 05:10AM BLOOD WBC-9.4 RBC-2.97* Hgb-8.3* Hct-27.1*
MCV-91 MCH-28.0 MCHC-30.7* RDW-14.3 Plt Ct-498*
[**2112-6-5**] 10:35AM BLOOD PT-19.5* PTT-48.9* INR(PT)-1.8*
[**2112-6-14**] 02:02AM BLOOD PT-13.4 PTT-37.3* INR(PT)-1.2*
[**2112-6-3**] 06:05AM BLOOD Glucose-79 UreaN-6 Creat-0.2* Na-138
K-3.9 Cl-110* HCO3-21* AnGap-11
[**2112-6-17**] 05:10AM BLOOD Glucose-101 UreaN-15 Creat-0.3* Na-137
K-3.9 Cl-94* HCO3-40* AnGap-7*
[**2112-6-3**] 06:05AM BLOOD Amylase-112*
[**2112-6-4**] 08:47AM BLOOD ALT-12 AST-22 CK(CPK)-21* AlkPhos-165*
Amylase-77 TotBili-0.4
[**2112-6-6**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe global left ventricular hypokinesis with relatlively
preserved basal inferior and inferolateral function (LVEF = 25
%). No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. with moderate global free
wall hypokinesis. 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 appears structurally normal with trivial
mitral regurgitation. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. The pulmonic valve leaflets are
thickened. There is no pericardial effusion.
[**2112-6-15**] 07:00AM BLOOD ALT-5 AST-12 AlkPhos-159* Amylase-31
TotBili-1.5
Brief Hospital Course:
Patient readmitted with dislodged cholecystotomy tube. On
[**2112-6-5**] patient was taken to the operating room for
cholecystectomy. Intraoperatively patient had hypotension and
ventricular tachycardia requiring cardioversion times two.
Postoperatively she was transferred to the intensive care unit.
In the intensive care unit she remained intubated. She was
eventually weaned off the vent and extubated on [**6-9**]. She
continued on a face tent and this was weaned off as her
saturations tolerated.
The patient was transferred to the floor for continued
monitoring on [**6-14**].
Cardiovascular - An ECHO performed on [**6-6**] showed no significant
change from an ECHO performed on [**6-3**]. She initially required
vasopressors for blood pressure control. These were
progressively weaned off as tolerated. She was started on
amiodarone for atrial fibrillation with an initial IV bolus of
150 and maintained on an IV drip for 24 hours. She was then
switched to PO amiodarone.
GI - The patient remained NPO following surgery until [**6-9**] when
a dobhoff feeding tube was placed. Tube feeds were started and
advanced as tolerated to goal. She was evaluated by speech and
swallow and initiated on pureed, nectar thick fluids. She will
be reevaluated again in the nursing home to advance her diet as
necessary.
FEN - She was started on a lasix drip on [**6-7**] to facilitate
fluid overload. The lasix drip was stopped on [**6-9**]. She
continued with prn lasix for fluid overload.
Heme - The patient required two units of red blood cells on [**6-7**]
for a hematocrit of 24.8 and responded appropriately.
ID - She was initially placed on unasyn post operatively which
was discontinued on [**6-7**]. She was then placed on Zosyn on [**6-8**]
for a two week course for blood cultures positive for GPR. She
continued on fluconazole for previous history of osteomyelitis.
Medications on Admission:
atenolol 25", fluconazole 200', lexapro 20', protonix, percocet,
methadone 12.5", tylenol, colace, senna, MOM, [**Name (NI) **] 0.25"
Discharge Medications:
1. Nystatin 100,000 unit/g Ointment [**Name (NI) **]: One (1) Appl Topical
QID (4 times a day) as needed.
2. Miconazole Nitrate 2 % Powder [**Name (NI) **]: One (1) Appl Topical TID
(3 times a day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1) ml
Injection TID (3 times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: as directed
Injection ASDIR (AS DIRECTED).
7. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Escitalopram 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
9. Methadone 5 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times a
day).
10. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours).
11. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a
day).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to L
shoulder on 12h, off 12h. Adhesive Patch, Medicated(s)
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to R
shoulder on 12h, off 12h.
14. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Last Name (STitle) **]: 2.5 Tablets
PO DAILY (Daily).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
16. Ropinirole 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
17. Atenolol 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
18. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: with 10 cc
ns flush.
19. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: Two (2) ml Injection [**Hospital1 **]
(2 times a day).
20. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Hospital1 **]: 4.5 gr Intravenous Q8H (every 8 hours): for 9 more days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Chronic cholecystitis
Ventricular fibrillation
Atrial fibrillation
Discharge Condition:
Fair
Discharge Instructions:
Please call your surgeon or return to the emergency room if you
have a fever greater than 101.5, chills, shortness of breath,
chest pain, nausea, vomiting, increasing or purulent drainage
from your wound or any other symptom that should worry you.
Please monitor fluid balance daily, your balance should be
roughly equal for intake (oral food and liquid) and output
(urine and stool). Your daily weight should remain stable. If
you gain more than 5 pounds, take one extra lasix tablet. If
you lose more than 5 pounds, do not take your lasix tablet that
day.
Followup Instructions:
PROVIDER: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] building [**Location (un) 470**] Friday [**7-1**] at
1 pm
Speech and swallow evaluation will be done at Nursing home to
advance her diet.
Completed by:[**2112-6-17**] Admission Date: [**2112-6-19**] Discharge Date: [**2112-6-22**]
Date of Birth: [**2031-10-23**] Sex: F
Service: SURGERY
Allergies:
Benzodiazepines / Vancomycin / Oxycontin / Rifampin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Readmitted from [**Hospital 14468**] Nursing home for IV access and
anorexia.
Major Surgical or Invasive Procedure:
PICC line Placement
History of Present Illness:
Patient was discharged on [**2112-6-17**] status post laparoscopic
cholecystectomy with intraoperative v-fib arrest. Patient
readmitted for IV access to complete course of zosyn for
cholecystitis per infectious disease. Her family also noted that
she was not tolerating her pureed diet.
Past Medical History:
Hypertension
Cholelithiasis,
T11-L1 osteomyelitis (s. epi, [**Female First Name (un) **]) c/b sepsis,
breast ca,
rotator calf injury R,
Past surgical history: status post Bilateral total hip
replacement THR,
status post L mastectomy,
status post L ankle repair
Social History:
Lives at [**Hospital 14468**] Nursing Home
Family History:
NC
Physical Exam:
Vital signs: 97 Heartrate 65 blood pressure 133/66 respiratory
rate 18, 98% on RA.
No apparent distress
Comfortable
NCAT
no lad or masses
CV: RRR
Resp: bilateral coarse bilaterally
Abdomen: nondistended, slightly hypoactive bowel sounds, soft,
nontender throughout.
Mild peripheral edema
Pertinent Results:
[**2112-6-19**] 02:15PM BLOOD WBC-12.1* RBC-3.18* Hgb-9.1* Hct-28.6*
MCV-90 MCH-28.5 MCHC-31.7 RDW-15.2 Plt Ct-866*#
[**2112-6-22**] 06:30AM BLOOD WBC-10.9 RBC-2.87* Hgb-8.1* Hct-25.9*
MCV-91 MCH-28.1 MCHC-31.1 RDW-15.7* Plt Ct-978*
[**2112-6-19**] 02:15PM BLOOD Glucose-91 UreaN-10 Creat-0.4 Na-138
K-3.9 Cl-97 HCO3-35* AnGap-10
[**2112-6-22**] 06:30AM BLOOD Glucose-79 UreaN-6 Creat-0.3* Na-137
K-3.8 Cl-97 HCO3-35* AnGap-9
[**2112-6-19**] 02:15PM BLOOD ALT-8 AST-16 AlkPhos-245* TotBili-1.2
[**2112-6-21**] 05:45AM BLOOD ALT-6 AST-13 AlkPhos-209* Amylase-25
TotBili-1.1
[**2112-6-19**] 02:15PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
[**2112-6-22**] 06:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
[**2112-6-19**] CXR
IMPRESSION:
1. No definite evidence of pulmonary edema within the limits of
this portable examination with poor inspiratory effort.
2. Persistent small left pleural effusion with presumed
relaxation atelectasis. A focal pneumonia within this region
cannot be excluded.
[**2112-6-19**] Right upper extremity ultrasound
IMPRESSION: No evidence of right upper extremity deep venous
thrombosis.
[**2112-6-21**] PICC line placement
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French double-lumen PICC line placement via the right brachial
venous approach. Final internal length is 40 cm, with the tip
positioned in SVC. The line is ready to use.
Microbiology
Urine positive for enterococcus. Foley changed on [**2112-6-22**],
urinanalysis is negative. Infectious disease consulted, they
feel this is colonized and no treatment is indicated except for
periodic catheter changes.
Brief Hospital Course:
Patient readmitted on [**2112-6-19**] from [**Hospital 14468**] Nursing Home when
they were unable to get intravenous access to give her
intravenous antibiotics. Family also noted she was unable to
tolerate the pureed foods at the nursing home and was taking in
very little. Chest x-ray done which was consistent with prior
reads. PICC line attempted but unable to do secondary to edema
of upper extremities. Upper extremitie ultrasound performed
which was negative for clot. Peripheral line attempt was
sucessful and patient resumed her zosyn course. Speech and
swallow revaluated patient and found that she is able to take
thin liquids and ground food instead of pureed. Urine culture is
positive for enterococcus. Infectious disease consulted, urine
culture is negative for infection so they believe that this is
colonization and no treatment is required beyond regular
catheter changes.
Problems
1. Iv access - PICC line placed. Has one more day of Zosyn.
2. Anorexia - Patient eating better now that she can eat thin
liquids/ground. We have also ordered supplements between meals.
3. Enterococcus in Urine - colonized, no treatment necessary.
4. Infectious Disease r/t osteomyelitis - follow up with
physician who ordered her fluconazole. Does not need follow up
with infectious disease at [**Hospital3 **].
5. CAD/CHF - continue current medication regimen with attention
paid to fluid status as lasix may need to be adjusted.
6. Follow up with Dr. [**Last Name (STitle) **] in 3 weeks.
Medications on Admission:
nystatin topical QID, hep SC tid, miconazole 2% topical TID,
prilosec 30', amio 200', celexa 20', methadone 12.5'',
fluconazole 200', captopril 6.125'', lidocaine patch, CaCO3
1250', lasix 20'', zosyn 4.5 IV Q8h due to stop [**6-25**], [**Month/Day (4) **]
0.25''
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) ml
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Cream [**Month/Day (4) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. Nystatin 100,000 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed.
4. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Escitalopram 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Methadone 5 mg Tablet [**Hospital1 **]: 2.5 Tablets PO BID (2 times a
day).
7. Fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
8. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Hospital1 **]: 2.5 Tablets
PO QID (4 times a day) as needed.
9. Ropinirole 0.25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
10. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for to left shoulder.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for to right shoulder.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: 4.5 gr Intravenous Q8H (every 8 hours): may discontinue on
[**5-24**].
15. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Month/Year (2) **]: One
(1) ML Intravenous every eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Failure to thrive and loss of IV access
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have 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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2112-7-22**] 1:00
Infectious Disease - Please follow up with your initial
physician who follows your osteomyelitis.
Completed by:[**2112-6-22**] Name: [**Known lastname 4609**],[**Known firstname 12571**] Unit No: [**Numeric Identifier 12572**]
Admission Date: [**2112-6-19**] Discharge Date: [**2112-6-22**]
Date of Birth: [**2031-10-23**] Sex: F
Service: SURGERY
Allergies:
Benzodiazepines / Vancomycin / Oxycontin / Rifampin
Attending:[**First Name3 (LF) 559**]
Addendum:
PICC line was placed for intravenous antibiotics for the chronic
cholecystits and fluids.
Stage 2 decubitis Ulcer is unchanged.
[**First Name8 (NamePattern2) 1239**] [**Last Name (NamePattern1) **] NP
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12573**] Nursing & Rehabilitation Center - [**Location (un) 4534**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2112-7-7**]
|
[
"575.12",
"401.9",
"427.41",
"785.51",
"427.1",
"V43.64",
"785.52",
"427.31",
"999.31",
"782.3",
"995.92",
"E879.8",
"412",
"038.8",
"V10.03",
"715.90",
"428.22",
"V58.61",
"783.0",
"414.01",
"458.29",
"707.03",
"E878.8",
"428.0",
"996.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.04",
"96.6",
"51.23",
"99.07",
"38.93",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
17959, 18224
|
12501, 13995
|
9836, 9858
|
16220, 16229
|
10865, 12478
|
17063, 17936
|
10537, 10541
|
14309, 16002
|
16157, 16199
|
14021, 14286
|
16253, 17040
|
10356, 10460
|
10556, 10846
|
9719, 9798
|
9886, 10174
|
10197, 10333
|
10476, 10521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,904
| 180,714
|
45566
|
Discharge summary
|
report
|
Admission Date: [**2174-4-22**] Discharge Date: [**2174-8-23**]
Date of Birth: [**2108-4-21**] Sex: M
Service: SURGERY
Allergies:
Oxycodone/Acetaminophen / Hydrocodone / Shellfish Derived
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatocellular carcinoma
Major Surgical or Invasive Procedure:
[**2174-4-22**] right trisegmentectomy
picc line
post pyloric feeding tube
ercp
paracentesis
intubation
Chest pigtail drain
History of Present Illness:
Per Dr.[**Name (NI) 1369**] operative note as follows:
65-year-
old male who was noted to have elevated liver function tests.
A CT scan of the chest and abdomen was obtained demonstrating
a large mass in the right lobe of the liver and a CT-guided
biopsy demonstrated hepatocellular carcinoma. A CT of the
chest and abdomen at [**Hospital1 18**] on [**3-8**] demonstrated a 4.9 x
10.6 x 10.4 cm mass involving the right lobe of the liver and
the medial segment of the left lobe (segments 4, 5, and 8)
which demonstrates washout on delayed images and exerts mass
effect on the portal vein branches without any clear
thrombosis or invasion. There was no ascites and the liver
contour appeared smooth. There was no evidence of portal
hypertension. The bone scan was negative. Hepatitis B
serology was negative. AFP was 21. He subsequently underwent
portal vein embolization in preparation for a right hepatic
trisegmentectomy. He subsequently became jaundiced and
underwent ERCP for compression of the biliary tree secondary
to the tumor mass. He has otherwise remained stable. He is
now brought to the operating room after informed consent was
obtained for right hepatic trisegmentectomy, cholecystectomy,
and intraoperative ultrasound.
Past Medical History:
PMH hypertension, type 2 diabetes mellitus, peripheral
neuropathy, and benign colonic polyps.
PSH: trauma to his left hand requiring repair of his middle and
ring finger in [**2168**], and bilateral wrist carpal tunnel syndrome
in [**2169**] requiring surgical correction
R portal vein embolization [**2174-3-22**]
[**2174-4-22**] Right hepatic trisegmentectomy, cholecystectomy,
intraoperative ultrasound.
Social History:
diabetic diet. He has a history of significant alcohol
intake with approximately 21 drinks per week, but he quit in
[**2173-12-17**]. He has a history of smoking but quit 30 years ago.
He has an occasional social cigarette. He has no history of IV
drug use, marijuana use, blood transfusions, tattoos, hepatitis,
or piercing. married and has two children. He is a retired
program manager for [**Company 22916**]. He has a bachelor's degree
Family History:
Non-contributory
Physical Exam:
At Admission to OR
Gen: NAD, AxOx3, generalized yellowing of skin
HEENT: + scleral icterus, dry MM, no cervical lymphadenopathy
Card: RRR, no bruits, no MRG
Lungs: CTAB
Abd: + bs, no rebound/guarding, non-tender, distended
extrem: no edema, 2+ DP pulses b/l,
skin: warm, dry with sl jaundice
Neuro: no asterixis, no focal deficit
Pertinent Results:
At Admsiion: [**2174-4-22**]
WBC-9.3 RBC-3.26* Hgb-10.3* Hct-29.6* MCV-91# MCH-31.7 MCHC-34.9
RDW-16.4* Plt Ct-148*
PT-13.8* PTT-31.1 INR(PT)-1.2*
Glucose-106* UreaN-15 Creat-1.1 Na-143 K-3.9 Cl-106 HCO3-19*
AnGap-22*
ALT-1333* AST-2410* AlkPhos-95 TotBili-5.0*
Albumin-4.0 Calcium-10.0 Phos-5.0* Mg-1.5*
At Time of discharge
[**2174-8-22**] WBC-11.8* RBC-3.19* Hgb-10.3* Hct-32.0* MCV-100*
MCH-32.2* MCHC-32.1 RDW-25.8* Plt Ct-83*
PT-17.8* PTT-47.3* INR(PT)-1.6*
Glucose-156* UreaN-111* Creat-4.5* Na-145 K-3.1* Cl-104 HCO3-20*
AnGap-24*
Calcium-8.8 Phos-4.8* Mg-3.0*
ALT-43* AST-76* AlkPhos-166* Amylase-42 TotBili-30.1*
Brief Hospital Course:
On [**2174-4-22**], patient underwent right hepatic trisegmentectomy,
cholecystectomy, with intraoperative ultrasound for HCC. Surgeon
was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for
details. Postop, he was transferred to the SICU for management.
Postop course was long and complicated with sequelae from liver
that was small for size. He developed recurrent ascites
requiring intermittent paracentesis, jaundice and confusion.
Hospital course was further complicated by acute renal failure
with persistently elevated creatine levels. Patient also
developed several episodes of melena requiring mulitple
transfusions to stabilize his HCT levels. During hospital course
patient required mulitple ICU stays. LFTs remained elevated
during entire hospital course, especially alkaline phosphatase
and bilirubin levels. Worsening renal function was noted with
rising BUN and Cr. Patient ultimately expired on POD123 due to
multiple episodes of bradycardia with decreased O2 saturation
and ultimately respiratory failure.
Significant events during hospital course are as follows:
He was found to have thrombosis of the main portal vein, splenic
vein and superior mesenteric vein on [**5-1**]. IV heparin was
started. Head was negative for bleed or stroke. Rifaximin and
lactulose were started for prevention of encephalopathy. There
was an unsuccessful attempt to recanalize the portal vein due to
inability to advance a guidewire into the main portal vein. The
pleura was traversed upon percutaneous attemt at accessing the
portal vein. CXR within angio suite demonstrated no
pneumothorax.
Bile Leak: Due to rising bilirubin levels, patient underwent
ERCP on [**2174-6-7**], which showed that previously inserted stent had
migrated proximally into the CBD. This stent was removed. [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 97186**] was seen. Injection of contrast showed disruption of
the biliary tree with extravasation of contrast into the liver
parenchyma.
Blood cultures were positive for enterococci on [**5-9**], so patient
was started on vancomycin and continued through [**5-24**]. Subsequent
blood cultures were negative. Urine culture from [**5-10**] grew yeast
and patient received fluconazole from [**Date range (1) 22229**]. Repeat urine
cultures on [**6-9**] were positive for VRE, and patient was started
on linezolid.
Pleural Effusion: CXR on [**8-3**] was significant for R pleural
effusion. Right pigtail catheter was placed and drained 2L of
serosanguinous fluid. Pigtail catheter was left to suction and
removed when drainage had subsided. Fluid was sent for analysis
and did not reveal any signs of infection or active bleeding.
Despite catheter placement, subsequent CXRs demonstrated
persistence of the stable pleural effusion.
Melena: On [**2174-8-3**], patient began to have several episodes of
dark, melanotic stools. Blood pressure became more labile into
the 80-90s systolic, and HCT began to fall. Patient was
transfused pRBCs to maintain HCT, and patient was transferred to
the ICU. Melana continued periodically throughout the remainder
of hospital course, occasionally requiring additional
transfusions. During final week of hospital course, HCT remained
stable in the upper 20s, and melena stopped. EGD was performed
on [**2174-8-3**] that showed high risk esophageal varices, but these
were not felt to be the cause of the bleeding. Colonoscopy on
[**2174-8-3**] showed clot in the rectum, but no signs of active
bleeding.
SBP: Patient required multiple paracenteses during his hospital
course. On [**2174-7-25**], peritoneal fluid tested positive for MRSA.
Patient was started on Vancomycin.
Nutrition/physical therapy: Throughout long hospital course
patient's nutritional status declined. Tube feeds were on/off
throughout his course with attempts at using various formulas to
improve nutritional status. TPN was also used. PO intake was
continually encouraged, but patient was unable to take adequate
po nutrition. As patient remained in bed for such a long time,
he became progressively more deconditioned. Physical therapy was
consulted throughout the hospitalization to work with the
patient. As patient became weaker, he was unable to engage in
significant physical therapy exercises, and consequently became
more deconditioned.
On POD 122, patient began to have episodes of bradycardia, with
heart rates into the high 20s. These episodes were accompanied
by O2 desaturations into the 60s. Patient's mental status
declined as he became minimally responsive. On POD 123, episodes
of bradycardia and desaturation continued. The family was
notified and patient was made DNR/DNI. The patient ultimately
expired at 10:19 am on [**2174-8-23**] with his family at the bedside.
Medications on Admission:
lisinopril 20 mg daily
amlodipine 10 mg daily
ciprofloxacin 500 mg daily
ursodiol 600 mg [**Hospital1 **]
glimepiride 2 mg daily prn glucose > 200
sitagliptin-metformin 50-500 mg [**Hospital1 **]
hydromorphone prn
docusate [**Hospital1 **]
diphenhydramine prn itching
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired; liver failure, cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2174-8-25**]
|
[
"707.05",
"729.2",
"276.7",
"789.59",
"E878.1",
"250.62",
"486",
"572.3",
"038.9",
"261",
"112.2",
"584.9",
"557.0",
"570",
"357.2",
"572.2",
"401.9",
"155.0",
"995.91",
"707.22",
"452",
"305.1",
"276.2",
"996.59",
"729.92",
"868.04",
"799.4",
"456.21",
"V12.72",
"112.0",
"250.82",
"E885.9",
"518.81",
"V85.1",
"289.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.04",
"96.71",
"54.91",
"51.10",
"86.27",
"34.91",
"96.04",
"88.64",
"99.15",
"34.04",
"51.22",
"45.24",
"49.21",
"97.55",
"50.22",
"45.23",
"45.13",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8852, 8861
|
3672, 7425
|
341, 468
|
8951, 8960
|
3025, 3649
|
9013, 9175
|
2641, 2659
|
8823, 8829
|
8882, 8930
|
8530, 8800
|
8984, 8990
|
2674, 3006
|
7443, 8504
|
277, 303
|
496, 1733
|
1755, 2165
|
2181, 2625
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,065
| 143,239
|
44778+58756
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-12-16**] Discharge Date: [**2200-12-22**]
Date of Birth: [**2121-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine / Sulfur / Hydrochlorothiazide / Lipitor
/ simvastatin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2200-12-16**] Coronary Artery Bypass surgery
(LIMA-LAD,SVG-RPDA,SVG-OM1, SVG-OM2)
History of Present Illness:
79 year old female with complaints of recurrent angina.She
remembers feeling pain like this in the past, when she had her
last MI 10years ago. Presented in [**10-21**] to ER, and was taken for
cardiac cath. During catheterization she had 4 BM stents placed
and also has two vessel disease. She is now being referred to
cardiac surgery for CABG after her 30 days of plavix. This drug
will be continued until surgical date is set.
Past Medical History:
CAD s/p MI with 2 stents and angioplasty [**2190**] (cardiac cath
showed single vessel disease with stenting to the LAD
percutaneous transluminal coronary angioplasty of diagonal. LAD
had an 80%
proximal lesion, 70% mid lesion, and diagonal branch had 90%
lesion.
1. CARDIAC RISK FACTORS: +Diabetes (last HbA1C 7.2%),
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- s/p hysterectomy for fibroids
- CVA, [**2-/2197**] Acute left PCA infarct
Social History:
Lives at home alone. Retired bookkeeper.
- Tobacco history: Denies
- ETOH: Denies
- Illicit drugs: Denies
Family History:
- Mother: had few MIs, died of MI at age 61
- Father: had emphysema
- Mother's brother: died of MI at age 47
Physical Exam:
Pulse:78 Resp:18 O2 sat:99%
B/P R 179/90 L 166/82
Weight:78.8 kgs
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable; very
mild ptosis R eyelid
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] 2-3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]; no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema [] none
Varicosities: None [x]
Neuro: Grossly intact [x],MAE [**5-15**] strengths; nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit: murmur faintly radiates to B carotids
Pertinent Results:
[**2200-12-16**] ECHO
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity is moderately
dilated. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the aortic
root. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is moderate thickening of the mitral valve chordae. There is a
trivial/physiologic pericardial effusion.
POST CPB:
1. Unchanged [**Hospital1 **]-ventricular systolic function, which improved to
normal with epinephrine infusion.
2. Moderate central mitral regurgitation
[**2200-12-21**] 05:30AM BLOOD WBC-9.8 RBC-3.59* Hgb-9.7* Hct-28.5*
MCV-79* MCH-27.0 MCHC-34.0 RDW-15.9* Plt Ct-217
[**2200-12-20**] 06:00AM BLOOD WBC-11.2* RBC-3.79* Hgb-10.2* Hct-30.1*
MCV-80* MCH-26.9* MCHC-33.8 RDW-15.9* Plt Ct-199
[**2200-12-20**] 06:00AM BLOOD Glucose-121* UreaN-33* Creat-1.3* Na-137
K-3.5 Cl-101 HCO3-26 AnGap-14
[**2200-12-19**] 01:08AM BLOOD Glucose-150* UreaN-34* Creat-1.9* Na-134
K-4.5 Cl-100 HCO3-24 AnGap-15
Brief Hospital Course:
Ms. [**Known lastname 95808**] was admitted to the [**Hospital1 18**] on [**2200-12-16**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent cornary
arytery bypass grafting to four vessels. Please see operative
note for details. Postoperatively she was taken to the intensive
care unit for monitoring. On postoperative day one, she awoke
neurologically intact and was extubated. She was hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated. On postoperative day 2 she developed
atrial fibrillation treated with amiodarone converted to a
junctional rhythm subsquently the amiodarone was discontinued.
Beta-blockers were continued. She converted to sinus
bradycardia and remained hemodynamically stable. She was gently
diuresed toward her preoperative weight. Blood sugars were
tightly managed with insulin drip to < 150 then to sliding scale
once transfer to the step-down unit. Warfarin was restarted
[**2200-12-19**] and she was anitcoagulated to an INR 2.0-3.0 for atrial
fibrillation. She transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. Her pain was well controlled with Ultram.
She was followed by physical therapy for strength and endurance
and they recommended rehab. On POD #6 she was tolerating a full
oral diet, wounds were healing well and she was ambulating with
assistance. She was safe for transfer to [**Doctor First Name 391**] [**Hospital **] rehab. All
follow up appointments were advised.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet PO daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet PO daily
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet PO TID
OLMESARTAN [BENICAR] - 40 mg Tablet - 1 Tablet PO daily
SIMVASTATIN - 20 mg Tablet - 1 Tablet PO daily-- REPORTS NOT
TAKING
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for sbp < 110.
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 7 days.
12. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ACHS: Per SS.
Disp:*qs * Refills:*2*
13. warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1
doses.
Disp:*1 Tablet(s)* Refills:*0*
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*60 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba.
Discharge Diagnosis:
coronary artery disease (LAD stent [**99**] yrs ago,three RCA and PDA
stents [**10-21**])
Myocardial infarction [**2190**]
NSTEMI [**10-21**]
mild aortic stenosis ([**Location (un) 109**] 1.2-1.9 cm2)
poorly controlled Diabetes (last HbA1C 7.5%)
Dyslipidemia
Hypertension
CVA, [**2-/2197**] Acute left PCA infarct
Atrial fibrillation (DCCV [**10-21**])on Pradaxa
Spinal stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
*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: [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2201-1-21**] 1:15
Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Cardiologist: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-15**] weeks [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
**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 Atrial Fibrillation
Goal INR: 2.0-3.0
First draw: [**2200-12-23**]
Coumadin follow up to be arranged upon discharge from rehab
Completed by:[**2200-12-22**] Name: [**Known lastname 15200**],[**Known firstname 3989**] Unit No: [**Numeric Identifier 15201**]
Admission Date: [**2200-12-16**] Discharge Date: [**2200-12-22**]
Date of Birth: [**2121-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Morphine / Sulfur / Hydrochlorothiazide / Lipitor
/ simvastatin
Attending:[**First Name3 (LF) 741**]
Addendum:
Correction on rehab she was discharged to [**Last Name (un) 7333**] House in
Auborn, MA
Discharge Disposition:
Extended Care
Facility:
tba.
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2200-12-22**]
|
[
"414.01",
"458.29",
"424.0",
"V17.49",
"401.9",
"427.31",
"412",
"413.9",
"V45.82",
"250.02",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10282, 10437
|
4039, 5647
|
357, 444
|
7749, 7960
|
2537, 3409
|
8861, 10259
|
1615, 1725
|
5976, 7272
|
7347, 7728
|
5673, 5953
|
7984, 8838
|
1740, 2518
|
1292, 1363
|
307, 319
|
472, 903
|
1394, 1473
|
925, 1272
|
1489, 1599
|
3419, 4016
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,967
| 137,743
|
29322
|
Discharge summary
|
report
|
Admission Date: [**2126-5-30**] Discharge Date: [**2126-6-1**]
Date of Birth: [**2061-12-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Sudden onset of dizziness and shortness of breath
Major Surgical or Invasive Procedure:
right heart catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 64 yo female with a history of pulmonary artery
hypertension (on a continous Flolan infusion via Hickman
catheter and 6L of O2), diastolic CHF, chronic afib, and HTN. On
the day of admission, the patient woke up at took her blood
pressure and found it to be in the 80's/40's. This is
significantly lower than her baseline blood pressure of 100/60.
The patient then went to the bathroom and had a BM. After she
got out of the bathroom, Ms. [**Known lastname **] suddenly became short of
breath, dizzy (she felt as if she would pass out), diaphoretic,
and felt her heart pounding. She did not have any chest pain,
nausea, or vomiting. At this time, she sat on the floor but this
did not improve her symptoms. There was no loss of consciousness
and the patient did not hit her head. While sitting on the
floor, the patient realized that she needed to change her Flolan
pump cassette and attempted to do so. However, this was a
difficult task due to her dizziness and she forgot to clamp the
Hickman catheter and blood began to backflow out of the catheter
onto the floor.
The patient then managed to activate EMS. EMS found Ms. [**Known lastname **] on
the floor, with cyanotic lips and breathless speech. The Hickman
catheter was clotted off and the Flolan would not infuse. Vitals
signs were as follows: HR: 80-120, BP: 100/60, RR: 26-28. She
was placed on 15L of O2 via NRB.
The patient was taken to [**Hospital3 3583**]. At this time the
patient felt much better and her vital signs normalized: HR:
73-76, BP: 99-123/54-83, 96-99% of 6L of O2 (here home dose.) On
exam, she was alert and oriented, with crackles at the base of
the lungs.
EKG: showed a rate of around 78 and afib. There were normal QRS
interval and normal axis. There was no ST segment elevations or
depressions. Possible Q waves in aVR, V1, and V2. There was no
hypertrophy and normal R wave progression. Labs showed Na-138,
K-4.2, Cl-105, HCO3-22, BUN 20, CR-1.1, Glucose 108, INR 1.66,
CPK 79,WBC-4.9, Hct 29.3. In the ED, Ms. [**Known lastname 62372**] Hickman's cath
was unclogged and Flolan infusion resumed.
.
On review of symptoms, the patient does endorse a [**1-27**] week
history of SOB on exertion and 1-pillow orthopnea. This SOB did
not improve with increases of Flolan and her pulmonologist was
concerned that her CHF was that actual cause of the SOB not her
PAH. In fact, it was planned for her to have a cardiac
catheterization. She has a long history of peripheral edema due
to her pulmonary artery hypertension which is unchanged in the
recent weeks. She does not report paroxysmal nocturnal dyspnea,
hyperlipidemia, or diabetes. She denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Past Medical History:
1) Severe pulmonary artery hypertension -Initially presented in
[**3-1**]. The etiology of this PAH is thought to be due to multiple
factors including left-sided diastolic CHF due to HTN and
interventricular septal dysplacement, emphysema, possible
rhematologic condition (CREST). She was admitted in [**10-1**], at
which point an extensive work-up was done.
2) Emphysema
3) Raynaud's phenomenonlikely CREST syndrome-Positive [**Doctor First Name **] with
positive anticentromere antibodies.
4) Congestive heart failue and diastolic dysfunction
5) Alcoholic induced cardiomyopathy-improved when alcohol was
discontinued.
5) Chronic Atrial fibrillation-Failed attempts at cardioversion.
Now, rate controlled. Anticoagulated with Coumadin with goal of
[**12-29**]
6) Hypertension
7) Right upper lobe pulmonary nodule and mediastinal LAD on CT
in [**10-1**].
8) Ventral Hernia-No symptoms of bowel obstruction or abdominal
pain.
9) Cataracts-Scheduled surgery [**2126-6-4**]
10) Chronic Anemia-Baseline Hct around 30. Normal iron studies.
.
Social History:
Ms. [**Known lastname **] is an ex-nurse who lives alone in [**Location (un) 3320**]. She has two
daughters whom live in the area. She smoked heavily in the past
but stopped 30 yeasr ago. She also drank heavily but stopped 1
year ago. She never had any seizures or withdrawl symptoms.
Family History:
The patient's father had a stroke at 65 years of age. Her mother
had lung cancer.
Physical Exam:
VS: T 99.1 , BP [**9-/2084**] , HR 68 , RR 20, O2 % 97 on 6L nasal
cannula
Gen: Female in no distress. She is oriented to person, place,
and time. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. Difficlut to assess JVP due to carotid pulse and
large external jugular.
CV: Irregular rate with normal S1 and S2. There is a III/VI
systolic murmur loudest at the right sternal border.
Chest: Patient is on nasal canula and breathing comfortably with
no accessory muscle use. No cyanosis. No chest wall deformities,
scoliosis or kyphosis. There where bilateral crackles. No
wheezes.
Abd: Soft, NTND with large right sided hernia.
Ext: 1+ bilateral pedal edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+; Femoral 2+ without bruit; 2+ DP
.
Pertinent Results:
ADMISSION LABS:
[**2126-5-30**] 09:27PM WBC-4.5 HGB-9.4* HCT-29.5* MCV-87 MCH-27.8
MCHC-31.8
[**2126-5-30**] 09:27PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
[**2126-5-30**] 09:27PM CK(CPK)-74 cTropnT-0.02*
[**2126-5-30**] 09:27PM PT-22.4* PTT-36.2* INR(PT)-2.2*
.
CHEST XRAY [**2126-5-30**]: Heart size is markedly enlarged increased
diameter compared to [**1-30**] due to known pericardial effusion
increased in size. The widespread bilateral interstitial
abnormalities represent known micronodular centrilobular
interstitial pattern which might be due to active inflammation
or lymphoproliferative disorder in the chest.
.
TTE [**2126-5-31**]: Mild symmetric LVH with normal cavity size and
systolic function (LVEF >55%). Moderately dilated RV with
moderate global free wall hypokinesis and abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. Moderate to severe [3+] tricuspid
regurgitation. Moderate sized circumferential pericardial
effusion without
echocardiographic signs of tamponade.
.
RIGHT HEART CATH [**2126-5-31**]: Elevated right-sided filling pressures
with RVEDP of 14 mm Hg. Severe pulmonary arterial systolic
hypertension with PASP of 90 mm Hg. The left sided filling
pressures were mildly elevated with mean PCWP of 13 mm Hg. The
cardiac index was preserved at 2.8 L/min/m2.
Brief Hospital Course:
Ms. [**Known lastname **] is a 64 yo female with a history of pulmonary artery
hypertension, diastolic CHF, and chronic A-fib, and HTN who
presented with an acute episode of SOB, dizziness, and
diaphoresis. This is in the setting of worsening SOB on exertion
for 3-4 weeks and a non-functioning flolan pump.
#) Pulmonary hypertension-- The etiology of her symptoms was
best explained by acute worsening of her pulmonary hypertension
due to lack of flolan, resulting in acute decompensated
right-sided heart failure. Right heart cath revealed severe
pulmonary arterial systolic hypertension. While the patient
reports dysfunction of the Flolan infusion after symptoms
started, it is possible that the pump was malfunctioning before
the event. Patients on Flolan can be very dependent on the
infusion for survival. The flolan pump was re-started and her
rate was up-titrated as tolerated to a rate of 27. The patient
responded well to this intervention. Her SOB improved and she
returned to her usual baseline. She was consulted by pulmonary
and rheumatology during this admission. Her chest CT looked
worse than prior and concern was brought up that she may have
CREST. A number of blood tests were sent for connective tissue
disorder work-up, to be followed up as an outpatient.
.
#) Diastolic CHF-- She has known diastyolic dysfuntion due to
LVH and interventricular septal displacement. Flolan can worsen
CHF. Patient did have crackles on exam but this may have beenb
due to her known emphysema. Her CXR was relatively dry. TTE
during this admission revealed moderately dilated RV cavity,
moderate global RV free wall hypokinesis, and abnormal septal
motion/position consistent with RV pressure/volume overload.
Lasix was held initially due to patient's hypotension, but she
was then re-started on her home dose of lasix. She was also
treated with lisinopril for afterload reduction.
.
#) Afib-- She was continued on digoxin and coumadin for her
Afib. On admission her INR was therapeutic at 2.2 and her dose
was titrated as necessary to maintain a therapeutic INR.
.
#) Depression- Her home does of Citalopram was continued.
.
#) Code- The patient was DNR/DNI for this admission
.
Medications on Admission:
ALLERGIES: NKDA
.
1) Digoxin 0.125mg PO Daily
2) Lasix 40mg PO BID Daily
3) Lisinopril 5mg PO Daily
4) Coumadin 2.5mg PO Daily
5) Coumadin 5mg on Wed,Fri
6) Flolan 83ml/24hrs with pump set at 25
7) 6L O2 via nasal cannula
8) Celexa 20mg PO Daily
.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Epoprostenol 0.5 mg Recon Soln Sig: One (1) Recon Soln
Intravenous INFUSION (continuous infusion): 27 nanograms/kg/
minute infusion.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime for
2 days: take 2 tablets on [**6-1**] and [**6-2**], then resume regular
dosing.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
pulmonary hypertension
diastolic congestive heart failure
atrial fibrillation
connective tissue disease
.
Discharge Condition:
stable, ambulating
.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please continue your home medications. We have increased the
dose of your flolan. You should take 5mg of coumadin on
Saturday [**2126-6-1**] and Sunday [**2126-6-2**] and have your coumadin level
checked on [**2126-6-3**] at the coumadin clinic in [**Location (un) 3320**].
.
You will need to follow up with your Pulmonologist,
Rheumatologist, and primary care physician.
.
You were admitted to the hospital for worsening of your
pulmonary hypertension secondary to malfunctioning of your
Flolan pump. Because of this, your heart was not able to pump
blood effectively to your brain and the rest of your body, which
resulted in your symptoms of shortness of breath and dizziness.
We were able to correct this by re-starting your pump and
increasing the flow rate. Please return to the hospital if you
experience worsening shortness of breath, chest pain, if you
have malfunctioning of your flolan, or any other concerning
symptoms.
.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45841**] office to schedule an outpatient
appointment as soon as possible.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Cardiology) Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2126-10-2**] 1:40
Please have your coumadin level checked on [**2126-6-3**] in [**Location (un) 3320**].
Please schedule follow-up with Rheumatology as previously
instructed.
.
|
[
"710.1",
"427.31",
"443.0",
"428.0",
"276.8",
"428.32",
"416.8",
"492.8",
"397.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
10389, 10447
|
7256, 9442
|
364, 393
|
10596, 10618
|
5832, 5832
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11703, 12179
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4780, 4863
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9740, 10366
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10468, 10575
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9468, 9717
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10642, 11680
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4878, 5813
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275, 326
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421, 3401
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5848, 7233
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3423, 4462
|
4478, 4764
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 110,998
|
48988
|
Discharge summary
|
report
|
Admission Date: [**2133-5-16**] Discharge Date: [**2133-5-21**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: fever,hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D,
h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis,
and h/o MRSA line sepsis [**5-6**] and presumed recurrence [**10-6**], who
presented to the ED [**5-16**] from dialysis with hypotension noted
after HD. Pt was recently admitted to vascular surgery service
for L TMA and d/c'd on Vanc (at HD) [**4-23**]. Pt was at [**Hospital **]
Rehab until the day of admission when he went to HD and became
hypotensive and was transferred to the ED.
.
In the [**Name (NI) **], pt had R femoral triple lumen placed and received 1L
NS, vanc, levo, and flagyl and due to persistent SBP in the 70s
he was admitted to the MICU. In the MICU his antibiotics were
continued and he was given an additional 1L NS. He has been
hemodynamically stable and is now being transferred to the
floor.
Past Medical History:
PMH:
Past Medical History:
1. ESRD s/p failed transplant [**7-4**] now collapsing
glomerulonephritis, HD qMWF at [**Location (un) 4265**]
2. Amyloidosis
3. Sarcoidosis
4. Hx of pulmonary aspergillosis - on itraconazole, followed by
pulm
5. Hx of hyperkalemia
6. Hep B, C, ? D
7. HTN
8. Hx of IV drug use
9. h/o sinusitis requiring drainage
10. recent epistaxis requiring intubation
11. SPEP/UPEP positive
12. paroxysmal atrial fibrillation - off BB, on coumadin
13. h/o C diff [**3-8**]
14. MRSA line sepsis ([**5-6**]), new tunneled fem line [**5-6**], TTE neg
for veg, line sepsis ([**11-5**]), new tunneled fem line [**12-6**]
15. h/o purulent ascites [**3-8**] while on PD
16. gynecomastia
17. iron deficiency anemia
18. renal osteodystrophy
19. adrenal insufficiency - on prednisone 5 mg po qd
20. h/o b/l UE DVT [**3-8**]: pt should not have IJ or SCL lines
21. h/o pancreatitis [**3-8**]
** ECHO [**5-6**]: EF > 55%, 1+ MR
Social History:
Soc Hx:
Lives with girlfriend, on disability; 1 packper day x30 years of
tobacco use, still currently smoking. No alcohol, but previous
history of abuse.
Family History:
Diabetes
Physical Exam:
PE: VS 98.4 HR 100 BP 120/64 R 12 O2 100% on 2L NC
Gen: lethargic but arousable to voice.
HEENT: EOMI, PERRL, OP clear, anicteric
Neck: supple, no appreciable LAD.
Chest: crackles at the bases bilaterally
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, ND +BS no guarding or rebound
Ext: R BKA, L TMA (dark skin around sutures, otherwise clean,
dry), right femoral triple lumen, left tunneled HD catheter.
Neuro: moves all 4, oriented to person, year, not to place,
answers questions, follows commands.
Pertinent Results:
Studies:
[**5-16**] CXR: IMPRESSION: No interval change from [**2133-4-19**], with
persisting calcified mediastinal and hilar lymphadenopathy,
biapical pleural scarring, and scarring/bronchiectasis in the
upper lobes and right lower lobe. No new consolidation to
suggest acute pneumonia.
.
[**5-16**] Head CT:
1. No evidence of intracranial hemorrhage.
2. Bilateral internal capsule hypodensities as well as
hypodensity adjacent to the frontal [**Doctor Last Name 534**] of the left lateral
ventricle which are new compared to the prior study of [**9-14**], [**2130**]. These may represent chronic microvascular infarction
or Virchow-[**Doctor First Name **] spaces. Given the patient's age, however, a
demyelinating process cannot be excluded. MRI with DWI is more
sensitive in the detection of acute infarction.
[**2133-5-16**] 03:55PM PLT SMR-VERY HIGH PLT COUNT-629*#
[**2133-5-16**] 03:55PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
TARGET-OCCASIONAL
[**2133-5-16**] 03:55PM NEUTS-73.7* BANDS-0 LYMPHS-11.4* MONOS-10.7
EOS-3.5 BASOS-0.7
[**2133-5-16**] 03:55PM WBC-13.5* RBC-4.12* HGB-10.6* HCT-34.0*
MCV-83# MCH-25.7* MCHC-31.2 RDW-19.1*
[**2133-5-16**] 03:55PM CALCIUM-9.6 PHOSPHATE-2.7# MAGNESIUM-2.0
[**2133-5-16**] 03:55PM GGT-206*
[**2133-5-16**] 03:55PM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-238*
AMYLASE-48 TOT BILI-0.1
[**2133-5-16**] 03:55PM GLUCOSE-239* UREA N-20 CREAT-5.0*# SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2133-5-16**] 04:11PM LACTATE-2.4*
[**2133-5-16**] 04:35PM URINE RBC-0-2 WBC-[**7-11**]* BACTERIA-FEW
YEAST-NONE EPI-0 TRANS EPI-0-2 RENAL EPI-0-2
[**2133-5-16**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2133-5-16**] 04:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2133-5-16**] 05:09PM PT-26.2* PTT-36.6* INR(PT)-2.7*
[**2133-5-16**] 07:20PM O2 SAT-73
[**2133-5-16**] 07:27PM TYPE-[**Last Name (un) **] PO2-26* PCO2-59* PH-7.30* TOTAL
CO2-30 BASE XS-0
[**2133-5-16**] 08:41PM FK506-2.0*
Brief Hospital Course:
This is a 48 y/o male with ESRD on HD with hx mult line
infections with recent L TMA (trans-metatarsal amp), who
presented to ED initially with hypotension, fever, requiring
monitoring in the MICU overnight, who remained hemodynamically
stable and was transferred to the medical floor for further
management.
1. Hypotension/sepsis - Pt was hemodynamically stable after
fluid resuscitation. Given his history of line infection, his
most likely source of possible sepsis was another line infection
from his HD line. His CXR, urine were all clear. He was
evaluated by vascular, who did not feel his L TMA was the source
of the infection, but that the patient would need an eventual
left BKA. His blood cultures from [**5-16**] and onwards have been no
growth to date. He was started on vancomycin/levofloxacin/flagyl
and then changed to just vancomycin once patient was stable and
it was felt that his infection was from his HD line. He needs to
continue vancomycin empirically for 2 weeks, to be dosed at HD.
As the patient has a history of extremely poor and difficult
access, his HD line CANNOT be removed. The patient remains on
daily low-dose prednisone given his history of adrenal
insuffieciency in the past.
The patient's MS was also lethargic initially, which has
improved to his baseline after starting appropriate treatment
with antibiotics.
.
2. ESRD - On HD Tues/Thurs/Sat. On sevelemer, cinecalcet, and
tacrolimus. Needs to be dosed vanco at HD until [**2133-5-27**].
.
3. Hx adrenal insufficiency - was on stress dose steroids
briefly, changed over to low-dose po prednisone as pt is
hemodynamically stable
.
4. DM - continue insulin SS as directed
.
5. Pain - continue lidocaine patches and oxycodone prn
.
6. Afib - Hold metoprolol as patient was initially hypotensive
and now normotensive. On coumadin 1 mg qod, which was increased
to 2 mg qod upon discharge as his INR was 1.5. His goal INR is
[**3-6**]. He should have repeat PT/PTT/INR in [**4-4**] days as dose
adjustment may be necessary.
.
7. Psych - On welbutrin and remeron. D/c'd zyprexa due to the
lethargy.
.
# FEN - Reg diet, monitor lytes. IVF prn hypotension.
# Code: Full. Confirmed with HCP
# PPx - heparin SQ, protonix for GI. bowel regimen.
# Access: L femoral tunneled HD cath, right femoral line was
d/c'd on [**5-21**] with good hemostasis
# Comm: HCP [**Name (NI) 102395**] [**Name (NI) 10664**] (girlfriend) [**Telephone/Fax (1) 102392**]
Medications on Admission:
Meds on admission:
Docusate Sodium 100 mg PO BID
Famotidine 20 mg PO Q24H
Itraconazole 100 mg PO BID
Oxycodone-Acetaminophen 5-325 mg [**2-2**] PO Q4-6H prn
Tacrolimus 0.5 mg PO DAILY
Lidocaine 5 % Adhesive Patch, 12 h on 12 h off
Senna 8.6 mg PO BID prn
Folic Acid 1 mg PO DAILY
Metoprolol Tartrate 12.5 mg PO BID
Sevelamer 800 mg PO TID
Prednisone 5 mg PO DAILY
Cinacalcet 30 mg PO DAILY
coumadin 1mg PO QOD
epo 20K T, th, sat
HD T, TH, Sat
Tylenol prn
Xenaderm
zyprexa 5 po QD
mirtazapine 15 mg PO qHS
wellbutrin 100 SR QD
Atarax 10 mg PO TID prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Itraconazole 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO QOD ().
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: for right femoral
line.
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD ().
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous QHD (each hemodialysis) for 10 days: to be
dosed on dialysis days during hemodialysis, last dose on [**5-27**] to
finish a 14 day course.
17. Epoetin Alfa 10,000 unit/mL Solution Sig: 15,000 Injection
ASDIR (AS DIRECTED): to be given during hemodialysis on HD days.
18. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Insulin
Insulin sliding scale as directed on attached sheet
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary - line infection
Secondary - ESRD, amyloidosis, sarcoidosis, HTN, PAF, MRSA line
sepsis
Discharge Condition:
Stable, afebrile with VSS
Discharge Instructions:
-continue with all medications as prescribed
-continue vancomycin to finish a 2-week course (last dose on
[**2133-5-27**]) - this should be dosed at hemodialysis
-continue coumadin every other day for goal INR [**3-6**] - recheck
PT/PTT/INR in [**4-4**] days for dose adjustment
-continue with hemodialysis as scheduled on Tues, Thurs, and Sat
-if symptoms of dizziness/lightheadedness, fevers, shortness of
breath, confusion, or any other concerning symptoms occur please
come to the ED or seek medical attention immediately
-vancomycin needs to be continued for 2 weeks and dosed at each
hemodialysis
Followup Instructions:
1) Dr. [**Last Name (STitle) **], [**2133-5-28**] at 9:25 am
2) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2133-7-13**] 9:50
Completed by:[**2133-5-21**]
|
[
"427.31",
"070.30",
"585.5",
"995.91",
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"V58.61",
"038.9",
"250.00",
"V49.76",
"117.3",
"403.91",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9868, 10022
|
5048, 7479
|
300, 307
|
10163, 10191
|
2881, 3182
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3191, 5025
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7524, 8056
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1233, 2139
|
2155, 2313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,656
| 130,791
|
40489
|
Discharge summary
|
report
|
Admission Date: [**2126-7-20**] Discharge Date: [**2126-7-25**]
Date of Birth: [**2106-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Headache and nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, 20yo F with s/p head injury 5 days ago after 2 story
fall in LA. Patient fell after a railing broke on a balcony
during [**7-15**] celebrations and taken to [**Hospital **] hospital. There
she was found to have a right sided skull fracture and many
abrasions but no ICH. Pt does not remember the incident or 3
days following it. She flew back to [**Location (un) 86**] 2 days prior to
admission and on the morning of admission had nausea, chills, 1
episode of vomiting. She said prior to the day of admission, she
has been more lethargic and tired, but no nausea, vomiting or
chills. She has been taking cipro 500mg PO Q12H for prophylaxis
prescribed to her at LAC and ibuprofen for pain. In [**Hospital **] clinic,
she was found to have CSF leak from right ear. She was seen by
her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 88695**] on [**7-19**] for evaluation. At this time labs
showed a Na of 138 (per Dr.[**Last Name (STitle) 88696**] report over the phone).
Radiology reports from LAC ED: CThead: normal brain, no bleed,
right temperal bone fx, cspine: negative for fx, CT torso:
negative
.
In the ED, labs notable for Na 123. The pt underwent CT head
that showed left temporal bone fracture with a small amount of
mastoid air cell fluid. The pt received Morphine 4mg IVx2,
Zofran 4mg x2 and tylenol 325mg PO x1 and 1L NS. She was seen by
Neurosurgery who recommended outpatient follow up with ENT and
admit to medicine for management of her hyponatremia.
On the floor the patient was fluid restricted and has been
becoming more somnolent since this morning. Her Na
123->122->118 over 12 hrs.
She was admitted to HMED service for treatment of SIADH. Of
note she was also found to have a new right facial droop that
was not immediately apparent after the accident.
Past Medical History:
Attention Defficit Disorder
Social History:
Does not smoke, drinks intermittently, no drug use, student at
NYU
Family History:
Grandparents with HTN, No DM, cancer
Physical Exam:
On ADDMISSION:
GENERAL: Well-appearing woman in NAD, somnolent but arousable
and AO x3.
HEENT: mild bruising around nose, PEERL, EOMI, sclerae
anicteric, MMM, OP clear, smile asymmetric (has been like this
since fall).
NECK: Supple.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/ND, mildly tender to palpation, no masses or HSM,
no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, CNs II-XII intact, smile asymmetric, muscle
strength 5/5 throughout.
On DISCHARGE:
Tm 97.7 Tc 97.3 BP 98-114/52-68 HR 64-95 RR 16-18 SpO2
98-100%/RA
GEN: pt awake and alert, A&Ox3.
HEENT: EOMI, no fluid in or around ears
Resp: CTAB
CVS: RRR, no m/r/g, S1, S2
Abd: soft/NT/ND, +BS
Ext: no c/c/e.
Neuro: A&Ox3, continues to have R sided CN VII nerve palsy
involving upper and lower face. No other neuro defecits
Pertinent Results:
Addmission Labs:
[**2126-7-20**] 02:35PM OSMOLAL-250*
[**2126-7-20**] 02:35PM WBC-8.4 RBC-4.20 HGB-12.8 HCT-35.7* MCV-85
MCH-30.4 MCHC-35.8* RDW-12.5
[**2126-7-20**] 02:35PM GLUCOSE-95 UREA N-10 CREAT-0.5 SODIUM-123*
POTASSIUM-4.5 CHLORIDE-90* TOTAL CO2-25 ANION GAP-13
[**2126-7-20**] 03:30PM URINE HOURS-RANDOM UREA N-352 CREAT-41
SODIUM-225 POTASSIUM-35 CHLORIDE-214
Discharge Labs:
[**2126-7-25**] 07:40AM BLOOD Glucose-80 UreaN-11 Creat-0.6 Na-140
K-4.0 Cl-105 HCO3-24 AnGap-15
[**2126-7-25**] 07:45AM BLOOD WBC-13.5* RBC-4.11* Hgb-12.6 Hct-36.2
MCV-88 MCH-30.7 MCHC-34.8 RDW-13.2 Plt Ct-325
[**2126-7-25**] 07:45AM BLOOD Neuts-71.3* Lymphs-23.4 Monos-3.9 Eos-0.6
Baso-0.8
CXR [**2126-7-20**]:
The lungs are well expanded and clear. The cardiomediastinal
silhouette,
hilar contours, and pleural surfaces are normal. No pleural
effusion or
pneumothorax is present.
CT-Head [**2126-7-20**]:
No acute intracranial hemorrhage, large vascular territory
infarct, shift of midline structures or mass effect is present.
The ventricles and sulci are normal in size and configuration.
The visible paranasal sinuses show a
sphenoidal sinus mucus retention cyst and mucus thickening in
the right
sphenoidal sinus as well as right mastoid air cell opacification
without
definite right temporal bone fracture seen. No definite right
temporal bone fracture is noted. Also noted is a small amount of
left mastoid air cell fluid with a non-displaced left temporal
bone fracture.
Brain MR [**2125-7-22**]: 1. Bilateral mastoid air cell fluid. 2. Left
sphenoid sinus retention cyst. 3. Unremarkable appearance to the
seventh and eighth cranial nerve complexes.
Brief Hospital Course:
20 yo woman s/p fall in LA resulting in L temporal fracture who
presented with vomiting, found to be hyponatremic to 123 with
new right sided facial droop.
#Hyponatremia: Patient found to have Na of 123 from 138 the day
prior at her PCP's office. Urine lytes/osms consistent with
SIADH thought secondary to head trauma and stress. She
initially did not respond to fluid restriction, pt was noted to
be increasingly somnolent upon arrival to floor. Nephrology was
consulted and felt the SIADH was likely a side effect of Advil
she had been taking and may have been worsened by her head
injury. Pt was transferred to the MICU for treatment with 3 % NS
for target correction of 12 meq over 24 hrs. She received q2
hour Na and neurochecks. Hypertonic saline was administered
from [**7-20**] until [**7-22**] with an initial drop in serum sodium to a
nadir of 118 before gradually improving to 125 prior to
discontinuing 3% NS on [**7-22**].
After transfer to the floor, her Na continued to correct
while she was initially placed on a 750cc/day fluid restriction.
On the day of discharge, Na was 140 and had been stable in the
138-140 range for 36 hours. Her fluid restriction was
liberalized to 1500cc on the day prior to discharge and her Na
remained normal. She will be discharged with a recommended
fluid intake of no greater than 2000cc, salt intake was
encouraged. Pt has close follow up scheduled with her PCP for
electrolyte monitoring.
#Vomiting/HA: Patient presented to the [**Hospital1 18**] ED approximately 6
days after suffering a two story fall with nausea, vomiting and
a new headache. She was initially evaluated in the ED for
diaphragmatic injury, but CXR and FAST Scan did not demonstrate
any abnormality or free fluid. Further head imaging did not
reveal any ICH or edema. Her symptoms were felt to be secondary
to hyponatremia, antiemetics were held and the patient's
headache treated with tylenol as needed. Symptoms improved with
correction of serum sodium. During the 2 days that she was on
the floor, she denied any nausea or headaches.
# Asymmetric smile: Patient was noted to have an obvious right
sided facial droop on clinical exam. She denied having these
findings immediately following her injury. On exam her symptoms
were consist with a right sided peripheral VIIth nerve
disturbance (unable to close her eye, unable to wrinkle her
forehead, weakness of smiling and impaired taste on the anterior
two-thirds of the right side of her tongue). By history, there
was no hyperacusis. The patient was seen by neurology who
recommended brain MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] for any delayed compression of
the nerve as well as Lyme/CRP/ESR. MRI did not show any
abnormalities of the facial nerve. ESR and CRP were normal,
Lyme titers returned negative soon after the patient was
discharged. She was treated with a seven day course of
prednisone and continued on her home suppressive dose of
acyclovir in case there was a viral component to her facial
nerve palsy.
#ADD: Adderall was held while she was an inpatient, restarted
after discharge.
#Transitional issues:
-Instructed to follow a 2000cc fluid restriction
-Will continue prednisone 60mg PO for total of 7 days, ends on
[**2126-7-30**]
-Has follow-up with PCP on Tuesday [**2126-7-30**], will need Na
measured at this time
-Arranged for follow-up with Neurology for her facial nerve
paralysis
-Arranged for follow-up with ENT for left temporal fracture
-Arranged for follow-up with Nephrology for SIADH and
hyponatremia
Medications on Admission:
Adderall 10mg PO bid
Valcyclovir - dose unknown
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic Q8H (every 8 hours) as needed for Inability to
blink.
3. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Adderall 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. acyclovir Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hyponatremia from SIADH
Temporal bone fx
Cranial Nerve VII palsy
Secondary diagnoses:
ADD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for low sodium and right sided
facial paralysis. You were treated with hypertonic saline in
the intensive care unit and we restricted your fluid intake to
improve the sodium level. This corrected during your
hospitalization and you will be discharged home. Please limit
your fluid intake to no more than 2 liters per day. We
encourage you to drink when you feel thirsty but do not drink
excessive amounts of water. We also encourage you to eat salty
foods. Dr. [**Last Name (STitle) 1407**] will recheck your sodium at your follow-up
appointment next week.
It was thought that the facial paralysis was caused by
inflammation of a nerve in your face after your fall. An MRI
did not show any obvious damage to this nerve. Please continue
to take prednisone 60mg daily until [**2126-7-30**] (total of 7 days) as
this will help reduce the inflammation. Please continue to use
artificial tears in your right eye as needed for dryness since
you are not able blink as well on that side. You will be seen
by neurology after discharge from the hospital. You will also
have follow-up with an ear nose throat doctor regarding the
fracture in your skull.
The following changes have been made to your medications:
START Prednisone 60mg by mouth daily for 5 more days (stop on
[**2126-7-30**])
START Artificial tears 2 drops to right eye as needed for
dryness
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 20**] R.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
When: Tuesday, [**7-30**], 1:45PM
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2126-8-7**] at 4:00 PM
With: [**Doctor Last Name **] [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2126-8-21**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Dr. [**Last Name (STitle) **] will call you if a sooner appointment opens up.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] - DIV OF PLASTIC & RECONSTRUCTIVE SURGERY
Address: [**Doctor First Name **], STE 5A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 6742**]
*Dr. [**First Name (STitle) **] will contact you with appointment information. You
should follow up with him within 2 weeks.
Ear Nose Throat Follow-up: An appointment has been made with the
ENT physician you have previously seen, please contact your PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 1407**] for the exact time and date of this appointment.
|
[
"905.0",
"253.6",
"E935.6",
"314.00",
"E929.3",
"351.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9140, 9146
|
5005, 8129
|
332, 338
|
9300, 9300
|
3322, 3700
|
10869, 12611
|
2323, 2361
|
8661, 9117
|
9167, 9252
|
8589, 8638
|
9451, 10845
|
3716, 4982
|
2376, 2959
|
9273, 9279
|
2973, 3303
|
8150, 8563
|
264, 294
|
366, 2171
|
9315, 9427
|
2193, 2222
|
2238, 2307
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,495
| 131,306
|
35992
|
Discharge summary
|
report
|
Admission Date: [**2179-12-27**] Discharge Date: [**2180-1-5**]
Service: CARDIOTHORACIC
Allergies:
Terazosin / Atenolol / Univasc / Clonidine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
congestive heart failure
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 4 (Left internal mammary artery
to left anterior descending, saphenous vein graft to diag,
saphenous vein graft to obtuse marginal, saphenous vein graft to
posterior descending artery), Aortic Valve Replacement (23mm St.
[**Male First Name (un) 923**] Tissue valve) [**2179-12-31**]
History of Present Illness:
This 87 year old white male was recently found to be in atrial
fibrillation and found to have coronary artery disease and
aortic stenosis during his workup. He had been scheduled for
surgical intervention, but was hospitalized at [**Hospital3 80253**] or dyspnea. He was treated medically and
referrred for earlier intervention due to his symptoms. He was
cleared by his neurologist, being stable on medications with his
last seizure in [**Month (only) 1096**] , [**2178**].
Past Medical History:
Coronary Artery Disease
Aortic Stenosis
Seizure disorder
h/o Atrial fribrillation
Hypertension
Dyslipidemia
Gastroesophageal reflux disease
Gout
s/p Hernia repair
Social History:
Denies tobacco
rare ETOH use.
Family History:
non-contributory
Physical Exam:
Admission:
VSS, afebrile. 136/86 bilat.
Neuro:grossly intact
HEENT: negative. Edentulous
Cor: 3/6 SEM radiating to neck
Lungs: Clear
Exts:trace bilateral edema
Pertinent Results:
[**12-28**] Chest CT: Severe coronary artery calcifications. Extensive
calcification of the aortic and mitral valves. Moderate
atherosclerotic calcification of the thoracic aorta. Small
bilateral pleural effusions and mild dependent atelectasis of
the lower lobes.
[**12-29**] Carotid CNIS: 1. No significant ICA stenosis on either
side. 2. Antegrade flow in both vertebral arteries.
[**12-31**] Echo: PRE-BYPASS: The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. Mild spontaneous echo contrast is present in
the left atrial appendage. Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). Mild to moderate ([**11-19**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on Mr[**Known lastname **] at before surgical incision.
POST-BYPASS: Preserved biventricular systolic function. LVEF
55%. The aortic bioprosthesis is insitu, stable and functioning
well and peak and mean gradients of 16 and 6mm of HG
respectively. Intact thoracic aorta. Trivial MR>
[**2179-12-31**] 01:20PM BLOOD WBC-20.8*# RBC-3.83* Hgb-10.8*# Hct-32.7*
MCV-86 MCH-28.3 MCHC-33.1 RDW-14.1 Plt Ct-328
[**2180-1-5**] 06:50AM BLOOD WBC-15.5* RBC-4.39* Hgb-12.3* Hct-37.7*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.6 Plt Ct-374
[**2180-1-5**] 06:50AM BLOOD Glucose-108* UreaN-25* Creat-1.2 Na-139
K-4.1 Cl-103 HCO3-24 AnGap-16
[**2180-1-5**] 06:50AM BLOOD Phos-2.7 Mg-2.2
Brief Hospital Course:
Following completion of his preoperative workup he was taken to
the Operating Room on [**12-31**] where aortic valve replacement and
quintuple bypass grafts were performed. See operative note for
details. He weaned from bypass in stable condition on Neo
synephrine and Propofol.
Following transfer to the ICU he remained stable, weaned from
pressors and was extubated the night of surgery.
Wires and tubes were d/c'd per cardiac surgery protocol. Pt
receiving ACE inhibitor, statin and betablocker. Has been in
rate controlled afib. Progressed well and was evaluated by
physical therapy and thought to benefit from rehab stay prior to
returning to home. The patient was discharged in good condition
to rehab on POD 5. All follow up instructions were advised.
Medications on Admission:
Nifedipine 90mg qd
Aspirin 81mg qd
Vit D
Lovastatin 40mg qd
Allopurinol 300mg qd
Dilantin 200qAM and 300qPM
Toporol XL 50mg qd
Amlodipine 5mg qd
Lisinopril 20mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 40 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. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QPM (once a day (in the evening)).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: dose to change daily for INR goal 1.5-1.8.
16. Furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2
times a day) for 10 days: 40mg IV BID, titrate as necessary
based on daily assessment.
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass Graft x 4
Aortic Stenosis
s/p Aortic Valve Replacement
Seizure disorder
Atrial fribrillation
Hypertension
Dyslipidemia
Gastroesophageal reflux disease
Gout
s/p Hernia repair
chronic obstructive pulmonary disease
Discharge Condition:
Good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 3659**] in 3 weeks
Dr. [**Last Name (STitle) 48633**] in 2 weeks [**Telephone/Fax (1) 35142**]
Completed by:[**2180-1-5**]
|
[
"427.31",
"272.4",
"293.9",
"274.9",
"414.01",
"530.81",
"345.90",
"424.1",
"401.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6067, 6157
|
3396, 4163
|
281, 597
|
6464, 6471
|
1564, 3373
|
6875, 7156
|
1351, 1369
|
4378, 6044
|
6178, 6443
|
4189, 4355
|
6495, 6852
|
1384, 1545
|
217, 243
|
625, 1102
|
1124, 1288
|
1304, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,001
| 110,867
|
6841
|
Discharge summary
|
report
|
Admission Date: [**2119-4-4**] Discharge Date: [**2119-4-18**]
Date of Birth: [**2053-5-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
Craniectomy
History of Present Illness:
Per admitting resident:
[**Known firstname **]-Pak-[**Known lastname **] is a 65 year-old man Vietinamese speaking only
with long standing history for HTN who presented to the ED after
acute left sided weakness. Patient was last seen normal around
5:40pm. By 6:30pm, patient was coocking in his kitchen when his
son heard a strong sound like something had fallen to the floor.
Later he heard his father calling for help. His son found him in
the floor lying in his left sided and he could not stand up. 911
was called and patient was brought to the hospital. Upon arrival
he was evaluated in the ED as described below.
Past Medical History:
? hypothyroidism
HTN
Family denied CHD
Social History:
Lives with his wife and sons. [**Name (NI) **] used to smoke and quit 21 years
ago. No drink.
Family History:
No family history of stroke, heart attack or seizures.
Physical Exam:
Physical Examination on admission:
NIH: score 18. (1a=2 1b=1 2=2 3=2 4=2 5a=3 5b=0 6a=2 6b0 7=0 8=1
9=0 10=1 11=2)
VS: BP 147\104 later 169\99mmHg HR 63 Sat 97% Room air
Genl: lethargic, following commands.
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: obtuned. Following simple commands with right
hand. fluent dysarthric speech. Clear signs of neglection to the
left side.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Visual fields with left hemianopsia. Eye
deviation to the right side. Sensation intact V1-V3. Left facial
weakness. Tongue midline, movements intact.
Motor: decreased tone in the left arm and leg. Left arm showed
feel spontaneous movements no antigravity. Left leg antigravity,
but not sustained.
Sensation: patient reacted to the pinprick, but less intense in
the left sided.
Reflexes: 2+ and symmetric throughout. Toes upgoing left side.
Coordination: no tremor.
Exam at time of discharge:
Pertinent Results:
[**2119-4-4**] 06:50PM BLOOD WBC-6.6 RBC-5.38 Hgb-15.0 Hct-46.7 MCV-87
MCH-27.8 MCHC-32.0 RDW-13.7 Plt Ct-212
[**2119-4-5**] 02:12AM BLOOD Neuts-83.6* Lymphs-10.8* Monos-4.4
Eos-1.0 Baso-0.2
[**2119-4-4**] 06:50PM BLOOD PT-11.7 PTT-31.4 INR(PT)-1.0
[**2119-4-4**] 06:50PM BLOOD Glucose-94 UreaN-17 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2119-4-5**] 02:12AM BLOOD ALT-14 AST-21 CK(CPK)-171 AlkPhos-75
TotBili-0.9
[**2119-4-5**] 02:12AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1 Cholest-196
[**2119-4-5**] 02:12AM BLOOD Triglyc-78 HDL-50 CHOL/HD-3.9
LDLcalc-130*
[**2119-4-5**] 02:12AM BLOOD %HbA1c-6.1* eAG-128*
Imaging:
CT head [**4-4**]
IMPRESSION: Right basal ganglia intraparenchymal hemorrhage. No
shift of
normally midline structures. Consider MRI with gadolinium to
exclude an
underlying lesion.
