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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
44,539
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|
40281
|
Discharge summary
|
report
|
Admission Date: [**2157-10-3**] Discharge Date: [**2157-10-7**]
Date of Birth: [**2111-10-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fexofenadine
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
RCA dissection
Major Surgical or Invasive Procedure:
Intra Aortic Balloon Pump- placed in OSH, removed here at [**Hospital1 18**]
History of Present Illness:
45yo Spanish-speaking woman w/ HTN, DM2, anxiety and seizure
disorder who presented to her PCP w/ chest pain. An EKG was doen
in clinic and was concerning for TW inversions in V5-V6 and she
was transferred to the ED for possible MI. Her chest pain was
relieved by nitro and she was admitted for r/o MI. She has
already had multiple negative stress tests, so the decision was
to go to cath to definitively rule-out coronary artery disease.
.
Catheterization revealed no left main disease or LAD disease.
LCX seperate ostium adjacent to RCA ostium, RCA non-obstructive
proximal plaque. Following Cath she developed chest pain and
reported ST elevations. Repeat cath revealed spiral dissection
to distal vessels with proximal occlusion. She reportedly became
bradycardic to the 30's and received 0.75 mg atropine. A stent
was deployed across the distention with likely jailing off of
the acute marginal branch. An IABP was placed to improve
myocardial oxygenation and she was transfferred to [**Hospital1 18**] for
managemetn of IABP.
.
On arrival she complained of chest pain with radiation to the
back.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 DM w/ A1c of 9
- Depression/anxiety
- Hyponatremia, attributed to polydipsia and diuretic use
- Seizure disorder - on Depakote and Keppra?
- s/p hysterectomy
Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Lives with her husband and daughter. [**Name (NI) **] by a VNA daily.
Family History:
Aunt with unknown cancer
Physical Exam:
Admission Exam:
VS: T=97.6 BP=100/70 in both arms HR=95 RR= O2 sat= 93%RA
GENERAL: Moderatly obese spanish speaking woman diaphoretic in
moderate distress. Oriented x3.
HEENT: NCAT. Sclera anicteric. Pupils pin point but reactive.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft nontender
EXTREMITIES: No femoral bruits.
SKIN: Stasis dermatitis. No ulcers or scars.
Right: R 2+ DP 2+
Left: R: not palpable [**12-21**] pressure dressing in place. DP 2+
Pertinent Results:
Echo:
Suboptimal image quality.The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The RV free wall appears hypokinetic (the apex is hyperdynamic).
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a minimally increased gradient
consistent with trivial mitral stenosis. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: RV infarction? If indicated, a repeat study with
echo contrast may better assess basl to mid RV free wall
function
Repeat Echo few days later:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with depressed 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 appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional left ventricular systolic
function. Dilated RV with free wall hypokinesis. The apex of the
right ventricle has preserved function. There is pressure/volume
overload of the right ventricle. The estimated pulmonary artery
pressures are only mildly elevated - may be UNDERestimated.
Small pericardial effusion located mostly posterior to the left
ventricle without tamponade physiology.
Brief Hospital Course:
48 YO woman with multiple cardiac risk factors s/p cardiac cath
to R/O CAD complicated by RCA dissection and likely jailing of
acute marginal branch in setting of placement of 3 stents,
transfered to [**Hospital1 18**] CCU with clinical picture concerning for
acute MI of the RV.
.
# Coronaries/Chest pain: Symptoms and EKG findings (STE in
Inferior leads III>II with STE in RV leads is consistent)
consistent with RV infarct likely proximal RCA. Pt's RCA
dissection was secondary iatrogenic causes which temporarily
disrutped flow through RCA. Three stents were placed which
jailed off some of the braching arteries resulting in
post-procedure troponin bump. Troponin peaked at 1.28 and
trended down. Pt transfered here on IABP and heparin drip. IABP
was weaned. Pt given plavix 75mg daily, ASA 325mg daily,
lovastatin 20mg daily for medical management of her CAD. Will
follow with cardiologist outpatient.
.
# PUMP: Initially on IABP which was weaned. Pt's EF is >55%.
Echo showed dilated RV with free wall hypokinesis. Apex has
preserved function.
.
# RHYTHM: Initially had Junctional escape rhythm and then atrial
escape rhythm likely secondary to ischemia of sinus node from
jailing off of proximal RCA branches. Asymptomatic and stable
hemodynamically.
.
# Hyperkalemia: Initially had hyperkalemia on transfer with some
T-wave elevations. Was given kayexelate and insulin with
stabalization of potassium. No further hyperkalemia.
.
# Seizure disorder: Spoke with outpatient neurologist and
patient was given her outpatient seizure regimen.
.
# DM: ISS and held metformin
.
# Dyslipidemia: Continued statin
.
# Anemia: Likely chronic in nature since pt is on ferrous
sulfate at home. It was stable at 28 range. Asymptomatic.
Medications on Admission:
Lantus 80u HS
Lisinopril (Patient has two prescriptions 40mg once a day and
40mg [**Hospital1 **])
Novolog 15u TID
Ativan 0.5mg QHS
Magnesium Oxide 400mg QD
Metformin 1000 MG [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Vitamin D 400U daily
Lovastatin 20mg QD
Asprin 81mg QD
Lasix 20mg Daily
Naprosyn 500mg [**Hospital1 **]
Depaktoe ER 1000mg [**Hospital1 **] (confirmed with Neurologist)
Risperdal 2mg QHS
Keppra 1000mg [**Hospital1 **] (confirmed with Neurologist)
Detrol 2mg Daily
Primidone 100mg [**Hospital1 **] (confirmed with Neurologist)
Albuterol MDI 2 puffs PRN wheezing
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
3. Novolog 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: Before meals.
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
8. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Outpatient Lab Work
Please check Chem-7 on Monday [**2157-10-10**] with results to Dr.
[**Last Name (STitle) **],KIAME J [**Telephone/Fax (1) 63099**]
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO BID (2 times a day).
15. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. primidone 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
18. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
Multicultural Home Care
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Seizure disorder
Hypertension
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a cardiac catheterization at [**Hospital6 3105**]
and one of your heart arteries was damaged and needed to be
fixed with a bare etal stent. You had some damage to the right
side of your heart that should get better over time. You will be
on a new medicine called Clopidogrel or Plavix and your will
need to increase your aspirin to 325 mg daily from 81 mg daily.
It is extremely important to take Aspirin and Plavix every day,
no not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix and aspirin unless
Dr. [**Last Name (STitle) **] tells you it is OK. You will need to see Dr.
[**Last Name (STitle) 66153**] in 1 week and Dr. [**Last Name (STitle) **] in 1 month. No lifting more
than 10 pounds for one week. Please watch the right groin area
for any increasing pain or bruising or any bleeding. Call Dr.
[**Last Name (STitle) **] if you notice any of these changes.
Medication changes:
1. Start Plavix to keep the stent in your heart artery from
clotting off
2. Increase Aspirin to 325 mg daily
3. Start taking Norvasc to control your blood pressure
4. Do not take your Lisinopril or naprosyn until Dr. [**Last Name (STitle) 66153**]
tells you it is ok to start.
5. You will need to have some blood drawn on Monday to check
your kidney function.
.
Make sure to follow up outpatient with Dr. [**Last Name (STitle) 66153**] to get a
sleep study for possible sleep apnea.
Followup Instructions:
Name: [**Last Name (STitle) **],KIAME J
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 63099**]
*Please call your PCP to book an appointment within 1 week.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES,LLC
Phone: [**Telephone/Fax (1) 63259**]
When: Wednesday, [**11-9**], 1PM
|
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icd9cm
|
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1893, 2021
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,467
| 164,211
|
28549
|
Discharge summary
|
report
|
Admission Date: [**2118-12-12**] Discharge Date: [**2118-12-25**]
Date of Birth: [**2069-10-26**] Sex: F
Service: SURGERY
Allergies:
Zantac 75 / Lipitor
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 69147**] was transferred from an OSH to [**Hospital1 18**]-ED on [**12-12**] for
further management of nausea and vomiting. She is well known to
the surgical service, had been discharged on [**12-10**] for sepsis and
drainage of abdominal abscess which was positive for
MRSA,E.Coli,and Klebsiella; she had been discharged home on oral
antibiotics and PICC line. She has a history of diverticulitis,
s/p colectomy with ileostomy, c/b abdominal abscess requiring
percutaneous drainage.
Past Medical History:
PMH:
1.)Colocutaneous Fistula
2.)Aspiration pneumonia with MRSA
3.)Diverticulitis
4.)Anxiety
5.)Depression
6.)afib
7.)Abdominal abscess with percuteous drain: +MRSA, E.Coli,
Klebsiella
PSH:
1.)[**2118-7-21**]- Exploratory laparotomy with total colectomy
2.)[**2118-7-23**]- Takedown of ileorectal anastomosis, [**Doctor Last Name **] pouch,
ileostomy
3.)[**2115**]- Sigmoid Colectomy
4.)[**2109**]- Cholecystectomy
Social History:
Mrs. [**Known lastname 69147**] lives in [**Location **] with her husband and four kids
(7,9, 17, and 19 years of age). This is her second marriage and
she stays at home and cares for the children. Before her first
marriage, she worked at a nursing home. She has a 16 pack-year
smoking history, quitting in [**Month (only) 216**] due to her hospitalization.
She drinks alcohol occassionally and has no history of illicit
drug use. She buckles up when she drives and does not own a
gun. She does not bike and has no history of felonies or
misdemeanors. She is on a limited hospital diet and does not
actively exercise. She has not been sexually active due to her
hospitalizations but otherwise, only has sex with her current
husband.
Family History:
Mother passed away of lung cancer and was a heavy smoker. Her
father is alive and well. There is no history of
diverticulitis, diabetes, cancer or cardiac problems.
Physical Exam:
Upon admission:
97.5 124 126/85 14 97% room air
Gen: Vomiting bilious fluid
Eyes: Pupils equal and reactive to light, extraocular movements
intact
Neck: No lymphadenopathy
Chest: Lungs clear
CV: Tachycardic
Abd: Non-distended, tender to palpation over midline/suprapubic
incision, no rebound or guarding. Colostomy draining liquid
brown stool. Right sided drain with minimal erythema over
insertion site
Ext: No edema, dorsalis pedis pulses 2+ bilaterally
Pertinent Results:
Admission:
[**2118-12-12**] 04:30PM BLOOD WBC-15.8*# RBC-4.16* Hgb-12.0 Hct-33.7*
MCV-81* MCH-28.7 MCHC-35.5* RDW-14.3 Plt Ct-742*#
[**2118-12-12**] 04:30PM BLOOD Neuts-83.2* Lymphs-10.4* Monos-6.0
Eos-0.1 Baso-0.2
[**2118-12-12**] 04:30PM BLOOD PT-14.9* PTT-23.8 INR(PT)-1.3*
[**2118-12-12**] 04:30PM BLOOD Glucose-98 UreaN-24* Creat-2.5* Na-136
K-3.6 Cl-85* HCO3-33* AnGap-22*
[**2118-12-12**] 04:30PM BLOOD CK(CPK)-11*
[**2118-12-12**] 04:30PM BLOOD ALT-9 AST-19 AlkPhos-262* Amylase-112*
TotBili-0.6
[**2118-12-12**] 04:30PM BLOOD Lipase-31
[**2118-12-12**] 04:30PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2118-12-12**] 04:30PM BLOOD Calcium-13.0* Phos-3.4 Mg-1.8
[**2118-12-12**] 10:30PM BLOOD PTH-12*
[**2118-12-12**] 04:30PM BLOOD Vanco-11.2
[**2118-12-12**] 06:09PM BLOOD Lactate-2.2*
[**2118-12-12**] 09:59PM BLOOD freeCa-1.31
Discharge:
[**2118-12-15**] 04:21AM BLOOD TSH-2.0
Psychiatry:
Impression:
1. Generalized anxiety disorder. Likely aggravated by anemia.
2. Adjustment disorder with anxious and depressed mood.
3. ?UTI
4. anemia
5. ?hx of DVT
6. AF
Suggest:
1. Check TSH
2. Increase Xanax to 1 mg po TID.
3. Start Remeron 15 mg po qhs
4. Decrease Lexapro to 10 mg po qam for 3 days, then 5 mg po
qam
for 3 days, then d/c
5. will arrange outpatient referral for psych f/u; as
outpatient
would switch to Klonopin from Xanax for steadier level with long
half-life BZP.
Cardiology Report ECG Study Date of [**2118-12-12**] 6:33:00 PM
Sinus tachycardia
Possible right atrial abnormality
Possible inferior/lateral infarct - age undetermined
Anterolateral ST-T changes are nonspecific
Early R wave progression
Since previous tracing, early R wave progression new, consider
posterior
myocardial infarct, QT interval prolonged for rate, ST segment
depression, T
wave inversion are new
Clinical correlation is suggested
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 136 86 378/439.28 75 55 73
[**2118-12-14**] 11:01 am STOOL CONSISTENCY: WATERY Source:
Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2118-12-15**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
CT scan [**12-20**]:
IMPRESSION:
1. Interval resolution of the right-sided retroperitoneal
collection. No IV contrast was used, limiting evaluation of this
collection, however, it appeared unchanged since prior
examination and due to lack of drainage from this collection,
the drain was pulled today.
2. Right lower quadrant ostomy.
3. Nonobstructive 2 mm right renal stone.
4. Degenerative changes of the lower lumbar spine with disc
bulges at L4-5 and L5-S1.
Bone scan [**12-20**]:
IMPRESSION: No evidence of metastatic disease. Mild increased
uptake in the
shoulders, upper sternum, cervical spine and left knee, most
likely degenerative change.
Brief Hospital Course:
Ms. [**Known lastname 69147**] was admitted to the surgical service, EKG on
admission with new ST depression, cardiac enzymes were negative
for ischemia. She was made NPO with intravenous hydration, she
was afebrile with a WBC of 15k, blood and urine cultures were
sent which were negative for bacteria, her electrolytes were
notable for dehydration and renal failure with a creatinine of
2.5 and serum calcium of 13; a foley catheter was placed and
notable for anuria, she remained normotensive; she was
transferred to the ICU for close monitoring and aggressive fluid
resuscitation. On HD 3 she had improvement, her urine output
responded, her creatinine had decreased to 1.6, and white blood
cell count was normal at 5.5k. On HD 4, she was transferred to
an in-patient nursing unit, was tolerating liquids, her foley
catheter was removed and she was voiding without difficulty; a
psychiatry consult was placed for further management of her
depression and anxiety with changes made in her medication
regimen as recommended. Her lexapro was stopped and she was
started on Remeron and Xanax. On HD 6, she had continued
intermittent nausea and vomiting, her ostomy was functioning
well, antiemetics were started, intravenous hydration was
started during the night shift, and a renal consult was placed
for further investigation of her persistent hypercalcemia and
renal failure for a total of two months with an unclear
etiology.
On HD 9, a bone scan was negative for metastatic disease, her
percutaneous abscess drain was removed after a non-contrast CT
scan demonstrated resolution of right retroperitoneal abscess;
she had good oral intake on a regular diet, her creatinine was
stable at 1.2, her calcium continued to have fluctuate between
10 and 11.6, twenty-four hour urine excretion of Calcium was
normal, along with a normal PTH, Vitamin D I-25; outside
laboratory results for PTHRP and Vitamin D 25 were pending, and
her anxiety and depression was well controlled.
Prior to discharge she was evaluated by nephrology and
endocrinology for the hypercalcemia. An exact cause could not
be elucidated and she was discharged home on HD14. As she had
finished her course of antibiotics her PICC line was removed
prior to discharge. In addition, she was on coumadin for an
upper extremity DVT. Since she had been treated for greater
than 3 months for this, the coumadin was stopped. Her
psychiatric medications at discharge were remeron, klonipin, and
trazadone. She will follow up as an outpatient with Dr.
[**Last Name (STitle) **], endocrinology, psychiatry, and her PCP.
Medications on Admission:
Trazadone
Lexapro
Xanax
Coumadin
Amoxicillin
Reglan
Protonix
Celexa
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
4. Klonopin 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Dehydration with acute renal failure and hypercalcemia
Abdominal abscess with MRSA, E.Coli, Klebsiella
Depression
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain
*Fever > 101.5
*Nausea, vomiting, or abdominal distention
*Inability to pass gas or stool from stoma
*Inability to pass urine
*Change in mental status (increased weakness, fatigue) over 24
hours
*Shortness of breath or chest pain
*If abscess drain leaks, exit site develops redness, or if it is
pulled out
*If otsomy outputs or decrease over 24 hours
*If stoma changes color or appearance
*Bleeding from any part of the body
*If abdominal wound develops tenderness, redness, an odor, or
increased drainage
*Any other symptoms concerning to you
You may shower, exit site of abscess drain must be covered at
all times
After you shower the abdominal dressing should be changed
No swimming or tub baths
Please take all medications as directed
Some of your anti-depressants were changed, please follow new
prescriptions
You no longer need to take coumadin.
You need to eat small frequent meals throughout the day
You need to drink fluids throughout the day (water, juice,
gatorade, vitamin water, etc), minimum of 10 glasses per day
Your abscess drain must be flushed with 10mL normal saline twice
a [**Name6 (MD) **]
Notify MD if you are unable to flush it or if there is leakage
Please empty the drainage bag every day and keep a record of the
outputs
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**12-6**] weeks, call ([**Telephone/Fax (1) 2300**]
for an appointment
Follow-up Outpatient psychiatric appointment made for pt for
[**2119-1-3**] at 12:30pm with [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) 30003**]. Office is:
Neurobehavioral
Associates, 169 [**Last Name (un) 69155**] Industrial Parkway, [**Location (un) **], [**Numeric Identifier 18367**].
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 42310**] in 1 weeks for review of
your blood work, medications, physical assessment; call
[**Telephone/Fax (1) 42311**] for an appointment
Follow-up with the endocrinologist regarding elevated calcium
levels, Dr. [**Last Name (STitle) **], in [**1-7**] weeks. Call [**Telephone/Fax (1) 9941**] to
schedule an appointment.