CT head [**4-5**]:
IMPRESSION: Significant interval increase in size of a right
putamen
hemorrhage with increased extent of surrounding vasogenic edema
leading to new
9 mm leftward subfalcine herniation and marked effacement of
sulci as well as
anterior [**Doctor Last Name 534**] of right lateral ventricle. No evidence of uncal
or tonsillar
herniation. No evidence of new additional hemorrhage.
CT head [**4-6**]
IMPRESSION: Allowing for differences in slice selection, little
change in the
right parenchymal hemorrhage and surrounding edema with
persistent subfalcine
herniation and leftward shift of the normally midline
structures. No new
hemorrhage.
CT head [**4-8**]: A large right putamen hemorrhage is similar in
size, measuring 4.7 x 5.2 cm, with surrounding vasogenic edema.
This causes
compression/effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle,
making evaluation for intraventricular hemorrhage difficult.
However, no
hemorrhage is seen in the remainder of the ventricular system.
There is a
stable 11-mm left shift of the midline structures indicative of
subfalcine
herniation. The study is otherwise unchanged, and no new
hemorrhage is
identified. The soft tissues appear unremarkable.
CT head [**4-10**];
IMPRESSIONS:
1. Large right frontotemporal hemorrhage slightly larger than
that seen two
days prior. Together with surrounding vasogenic edema, this
causes leftward
subfalcine herniation and right uncal herniation.
2. Subtle relative hypodensity along the medial right occipital
lobe with
loss of [**Doctor Last Name 352**]-white matter differentiation is concerning for
infarction,
possibly due to the leftward subfalcine herniation.
3. Dilatation of the left lateral ventricle, likely due to
compression on the
F. of [**Last Name (un) 2044**] from the mass effect, with slowly progressing
periventricular
hypodensities likely due to transependymal CSF migration.
CT head [**4-11**]
IMPRESSION:
1. Status post right frontotemporal craniectomy with evacuation
of large
right frontotemporal intraparenchymal hematoma with residual
gas, blood and
edema in the resection cavity. Associated mass effect, including
leftward
midline shift has slightly decreased, now measuring 8 mm.
2. Evolving right PCA territory infarct.
3. Unchanged hypodensity along the left lateral ventricle, again
consistent
with transependymal CSF migration.
4. Unchanged right posterior mid brain high-density focus, again
concerning
for hemorrhage.
MRI brain +/- [**4-11**];
IMPRESSION:
1. Persistent moderate mass effect from the right frontal
parenchymal
hemorrhage, status post partial evacuation without interval
change from the
most recent CT scan.
2. Persistent hydrocephalus with transependymal flow of CSF.
3. Focal hemorrhage within the mid brain and pons.
4. Evolving infarcts in the brainstem, splenium and right PCA
distribution.
5. Blush of enhancement surrounding the post-surgical changes in
the right
frontal lobe without evidence for an underlying mass.
CT head [**4-12**];
Continued evolution of known infarctions within the right
occipital lobe,
splenium, midbrain/pons, and left internal capsule, with
unchanged small
hemorrhage in the right posterior mid brain/pons. Dedicated MRA
can be
considered for assessment of vessels, if there is no
contra-indication.
Little change in exam, with small amount of residual hematoma
within the right
frontotemporal lobe and large amount of surrounding edema
causing 9-mm
leftward shift of normally midline structures. Unchanged
dilatation of left
lateral ventricle, with transependymal CSF migration.
Brief Hospital Course:
65 year-old man Vietinamese speaking only with long standing
history for HTN who presented to the ED after acute left sided
weakness. Patient had complete
arm>face>leg hemiparesis with signs of neglect.
.
Head CT showed a deep putamenal hematoma suggestive of
hypertensive etiology.
.
NEURO: Admitted w/ HOB elevation to 30 degrees, I/O goal of
-500 and SBP control to < 150. Normothermia and normoglycemia
were maintained via Tylenol and ISS.
.
By morning of HD1 patient had deteriorated clinically and on CT,
with midline shift and subfacline herniation. He was started on
mannitol. With this treatment he temporarily maintained his
examination until Monday [**4-10**]. However, in the evening of [**4-10**],
the patient was found to have blown pupils, became hypertensive,
and in respiratory distress. He was intubated, hyperventilated,
and received additional mannitol. A repeat CT head showed
worsening edema with subfalcine and bilateral uncal herniation
and was emergently taken to the OR for a decompressive
craniectomy for increased vasogenic edema. His exam post
operatively was poor, as his pupils were asymetric and minimally
reactive, he demonstrated extensor posturing in his upper
extremities and triple flexion in his lower extremities.
Post-operatively on repeat imaging he was found to have a right
PCA infarction thought to be secondary to compression from the
uncal herniation, as well as a small right midbrain duret
hemorrhage.
.
CV: BP was maintained via PO meds and NGT (Lisinopril) and
labetalol IV prn. Post-operatively the patient was hypotensive,
requiring pressors intermittently for POD # 1 and 2. His SBP
goal is 120-140.
.
PULM: The patient was intubated emergently on [**4-10**] at the time
of his clinical decompensation.
.
ID: Post-operatively, the patient spiked fevers with a T max of
104.9. He was empirically started on vancomycin and cefepime.
Blood cultures from [**4-11**] and [**4-12**] grew coagulase negative staph.
A respiratory culture grew gram negative rods. Ciprofloxacin
was added on [**4-13**].
.
GI: The patient was on IV famotidine for GI prophylaxis and
maintained on tube feeds for nutritional support.
.
Endocrine: The patient was continued on his home synthroid and
fingersticks were covered with regular insulin sliding scale.
.
Code status: Multiple family discussions were held throughout
the hospital course regarding goals of care. On [**4-13**] a family
meeting was held to further clarify goals of care, to discuss
rather the family would like a tracheostomy and PEG placement or
make the patient CMO. On [**4-17**], the family reported they
intended to withdraw care on [**4-18**] once the family could be
present. On the morning of [**4-18**] the patient once again had
blown pupils, agonal respirations and was becoming hypotensive.
His family was contact[**Name (NI) **] and present later that morning. He was
extubated and died shortly after extubation.
Medications on Admission:
Atenolol
ASA
Lisinopril
Levothyroxin
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparencyhmal hemorrhage
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
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47,511
| 132,223
|
47725
|
Discharge summary
|
report
|
Admission Date: [**2139-4-16**] Discharge Date: [**2139-4-19**]
Date of Birth: [**2073-7-15**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Percocet / Penicillins / acetaminophen /
Duloxetine
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Chief Complaint: Found at home altered
Reason for MICU transfer: Intubated and on pressors
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
Central Venous Access Placement
Continuous EEG monitoring
History of Present Illness:
65 yr/o F with history of [**First Name3 (LF) 2320**], steroid dependent asthma, CAD
with old MI presented to ED with altered mental status.
Patient was recently admitted to [**Hospital6 2561**] and
diagnosed with a pneumonia. Discharged home yesterday on course
of cefpodoxime. This AM, family found her at home altered.
Called EMS who found her confused, poorly responsive, and not
following commands. Blood sugar was in low 60s but did not
improve with glucose administration. She was transported to the
[**Hospital1 18**] ED.
On arrival to the ED, VS - 98.6 77 103/63 18 97% 2L Nasal
Cannula. Found to have tremors UE bilat with some myoclonic
jerks, ? R sided gaze preference, not really following exams.
Strange breathing with periods of apnea, then rapid breathing.
ED thought seizures so gave ativan which didn't help. More
sedated and sats dipped to 80s. Due to this and concern for
airway protection was intubated so could get head CT. Neuro was
consulted. Didn't think this seizures, EEG didn't look that
concerning but recommended 24hr EEG. Head CT negative. After
intubation BP dropped to 80s and stayed there despite a couple
liters of fluid. Started on peripheral norepi and R IJ placed.
Given Vancomycin and Levofloxacin. BP 30min before ICU transfer
HR 60, BP 101/56, RR 16, 100% on AC, on norepi.
On review of information sent from [**Hospital3 2568**], there is a
discharge summary from [**Date range (1) 81029**] and then radiology and labs
from later in [**Month (only) 116**]. Discharge summary from [**Date range (1) 81029**] mentions
admission to r/o PNA without evidence of PNA although mentions a
recent pneumonia. Was given one day of abx and then stopped and
discharged. CXR from [**4-9**] read as patchy opacity of RLL
concerning for developing PNA. Also Air contrast exam of
esophagus with evidence of silent aspiration. Head CT on [**4-6**]
without acute changes, and CXR on [**4-5**] with retrocardiac
opacity. Labs from [**4-9**] with WBC 15.8, Hgb 13.3, Hct 39.5, Plts
187. Discharge med sheet from [**Hospital3 2568**] showing Cefpodoxime
200mg [**Hospital1 **] to be taken for 10 days until [**4-19**] (meaning must have
been started [**4-10**]).
On arrival to the MICU, intubated and sedated. No family present
and currently trying to identify contact information.
Review of systems: Unable to obtain
Past Medical History:
- DM II on Insulin, complicated by Neuropathy and Retinopathy
- ASTHMA - Steroid Dependent in past
- COPD on home O2
- OSA not on CPAP
- HTN
- CVA
- HLD
- CHF and HX of MI at age 20
- Hx SEIZURE (1x in setting of supra-therapeutic theophylline.)
- Chronic Pain (neck and low back)
- GLAUCOMA - PRIMARY OPEN ANGLE
- OBESITY - MORBID
- PUD
- CARPAL TUNNEL SYNDROME s/p multiple surgeries
- S/p Cholecystectomy
- S/p C-section x 2
- S/p Tubal Ligation
Social History:
Lives with daughter and husband
Family History:
Maternal Grandfather/Grandmother Diabetes - Type II
Maternal Grandmother Diabetes - Type II
Paternal Grandmother Diabetes - Type II
Mother Diabetes - Type II
[**Name (NI) 18806**] - [**Name (NI) 2320**]
HTN in multiple family members
Physical Exam:
Admission exam:
General: Intubated and sedated, no responsive to voice or
noxious stimuli
HEENT: ET tube in place, OGT in place, buffalo hump and thick
neck, unable to see JVP, pupils equal but constricted
bilaterally, poorly responsive to light
Neck: supple, RIJ in place, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi, some transmitted upper airway sounds from the
vent
Abdomen: very distended [**12-18**] to habitus, soft, old chole and
C-section scars, cannot appreciate adominal organs , backside
with decubius ulcers, unlcear stage
GU: foley in place
Ext: warm, well perfused, 2+ pulses, trace LE edema, has stage
II decub ulcer on R heel
Neuro: completely sedated and not responsive to voice/stimuli,
not moving any of extremities due to sedation
DISCHARGE EXAM:
97.7, 117/79, 81, 18, 98%RA
FBS: 164 @ 0700
General: alert, Ox3
HEENT: EOMI, PERRLA
Neck: supple, no errythema around old line site
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft non-tender non-distented
Ext: warm, well perfused, 2+ pulses, trace LE edema, has stage
II decub ulcer on R heel
Neuro: no evidence of siezure acitivty, normal strenght,
senssation and reflexes through out, CN grossly intact
Pertinent Results:
Admission labs:
[**2139-4-16**] 03:30PM BLOOD WBC-10.4 RBC-4.50 Hgb-13.4 Hct-41.4
MCV-92 MCH-29.8 MCHC-32.4 RDW-15.4 Plt Ct-254
[**2139-4-16**] 03:30PM BLOOD Neuts-85.3* Lymphs-12.1* Monos-1.9*
Eos-0.3 Baso-0.4
[**2139-4-16**] 03:30PM BLOOD PT-11.7 PTT-28.0 INR(PT)-1.1
[**2139-4-16**] 03:30PM BLOOD Glucose-88 UreaN-23* Creat-1.2* Na-137
K-4.5 Cl-96 HCO3-29 AnGap-17
[**2139-4-16**] 03:30PM BLOOD ALT-28 AST-37 LD(LDH)-335* CK(CPK)-86
AlkPhos-91 TotBili-0.7
[**2139-4-16**] 03:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2139-4-17**] 02:59AM BLOOD Albumin-3.4* Calcium-8.5 Phos-2.8 Mg-1.9
[**2139-4-17**] 02:59AM BLOOD %HbA1c-7.2* eAG-160*
[**2139-4-16**] 04:32PM BLOOD Type-ART Rates-16/0 Tidal V-450 PEEP-5
FiO2-100 pO2-385* pCO2-49* pH-7.43 calTCO2-34* Base XS-7
AADO2-276 REQ O2-53 -ASSIST/CON Intubat-INTUBATED
[**2139-4-16**] 09:14PM BLOOD Lactate-1.1
[**2139-4-16**] 10:13PM BLOOD Lactate-1.2
DISCHARGE LABS:
[**2139-4-19**] 06:30AM BLOOD WBC-6.4 RBC-4.12* Hgb-12.4 Hct-37.7
MCV-91 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-229
[**2139-4-19**] 06:30AM BLOOD Glucose-159* UreaN-12 Creat-0.7 Na-142
K-3.4 Cl-101 HCO3-33* AnGap-11
MICROBIOLOGY:
Legionella Urinary Antigen (Final [**2139-4-17**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
SPUTUM CULTURE:
GRAM STAIN (Final [**2139-4-17**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2139-4-19**]):
MODERATE GROWTH Commensal Respiratory Flora.
[**2139-4-16**] 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
[**2139-4-16**] Head CT:
IMPRESSION: No acute intracranial abnormality. Please note
that MRI is more sensitive for detection of acute stroke.
[**2139-4-16**] EEG:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized background rhythm and occasional bursts of
generalized slowing. These findings indicate a widespread
encephalopathy, affecting both cortical
and subcortical structures. Medications, metabolic disturbances,
and infection are among the most common causes. There were no
areas of prominent focal slowing, but encephalopathies may
obscure focal findings. There were no epileptiform features.
[**2139-4-17**] Chest x-ray:
Mild interstitial edema is new, accompanied by increasing
moderate
cardiomegaly and mediastinal and pulmonary vascular engorgement.
Focal
abnormality at the bases of both lungs, not as readily visible
now as it was on [**4-16**], could be pneumonia but is readily
explained by atelectasis. Pleural effusions are small if any.
No pneumothorax. ET tube and right jugular line are in standard
placements and nasogastric tube passes below the diaphragm and
out of view.
Brief Hospital Course:
65 yr/o F with multiple medical problems and recent admission to
[**Hospital6 4287**] for pneumonia (discharged yesterday) found
today at home poorly responsive. There was concern that patient
was having seizures, she recived ativan in ED and became more
somnolent. She was intubated for airway protection and then
became hypotensive following intubation. Patient was admitted
to MICU intubated on pressors. Pressors were quickly weaned and
patient was extubated the morning following admission.
.
# Acute Encephalopathy: Unclear etiology. Most likely etiolog is
that she became hypoglycemic overnight on new insulin regimen.
As per daughter patient had been intermittently AMS in morning
either due to hypoglycemia ever since being started on lantus
with standing Humalog meal coverage from her prior 70/30 regimen
several weeks earlier. Patient was also noted to have acute
renal insufficency which may have caused poor clearance of long
acting opitaes and gabapentin. The patient was intubated in the
ED for airway protection and weaned from the vent/extubated 12
hours later. Her mental status was clear post-extubation.
Neurology was consulted for ? seizure activity in the ED, but
did not feel he myoclonis was true seizure activity. 8hours of
continuous EEG monitoring did not reveal seizure activity. She
was discharged home with a lower dose of gabapentin and MS
contin held.
.
# [**Hospital6 2320**]: On very elevated lantus dosing at home with recent
discharge summary reporting 70units. When found altered with
blood sugar in 60s. Reporting has been worse even since changed
to lantus, used to be on 70/30 regimen of 80s in AM and 30s in
PM. Concern that with current regimen of long acting insulin
she is getting too low at night as was not getting nearly as
much nighttime coverage. [**Last Name (un) **] service was consulted and
recommended 70/30 22 units QAM and 18 units QPM.
.
# Respiratory Failure: Was intubated in the ED for airway
protection in setting of AMS. Does not appear to have had
respiratory distress as part of presentation and sats were okay
in the ED. Has history of COPD on home O2 at night, asthma that
has been steroid dependent, and OSA (not on CPAP), so poor
underlying respiratory substrate. Breathing well overnight on
minimal vent settings and now extubated this AM and breathing
comfortably on minimal oxygen support. CXR with low lung volumes
but otherwise clear. Low concern for infection in this setting.
Unclear if had a pneumonia at [**Hospital3 2568**] but has finished 8 day
Abx course at this point. Legionella Uag negative. Patient was
initially treated for HAP with vancomycin and meropenem, but
this was stopped as patient did not have evidence of infection
and had already completed eight days of antibiotics for
pneumonia. Patient was seen by speech and swallow given concern
of recurrent lower lobe pneumonias and a barium swallow at [**Last Name (un) 1724**]
that showed slient aspiration. She will need to be followed up
by her pcp about referral to speech and swallow(pt did not want
to stay to be evaluated by [**Hospital1 18**] speech therapy)
.
# Hypotension: Likely hypotensive in setting sedation after
intubation, although initially treated as if septic shock.
Weaned off pressors overnight after first night in ICU. Also has
decubs on backside and feet so skin source is possible. Lactate
normal. Cardiac markers/EKG with no ischemia. CXR is clear. No
significant infections symptoms now that patient clear enough to
say. Patient originally was treated with stress dose steroids
but this was stopped because she had no further hypotension,
felt hypotension was secondary to medication administration.
.
# Skin Breakdown: Likely due to her neuropathy and fact that she
doesn't move around much at home. Has stage II decub on R heel
as well as sacrum. Don't appear infected currently. [**Last Name (un) **] boots
on feet to help offload.
.
# HTN: atenolol initially held due to hypotension in the ED,
likely secondary to intubation. restarted prior to discharge.
.
# Chronic Pain: due to concern that [**Last Name (un) **] and polypharmacy may
have been contributing to her altered mental status her
oxymorphone was discontinued, gabapentin decreased to 200 mg TID
and kept on oxycodone 5 mg PRN:[**Hospital1 **] for pain.
.
TRANSITIONAL ISSUES:
-oxymorphone discontinued
-antibiotics held
-gabapentin dose decreased
-final blood and urine cultures pending at time of discharge
-Patient will need outpatient speech therapy follow up for her
silent aspiration
Medications on Admission:
- Cefpodoxime 200mg [**Hospital1 **] for 10 days (last day [**2139-4-19**])
- Gabapentin 600mg Qhs and 400mg TID (total of 1800mg daily)
- Oxycodone 5mg [**Hospital1 **]
- Oxymorphone 20mg TID
- Prednisone 10mg daily
- Singulair 10mg daily
- Fluticasone/Salmeterol 500/50 (Advair) 1 puff [**Hospital1 **]
- Lasix 20mg TID
- Atenolol 50mg daily
- Lantus 70 units Qhs
- Humalog 15 units before meals
- Rosuvastatin 20mg daily
- ASA 81mg daily
- Vit D 50,000 units Qweek
- Oyster calcium 500mg daily
- Lumigan eye drops Qhs
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing/SOB.
Disp:*1 inhaler* Refills:*0*
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
13. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): while on oxycodone
.
Disp:*60 * Refills:*2*
14. Vitamin D3 Oral
15. Oyster Shell Calcium 500 mg calcium (1,250 mg) Tablet Sig:
One (1) Tablet PO once a day.
16. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Twenty Two (22) units Subcutaneous QAM.
Disp:*100 units* Refills:*0*
17. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous QPM.
Disp:*300 units* Refills:*0*
18. insulin regular human 100 unit/mL Solution Sig: as on
sliding scale units Injection four times a day: as on sliding
scale.
Discharge Disposition:
Home With Service
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] VNA
Discharge Diagnosis:
PRIMARY
-hypoglycemia
-hypoxia
-hypotension
-diabetes
SECONDARY
-asthma
-high blood pressure
-chronic low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your altered
mental status which was felt to be caused by low blood sugars
and the sedating effects of your pain medications. There was
concern that you might have been having seizures and were
intubated out of concern that you were not breathing well enough
on your own. You were admitted to the intensive care unit and
extubated once you were able to breath without assistance. You
were seen by our [**Last Name (un) **] Diabetes experts who helped to manage
your blood sugars. There was no evidence of pneumonia during
this admission. You were recommended to be seen by our speech
and swallow experts to evaluate your oral intake and its effect
on your recent pneumonias. This test was not completed during
this stay, but should be done as an outpatient. Please discuss
this issue with your primary care doctor at your follow-up
visit.
The following changes were made to your medications:
-INSULIN 70/30: 22 Units in AM and 18 Units in PM
-INSULIN SLIDING SCALE: follow print out given to you today
-DECREASE Gabapentin to 200 mg three times a day.
-STOP Oxymorphone
-STOP Cefpedoxime
-START Albuterol 1 puff every 4 hrs as needed for wheezing
-START Docusate 50mg (liquid) twice daily with oxycodone
Followup Instructions:
Please contact your primary care doctor to discuss your diabetes
management in the next 7-10 days.
|
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"V12.54",
"428.22",
"V58.65",
"365.70",
"707.22",
"250.50",
"348.31",
"707.07",
"707.03",
"401.9",
"458.29",
"362.01",
"E937.9",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14720, 14820
|
7953, 12259
|
424, 518
|
14981, 14981
|
5029, 5029
|
16472, 16574
|
3429, 3668
|
13066, 14697
|
14841, 14960
|
12520, 13043
|
15132, 16449
|
5939, 6774
|
3683, 4529
|
4545, 5010
|
6809, 6825
|
12280, 12494
|
2872, 2891
|
309, 386
|
546, 2853
|
6834, 7930
|
5045, 5923
|
14996, 15108
|
2913, 3364
|
3380, 3413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,936
| 193,835
|
8914
|
Discharge summary
|
report
|
Admission Date: [**2135-4-10**] Discharge Date: [**2135-4-15**]
Date of Birth: [**2064-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
swollen abdomen and vomitting "dark stuff"
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Pt is a 70yoM with ESLD [**12-31**] etoh and new diagnosis of diabetes,
presenting complaining of swollen abdomen, dark emesis. Pt poor
historian. He had an episode of vomiting "dark stuff, like
chocolate" yesterday at 11:30 am. Also with "swelling stomach."
Pt needs occasional [**Doctor First Name 4397**] as out-pt and was requesting one.
.
Pt brought to [**Hospital1 **] by daughter who is primary caregiver. In the ED
vitals: 96.4, hr 75, bp 136/83, rr 17, sat 98% ra. In ED had
episode of coffee ground emesis, refused NGL. Refused central
line or foley placement. Received NS 1 liter, zofran 4 mg iv X1,
protonix 40 mg iv x 1. Of note on labs: AG 14, high blood
glucose, insulin 4 units for FS 550, then 8 units for FS 438.
Hct 43 (baseline mid to high 30s). Cr elevated to 2.2 from
baseline 1.6. Liver consulted: pt will likely need EGD.
Transferred to ICU for further evaluation.
Past Medical History:
EtOH cirrhosis
CKD
Laryngeal cancer status post XRT
Anemia
Colonic adenoma
GERD
Social History:
lives with daughter, smoked since age 12, stopped drinking
"years ago"
Family History:
Non-contributory.
Physical Exam:
Temp 97.3
BP 159/69
Pulse 96
Resp 16
O2 sat 99% ra
Gen - slightly agitated, not wanting to participate in hx/exam
HEENT - anicteric, mucous membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - tense, significantly distended, nontender, diminished
bowel sounds
Extr - No edema. 2+ DP pulses bilaterally
Skin - No rash
Pertinent Results:
[**2135-4-10**] 05:40AM BLOOD WBC-5.8 RBC-4.87 Hgb-13.6* Hct-41.6
MCV-85 MCH-27.8 MCHC-32.6 RDW-15.7* Plt Ct-514*#
[**2135-4-10**] 05:40AM BLOOD Neuts-78.3* Lymphs-15.1* Monos-4.7
Eos-0.9 Baso-1.0
[**2135-4-10**] 05:40AM BLOOD PT-10.1* PTT-20.3* INR(PT)-0.8*
[**2135-4-10**] 05:14AM BLOOD Glucose-552* UreaN-34* Creat-2.2* Na-132*
K-5.4* Cl-99 HCO3-19* AnGap-19
[**2135-4-10**] 05:14AM BLOOD ALT-55* AST-47* Amylase-147* TotBili-0.1
[**2135-4-10**] 05:14AM BLOOD Albumin-3.6 Calcium-9.9 Phos-4.1 Mg-2.3
[**2135-4-10**] 08:41AM BLOOD %HbA1c-12.6*
.
ekg: sb @ 52 bpm, pr 208, TWI v1, v2, avl, more pronounced
compared to prior ekg in '[**28**]
.
[**4-10**] CXR
Single portable radiograph of the chest demonstrates no change
in the cardiomediastinal contour when compared with [**2134-10-8**].
Increased linear opacities involving the bilateral lung bases
may represent mild atelectasis versus scarring. No effusion.
Trachea is midline. No consolidation. No pneumothorax.
IMPRESSION:
Linear markings involving the bilateral lung bases likely
represnt scarring. The findings are similar to that seen on
[**2134-10-8**].
Brief Hospital Course:
A/P: 70 yo M with h/o etoh cirrhosis p/w hemetemasis,
hyperglycemia. His active medical issues include:
.
# UGIB: Patient's Hct remained stable in ICU and he was
subsequently transferred to floor. EGD revealed gastritis and
duodenitis but no varices. He had no varices. He required no
transfusions this admission.
# Hyperglycemia: Patient was diagnosed with diabetes, HA1C 12.6
suggesting chronically high sugars. His fingersticks ranged
intially fr om critically high to 300's. He was started on [**Hospital1 **]
regimen of 70/30 given his problems with compliance. By
discharge, his dose was 12units in AM, 20 units in PM.
Fingersticks on this regimen ranged from 90-250's. Diabetic
teaching, nutrition teaching were arranged. He was also
instructed regarding signs and symptoms to look out for for
hypoglycemia. His daughter, who is familiar with administering
insulin, will give him his home injections. Patient will have
outpatient follow-up.
# Ascites: Patient has diuretic resistant ascites requiring
regular paracentesis. He was tapped 5.5 L. Peritoneal cx
revealed no PMNs on gram stain but grew sparse coag neg staph
believed to be contaminant. There was also a macrphage
predominance to the ascitic cell count, which was unclear in
etiology. Upon admission to unit, he was started on prophylactic
dose cipro for SBP, then in light of a one time temp of 101 (no
leukocytsosis, no subsequent fever), the macrophage
predominance, and the coag neg staph, it was decided to treat
him for SBP with a very short course of treatment dose
ciprofloxacin 500 mg [**Hospital1 **] X 5 days.
# CKD: His CKD was attributed to long-standing diabetes,
baseline cr 1.6. He remained at his baseline this admission.
# GERD: PPI
# Anemia: baseline hct mid to high 30s. Fe studies were
consistent with anemia of chronic disease.
FEN: clear DM diet. Nutrition was consulted.
ppx: ppi as above, hep sc
full code
Communication: w/ pt and Daughter [**Name (NI) **] ([**Telephone/Fax (1) 30990**] or ([**Telephone/Fax (1) 30991**]
Medications on Admission:
Cannot remember his medications.
Per OMR:
hexavitamin
lactulose
folate
mgox
prilosec
thiamine
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lancets & Blood Glucose Strips Combo Pack Sig: qs
Miscellaneous four times a day.
[**Telephone/Fax (1) **]:*qs qs* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
[**Telephone/Fax (1) **]:*10 Tablet(s)* Refills:*0*
6. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: as directed Subcutaneous twice a day: Please inject 12
units at before breakfast and 20 units at night.
[**Telephone/Fax (1) **]:*qs qs* Refills:*2*
7. Glucose 4 g Tablet, Chewable Sig: One (1) Tablet, Chewable PO
as needed as needed for low blood sugar.
[**Telephone/Fax (1) **]:*30 Tablet, Chewable(s)* Refills:*2*
8. Syringe with Needle, Insulin 3 mL 20 x 1 Syringe Sig: qs
Miscellaneous twice a day: use syringes with your insulin only
and use as directed.
[**Telephone/Fax (1) **]:*qs qs* Refills:*2*
9. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection four times a day: 2 Units for blood sugar 150-200, 4
Units for blood sugar 201-250, 6 units for blood sugar 251-300,
8 units for blood sugar 301-400, 10 units for blood sugar above
400 and call your doctor.
[**Last Name (Titles) **]:*10 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Diabetes
cirrhosis
chronic renal insufficiency
spontaneous bacterial peritonitis
Secondary:
Laryngeal cancer status post XRT
Anemia
Colonic adenoma
GERD
Discharge Condition:
stable, pain free
Discharge Instructions:
You have gastritis and diabetes. You are getting treatment for
an infection in your abdomen.
You have a new diagnosis of diabetes and should take your
insulin injection every day. You should check your fingerstick
blood sugar 4 times a day. If you have symptoms of low blood
sugar (dizzyness, nausea, palpitiations, sweating), check your
blood sugar and take either a sugar pill or drink some juice.
Please take all medications as prescribed.
Please go to the hospital or call your doctor if you have any
worsening symptoms of pain, lightheadedness, fever, chills,
nausea, vomiting, abdominal pain or any other concerning
symptoms.
Followup Instructions:
Primary care doctor: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 30886**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-4-20**] 3:30PM
Liver: DR. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2135-5-2**]
2:30
[**Hospital Unit Name 1825**] [**Hospital1 18**] [**Hospital Ward Name 516**].
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-5-16**] 1:00
|
[
"250.42",
"583.81",
"276.1",
"276.7",
"578.9",
"285.21",
"567.23",
"V10.21",
"530.81",
"789.5",
"571.2",
"585.9",
"276.52",
"250.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6760, 6818
|
3115, 5141
|
357, 371
|
7024, 7043
|
1971, 3092
|
7726, 8269
|
1498, 1517
|
5286, 6737
|
6839, 7003
|
5167, 5263
|
7067, 7703
|
1532, 1952
|
275, 319
|
399, 1290
|
1312, 1393
|
1409, 1482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,175
| 136,796
|
18238+18273
|
Discharge summary
|
report+report
|
Admission Date: [**2139-10-5**] Discharge Date: [**2139-10-30**]
Date of Birth: [**2074-11-15**] Sex: F
Service: TRAUMA
HISTORY OF THE PRESENT ILLNESS: This is a 65-year-old
female, status post MVA, restrained driver at high-speed with
considerable damage to the front and back of the vehicle.
The patient was initially seen at [**Hospital3 **]. The patient
had an INR of 1.8. She is on Coumadin. She received 2 units
of FFP. The patient developed a left neck hematoma, became
hypotensive, and was intubated and transported to [**Hospital1 **].
In the ED, her initial blood pressure was in the 80s. She
was given 5 units of packed red blood cells. A right
subclavian and right femoral cordis was placed and bilateral
chest tubes were placed. A DPL was performed which was
positive. The patient was taken to the OR.
PAST MEDICAL HISTORY:
1. Hypertension.
2. DVT.
3. History of PE.
4. History of thyroid disease.
5. History of depression.
ADMISSION MEDICATIONS:
1. Coumadin.
2. Zoloft.
3. Synthroid.
4. Lasix.
5. Toprol.
6. Cozaar.
7. Zocor.
8. Paxil.
9. Nexium.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: HEENT: The pupils were
equal, round, and reactive to light. The patient was
intubated and sedated. Chest: Decreased breath sounds on
the left. Heart: Regular rate and rhythm. Abdomen: Obese,
seatbelt bruise across the umbilicus. Extremities: The left
lower extremity was ischemic appearing at first but regained
pulse after blood transfusion. No other apparent injuries.
Back: No step-off. Fast examination was negative. DPL was
grossly positive. Bilateral chest tubes were inserted with
30 cc of blood each.
HOSPITAL COURSE: The patient was taken to the OR for an
exploratory laparotomy. The patient had an exploratory
laparotomy with a liver laceration repair and thyrocervical
trunk injury that was coiled. The patient also had an IVC
filter placed on [**2139-10-6**] in order to discontinue Coumadin
for her history of DVT and PE.
The patient was sent to the Trauma SICU intubated. Studies
done while the patient was in the Trauma SICU revealed a head
CT with a small subarachnoid hemorrhage and bilateral
subdural hemorrhages. A CT of the C-spine revealed widened
space between C4-5. A right knee x-ray was negative. An MRI
showed no infarct. An MRA of the C-spine showing right side
paracentral disk protrusion at C4-5. A CT of the TLS showing
a right lamina fracture at T4 and an L1 transverse process
fracture. The patient had a repeat head CT on [**2139-10-6**]
showing an improved subarachnoid hemorrhage and a subdural
hemorrhage unchanged. A CT of the chest showed no PE and no
great vessel injury, and a right sternoclavicular joint
dislocation and a rib fracture on the left side at rib 7 and
on the right side ribs [**3-26**]. The CT of the pelvis was
negative for fracture.
While in the Trauma SICU, the patient began to spike
temperatures to a temperature of 101 but workup was negative
except for a sputum culture which grew out coagulase-positive
Staphylococcus. The patient completed a seven day course of
vancomycin and a ten day course of levofloxacin. The patient
also grew urine culture positive for greater than 100,000
yeast. She completed a seven day course of fluconazole as
well.
The patient was difficult to wean from the ventilator until
[**2139-10-26**], at which point she was extubated and remained in no
respiratory distress. The patient was transferred to the
floor on postoperative day number 18. The patient remained
hemodynamically stable and had aggressive chest PT and
remained without respiratory distress. The patient remained
afebrile throughout the remainder of the hospitalization.
The patient remained in the TLSO brace and the C collar for
her fractures.
On [**2139-10-28**], the patient pulled her NG tube out and had a
swallowing study performed which she passed and a video
swallow performed which she also passed and was placed on a
diet of nectar thick liquids and pureed foods. The patient
did well until discharge to her rehabilitation facility.
CONDITION ON DISCHARGE: Good. She was discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post motor vehicle collision.
2. Status post liver laceration repair.
3. Status post thyrocervical trunk injury.
4. Small subarachnoid hemorrhage.
5. Bilateral small subdural hemorrhages.
6. Right sternoclavicular joint dislocation.
7. Multiple bilateral rib fractures.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg p.o. q.d.
2. Levothyroxine 75 micrograms p.o. q.d.
3. Metoprolol 50 mg p.o. q.i.d.
4. Sertraline 25 mg p.o. q.d.
5. Tylenol p.r.n.
6. Percocet p.r.n. pain.
FOLLOW-UP: The patient is to follow-up with the Trauma
Service as discussed with the patient and as described in
discharge instructions and with Orthopedic Surgery as
described in discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 7586**]
MEDQUIST36
D: [**2139-10-29**] 04:07
T: [**2139-10-29**] 18:28
JOB#: [**Job Number 50347**]
Admission Date: [**2139-10-5**] Discharge Date: [**2139-11-3**]
Date of Birth: [**2074-11-15**] Sex: F
Service:
ADDENDUM: The patient was ready for discharge on [**2139-10-30**].
While awaiting placement for rehabilitation facility, the
patient became febrile on [**2139-11-1**]. The patient had a chest
x-ray done which showed a possible retrocardiac opacity, but
urine cultures were done which, to date, have been negative.
The patient had a PICC line placed on [**2139-11-2**], and was
restarted on vancomycin 1,000 mg IV q 12 h. The patient
defervesced and remained afebrile for the remainder of her
hospital course. The patient's white count, which had been
elevated to 19, decreased to 13. She remained in stable
condition. She is to complete a 10-day course of vancomycin
through her PICC line at rehabilitation facility.
DISCHARGE MEDICATION ADDENDUM: Vancomycin 1,000 mg IV q 12 h
x 9 more days.
DISCHARGE DIAGNOSIS ADDENDUM: Pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D.
[**MD Number(1) 14131**]
Dictated By:[**MD Number(1) 50407**]
MEDQUIST36
D: [**2139-11-3**] 10:25
T: [**2139-11-3**] 10:32
JOB#: [**Job Number 50408**]
|
[
"900.89",
"568.0",
"864.02",
"482.40",
"599.0",
"852.01",
"E812.0",
"807.08",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"54.19",
"88.41",
"88.51",
"96.72",
"38.7",
"99.29",
"39.30",
"96.6",
"99.04",
"34.04",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
4553, 6463
|
4242, 4530
|
1741, 4139
|
998, 1184
|
1199, 1723
|
869, 975
|
4164, 4221
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,602
| 106,255
|
10834
|
Discharge summary
|
report
|
Admission Date: [**2113-9-23**] Discharge Date: [**2113-9-28**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
nausea/vomiting, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F with Alzheimer's and recent admit for GI bleed from
gastritis and metaplastic pyloric mass presented with an episode
of nausea / vomiting / and a fall from her bed. She is a poor
historian, but records from [**Location (un) **] indicate that she had
vomited w/o blood x 1 around 2 pm on [**2113-9-23**], and possibly
fell/slid from bed. Pt denies F/C/abd pain/diarrhea/melena /
BRBPR. In ED, she had episode of vomiting with SBP 60's,
bradycardia to 30's --> given atropine.She was transferred to
the MICU for further mgmt.
Past Medical History:
Alzheimer's dementia
HTN
OCD
h/o recent GIB w/ EGD revealing
high grade duodenal dysplasia and intestinal metaplasia ([**8-9**])
EGD [**9-9**] with ulcerating pyloric mass increased in size.
Social History:
She lives at [**Hospital3 **] facility). Has a
remote history of tobacco use, quit 40 years ago. No EtOH.
Family History:
NC
Physical Exam:
O: V: T96.4 BP 114/84 P74 R20 94% 2L
Gen: NAD
HEENT: OP clear, NG tube in place
Resp: lungs coarse bilaterally
CV: distant, RRR
Abd: soft NTND +BS
Ext: no edema
Neuro: A+Ox1 (to person), oriented to season and general place
Pertinent Results:
[**2113-9-23**] 03:45PM BLOOD WBC-7.7 RBC-2.07*# Hgb-6.4*# Hct-20.5*#
MCV-99*# MCH-31.1 MCHC-31.4 RDW-18.9* Plt Ct-371#
[**2113-9-24**] 01:16AM BLOOD WBC-12.4*# RBC-3.01*# Hgb-9.5*#
Hct-28.7*# MCV-95 MCH-31.4 MCHC-33.0 RDW-18.7* Plt Ct-318
[**2113-9-24**] 05:59AM BLOOD Hct-29.0*
[**2113-9-24**] 02:54PM BLOOD Hct-31.7*
[**2113-9-24**] 09:05PM BLOOD Hct-35.9*
[**2113-9-25**] 05:35AM BLOOD WBC-14.7* RBC-3.63* Hgb-11.2* Hct-34.1*
MCV-94 MCH-30.8 MCHC-32.9 RDW-19.5* Plt Ct-264
[**2113-9-25**] 03:15PM BLOOD Hct-35.2*
[**2113-9-26**] 06:00AM BLOOD Hct-33.8*
[**2113-9-27**] 05:30AM BLOOD Hct-33.3*
[**2113-9-24**] 01:16AM BLOOD CK-MB-86* MB Indx-18.5* cTropnT-1.62*
[**2113-9-24**] 02:54PM BLOOD CK-MB-135* MB Indx-16.2* cTropnT-3.06*
[**2113-9-24**] 09:05PM BLOOD CK-MB-97* MB Indx-13.3*
[**9-23**] CT head - negative
[**9-23**] CXR - unremarkable
Brief Hospital Course:
1. Anemia - on admission her Hct was 20.3 so she received total
of 3 units PRBCs with an appropriate Hct bump to around 33-35.
She was given 2 L NS in ED. This was felt to be secondary to
bleeding from the pre-pyloric mass. GI was consulted and felt
that she would benefit from stent placement only if she was
nauseated/vomiting, but that it would not control the bleeding,
so she was tried on food and tolerated all foods well. Her PPI
was continued twice a day. It was discussed with her family that
a conservative/palliative approach will be pursued, with
symptomatic control with PPI twice a day, biweekly hct checks,
and likely no readmission if she has a massive GI bleed. This
will be conveyed to her [**Hospital3 **] facility, where she is
to return.
2. Cardiac ischemia: Her troponins/CK were elevated during
admission, likely secondary to ischemia from low hematocrit. As
pt has history of bleeding, anticoagulation with heparing was
contraindicated anyway. A betal blocker was added to her regimen
instead of her calcium channel blocker. She was monitored on
telemetry without any adverse events. As she is DNR/DNI, no
further enzymes will be drawn.
3. HTN: A beta blocker was substituted for her calcium channnel
blocker for its cardioprotective effects. Her BP was stable.
4. s/p fall: She was noted to have had a fall at the outside
hospital, but her head CT was negative for bleed and her mental
statyus
5. Nausea/vomiting: She tolerated clears then solid food in the
hospital without aspiration or vomiting. She did not need
antiemetics.
6. Code status: DNR/DNI - This was discussed with the family and
palliative care. Also no invasive procedures (i.e. cath, EGD for
massive GI bleed) should be done but will consider EGD/stent as
outpatient if gastric outlet obstruction develops. The family
will clarify her status further, with possible CMO, as an
outpatient, and may fill out a do not hospitalize plan.
Medications on Admission:
home meds:pantoprazole 40 mg PO BID, B-12 1000 mcg PO QD,
ferrous sulfate 5 g PO TID, folic acid 0.4 mg PO BID, diltiazem
(Tiazac) 240
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-C Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
6. Multi-Vit 55 Plus Tablet Sig: One (1) Tablet PO once a
day.
7. Outpatient Lab Work
Please draw HCT every Monday and Thursday and send results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**0-0-**]
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Homecare Solutions
Discharge Diagnosis:
Pyloric mass with subacute bleeding
dementia
cardiac ischemia
Discharge Condition:
Pt was eating and drinking well. She was ambulating, and had no
complaints of pain.
Discharge Instructions:
Please administer her current medications, and give colace and
senna if constipated.
She may resume a normal diet.
Please have the nurse or laboratory draw her blood Monday [**10-2**], and each Thursday and Monday after that, with results sent
to Dr. [**Last Name (STitle) **].
If she has vomiting, nausea, bleeding or dark stools, please
contact Dr. [**Last Name (STitle) **]. Please do not hospitalize without contacting
her daughter first.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] early next week for check of
your blood count ([**0-0-**]).
Follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3815**] (GI) as needed, ([**Telephone/Fax (1) 8892**].
|
[
"E884.4",
"294.10",
"578.9",
"787.01",
"331.0",
"280.0",
"151.1",
"410.71",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5530, 5580
|
2345, 4276
|
283, 290
|
5686, 5771
|
1470, 2322
|
6265, 6546
|
1206, 1210
|
4461, 5507
|
5601, 5665
|
4302, 4438
|
5795, 6242
|
1225, 1451
|
218, 245
|
318, 852
|
874, 1067
|
1083, 1190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,093
| 161,603
|
2802
|
Discharge summary
|
report
|
Admission Date: [**2132-10-23**] [**Month/Day/Year **] Date: [**2132-10-29**]
Date of Birth: [**2081-2-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Bactrim / clindamycin / latex
Attending:[**Last Name (NamePattern1) 13159**]
Chief Complaint:
Vomiting and fatigue
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
51 year old female with history of stage V CKD, t2DM c/b by
neuropathy/nephropathy/retinopathy, HTN, and chronic
pancreatitis, presenting with RUQ pain and decreased PO intake x
1 week. For 1 week prior to admission, she recalls feeling very
fatigued and had some mild shortness of breath as well. Her
urine was also very dark and she describes it as "bloody",
though she points at a more [**Location (un) 2452**]-like color. Her poor intake
started 3-4 days prior to admission, with vomiting starting 1
day ago. It started as normal vomitous and then became darker.
After vomiting numerous time, she was spitting blood. She first
described the vomitous as coffee grounds, but reports that it
was actually a green tinge.. She reports that she has been
urinating, last void just before coming to the ED. She called
EMS today because her fatigue was getting worse and her
abdominal pain (different than her normal pancreatitis pain) was
becoming more intense. She tried to avoid seeing a doctor
because she thought she would just get better. She did have
episodes of feeling dizzy. Per EMS, her systolic BPs were
running in the 80s-90s en route.
On her last [**Hospital 10701**] clinic visit, her progression of her CKD
was felt to be secondary to significant diabetic involvement of
her kidney. She was also noted to have nephrotic range
proteinuria and increased blood pressure. They discussed the
possible need of renal replacement therapy in the future with
possibilities of kidney transplant or dialysis. They referred
here to the [**Hospital 1326**] Clinic to get the workup started.
In the ED, initial vitals were: 75 103/67 (after 1L IVF) 14 99%
RA.
Exam was guaiac negative from below with a hematocrit well above
her baseline of 30-33. No pericardial rub on exam. Abdominal
pain much improved after 5mg of morphine. Other labs are
notable for acute on chronic renal failure with BUN/creat
126/9.1. Na 129, K 4.1, HCO3 9 (AG of 28) and WBC 17.5 with left
shift. CXR was unremarkable and CT abdomen showed cholelithiasis
in a distended GB but no apparent wall edema, pericholecystic
fluid, or surrounding inflammation to suggest cholecystitis.
She received 2L IVF and was covered with Cipro/Flagyl. Renal
was [**Hospital 4221**] and recommended giving D5W with 150 mEq NaHCO3 and
sending off urinalysis and urine electrolytes.
On arrival to the MICU, she is in some abdominal pain but
conversant and with stable vital signs (normal BP).
Past Medical History:
-IDDM, secondary to chronic pancreatitis, complicated by
retinopathy and nephropathy; reports h/o hypoglycemic seizure in
past
-hypertension
-Chronic Kidney Disease secondary to HTN and IDDM
-tobacco abuse
-idiopathic chronic pancreatitis
-history of splenic vein thrombosis [**2119**] - ?d/t hypercoaguable
state vs. chronic pancreatitis, hyperocag w/u at the time was
neg
-depression
-mitral regurgitation
-History of multiple abscesses, including MSSA and MRSA
Social History:
Ms. [**Known lastname **] lives in [**Location 686**]. She smokes about 1 pack every
three days, and has been working to decrease use. No alcohol or
illicits. Does not want blood transfusions.
Family History:
Her father had pancreatitis and died of pancreatic cancer at age
56. Her mother died from anesthesia reaction. + h/o breast
cancer in family. History of CAD and diabetes in other family
members.
Physical Exam:
Admission exam:
Vitals: T: 97.9 BP:114/75 P:70 R:13 O2:100% RA
General: Alert, oriented, no acute distress
HEENT: mild proptosis, sclera anicteric, MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, diffuse tender, non-distended, bowel sounds
present, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
[**Location **] exam:
VS: Tm 99.1 Tc 98.8 71-82 162/91 18 100% RA
General: Alert, oriented, no acute distress
HEENT: Multiple fixed masses with central necrotic area on her
head. Largest over occiput about 1x1x1cm. Also over R temporal
area and R crown. mild proptosis, sclera anicteric, MMM,
oropharynx clear, EOMI
Neck: supple, JVP not elevated, right posterior cervical LAD 1cm
in diameter, mobile, nontender
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
heard best over RUSB, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, tender to palpation in all quadrants of abdomen
worst in RUQ. No guarding/rebound. non-distended, bowel sounds
present, no organomegaly. No CVA tenderness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Pertinent Results:
Labs on admission:
[**2132-10-23**] 08:45PM BLOOD WBC-17.5*# RBC-4.86# Hgb-13.9# Hct-39.1
MCV-80*# MCH-28.5 MCHC-35.5* RDW-14.5 Plt Ct-412
[**2132-10-23**] 08:45PM BLOOD Neuts-84.3* Lymphs-12.6* Monos-2.7
Eos-0.2 Baso-0.2
[**2132-10-23**] 08:45PM BLOOD PT-13.1* PTT-34.9 INR(PT)-1.2*
[**2132-10-23**] 08:45PM BLOOD Glucose-127* UreaN-126* Creat-9.1*#
Na-129* K-4.1 Cl-92* HCO3-9* AnGap-32*
[**2132-10-23**] 08:45PM BLOOD ALT-9 AST-12 AlkPhos-126* TotBili-0.1
[**2132-10-23**] 08:45PM BLOOD cTropnT-0.19*
[**2132-10-24**] 04:37AM BLOOD CK-MB-7 cTropnT-0.16*
[**2132-10-24**] 04:37AM BLOOD Albumin-3.0* Calcium-7.6* Phos-11.5*#
Mg-2.1
[**2132-10-24**] 04:37AM BLOOD PTH-373*
[**2132-10-24**] 02:49AM BLOOD Type-ART pO2-95 pCO2-42 pH-7.27*
calTCO2-20* Base XS--7
[**2132-10-23**] 08:56PM BLOOD Lactate-0.7
Labs on [**Month/Day/Year **]:
[**2132-10-29**] 07:20AM BLOOD WBC-12.7* RBC-4.09* Hgb-11.3* Hct-34.4*
MCV-84 MCH-27.6 MCHC-32.8 RDW-13.8 Plt Ct-376
[**2132-10-29**] 07:20AM BLOOD Glucose-248* UreaN-83* Creat-4.7* Na-130*
K-3.7 Cl-93* HCO3-25 AnGap-16
[**2132-10-29**] 07:20AM BLOOD ALT-18 AST-30 LD(LDH)-256* AlkPhos-126*
TotBili-0.1
[**2132-10-29**] 07:20AM BLOOD Calcium-9.3 Phos-5.0* Mg-2.0
MICRO: Urine culture - multiple organisms/ likely contaminant
Blood Cultures 9/20: Pending
IMAGING:
CT abd/pelv: IMPRESSION:
1. Cholelithiasis with gallbladder distension without other CT
signs of
cholecystitis. Clinical correlation suggested regarding need
for ultrasound.
2. No acute intra-abdominal process.
CXR: IMPRESSION: No acute cardiopulmonary process.
RUQ U/S [**10-27**]: IMPRESSION:
1. Cholelithiasis, with no evidence of cholecystitis.
2. Mildly dilated extra-hepatic biliary ducts. No obstructing
stone.
3. Echogenic kidney as seen on renal ultrasound of [**2131-8-23**].
[**10-27**] Gastric Emptying Study:
IMPRESSION: Delayed gastric emptying with residual activity in
the gastric antrum.
Brief Hospital Course:
51 year old female with stage V CKD secondary to diabetic
nephropathy/HTN with nephrotic range proteinuria presenting with
acute on chronic renal failure likely secondary to hypovolemia.
ACTIVE ISSUES:
# Acute on chronic renal failure: Given her history of
abdominal pain resulting in poor PO intake and ?coffee-ground
emesis, she was likely hypovolemic. She responded well to
volume resuscitation with D5W + bicarbonate given her acidosis.
She was oliguric but her urine output recovered after
rehydratoin. Her elevated hematocrit likely represented
hemoconcentration. She had no indications for hemodialysis.
Her anioin gap of 28 closed and ABG showed improving acidemia
with majority contribution likely from her renal failure with no
appreciable lactate and urinalysis w/o ketones. Her creatinine
also continued to improve and on [**Month/Year (2) **] was 4.7 from a high
of 8.1. Metolazone, furosemide, and lisinopril were all held at
admission. On the day of [**Month/Year (2) **] lisinopril 10mg (half of her
normal dose) was restart per Renal Consult recommendations.
# Hematuria: Patient with hematuria of an unclear cause. She was
denying any dysuria, frequency or urgency. Previous urine
culture grew mixed flora. Could be due to her CKD or possibly
from an intrinsic renal process. Per renal, she began treatment
for a UTI with Cipro on [**2132-10-23**]. Cipro was continud for a total
antibiotic course of 14 days. Can recheck UA to ensure
resolution following treatment of UTI.
# Nausea/Abdominal pain: Possibly due to gastroparesis v.
chronic pancreatitis. Cardiac etiology considered but less
likely given normal EKG and at baseline cardiac enzymes. LFTs
normal except Alk phos was 120. She was given Metoclopromide
PRN, Ondansetron PRN, lorazepam PRN for her nausea. RUQ
ultrasound showed no acute causes of abdominal pain. Patient had
a gastric emptying study which showed delayed gastric emptying.
She also commonly has worsening abdominal pain and nausea from
her chronic pancreatitis in setting of acute illness. On
[**Date Range **], her nausea and pain were at basline while she was
receiving PO metoclopramide before meals and compazine prn.
# Hypertension: Mildly hypotensive in the ED, likely secondary
to volume depletion. She is on a multi-drug regimen, much of
which was held. She became hypertensive over last few days of
admission. Amlodipine was restarted but Lisinopril was still
held due to [**Last Name (un) **] for several days. She was given labetalol 100mg
prn for elevated blood pressure. As her renal function improved
lisinopril at half of her home dose was restarted, as per Renal
Consult recommendations. Labetalol 100mg [**Hospital1 **] was continued at
[**Hospital1 **].
# Hyponatremia: Likely Hypovolemic. Bicarbonate was used for
resuscitation and her Na returned to her baseline.
# Leukocytosis: Etiology is possibly infectious vs. stress
response. UA was consistent with UTI (culture was
contaminated). She was treated with ciprofloxacin (started [**10-23**])
for complicated UTI. Her WBC initially improved from 17.5 to 11
but then was trending up at [**Month/Year (2) **]. Her CT abdomen was
negative for infectious etiology including pyelonephritis.
Clinically she felt at her baseline without localizing symptoms
and remained afebrile. Blood cultures from earlier in hospital
course were negative. Urine culture was repeated and is pending
at [**Month/Year (2) **]. C. Difficile considered but bowel movements were
not loose at time of [**Month/Year (2) **]. Will require repeat CBC as
outpatient and if elevated further evaluation.
# Hyperphophatemia/Hypocalcemia: Patient with increasing
hyperparathyroidism (232->373) over past month. Low Vitamin D
level from previous check. Secondary hyperparathyroidism from
kidney failure. She was switched from Sevelamer to Ca Carbonate
-- and later back to Sevelamer when Calcium returned to [**Location 213**].
Calcitriol was held while phosphate was elevated.
# Constipation: Patient was without a bowel movement for first 5
days of admission. Likely due to narcotic pain medications.
Constipation resolved with aggressive bowel regimen.
# Elevated Troponin: Elevation likely secondary to renal
failure. Initially, symptoms were thought to possibly be her
possible abdominal anginal equivalent, but troponins remained
elevated but decreased. They were near her baseline with
elevation likely from worsening renal failure.
CHRONIC ISSUES:
# Diabetes mellitus: On insulin regimen as outpatient. Last A1c
of 8.2 on [**2132-10-7**]. Patient was switched to 1/2 dose of [**Date Range **]
while she had poor PO intake. She was also on a sliding scale.
At [**Date Range **] she was restarted on her home insulin regimen.
# Chronic pancreatitis/pain control: med regimen as above
TRANSITIONAL ISSUES
-evaluate lower extremity edema - if worsening would restart her
lasix and metolazone
-recheck WBC count, if remains elevated will require further
evaluation
-Renal f/u for dialysis evaluation - will be seen by Renal on
[**11-12**]
-Will f/u with transplant surgery (Dr. [**Last Name (STitle) **] for placement of
fistuala on [**11-11**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 20 mg PO DAILY
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Docusate Sodium 100 mg PO BID
4. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWEEKLY
5. Amlodipine 10 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. [**Month (only) 7452**] 40 Units Bedtime
Humalog 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Ferrous Sulfate 325 mg PO BID
9. Furosemide 80 mg PO BID
10. Fentanyl Patch 75 mcg/h TP Q72H
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
12. sevelamer HYDROCHLORIDE *NF* 800 mg Other TID
13. Omeprazole 20 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Aspirin 81 mg PO DAILY
16. Metolazone 5 mg PO DAILY
17. Calcitriol 0.25 mcg PO DAILY
18. Creon 12 Dose is Unknown CAP PO Frequency is Unknown
[**Month (only) **] Medications:
1. Amlodipine 10 mg PO DAILY
Please hold for SBP<100
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWEEKLY
5. Docusate Sodium 100 mg PO BID
6. Fentanyl Patch 75 mcg/h TP Q72H
7. Ferrous Sulfate 325 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth as
needed for nausea every 6 hours Disp #*30 Tablet Refills:*0
10. Senna 2 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1-2 tabs by mouth as needed for
constipation while taking oxycodone Disp #*30 Tablet Refills:*0
11. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Ciprofloxacin HCl 500 mg PO Q24H
day 1 = [**2132-10-23**]
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*8
Tablet Refills:*0
13. Labetalol 100 mg PO BID
Hold for HR<55 or SBP <130
RX *labetalol 100 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
14. Metoclopramide 5 mg PO QIDACHS
RX *metoclopramide HCl 5 mg 1 tablet by mouth before meals as
needed for nausea Disp #*30 Tablet Refills:*0
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
hold for RR<10
RX *oxycodone 5 mg 1 tablet(s) by mouth as needed for pain every
6 hours Disp #*13 Tablet Refills:*0
16. Calcitriol 0.25 mcg PO DAILY
17. Creon 12 0 CAP PO Frequency is Unknown
18. sevelamer HYDROCHLORIDE *NF* 800 mg OTHER TID
19. Potassium Chloride 20 mEq PO DAILY
Hold for K > 5
20. [**Month/Day/Year 7452**] 40 Units Bedtime
Humalog 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
[**Month/Day/Year **] Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
[**Hospital **] Diagnosis:
Primary diagnosis:
Acute kidney injury on chronic kidney disease
Secondary Diagnosis:
Abdominal pain likley secondary to delayed gastric emptying and
chronic pancreatitis
Hypertension
Diabetes mellitus Type 2, insulin dependent
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Hospital **] Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You came to the hospital with nausea,
vomiting, and worsening kidney failure. Your kidney failure was
felt to be due to dehydration and it improved with us giving you
fluids. For your nausea and vomiting, we did a gastric emptying
study and this showed some delayed gastric emptying with
residual activity in the gastric
antrum.
For your abdominal pain, we got an abdominal ultrasound that
showed no acute findings that were thought to be responsible for
your pain. The kidney doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**] and they wanted to
begin the process of readying you for dialysis so an AV fistula.
The kidney team and the surgeons decided it would be best for
you to have the fistula placed after you leave the hospital. On
[**Last Name (Titles) **], your pain was much better, as was your nausea. You
should follow up with your primary care doctors as [**Name5 (PTitle) **] as your
kidney doctors.
Followup Instructions:
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Department: [**Hospital3 249**]
When: THURSDAY [**2132-11-6**] at 1:10 PM
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Department: WEST [**Hospital 2002**] CLINIC
Specialty: Nephrology
When: WEDNESDAY [**2132-11-12**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2132-11-11**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2132-10-29**]
|
[
"577.1",
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"250.50",
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"585.5",
"536.8",
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"276.1",
"276.52",
"536.3",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7256, 7444
|
363, 370
|
5312, 5317
|
16519, 17812
|
3574, 3772
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12434, 15054
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5332, 7233
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15327, 16496
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11712, 12408
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2882, 3348
|
3364, 3558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,888
| 100,250
|
51733
|
Discharge summary
|
report
|
Admission Date: [**2106-2-18**] Discharge Date: [**2106-2-21**]
Date of Birth: [**2056-2-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
constrictive pericarditis
Major Surgical or Invasive Procedure:
Pericardiectomy for constrictive pericarditis.
History of Present Illness:
This 49-year-old patient with
history of pericarditis since the 80s after a viral infection
presented with worsening excised tolerance, lower extremity
edema and abdominal swelling. Further investigations revealed
severe calcific constrictive pericarditis confirmed by echo
and cardiac angiogram and he was admitted for elective
pericardiectomy. The coronary arteries were normal. There
was no valvular pathology. Past medical history was
significant for type 2 diabetes mellitus, atrial flutter-
fibrillation and the constrictive pericarditis, obstructive
sleep apnea, depression, asthma and CVA in [**2100**] with no
residual deficiencies.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes
2. CARDIAC HISTORY:
Constrictive pericarditis (TTE [**1-12**] showed EF 55%); hx of
pericarditis since the 80s
Atrial flutter / fibrillation s/p CV (on coumadin and
sotalol)
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Obesity
Obstructive sleep apnea (uses CPAP)
Depression
Asthma
CVA [**2100**] - no residual deficits
Renal calculi s/p lithotripsy
Social History:
lives with life, unemployed and filing for disability from
merchant marine job
-Tobacco history: chewing tobacco daily for 3-4 years; smoked
[**2-4**] PPD for 13 years, quit in [**2082**]
-ETOH: occasional
-Illicit drugs: none
Family History:
mother died at age 54 and had a stroke at age 35.
Father died at age 65 r/t an embolus following surgery
Physical Exam:
Physical Exam:
On admission:
VS: T 97.8, 108/75, 81, 20, 96% 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.
NECK: Obese neck, cannot assess for JVP, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Distant heart sounds.
LUNGS: Mild thoracic scoliosis. Resp were unlabored, no
accessory muscle use. Bibasilar rales
ABDOMEN: Obese, soft, NTND. No HSM or tenderness.
EXTREMITIES: [**1-3**]+ edema to knees bilaterally, chronic venous
stasis changes on anterior shins R>L; 1x1cm on anterior shin
superficial ulcer with clear fluid expressed
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:
[**2106-2-20**] 11:25AM BLOOD
WBC-11.8* RBC-3.89* Hgb-11.6* Hct-34.3* MCV-88 MCH-29.9
MCHC-33.8 RDW-14.2 Plt Ct-113*
[**2106-2-18**] 12:12PM BLOOD
PT-13.3 PTT-24.2 INR(PT)-1.1
CXR:
FINDINGS: In comparison with the study of [**2-18**], the monitoring
and support
devices have been removed. Specifically, there is no interval.
There is no
pneumothorax. Enlargement of the cardiac silhouette persists
with some
diffuse prominence of interstitial markings consistent with
elevated pulmonary venous pressure.
ECHO:
Pt presented for pericardectomy. LV systolic function was normal
with no segmental wall motion abnormalities and a LVEF>55%. The
valves are essentially normal. RV function was normal. A patent
foramen ovale is present. 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 stenosis. The mitral valve leaflets are structurally
normal. The pericardium appears thickened. Lateral mitral
annular tissue Doppler measures E' 19cm/sec.
[**2106-2-19**] 04:04AM BLOOD
Glucose-165* UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-103 HCO3-29
AnGap-11
Brief Hospital Course:
The patient was brought to the operating room on [**2-18**] where the
patient underwent Pericardiectomy. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 3 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics.
The patient was discharged [**2-21**] in good condition with
appropriate follow up instructions.
Medications on Admission:
duloxetine 60', gabapentin 200mg qAM, 200mg in afternoon, 300mg
qHS, Lasix 80", sotalol 120", Metformin 1500mg qAM, 1000mg qHS,
KCL 20", insulin regular hum U-500 20 with each meal
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO LUNCH
(Lunch).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
6. metformin 500 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain for 10 days: prn for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
10. potassium chloride 20 mEq Packet Sig: One (1) PO twice a
day.
11. Insulin
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast Lunch Dinner Bedtime
U500 25U U500 25U U500 25U U500 25U U500
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia
71-200 mg/dL 0 Units 0 Units 0 Units 0 Units
201-240 mg/dL 20 Units 20 Units 20 Units 20 Units
241-280 mg/dL 25 Units 25 Units 25 Units 25 Units
281-320 mg/dL 30 Units 30 Units 30 Units 30 Units
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
constrictive pericarditis.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Dr [**Last Name (STitle) **] office should call you with an appointment.
They have been notified to contact you, If they do not please
call his office.
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Department:Surgery
Office Location:W/LMOB 2A
Office Phone:([**Telephone/Fax (1) 1504**]
Dr [**Last Name (STitle) **] office should call you with an appointment. They have
been notified to contact you, If they do not please call his
office.
Name: [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern1) **] Title:MD
Organization:[**Hospital1 18**]
Office Location:W/[**Hospital Ward Name **] 4
Patient Phone:([**Telephone/Fax (1) 2037**]
You have to come i for a wound check, This is [**3-2**] at 1010
hrs. Come to [**Hospital Ward Name 121**] 6
Please schedule an appointment in [**1-5**] weeks with your PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] S
Address: 650 EVERGREEN [**Doctor Last Name **], [**Location (un) 36372**],[**Numeric Identifier 107172**]
Phone: [**Telephone/Fax (1) 107173**]
Fax: [**Telephone/Fax (1) 107174**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2106-2-21**]
|
[
"357.2",
"327.23",
"423.9",
"250.60",
"278.00",
"V12.54",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
6701, 6784
|
3919, 4940
|
301, 350
|
6855, 7011
|
2739, 3896
|
7883, 9148
|
1782, 1888
|
5171, 6678
|
6805, 6834
|
4966, 5148
|
7035, 7860
|
1918, 1918
|
1109, 1326
|
236, 263
|
378, 1024
|
1932, 2720
|
1362, 1518
|
1046, 1084
|
1534, 1766
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,231
| 108,116
|
44654
|
Discharge summary
|
report
|
Admission Date: [**2108-3-9**] Discharge Date: [**2108-3-30**]
Service: GENERAL SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
woman with a previous medical history of coronary artery
disease and hypothyroidism who presented to the Medical
Service a couple of days ago with "constipation". During
further observation and workup, the patient has been found to
have an obstructing lesion in the distal transverse colon and
presents to the Surgical Service with a massively dilated
cecum secondary to the obstructing colon lesion. The patient
was admitted to the Surgical Service for laparotomy.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypothyroidism.
PAST SURGICAL HISTORY: None.
ADMISSION MEDICATIONS:
1. Synthroid.
2. Fosamax.
3. Zoloft.
4. Lopressor.
5. Lasix.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: General: On admission to
the Surgical Service, the patient presented with a distended
abdomen and tenderness in the right part of the abdomen.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2108-3-9**] for exploration. A massively dilated cecum
secondary to an obstructing lesion in the splenic flexure was
found. Considering the patient's age and somewhat unstable
condition, it was decided to only do a cecostomy at this
procedure.
The patient underwent that procedure without complications
and had a relatively uneventful postoperative course. The
patient was then taken back to the Operating Room on [**2108-3-21**]
for a definitive procedure regarding her obstructing colon
cancer. At that procedure, a right hemicolectomy was
performed.
The patient's initial postoperative course was relatively
uneventful. Subsequently, the patient developed pulmonary
insufficiency and on postoperative day number eight, after
the right hemicolectomy, the patient's family made the
patient DNR and she expired on the following day, [**2108-3-30**].
DISCHARGE DIAGNOSIS:
1. Obstructing colon cancer.
2. Status post exploratory laparotomy and cecostomy.
3. Status post right hemicolectomy.
4. Hypothyroidism.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 49859**]
Dictated By:[**Last Name (NamePattern4) 95573**]
MEDQUIST36
D: [**2108-6-27**] 10:21
T: [**2108-7-4**] 09:54
JOB#: [**Job Number 95574**]
|
[
"414.01",
"412",
"518.81",
"153.1",
"244.9",
"733.00",
"196.2",
"560.9",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.93",
"46.10",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
2019, 2418
|
1090, 1998
|
770, 912
|
740, 747
|
927, 1072
|
667, 717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,884
| 127,879
|
39032
|
Discharge summary
|
report
|
Admission Date: [**2128-2-29**] Discharge Date: [**2128-3-6**]
Date of Birth: [**2049-1-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2-29**]: Emergent R craniotomy for SDH evacuation
History of Present Illness:
78 year old male on coumadin who was standing on a stool
adjusting his curtain
when he slipped and fell backwards hitting his head without loss
of consiousness at approx 1100 am on [**2128-2-29**]. He proceeded to
visit one of his 3 daughters and at 3pm complained of a headache
and headed home. At approximately 430 pm another daughter
called the patient at home and stated that the patient was
consfused. She immediately went to Mr [**Known lastname 86548**] house and found
him to be confused, feeling "cold", complaining of a headace
with extreme
fatigue. The daughter called 911 and the patient was brought by
EMS to [**Hospital **] Hospital. At [**Hospital **] Hospital, the patient had
imaging that was consistent with large right sided SDH. He was
reversed with 2 units FFP and vitamin K. The patient then
experienced an acute mental status decline and was emergently
intubated and brought here for further management. This HPI was
obtained from three daughters present at the time of patient
admission. The patient was non responive and intubated
onarrival to the ED.
Past Medical History:
CABG [**39**] years ago (on Coumadin since), ardiac stent [**2125**] at
[**Hospital1 2025**]- cardiologist Dr [**Last Name (STitle) 42317**]
Social History:
Social Hx:The patient works five days a week in construction
supply store. Commutes from [**Location (un) 13011**] to [**Location (un) 86**] 5 days a week. He
is widowed and lives independently alone. He has 3 daughters
and the health care proxy is [**Name (NI) **] [**Name (NI) **] his daughter that can
be reached by cell phone [**Telephone/Fax (1) 86549**].
Family History:
N/C
Physical Exam:
ADMISSION
PHYSICAL EXAM:
Gen/Mental status:intubated GCS-E:1, V-1T, M-4=6T
HEENT: Pupils:right appears surgical 2mm NR, left 1.5 mm NR
EOMs:pt unresponsive
Neck: hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Cranial Nerves:
I: Not tested
II: Pupils right appears surgical 2mm NR, left 1.5 mm NR
Visual fields unable to test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength appears grossly symetric
VIII,IX, X,[**Doctor First Name 81**], XII: unable to test due to poor mental status
Motor:minimal flexion and withdrawal to deep painful stimulus in
BUE, no movement in BLE
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination:unable to test
Exam on Discharge:
Expired
Pertinent Results:
ADMISSION LABS:
[**2128-2-29**] 08:10PM WBC-14.6* RBC-4.66 HGB-13.7* HCT-39.2* MCV-84
MCH-29.5 MCHC-35.1* RDW-14.9
[**2128-2-29**] 08:10PM PLT COUNT-144*
[**2128-2-29**] 08:10PM GLUCOSE-160* UREA N-21* CREAT-1.0 SODIUM-141
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-24 ANION GAP-20
[**2128-2-29**] 08:45PM PT-17.9* PTT-22.3 INR(PT)-1.6*
Head CT [**2-29**]
IMPRESSION: Large right-sided acute on chronic subdural hematoma
measuring up to 1.7 cm in maximum thickness. Significant
leftward shift of midline
structures of 1.3 cm. Early right uncal herniation with
entrapment of the
right temporal [**Doctor Last Name 534**].
Head CT [**3-1**]:
IMPRESSION:
1. Redistribution of the intracranial extra-axial pneumocephalus
with new air anterior to the left frontal lobe and decreased air
anterior to the right temporal lobe.
2. Unchanged right frontoparietal extra-axial air and
extra-axial
frontoparietal fluid collection at the prior subdural hematoma
evacuation
site.
3. Unchanged 1.3-cm midline shift to the left, right
perimesencephalic
cistern effacement and right cerebral edema.
4. Increase width of the left temporal [**Doctor Last Name 534**], possibly secondary
to left
foramen of [**Last Name (un) 2044**] compression. Followup CT exam for monitoring is
recommended.
Head CT [**3-2**]:
IMPRESSION:
1. Unchanged postsurgical right epidural collection. Slightly
decreased anterior frontal right subdural collection, with
increased
fluid to air ratio. Unchanged small residual subdural hematoma
along the
right occipital convexity, medial right occipital lobe, and
right tentorium.
2. Subtle progressive effacement of the right perimesencephalic
cistern
since [**2-29**]. Presence of subtle right uncal herniation is
difficult to
determine at this time.
3. Unchanged effacement of the right lateral and third
ventricles.
Unchanged enlargement of the left temporal [**Doctor Last Name 534**].
MRI Head [**3-4**]:
IMPRESSION:
1. A few small scattered foci of decreased diffusion, in the
splenium of the corpus callosum and in the left occipital
parasagittal cortex and a tiny focus in the right temporal lobe
which may represent acute-subacute infarcts.
2. Fluid collection in the right side of the head along the
cerebral
convexity, in the frontal, parietal, and temporal lobes,
representing
previously known chronic subdural hematoma, with some areas of
persistent
hemorrhage within. Significant mass effect on the right cerebral
hemisphere with shift of midline structures to the left by 1.4
cm and right-sided uncal herniation
3. While there is no obvious and definite increased signal
intensity in the brainstem structures, there is some deformity
of the mid brain related to the mass effect and subtle increased
T2 signal in the cervicomedullary junction, which is not
conformed on other sequences. Significance of this finding is
uncertain.
4. Paranasal sinus disease as well as diffuse mucosal
thickening/fluid in the mastoid air cells on both sides.
Brief Hospital Course:
The patient was taken emergently from the ED to the operating
room where he underwent a R craniotomy for evacuation of the
hematoma. He tolerated the procedure well, and was transferred
to the ICU where he reamined intubated. A post op head CT
demonstrated a good amount of pneumocephalus, but no acute
hemorrhage. He was initially able to move all extremities, R>L,
and followed simple commands.
On POD #1, he was extubated, and was found to be slightly more
difficult to arouse. A CT was performed, which demonstrated a
slight increase in his midline shift (~1mm) but no hemorrhage or
increase in the pneumocephalus.
On POD #2, [**3-2**], he devloped an increased work of breathing; he
was subsequently re-intubated. His neurological exam worsened,
as he exhitibed minimally reactive pupils and extensure
posturing of upper and lower extremities. Head CT showed
increase in edema. Mannitol was given.
MRI Brain was ordered on [**3-4**]. This showed normal cerebral
perfusion. He remained intubated with a poor neurological
examination. A family mtg was conducted on [**3-5**], and he was made
DNR/DNI.
On [**3-6**] after a family discussion he was made comfort measures
only and extubated at approximately 130pm. At approximately 7pm
the patient expired in the surgical ICU.
Medications on Admission:
Coumadin, patient family unable to list pt medications taken at
home.
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2128-3-6**]
|
[
"348.5",
"V45.81",
"V58.61",
"851.41",
"518.81",
"V45.82",
"E884.2",
"486",
"348.4",
"401.9",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.31",
"96.71",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7274, 7283
|
5835, 7121
|
286, 341
|
7331, 7341
|
2843, 2843
|
7394, 7429
|
2018, 2023
|
7242, 7251
|
7304, 7310
|
7147, 7219
|
7365, 7371
|
2063, 2067
|
242, 248
|
369, 1456
|
2277, 2795
|
2814, 2824
|
2859, 5812
|
2081, 2261
|
1478, 1621
|
1637, 2002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,496
| 165,250
|
36310
|
Discharge summary
|
report
|
Admission Date: [**2168-6-6**] Discharge Date: [**2168-6-16**]
Date of Birth: [**2117-8-31**] Sex: M
Service: MEDICINE
Allergies:
Fish derived
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
1. right internal jugular line placed in SICU
History of Present Illness:
Mr. [**Known lastname 26438**] is a 50 yo M with history of PSC cirrhosis,
varices, encephalopathy in addition to portal hypertension, on
the transplant list who presents with hypotension from an OSH.
Pt was recently admitted last week from [**Date range (2) 82268**] for
hematemesis. He says that he had been feeling well up until
Saturday. He filled his prescription and took the medication, a
"green pill". He wasn't quite feeling himself, feeling nauseas
and dizzy. He felt better Saturday, but on Sunday again was not
feeling well. He took a nap, and when he woke up, his cousin
checked his blood pressure and it was 60/40. His VNA discovered
that he had been givne the wrong medication (sounds like
Losartan) instead of the Carafate. He was taken in an OSH in RI,
where he was hypotensive and in renal failure. His SBP was in
the 60s, and he was started on empiric abx of Vanc/Zosyn, and
Levophed. A CXR at the OSH showed possible RLL consolidation. He
was transferred to the SICU here, and has been off pressors
since yesterday mnorning. When asked about his course prior to
admission, he denied any fevers, but had "chills." He has had a
mildly productive cough of yellow sputum for the past couple of
days in the ICU, but does not recall at cough at home. He does
feel mildly SOB.
.
During his ICU stay here, he was continued on broad spectrum abx
though CXR here not particularly suggestive of pneumonia. He was
continued on Vanc/Zosyn. Renal was consulted given ARF, and
concern for HRS. He was given 2 doses of albumin, started on
Octreotide and Midrodrine for HRS. He had 2 paracenteses (1.5 L
removed [**6-8**], and 1.25L removed [**6-9**]), neither showed evidence of
SBP. He remains A&Ox3.
.
During his last admission he had an EGD suggestive of portal
hypertensive gastropathy with varices banded prophylactically.
He was treated with 5 days of ceftriaxone for SBP ppx. He was
transferred to the medicine floors and remained stable without
further episodes of bleeding. He was discharged with a MELD of
17, and was feeling well.
.
He says that he feels better, but continues to have leg
swelling. He has had some headaches in the ICU, for which he has
been receiving morphine IV. He also had some nausea, and an
episode of non-bloody, non-bilious emesis a couple days ago.
Prior to transfer to the floors, his vital signs are T 98 HR 66
BP 92/55 23 CVP 5 100% 2LNC I/0 - 605 for 24h.
.
Review of sytems:
(+) Per HPI. Also positive for mild dysuria the past couple
days.
(-) Denies fever, night sweats, recent weight loss or gain.
Denied chest pain or tightness, palpitations. Denied
constipation, diarrhea, bloody or black stools. No recent change
in bowel or bladder habits. Denied arthralgias or myalgias.
Past Medical History:
# Primary sclerosing cholangitis
# History of UGIB in [**10-12**]
# Hepatic encephalopathy
# HCV: by history, had positive HCV with HCV VL in [**2157**], but on
follow up cleared HCV spontaneously
# Horseshoe kidney
# Heart murmur
# Distant history of polysubstance abuse
# History of dysphagia with normal barium swallow on [**2167-11-24**]
# Typical Angina
Social History:
Last drink 20 years ago. Quit smoking 14 years ago. Not
employeed. Lives alone.
Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. Grandfather with diabetes.
Physical Exam:
ADMISSION PHYSICAL: (per medicine service on transfer of care
[**6-10**])
GENERAL - well-appearing man sitting up in chair, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, icteric sclerae, mildly dry MM, OP
clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use, slightly decreased BS on
left compared to right
HEART - RRR, 2/6 systolic murmur loudest LLSB, nl S1-S2
ABDOMEN - NABS, distended, mildly firm, non-tender, tympanic to
percussion, no rebound/guarding, unable to appreciate
hepatosplenomegaly
EXTREMITIES - warm, dry [**2-4**]+ pitting edema up to thigh
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities, no gross deficits, no asterixis
DISCHARGE PHYSICAL:
VS - 98.6 98.5 114-127/65-74 52-66 18 96%RA
8H --/550
24H I/O: 1180/2200, BMx4
GENERAL - lying down in bed, appears fatigued but NAD
HEENT - icteric sclerae, mildly dry MM
NECK - supple, no JVD
LUNGS - CTA bilat anteriorly, no r/rh/wh, good air movement,
resp unlabored, no accessory muscle use
HEART - RRR, 2/6 systolic murmur loudest LLSB, nl S1-S2
ABDOMEN - NABS, distended, firm, mildly tender to palpation
diffusely, no rebound/guarding
EXTREMITIES - warm, dry 3+ pitting edema up to mid-thigh,
unchanged
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities, no gross deficits, no asterixis
Pertinent Results:
ADMISSION LABS:
[**2168-6-6**] 08:15PM BLOOD WBC-8.7 RBC-3.10* Hgb-10.0* Hct-28.8*
MCV-93 MCH-32.2* MCHC-34.6 RDW-18.3* Plt Ct-122*
[**2168-6-6**] 08:15PM BLOOD PT-18.7* PTT-39.1* INR(PT)-1.7*
[**2168-6-7**] 03:56AM BLOOD Fibrino-312
[**2168-6-6**] 08:15PM BLOOD Glucose-158* UreaN-43* Creat-4.2*# Na-134
K-4.5 Cl-98 HCO3-20* AnGap-21*
[**2168-6-6**] 08:15PM BLOOD Albumin-3.5 Calcium-8.2* Phos-4.1 Mg-2.1
[**2168-6-7**] 12:20AM BLOOD calTIBC-161* Ferritn-167 TRF-124*
[**2168-6-8**] 03:10AM BLOOD Cortsol-12.5
[**2168-6-6**] 08:29PM BLOOD Lactate-3.1*
DISCHARGE LABS:
[**2168-6-16**] 05:00AM BLOOD WBC-4.7 RBC-2.95* Hgb-9.7* Hct-28.3*
MCV-96 MCH-32.8* MCHC-34.2 RDW-18.0* Plt Ct-97*
[**2168-6-16**] 05:00AM BLOOD PT-23.4* PTT-44.1* INR(PT)-2.2*
[**2168-6-16**] 05:00AM BLOOD Glucose-114* UreaN-13 Creat-1.8* Na-139
K-4.8 Cl-104 HCO3-26 AnGap-14
[**2168-6-16**] 05:00AM BLOOD ALT-39 AST-78* AlkPhos-172* TotBili-7.1*
PARACENTESES:
[**2168-6-8**] 10:37AM ASCITES WBC-325* RBC-1300* Polys-19* Lymphs-13*
Monos-12* Eos-1* Mesothe-6* Macroph-49*
[**2168-6-9**] 09:37AM ASCITES WBC-640* RBC-570* Polys-26* Lymphs-19*
Monos-0 Mesothe-2* Macroph-52* Other-1*
LFT'S TREND:
[**2168-6-6**] 08:15PM BLOOD ALT-82* AST-108* LD(LDH)-167 CK(CPK)-42*
AlkPhos-186* Amylase-63 TotBili-4.7*
[**2168-6-7**] 03:56AM BLOOD ALT-85* AST-104* LD(LDH)-172 CK(CPK)-42*
AlkPhos-203* Amylase-68 TotBili-6.8*
[**2168-6-7**] 01:14PM BLOOD CK(CPK)-48
[**2168-6-8**] 03:10AM BLOOD ALT-75* AST-84* LD(LDH)-171 AlkPhos-166*
TotBili-4.9*
[**2168-6-9**] 03:22AM BLOOD ALT-55* AST-66* LD(LDH)-141 AlkPhos-136*
TotBili-5.4*
[**2168-6-10**] 03:48AM BLOOD ALT-44* AST-58* AlkPhos-107 TotBili-5.0*
[**2168-6-11**] 04:49AM BLOOD ALT-44* AST-65* AlkPhos-139* TotBili-6.1*
[**2168-6-12**] 06:15AM BLOOD ALT-49* AST-76* LD(LDH)-182 AlkPhos-154*
TotBili-6.6*
[**2168-6-13**] 04:35AM BLOOD TotBili-6.4*
[**2168-6-14**] 05:05AM BLOOD ALT-44* AST-78* AlkPhos-163* TotBili-7.2*
[**2168-6-15**] 05:05AM BLOOD ALT-36 AST-69* AlkPhos-148* TotBili-7.1*
[**2168-6-16**] 05:00AM BLOOD ALT-39 AST-78* AlkPhos-172* TotBili-7.1*
CARDIAC ENZYMES:
[**2168-6-6**] 08:15PM BLOOD CK-MB-3 cTropnT-0.01
[**2168-6-7**] 03:56AM BLOOD CK-MB-4 cTropnT-0.03*
[**2168-6-7**] 01:14PM BLOOD CK-MB-4 cTropnT-0.03*
[**2168-6-14**] 07:05PM BLOOD CK-MB-2 cTropnT-<0.01
STUDIES:
TTE [**2168-6-7**]:
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. 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 [**2167-8-12**],
there is now a very small pericardial effusion.
.
PORT LINE PLACEMENT [**2168-6-7**]:
FINDINGS: As compared to the previous radiograph, the patient
has received a right central venous access line. The tip of the
line projects over the lower SVC. There is no evidence of
pneumothorax or other complication. Unchanged areas of
atelectasis at the left and right lung base. Unchanged
appearance of the mediastinum.
.
RENAL U/S [**2168-6-7**]:
IMPRESSION: No hydronephrosis and no renal stones identified
within the crossed fused kidney.
.
CXR [**2168-6-8**]:
The known right aortic arch is redemonstrated. There is some
widening of the mediastinum on the right, which might be
attributed to portable culture of the study as well as vascular
engorgement. The patient continues to be in mild interstitial
pulmonary edema, unchanged since the prior study. There is
interval improvement of bilateral bibasilar aeration in
particular in the right with only minimal atelectasis present.
Left internal jugular line tip is at the level of low SVC. There
is no pneumothorax. There is small bilateral pleural effusion
noted.
.
PARA [**2168-6-9**]:
IMPRESSION:
Successful therapeutic and diagnostic paracentesis yielding 1.25
L of clear yellow fluid.
MICRO:
URINE CX [**2168-6-6**]: NO GROWTH.
BLOOD CX [**2168-6-7**]: NO GROWTH.
BLOOD CX [**2168-6-11**]: PENDING.
BLOOD CX [**2168-6-12**]: PENDING.
PERITONEAL CX [**2168-6-8**]:
[**2168-6-8**] 10:37 am PERITONEAL FLUID
GRAM STAIN (Final [**2168-6-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2168-6-9**] 9:37 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2168-6-15**]**
GRAM STAIN (Final [**2168-6-9**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2168-6-12**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2168-6-15**]): NO GROWTH.
C. DIFF [**2168-6-10**]: Feces negative for C.difficile toxin A & B by
EIA.
Brief Hospital Course:
Mr. [**Known lastname 26438**] is a 50 yo M with history of PSC cirrhosis,
varices, encephalopathy in addition to portal hypertension, on
the transplant list who presents with hypotension. He was
admitted to the SICU, and placed on pressors. He was initially
started on broad-spectrum abx. Infectious workup was negative.
He had acute renal failure, and was treated with albumin,
midrodrine & octreotide. His renal failure improved. His BP
improved, and he was transferred to the medicine floors. His
antibiotics were discontinued as there was no clear source of
infection. His creatinine remained stable. Diuresis was held
given renal function. He was discharged with close follow-up.
ACTIVE ISSUES:
#. Hypotension: Most likely intial drop due to medication. He
had a documented medication mistake this could drive the
hypotesion. Sepsis considered, especially in setting of
questionable infiltrate on CXR, though he had no cough or
fevers. He was treated with Vanc/Zosyn initially in the SICU. He
had 2 paracenteses that were negative for SBP. AI was ruled out
with cortisol of 12. C. diff negative. He was treated with
pressors in the ICU, which were able to be weaned off. His
diuretics and nadolol were held. He was transferred to the
medicine floors, where his antibiotics were discontinued given
no clear source of infection. His BP remained stable. Nadolol
continued to be held in addition to diuretics. He was
normotensive with no repeat drop in BP while on the medicine
floor.
#. Acute renal failure: Baseline Cr 0.9-1.1. Presented with Cr
up to 4.2 on admission. Likely [**2-3**] acute hypotension, ATN, and
possible HRS. Pt treated with albumin x2 doses while in the
SICU, and started on midodrine in addition to octreotide, with
Cr that downtrended. Renal was consulted, and was concerned for
HRS. However, Cr downtrended, but remained stable at 1.7-1.9 for
the last 3 days prior to discharge. He was discharged to
continue midodrine and given another dose of Albumin 50g prior
to discharge. Diuretics were held. Pt will have repeat labs as
an outpatient with results faxed to the liver transplant center.
#. ESLD: [**2-3**] PSC, MELD 17 on last discharge. Has been
complicated by variceal bleeding, hepatic encephalopathy
previously. On admission, his MELD is 34 given acute renal
failure. He was continued on Rifaximin and Lactulose. Diuretics
and nadolol were held given hypotension as discussed above. Pt
was autodiuresing for last 3 days prior to discharge, ~ 1L
negative per day. Pt will follow-up with Hepatology on
discharge. His MELD was 28 on the day of discharge.
INACTIVE ISSUES:
#. Normocytic anemia: Hct baseline ~ low 30s on last discharge.
Iron mildly low, which is not surprising given recent GIB on
last admission. Hct remained stable without any evidence of
re-bleeding.
#. Thrombocytopenia: likely [**2-3**] cirrhosis, and sequestration.
Plts were trended and remained stable.
#. Chronic abdominal pain: Pt noted to have possible colopathy
[**2-3**] cirrhosis vs. colitis on previous imaging. Pt treated last
admission with gabapentin & tramadol. Pt has been receiving
morphine IV in the ICU. He was placed on tramadol. Gabapentin
was held given ARF.
#. Depression: no active issues. Continued citalopram 20mg
daily.
TRANSITIONAL CARE:
1. CODE: FULL
2. CONTACT: [**Name (NI) **] [**Name (NI) 26438**] sister Phone: [**Telephone/Fax (1) 82266**]
3. FOLLOW-Up;
- PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] TRANSPLANT
4. MEDICAL MANAGEMENT:
- STOP Nadolol, Lasix, Spironolactone, Gabapentin,
Nitroglycerin, Sucralfate
- Decreased Pantoprazole 40mg [**Hospital1 **] to daily
- START Midrodrine, Ondansetron 4mg prn
5. OUTSTANDING TASKS: blood cultures from [**6-11**], [**6-12**] pending
6. RISKS TO REHOSPIALIZATION:
- high MELD score, at risk for decompensations
Medications on Admission:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: Do not exceed [**2157**] mg daily as
this can damage the liver.
4. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day).
5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once may repeat x1 as needed for chest pain: Use for
chest pain. If chest pain persists after 3
doses, call 911 or report to the nearest emergency room. .
10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. tramadol 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours) as needed for abd pain: Do not drive or operate
machinery while using this medication. [**Month (only) 116**] cause confusion or
somnolence.
12. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four
times a day.
13. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain: do not exceed more than
2grams/24hrs.
4. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day).
5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
6. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO three
times a day.
7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. tramadol 50 mg Tablet Sig: 1.5 Tablets PO every six (6) hours
as needed for pain: Do not drive or operate
machinery while using this medication. [**Month (only) 116**] cause confusion or
somnolence.
.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
VNAs of [**Location (un) 511**]
Discharge Diagnosis:
Primary Diagnoses:
1. Hypotension
2. Acute renal failure
3. End-stage liver disease
Secondary Diagnoses:
1. Anemia
2. Thrombocytopenia
3. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 26438**],
It was a pleasure taking care of you during this admission.
You were admitted for low blood pressure. You were initially
started on antibiotics in case there was an infection. You were
monitored closely in the ICU. You were found to have kidney
failure. The kidney doctors saw [**Name5 (PTitle) **], and you were started on
medication and albumin to help the kidney function, which slowly
improved.
Once your blood pressure improved, you were cared for on the
general medicine floors. Your blood pressure remained stable.
The antibiotics were stopped since there was no evidence of
infection.
We tried gentle diuresis to pull of the fluid but the kidneys
were still not doing well enough to restart the diuretics.
The following medications were changed during this admission:
- STOP Nadolol
- STOP Lasix
- STOP Spironolactone
- STOP Gabapentin for now until we know where your renal
function settles out
- STOP Nitroglycerin tablets (this can cause low blood pressure)
- STOP Sucralfate
- STOP Clotrimazole troches (as you no longer need these)
- DECREASE the dose of Pantoprazole from 40mg by mouth twice
daily to once daily (you have the prescription for twice daily,
so just take it once daily for now)
- START Midrodrine 10mg by mouth three times daily
- START Ondansetron 4mg by mouth every 8 hours as needed for
nausea
Please continue the other medications you were taking prior to
this admission.
You will need to have your labs checked on Monday, [**2168-6-20**], and
have the results faxed to Dr.[**Name (NI) 948**] office at [**Telephone/Fax (1) 4400**]. We
need to make sure the kidney function remains stable.
Followup Instructions:
Please follow-up with the following appointments:
Department: TRANSPLANT
When: WEDNESDAY [**2168-6-22**] at 1:40 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Street Address(2) 82262**], E. [**Hospital1 **],[**Numeric Identifier 82263**]
Phone: [**Telephone/Fax (1) 82264**]
When: [**Last Name (LF) 2974**], [**6-24**], 8:30AM
Completed by:[**2168-6-16**]
|
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"E858.3",
"972.9",
"285.9",
"572.3",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
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10484, 11171
|
283, 331
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17563, 17563
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|
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|
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|
9941, 9955
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,551
| 183,876
|
32335
|
Discharge summary
|
report
|
Admission Date: [**2114-6-23**] Discharge Date: [**2114-6-27**]
Date of Birth: [**2057-5-14**] Sex: M
Service: MEDICINE
Allergies:
Toradol
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stone/sludge extraction
History of Present Illness:
Mr. [**Known lastname 75547**] is a 57M with being transferred from the [**Location 75548**] ICU for ERCP.
He was recently admitted to the [**Hospital6 19155**]
[**2114-6-17**] for abdominal pain, inability to tolerate PO, nausea,
and vomiting x 1.5 weeks. Prior to this admission he developed a
wound in his abdomen after a previous hernia repair, and was
treated surgically at the [**Hospital1 112**] for an abdominal abscess. At
[**Location (un) **], he received a CT scan which showed interval
enlargement of his ventral hernia, and underwent surgical repair
on [**6-21**] with placement of two JP drains. US showed gallbladder
sludge with enlarged common bile duct 6-8mm. CXR was concerning
for pneumonia, and he was started on levofloxacin [**6-17**].
Pertinent labs included Na 130, WBC 11.6, Hct 34, Tbili 5.9, AST
149, ALT 207, Alk Phos 51, amylase 89, lipase 28, haptoglobin
235. Vitals T 98.8, RR 16, BP 111/65, 94% / 2L NC. He was
transferred to the [**Hospital1 18**] ICU for worsening liver enzymes,
abdominal pain, concern for cholangitis and plan for ERCP.
On arrival to the MICU, patient's VS: 98.2, 97, 117/89, 17, 97%
on RA
Past Medical History:
Past Medical History:
- Ventral hernia repair [**2114-6-21**] [**Hospital6 19155**]
- incisional hernia repair [**6-/2113**]
- small bowel perforation s/p repair [**11/2112**]
- COPD
- Osteoporosis
- GERD
- Hyperlipidemia
- L Hip Fx
- Appendectomy
Social History:
- Lives alone in [**Location (un) **]. Disabled. He has one child. Used to
smoke 3ppd, currently smokes [**11-27**] ppd. Denies alcohol and other
recreational drugs. Previously chef.
Family History:
- Mother with COPD, father with [**Name (NI) 11964**].
Physical Exam:
Admission exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, oropharynx dry but 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: large midline incisional hernia with dressings,
bilateral JP drains with serosanginous fluid. Moderate
tenderness throughout, worse in epigastric, left-side. Bowel
sounds diminished. no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
Admission Labs:
[**2114-6-23**] 05:44PM BLOOD WBC-8.5 RBC-3.95* Hgb-11.7* Hct-34.4*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.2 Plt Ct-255
[**2114-6-23**] 05:44PM BLOOD Neuts-79.6* Lymphs-11.5* Monos-7.2
Eos-1.5 Baso-0.2
[**2114-6-23**] 05:44PM BLOOD PT-12.5 PTT-30.3 INR(PT)-1.2*
[**2114-6-23**] 05:44PM BLOOD Glucose-91 UreaN-3* Creat-0.5 Na-139
K-3.9 Cl-101 HCO3-25 AnGap-17
[**2114-6-23**] 05:44PM BLOOD ALT-73* AST-52* LD(LDH)-175 AlkPhos-56
TotBili-6.1* DirBili-4.0* IndBili-2.1
[**2114-6-23**] 05:44PM BLOOD Albumin-3.0* Calcium-7.9* Phos-1.8*
Mg-1.8
[**2114-6-23**] 10:16PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2114-6-23**] 10:16PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-7.5 Leuks-NEG
[**2114-6-23**] 10:16PM URINE RBC-6* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**6-23**] CXR: IMPRESSION: 1. Right subclavian PICC line has its tip
in the distal SVC near the cavoatrial junction. Lung volumes
are low with small bilateral layering effusions and patchy
bibasilar opacities which most likely represent compressive
atelectasis, although bilateral pneumonia or aspiration cannot
be entirely excluded. No pneumothorax. No evidence of
pulmonary edema. Overall cardiac and mediastinal contours are
likely within normal limits given portable technique. Surgical
clips are seen overlying the epigastric region. Midline
surgical skin staples are seen overlying the mid abdomen along
with at least two abdominal surgical drains
[**6-23**] RUQ U/S: IMPRESSION: 1. No evidence of biliary
obstruction. Prominence of the free segment of the common duct
is noted, a commonly seen finding, but the common hepatic duct
is nondilated and there is no intrahepatic biliary ductal
dilation. Distal common bile duct and pancreatic duct could not
be evaluated due to overlying bowel gas. 2. No gallstones or
evidence of cholecystitis.
Brief Hospital Course:
57M s/p ventral hernia repair [**2114-6-21**] at OSH, COPD, numerous
previous abdominal surgeries who presents with abdominal pain,
elevated Tbili, CBD dilatation transferred from OSH for ERCP.
# Biliary obstruction: underwent ERCP on [**6-25**] for rising
bilirubin. Sphincterotomy done w/ stone and sludge extraction.
He was treated with post-procedure ciprofloxacin to continue
through [**2114-6-30**]. His diet was gradually advanced, which he
tolerated without N/V. He had formed BM. Transaminases and
bilirubin improved. Elective cholecystectomy is recommended,
for which follow up with his surgeon at [**Location (un) **] was arranged.
No follow-up with [**Hospital1 18**] GI is required.
# post-op ileus: Pt was transferred from OSH with NG tube for
decompression, and this was removed at time of ERCP. Diet
advanced with success, passed flatus and stool.
# Ventral hernia: recently repaired on [**6-21**] at OSH, with two JP
drains still in place. Surgery consult service following.
Incisional pain was managed with oxycodone and ultimately
oxycontin was added. He continued to have 25-50cc/24h per JP
[**Last Name (LF) 19843**], [**First Name3 (LF) **] drains were kept in place. This was discussed with his
surgeon Dr [**First Name8 (NamePattern2) 12395**] [**Last Name (NamePattern1) 75549**] at [**Location (un) **], who agreed with plan to
discharge pt home with drains in place. He will see patient in
follow up next week. VNA was arranged for [**Location (un) 19843**] care.
# Chest imaging showed bibasilar opacities. Patient did not have
clinical signs/sx of pneumonia. Picture more consistent with
atelectasis.
Chronic issues:
# COPD: outpatient on Flovent, in hospital was stable on
Ipratropium, albuterol PRN without sx or oxygen requirement.
# OSTEOPOROSIS: stable. Continued home Calcium carbonate 1.25g
PO once daily and Vit D 1000U daily. Held Alendronate 70mg PO
(once weekly)
# GERD: Continued Omeprazole 20mg PO BID
# ANEMIA: normocytic anemia. Continued home Cyanocobalamin
1000mcg PO daily
Transitional issues:
- cholecystectomy recommended
- Follow-up with Dr. [**Last Name (STitle) 75549**] as above
- continue cipro through [**2114-6-30**]
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from transfer
records.
1. Alendronate Sodium 70 mg PO WEEKLY
2. Calcium Carbonate 1250 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. Pravastatin 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 1250 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
end date [**2114-6-30**]
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*1
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Duration:
7 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
8. Oxycodone SR (OxyconTIN) 10 mg PO Q12H pain
please hold for sedation
RX *OxyContin 10 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*7 Packet Refills:*1
10. Senna 1 TAB PO BID:PRN Constipation
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*14 Tablet
Refills:*1
11. Promethazine 25 mg PO Q6H:PRN nausea
RX *promethazine 25 mg 1 tablet by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
12. Alendronate Sodium 70 mg PO WEEKLY
13. Pravastatin 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
# biliary obstruction
# s/p ventral wall hernia repair at [**Hospital6 19155**]
Secondary diagnoses:
# COPD
# osteoporosis
# hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
see below
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 75550**],MD
When: Friday [**7-6**] at 1pm
Location: [**Hospital3 **]SURGICAL SPECIALTIES
Address: [**Street Address(2) 75551**], [**Apartment Address(1) 75552**], [**Location (un) **],[**Numeric Identifier 75553**]
Phone: [**Telephone/Fax (1) 75554**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2114-6-27**]
|
[
"285.1",
"496",
"733.00",
"574.51",
"560.1",
"272.4",
"530.81",
"997.49",
"E878.8",
"V58.49",
"305.1",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
8543, 8626
|
4761, 6397
|
283, 338
|
8811, 8811
|
2837, 2837
|
8996, 9470
|
2002, 2059
|
7330, 8520
|
8647, 8728
|
6972, 7307
|
8962, 8973
|
2074, 2818
|
8749, 8790
|
6812, 6946
|
228, 245
|
366, 1513
|
2853, 4738
|
8826, 8938
|
6413, 6791
|
1557, 1785
|
1801, 1986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,687
| 199,703
|
7174
|
Discharge summary
|
report
|
Admission Date: [**2125-8-23**] Discharge Date: [**2125-8-28**]
Date of Birth: [**2074-6-22**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Iodine / Augmentin
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
nausea and vomiting x 4 days
Major Surgical or Invasive Procedure:
[**2125-8-27**] Cardiac catherization
History of Present Illness:
Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration. Pt stated that this
episode was more severe that her usual gastroparesis, and that
while her vomiting has eased up in the last two days, she has
not been able to tolerate any POs including water, causing her
to miss all of her medications since [**2125-8-20**]. Pt also had loose
stools x 4 since yesterday. She had chills, but no fevers that
she knows of.
.
In the ED, she complained of substernal chest pain that felt
like pressure with no radiation. Vitals were: 97.7 123 144/72
28 100% on RA. Pt was started on IVF 200cc/hr, Insulin drip 6
units/hr with Q 1hr FS, was given [**Month/Day/Year **] 750 mg IV x 1, ASA
325 mg PO x 1, and Zofran 4 mg IV x 1. U cx and B cx were sent.
EKG showed demand ischemia (was faxed to Cards fellow for
review). CK and Trop sent. Kidney U/S showed mild pelviectasis.
CXR demonstrated no acute process.
.
ROS: Positive for SOB, worse with activity; unintentional weight
loss of [**5-26**] pounds in 3 months; worsening visual acuity; mild
abdominal pain in lower quadrants. Negative for melena,
hematochezia, chest pain, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
.
Past Medical History:
Diabetes Type 1, s/p renal transplant in [**2118**], with a history of
episodes of diabetic ketoacidosis.
Gastroparesis secondary to DM.
Hypertension.
Hypercholesterolemia.
Coronary artery disease with an ejection fraction of 55%
in [**2118**], MI x2 and a three-vessel CABG in [**2116**].
Left below the knee amputation in [**2118**].
Vascular procedures on the right lower extremity.
Heel ulcers due to diabetes, s/p bypass graft surgeries
Peripheral neuropathy
CVA x2.
S/p cholecystectomy
S/p cataract surgery
Depression.
Social History:
The patient smokes [**3-20**] of a pack of [**State 622**] slim lights. Has
been smoking ~1ppd since age 14. No alcohol or IVDU. She is
married. She lives in [**Location **] with her husband, [**Name (NI) 1158**].
Family History:
Uncle with diabetes
Sister died of colon CA
Mother died of brain CA
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Labs (blood)
[**2125-8-23**] 03:30PM WBC-14.7 Hgb-12.6 Hct-41.1 MCV-92 MCH-28.3
MCHC-30.7 RDW-13.7 Plt Ct-333
Neuts-92* Bands-0 Lymphs-5.0* Monos-3 Eos-0 Baso-0
PT-11.5 PTT-24.2 INR(PT)-1.0
Glucose-759* UreaN-49* Creat-1.7* Na-130* K-5.6* Cl-86* HCO3-11*
Calcium-9.6 Phos-4.2# Mg-2.3
ALT-18 AST-16 LD(LDH)-181 CK(CPK)-77 AlkPhos-213* TotBili-0.5
Lipase-12
cTropnT-0.10*
Acetone-LARGE
ASA-4 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
pH-7.31* Glucose-GREATER TH Lactate-3.0* Na-132* K-5.4* Cl-93*
calHCO3-11* freeCa-1.04*
.
Labs (urine)
[**2125-8-23**] 04:20PM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
Blood-LG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RBC-21-50* WBC-[**3-21**] Bacteri-FEW Yeast-NONE Epi-[**3-21**]
UTox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
.
[**2125-8-23**] renal transplant ultrasound
FINDINGS: A transplanted kidney is visualized in the right lower
quadrant of the abdomen and measures 10.8 cm in length. The
corticomedullary differentiation is preserved. Mild pelviectasis
is noted which appears new compared to the most recent prior
study in [**2117**]. Doppler assessment demonstrates resistive indices
of the upper, mid and lower poles of 0.8, 1.0, and 1.0. Normal
venous flow is demonstrated in the main renal vein. While the
arterial upstroke is good in the main renal artery there is
minimal diastolic flow.
Limited images of the bladder are unremarkable.
IMPRESSION: Right lower quadrant transplanted kidney with mild
new pelviectasis. Elevated resistive indices as described.
Clinical correlation is recommended.
.
[**2125-8-23**] CXR
FINDINGS: The lungs are clear without consolidation or edema.
There is evidence of prior median sternotomy and CABG. There is
convexity involving the AP window which is stable from the prior
exam. The cardiac silhouette size is within normal limits. Again
seen is minimal blunting of the left costophrenic angle possibly
due to the scarring or small effusion. No pneumothorax is noted.
The bones are diffusely osteopenic but otherwise unremarkable.
The patient has had prior cholecystectomy.
IMPRESSION: Relatively stable radiographic examination
demonstrating no acute process.
.
[**2125-8-23**] ECG: Sinus tachycardia at 127 bpm, nl axis, nl PR, QRS,
and QT intervals, fair R-wave progress, 2mm ST depression in
V4-6.
.
[**2125-8-27**] Cardiac cath: 1. Selective coronary angiography of this
left dominant system revealed 3 vessel coronary artery disease.
The LMCA was normal. The LAD had mild luminal irregularities
proximally with a total mid-segment occlusion. D1 was patent
with moderate diffuse disease. The LCX is a dominant vessel with
mild luminal irregularities. The non-dominant RCA had moderate
diffuse disease.
2. Graft arteriography revealed a patent LIMA-LAD, and stump
occluded SVGs to OM1 and PDA.
3. Limited resting hemodynamics revealed systemic arterial
hypertension with aortic pressures of 178/64 and mildly elevated
left sided filling pressures with LVEDP of 17. There was no
transaortic pressure gradient on pullback of catheter from LV to
aorta.
4. Left ventriculography was not performed.
.
[**2125-8-28**] L femoral U/S
No evidence of pseudoaneurysm.
.
Brief Hospital Course:
Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration, and found to be in DKA.
1) DKA: Anion gap closed with aggressive hydration and insulin
drip per DKA protocol. Pt was started on subcutaneous Insulin
coverage once gap had closed, with frequent finger sticks.
Potassium was repleted PRN. Differential for precipitating
factors included diarrhea, gastroparesis, c.diff, MI, infection,
or viral gastroenteritis (given pt's lower abdominal discomfort
on admission). Pt also may have had TSS with history that a
tampon was left in place for 5 days (this history was revealed
on a few days after admission). Pt received a single dose of
Levoquin in ED on admission, which was not continued in the ICU
given that she had borderline high normal WBC and afebrile.
Tachycardia resolved with hydration. Upon discovery of retained
tampon during hospital stay, vancomycin was started, however,
this too was discontinued based on the absence of clinical
symptoms and signs.
2) Unstable angina:
Pt complained of substernal chest pain in the ED. EKG changes
were initially felt to be consistent with demand ischemia due to
tachycardia. Pt had cardiac enzyme elevation that peaked then
slowly trended down. Pt continued to have short episodes of
chest tightness, and cardiac enzymes were cycled. ASA, statin
(80 mg daily rather than 10 mg daily, which is her home dose),
metoprolol, isosorbide dinitrate (later switched to isosorbide
mononitrate extended release) were continued. Heparin gtt were
used intermittently with her symptoms. Pt underwent cardiac
catherization on [**2125-8-27**], which showed diffusely diseased
vessels and two out of three occluded grafts (which were
previously seen in [**2117**]). No interventions were made.
3) DM, type 1
[**Last Name (un) **] followed the patient during her stay. Pt's insulin
regimen were optimized according to blood sugar checks. Pt was
encouraged to take part in sliding scale insulin administration.
Pt was discharged home on Glyburide 5 mg daily, Lantus 18 units
at dinner time, and short-acting insulin with carbohydrate
counting. Pt has an appointment to follow up at [**Last Name (un) **].
4) ARF: Cr 1.7 on admission. Improved to 0.7 with aggressive
hydration. U/S of transplanted kidney showed mild pelviectasis.
Because pt received dye for cardiac cath, pt was instructed to
get a check of BUN and Cr when she follows up with her PMD.
5) Lower abdominal tenderness: unclear etiology. UCG was neg.
Resolved shortly after admission.
6) S/p renal transplant:
Pt's regular immunosuppressive therapy was continued. Renal team
followed pt as inpatient. Pt was advised not to miss [**First Name (Titles) 691**] [**Last Name (Titles) 26642**]n medications (may open capsules and take the
powder sublingually if unable to tolerate PO due to nausea).
Pt's Prograf levels were in the lower limits of therapeutic
range when checked during hospitalization. Pt was instructed to
get a repeat level at her PMD's office when she goes for her
follow-up appointment.
7) Right heel ulcer
She regularly sees a podiatrist as outpatient for foot care.
Podiatry was consulted as inpatient, who recommended that
adaptic and guaze dressing be continued, as the ulcer is healing
well.
8) Depression: stable
- continued cymbalta
9) Code: DNR, but do wish to be intubated if necessary. Husband
[**Name (NI) 1158**] is her health care proxy.
Medications on Admission:
Cymbalta, hydromorphone, furosemide, prednisone, nitroglycerin,
Isordil, Plavix, Prograf, glyburide, tramadol, metoprolol,
CellCept, gabapentin, ASA, piroxicam, Lipitor, and insulin.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Non ST-elevation myocardial infarction
Right foot ulcer
.
Secondary:
Diabetes Type 1, s/p renal transplant
Gastroparesis secondary to diabetes.
Hypertension.
Hypercholesterolemia.
Left below the knee amputation
Vascular procedures on the right lower extremity.
Peripheral neuropathy
cerebrovascular accident x2.
S/p cholecystectomy
S/p cataract surgery
Depression.
Discharge Condition:
Good, stable. Tolerating POs well
Discharge Instructions:
You were admitted to the hospital because you were extremely
dehydrated and had high blood sugars. We treated you with
intravenous fluids and insulin drip, which resolved the acidosis
of your blood caused by high sugar.
.
You had episodes of chest pain during this hospitalization, with
elevation of cardiac enzymes. We performed cardiac catherization
to evaluate the cause of these frequent chest pains. It showed
that your heart arteries are diffusely narrow, with blockage of
two out of three bypass grafts, which were also previously seen
in [**2117**]. No interventions were made.
.
The following changes were made to your medication regimen:
Isordil 20 mg twice a day --> Imdur 60 mg daily
Lipitor 10 mg daily --> Lipitor 80 mg daily
Aspirin 81 mg daily --> Aspirin 325 mg daily
Please resume all of your other medications. It is very
important that you take all medications, especially your
immunosuppression medications (CellCept, Tacrolimus,
Prednisone).
.
Please attend all of your follow-up appointments.
.
If you have severe chest pain, nausea/vomiting, shortness of
breath, palpitations, or any other concerning symptoms, please
call your primary care physician or return to the emergency
room.
.
***For today, [**2125-8-28**], please take 12 units of Lantus
with dinner. Starting tomorrow, you can resume taking 18 units
of Lantus once a day with dinner, along with Glyburide and
carbohydrate counting for short-acting insulin.***
Followup Instructions:
Please attend the following appointments that have been made for
you:
[**2125-9-6**] 3:30 PM with Dr. [**Last Name (STitle) 17887**] (tel [**Telephone/Fax (1) 6699**])
Please have labs (electrolytes including BUN and Cr, and prograf
level) drawn during your appointment with Dr. [**Last Name (STitle) 17887**], and have
the result be faxed to Dr. [**Last Name (STitle) **] also (fax: [**Telephone/Fax (1) 26643**]).
[**2125-9-3**] 2 pm at [**Hospital **] Clinic to meet with nurse practitioner
[**2125-9-21**] 3 pm with Dr.[**Doctor Last Name 4849**] (Nephrology-kidney)
[**2125-10-3**] 3:30 pm with Dr. [**Last Name (STitle) **] (Diabetes)
.
You will also want to continue foot ulcer care with your
podiatrist.
Completed by:[**2125-8-28**]
|
[
"414.02",
"412",
"276.1",
"V12.54",
"362.01",
"414.01",
"250.13",
"V58.67",
"V49.75",
"707.15",
"272.0",
"536.3",
"250.63",
"357.2",
"311",
"250.53",
"410.71",
"401.9",
"V42.0",
"584.9",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10587, 10642
|
6787, 10353
|
318, 358
|
11082, 11118
|
3502, 6764
|
12612, 13355
|
2677, 2746
|
10663, 11061
|
10379, 10564
|
11142, 12589
|
2761, 3483
|
250, 280
|
386, 1878
|
1900, 2427
|
2443, 2661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,128
| 117,798
|
19990
|
Discharge summary
|
report
|
Admission Date: [**2143-4-17**] Discharge Date: [**2143-5-1**]
Service: MED
Allergies:
Aspirin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
syncope and bright red blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86yo male with gastrointestinal stromal tumor diagnosed in
[**2142-11-5**] after he presented with a lower GI bleed and was
found to have a 17x17 cm abdominal mass, with a negative EGD and
colonoscopy. He required multiple transfusions at that time,
and was started on gleevec, which was subsequently stopped
secondary to lower extremity edema and diarrhea. It was
restarted on [**4-5**], with some shrinkage in tumor. He was then
readmitted to [**Hospital1 18**] on [**2143-4-17**] after he presented with bright
red blood per rectum. He was admitted to the MICU, and
transfused as needed. No further oncologic management was felt
necessary, nor possible, and he was subsequently transferred to
the regular floor with the goal of comfort and support with
blood transfusions until the rest of his family arrived.
Past Medical History:
GIST-unresectable, manifested with LGIB
RBBB
PNA
CRF
chronic lower extremity edema
Social History:
Retired Laoatian general with 13 kids. He denies alcohol or
tobacco use.
Family History:
noncontributory
Physical Exam:
Gen-chronically ill-appearing male, fatigued, nad
HEENT-op with thrush, mmm, eomi, perrl, no scleral icterus
Neck-supple, no jvd or [**Doctor First Name **]
Pulm-cta bilaterally
CV-regular, no m/r/g
Abd-distended, hyperactive bowel sounds, large right-sided mass
that was nontender
Ext-2+ edema to knees bilaterally, trace distal pulses
Pertinent Results:
[**2143-4-19**] 05:30PM BLOOD WBC-11.4* RBC-3.50* Hgb-10.6* Hct-29.5*
MCV-84 MCH-30.2 MCHC-35.8* RDW-14.7 Plt Ct-180
[**2143-4-19**] 05:30PM BLOOD Plt Ct-180
[**2143-4-19**] 02:42AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-140
K-3.9 Cl-113* HCO3-19* AnGap-12
[**2143-4-19**] 02:42AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.8
Brief Hospital Course:
Briefly, Mr. [**Known lastname 53885**] was transferred to the floor with the
goal of comfort and blood transfusions and fluid as needed for
support until further family members could arrive. He received
multiple transfusions as he was having [**2-7**] large bloody bowel
movements per day. He required approximately [**1-9**]
transfusions/day. On [**4-25**], a family meeting was held at which
time it was decided to withdraw support with the feeling that he
would pass away within hours, and with a change in the goals of
care to comfort, with no further support with transfusions, etc.
After withdrawing support, he was placed on multiple
medications for comfort, and became unresponsive. He remained
alive for days longer than the team had anticipated. He
continually appeared comfortable, and was intermittently
tachypnic, requiring morphine.
The patient passed away on [**5-1**] at 2:30 am. His family was at
his bedside and he appeared comfortable throughout.
Medications on Admission:
tylenol prn
protonix 40qd
Discharge Medications:
none
Discharge Disposition:
Home with Service
Discharge Diagnosis:
inoperable gastric stromal cancer
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2143-5-1**]
|
[
"197.5",
"285.1",
"578.9",
"585",
"151.8",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
3129, 3148
|
2045, 3022
|
248, 255
|
3226, 3231
|
1705, 2022
|
3283, 3446
|
1316, 1333
|
3099, 3106
|
3169, 3205
|
3048, 3076
|
3255, 3260
|
1348, 1686
|
169, 210
|
283, 1103
|
1125, 1209
|
1225, 1300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,112
| 104,579
|
2645
|
Discharge summary
|
report
|
Admission Date: [**2122-8-4**] Discharge Date: [**2122-8-7**]
Date of Birth: [**2092-9-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This very pleasant 29-year-old
woman had a temporary loss of consciousness following a fall
from a chair. She also had experienced increasing left-sided
headaches for many months.
A computed tomography scan of the head was obtained. This
showed a left-sided frontal skull lesion. A magnetic
resonance imaging scan was then obtained. This showed a
likely hemangioma. This had completely infiltrated through
the inner table of the skull and had expanded the diploic
space. There was a small amount of the outer table of the
skull remaining.
The patient's headaches had been progressive and disabling.
She states that for some time she has been able to hear her
heart beat in her left hear. She also has had pain in the
region of her temporomandibular joint dysfunction.
PAST MEDICAL HISTORY: The patient is otherwise healthy.
ALLERGIES: She is allergic to TYLENOL WITH CODEINE.
SOCIAL HISTORY: She is getting married next year. She does
not smoke.
FAMILY HISTORY: There is no history of family
cardiovascular disease or strokes.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was awake and alert. She appeared
in no acute distress. She was walking without difficulty.
Her neck was had full painless range of motion. Her carotid
pulses were 2+ and symmetric. She had severe point
tenderness over her left frontal skull just above her left
ear. I could not appreciate any bruit. She had no drift.
Her reflexes were 2+ and symmetric. Her toes were downgoing.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken to
the operating room on [**2122-8-4**]. At that time, she
had a left frontal craniectomy for removal of the skull
lesion. This had been embolized the day before. The lesion
was easily removed. A cranioplasty was done at the same
time. A Hemovac drain was left in place.
Postoperatively, the patient was awake and alert. She had
moderate incisional pain. She was up and ambulating. Her
drain had minimal output. It was removed on the second
postoperatively day. The patient was up and ambulating. She
was tolerating oral medication. Her incisional pain
diminished. Her postoperative hematocrit was 29.
Plans were made to discharge the patient on [**2122-8-7**].
FINAL DISCHARGE DIAGNOSES: Hemangioma of the left frontal
bone.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to keep her wound clean and dry.
2. The patient was to increase her activity as tolerated.
3. The patient was to be seen in followup in 10 days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**]
Dictated By:[**Last Name (NamePattern4) 3655**]
MEDQUIST36
D: [**2122-8-6**] 18:24
T: [**2122-8-8**] 07:20
JOB#: [**Job Number 13264**]
|
[
"228.02",
"E884.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"01.6",
"02.06"
] |
icd9pcs
|
[
[
[]
]
] |
1135, 1671
|
2558, 3005
|
1700, 2400
|
2491, 2525
|
2428, 2476
|
154, 932
|
955, 1044
|
1061, 1117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,079
| 117,938
|
20766
|
Discharge summary
|
report
|
Admission Date: [**2150-5-22**] Discharge Date: [**2150-6-5**]
Date of Birth: [**2102-12-1**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: Patient is a 47-year-old female
with history of polysubstance abuse and asthma as well as
question of a seizure disorder secondary to head injury
greater than 10 years ago, history of depression and anxiety
admitted to the Medical Intensive Care Unit from the outside
hospital on [**2150-5-22**] for a Klonopin/Dilaudid overdose
complicated by rhabdomyolysis and transaminitis, change in
mental status, and intubated for airway protection and
hypercarbic respiratory failure who was transferred to the
floor on [**2150-5-24**] after extubation for further management.
Patient apparently had a suicide pact with her husband two
days prior to admission on [**2150-5-20**] and overdosed on
Dilaudid 300 mg (150, 2 mg tabs) and Klonopin 200 mg (50, 4
mg tabs).
Patient was found unresponsive by the patient's sister-in-law
who found both her husband and the patient lying on the
floor. Patient was brought to the emergency department at
the outside hospital and received Narcan with good effect.
Patient did not receive charcoal and was given intravenous N-
acetyl cysteine for question of Tylenol overdose (although
unlikely) and Ceftriaxone 2 mg intravenous times one.
Per the outside hospital records head CT and chest x-ray were
normal and urine toxicology screen was positive for
benzodiazepines and opiates. Labs at the outside hospital
showed an increased creatinine of 15, AST of 4600, ALT of
[**2146**], CPK of [**2146**], CPK of 25,000.
In the Emergency Department at [**Hospital1 188**] patient was arousable, satting 100 percent on
nonrebreather with an ABG of 7.36/67/167. The patient,
however, was intubated later on [**2150-5-22**] for hypercarbia
with an ABG of 7.15, PCO2 of 108, and PAO2 of 96.
Patient was seen by the Liver service, as well, and it was
agreed that patient should continue with N-acetyl cysteine
for five more days for hepato protective effects and a
question of ischemic liver injury. Patient was extubated on
[**2150-5-23**] and was satting well on 2 liters nasal cannula and
had slightly improved mental status upon transfer to the
Medicine floor on [**2150-5-24**].
Patient was also seen by Toxicology while in the Medical
Intensive Care Unit and it was agreed to continue with
anacetylcysteine since patient had increased liver function
tests and an increased total bilirubin.
On transfer to the Medicine floor patient complained of some
lower back pain which is chronic and bilateral knee pain but
otherwise was breathing comfortably.
PAST MEDICAL HISTORY:
1. Asthma.
2. Polysubstance abuse with questionable history of heroin
use in the past. Patient has been on Methadone in the
past but unclear when last taken.
3. Status post GYN surgery.
4. Lower back pain.
5. Depression and anxiety.
6. Question of seizure disorder secondary to head injury
greater than 10 years ago. Per the patient's sister the
patient was apparently on Dilantin which had since been
discontinued for unknown reasons.
7. Endometriosis status post hysterectomy at age 21.
8. Questionable history of lupus with a positive [**Doctor First Name **] but no
therapy. This history was also given by the patient's
sister.
MEDICATIONS PRIOR TO HOSPITALIZATION:
1. Klonopin.
2. Dilaudid.
3. Asthma inhalers.
MEDICATIONS ON TRANSFER TO THE FLOOR:
1. IV fluids, normal saline at 250 cc an hour.
2. Humalog insulin sliding scale.
3. Heparin 5000 units subq b.i.d.
4. Famotidine 20 mg IV b.i.d.
5. Thiamine 100 mg IV q.d.
6. Folic acid 1 mg IV q.d.
7. Salmeterol Diskus b.i.d.
8. Flovent inhaler b.i.d.
9. Albuterol nebulizers q. 4 hours.
10. Atrovent nebulizers q. 4 hours.
11. Clindamycin 600 mg p.o. t.i.d. day number one
(patient had previously been on Flagyl and Ceftriaxone for
the last two days prior to transfer).
12. N-acetyl cysteine times eight doses intravenous.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient is married. Her husband's name is
[**Name (NI) 122**] [**Name (NI) 55404**] and his phone number is [**Telephone/Fax (1) 55405**]. She also
has a sister, [**Name (NI) **] [**Name (NI) 55406**], phone number [**Telephone/Fax (1) 55407**]. Per
the patient's sister patient had recently lost her pet dog
and from the trauma of this loss, the patient's husband and
her made this suicide pact. [**Name (NI) **] husband at the time of
this dictation is currently discharged from the hospital but
had been hospitalized at [**Hospital 5503**] [**Hospital 7637**] Hospital
with question of transfer to the CCU for management of
cardiac issues. He is currently doing well.
Also of note, patient's new primary care physician is [**Last Name (NamePattern4) **].
[**Last Name (STitle) 55408**], phone number [**Telephone/Fax (1) 55409**]. Previous primary care
physician was Dr. [**Last Name (STitle) 4610**].
PHYSICAL EXAMINATION ON TRANSFER: Temperature 98.1, BP
134/73, pulse 86, respirations 17, satting 96 percent on 2
liters nasal cannula. ABG checked the morning of [**2150-5-24**],
was 7.54, PCO2 of 38, and PAO2 of 109. In general, patient
is alert and oriented times two to person and year although
did not know the month, and patient knew that she was in a
"hospital" but did not know the name of the hospital. HEENT:
Pupils equal, round, and reactive to light. Extraocular
movements intact. Oropharynx is clear with moist mucous
membranes but poor dentition. Neck: Cool and supple;
nontender; no jugular venous distention. Pulmonary: Clear
to auscultation bilaterally with poor inspiratory effort.
Cardiovascular: Regular rate and rhythm with no murmurs,
rubs, or gallops. Abdomen: Soft, nontender, nondistended,
with good bowel sounds. Femoral line was in place, clean,
dry, and intact. Extremities: No edema, no calf tenderness,
with 2 plus dorsalis pedis pulses present bilaterally.
LABS ON TRANSFER: White blood cell count 8.5, hematocrit
34.1, platelets 120. Chem-7: Sodium of 146, potassium of
2.3, chloride 108, bicarbonate 32, BUN 7, creatinine 0.3,
glucose 84, magnesium 1.4, calcium 7.5, phosphorus 1.4, ALT
649, AST 640, CK 16,278, alkaline phosphatase 44, total
bilirubin 2.3 mostly, indirect at 1.4, direct bilirubin 0.9,
PTT 38, INR 2.0, troponin less than 0.01, CK-MB of 20, lipase
37, HCV antibody negative, Dilantin level less than 0.06, D-
Dimer at 3258.
Chest x-ray on [**2150-5-22**] showed persistent small peripheral
opacity in the right lower lobe, small right pleural effusion
versus pleural thickening.
Abdominal ultrasound showed patent pleural vein with no
lesions, no obstruction, positive echogenic kidneys with
appropriate flow, normal liver. Gallbladder showed
thickening but no signs of cholecystitis,. No ascites.
CT of the head showed no hemorrhage, normal ventricles and
sulci. There was a focal region of encephalomalacia in the
right frontal lobe, but otherwise unremarkable.
ASSESSMENT: 47-year-old female with history of substance
abuse and question of seizure disorder in the past, asthma
status post Dilaudid and Klonopin overdose who was admitted
to the Medical Intensive Care Unit with mental status change,
rhabdomyolysis, transaminitis, and hypercarbic respiratory
failure now transferred to the Medicine floor after
extubation, improved, for further management.
HOSPITAL COURSE:
1. Medication overdose/Psychiatry: On transfer to the
Medicine floor patient was maintained on a one-to-one
sitter and was followed by Psychiatry throughout her
hospitalization. Given her mental status change she was
not restarted on her antidepressants. Psych and
Toxicology both were following the patient.
As far as from a Toxicology standpoint, patient shortly had
her N-acetyl cysteine discontinued on transfer to the
Medicine floor since her liver function tests began to trend
downward. It was unlikely that patient overdosed on Tylenol,
but the N-acetyl cysteine was kept on per Toxicology
recommendations for hepato protective effects. Patient
showed no signs of benzodiazepine withdrawal and was
maintained on a Clinical Institute Withdrawal Assessment
scale for several days and required no Ativan per CIWA scale.
The CIWA scale was subsequently discontinued after events on
[**2150-3-27**], which will be discussed below. The patient
showed no signs of narcotics withdrawal with no nausea,
vomiting, or any other associated symptoms. Currently at
time of this dictation patient is awaiting inpatient
psychiatric treatment either at a rehab facility or at [**Hospital1 1444**].
1. Mental status change: Initially on transfer to the
Medicine floor patient's mental status seemed slightly
improved, although patient still was disoriented and
somewhat confused. It was thought initially that patient
most likely had a toxic metabolic encephalopathy from her
overdose. Initial EEG, which was checked on [**2150-5-24**],
was consistent with a diffuse encephalopathy. Given
patient's very high liver function tests, decision was
made to hold off on Dilantin loading on transfer on
[**2150-5-24**] given possible hepatotoxic effects on Dilantin
and a questionable history of seizure disorder in the past
but no evidence of seizures at the time of transfer.
Over the next several days from [**2150-5-25**] to [**2150-5-26**]
patient began to appear more lethargic and her mental status
declined. She received no Valium to explain her mental
status change, and the Valium per CIWA scale was
discontinued. A head CT was checked on [**2150-5-25**] to rule
out anoxic brain injury and results showed bilateral
hypodense zones in the main inferior orbital portion of both
frontal lobes as well as a 2 cm triangular area of decreased
absorption in the right frontal lobe suggesting chronic
malasic change in frontal lobes. Dictation suggested a
questionable history of prior trauma, and thus it was thought
that her head CT was stable. It was most likely chronic
change from previous head injury. It was thought that
patient still may likely have a toxic metabolic
encephalopathy.
However, during the course on [**2150-5-26**] patient began to
manifest a worsening mental status and stopped following
commands and was not responding even to sternal rub. At the
same time patient spiked fevers to 102 and 103. At 5 p.m. on
[**2150-5-26**] patient became tachycardiac in the 100s. Systolic
blood pressure rose to the 160s when they had previously been
in the low 100s and temperature rose to 102 with a
respiratory rate of 40. HEENT exam showed dilated pupils
that were minimally active, scleral icterus with bulging
sclerae. Funduscopic exam was performed which showed no
papilledema. Neuro exam: As mentioned above, patient was
not responding to sternal rub and no withdrawal to pain. She
was not opening her eyes or following commands. Her deep
tendon reflexes were still 2 plus throughout with downgoing
Babinski's.
With the mental status change and fever, it was concerning
that patient was either suffering from a seizure,
benzodiazepine withdrawal, or some other neurologic process.
Patient was given 1 mg of Ativan times one for question of
seizure and benzodiazepine withdrawal but with no effect.
Stat chest x-ray showed a question of an aspiration pneumonia
in the right lower lobe, but this was most likely secondary
to mental status change and not the cause of recurrent fever
and mental status. Blood cultures were drawn which showed no
growth. Urinalysis was negative.
At this point it was attempted to perform an lumbar puncture.
Head CT had just been performed the night before and there
was no papilledema on funduscopic exam. It was felt
comfortable to perform the lumbar puncture. Several attempts
were made by two differential physicians and lumbar puncture
was unsuccessful on the evening of [**2150-5-26**] with no fluid
retrieval. There were no complications at the attempts.
ABG was also checked at that time and it was 7.54, PCO2 of
29, and PAO2 of 99, suggesting a respiratory alkylosis. Of
note, patient was also given two units of fresh frozen plasma
for an elevated INR of 1.7 prior to lumbar puncture.
Since patient was and the lumbar puncture was unsuccessful on
the evening of [**2150-5-26**] patient was empirically placed on
Ceftriaxone 2 grams q.d., Vancomycin, and Flagyl for coverage
of aspiration pneumonia.
The patient continued to spike fevers throughout the night of
[**2150-5-27**] and on [**2150-5-28**] patient was not responding to
sternal rub, following commands, or responding to any pain.
Her white count was elevated at 15,000. A tox screen was
checked which was negative.
At 9 a.m. on [**2150-5-27**] patient had a grand mal seizure with
tonic-clonic movements that were generalized and witnessed by
the nursing staff. The seizure resolved after a few seconds.
Patient was given Ativan 2 mg times one, but the seizure had
already resolved. Her temperature was 103 at that time and
her saturations were initially at 95 percent on 2 liters, but
they decreased to 70 percent 4 liters. Patient was put on
100 percent nonrebreather with only an O2 saturation at 94
percent on nonrebreather. Anesthesia was called to intubate
the patient for airway protection. They performed a
nasotracheal intubation most probably secondary to mouth
rigidity. Patient was emergently transferred to the Medical
Intensive Care Unit after intubation.
Repeat head CT at the MICU showed extensive cerebral edema
primarily in the white matter in a pattern consistent with
reversible leukoencephalopathy syndrome. There were open
ventricles and the basal cisternal spaces remain visualized.
Neurosurgery was consulted and it was felt that patient would
most likely benefit from some type of intracranial monitoring
device. Patient was given Mannitol q. 6 hours to keep serum
osms less than 320, four units of fresh frozen plasma, and
had an intracerebral pressure monitor placed as well as an
external ventriculostomy drain. Patient had cerebrospinal
fluid sample sent from this drain which showed no signs of
infection. CSF showed only 1 white blood cell and normal
glucose and total protein.
Patient had the drain placed for one day and intracerebral
pressures remained stable and the drain was discontinued on
[**2150-5-29**] by Neurosurgery. Repeat EEG still showed just
diffuse encephalopathy. MRI of the head was unrevealing.
Patient was initially started on Dilantin and then
transitioned to Keppra for ease of usage and no monitoring.
Patient was also treated with meningitis doses of Ceftriaxone
2 grams q. day for a total of a seven-day course completed on
[**2150-6-2**] for empiric coverage of meningitis since LP could
not be performed in the acute setting, and patient had
received 24 hours of antibiotics prior to shunt placement and
retrieval of CSF.
Even at the time of this dictation it is still unclear why
patient had this diffuse cerebral edema, and there have been
no clear hypotheses as to why this may have occurred.
Patient was transferred from the ICU back to the Medicine
floor after improvement of her mental status and
discontinuation of the intracerebral pressure monitoring and
patient has been alert, lucid, and her mental status has been
stable. She is alert enough to give a thorough history and
is aware of her surroundings as well as her caretakers, which
is quite different from her initial presentation. As far as
her seizure disorder, she will continue with the Keppra and
has not manifested any further seizures.
Fevers: It is unclear whether patient may have had an
aspiration pneumonia so she was treated briefly with a
course of Clindamycin which was subsequently discontinued
after her second transfer to the Medicine floor since her
chest x-ray from [**2150-5-28**] was entirely clear. The
patient did complete a full course of seven days for a
treatment of meningitis with Ceftriaxone 2 grams per day
since it was unclear what precipitated her event.
Patient had a mild low-grade fever on [**2150-6-4**], but this
has resolved and she has had no further infectious issues at
the time of this dictation. She is currently on no
antibiotics.
Transaminitis: Patient's liver function tests continued
to decline and it was thought likely that patient's
transaminitis and increased INR were secondary to ischemic
liver injury from her initial event. These AST and ALT
are almost at normal levels at the time of this dictation.
Rhabdomyolysis: Patient's rhabdomyolysis also continued
to improve throughout the course of her hospitalization.
At the time of this dictation her CK level is now down to
500 from a peak of 26,000, and it is felt there is no need
to follow these since they have continued to trend
downwards. Patient was maintained on aggressive
intravenous hydration at first and now is continuing on
maintenance fluids since she continues to have poor p.o.
intake.
Nutrition goal: Patient initially presented with
decreased mental status and was not able to take
nutrition, but since her mental status has improved
patient has passed a speech and swallow evaluation and is
tolerating good Pos. Would continue to encourage fluid
intake.
Access: Patient had a right femoral groin line placed
initially when she was in the Unit and this was
subsequently discontinued on her first transfer to the
Medicine floor. However, when she decompensated with a
grand mal seizure and was intubated, she had a left IJ
placed in the MICU. This left IJ remained in place until
[**2150-6-4**] when it was discontinued. The catheter check
has been sent for culture since the line site was somewhat
erythematous. The culture data is still pending at the
time of this dictation.
DISPOSITION: Patient has been working with Physical Therapy
and has been regaining her strength daily. She still
requires some assistance with moving around, but this is felt
that it would likely improve with further strengthening. The
decision is currently being made at the time of this
dictation whether to transfer the patient to the inpatient
psychiatric unit or to discharge the patient to psychiatric
unit at [**Hospital1 69**]. It has been
confirmed that patient does indeed have insurance, Medicare.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Still unknown at the time of this
dictation but likely to an inpatient psychiatric facility
with a rehab potential.
A discharge addendum will be added to cover the medications
and follow-up plans.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**]
Dictated By:[**Name8 (MD) 5706**]
MEDQUIST36
D: [**2150-6-4**] 20:14:55
T: [**2150-6-4**] 22:39:26
Job#: [**Job Number 55410**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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18411, 18894
|
7420, 18389
|
163, 2647
|
2669, 4034
|
4051, 7403
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,843
| 121,353
|
35034
|
Discharge summary
|
report
|
Admission Date: [**2131-10-11**] Discharge Date: [**2131-10-16**]
Date of Birth: [**2065-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Found down, acidosis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
66 M with PMH of bladder and prostate Ca s/p cystectomy and
surgical reconstruction, EtOH abuse; admit with severe metabolic
acidosis and altered mental status. Patient was last known okay
on [**10-9**]. He called his nephew that morning to try to arrange a
nephew assumed he took the shuttle. No answer at home when
sister visited on [**10-10**]; she left a note in the doorway which was
still there on [**10-11**]. She then called maintenance at his living
facility to break into his apartment. Found minimally
responsive. Incontinent of urine. ? next to bottle of vicodin
(unclear if he took this). Brought to [**Hospital 1562**] hospital; notable
lab findings include K 8, bicarb of 6 and pH 7.00. CXR and head
CT reportedly negative. He received sodium bicarb. EtOH was
negative as was other tox screen.
.
In the ED, patient confused, oriented x 1 only but alert and
protecting airway. Afebrile, P86 126/57, R12, 100% on ?. Labs
reveal severe nongap metabolic acidosis (ABG 7.00/25/122 with
chem 7 bicarb of 7 and anion gap of 11). In our ED he received 2
liters of IV fluids, dextrose and insulin, 1 amp bicarb.
Reportedly putting out excellent urine. Tox consulted in ED;
prelim recs include no NAC given negative level and likely time
course.
Past Medical History:
- Bladder and prostate Ca, diagnosed ~ 5 years ago, ?actively
treated now - seen at VA [**Hospital1 789**]. s/p cystectomy and ?ileal
reconstructive surgery (still with transurethral urination).
- EtOH abuse, per neighbors drinking heavily recently, though
amounts unclear.
- HTN
- Intermittent ?ARF (has occurred 2 or 3 times) ?obstructive
(has required intermittent catheterization in the past)
- DM type II
- Peripheral neuropathy
- H/o empyema ~ 5 years ago requiring thoracotomy.
- Tobacco use
- No known history of suicide attempt
Social History:
Moved from [**State 4565**] a couple years ago. Lives alone in senior
housing. EtOH as above. Tobacco use currently, unclear how much.
Per sister, no h/o IVDU. Never married, no children.
Family History:
NC
Physical Exam:
On Admission:
VS: T 96.6 (rectal), BP 133/47, HR 89, RR 19, O2 sat 98% 2L
GEN: Disheveled, confused.
HEENT: NCAT, EOMI, PERRL, no icterus.
NECK: Prominent EJ.
PULM: CTAB, no w/r/r.