Completed by:[**2118-12-25**]
|
[
"300.00",
"584.9",
"V09.0",
"721.3",
"567.22",
"285.9",
"427.31",
"444.21",
"562.11",
"V44.3",
"041.4",
"275.42",
"311",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8693, 8764
|
5601, 8185
|
301, 308
|
8922, 8931
|
2723, 5578
|
10331, 11201
|
2058, 2226
|
8303, 8670
|
8785, 8901
|
8211, 8280
|
8955, 10308
|
2241, 2243
|
242, 263
|
336, 843
|
2258, 2704
|
865, 1284
|
1300, 2042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,197
| 101,959
|
28328
|
Discharge summary
|
report
|
Admission Date: [**2186-9-21**] Discharge Date: [**2186-9-22**]
Date of Birth: [**2122-12-11**] Sex: M
Service: MEDICINE
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain on exertion
Major Surgical or Invasive Procedure:
Cardiac catheterization, access through left brachial artery
History of Present Illness:
63yo male with early onset CAD s/p CABG [**2171**] (LIMA-->LAD, SVG
--> OM2 and LPLB), HTN, Hyperlipidemia who presented for
elective heart catheterization with a history of stable angina.
Pt reports chest pain with exertion for last several months,
worse recently while mowing his lawn. Baseline two flights of
stairs and develops CP. He denies any rest pain, PND or
orthopnea.
.
Pt underwent heart catheterization complicated by multiple
bilateral femoral sticks and required L brachial artery for
access. Catheter was unable to advance to LIMA or SVG grafts to
deliver stents due to severe vessel tortuosity. No stents were
deployed. Pt became hypotensive after nitroglycerin gtt was
started in the cath lab, required brief period on dopamine.
.
Pt arrived to CCU c/o [**2-10**] substernal chest pain consistent with
prior anginal pain. SBP 190's on arrival. Low dose nitroglycerin
gtt was started and patient became hypotensive to SBP 40's and
tachycardic to 150's. IVF's, dopamine, atropine was given with
return of SBP's 120's. Pt had HR 150's, SVT, adenosine given
without effect. HR gradually returned to 100's. Metoprolol 5mg
IV given and brought HR to 80's, 90's. The patient was monitored
in the CCU overnight.
Past Medical History:
CABG- [**2171**] (LIMA-->LAD, SVG --> OM2 and LPLB)
HTN
Hyperlipidemia
Social History:
worked as manager of computer company, widowed, wife died of
ovarian CA two years ago, now in a long term committed
relationship with female sig other. Drinks 1-2 drinks once per
week. 15py smoking history, quit 15 years ago. No Illicits.
Remains independent of all ADL's prior to admission.
Family History:
Mother d.57 DM, CAD
Maternal Aunts and uncles with multiple heart dx related
premature deaths
Brother CABG @ 51
Physical Exam:
Vitals: BP 190/100, HR 70, R 16, Sat 94% 4LNC
Ht: 6'5", Wt. 275lbs
Gen: Pleasant, lying flat in bed, c/o [**2-10**] SS CP.
HEENT: NCAT, PERRL, MMM
CV: Nl S1 and S2, no MRG, JVP 7cm
PULM: CTA B
ABD: obese, soft, NT, no masses
Extrem: no CCE, 2+ DP, PT pulses
Groin- No hematoma, No Bruits Bilaterally, Good pedal pulses as
above.
Pertinent Results:
[**2186-9-21**] 08:30PM WBC-11.7* RBC-4.69 HGB-15.8 HCT-44.2 MCV-94
MCH-33.8* MCHC-35.8* RDW-13.6
[**2186-9-21**] 08:30PM PLT COUNT-184
[**2186-9-21**] 08:30PM MAGNESIUM-2.2
[**2186-9-21**] 08:30PM CK-MB-NotDone cTropnT-0.06*
[**2186-9-21**] 08:30PM CK(CPK)-73
[**2186-9-21**] 08:30PM CK(CPK)-73
[**2186-9-22**] 04:04AM BLOOD WBC-10.8 RBC-3.87* Hgb-13.0* Hct-37.4*
MCV-97 MCH-33.6* MCHC-34.8 RDW-13.4 Plt Ct-154
[**2186-9-22**] 04:04AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-25 AnGap-11
.
Cardiac Catheterization [**2186-9-21**]
**Preliminary Report**
1) Coronary angiography revealed a right dominant system status
post
coronary artery bypass grafting with three vessel disease. The
LMCA had
no stenosis. The LAD gave off a single, large patent D1 branch
prior to
a 100% proximal segment stenosis. The LCx showed a 100%
proximal
segment stenosis. The RCA showed a 100% midsegment stenosis
with right
to left collaterals to the distal LCx system. Graft angiography
revealed a stump occlusion of a graft which is likely the
SVG-LPL
branch. No other graft could be engaged or seen, suggesting
likely
occlusion of the SVG-OM2 graft. The LIMA-LAD graft revealed a
patent
LIMA graft with an 80% stenosis of the LAD immediately distal to
the
anastomosis site.
2) Hemodynamic studies demonstrated normal right atrial filling
pressures of
3) Unsuccessful attempts at PCI of the LAD distal to the [**Female First Name (un) 899**]
insertion
was performed. The attempts were unsuccesful due to the poor
guide
support from the brachial access and the excessive tortuousity
of the
[**Female First Name (un) 899**]. Further attempts were aborted due to the concern over
radiation
and dye exposure.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Unsuccessful attempts at PCI of the LAD after the insertion
of the
[**Female First Name (un) 899**].
.
ECHOCARDIOGRAM [**2186-9-22**]- **PRELIMINARY [**Location (un) **] ONLY**
The left atrium is dilated. The right atrium is moderately
dilated. The left ventricular cavity is mildly dilated. Overall
left ventricular systolic function is severely depressed.
Resting regional wall motion abnormalities include mid
anteroseptal and inferior akinesis with hypokinesis elsewhere.
Right ventricular chamber size is normal. Right ventricular
systolic function is borderline normal. The aortic root is
moderately dilated. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
63yo M with early onset CAD s/p CABG [**2171**] (LIMA-->LAD, SVG -->
OM2 and LPLB), HTN, Hyperlipidemia. s/p heart cath complicated
by difficult vascular access, tortuous coronary vascular supply
impeding stent delivery, hypotension following administration of
nitrates.
.
1) Cardiac:
Ischemia- The patient presented with stable angina. No stents
were able to be delivered due to severely tortuous coronary
vessels. Cardiac enzymes were cycled and negative post
intervention. The patient was started on Metoprolol 12.5mg [**Hospital1 **]
for rate control given rate related LBBB. He was started on
Aspirin 325mg daily, Clopidogrel 75mg daily, Lisinopril 5mg
daily. Nitrates in any form were avoided due to episodes of
hypotension. A strict contraindication to nitrates should be
noted in all future patient records.
.
Rhythm- The patient remained in normal sinuse rhythm, he was
noted to have a rate related LBBB as noted on prior exercise
tolerance tests. Low dose Metoprolol 12.5mg was started while
inpatient.
.
Pump- Preliminary read revealed moderate dilation,
multi-regional hypokinesis/akinesis, severely depressed LVEF
~20%. The patient is well-compensated at present, no pulmonary
edema, peripheral edema, orthonea/PND. However is at high risk
of congestive failure. Given failure of percutaneous
revascularization, strict compliance and optimization of medical
therapy should continue as an outpatient. He was started on
Lisinopril and Metoprolol while inpatient.
.
2) Pulmonary- The patient had multiple apneic episodes overnight
with bradycardia to 50's. Pt had sleep study 1yr ago but could
not tolerate mask. Pt was informed of risks to his cardiac fx
and is amenable for re-evaluation for trial of [**Hospital1 **]/BiPAP.
He should be scheduled for repeat Sleep/Pulmonary evaluation as
an outpatient at the discretion of his primary care provider.
[**Name10 (NameIs) **] will likely improve his severely impaired cardiac
parameters and he should be strongly encouraged to re-trial the
device.
.
3) Seizure disorder-
No seizure activity was observed while during this
hospitalization. We continued his home dosage of phenytoin
during his inpatient stay.
.
4) Renal- Creatinine clearance was stable following dye-load
associated with catheterization and peri-procedure hypotension.
He had excellent urine output without the aide of urinary
catheter prior to discharge.
.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Code: Full
Contact: (fiance) [**Name (NI) **] [**Name (NI) 68776**] [**Telephone/Fax (1) 68777**]
Medications on Admission:
Atorvastatin 80mg PO daily
Phenytoin 300mg PO qam
Phenytoin 200mg PO qpm
Multivitamin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QAM (once a day (in the morning)).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QPM (once a day (in the evening)).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Elective cardiac catheterization
Coronary artery disease
Secondary:
Hypertension
Hyperlipidemia
Discharge Condition:
Stable. The patient is currently chest pain free.
Discharge Instructions:
You came to the hospital for an elective cardiac catheterization
which was complicated by difficulty accessing your arteries. In
addition, your blood pressure dropped while on a nitroglycerin
drip. No stents were placed.
You are taking some new medications: Plavix, aspirin,
lisinopril, and carvedilol.
You will continue to take a multivitamin, atorvastatin, and
dilantin as you were before.
Please keep all outpatient appointments.
If you begin to experience shortness of breath, chest pain,
dizziness or lightheadedness or any other concerning symptom
please call 911 or your physician right away.
Followup Instructions:
Please schedule the following appointments:
1. [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 2394**] Appointment should be in [**6-12**]
days
2. [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 48826**] Call to schedule appointment
|
[
"V45.81",
"458.9",
"427.89",
"411.1",
"401.9",
"272.4",
"414.01",
"412",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8995, 9001
|
5439, 7998
|
298, 361
|
9151, 9204
|
2512, 4240
|
9859, 10144
|
2033, 2147
|
8135, 8972
|
9022, 9130
|
8024, 8112
|
4257, 5416
|
9228, 9836
|
2162, 2493
|
236, 260
|
389, 1613
|
1635, 1708
|
1724, 2017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,378
| 102,486
|
1636
|
Discharge summary
|
report
|
Admission Date: [**2141-7-18**] Discharge Date: [**2141-7-25**]
Date of Birth: [**2060-5-11**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Lisinopril / Penicillins / Flagyl / Ultram
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
right sided pleuritic chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 81 yo F with h/o chronic eosinophilic lung disease,
COPD (FEV1 0.74, FEV1/FVC 72% predicted in [**5-25**]), diastolic CHF,
atrial fibrillation/atrial tachycardia, and HTN with recent
hospitalization at [**Hospital1 18**] from [**6-8**] - [**6-21**] for MSSA and
Psueodmonas RLL PNA requiring intubation, pressor support for
hypotension, L sided PTX, and C diff colitis who presents from
her nursing home with fever and increasing right sided pleuritic
chest pain. Pt describes sudden onset of lower right sided
pleuritic chest pain yesterday that was non-radiating, [**2142-9-24**].
Feels SOB at baseline and does not feel SOB is significantly
worse from baseline although she feels she is unable to take as
deep of a breath than usual. The pt also describes a chronic
cough for years that has not changed. The pt also complains of
subjective and objective fevers, up to 101 at rehab 2 days ago.
Denies diarrhea but describes some increased abdominal
distention. No nausea, vomiting, neck pain, photophobia,
increasing confusion, dysuria, urinary frequency.
.
In the ED, Tm 103.4, BP 89/42, HR 126, RR 27, O2 sat 98% RA.
Labs notable for WBC 10.5 without bands, Hct 32.2 (prior
baseline mid to upper 20s), Cr 0.9, CE neg X 1, and lactate 1.5.
EKG with sinus tachycardia and no signs of right sided heart
strain. CXR with RLL infiltrate. Chest CTA preliminarily read as
extensive right sided PE with RLL infiltrate possibly concerning
for infarcted lung. She was started on heparin gtt with bolus,
given Vancomycin 1 gm IV X 1, Cefepime 1 gm IV X 1, and
acetaminophen 1 gm po X 1. Admitted to [**Hospital Unit Name 153**] for further care.
.
ROS as above. Otherwise notable for some increased fatigue.
Denies myalgias, sore throat, recent travel. Has been in rehab
for past month.
Past Medical History:
-h/o C. diff colitis
-h/o MSSA PNA
-AF/AT
-COPD
-diastolic CHF, EF 55%
-Osteoarthritis
-H/o myocarditis in [**2137**] with EF 20-25% at that time, cath
negative
-Hyperlipidemia
-Peripheral artery disease
-HTN
-Migraine HA
-Chronic eosinophilic lung disease (chronic eosinophilic
pneumonia or Churg-[**Doctor Last Name 3532**] syndrome)
-Hypoalbuminemia
-History of angioneurotic edema on [**Last Name (un) **] therapy
Social History:
Pt has a previous 40 pack-year history of smoking (stopped 25
yrs ago). She does not drink alcohol and denies other drug use.
She lives with her husband and has three grown children.
Family History:
[**Name (NI) 1094**] mother's side notable for "extensive" heart disease
(several of her family members died from this); pt's father died
of "cancer of the spleen." No history of diabetes or stroke.
Physical Exam:
98.7 127 85/42 16 96% 2L NC
Gen - elderly female in NAD, speeaking in full sentences without
significant difficulty
HEENT - sclerae anicteric, dry MM, OP clear, JVD not distended,
no LAD appreciated
CV - tachycardic, nl s1/s2, no m/r/g appreciated
Lungs - fair air mvmt b/l, but otherwise CTA b/l without w/r/r
Abd - Soft, moderate distention, normoactive BS, no masses
Ext - no LE edema, WWP, cap refill < 2 sec
Neuro - AAO X 3
Pertinent Results:
[**Hospital Unit Name 153**] labs on admission:
[**2141-7-18**] 12:15PM BLOOD WBC-10.5 RBC-3.79* Hgb-10.3* Hct-32.2*
MCV-85 MCH-27.1 MCHC-31.9 RDW-18.2* Plt Ct-322
[**2141-7-18**] 12:15PM BLOOD Neuts-84.5* Lymphs-9.3* Monos-4.6 Eos-1.3
Baso-0.2
[**2141-7-18**] 12:45PM BLOOD PT-14.1* PTT-22.9 INR(PT)-1.2*
[**2141-7-18**] 12:15PM BLOOD Glucose-115* UreaN-12 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
[**2141-7-18**] 12:15PM BLOOD CK(CPK)-26
[**2141-7-19**] 04:10AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.1
[**2141-7-18**] 12:37PM BLOOD Lactate-1.5
.
Troponin:
[**2141-7-18**] 12:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-7-18**] 08:16PM BLOOD CK-MB-3 cTropnT-0.01
[**2141-7-19**] 04:10AM BLOOD CK-MB-3 cTropnT-<0.01
.
Labs on day of transfer to hospital floor:
[**2141-7-20**] 02:55AM BLOOD WBC-8.3 RBC-2.88* Hgb-8.1* Hct-25.0*
MCV-87 MCH-28.2 MCHC-32.5 RDW-18.0* Plt Ct-293
[**2141-7-20**] 02:55AM BLOOD Neuts-77.2* Lymphs-17.6* Monos-4.6
Eos-0.5 Baso-0.1
[**2141-7-20**] 02:55AM BLOOD Glucose-101 UreaN-9 Creat-0.6 Na-143
K-3.2* Cl-111* HCO3-22 AnGap-13
.
Imaging:
CXR [**2141-7-18**] 12:44:
1. Persistent left pleural effusion.
2. Right basilar opacification likely atelectasis.
3. Upper lobe lucency suggests emphysema. .
.
CTA chest [**2141-7-18**]:
1. Extensive PE on the right.
2. Airspace opacification in the right lower lobe, concerning
for pulmonary infarction, but superinfection, aspiration and/or
partial collapse cannot be excluded. Opacities at the left lung
base could be related to aspiration, atelectasis or small
infarct.
3. Multiple borderline enlarged likely reactive mediastinal
lymph nodes.
4. Emphysema.
5. Multiple bilateral calcified granuloma with several
noncalcified
micronodules.
.
LENI:
1. Nonocclusive thrombus in the right common femoral vein
extending into the greater saphenous and profunda femoris vein.
2. Left peroneal vein thrombosis.
.
ECHO: The left atrium is elongated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**2-17**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2140-11-4**] ,
the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] [**Doctor Last Name **] has decreased. The LV and RV look
similar.
.
CXR: Hyperlucency in the upper lobes corresponded to
the known emphysema. The opacity in the left lower lung
corresponds to a
combination of atelectasis and ground-glass opacity demonstrated
in the recent CAT scan. The ground-glass opacity could be due to
perfusion abnormality distal to the pulmonary embolism. Mild
cardiomegaly. Improvement of the atelectasis in the left lung
base. Mediastinal contours appear remarkable.
.
Micro data:
URINE CULTURE (Final [**2141-7-19**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION.
.
Blood culture: ngtd
Brief Hospital Course:
81 yo F with a h/o eosinophilic lung disease, COPD, diastolic
CHF, recent admission for MSSA and pan-sensitive pseudomonas PNA
who presents with fevers and right-sided pleuritic chest pain,
found to have extensive right-sided PE and possible RLL
pneumonia on chest CT.
<br>
#)PE- The patient was admitted to the [**Hospital Unit Name 153**] after being
transported to the [**Hospital1 18**] ED via EMS from her rehab facility.
She had been quite immobile at that facility and it appears that
she was not receiving DVT prophylaxis with subcutaneous heparin.
CTA revealed large right-sided PE and LENIs revealed
significant clot burden in bilateral lower extremities. She was
given a heparin bolus and started on a heparin drip. She was
initially hemodynamically unstable with BP 89/42, P 126 and RR
27, however quickly improved with supplemental O2, heparin and
morphine. She was transfered to the [**Hospital Unit Name 153**]. She was initially
managed with a heparin drip, and was subsequently transitioned
to lovenox bridge to therapeutic coumadin. Neither TPA nor
surgical intervention were required. Therapeutic lovenox was
continued for 48 hours after INR was greater than 2. Goal INR
is [**3-21**].