CV: RRR, no m/r/g.
ABD: Normoactive BS, soft, NT, ND
EXTREM: No c/c/e.
NEURO: Oriented x [**12-6**], CN II-XII grossly intact, good grip
strength bilaterally, moves toes bilaterally.
.
On discharge:
VS: T 98.6, BP 140/72, HR 66, RR, 20, O2 sat 95% RA.
GEN: NAD.
NECK: Supple.
PULM: CTA b/l.
CV: RRR, no m/r/g.
ABD: Normoactive BS, soft, ND, no tenderness (including over
suprapubic region).
EXTREM: No c/c/e, LUE swelling [**1-6**] periph IV infiltrate
resolved.
NEURO: AAO x 3, non-focal, able to ambulate without difficulty.
Pertinent Results:
Admission Labs:
[**2131-10-11**] 08:15PM BLOOD WBC-4.6 RBC-3.73* Hgb-12.0* Hct-38.2*
MCV-103* MCH-32.2* MCHC-31.4 RDW-15.2 Plt Ct-215
[**2131-10-11**] 08:15PM BLOOD Neuts-76.5* Lymphs-15.6* Monos-7.3
Eos-0.3 Baso-0.3
[**2131-10-11**] 08:15PM BLOOD Glucose-150* UreaN-153* Creat-4.4*
Na-150* K-6.7* Cl-132* HCO3-7* AnGap-18
[**2131-10-11**] 08:15PM BLOOD ALT-9 AST-6 CK(CPK)-72 AlkPhos-78
TotBili-0.3
[**2131-10-11**] 08:15PM BLOOD Lipase-60
[**2131-10-11**] 08:15PM BLOOD cTropnT-0.02*
[**2131-10-12**] 02:48AM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.9 Mg-2.4
[**2131-10-13**] 12:26AM BLOOD Ammonia-34
[**2131-10-12**] 02:48AM BLOOD Osmolal-367*
[**2131-10-11**] 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-10-11**] 08:21PM BLOOD pO2-122* pCO2-25* pH-7.00* calTCO2-7*
Base XS--24 Comment-GREEN TOP
[**2131-10-11**] 08:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2131-10-11**] 08:15PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2131-10-11**] 08:15PM URINE RBC-[**5-15**]* WBC-[**5-15**]* Bacteri-MANY
Yeast-NONE Epi-0
.
Discharge Labs:
[**2131-10-16**] 06:00AM BLOOD WBC-7.7 RBC-3.27* Hgb-10.0* Hct-31.1*
MCV-95 MCH-30.6 MCHC-32.2 RDW-15.0 Plt Ct-232
[**2131-10-16**] 06:00AM BLOOD Glucose-145* UreaN-38* Creat-1.9* Na-140
K-4.0 Cl-107 HCO3-25 AnGap-12
[**2131-10-16**] 06:00AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.8
.
[**2131-10-11**] 8:15 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL
MORPHOLOGIES.
.
[**2131-10-11**] 8:40 pm BLOOD CULTURE x 2: NO GROWTH.
.
EKG [**2131-10-11**]: Sinus rhythm at 79 bpm and diffuse non-specific
ST-T wave changes. The phasic variation in axis suggests
tachypnea. No previous tracing available for comparison
.
EKG [**2131-10-12**]: Sinus rhythm at 81 bpm and occasional atrial
ectopy. Phasic variation in axis with respiration. Compared to
the previous tracing of [**2123-10-11**] the T waves are now biphasic to
inverted in leads V4-V6 and, in the context of delayed
precordial R wave transition, may represent active lateral
ischemia. Followup and clinical correlation are suggested.
.
CXR [**2131-10-12**]: No areas of focal infiltrate. Minimal bilateral
basilar
atelectasis.
.
Renal U/S [**2131-10-12**]: The right kidney measures 10.9 cm. The left
kidney
measures 12.4 cm. There is no hydronephrosis or stones. The
patient is
status post cystectomy. IMPRESSION: Normal examination of the
kidneys.
.
LUE U/S [**2131-10-14**]: FINDINGS: Grayscale and color Doppler images of
the left internal jugular, subclavian, axillary, brachial,
basilic and cephalic veins were obtained. These demonstrate
normal flow, compressibility and augmentation. Note is made of
arterial calcifications. IMPRESSION: No evidence of deep venous
thrombosis of the left upper extremity.
Brief Hospital Course:
66 M with h/o hypertension, bladder and prostate cancer s/p
cystectomy and surgical reconstruction, EtOH abuse who was found
unresponsive at home, with severe non-gap metabolic acidosis and
acute renal failure on presentation.
.
# Non-anion gap metabolic acidosis: Pt admitted to the ICU with
severe non-anion gap metabolic acidosis. Toxicology consulted in
ED and recommended sending methanol and ethanol levels to the
[**Hospital1 498**] lab. Pt initially given one dose of fomepizole per
toxicology recommendations but this was subsequently
discontinued. Pt treated with D5W infusions with sodium bicarb
to correct hypernatremia and metabolic acidosis. Renal consulted
for his acute renal failure and creatinine of 4.2; renal
ultrasound done was normal. His acidosis and hyponatremia
gradually corrected on IVF D5W with sodium bicarb and frequent
lab checks. Renal function improved to a creatinine of 2.1,
baseline unclear but with some baseline dysfunction per sister.
.
Toxic Metabolic Encephalopathy:
Medical records from the [**Hospital1 789**] VA were obtained on [**2131-10-12**]
and part of his home medication regimen was restarted, including
Levothyroxine and aspirin and he was placed on Hydralazine for
BP control. His TSH was checked and was 2.6. His mental status
improved; however was still not oriented X 3 when he left the
MICU. His urine culture grew E. Coli; however given that he was
afebrile and had no elevation in WBCs. There was also some
thought that he had had a prior surgery with ileal conduit to
his bladder.
.
# Acute Renal failure/CKD. Baseline unknown. Renal US wnl. Cr
getting better with hydration. fena was 2.6
Followed by nephrology, improved by dischareg.
Medications on Admission:
Levothyroxine 100 mcg daily
Glipizide 5 mg [**Hospital1 **]
ASA 81 mg daily
Lisinopril 20 mg daily
Hydrocodone-Acetaminophen 5-500 1 tab qid prn pain
Gabapentin 400 mg daily (just started with instructions to
increase slowly)
Alprostadil prn
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day:
Stop medication and call your doctor if you are not having good
urine output.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Toxic Metabolic Encephalopathy
- Non-gap metabolic acidosis
- Acute on chronic renal failure
Secondary:
- Bladder and prostate cancer s/p cystectomy and ileal
reconstructive surgery
- HTN
- DM type II
- Chronic Renal failure
- Peripheral neuropathy
- Anemia
- EtOH use
Discharge Condition:
Stable.
Discharge Instructions:
You were transferred from [**Hospital 1562**] Hospital and admitted to our
ICU after being found down with altered mental status. Your
blood electrolytes were very abnormal. These were repleted with
IV medications and are normal on discharge. Your kidney function
has improved, but your baseline is unknown. You were noted to be
anemic but your baseline is unknown and your blood count
remained stable. Please follow up with your PCP regarding all of
these issues and further work-up as needed.
You were started on folate and thiamine. Follow up with your PCP
whether you need to continue these.
We are restarting your lisinopril on discharge as your kidney
function has improved and you are having good urine output.
We have held your gabapentin. Please ask your PCP when you
should restart it.
Please take all of your other medications as prescribed.
Please call your doctor or return to the ED if you develop
fevers > 100.4, chest pain, shortness of breath, severe nausea
or diarrhea, inability to urinate, or any other concerning
symptoms.
Followup Instructions:
Please make a follow up appointment with your PCP [**Name Initial (PRE) 176**] [**12-6**]
weeks and make sure you have your blood counts, electrolytes,
and kidney function checked. Your discharge summary will be
faxed to the [**Location (un) 9101**] VA.
|
[
"276.7",
"V10.51",
"349.82",
"357.2",
"250.60",
"585.9",
"285.9",
"276.0",
"403.90",
"584.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8682, 8688
|
6103, 7808
|
337, 345
|
9012, 9022
|
3157, 3157
|
10117, 10374
|
2410, 2414
|
8100, 8659
|
8709, 8991
|
7834, 8077
|
9046, 10094
|
4322, 4635
|
2429, 2429
|
2809, 3138
|
277, 299
|
4670, 6080
|
373, 1629
|
3173, 4306
|
2443, 2795
|
1651, 2189
|
2205, 2394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,644
| 123,285
|
26850
|
Discharge summary
|
report
|
Admission Date: [**2133-2-11**] Discharge Date: [**2133-3-7**]
Date of Birth: [**2062-9-14**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 8739**]
Chief Complaint:
shortness of breath, diplopia
Major Surgical or Invasive Procedure:
Plasmapheresis
left femoral CVL placement
Intubation
History of Present Illness:
The patient is a 70 year old woman with a history of myasthenia
[**Last Name (un) 2902**] now presenting with chest pain and shortness of breath.
She is a fair historian in some discomfort so details are
limited. About 2 weeks ago she began to feel intermittant left
sided chest pain that radiates into her left arm and jaw. She
describes the pain as dull and pressure-like in the chest and
sharper in the arm. She also experienced shortness of breath
and has become increasingly less mobile in this time period.
She visited her PCP last week who was planning on arranging a
stress test for her. She was also complaining of a cough and
upper respiratory symptoms; she was treated with a
cephalosporin. Over this past week, her symptoms of fatigue and
pain have worsened. Today, she visited her PCP and could barely
walk into the office. He arranged for her to be taken to the
ED. She feels her eyes have been a bit more droopy in this time
period as well. She complains of some diplopia. In the ED, her
NIF is -20 and her vital capacity is 1.35.
She has a history of myasthenia since [**2118**], has been intubated
in the past for similar symptoms ([**1-24**] lifetime intubations).
Some of her symptoms include ptosis, double vision and shortness
of breath. Her last intubation was in [**2129**] and was prolonged,
requiring a trach; she developed a DVT from a femoral line
placed for pheresis. According to her outpatient neurologist,
she has done well on Cellcept and Mestinon, in general. She has
failed Imuran, Cyclosporin and Cytoxan. Steroids have produced
more side effects than benefit for her. Respiratory illnesses
have triggered crises in the past.
Her last hospitalization at [**Hospital1 2177**] was in [**8-26**] when she had
presented with weakness, shortness of breath and chest pain -
she had responded to Mestinon 30 mg; she also was noted to have
an adjustment disorder by psychiatry consult with anxiety and
perseveration on "staying alive" exacerbating her symptoms; she
had been discharged home on the same regimen for the myasthenia
at the time (cellcept and mestinon) and also with some low-dose
klonopin 0.25 mg [**Hospital1 **]. She has not been taking the Klonopin, as
she has not felt that she needed it. She has not been admitted
to the hospital for at least 12 months prior to her last visit
to Dr. [**Last Name (STitle) 66083**], which was in [**9-27**].
Past Medical History:
-h/o myasthenia [**Last Name (un) 2902**] dx in [**2119**]
-s/p thymectomy
-diabetes
-high cholesterol
-h/o shingles in [**Month (only) 205**], on right leg
-osteopenia
-seasonal allergies
Social History:
-lives by self in an elderly home
-no smoking or drinking
-owned a laundromat
Family History:
-father with CHF
-mother with pancreatic cancer
-daughters with thyroid disease
Physical Exam:
Physical Exam
Vitals: 97.1 68 168/77 15
General: older woman breathing with some difficulty
Neck: supple
Lungs: Clear to auscultation
CV: Regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
awake, alert, answering questions appropriately, oriented x3,
able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] backward, language is fluent, naming and
repetition intact; b/l ptosis that worsened a bit during
sustained upgaze x60 sec., pupils equally reactive to light, eye
movements full (after sustained upgaze, pt experienced
difficulty
of right eye aBduction and double vision), face symmetric;
tongue
midline; normal bulk and tone; motor exam limited by fatigue,
mild proximal weakness in arms; unable to hold legs off bed for
1
sec; mild neck flexor weakness 5-/5; sensory exam intact to
light
touch on all extremities; fnf with no ataxia; gait exam deferred
Pertinent Results:
[**2133-2-11**] 03:55PM WBC-6.1 RBC-5.73* HGB-15.9 HCT-47.2 MCV-82
MCH-27.8 MCHC-33.7 RDW-14.2
[**2133-2-11**] 03:55PM NEUTS-75.7* LYMPHS-18.8 MONOS-4.8 EOS-0.5
BASOS-0.3
[**2133-2-11**] 03:55PM PLT COUNT-183
[**2133-2-11**] 03:55PM cTropnT-<0.01
[**2133-2-11**] 03:55PM CK-MB-NotDone
[**2133-2-11**] 03:55PM CK(CPK)-44
[**2133-2-11**] 03:55PM GLUCOSE-143* UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14
[**2133-2-11**] 04:20PM LACTATE-2.9*
[**2133-2-11**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2133-2-11**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2133-2-11**] 06:00PM URINE GR HOLD-HOLD
[**2133-2-11**] 06:00PM URINE HOURS-RANDOM
[**2133-2-11**] 07:16PM PO2-100 PCO2-37 PH-7.45 TOTAL CO2-27 BASE
XS-1
CTPA:
IMPRESSION:
1. No evidence of pulmonary embolism. Although the bolus for the
aorta is somewhat limited, no signs of thoracic aortic
dissection are seen.
2. Bilateral lower lobe atelectasis.
3. 1.7-cm calcified nodule or conglomeration of multiple small
calcified stones (? clustered within a calyceal diverticulum) at
the upper pole of the right kidney.
CXR:
FINDINGS: The patient is status post CABG with median
sternotomy. Cardiac and mediastinal contours are unremarkable.
Left basilar atelectasis, however, no definite consolidation is
seen.
Note is made of surgical staples overlying the right upper
quadrant. There is 1.7 cm calcified density overlying the right
upper quadrant, representing kidney stones.
IMPRESSION: No evidence of pneumonia. 1.7 cm rounded calcified
opacity overlying the right upper quadrant, probably
representing kidney stone.
REPEAT CXR [**2-11**]:
SUPINE PORTABLE VIEW OF THE CHEST: There is interval placement
of an endotracheal tube terminating at the thoracic inlet.
There is interval development of a left retrocardiac opacity. No
evidence of pneumothorax. Right lung is grossly clear.
[**2-13**]:
CHEST PORTABLE: Comparison is made to a prior study of [**2133-2-11**].
The heart size is in the upper limits of normal. The mediastinal
and hilar contours are unchanged. The pulmonary vasculature is
unremarkable. Again noted is the retrocardiac opacity, which is
stable in appearance. No new consolidation. A left central
venous line is seen with its tip in the distal SVC. The ET tube
is identified 1.7 cm from the carina. A feeding tube is seen
passing through the stomach, the tip of which is not depicted on
this film.
IMPRESSION:
1. Left central venous line with its tip in the distal SVC.
2. No change in the appearance of the heart and lungs with
persistent retrocardiac opacity consistent with atelectasis
versus consolidation.
-------
[**2-26**]:CXR: negative
Brief Hospital Course:
70 yo woman with MG dxd [**2119**], followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66083**] at [**Hospital1 2177**],
hx of hospitalizations with 3-4 intubations in past (last [**2129**],
with prolonged intubation requiring trach, complicated by DVT
from pheresis cath) who had URI for past 2 wks, treated with
cephalosporin who p/w worsening cp, sob, diplopia and ptosis.
In ED, she was using accessory muscles, unable to keep neck or
limbs up. NIF -20 and VC 1.35l; she was intubated electively.
She had a cta with no PE.
1. Neuro -
-After discussion with neuromuscular department as well as email
correspondence with outpatient neurologist Dr. [**Last Name (STitle) 66083**], opted to
treat with IVIG (no steroids - patient has had more
complications than benefits in the past). This was started
within 24 hours of hospitalization.
-Temperature spiked to 102 with IVIG - cultures were sent to
rule out infection, and IVIG was held for one hour and restarted
at a slower rate according to blood bank recommendations. She
continued to have fevers with administration of IVIG, but
premedication with tylenol, benadryl and ranitidine helped.
-Cellcept was changed from 750mg [**Hospital1 **] to 1000 mg [**Hospital1 **] per
neuromuscular recommendations.
-Mestinon was continued at an IV equivalent dose to the
patient's PO dose; this was changed to PO after NGT was placed
After completion of IVIG and transfer to the floor, the patient
had another respiratory decompensation with in creased WOB and
proximal neck and facial weakness. She was re-admitted to the
ICU. Plasmapheresis was recommended after re-consultation with
the Neuromuscular team. This was started in the ICU and she did
very well. She initially had additional decompensations, but
did not require intubation. After several pheresis treatments,
she was looking much better. She was transferred back to the
floor. She completed her 5 plasmapheresis treatments and then
had her left femoral CVL removed without problems. [**Name (NI) **] mestinon
was also chanegd to 60 mg four times a day from 45 mg 4x/day.
She had no problems with this dose.
She was much improved from a pulmonary and weakness standpint
and was discharged home in good condition. She had VC in the 1.5
L range and NIFs in the -30 to -40 range. She was ambulating
well.
2. CV -
-There was some bradycardia on first 24 hrs of admission, the
significance of which was unclear. We continued to follow heart
rate on telemetry (per family, this has happened before during
hosp stay); atropine was placed at bedside. Bradycardia
improved after 36-48 hrs post-admission. It did not return.
3. Pulm -
-CTA was negative for pulmonary embolus.
-She was kept on the ventilator to reduce work of breathing;
NIFs continued to be low
-As part of the patient's fever workup, we checked several chest
xrays - the first demonstrated a faint retrocardiac opacity
thought to be either atelectasis or consolidation; the second
was read as unchanged. As her white blood cell count came down
on its own following the second xray, she was not treated with
antibiotics.
-On [**2-15**] she spiked a temp again and had increased secretions;
sputum sent [**2-12**] was growing strep pneumoniae. ID was consulted
for the difficulty of choosing an antibiotic that would not
exacerbate her myasthenia. Penicillin G was chosen. She was
treated with a complete course of this antibiotic without
complications. She then had a repeat CXR several days later
with no evidence of PNA/consolidation.
6. ID -
-BCx were drawn and sputum was cultured when she had a fever;
blood cultures were negative to date. Sputum grew strep
pneumoniae. A right SVC central line was removed as there was
surrounding erythema. A femoral line was placed later when she
needed pheresis.
8. Endo -
-Blood glucose was carefully monitored, and the patient remained
on an insulin sliding scale for tight control. Metformain was
continued.
Medications on Admission:
cellcept [**Pager number **] [**Hospital1 **]
mestinon 45 4xd
metformin 500 mg [**Hospital1 **]
glipizide 10 mg qd
lipitor 10 mg qd
calcium
mvi
clarinex 5 mg qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
four times a day.
Disp:*120 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. See below
Please restart all of your other medications as you were
previously taking
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Myasthenia [**Last Name (un) **] flare
--
UTI
Discharge Condition:
Stable. Pt had stable and good NIF and VCs. She was ambulating
alone. She still has fatigueable upgaze
Discharge Instructions:
Please call your PCP or return to the ED if you have any
shortness of breath, severe weakness, fever, chest pain,
fainting, or falls.
--
Take your medications as directed. The only changes made are as
below, otherwise, take everything as you were previously.
1.Your mestinon will now be 60 mg 4 times/day.
2.Your cellcept dose was increased to 1000 mg twice a day
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) 66084**] in next 1-2 weeks. Please call
her office on Monday to get an appointment. She is expecting
your call.
---
Follow-up with your PCP [**Last Name (NamePattern4) **] ~1 month
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4406**] MD, [**MD Number(3) 8740**]
|
[
"327.23",
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"733.90",
"250.00",
"481",
"724.3",
"599.0",
"518.81",
"427.89",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72",
"99.14",
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] |
icd9pcs
|
[
[
[]
]
] |
12022, 12071
|
7006, 10972
|
298, 353
|
12161, 12267
|
4186, 6983
|
12679, 13039
|
3114, 3195
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12092, 12140
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12291, 12656
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3210, 3455
|
229, 260
|
381, 2789
|
3479, 4167
|
2811, 3002
|
3018, 3098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,100
| 151,992
|
34095
|
Discharge summary
|
report
|
Admission Date: [**2175-2-23**] Discharge Date: [**2175-3-3**]
Date of Birth: [**2106-2-14**] Sex: M
Service: SURGERY
Allergies:
Adhesive
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
esld [**1-23**] NASH vs. autoimmune hepatitis
Major Surgical or Invasive Procedure:
[**2175-2-23**] liver [**Month/Day/Year **]
History of Present Illness:
68 y.o. M with pmh of cirrhosis of unknown etiology (? NASH vs
autoimmune hepatitis vs hemochromatosis/etoh). Recently
hospitalized for MS changes, encephalopathy and lethargy. Found
to have Coagulase Negative Staphylococcus Bacteremia sensitive
to vanco. Discharged home on [**2-21**] to complete 5 more days of
vanco rx via picc line. Presented to liver [**Month/Day (4) **].
Past Medical History:
1. Cirrhosis. NASH vs autoimmune vs alcohol related per biopsy
at outside hospital. He also has heterozygote related to
hemachromatosis
gene mutation. His biopsy results demonstrate hemosiderin
deposits.
2. History of spontaneous bacterial peritonitis in [**2174-4-21**].
3. History of GI bleed in [**2174-7-22**] secondary to portal
gastropathy as well as esophageal varices.
4. Peripheral arterial disease status post stent to superficial
femoral artery approximately 10 years ago.
5. Hypertension.
6. Liver [**Year (4 digits) **] [**2175-2-24**]
Social History:
Former smoker, 20-pack-year history, quit [**2146**]. Prior
social EtOH drinker, none in 5 years. No h/o IVDU or other
drugs.
No tatoos or piercings. Retired Home Care and Home Oxygen
company
co-partner. Married x 42 years.
Family History:
Mother d. age 51 from leukemia. Father d. age 59 from
gastric cancer, and he had stomach ulcers and CAD. Brother d.
age
51 from alcohol, ? cirrhosis. Sister d. age 61 from cervical and
ovarian cancer.
Physical Exam:
97.3 63 90/50 18 97%RA
A&O x 3, NAD, scleral icterus, clearly jaundiced
RRR
nl S1S2
Pertinent Results:
On Admission: [**2175-2-23**]
WBC-10.7 RBC-2.96*# Hgb-10.2*# Hct-29.3*# MCV-99* MCH-34.6*
MCHC-34.9 RDW-23.1* Plt Ct-63*
PT-26.4* PTT-66.3* INR(PT)-2.6*
Glucose-98 UreaN-57* Creat-3.2*# Na-133 K-4.1 Cl-107 HCO3-16*
AnGap-14
ALT-30 AST-59* AlkPhos-173* TotBili-18.6*
Albumin-3.2* Calcium-8.5 Phos-2.8 Mg-2.3
At Discharge [**2175-3-3**]
WBC-13.1* RBC-3.70* Hgb-11.5* Hct-33.8* MCV-91 MCH-31.0
MCHC-33.9 RDW-18.9* Plt Ct-181
Glucose-94 UreaN-87* Creat-2.5* Na-136 K-4.6 Cl-105 HCO3-23
AnGap-13
ALT-39 AST-23 AlkPhos-227* TotBili-4.1*
Albumin-2.5* Calcium-8.0* Phos-4.4 Mg-1.8
tacroFK-11.6
Brief Hospital Course:
On [**2175-2-24**], he underwent orthotopic liver [**Date Range **] for
etoh/hemocromatosis esld. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two 19
[**Doctor Last Name 406**] drains were placed in the recipient, one behin the right
lobe of liver, second behind the porta hepatis. Please refer to
operative note for complete details. Induction immunosuppression
was given (solumedrol and cellcept). Postop, he was sent to the
SICU where he was given blood products to maintain hemodynamic
stability. He was extubated without incident. LFTS trended down.
Prograf was started on postop day 1. He continued on IV vanco
that was started on previous admission for Coagulase Negative
Staphylococcus Bacteremia (started [**2-13**] x 2 weeks). This was
continued until [**2-26**] then stopped.
He was transferred to the med-[**Doctor First Name **] unit on [**2-26**] where diet was
advanced and tolerated. Lasix was given for generalized edema.
He diuresed nicely. The JP drains were non-bilious. The lateral
JP was removed on pod 5 and the medical drain was removed prior
to discharge.
PT evaluated and felt that he would likely need PT at home. He
was ambulating with a walker.
During the night of [**3-1**], he complained of some RUQ/chest
burning. EKG showed a RBBB otherwise no acute changes. CK and
troponin were checked x 3 and were negative. CXR revealed a new
rounded contour of the heart on lateral view. The cardiac
silhouette was not enlarged. Persistent small bilateral
effusions. There was no pneumonia.
He continued to progress nicely post-op. He is ambulating with a
walker and will have PT at home. He is tolerating diet, although
appetite is reported as fair, eating about [**12-23**] of meals
currently. He is being sent home on lasix to continue diuresis,
to be re-evaluated in clinic. Blood sugars to be followed at
home, glucometer sent with patient, evaluate in clinic.
Medications on Admission:
cholestryramine-aspartame 4"', clotrimazole prn, lasix 40,
levofloxacin 250, megestrol 40mg/ml 20mL', nadolol 20,
omeprazole 20", spironolactone 100mg qday (stopped [**2-7**]),
carafate 1"",
ergocalciferol 1000U, ferrous gluconate 325
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 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): Take as needed to avoid constipation.
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Follow [**Month/Year (2) **] clinic taper schedule.
7. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. ValGANCIclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a
day.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
cryptogenic cirrhosis now s/p Orthotopic liver [**Company **]
Discharge Condition:
good
Discharge Instructions:
Please call the [**Company 1326**] office [**Telephone/Fax (1) 673**] if fever >101,
chills, nausea, vomiting, inability to take any of your
medication, increased abdominal pain/distension, jaundice,
incision redness/bleeding/drainage or any concerns
Labs every Monday and Thursday at [**Hospital6 1109**]. Labs
to be faxed to [**Telephone/Fax (1) 697**]
[**Month (only) 116**] shower
No heavy lifting
No driving
Check finger stick blood sugars four times daily and record.
Call office if more than 2 sugars greater than 200 in a 24 hour
period.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-3-9**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-3-16**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-3-23**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2175-3-3**]
|
[
"790.7",
"401.1",
"V15.82",
"571.5",
"575.8",
"789.59",
"443.9",
"511.9",
"456.21",
"287.5",
"275.0",
"285.9",
"572.8",
"790.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.4",
"50.59",
"51.03",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
5819, 5868
|
2531, 4463
|
312, 358
|
5974, 5981
|
1921, 1921
|
6575, 7154
|
1595, 1797
|
4749, 5796
|
5889, 5953
|
4489, 4726
|
6005, 6552
|
1812, 1902
|
227, 274
|
386, 765
|
1935, 2508
|
787, 1337
|
1353, 1579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,385
| 174,825
|
24978
|
Discharge summary
|
report
|
Admission Date: [**2192-7-12**] Discharge Date: [**2192-7-23**]
Date of Birth: [**2122-4-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
CABG x2
History of Present Illness:
Mr. [**Known lastname 916**] is a 70-year-old male who was transferred from an
outside institution urgently with an intra-aortic balloon pump
in place after he was found to have
a 90% left main stenosis involving the origin of the left
anterior descending. His ejection fraction was preserved. He is
presenting for urgent coronary surgery.
Past Medical History:
Diabetes mellitus (diet controlled)
Hyperlipidemia
Gout
COPD/asthma
Social History:
Patient has a 90 pack-year history of smoking, quit 8 years ago,
rare ETOH, denies drugs
Family History:
Mother and father had both CAD and DM
Physical Exam:
Afebrile, HR 60's, BP 138/78, RR 20, SPO2 99%2L
NAD, awake and alert
PERRLA, no carotid bruits
RRR, +2/6 SEM at LUSB
CTA b/l
Abd soft, NT/ND, NABS
Ext warm, no varicosities
Pertinent Results:
[**2192-7-12**] 11:19AM BLOOD WBC-8.2 RBC-4.91 Hgb-15.2 Hct-43.5 MCV-89
MCH-31.0 MCHC-34.9 RDW-13.9 Plt Ct-385
[**2192-7-12**] 11:19AM BLOOD Plt Ct-385
[**2192-7-12**] 11:19AM BLOOD PT-14.2* PTT-94.7* INR(PT)-1.3
[**2192-7-12**] 11:19AM BLOOD Glucose-126* UreaN-22* Creat-0.8 Na-137
K-4.4 Cl-100 HCO3-27 AnGap-14
[**2192-7-12**] 03:42PM BLOOD ALT-22 AST-23 LD(LDH)-165 AlkPhos-59
Amylase-90 TotBili-0.4
[**2192-7-12**] 03:42PM BLOOD Lipase-34
[**2192-7-12**] 11:19AM BLOOD Calcium-10.1 Phos-2.2* Mg-2.1
Cholest-219*
[**2192-7-12**] 11:19AM BLOOD Triglyc-67 HDL-66 CHOL/HD-3.3
LDLcalc-140*
Brief Hospital Course:
The patient was admitted to the hospital on [**2192-7-12**] and was
urgently taken to the operating room the following day, where he
underwent a CABG x2. Please see operative note for full details.
The patient tolerated this procedure well. Following surgery, he
was transferred to the CSRU for recovery. That night, the
patient acutely desaturated. A chest xray showed a right tension
penumothorax, and a chest tube was emergently placed. The IABP
was removed on post-op day #1. That day, the patient's LFT's
were found to be markedly elevated, and a hepatico-biliary
surgery consult was called. Work-up included a right upper
quadrant ultrasound, which revealed a few gallstones but did not
show evidence of cholecystitis, biliary tree dilation, or
enlarged common bile duct. The patient's transaminitis
eventually improved, and it was felt that, in the end, this was
most likely due to hemolysis secondary to IABP. On post-op day
#3, the patient was transferred to the floor. On post-op day #4,
routine chest xray demonstrated a persistent pneumothorax that
was refractory to chest tube suctioning. A thoracic surgery
consult was called, and a new chest tube was inserted. On
post-op day #5, repeat chest xray demonstrated an interval
increase in the pneumothorax, and the chest tube was replaced by
thoracic surgery. On post-op day #7, the decision was made to
undergo doxycycline pleurodiesis. On post-op day #10, chest xray
showed near resolution of the patient's pneumothorax. The chest
tube was removed, and the patient was discharged home in stable
condition.
Medications on Admission:
ASA 325mg PO Qdaily
Lopressor 25mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
5. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q4H (every 4 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
Please return tot he hospital or call Dr. [**Last Name (STitle) **] office of you
experience chills or fever greater than 101 degrees F. Please
call if you notice redness, swelling, or tenderness of your
chest wound, or if it begins to drain pus.
No heavy lifting or driving until follow up with Dr. [**Last Name (STitle) **].
You may shower. Wash incision with mild soap and waten, then pat
dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 62755**], MD Follow-up appointment should be in 1 week
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
|
[
"574.20",
"996.74",
"401.9",
"414.01",
"274.9",
"V17.3",
"790.4",
"272.4",
"782.1",
"V18.0",
"493.20",
"V15.82",
"530.81",
"512.1",
"250.00",
"411.1",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"34.04",
"36.11",
"36.15",
"39.61",
"88.72",
"97.44",
"99.04",
"39.64",
"38.91",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
4665, 4720
|
1797, 3367
|
345, 355
|
4788, 4797
|
1184, 1774
|
5242, 5546
|
937, 976
|
3459, 4642
|
4741, 4767
|
3393, 3436
|
4821, 5219
|
991, 1165
|
282, 307
|
383, 724
|
746, 815
|
831, 921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,071
| 125,295
|
7432
|
Discharge summary
|
report
|
Admission Date: [**2138-8-12**] Discharge Date: [**2138-8-18**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
male transferred from [**Hospital 1474**] Hospital status post cardiac
catheterization on the morning of admission for possible left
circumflex intervention. His cardiac history is as follows:
In [**2126**] he had a coronary artery bypass graft with an SVG to
PDA and SVG to diagonal graft. From [**2126**] to [**2135**] the patient
states that he has had three other cardiac catheterizations
but denies the knowledge of having any intervention. His
last catheterization was in [**2135**]. The patient complains of
several months worth of substernal chest pain increasing in
severity and frequency over the past few weeks. He underwent
an exercise treadmill test last week, exercising 6 minutes
with a blunted heart rate response secondary to beta
blockade. The test was stopped due to dyspnea on exertion
and EKG revealed non diagnostic ST changes, however,
Cardiolite demonstrated a probable reversible defect
involving the anteroseptal wall, apex and partial inferior
wall. The patient underwent elective cardiac catheterization
at [**Hospital 1474**] Hospital on the morning of admission and was
found to have an ejection fraction of 50%, an LM of 20%, a
left circumflex 80-90% and LAD of 10%, diagonal of 90%, RCA
of 100%, SVG to PDA of 50%, SVG to diagonal patent. He was
transferred to [**Hospital1 69**] with a
sheath in for a left circumflex intervention. His coronary
artery disease risk factors include hypertension,
hypercholesterolemia.
FAMILY HISTORY: Tobacco and diabetes mellitus.
PAST MEDICAL HISTORY: CABG in [**2126**], status post removal of
colon polyps while on Plavix and Aspirin, complicated by
lower GI bleed, requiring 6 units of blood transfused. The
patient has had subsequent polyp removals without
complication, diabetes mellitus, diet controlled after
significant weight loss, sleep apnea using bi-pap at home,
radiculopathy, obesity, migraine headaches. No history of
TIA, CVA or melena/GI bleed.
ALLERGIES: Penicillin.
MEDICATIONS: Aspirin 325 mg po q day, Plavix 75 mg po q day,
Lipitor 10 mg po q day, Plendil 2.5 mg po q d, Mavik 4 mg po
q day, Toprol XL 100 mg po q day, Prilosec 20 mg po bid,
Imdur 60 mg po bid, Xalatan eyedrops.
LABORATORY DATA: Hematocrit 44, white blood cell count 6.4,
platelet count 250,000, sodium 139, potassium 5, chloride 98,
CO2 28, BUN 12, creatinine .8, glucose 93, INR .8.
HOSPITAL COURSE: During his cardiac catheterization on the
day of admission, there was a complication involving the
PTCA/stent of OM causing jailing of his AV groove, left
circumflex with loss of dissection of his lower OM. Post
procedure the patient experienced persistent chest pain,
hypotension to the 60's/30's and was noted to have hematocrit
drop from 44 to 34.9. Also with increasing right groin pain.
The patient had CT of abdomen and pelvis showing mild to
moderate hematoma and no retroperitoneal bleed. Patient also
had several episodes of bradycardia requiring Atropine. He
was transferred to the CCU on [**8-13**] for further management of
his chest pain, hypotension and decreased hematocrit.
The patient ruled in for an MI by enzymes, likely secondary
to include OM/jailed AV groove, left circumflex with positive
CKs which peaked at 763/45 on [**8-13**]. The patient was
maintained on Aspirin, Lipitor and Plavix. Once he became
hemodynamically stable on [**8-13**] he was started on Metoprolol
and Captopril which were titrated upwards as blood pressure
tolerated. He continued to have mild to moderate pain
intermittently on [**8-13**] and [**8-14**] without EKG changes in
response to sublingual Nitroglycerin. The patient's episodes
of hypotension responded well to 4-6 liters of IV fluids on
[**8-12**] to [**8-13**], as well as two units of packed red blood cells.
This was thought to be secondary to difference in blood
pressure cuff measurements between the floor and CCU as his
blood pressure was not as low when measured in the CCU after.
The patient had a bedside echo on [**8-12**] which was notable for
a limited view of left ventricular ejection fraction of 50%,
no obvious effusion but could not rule out possible effusion,
no tamponade was noted. An official TTE on [**8-13**] showed post
echo density consistent with pericardial effusion hematoma,
etc. The patient will most likely get an outpatient stress
test with EF evaluation as an outpatient.
The patient's initial hematocrit drop of 10 points may have
reflected blood loss from two catheterizations and dilution
after 4-6 liters of fluid resuscitation, however, he received
two units of packed red blood cells on the morning of [**8-13**]
and his hematocrit was checked [**Hospital1 **], remaining fairly stable.
He was guaiac negative throughout. On [**8-13**] he was noted to
have non palpable right foot pulses found on the evening of
[**8-13**]. The patient complained of increasing right groin pain
and was found to have a right groin bruit on exam.
Ultrasound was done on [**8-14**] revealing a 5 by 3 bilobed
pseudoaneurysm with a narrow neck associated with the right
common femoral artery. The patient's hematocrit remained
stable. The patient underwent an interventional radiology
procedure with thrombin injection on [**8-15**]. A repeat
ultrasound was done on the day of discharge which revealed a
successful thrombosing of the right groin pseudoaneurysm.
The patient did not require any additional intervention with
regard to the right groin pseudoaneurysm. The patient did
well throughout the remainder of his hospital stay, remained
hemodynamically stable with stable hematocrit. He was noted
to have several bradycardic episodes overnight with heart
rate as low as mid 40's, but these only occurred overnight
while the patient was sleeping. Since these episodes were
not symptomatic and did not occur during the day, the patient
was continued on his Atenolol. The patient was discharged
stable.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 8098**], his
primary cardiologist, as well as Dr. [**Last Name (STitle) 27262**], his primary care
provider, [**Name10 (NameIs) 176**] two weeks.
DISCHARGE MEDICATIONS: Enteric coated Aspirin 325 mg po q
day, Plavix 75 mg po q day, Lipitor 10 mg po q h.s., Prilosec
20 mg po bid, Lisinopril 10 mg po q day, Atenolol 25 mg po q
day.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post PTCA stent of the
upper pole of the OM, complicated by dissection and loss of
the lower pull of the OM and jailing of the AV groove left
circumflex.
2. Right femoral pseudoaneurysm status post successful
thrombin injection.
3. Diabetes mellitus.
4. Hypercholesterolemia.
5. Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2138-8-18**] 12:21
T: [**2138-8-20**] 09:52
JOB#: [**Job Number 27263**]
|
[
"410.71",
"285.1",
"414.01",
"411.1",
"458.2",
"E879.8",
"996.72",
"442.3",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.22",
"36.06",
"36.01",
"99.10",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
1654, 1686
|
6307, 6471
|
6492, 7105
|
2559, 6283
|
148, 1637
|
1709, 2541
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,312
| 158,950
|
43589
|
Discharge summary
|
report
|
Admission Date: [**2127-2-5**] Discharge Date: [**2127-2-13**]
Date of Birth: [**2054-7-11**] Sex: F
Service: SURGERY
Allergies:
Levofloxacin
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Descending loop colostomy.
History of Present Illness:
72 year old woman one month s/p right colectomy for
adenocarcinoma of the cecum, now with 3 days of abdominal pain
and obstipation. Minimal nausea/vomiting. No fever or chills.
Known non-obstructive rectal stricture.
Past Medical History:
1. asthma (PFTs in [**7-13**] show mild ostruction)
2. shingles
3. pedal edema
4. depression
5. fibromyalgia
6. DVT
7. cecal adenocarcinoma (T3N2MX)
Social History:
Patient lives with her son in [**Name (NI) **]. Her husband died last
year from ESRD. She has three sons two are in prison.
Family History:
noncontributory
Physical Exam:
Temp 97.7, HR 87, BP 130/77, RR 20, SaO2 97% on 2 liters NC.
Chest: CTA bilateral, RRR
Abdomen: incision clean and dry, staples intact. Stoma pink
with stool output. Obese, soft, non-tender, non-distended.
Extremities: 1+ pedal edema
Pertinent Results:
[**2127-2-12**] 05:49AM BLOOD WBC-6.0 RBC-3.01* Hgb-7.4* Hct-23.1*
MCV-77* MCH-24.7* MCHC-32.1 RDW-15.6* Plt Ct-399
[**2127-2-12**] 05:49AM BLOOD Glucose-86 UreaN-4* Creat-0.5 Na-135
K-4.1 Cl-106 HCO3-25 AnGap-8
Brief Hospital Course:
Patient taken to operating room ([**2-6**]) for large bowel
obstruction. Descending loop colostomy performed, pelase see
previoius op note for details.
Post-operatively, patient had an unremarkable course. Her
stoma began to have stool output, and her diet was advanced as
tolerated. She was begun on a course of diuresis for peripheral
edema, but had no clinical signs of CHF. Ultimately, she was
discharged on POD #6 tolerating a regular diet and in adequate
pain control.
Medications on Admission:
Advair, Aspirin, Prilosec, Synthroid 200mcg, Zoloft 50, Premarin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
10. Hydromorphone 2 mg/mL Syringe Sig: 0.5 - 1 mg Injection Q6H
(every 6 hours) as needed for breakthrough pain.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Large bowel obstruction.
Discharge Condition:
Stable. Tolerating regular diet. Stoma pink and with stool
output.
Discharge Instructions:
DC to rehab. Please return for worsening pain, discoloration of
stoma, fever, chills, or signs of wound infection. Continue
with abdominal binder. Continue with incentive spirometry,
ambulation. Continue with 5 days of Lasix for diuresis.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 5182**] in 2 weeks time. Please call for
appointment. [**Telephone/Fax (1) 5189**]
Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2127-2-25**] 10:00
Provider: [**Name10 (NameIs) 17512**],[**First Name7 (NamePattern1) 8826**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2127-2-25**] 10:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 9045**] Date/Time:[**2127-3-13**] 9:00
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**0-0-0**]
|
[
"244.9",
"567.9",
"197.6",
"V10.05",
"560.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.4",
"46.03"
] |
icd9pcs
|
[
[
[]
]
] |
3187, 3252
|
1417, 1899
|
287, 315
|
3320, 3390
|
1181, 1394
|
3681, 4383
|
893, 910
|
2014, 3164
|
3273, 3299
|
1925, 1991
|
3414, 3658
|
925, 1162
|
233, 249
|
343, 563
|
585, 735
|
751, 877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,794
| 112,826
|
35166
|
Discharge summary
|
report
|
Admission Date: [**2158-10-10**] Discharge Date: [**2158-10-16**]
Date of Birth: [**2133-4-11**] Sex: M
Service: MEDICINE
Allergies:
Dimetapp
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Leg Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
25yoM with no significant [**Hospital **] transferred from an OSH with
bilateral leg weakness and acute renal failure. On [**10-8**] he had
3-4 beers, following which he "did [**1-11**] lines" of cocaine and
acknowledges potential snorting of Oxycontin. On [**10-9**] he woke up
upable to stand with weakness and associated numbness on the
anterior of his legs R > L. He presented to OSH and was found to
be in ARF with elevated CKs. He was transferred to the [**Hospital1 18**] and
admitted to MICU.
.
In the MICU he had foley placed and was treated for
rhabdomylosis with IVF. His labs inititally showed CK of [**Numeric Identifier 32925**],
AST of 1900, ALT of 1400 and Cr of 5.5. Most recently CK of
9000, AST of 800, ALT 600, tbili of 0.7 and cr of 6.4, INR 1.1.
Past Medical History:
Remote hx of Knee Surgery
Social History:
Lives with mother, father and sister in [**Name (NI) 3494**]. Longshoreman
in [**Location 8391**]. [**3-14**] pack of cigarette daily for 2 years. EtOH
on [**3-14**] beers (up to 10), 3-4x/week since [**71**] and + coccaine 1x
/wk (snorting) for the last year. Denies IVDU or other drug use.
Family History:
Non-Contriburtory
Physical Exam:
VITALS: Afebrile. Satting well on room air. Good urine output.
GEN: NAD, A0x3
HEENT: PERRLA, EOMI, Anicteric Sclera, seborrheic dermatitis on
face
NECK: SUPPLE, NO LAD
RESP: CTAB b/l.
CARD: S1 S2 No Murmurs, Rubs or Gallops.
ABD: Soft Mild Tender on deep palpation LLQ, Non-Distended, BS+.
Negative Murphys
EXTR: No clubbing, cyanosis or edema. 2+ DP.
NEURO: A0x3.
Pertinent Results:
Admission Labs:
[**2158-10-10**] 11:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-21
GLUCOSE-83
[**2158-10-10**] 11:45PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-3* POLYS-0
LYMPHS-60 MONOS-40
[**2158-10-10**] 10:14PM URINE HOURS-RANDOM
[**2158-10-10**] 10:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2158-10-10**] 10:14PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2158-10-10**] 10:14PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2158-10-10**] 10:14PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2158-10-10**] 10:14PM URINE GRANULAR-0-2
[**2158-10-10**] 10:14PM URINE AMORPH-FEW
[**2158-10-10**] 05:47PM COMMENTS-GREEN TOP
[**2158-10-10**] 05:47PM LACTATE-1.5
[**2158-10-10**] 05:35PM GLUCOSE-135* UREA N-57* CREAT-5.5* SODIUM-133
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-23 ANION GAP-21*
[**2158-10-10**] 05:35PM estGFR-Using this
[**2158-10-10**] 05:35PM ALT(SGPT)-1492* AST(SGOT)-[**2086**]* LD(LDH)-1843*
CK(CPK)-[**Numeric Identifier **]* ALK PHOS-82 AMYLASE-47 TOT BILI-0.8
[**2158-10-10**] 05:35PM LIPASE-31
[**2158-10-10**] 05:35PM CK-MB-168* MB INDX-0.8 cTropnT-0.15*
[**2158-10-10**] 05:35PM ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-2.1*
MAGNESIUM-1.8
[**2158-10-10**] 05:35PM CRP-256.5*
[**2158-10-10**] 05:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-10-10**] 05:35PM WBC-10.7 RBC-5.00 HGB-16.2 HCT-43.4 MCV-87
MCH-32.3* MCHC-37.2* RDW-13.2
[**2158-10-10**] 05:35PM NEUTS-92.5* LYMPHS-5.7* MONOS-1.5* EOS-0.2
BASOS-0.1
[**2158-10-10**] 05:35PM PLT COUNT-132*
[**2158-10-10**] 05:35PM PT-13.0 PTT-26.1 INR(PT)-1.1
[**2158-10-10**] 05:35PM SED RATE-21*
Hospital and Discharge pertinent labs:
CBC:
[**2158-10-16**] 05:25AM BLOOD WBC-11.2* RBC-4.37* Hgb-13.9* Hct-37.6*
MCV-86 MCH-31.8 MCHC-37.0* RDW-13.4 Plt Ct-232
Coags:
[**2158-10-12**] 03:00AM BLOOD PT-12.6 PTT-29.8 INR(PT)-1.1
ESR:
[**2158-10-12**] 03:00AM BLOOD ESR-30*
Chemistry:
[**2158-10-16**] 05:25AM BLOOD Glucose-86 UreaN-95* Creat-10.2* Na-137
K-4.0 Cl-100 HCO3-23 AnGap-18
[**2158-10-16**] 05:25AM BLOOD Calcium-8.9 Phos-7.5* Mg-2.5
LFTs:
[**2158-10-16**] 05:25AM BLOOD ALT-107* AST-22 LD(LDH)-346* AlkPhos-52
TotBili-0.6
CK:
[**2158-10-16**] CK(CPK)-154
[**2158-10-15**] 06:00AM BLOOD CK(CPK)-275*
[**2158-10-11**] 11:36AM BLOOD CK(CPK)-7015*
[**2158-10-10**] 05:35PM BLOOD CK(CPK)-[**Numeric Identifier **]*
Cardiac enzymes:
[**2158-10-13**] 04:25AM BLOOD CK-MB-6 cTropnT-0.42*
[**2158-10-12**] 02:57PM BLOOD CK-MB-9 cTropnT-0.35*
Lipids:
[**2158-10-11**] 11:36AM BLOOD Triglyc-277* HDL-22 CHOL/HD-5.3
LDLcalc-40
Hepatitis serologies:
[**2158-10-11**] 11:36AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE, BLOOD HCV
Ab-NEGATIVE
CRP:
[**2158-10-12**] 03:00AM BLOOD CRP-175.2*
HIV AB:
[**2158-10-12**] 02:57PM BLOOD HIV Ab-NEGATIVE
Blood tox screen:
[**2158-10-10**] 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Lactate:
[**2158-10-10**] 05:47PM BLOOD Lactate-1.5
MRI: Spine
IMPRESSION:
1. No evidence for cord compression or spinal canal narrowing.
2. Mild fluid accumulation in the right retroperitoneal space,
possibly
related to history of rhabdomyolysis.
3. Bilateral lobe opacities concerning for pneumonia.
2. No evidence for aortic dissection on this study, however,
this study is
inadequate to rule out dissection given significant flow related
and pulsation artifacts. Given the patient's acute renal
failure, would recommend non- contrast time-of-flight MRA to
further evaluate vascular structures.
Echo:
The left atrium is mildly dilated. The left ventricular cavity
is mildly dilated. Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. An aortic dissection cannot be
excluded. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mildly dilated left ventricular cavity (probably
normal when indexed to patient's body size). Normal global and
regional biventricular systolic function. No diastolic
dysfunction, pulmonary hypertension or significant valvular
disease seen. No evidence of aortic dissection however, the
sensitivity of trans-thoracic echo in detection of aortic
dissection is low.
MRA AB:
IMPRESSION:
1. No evidence of aortic dissection.
2. Widely patent appearance of both renal arteries.
3. Multifocal consolidation throughout both lungs but
predominantly in the
lower lobes, with small right-sided pleural effusion
CXR:
REASON FOR EXAMINATION: Followup of a patient with
rhabdomyolysis and acute renal failure.
Portable AP chest radiograph was compared to prior study
obtained on [**2158-10-10**].
The lung volumes are lower compared to the prior study with new
bibasal linear opacities that might represent atelectasis or
aspiration. The more
pronounced opacity is on the right and given it's progression
since [**10-10**], [**2158**], might represent infection. There is no evidence of
failure. There is no pneumothorax. The cardiomediastinal
silhouette is stable.
Brief Hospital Course:
25M with recent cocaine use now with lower extremity weakess
with rhabdomyolysis, ARF, Shock Liver, + Troponins
# Rhabdomylosis: CK >20K on admission this AM, 10K overnight. Pt
received 5L of fluid prior to coming to the floor. U/A with 0-2
RBCs but large blood indicative of myoglobin. Source is
potentially in legs given his focal weakness. However no focal
finds indicative of necrosis on exam. Lactate WNL. Pt seen by
Nephrology that recommended decreasing from 100ccc/hr and then
subsequently d/c'd. CKs eventually trended down without any
intervention. Patient was discharged with instructions to
follow up in renal clinic and with PCP.
.
# ARF: Pts Cr up to 5.8 from 5.0 at OSH on presentation from
presumed normal levels since no baseline levels availbale.
Initial etiology potentially mulit-factorial including:
glomerular damage secondary to myoglobinuria, pre-renal
secondary to cocaine vasoconstriction, ATN secondary to
hypotensive and/or ischemia from cocaine as evident by 0-2
granular casts. Pt was anuric on Sunday/Monday, patient had
20cc/hr during his hospital ICU course, and was given Lasix 20mg
IV x 1 without change in UOP. Creatinine increased to 11.2 and
started to trend down before discharge. He was making good
urine and was not dialysed. He will follow up in the renal
clinic.
# Transaminitis: AST/ALT in >1000 on admission. Etiologies
include shock liver in setting of cocaine use, less likley viral
hepatitis. During his ICU cours the patients transaminitis
improved, TB and INR remained stable. His hepatitis serologies
were negative. LFTs improved and were trending down on
discharge.
.
# + Troponins: Trop 0.15 on admission without CP. Pt without
known cardiac disease. Etiology potentially ischemia secondary
to cocaine with troponins remaining elevated in setting of ARF.
No troponins available found from OSH. The pt's transaminases
remained elevated in setting of ARF. TTE was performed and ECHO
found to have >60%. Possible that patient had small infarct
with global preservation of heart function.
.
# Metabolic Acidosis: Pt presented with Gap Metabolic Acidosis
on presentation to E.D. with gap of 16 which resolved to 11 upon
arrival to the ICU. Since lactate not drawn prior to closure
unclear the etiology. Lactate WNL. Repeat ABG now with very mild
respiratory alkalosis with pt slightly tachypnic. The pts GAP
improved
.
# ?PNA: Pt afebrile, without leukocytosis, or increased sputum.
CXR and MR [**First Name (Titles) **] [**Last Name (Titles) **] demonstrated potential evolving PNA. Pt
receive Abx on arrival. Abx were held in the setting of low
clinical suspicion for PNA. The pt was given insentive
Spirometry and remained afebrile. Given his lack of symptoms
clinically he was not treated for pneumonia.
.
# Neurologic Deficits: Patient complained of R Leg weakness and
decreased sensation anteriorly. Seen by neurology that stated
his deficits were possibly from lumbar plexopathy or upper
cervical involvement and unlikely a central involvement. Pt was
given acyclovir for ?HSV which was later held by the MICU team.
MR of the [**Last Name (Titles) **] revealed a R Psoas fluid collection. His
strength in his legs increased although was not back to his
baseline upon discharge.
# Medication changes:
Patient started on Docusate and Senna as needed for constipation
Started on Metoprolol 50mg [**Hospital1 **]. After discharge he was called
and sent a letter instructing him not to take metoprolol.
Amlodipine 5mg daily
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed for cough.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2* --> Instructed to not take after
discharge.
6. Outpatient Lab Work
Check Chem-10 including creatinine. Please fax results to [**Hospital 191**]
clinic attn Dr. [**Last Name (STitle) **] fax #[**Telephone/Fax (1) 6309**] and Dr. [**Last Name (STitle) 4920**] Fax
#[**Telephone/Fax (1) 26643**].
Discharge Disposition:
Home
Discharge Diagnosis:
Rhabdomyolysis
Acute Renal Failure
Cocaine Abuse
Alcohol Abuse
Discharge Condition:
All vital signs stable, kidney function improving.
Discharge Instructions:
You were admitted with acute muscle breakdown (likely caused by
cocaine use) that caused damage to your kidneys. Eventually this
your kidney began to heal from this damage without dialysis. You
should not take cocaine again. You should also avoid medications
such as ibuprofen, Advil, or Naproxen until your kidney function
returns to normal. You will need to follow up with a new primary
care physician and [**Name Initial (PRE) **] kidney doctor. You should also decrease
your alcohol intake as you are at risk for becoming and
alcoholic. You discussed options for treatment with the social
worker.
New Medications:
1) Metoprolol 50mg one tab twice a day
2) Amlidpine 5mg one tab daily
Please take all your medications as prescribed and attend all
your follow up appointments.
Please call your doctor or return to the emergency room if you
notice a sharp decrease in the amount of urine you make,
experience chest pain, shortness of breath or any other symptom
that concerns you.
Followup Instructions:
Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2158-11-1**] 1:00
|
[
"584.5",
"305.60",
"305.00",
"728.88",
"570",
"276.2",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11941, 11947
|
7498, 10748
|
283, 290
|
12054, 12107
|
1884, 1884
|
13139, 13358
|
1463, 1482
|
11044, 11918
|
11968, 12033
|
11015, 11021
|
12131, 13116
|
1497, 1865
|
4396, 7475
|
10768, 10989
|
231, 245
|
318, 1089
|
1900, 3673
|
3690, 4379
|
1111, 1138
|
1154, 1447
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,580
| 192,528
|
25166
|
Discharge summary
|
report
|
Admission Date: [**2111-11-15**] Discharge Date: [**2111-12-10**]
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Repair of ruptured AAA.
Closure of open abdomen, with Vicryl mesh overlay.
Bronchoscopy with lavage.
History of Present Illness:
Patient had acute onset of abdominal pain, evaluated at
[**Hospital2 **] [**Hospital3 **], found to have ruptured AAA on CT scan.
Patient was transferred emergently to [**Hospital1 18**] for operative
repair.
Past Medical History:
1. CAD
2. chronic atrial fibrillation
3. L breast CA s/p mastectomy
4. HTN
5. hypothyroid
6. osteoporosis
Physical Exam:
Temp 97.3, HR 95 atrial fibrillation, BP 145/83, RR 30, SaO2 98%
on 3L
Gen: NAD
Chest: decreased breath sounds at bases
CV: irregularly irregular
Abdomen: S, NT, ND. Incision clean and dry with minimal
erythema/necrosis centrally, no purulence.
Ext: 1+ pedal edema, 1+ DP pulses bilaterally.
Pertinent Results:
[**2111-12-10**] 02:45AM BLOOD WBC-8.1 RBC-3.49* Hgb-11.0* Hct-32.5*
MCV-93 MCH-31.4 MCHC-33.7 RDW-15.5 Plt Ct-369
[**2111-12-10**] 02:45AM BLOOD PT-13.3 PTT-29.3 INR(PT)-1.2
[**2111-12-10**] 02:45AM BLOOD Glucose-106* UreaN-13 Creat-0.6 Na-141
K-3.5 Cl-102 HCO3-29 AnGap-14
[**2111-12-5**] 11:59 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2111-12-6**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2111-12-6**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2111-12-2**] 11:43 pm SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2111-12-5**]**
GRAM STAIN (Final [**2111-12-3**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2111-12-5**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. MODERATE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
[**2111-12-2**] 11:52 pm BLOOD CULTURE
**FINAL REPORT [**2111-12-9**]**
AEROBIC BOTTLE (Final [**2111-12-9**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2111-12-9**]): NO GROWTH.
[**2111-12-2**] 11:53 pm URINE
**FINAL REPORT [**2111-12-5**]**
URINE CULTURE (Final [**2111-12-5**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Patient was transferred for emergent repair of ruptured AAA.
For details of this, please see the previously dictated
operative note.
Post-operatively, the patient was brought to the ICU for
monitoring. She remained intubated for 10 days secondary to her
open abdomen and volume overload following resuscitation.
Throughout this period, she was maintained on vancomycin,
Levaquin and Flagyl for antibiotic prophylaxis, fearing a graft
infection. On POD #10, she was brought back to the operating
room for closure of her abdomen. For details of this, please
see the previously dictated operative note.
The patient then had a slow wean from mechanical ventilation
and was intermittently diuresed with Lasix prn and Lasix gtt.
She extubated on POD #20 without event. She did spike fevers
and had a mildly elevated WBC (12 - 13) which prompted an
infectious work-up which revealed an E. coli pneumonia and
urinary tract infection. She was empirically begun on Zosyn
while culture data was pending, and continued on Zosyn based on
sensitivities.
Ultimately, the patient was discharged to rehab on PODs #25 &
15 tolerating a regular diet, in adequate pain control, afebrile
and with a normal white count. She has been working with
physical therapy to regain her strength and motor function.
Neurologic: no issues
Cardiac: Lopressor for rate control and HTN; restart quinapril
Pulmonary: continue with pulmonary toilet; incentive spirometry;
out of bed to chair and ambulation with assistance
GI: passed a swallow evaluation for aspiration risk; tolerating
a cardiac diet and Boost supplementation
GU: Foley in place for continued diuresis; Lasix 20 mg IV BID
x7 more days
Hematologic: heparin SQ for DVT prophylaxis; begin Coumadin 5 mg
QD for chronic atrial fibrillation
ID: Zosyn for 5 more days to complete 14 day course (E. coli
pneumonia and urinary tract infection)
Endo: insulin sliding scale while on tube feeds, can be weaned
off
Medications on Admission:
1. Lopressor 100 mg [**Hospital1 **]
2. quinapril 20 mg QD
3. Zantac 150 mg [**Hospital1 **]
4. Tricor 145 mg [**Hospital1 **]
5. levothyroxine 150 mg QD
6. Fosamax
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 1 doses.
6. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day) for 7 days.
7. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 5 days.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
9. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
11. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
12. Quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm.
Respiratory failure.
Escherichia coli pneumonia and urinary tract infection.
Atrial fibrillation.
Discharge Condition:
Stable. Alert and oriented x3. 1+ dorsal pedal pulses
bilaterally. Wound with minimal necrosis and erythema
centrally, no purulence.
Discharge Instructions:
DC to rehab facility. Please continue work with physical
therapy, pulmonary toilet and wound care. Continue Lasix 20 mg
IV BID for one week. Continue Zosyn for 5 days to complete 14
day course for E. coli pneumonia and urinary tract infection.
Monitor INR daily and adjust Coumadin to keep INR > 2.0 for
atrial fibrillation.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks time. Call for
appointment ([**Telephone/Fax (1) 18181**].
Completed by:[**0-0-0**]
|
[
"482.82",
"441.3",
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"V10.3",
"427.31",
"518.81",
"041.4",
"997.3",
"244.9",
"733.00",
"414.01",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.44",
"54.12",
"54.72"
] |
icd9pcs
|
[
[
[]
]
] |
7331, 7403
|
3990, 5938
|
232, 334
|
7580, 7717
|
1035, 3967
|
8093, 8235
|
6159, 7308
|
7424, 7559
|
5964, 6136
|
7741, 8070
|
722, 1016
|
178, 194
|
362, 572
|
594, 707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,852
| 136,802
|
33954
|
Discharge summary
|
report
|
Admission Date: [**2114-10-17**] Discharge Date: [**2114-10-30**]
Date of Birth: [**2030-3-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2114-10-23**]: Aortic valve replacement with a size 19-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.
History of Present Illness:
84 year old female who was brought to the ED after syncope/fall,
and is admitted to medicine due to elevated troponin. At her
baseline, she feels well and is active, able to climb a few
flights of stairs without complaints. She was
brought to [**Hospital1 18**] Ed for further evaluation. During admission an
echocardiogram was done and she was found to have aortic
stenosis [**Location (un) 109**]=0.4 and is now being referred to cardiac surgery
for an aortic valve replacement.
Past Medical History:
-s/p fall a few years ago with small SAH
fall
Social History:
-Home: Married, lives with husband. Three grown kids.
-Occupation: Retired dressmaker.
-Tobacco: None
-EtOH: None
-Illicits: None
Family History:
No MI, stroke. Mother died of "lung problems," father died of
colon cancer.
Physical Exam:
Admission Exam:
VS - Temp 99.7 F, BP 113/64, HR 72, R 20, O2-sat 96% RA
GENERAL - well-appearing lady in NAD, comfortable, appropriate
HEENT - EOMI, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilaterally
HEART - PMI non-displaced, RRR, nl S1-S2 , grade 3 systolic
crescrndo-decrescendo murmur that radiates to carotids; no loss
of S2 and murmur is not late-peaking
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
--no pulsus parvus et tardus; left knee with 3cm area of
erythema at site of impact but knee has full ROM and is not very
tender
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred
Pertinent Results:
[**2114-10-30**] CXR: In comparison with the study of [**10-29**], there is
little change in the appearance of the small-to-moderate apical
pneumothorax on the right. Bilateral pleural effusions are more
prominent on the left. Continued evidence of chronic pulmonary
disease without definite acute pneumonia.
.
[**2114-10-23**] Echo: PRE-CPB: Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. The aortic valve
is functionally bicuspid with apparent fusion of the right and
left coronary cusps. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
Post CPB: 1. Prserved [**Hospital1 **]-ventricular systolci function. 2.
Bioprosthetic valve visualized in aortic position.Well seated
and stable with good leaflet excursion. There was intially [**12-10**] +
perivalvular AI immediately after separation from CPB which
improved to 1+ AI after protamine administration. There are two
perivalvular jets (low velocity and trace) and located on the
right and left coronary cusps. Peak gradient across the valve -
14 mm Hg. 3. No other change in an y other valve structure and
function.
.
[**2114-10-22**] Carotid U/S: Mild heterogeneous plaque is seen
bilaterally at the carotid bulb and the proximal internal
carotid arteries. The peak systolic velocity and right internal
carotid artery ranges from 77 to 102 cm/sec and in the left
internal carotid artery from 72 to 96 cm/sec. The peak systolic
velocity in the right common carotid artery 71 cm/sec and in the
left common carotid artery is 80 cm/sec. Bilateral external
carotid arteries are patent. There is antegrade flow in the
bilateral vertebral arteries. The ICA to CCA ratio on the right
is 1.4 and on the left was 1.2.
.
[**2114-10-19**] Cath: 1. No angiographically-apparent coronary artery
disease. 2. Severe aortic stenosis. 3. No pulmonary arterial
hypertension. 4. Slightly depressed cardiac output.
.
[**2114-10-17**] Head CT: There is no evidence of hemorrhage, edema, mass
effect, or territorial infarction. The ventricles and sulci are
mildly prominent
consistent with atrophy. There is a small hypodensity in the
left basal
ganglia which could be an old lacunar infarct or Virchow-[**Doctor First Name **]
vascular space. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The osseous structures
are intact. There is no fracture.
.
[**2114-10-17**] 01:00PM BLOOD WBC-6.8 RBC-4.04* Hgb-12.5 Hct-37.2
MCV-92 MCH-30.9 MCHC-33.6 RDW-12.4 Plt Ct-250
[**2114-10-29**] 05:37AM BLOOD WBC-6.8 RBC-3.54* Hgb-10.9* Hct-32.5*
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.0 Plt Ct-274#
[**2114-10-17**] 01:00PM BLOOD PT-12.3 PTT-27.8 INR(PT)-1.0
[**2114-10-23**] 06:44PM BLOOD PT-13.7* PTT-47.6* INR(PT)-1.2*
[**2114-10-17**] 01:00PM BLOOD Glucose-156* UreaN-15 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
[**2114-10-27**] 04:40AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-139
K-4.4 Cl-102 HCO3-31 AnGap-10
[**2114-10-29**] 05:37AM BLOOD UreaN-21* Creat-1.1 Na-138 K-4.4 Cl-99
[**2114-10-25**] 03:48AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2114-10-22**] 07:30AM BLOOD Triglyc-93 HDL-73 CHOL/HD-2.7 LDLcalc-108
[**2114-10-20**] 08:00AM BLOOD %HbA1c-5.5 eAG-111
Brief Hospital Course:
The patient was admitted to the hospital after syncope/fall, to
medicine service for elevated troponin. During admission she
underwent an echocardiogram and she was found to have aortic
stenosis with [**Location (un) 109**]=0.4cm2. In addition she underwent a cardiac
cath and complete surgical work-up. On [**10-23**] she was brought to
the operating room where the patient underwent Aortic valve
replacement with a size 19-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue
valve. Please see operative note for surgical details. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. On post-op
day 5 she had a brief burst of atrial fibrillation which was
treated with beta-blockers and Amiodarone. She converted to
sinus rhythm and remained in SR at discharge. By the time of
discharge on POD 7 the patient was ambulating with assistance,
the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital 1036**] rehab in
good condition with appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take two 200mg tablets twice daily for 5 days.
Then one 200mg tablet twice daily for 7 days. Then one 200mg
table once daily until stopped by cardiologist.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Aortic Stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema: Trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 [**First Name (STitle) **] on [**11-27**] at 2:00pm
Cardiologist/PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] on [**11-14**] at 1:20pm
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2114-10-30**]
|
[
"427.31",
"E878.1",
"780.2",
"512.1",
"V15.88",
"424.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"34.91",
"34.04",
"88.56",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8550, 8627
|
5701, 7368
|
319, 452
|
8686, 8855
|
2116, 3088
|
9778, 10268
|
1195, 1272
|
7423, 8527
|
8648, 8665
|
7394, 7400
|
8879, 9755
|
1287, 2097
|
272, 281
|
480, 963
|
4426, 5678
|
985, 1032
|
1048, 1179
|
3098, 4417
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,160
| 148,208
|
27960
|
Discharge summary
|
report
|
Admission Date: [**2111-1-18**] Discharge Date: [**2111-1-25**]
Date of Birth: [**2053-12-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Nitroglycerin Transdermal
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Persistant vomiting, dizziness
Major Surgical or Invasive Procedure:
[**2111-1-20**]:Left Parietal Craniotomy
History of Present Illness:
Pt is a 57 yo RHM with h/o HTN, hyperlipidemia, and renal
cell carcinoma with lung mets on treatment with Sutent, and s/p
left nephrectomy who is here with ~1 week of headache, nausea,
and vomiting. He was found to have a 2x1.8 cm mass in the left
parietal lobe with significant edema and 6 mm of rightward
shift.
There is no obvious uncal herniation. He had been having a
"swishing sound" in both ears for the last 6 weeks that was
being
followed as possible ear infection or inner ear dysfunction. He
was put on Zyrtec recently. It started with a bad cold. His
most recent torso CT [**12-30**] showed stable disease from scan in
[**Month (only) **].
on [**2109**]. He got his last Sutent on [**12-29**]. He has been on this
for ~11 months. He was started on Amoxicillin for the ear
swishing and went to the Cayman's for vacation. There, he had a
Headache Mon-Wed that woke him at night but wasn't otherwise
positional. Wed. he started vomiting, was admitted to a
hospital
there and hydrated. He improved and they came back here
yesterday. He felt well then, but got the HA back. They
came in and found the mass as above on head CT.
Past Medical History:
Renal Cell Carcinoma, Hypertension, Hypothyroidism,
Hyperlipidemia, s/p Left Nephrectomy [**4-14**], Hemorrhoids
Social History:
The patient was born in [**State 9512**]. He is a graduate of [**Location (un) 68081**]. He has worked for the Caterpillar Tractor Company for
the last 22 years. He lives in [**Location 1294**] with his wife. [**Name (NI) **]
enjoys golf. He has a daughter of 30 and
another child as well.
Family History:
Non-contributory
Physical Exam:
Subjective: reports right eye blurry with peripheral views. Pain
is being well controlled with oral medication
Objestive:
Vitals: 98.2, BP 141/77, HR 93, RR 16, O2 Sat 96%
General: No apparent distress
Neuro:
AOx3, eyes open spontaneously, follows all commands
appropriately
Motor: 5/5 strength bilaterally of both upper and lower
extremities.
Pertinent Results:
[**2111-1-23**] 05:00AM BLOOD WBC-13.2* RBC-3.71* Hgb-8.8* Hct-29.9*
MCV-81* MCH-23.7* MCHC-29.4* RDW-18.9* Plt Ct-306
[**2111-1-23**] 05:00AM BLOOD Glucose-98 UreaN-26* Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-29 AnGap-11
CT HEAD W/O CONTRAST [**2111-1-21**] 4:12 PM
FINDINGS: Since the previous study, the patient has undergone
resection of the previously noted left occipital lesion. Small
amount of blood products and air are seen in this region
secondary to recent surgery. There is still edema identified in
the left parieto-occipital lobe as before. There is no
significant midline shift seen. There is no hydrocephalus.
CHEST (PA & LAT) [**2111-1-18**] 7:31 PM
FINDINGS: The indistinct opacity of the medial left apex is
again noted and consistent with the known metastatic disease.
Otherwise, no definite further pulmonary nodule or mass is seen.
There is no superimposed consolidation or edema. There is mild
tortuosity of the thoracic aorta. The cardiac silhouette is
within normal limits for size. No effusion or pneumothorax is
evident. The visualized osseous structures are unremarkable.
ROUTINE MRI OF THE BRAIN WITHOUT & WITH GADOLINIUM [**2111-1-22**]
FINDINGS:
There are changes from a left parietal craniotomy for resection
of left parietal occipital mass with subependymal spread. There
is an_operative cavity which contains T1 birght blood which
limits evaluation for residual enhancing neoplasm. There is mild
linear enhancement along the anteroinferior aspect of the
operative cavity which could represent post-surgical sequela. No
convincing evidence for residual neoplasm is seen but would
recommend follow up imaging after resolution of T1 hyperintense
hemorrhage in the operative bed to assess for this better.
There is no evidence for acute ischemia.
There is approximately 5 mm of midline shift to the right which
has slightly improved compared to the prior study. There is
stable edema in the left operative bed and parietal lobe.
Intracranial flow voids are maintained.
IMPRESSION:
Presence of hemorrhage in the operative cavity limits evaluation
for residual neoplasm. Would recommend a follow up study in one
to two weeks to establish a true baseline for possible residual
neoplasm.
Brief Hospital Course:
[**2111-1-18**] Patient presented to the ER with 1 week history of
headache, nausea and vomiting. He was evaluated and admitted to
the surgical ICU for closer monitoring given his metastatic
cancer history pending surgical intervention. On [**1-18**] a CT HEAD
W/O CONTRAST was performed. Findings were as follows: "There is
a 21 x 18 mm hyperattenuating round soft tissue lesion within
the left parietal lobe posteriorly, with significant associated
vasogenic edema extending through the posterior aspect of the
parietal subcortical white matter. There is significant mass
effect with left cerebral sulcal effacement and effacement of
the occipital and frontal horns of the left lateral ventricle.
Additionally, there is subfalcine herniation and 6 mm of
rightward midline shift. No definite additional lesions are
identified, though non- contrast CT is limited in evaluating for
small lesions. No acute hemorrhage. There is mild effacement of
the left supra- sellar cistern and mild rightward shift of the
interpeduncular cistern, indicating very early uncal herniation.
The paranasal sinuses and mastoid air cells are clear. No
suspicious lytic or sclerotic lesions within the calvarium."
On [**2111-1-19**], he has a MRI performed with the following findings:
"Again seen is an inhomogeneously enhancing left occipital mass
with profound surrounding edema. This edema extends forward into
the internal capsule and enters the splenium of the corpus
callosum. It produces mass effect and left to right midline
shift. The enhancement extends to the ventricular surface and
along the surface of the occipital [**Doctor Last Name 534**] in a subependymal
fashion.
No other lesions are seen. The findings are compatible with
metastatic carcinoma with severe edema."
On [**2111-1-20**] a Left parietal craniotomy for tumor was performed
uneventfully. Post-operatively, patient was admitted to the
surgical intensive care for monitoring purposes. He was
transferred to the neurosurgical floor on post-operative day #2.
On [**2111-1-23**], he continued to progress in his recovery from
surgery. The patient had some "whooshing" noises in his ears and
was congested. Due to his previous h/o sinus hemorrhage an ENT
consult was obtained. There was no immediate concerns but the
team did recommend a hearing test and follow-up with Dr.
[**Last Name (STitle) **].
The patient was oriented x 3, no drift, PERRL, and full strength
throughout on [**2111-1-24**]. He was deemed ready for discharge.
The patient does require insulin at home because he is on a high
dose of steroids. VNA was able to see him on [**2111-1-25**] so he had
to stay one more night. This is the first time the patient has
ever needed insulin so it was not safe to discharge him without
VNA services on [**2111-1-24**]. He had some teaching with the nurse on
[**2111-1-24**] and he was ready felt safe to be discharged on [**2111-1-25**].
He had his morning glucose check and insulin dose prior to
dicharge and VNA will see [**Last Name (un) **] twice for his other doses today.
Medications on Admission:
Atenolol 50mg once daily
Compazine as needed for nausea
HCTZ 12.5mg daily
Lomotil 2.5mg as needed for diarrhea
Nexium 40mg daily
Norvasc 10mg daily
Sutent 50mg daily (4 weeks on, 3 weeks off)
Synthroid 100mcg daily
Zyrtec 5mg daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zyrtec 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
7. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for diarrhea.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Do Not Exceed 4,000mg of
Tylenol in a 24 hour period.
Disp:*40 Tablet(s)* Refills:*0*
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: [**Month (only) 116**] be used for breakthrough pain.
Disp:*40 Tablet(s)* Refills:*0*
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Do Not Exceed 4,000mg of
Tylenol in a 24 hour period. .
14. Sutent 50 mg Capsule Sig: One (1) Capsule PO once a day:
continue present dosing schedule (4 weeks on, 3 weeks off)until
your next appointment with Dr. [**Last Name (STitle) 3929**].
15. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*120 Tablet(s)* Refills:*1*
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please follow the schedule in the
discharge papers.
Disp:*2 vials* Refills:*2*
17. syringes Sig: One (1) four times a day.
Disp:*120 syringes* Refills:*2*
18. Blood-Glucose Meter Kit Sig: One (1) Miscellaneous four
times a day.
Disp:*1 glucometer* Refills:*0*
19. glucose strips Sig: One (1) three times a day: Please
check your blood glucose 3 times a day.
Disp:*3 bottles* Refills:*2*
20. Lancets Misc Sig: One (1) Miscellaneous three times a
day.
Disp:*100 lancets* Refills:*2*
21. Humalog Pen 100 unit/mL Insulin Pen Sig: One (1)
Subcutaneous three times a day: Please follow insulin sliding
scale in your discharge papers.
Disp:*QS QS* Refills:*2*
22. Pen needles Sig: One (1) three times a day: Short length.
Disp:*90 pen needles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Left Parietal Mass, pathology consistant with Renal Cell
Carcinoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up in 10 days for staple removal. This may be done at
your appointment with Dr. [**Last Name (STitle) 3929**]. Your appointment with Dr.
[**Last Name (STitle) 68082**] ([**Telephone/Fax (1) 9710**]is scheduled for [**2111-2-2**] at 10am
(following your MRI). His office is located on the [**Location (un) 442**] of
the [**Hospital1 18**] [**Hospital Ward Name 23**] Building (located on the [**Hospital Ward Name 516**]).
Please call [**Telephone/Fax (1) 1669**] to schedule and appointment with Dr.
[**Last Name (STitle) **] in [**3-15**] weeks, you will need a CT of your head. This is in
addition to the MRI scheduled below.
You presently have a MRI scheduled as below:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-2-2**] at
8:35am
You also presently have an appointment scheduled with
Provider: [**Known firstname **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2111-2-17**] at 2:00pm
Completed by:[**2111-1-25**]
|
[
"401.9",
"198.3",
"244.9",
"285.9",
"348.4",
"V10.52",
"348.5",
"366.9",
"272.4",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
10630, 10682
|
4651, 7697
|
321, 364
|
10793, 10817
|
2406, 4628
|
12188, 13209
|
2007, 2025
|
7979, 10607
|
10703, 10772
|
7723, 7956
|
10841, 12165
|
2040, 2387
|
251, 283
|
392, 1541
|
1563, 1678
|
1694, 1991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,778
| 131,449
|
9737
|
Discharge summary
|
report
|
Admission Date: [**2151-6-4**] Discharge Date: [**2151-6-10**]
Date of Birth: [**2077-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p AVR
History of Present Illness:
74 year old male with known aortic stenosis who had noticed a
steady progression of dyspnea on exertion. He underwent
exercise stress testing that revealed inferolateral and inferior
ischemia. A cathterization was performed that showed an aortic
valve area of 0.5 cm2, and a 90 percent stenosis in a very small
non-dominant RCA.
Past Medical History:
CAD s/p PTCA and stenting of obtuse marginal
Aortic stenosis
hypertension
obesity
s/p bilateral knee surgeries
benign prostatic hypertrophy
hyperlipidemia
Social History:
Retired. Lives with wife. Former [**Name2 (NI) 1818**] having quit 27 tears
ago, social alcohol consumption.
Family History:
Mother had an MI at age 53.
Physical Exam:
Pulse: 66 Resp: 20 O2 sat: 97% RA
B/P Right: 127/82 Left: 137/87
Height: 66" Weight: 195#
General:obese
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM [] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM radiates through
chest to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema:none
Varicosities: None [] mild spider veins
Neuro: Grossly intact, nonfocal exam, MAE [**3-23**] strengths
Pulses:
Femoral Right: 1+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit murmur radiates to both carotids
Pertinent Results:
[**2151-6-4**] 11:25AM BLOOD WBC-14.4*# RBC-3.36* Hgb-10.5* Hct-30.8*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.5 Plt Ct-184
[**2151-6-5**] 02:24AM BLOOD Glucose-140* UreaN-13 Creat-0.7 Na-135
K-4.6 Cl-106 HCO3-20* AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 32861**]
(Complete) Done [**2151-6-4**] at 11:05:09 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2077-2-3**]
Age (years): 74 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intra-op TEE for AVR
ICD-9 Codes: 786.05, 424.1, 745.5, 440.0
Test Information
Date/Time: [**2151-6-4**] at 11:05 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32862**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW000-0: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *102 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Severe mitral annular calcification. Mild to
moderate ([**11-20**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the left
atrial appendage. No thrombus is seen in the left atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. There is severe mitral
annular calcification. Mild to moderate ([**11-20**]+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions includingphenylephrineand is
being AV paced.
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 15 mmHg).A small paravalvular leak is seen near the native RCC
of the prosthetic valve.
2. Biventricular function is unchanged.
3 Aortic contorus appear intact post decannulation.
Dr. [**Last Name (STitle) **] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2151-6-4**] 14:37
Brief Hospital Course:
On [**2151-6-4**] Mr. [**Known lastname **] was brought to the operating room and
underwent an aortic valve replacement with a 23mm [**Company **]
ultra porcine valve. Vein was harvested for a coronary artery
bypass, but it was aborted secondary to target vessels of
insufficient caliber. Please see the operative note for details.
He tolerated this procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. He was extubated and weaned from his pressors. He was
transferred to the surgical step down floor. His chest tubes
and epicardial wires were removed. He was started on amiodarone
for atrial fibrillation and he converted into a sinus rhythm.
On post operative day three he was noted to have intermittent
post-operative delerium and therefore his narcotics were
discontinued. He was gently diuresed and his beta-blockade was
titrated up as tolerated. By post-operative day 6 his mental
status cleared and he was cleared for discharge to home by Dr.
[**Last Name (STitle) **].
Medications on Admission:
plavix 75 mg daily
HCTZ 25 mg daily
lisinopril 30 mg daily
simvastatin 80 mg daily
tylenol 1300 mg [**Hospital1 **]
ASA 81 mg daily
calcium daily
glucosamine1500 mg [**Hospital1 **]
MVI daily
selenium 100 mcg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Disp:*qs qs* Refills:*0*
8. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID () for 3 days.
Disp:*6 Tablet Sustained Release(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 400mg a day for 7 days then decrease to 200 mg a day
until follow up with cardiologist .
Disp:*40 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p AVR
Hypertension
Dyslipidemia
BPH
CAD
Obesity
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**Last Name (STitle) 7389**] in 1 week please call for appointment
Dr. [**Last Name (STitle) 5456**] in [**12-22**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2151-6-10**]
|
[
"293.0",
"V45.82",
"401.9",
"272.4",
"424.1",
"V43.64",
"427.31",
"997.1",
"278.00",
"600.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9792, 9850
|
6842, 7880
|
339, 348
|
9944, 9951
|
1901, 6819
|
10463, 10858
|
1029, 1058
|
8146, 9769
|
9871, 9923
|
7906, 8123
|
9975, 10440
|
1073, 1882
|
280, 301
|
376, 708
|
730, 887
|
903, 1013
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,339
| 127,888
|
50588
|
Discharge summary
|
report
|
Admission Date: [**2140-1-13**] Discharge Date: [**2140-1-27**]
Date of Birth: [**2071-3-16**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Percocet / Lisinopril
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
respiratory failure s/p intubation
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
flexible bronchoscopy with moderate sedation
percutaneous tracheostomy placement
PEG tube placement [**2140-1-19**]
History of Present Illness:
68F with COPD, CAD, systolic CHF, and tracheal stensosis s/p
complicated respiratory failure history, transferred from OSH
with recurrent respiratory failure for consideration of
tracheostomy. She presented with acute respiratory distress to
OSH one day PTA and was subsequently intubated for
hypercarbic/hypoxic respiratory failure.
.
She was recently admitted to [**Hospital 105299**] hospital on [**2139-11-20**]
after acute respiratory distress and short PEA arrest at home.
Led to intubation. Per notes treated for CHF and pneumonia.
She failed at least one extubation trial, and had subsequent
transfer, while intubated, to [**Hospital1 18**] from [**Date range (1) 78750**] on the
thoracics/IP service. She was extubated on the day of transfer.
Bronch noted to have stable tracheal stenosis. Did well on
nightly bipap and pulmonary toilet with O2 sats 90-92% on 4L
during day. Discharged to [**Hospital **] rehab on [**12-15**]. Following
this rehab admission she was sent to a different OSH on
[**2139-12-21**], for acute CHF and at least one PEA arrest. Had AICD
placement and reports ?cardiac cath. Intubated at least twice
during that admission. Respiratory distress frequently
accompanied by elevated blood pressures. Troponin during that
admission elevated to 0.4 with one episode of resp distress.
Also noted that anxiety seems to be a trigger, and was given
scheduled 1 mg Ativan prior to Bipap removal. Following this
admission she went to a rehab facility again. Discharged from
rehab to home on [**1-11**]. That evening (yesterday) she became
cyanotic at home reportedly after having a milkshake and Ativan.
EMS brought patient to [**Hospital3 13313**] on bipap and she
was eventually intubated in the ED, uncomplicated. On arrival
to ED, tachypneic to 30s with bipap at 20/4, sats in low 90s on
FiO2 1. HR 80, BP 170/62 initially. Prior to intubation given
flumazenil and narcan. Lasix and bumex as well as IV ativan and
versed at OSH. ABG at some point 7.15/76/84. CXR per notes
with cardiomegaly, volume excess, new pacer. Patient reports
also having an echo today but no report available.
.
On the floor, patient denies current respiratory difficulties.
C/o pain in the throat and at her pacer site. Denies any chest
pain, N/V, diaphoresis prior to onset of her recurrent dyspnea.
Does endorse anxiety prior to symptoms onset.
Past Medical History:
-Coronary artery disease s/p CABG in [**2118**] and "recent" PCI
-CHF, last TTE [**2138-9-12**] EF 60% with mild LVH and some focal
hypokinesis at base.
-OSA
-Dyslipidemia
-HTN
-Left total hip replacement-[**1-28**], elective. Complicated
postoperative course with post-operative atrial fibrillation
wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE
UT, and prolonged intubation leading to trach/PEG. Discharged to
chronic wean facility but unable to decannulate. Bronchoscopy
revealed tracheomalacia of subglottic region.
-Supraglottic edema from GERD
-Bipolar disorder
-Depression
-chronic atrial fibrillation, developed postop from THR, not
anticoagulated
-Chronic constipation
-HIT during Fragmin therapy
Social History:
Married. Very supportive husband. When she is not
hospitalized/in rehab, she lives with him. No ETOH or current
smoking. Has 35 pack year smoking history, quit 13 years ago.
Family History:
Depression
Physical Exam:
On admission:
General: Alert, intubated but comfortable appearing, no acute
distress. follows all commands and communicates by writing as
well.
HEENT: Sclera anicteric, MMM though c/o thirst, oropharynx
clear, ETT and OGT in place.
Neck: supple, JVD elevated though difficult to appreciate how
high with body habitus and tubes, no LAD
Lungs: Bilaterally rhonchorous, no appreciated rales.
CV: Regular rate and rhythm, normal S1 + S2, [**2-27**] SM at LUSB.
Pacer pocket site in L chest quite ecchymotic with swelling,
ecchymoses tracing down toward axilla. Moderately tender to
palpation. No erythema. No appreciated fluctuance.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
appreciable edema.
Neuro: Follows complex commands. 5/5 strength in distal
UEs/LEs.
.
On discharge:
Pertinent Results:
today's at OSH:
Na 143 K 3.5, CL 103, bicarb 31, BUN 21, creat 1.1. LFTs WNL.
WBC 12K
.
Micro:
OSH urine [**1-11**]: >10^5 GNRs, lactose fermentors
[**1-11**] labs: CK 34, MB 3.2, troponin I 0.06, creat 1.3
.
Images:
OSH CXR report [**1-11**]: pacer and sternal wires present. Diffuse
bilateral pulmonary vascular redistribution and diffusely
increased interstitial markings. Later film with ETT tip 2.7 cm
above carina.
.
OSH CXR report [**1-12**]: Diffuse changes of CHF. Improved lung
volumes. Persistent LLL consolidation.
.
EKG at OSH:
poor baseline, at least partially Apaced, rate 63, normal axis,
normal intervals, inferior and precordial TWF/TWIs.
.
[**2140-1-13**] 11:14PM GLUCOSE-90 UREA N-34* CREAT-1.3* SODIUM-145
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-32 ANION GAP-14
[**2140-1-13**] 11:14PM estGFR-Using this
[**2140-1-13**] 11:14PM CK(CPK)-21*
[**2140-1-13**] 11:14PM CK-MB-NotDone cTropnT-0.05* proBNP-1376*
[**2140-1-13**] 11:14PM CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-1.9
[**2140-1-13**] 11:14PM WBC-5.9 RBC-3.42* HGB-10.2* HCT-30.8* MCV-90
MCH-29.9 MCHC-33.1 RDW-16.1*
[**2140-1-13**] 11:14PM NEUTS-66.9 LYMPHS-23.8 MONOS-3.4 EOS-5.4*
BASOS-0.5
[**2140-1-13**] 11:14PM PLT COUNT-239
[**2140-1-13**] 11:14PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2140-1-13**] 11:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
[**2140-1-13**] 11:14PM URINE RBC-1 WBC-21* BACTERIA-FEW YEAST-NONE
EPI-1
[**2140-1-13**] 11:14PM URINE HYALINE-8*
[**2140-1-13**] 11:14PM URINE MUCOUS-RARE
[**2140-1-19**] 08:55AM 5.1 3.37* 9.7* 30.1* 89 28.8 32.3 16.6*
369
[**2140-1-18**] 12:40PM 6.2 3.46* 10.4* 31.2* 90 30.0 33.2 16.1*
327
[**2140-1-17**] 08:00AM 5.6 3.20* 9.3* 29.3* 92 29.0 31.7 16.8*
326
[**2140-1-16**] 02:52AM 6.1 3.64* 10.8* 32.6* 89 29.5 33.0 16.7*
251
[**2140-1-15**] 04:07AM 7.1 3.55* 10.4* 32.6* 92 29.2 31.9 16.4*
286
Source: Line-PIV
[**2140-1-13**] 11:14PM 5.9 3.42* 10.2* 30.8* 90 29.9 33.1 16.1*
239
.
On discharge:
[**2140-1-26**] 10:45AM BLOOD WBC-9.0 RBC-3.53* Hgb-10.3* Hct-31.6*
MCV-90 MCH-29.1 MCHC-32.5 RDW-16.0* Plt Ct-382
[**2140-1-26**] 10:45AM BLOOD PT-23.7* PTT-37.6* INR(PT)-2.3*
[**2140-1-26**] 10:45AM BLOOD Glucose-109* UreaN-39* Creat-1.8* Na-140
K-4.6 Cl-98 HCO3-32 AnGap-15
[**2140-1-26**] 10:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.5
.
**FINAL REPORT [**2140-1-16**]**
URINE CULTURE (Final [**2140-1-16**]):
ENTEROBACTER ASBURIAE. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER ASBURIAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
Final Report
CHEST RADIOGRAPH
INDICATION: New tracheostomy tube, evaluation for interval
change.
COMPARISON: [**2140-1-13**].
FINDINGS: As compared to the previous radiograph, the
tracheostomy tube has been placed and the ET tube and the
nasogastric tube have been removed. The tip of the endotracheal
tube projects 4.8 cm above the carina.
Unchanged position and course of the pacemaker leads. The
ventilation of the lung has improved. The costophrenic sinuses
are substantially better visible than on the previous
examination. Unchanged size of the cardiac silhouette,
regression of the bilateral supradiaphragmatic areas of
atelectasis. No evidence of newly occurred focal parenchymal
opacities.
.
[**1-17**] CXR: IMPRESSION: Improved left basilar aeration.
.
[**1-17**] video swallow: Aspiration of all consistencies of barium
in a neutral position. With the patient in chin tuck position,
no aspiration was observed with puree consistency barium.
.
[**1-20**] CXR:
FINDINGS: Comparison made to [**2140-1-18**]. Left
pacemaker/ICD and
intracardiac leads are unchanged in position. Cardiomediastinal
contours are
stable. Mild bibasilar atelectasis is unchanged. Mild pulmonary
edema shows
minimal improvement. There is no new or worsening airspace
opacity.
.
[**1-24**] CXR:
The left-sided AICD and tracheostomy are in unchanged position.
Median
sternotomy wires are seen. There is again seen cardiomegaly
which is stable.
There are low lung volumes with crowding of the pulmonary
vascular markings at
the bases; however, no definite consolidation is seen. Overall,
these
findings are unchanged.
Brief Hospital Course:
68F with COPD, CAD, systolic CHF, and tracheal stenosis s/p
complicated respiratory failure history, presenting with
recurrent acute pulmonary edema of unclear etiology and
respiratory failure now s/p tracheostomy.
.
# Respiratory failure: The patient has a complicated tracheal
history as above with past trach now decannulated; she presented
with multiple recent reintubations for acute onset respiratory
distress and reported pulmonary edema since [**10-29**]. Etiology of
acute pulmonary edema not entirely clear - there has been
discussion of negative pressure edema from negative pressure
generation with pulling against stenosed trachea, acute ischemic
heart disease leading to diastolic dysfunction, other cause of
acute afterload increase (particularly likely as seems to have
clear relation to anxiety), but her respiratory failure seems
less likely due total body volume overload given acuity of
symptom onset. Respiratory failure does not seem to be OSA
related though that is in her history (no nighttime occurances).
It is likely that her respiratory failure is multifactorial,
with anxiety leading to increased afterload and poor forward
flow leading to dyspnea, then severe dyspnea leading to
increased intrathoracic pressures and worse dynamic airway
stenosis all contributing. She was originally admitted to the
MICU. In order to provide more definitive airway management as
well as to prevent further tracheal injury with repeated
intubations, and bypass stenosed area if NPPE playing a role,
the patient had a tracheostostomy placed and was successfully
weaned to trach collar. She appeared euvolemic after IV lasix
given in MICU and then transitioned back to PO lasix. She was
able to eat with cuff down but failed swallow eval and was
likely aspirating. She was then transferred to the floor. Had a
lot of secretion and needed frequent suctioning. Unable to do
PMV because of either trach size too big or tracheal stenosis.
Once patient made NPO her sectretions improved and air movement
improved. Repeat CXR showed improved aeration. She underwent a
PEG placement. Continued CAD and CHF meds as below. Successfully
weaned to trach collar, cont 70% FM currently as patient prefers
to have oxygen high. Tried to encourage pt to suction upper
airway secretions by herself but not really willing. Continued
lasix to maintain euvolemia. We treated anxiety as below. Per IP
we started [**Hospital1 **] PPI and H2B to help improved reflux and airway
inflammation. Patient experienced peridoic asymptomatic
desaturations, that improved with suction and nebulizer
treatments. Patient was discharged home, with her husband and
children instructed on suction technique.
.
# COPD and tracheal stenosis. Recent PFTs as per PMH. Bronch
during last admission revealing mild tracheal stenosis. Unclear
if this is contributing to her dyspnea and/or respiratory
failure (primarily via negative pressure pulmonary edema and/or
dynamic collapse of airways). No inhalers currently listed on
home meds. Cont trach and 50%TM, inhalers prn.
.
# ARF: PO intake poor and started lasix, likely pre-renal. Cr
fluctuated between 1.1 and 1.9 throughout this hospitalization.
Avoided nephrotoxins and reduced her lasix to 40 PO daily.
.
# Foot pain: Consistent with gout flare, likely in the setting
of diuresis improved today. Resumed home colchicine.
.
# Pacer pocket pain/swelling. Tender on exam though no erythema.
Now about 3 weeks out from AICD lacement. Tender on exam
though no erythema. Ultrasound chest pocket showed no abscess.
Pain control prn.
.
# UTI. Ucx from [**1-12**] growing ENTEROBACTER ASBURIAE. Completed 7
day course of cipro.
.
# Systolic CHF. EF 40-50%, likely ischemic in nature. Patient
appeared euvolemic on most of stay. Reportedly had TTE at OSH.
Would benefit from excellent BP and rate control. CXR yesterday
am patient looked improved. Continue metoprolol xl, lisinopril
at 2.5mg, and lasix 80mg. (Does have documented allergy to
lisinopril but tolerated it in house without complications.)
.
# CAD. Consideration of ischemia as cause of diastolic
dysfunction. Underwent cardiac cath at [**Hospital2 **] [**Hospital3 6783**] in early
[**Month (only) **] which showed some of her grafts were down which was not
new. Had an AICD put on there because of the thought that her
PEA arrests were [**2-23**] ischemic focus causing VFib/tach. Continue
Statin, ASA, BB, ACEI
.
# Afib. Chronic. St. Vincents had put her on sotalol but this
was not continued upon readmission to [**Hospital1 10478**] in [**12-29**].
Currently rate controlled. Has never been on anticoagulation for
unclear reasons but was started on coumadin yesterday which she
warrants for a CHADS2 of 2. Cont rate control with metoprolol
12.5mg PO BID. Cont asa and coumadin, INR was 2.6 on discharge,
with a goal of [**2-24**]. Monitored on tele with no events. Should see
EP as outpatient.
.
# Depression/anxiety. Significant player in her respiratory
distress episodes; not well managed as an outpatient with
frequent admissions as per HPI. Takes Ativan at home per
patient, denies clonazepam. Continue citalopram, Seroquel,
lamictal per home regimen. Started Ativan q4-6h PO PRN for
anxiety.
.
# Anemia: Iron studies wnl. Hct at baseline.
.
#Stage II decub: Per patient chronic and not painful. Nurses
assessed for wound care.
.
# Nutrition: Patient underwent a PEG placement during this
admission. Tube feeds were initiaed with Isosource 1.5 Cal,
with feeding from 1800 to 0600 @ 70 cc/hr with q 4 hr flushes
and residual checks. All of her medications were given through
the PEG to reduce risk of aspiration.
.
# Disposition. Given tracheostomy, PEG tube placement, and
periodic episodes of desaturation, there was significant
discussion with the family regarding appropriate disposition for
Ms. [**Known lastname 16471**]. It was the initial assessment of the primary team
that the patient had needs beyond what could be performed safely
at home and recommended placement in a rehabilitation facility.
She was accepted for a bed at a skilled nursing facility, but
the patient refused placement and insisted on being discharged
home. Extensive home services were arranged and family members
were instructed on suction technique and appropriate home care.
Family were also instructed regarding warning signs that would
warrant contacting their physician, [**Name10 (NameIs) **] coming to the emergency
room. Follow-up appointments were arranged with Dr. [**Last Name (STitle) 48006**]
and Dr. [**Last Name (STitle) **].
Medications on Admission:
Medications on transfer:
ASA 81 mg daily
Lipitor 80 mg daily
Colchicine 0.6 mg daily
Lasix 40 mg IV Q12H
Protonix 40 mg IV daily
Seroquel 100 mg HS and 50 mg TID
Lamotrigine 100 mg HS
Citalopram 20 mg daily
Nitrofurantoin 50 mg QID planned thru [**1-19**]
D51/2NS at 75 cc/hr
.
Medications at home:
Nexium 40 mg daily
Senna 2 tabs daily
MVI daily
ASA 81 mg daily
Seroquel 50 mg TID and 100 mg HS
Metoprolol tartrate 12.5 mg [**Hospital1 **]
Lisinopril 5 mg daily
Lipitor 80 mg daily
Citalopram 20 mg [**Hospital1 **] (12pm and 4pm)
Lamictal 100 mg [**Hospital1 **]
Lasix 80 mg QAM, 40 mg QPM
Clonazepam 2 mg [**Hospital1 **]
KCL unknown dose [**Hospital1 **]
Colchicine 0.6 mg daily
Discharge Medications:
1. Quetiapine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
8. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily) as
needed for Constipation.
9. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*1*
10. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM.
11. Colchicine 0.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
13. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for secretions.
14. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
15. Quetiapine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times
a day).
16. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
17. Tube Feeds
Isosource 1.5 Cal Full strength;
Starting rate:70 ml/hr
Cycle start:1800 Cycle end:600
Residual Check:q4h Hold feeding for residual >= :200 ml
Flush w/ 100 ml water q4h
18. Enteral Pump
Please provide 1 enteral pump.
19. IV Pole
Please provide IV Pole.
20. Feeding Tube Bags
Please provide 30 feeding tube bags.
Refill: 11
21. G tube supplies
Please provide feeding tube supplies.
Quantity sufficient.
22. Colchicine 0.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily) as needed for gout.
23. Hospital bed
Semi-electric hospital bed. Diagnosis - Acute respiratory
failure, gastric tube with risk for aspiration. Length of
duration - lifetime.
24. Suction machine
Suction machine with supplies. Diagnosis - tracheostomy. Length
of need - lifetime. 14 french suction catheters.
25. Humidified O2 compressor
Humidified O2 compresor. Cool mist to trach. Duration -
lifetime. Diagnosis - trach.
26. Trach
Portex Per-fit #7. Duration - lifetime. Diagnosis - respiratory
failure s/p trach.
27. Lasix 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
29. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
30. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
31. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
32. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Carenetwork
Discharge Diagnosis:
Primary:
- Respiratory failure
- Acute systolic heart failure
- Enterobacter UTI
- Subglottic edema c/b dysphagia
Secondary:
- Atrial fibrillation
- Recurrent mutlifactorial respiratory failure c/b PEA arrest x
2
- Tracheostomy-reversed on [**3-25**] c/b tracheocuteous
fistula.
- Tracheocutaneous fistula repair [**8-28**]
- Post-tracheostomy tracheal stenosis
- Severe cervical tracheomalacia.
- Mixed restrictive/obstructive airway disease
- CKD stage II/III
- CAD s/p CABG in [**2118**]
- Anemia of chronic inflammation
- Gout
- Hypertension
- Bipolar disorder
- GERD
- h/o HIT
- MRSA/VRE
- Left THR
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital3 **] Medical Center for respiratory
failure. You had a tracheostomy placed to try to bypass the
area of your airway that has become narrow--likely due to
repeated intubations--to try to prevent this situation from
occurring again. You also had fluid taken off with IV Lasix
(furosemide). You were also found to have a urinary tract
infection.
.
We have scheduled you an appointment to follow up with Dr.
[**Last Name (STitle) **]. You will need to follow up with your PCP on Dr. [**Last Name (STitle) 48006**]
on [**2140-2-5**] at 10:30 am.
.
The following changes were made to your medication regimen.
1)Lasix was changed to 60mg daily.
2)Celexa changed to 40mg daily
3)We added lansoprazole 40mg twice a day and famotidine 20mg
daily to prevent the acid from irritating your airway. We
stopped your nexium.
4)We also started you on coumadin to thin your blood. Goal INR
[**2-24**].
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, nausea, vomiting, diarrhea,
abdominal pain, headache, or lightheadness, please contact your
primary care physician or go to your local emergency room.
Followup Instructions:
You will need to follow up with Interventional Pulmonology.
Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2140-2-16**] 10:30
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2140-2-16**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2140-2-16**]
11:30
.
You will need to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48006**] on
[**2140-2-5**] at 10:30 am. Fax PCP: [**Telephone/Fax (1) 105300**]. He will need to
help coordinated your cardiology follow up as well as EP follow
up for your new ICD.
|
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42,585
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36177+58066
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-2-22**] Discharge Date: [**2150-2-26**]
Date of Birth: [**2068-6-26**] Sex: M
Service: SURGERY
Allergies:
Flurazepam
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
lower back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81M retired internist w/ PMH of diverticulitis, afib on coumadin
c/o lower back pain x 3 wks.
Lower back pain described as constant, band-like, not relieved
by
anything. Pt denied abdominal pain. In addition, he had
persistent diarrhea x 1 wk (2-3x/day) - non-bloody. Mild
confusion noted by daughter during that week. Denies f/c/n/v.
Denies sick contact.
Of note, pt accidentally took extra coumadin yesterday (4mg
instead of usual 2mg). Noted epistaxis today but was able to
stop
it. Denies hematuria.
Past Medical History:
ischemic cardiomyopathy
afib w/ complete heartblock
s/p single chamber ICD [**3-19**]
s/p CABG, MVR (porcine) '80s
CVA '80s
sacral decubitius
depression
diverticulitis (no OR)
s/p subtotal gastrectomy, splenectomy for bleeding DU '70s
Social History:
former smoker, quit 30 yrs ago (<1ppd x 20 yrs)
former ETOH, quit 10 yrs ago
denies IVDU
retired internist at [**Hospital1 1559**]
Family History:
noncontributory
Physical Exam:
At Discharge:
Vitals: 97.8, 66, 108/60, 24, 99% on RA
GEN: NAD, A/Ox3
CV: RRR
RESP: CTAB
ABD: soft, NT/ND, +BS, +flatus, Loose stools
Sacral-two small pin-point stage 2 ulcers-duoderm gel &allovyne
dressing
Skin: emaciated, macular rash across back and back or LE's.
Extrem: no c/c/e
Pertinent Results:
CT PELVIS W/O CONTRAST Study Date of [**2150-2-21**] 11:16 PM
IMPRESSION:
1. Acute sigmoid diverticulitis. A small air collection along
the inferior
aspect of the sigmoid colon and dome of the bldder may represent
a large
diverticulum or a contained perforation. No drainable fluid
collection is
seen.
2. Noncontrast evaluation of the aorta demonstrated mild
atherosclerotic
changes without aneurysm.
3. Mild T12 compression deformity, of unknown chronicity.
.
[**2150-2-21**] 08:40PM BLOOD PT-150* PTT-64.3* INR(PT)-22.3*
[**2150-2-22**] 03:41AM BLOOD PT-150* PTT-70.5* INR(PT)-27.4*
[**2150-2-22**] 02:52PM BLOOD PT-20.8* PTT-35.1* INR(PT)-2.0*
[**2150-2-24**] 07:40AM BLOOD PT-16.9* PTT-31.8 INR(PT)-1.5*
[**2150-2-21**] 08:40PM BLOOD Glucose-108* UreaN-32* Creat-1.8* Na-140
K-3.2* Cl-100 HCO3-25 AnGap-18
[**2150-2-22**] 03:41AM BLOOD Glucose-103 UreaN-27* Creat-1.4* Na-139
K-2.7* Cl-103 HCO3-22 AnGap-17
[**2150-2-22**] 02:52PM BLOOD Glucose-111* UreaN-21* Creat-1.1 Na-142
K-3.6 Cl-105 HCO3-25 AnGap-16
[**2150-2-24**] 07:40AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-138
K-3.5 Cl-106 HCO3-27 AnGap-9
[**2150-2-21**] 08:40PM BLOOD ALT-10 AST-22 AlkPhos-144* TotBili-0.4
[**2150-2-21**] 08:40PM BLOOD Lipase-32
[**2150-2-21**] 08:40PM BLOOD Albumin-3.4 Calcium-9.9 Phos-2.3* Mg-2.4
[**2150-2-22**] 03:41AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
[**2150-2-23**] 08:00AM BLOOD Calcium-9.2 Phos-1.8* Mg-2.1
[**2150-2-24**] 07:40AM BLOOD Calcium-8.4 Phos-1.3* Mg-1.9
[**2150-2-21**] 08:40PM BLOOD Digoxin-1.7
[**2150-2-24**] 07:40AM BLOOD Digoxin-1.6
[**2150-2-21**] 08:40PM BLOOD WBC-16.2* RBC-4.00* Hgb-11.6* Hct-35.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-16.0* Plt Ct-462*
[**2150-2-22**] 03:41AM BLOOD WBC-23.1* RBC-3.62* Hgb-10.6* Hct-31.5*
MCV-87 MCH-29.3 MCHC-33.6 RDW-16.0* Plt Ct-427
[**2150-2-23**] 02:57AM BLOOD WBC-12.8* RBC-3.51* Hgb-10.7* Hct-31.2*
MCV-89 MCH-30.4 MCHC-34.2 RDW-16.2* Plt Ct-383
[**2150-2-24**] 07:40AM BLOOD WBC-14.7* RBC-3.37* Hgb-9.7* Hct-29.9*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.3* Plt Ct-343
Brief Hospital Course:
[**Date range (1) 82049**]-Mr. [**Known lastname **] presented to [**Hospital1 18**] with complaints of back
pain. He was found to have a tender abdomen upon exam. He
underwent CT scan and was noted to have diverticulitis. In
addition, his INR was elevated to 22.3 at admission due to
accidentally ingestion of addtiontal Coumadin per patient. Due
to INR level, dehydration related to diarrhea at home as
evidence by increased creatinine to 1.8, the patient was
admitted to General surgery service for possible surgical
management of diverticulitis. The patient was transferred to
SICU from ED due to profound dehydrated status, and semi-acute
appearance. He was resusciated with IV fluid. Given Vitamin K
and Frozen plasma to reverse INR. His clinical appearance
improved with hydration, and abdomen appeared less tender.
Patient's Cardiologist was consulted due to his extensive
cardiac history. He remained stable, surgical intervention was
not imminently required. Patient was transferred to Stone 5 for
continued monitoring.
.
[**2-24**]-Due to extensive Psychsocial issues following services
consulted: Speech/Swallow to rule out aspiration, Physical
Therapy to assess safety for discharge. Geriatrics due to
medication errors and multiple concerns posed by patient's
daughter whom he lives with including lack of appetite, mis
management of medications, safety at home, and changes in
cognitive status, voice, speech. Social Work consulted to offer
resources/supports. Cardiology continues to follow patient.
Coumadin discontinued. Patient started on baby aspirin.
.
[**2-25**]-Screened for REHAB to continue physical therapy, assessment
of nutritional status/hydration, aspiration precautions, and
assessment of post-Rehab disposition. In addition, patient will
require follow-up with geriatrics, ENT for voice evaluation, and
further evaluation of back pain. Dr. [**Last Name (STitle) **] should be
contact[**Name (NI) **] primarily regarding any concerns regarding this
patient's ongoing care. The patient should continue with
Cipro/Flagyl for total of 2 weeks to treat diverticulitis.
Contact Dr. [**Last Name (STitle) **] with concerns regarding abdominal pain,
etc.
Medications on Admission:
coumadin 2mg daily
lasix 20mg daily
digoxin 0.125 daily
avapro 150mg daily
ambien 10mg daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever or pain for 10 days: Do not
exceed 4000mg in 24hrs .
Discharge Disposition:
Extended Care
Facility:
Aberjona
Discharge Diagnosis:
Primary:
Hypercoagulopathy
Acute Renal Failure due to dehydration and diarrhea
Acute diverticulitis
Sacral decubitus ulcer
Malnutrition
.
Secondary:
Decreased in cognition-possible early dementia
ischemic cardiomyopathy (EF unknown)
afib w/ complete heartblock s/p single chamber ICD [**3-19**]
CAD s/p CABG and MVR (porcine) in [**2121**]
CVA [**2121**]
depression
diverticulitis (non-operative)
s/p subtotal gastrectomy and splenectomy for bleeding DU in
[**2111**]
Discharge Condition:
Stable
Tolerating low residue regular, pureed diet with thick liquids.
Back pain well controlled with oral medication
Discharge Instructions:
REHAB Instruction:
Please call or return to the ER for any of the
following:
* New chest pain, pressure, squeezing or tightness.
* New or worsening cough or wheezing.
* vomiting and cannot keep in fluids or your medications.
* dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Nutrition:
-Continue soft dysphagia diet. Continue assessing patient's
swallowing, adjust diet as tolerated. Continue aspiration
precautions.
.
Medications:
-Continue PO Flagyl and Cipro for another 13 days to treat
diverticulitis.
.
Coagulation management:
-Dr. [**Last Name (STitle) **] has discontinued the Coumadin. The patient was
started on a baby aspirin during this admission. Please continue
this medication as prescribed.
.
Out-patient follow-up:
-Patient requires follow-up with Geriatrics, Nutrition, ENT, &
Back pain.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in [**2-17**]
weeks or as needed.
2. Follow-up with your Cardiologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],([**Telephone/Fax (1) 3942**] in [**1-16**] week.
3. Follow-up with Gerontologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 719**] in [**1-16**] week.
***Please arrange for out-patient Nutrition management, and ENT
consultation for evaluation of speech/voice changes.
.
Previous appointments:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-7-6**] 12:40
Completed by:[**2150-2-25**] Name: [**Known lastname **],[**Known firstname 389**] Unit No: [**Numeric Identifier 13146**]
Admission Date: [**2150-2-22**] Discharge Date: [**2150-2-26**]
Date of Birth: [**2068-6-26**] Sex: M
Service: SURGERY
Allergies:
Flurazepam
Attending:[**First Name3 (LF) 4**]
Addendum:
Patient remained in-patient at [**Hospital1 8**] from 2/1i/09 to [**2150-2-26**] due
to inter-family conflict regarding REHAB facility site.
Arrangements were made to have patient transferred to REHAB son,
[**Name (NI) 13147**] choice who is health care proxy. [**Name (NI) **] now going to
Aberjona [**Hospital1 1354**] [**Location (un) 13148**], [**Hospital1 8750**] MA [**Telephone/Fax (1) 13149**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1353**]/Elmhurst [**Hospital1 1354**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**]
Completed by:[**2150-2-26**]
|
[
"V45.81",
"V58.61",
"263.9",
"V45.01",
"707.03",
"584.9",
"V42.2",
"426.0",
"707.22",
"414.8",
"276.51",
"964.2",
"562.11",
"E858.2",
"790.92",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10362, 10596
|
3629, 5810
|
284, 291
|
7058, 7177
|
1587, 3606
|
8856, 10339
|
1251, 1268
|
5954, 6488
|
6567, 7037
|
5836, 5931
|
7201, 8833
|
1283, 1283
|
1297, 1568
|
228, 246
|
319, 827
|
849, 1086
|
1102, 1235
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,024
| 106,374
|
6020
|
Discharge summary
|
report
|
Admission Date: [**2127-9-25**] Discharge Date: [**2127-10-8**]
Date of Birth: [**2057-7-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Found Unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN,
COPD, and CKD w/ a baseline Cr of 2.0 who presents with not
being "quite her self" x 1 days and found unresponsive at home
by husband. FS was 20 given glucose and FS normal in ER.
Initially upon presentation to ER was obtunded and since has
been improving. Non cooperative to questioning.
.
In the ED, rectal temp 104. BP and HR had been normal as well
as O2 sats normal. Lactate 7. CVP was initially 13. Given Vanc
and Ceftriaxone (at meningitis doses) and flagyl. CT of abd /
pelvis was s/p 3 liters IVF in ED. INR was 5.6. EKG J point
elevation in V3, ST depressions in V5-V6 which are not new.
Most recent set of vitals 36.7, 67, 107/68, 17, 100% on nasal
cannula but now on non rebreather because SvO2 is low.
Past Medical History:
PMH:
1. Diabetes Mellitus type II on orals
2. CAD 3vd
3. Chronic systolic heart failure , EF 20%
4. Multinodular goiter
5. Hypertension
5. Spinal stenosis
6. PVD s/p aortobifemoral bypass, left toe amputations
7. Peripheral neuropathy
8. Hyperlipidemia
9. Depression
10. Anemia
11. CKD Stage III with neuropathy, nephropathy
12. Frequent falls/gait instability
13. Cervical spondylosis s/p C4-7 laminectomy and fusion in [**2-4**]
14. s/p choly
15. h/o SBOs
16. COPD
Social History:
Level of function prior to [**5-8**] admission was ambulate household
distances, wheelchair for community. Lives in senior
housing/elevator building with husband. Used bedside commode in
home. Pack per day smoker for >40 yrs, denies EtOH, denies
illicit drug use.
Worked as salesclerk and for the turnpike. Has five children,
two living.
Family History:
Five children, three living. One from HIV, one shot, one drugs.
Husband reports both her parents died from "cancer I think,
trouble breathing." One son has seizures.
Physical Exam:
Vitals: T: 104.8 in ER (axillary 95 in ICU) BP: 125/70 HR: 64
RR: 15 w/ periods of apnea O2Sat: 99-100% RA
GEN: patient is responsive to verbal stimuli, she is able to
follow with her eyes the interviewer but unable to follow any
other commands, she is unable to answer any questions.
HEENT: PEERL (3-4mm bilat), EOMI, sclera anicteric, no epistaxis
or rhinorrhea
NECK: JVP 14cm, no thyromegaly or cervical lymphadenopathy,
trachea midline
COR: RRR, [**2-5**] HSM at LLSB and at apex
PULM: Lungs CTAB, no W/R/R, however patient not following
commands so poor inspiratory effort
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: Pitting 1+ edema to knees, darkening of skin on lower
extremities.
NEURO: 1+ reflexes biceps, triceps, achilles, patellar reflexes
all bilaterally symmetric, muscle tone is increased in the upper
and lower extremities
Pertinent Results:
[**2127-9-25**] 07:19PM POTASSIUM-5.1
[**2127-9-25**] 07:19PM CK(CPK)-85
[**2127-9-25**] 07:19PM CK-MB-4 cTropnT-0.18*
[**2127-9-25**] 04:36PM URINE HOURS-RANDOM UREA N-251 CREAT-87
SODIUM-56
[**2127-9-25**] 04:36PM URINE bnzodzpn-NEGATIVE barbitrt-NEGATIVE
opiates-NEGATIVE cocaine-NEGATIVE amphetmn-NEGATIVE
mthdone-NEGATIVE
[**2127-9-25**] 01:49PM LACTATE-3.3*
[**2127-9-25**] 01:49PM HGB-11.1* calcHCT-33 O2 SAT-83
[**2127-9-25**] 12:33PM LACTATE-3.2*
[**2127-9-25**] 11:32AM LACTATE-3.8*
[**2127-9-25**] 11:25AM CK(CPK)-75
[**2127-9-25**] 11:25AM CK-MB-3 cTropnT-0.16*
[**2127-9-25**] 11:25AM VIT B12-GREATER TH FOLATE-GREATER TH
[**2127-9-25**] 11:25AM FREE T4-0.79*
[**2127-9-25**] 11:25AM ASA-NEG ACETMNPHN-6.0 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2127-9-25**] 10:37AM TYPE-MIX INTUBATED-NOT INTUBA COMMENTS-GREEN
TOP
[**2127-9-25**] 10:37AM LACTATE-4.5* K+-5.5*
[**2127-9-25**] 10:37AM O2 SAT-84
[**2127-9-25**] 08:44AM COMMENTS-GREEN TOP
[**2127-9-25**] 08:44AM GLUCOSE-122* LACTATE-7.6* NA+-142 K+-6.3*
CL--102
[**2127-9-25**] 08:30AM GLUCOSE-126* UREA N-59* CREAT-3.9*#
SODIUM-140 POTASSIUM-6.3* CHLORIDE-101 TOTAL CO2-23 ANION
GAP-22*
[**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK
PHOS-103 TOT BILI-1.5
[**2127-9-25**] 08:30AM LIPASE-28
[**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21*
[**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*#
MAGNESIUM-2.0
[**2127-9-25**] 08:30AM TSH-36*
[**2127-9-25**] 08:30AM T4-4.4* T3-41*
[**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5*
MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5*
[**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1
BASOS-0
[**2127-9-25**] 08:30AM PLT COUNT-197
[**2127-9-25**] 08:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2127-9-25**] 08:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2127-9-25**] 08:30AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2127-9-25**] 08:30AM PT-49.2* PTT-33.9 INR(PT)-5.6*
[**2127-9-25**] 08:30AM PLT COUNT-197
[**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1
BASOS-0
[**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5*
MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5*
[**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-9-25**] 08:30AM T4-4.4* T3-41*
[**2127-9-25**] 08:30AM TSH-36*
[**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*#
MAGNESIUM-2.0
[**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21*
[**2127-9-25**] 08:30AM LIPASE-28
[**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK
PHOS-103 TOT BILI-1.5
,
CT abdomen/pelvis:IMPRESSION:
1. Limited study without oral or intravenous contrast.
Sensitivity for
detecting abscess or bowel ischemia is markedly diminished.
2. Umbilical hernia is seen containing non-obstructed bowel
loops.
3. Multiple bilateral non-obstructing renal stones without
evidence of
hydronephrosis.
4. Cardiomegaly and bilateral pleural effusions.
5. Ascites.
6. Diffuse atherosclerotic disease.
,
TTE:The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 10-20mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. There is severe
global left ventricular hypokinesis (LVEF = 15-20 %). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is dilated with severe 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. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
CXR [**9-29**]:IMPRESSION:
Likely slight increase in right pleural effusion compared to
[**2127-9-26**] with
difficult comparison to [**2127-9-27**] because of differences in
position. Persistent
CHF and left lower lobe atelectasis.
.
RUQ US:
IMPRESSION: Very limited examination secondary to patient
cooperation.
Patent hepatic veins and IVC. To-and-fro flow within the main
portal vein may
indicate underlying hepatic congestion or an underlying primary
hepatic
process.
,
CT head;FINDINGS: There is no evidence of hemorrhage, recent
infarction,
hydrocephalus or edema. There is an old lacune in the extreme
capsule on the
left. There is cerebral atrophy and small vessel ischemic
change. The
included paranasal sinuses and mastoid air cells are clear.
There are no
fractures.
IMPRESSION: No acute intracranial processes. Old lacune.
.
CXR [**10-1**]:
IMPRESSION:
1. Low lung volumes and interval increase in bilateral pleural
effusions and
pulmonary vascular congestion.
2. Paucity of abdominal gas suggesting ascites.
Brief Hospital Course:
This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN,
COPD, and CKD w/ a baseline Cr of 2.0 found unresponsive by her
husband. [**Name (NI) **] initial presentation was felt to be due to acute
liver failure. Her course was complicated by acute renal failue,
liver failure, coagulopathy, and DIC. Below is her course by
system. She was in the ICU from [**Date range (1) 23681**], and then on the
general medical floor.
.
# Delerium/Altered mental status/Dementia: The patients acute
change in mental status was ultimately thought to be due to The
patient initially was found to be unresponsive by husband- seems
as though she had been lethargic for at least 10 days. She
also has been profoundly hypothyroid in the past and also has a
? of underlying alzheimers dementia with fluctuating mental
status in the past as well. In the presence of fever, it was
thought that patient was infected. Given mental status was
altered and no other localizing source,there was initial concern
for meningitis. LP was not attempted because of elevated INR
and thrombocytopenia. The patient was covered for several days
with Vanc/CTX/Amp for empiric meningitis coverage (2 days) and
then just CTX/flagyl for 3 days to cover for SBP. She ruled out
for pneumonia with a negative CXR, head CT was negative, CT
abd/pelvis negative, there was no clot in IVC on RUQ US, and
minimal ascites on ultrasound. The pt did have elevated TSH
levels, but thyroid function is unreliable in this setting of
acute illness. Her TSH prior to admission was similar, and her
levothyroxine had recently been increased to 88 mcg daily as an
outpatient. The patient was started on lactulose as per below,
and her mental status gradually improved. Of note, recent MRI
showed changes most consistent with Alzheimer's dementia. She
had been seen by behavioral neurology by Dr. [**Last Name (STitle) 724**], and it is
felt she suffers from a mixed etiology disorder involving
microvascular and probable Alzheimer's disease encephalopathy.
She was noted to have some rigidity and cogwheeling on exam, [**First Name8 (NamePattern2) **]
[**Last Name (un) 309**] body dementia and Parkinsons' need to be evaluated as an
outpatient. She will follow up with neurology (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **])
.
# Lactic Acidosis: Initial lactate of 7.6 on admission resolved
with fluid resuscitation.
.
# Renal failure: Her creatinine was 3.9 on admission, with
baseline of 2.0. Thought to be prerenal, trended down with IVF.
No hydronephrosis on ct scan. Her HCTZ, lisinopril, and lasix
were all held. After her renal failure was resolving with Cr
down to 2.3 and pt was in acute CHF, lisinopril and lasix were
restarted.
.
# Acute Hepatitis: The patient presented with picture c/w acute
hepatitis, of unclear etiology. Her ALT was 412 and AST 1161 on
admission. Tox screen was negative. The patient was seen by
hepatology and it was felt that perhaps her hepatitis was drug
induced. She has known hepatitis C, but this was felt unlikely
to cause her acute liver failure. Liver US was negative for
portal vein thrombosis. She was started on rifaximin and
lactulose with improvement in her encephalopathy. Hep B
serologies, Hep A serologies were negative. Hep C viral load was
greater than 1,000,000. She will need outpatient hepatology
follow up (has follow up at the end of [**Month (only) 359**]).
-Hepatitis E Ab ordered and pending
.
# Coagulopathy: Felt to be due to DIC and worsening liver
failure. Schisotcytes were seen on initial smear, which
improved. Hematology/oncology was consulted and felt pt likely
had DIC. Her platelets dropped to the 30s and then began to
recover. Her INR rose to 11.3 and then improved. She did receive
some vitamin K. Heparin dependent Ab was negative. Antithrombin
(AT), protein C, and protein S, Factor V and VIII levels were
all low. Hematology felt....
.
# Acute on Chronic systolic heart failure: EF 15-20%. Appeared
stable on repeat echo this admission. Pt also has mod-severe
TR/MR. [**Name13 (STitle) **] last stress test had shown no defect, but this was on
rest imaging. Per her cardiologist, Dr. [**First Name (STitle) 437**], the patient's
heart failure is not likely ischemic in nature. This
cardiomyopathy has been new since [**2122**]. The etiology of her
chronic systolic heart failure is unclear. [**Name2 (NI) **] lasix,
lisinopril, and hctz were held on admission for acute renal
failure, hypernatremia, and dehydration. She was treated with
several days of IV D5W. She was noted to have increasing pleural
effusions, O2 requirement, and BNP of >70,000. Her lisinopril
was restarted once her creatinine was 2.3 and she was given IV
Lasix. Her metoprolol was changed to carvedilol per Dr. [**First Name (STitle) 437**] to
give better afterload reduction. Dr. [**First Name (STitle) 437**] advised against
aladactone given her CRF and predisposition to hyperkalemia.
.
# Macrocytic Anemia: B12 and folate were normal, Her hct
remained stable around 34 despite DIC.
.
# Fever: The patient had a fever of 104 on presentation.
Ultimately this was felt to be due to hepatitis. Her initial
work up was negative for any other acute infectious source. As
per above, she was covered with antibiotics initially for
concern of meningitis or SBP. Her fever had resolved by HD #3.
Urine cultures grew yeast. Her foley was removed.
.
# HTN: The pt is on metoprolol, lisinopril and hctz at home. Her
hctz and lisinopril were held given her acute renal failure. Her
metoprolol was increased and she was started on norvasc.
Lisinopril was restarted after her acute renal failure resolved.
,
# ? CAD: No history of recent stents in our system but on
aspirin and plavix on admission. In fact, there is no evidence
the patient has CAD, but this keeps being written in her notes.
She was cotinued on metoprolol and aspirin, but her plavix was
held in the setting of DIC/thrombocytopenia. Per Dr. [**First Name (STitle) 437**], her
cardiologist, the plavix does not need to be restarted as we
have no evidence the pt has CAD.
.
.
# Elevated D-dimer/FDP: The patient had a D dimer trending up to
7000, but no further evidence of DVT. LENI of the BL LE were
negative for DVT. It is possible the pt has a PE which has been
brought up before, but she could not have a CTA due to her renal
failure, no VQ scan due to pulmonary edema, and no heparin given
her thrombocytopenia and elevated INR. She had no DVT in either
the L or R lower extremity and no portal vein clot on US.
.
Thrombocytopenia: Due to DIC, the pts plts decreased to the 30s
but gradually trended back up to ____ at the time of discharge.
.
#. LLE DVT: Diagnosed [**5-8**]. Was on coumadin as an outpatient.
Her coumadin was stopped given her DIC and coagulopathy. Repeat
LE US showed no DVT. In discussion with hematology oncology, it
was felt further anticoagulation is not necessary.
.
.#. Hypernatremia: Thought to be due to poor po intake. The
patient had a sodium up to 149, improved with D5W.
.
#. Hypoglycemia/Diabetes Mellitus Type II, controlled, no
complications: Hypoglycemia on admission was thought to be in
setting of liver failure. This was treated with several days of
D5W infusion. She was maintained on sliding scale insulin.
,
# Pleural Effusions: [**Month (only) 116**] be related to 3rd spacing in setting
of acute illness, chronic CHF. Her CHF was treated as per above.
.
#. Hypothyroidism: Labs unreliable in setting of acute illness.
Most recently pts levothyroxine had been increased to 88 mcg as
outpatient due to elevated TSH. She was continued on this dose.
.
#. COPD: No evidence of flare. She was continued on
albuterol/ipratropium nebs prn
.
# Depression: holding wellbutrin in setting of hepatic failure
.
#. FEN. Thin liquids, Ground consistency solids; w
Medications on Admission:
colace
coumadin 2 mg daily
omeprzole 20 mg daily
Lasix 20 mg in AM and 80 mg in PM
Vit D 400
Plavix 75 mg daily
metoprolol 25 mg daily
lisinopril 40 mg daily
HCTZ 25 mg daily
Buproprion 150 mg daily
ASA 81 mg daily
Neurontin 100 mg at night
Levothyroxine 75 mcg daily
Imdur 30 mg daily
Ultram
MS [**First Name (Titles) **] [**Last Name (Titles) 8910**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Last Name (Titles) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup [**Last Name (Titles) **]: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Furosemide 20 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine 88 mcg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet [**Last Name (Titles) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Carvedilol 25 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Norvasc 5 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 1* Refills:*2*
10. Tramadol 50 mg Tablet [**Last Name (STitle) **]: [**1-1**] pill Tablet PO Q12H (every 12
hours) as needed for PRN PAIN.
Disp:*30 Tablet(s)* Refills:*0*
11. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Bupropion 150 mg Tablet Sustained Release [**Month/Day (2) **]: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
13. Vitamin D 1,000 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
14. Plavix 75 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Day (2) **]:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute liver failure
Acute renal failure
Diffuse intravascular coagulation
Hypoglycemia
Acute on chronic systolic heart failure
Delirium
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with acute liver failure, acute renal failure,
hypoglycemia, and delerium. You were treated supportively. You
also developed acute heart failure, which was treated with
diuretics.
Followup Instructions:
1. Neurology: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]; appointment on [**11-12**] at 1
PM; [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Hospital1 18**],
Phone:[**Telephone/Fax (1) 657**]
.
2. Hepatology (Liver doctor): Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2127-10-27**] 12:00 PM, at [**Hospital1 18**] [**Hospital Unit Name 3269**], [**Hospital Ward Name 517**], [**Location (un) **], Liver Center
.
3. Needs appt with Dr. [**Last Name (STitle) 23537**] (a resident at [**Company 191**]) [**Telephone/Fax (1) 250**]
4. Needs appt with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**3-4**] weeks
|
[
"V12.51",
"357.2",
"414.01",
"285.21",
"038.9",
"403.90",
"286.6",
"241.1",
"250.80",
"331.0",
"585.3",
"496",
"250.40",
"272.4",
"V58.61",
"425.4",
"070.44",
"294.10",
"995.94",
"276.2",
"276.0",
"428.0",
"250.60",
"428.23",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18813, 18870
|
8532, 16312
|
295, 301
|
19065, 19074
|
3029, 8509
|
19320, 20098
|
1980, 2147
|
16715, 18790
|
18891, 19044
|
16338, 16692
|
19098, 19297
|
2162, 3010
|
237, 257
|
329, 1116
|
1138, 1607
|
1623, 1964
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,674
| 158,715
|
40205
|
Discharge summary
|
report
|
Admission Date: [**2103-11-12**] Discharge Date: [**2103-11-22**]
Date of Birth: [**2041-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
percocet
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2103-11-14**]
1. Coronary artery bypass grafting x3 with the left internal
mammary artery to left anterior descending artery, and reverse
saphenous vein graft to the posterior descending artery and the
obtuse marginal artery.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Regent
mechanical valve, model #23AGFN-258.
History of Present Illness:
62 year old male over the last six months has been having chest
pain that he initially thought was was due to his reflux
disease. Symptoms are described as upper chest and throat
discomfort that is associated with nausea, shortness of breath,
and lightheadedness occuring with exposure to cold and when
working. Symptoms resolve with rest.
Past Medical History:
Hypertension
Hyperlipidemia
Peripheral Vascular Disease
Gastroesophageal reflux disease
Past Surgical History
Right common iliac artery stent and right external iliac artery
balloon angioplasty [**2-/2102**]
Social History:
Race: Caucasian
Last Dental Exam: > 1 year
Lives with: spouse
Occupation: Electrician
Tobacco: quit [**2075**] - 20 pack year history
ETOH: 2 beverages daily wine with rum and coke on weekends
Previous cocaine years ago
Family History:
Family History: Father CAD in 60's
Physical Exam:
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 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: Grossly intact [x]
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: ?murmur vs bruit
Pertinent Results:
[**2103-11-14**] Echo: Pre Bypass: Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is critical aortic valve
stenosis (valve area = 0.76 cm2). No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen
Post Bypass: Patient is A paced on Phenylepherine infusion.
There is a mechanical prosthesis in the aortic valve position
(#23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] per surgeon). Peak gradient 9-16 mm hg, mean
gradients 3-6 mm Hg. There is a paravaluvlar leak with an
eccentric jet directed across the lvot toward the anterior
mitral leaflet. The jet appears mild, but evaluation is limiated
by shadowing and eccentric nature. Normal symmetric washing jets
are also seen. Preserved biventricular function, LVEF > 55%. MR
remains mild, TR remains mild. Aortic contours intact. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
[**2103-11-13**] Vein mapping: Bilateral greater saphenous veins are
patent.
[**2103-11-13**] Carotid U/S: Findings are consistent with less than 40%
stenosis bilaterally.
Admission labs:
[**2103-11-12**] 06:50PM BLOOD WBC-8.5 RBC-4.98 Hgb-15.7 Hct-45.6 MCV-92
MCH-31.6 MCHC-34.5 RDW-13.3 Plt Ct-220
[**2103-11-19**] 06:30AM BLOOD WBC-10.9 RBC-3.93* Hgb-12.3* Hct-35.7*
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.2 Plt Ct-249
[**2103-11-12**] 06:50PM BLOOD PT-13.1 PTT-22.2 INR(PT)-1.1
[**2103-11-18**] 07:00AM BLOOD PT-14.1* PTT-31.1 INR(PT)-1.2*
[**2103-11-19**] 06:30AM BLOOD PT-15.0* PTT-81.8* INR(PT)-1.3*
[**2103-11-12**] 06:50PM BLOOD Glucose-133* UreaN-19 Creat-1.1 Na-138
K-4.6 Cl-100 HCO3-29 AnGap-14
[**2103-11-19**] 06:30AM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-131*
K-3.8 Cl-98 HCO3-28 AnGap-9
[**2103-11-12**] 06:50PM BLOOD Albumin-4.4 Calcium-9.5 Phos-4.1 Mg-2.1
Discharge labs:
[**2103-11-20**] 04:50AM BLOOD WBC-12.1* RBC-3.72* Hgb-11.6* Hct-33.9*
MCV-91 MCH-31.2 MCHC-34.2 RDW-13.2 Plt Ct-267
[**2103-11-20**] 04:50AM BLOOD Plt Ct-267
[**2103-11-20**] 04:50AM BLOOD PT-17.1* PTT-88.3* INR(PT)-1.5*
[**2103-11-20**] 04:50AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-134
K-4.7 Cl-100 HCO3-28 AnGap-11
[**2103-11-20**] 04:50AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
Radiology Report CHEST (PA & LAT) Study Date of [**2103-11-19**] 9:05 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 88271**]
Final Report
There is no significant interval change or may be small interval
decrease in the right apical pneumothorax. There is a small
amount of left pleural
effusion, grossly unchanged. Multiple left rib fractures are
unchanged.
Cardiomediastinal silhouette is unchanged. The replaced aortic
valve is in
unchanged position.
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac cath in outside hospital which
revealed severe coronary artery disease. Following cath he was
transferred to [**Hospital3 **] for surgical management. Upon
admission he [**Hospital3 1834**] pre-operative work-up, including
vein-mapping, carotid U/S and dental clearance. On [**11-13**] he was
brought to the operating room where he [**Month/Year (2) 1834**] an AVR/CABG.
Please see operative report for surgical details. In summary he
had: Coronary artery bypass grafting x3 with the left
internal mammary artery to left anterior descending artery, and
reverse saphenous vein graft to the posterior descending artery
and the obtuse marginal artery.
2. Aortic valve replacement with a 23-mm St. [**Male First Name (un) 923**] Regent
mechanical valve, model #23AGFN-258. His bypass time was 126
minutes, with a crossclamp of 111 minutes.
He tolerated the operation well and 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. Beta blockers and diuretics
were started and he was gently diuresed towards his pre-op. On
post-op day one he was transferred to the step-down floor for
further care. Chest tubes and epicardial pacing wires were
removed per cardiac surgery protocol. He did have a tiny right
apical pneumothorax post-operatively, which was stable on his
chest x-ray before discharge. Coumadin was started on post-op
day two and Heparin the following day for mechanical valve
anticoagulation. Both were titrated until his INR was
therapeutic for his mechanical valve with goal INR 3.0-3.5.
[**Last Name (un) **] diabetes center was consulted for assistance with
diabetes management, he was started on Metformin following
[**Last Name (un) **] recommendations and he was instructed on checking finger
sticks at home. He developed diarrhea 2 hours after each dose of
metformin. He refused to take metformin and was started on
glipizide 2.5mg [**Hospital1 **]. He worked with physical therapy for
strength and mobility. Beta blockers and ACE were started for
hemodynamic management. The remainder of his post-operative stay
was uneventful.
On post-op day 8 his INR was therapeutic and was discharged home
with VNA services and the appropriate follow-up appointments.
His INR will be followed by [**Hospital **] [**Hospital 197**] clinic and they
have been contact[**Name (NI) **] with recent Coumadin doses and INR levels.
Medications on Admission:
Aspirin 325 mg daily
Quinapril/HCTZ 20/12.5 mg twice a day
Atenolol 50 mg daily
Crestor 20 mg daily
Omeprazole 20 mg twice a day
Fish Oil twice day
Metamucil daily
Vitamin E daily
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Coumadin 5 mg Tablet Sig: Two (2) Tablet PO once a day: as
directed based on INR for mechcanical valve
INR goal 3.0-3.5.
Disp:*60 Tablet(s)* Refills:*2*
15. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Aortic Stenosis and Coronary artery disease s/p Aortic Valve
Rreplacement(23mm StJude Mech)/Coronary Artery Bypass Graft x 3
(LIMA>LAD,SVG>OM,SVG>PDA)
Past medical history:
Hypertension
Hyperlipidemia
Peripheral Vascular Disease s/p Right common iliac artery stent
and right external iliac artery balloon angioplasty [**2-/2102**]
Gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Vicodan
Incisions:
Sternal - healing well, no erythema or drainage
Leg- Left -healing well, no erythema or drainage.
Edema 1+ pedal edema bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The following appointments have been scheduled for you
Your surgeon Dr.[**Last Name (STitle) **] # [**Telephone/Fax (1) 170**] on [**2103-12-12**] at 1:30pm
Your cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] at MWMC on [**2103-12-20**] at 3pm
Please call and schedule a follow up appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**] 5[**Telephone/Fax (1) 37064**] in [**2-19**] weeks
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 3.0-3.5
First draw [**2103-11-23**]
Results to phone fax [**Hospital 88272**] [**Hospital 197**] Clinic [**Telephone/Fax (1) 31080**]
Completed by:[**2103-11-22**]
|
[
"530.81",
"E878.2",
"250.00",
"E932.3",
"440.20",
"511.9",
"424.1",
"285.1",
"787.91",
"414.01",
"V15.82",
"E937.8",
"V58.61",
"276.1",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"35.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9709, 9772
|
5068, 7591
|
287, 637
|
10178, 10412
|
2195, 3479
|
11252, 11952
|
1507, 1527
|
7821, 9686
|
9793, 9944
|
7617, 7798
|
10436, 11229
|
4195, 5045
|
1542, 2176
|
237, 249
|
665, 1007
|
3495, 4179
|
9966, 10157
|
1254, 1475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,787
| 158,429
|
20415
|
Discharge summary
|
report
|
Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-23**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Tetanus Toxoid / Fish Oil
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain ans shortness of breath
Major Surgical or Invasive Procedure:
[**2106-4-15**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM,
SVG to PDA), Aortic Valve Replacement w/ 21mm St. [**Male First Name (un) 923**] tissue
valve
History of Present Illness:
83 y/o female with known coronary artery disease s/p stent in
[**2102**] and s/p Myocardial Infarction in [**6-18**] now with increased
dyspnea on exertion and more frequent angina. Presented to OSH 2
wks ago with SOB. R/o for MI and treated for community acquired
pneumonia and discharged. Had 2 episodes of angina and SOB since
that admission. Transferred from rehab to MWMC for cardiac cath.