-***Patient will follow up with coumadin clinic via [**Company 191**] - with
instructions to be seen this week with INR check by VNA service
[**7-25**] - pt noted with mild blood tinged sputum at time of
discharge - noted multiple chronic pulmonary processes, with
recent PNA - needs to be monitored closely at home as given
strict instructions -
(note called PCP office [**Name Initial (PRE) **] unable to get through (hold for 25min)
- family instructed to call/stop by office as with pt during
encounters last day)) - able to make appointment with PCP RN on
[**Name9 (PRE) 2974**] [**2141-7-28**]
-*****Note INR up at 3.8 day of discharge - pt instructed to
hold coumadin tonight - will be restarted at 2.5mg tomorrow
(unless INR still >3.0 as VNA will check TOMORROW and report to
PCP's office
-instructed pt and family of strict fall precautions
<br>
#)Fever- The patient's initial temperature on arrival to the ED
was 103.4 therefore an additional infectious process in the
lungs was considered possible. CT of the chest revealed a
possible area of consolidation in the RLL in the same region as
her previous pneumonia. She received 1 gm IV vancomycin and 1
gm cefapime IV in the ED. Her coverage was changed in IV vanc
and cipro in the [**Hospital Unit Name 153**] to cover for possible
healthcare-associated PNA in the setting of the patient's
penicillin allergy. She was afebrile throughout her time in the
[**Hospital Unit Name 153**] and antibiotics were discontinued on hospital day 2 when
she had been afebrile for 24 hours and it was felt that her
temperature, though somewhat high for a PE, was most likely due
to the PE and not an infectious process. A urinary tract
infection was considered possible with a borderline UA, and she
was started on Macrobid. This was discontinued after 4 days
when urine cultures were negative. Pt afebrile and stable from
infectious perspective at time of discharge.
<br>
#)Hypotension- This was likely primarily cardiogenic in etiology
given the patient's large PE. A possible septic component was
considered and the patient was appropriately covered with
antibiotics. A possible distributive component (due to adrenal
insufficiency in this patient who takes 5mg hydrocortisone
daily) was also considered and she was given a
"mini-stress-dose" of steroids (50mg q8hr for one day). Her
hemodynamics improved with fluid resuscitation with boluses prn
to maintain SBP >90 and UOP >30 cc/hr. She returned to low dose
prednisone without incident.
<br>
#)ST depression- The patient was found to have minimal ST
depression (<1mm) in leads V4-V6 in the ED. Cardiac enzymes
were negative x3. These EKG changes were therefore felt to be
related to demand in the setting of PE, not ACS. Pt CP free
without further issues at time of discharge with cont treatment
of PE as above.
<br>
#)COPD- The patient did not report increased SOB or cough,
however her O2 requirement increased to 2L NC likely due to PE.
She was given morphine for her chest pain with the added benefit
of decreasing air hunger. She was started on her home COPD
medications. O2 sats remained stable. Noted with ambulatory o2
sat of 93% on [**7-24**].
<br>
# diastolic CHF - pt mildly hypervolemic - noted Na 146
yesterday (mild hypervolemic hypernatremia. [**Name (NI) 9503**] pt's
home lasix dose - given pt will be in-house till [**7-25**] due to
refusal of discharge - repeated Na check - was 140 at time of
d/c - pt cont on 20mg lasix (Rx given to pt).
<br>
#)h/o A fib- The patient was in afib on presentation in the
setting of fever, tachycardia and hypotension. She was in NSR
throughout the remainder of her hospitalization. Note atenolol
was d/c due to hypotension - BP stable and HR controlled at time
of discharge - ******PCP to [**Name Initial (PRE) **]/u and re-start as appropriate.
<br>
#)Eosinophilic lung disease- Not an active issue during this
admission. She was restarted on her maintenance steroid dose
after receiving a mini-stress dose on hospital day 1. Note may
be contributing to sputum sx at time of dischage - **close
survelliance as above.
<br>
# Anemia, chronic disease - Hct controlled and stable at 27.9 at
time of d/c.
<br>
# Headache - ?migraines - pt states has had chronic HA in past -
only in early AM - only occasionally requirement pain relief
from medications - *(usually 1/week or so) - here regular
tylonol didn't give complete relief - positive relief with T3 -
gave 10 tabs at time of d/c - if needing qam - to contact
provider for further [**Name9 (PRE) **].
<br>
The patient was reluctant to go to [**Hospital 3058**] rehab, and
physical therapy was consulted and worked with the patient
during the hospitalization - with evaluation recs for HOME PT.
Pt was medically stable for discharge on [**7-24**] - however pt
refusing to go as she was not mentally prepared to leave on this
day - counciled extensively- on risks of hospital infections etc
and medical stability - pt agreed but still refused to go, PT/RN
counciled, and finally case-management discussed - pt cont to
refuse - will as a result was monitored overnight - no events
except noted INR elevation as noted above.
Medications on Admission:
Simvastatin 40 mg daily
Salmeterol/Fluticasone 1 puff [**Hospital1 **]
Tiotropium 1 puff daily
Aspirin 81 mg daily
Trazodone 25 mg qhs prn
Lorazepam 0.5 mg po q8h prn
Benzonatate 100 mg tid
Codeine-Guaifenesin 10 ml q4h prn
Metoprolol Tartrate 12.5 mg daily
Furosemide 20 mg daily
Prednisone 5 mg daily
Esomeprazole 40 mg daily
Montelukast 10 mg PO qhs
Gabapentin 100 mg PO qhs
Ergocalciferol 50,000 units q7d
Potussium tablet (unknown brand, dose) PO daily
Calcium carbonate 1250 mg PO tid
Saccharomyces Boulardii 250 mg PO bid
Docusate 100mg PO bid prn
Acetaminophen 650 mg q4hr prn
Acetaminophen/Butalbital/Caffeine po q6hr prn
Albuterol/Ipratropium 3ml neb qid prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily): can resume your own simvastatin instead.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): can
resume your own esomeprazole instead.
4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
5. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) ML Inhalation q4h prn () as needed for sob, wheezing.
6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
[**Hospital1 **]:*qs qs* Refills:*0*
7. Gabapentin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
8. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
12. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
13. Benzonatate 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day) as needed for cough.
[**Hospital1 **]:*50 Capsule(s)* Refills:*0*
14. Acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
15. Florastor 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO bid ().
16. [**Hospital **] Rehab
Pulmonary Rehab - evaluation and treatment
17. Warfarin 2.5 mg Tablet [**Hospital **]: One (1) Tablet PO QDAILY at
16:00.
[**Hospital **]:*30 Tablet(s)* Refills:*0*
18. Acetaminophen-Codeine 300-15 mg Tablet [**Hospital **]: Two (2) Tablet
PO every six (6) hours as needed for pain: only take for HA in
am - if needing more than just in am for more than 2 days - call
provider for further recommendations.
[**Hospital **]:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
# Pulmonary embolism
# LE DVT's
# COPD
# eosinophilic lung disease
# deconditioning
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2141-7-25**]
2:00
Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB)
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2141-7-31**] 10:45
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-9-12**] 9:40
.
You need to have your INR followed closely via your PCP's
office. You will be scheduled for this appointment, or please
call [**Telephone/Fax (1) 250**] to make this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2141-7-25**]
|
[
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"443.9",
"276.0",
"401.9",
"415.19",
"458.9",
"285.29",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16537, 16588
|
7193, 13569
|
347, 353
|
16715, 16724
|
3498, 3532
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|
381, 2173
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|
2631, 2817
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
518
| 153,168
|
44018
|
Discharge summary
|
report
|
Admission Date: [**2109-7-7**] Discharge Date: [**2109-7-9**]
Date of Birth: [**2062-9-18**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
High Blood Pressure
Major Surgical or Invasive Procedure:
Hemodialysis on [**2109-7-8**]
History of Present Illness:
46 yo M with h/o DMI, ESRD on HD, HIV(VL <50, CD4 393 [**2-13**]),
recently diagnosed PE, and multiple ED admissions for HTN
emergency, nausea, and vomiting who presented to [**Hospital1 18**] [**2109-7-6**]
with acute onset SOB, nausea, and vomiting. Patient had been in
his usual state of health prior and went to usual HD session
[**2109-7-5**] where reportedly had the standard amount of UF taken
off. That evening, he felt acutely SOB with nausea and
subsequent vomiting. He denied any associated chest pain,
palpitations, lightheadedness, focal numbness or weakness, or
changes in vision although he did note headache at that time.
.
Of note, he last took his po meds yesterday afternoon but has
since been unable to take po meds due to nausea and vomiting. Of
note, he has been admitted with similar symptoms 5 times since
[**3-/2109**], three times in last month prior. On recent admission was
found to have chronic PEs that are of unclear relation, but was
started on anticoagulation. On his most recent admission
[**Date range (3) 94521**], he was admitted to the ICU and was initially
managed with Nipride gtt which was transitioned to NTG gtt. He
was then transitioned to his oral regimen and was discharged
with the addition of clonidine patch. He refused to stay until
his INR was therapeutic.
.
In the ED, his initial vitals were signifanct for SBP in 230s.
He was given lopressor 5 IV without any change in BP.
Subsequently given hydralazine 10 IV X 1 followed by hydralazine
20 IV X 2 with minimal improvement in blood pressure. CTA was
performed for c/o SOB which showed new PEs in RLL but decrease
in size of other chronic PEs.
He was started on a nitro gtt and was transferred to the floor.
.
On the floor, patient continued to complain of HA and nausea.
However, he was able to take valsartan 160 mg po x1. He felt his
SOB was improved. He was continued on the nitro gtt with SBPs
remaining in the 200s. Renal was consulted but noted that
patient was at his new dry weight and did not feel that there
was significant volume contribution to current presentation. He
received labetolol 20 mg IV x 1 with response in his SBP to
170s. However, required a second dose for return of SBPs to
200s with again drop to 170s. He continued to complain of mild
HA and nausea but but otherwise denied CP, SOB, lightheadedness,
numbness, tingling, vision changes, abdominal pain. He was then
transferred to the ICU for further management.
Past Medical History:
- Type 1 diabetes
- HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**]
VL <50, CD4 393 [**2-13**])
- ESRD previously on HD, attempted on PD
on transplant list (clinical study for HIV/solid organ
transplant)
- Malignant Hypertension
- hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem
- Hx schistosomiasis
- Restless leg syndrome
- Peripheral neuropathy on gabapentin
- S/p cholecystectomy
- s/p R nephrectomy in [**2092**] secondary renal nephrolithiasis
Social History:
Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**].
Works in support services for a law firm. Denies any alcohol or
IV drug use. Quit smoking last year; previous 30 pack-year
history.
Family History:
Non-contributory.
Physical Exam:
T: 99.6 BP: 166/80 HR: 81 RR: 17 O2 98% 2LNC
Gen: drowsy but easily arousible. NAD
HEENT: No conjunctival pallor. MMM. OP clear. Mild left ptosis
NECK: Supple, No LAD, JVP low. R IJ line CDI
CV: RRR. II/VI sys murmur
LUNGS: bibasilar rales.
ABD: NABS. Soft, NT, ND. No HSM. Large right flank hernia
secondary to nephrectomy unchanged per patient
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 intact except for slight L
ptosis and L lower facial droop. Preserved sensation throughout.
5/5 strength throughout.
Pertinent Results:
[**2109-7-7**] 03:13PM GLUCOSE-107* UREA N-45* CREAT-10.3*#
SODIUM-136 POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-27 ANION GAP-19
[**2109-7-7**] 03:13PM CALCIUM-9.8 PHOSPHATE-7.6* MAGNESIUM-2.6
[**2109-7-7**] 03:13PM TSH-3.7
[**2109-7-7**] 03:13PM WBC-6.4 RBC-2.61* HGB-9.8* HCT-28.2* MCV-108*
MCH-37.4* MCHC-34.6 RDW-15.4
[**2109-7-7**] 03:13PM PLT COUNT-253
[**2109-7-7**] 03:13PM PT-14.9* PTT-90.9* INR(PT)-1.3*
[**2109-7-6**] 11:45PM GLUCOSE-74 UREA N-38* CREAT-8.7*# SODIUM-137
POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-29 ANION GAP-17
[**2109-7-6**] 11:45PM estGFR-Using this
[**2109-7-6**] 11:45PM CK(CPK)-72
[**2109-7-6**] 11:45PM CK-MB-4 cTropnT-0.36*
[**2109-7-6**] 11:45PM WBC-6.8 RBC-2.82* HGB-10.2* HCT-29.6*
MCV-105* MCH-36.1* MCHC-34.3 RDW-16.1*
[**2109-7-6**] 11:45PM NEUTS-64.3 LYMPHS-23.7 MONOS-6.5 EOS-5.2*
BASOS-0.3
[**2109-7-6**] 11:45PM PT-14.7* PTT-29.7 INR(PT)-1.3*
Brief Hospital Course:
The patient was brought to the ICU on Nitro and Labetalol drips
for hypertension, and heparin drip for new PE. The Nitro drip
was weaned without difficulty. The Labetalol drip was weaned
within the first 24 hours of admission after giving the patient
his po blood pressure medications including po propranolol
100mg. The patient received hemodialysis on the morning of
[**2109-7-8**]. On the morning of [**2109-7-8**] the patient's headache and
nausea had resolved and he advanced to a regular diet. He had no
complaints and was observed overnight for maintenance of blood
pressure. he will continue coumadin for his PE and follow-up as
an outpatient with his regular doctors.
Medications on Admission:
Lovenox 60 mg SQ daily (per pt, d/c'd by [**Name8 (MD) 3782**] MD)
Coumadin 5 mg qhs
Gabapentin 100 mg tid
Lanthanum 2 gm tid
Cinacalcet 60 mg daily
Lisinopril 20 mg daily
Atenolol 100 mg daily
Valsartan 160 mg [**Hospital1 **]
Prochlorperazine 10 mg q6h prn
Tenofovir Disoproxil Fumarate 300 mg qSat
Ritonavir 100 mg daily
Atazanavir 300 mg daily
Stavudine 20 mg daily
Lamivudine 10 mg/mL Solution daily
Metoclopramide 10 mg Tablet qidachs
Albuterol/Ipratropium neb q6h prn
Clonidine 0.2 mg [**Hospital1 **]
Nifedipine 90 mg daily
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: Three (3) Tablets PO HS (at
bedtime).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day). Capsule(s)
3. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day).
4. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Prochlorperazine 10 mg Tablet Sig: Two (2) Tablet PO every
six (6) hours as needed for nausea.
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QSAT (every Saturday).
10. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
12. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
13. Lamivudine 10 mg/mL Solution Sig: One (1) PO DAILY (Daily).
14. Metoclopramide 10 mg IV Q6H
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
16. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertensive Urgency
2. Pulmonary embolism
.
Human Immunodeficiency Virus
diabetes
hypertension
End Stage Renal Disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with extremely high blood pressure and new
clots to your lungs. Your blood pressure is now under better
control and are now ready for discharge. YOU WILL NEED TO HAVE
YOUR INR DRAWN TOMORROW AT DIALYSIS TO CHECK YOUR COUMADIN LEVEL
!
Please take your medications as prescribed.
.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 4026**] at [**Telephone/Fax (1) 250**] to schedule an [**Telephone/Fax (1) 648**]
within the next month. YOU WILL NEED TO HAVE YOUR INR DRAWN
TOMORROW AT DIALYSIS TO CHECK YOUR COUMADIN LEVEL !
.
Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2109-7-25**]
9:40
.
Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2109-7-25**] 10:45
|
[
"428.0",
"250.41",
"536.3",
"250.61",
"403.91",
"042",
"415.19",
"333.94",
"583.81",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7695, 7701
|
5121, 5802
|
288, 321
|
7868, 7877
|
4192, 5098
|
8227, 8751
|
3565, 3584
|
6384, 7672
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7722, 7847
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5828, 6361
|
7901, 8204
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3599, 4173
|
229, 250
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349, 2805
|
2827, 3310
|
3326, 3549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,931
| 139,565
|
3365
|
Discharge summary
|
report
|
Admission Date: [**2123-12-6**] Discharge Date: [**2124-1-3**]
Date of Birth: [**2070-12-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Altered mental status/ failure to thrive
Major Surgical or Invasive Procedure:
Lumbar puncture x 4
History of Present Illness:
Note: history obtained from mother as patient unable to provide
52 y/oM with hx of HIV (CD4 in [**2122**] 598), HCV, HBV who presents
with acute on chronic mental status changes over the past
several days. As per patient's mother, he has been "wasting
away" with decrease in oral intake and progressive forgetfulness
for the last 2-3 months. Recently, mental status has
deteriorated significantly, with lethargy, and refusal to eat/
drink "besides alcohol". As per family members, the patient also
complained of intermittent abdominal pain but otherwise denied
fevers, cough, shortness of breath, headache or [**Last Name **] problem.
Of note, patient was diagnosed with a pancreatic mass/ cancer 1
year prior at [**Hospital1 2177**].
In ED, initial VS: 98.0 124 115/83 18 99% on RA; FS 145. He was
awake and alert, in generally appropriate but with tangential
speech/ talking to people who were not in the room. Head CT
showed prior L. eye enucleation but was negative for acute
process. CXR showed subtle opacity in RUL. EKG showed new TWI in
v3-v6 (V4-5 inverted in [**2121**]). LP showed meningitis with 960
WBCs, 62% PMNs, with protein of 292 and glucose of 43. Received
vanco/solumedrol/fluconazole, acyclovir and ceftriaxone prior to
transfer to the floor.
On transfer to floor, VS: HR 104, BP 124/79, RR 22 sat 98% on
RA. No specific complaints but on questioning does admit to neck
pain and abdominal discomfort.
Past Medical History:
1. HIV not on HAART therapy, CD4 598 in [**2122**].
2. Hepatitis C, chronic
3. Seizure disorder.
4. Intravenous drug abuse/heroin
5. Chronic pancreatitis
6. Hep B carrier
7. Hx vertebral osteomyelitis
8. DJD and sciatica
9. Enucleation left eye
10. Latent tuberculosis
11. ETOH abuse
12. tobacco user
13. pancreatic mass
14. insulin dependent DM
Social History:
Homeless; but currenly staying with brother. +MSM but not
sexually active at the time. +hx alcohol use and prior IVDU
(heroin), currently on methadone. Drinks [**1-15**] gallon of vodka per
day: with history of seizures and DTs with withdrawal. Smokes 1
ppd. Has a hx DTs/withdrawal seizures.
Family History:
Noncontributory
Physical Exam:
Vitals: HR 104, BP 124/79, RR 22 sat 98% on RA.