Cath revealed three vessel disease. She was than transferred to
[**Hospital1 18**] for surgical management.
Past Medical History:
Coronary Artery Disease s/p LAD stent, h/o Aortic Stenosis,
Diabtes Mellitus, h/o Breast Cancer s/p
radiation/chemo/implants, Congestive heart failure,
Hypertension, Chronic pleural effusion, Diverticulitis, s/p
Colonic resection [**2082**], chronic renal insufficiency, pulmonary
hypertension
Social History:
Lives with son and his family. Denies tobacco or ETOH use.
Family History:
Father and brother with CAD.
Physical Exam:
VS: 82 108/48 18 97% 68.4kg
Gen: NAD
Neuro: A&O x 3, MAE, Non-focal
HEENT: PERRL, EOMI, Anicteric, nl buccosa
Neck: Supple, FROM, -carotid bruit
Pulm: CTAB
CV: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, -edema, -varicosities
Pertinent Results:
[**2106-4-6**] CXR: Compared with [**2103-3-28**], there is new diffuse
haziness over the right hemithorax consistent with a moderate
pleural effusion. There is a triangular density at the right
lung base, which may indicate right middle lobe collapse. The
left lung remains clear. No overt CHF.
[**2106-4-7**] CNIS: There is no significant common or internal carotid
stenosis bilaterally.
[**2106-4-8**] Chest CT: 1. Longstanding, large right pleural effusion
with relaxation atelectasis. No pleural mass or other evidence
of intrathoracic malignancy or infection. Small left pleural
effusion. 2. Widespread vascular calcifications including three
major coronary arteries. Significant narrowing of the origin of
innominate trunk may be present. Calcific aortic stenosis. 3.
Right breast skin thickening with retroareolar mass containing
clips and calcifications. All the findings might represent post-
treatment appearance but in the absence of previous imaging
including dedicated mammography recurrence cannot be excluded.
4. General fat stranding might represent anasarca.
[**2106-4-11**] Chest CT: 1. Improving small right pleural effusion
without evidence for underlying mass. 2. Right breast skin
thickening and retroareolar mass with clips and calcifications,
most likely postoperative but indeterminate. Further imaging
including dedicated mammography would be necessary if there is
clinical suspicion. 3. Widespread atherosclerotic disease
involving the aorta, its major branches, and coronary arteries.
[**2106-4-15**] Echo: PRE-BYPASS: The left atrium is mildly dilated.
Moderate to severe spontaneous echo contrast is present in the
left atrial appendage. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe regional left ventricular systolic dysfunction with
focalities in the mid and apical anterior, anteroseptal,
inferoseptal walls. There is severe apical akinesis and apical
inferior and lateral walls as well. Rest of the segments are
mildly hyponetics. Overall left ventricular systolic function is
severely depressed with an EF of 25%. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the thoraic aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild to moderate ([**12-15**]+) aortic regurgitation is seen.
Note the low Cardiac output as the peak and mean gradients are
28 and 16mm of Hg only. No inotropes given pre bypass to see the
change in gradient with the increase in cardiac output due to
the severe coronary lesions. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-15**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion. Post_bypass: Patient is on
milrinone (0.25mcg/kg/min), epinephrine (0.02mcg/kg/min).
Thoracic aortic contour is preserved. Normal RV systolic
function. Mild improvement in the overall LV systolic function
to LVEF of 30%-35%. Mild MR. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 43404**] is seen well seated
in the native aortic positiion, with no leaks and a residual
mean gradient of 16mmof hg.
[**2106-4-20**] CXR: Questionable new loculated right basilar
pneumothorax status post chest tube removal with either
atelectasis or fluid within the fissure on the right. 2.
Slightly increased left pleural effusion with underlying
atelectasis/consolidation.
[**2106-4-6**] 05:00PM BLOOD WBC-8.5 RBC-3.40* Hgb-9.8* Hct-29.8*
MCV-88 MCH-28.9 MCHC-33.0 RDW-17.2* Plt Ct-396#
[**2106-4-14**] 06:55AM BLOOD WBC-5.5 RBC-3.66* Hgb-10.4* Hct-32.1*
MCV-88 MCH-28.5 MCHC-32.5 RDW-17.7* Plt Ct-308
[**2106-4-21**] 07:00AM BLOOD WBC-9.0 RBC-3.36* Hgb-9.9* Hct-30.0*
MCV-89 MCH-29.5 MCHC-33.1 RDW-16.7* Plt Ct-165
[**2106-4-6**] 05:00PM BLOOD PT-12.6 PTT-53.0* INR(PT)-1.1
[**2106-4-14**] 06:55AM BLOOD PT-13.0 PTT-73.0* INR(PT)-1.1
[**2106-4-20**] 03:04AM BLOOD PT-13.6* PTT-35.9* INR(PT)-1.2*
[**2106-4-6**] 05:00PM BLOOD Glucose-335* UreaN-62* Creat-2.0* Na-134
K-4.6 Cl-104 HCO3-21* AnGap-14
[**2106-4-14**] 06:55AM BLOOD Glucose-113* UreaN-69* Creat-1.9* Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
[**2106-4-21**] 07:00AM BLOOD Glucose-77 UreaN-82* Creat-2.5* Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2106-4-21**] 07:00AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.2
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 1391**] was transferred to [**Hospital1 18**]
for surgical care. She underwent the routine pre-operative
testing. A dental consult was performed given the planned aortic
valve replacement. On her pre-op chest x-ray there was a new
diffuse haziness over the right hemithorax consistent with a
moderate pleural effusion. She also underwent chest CT which
revealed a right breast skin thickening with retro areolar mass.
The thoracic and pulmonary services were [**Hospital1 4221**] for effusion
drainage and a breast surgery consult was obtained secondary to
new right breast findings. Her effusion was negative for
malignant cells. Medical management was continued for several
days prior to surgery and was treated for UTI with antibiotics.
She was cleared for surgery by thoracic and breast surgical
services. She will resume her close observation at [**Hospital1 25157**] for her history of breast cancer. On [**2106-4-15**] she
was taken to the operating room where she underwent coronary
artery bypass grafting to three vessels and aortic valve
replacement with a tissue prosthesis. Please see operative
report for surgical details. Within 24 hours she was weaned from
sedation, awoke neurologically intact and was extubated. She
required inotropic support for several days which was eventually
weaned off. Beta blockers and diuretics were started and she was
gently diuresed towards he pre-op weight. Chest tubes were
removed on post-op day two and epicardial pacing wires on
post-op day four. Do to a rising creatinine her diuretics were
stopped on post-op day four. On post-op day five she was
transferred to the telemetry floor for further care. As her
creatinine stabilized, low dose diuretics were resumed given her
peripheral edema and preoperative daily requirement of 80mg
daily. Her electrolytres and renal function will be followed at
rehab and her dose will be adjusted based on her volume status.
The physical therapy service was [**Date Range 4221**] for assistance with
her postoperative strength and mobility. Ciprofloxacin was
started for a urinary tract infection. The nutritionist
recommended supplemental shakes between meals which were
started. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for a sacral/coccyx
ulcer and recommendations were made and closely followed to
protect from further skin breakdown. Her plavix was continued
given her recent drug eluting stents. The length of treatment
with plavix will be decided by her cardiologist Dr. [**Last Name (STitle) 2232**]. Ms.
[**Known lastname 1391**] continued to make steady progress and was discharged to
rehabilitation on [**2106-4-23**]. She will follow-up with Dr. [**Last Name (STitle) **],
her cardiologist and her primary care physician. [**Name10 (NameIs) **] will also
follow-up with the breast [**Name10 (NameIs) 5059**] at [**Hospital1 **] for further care
of her right breast mass.
Medications on Admission:
Glipizide 5mg qam 2.5mg qpm, Lisinopril 2.5mg qd, Lasix 80mg qd,
Lopressor 100mg [**Hospital1 **], Lipitor 40mg qd, Plavix 75mg qd, Aspirin
325mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
4. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
Length of treatment to be addressed by cardiologist.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Diabtes Mellitus, h/o Breast Cancer s/p
radiation/chemo/implants, s/p LAD stent, Congestive heart
failure, Hypertension, Chronic pleural effusion, Diverticulitis,
s/p Colonic resection [**2082**], chronic renal insufficiency,
pulmonary hypertension
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Take lasix as directed. Weigh patient daily and
follow/replete electrolytes as needed. After 7 days, reassess if
more diuretic needed.
8) Please monitor BUN/CREATINE at rehab.
9) Take ciprofloxacin for 5 more days to stop [**2106-4-28**].
10) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Last Name (STitle) **]) in 1 month ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 2232**] (cardiologist) in [**12-15**] weeks
Dr. [**Last Name (STitle) 6051**] (PCP) in [**1-16**] weeks ([**Telephone/Fax (1) 54710**]
Please call all providers for appointments
Completed by:[**2106-4-23**]
|
[
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"593.9",
"250.00",
"707.8",
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"414.01",
"416.0",
"457.0",
"412",
"V15.3",
"411.1",
"428.0",
"611.72",
"511.9",
"V10.3",
"V43.82",
"V17.3",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"34.91",
"36.15",
"36.12",
"99.04",
"39.61",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
10327, 10467
|
6099, 9055
|
297, 466
|
10870, 10879
|
1700, 6076
|
11837, 12171
|
1407, 1437
|
9254, 10304
|
10488, 10849
|
9081, 9231
|
10903, 11814
|
1452, 1681
|
223, 259
|
494, 998
|
1020, 1315
|
1331, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,106
| 155,684
|
34846
|
Discharge summary
|
report
|
Admission Date: [**2132-9-25**] Discharge Date: [**2132-10-3**]
Date of Birth: [**2087-6-17**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Hematobillia, Acute Blood Loss Anemia, Alcohol Withdrawal
Major Surgical or Invasive Procedure:
ERCP x 2
Mesenteric angio x 2
Pseudoaneurysm coil embolized
History of Present Illness:
44 year old male with history of duodenal mass and chronic
idiopathic GI bleeding transferred urgently from [**Hospital3 4107**]
for workup of hematobillia.
The patient has had multiple EGD's for workup of his duodenal
mass and bleeding, which so far have been unrevealing. His last
EGD prior to this admission was on [**2132-8-8**] which apparently
demonstrated blood in the duodenum with possible hematobillia as
well as gastritis and the duodenal mass. A Biopsy of the mass
was negative for a diagnosis. A Colonoscopy in [**5-/2132**] was also
negative for pathology.
He presented to [**Hospital3 4107**] 1 day prior to admission with
complaints of nausea, vomiting, abdominal pain and melena. Prior
to this admission he was seen on multiple occasions at [**Hospital1 **]
hospitals for Acute Alchol Intoxication as well as similar
complaints. He reports the pain, as always is dull and aching.
This was associated with nausea, vomiting for the 5 days prior
to admission accompanied by anorexia. The patient states, that
despite the nausea and vomitting he continued to drink with last
drink 2 days prior to admission with about 4 beers. He was
transfused 3 units of PRBC at [**Hospital3 **].
He states his vomit was non-bloody but he did have hematochezia
and melena in stool. At [**Hospital3 **] an EGD was performed by
Dr. [**First Name (STitle) 15532**] on [**9-25**]/8 which again demonstrated a duodenal mass.
There was no bleeding however seen from that mass, but of great
concern, he was noted to have hematobilia with frank blood
pouring out of his bile duct. He was transferred for urgent ERCP
consultation.
Past Medical History:
chronic idiopathic GI bleeding
Alcohol Dependence with withdrawal induced seizures
Duodenal mass (3-4 cm in size, normal mucosa, stable on CT scan
for the last 3 years)
chronic pancreatitis
Type 2 Diabetes
Benign Hypertension
Diverticulosis
psoriasis
Depression
Social History:
- TOB, drinks 12 packs of beer a day, lives with girl friend
Family History:
Non-Contributory
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, + Vomitting, - Diarhea, + Abdominal Pain, -
Constipation, + Hematochezia, + Melena
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: + Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99, 146/86, 106, 97%
GEN: NAD
Pain: [**3-31**]
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Diffuse Tenderness, ND, +BS, - CVAT, - Rebound/Guarding,
GAUIAC (+)
EXT: - CCE
NEURO: CAOx3, Non-Focal, Tremulous, anxious
Pertinent Results:
[**2132-9-26**] 08:10AM BLOOD WBC-9.1 RBC-3.74* Hgb-11.2* Hct-32.6*
MCV-87 MCH-29.9 MCHC-34.3 RDW-15.3 Plt Ct-161
[**2132-9-25**] 09:00PM BLOOD WBC-7.5 RBC-3.98* Hgb-11.5* Hct-34.2*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.9 Plt Ct-165
[**2132-9-26**] 08:10AM BLOOD PT-13.2 PTT-29.5 INR(PT)-1.1
[**2132-9-26**] 08:10AM BLOOD Glucose-180* UreaN-9 Creat-0.7 Na-133
K-4.2 Cl-97 HCO3-20* AnGap-20
[**2132-9-25**] 09:00PM BLOOD Glucose-138* UreaN-9 Creat-0.6 Na-134
K-3.8 Cl-98 HCO3-22 AnGap-18
[**2132-9-26**] 08:10AM BLOOD ALT-22 AST-27 LD(LDH)-154 AlkPhos-85
Amylase-62 TotBili-0.5
[**2132-9-25**] 09:00PM BLOOD ALT-25 AST-36 LD(LDH)-146 AlkPhos-88
Amylase-57 TotBili-1.2
[**2132-9-26**] 08:10AM BLOOD Lipase-56
[**2132-9-25**] 09:00PM BLOOD Lipase-35
[**2132-9-26**] 08:10AM BLOOD Albumin-4.2 Calcium-8.3* Phos-2.5* Mg-1.7
[**2132-9-25**] 09:00PM BLOOD Albumin-4.1 Calcium-8.7 Phos-2.3* Mg-1.7
ERCP [**2132-9-26**]: Findings: Other There was no evidence of
esophageal varices.
Stomach: Limited exam of the stomach was normal
Protruding Lesions A sub-mucosal non-bleeding 4cm mass was
found at the duodenal bulb. The mass caused a partial
obstruction. The scope traversed the lesion. There was a 8 mm
ulceration on the mass that was not bleeding.
Major Papilla: Blood was seen coming from the major papilla at
the level of the pancreatic orifice. These findings are
consistent with hemosuccus pancreaticus.
Minor Papilla: Blood was seen coming from the minor papilla.
Cannulation: Cannulation of the pancreatic duct was successful
and superficial with a sphincterotome using a free-hand
technique. Contrast medium was injected resulting in partial
opacification. A 0.035in in diameter and 260cm in length
straight tip glidewire was placed.
Pancreas: An irregular stricture that was 8mm long was seen at
the main pancreatic duct. These findings are compatible with
chronic pancreatitis.
Impression: There was no evidence of esophageal or gastric
varices.
Mass in the duodenal bulb
Blood seen coming from the major and the minor papilla. The
blood from the major papilla appeared to be coming from the
pancreatic orifice.
There were multiple calcifications seen in the pancreas.
An irregular stricture that was 8mm long was seen at the main
pancreatic duct. This is compatible with chronic pancreatitis
secondary to alcohol abuse
.
ERCP [**9-30**]
Minor Papilla: Blood was seen in the minor papilla consistent
with hemosuccus pancreaticus.
Impression: Hemosuccus pancreaticus in the minor papilla
3 cm submucosal duodenum bulb mass causing partial obstruction
NG tube was placed post endoscopy and confirmed with
auscultation
Recommendations: Angiography to identify the source of bleeding
Follow H/H
EUS to assess the lesion within the duodenum bulb according to
angiographic evaluation
.
Radiology Report CTA ABD W&W/O C & RECONS Study Date of [**2132-9-26**]
4:34 PM
IMPRESSION:
1. Findings consistent with acute on chronic pancreatitis. The
pancreatic duct is dilated up to approximately 1.7 cm in the
pancreatic neck consistent with the patient's provided history
of pancreatic stricture. No evidence of pseudoaneurysm, splenic
vein thrombosis or gallbladder hemorrhage.
2. Mild tree in [**Male First Name (un) 239**] opacities are noted in the left lower lobe.
These findings may be seen with bronchopneumonia or aspiration.
.
Radiology Report MESSENERTIC Study Date of [**2132-10-1**] 8:38 AM
Preliminary Report !! PFI !!
Uncomplicated mesenteric angiogram demonstrating aberrant
vasculature
including the following:
1. Splenic artery arising from the abdominal aorta directly.
2. Hepatic artery (common) and SMA showing a common trunk from
the aorta.
The GDA arises from the mid hepatic artery heading cephalad and
lies parallel
to the artery (hepatic). Superior pancreatic artery arising from
the GDA.
3. PIPD arising from a short trunk off of the SMA that is
tortuous. Of note,
small pseudoaneurysm was seen arising from the PIPD. However,
given the
tortuosity of the vasculature we could not cannulate this vessel
thus cannot
treat the false aneurysm. In light of the contrast given it was
decided to
repeat the examination at a later date given the patient's
hemodynamic
stability.
.
Radiology Report MESSENERTIC Study Date of [**2132-10-2**] 9:32 AM
Preliminary Report !! PFI !!
1. Mesenteric angiogram again demonstrating aberrant vasculature
with a
replaced common hepatic artery arising from a common trunk off
of the
abdominal aorta with the SMA as well as a solitary splenic
artery arising in
the expected region of the celiac trunk. Again, a 9.3 x 5.0 mm
pseudoaneurysm
was identified within the distribution of the anterior superior
pancreaticoduodenal artery.
2. Cannulation of diseased vessel with coil embolization and
thrombin
injection of pseudoaneurysm as well as coil embolization of
diseased anterior
superior pancreaticoduodenal artery. Prior to embolization, note
was made of
contrast extending from the pseudoaneurysm in to the presumed
pancreatic duct
and then in to the duodenum consistent with the patient's
history.
3. Completion angiogram demonstrating no direct blood flow to
the
pseudoaneurysm.
.
COMPLETE BLOOD COUNT Hct
[**2132-10-2**] 07:15AM 29.3*
.
Brief Hospital Course:
1. Acute Blood Loss Anemia due to GI Bleeding due to pancreatic
hemorage causing Hematobillia
- Urgent ERCP consultation
- EGD/ERCP today
- Type & Screen through [**2132-9-28**]
- IV hydration
- NPO
- Pain Control
- Antiemetics
- PPI, Will ask GI about stopping sucralafate
- Given ERCP results, will obtain CTA-P and contact IR about
coil/embolization
- concern for varix vs. pseudoaneurysmal bleed
- Given concern of uncontrollable bleeding, despite currently
hemodynamically stable, in discussion with Dr. [**Last Name (STitle) **] of
Surgery, we will transfer him to surgery after the CTA-P on the
[**Hospital Ward Name 517**], given availability of an urgent OR if needed.
2. Alcohol Withdrawal, Substance Dependence - Alcohol
- Patient in active withdrawal. He was monitored closely and had
a CIWA scale.
- Increase valium to 10mg, and change interval to Q2h
- Social Work Consultation
- Thiamine, Folate, MVI
3. Type 2 Diabetes Uncontrolled without Complications
- Hold Glyburide and Metformin while NPO
- HISS
- Careful monitoring of blood glucose
4. Benign Hypertension
- Lisinopril
- Metoprolol
5. Depression
- Topamax, Venlafexine
=====================================================
He was transferred to the Surgery Service and was in the ICU for
monitoring of DTs and possible hemodynamic decompensation.
The following procedures were performed:
[**9-26**] CTA [**9-26**] CT ABD: Acute-on-chronic pancreatitis with the
pancreatic duct measuring up to approximately 1.7 cm in the
pancreatic neck/proximal body. No evidence of intra- or
extra-hepatic bile duct dilation. The gallbladder appears normal
without intraluminal hyper-attenuation to suggest hemorrhage or
blood clot.
No evidence of pseudoaneurysm. Portal venous system is patent.
[**9-26**] ERCP: no evidence esoph/[**Last Name (un) **] varices, mass in the duodenal
bulb, irreg stricture 8mm long at the main pancreatic duct
[**2132-9-30**] ERCP: Hemosuccus pancreaticus in the minor papilla;
Submucosal mass in the duodenal bulb; Otherwise normal ercp to
third part of the duodenum.
[**10-1**] Mesenteric angio: no definite bleeding source ID'd. variant
anatomy. will bring back for left brachial approach.
[**10-2**] Mesenteric angio: pseudoaneurysm coil embolized (5th order
branches) Thrombin also injected. Need to check groin. If he
rebleeds, probalbly from the vessels distal to the neck (we
could not get to them)
CV: He was tachycardic, related to relative hypovolemia and
[**Name (NI) **]. This resolved eventually and he was CV and hemodynamically
stable.
Heme: His HCT was monitored closely and he received transfusions
as necessary for acute blood loss anemia. His INR was elevated
and he received FFP as necessary prior to his angio procedures.
Following his Angio on [**2132-10-2**] his HCT was stable at 25.6.
Endo: Once tolerating a diet, his home meds, including Metformin
and Glyburide were restarted for diabetes. He will continue with
his normal blood glucose monitoring and regimine at home.
FEN: His diet was advanced following embolization and he was
tolerating food.
Social: He is agreeable to [**Hospital **] rehab next week.
Medications on Admission:
Lisinopril 10mg daily
glyburide 6mg [**Hospital1 **]
topamax 25mg [**Hospital1 **]
pepcid 20mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lopressor 25mg [**Hospital1 **]
thiamine 100mg daily
folate 1mg daily
venlafaxine 75mg daily
sucralfate 1gram qid
vitamin d [**2124**] iu daily
lunesta 2mg qhs
mvi 1 tab daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
EtOH Withdrawl
Hemobilia / GI Bleed / Acute Blood loss anemia
Duodenal mass and stricture in head of pancreas
Hemosuccus pancreaticus in the minor papilla
Pseudoaneurysm
Tachycardia
Discharge Condition:
Good
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 skin, or the whites of your eyes become yellow.
* 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.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-5**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
* No Alcohol
Followup Instructions:
Follow-up with GI for a repeat ERCP on Tuesday [**2132-10-7**]. Arrive
at 1:00pm to [**Hospital Ward Name 1950**] [**Location (un) **].
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call [**Telephone/Fax (1) 1231**]
to schedule an appointment.
Follow-up with Dr. [**Last Name (STitle) 174**] from GI on [**10-27**] at 11:00 at [**Hospital Ward Name 452**]
[**Location (un) 453**]. Call ([**Telephone/Fax (1) 22346**] with questions or concerns.
Completed by:[**2132-10-3**]
|
[
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"577.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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icd9pcs
|
[
[
[]
]
] |
12813, 12819
|
8467, 11605
|
329, 391
|
13045, 13052
|
3247, 8444
|
14526, 15020
|
2422, 2440
|
11977, 12790
|
12840, 13024
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11631, 11954
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13076, 14503
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2980, 3228
|
231, 291
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419, 2043
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2065, 2328
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2344, 2406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,263
| 187,032
|
14401
|
Discharge summary
|
report
|
Admission Date: [**2126-4-20**] Discharge Date: [**2126-4-23**]
Date of Birth: [**2079-9-8**] Sex: M
Service: MEDICINE
Allergies:
Mefoxin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 42667**] is a very pleasant 46 yo man with Ehlers-Danlos
syndrome (type 4), h/o multiple lower GIB requiring
transfusions, s/p R colectomy for ischemia, carotid artery
aneurysms, who presented to an OSH with hemoptysis.
.
He was in his usual state of health on the morning of admission
when he had a 15-minute period of scant hemoptysis (~2
tablespoons of blood). He denied any chest pain or shortness of
breath.
.
At the OSH, he had a chest x-ray that demonstrated blunting of
the costophrneic angle, a normal Hct and a normal EKG. He was
transferred to the [**Hospital1 18**] for CTA out of concern for PE and the
likely management deciions that could ensue from the diagnosis.
.
In the [**Hospital1 18**] ED, his initial VSs were HR 82, BP 110/70, RR 22,
97% 2LNC. His blood pressure remained stable (>115 systolic
throughout), and he was never tachycardic. CTA of the chest
demonstrated bilateral pulmonary embolism.
.
After discussion with [**Hospital1 1106**] surgery, the decision was made to
anticoagulate. The pt received a bolus of heparin (5,400 units)
and was started on a 1,200 unit/hr drip and sent to the ICU for
closer monitoring.
.
Upon arrival to the ICU, the pt denies chest pain, shortness of
breath or recurrent hemoptysis. He denies any recent travel or
illnesses. He denies recent surgery or immobilization.
Past Medical History:
- Ehlers-Danlos syndrome, type 4 ([**Hospital1 1106**] type) with GI
bleeding and multiple aneurysms
- multiple GI bleeds: 17 Unit bleed (rectal bleeding) in
[**11-1**], tagged scan +RUQ. CT scan showed extravasation of
contrast
at colon anastomosis. treated with DDAVP and bleeding eventually
stopped. Most recent lower GIB [**1-2**].
- h/o right colectomy for ischemic right colon
- s/p multiple SB resections
- short bowel syndrome
- h/o GERD
- Gallstones
- celiac artery aneurysm
- bilateral club feet, with ankle surgeries
- spontaneous RP bleed in [**2119**], no intervention
- HTN
- Left inguinal hernia repair
- h/o TIA w/ temporary Left eye blindness
- Bilateral carotid artery aneurysm, h/o bilateral carotid
artery thrombi (most recent [**Year (4 digits) 1106**] study only shows L ICA
thrombus)
- s/p bilateral ankle reconstructions
Social History:
No smoking, no drugs, no EtOH, works in computers.
Family History:
NC
Physical Exam:
Vitals: T: 98.3 BP: 130/70 P: 84 R: 12 SaO2: 95%RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, EOMI, no scleral icterus, MMM
Neck: supple, no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: thin legs bilaterally with evidence of prior ankle
surgeries, no swelling, redness in either calf
Pertinent Results:
Admission labs:
WBC-10.3# RBC-5.10# HGB-15.9# HCT-44.9# MCV-88 MCH-31.2
MCHC-35.4* RDW-13.6
PLT COUNT-215
- NEUTS-82.6* LYMPHS-13.3* MONOS-3.2 EOS-0.7 BASOS-0.2
GLUCOSE-98 UREA N-12 CREAT-0.8 SODIUM-142 POTASSIUM-4.3
CHLORIDE-109* TOTAL CO2-23
ALT(SGPT)-23 AST(SGOT)-20 CK(CPK)-115 ALK PHOS-113 TOT BILI-0.8
LIPASE-32
CK-MB-4 ->3
cTropnT-0.03* -><0.01
CK(CPK)-109
proBNP-279*
CTA chest: 1. Massive bilateral acute pulmonary embolism with no
CT evidence of right heart strain.
2. Focal consolidation at the mediastinal aspect of right upper
lobe. This
appearance is most likely related to focal atelectasis.
3. Unusual aneurysmal of the celiac trunk, with possible
dissection of the
common hepatic artery, unchanged, related to underlying
connective tissue
disease.
bilateral LE ultrasound: Left popliteal varix, likely related to
underlying Ehlers-Danlos syndrome, containing non-occlusive
thrombus, with no more central thrombus seen.
CXR: The heart size is normal. There is no change in the
mediastinal contours compared to the prior study. The lungs are
essentially clear. Right hemidiaphragm is elevated with adjacent
pleural thickening, findings are unchanged since [**2124-1-22**]. There is no evidence of failure as well as there is no
increase in pleural effusion or pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 42667**] is a 46yo Man with Ehlers-Danlos syndrome (type 4),
h/o multiple lower GIB requiring transfusions, s/p R colectomy
for ischemia, carotid artery aneurysms, who presented with
hemoptysis and was found to have bilateral massive pulmonary
emboli as well as left poplieal nonocclusive DVT.
.
# Pulmonary embolism: This patient did not at any time have
clinical evidence of hemodynamic compromise or RV dysfunction.
There was no evidence of right heart strain on CT scan; troponin
of <0.1 and BNP of 79 placed him at low risk stratification.
LENIs demonstrated a L popliteal vein thrombus. Per [**Known lastname 1106**]
surgery ([**First Name4 (NamePattern1) 11805**] [**Last Name (NamePattern1) 29316**]), the pt was not a candidate for IVC
filter given the risk of erosion into the vessel wall with his
underlying Ehlers Danlos Syndrome. He received a bolus (5,400
units) and infusion (1,200 units/hr) of heparin was begun in the
ED prior to transfer. He was continued on heparin gtt with goal
PTT of 50-70. Hct was stable during stay, and all stools were
guiac negative. Before discharge he was seen by the hematology
team to discuss need for long term anticoagulation. They
recommended that the patient be discharged with four weeks of
lovenox 60mg sQ [**Hospital1 **], followed by 100mg lovenox SC qday for 8
weeks for a total of three months of anticoagulation. The
patient will call Dr. [**Last Name (STitle) 3060**] for an outpatient hematology
appointment during the next 1-2 months to discuss whether he
will need further work-up for etiology or prolonged
anticoagulation. Due to insurance limitations (they will only
pay in three week increments for lovenox) the patient was
discharged with lovenox 60mg sq [**Hospital1 **] for three weeks, followed by
100 mg sq qday for 9 weeks. Prior to discharge his prescription
was called in to his local CVS and the pharmacist ordered this
to be delivered the following morning. He was given education
about self injection and gave himself one dose of lovenox
(overlapped by one hour with heparin drip) in the evening prior
to discharge.
The etiology of thromboembolism remained uncertain. The patient
reported a remote h/o injury to the posterior L knee resulting
in significant hematoma for which he did not seek medical help.
He has not been immobilized or undergone surgery. He does not
have a history of malignancy, and he has had no recent trauma to
the L leg.
He will call his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] for additional follow up,
including ordering an echocardiogram to evaluate for right heart
strain at a local hospital, as it is difficult for him to come
to [**Location (un) 86**].
.
# HTN - His HTN was well controlled at the time of admission on
metropolol XL 50mg PO BID and valsartan. During his hospital
stay, his SBP remained <120. It is very important to control his
BP given his h/o aneurysms. He will be discharged on his same
home regimen of metropolol and valsartan.
.
# Anxiety - the patient was kept on his usual ativan prn anxiety
throughout his stay without further problem.
.
# chronic pain - the patient was kept on his usual percocet prn
pain throughout his stay without further problem.
.
# gallstones - the patient was kept on his usual ursodiol
throughout his stay without further problem.
Medications on Admission:
Lorazepam 0.5mg prn
Metoprolol XL 50mg [**Hospital1 **]
Valsartan 160mg [**Hospital1 **]
Ursodiol 300 mg tid
Oxycodone-acetaminophen prn
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 0.5
Tablet Sustained Release 24 hr PO twice a day: half tablet twice
per day.
4. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 21 days: take 60mg twice
per day for three weeks, then change to 100mg daily for 9 weeks.
Disp:*42 injection* Refills:*0*
7. Lovenox 100 mg/mL Syringe Sig: One (1) injection Subcutaneous
once a day for 21 days: take 60mg twice per day for three weeks,
then change to 100mg daily for 9 weeks.
Disp:*21 syringes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral PE
left popliteal vein DVT
[**Last Name (un) 42664**] Danlos Syndrome
Arterial Aneurysms
Hypertension
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because of a blood clot in the
blood vessels of your lungs that traveled from a blood clot in
your leg. You were treated with the anticoagulation medicine
heparin to break up the clots. Please continue to take this
lovenox injection for three months total (60mg twice per day for
three weeks, then 100mg once per day for 9 weeks).
Please be sure to call Dr. [**First Name (STitle) **] tomorrow at [**Telephone/Fax (1) 42666**]. He
will not yet have received your paperwork, but tell him you have
a "pulmonary embolism" and need to have an "echocardiogram"
ordered to evaluate your heart function. He should be able to
set this up for you at your local hospital.
Please make a follow up appointment in the next 1-2 weeks with
Dr. [**First Name (STitle) **].
Please call Dr. [**Last Name (STitle) 3060**] for a follow up appointment in the next
month or two to discuss wehther you will need to be
anticoagulated beyond three months. [**Telephone/Fax (1) 42668**]
If you have bloody stool, black stool, or any sign of bleeding,
or chset pain, trouble breathing or other concerning symptoms,
please call Dr. [**First Name (STitle) **] or go to a local emergency room.
Followup Instructions:
Please be sure to call Dr. [**First Name (STitle) **] tomorrow at [**Telephone/Fax (1) 42666**]. He
will not yet have received your paperwork, but tell him you have
a 'pulmonary embolism' and need to have an 'echocardiogram'
ordered to evaluate your heart function. He should be able to
set this up for you at your local hospital.
Please make a follow up appointment in the next 1-2 weeks with
Dr. [**First Name (STitle) **].
Please call Dr. [**Last Name (STitle) 3060**] for a follow up appointment in the next
month or two to discuss wehther you will need to be
anticoagulated beyond three months. [**Telephone/Fax (1) 42668**]
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2126-6-3**] 11:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2126-6-3**] 12:45
Completed by:[**2126-4-27**]
|
[
"V12.54",
"756.83",
"530.81",
"401.9",
"V12.59",
"453.41",
"300.00",
"574.20",
"338.29",
"415.19",
"579.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8913, 8919
|
4490, 7830
|
277, 284
|
9075, 9082
|
3170, 3170
|
10332, 11345
|
2621, 2625
|
8018, 8890
|
8940, 9054
|
7856, 7995
|
9106, 10309
|
2640, 3151
|
227, 239
|
312, 1668
|
3186, 4467
|
1690, 2537
|
2553, 2605
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,108
| 149,009
|
4113
|
Discharge summary
|
report
|
Admission Date: [**2166-1-2**] Discharge Date: [**2166-1-11**]
Date of Birth: [**2091-3-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
recurrent VT
Major Surgical or Invasive Procedure:
1. EP study w/ V tach ablation
History of Present Illness:
74 yo m with h/o 3VD CAD (inoperable), CHF, afib, CRI, h/o VT
with ICD and BiV pacer placement whi presented to device clinic
today and was noted to be having frequent episodes of VT - at
least 20 since noon today and over 100 since [**12-31**]. He has been
paced out of these rhythms. He recalls one shoch on [**12-24**] and a
smaller shock on [**12-28**]. He has been feeling tired for the last 3
- 4 weeks. He denies CP but has had somce wordening of SOB over
the last few weeks not associated with PND/orthopnea. Also c/o
epidoses of hot flashes 2 - 3 times per day with some
lightheadness. Also went to see Dr. [**Last Name (STitle) **] today after device
clinic appointment. He was admitted to the CCU on the EP
service.
Past Medical History:
CAD s/p cath [**12/2161**]: 3VD: 100% occlusion in prox RCA, 100% mid
LAD and 100% intermedieus disease
MI [**4-18**] (markedly elevated TnT, negative CK)
profound ischemic cardiomyopathy with an EF of 15-25%
chronic atrial fibrillation
s/p ICD, Biventricular PPM [**2163**]
h/o monomorphic VT [**2165**], s/p successful ablation of three VT
circuits
CHF
CRI - baseline 1.3-1.9.
4+MR, 2+TR
HTN
hyperlipidemia
PVD
CVA x 2 12 years ago, 6 years ago. Residual L-sided weakness
He had a nephrectomy in [**2153**] secondary to complication of
nephrolithiasis.
pulm HTN (TR grad 72 [**12-19**]).
He had a LV thrombus documented in [**2161**] by echocardiogram
Depression
LBP
BPH
Social History:
Married, lives with wife. Former tobacco and EtoH use.
Family History:
NC
Physical Exam:
Vitals: T= AF, HR = 66, BP = 98/59, RR =12 , SaO2 = 100% on RA.
General: Pleasant Russian speaking male, appears comfortable,
NAD.
HEENT: Normocephalic and atraumatic head, anicteric sclera,
moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. no
nuchal rigidity ; elevated JVD
Chest: Chest rose and fell with equal size, shape and symmetry,
lungs were clear to auscultation bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 III/VI HSM no
rubs or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: No cyanosis, no clubbing or edema with 2+ dorsalis pedis
pulses bilaterally
Integument: no rash
Neuro: CN II-XII symmetrically intact, PERRL . Strength 5/5
throughout.
Pertinent Results:
[**2166-1-2**] 03:59PM GLUCOSE-93 UREA N-45* CREAT-1.8* SODIUM-140
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2166-1-2**] 03:59PM ALT(SGPT)-7 AST(SGOT)-9 CK(CPK)-34* ALK
PHOS-100 TOT BILI-2.2*
[**2166-1-2**] 03:59PM cTropnT-0.05*
[**2166-1-2**] 03:59PM CK-MB-NotDone
[**2166-1-2**] 03:59PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-2.4
[**2166-1-2**] 03:59PM WBC-9.8 RBC-4.51* HGB-12.6* HCT-37.0* MCV-82
MCH-27.9 MCHC-34.0 RDW-16.2*
[**2166-1-2**] 03:59PM PLT COUNT-156
[**2166-1-2**] 03:59PM PT-23.1* PTT-37.1* INR(PT)-3.4
CHEST SINGLE AP FILM
HISTORY: CHF.
The left costophrenic region is not included on the film. There
is cardiomegaly with LV predominance and some blunting in the
left costophrenic angle. A left-sided transvenous
pacer/fibrillator is present with atrial ventricular and
coronary sinus leads in situ unchanged in location in this
single view and compared with the prior study of [**2165-5-2**].
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
LIVER OR GALLBLADDER US (SINGL
Reason: please eval for cholelithiasis or evidence of
obstruction
[**Hospital 93**] MEDICAL CONDITION:
74 year old man with recurrent VT, abd pain/n/v
REASON FOR THIS EXAMINATION:
please eval for cholelithiasis or evidence of obstruction
HISTORY: Abdominal pain with vomiting.
COMPARISON: Abdominal CT of [**2163-5-5**] is available for
correlation.
FINDINGS: The gallbladder appears normal without evidence of
stones. There is no intrahepatic or extrahepatic biliary ductal
dilatation. The head of the pancreas is unremarkable. The liver
is normal in echotexture without focal masses. There is no
perihepatic fluid.
IMPRESSION: Normal gallbladder and bile ducts.
ECHO
Conclusions:
The left ventricular cavity is dilated. Overall left ventricular
systolic
function is severely depressed (basal septum and basal
anterolateral wall
contracts best). Right ventricular chamber size is normal. The
aortic valve
leaflets are mildly thickened. The mitral valve leaflets are
mildly thickened.
The tricuspid valve leaflets are mildly thickened. There is no
pericardial
effusion.
[**Hospital 93**] MEDICAL CONDITION:
74 year old man s/p nephrectomy admitted for VT. Now with acute
on CRI
REASON FOR THIS EXAMINATION:
r/o obstruction
HISTORY: A 74-year-old man status post left nephrectomy now with
acute on chronic renal insufficiency.
The right kidney measures 10.6 cm. The left kidney is absent.
There is no hydronephrosis, stones, or mass. The bladder is
unremarkable. The prostate is enlarged.
IMPRESSION:
Normal right renal ultrasound.
Brief Hospital Course:
# Recurrent VT: The patient had VT that was very difficult to
control with the many antiarrhtymics tried. Initially he was
placed on procainamide which was useful for his VT because
caused him to have serious N/V with hypotension. Therefore, he
was switched to lidocaine but still had VT runs with ICD firing.
Finally he underwent a
VT ablation on [**1-7**] with 2 foci ablated. 3rd foci not ablated.
He was restarted on amiodarone 400 qd and was stable with only
occasoinal runs of NSVT.
# ARF on CRI s/p nephrectomy - The patient was thought to have
nre renal failure from epidosed of dehydration and hypotension
from VT and nausea and vomiting. Renal was consulted. The
patient underwent a renal ultrasond of his transplant which was
unreavealing. Slowly her Cr trended downwards.
Medications on Admission:
. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day). Disp:*60 Tablet(s)* Refills:*2*
4. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Tolterodine Tartrate 1 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed. Disp:*60 Tablet(s)* Refills:*1*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day). Disp:*90 Tablet(s)* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR). Disp:*90 Capsule(s)* Refills:*2*
11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: please begin amiodarone 200 mg by mouth once per day after
2 months of 400 mg a day. Disp:*30 Tablet(s)* Refills:*2*
13. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a
day for 2 months: please continue on amiodarone 400 mg by mouth
once daily for 2 months and then change to 200 mg once a day.
Disp:*60 Tablet(s)* Refills:*0*
14. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Tolterodine Tartrate 1 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*1*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
Disp:*90 Capsule(s)* Refills:*2*
11. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: please begin amiodarone 200 mg by mouth once per day after
2 months of 400 mg a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a
day for 2 months: please continue on amiodarone 400 mg by mouth
once daily for 2 months and then change to 200 mg once a day.
Disp:*60 Tablet(s)* Refills:*0*
14. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
please call dr. [**Last Name (STitle) **] for inr check on [**1-14**] - goal inr is 2.0
Discharge Disposition:
Home
Discharge Diagnosis:
ventricular tachycardia s/p ablation x 2, now resolved
Coronary artery disease stable
Congestive heart failure stable
Acute renal failure resolved
Discharge Condition:
fair
Discharge Instructions:
breath, palpitations, light-headedness, or shocks.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
Followup Instructions:
Please call pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] for appt in [**2-15**] weeks.
Please call cardiologist dr. [**Last Name (STitle) **] for appt at [**Telephone/Fax (1) 7332**]
in one month
Please call cardiologist dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 3512**] for appt
in [**3-19**] weeks or as previously scheduled
please call pulmonary function test lab at [**Telephone/Fax (1) 609**] for appt
to check lung function as baseline on amiodarone
|
[
"443.9",
"427.1",
"414.01",
"584.9",
"428.23",
"424.0",
"428.0",
"458.9",
"V53.39",
"403.91",
"425.4",
"V58.61",
"787.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.26",
"89.49",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
9576, 9582
|
5406, 6193
|
328, 361
|
9773, 9779
|
2778, 3909
|
10007, 10570
|
1906, 1910
|
7841, 9553
|
4954, 5025
|
9603, 9752
|
6219, 7818
|
9803, 9984
|
1925, 2759
|
276, 290
|
5054, 5383
|
389, 1118
|
1140, 1816
|
1832, 1890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 104,433
|
33061
|
Discharge summary
|
report
|
Admission Date: [**2179-3-9**] Discharge Date: [**2179-3-12**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Hypertensive Emergency
Major Surgical or Invasive Procedure:
renal vein sampling in interventional radiology
History of Present Illness:
In brief, the pt is a 20y/o F with MPGN s/p renal xplant in [**7-13**]
c/b multiple admissions for hypertensive emergency who presented
on this admission with SOB/cough, N/V, and systolic BP in the
230s. She was admitted to the ICU where she was managed with a
labetolol drip until her BP and N/V improved and she was able to
tolerate PO medications. She responded rapidly in the ICU and
her BP was well controlled by d2 of her hospitalization and
remained so on oral medications. She received dialysis today and
was called out to the floor team for further management. Of
note, because of her frequent episodes of hypertension there is
concern that the patient may have a kidney secreting higher than
normal levels of renin and IR was contact[**Name (NI) **] to obtain a renal
vein sample tomorrow for further analysis.
.
On the floor, the patient notes resolution of all the symptoms
that brought her to the emergency room and denies current chest
pain, shortness of breath, headache, blurry vision, abdominal
pain, nausea, dysuria, fever, weakness, or paresthesias.
Past Medical History:
#)MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. On
[**6-/2178**], pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **]
at [**Hospital1 18**] to an adult clinic.
#)Peripheral edema and abdominal striae [**1-9**] steroids
#)HTN [**1-9**] steroids and renal disease, multiple admissions for
Hypertensive Emergency. Most recently one month ago,
[**Date range (1) 76875**]
#)Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**] to
malignant hypertension
#)Migranes
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: T 99.7, BP 141/84, HR 93, RR 22, 94% on 3 liters
GEN: Eyes closed. Comfortable with flat affect.
HEENT: EOMI, PERRL, MMM, OP clear
NECK: Supple, no LAD
RESP: Crackles ~1/2 up bilterally.
CV: RRR 3/6 SEM heard best at LUSB and throughout precordium
CHEST: Catheter intact, no tenderness noted
ABD: Soft NT/ND + BS no rebound or guarding. No renal bruits
noted.
EXT: Warm well perfused, no peripheral edema
SKIN: No rashes, mildly icteric
NEURO: CN II-XII intact, strength 5/5 in all ext, no gross
sensory deficits. Did not assess gait
Pertinent Results:
VENOUS SAMPLING [**2179-3-11**] 10:25 AM
VENOUS SAMPLING
Reason: PLEASE SAMPLE ALL 3 RENAL VEINS FOR RENIN LEVELS
Contrast: VISAPAQUE
[**Hospital 93**] MEDICAL CONDITION:
20 year old woman with MPGN with renal transplant with severe
HTN
REASON FOR THIS EXAMINATION:
PLEASE SAMPLE ALL 3 RENAL VEINS FOR RENIN LEVELS
RADIOLOGISTS: The procedure was performed by Dr. [**Last Name (STitle) 15785**], Dr.
[**Last Name (STitle) **], and Dr. [**First Name (STitle) 3175**], the atending radiologist who was present
and supervisiong throughtout the procedure.
INDICATION FOR EXAM: This is a 20-year-old woman s/p renal
transplant and hypertension.
PROCEDURE: VENOUS RENAL SAMPLING.
PROCEDURE AND FINDINGS: After informed consent was obtained from
the patient explaining the risks and benefits of the procedure,
the patient was placed supine on the angiographic table and the
left groin was prepped and draped in standard sterile fashion.
Using palpatory technique and after injection of 5 cc of 1%
lidocaine, the left common femoral vein was accessed with a
19-gauge needle and a 0.035 guidewire was advanced through the
needle up to the level of the inferior vena cava under
fluoroscopic guidance. Using a 5 French SOS catheter, access was
gained into the contralateral common iliac vein and then into
the vein draining the transplanted kidney. 5 cc of blood were
collected from the renal vein of the transplanted kidney and
from the left iliac vein. Subsequently, using a Cobra catheter,
access was gained into the left and right native renal veins and
5 cc of blood draws were obtained. Blood draws were also
obtained from the inferior vena cava above the level of the
renal veins and inferior to the level of the renal veins.
All the samples were sent for chemical analysis.
The catheter was removed and manual compression was held for 5
minutes until hemostasis was achieved.
Moderate sedation was provided by administering divided dose of
150 mcg of fentanyl and 3 mg of Versed throughout the total
intraservice time of 1 hour and 30 minutes during which the
patient's hemodynamic parameters were continuously monitored.
IMPRESSION: Successful renal venous sampling from the native
bilateral renal veins, transplanted kidney renal vein, left
common iliac and inferior vena cava above and below the level of
the renal veins
Brief Hospital Course:
A/P: 20y/o F w/ MPGN s/p renal xplant c/b failure and now back
on HD presenting with hypertensive emergency
.
# Hypertensive Emergency
Unclear etiology though thought to be partially due to her renal
failure along with question of transplanted kidney excreting
massive amounts of renin with the thought being it is not being
perfused well. Patient underwent renal vein sampling of
transplanted kidneys along with native kidneys. Results will be
available in a few weeks to be followed up by renal. The results
of the renin levels will have to be adjusted to the velocities
in the renal vein. In the meantime the patient's blood presssure
was well controlled on her current discharge regimen along with
aggressive dialysis. Patient was symptom free at discharge with
follow up scheduled with Dr. [**Last Name (STitle) **] on [**3-18**]. Patient had
ample medications at home, no prescriptions were needed.
Medications on Admission:
1. Prednisone 5 mg every other day
2. Clonidine 0.2 mg/24 hr Patch Weekly (every Tuesday)
3. Hydralazine 50 mg Q8H
4. Furosemide 80 mg [**Hospital1 **]
5. Losartan 75 mg [**Hospital1 **]
6. Mycophenolate Mofetil 500 mg [**Hospital1 **]
7. Labetalol 800 mg TID
8. Captopril 75 mg TID
9. Calcium Acetate 667 mg TID
10. B Complex-Vitamin C-Folic Acid 1 mg daily
11. Isradipine 15 mg TID
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
5. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Losartan 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
10. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
Renal failure
MPGN
Anemia
Discharge Condition:
Stable, blood pressure controlled on oral medications
Discharge Instructions:
You were admitted with hypertensive emergency to 220/180, you
were briefly in the ICU to control your blood pressure with IV
medications. Your blood pressure was controlled and you
underwent a study to sample blood from each of your kidneys to
see if they are releasing an enzyme which could be causing your
blood pressure to elevate. You received dialysis on the day of
discharge which will help with your blood pressure.
You have an appointment to follow up with Dr. [**Last Name (STitle) **] on [**3-18**]
to check on how you are doing.
If your blood pressure is systolic>180 or diastolic>110 call the
renal clinic or present to the ER for treatment. If you develop
any chest pain, shortness of breath, headache, visual blurring
when your blood pressure is elevated you must go to the ER for
urgent evaluation as this may be life threatening.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-3-18**] 9:00
|
[
"E878.0",
"V45.1",
"285.21",
"585.6",
"403.01",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.45",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8014, 8020
|
5844, 6753
|
354, 403
|
8113, 8169
|
3490, 3628
|
9065, 9201
|
2845, 2916
|
7188, 7991
|
3665, 3731
|
8041, 8092
|
6779, 7165
|
8193, 9042
|
2931, 3471
|
292, 316
|
3760, 5821
|
431, 1502
|
1524, 2631
|
2647, 2829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,844
| 166,054
|
16336
|
Discharge summary
|
report
|
Admission Date: [**2172-4-19**] Discharge Date: [**2172-5-3**]
Date of Birth: [**2143-7-2**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Gleevec / Cefepime Hcl / Clindamycin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
chest and neck pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 16368**] is a 28-year-old man with a history of biclonal
leukemia, diagnosed in [**2169-12-20**] status post chemo initially
and then after a relapse of his ALL, he underwent allo BMT
transplant on [**2170-5-3**], but his ALL relapsed in [**2171-7-21**]
and was treated with vincristine, prednisone, and Gleevec. The
Gleevec was discontinued because of a reaction to it. Most
recently he has received Clofarabine after which he had an
aplastic-looking marrow and received a stem cell boost. His most
recent hospitalization was [**10-23**] until [**2172-3-26**] during which he
was noted to have pulmonary nodules, and was treated empirically
with ambisome, voriconazole, and initially capsofungin and was
sent home on ambisome and voriconazole. Last dose of ambisome
was [**3-31**], and he was continued on voriconazole alone with his
last dose on [**4-16**] because the the medication.
He was last seen in Dr. [**Last Name (STitle) **]??????s clinic on [**2172-4-16**] and had been
doing well. He had a bone marrow biopsy performed on that day as
well. The bone marrow biopsy is pending at this time.
The patient presented to the ED on [**4-19**] at 04:30 complaining of
chest and neck pain. The patient states that he was in his usual
state of good health until last night when he had gradual onset
left neck to substernal chest pain described as "something
squeezing in from my lungs," "pressure," 15/10 and pleurtic. He
also complains of neck pain which is worse with movement. No
associated SOB or diaphoresis. Has had mild nausea since his
discharge without emesis. Patient denies f/c, cough, abdominal
pain, rash. This pain is similar to pulmonary nodule pain he has
had in the past.
In the ED, his initial VS were 99.2, HR 121 BP 126/78 RR 16 100%
on RA. He was given Morphine 8 mg iv and dilaudid 8mg iv for
pain control and became hypotensive with VS 116, 78/44 while in
the ED. He recieved 6 L NS with only 500 cc of dark urine output
over several hours and was then started on Levophed for pressure
support. Seen by cardiology consult who felt not consistent with
cardiogenic shock. He was admitted to the MICU for further work
up and management.
Past Medical History:
1. Biclonal leukemia:
-Diagnosed [**12-23**] -- Presenting with sore throat, severe upper
airway inflammation requiring intubation, and a WBC of 130,000.
Examination of the marrow demonstrated nearly 100%blasts, and
cytogenetic examination showed t9;22 and q341.-q11.2. He was
initially treated with emergent pheresis, steroids, and
hydroxyurea, then was started on regimens to address both ALL
and the AML component. He underwent hyperCVAD regimen without
complete remission.
-[**4-21**] -- Pt had matched unrelated donor allo-BMT with preceding
total body radiation and cytoxan conditioning regimen. Following
this, he exeperienced grade 1 GvHD with rash, treated with
steroid taper. He had a transaminitis at the time, but bx
excluded hepatic GvHD involvement.
-[**Date range (1) 46485**] -- Marrow bx indicated remission
-[**7-23**] -- Pt developed petechiae, WBC found to be 18.4, platelets
of 19, 18%blasts, and a marrow bx indicated ALL recurrence. He
was treated with vincristine and prednisone.
-[**2171-8-29**] -- A repeat marrow bx indicated residual leukemia,
though improved from previous.
-[**2171-9-4**] -- Pt underwent donor lymphocyte infusion
-[**2171-10-14**] -- Marrow biopsy shows leukemia with 80% involvement,
and pt is admitted for hyperCVAD, discharged [**10-17**].
-[**10-23**]- Received Clofarabine after which he had an
aplastic-looking marrow and received a stem cell boost.
2. Prolonged Febrile Neutropenia complicated by severe
infections including probable fungal infection with pulmonary
nodules and mesenteric mass.
3. Transaminitis -- Liver bx with focal pmn aggregates, no
evidence of GvHD [**6-21**].
4. Typhilitis
5. Line infection
Social History:
Lives in [**Location 86**] and works as a mechanical engineer. Has a
girlfriend. Family is supportive. No tobacco use. Previous
occasional etoh use, none currently. No illicit drug use.
Family History:
NC
Physical Exam:
PE: T 100.5 HR 115 BP 76/32 - 106/58 (current) R 16 %Sat 99 RA
Pulsus [**7-29**]
Gen: Fatigued, A&O x 3, appears mildly uncomfortable
HEENT: ATNC, PERRLA, anicteric, OP clear, MMM
Neck: Supple, no LAD,
Chest: CTA bilat, no egophany or fremitus, resonant
Cor: Tachy, nl S1 S2 no m/r, JVP flat
Abd: Soft, nt/nd, no HSM/M hypoactive BS
Ext: Warm,
Skin: No rashes, petechiae. Flat smooth 1.3 cm eschar on L
medial shin [burn site]
Pertinent Results:
CXR: [**4-20**]
There has been interval development of patchy opacification at
the left lung base peripherally. Cardiac and mediastinal
contours are normal. Pulmonary vasculature remains normal. The
osseous structures are unremarkable. The right-sided central
venous catheter is stable in position.
IMPRESSION:
Interval development of new left-sided patchy opacification,
left lung base. Given the patient's history of ALL, this is
concerning for developing pnemonia.
Chest/Abd/pelvis CT [**2172-4-19**]:
1) Hazy opacity within the right lower lobe, a finding that
could partly related to atelectasis, although is suspicious for
pneumonia given its asymmetry.
2) No evidence of pulmonary embolus or aortic dissection.
3) Stable small to moderate pericardial effusion.
4) Decreased size of mesenteric mass, which is now not
measurable, with minimal residual haziness in the mesentery.
[**2172-4-21**] 05:50AM BLOOD WBC-3.3*# RBC-3.18* Hgb-10.2* Hct-28.6*
MCV-90 MCH-32.1* MCHC-35.7* RDW-18.3* Plt Ct-118*
[**2172-4-20**] 05:05AM BLOOD WBC-8.2 RBC-3.91*# Hgb-12.1*# Hct-34.4*#
MCV-88 MCH-31.0 MCHC-35.2* RDW-16.9* Plt Ct-130*
[**2172-4-19**] 08:05AM BLOOD WBC-7.1 RBC-2.68*# Hgb-8.4*# Hct-24.4*#
MCV-91 MCH-31.5 MCHC-34.5 RDW-17.5* Plt Ct-145*
[**2172-4-19**] 02:20AM BLOOD Neuts-84.2* Lymphs-9.7* Monos-4.2 Eos-1.6
Baso-0.3
[**2172-4-20**] 05:05AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-2 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2172-4-21**] 05:50AM BLOOD PT-14.1* PTT-31.8 INR(PT)-1.3
[**2172-4-21**] 05:50AM BLOOD Glucose-108* UreaN-17 Creat-1.2 Na-141
K-3.9 Cl-113* HCO3-22 AnGap-10
[**2172-4-19**] 02:20AM BLOOD LD(LDH)-152 CK(CPK)-26*
[**2172-4-19**] 08:05AM BLOOD LD(LDH)-83* CK(CPK)-15* TotBili-0.8
DirBili-0.2 IndBili-0.6
[**2172-4-19**] 04:12PM BLOOD CK(CPK)-23*
[**2172-4-19**] 02:20AM BLOOD cTropnT-<0.01
[**2172-4-19**] 08:05AM BLOOD cTropnT-<0.01
[**2172-4-19**] 04:12PM BLOOD CK-MB-1 cTropnT-<0.01
[**2172-4-21**] 05:50AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2172-4-19**] 08:05AM BLOOD Hapto-72
[**2172-4-21**] 05:50AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
Brief Hospital Course:
#Hypotension: Original ddx was early sepsis vs. narcotics
related vs. cardiogenic vs adrenal insufficiency. He required
levophed and aggressive fluid hydration to maintain SBP>100 and
was started on fludrocotisone for possible adrenal
insufficiency. Pt had flat JVP and warm extremities, no evidence
of tamponade. He was ruled out for MI by enzymes, and cardiology
consult did not not think picture was c/w cardiogenic shock. A
cortasyn stim test was performed and he was seen to respond, so
we discontinued fludrocortisone and hydrocortisone. Sepsis was
considered and he was broadly covered on admission with
ambisome, imipenem, voriconazole. He was weaned off vasopressors
and IVF on HD3 and SBP's remained in the 90's but he was
asymptomatic, making urine, and had normal lactate so no further
intervention was made.
.
#ID:
a) Pulmonary nodules:
Pt had history of pulmonary nodules thought to be of fungal
origin without positive cultures data. He had been on empiric
treatment for fungal process with ambisome and vorinazole for 3
months, then voriconazole alone since [**4-1**], but was off this for
four days before admission. Chest CT revealed no nodular
infection but a RLL infiltrate concerning for CAP and on HD2 was
started on levofloxacin. At that same time he was started on
Vancomycin since his allergy was questionable and he had a
permanent tunneled line. He developed periorbital edema and
diffuse skin etyhema, elevated LFT's and eosinophilia thought
initially due to vancomycin so this was stopped. Vancomycin was
changed to daptomycin which was stopped [**4-21**] given blood cultures
remained negative x 48 hours. Infectious workup in looking for
source of sepsis included urine, blood and sputum culture,
fungal , AFB, PCP, [**Name10 (NameIs) 14616**], mycoplasma, [**Name10 (NameIs) 14616**] urine Ag,
galatomannan all of which were negative. Pt's LFT's continued to
rise off of the vancomycin so the levofloxacin was changed to
azithromycin which he completed a 10 day course of. He was then
started on voriconazole as below for risk of recurrence of
fungal infection with immunosuppressive treatment for GVHD as
below.
Elevated LFT's-Pt continued to have climbing LFT with a
cholestatic picture initially thought to be due to drug reaction
by both ID and dermatology. Skin biopsy showed complete
separation of dermis and epidermis consistent with drug rash.
Alkaline phosphatase continued to rise despite rash improving so
then arose concern for GVHD as had occured in the past. At this
point he was started on cyclosporine dosed to trough >100 and a
day later Mycofenolate was added. Liver team was consulted and
felt this was most likely GVHD and got a liver biopsy. Biopsy
revealed diffuse biliary destruction consistent with GVHD
although it was unclear if this was old or new. He was continued
on immunosuppressive therapy as above and on [**5-3**] was feeling
well so plan was made for further workup and treatment of
elevated LFT's as an outpt.
.
#Chest/Neck pain: T wave changes on EKG were non-diagnostic. It
didn't appear to be due to ischemia given he was ruled out for
MI with serial enzymes and had no events on telemetry. CTA
showed no PE/aortic dissection. Most likely cause of pain is
pleuritic chest pain from pneumonia. He was treated with his
outpatient dose of oxycontin in hospital which he responded well
to.
.
#Anemia: baseline hct was around 28 thought to be anemia of
chronic diseae.
Hemolysis labs were negative
Medications on Admission:
Acyclovir 400 mg po bid (For Zoster ppx)
Voriconazole 200 mg po bid (unable to fill for last three days)
Imipenenem 500mg q 6 hour
Aerosolized pentamidine qmonth (For PCP [**Name9 (PRE) **] last dose4/19)
Diphenhydramine prn
Oxycodone SR 60 mg po bid
Oxycodone 5-10 mg po q6h breakthrough
Lorazepam 2 mg po q4-6h prn
Discharge Medications:
1. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*28 Tablet(s)* Refills:*0*
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
4. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
6. [**Doctor First Name **] 30 mg Tablet Sig: 1-2 Tablets PO qhs/prn.
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6 hous/prn
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO twice a day.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
GVHD
CAP
Discharge Condition:
Stable
Discharge Instructions:
Please follow-up daily on [**Hospital Ward Name 1826**] 7 for measurement of your
LFT's and to continue following your rash.
Followup Instructions:
Needs ECHO in 2 weeks.
|
[
"693.0",
"723.1",
"285.29",
"458.9",
"204.01",
"571.8",
"511.0",
"996.85",
"205.01",
"486",
"276.5",
"E930.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"00.17",
"86.11",
"50.11",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12018, 12070
|
7042, 10511
|
328, 334
|
12123, 12131
|
4934, 7017
|
12304, 12330
|
4467, 4471
|
10880, 11995
|
12091, 12102
|
10537, 10857
|
12155, 12281
|
4486, 4915
|
269, 290
|
362, 2546
|
2568, 4245
|
4261, 4451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,136
| 137,832
|
54873
|
Discharge summary
|
report
|
Admission Date: [**2145-8-27**] Discharge Date: [**2145-9-6**]
Date of Birth: [**2090-7-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
found down x 2 days
Major Surgical or Invasive Procedure:
Right Hand Amputation
History of Present Illness:
55F with DMII, HTN, Bipolar d/o here with altered mental status.
Per friend, patient was in USOH until approximately last week
when she began having diarrhea. Patient became increasingly more
confused, incoherent, and lethargic, sleeping most of the day.
She was also incontinent of urine and stool and intermittently
shaking. She was not eating, drinking, or taking her
medications. She was sleeping most of the day and friend is
unsure of how often she was moving. He called EMS because he was
concerned of her worsening health. Per EMS, patient was found
lying on her right upper extremity on a tarp in her own
excrement and urine. Initially BPs in the 110s and obtunded at
[**Hospital3 **] Hospital but received unknown amount of fluids and
mental status and pressures improved to 140s. Pt became AOx1,
able to follow simple commands. Right hand noted to be ischemic
with no radial or ulnar pulse and sloughing of the epidermis. At
OSH, lithium 3.2, trop negative, TSH 5.3, CK 1676, K 5.3, Cr
2.14, serum/urine tox were negative, UA positive. Pt received
ceftriaxone prior to transfer.
Of note, patient was seen at CCH on [**7-17**] with similar complaint
of weakness. Pt had been found in her own stool by her sister
who was concerned that she was not able to take care of herself.
She was on vancomycin at that time but sister did not think
patient was administering it appropriately. Her labs at the time
were notable for Cr 1.5, Na 129, Hct 40.
In the ED, initial vitals 37.3 73 110/73 20 98%4L. Pt is [**Name (NI) **]1,
able to follow simple commands. Exam notable for clonus in all
extremities and degloved right hand. Labs notable for WBC 15.2,
Hct 49.4, Cr 2.1, HCO3 17 (AG = 12), Ca [**43**].4, lithium 3, grossly
positive UA, K 4.5, normal lactate and troponin. Imaging notable
for negative Head CT.
EKG with lateral and inferior TWIs, QTc 463. Hand evaluated
patient and felt there was no indication for urgent amputation
currently.
Patient received 100mg IV thiamine
On arrival to the MICU, patient is alert, responds to voice but
not able to answer questions reliably.
Review of systems:
Could not be obtained
Past Medical History:
HTN
Diabetes II not on insulin
HL
R arm fracture repaired with rods and pins [**10/2144**] c/b MRSA
infection for which pt was on IV vanc x 3weeks until [**8-13**];
hardware has since been removed. Ortho surgeon at [**Hospital1 2177**] is Dr.
[**Last Name (STitle) 112108**] [**Telephone/Fax (1) 112109**]
Bladder repair
Bipolar disorder
Depression
Social History:
Smokes 1ppd x 30 yrs, hx of EtOH abuse
Lives with roommate
Family History:
not obtained
Physical Exam:
Admission exam:
Physical Exam:
Vitals: T:98.3 BP:126/95 P:72 R:19 O2: 97%2L
General: Alert, not oriented, only intermittently following
commands or verbalizing responses, fluttering eyelids and making
automatic motions with her jaw
HEENT: Sclera anicteric, dry MM, EOMI, PERRL
Neck: supple, JVP flat
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: coarse breath sounds and rhonchi diffusely, no rales
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: foley in place draining light yellow urine
Ext: warm, well perfused, 2+ pulses in lower extremities; right
hand is cold with blue fingers, pulseless, partly degloved over
the index and middle finger and with weakening of skin integrity
over remaining fingers, slightly malodorous
Skin: mild petechial streaking over right back, no ecchymoses
Neuro: moves [**4-18**] limbs purposefully (not right arm), +clonus and
fasciculations in all extremities
Discharge exam:
Vitals: afebrile mildly hypertensive to 150s systolic, not
tachycardic
General: NAD
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, no jvd
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no w/r/r
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
Ext: warm, well perfused, 2+ pulses in lower extremities; right
hand amputated , bandage c/d/i
Skin: no rash
Neuro: moves [**4-18**] limbs purposefully (not right arm), A&Ox3,
sensation in tact throughought, CNII-XII intact
Pertinent Results:
Admission
[**2145-8-27**] 05:55PM PT-11.8 PTT-20.3* INR(PT)-1.1
[**2145-8-27**] 05:55PM PLT COUNT-137*
[**2145-8-27**] 05:55PM NEUTS-84.7* LYMPHS-9.5* MONOS-5.0 EOS-0.5
BASOS-0.3
[**2145-8-27**] 05:55PM WBC-15.2* RBC-4.96 HGB-15.7 HCT-49.4*
MCV-100* MCH-31.7 MCHC-31.8 RDW-13.4
[**2145-8-27**] 05:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2145-8-27**] 05:55PM LITHIUM-3.0*
[**2145-8-27**] 05:55PM OSMOLAL-349*
[**2145-8-27**] 05:55PM ALBUMIN-4.2 CALCIUM-10.4* PHOSPHATE-4.2
MAGNESIUM-2.3
[**2145-8-27**] 05:55PM cTropnT-<0.01
[**2145-8-27**] 05:55PM LIPASE-115*
[**2145-8-27**] 05:55PM ALT(SGPT)-20 AST(SGOT)-47* ALK PHOS-219* TOT
BILI-0.2
[**2145-8-27**] 05:55PM estGFR-Using this
[**2145-8-27**] 05:55PM GLUCOSE-384* UREA N-89* CREAT-2.1* SODIUM-139
POTASSIUM-7.0* CHLORIDE-110* TOTAL CO2-17* ANION GAP-19
[**2145-8-27**] 06:01PM LACTATE-1.9 K+-6.5*
[**2145-8-27**] 06:30PM URINE WBCCLUMP-MOD MUCOUS-RARE
[**2145-8-27**] 06:30PM URINE HYALINE-2*
[**2145-8-27**] 06:30PM URINE RBC-7* WBC-167* BACTERIA-MANY YEAST-NONE
EPI-1 RENAL EPI-1
[**2145-8-27**] 06:30PM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2145-8-27**] 06:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2145-8-27**] 06:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2145-8-27**] 06:40PM URINE OSMOLAL-524
[**2145-8-27**] 06:40PM URINE HOURS-RANDOM UREA N-998 CREAT-86
SODIUM-23 POTASSIUM-42 CHLORIDE-27
[**2145-8-27**] 07:55PM K+-4.5
[**2145-8-27**] 09:01PM LITHIUM-2.4*
[**2145-8-27**] 09:01PM VANCO-1.8*
[**2145-8-27**] 09:01PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2145-8-27**] 09:01PM CK(CPK)-1063*
[**2145-8-27**] 09:01PM GLUCOSE-321* UREA N-76* CREAT-1.8* SODIUM-145
POTASSIUM-5.2* CHLORIDE-119* TOTAL CO2-17* ANION GAP-14
[**2145-8-27**] 09:21PM LACTATE-2.0
[**2145-8-27**] 10:47PM URINE OSMOLAL-524
[**2145-8-27**] 10:47PM URINE HOURS-RANDOM CREAT-58 SODIUM-44
POTASSIUM-25 CHLORIDE-52
.