General: dishevelled, cachetic gentleman lying with legs curled
up; Alert + oriented x 2; in NAD
HEENT: scleral icterus. Left eye enucleation. Right eye:
reactive to light. dry oral mucosa, oropharynx clear
Neck: JVP not elevated, no LAD palpable; +nuchal rigidity;
well-healed scar
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, generalized tenderness to palpation,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact. No nystagmus. Strength:
difficult to assess [**2-15**] mental status but > [**3-18**] on all
extremities
Pertinent Results:
[**2123-12-5**] 11:10PM PLT COUNT-165
[**2123-12-5**] 11:10PM NEUTS-72.0* LYMPHS-21.6 MONOS-5.6 EOS-0.4
BASOS-0.4
[**2123-12-5**] 11:10PM WBC-6.4# RBC-3.37* HGB-11.9* HCT-34.8*
MCV-103* MCH-35.4* MCHC-34.3 RDW-14.7
[**2123-12-5**] 11:10PM ASA-NEG ETHANOL-15* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-12-5**] 11:10PM HAPTOGLOB-235*
[**2123-12-5**] 11:10PM CALCIUM-9.6 PHOSPHATE-3.6 MAGNESIUM-1.4*
[**2123-12-5**] 11:10PM CK-MB-NotDone cTropnT-<0.01
[**2123-12-5**] 11:10PM LIPASE-114*
[**2123-12-5**] 11:10PM ALT(SGPT)-47* AST(SGOT)-190* LD(LDH)-554*
CK(CPK)-57 ALK PHOS-56 TOT BILI-2.7* DIR BILI-0.9* INDIR BIL-1.8
[**2123-12-5**] 11:10PM GLUCOSE-116* UREA N-22* CREAT-0.9 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-17* ANION GAP-20
[**2123-12-5**] 11:49PM PT-17.7* PTT-32.1 INR(PT)-1.6*
[**2123-12-6**] 03:45AM AMMONIA-25
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-360 RBC-190*
POLYS-4 LYMPHS-69 MONOS-0 MACROPHAG-3 OTHER-24
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-960 RBC-30*
POLYS-62 LYMPHS-5 MONOS-0 ATYPS-11 MACROPHAG-9 OTHER-13
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-292*
GLUCOSE-43 LD(LDH)-130
[**2123-12-6**] 07:08PM URINE OSMOLAL-687
[**2123-12-6**] 07:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
IMAGING:
MRI head [**2123-12-9**]:
1. Leptomeningeal enhancement along pons and cerebellum
suggestive of meningeal inflammation/infection. This is a
non-specific finding and correlate with CSF analyses results for
further assessment.
2. Parenchymal volume loss which may be related to the patient's
underlying HIV or alcohol use. T2 and FLAIR hyperintense white
matter foci are a nonspecific finding.
MRI spine [**2123-12-9**]:
1. Endplate destruction with near obliteration of the
intervertebral disc
space at L4-5, which may represent the sequela of prior
infection given the patient's history. There are no findings
specific for ongoing infection at this time, with no evidence of
surrounding edema, enhancement, or evidence of epidural
involvement.
2. No evidence of spinal canal or neural foraminal narrowing in
the cervical, thoracic, or lumbar spine. Linear enhancement
along the ventral aspect of the cord likely represents a vessel,
but is difficult to fully characterize given the large field of
view and decreased resolution.
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL: [**2123-12-10**]
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Normal liver Doppler. Small cyst in the left liver lobe.
3. Cholelithiasis and sludge within the gallbladder, with mild
wall
thickening of the gallbladder wall, an unchanged finding that
could suggest HIV cholangiopathy or relate to chronic liver
disease.
4. Small amount of ascites.
5. Multiple calcifications in the pancreas in keeping with
chronic
pancreatitis.
MRI ([**2123-12-28**])-
IMPRESSION:
1. New acute infarcts in the cerebellar hemispheres on both
sides, the right middle cerebellar peduncle and the inferior
cerebellar peduncle with mildly increased enhancement on the
surface of the pons and the right temporal lobe, related to
leptomeningeal enhancement.
RUQ ([**2123-12-28**])-
IMPRESSION:
1. Coarsened hepatic architecture with no focal solid mass
identified.
Unchanged small left hepatic cyst.
2. Trace of ascites in the perihepatic space, but no pocket
suitable for
paracentesis could be located in the lower quadrants.
3. Patent hepatic vasculature.
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-360 RBC-190*
Polys-4 Lymphs-69 Monos-0 Macroph-3 Other-24
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-960 RBC-30*
Polys-62 Lymphs-5 Monos-0 Atyps-11 Macroph-9 Other-13
[**2123-12-24**] 02:19PM CEREBROSPINAL FLUID (CSF) WBC-95 RBC-1550*
Polys-72 Lymphs-27 Monos-1
[**2123-12-24**] 02:19PM CEREBROSPINAL FLUID (CSF) WBC-40 RBC-810*
Polys-76 Lymphs-19 Monos-5
[**2123-12-6**] 05:30AM CEREBROSPINAL FLUID (CSF) TotProt-292*
Glucose-43 LD(LDH)-130
[**2123-12-24**] 02:19PM CEREBROSPINAL FLUID (CSF) TotProt-1290*
Glucose-34
[**2123-12-31**] 03:33AM BLOOD WBC-6.5 RBC-2.14* Hgb-7.3* Hct-22.8*
MCV-107* MCH-34.3* MCHC-32.2 RDW-23.6* Plt Ct-60*
[**2123-12-30**] 04:19AM BLOOD PT-25.5* PTT-46.9* INR(PT)-2.5*
[**2123-12-30**] 04:19AM BLOOD Plt Ct-61*
[**2123-12-10**] 12:06PM BLOOD ESR-88*
[**2123-12-11**] 06:08AM BLOOD Parst S-NEGATIVE
[**2123-12-30**] 04:19AM BLOOD Glucose-104 UreaN-11 Creat-0.9 Na-144
K-3.8 Cl-121* HCO3-15* AnGap-12
[**2123-12-31**] 03:33AM BLOOD Glucose-99 UreaN-14 Creat-0.9 Na-143
K-3.4 Cl-120* HCO3-17* AnGap-9
[**2123-12-30**] 04:19AM BLOOD ALT-42* AST-61* LD(LDH)-217 AlkPhos-82
TotBili-2.6*
[**2123-12-31**] 03:33AM BLOOD ALT-35 AST-56* LD(LDH)-237 AlkPhos-78
TotBili-2.7*
[**2123-12-31**] 03:33AM BLOOD Albumin-2.3* Calcium-7.8* Phos-3.0 Mg-1.6
[**2123-12-28**] 03:47AM BLOOD Vanco-19.6
[**2123-12-30**] 11:20AM BLOOD Type-[**Last Name (un) **] O2 Flow-5 pO2-47* pCO2-30*
pH-7.36 calTCO2-18* Base XS--6 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2123-12-29**] 03:18AM BLOOD Lactate-2.4*
Brief Hospital Course:
# Altered mental status: Patient admitted with acute on chronic
AMS. Initial concern was for meningitis given presentation and
risk factors. Mental status on admission- opened eyes,
responded to questions (full sentences), and follow commands.
LP showed purulent CSF with no culture growth. He was started
vanc and ceftriaxone for empiric coverage. Patient was 100.0 in
the ED and remained afebrile throughout his [**Last Name (un) 10128**]. ID was
consulted. Patient underwent head CT which initially showed no
pathology. He was pan-cultured with no growth. Underwent
repeat LP to send off AFB, HSV PCR, VZV PCR- all of which were
negative. Crypto, RPR, CSF-FTA ABS, CSF HIV VL, CMV were all
negative. Also performed AFB concentrated smear/culture and TB
PCR are all negative to date. On [**12-11**], patient noted to have
new left-sided paralysis in arm, leg, left face. Neuro
consulted and recommended STAT CT head, which was negative, as
well as MRI. MRI showed acute pontine infarct at the level of
his leptomeningeal disease. Most likely, it was secondary to
inflammation. He was not a candidate for TPA. This raised
concern for TB meningitis given cranial nerve palsy, negative
CSF cultures, and risk factors (HIV, latent TB- untreated, etc).
This was discussed with ID and they recommended deferred
treating given atypical appearance on MRI. Discussed patient
with our attending and initiated empiric treatment for TB
meningitis given high mortality for untreated TB. Patient was
started on rifampin, ethambutol, INH and pyrazinamide. Mental
status at this time had worsened. Patient less responsive and
spoke in mumbled one-two words sentences. EBV PCR returned
positive so LP was repeated for flow cytometry given concern for
CNS lymphoma. Patient became tachypneic on AM of [**12-18**] and went
into respiratory distress leading to a code blue. He was
transferred to the MICU on [**12-18**]. While in the MICU, he was
continued on antibiotics despite negative cultures. CXR showed
new left consolidation with left retrocardiac opacity and
increased left pleural effusion (concern for pneumonia, per
radiology) so patient treated for VAP. Given transaminitis and
elevated t-bili, TB medications were discontinued per Liver team
recs. Patient transferred back to the floor after respiratory
status was stabilized but went back to the MICU after becoming
tachypneic to the 50's with accompanying desaturations. He was
restarted on TB medications given negative work-up to date.
Mental status remained at level prior to MICU transfer despite
active treatment. Work-up (including flow cytometry) was
negative. Repeat MRI showed new bilateral cerebellar infarcts.
Palliative care was consulted and patient was made DNR/DNI-
eventually was transitioned to CMO. Patient expired on
[**2124-1-3**]. Family refused autopsy.
# Tachycardia/tachypneic: Initial concern was for PE. CTA and
cardiac enzymes were negative. Patient was maintained on IV
fluids and tube feeds. Patient remained tachycardic throughout
course. Potential etiologies include PE, infection, or
centrally mediated process in patient with known leptomeningeal
inflammation and pontine CVA. Patient thought to have
mucus-plugged leading to acute desaturations requiring MICU
transfers.
# Hyponatremia: Patient became hyponatremic to 119 during
course. Thought to be secondary to SIADH. Renal consulted,
lytes sent. Patient started on salt tabs and fluid restricted to
1L per day. Last sodium value was 143.
# Cirrhosis: Patient developed worsening synthetic function
over the course of his hospital stay with progressively
worsening hyperbilirubinemia. INR also trended up. Hepatology
consulted. Underwent RUQ- showed coarsened hepatic architecture
with no focal solid mass identified. There was an unchanged
small left hepatic cyst with trace of ascities in the
perihepatic space. Patent hepatic vasculature. He was given
lactulose regularly given concern for hepatic encephatology.
Monitored LFT's- trended down over remainder of hospital course.
TB medications were resumed after remainder of work-up was
negative without another bump in LFTs. T-bili also trended
down.
# HIV- Patient has never been treated. Last CD4 was >600 with
undetecable viral load. Thought to be elite controller.
# IDDM: HISS and accuchecks. Sugars under good control while
here.
Medications on Admission:
Acyclovir 400 mg IV Q8H
CefePIME 2 g IV Q8H
FoLIC Acid 1 mg PO/NG DAILY
Insulin SC (per Insulin Flowsheet)
Lactulose 30 mL PO/NG Q8H:PRN constipation
Multivitamins 1 TAB PO/NG DAILY
Vancomycin 1000 mg IV Q 12H
Vitamin D [**2114**] UNIT PO/NG DAILY
Discharge Disposition:
Expired
Discharge Diagnosis:
Meningitis, not otherwise specified
Completed by:[**2124-1-9**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,987
| 143,224
|
25274
|
Discharge summary
|
report
|
Admission Date: [**2202-12-19**] Discharge Date: [**2202-12-29**]
Date of Birth: [**2131-1-17**] Sex: M
Service: SURGERY
Allergies:
Ciprofloxacin / Levofloxacin / Fentanyl
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
RLE ischemia s/p failing bypass
Major Surgical or Invasive Procedure:
Right-sided femoral endarterectomy, redo right lower extremity
bypass, right femoral to above-knee popliteal artery bypass with
7 mm Dacron graft.
History of Present Illness:
Patient is a 71 year old male with a medical history significant
for PVD and DM2 who presents s/p right SFA-PT bypass in [**11-26**].
He now presents with a failing bypass graft demonstrated by
elevated flow velocities on duplex exam. He underwent an
angiography in [**9-29**] which showed a failing bypass graft with
potential for re-bypass with target in the above-knee popliteal
artery. He is now admitted for pre-op prior to OR in the
morning. Of note, the patient complains of RLE pain in the toes
and dorsum of foot for "a couple of days." He reports a wound
present on his toe that his wife has been helping him bandage
daily. He is unable to quantify the length of time this wound
has been
present. Currently denies fevers and chills. Only reports a
cough that has been presents for "a couple of days."
Past Medical History:
PMH: Hypertension, hyperlipidemia, DM2 w/ neuropathy, PVD, Hx of
prior GIB with erosive esophagitis and ? AVM??????s of the colon,
GERD, BPH, CRI, Hx of MRSA, anxiety, depression
PSH: CABG [**2194**] @ [**Hospital1 2025**] (LIMA to LAD, SVG to PDA), appendectomy,
bladder cystoscopy for non cancerous bladder growths, L SFA-PT
bypass [**7-27**], R SFA-PT [**11-26**], redo L fem-[**Doctor Last Name **] bypass [**2-25**], L BKA
[**2-25**], removal infected L graft [**5-28**], L BKA stump revision [**9-27**],
L AKA [**1-29**], angio [**9-29**]
Social History:
The patient is a former smoker. He has not smoked for 1 year.
He denies alcohol. He is married and lives with his wife.
Family History:
N/C
Physical Exam:
At admission:
VS: T 98.9 HR 98 BP 150/80 RR 24 SpO2 97%2LNC
General: awake and alert
CV: RRR
Lungs: coarse BS bilaterally
Abdomen: soft, obese, NT/ND, NABS
Ext: RLE w/ wet gangrene on tip of 3rd digit, blanching of all 5
digits, rubor of dorsum of right foot without
induration/erythema, tenderness to palpation of all 5 digits and
with palpation of distal [**12-24**] of dorsum
Pulses:
Femoral Popliteal DP PT
R 1+ triphasic -- triphasic
L triphasic -- -- --
At discharge:
VS: Tm 99.6 Tc 98.1 HR 102 BP 142/78 RR 20 O2sat 98RA
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: soft, nt/nd
wound: c/d/i (dry gangrene on right 3rd toe, stable)
pulses: R fem palp, DP and PT dop
Pertinent Results:
[**2202-12-19**] 09:40PM BLOOD WBC-9.4# RBC-3.12* Hgb-9.9* Hct-28.9*
MCV-93 MCH-31.8 MCHC-34.3 RDW-14.1 Plt Ct-134*
[**2202-12-20**] 06:25AM BLOOD WBC-10.7 RBC-3.14* Hgb-10.0* Hct-29.8*
MCV-95 MCH-31.8 MCHC-33.5 RDW-14.1 Plt Ct-147*
[**2202-12-28**] 06:20AM BLOOD WBC-12.2* RBC-4.06* Hgb-12.5* Hct-35.8*
MCV-88 MCH-30.9 MCHC-34.9 RDW-14.6 Plt Ct-299
[**2202-12-29**] 06:25AM BLOOD WBC-11.0 RBC-3.96* Hgb-12.9* Hct-35.1*
MCV-89 MCH-32.5* MCHC-36.6* RDW-14.5 Plt Ct-269
[**2202-12-19**] 09:40PM BLOOD PT-12.2 PTT-24.6 INR(PT)-1.0
[**2202-12-20**] 12:19PM BLOOD PT-14.1* PTT-48.0* INR(PT)-1.2*
[**2202-12-26**] 03:32AM BLOOD PT-12.4 PTT-25.8 INR(PT)-1.0
[**2202-12-19**] 09:40PM BLOOD Glucose-135* UreaN-38* Creat-1.0 Na-135
K-5.7* Cl-105 HCO3-24 AnGap-12
[**2202-12-20**] 06:25AM BLOOD Glucose-201* UreaN-42* Creat-1.7* Na-136
K-6.5* Cl-104 HCO3-24 AnGap-15
[**2202-12-28**] 06:20AM BLOOD Glucose-163* UreaN-26* Creat-0.9 Na-143
K-3.3 Cl-106 HCO3-27 AnGap-13
[**2202-12-29**] 06:25AM BLOOD Glucose-188* UreaN-27* Creat-0.9 Na-145
K-3.2* Cl-108 HCO3-23 AnGap-17
[**2202-12-22**] 06:52AM BLOOD ALT-24 AST-40 LD(LDH)-404* CK(CPK)-600*
AlkPhos-79 Amylase-103* TotBili-0.6
[**2202-12-23**] 08:47PM BLOOD CK(CPK)-167
[**2202-12-20**] 12:19PM BLOOD CK-MB-7 cTropnT-0.07*
[**2202-12-20**] 04:11PM BLOOD CK-MB-7 cTropnT-0.09*
[**2202-12-20**] 11:39PM BLOOD CK-MB-7 cTropnT-0.10*
[**2202-12-21**] 08:54AM BLOOD CK-MB-6 cTropnT-0.07*
[**2202-12-22**] 06:52AM BLOOD CK-MB-6 cTropnT-0.16*
[**2202-12-22**] 03:01PM BLOOD CK-MB-5 cTropnT-0.10*
[**2202-12-23**] 01:15AM BLOOD CK-MB-5 cTropnT-0.11*
[**2202-12-23**] 08:47PM BLOOD CK-MB-4 cTropnT-0.05*
[**2202-12-19**] 09:40PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2
[**2202-12-20**] 06:25AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.2
[**2202-12-28**] 06:20AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.4
[**2202-12-29**] 06:25AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
Cultures:
[**12-19**] wound (R 3rd toe): no PMN, 3+GPC; MRSA
[**12-21**] sputum: no PMN, no micro, NG
Imaging:
[**12-22**] TTE: LA normal in size. LV cavity size, regional wall
motion normal. LV systolic function is hyperdynamic (EF>75%).
abnormal systolic flow contour at rest, but no LV outflow
obstruction. RV chamber size, free wall motion normal. number of
AV leaflets cannot be determined. No AS. No AR. MV valve
leaflets mildly thickened. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **] systolic
hypertension. no pericardial effusion.
[**12-24**] CT head: No acute intracranial abnormalities
Brief Hospital Course:
[**12-19**]: admit to floor for work up and evaluation for OR
[**12-20**]: to OR for right-sided femoral endarterectomy, redo right
lower extremity bypass, right femoral to above-knee popliteal
artery bypass with 7 mm Dacron graft. Intra-operative EF was
30%, elevated PA pressures so he was taken to the CVICU
intubated for further monitoring and recovery. He was placed on
pressor support for hypotension. Propofol gtt switched to
fent/versed gtt. Bicarb for acidosis. Lactates normal.
[**Date range (1) 20674**]: patient remained in ICU for post-op shock and
hypotension with acute systolic heart failure, on pressor
support and intubated. He was continued on vanc/zosyn. Placed on
insulin gtt for sugar control which was changed to sliding
scale. Diuresed as pressure supported. A dobhoff was placed for
tube feeding. He was extubated on [**12-25**]. The wound culture from
his foot grew out MRSA that was vanc and bactrim sensitive.
1/4-6: transferred to floor on [**12-26**]. ADAT. Seen and treated by
PT, who recommended rehab. He had confusion at times, but was
easily reoriented. His pressures were controlled with lopressor
and prn hydralzine. Antibiotics were continued. His foley was
taken out and he voided. His central line was removed. He was
tolerating a diet, and given supplements. [**Last Name (un) **] was consulte,
who modifed his sliding scale and medication regimen. He is
being discharged to rehab on PO bactrim, with follow up
instructions.
Medications on Admission:
[**Last Name (un) 1724**]: lisinopril 20', ASA81, vytorin [**9-/2174**]', Xanax 0.5'''prn,
amaryl 4mg", actos 45mg', celexa 60', omeprazole 40', proscar
5', neurontin 900''', atenolol 50' , flomax 0.4mg', metformin
1000"
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed.
6. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
14. Neurontin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold for sbp < 150.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
19. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day).
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
21. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
22. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
23. sliding scale
Breakfast: glargine 22U
SSI: humalog
br lunch supper bedtime
Glucose Insulin Dose
0-70 4 oz. Juice and 15 gm crackers 4 oz. Juice
71-80 0U 0U 0U 0U
81-130 8U 8U 8U 0U
131-180 10U 10U 10U 0U
181-230 12U 12U 12U 4U
231-280 14U 14U 14U 6U
281-330 16U 16U 16U 8U
331-380 18U 18U 18U 10U
381-400 20U 20U 20U 12U
> 400 Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right lower extremity ischemia, occluded bypass graft
Discharge Condition:
good, stable condition
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-25**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office: ([**Telephone/Fax (1) 1393**])
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] on [**1-14**], at 1:30PM at the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] clinic in Newburryport, [**Telephone/Fax (1) 43906**]
Please call the [**Last Name (un) **] Diabetes Center to set up a follow up
appointment - ([**Telephone/Fax (1) 3537**]
Please call you primary care physician to set up a follow up
appointment: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 34574**]
Completed by:[**2202-12-29**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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5343, 6813
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333, 482
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9838, 9863
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2830, 5273
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12199, 12613
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2067, 2604
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2618, 2811
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262, 295
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510, 1322
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5282, 5320
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1344, 1891
|
1907, 2031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,252
| 135,623
|
34356
|
Discharge summary
|
report
|
Admission Date: [**2130-5-23**] Discharge Date: [**2130-7-11**]
Date of Birth: [**2077-4-12**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Ciprofloxacin / Latex
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
[**2130-6-9**] Thoracotomy, placement of chest tube x 2. T5-T8
corpectomy.
[**2130-6-13**] PSIF T2-T11
History of Present Illness:
54 yoF w/ a h/o IDDM, CAD s/p CABG in [**2128**], CHF with an EF of
30% s/p ICD plcmt who initially presented to [**Hospital3 2568**] on [**4-24**]
with a complaint of R sided back pain (sudden onset, R mid back
pain, worsened with coughing) and shortness of breath, as well
as a few weeks of increasing lower extremity edema. Her BNP was
noted to be 2700 and the thought was this was a CHF exacerbation
(or possibly pneumonia given cough) so she was treated with
levaquin and diuresed. She was aggressively diuresed initially
to the point which her Cr increased from initiall normal to 4.9.
An initial CT of the chest showed mild angulation of the
thoracic spine as well as multilobar pneumonia, so the patient
was started on vanc in addition to her levaquin. Her admission
was complicated by MRSA bacteremia and the patient was started
on vancomycin. A repeat CT of the spine on [**5-20**] revealed major
thoracic kyphosis and compression, in addition she was noted to
have an fluid collection (possible abscess) extending along the
soft tissue pre vertebral surface from T7-T9. Of note this
abscess abuts the thoracic aorta.
.
The patient has since been in a TLSO brace and is ambulating
freely. Her VS are stable and she is being transferred to [**Hospital1 18**]
for further management / drainage of abscess.
On transfer to [**Hospital1 18**], the patient has "severe" back pain to R of
midline of her mid back, it radiates to her abdomen. This has
been stably worsening for 5 weeks. She denies any other pain. no
paresthesias or anesthesia. She denies weakness in lower ext.
She had a foley place today, but prior had no urinary retention.
No bowel incontinence. No upper ext neurologic sx or other
complaints. No cough. No SOB. No chest pain. Denies F/C. States
home dry weight is 210.
Past Medical History:
CHF EF 30-35%
s/p ICD plcmmt in [**2128**]
CAD s/p CABG in [**2128**]
DM
HTN
Hyperlipidemia
Social History:
Works as a cashier. Takes care of her ill mother. Quit smoking 1
year ago, 30 pk year history of smoking. No etoh or drug use
Family History:
Father with DM, MI, and blindness. Aunt with MI and DM. Mother
with blindness. Sister with pancreatic cancer
Physical Exam:
Vitals: 96.1 BP 106/80 HR 86 RR 20 O2 95% RA
General: NAD, AOX3
HEENT: MMM, OP CLear, unable to assess JVP
CV: RRR, [**11-27**] HSM @ apex, no radiation, no thrill. Hyperdynamic
precordium.
Lungs: R lung rales [**11-23**] way up, L lung dullness at base with
slight rales superior
Abdomen: soft, NT, ND, no masses or organomegaly. Pt tenderness
of T8-T10 upon light palptation.
Rectal: normal rectal tone
Ext: 1+ non pitting edema of lower ext. RLE area of redness with
associated dry superficial ulceration. no weeping. + erythema,
induration, and warmth. Erythema of palms bilaterally and on
extensor surfaces of forearms non blanching maculopapular rash
Neuro: CN2-12, normal sensation to light touch of upper and
lower extremities to all distributions. [**3-27**] stregnth bilat in
all muscle groups including bicep, tricep, forearm flex / exten,
grip, delt, hip abduction, adduction, quad, hams, dorsiflexion /
plantar flexion, relexes dimished bilaterally symmetrical
Pertinent Results:
LAB VALUES ON ADMISSION
[**2130-5-23**] 10:49PM WBC-8.4 RBC-3.22* HGB-9.1* HCT-27.7* MCV-86
MCH-28.1 MCHC-32.7 RDW-19.3*
[**2130-5-23**] 10:49PM NEUTS-86.4* BANDS-0 LYMPHS-5.7* MONOS-4.2
EOS-3.3 BASOS-0.3
[**2130-5-23**] 10:49PM PLT COUNT-223
[**2130-5-23**] 10:49PM PT-18.2* PTT-43.3* INR(PT)-1.7*
[**2130-5-23**] 10:49PM GLUCOSE-109* UREA N-99* CREAT-1.7*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-25 ANION GAP-18
[**2130-5-23**] 10:49PM CALCIUM-8.0* PHOSPHATE-5.0* MAGNESIUM-2.7*
[**2130-5-23**] 10:49PM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-252* ALK
PHOS-76 TOT BILI-0.8
PERTINENT STUDIES THROUGHOUT HOSPITAL COURSE
STUDY: CT of the thoracic spine. [**2130-5-24**]
Compression fracture of the vertebral body of T7 is visualized
without
evidence of retropulsion or spinal cord compression. Soft tissue
density and mass effect is visualized in the paravertebral soft
tissues at this level with some low-density areas suggesting
necrotic changes, the possibility of a paravertebral mass is a
consideration; however, an abscess cannot be completely
excluded, this is a limited examination without contrast.
Bilateral ground-glass opacities, pleural effusion, and
plate-like atelectasis are noted. Correlation with a dedicated
CT of the chest is recommended if clinically warranted.
CT THORACIC SPINE WITH INTRAVENOUS CONTRAST [**2130-5-29**]
IMPRESSION:
1. Severe compression deformity of T7, with paravertebral
abscess,
surrounding the aorta, and possibly extending into the left
pleural space. The appearance of the abscesses is similar to
prior study of [**2130-5-20**]. The extent of bilateral pleural
effusions, partially loculated on the left as well as bilateral
parenchymal opacities have slightly increased, when compared to
the prior study.
2. Mediastinal and bilateral hilar lymphadenopathy.
3. Thickened appearance of the esophagus with an air-fluid
level.
CT MYELOGRAM T-SPINE [**2130-6-7**]
IMPRESSION:
Compression deformity with moderate-to-severe spinal stenosis
and borderline cord compression at the T7 vertebral level.
Additionally, there is extensive inflammatory soft tissue
changes at the T7 level with decreased contrast transit time
during real-time myelography. Please see report of the cervical
and lumbar spines for additional information.
PATHOLOGY
SPECIMEN SUBMITTED: Bone vertebral body T7.
Procedure date Tissue received Report Date Diagnosed
by
[**2130-6-9**] [**2130-6-10**] [**2130-6-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/axg
DIAGNOSIS:
Bone, vertebral body:
1. Osteonecrosis without associated acute inflammation.
Histologic features of osteomyelitis are not seen.
2. Bone with maturing trilineage hematopoiesis and marrow
fibrosis.
3. Degenerated fibrocartilage.
EEG [**2130-6-14**]
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
was of
very low voltage such that no definite activity of cortical
origin could
be seen. There were frequent bursts of generalized slowing that
usually
correlated with respiratory or swallowing artifact by video
observation.
There was also extensive muscle and other artifact obscuring
large
portions of the background.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Markedly abnormal portable EEG due to the profoundly
suppressed background rhythms such that no activity of
definitely
cortical origin could be seen. This suggests a severe
encephalopathy.
Anoxia is one possible cause. Major medication effect is
another. The
recording cannot be judged as completely without brain activity
because
of the prominent background artifact. No epileptiform features
were
evident.
ECHOCARDIOGRAM [**2130-6-14**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-25 %) with
global hypokinesis and infero-lateral/apical akinesis. There is
no ventricular septal defect. with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**11-23**]+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
ECHOCARDIOGRAM [**2130-6-29**] - no significant change from [**2130-6-14**]
PORTABLE CHEST [**2130-7-9**] AT 05:20
FINDINGS:
Compared to the prior study there is no significant interval
change with
continued demonstration of distended pulmonary vasculature,
cardiomegaly and blunted CP angle. The pleural-based densities
in the right have not changed substantially. No new
consolidations and no PTX.
IMPRESSION: Stable appearance of fluid overload.
PERTINENT LABORATORY VALUES UPON DISCHARGE:
[**2130-7-10**] 03:00AM BLOOD WBC-5.9 RBC-3.01* Hgb-9.4* Hct-30.5*
MCV-101* MCH-31.3 MCHC-30.9* RDW-21.3* Plt Ct-297
[**2130-6-17**] 03:05AM BLOOD PT-15.6* PTT-29.8 INR(PT)-1.4*
[**2130-7-5**] 05:39AM BLOOD ESR-70*
[**2130-6-28**] 03:49AM BLOOD ESR-104*
[**2130-5-24**] 05:51AM BLOOD ESR-70*
[**2130-7-10**] 03:00AM BLOOD Glucose-75 UreaN-69* Creat-0.8 Na-138
K-5.1 Cl-107 HCO3-25 AnGap-11
[**2130-6-17**] 03:05AM BLOOD ALT-34 AST-26 LD(LDH)-343* AlkPhos-111
TotBili-1.0
[**2130-6-14**] 06:00AM BLOOD CK-MB-15* MB Indx-4.3 cTropnT-0.53*
[**2130-6-14**] 01:47PM BLOOD CK-MB-16* MB Indx-4.6 cTropnT-0.80*
[**2130-6-14**] 09:16PM BLOOD CK-MB-13* MB Indx-4.1 cTropnT-0.74*
[**2130-6-15**] 03:35AM BLOOD CK-MB-9 cTropnT-0.71*
[**2130-7-2**] 10:41PM BLOOD CK-MB-NotDone cTropnT-0.32*
[**2130-7-3**] 06:37AM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2130-7-3**] 02:05PM BLOOD CK-MB-NotDone cTropnT-0.32*
[**2130-5-24**] 05:51AM BLOOD CRP-140.1*
[**2130-6-29**] 01:44AM BLOOD CRP-56.9*
[**2130-7-5**] 05:39AM BLOOD CRP-44.7*
[**2130-7-5**] 05:39AM BLOOD Vanco-26.0*
[**2130-7-6**] 02:20AM BLOOD Vanco-19.9
[**2130-7-8**] 05:27AM BLOOD Vanco-17.9
[**2130-7-10**] 03:00AM BLOOD Digoxin-1.1
[**2130-7-9**] 11:33AM BLOOD Type-ART pO2-44* pCO2-64* pH-7.24*
calTCO2-29 Base XS--1
Brief Hospital Course:
53 yoF w/ CAD s/p CABG in [**2128**], CHF EF 30-35%, [**Hospital **] transferred to
[**Hospital1 18**] from [**Hospital3 2568**] with paraspinal abscess and osteomyelitis,
complicated by spinal cord compression.
# Osteo T7 w/ associated Abscess: Pt initially presented with
back pain and found to have MRSA bacteremia, subsequently
seeding an already present T7 compression fracture, leading to
osteomyelitis and paraspinal abscess. Pt was though to need
drainage however the abscess is abutting the aorta thus pt was
transferred from [**Hospital3 2568**] assuming she would also require
reconstructive surgery of the spine given the extensive damage.
On transfer pt appeared to have no neurological compromise, and
was monitored closely with q4h neuro checks. Several days after
transfer pt began having weakness of R hip flexor, with spared
distal strength and sensation. Pt also described extreme pain in
the posterior leg, but had negative doppler US. Weakness
progressed to involve entire right lower extremity, followed by
left lower extremity over the course of 2 weeks. Upper extremity
strength remained at baseline. Of note, pt's strength exam was
very inconsistent and thought to possibly have a component of
lack of effort as she did not move on command but was able to
withdraw from pain/Babinski. Pt's urinary continence was not
able to be monitored due to foley necessary for diuresis. 14
days after transfer pt had episode of fecal incontinence.
Pt received multiple imaging studies including spine CT without
contrast, spine CT with contrast, chest/abd/pelvis CT with
contrast, EMG, bone scan and tagged WBC. All showed stable
osteomyelitis with associated paraspinal abscess and no visible
process that would explain lower extremity symptoms. Pt unable
to get MRI due to ICD in place.
On [**2130-6-7**] she developed acute worsening of neurologic status
such that she had no motor function in bilateral legs. Repeat CT
scan was obtained (see results section) and the decision was
made to proceed with surgical intervention. On [**2130-6-9**] she
underwent a thoracotomy with T5-8 corpectomies by Thoracic and
Orthopaedic Surgery. Posterior spinal fusion was planned but
unable to be completed due to hemodynamic instability in the OR.
She recovered in the SICU and was taken back to the OR on
[**2130-6-13**] for posterior spinal instrumentation and fusion T2-T11.
Immediately postoperatively, she developed a cardiac dysrhythmia
and went into cardiac arrest. CPR was performed and the rhythm
was pharmacologically converted. She was stabilized in the OR
and taken back to the SICU. All wounds healed well over the
course of her time in the SICU.
Pt was treated with Vancomycin based on troughs due to
fluctuating renal function, finally settling at 1g q48h, as well
as rifampin. She will require at least an 8 week course of
antibiotics following her last procedure ([**2130-6-13**]) and will be
followed by [**Hospital1 18**] Infectious Diseases as an outpatient. All
staples were removed on the day of discharge.
She was followed closely by CT surgery, Ortho/Spine, ID, renal
and neurology consulting teams.
# Anoxic brain injury. Postoperatively the patient did not
recover her baseline mental status. Neurology was consulted and
EEG was performed which was consistent with anoxic brain injury.
CT head did not reveal any bleed or large infarct. MRI head was
not obtainable due to the patient's pacemaker. She required
placement of tracheostomy and PEG tube due to persistently
depressed mental status on [**2130-6-20**]. At the time of discharge she
was able to follow commands midline and with bilateral upper
extremities. She was able to grossly move bilateral lower
extremities by rolling her hips, but no more distal movement was
observed.
# Acute renal failure: Pt's creatinine rose on [**5-4**] from
baseline of 1.2-1.5 and peaked on [**5-10**] at 4.9. Etiology was
believed to be prerenal vs HSP (pt had developed new rash. Cr
upon transfer to [**Hospital1 18**] was 1.4-1.6 and trended down to baseline
with aggressive diuresis. Pt continued to be hypervolemic and
required Furosemide 120mg IV BID and Chlorothiazide 500mg IV BID
to continue negative fluid balance. Pt developed alkalosis with
aggressive diuresis but was monitored closely and continued on
the diuresis. Renal failure remained stable postoperatively.
# Rash: Petechial rash on hands thought to be HSP per outside
hospital records. Pt underwent biopsy at [**Hospital3 2568**], with
nonspecific results not ruling out Henoch Schlonlein Purpura.
Resolved without intervention.
# CHF: Pt known to have ischemic CHF with EF 30-35%. She was
agressively diuresed both at [**Hospital3 2568**] (weight 240 to 221 lbs)
and at [**Hospital1 18**] due to obvious fluid overload. Postoperatively she
required intermittent Lasix IV drips and was finally converted
to PO Lasix. She will require continued diuresis.
# Pneumonia: Patient initially admitted and treated for
pneumonia at [**Hospital3 2568**]. Initially was RLL, progressed to multi
lobar pneumonia. Her WBC count was 19,000 and she had a R sided
pleural effusion requiring chest tube. Since transfer pt had
been afebrile, had normal WBC count, and CXR showed small
persistent effusions but consolidation resolved.
Postoperatively, she required ventilator support due to her
altered mental status as noted above. She developed ventilator
associated pneumonia and completed a 10 day course of Meropenem.