Discharge
[**2145-9-6**] 06:03AM BLOOD WBC-9.1 RBC-3.68* Hgb-11.3* Hct-34.5*
MCV-94 MCH-30.6 MCHC-32.7 RDW-13.6 Plt Ct-417
[**2145-9-6**] 06:03AM BLOOD Glucose-196* UreaN-9 Creat-0.8 Na-140
K-3.8 Cl-97 HCO3-34* AnGap-13
[**2145-9-6**] 06:03AM BLOOD Calcium-10.5* Phos-5.3* Mg-1.7
[**2145-9-1**] 06:34AM BLOOD %HbA1c-8.0* eAG-183*
[**2145-8-31**] 11:30AM BLOOD TSH-4.2
[**2145-8-29**] 04:57AM BLOOD Lithium-1.4
.
CT Head [**8-27**]- FINDINGS: There is no intracranial hemorrhage,
mass effect, edema, or shift of normally midline structures.
The [**Doctor Last Name 352**]-white matter differentiation appears preserved. A tiny
probable lacune is seen in the right frontal subcortical white
matter (2, 17). Bifrontal extra-axial CSF spaces are prominent.
Ventricles and sulci are mildly prominent. Suprasellar and
basilar cisterns are patent. Paranasal sinuses and mastoid air
cells are well aerated. There is pneumatization to the petrous
apices. Vascular calcifications are seen in the carotid
arteries. Globes and orbits are preserved. Slightly dense foci
in frontal lobes are related to volume ageraging of the adjacent
bones. Evaluation of posterior fossa and temporal lobes is
limited due to artifacts.
IMPRESSION: Limited evaluation of posterior fossa and temporal
lobes.
Allowing for this, no acute intracranial hemorrhage or mass
effect. F/u or
further work up as clinically indicated.
.
CXR [**8-27**]- FINDINGS: As compared to the previous radiograph,
there is no relevant change. Normal size of the cardiac
silhouette. No hilar or mediastinal abnormalities. No pleural
effusions. No pulmonary edema. No other acute changes. No
pneumothorax or pleural effusions. The lung parenchyma has
normal structure and transparency.
Shoulder Xray
FINDINGS: Two portable radiographs are provided for
documentation. There is
a complete fracture of the right humeral shaft. The rather
rounded contours
of the fracture indicate a non-recent event. This is confirmed
by the
presence of the fracture on an outside chest radiograph from
[**2145-7-18**].
The outside radiograph, as well as a second chest radiograph
from an outside
hospital, performed on [**2145-7-16**], additionally indicate
luxation of the
humeral head with respect to the acetabulum. No safe evidence
of cortical
erosion in addition to the fracture or of spongiosal destruction
is provided
by the limited quality radiographs.
Brief Hospital Course:
55F with DM, bipolar d/o on lithium, s/p right arm surgery c/b
MRSA infection here with AMS, [**Last Name (un) **], and hand ischemia.
# AMS: Appears to have been subacute in nature, more suggestive
of acute on chronic lithium toxicity. Presentation similar to
but more severe than presentation last month. Per friend, it
appears patient has been increasingly more confused and
lethargic with decreasing PO intake and urinary/fecal losses
which probably led to dehydration. This increased dehydration
potentially led to decreased clearance of lithium, explaining
elevated level and worsening mental status. Though osmolar gap
is elevated at 17 and pt has hx of EtOH abuse, serum and urine
tox are negative x 2. Head CT also negative for organic causes.
Lithium level decreased with aggressive hydration - pt received
6L in the ER and UO remains robust. On hospital day 2, Li level
normalized at 1.4. Once patient was transferred out of unit,
her mental status improved dramatically and by date of
dishcarge, she was A&Ox3. Of note, during her stay, concern was
expressed by family over her ability to care for herself at
home. As a result, the pts sister became her medical proxy.
# [**Last Name (un) **]: Likely due to severe dehydration given history (diarrhea,
poor PO intake) and presentation. [**Last Name (un) **] likely contributing to
decreased lithium clearance and AMS as above. Creatinine and CK
appears to be improving with fluids. Sodium is currently in the
normal range which likely indicates dehydration as pt's baseline
Na is likely low due to lithium-induced DI. Uosm currently in
the 500s, appropriately more concentrated than serum. Upon
transfer from the ICU, the patient Cre continued to decrease to
her baseline of 1, further demonstrating its likely prerenal
etiology. The patient continued to take in adequate oral intake
to improved renal clearance.
# Bipolar: Paxil, Buspar, and Lithium were held on admission and
during her hospital stay. Psych was consulted and there remains
some question as to the validity of her bipolar diagnosis. She
was started on geodon 80 on the night before discharge. This
was decreased to 40 nightly after she was noted to be
oversedated the next day.
# Right hand ischemia: Pt was found down on this hand and may
have been on it for at least 2 days. Seen by Hand team in ER who
felt there was no indication for urgent amputation or IV abx. Pt
was on clindamycin for anaerobic coverage. This was then
broadened to vanc and zosyn out of concern for it being a nidus
of infection. She was also placed on a heparin gtt for seven
days. She was ultimatetely taken to the OR for an above the
wrist right hand amputation. She will follow-up in hand clinic
in 1 week for further recs. She will need to continue xeroform
kerlex dressing changes [**Hospital1 **]. No abx are indicated at this time.
# MRSA infection of right shoulder: Pt reportedly completed IV
abx course for this in late 6/[**2145**]. In [**10/2144**] had R humeral
fracture which was repaired with pins and rods and was
complicated by MRSA infection, which required removal of
hardward and finished 3 week course of IV vanc (per pt,
administered by a home nurse daily) in 6/[**2145**]. [**8-29**] radiograph
of R shoulder shows subluxation of humeral head from acetabulum
and at least 1 inch of missing bone; complete humeral shaft
fracture that is most likely old. Ortho felt like this was an
old fracture and non-operable. They recommended that she f/u
with the surgeon who performed the procedure, or she could
follow-up with orthopedics at [**Hospital1 18**].
# UTI: Grossly positive UA on admission. Pt had slight white
count but does not meet other SIRS criteria. Pt empirically
treated with ceftriaxone. Urine culture was contaminated. She
completed a 7 day course of abx which included ceftriaxone and
then vanc and zosyn.
# Diarrhea: Pt presented with fecal incontinence and diarrhea of
unclear etiology. She was recently on abx so at risk for Cdiff.
Abdominal exam currently unremarkable and no leukocytosis.
C.diff was checked and was negative. Diarrhea was not an issue
while in house and may have been due to lithium.
# DM: Elevated blood glucose on presentation but no gap or
ketones in urine to suggest DKA. Pt was put on insulin sliding
scale during hospital course while having oral hypoglycemics
held. Her A1c was checked and was 8.0. She was continued on
basal bolus insulin on discharge, and her metformin was
restarted.
# HTN: Lisinopril and HCTZ were initially held in setting of
[**Last Name (un) **]. She was discharged with the same antihypertensives as
originally prescribed after pressures improved.
# HL: Has a history of hyperlipidemia and statin was initially
held with initial concerns for rhabdomyolysis. Zocor was
restarted again once CK was found to be trending down to normal
levels.
# COPD: Rhonchorous on exam initially without wheeze. CXR
remained clear. Pt remained stable throughout hospitalization
with spiriva, flovent and proair.
Transitional issues:
# F/U with Hand clinic next week
# F/U with outpatient psych providers -> psych at [**Hospital1 18**] will
discuss with them once they return to town
# F/U regarding R shoulder -> should f/u with original provider
who performed surgery
# F/U with PCP at [**Name9 (PRE) 112110**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientPharmacy OSH records.
1. BusPIRone 30 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Tiotropium Bromide 1 CAP IH DAILY
4. Simvastatin 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lithium Carbonate CR (Eskalith) 450 mg PO BID
Eskalith CR
7. Paroxetine 60 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Amlodipine 5 mg PO DAILY
6. Bisacodyl 10 mg PR HS:PRN constipation
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. FoLIC Acid 1 mg PO DAILY
9. Glargine 21 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Morphine SR (MS Contin) 30 mg PO Q12H
RX *Avinza 30 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*1
11. Morphine Sulfate IR 15 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth q4hrs Disp #*120 Tablet
Refills:*0
12. Multivitamins 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 1 TAB PO BID:PRN constipation
15. Thiamine 100 mg PO DAILY
16. Ziprasidone Hydrochloride 40 mg PO QHS
Give with food
17. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
18. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38380**] skilled Nursing & Rehab Center
Discharge Diagnosis:
Primary: Right hand ischemia, Lithium toxicity, Acute kidney
injury, Urinary tract infection
Secondary: Bipolar Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 33733**],
It was our pleasure taking care of you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
after being found down at your home for an unknown amount of
time. You were found to have a urine infection and a very high
level of your bipolar medication, lithium, in your bloodstream.
We gave you IV fluids which helped the function of your kidneys
to flush out the toxic levels of lithium and your mental status
improved. Your right hand was severely damaged after you were
found to be lying on it for at least two days, and the surgical
team decided to amputate.
We made the following changes to your medications. Buspar,
lithium, glipizide, and paxil will be discontinued. YOu will be
starting geodon as well as insulin.
Please take all other medications as previously prescribed.
Followup Instructions:
[**2145-9-14**] 10:00am, [**Hospital Ward Name 23**] 2
Hand Clinic
Division of Plastic and Reconstructive Surgery
Department of Surgery
[**Hospital1 69**]
[**Hospital **] Medical Office Building
[**Hospital Unit Name 11610**]
[**Location (un) 86**] , [**Telephone/Fax (1) 112111**]
[**Hospital 112110**] Health Center
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
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26,913
| 178,734
|
31365
|
Discharge summary
|
report
|
Admission Date: [**2167-7-21**] Discharge Date: [**2167-7-31**]
Date of Birth: [**2094-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic Ascending Aortic Aneurysm
Major Surgical or Invasive Procedure:
[**2167-7-23**] - Redo Sternotomy, Replacement of Ascending Aorta (32mm
gelweave tube graft)
History of Present Illness:
Mr. [**Known lastname **] is a 72-year-old male who in [**2146**] underwent an aortic
valve replacement with a mechanical Bjork-Shiley valve. He has
been followed for an enlarging ascending aorta and his most
recent echo showed it to be now at 6 cm. He is now presenting
for repair of the ascending aortic aneurysm
Past Medical History:
s/p AVR (Bjork-Shiley) [**2146**]
s/p ICD [**2161**]
MI at age 46
Cardiomyopathy
CHF
AAA
Colorectal Cancer
UTI
Colostomy [**2144**]
Hyperlipidemia
HTN
Social History:
Retired lift truck operator. 60 pack year history of smoking. He
quit over 10 years ago. Lives with his wife. [**Name (NI) **] does not drink
alcohol. He is edentulous.
Family History:
Noncontributory
Physical Exam:
GEN: NAD
NECK: Supple, FROM
LUNGS: Clear
HEART: RRR, Crisp valve click, Nl S1-S2
ABD: Soft, NT/ND/NABS
EXT: Warm, well perfused, 1+ edema.
NEURO: Nonfocal. No carotid bruits.
Pertinent Results:
[**2167-7-23**] ECHO
PRE CPB 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. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is moderate to severe global
left ventricular hypokinesis (LVEF = 30 %). There is moderate
global right ventricular free wall hypokinesis. The ascending
aorta is markedly dilated. This dilation appears to taper down
near the arch but limited views prevent full assessment. There
are simple atheroma in the aortic arch. There are focal
calcifications in the aortic arch. The descending thoracic aorta
is mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. A single tilting disk type aortic
valve prosthesis is present. The aortic valve prosthesis appears
to be well seated. The disk is poorly seen but appears to be
moving appropriately. Some fibrinous echodensities are seen on
the LVOT side of the valve and are likely evidence of some
degeneration. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is a trivial/physiologic
pericardial effusion.
POST CPB The patient is receiving epinephrine by infusion. The
left ventricle continues to display moderate to severe global
dysfunction, but now with slightly more hypokinesis of the
inferior wall. The EF is about 30%. The right ventricle displays
somewhat improved function from pre-bypass study - now mildly
globally hypokinetic. The ascending aortic graft is only poorly
seen. The thoracic aorta appers intact distal to the graft.
Mitral regurgitation is now trace. No other changes from pre-cpb
study.
[**2167-7-30**] 07:00AM BLOOD WBC-7.1 RBC-3.02* Hgb-9.9* Hct-28.8*
MCV-95 MCH-32.8* MCHC-34.5 RDW-13.9 Plt Ct-288
[**2167-7-31**] 06:45AM BLOOD PT-25.8* PTT-46.2* INR(PT)-2.6*
[**2167-7-30**] 07:00AM BLOOD Glucose-118* UreaN-21* Creat-1.7* Na-137
K-3.8 Cl-100 HCO3-28 AnGap-13
[**2167-7-21**] 08:55PM BLOOD ALT-17 AST-23 LD(LDH)-153 AlkPhos-61
Amylase-47 TotBili-1.3
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-7-28**] 2:36 PM
CHEST (PA & LAT)
Reason: evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with s/p asc aorta replac
REASON FOR THIS EXAMINATION:
evaluate for effusion
CHEST X-RAY
HISTORY: Status post ascending aorta repair, evaluate for
effusion.
Two views. Comparison with [**2167-7-24**]. The patient is status post
median sternotomy and MVR, as before. Mediastinal structures are
unchanged. An ICD remains in place. A right internal jugular
catheter has been withdrawn. Allowing for differences in
technique, there is no other significant change.
IMPRESSION: No significant interval change.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2167-7-21**] for surgical
management of his dilated ascending aorta. Heparin was started
as he had been off his coumadin for 5 days in aticipation of
surgery. On [**2167-7-23**], Mr. [**Known lastname **] was taken to the operating room
where he underwent a redo sternotomy with replacement of his
ascending aorta. An intraopertaive vascular surgery consult was
obtained as it was decided to use his right axillary artery for
arterial cannulation. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. By postoperative day one, Mr. [**Known lastname **] had awoke
neurologically intact and was extubated. Aspirin, beta blockade
and a statin were resumed. The electrophysiology service was
consulted for interrogation of his pacemaker and it was
reprogrammed to function appropriately. Haldol was used for some
mild postoperative aggitation. Coumadin was resumed for his
mechanical valve. Mr. [**Known lastname **] developed atrial fibrillation for
which amiodarone was started. Mr. [**Known lastname **] remained in the
intensive care unit for a few extra days due to agitation and
confusion however this slowly cleared. On postoperative day
three, 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. His
mental status cleared and on POD 7 he was discharged to rehab in
stable condition.
Medications on Admission:
Aldactone 25mg QD
Captopril 25mg TID
Coreg 12.5mg [**Hospital1 **]
Coumadin
Lasix 80mg QD
Lovastatin 40mg QD
Multivitamin
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): Dose
for INR goal of 2.5-3.0.
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed for UTI for 3 days.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] Health Network
Discharge Diagnosis:
Mild AI/Dilated ascending aorta s/p Replacement
s/p AVR [**2146**]
s/p ICD
s/p Colostomy
AF
MI at age 46
Cardiomyopathy
CHF
UTI
Colorectal Cancer
AAA
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 5017**] in 2 weeks.
Follow-up with pcp [**Last Name (NamePattern4) **]. [**First Name (STitle) 745**] in [**1-31**] weeks. [**Telephone/Fax (1) 68885**]
Call all providers for appointments.
Completed by:[**2167-7-31**]
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icd9cm
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360, 455
|
7595, 7604
|
1402, 3803
|
8319, 8681
|
1175, 1192
|
6226, 7315
|
3840, 3882
|
7422, 7574
|
6080, 6203
|
7628, 8296
|
1207, 1383
|
282, 322
|
3911, 4443
|
483, 799
|
821, 973
|
989, 1159
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,181
| 149,771
|
34816
|
Discharge summary
|
report
|
Admission Date: [**2171-10-24**] Discharge Date: [**2171-10-25**]
Date of Birth: [**2104-6-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Tracheomalacia
Major Surgical or Invasive Procedure:
Bronchoscopy by IP [**2171-10-25**]
History of Present Illness:
67yo female with hx of HTN, Type 2 DM, [**Hospital 4747**] transferred from
[**Hospital 79264**] Medical Center ([**Hospital1 2177**]) s/p prolonged admission for
massive ventral wall hernia with incarcerated bowel complicated
by post-operative enterocutaneous fistula and prolonged
ventilator dependence requiring tracheostomy now transferred for
IP evaluation. She initially presented [**2171-7-9**] with weakness and
abdominal pain, and was found to have a large ventral hernia
with extensive necrosis and associated cellulitis of the
abdominal wall extending to her thighs. Wound cx + for Proteus,
E.Coli, MSSA and Serratia. She was taken to the operating [**2171-7-11**] (plastics and general surgery)for extensive debridement,
including lysis of significant adhesions and subtotal
ileocolectomy. Post-operatively, she developed a high-output
enterocutaneous fistula requiring TPN and octreotide.
She was initially able to be extubated, but had an episode of
desaturation with altered mental status (maintained BP and HR
throughout) post-op day #14 requiring re-intubation.
Subsequently, she was unable to be weaned from the ventilator,
so underwent tracheostomy post-op day #21 ([**2171-8-1**]). She was
weaned to trach mask, but has been unable to tolerate several
attempts at decanulation or even placement of speaking
valve/trach tube capping secondary to episodes of respiratory
distress. Bronchoscopy [**2171-10-11**] revealed subglottic stenosis with
granulation tissue by report. Bronchoscopy [**2171-10-17**] revealed
tracheomalacia (almost complete collapse of the trachea 2-3cm
distal to end of trach tube with inspiration) without signs of
stenosis. Given these findings, she was transferred to our
facility for IP evaluation and possible stenting.
Other active issues during [**Hospital1 2177**] admission:
C. diff colitis
B/l DVTs (L brachial vein in setting of a PICC), initially
treated with Heparin gtt
Line sepsis (Citrobacter, Coag Negative Staph)
Afib requiring diltiazem drip, digoxin
CHF
Pseudomonas and Klebsiella UTIs
Past Medical History:
Obesity
Hypertension
Type 2 DM
Atrial fibrillation
Nephrolithiasis
Cholelithiasis
Severe atherosclerosis abdominal aorta
Depression
Social History:
Soc Hx: Tobacco 2-2.5ppd x 20 years, quit ~ 25 years ago. Hx of
poor self-care/hygiene.
Family History:
not contributory
Physical Exam:
VS: 98.9 124 127/74 12 97%RA
Gen: young female in NAD, a+o x 3
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: tachy, no m/r/g
Pulm: CTAB
Abd: +BS, NTND, No HSM
Extrem: no c/c/e
Skin: no rashes
Neuro: non-focal
Pertinent Results:
[**2171-10-25**] 03:12AM BLOOD WBC-9.3 RBC-3.52* Hgb-9.1* Hct-29.3*
MCV-83 MCH-25.9* MCHC-31.1 RDW-15.3 Plt Ct-439
[**2171-10-25**] 03:12AM BLOOD PT-34.3* PTT-35.7* INR(PT)-3.6*
[**2171-10-25**] 03:12AM BLOOD Glucose-141* UreaN-25* Creat-0.5 Na-135
K-4.4 Cl-103 HCO3-29 AnGap-7*
[**2171-10-25**] 03:12AM BLOOD ALT-62* AST-71* AlkPhos-345* TotBili-0.1
[**2171-10-25**] 03:12AM BLOOD Albumin-1.9* Calcium-8.0* Phos-3.7 Mg-1.8
CXR [**10-25**]: Read pending
Bronchoscopy [**10-25**]: Final report pending. Please see brief
hospital course for summary.
BAL [**10-25**], final pending:
GRAM STAIN (Final [**2171-10-25**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): BUDDING YEAST.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Brief Hospital Course:
Pt is a 67yo female with hx of HTN, Type 2 DM, Afib transferred
from [**Hospital 79264**] Medical Center ([**Hospital1 2177**]) s/p prolonged admission for
massive ventral wall hernia with incarcerated bowel complicated
by post-operative enterocutaneous fistula and prolonged
ventilator dependence requiring tracheostomy now transferred for
IP evaluation
# Subglottic Stenosis/failure to decannulate:
Bedside bronchoscopy by IP [**2171-10-25**] revealed thick secretions,
adherent to trach. Trach removed and thoroughly cleaned. There
was granulation tissue anteriorly starting 5mm below the vocal
cords and involving the cricoid and to the level of the stoma.
The posterior cricoid and trachea was not involved. The trach
was removed and the scope passed into the mid trachea easily,
however the patient became hypoxic and the trach had to be
replaced. Bronch via trach demonstrated thick secretions
bilaterally. There was moderate tracheomalacia and severe
bilateral bronchomalacia. Given likely tracheobronchitis and
comorbid conditions, IP did not feel that a stent would be
beneficial. Malacia would not explain inability to cap trach,
SGS is the likely etiology. ENT may be consulted at [**Hospital1 **] to consider CO2 laser for granulation tissue
ablation of the anterior trachea, however, this is unlikely to
be successful in the long run. A laryngotracheal resection and
anastomosis would be the ideal solution should the patient
recover from her acute medical illnesses. Tracheal stenting or
t-tube would not be helpful given the proximity to the vocal
cords.
# Tracheobronchitis:
BAL sent and cultures pending. Started on Vancomycin (hx of
MRSA) and Zosyn (hx of Serratia and Pseudomonas) [**2171-10-25**]
empirically pending cultures. Should complete a course for
tracheobronchitis.
# Enterocutaneous fistula/Abdominal wound:
Pt unable to take po due to large output from fistula. Continued
wound vac and wound care per [**Hospital1 2177**] protocol, wound care consulted
for further recs. Continued octreotide per [**Hospital1 2177**] regimen for large
output. Continued TPN, albumin low at 1.9.
# Afib:
Continued current regimen of toprol, digoxin, and cardizem.
# History of DVTs:
Transferred on Coumadin. Coumadin held during this admission
given possibility of invasive procedure. INR on the day of
transfer was elevated at 3.6.
# Type 2 DM:
Continued fixed dose and sliding scale insulin. Followed
fingersticks per ICU protocol.
# Pain control: Morphine as needed.
# Nutrition: Continued TPN.
# Depression: Continued Celexa.
#Access: R PICC line placed at [**Hospital1 2177**]
#Code: DNR, confirmed with patient.
Medications on Admission:
Lisinopril 10mg po daily
Celexa 20mg po daily
Toprol XL 100mg po ?bid
Digoxin 0.125mg po daily
Cardizem 360mg po daily
Octreotide 200micrograms IV bid
Coumadin 8mg po qpm
Bactrim DS 1 tab po bid
Lantus 15 units sc qhs
Humalog insulin sliding scale
Atrovent 2.5mL, 1 inhalation q4h while awake
Xopenex MDI 2 puffs q4h prn
Ativan 0.5mg po bid prn agitation
Morphine 1-2mg IV q2h prn pain
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
8. Octreotide Acetate 100 mcg/mL Solution Sig: Two Hundred (200)
mcg Injection [**Hospital1 **] (2 times a day).
9. Coumadin Oral
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. Lantus
15 units subcutaneous QHS
12. Humalog
according to insulin sliding scale you have been using at
[**Hospital1 **]
13. coumadin
as needed to maintain INR between 2 and 3
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours): while awake. inhalation
15. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
16. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q6H (every 6
hours) as needed for pain.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for agitation.
18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours): will need level checked
with third dose. started [**2171-10-25**] in AM.
19. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: 4.5 g
Intravenous Q8H (every 8 hours): Started [**2171-10-25**] in AM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6689**] - [**Location (un) 6691**]
Discharge Diagnosis:
Primary Diagnosis: Respiratory failure
Secondary Diagnoses: Pneumonia, Diabetes, Hypertension,
Abdominal wall wound
Discharge Condition:
Stable. Tolerating trach mask with oxygen sat's in mid 90s.
Discharge Instructions:
You were admitted for evaluation of possible
tracheobronchomalacia, or narrowing of your airways that might
make it difficult for you to cap your trach. We did a
bronchoscopy, which showed thick secretions concerning for
infection. We recommend that you receive treatment for
infection. Once your infection has resolved, you should be
evaluated further by ENT for narrowing at the top of your tube.
Please take all medications as directed. We started you on
vancomycin and zosyn for treatment of your lung infection.
Followup Instructions:
Please continue to receive care from the physicians at
[**Hospital1 **]. Once your pneumonia has improved, we recommend that
you have further evaluation by ENT for the narrowing above your
vocal cords.
Completed by:[**2171-10-25**]
|
[
"519.09",
"518.81",
"427.31",
"707.03",
"E878.8",
"401.9",
"486",
"998.6",
"250.00",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"99.15",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8997, 9071
|
4130, 6784
|
331, 368
|
9233, 9296
|
3002, 4037
|
9866, 10101
|
2722, 2740
|
7221, 8974
|
9092, 9092
|
6810, 7198
|
9320, 9843
|
2755, 2983
|
9154, 9212
|
4107, 4107
|
4076, 4076
|
277, 293
|
396, 2445
|
9112, 9132
|
2467, 2601
|
2617, 2706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,633
| 121,582
|
7315
|
Discharge summary
|
report
|
Admission Date: [**2112-6-3**] Discharge Date: [**2112-6-14**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
female with a history of diabetes, hypertension and
hypercholesterolemia and a questionable history of myocardial
infarction who was to undergo laparoscopic placement of
peritoneal dialysis catheter on [**2112-6-3**]. However, the
beginning of the procedure was complicated by bowel
perforation via trocar placement. The procedure was converted
to an open procedure and the perforation was closed. No
peritoneal dialysis catheter was placed. For operative
details, please see operative note. There was a small pinhole
injury at the transverse colon which was repaired. There was
no gross peritoneal contamination identified. The patient was
stable. Postoperatively, the patient did well, was afebrile
and the vitals were stable. However, the postop course was
complicated by bouts of atrial fibrillation and the patient
was seen by Cardiology immediately postoperatively. The
patient had a brief, about 30 minute, bout of atrial
fibrillation postop in the setting of decreased blood
pressure thought to be secondary to sedation and converted
spontaneously and the blood pressure improved. However, over
the course of the next few days, the patient continued to go
back into atrial fibrillation and was ultimately placed on
amiodarone drip.
ALLERGIES: ACE inhibitor causes increased K.
MEDICATIONS ON ADMISSION: Lopressor 150 mg [**Hospital1 **], levofloxacin
250 mg qd, Flagyl 500 mg tid, Valsartan 80 qd, Lipitor 20.
PHYSICAL EXAMINATION: General - HEENT - pupils are equal,
round, react to light and accommodation. Extraocular muscles
were intact. Sclera are anicteric. Neck was supple without
lymphadenopathy. Heart is regular rate and rhythm with no
murmurs, rubs or gallops. Abdomen is soft, nontender and
nondistended.
LABORATORY: PT is 26 and INR of 1.3. Sodium is 143, K is
4.3, chloride 104, bicarb 23, BUN 51, creatinine 2.7, glucose
311.
HOSPITAL COURSE: On postop Day 1, the patient was continued
on Levo/Flagyl and continued to be followed by the Renal
Team. In order to initiate dialysis, the patient had a
Permacath placed by Interventional Radiology on postop Day 4.
The patient was followed for her increasing sugars. The
patient was on insulin drip until postop Day 3. On postop Day
6, she began to tolerate a diet and had frequent dialysis on
Tuesday, Thursday, Saturday schedule. The patient's sugars
were well controlled on an insulin regimen. Physical Therapy
evaluated the patient on [**2112-6-10**] and deemed her suitable
for rehabilitation secondary to generalized weakness. The
patient had been in normal sinus rhythm 48 hours prior to
discharge on stable PO amiodarone regimen. She was changed to
Levo/Flagyl PO on [**2112-6-13**] and discharged to Rehabilitation
on [**6-14**] on postop Day 11, Levo/Flagyl Day 12.
DISCHARGE DIAGNOSIS: Iatrogenic bowel perforation status
post attempted peritoneal dialysis catheter placement
laparoscopically converted to open procedure, status post
postop atrial fibrillation, acute renal disease with
hemodialysis status post Permacath placement.
DISCHARGE INSTRUCTIONS: The patient was discharged to
Rehabilitation and instructed to follow up with Transplant
Service at the next available visit. She was to call [**Telephone/Fax (1) 27019**] for an appointment.
DISCHARGE MEDICATIONS: The patient was discharged on
medications of levofloxacin 250 mg po q48h, Coumadin 1 mg po
hs, Flagyl 500 mg po tid, Flagyl and Levo for two weeks,
Lopressor 50 mg po tid, amiodarone 400 mg po qd, insulin
sliding scale and Pepcid 20 mg po qd.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2112-6-14**] 08:26:57
T: [**2112-6-14**] 09:24:58
Job#: [**Job Number 27020**]
|
[
"403.91",
"584.5",
"E878.8",
"998.2",
"568.0",
"428.0",
"428.30",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"46.75",
"39.95",
"54.59",
"99.07",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
3432, 3904
|
2942, 3190
|
1480, 1588
|
2041, 2920
|
3215, 3408
|
1611, 2023
|
135, 1453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,685
| 174,810
|
53206+53207
|
Discharge summary
|
report+report
|
Admission Date: [**2187-2-14**] Discharge Date: [**2187-2-21**]
Date of Birth: [**2111-8-11**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Gangrene of left toes.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with
multiple medical problems who was admitted in [**Name (NI) 404**] of this
year for ischemic right foot and gangrenous toes. He
underwent a right popliteal to dorsalis pedis bypass with
vein on [**2187-1-2**], which failed. He underwent a right
TMA which was done on [**2187-1-9**], which did not appear
viable.
He underwent with Dr. [**First Name (STitle) **] of Interventional Cardiology an
attempt to improve the distal circulation with an
angioplasty, but this was unsuccessful. The patient
underwent a right below-the-knee amputation on [**2187-1-19**].
During his hospitalization, wound cultures grew pansensitive
Staphylococcus aureus. He was treated with Kefzol.
Postoperatively he had a fever with positive blood cultures
of beta-strep group B. He was treated with Oxacillin per
Infectious Disease. He also had C-diff on the day of
transfer to [**Hospital **] Rehabilitation. He was discharged on
Augmentin with Flagyl for ten days.
He also has gangrenous left toe changes and returned because
of severe ischemic rest pain. TMA was planned for the
patient. Glucoses have been elevated to greater than 350
over the last day. He was admitted for further evaluation
and treatment.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Lantus 32 U at hs, regular Insulin
sliding scale before meals and at [**Hospital 21013**], Lopressor 50 mg
b.i.d., Lisinopril 10 mg q.d., Lasix 60 mg b.i.d., Lipitor 20
mg hs, Plavix 75 mg q.d., Aspirin 325 mg q.d., Heparin 5000 U
subcue b.i.d., Prevacid 30 mg q.d., Neurontin 300 mg b.i.d.,
Calcium Carbonate 100 mg b.i.d., Tamsulosin 0.4 mg b.i.d.,
Urecholine 25 mg b.i.d., Fentanyl patch 25 mcg/hr change q.2
hours, Morphine Sulfate 10 mg p.o. q.4 hours for breakthrough
pain, Tylenol 650 mg q.4 hours p.r.n. pain, Creon 10 three
tabs with meals, Ambien 5 mg at hs p.r.n., Trazodone 50 mg hs
p.r.n., Colace 100 mg b.i.d., Dulcolax suppository q.d.
p.r.n., Lactulose 20 mg q.d. p.r.n.
PAST MEDICAL HISTORY: Coronary artery disease with
myocardial infarction times four. Last myocardial infarction
was in [**2185-9-27**]. The patient underwent a coronary artery
bypass grafting in [**2185-10-28**]. He has ischemic
cardiomyopathy with an ejection fraction of 15-20%. The
patient's cardiac postoperative course was complicated by
atrial fibrillation. He has asymptomatic carotid stenosis by
ultrasound, less than 40% bilaterally. Type 1 diabetic with
neuropathy. History of hypertension. History of
dyslipidemia. History of gastroesophageal reflux disease.
History of chronic pancreatitis. History of malabsorption.
History of chronic renal insufficiency. History of benign
prostatic hypertrophy with urinary retention and Foley
placement. History of duodenal ulcer with gastrointestinal
bleed, remote.
PAST SURGICAL HISTORY: Bilateral SFA angioplasty with stents
in [**2182**]. Left SFA stent in [**2186-6-27**]. C-diff colitis in
[**2183-12-29**], treated. Coronary artery bypass grafting times
three in [**2185-10-28**] by Dr. [**Last Name (STitle) 70**]. Right popliteal to
dorsalis pedis vein bypass with right TMA in [**Month (only) 404**] of this
year. Right below-the-knee amputation in [**Month (only) 404**] of this
year.
SOCIAL HISTORY: He is widowed. He lives with his two sons.
[**Name (NI) **] has been at rehabilitation since his last hospitalization.
He has had blood transfusions in the past. He has a 30
pack-year smoking history. He has not smoked for 17 years.
He has alcohol occasionally.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7??????, heart
rate 78, respirations 18, blood pressure 124/62, oxygen
saturation 96% on room air. General: He was an alert and
cooperative white male in no acute distress. HEENT:
Unremarkable. Carotids palpable without bruits. Pulse exam:
Exam showed palpable carotids bilaterally. Right radial is
1+, left radial 2+ and palpable. Abdominal aorta was
nonprominent. Femoral pulses were 2+ bilaterally.
Popliteals were absent bilaterally. He had a right
below-the-knee amputation, well-healed stump, clean, dry, and
intact, with staples in place. The left foot showed mild
erythema with ruborous changes, and the foot was very warm.
There were gangrenous toes, 1 and 2. Dorsalis pedis and
posterior tibial on the left were triphasic Dopplerable
signals. Chest: Lungs clear to auscultation. Heart:
Regular, rate and rhythm. Without murmur. The median
sternotomy was well healed. Abdomen: Unremarkable.
LABORATORY DATA: On admission white count was 5.8,
hematocrit 31.7, platelet count 350,000; BUN 30, creatinine
0.9.
Chest x-ray was not repeated on this admission with no active
cardiopulmonary disease.
Electrocardiogram showed sinus rhythm, normal axis, Qs in II,
III and AVF, no acute ST changes.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. PVRs were obtained which demonstrated significant
left SFA tibial disease with noncompressible vessels. Pulse
volume recordings on the left showed ankle amplitude of 11
mm, on the tarsal 7 mm. Ankle brachial index could not be
calculated secondary to noncompressibility of vessels.
Anticipated TMA was deferred. The patient underwent a
peripheral catheterization by Dr. [**Last Name (STitle) 911**] in the Cardiac
Catheterization Lab on [**2187-2-16**], and the patient at
that time underwent angioplasty of the anterior tibial with
residual 20% stenosis distally. It was a linear stable type
A dissection distally.
Vancomycin, Levofloxacin, and Flagyl were instituted at the
time of admission. The patient underwent on [**2-19**] a
left TMA. He tolerated the procedure well and was
transferred to the PACU in stable condition. He was returned
to the regular nursing floor for continued care.
His initial dressing was removed on postoperative day #1.
The TMA site was well approximated. Physical Therapy was
requested to see the patient for strict nonweightbearing.
The remaining hospital course was unremarkable. The patient
was discharged in stable condition. Wounds were clean, dry,
and intact. TMA dressing to be dry sterile dressing q.d.
DISCHARGE MEDICATIONS: Metoprolol 25 mg b.i.d., hold for
systolic blood pressure less than 100 or heart rate less than
55, Lisinopril 10 mg q.d., hold for systolic blood pressure
less than 100, Atorvastatin 20 mg at hs, Protonix 40 mg q.d.,
Tamsulosin 0.4 mg b.i.d., Bethanechol 25 mg b.i.d.,
Gabapentin 300 mg b.i.d., Creon 10 3 cap with meals and at
bed time, Calcium Carbonate 500 mg t.i.d., Zolpidem 10 mg at
hs p.r.n., Fentanyl patch 25 mcg/hr topical change q.72
hours, Colace 100 mg b.i.d., Senna 2 tab p.r.n., Colace
suppository 10 mg p.r.n., Lactulose 30 mg q.d. p.r.n.,
Aspirin 325 mg q.d., Plavix 75 mg q.d., Lasix 60 mg b.i.d.,
Morphine Sulfate immediate release 15-30 mg q.4 hours p.r.n.
For breakthrough pain.
DISCHARGE DIAGNOSIS:
1. Left foot gangrene secondary to peripheral vascular
disease.
2. Status post angioplasty of the left anterior tibial
artery.
3. Status post left transmetatarsal amputation.
4. Type 1 diabetes, Insulin controlled, stable.
5. Hypertension, controlled.
6. Coronary artery disease, stable.
7. Hyperlipidemia, treated.
8. Urinary retention.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2187-2-20**] 09:51
T: [**2187-2-20**] 09:56
JOB#: [**Job Number 109530**]
Admission Date: [**2187-2-14**] Discharge Date: [**2187-3-2**]
Date of Birth: [**2111-8-11**] Sex:
Service: Vascular Surgery
CHIEF COMPLAINT: Gangrene - left toes.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
white gentleman with coronary artery disease, status post
multiple myocardial infarctions, status post coronary artery
bypass graft with postoperative atrial fibrillation in [**2184**],
ischemic cardiomyopathy, type 1 diabetes, hypertension,
hypercholesterolemia, gastroesophageal reflux disease, and
peptic ulcer disease (status post gastrointestinal bleed) who
was admitted to [**Hospital1 69**] in
[**2186-12-28**] with an ischemic right foot an gangrenous
toes.
The patient underwent a right popliteal to dorsalis pedis
vein graft on [**2187-1-2**] which failed. A right
transmetatarsal amputation was done on [**2187-1-9**] but
did not appear viable. Dr. [**First Name (STitle) **] (Interventional
Cardiology) attempted to improve distal circulation with
angioplasty but was unsuccessful. The patient went on to
have a right below-knee amputation on [**2187-1-19**].
During hospitalization, the patient's wound cultures grew
pan-sensitive Staphylococcus aureus. The patient was treated
with Kefzol. Postoperatively, the patient had fevers and
positive blood cultures growing beta streptococcus group B.
The patient was treated with oxacillin per the Infectious
Disease Service. The patient was also Clostridium difficile
positive on the day of transfer to [**Hospital **] [**Hospital **]
Hospital. The patient was discharged on Augmentin and 10
days of Flagyl.
The patient also had gangrenous left toes and returns for
admission because of severe rest pain. Left transmetatarsal
amputation planned. Blood sugars have been greater than 350
twice on the day of admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
(a) Myocardial infarction times four; last myocardial
infarction in [**2185-9-27**].
(b) coronary artery bypass graft in [**2185-10-28**].
2. Ischemic cardiomyopathy; ejection fraction of 15% to
20%.
3. Postoperative atrial fibrillation in [**2185-10-28**].
4. History of asymptomatic carotid stenosis; ultrasound in
[**2186-11-27**] showed less than 40% stenosis bilaterally.
5. Type 1 diabetes; diagnosed at the age of 25 - with
neuropathy.
6. Hypertension.
7. Hypercholesterolemia.
8. Gastroesophageal reflux disease.
9. Chronic pancreatitis.
10. History of malabsorption.
11. Chronic renal insufficiency.
12. Benign prostatic hypertrophy.
13. Urinary retention; Foley catheter placed.
14. Duodenal ulceration with gastrointestinal bleed.
15. Clostridium difficile colitis in [**2186-12-28**];
treated with 10 days of Flagyl.
16. Peripheral vascular disease.
(a) Percutaneous transluminal angioplasty/stents of the
bilateral superficial femoral artery in [**2182**].
(b) Stent to left superficial femoral artery in [**2185-12-28**].
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times three - with left leg
vein on [**2185-10-28**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] at [**Hospital1 346**].
2. Right popliteal to dorsalis pedis vein graft (failed
postoperative day one) on [**2187-1-2**] by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**].
3. Right transmetatarsal amputation on [**2187-1-9**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
4. Right below-knee amputation on [**2187-1-19**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (From [**Hospital **] Rehabilitation)
1. Lantus 32 units subcutaneously at hour of sleep.
2. Regular insulin sliding-scale four times per day.
3. Lopressor 50 mg by mouth twice per day.
4. Lisinopril 10 mg by mouth once per day.
5. Lasix 60 mg by mouth twice per day.
6. Lipitor 20 mg by mouth at hour of sleep.
7. Plavix 75 mg by mouth once per day. \
8. Aspirin 325 mg by mouth once per day.
9. Heparin 5000 units subcutaneously twice per day.
10. Prevacid 30 mg by mouth once per day.
11. Neurontin 300 mg by mouth twice per day.
12. Calcium carbonate 1000 mg by mouth twice per day.
13. Tamsulosin 0.4 mg by mouth twice per day.
14. Urecholine 25 mg by mouth twice per day.
15. Fentanyl patch 25 mcg q.72h.
16. Morphine sulfate 10 mg by mouth q.4h. as needed (for
breakthrough pain).
17. Tylenol 650 mg by mouth q.4h. as needed.
18. Creon #10 four tablets by mouth three times per day
(with meals).
19. Ambien 5 mg by mouth at hour of sleep as needed.
20. Trazodone 50 mg by mouth at hour of sleep as needed.
21. Colace 100 mg by mouth twice per day.
22. Dulcolax suppository once per day as needed.
23. Lactulose 20 g once per day as needed.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient lives with his two sons. The
patient quit smoking cigarettes 17 years ago after smoking
one pack per day for 30 years. He occasionally drinks
alcohol. Currently, the patient has been at [**Hospital **]
Rehabilitation following his below-knee amputation on the
right.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 98.7, his pulse was 78, his respiratory
rate was 18, his blood pressure was 124/62, and his oxygen
saturation was 96% on room air. His height was 5 feet 9
inches with a weight of 143 pounds. In general, an alert and
cooperative white male in no acute distress. The skin was
warm and dry. There were no rashes. Head, eyes, ears, nose,
and throat examination revealed the sclerae were anicteric.
The pupils were equal and round. Mouth with extensive
permanent bridge work. There were no lesions. Neck
examination revealed range of motion was within normal
limits. There was no lymphadenopathy or thyromegaly.
Carotids were palpable. No bruits. Chest revealed the lungs
were clear bilaterally. Heart was regular in rate and
rhythm. There were no murmurs. The abdomen was soft and
nontender. Bowel sounds were present. No masses or
hepatosplenomegaly. Rectal examination was deferred.
Extremities revealed the right below-knee amputation was
clean, dry, and intact. There were surgical staples in
place. The left foot with mild edema. Rubrus and very warm.
Gangrene on the left first and second toes was present.
Pulse examination revealed carotid pulses were 2+
bilaterally. Right radial pulse was 1+ and left was 2+.
Abdominal aorta was not palpable. Femoral pulses were 2+
bilaterally. Popliteal pulses were not palpable bilaterally.
Left pedal pulses had triphasic doppler signal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed his white blood cell count was 5.8, his
hemoglobin was 10.4, his hematocrit was 31.7, and his
platelets were 350,000. Sodium was 136, potassium was 4.7,
chloride was 95, bicarbonate was 35, blood urea nitrogen was
30, creatinine was 0.9, and his blood glucose was 87.
Prothrombin time was 12.3, partial thromboplastin time was
24.8, and his INR was 1. Urinalysis was negative.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on [**2186-12-2**] showed no acute cardiopulmonary disease.
An electrocardiogram on admission showed a normal sinus
rhythm at a rate of 65. Old inferior myocardial infarction.
Occasional ventricular ectopy.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the hospital on [**2187-2-14**]. He was started on
vancomycin 1 g intravenously q.24h., levofloxacin, and
intravenous Flagyl empirically for cellulitis of the left
foot. No cultures were possible because toe gangrene was
dry.
A pulmonary vascular resistance of the left lower extremity
was done on [**2187-2-15**] and showed a 7-mm deflection at
the level of the metatarsals.
On the following day, the patient was taken to the Cardiac
Catheterization Laboratory for a left lower extremity
angiogram by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]. The patient's previous stents
were found to be widely patent. There was a patent popliteal
to tibial peroneal trunk. Posterior tibialis and peroneal
arteries had diffuse disease. The peroneal artery was
occluded at the shin, and the posterior tibialis occluded at
the heel. The anterior tibial artery had serial stenoses
with focal 70% to 80% stenosis at midshin and 70% stenosis at
the ankle. The proximal and distal anterior tibial artery
underwent successful balloon angioplasty. There was only 20%
residual stenosis following the procedure. The patient was
then scheduled for a right transmetatarsal amputation.
The patient had an episode of hypertension with decreased
urine output and elevated blood sugars which was treated and
resolved on the day prior to surgery.
On [**2187-2-19**] the patient underwent an uneventful
right transmetatarsal amputation. Postoperatively, the
incision site was clean, dry, and intact. The
transmetatarsal amputation appeared viable. The patient was
to continue nonweightbearing for a total four weeks until
sutures were removed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in the office.
On [**2187-2-23**] the patient developed hypotension with
abdominal pain and bloody diarrhea. His electrocardiogram
showed some ST depressions. Cardiology was consulted and
followed the patient. General Surgery was consulted and
requested a computed tomography of the abdomen and pelvis.
Gastroenterology was also consulted. The patient was
transferred to the Intensive Care Unit on [**2187-2-23**]
for a possible peritonitis and aggressive fluid resuscitation
was continued.
The patient's Clostridium difficile stool cultures were
negative times three. However, the patient seemed to improve
on vancomycin, levofloxacin, and Flagyl. Therefore,
antibiotics were continued. The patient's abdominal pain
resolved. His blood pressure remained stable. However, he
continued to have diarrhea which was improving at a very slow
rate.
The patient left the Intensive Care Unit after several days
and has been doing well except for an episode of tachycardia
to a rate of 135 on [**2187-2-27**]. A repeat echocardiogram
showed an ejection fraction of 20% to 25% with global
hypokinesis. Cardiology felt that the patient's symptoms did
not suggest progressive heart failure. A beta blocker and
ACE inhibitor were recommended when the patient's blood
pressure stabilized. The patient was started on Lopressor
which was titrated to 37.5 mg by mouth three times per day.
An ACE inhibitor may be added at a later date.
The [**Last Name (un) **] Service was asked to evaluate the patient on [**2187-3-1**] regarding resuming the patient's fixed insulin dose.
Up to this time, the patient had been on an insulin
sliding-scale. A suggestion was made that perhaps the
patient's diarrhea was due to diabetic autonomic neuropathy
given that the patient's Clostridium difficile cultures had
been negative.
At the time of this dictation, the patient's transmetatarsal
amputation incision was clean, dry, and intact. There was a
minimal amount of rubor adjacent to the incision. The
patient was to remain nonweightbearing on the transmetatarsal
amputation for three more weeks. Antibiotics have been
stopped.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to be treated with a total of two weeks
of oral vancomycin for presumptive Clostridium difficile
colitis.
2. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in
the office for suture removal from the transmetatarsal
amputation incision.
MEDICATIONS ON DISCHARGE:
1. Vancomycin oral liquid 250 mg by mouth q.6h. (for two
weeks - from [**2-25**] to [**2187-3-10**]).
2. Plavix 75 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Metoprolol 37.5 mg by mouth three times per day (hold
for a systolic blood pressure of less than 100 - heart rate
of less than 60).
5. Lasix 80 mg by mouth once per day.
6. Protonix 40 mg by mouth q.24h.
7. Heparin 5000 units subcutaneously q.12h.
8. Ambien 5 mg by mouth at hour of sleep.
9. Ibuprofen 400 mg by mouth q.8h. as needed (for pain).
10. Neurontin 300 mg by mouth q.12h.
11. Glargine 14 units subcutaneously at hour of sleep.
12. [**Year (4 digits) 3435**] sliding-scale four times per day.
DISCHARGE DISPOSITION: The patient was to return to [**Hospital3 5090**] for [**Hospital 3058**] rehabilitation.
CONDITION AT DISCHARGE: Condition on discharge was
satisfactory.
PRIMARY DISCHARGE DIAGNOSES:
1. Ischemic gangrene of left toes.
2. Balloon angioplasty of the left proximal and distal
anterior tibial artery on [**2187-2-16**] by Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**].
3. Left transmetatarsal amputation on [**2187-2-19**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
SECONDARY DISCHARGE DIAGNOSES:
1. Presumed/recurrent Clostridium difficile colitis;
treatment with oral vancomycin times two weeks.
2. Hypovolemia secondary to dehydration from diarrhea.
3. Coronary artery disease.
4. Type 1 diabetes.
5. Hypertension.
6. Hyperlipidemia.
7. Chronic pancreatitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2187-3-1**] 15:45
T: [**2187-3-1**] 15:46
JOB#: [**Job Number 109531**]
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78,309
| 156,098
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55145
|
Discharge summary
|
report
|
Admission Date: [**2133-10-24**] Discharge Date: [**2133-11-6**]
Date of Birth: [**2055-7-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
L IT femur fracture
Major Surgical or Invasive Procedure:
Left open reduction internal fixation
History of Present Illness:
Ms. [**Known lastname **] is a 78 y/o F with PMHx of DM II and HTN, who was
initially
aditted on [**10-24**] to the orthopedics service with L femur fx from
mechanical fall. She underwent left hip ORIF on [**10-25**]. On POD #2
([**10-27**]), medical team was consulted for hypoxia. Patient had
2-3LNC O2 requirement since surgery, but acutely worsened over
the course of [**10-26**], where she was hypoxic to the 70s on RA, and
low 90s on 10L ventimask. She was found to have PE on CTA and
was started on heparin gtt. She was also started on vancomycin
and cefepime empirically for HCAP before being transferred to
the MICU. While in the MICU she was initially on NRB, but has
been weaned to 3 O2.
Currently, patient is sleeping comfortably, but awakens easily.
With her daughter translating, she notes persistent SOB and
cough. She denies any pain at this time, but has had persistent
soreness from her surgical site. She reports having a fever 2
days ago.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria.
Past Medical History:
DM II
HTN
Social History:
Lives in [**Country 11150**], currently visiting family in the US.
Denies smoking, EtOH or illicits
Family History:
NC
Physical Exam:
Admission physical exam:
Afebrile
NAD, Alert x oriented x 3.
NCAT
Breathing comfortably on RA
Pulse regular
BUE: Nontender, no deformity or echhymoses. No pain w/ ROM.
Fires [**Hospital1 **], Tri, grasp. 2+DP
LLE: Internally rotated. Pain hip w/ log roll. No TTP
thigh/knee/leg. Fires [**Last Name (un) 938**]/FHL/TA/GS. SILT DP SP S S T. 2+DP.
RLE: No deformity or ecchymoses. No pain w/ ROM. No TTP
thigh/knee/leg. Fires [**Last Name (un) 938**]/FHL/TA/GS. SILT DP SP S S T. 2+DP.
Discharge physical exam:
Vitals: Tc 98.3, BP 134/61, HR 71, RR 18, O2 98% RA
General: Sleeping but easily arousable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Breathing comfortably without accessory muscle use.
Diffuse wheezing through the lung fields bilaterally,
anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM heard best
over LSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left hip incision with no erythema, drainage.
Neuro: CNII-XII intact, responds appropriately. Moving all
extremities.
Pertinent Results:
Admission Labs:
[**2133-10-24**] 09:15PM BLOOD WBC-15.5* RBC-4.53 Hgb-12.1 Hct-36.2
MCV-80* MCH-26.8* MCHC-33.5 RDW-13.2 Plt Ct-287
[**2133-10-24**] 09:15PM BLOOD Neuts-84.7* Lymphs-10.5* Monos-3.2
Eos-1.4 Baso-0.3
[**2133-10-24**] 09:15PM BLOOD PT-10.7 PTT-30.1 INR(PT)-1.0
[**2133-10-24**] 10:30PM BLOOD Glucose-261* UreaN-12 Creat-0.7 Na-137
K-4.6 Cl-100 HCO3-26 AnGap-16
[**2133-10-25**] 12:01PM BLOOD Calcium-8.6 Phos-3.1 Mg-1.5*
[**2133-10-26**] 05:56AM BLOOD %HbA1c-7.6* eAG-171*
IMAGING:
Knee Xray
FINDINGS: Two views of the left knee were obtained. Severe
osteoarthritic changes are seen, including lateral greater than
medial joint space narrowing and adjacent tibial plateau
irregularity. No suprapatellar joint effusion is seen.
Condylar spurring is noted.
Hip Xray:
FINDINGS: AP view of the pelvis and AP and lateral views of the
left hip were obtained. There is a comminuted left
intertrochanteric fracture with varus angulation of the left
femoral head. No dislocation is seen. The pubic symphysis and
sacroiliac joints are intact. Degenerative changes are seen
along the lower lumbar spine. Soft tissue calcifications are
seen overlying bilateral buttock at the level of superior iliac
[**Doctor First Name 362**] may represent calcified granulomas.
IMPRESSION: Comminuted left intertrochanteric fracture with
varus angulation of the left femoral head.
Hip Xray post ORIF:
FINDINGS: Two spot films from the OR were obtained. There is a
total of
136.0 seconds of fluoroscopy time. There is interval placement
of an
intramedullary rod and hip screw. At the end of the procedure
the alignment was good.
CTA [**2133-10-27**]:
FINDINGS: The pulmonary vasculature is well opacified and with
an eccentric nonocclusive filling defect noted in the
subsegmental branches of the right upper lobe (3:14). No other
lobes appear affected. Heart size is normal without evidence of
right heart strain. Atherosclerotic calcifications are evident
within the thoracic aorta without aneurysmal dilatation or
dissection.
CT CHEST: There is no supraclavicular or axillary
lymphadenopathy identified. Multiple lymph nodes are noted
within the prevascular, right upper paratracheal and subcarinal
space, none of which meet CT criteria for pathological
enlargement. No hilar lymphadenopathy identified. Secretions
are evident within the segmental and subsegmental branches of
the bilateral lower lobe airways with associated partial left
lower lobe collapse. Of note, area of left lower lobe collapse
is hypodense to surrounding collapsed lung concerning for
developing pneumonia (3:38). No pleural effusion or
pneumothorax identified.
Limited assessment of the abdomen demonstrates a
normal-appearing liver,
pancreas, spleen, and bilateral adrenal glands.
No suspicious lytic or blastic lesions identified.
IMPRESSION:
1. Subsegmental pulmonary embolism of the right upper lobe. No
right heart strain.
2. Secretions within the segmental and subsegmental branches of
the bilateral lower lobes and associated partial left lower lobe
collapse with areas of relative hypodensity. Findings consistent
with aspiration complicated by developing pneumonia. No
pleural effusion identified.
Echo [**2133-10-27**]:
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Mild mitral annular calcification. Calcified tips of
papillary muscles.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Suboptimal
image quality as the patient was difficult to position.
Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
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 stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: No PFO or ASD. Normal global and regional
biventricular systolic function. Mild pulmonary hypertension.
Microbiology:
[**2133-11-3**] 6:00 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2133-11-4**]**
C. difficile DNA amplification assay (Final [**2133-11-4**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
[**2133-10-27**] 3:15 pm BLOOD CULTURE
**FINAL REPORT [**2133-11-2**]**
Blood Culture, Routine (Final [**2133-11-2**]): NO GROWTH.
[**2133-11-3**] 1:36 pm URINE Source: CVS.
**FINAL REPORT [**2133-11-4**]**
URINE CULTURE (Final [**2133-11-4**]): NO GROWTH.
[**2133-11-1**] 5:09 pm BLOOD CULTURE Source: Venipuncture #1 and
2.
**FINAL REPORT [**2133-11-7**]**
Blood Culture, Routine (Final [**2133-11-7**]): NO GROWTH.
HIP UNILAT MIN 2 VIEWS
IMPRESSION
1. Status post open reduction internal fixation of a comminuted
left
intertrochanteric femur fracture which secured in good anatomic
alignment.
2. Surgical hardware intact with no evidence for hardware
failure.
Discharge labs:
[**2133-11-5**] 07:25AM BLOOD WBC-14.9* RBC-3.50* Hgb-9.1* Hct-28.2*
MCV-81* MCH-26.0* MCHC-32.2 RDW-16.0* Plt Ct-632*
[**2133-11-6**] 07:50AM BLOOD PT-27.3* PTT-47.0* INR(PT)-2.6*
[**2133-11-4**] 07:40AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-110* HCO3-20* AnGap-14
Brief Hospital Course:
Hospital course by service:
Orthopaedic course: Patient had mechanical fall and noted to
have internally rotated left leg. Films showed comminuted
intertrochanteric fracture. Admitted to Ortho and underwent
ORIF on [**2133-10-25**]. Tolerated procedure well. On POD #2, became
suddenly hypoxic - CTA showed subsegmental Pulmonary embolism
and left pneumonia. Patient was started on heparin gtt,
levoflox, flagyl initially for aspiration pneumonia and
transferred to MICU.
Medical ICU course- Patient sent to ICU due to increased oxygen
requirement. Patient placed on NRB initially and was able to
maintain oxygen sat in the high 90's. Given recent intubation
and hospital stay of 48 hours, antibiotics were broadened to
vancomycin/cefepime. She was continued on heparin gtt and
initiated on coumadin. Echo showed no right heart strain.
oxygen was able to be weaned to nasal cannula and patient was
transferred to the medicine floor. Hypoxemia was felt to be
more likely from pneumonia than pulmonary embolism given
subsegmental nature of them.
Medicine floor course - Vancomycin/Cefepime were continued to
complete 8 day course of antibiotics (completed [**11-3**]). The
patient was successfully weaned from oxygen during her course on
the medicine floor. Heparin drip was discontinued on the floor,
once coumadin was therapeutic (goal 2.0-3.0). The decision was
made with her family to continue the patient on coumadin as
opposed to transitioning to Lovenox secondary to family's
comfort with administration of Lovenox injections. She will need
to complete at least a 3 month course of coumadin for treatment
of her pulmonary emoblism. As the patient as greater support in
[**State 760**], the decision was made by the patient's family to
transition her care to [**State 760**]. Dr. [**Last Name (STitle) 112496**] [**Name (STitle) **]
([**Telephone/Fax (1) 112497**]) of [**Male First Name (un) 17703**] NJ was personally contact[**Name (NI) **] by the
inpatient team to notify the patient of her need for coumadin
for treatment of pulmonary embolism and to make him aware that
the patient will need her next INR check on [**Name (NI) 766**], [**2133-11-9**]. The patient was seen by PT regularly and was able to bear
weight as tolerated on her left lower extremity by day of
discharge. Orthopaedics followed the patient through her
hospitalization. Her surgical incision site was non-erythematous
withour drainage throug her hospitalization. Staples were
removed by orthopaedics on day of discharge and repeat left hip
films were obtained prior to the patient's discharge.
Orthopaedics evaluated the patient on day of discharge and
evaluated films of the left hip; radiology noted that the
fracture and hardware were unremarkable. In regards to her
diabetes mellitus, the endocrine consult service initially
followed the patient and agreed with discharging the patient on
oral medications. Patient's hypertension was controlled with
atenolol and amlodipine through her floor course.
Transitional Issues:
- Orthopaedic follow-up to be arranged by the patient's family.
- INR to be monitored by Dr. [**Last Name (STitle) 112496**] [**Name (STitle) **] ([**Telephone/Fax (1) 112497**]) of
[**Male First Name (un) 17703**] NJ. Goal INR 2.0-3.0 for the next 3 months. Her next
scheduled INR check is [**Male First Name (un) 766**], [**2133-11-9**] by Dr. [**Last Name (STitle) **].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. glimepiride *NF* 4 mg Oral daily
3. Amlodipine 5 mg PO DAILY
4. Atenolol 50 mg PO DAILY
Discharge Medications:
1. glimepiride *NF* 4 mg Oral daily
RX *glimepiride 4 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*28 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H
4. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
5. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg Half to 1 tablet(s) by mouth every 6 hours
Disp #*56 Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN Constipation
9. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
Rehab in NJ
Discharge Diagnosis:
Primary: Left intertrochanteric femur fracture, HCAP, pulmonary
embolism, diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You were admitted to
the Orthopedic service because of a broken femur (hip bone) you
had after a fall. They repaired this in the oeprating room.
While you were recovering, you unfortunately developed a
pneumonia and blood clots in your lungs. We treated this with
antibiotics and blood thinners, respectively. Your breathing
status improved. You will be going to rehab to continue to gain
strength and improve your ability to walk.
Take all medications as instructed. Please note the following
medication changes: You are being discharged home on a new
medication called coumadin to treat the clot in your lung
(pulmonary emoblism). You are also being discharged home on new
pain medications- oxycodone and acetaminophen (tylenol)- to be
taken as needed. If you find yourself taking oxycodone recently
then take senna, colace to prevent constipation.
Keep all hospital follow-up appointments. You will need to have
your blood check to ensure coumadin (blood thinning medication)
is at the appropriate level on [**Last Name (LF) 766**], [**2133-11-8**] By Dr.
[**Last Name (STitle) 112496**] [**Name (STitle) **] in [**Hospital1 **] NJ at [**2133**], telephone
number [**Telephone/Fax (1) 112497**]. It is EXTREMELY important that you keep
this appointment. They are provided in a list for you in your
discharge paperwork.
Followup Instructions:
You will need to go on [**Last Name (LF) 766**], [**2133-11-8**] for a blood
check to ensure that coumadin (blood thinning medication) is at
the appropriate level on [**Last Name (LF) 766**], [**2133-11-8**] By Dr.
[**Last Name (STitle) 112496**] [**Name (STitle) **] in [**Hospital1 **] NJ at [**2133**], telephone
number [**Telephone/Fax (1) 112497**].
Please follow up with your orthopaedic surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
When: Please make an appiontment for 2-3 months after discharge
Department of Orthopedics
[**Location (un) 830**], [**Hospital Ward Name 23**] 2
[**Location (un) 86**], [**Numeric Identifier 40974**]
Phone: [**Telephone/Fax (1) 1228**]
Fax: [**Telephone/Fax (1) 10522**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"E878.1",
"820.21",
"997.32",
"E880.9",
"482.9",
"415.11",
"250.02",
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icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
13990, 14032
|
9475, 12470
|
324, 364
|
14168, 14168
|
2982, 2982
|
15930, 16770
|
1784, 1788
|
13163, 13967
|
14053, 14147
|
12893, 13140
|
14351, 15077
|
9171, 9452
|
1828, 2292
|
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|
1370, 1618
|
15097, 15907
|
265, 286
|
392, 1351
|
2999, 9154
|
14183, 14327
|
1640, 1651
|
1667, 1768
|
2318, 2963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,637
| 107,821
|
53376
|
Discharge summary
|
report
|
Admission Date: [**2196-4-28**] Discharge Date: [**2196-4-29**]
Date of Birth: [**2120-3-31**] Sex: F
Service:
CHIEF COMPLAINT: Internal carotid artery stenosis.
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female
with multiple medical problems including coronary artery
disease, peripheral vascular disease, hypertension,
insulin-dependent diabetes mellitus, hypercholesterolemia
(with critical stenosis of the of the right internal carotid
artery of 80% to 99%) who was admitted for stenting and for
angiography.
A preoperative computerized axial tomography of the head on
[**2196-4-19**] was negative for any major vascular and
territorial infarction but was positive for heavy
atherosclerotic calcifications within the cavernous portions
of the internal carotid arteries.
A subclavian angiography, as well as carotid and cerebral
angiography, showed proximal left subclavian disease,
hypoplastic left vertebral artery, tortuous right
brachiocephalic artery with a full 360-degree loop in the
common carotid artery and right subclavian artery. There was
an 80% calcified lesion at the origin of the internal carotid
artery and a tortuous right common carotid artery. Due to
the tortuosity of her vessels, angioplasty and stent of the
right internal carotid artery was unsuccessful. Of note, a
small type A dissection of the proximal carotid artery from
the sheath position occurred during the procedure.
The patient was admitted to the Coronary Care Unit for
observation after the procedure.
REVIEW OF SYSTEMS: No fevers or chills. No chest pain.
The patient denies any shortness of breath, nausea, vomiting,
or lightheadedness. She also denies abdominal pain,
diarrhea, and constipation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Insulin-dependent diabetes mellitus.
3. Hypercholesterolemia.
4. Right shoulder surgery.
5. Hysterectomy.
6. Bilateral vein stripping and ligation.
7. Right femoral artery pseudoaneurysm repair.
8. Coronary artery disease with an inferior myocardial
infarction in [**2183**] and a non-Q-wave myocardial infarction in
[**2192**]. In [**2193-12-23**], coronary artery bypass graft times
two with left internal mammary artery to left anterior
descending artery and right internal mammary artery to first
obtuse marginal. She was admitted most recently in [**2195-10-23**] for chest pain. A catheterization at that time
showed patent grafts.
9. Class III congestive heart failure with biventricular
pacemaker and an ejection fraction of 20%.
10. Gastrointestinal bleed with urgent colectomy in [**2194-9-22**].
11. Chronic anemia.
12. Chronic renal insufficiency (with a baseline creatinine
of 1.3 to 2).
13. Peripheral neuropathy.
14. Peripheral vascular disease and claudication.
15. Neurogenic bladder.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON DISCHARGE: (At home she is on)
1. Toprol-XL 50 mg p.o. twice per day.
2. Imdur 30 mg p.o. twice per day.
3. Lipitor 20 mg p.o. q.h.s.
4. Neurontin 600 mg p.o. three times per day.
5. Protonix 40 mg p.o. once per day.
6. Lasix 80 mg p.o. three times per day (recently increased
from twice per day).
7. Aldactazide 25 mg/25 mg p.o. once per day.
8. Humalog sliding-scale.
9. NPH insulin 55 units subcutaneously q.a.m. and 32 units
subcutaneously q.p.m.
10. Ciprofloxacin 250 mg p.o. twice per day (started on [**2196-4-27**] for a urinary tract infection).
SOCIAL HISTORY: She denies any tobacco history. She has
occasional alcohol. She lives with her husband and her
daughter. She has occasional [**Hospital6 407**]
services.
FAMILY HISTORY: No family history of coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient's temperature was 99.8, blood pressure was 132/73,
heart rate was 96, respiratory rate was 12, and oxygen
saturation was 98% on room air. She was a pleasant, obese,
elderly woman in no acute distress. Obese neck, difficult to
assess neck veins. She had bilateral carotid bruits (left
greater than right). The lungs were clear to auscultation
bilaterally anteriorly. The heart was regular in rate and
rhythm. Distant heart sounds. The abdomen was obese, soft,
and nontender. She had no clubbing, cyanosis, or edema in
her extremities. She had warm extremities with trace
palpable dorsalis pedis pulses. She was alert and oriented
times three. Cranial nerves II through XII were grossly
intact. Motor strength was [**4-25**] in all extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 12.2 on admission, hematocrit was 44, and
platelets were 286. INR was 1.2 and partial thromboplastin
time was 24. Sodium was 137, potassium was 4.3, chloride was
92, bicarbonate was 30, blood urea nitrogen was 45,
creatinine was 1.9, and blood glucose was 150.
HOSPITAL COURSE: The patient remained stable throughout her
hospital course. She was given heparin six hours after the
sheaths were removed. Aspirin and Plavix were added to her
regimen. She had neurologic checks every two hours, which
were stable.
The patient's creatinine bumped to 2.1 but again trended down
to 1.9. She was also given post catheterization intravenous
fluids with Lasix as well as Mucomyst for its renal
protective affects.
The patient's hematocrit status post catheterization drifted
down to 37.1, but she remained asymptomatic.
CONDITION AT DISCHARGE: She was discharged in good
condition.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**] services.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 2578**], and with her neurologist.
DISCHARGE DIAGNOSES:
1. Cerebral atherosclerosis.
2. Native coronary artery disease.
3. Subclavian carotid and cerebral angiography unsuccessful.
4. Attempted angioplasty and stent of the right internal
carotid artery requiring critical care observation overnight.
MEDICATIONS ON DISCHARGE:
1. Toprol-XL 50 mg p.o. twice per day.
2. Imdur 30 mg p.o. twice per day.
3. Lipitor 20 mg p.o. q.h.s.
4. Neurontin 600 mg p.o. three times per day.
5. Protonix 40 mg p.o. once per day.
6. Lasix 80 mg p.o. three times per day (recently increased
from twice per day).
7. Aldactazide 25 mg/25 mg p.o. once per day.
8. Humalog sliding-scale.
9. NPH insulin 55 units subcutaneously q.a.m. and 32 units
subcutaneously q.p.m.
10. Ciprofloxacin 250 mg p.o. twice per day (started on [**2196-4-27**] for a urinary tract infection).
11. Aspirin 325 mg p.o. once per day.
12. Plavix 75 mg p.o. once per day.
DR [**First Name8 (NamePattern2) **] [**Name (STitle) **] 12.953
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2196-4-29**] 13:24
T: [**2196-5-3**] 08:45
JOB#: [**Job Number 109789**]
|
[
"437.0",
"443.21",
"433.10",
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"V64.3",
"250.00",
"424.0",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3630, 4837
|
5727, 5976
|
6003, 6837
|
4856, 5405
|
5578, 5706
|
5420, 5544
|
1547, 1728
|
145, 180
|
209, 1526
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|
3454, 3612
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,135
| 159,998
|
51231
|
Discharge summary
|
report
|
Admission Date: [**2163-7-24**] Discharge Date: [**2163-8-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
Tunnelled line removal and placement
PICC line placement
History of Present Illness:
86 y/o female with CHF (EF 25-30%), CKD/ESRD on HD (last
dialyzed [**2163-7-22**]) brought in by ambulance [**2-7**] SOB. Per pt, the
onset of the SOB has been since the middle of the week, with
unclear precipitant. Her SOB is markedly worse at night, as she
has 3+ pillow orthopnea. Of note, during her Wed and Friday HD
sessions, she states she was placed on oxygen by nasal cannula,
which is new for her. She awoke from sleep on Sat AM with
shortness of breath, without chest pain. She denies cough and
fever. She also reports decreased PO intake for the past 3
months with 30 lb weight loss over 3-4 months, as "food has no
appeal."