She underwent tracheostomy and was gradually weaned from the
ventilator. At the time of discharge she is able to tolerate 2
hour intervals of trach collar and is otherwise requiring CPAP
with minimal settings.
# CAD: Pt had a recent CABG ([**2128**]) and was continued home
medications including aspirin per okay of spine surgery.
# DM: Pt's blood sugars were well controlled on HISS.
Medications on Admission:
Home Medications:
Lasix 40mg po bid
Coreg 12.5mg po bid
Simvastatin 20mg po daily
Omeprazole 20mg po daily
Fluoxetine 20mg po daily
Wellbutrin 150mg po bid
Vytorin 10/40 daily
Lisinopril 10mg po daily
Dig 0.0625 po daily
Lantus 55 units sc qhs
Novolog sliding scale
.
Transfer Medications:
Aspirin 325mg daily
Fondaparinux 2.5mg daily at 6p.m.
colace 100mg po bid
Coreg 12.5mg po bid
Saccharomyces 250mg po bid
Lasix 20mg daily
Novolog sliding scale
Oxycontin 20mg po bid
Oxycodone 5mg po q4hrs prn
Fluoxetine 20mg po daily
Tylenol 1g tid
Vanc 1g q24hrs
Vytorin (zetia / simvastatin) 10-40 daily
Wellbutrin 150mg po bid
Simvastatin 20mg daily
prilosec 20mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day) for 4 weeks.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs
Inhalation Q4-6H () as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4-6H () as needed.
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): only while on mechanical
ventilation.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours): end date [**8-9**].
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
Four (24) units Subcutaneous breakfast and dinner.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous q6h as directed: sliding scale.
16. Vancomycin 1,000 mg Recon Soln Sig: 1,000 mg Intravenous
q48h: end date [**8-9**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Osteomyelitis, paraspinal abscess, lower extremity weakness
Discharge Condition:
stable
Discharge Instructions:
Wound care: Keep incisions covered with dry dressings, change
daily and prn. Once incisions are dry they may be left open to
air.
Activity: No restrictions. Pt may be out of bed as tolerated.
[**Month (only) 116**] have head of bed elevated as tolerated.
Call your doctor or return to the ER if you have: fevers > 101.5
F, shaking chills, change in neurologic status, or any other
concerns.
Physical Therapy:
activity as tolerated, may be out of bed as tolerated.
Treatments Frequency:
Site: Posterior back incisions/Coccyx
Description: staples intact, no drainage or redness present
Coccyx-healing partial thickness ulcers
Care: incisions left OTACoccyx with allevyn to cover
Site: Right heel
Description: 6 X 5 intact blister with dark tissue to heel. Also
with dark tissue present approximately 1cm X 1cm to anterior
ankle.
Care: Wound cleanse or NS to clean blister then Aloe Vesta cream
to surrounding tissue, cover with heel cup (ABD pads) and
kerlix.
Site: Left achilles
Description: intact, dry eschar approximately 1 X 1.5cm
Care: NS or wound cleanse to cleane eschar area tnen Aloe vesta
to skin, heel cup with kerlix wrap to cover
Followup Instructions:
2 weeks after discharge with Dr. [**Last Name (STitle) 1007**] at [**Hospital1 **] Spine Center.
Call ([**Telephone/Fax (1) 2007**] to schedule.
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] at the [**Hospital1 18**] Infectious Disease
Clinic week of [**7-24**]. Call ([**Telephone/Fax (1) 4170**] to schedule.
|
[
"V09.0",
"730.28",
"324.1",
"V45.81",
"427.89",
"278.01",
"272.4",
"584.5",
"782.1",
"788.20",
"041.11",
"486",
"790.7",
"733.13",
"276.3",
"V45.02",
"428.0",
"428.23",
"V58.67",
"401.9",
"780.1",
"999.9",
"427.5",
"707.06",
"344.1",
"584.9",
"518.81",
"482.0",
"414.00",
"787.6",
"348.1",
"707.09",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"84.51",
"99.69",
"96.04",
"99.60",
"31.1",
"96.05",
"99.29",
"81.04",
"81.64",
"87.21",
"89.49",
"81.05",
"96.72",
"80.99",
"77.49",
"43.11",
"96.71",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
18498, 18577
|
10303, 16149
|
296, 401
|
18680, 18689
|
3618, 9001
|
19884, 20241
|
2499, 2609
|
16863, 18475
|
18598, 18659
|
16175, 16175
|
18713, 18713
|
2624, 3599
|
19124, 19179
|
19201, 19861
|
16193, 16443
|
247, 258
|
18725, 19106
|
16465, 16840
|
9018, 10280
|
429, 2225
|
2247, 2340
|
2356, 2483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,276
| 153,305
|
20438
|
Discharge summary
|
report
|
Admission Date: [**2166-5-30**] Discharge Date: [**2166-6-5**]
Date of Birth: [**2119-8-27**] Sex: F
Service: NEUROSURGEY
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
woman with a family history of subarachnoid hemorrhage. She
underwent MRI imaging of her brain which revealed the
presence of a basilar tip aneurysm and she was referred to
Dr. [**Last Name (STitle) 1132**] for conventional angio and possible treatment of
this aneurysm. She had an angiogram which revealed three
aneurysms, the largest being a basilar apex aneurysm. She
also had a 2.5 mm aneurysm at the carotid siphon proximal to
the takeoff of the ophthalmic artery and a 3.5 mm wide neck
aneurysm proximal to the posterior communicating artery. The
patient was admitted status post stent coil embolization. The
patient was monitored in the ICU for close neurologic
observation.
PHYSICAL EXAMINATION: Vital signs: Her vital signs are
stable. She was afebrile. General: She was awake, alert,
oriented times three. The pupils were equal and reactive to
light. She was moving all extremities. Lungs: The lungs
were clear to auscultation. Cardiac: Regular rate and
rhythm. Abdomen: Benign. Extremities: No edema.
HOSPITAL COURSE: On [**2166-5-31**], the patient had a mild
headache, some neck stiffness. She was awake and alert.
Speech was fluent and she was oriented to details. EOMs were
full. She had no nystagmus. Visual fields were full. She
had no drift. Her strength was [**6-18**]. Blood pressure was kept
less than 140. She was started on Plavix and aspirin. The
sheath was discontinued and her groin site was clean, dry,
and intact with no hematoma. She did have a small leak of
contrast during the aneurysm coiling but that was sealed off
and there was no further problem. Repeat angio showed no
evidence of aneurysm.
She remained neurologically stable and was transferred to the
regular floor on [**2166-6-2**]. She was out of bed, ambulating,
tolerating a regular diet, and voiding spontaneously.
She was discharged on [**2166-6-5**] in stable condition with
follow-up with Dr. [**Last Name (STitle) 1132**] in six months for repeat angio. She
remained neurologically stable.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Lisinopril 30 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Amlodipine 10 mg p.o. q.d.
5. Levothyroxine 75 micrograms p.o. q.d.
6. Hydrochlorothiazide 25 p.o. q.d.
7. Metoprolol 75 p.o. t.i.d.
8. Pantoprazole 40 mg p.o. q. 24 hours.
9. Dilantin 300 mg p.o. q.h.s.
10. Aspirin 325 p.o. q.d.
11. Plavix 75 p.o. q.d.
DISPOSITION: The patient was stable at the time of
discharge.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in six
months for repeat angio.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2166-6-5**] 11:26
T: [**2166-6-6**] 11:20
JOB#: [**Job Number 54754**]
|
[
"997.02",
"747.81",
"E878.8",
"244.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
2246, 3026
|
1248, 2223
|
907, 1230
|
168, 884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,533
| 178,350
|
29085
|
Discharge summary
|
report
|
Admission Date: [**2151-10-18**] Discharge Date: [**2151-10-23**]
Date of Birth: [**2099-12-25**] Sex: F
Service: MEDICINE
Allergies:
Augmentin / Doxycycline
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known lastname **] is a 51 F with metastatic breast ca who went for her
first dose of Herceptin (traztuzumab) today. Once the infusion
started, she developed a subjective feeling of cold and rigors.
The infusion was stopped for rigors and fever to 102 and the
patient was sent to the ED for further evaluation. There, she
was found to be tachycardic to the 140s and slightly more
tachypneic than usual. She initially was found to be saturating
92% on 4L, an increase from her home 02, which is 2L at baseline
and used for management of her malignant pleural effusions.
Chest X ray was unchanged but she was found to have left shifted
differential with 9 bands and of lactate 2.1. It was thought
that these symptoms were either a rxn to Herceptin or an
infectious process.
.
Of note, patient is s/p VATS with talc pleurodesis for malignant
pleural effusions on [**10-16**] by Dr. [**Last Name (STitle) **] [**Name (STitle) **].
.
In the ED, blood cultures were drawn peripherally and off the
portacath. She was volume resuscitated with 1 L NS and also 1 gm
vancomycin and 500 mg levofloxacin were administered. She is
admitted to the ICU for concern for sepsis.
Past Medical History:
ER-/PR- Her2+ Invasive ductal carcinoma grade [**1-22**] in R breast,
metastatic to lung and liver
s/p R lumpectomy/mastectomy and chemotherapy in [**2147**]
s/p VATS and talc pleurodesis [**10-16**]
Cat scratch disease--[**2107**]
Left groin excision (cyst)--[**2107**]
HTN (SBP 150s) while smoked ([**2147-3-22**]), no htn after quit smoking
Social History:
Former homemaker x 20 yr, currently working as LNA for 2.5 yrs
up until [**2151-9-13**]. Divorced with 1 daughter in her 20's who
lives in [**State 108**] and is not in close contact. The patient is
from NH and is in the process of moving to MA to be closer to
her boyfriend and to have further care of her breast cancer.
Support from her bf (her health care proxy) and
friends/boyfriend's family. Smoked 1 ppd x 3 years, stopped
[**6-26**], drinks wine weekly, denies drug use.
Family History:
Mother--HTN, DM, heart disease, sarcoid, obesity
Maternal uncle--prostate cancer
Father with parkinson's disease
Physical Exam:
Physical Exam:
Tm 103.7 Tc 96.6 HR 111 BP 96/74 RR 16 94% on 4L NC
Gen appears tired
HEENT: dry MM, PERRLA EOMI
Neck: supple
Cor: tachy, regular, no murmurs
Pulm: crackles bilaterally, R> L 3/4 up
Abd: soft mild TTP on RUQ
Ext: WWP trace pedal edema strength 5/5 upper and lower
extremities bilaterally to flexion and extension
Pertinent Results:
CXR: Again demonstrated are bilateral diffuse opacities as well
as
pleural thickening most prominent along the right lateral
pleural surface, unchanged. No pneumothorax is evident. Paired
to prior radiograph, there is decreased subcutaneous emphysema
along the right lateral chest wall. There may be a small right
pleural effusion unchanged. A left subclavian -Cath is seen with
tip overlying the expected region of the mid SVC, unchanged. The
cardiomediastinal silhouette and hilar is unchanged.
IMPRESSION: No significant change compared to prior radiograph
four hours prior. Persistent bilateral diffuse opacities and
pleural thickening consistent with given history of metastatic
breast cancer, unchanged.
.
EKG: sinus tach at 142 normal axis normal intervals, T wave
inversion in III, late R wave transition
.
CXR ([**2151-10-18**]): Unchanged diffuse bilateral opacities, pleural
thickening, and right- sided pleural effusions.
.
Bone scan ([**2151-10-20**]): No evidence of osseous metastasis.
Brief Hospital Course:
Assessment: 51 woman with widely metastatic breast CA, now with
fevers, rigors, hypoxia and bandemia in setting of herceptin
infusion with recent portacath placement.
.
Plan:
# Fevers and hypoxia. This was concerning for an infectious
process vs. an atypical herceptin reaction. The patient was
cultured and placed on broad spectrum antibiotics and initially
sent to the ICU. There was high concern for community acquired
or post obstructive pneumonia, empyema or hepatic abscess as the
patient had a transaminitis (not new). The patient's chest x-ray
revealed an unchanged R sided pleural effusion at the site of
prior malignant effusion s/p recent talc pleurodesis. It was
difficult to assess for infiltrate given the underlying
pathology. The patient's cultures were without growth and the
patient's antibiotic regimen was trimmed to 10 total days of
levofloxacin. Her transaminitis resolved and this was felt
consistent with known liver metastases. The patient quickly
deffervesced, her hypoxia returned to her 2L NC baseline
requirement and her somewhat cloudy mental status improved over
days. It seems likely that this represented an atypical drug
reaction to herceptin.
.
# Breast CA. The patient received a dose of Taxol for initiation
of therapy on the day prior to discharge. She had good pain
control with a lidoderm patch and PO oxycodone. The patient had
a bone scan prior to discharge that revealed no osseous
metastases.
.
# Hypoxia. The patient was at her baseline O2 requirement of 2L
NC at the time of discharge. She desaturated to <90% with
ambulation on room air and maintained an O2 saturation at 95% on
2L with ambulation. This is likely secondary to her known
malignant effusion.
Medications on Admission:
lopressor 12.5 mg [**Hospital1 **]
oxycodone 5 mg Q 4 PRN
seroquel 25 mg HS
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*1*
9. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Nausea/vomiting.
Disp:*15 Tablet(s)* Refills:*1*
10. Home oxygen
Please provide the patient with home oxygen, 2L by nasal
cannula, continuous, titrate to SaO2>90%.
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical herceptin reaction vs. pulmonary infection
.
Breast cancer
Discharge Condition:
Good, without fevers, hypoxia at baseline
Discharge Instructions:
You were admitted with fevers, chills, hypoxia and tachycardia,
all occurring while your were being infused with Herceptin. This
was likely due to either an unusual drug reaction or an
infection. You were started on chemotherapy for your breast
cancer while you were in the hospital. You will follow-up with
your oncologist for these issues on [**2151-11-1**].
.
Take all medications as prescribed. You should take the
antibiotic levofloxacin for 5 additional days. You have
prescriptions for pain medications, including a fentanyl patch
which should be applied for 12 hours and then removed for 12
hours, oxycodone 5mg to be taken as needed for breakthrough
pain. Fentanyl and oxycodone are narcotic pain medications and
as such can cause constipation and nausea. For possible
constipation you have prescriptions for docusate and senna. For
possible nausea you have compazine (also called
prochlorperazine). Also you have a prescription for ativan
(also called lorazepam) to be used as needed for anxiety.
.
Call your physician or return to the hospital for any new or
worsening fevers, shaking chills, nausea, vomiting, shortness of
breath, confusion or other concerning signs.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2151-11-1**] 11:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"799.02",
"197.7",
"E933.1",
"197.2",
"197.0",
"780.6",
"174.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6925, 6931
|
3875, 5580
|
293, 300
|
7043, 7087
|
2850, 3852
|
8316, 8553
|
2372, 2486
|
5707, 6902
|
6952, 7022
|
5606, 5684
|
7111, 8293
|
2516, 2831
|
248, 255
|
328, 1493
|
1515, 1860
|
1876, 2356
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,754
| 109,161
|
11767
|
Discharge summary
|
report
|
Admission Date: [**2140-9-21**] Discharge Date: [**2140-10-12**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
gentleman who presented to the hospital on [**2140-9-21**] with
complaint of palpitations, chest heaviness and shortness of
breath. On presentation in the Emergency Department he was
found to be hypoxic with an oxygen saturation of 80% on room
air. He had a chest x-ray which showed bilateral
infiltrates, question of pneumonia versus pulmonary edema.
He was treated with pneumonia with Levaquin. Cardiac enzymes
were sent, returning several hours later showing a CK of 690,
MB of 48, MB index of 7 and a troponin of 47. He was
heparinized for potential catheterization and subsequently
had worsening hypoxia and hypotension necessitating elective
intubation. He was started on dopamine and ETT. He was
subsequently transferred to the Coronary Care Unit for
further management.
PAST MEDICAL HISTORY: Diabetes mellitus, hypertension,
monoclonal gammopathy of unknown significance, peripheral
vascular disease status post right femoral to dorsalis pedis
bypass, and status post appendectomy.
SOCIAL HISTORY: The patient is a former cigar smoker, no
alcohol. He is married. His wife is demented and was
recently placed in a [**Hospital 4820**] nursing care facility. He
lived at home with VNA assistance.
MEDICATIONS ON ADMISSION: Aspirin 81 mg once daily;
lisinopril 20 once daily; Zoloft 50 once daily; glyburide 2.5
once daily; Norvasc 5 once daily; Lopressor 25 b.i.d.
ALLERGIES: The patient has no known drug allergies..
PHYSICAL EXAMINATION: On presentation the patient was
afebrile and had a blood pressure of 92/60. Blood pressure
was 92/60 on 15 of dopamine. Pulse was 119. The patient was
on the vent assist control, tidal volume 600, respiratory
rate 16, PEEP of 10, FIO2 of 1, saturating 99%. Generally he
was a thin elderly gentleman intubated and sedated. Head,
eyes, ears, nose and throat: The patient had thin pink
secretions coming from his endotracheal tube, jugular venous
pressure was 6-7 cm. Chest: He had diffuse coarse rhonchi
anteriorly, no wheezing, no crackles. Cardiovascular:
Tachycardic with distant heart sounds, no appreciable
murmurs. Abdomen: Soft, nontender, and nondistended with
normal active bowel sounds. Extremities: The right groin
had a bypass surgical scar. The patient did not have
palpable dorsalis pedis or posterior tibial pulses
bilaterally, although they were dopplerable. The patient had
1+ edema bilaterally at the ankles.
LABORATORY DATA: White blood cell count on admission was
12.6 with a differential of 89 neutrophils, no bands.
Hemoglobin was 33%. Labs: 143/4.2, 108/21, 68/2.3 which is
an increase from 0.9. The patient's lactate was 4.7 and his
CK was 690, CK MB 48, MBI 7, troponin 47. Blood cultures
were pending.
Chest x-ray showed bilateral lower lobe infiltrates.
Electrocardiogram showed sinus tachycardia with left bundle
branch.
IMPRESSION: This is a [**Age over 90 **]-year-old gentleman with a history
of diabetes mellitus, peripheral vascular disease and
hypertension admitted to the Coronary Care Unit with acute
myocardial infarction, respiratory distress likely secondary
to pneumonia and acute renal failure.
HOSPITAL COURSE: Cardiovascular: The patient was found to
have acute myocardial infarction. He ruled in by enzymes on
[**9-21**] and [**9-22**]. His enzymes were trending down until [**9-23**]
when he was extubated. The patient failed extubation and
subsequently had a bump in his enzymes again. The patient
was taken to the catheterization laboratory where his right
coronary artery was stented. He remained stable, was weaned
off pressors, and was successfully extubated on [**10-4**]. He
did well extubated and was hemodynamically stable until [**10-7**]
at which time he became acutely short of breath and was found
to be in pulmonary edema. The patient responded to diuresis,
however his enzymes were found to have bumped again. The
patient ruled in for myocardial infarction by enzymes yet
again and had no changes in his electrocardiogram again. The
patient subsequently developed cardiogenic shock with anuric
renal failure and at that point was made DNR/DNI by his
family. The patient was maintained on pressors until [**10-11**]
at which time the family decided to make him comfort care
only. The patient was started on morphine drip, titrated to
comfort, and had asystolic arrest on the morning of [**2140-10-12**].
Pulmonary: The patient had bilateral methicillin-resistant
Staphylococcus aureus pneumonia throughout the course of his
stay that was treated with vancomycin. The patient's
ischemia was thought likely to be secondary to increased
demand on his myocardium secondary to respiratory distress
and increased ortho breathing from his pneumonia.
Renal: The patient had acute renal failure upon admission
which subsequently resolved with normal urine output.
Following his second bump in enzymes he again had some
increase in his creatinine but maintained good urine output.
Following his third bump of enzymes the patient became
increasingly anuric despite pressors with BUN and creatinine
trending upward and a urine output that dwindled to as low as
100 cc a day.
The patient was noted to be in asystole on the morning of
[**2140-10-12**]. He had been bradycardic and hypotensive throughout
the night on his morphine drip and off pressors. His family
was with him at the bedside. His pupils were fixed and
dilated. There was no pulse, no heart sounds were present
and the patient had no breath sounds bilaterally. He was
pronounced dead at 10:10 AM on [**2140-10-12**].
DR.[**Last Name (STitle) 2052**],[**First Name3 (LF) 2053**] 12-462
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2140-10-12**] 10:45
T: [**2140-10-12**] 11:47
JOB#: [**Job Number 37205**]
1
1
1
DR
|
[
"414.01",
"482.41",
"584.9",
"250.00",
"410.91",
"785.51",
"276.5",
"785.59",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"88.56",
"89.64",
"36.06",
"96.04",
"36.01",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1400, 1598
|
3298, 5933
|
1621, 3280
|
112, 942
|
965, 1156
|
1173, 1373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,093
| 146,094
|
11848
|
Discharge summary
|
report
|
Admission Date: [**2172-4-12**] Discharge Date: [**2172-4-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Central line placement
ERCP
History of Present Illness:
89yo F with COPD/emphysema, chronic back pain who presented with
sepsis. Patient's daughter called EMS on the day of admission
after she found her mother by the bed with mental status
changes. Upon EMS arrival, she was tachypneaic to 40,
tachycardic to 170s , disoriented, and hypertensive to 200s. In
EW, code sepsis called, RIJ placed. She was given
levo/flagyl(for fever and luekocytosis). Her intial vitals were
T103, P133 BP176/50 RR23. Her initial lactate was 6.5 which
decreased to 1.6 with hydration.
Past Medical History:
emphysema/COPD
Hypertension
hyperlipidemia
Chronic low back pain
osteoarthritis
cholecystectomy [**96**] years ago
s/p TAH
Social History:
Widowed with one daughter.
Denied [**Name2 (NI) **]
Denied alcohol use
Family History:
NC
Physical Exam:
VS: T 103, 154/65 111, 22, 100% RA
Gen: frail
HEENT: EOMI, PERRL, poor dentition
Neck: s/p IJ placement
Chest: dimished effort, rhonchorous
CV: hyperdynamic PMI, distant S1 s2, no mrg
Abd: obese tender diffusey, no rebound
Ext: no edema
Neuro: oriented to person and place
Pertinent Results:
Admission labs significant for WBC of 18, AST 58, ALT 46 AP 118,
lactate 6.8.
CT abdomen: CBD dilitation
ERCP: difficult cannulation prequiring precut sphincterotomy for
CBD acces. Biliary dilation with distal CBD stricture suggestive
of neoplasm. Cytology obtained.
EKG: on third day of admission showed lateral EKG changes and
cardiac enzymes revealed NSTEMI. Troponin I peaked at 0.37. At
the time of discharge had returned to baseline.
CTA abdomen: no mass in the pancreas, but pt does have L kidney
mass and L renal vein thrombus
Brief Hospital Course:
89yo F with COPD/emphysema, chronic back pain who presented s/p
fall with altered mental status found to have cholangitis and
NSTEMI. While hospitalized CTA of abdomen revealed L kidney
mass suspicious for renal cancer.
#ID: Cholangitis: patient underwent ERCP and sphincterotomy and
stent placement in CBD. She will complete a 21 day course of
antibiotics. At the time of discharge she has 10 additional days
of antibiotics (levofloxacin and flagyl) left.
#Renal mass: CT scan to evaluate possible pancreatic mass found
on ERCP found that pt did not have pancreatic mass, but was
found to have L renal mass and renal vein thrombus. Pt was
started on low dose coumadin. She should have her INR checked
on [**4-26**] with results faxed to her primary care physcian.
She has an appointment for an MRI of the kidneys [**5-6**] at
[**Hospital3 **]. She was evaluated by urology and will be seen by
them in followup. The implications of this mass was discussed
with the patient and her daughter.
#CAD: NSTEMI: Pt ruled in for MI, enzyme peak at 0.37, EKG
diffuse lateral ST depression, cardiac enzymes have trended down
to baseline. Pt was started on aspirin and had 48 hours of
heparin. Echocardiogram showed EF 60%, mild-mod TR, mod PA HTN.
Pt will need outpatient p-MIBI for risk stratification,
especially if she decides to pursue treatment of renal mass.
#COPD/emphysema: Pt received stress dose steroids while in the
ICU, she was then tapered down to home dose of prednisone and
remains on her regular inhalers.
#HTN-
- Continue metoprolol and captopril
#chronic low back pain
- tylenol, morphine prn with aggressive bowel regimen
Medications on Admission:
Dolansetron
Tylenol
Albuterol
Prednisone
Atrovent
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
15. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Cholangitis
NSTEMI
Discharge Condition:
Stable
Discharge Instructions:
Return to the emergency room or call your primary care physician
if you have fevers, abdominal pain, chest pain, or shortness of
breath or any other symptom that bothers you.
Followup Instructions:
Please call your primary care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 17753**] to make
an appointment within the next 2 weeks.
Please return to the [**Hospital Ward Name 23**] building Wednesday [**5-6**] at
1:45p [**Location (un) **]. Please do not eat or drink anything 4 hours
before the MRI.
|
[
"272.4",
"401.9",
"285.9",
"593.9",
"410.71",
"576.1",
"496",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.14",
"88.72",
"51.87",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5086, 5159
|
1964, 3605
|
269, 298
|
5222, 5230
|
1401, 1941
|
5453, 5776
|
1089, 1093
|
3705, 5063
|
5180, 5201
|
3631, 3682
|
5254, 5430
|
1108, 1382
|
223, 231
|
326, 838
|
860, 985
|
1001, 1073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,132
| 105,454
|
49756
|
Discharge summary
|
report
|
Admission Date: [**2198-12-26**] Discharge Date: [**2198-12-28**]
Date of Birth: [**2143-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
55 year old female with history of metastatic breast cancer with
mets to cervical spine, right hip and history of malignant
pericardial and pleural effusions. Pt underwent pericardial
window on [**7-30**] for pericardial effusion with improvement in
symptoms of dyspnea. Subsequently developed a left > right
pleural effusion, which was managed with thoracentesis and
placement of a pleurex catheter in [**9-29**]. Since that time pt has
noted persistent weakness and dyspnea on exertion, now worsened
to the point where the patient has difficulty with dressing,
transfer and is unable to walk between rooms. She reports having
worsening right hip pain recently, was found on MRI to have
evidence of bony mets and earlier today had cycle [**2-24**] of
radiation to this area with her radiation oncologist Dr. [**Last Name (STitle) **].
She noted that whereas she us usually able to walk from her car
to the lobby for these appointments she was unable to do so
today and required a wheelchair. Called EMS, was noted to by
hypoxic to 87% on RA.
.
Otherwise on notable history pt notes chronic cough x years,
mildly worse lately with clear to yellow sputum production.
Weight loss (was 200lbs, now 128) with decreased appetite,
weakness. Had one episode of n/v over the weekend with low grade
temp to 100.3. Has since resolved.
.
On ROS denies headache, vision changes, neck pain/stiffness,
nausea, vomiting. Has mild chest discomfort with coughing and
dyspnea as above. No palpitations, abd pain. No diarrhea. +
Occasional constipation. No LE edema. No rashes.
.
In the ED, 02 sat increased from 88% on RA to 93% on 2L. Had CXR
which showed bibasilar pleural effusions L>R and LLL infiltrate.
Bedside TTE showed suggestion of pericardial effusion. F/u
formal TTE showed LVEF 35-40% with increased echo-dense
loculated pericardial effusion and some evidence of increased
pericardial pressure.
Inital VS: 97.4 123 161/92 24 93% 2L (88% RA). She was given 1L
NS, vanc and cefepime for the pneumonia. Had an elevated WBC
with left shift. Admitted to the CCU for monitoring of
pericardial effusion with concern for evolving tamponade. Upon
arrival to CCU pt underwent thoracentesis with interventional
pulmonology, with removal of 200cc cloudy fluid, pt reported
interval symptom improvement.
Past Medical History:
1) Metastatic breast adenocarcinoma: Breast cancer diagnosis in
[**2185**] s/p mastectomy and CA chemotherapy. Recurrence in neck in
[**2189**] with XRT. In [**2192**] known metastatic disease to spine,
supraclavicular node, and right hip. She has tried and failed
multiple chemotherapy regimens, now cycle 1, day 16 of
Herceptin/Xeloda
2) Anxiety
3) Hypertension (has been on lisinopril but stopped on own)
4) s/p appendectomy
5) Hypothyroidism
.
Social History:
Social history is significant for no tobacco since [**2165**]. The
patient drinks socially and quite infrequently with no history
of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father died of a AAA rupture. There is a
history of cancer in multiple family members.
Physical Exam:
VS: HR 115 BP 139/82 93% 2L 18
GENERAL: Middle aged - elderly woman, older than stated aged.
Tachypneic, anxious.
HEENT: Alopecia, multiple scabs.
NECK: Extensive radiation changes, difficult to appreciate neck
veins, no distention noted.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR. Nl S1/S2. Tachycardic. Unable to take pulsus (s/p
axillary LN dissection on R and PICC on L) Evidence of venous
distention of L superfical thoracic wall veins.
LUNGS: s/p R mastectomy and LN dissection, swelling R breast,
chronic. s/p L thoracentesis. Decreased BS R>L, poor air
movement.
ABDOMEN: Soft, NTND. + BS
EXTREMITIES: Slight pitting edema L breast, b/l elbows. s/p left
PICC line placement. S/p removal of L port-a-cath. Some
surrounding erythema, nothing expressible, not warm.
SKIN: Multiple scabs on shins, hands, scalp, per pt self
inflicted.
Pertinent Results:
[**2198-12-26**] 10:00AM BLOOD WBC-16.0*# RBC-4.27 Hgb-10.7* Hct-33.8*
MCV-79* MCH-25.0* MCHC-31.6 RDW-20.5* Plt Ct-451*
[**2198-12-26**] 10:00AM BLOOD Neuts-87.0* Lymphs-3.2* Monos-9.4 Eos-0.3
Baso-0.1
[**2198-12-26**] 10:00AM BLOOD PT-16.9* PTT-32.2 INR(PT)-1.5*
[**2198-12-26**] 10:00AM BLOOD Glucose-149* UreaN-13 Creat-0.5 Na-138
K-4.2 Cl-95* HCO3-33* AnGap-14
[**2198-12-28**] 05:18AM BLOOD ALT-9 AST-19 LD(LDH)-245 CK(CPK)-17*
AlkPhos-92 TotBili-0.4
[**2198-12-26**] 10:00AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2198-12-27**] 05:33AM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.0 Mg-2.1
[**2198-12-27**] 05:33AM BLOOD TSH-3.6
[**2198-12-27**] 07:26AM BLOOD Type-ART pO2-98 pCO2-109* pH-7.12*
calTCO2-38* Base XS-2
[**2198-12-26**] 10:14AM BLOOD Lactate-1.8
[**2198-12-27**] 07:26AM BLOOD O2 Sat-95
.
EKG - Sinus tachycardia. Left atrial abnormality. Low limb lead
voltage. Probable prior anterior myocardial infarction. Compared
to the previous tracing of [**2198-11-6**] the rate has increased.
Otherwise, no diagnostic interim change.
.
Echo - Left ventricular wall thicknesses and cavity size are
normal. There is moderate global left ventricular hypokinesis
(LVEF = 35-40 %). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. There is a moderate sized partially echo filled
loculated pericardial effusion most prominent anterior to the
right ventricle (1.8cm) and anterolateral to the left ventricle
(1.8) with minimal (1.1cm) inferior to the left ventricle and
minimal around the lateral left ventricle and apex. The effusion
is echo dense, consistent with blood, inflammation or other
cellular elements. There is mild intermittent right ventricular
diastolic collapse but no exacerbation of transmitral Doppler
inflow.
.
Compared with the prior study (images reviewed) of [**2198-9-13**],
the effusion is larger and increased pericardial pressure is
suggested. A prominent pleural effusion is also now present.
Left ventricular systolic dysfunction is also now present.
Brief Hospital Course:
Patient was admitted to the CCU in respiratory distress. Patient
was placed on BiPAP. Family and patient decided that patient was
to be DNR/DNI and only wanted nasal cannula for oyxgen withoute
bipap. The following day patient and family decided to make
patiet comfort measures only. Patient expired with husband
present.
Medications on Admission:
Clonazepam 0.5mg prn
Compazine 10mg PO Q6 prn nausea
Fentanyl patch 25mcg Q 72 hours
Levothyroxine 150mcg daily
Metoprolol tartrate 25mg [**Hospital1 **]
Oxycodone 5mg PO Q4 prn
Vitamin D 400 units daily
Zometa 4mg IV Q 3 months
Herceptin Q 3 weeks
Adriamycin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic breast cancer
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2198-12-31**]
|
[
"511.81",
"401.9",
"423.8",
"486",
"V10.3",
"272.4",
"250.00",
"423.3",
"V66.7",
"198.5",
"428.0",
"510.9",
"244.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7124, 7133
|
6461, 6786
|
325, 341
|
7201, 7210
|
4391, 6438
|
7261, 7295
|
3312, 3488
|
7097, 7101
|
7154, 7180
|
6812, 7074
|
7234, 7238
|
3503, 4372
|
278, 287
|
369, 2657
|
2679, 3130
|
3146, 3296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,446
| 123,544
|
1856
|
Discharge summary
|
report
|
Admission Date: [**2122-8-4**] Discharge Date: [**2122-8-11**]
Date of Birth: [**2037-8-15**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Pravastatin
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
cough, hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
84 y/o M with hx of ESRD on HD, Wegner's granulomatosis on
chronic steroids, afib/flutter, hx of prostate cancer and
baseline low BPs who presented to an outpatient office visit
today due to 3 days of productive cough with yellow sputum. No
hemoptysis. He was also feeling very weak and had a hard time
getting out a bed this morning. His wife took his temperature
and it was 100 (which is high for him). His sputum has been
yellow and increasing in thickness the last few days. He denies
any other symptoms like nausea, vomiting, diarrhea, abdominal
pain, headaches, fainting, dizziness. He does have a hx of
falls and unsteadiness, especially when he first stands up. He
fell about 2-3 weeks ago and hit his head. Had a head CT in the
ED that was negative at that time.
.
In the ED, initial vitals were T 98.6, P 67, BP 67/40, R 20 and
93% on RA. He received stress dose steroids with
methylprednisone 125 mg once, ceftriaxone 1 gm IV once and
azithromycin 500 mg IV once. He required 4L NC. He had a CXR
that showed a new R effusion and questionable increased opacity
in the RLL, although difficult to tell based on his chronic lung
disease.
.
On arrival to the floor, he is feeling well. He still is
coughing, but is feeling better from when he first came to the
ED.
Past Medical History:
-Wegner's Granulomatosis, dx [**12/2121**] c-anca + and bx +, on
cytoxan/steroids
-DM 2 on insulin since [**2082**], typical A1c around 7.5%
-ESRD on HD
-Monoclonal gammopathy most likely a smoldering multiple myeloma
-HTN, well-controlled
-Bronchiectasis with baseline grossly abnormal CXR
-SSS with intermittent afib and bradycardia
-Mitral Regurgitation
-Chronic anticoag (indication: AF) on coumadin
-Prostate cancer --> radiation therapy [**2118**], normalized PSA
-Radiation proctitis with rectal bleeding --> laser rx
- GI bleed [**3-10**] radiation proctitis
-Malignant melanoma left thigh s/p excision
-Anemia attributed to CKD
-R ingunal hernia
-S/p appy
-S/p L inguinal hernia repair
-hyperlipidemia
-Fe deficiency
-TB: latent, Patient had a history of TB with treatment in
sanitarium in [**2052**]'s, h/o INH toxicity so no treatment of latent
TB
- MAC: Bronchoscopy with BAL was performed on [**12-23**], and AFBs
found on smear c/w MAC per lab results/ID consult. patient opted
to forego MAC therapy
-hx of pericardial effusion, no drainage needed
-Question of an inflammatory musculoskeletal condition as above
Social History:
Lives with wife. [**Name (NI) **] 1 son. [**Name (NI) **] tobacco. ~1 drink EtOH/day. The
patient is retired, was employed as an international business
consultant. Married, lives with second wife. [**Name (NI) **] has a PhD in
industrial engineering. He was born in Europe, in Eastern
[**Country 10363**], and has traveled throughout the world over his
lifetime. He came to the United States in [**2068**]. His first wife
died in [**2104**]. He is a very active individual, walks regularly.