.
In the ER, pt afebrile, 139/59, 66, 97-99% 3L NC. Was hypoxic
at 90% on RA, with RR 40, and fluid overloaded on CXR.
.
Upon arrival to the floor, pt resting comfortably in bed on 3L
NC.
.
ROS: as per HPI. Of note, pt is not on home O2. She states she
feels cold "all the time."
Past Medical History:
Coronary Artery Disease with Coronary artery bypass graft x 3
[**2162-8-16**] (LIMA-LAD, SVG-OM, SVG-PDA)
Mitral valve annuloplasty [**2162-8-16**]
Systolic CHF (LVEF 30% on TTE [**2162-8-27**])
Chronic Kidney Disease
Hyperlipidemia
Hypertension
Gout
Diverticulosis
Depression
Status post choleycystectomy
Status post hernia repair
Status post hip fracture repair
Social History:
She is a retired travel [**Doctor Last Name 360**]. She recently quit smoking but
previously smoked one pack per week for 70 years. She denies
alcohol use. No illicit drug use. She is now coming from rehab
but previously lived with her husband until he had an MI. She
has two children [**Location (un) 86**] and [**Hospital1 614**] who are very involved.
Family History:
Mother had hypertension. Father had hypertension and CVA. No
family history of cardiac disease or sudden cardiac death.
Physical Exam:
VS: T 97.3, 155/85, 73, 22, 98% on 4L NC
Gen'l: chronically ill-appearing elderly female, comfortable,
speaking in full sentences, appropriate. Good recall of events.
She can clearly tell me about her PMH. No evidence of delirium.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMD, lower
dentures in place
Neck: supple, appears elevated but difficult to assess JVD [**2-7**]
right IJ HD catheter
Lungs: decreased BS R>L, inspiratory crackles, coarse with
occasional rhonchi and expiratory wheezes
CV: HS distant, RRR, no MRG, nl S1-S2
Abd: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
Ext: WWP, trace edema, 1+ peripheral pulses (radials, DPs), left
heel exophytic ulceration
Skin: 1x1cm 0.5cm deep sacral decubitus ulcer, no drainage
Neuro: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-10**] throughout, sensation grossly intact throughout
Pertinent Results:
Labs on Admission [**2163-7-24**]
WBC-6.1 RBC-3.24* Hgb-11.4* Hct-34.1* MCV-105* MCH-35.1* Plt
Ct-118*
Neuts-75.5* Lymphs-16.1* Monos-4.4 Eos-3.7 Baso-0.3
PT-13.3 PTT-25.7 INR(PT)-1.1
Glucose-91 UreaN-19 Creat-3.8* Na-139 K-7.8* Cl-98 HCO3-31
AnGap-18
Lactate-1.3
freeCa-1.07*
.
[**2163-7-24**] 05:40AM BLOOD CK-MB-3 cTropnT-0.13*
[**2163-7-24**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2163-7-29**] 10:00PM BLOOD CK-MB-5 cTropnT-0.23*
[**2163-7-30**] 05:33AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2163-7-30**] 12:05PM BLOOD CK-MB-NotDone cTropnT-0.23*
.
[**2163-8-12**] 01:53PM BLOOD Hct-23.2*
[**2163-8-12**] 07:10AM BLOOD WBC-5.4 RBC-2.08* Hgb-7.1* Hct-22.4*
MCV-108* MCH-34.3* MCHC-31.8 RDW-18.2* Plt Ct-179
[**2163-8-11**] 02:25PM BLOOD Hct-23.7*
[**2163-8-11**] 05:48AM BLOOD WBC-4.3 RBC-2.05* Hgb-7.1* Hct-21.9*
MCV-107* MCH-34.7* MCHC-32.4 RDW-16.9* Plt Ct-168
[**2163-8-12**] 07:10AM BLOOD Plt Ct-179
[**2163-8-12**] 07:10AM BLOOD Glucose-78 UreaN-18 Creat-3.9*# Na-139
K-3.9 Cl-101 HCO3-30 AnGap-12
[**2163-8-11**] 05:48AM BLOOD Glucose-77 UreaN-10 Creat-2.7*# Na-143
K-3.9 Cl-104 HCO3-32 AnGap-11
[**2163-8-10**] 06:33AM BLOOD WBC-5.8 RBC-2.27* Hgb-7.6* Hct-24.6*
MCV-108* MCH-33.5* MCHC-31.1 RDW-16.5* Plt Ct-213
[**2163-8-9**] 03:04AM BLOOD WBC-5.3 RBC-2.22* Hgb-7.4* Hct-23.5*
MCV-106* MCH-33.5* MCHC-31.6 RDW-16.5* Plt Ct-208
[**2163-8-4**] 07:40AM BLOOD Neuts-68.9 Lymphs-23.4 Monos-4.3 Eos-3.0
Baso-0.4
[**2163-8-10**] 06:33AM BLOOD Glucose-74 UreaN-23* Creat-4.5*# Na-143
K-4.6 Cl-103 HCO3-30 AnGap-15
[**2163-8-1**] 05:17AM BLOOD CK-MB-NotDone cTropnT-0.41*
[**2163-7-31**] 05:16AM BLOOD CK-MB-4 cTropnT-0.30*
[**2163-7-30**] 12:05PM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2163-7-30**] 05:33AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2163-7-29**] 10:00PM BLOOD CK-MB-5 cTropnT-0.23*
[**2163-7-24**] 08:30PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2163-7-24**] 05:40AM BLOOD CK-MB-3 cTropnT-0.13*
.
Other Studies:
[**2163-7-24**] EKG: Normal sinus rhythm with intraventricular
conduction defect consistent with incomplete right bundle-branch
block. Occasional ventricular premature beats. Cannot exclude
prior inferior wall myocardial infarction. Compared to the
previous tracing of [**2163-7-11**] no diagnostic interim change.
.
[**2163-7-29**] CXR: In comparison with previous study of [**7-27**], there
is again
enlargement of the cardiac silhouette with continued small
bilateral effusions in a patient with intact sternal sutures and
previous CABG and valve replacement. There is somewhat
ill-defined areas of increased opacification at the right base,
the right mid zone, and the left base in the retrocardiac
region. Although all this could represent atelectatic change, in
view of the clinical history, the possibility of a supervening
consolidation cannot be definitely excluded.
.
[**2163-7-30**] TTE: Suboptimal image quality. Possible aortic valve
vegetation. Transesophageal echocardiography is recommended to
diagnose endocarditis if clinically indicated.
.
[**2163-8-1**] TEE: IMPRESSION: Technically suboptimal study. No
definite evidence of valvular vegetation. Well seated mitral
annuloplasty ring with moderate mitral regurgitation. Focal
thickening of the aortic valve without aortic regurgitation.
Compared with the prior intraoperative study (images reviewed)
of [**2162-8-16**], the findings are similar.
.
[**2163-8-6**] CXR: Compared with [**2163-8-5**], the CHF findings have
improved, but remain present.
1) Interstitial edema, possibly with small alveolar component
2) Bilateral effusions with underlying collapse and/or
consolidation.
3) Stable left retrocardiac density. Possibility of a pneumonic
infiltrate at the left base cannot be entirely excluded.
.
Blood cultures were positive for VISA.
Brief Hospital Course:
86 y/o WF with PMH significant for ESRD on HD, systolic CHF with
EF 25-30%, paroxysmal atrial fibrillation initially admitted to
hospital with CHF exacerbation, now with VISA line related
bacteremia (6/6 bottles).
.
# VISA bacteremia/sepsis: Patient spiked fever on [**7-27**], blood
cultures drawn which grew GPCs in pairs and clusters and was
intially started on vancomycin. GPCs speciated as VISA and
patient switched to daptomycin. She had a TEE negative for any
vegetations. Patient's RIJ HD line suspected as infectious
source. This line was removed on [**2163-8-2**] and switched over a
wire given concerns that patient would not agree to additional
procedure for line placement. However, when blood cx from
[**2163-8-2**] cont to grow VISA the line was removed on [**8-4**] and
patient given 72 hr line holiday. She had a new tunnelled HD
cath placed on [**2163-8-8**] (this was re-sited and placed on the left)
as well as a right sided PICC line placed. Blood cultures have
remained no growth since [**2163-8-8**]. Patient was followed by the
infectious disease service who has recommended a 4 week course
of daptomycin ([**Date range (3) 106288**]). She will need weekly CK checked
while on Daptomycin. Patient has scheduled follow up with ID.
.
# Dyspnea/Acute on Chronic Systolic Heart Failure: Most likely
due to acute on chronic systolic heart failure given history,
fluid overload on physical exam, and radiographic findings.
Etiology of exacerbation unclear, but may be secondary to
infection as above. [**Date range (3) **] in [**10-13**] showed EF of 25-30% and a
repeat [**Date Range 113**] during admission showed severely reduced global
systolic function. Pneumonia was unlikely given lack of cough,
fever, leukocytosis, or focal CXR findings. ACS was unlikely
given lack of acute changes on EKG and stable cardiac enzymes.
Her dyspnea responded well to dialysis treatment and her oxygen
saturation remained stabely in the high 90's on [**1-7**] liters of
oxygen.
# CKD/ESRD on HD - Pt has been on dialysis for past 6 months via
R Quintin. HD was continued on MWF, with exception of line
holiday from [**2163-8-4**] - [**2163-8-8**] (while awaiting multiple negative
blood cultures). New HD line planed on [**2163-8-8**] and dialysis
treatments resumed. Calcitriol was stopped on this admission per
the renal team as she receives zemplar at HD. Patient continues
on sevelamer.
.
# LLE Ulcer: Patient has been followed by Dr. [**Last Name (STitle) 3407**] for this
issue and was actually scheduled to undergo angiography and heel
debridement prior to her admission. Given her multiple medical
problems on this admission the angio was postponed and plan is
for patient to follow up with Dr. [**Last Name (STitle) 3407**] in 2 weeks and
reschedule procedure.
.
# CAD - No active issues on this admission. BB held in setting
of hypotension while septic/bactermic. She was cont on daily
ASA. A low dose of lisinpril started at time of discharge. Would
suggest restarting metoprolol succinate in the future if blood
pressure can tolerate this.
.
# Anemia: Hematocrit levels were measured daily and a slow
trending down was noted. Most likely secondary to end stage
renal disease. No obvious source of bleeding. No transfusions
were necessary. Patient received epo with HD. Iron studies
pending at time of discharge which renal has agreed to follow as
pt may require IV iron with HD.
.
# Paroxysmal Atrial Fibrillation: Patient remained in sinus for
the duration of her hospitalization. She was continued on her
outpatient regimen of amiodarone. As noted above, her metoprolol
was held given episodes of hypotension in setting of infection.
Would suggest restarting metoprolol succinate when blood
pressure can tolerate this.
.
# breast mass: 1 inch diameter mass located in the 12 o'clock
position. Patient should be evaluated by primary care physician
upon discharge for follow up.
.
# Code: extensively discussed with patient and daughter (HCP).
DNR/DNI confirmed with pt and daughter (HCP).
Medications on Admission:
Meds (active list as of [**2163-7-19**]):
AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDRALAZINE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [CO-GESIC] - 5 mg-500 mg Tablet - [**1-7**]
Tablet(s) by mouth q6hr as needed for pain
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a
day hold for sbp<100, hr<55
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**1-7**] Tablet(s) by
mouth q6hrs as needed for pain
SEVELAMER HCL [RENAGEL] - 800 mg Tablet - 1 Tablet(s) by mouth
three times a day
SIMVASTATIN [ZOCOR] - 80 mg Tablet - 1 Tablet(s) by mouth once a
day
TRAMADOL - 50 mg Tablet - 0.25 Tablet(s) by mouth q8 as needed
for pain
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet, Chewable(s) by mouth daily start when INR
improves
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day as needed for
constipation
ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) -
400 unit Capsule - 2 Capsule(s) by mouth once a day
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
Iron) Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
SENNA - (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth twice a day
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
12. Daptomycin 500 mg Recon Soln Sig: 350mg Recon Solns
Intravenous Q48H (every 48 hours) as needed for VISA: Please
350mg IV q48 hours. (M-W-F-Sun. Give after HD).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for foot pain.
14. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Congestive heart failure exacerbation/pulmonary edema
2. End Stage Renal Disease on hemodyalysis
3. Vancomycin intermediate staphlococcus aureus
bacteremia/sepsis
.
Secondary:
1) Coronary Artery Disease
2) Paroxysmal atrial fibrillation since [**8-13**]
3) Mitral valve annuloplasty ([**2163-8-16**])
4) Hyperlipidemia
5) Hypertension
6) Status Post Coronary Artery Bypass Grafting
7) gout
7) diverticulosis
8) depression
Discharge Condition:
afebrile, vital signs stable. Shortness of breath improved with
dialysis treatments. On 4 week course of IV antibiotics.
Discharge Instructions:
You were admitted with fluid build-up in the lungs causing
shortness of breath. In the hospital, you received dialysis
which improved your volume status and shortness of breath. Your
hospital course was complicated by a bloodstream infection with
a highly resistant organism, thought to be from an infected
hemodialysis line, which was replaced. You will need to finish
your 4 week course of antibiotic therapy to clear this bacteria.
You underwent cardiac echocardiography which showed severely
reduced heart function.
.
Please attend your regular dialysis sessions.
.
We have added the following NEW MEDICATIONS:
- daptomycin 350 mg IV every 48 hours (M-W-F-Sun. This should be
given after dialysis on dialysis days). Your CK will need to be
checked on a weekly basis.
- lisinopril: this is a medication for your blood pressure
Please take all other medication as previously directed prior to
your hospitalization.
.
We STOPPED:
- hydralazine
- calcitriol
.
Please seek medical attention for fevers, chills, shortness of
breath, chest pain, abdominal pain, or lower extremity swelling.
Followup Instructions:
Please keep the following scheduled appointments:
.
You will follow up with your scheduled appointment with the
infectious disease doctors:
[**Name6 (MD) 1423**] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-9-1**] 10:00 AM
.
You will follow up with your scheduled appointment with the
vascular surgeon:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time: [**2163-9-6**] at 10:30 AM
.
Please follow up with your primary care physician:
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**]. Phone: [**Telephone/Fax (1) 133**]. Date: [**2163-8-30**] at 1:30PM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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58,781
| 170,511
|
45873
|
Discharge summary
|
report
|
Admission Date: [**2167-10-26**] Discharge Date: [**2167-11-18**]
Date of Birth: [**2101-5-5**] Sex: F
Service: SURGERY
Allergies:
Codeine / Phenergan / Tylenol / Quinolones / Oxycodone /
Enalapril
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Acute on chronic renal failure, decompensated heart failure
Major Surgical or Invasive Procedure:
HD line placement
History of Present Illness:
66 year old woman with end-stage renal disease s/p deceased
donor renal transplant in [**2160**] who initially presented to [**Hospital 7912**] yesterday, [**10-25**] with hypoxia, acute renal
failure and congestive heart failure. Per patient's family, the
patient was appearing more short of breath and lethargic since
[**Holiday 1451**] day; she started using her home oxygen (1-1.5L)
throughout the day when she usually only uses it at night.
[**Name (NI) **] husband notes decreased urine output in the evenings
but same color, consistency. Patient and husband state she has
been compliant with her medications and has not noticed any
lower extremity edema.
.
Review of systems is otherwise negative. Patient denies
fevers/chills, nausea/vomiting, chest pain, palpitations,
orthopnea, paroxysmal nocturnal dyspnea, diarrhea/constipation,
gastrointestinal bleeding, changes in urine color/consistency.
.
At [**Hospital6 33**] (OSH), chest xray was consistent with
heart failure although patient did not appear volume overloaded.
She appeared more fluid overloaded on the second day of
hospitalization and BNP was 12,726. Patient responded minimally
to Lasix 40mg IV with 200mL of urine although pulmonary exam
improved. Cardiology felt she would benefit from a right heart
catheterization to establish volume status (if increased
pulmonary wedge pressure, should not overdiurese).
.
Given her elevated creatinine (from baseline), patient was given
gentle intravenous fluids but her creatinine continued to
increase. Urinalysis was only notable for 2+ protein (no casts)
and renal ultrasound was normal (no hydronephrosis in
transplanted kidney, incidental cholelithiasis with dilated
common bile duct, normal Doppler flow). Patient was given
erythropoiten 20,000 units per Renal consult recommendations
Given the concern for transplant failure in the setting of
rapidly advancing renal failure and other co-morbidities, she
was transferred to [**Hospital1 18**] for possible renal biopsy. In
anticipation of the renal biopsy, patient was started on a
heparin drip for atrial fibrillation, PTT>150 X3. Upon transfer,
patient was noted to have a BUN increased from 88 --> 93,
creatinine 3.9 --> 4.0 with hyperkalemia at 5.0 --> 4.8.
Hematocrit noted to have dropped to 24.8.
.
Past Medical History:
1. s/p cadaveric renal transplant in [**2160**], baseline Cr 1.7
2. Type 2 diabetes mellitus complicated by neuropathy,
retinopathy, nephropathy
3. Diastolic Congestive Heart Failure (LVEF 60% in [**2-/2167**])
4. Atrial fibrillation - diagnosed in [**2166-6-27**]. S/p
cardioversions x2 unsuccessful. On Warfarin.
5. Hypertension
6. Hyperlipidemia
7. Peripheral vascular disease with no claudication
8. [**Country **] stenosis
9. Cholelithiasis
10. Hypothyroidism on replacement
11. Chronic anemia (baseline thought to be approx 27)
12. GERD
13. s/p appy
14. s/p eye surgery
[**72**]. gout
Social History:
Lives with husband, [**Name (NI) **] parent has daughter. Used to be
secretary. Mother died recently.
Smoking: 5py, quit at age 20yrs
EtOH: occasional
IVDU: denies
Family History:
Gestational diabetes (both daughters), no htn, no heart disease.
Father had [**Name2 (NI) 40342**] and skin cancer. Aunt had lung cancer.
Physical Exam:
Vital Signs: Temp: 95.6 RR: 18 Pulse: 43 BP: 138/40
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Skin: No atypical lesions.
Heart: Abnormal: Bradycardia, reg rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, Guarding or rebound,
No hernia, No AAA, abnormal: Obese.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No [**Name2 (NI) **] Edema, No varicosities, No skin changes.
Pulse Exam
RLE Femoral: MP weak Popiteal: MP DP: - PT: MP
[**Name (NI) **] Femoral: MP Popiteal: MP DP: MP PT: MP
DESCRIPTION OF WOUND: left heel with dry eschar, no surrounding
erythema right heel with small dry ulcer, minimal surrounding
erythema
Pertinent Results:
[**2167-11-18**] 05:41AM BLOOD
WBC-9.9 RBC-3.38* Hgb-9.6* Hct-30.7* MCV-91 MCH-28.3 MCHC-31.1
RDW-18.4* Plt Ct-199
[**2167-11-18**] 05:41AM BLOOD
Glucose-75 UreaN-18 Creat-1.6* Na-138 K-3.9 Cl-101 HCO3-33*
AnGap-8
[**2167-11-18**] 05:41AM BLOOD
Calcium-8.4 Phos-3.0 Mg-1.8
ECHO:
Conclusions
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. There is severe regional left ventricular systolic
dysfunction with basal and mid septal akinesia and apical
dyskinesia. The remaining left ventricular segments are
hypokinetic. The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are three aortic valve leaflets. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is moderate thickening of the mitral
valve chordae. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is no
pericardial effusion.
FINDINGS: The right-sided hemodialysis catheter tip is
satisfactorily in the cavoatrial junction. Elevation of the
right hemidiaphragm is chronic and seen on previous chest
radiographs back to [**2160**].
No consolidation, pneumothorax or pleural effusion, mild
perihilar haziness is slightly worse than on the previous study.
IMPRESSION:
Mild vascular congestion, no consolidation.
Brief Hospital Course:
Pt admitted on [**10-26**] for CHF and ARF in setting of transplanted
kidney with worsening rest pain and cool mottled right foot.
Pt originally on Medicine service. Pt has transplanted kidney.
Diagnosis of [**Last Name (un) **]. Oliguric. Creatine was at baseline 2.0. On
admission 4.1. also found to be hyponatremic. Documented Acute
on Systolic CHF.
Coumadin held for Afib.
[**Date range (1) 97686**]
Pt had TTE.
ECHO: The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
akinesis of the mid to distal septum, distal inferior wall, and
apex. The remaining segments contract normally (LVEF = 45-50 %).
The right ventricular cavity is mildly dilated with normal free
wall contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Regional left ventricular dysfunction consistent
with multivessel CAD. Mild right ventricular cavity dilation.
Severe pulmonary hypertension. Moderate tricuspid and mitral
regurgitation
Tacrolimus, MMF, and prednisone continued.
Wound consult for heel ulcer.
Vascular Surgery Consulted. Heparin drip started. PTT followed.
Vascular studies completed.
Pt booked for angiogram to check if transplanted renal artery
present
OPERATION PERFORMED:
1. Ultrasound-guided puncture of the left common femoral
artery.
2. Introduction of catheter into the aorta.
3. Abdominal aortogram and pelvic angiogram.
The above was done with C02. Renal Artery patent. sheath pulled
with mild hematoma.
Pt transfered to the MICU.
[**10-29**] - [**11-2**]
Pt with altered mental status - presumed uremia or infectous
process. Neurology consulted. ID consulted.
Battery of test, pan cx's includin LP, MRI, CAT scan - Of all
cx's and tests, 1 bottle of blood, pos for STAPHYLOCOCCUS,
COAGULASE NEGATIVE
HD tunneled catheter placed, recieves dialysis to improve
potassium and CHF exacerbation, hypoxia.
Heparin resumed post angio. PTT followed. Goal PTT 60-80
Treated for presumed infection. On vanc / Levo / Flagyl.
Multifactoral
Resume HD
[**11-3**] - [**11-9**]
Transfered from MICU to floor
Medical Management of aforementioned medical issues. Pt improves
woth HD. Heparin continued with goal of 60-80.
Since pt on HD, Angiogram planned.
Resume HD
[**11-10**]:
OPERATIONS:
1. Ultrasound-guided puncture of the left common femoral
artery.
2. Contralateral second-order catheterization of the right
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of the right lower extremity.
found to have significant CFA desease at significant risk for
embolization and residual stenosis with PTA so endarterectomy
planned.
[**11-10**] - [**11-14**]
Medical Management of aforementioned medical issues. Pt improves
woth HD. Heparin continued with goal of 60-80.
Pre - op'd and consented
Resume HD
OPERATION PERFORMED: Right femoral endarterectomy with
greater saphenous vein patch angioplasty.
Post procedure pt had bradycardia, hypotensive arrest. Recieved
chest compressions on table. Resesitated successfully. TEE
showed severe WMA and ER<15%.
Cardiology consult obtained. Transfered to the CVICU, transfered
to Vascular Surgery.
Nitro drip, BB, asa, heparin, plavix. Pt cardiac enzymes
essentially negative.
Clear for transfer.
[**11-15**] - [**11-18**]:
Resume HD
Transered to the VICU
Medical Management of aforementioned medical issues. Pt improves
woth HD. Heparin continued with goal of 60-80.
JP drain removed.
PRBC, transfuse to HCT 30
[**11-17**]:
OPERATIONS:
1. Ultrasound-guided puncture of the left brachial artery.
2. Ultrasound-guided puncture of the left common femoral
artery.
3. Serial arteriogram of the left lower extremity.
4. Stenting of the left external iliac artery.
5. Star Close closure of the left common femoral
arteriotomy.
Pt stable
PT consult. Pt stable for home with VNA. Will need future
angiogram and further revasc of left leg.
Medications on Admission:
prednisone 5', ASA 81', Procrit", Imdur 30', Coumadin 2', Coreg
6.25", Calcitril 0.25', Plavix 75', Calcium acetate 667 2
tab''', Lasix 60', Hydralazine 10''', Colchicine 0.6', Ambien
10', Protonix 40", CellCept [**Pager number **]", Vytorin
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain: prn.
Disp:*50 Tablet(s)* Refills:*0*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day: q 6 hrs prn.
12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Have
your INR checked in the usual manner.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Temporary Dialysis Catheyer Care
Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line
flush.
Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens.
DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL
NS followed by Heparin as above according to volume per lumen.
15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Levemir 100 unit/mL Solution Sig: One (1) dosage per PCP
Subcutaneous once [**Name Initial (PRE) **] day: per PCP.
17. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO three times a day:
PRN.
18. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
19. Novolin N 100 unit/mL Suspension Sig: One (1) per PCP
Subcutaneous three times a day: Sliding Scale per PCP.
20. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
21. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a
day: prn.
22. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
23. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
25. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO four
times a day for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
B/L LE Ischemia
MI with PE arrest, requiring CPR
CHF exacerbation Chronic Systolic
ARF on Chronic Renal Failure - Now on hemodilysis
PAD with heel ulcers
ESRD s/p CRT '[**60**], DMII (insulin-dependent) systolic/diastolic
CHF(LVEF 30-35% in [**6-/2167**]), s/p NSTEMI w/ PTCA/stent, afib, HTN,
hypercholesterolemia, PVD, hypothyroidism, chronic anemia, OSA,
OA, obesity, GERD, gout
PSH: cadaveric renal transplant ([**2160**]), appy, eye surgery, PTCA
w/ stents
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? 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 [**12-30**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? 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 [**1-28**] weeks for
post procedure check and ultrasound
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)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2167-12-2**] 1:15
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-12-8**] 10:40
Completed by:[**2167-11-18**]
|
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"39.50",
"38.93",
"88.48",
"00.40",
"39.95",
"38.18",
"00.46",
"38.16",
"38.95",
"88.42",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
13415, 13466
|
6198, 10679
|
387, 406
|
13974, 13974
|
4422, 6175
|
16797, 17134
|
3527, 3667
|
10971, 13392
|
13487, 13953
|
10705, 10948
|
14119, 16111
|
16137, 16774
|
3682, 4403
|
288, 349
|
434, 2714
|
13988, 14095
|
2736, 3329
|
3345, 3511
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,436
| 140,997
|
43545
|
Discharge summary
|
report
|
Admission Date: [**2166-10-26**] Discharge Date: [**2166-10-30**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
female well known to the Medical Intensive Care Unit team
with morbid obesity, admitted on [**2166-10-26**] with
fever, lethargy, apnea, and hypertension.
On [**10-28**], the patient had rapid atrial fibrillation
and line sepsis, with decreased urinary output. The patient
was controlled with Lopressor, and blood pressure improved.
Output improved, and the patient was transferred to the floor
on [**10-28**].
Last night, the patient had frank melanotic stools times
four. She was on Protonix 40 mg p.o. q.d. The patient's
hematocrit fell from 35 to 28 overnight. She denied nausea,
vomiting, and abdominal pain. An esophagogastroduodenoscopy
was done, and revealed fresh bleeding with large blood in the
fundus of the stomach.
PAST MEDICAL HISTORY: (Past medical history includes)
1. Coronary artery disease, status post myocardial
infarction in [**2163**].
2. Congestive heart failure.
3. Type 2 diabetes mellitus.
4. Osteoarthritis.
5. Morbid obesity.
6. Increased cholesterol.
7. History of gastrointestinal bleed.
MEDICATIONS ON TRANSFER: Medications on transfer to the
Medical Intensive Care Unit included regular insulin
sliding-scale, Ditropan, subcutaneous heparin, Lopressor,
digoxin, Protonix, statin powder, Epogen, aspirin, Isordil,
and Levaquin, and vitamin K.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a temperature of 98, blood pressure of 123/76, pulse
of 76, oxygen saturation of 85% on room air. Generally,
examination revealed an obese and sleepy 68-year-old female.
Mucous membranes were dry. Cardiovascular examination
revealed distant heart sounds. Lungs revealed mild wheezing
diffusely. The abdomen was obese, edematous. Extremities
revealed dressing over both ankles, 3+ edema, and there was
cellulitis in the left arm. Neurologically, the patient was
alert and oriented times two, moved all extremities
spontaneously.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 15.8,
hematocrit of 28.7, platelets of 160. Sodium of 136,
potassium of 5.1, chloride of 97, bicarbonate of 25, blood
urea nitrogen of 103, creatinine of 3.3, with a glucose
of 174. Creatine kinase was 186. Troponin was 6.2. ALT
was 14, AST of 53, alkaline phosphatase was 76. Blood
cultures from the [**10-26**] showed Staphylococcus
coagulase negative in one bottle only. Sputum from [**10-28**] was contaminated, and wound culture showed coagulase
positive Staphylococcus aureus and carinii bacterium.
A CT of the abdomen on [**10-27**] showed perihepatic fluid
with no evidence of intrahepatic or extrahepatic ductal
dilatation. No obvious varices.
HOSPITAL COURSE: This is a 68-year-old female with morbid
obesity, admitted for line sepsis, methicillin-resistant
Staphylococcus aureus with a transient decrease in urinary
output, and atrial fibrillation, now controlled, who is now
re-admitted to the Medical Intensive Care Unit with an upper
gastrointestinal bleed.
There was blood seen in her lower esophagus by
esophagogastroduodenoscopy with a large amount of clots and
oozing red blood in the fundus. The patient was not able to
protect airway herself, and she was do not intubate (per her
sister who was her health care proxy). An nasogastric tube
was placed, and the patient did not clear after 8 liters of
fluid. A blood transfusion was initiated. The patient was
given Protonix intravenously.
Per, the Gastrointestinal Service, the patient was unable to
be re-scoped without intubation. However, since she was
refusing intubation because the patient wanted to be do not
intubate even for temporary measures. The patient understood
that this eliminated the possibility of gaining control of
bleed via esophagogastroduodenoscopy. The Interventional
Radiology Service was consulted, but they were unable to take
the patient to angiography for possible embolization
secondary to the patient's weight and difficulty in accessing
groin and problems of ascites. The patient also received 2
units of fresh frozen plasma to correct coagulation.
The team had a conversation with her sister regarding limited
options at this point. We reiterated that
esophagogastroduodenoscopy with intubation might be her last
hope. The sister did understand the situation, but reported
that the patient repeatedly expressed the desire to be do not
resuscitate/do not intubate. Meanwhile, the patient was
receiving blood transfusions and fluid resuscitation.
The team was called at 6:30 in the morning by bedside and
found the patient having no respirations. The patient
subsequently passed away at that time. The patient was
pronounced dead at 6:30 in the morning on [**2166-10-30**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Name8 (MD) 7892**]
MEDQUIST36
D: [**2167-5-12**] 13:50
T: [**2167-5-13**] 10:15
JOB#: [**Job Number 93685**]
|
[
"278.01",
"996.62",
"428.0",
"038.11",
"578.9",
"427.31",
"280.0",
"585",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.34",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2868, 5150
|
153, 919
|
1245, 2850
|
942, 1219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,295
| 101,947
|
53133+59507
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-2-9**] Discharge Date: [**2113-2-14**]
Date of Birth: [**2055-8-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old man
with no medical care in many years several months of
exertional chest pain, no hest pain at rest. The patient was
recently ruled out for an myocardial infarction and had a
positive exercise tolerance test. An echocardiogram showed
multiple areas of hypokinesis. Electrocardiogram showed left
anterior vesicular block with questionable ischemia
laterally. A catheterization done on [**1-10**] showed an EF
of 60% and three vessel disease.
PAST MEDICAL HISTORY:
1. Pancreatitis.
2. ETOH, marijuana and cocaine abuse.
3. Gastroesophageal reflux disease.
4. Urinary retention.
5. Benign prostatic hypertrophy.
6. Obesity.
PAST SURGICAL HISTORY: Questionable pancrease surgery and
other abdominal surgeries for fluid drainage as well as
testicular surgery.
SOCIAL HISTORY: The patient uses one to two bags of heroine
several times per week, nasally. States no intravenous drug
use. No alcohol use in 20 years. No cocaine or marijuana
use at this time.
PHYSICAL EXAMINATION AT THE TIME OF PREADMISSION TESTING:
Heart rate 77. Blood pressure 160/74. Respiratory rate 18.
O2 sat 98% on room air. Cardiac regular rate and rhythm. S1
and S2. No murmur. Lungs clear to auscultation bilaterally
with faint expiratory wheezes. Abdomen is soft and guarded
with tenderness in the right upper quadrant and the right
lower quadrant. Also costovertebral angle tenderness. No
hepatosplenomegaly. Active bowel sounds. Extremities are
warm and well perfuse with no clubbing, cyanosis or edema.
Neck is supple with no JVD or bruits. Pulses carotids are 1+
bilaterally, radial 2+ bilaterally, femoral 2+ bilaterally,
dorsalis pedis pulses and posterior tibial pulses are both 2+
bilaterally. Neurological extraocular movements intact.
Grossly nonfocal examination. Excellent strength in all
extremities.
REVIEW OF SYSTEMS: No claudication. No melena. No bleeding
disorders. No CVAs or TIAs.
ALLERGIES: Penicillin.
MEDICATIONS PREOPERATIVELY:
1. Protonix.
2. Atenolol.
3. Aspirin.
4. Doxazosin.
5. Flomax.
No known doses.
LABORATORY DATA AT THE TIME OF PREADMISSION TESTING: White
blood cell count 5.2, hematocrit 35.9, platelets 315, sodium
137, potassium 4.0, chloride 104, CO2 28, BUN 14, creatinine
0.6, glucose 88, ALT 23, alkaline phosphatase 95, total
bilirubin 0.4, albumin 3.9, INR 1.1.
HOSPITAL COURSE: As stated previously the patient is a
direct admission for to the Operating Room. On [**2-9**]
he underwent at that time coronary artery bypass grafting
times four. Please see the Operating Room report for full
details. In summary he had a coronary artery bypass graft
times four with a left internal mammary coronary artery to
the left anterior descending coronary artery, saphenous vein
graft to the posterior descending coronary artery, saphenous
vein graft to the diagonal and saphenous vein graft to the
obtuse marginal. His bypass time was 117 minutes with a
cross clamp time of 98 minutes. He tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient's mean arterial pressure was 83 with a CVP of 13.
He was A paced at 80 beats per minute and he had
neo-synephrine at 0.5 micrograms per kilogram per minute.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was successfully weaned from
the ventilator and extubated. On postoperative day one the
patient remained hemodynamically stable. He was weaned off
all vaso active intravenous medications. He was started on
oral beta blockers as well as diuretics. At that time he was
seen by the acute pain service and he was transferred from
the Intensive Care Unit to the Far 2 for continuing
postoperative care and cardiac rehabilitation.
On postoperative day two the patient remained hemodynamically
stable. His chest tubes and temporary pacing wires were
discontinued. With the assistance of the nursing staff and
the physical therapy staff his activity level was gradually
increased over the next several days. He had an uneventful
postoperative course and on postoperative day five it was
decided that the patient was stable and ready to be
discharged to home. At the time of this dictation the
patient's physical examination is vital signs temperature
98.6, heart rate 78 sinus rhythm, blood pressure 101/55,
respiratory rate 18, O2 sat 96% on room air. Weight
preoperatively 77.2 kilograms at discharge 82 kilograms.
Laboratory data white blood cell count 11.5, hematocrit 28.2,
platelets 247, sodium 142, potassium 3.9, chloride 107, CO2
30, BUN 17, creatinine 0.7, glucose 122. Examination alert
and oriented times three, moves all extremities, follows
commands, respirations clear to auscultation bilaterally.
Cardiac regular rate and rhythm. S1 and S2. No murmur.
Sternum is stable. Incision with Steri-Strips. Open to air
clean and dry. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. Extremities are warm and well
perfuse with no edema. Right saphenous vein graft site with
Steri-Strips open to air clean and dry.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg b.i.d.
2. Pantoprazole 40 mg q.d.
3. Enteric coated aspirin 325 mg q.d.
4. Flomax 0.4 q.h.s.
5. Lasix 20 mg q.d. times seven days.
6. Potassium chloride 20 milliequivalents q.d. times seven
days.
7. Dilaudid 2 to 8 mg q 4 to 6 hours prn as needed for pain.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times four with a left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the obtuse marginal,
saphenous vein graft to posterior descending coronary artery
and saphenous vein graft to diagonal.
2. History of pancreatis.
3. History of alcohol, marijuana, and heroine abuse.
4. Gastroesophageal reflux disease.
5. Urinary retention and benign prostatic hypertrophy.
6. Abdominal surgery.
7. Testicular surgery.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: He is discharged to home.
FOLLOW UP: He is to have follow up in the [**Hospital 409**] Clinic in
two weeks. He is to have follow up with his primary care
physician in two to three weeks and follow up with Dr. [**Last Name (STitle) 1537**]
in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2113-2-14**] 11:59
T: [**2113-2-14**] 12:20
JOB#: [**Job Number 109443**]
Name: [**Known lastname 17965**], [**Known firstname 15573**] Unit No: [**Numeric Identifier 17966**]
Admission Date: [**2113-2-9**] Discharge Date: [**2113-2-14**]
Date of Birth: [**2055-8-26**] Sex: M
Service:
After consult with the acute pain service, it was agreed that
the patient should be discharged home on methadone 15 mg
q.i.d. for a period of one week. He is to have followup in
acute pain clinic. The patient is to call to arrange for an
appointment after discharge. He also is to call his primary
care to get a referral form for the acute pain clinic.
Again, additional medication includes methadone 15 mg four
times a day.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D:
T: [**2113-2-14**] 14:33
JOB#: [**Job Number 17967**]
|
[
"278.00",
"414.01",
"577.1",
"530.81",
"304.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"89.68",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5624, 6167
|
5318, 5603
|
2531, 5295
|
845, 957
|
6257, 7670
|
2026, 2513
|
159, 634
|
656, 821
|
974, 2006
|
6192, 6245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,521
| 195,931
|
35409+58000
|
Discharge summary
|
report+addendum
|
Admission Date: [**2179-2-7**] Discharge Date: [**2179-2-17**]
Date of Birth: [**2099-1-29**] Sex: F
Service: MEDICINE
Allergies:
Lamictal / Niaspan Starter Pack
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Hypoxia, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient was unable to give much history at presentation due to
possible delirium and aphasia. Information she was able to
provide as well as notes were used to formulate HPI.
This is an 80 year-old female with past medical history of CAD
s/p CABG, left CVA with residual right sided weakness and
expressive aphasia, and multiple bouts of pneumonia who
presented from [**Hospital **] [**Hospital **] Nursing Home with lethargy and
fever to 102. Patient had been noted to be falling asleep at
nursing home and had a non-productive cough. She had labs drawn
that showed a WBC of 28 and was sent to the emergency.
In the ED, initial vs were: 98.3 110/68 130 16 93%2L. Patient
was triggered for hypoxia to 83% on RA which rose to 93% on 2L
O2. She was tachycardic to the 130s. She received vancomycin and
levofloxacin but developed redness around the IV and was
switched to pipercillin-tazobactam. Also got 1L NS. On transfer,
her vitals were P 86, BP 122/102, RR 18, O2 97% on 4L O2 by
nasal cannula.
On the floor, the patient complained of left abdominal pain as
well as shortness of breath and left flank pain. She endorsed
chills with cough, dysuria. Denied fevers, chest pain,
palpitations, N/V/D. Has residual right sided weakness of
upper/lower extremities and aphasia.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel habits. Denied arthralgias or myalgias.
Past Medical History:
H/o stroke with expressive aphasia and R hemiparesis
s/p cardiac cath
Obesity
Depression
HTN
Hyperlipidemia
Bladder spasm
CAD s/p CABG (details of anatomy not available)
PVD s/p fem-[**Doctor Last Name **] bypass
Adrenal adenoma
Social History:
Lives in nursing home since [**2174**]. Widowed. Eats regular diet,
takes meds in pudding or applesauce.
Family History:
Noncontributory
Physical Exam:
On admission:
Vitals: 100.0 106/53 104 22 93%1L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, dry oral mucosa, clear OP
Neck: supple, no LAD
Lungs: Decreased breath sounds LLL, diffuse expiratory wheezing
throughout, dullness to percussion
CV: tachycardic, regular, +S1, S2, no m/r/g
Abdomen: soft, tenderness to moderate palpation of left abd,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly, +left CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, right sided paresis, able to wiggle toes
slightly, no movement of right arm. 4/5 strength left leg, [**5-13**]
left arm.
On discharge:
Vitals: 98.5 120/70 78 18 100%2L NC 85% RA
General: alert, responsive with 'yes' or shaking head to
questioning
HEENT: PERRL, MMM,
Neck: JVP at above clavicle with bed 45 degrees; EJ raises with
expiration and falls with inspiration
Lungs: faint crackles lower [**1-11**] of lung base, mild expiratory
wheezing. clear rest of lung fields with air movement.
CV: II/VI systolic ejection murmur R sternal border, unchanged
from previous, regular
Abdomen: obese, +BS, soft, NTTP, no masses
GU: No foley
Ext: pink, warm, 2+ DP, +1 pitting edema bilateral feet
Neuro: Right side paresis of face, RUE/RLE, 4/5 strength
LLE/LUE, right lower facial paralysis, dysarthria unchanged from
baseline
Pertinent Results:
==================
LABORATORY STUDIES
==================
[**2179-2-7**]:
WBC-25.4 Hgb-11.9* Hct-34.6* MCV-89 RDW-14.7 Plt Ct-231
PT-14.0* PTT-24.7 INR(PT)-1.2
Glucose-242* UreaN-13 Creat-0.7 Na-139 K-3.4 Cl-101 HCO3-25
AnGap-16
[**2179-2-14**]:
WBC-9.0 RBC-3.38* Hgb-10.3* Hct-29.8* MCV-88 RDW-14.2 Plt Ct-315
[**2179-2-17**]:
WBC-14.6* RBC-3.55* Hgb-10.7* Hct-32.3* MCV-91 RDW-14.9 Plt
Ct-401
---Neuts-79.7* Lymphs-15.5* Monos-1.9* Eos-2.1 Baso-0.8
Glucose-228* UreaN-18 Creat-0.6 Na-140 K-4.2 Cl-100 HCO3-31
[**2179-2-10**] proBNP-2385*
============
MICROBIOLOGY
============
[**2179-2-7**] 04:55PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2179-2-7**] Urine culture: pan-sensitive e. coli
[**2179-2-10**] Urine culture: negative
[**2179-2-8**] 9:31 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2179-2-10**]**
GRAM STAIN (Final [**2179-2-8**]):
[**11-2**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2179-2-10**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
[**2-7**], [**2-9**], [**2-10**], [**2-11**] Blood cultures: negative
[**2179-2-17**] 9:30 am STOOL **FINAL REPORT [**2179-2-18**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2179-2-18**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
==============
OTHER RESULTS
==============
ECG [**2179-2-7**]:
Regular tachy-arrhythmia of uncertain mechanism - may be sinus
tachycardia with ventricular premature beat or possible other
supraventricular tachy-arrhythmia. Modest intraventricular
conduction delay. Consider prior septal myocardial infarction,
although it is non-diagnostic. ST-T wave abnormalities are
non-specific but cannot exclude ischemia. Clinical correlation
is suggested. Since the previous tracing of [**2178-2-4**]
tachy-arrhythmia is now present and ST-T wave changes are more
prominent.
ECG [**2179-2-13**]:
Sinus rhythm. Intraventricular conduction delay of left
bundle-branch block type. Compared to the previous tracing of
[**2179-2-11**] there is no change.
Chest Radiograph [**2179-2-7**]:
IMPRESSION: Mild central congestion with left basilar opacity
likely
reflective of atelectasis and effusion though cannot exclude
pneumonia
Chest Radiograph [**2179-2-13**]:
FINDINGS: As compared to the previous radiograph, the
pre-existing pulmonary edema has slightly worsened. Otherwise,
the radiograph is unchanged, with moderate cardiomegaly, a small
left pleural effusion and a retrocardiac atelectasis.
Chest Radiograph [**2179-2-14**]:
IMPRESSION: AP chest compared to [**2-10**] through 5:
Mild pulmonary edema continues to clear. Left lower lobe remains
consolidated, probably due to atelectasis and moderate left
pleural effusion. Heart is somewhat enlarged but difficult to
see because of overlying left hemidiaphragm and lower lobe
atelectasis. No pneumothorax
Brief Hospital Course:
80 year old woman with a h/o CAD s/p CABG, PVD, stroke with
expressive aphasia and R sided weakness, who was admitted from
nursing home on [**2179-2-7**] for fever 101 and desat to mid 80s on RA
and found to have a probable healthcare associated pneumonia.
1) Health Care Associated Pneumonia: On presentation the patient
had a reported history of cough and fever with a ? of left
basilar infiltrate. Given combination of clinical symptoms and
imaging finding she was started on treatment for pneumonia with
intravenous levofloxacin. Unfortunately, she began to develop
infiltration at the site of her IV with redness and pain, which
raised concern for allergy. Given this concern and her status
as a long-term resident of a nursing facility she was
empirically covered with pipercillin-tazobactam and vancomycin.
After transfer to the ICU on [**2-10**] for increased respiratory
distress (most likely due to CHF exacerbation) the
pipercillin-tazobactam was changed to cefepime and levofloxacin
was added back on without any signs of allergic phenomena.
Patient was also noted to have thick secretions at the time of
transfer, which was thought to be contributing to her hypoxia as
well therefore she was started on acetycysteine nebs with
improvement in secretions so these were then stopped.
Vancomycin was stopped after transfer back to the floor and
after a sputum culture failed to reveal GPCs in clusters. She
completed a total of 7 days of cefepime on [**2179-2-16**] and seven
days of levofloxacin on [**2179-2-17**]. Upon discharge, she was
sat-ing 100% 2L; 85% RA.
2) Acute on chronic systolic CHF: The patient has a history of
CAD and a slightly depressed EF of 45%. On [**2179-2-10**] she
developed increased work of breathing with a respiratory rate in
the 30s and an increased O2 requirement. She was transferred to
the ICU, and chest radiograph revealed increased pulmonary
edema. Therefore, she was aggressively diuresed with IV
furosemide for a total of 4L negative volume status while in the
ICU. She remained euvolemic on the floor and will restart her
baseline dose of 40 mg PO furosemide daily at discharge.
3) ? COPD exacerbation: On transfer to the MICU the patient had
significant wheezing and given unclear smoking history was
treated with bronchodilators and five day burst of prednisone 40
mg PO daily. Prednisone course was completed on [**2179-2-16**] and
the patient had no wheezing at the time of discharge. She will
be continued on albuterol inhalers PRN.
4) Toxic-metabolic Encephalopathy: On the day of transfer to
the ICU on [**2179-2-10**] the patient developed significant agitation
in the context of multiple attempts to obtain IV access. She
was physically resisting. She also received a dose of
olanzapine on the evening after her transfer out of the unit due
to agitation. Otherwise she followed commands appropriately and
responded relatively appropriately to questions with guestures
and signs (given baseline aphasia). These moments of delirium
were felt due to underlying infection and respiratory
difficulties. At time of discharge with management of her
infection and respiratory status she was completely appropriate
and following commmands.
5) UTI- Initial urine culture with pan-sensitive E. coli. Was
covered broadly with pipercillin-tazobactam on the floor and
then cefepime (for HCAP as above) for >7 days, which should be
adequate coverage. Repeat urine culture with no growth.
6) History of CVA: Patient with exam consistent with previously
reported deficits. Right sided paresis and expressive aphasia.
She was continued on her ASA and clopidogrel.
7) CAD s/p CABG: No signs of ACS. She was continued on her home
ASA and clopidogrel. Unclear why she is not on a BB.
8) Anemia: Patient's Hct remained around 31, which is stable
from labs done at her nursing home. No guiac + stools. She was
continued on her home iron sulfate.
9) Diabetes Mellitus : The patient had glipizide held on
presentation and she was covered by an insulin sliding scale
with reasonable control of blood glucose. On discharge she was
restarted on her home glipizide.
10) Hyperlipidemia: On presentation the patient was on 80 mg of
simvastatin a day as well as gemfibrazole. Given recent
concerns by FDA about high dose simvastatin predisposing to
rhabdomyolysis, particularly given increased risk when paired
with gemfibrazole, she was switched to high dose atorvastatin.
11) Leukocytosis: On the last two days of the hospitalization
the patient was noted to have a leukocytosis without fever or
any localizing signs of infection. Differential was without
bands. Given abx exposure the patient had a stool sent for C
difficile testing. Given no diarrhea or abdominal pain the odds
of C diff were considered low. C. diff final result was
negative.
She was kept on subcutaneous heparin for DVT prophylaxis. She
tolerated a regular diet prior to discharge. Her code status
was full after discussion with her daughters. The primary team
will contact her rehab facility with the results of this test on
the day after discharge. Issue pending to discharge was slight
leukocytosis without increased cough or any other signs of
infection. Given antibiotic exposure C difficile toxin assay
was sent and was pending at time of discharge. The care team
will contact the rehabilitation facility on the day after
discharge with the results of this test.
Medications on Admission:
Per Nursing Home records
Vit D3 [**Numeric Identifier 1871**] units weekly for 6 weeks
Aspirin EC 81 mg daiy
Ferrous sulfate 325 mg daily
Lasix 40mg PO qAM
Glipizide 2.5mg PO daily
Plavix 75mg PO daily
Gemfibrizil 600mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Baclofen 20mg TID
Senna 8.6 mg 2 tabs qHS
Simvastatin 80 mg qHS
Paxil 60mg daily
Seroquel 12.5 mg q1300
Neurontin 600mg qHS
Tylenol 650mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-10**] Inhalation every six (6) hours as needed
for shortness of breath or wheezing.
5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS.
10. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO every
twenty-four(24) hours.
11. ferrous sulfate 325 mg (65 mg Iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO once a day.
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO once a
day.
16. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
17. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
-Health Care Associated Pneumonia
-Acute on Chronic Systolic Congestive Heart Failure
-Reactive Airway Disease exacerbation (asthma vs chronic
obstructive pulmonary disease)
-Acute bacterial cystitis
Secondary Diagnoses:
-Coronary artery disease status post CABG
-Hypertension
-Cerebrovascular accident with residual aphasia and right sided
hemimplegia
-Depression
-Non insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Responsive, interactive, baseline aphasia.
Level of Consciousness: Alert and interactive.
Activity Status:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for pneumonia and treated with antibiotics.
You also developed an exacerbation of your heart failure and
were treated with diuretics (medications to remove excess fluid)
as well for a possible exacerbation of chronic obstructive
pulmonary disease. Your symptoms improved. You are being
discharged back to your residential facility.
Your medications have been changed.
-You were started on ALBUTEROL, an inhaler to help open your
airways and improve your breathing, you will continue to use
this as needed
-Your SIMVASTATIN was switched to ATORVASTATIN as the FDA has
recently recommended against using these very high doses of
SIMVASTATIN
-You should have a follow up chest radiograph in 6 wks to assess
for resolution of your pneumonia
Followup Instructions:
You will follow up with the doctors at your nursing facility and
they will help address any issues that arise.
Name: [**Known lastname 12960**],[**Known firstname 779**] Unit No: [**Numeric Identifier 12961**]
Admission Date: [**2179-2-7**] Discharge Date: [**2179-2-17**]
Date of Birth: [**2099-1-29**] Sex: F
Service: MEDICINE
Allergies:
Lamictal / Niaspan Starter Pack
Attending:[**First Name3 (LF) 11437**]
Addendum:
Called floor where patient is now located at [**Hospital **] [**Hospital 345**]
Nursing Home. Spoke to [**Name8 (MD) **], RN on floor. Informed her of
patient's negative C difficile toxin assay.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital 345**] Nursing Home - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11438**] MD [**MD Number(2) 11439**]
Completed by:[**2179-2-18**]
|
[
"428.23",
"278.00",
"999.9",
"428.0",
"414.01",
"349.82",
"401.9",
"311",
"595.0",
"486",
"285.9",
"E879.8",
"799.02",
"250.00",
"438.20",
"438.11",
"491.21",
"V45.81",
"041.4",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16541, 16797
|
6947, 12362
|
306, 312
|
14839, 14839
|
3796, 6924
|
15837, 16518
|
2350, 2367
|
12867, 14253
|
14391, 14611
|
12388, 12844
|
15054, 15814
|
2382, 2382
|
14632, 14818
|
3090, 3777
|
1639, 1960
|
252, 268
|
340, 1620
|
2396, 3076
|
14854, 15030
|
1982, 2212
|
2228, 2334
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,781
| 152,814
|
5890
|
Discharge summary
|
report
|
Admission Date: [**2175-11-8**] Discharge Date: [**2175-11-11**]
Date of Birth: [**2106-6-10**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath
EP study s/p ablation
ICD placement
History of Present Illness:
69 yom with known CAD h/o MI in '[**59**], s/p PTCA in '[**55**], PAF, HTN,
DM, COPD, CRF, and hx of meningioma presented to [**Location (un) **] w/ [**7-4**]
SSCP for 4 hours. Pt also complained of associated dizziness.
This pain was completely resolved with SLNTG. He was found to
be in stable VT and was converted to NSR with lidocaine bolus +
gtt. This sinus EKG was noted to be no different from the prior
ones. Pt also got ASA, BB, Heparin gtt, ativan, lasix 20 mg iv
there. Pt was transferred to [**Hospital1 18**] for further evaluation. Pt
CP free on arrival. Pt was taken straight to the cath lab/EP
lab.
Past Medical History:
CAD s/p MI [**2159**], PTCA [**2155**]
HTN
PAF
Hyperlipidemia
L cataract surgery
Type II DM
Hx of meningioma
Social History:
1ppd x 40 years, Denies EtOH or IV drug use
Family History:
+Type II DM, HTN
Physical Exam:
VS: Afebrile, BP 133/55 HR 65 RR 14 O2sat 100% 4L
GEN: Laying in bed, sleeping
HEENT: PERRL, EOMI, neck supple, unable to visualize JVD from
obesity
Lungs CTA bilaterally, no rales
COR: RRR S1, S2, II/VI SEM at LSB
ABD: soft, NABS, NTND, no rebound
Extrem: + femoral pulses bilaterally, no bruits. No edema,
dopplable DP bilaterally.
NEURO: Alert+ oriented x3, CN III- XII intact. Visual acuity
not tested. strengths [**3-29**] all major muscle groups.
Pertinent Results:
EKG: NSR 68 BPM, nl axis, deep S in V1-V4, J-point elevation in
V1-V2, III, q-wave in III. ST depression in V4-V6, I, aVL. No
significant changes compared to the EKG from [**4-26**] except for
J-point elevation in III.
Cath ([**11-8**]): chronic occlusions of RCA + LCx with collaterals.
LMCA 30%, 50% LAD, 40% Ramus. elevated LVEDP with LVEF 45%,
+MR, infero basal akinesis, inferior hypokinesis.
EP ([**11-8**]): Showed 2 foci of inducible VT which pt became
hypotensive requiring 200 J shock -> sinus rhythm. These foci
were ablated. A fib occured during the case and terminated
sponteneously c/w PAF. The main foci of VT with same morphology
as the presentation EKG, unable able to map out and ablate.
Possibly in epicardium.
Echo: EF 45% E;A ratio 1.50 The left atrium is elongated. There
is moderate symmetric left ventricular hypertrophy. 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 thinned/aneurysmal basal to mid
inferolateral segment and hypokinesis/akinesis of the basal
inferior wall. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are
mildly thickened. There is a minimally increased gradient
consistent with
trivial mitral stenosis. There is borderline pulmonary artery
systolic
hypertension. There is a small pericardial effusion.
[**2175-11-8**] 04:15AM CK(CPK)-226*
[**2175-11-8**] 04:15AM cTropnT-0.25*
[**2175-11-8**] 04:15AM CK-MB-28* MB INDX-12.4*
Brief Hospital Course:
1)Rhythm: Pt presented to the OSH with stable VT that was
terminated with lidocaine bolus and drip. Pt was in sinus
rhythm on arrival and went to the cath lab and underwent EP
study. Multiple sites were mapped and ablated. There were 2
foci that induced rapid VT resulting in hypotension requiring
cardioversion with 200 J. These foci are were ablated
successfully. They also detected a-fib whch terminated
spontaneously which is consitent with his history of PAF. There
was a main focus of VT with the same morphology as the VT shown
on EKG at OSH. This focus could not be mapped and ablated. The
location wa inferobasal area that is presumed to be in
epicardium. After transferred to the unit for observation, pt
had 5 episodes of asymptomatic 30-50 beat NSVT that terminated
on it's own. Several hours later, pt had an episode of
sustained VT lasting 1-2 min and subsequently had chest pain and
became hypotensive to the SBP 50's. Lidocaine 100 mg was given
and the VT terminated. Pt was placed on lidocaine drip
initially at 3 mg/hr and was weaned to 1mg/hr. Pt then got ICD
placed (Guidant VITALITY DS Model T125 DR [**Last Name (STitle) 23278**] [**Numeric Identifier 23279**]). Due
to the history of paroxysmal a-fib, pt is recommended to be
started on coumadin as outpatient. Pt was discharged with
metoprolol 50 mg po bid for rate control. Pt got TSH and LFT's
which were normal. CXR showed no acute pulmonary processs. Pt
should get an outpatient PFT's since he will be started on
amiodarone.
2)CAD: Pt underwent cath prior to the EP study which showed
chronic occlusions of RCA + LCx with collaterals. 30% LMCA, 50%
LAD, 40% Ramus. Elevated LVEDP with LVEF 45%, +MR, infero basal
akinesis, inferior hypokinesis. Pt had an elevated CK, most
likely in a setting of VT with old occlusion of RCA + LCx. Pt
was discharged with ASA, BB, Lipitor.
3)Pump: EF 45%, pt was continued on lisinopril 40 mg po qd, and
metoprolol 50 mg po tid. Pt appeared euvolemic.
4)HTN: BP in good range with metoprolol + lisinopril
5)COPD: Advair and albuterol was initially held since it could
potentially trigger VT from B-receptor. Smoking cessation was
encouraged. Atrovent was continued but pt became wheezy. After
the ICD placement, pt resumed his Advair, Atrovent, and
Albuterol.
6)F femoral a. bruit: Pt noted to have R femoral bruit after the
cath to the right groin. Femoral artery ultrasound was done
which showed ###################.
5)DM: Glipizide was held initially for cath but was later
re-stasrted.
6)CRI: Pt got Mucomyst and peri-cath hydration. Creatine was
stable post-cath.
7)Hyperlipidemia: Lipitor was continued
Medications on Admission:
Pletal 50 mg po qd
Lipitor 80 mg po qd
Glipizide 25 mg po qd
ASA 325 mg po qd
Albuterol
Atrovent
Advair
Lisinopril
Digoxin 0.25 mg po qd
Terazosin
Acetazolamide
Norpace
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
5. Terazosin HCl 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**11-25**] Inhalation [**Hospital1 **] (2 times a day).
11. Pletal 50 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 4 doses.
Disp:*4 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
CAD
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
Patient was instructed to take all of the medications as
instructed. Pt was instructed to seek medical attention if he
were to develop chest pain, SOB, dizziness, palpitation,
diaphoresis, syncope, pain at the ICD site, fever/chills, or any
other concerning symptoms. Pt should follow up with Dr.
[**Last Name (STitle) 1911**]. Pt needs to go to device appointment in 1 week.
Pt needs to follow up with PCP [**Last Name (NamePattern4) **] [**11-13**] at 11:30am and need to
be started on Coumadin.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2175-11-16**] 9:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2175-11-23**] 4:00
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20585**] ([**Telephone/Fax (1) 1160**] [**2175-11-13**] 11:30am
Completed by:[**2175-11-11**]
|
[
"427.31",
"496",
"403.91",
"427.1",
"414.01",
"423.9",
"428.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"88.53",
"88.56",
"37.22",
"37.94",
"37.27",
"37.34",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7434, 7440
|
3409, 6065
|
282, 332
|
7512, 7536
|
1700, 3386
|
8085, 8607
|
1191, 1209
|
6284, 7411
|
7461, 7491
|
6091, 6261
|
7560, 8062
|
1224, 1681
|
232, 244
|
360, 982
|
1004, 1114
|
1130, 1175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,995
| 151,468
|
46141
|
Discharge summary
|
report
|
Admission Date: [**2173-12-11**] Discharge Date: [**2173-12-21**]
Date of Birth: [**2107-9-11**] Sex: F
Service: MEDICINE
Allergies:
Gantrisin / Lactose
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
66 year old woman admitted to [**Hospital1 18**] with altered mental status
Major Surgical or Invasive Procedure:
Dialysis twice weekly
History of Present Illness:
HPI: The patient is a 66 year old woman with MMP including DM1,
CAD, ESRD on HD, UTI recently admitted to [**Hospital1 18**] for hypotension
felt to be secondary to antibiotic associated diarrhea. During
that hospital stay she was hypotensive on presentation which
resolved with IVF. She completed her prior course of tobramycin
for the UTI and was started on empiric PO flagyl for presumed c
dif although c. dif tox A was negative x3 and toxin B was
pending on discharge. She was discharged from [**Hospital1 18**] to [**Hospital1 **]
the day prior to this admission.
.
At [**Hospital1 **], midnight vitals were reported as a fingerstick of
186, BP 103/55 and temp of 99.4. The patient was responding to
verbal commands. At 4am, she was was found to have altered
mental status and a FS was 21. She was given D50 but no
improvement. She transferred to [**Hospital1 18**] for further evaluation.
In the ED she was minimally responsive but gradually improving.
Upon arrival her vital signs were BP 80/50, HR 80, SpO2 100 RA
upon arrival She was also hypothermic to 91.1 degrees axillary.
CXR showed concern for early RLL pneumonia. Urine positive for
21-50 WBC, mod leuk, many bacteria and large blood, A CT head
was unremarkable. She was given vanc/levo/flagyl and placed on a
warming blanket. In addition, she received 10mg IV decadron.
On arrival at the floor the patient was alert and responsive,
WBC count was within normal limits and vital signs were stable.
She was set up to receive hemodialysis.
Past Medical History:
1. DM type 1 x 35 years. Previous admissions for DKA and
hypoglycemic episodes. Her DM is complicated by peripheral
neuropathy, proliferative retinopathy (left eye blindness), and
nephropathy. Followed at [**Last Name (un) **].
2. Chronic renal failure: Appears [**2-19**] to DM and Cr has been 5
over past few months. On hemodialysis.
3. CAD - NSTEMI [**10-23**] in the setting of hospitalization for DKA,
Nuclear stress test [**8-23**]: P-MIBI, without fixed or reversible
defects, normal wall motion. EF 72%.
4. Hypertension
5. History of osteomyelitis, status post left transmetatarsal
amputation.
6. History of herpes zoster of left chest in [**2163**].
7. Bezoar, disclosed on UGI series [**7-/2166**].
8. Achalasia
9. Carpal Tunnel Syndrome
Social History:
She lives at home with her son, who is mentally retarded. Past
history of EtOH use. Ex-smoker, quit in [**2154**]. Previously smoked
for 8yrs. No history of illicit drug use.
Family History:
Mother - DM
Sister - breast ca, DM
Brother - HTN
[**Name (NI) 2957**] - SLE, d. renal failure
Physical Exam:
On admission:
P 105, BP 96/63, RR 20, O2 100%RA, T 98.7
HEENT: no jaundice
Lungs: CTA
CVS: reg
Abd: soft, NT, BS+
Ext: no edema
Rectal: brown semiformed stools. guaiac neg per nurse
Pertinent Results:
[**2173-12-10**] 11:00AM PT-17.6* PTT-58.2* INR(PT)-1.6*
[**2173-12-10**] 11:00AM WBC-12.7*# RBC-4.14* HGB-11.2* HCT-36.6
MCV-88 MCH-27.0 MCHC-30.6* RDW-16.5*
[**2173-12-10**] 11:00AM GLUCOSE-88 UREA N-16 CREAT-3.8*# SODIUM-136
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2173-12-11**] 06:20AM cTropnT-0.06*
[**2173-12-11**] 07:55AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2173-12-11**] 07:55AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-OCC EPI-0-2
URINE CULTURE (Final [**2173-12-13**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CXR - Ill-defined opacity within the right lower lobe, which may
represent atelectasis, however, early airspace consolidation
cannot be entirely excluded.
.
CT head - There is no hemorrhage, mass effect, hydrocephalus, or
shift of normally midline structures. Low densities are seen
within the periventricular and subcortical white matter
reflecting chronic microvascular ischemic disease. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles
and sulci are prominent reflective of age-related involutional
change. The visualized paranasal sinuses and mastoid air cells
remain normally aerated. Note is made of phthisis bulbi of the
left globe
Brief Hospital Course:
# Altered mental status - Pt experienced altered mental status
in the setting of severe hypoglycemia. Differential included
acute intracranial event, infection, and non-convulsive
status/seizure. CT scan of head negative for acute process.
Patient received antibiotics w/ improvement but unclear source
of infection. Pt does have seizure history, however no evidence
to support recent epileptic event. Likely, mental status was
altered in the setting of extremely low blood sugar. Patient
cleared with resolution of hypoglycemia.
#Right Wrist Cellulitis - Patient developed worsening right
wrist pain after admission. Patient was not able to state the
duration of pain, but does state that it had been days rather
than weeks. Afebrile, no elevation of WBC count. Pain from
physical trauma v. infection/tenosynovitis.
- Plastics hand consult stated that no intervention was needed.
- plain films right hand - no fracture, no gross abnormalities
- Vancomycin with dialysis was continued for 10 day course, with
HD dosing, given high likelihood of MRSA in this diabetic,
institutionalized patient
.
# Labile Blood Glucose/Type I Diabetes - Differential for
hypoglycemia prior to admission included infection v. insulin
excess. Pt stated that she did not eat dinner the night before
admission night but was given a full dose of glargine. She had a
mildly elevated WBC of 12.7 on admission. CXR was likely
atelectasis however an early pneumonia could not be excluded. BS
on arrival to the floor 267. Patient received 10mg IV decadron
in the ED which could explain recent elevated BS.
- sliding scale insulin used for fixed meal time dose
- Glargine was adjusted on several occasions - at time of
discharge is 16 units q hs. This was an increase in response to
high daytime glucose levels but will need to continue close
monitoring of fingersticks.
#Diarrhea - pt continued to have loose bowel movements,
gradually improving towards the end of her hospital course.
This was presumed to be nonspecific antibiotic-associated
colitis.
- c.diff negative
- continue flagyl to 14 day course from [**12-12**]
.
# ?Pneumonia - CXR in ED suggested atelectasis vs early PNA, but
patient improved with vanc and levo. A repeat CXR was not
convincing for a PNA
# ?UTI - patient with known history of citrobacter infection.
F/u C&S showed skin contamination. Additional antibiotics were
not given.
# ESRD on HD: Continued HD as scheduled TThSat
# CAD - h/o NSTEMI. She was continued on ASA and statin, and
restarted on Metoprolol 12.5 TID
# Conjunctivitis - s/p course of cipro eye drops, improved.
# Code: Note, patient is DNR/DNI per HCP
Medications on Admission:
Heparin 5,000 unit TID
Atorvastatin 80 mg DAILY
Aspirin 81 mg DAILY
Folic Acid 1 mg DAILY
Acetaminophen 325-650 mg Q6H:PRN
Metoprolol Tartrate 37.5 mg TID
Calcium Carbonate 500 mg [**Hospital1 **]
Pantoprazole 40 mg Q24H
B Complex-Vitamin C-Folic Acid 1 mg DAILY
Metronidazole 500 mg TID
Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours) for 4 days.
Epoetin Alfa 2,000 unit qHD
Psyllium 1.7 g [**Hospital1 **]
Insulin Glargine 10 units at bedtime
Humalog sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection with meals an at bedtime.
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Epoetin Alfa 10,000 unit/mL Solution Sig: as per renal
Injection ASDIR (AS DIRECTED).
9. Vancomycin dosed with dialysis - to complete a 14 day course
(day of discharge = day 10)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital- [**Location (un) 86**]
Discharge Diagnosis:
Septicemia
Diabetes Mellitus
Cellulitis right wrist
hypovolemia
Diarrhea - possibly antibiotic-associated
decubitus ulcers
Hypertension
Urinary Tract Infection
Discharge Condition:
stable
Discharge Instructions:
Continue to follow fingersticks closely.
Physical and occupational therapy to build strength.
Monitor right wrist cellulitis.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2173-12-28**] 11:00
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2174-1-6**] 2:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.: schedule upon discharge from Rehab
|
[
"412",
"558.9",
"403.91",
"368.8",
"V09.0",
"585.6",
"285.21",
"E901.8",
"V45.1",
"372.39",
"458.8",
"357.2",
"991.6",
"250.83",
"250.53",
"276.52",
"V58.66",
"780.39",
"518.0",
"250.63",
"787.6",
"362.02",
"787.91",
"682.4",
"V58.67",
"038.11",
"530.0",
"707.03",
"275.3",
"354.0",
"V15.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8588, 8686
|
4610, 7240
|
358, 382
|
8890, 8899
|
3213, 4587
|
9073, 9552
|
2898, 2993
|
7782, 8565
|
8707, 8869
|
7266, 7759
|
8923, 9050
|
3008, 3008
|
243, 320
|
410, 1917
|
3022, 3192
|
1939, 2689
|
2705, 2882
|
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