He is a former mountain climber, tennis player, and skier. He
enjoyed playing soccer in his younger yrs. He smoked only during
WWII and DC'd in [**2057**] with none thereafter. There is no history
of drug use. He reports consumes espresso and an occasional
cocktail before dinner.
Family History:
Patient reports a history of diabetes only in his maternal
grandmother. His father died at an older age with complications
of infection. There is no familial pattern of malignancy,
hypertension, or heart disease.
Physical Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical
adenopathy
Cardioascular: (Murmur: Systolic), irregularly irregular
Peripheral [**Year (4 digits) **]: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at R base; mild at L base), otherwise clear, with
good airmovement to the bases
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Cool, cool hands, warm feet; brusing on arms and legs;
thin skin
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed, A+Ox3
Pertinent Results:
Labs on admission:
[**2122-8-4**] 12:34PM LACTATE-2.3*
[**2122-8-4**] 12:20PM GLUCOSE-283* UREA N-58* CREAT-6.0* SODIUM-135
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-30 ANION GAP-18
[**2122-8-4**] 12:20PM estGFR-Using this
[**2122-8-4**] 12:20PM LD(LDH)-279*
[**2122-8-4**] 12:20PM CRP-58.8*
[**2122-8-4**] 12:20PM WBC-5.7 RBC-3.40* HGB-11.1* HCT-33.0* MCV-97
MCH-32.6* MCHC-33.6 RDW-17.5*
[**2122-8-4**] 12:20PM NEUTS-93.4* LYMPHS-4.3* MONOS-1.9* EOS-0
BASOS-0.3
[**2122-8-4**] 12:20PM PLT COUNT-123*
[**2122-8-4**] 12:20PM PT-24.4* PTT-34.2 INR(PT)-2.3*
[**2122-8-4**] 12:20PM SED RATE-60*
[**2122-8-3**] 04:26PM PT-25.4* INR(PT)-2.4*
IMAGES:
__________________
Chest XRAY [**2122-8-4**]
HISTORY: Desaturation, worsening effusion.
IMPRESSION: AP chest compared to chest radiographs since [**2117**],
most recently [**6-11**] and [**2122-8-4**]: Since [**2121**], previous
small right pleural effusion has decreased and what was probably
aspiration or asymmetric edema in the right lower lobe has
cleared. Moderate cardiomegaly, severe left upper lobe pleural
parenchymal scarring with bronchiectasis and emphysema are
longstanding. Dual-channel [**Year (4 digits) 2286**] catheter ends in the SVC and
upper right atrium respectively. No pneumothorax.
_____________________
CT- L Shoulder [**2122-8-6**];
IMPRESSION: Non-displaced fracture of the posteroinferior
glenoid.
_____________________
CT- Chest [**2122-8-6**];
IMPRESSION:
1. Bilateral non-hemorrhagic pleural effusions; improvement of
right effusion leading to resolution of right lower lobe
collapse; relatively unchanged left effusion.
2. Interval resolution or decrease of previously described
pulmonary nodules, likely representing a resolving infectious
process; no new nodules seen.
3. Stable-appearing bronchiectasis.
4. L1 compression fracture, new from prior study but of
indeterminate age.
5. Left renal cyst.
_____________________
Labs at Discharge:
[**2122-8-11**] 06:00AM BLOOD WBC-4.3 RBC-3.07* Hgb-10.0* Hct-30.0*
MCV-98 MCH-32.7* MCHC-33.4 RDW-18.4* Plt Ct-120*
[**2122-8-11**] 06:00AM BLOOD Plt Ct-120*
[**2122-8-11**] 06:00AM BLOOD PT-23.8* PTT-33.6 INR(PT)-2.3*
[**2122-8-11**] 06:00AM BLOOD Glucose-101* UreaN-46* Creat-4.9*# Na-140
K-4.8 Cl-97 HCO3-34* AnGap-14
[**2122-8-11**] 06:00AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.9
Brief Hospital Course:
# Cough/Hypoxia: The patients cough - hypoxic episode was likely
from an infection, either bacterial vs. viral infection (he does
have hx of H1N1 earlier this year). His CXR on admission was
unrevealing for large consolidation, but he does have a new
right sided pleural effusion. In the setting of no generalized
fluid overload, the effusion may also be secondary to infection
or secondary to progressing Wegners with pulmonary involvement,
although none in the past. As the patient is also on chronic
steroids, PCP pna may also be on the differential. In the MICU
the patient was started on broad antibiotic coverage for
community acquired pneumonia (Ceftrixone, azithromycin). Sputum
cultures, a urine legionella and blood culture were negative.
The patient's antibiotics were narrowed to Levoquin. Pt
respiratory status improved during the next week. He had no
requirement for O2. He did receive an albuterol nebulizer
treatment during an episode of choking on his secretions. This
episode self-resolved without complications.
.
.# Afib/flutter: EKG in flutter, well rate controlled without a
nodal blocker (would want to avoid given orthostasis and
hypotension). The patient was therapeutic on coumadin. During
his stay he had at least 1 episode of aflutter with RVR that
last 5 minutes and self-resolved. Coumadin was held on the night
of [**2122-8-4**] as antibiotics were started and procedures were
considered for the next day. Coumadin was restarted at 1mg/daily
since he began taking the levoquin however it decreased from
3.1-->2.3 today and was increased to 1.5mg daily. His INR must
be checked daily at rehab until he is off of levoquin and
stable.
.
# Fever: The patient had a temperature of 100 (baseline 96
degrees usually) on [**8-4**] which was likely secondary to the
pneumonia. Other etiology could be a line infection in his HD
line. No pain or tenderness or redness. Blood cultures were
negative. He remained afebrile for several days before
discharge.
.
# Hypotension: The patient's blood pressures were mildly below
baseline. Etiologies considered included adrenal insufficiency
from chronic steroid use, mild infection versus early sepsis.
The patient was not warm or [**Last Name (un) **]-dilated. A stress dose of
steroids was given overnight (hydrocortisone 100mg q8hrs).
Taper of the steroids should be initiated on [**2122-8-6**] to 50mg
q8hrs. The patient reported that baseline systolic blood
pressures were in the 80s at home. He was given midodrine 5mg
to improve his pressure (given at 8am, 2pm and 6pm). However he
continued to exhibit hypotension with some unsteadiness while
standing and ambulating.
.
# Wegners: Stable, just had involved kidneys in the past; have
been following ESR/CRPs and adjusting steroid dosing based on
that. Currently on steroid taper of 15mg Prednisone Daily for
the next three days, and then 10mg daily after that, with a plan
to subsequently taper to 5 mg then off.
.
# Shoulder Pain: The patient reports left shoulder pain for
some time after a fall. An xray of his shoulder revealed a
small lucency at glenoid. In the setting of acute trauma, a
fracture is not excluded. A CT of the left shoulder was ordered
for further evaluation of the glenoid prior to discharge and
revealed a non-displaced glenoid fx that should be followed in 4
weeks. For the meantime, his left arm should be placed in a
sling and he should do pendulum motions with his arms to avoid a
frozen shoulder.
.
# s/p fall: CT of his neck and head was negative for acute
fracture or bleed.
.
# ESRD on HD: Stable, has fistula that is not mature on L and R
tunneled line. Is euvolemic on exam. Is MWF [**Year (4 digits) 2286**] patient.
Revieved hemodialysis today - 750 mL. Vitamin D and nephrocaps
were continued..
.
# Hyperlipidemia: The patient was continued on his home statin.
.
# GERD: The patient had no symptoms of GERD. He was continued
on daily pantoprazole.
.
# Diabetes: The patients diabetes was well controlled recently
per patient. He was given Lantus 20qAm per home dose and was
put on a sliding scale. Blood sugars were in the 200s
throughout the day but sometimes were low during the morning.
His lantus was decreased today to 16U with breakfast because of
FS of 78 this morning.
Medications on Admission:
Lipitor 20 mg daily
Lanuts 10 unit qPM
Humalog sliding scale
Pantoprazole 40 mg daily
Prednisone 20 daily
Urea Cream 40% to feet [**Hospital1 **]
Coumadin 2 mg qMWF, 3mg the other days
Acetaminophen 325 mg q6hrs PRN
Cholecalciferol D3 800 u daily
MVI daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily)
for 3 days.
7. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Give at 8 a.m., 2 p.m., and 6 p.m.
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2122-8-15**].
14. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous once a day: Administered in the morning.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Pneumonia
Hypotension
Secondary:
ESRD on HD
Wegener's Granulomatosis
Diabetes mellitus
Bronchiectasis
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
for cough, fever and feeling weak. Based on our exam and chest
x-ray, we determined that you likely had a pneumonia. You were
successfully treated with antibiotics and your fevers went away.
During your stay we also managed your blood sugar and your blood
pressure. You continued to receive your hemodialysis 3 times a
week. We now feel that you were stable to discharge to a
rehabilitation facility where you will be able to build up your
strength.
During your stay we modified several medications. You should:
START: Midodrine 5mg three times daily @8am, 2pm, 6pm
START: Levoquin 250mg daily for 3 days
CHANGE: Insulin regimen as newly prescribed
DECREASE: Coumadin to 1.5mg Daily. You will need to get your INR
checked daily at rehab with Coumadin dosing adjusted as needed.
DECREASE: Prednisone to 15mg Daily for 3 days, then 10mg daily.
Thereafter, would taper to 5 mg daily, then off.
Please take all your other medications as prescribed by your
physician.
Please continue to work with physical therapy to increase your
strength.
Please follow-up with your primary care appointments
Followup Instructions:
Please make an appointment from [**Hospital3 2558**] rehab center with
your primary care physician:
Name: [**Last Name (LF) **], [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Email: [**University/College 10366**]
Please also follow up with these following appointments:
Department: HEMODIALYSIS
When: WEDNESDAY [**2122-8-12**] at 7:30 AM
Department: ADVANCED VASC. CARE CNT
When: TUESDAY [**2122-8-18**] at 10:45 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: WEDNESDAY [**2122-8-26**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
[
"486",
"403.91",
"458.9",
"427.32",
"799.3",
"V45.11",
"V12.01",
"285.21",
"V10.46",
"530.81",
"V58.65",
"585.6",
"780.79",
"272.4",
"446.4",
"V58.61",
"494.0",
"811.03",
"E888.9",
"250.00",
"427.31",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12929, 12999
|
7041, 11296
|
305, 312
|
13175, 13175
|
4683, 4688
|
14515, 15856
|
3581, 3795
|
11604, 12906
|
13020, 13154
|
11322, 11581
|
13351, 14492
|
3810, 4664
|
246, 267
|
6636, 7018
|
340, 1625
|
4702, 6616
|
13190, 13327
|
1647, 2776
|
2792, 3565
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,751
| 140,729
|
13929
|
Discharge summary
|
report
|
Admission Date: [**2102-8-31**] Discharge Date: [**2102-9-5**]
Date of Birth: [**2022-7-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Adhesive Tape / Sudafed / Percocet
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2102-8-31**] Minimally invasive MVR (25mm Mosaic porcine heart valve)
History of Present Illness:
Ms. [**Known lastname **] is an 80 year old woman has a history of worsening
mitral valve prolapse, which has been followed for some time via
serial echocardiograms. She has become increasingly symptomatic
and a recent echo revealed 3+ mitral regurgitation, so she was
referred for surgical evaluation.
Past Medical History:
mitral valve prolapse
hyperlipidemia
hypertension
chronic renal insufficiency
sleep apnea without CPAP
depression
atrial fibrillation
tachy-brady syndrome
asthma
restless leg syndrome
osteoarthritis
osteoporosis
[**Hospital Ward Name **] cyst
s/p PPM [**2099**] DDD
resection of thyroid goiter
cataract surgery
Social History:
Ms. [**Known lastname **] is retired and lives with her husband. She has never
smoked and reports drinking 3 alcoholic beverages per week.
Family History:
Ms. [**Known lastname **] father passed away at the age of 54 years of a
myocardial infarction and her sister passed away of heart
disease in her 60s.
Physical Exam:
PE on Discharge:
VSS: 98.9, 127/46, 66, RR:20, 98% R/A 02SAT, 68.9Kg
General:A&Ox3, NAD
CVS: RRR, No m/r/g
Lungs: right basilar crackles
ABd: benign
EXT:(B) LE edema.
Incisions: right axillary incision:C/D/I, right groin incion:
C/D/I
Pertinent Results:
[**2102-9-3**] 06:45AM BLOOD WBC-8.8 RBC-2.79* Hgb-8.7* Hct-24.7*
MCV-89 MCH-31.0 MCHC-35.0 RDW-15.5 Plt Ct-93*
[**2102-8-31**] 05:14PM BLOOD WBC-9.1# RBC-2.81*# Hgb-8.8*# Hct-25.7*#
MCV-92 MCH-31.3 MCHC-34.2 RDW-13.4 Plt Ct-118*#
[**2102-9-3**] 06:45AM BLOOD Glucose-107* UreaN-24* Creat-1.0 Na-134
K-3.5 Cl-100 HCO3-29 AnGap-9
[**2102-8-31**] 05:57PM BLOOD UreaN-18 Creat-0.8 Cl-110* HCO3-23
[**Known lastname **],[**Known firstname 10588**] [**Medical Record Number 41682**] F 80 [**2022-7-3**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2102-9-3**] 2:45
PM
Final Report
HISTORY: Chest tube removal.
FINDINGS: In comparison with the study of [**9-1**], the right chest
tube has been
removed. The endotracheal tube, nasogastric tube, and Swan-Ganz
catheter have
all been removed. Bibasilar atelectasis persists. Subcutaneous
gas along the
right lateral chest wall and pectoral muscles is slightly more
prominent than
on the previous study.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: SUN [**2102-9-3**] 4:51 PM
Imaging Lab
Brief Hospital Course:
[**2102-8-31**] Mrs. [**Known lastname **] was taken to the OR by Dr.[**Last Name (STitle) **] and
underwent a minimally invasive MVR (#25mm Mosaic porcine valve).
Please refer to Dr.[**Name (NI) 11272**] operative report for further
details. XCT:68min. CPB:87min. She was intubated and sedated ,
requiring Neosynephrine to optimize her BP and CO when
transferred to the CVICU.All drips were weaned to off and the
pt. was extubated in a timely fashion. POD#1 EP interrogated
her PPM. Lines and tubes were discontinued and she was
transferred to the SDU on POD#2. On POD#3 One unit of PRBCs was
transfused for anemia. During the evening hours, Mrs.[**Known lastname **]
became confused and agitated. By the morning of POD#4 her mental
status was improved but she was still having episodes of
confusion. All narcotics were discontinued and she kept for
observation for an additional 24 hours. On POD#5 Mrs[**Known lastname **]
mental status was markedly improved, back to baseline, and was
discharged to rehab for further increase in strength and
endurance. She was instructed on all neccessary followup
appointments once discharged from rehab.
Medications on Admission:
rythmol 225mg [**Hospital1 **]
effexor 37.5mg
atenolol 25mg
triamterene/HCTZ 36.5/25mg
MVI
glucosamine
aspirin 81mg
vitamin D calcium 600
singulair 10mg
lipitor 40mg
diovan 20mg
actonel 35mg on tuesdays
advair 250/50 2 puffs
combivant 2 puffs PRN
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. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-25**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Propafenone 225 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): x6weeks.
12. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
mitral regurgitation
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:
Following discharge from rehab:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17918**] (PCP) in [**1-25**] weeks ([**Telephone/Fax (1) 17919**]) please call
for appointment
Dr [**Last Name (STitle) 7047**] in [**1-25**] weeks, please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2102-9-5**]
|
[
"427.31",
"493.90",
"272.4",
"518.0",
"427.81",
"733.00",
"780.57",
"333.94",
"403.90",
"585.9",
"788.20",
"424.0",
"V45.01",
"293.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5760, 5827
|
2825, 3971
|
338, 413
|
5892, 5899
|
1675, 2802
|
6411, 7013
|
1252, 1404
|
4268, 5737
|
5848, 5871
|
3997, 4245
|
5923, 6388
|
1419, 1422
|
1437, 1656
|
279, 300
|
441, 745
|
767, 1079
|
1095, 1236
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,099
| 161,954
|
18606
|
Discharge summary
|
report
|
Admission Date: [**2176-6-12**] Discharge Date: [**2176-6-17**]
Date of Birth: [**2141-11-1**] Sex: F
Service: OB/GYN
ADMISSION DIAGNOSIS:
1. SIUP at 31 4/7 weeks.
2. Pericarditis.
HISTORY OF THE PRESENT ILLNESS: This is a 34-year-old
gravida II, para I-0-0-I, who presented at 31 4/7 weeks as a
transfer from [**Hospital3 **] Hospital with the diagnosis of a
pericardial effusion. She was initially admitted to [**Hospital3 **]
Hospital on [**2176-6-10**] with the sudden onset of left neck and
chest pain three to four days preceding admission. The
initial differential diagnosis included musculoskeletal pain
and physical therapy was recommended; however, the pain had
persisted. She was then seen in the Emergency Room for
multiple visits at which time she received some sort of an
injection for the pain. The patient said that the workup
with this particular episode, including a chest x-ray, showed
a poor definition of the left diaphragmatic margins
suggesting a left basilar pleural reaction. A CT angiogram
showed no evidence of a pulmonary emboli but there was a
small amount of left pleural fluid and a small amount of
pericardial fluid. In addition, there were a few small lymph
nodes in the mediastinum.
At that time, she was started on a cephalosporin and heparin
due to the differential diagnosis including pneumonia versus
pulmonary embolism. A pulmonary angiogram showed no evidence
of a pulmonary embolism and the heparin was discontinued at
that time. An echocardiogram at the outside hospital showed
a moderate pericardial effusion. She spent 1 1/2 days in the
Intensive Care Unit at the outside hospital for pain
management with Dilaudid. Lyme titers and liver enzymes were
all within normal limits and the EKG showed sinus
tachycardia. At this point, due to the echocardiogram
findings, she was transferred to the [**Hospital6 649**] for further management.
During this hospitalization, fetal heart tones were checked
regularly and initial ultrasound showed a BPP of [**7-26**] (on [**2176-6-9**]) with positive fetal movement, no leaking fluid, no
vaginal bleeding, and no contractions. On the day of
admission, the patient still complained of left shoulder/neck
pain, worse with inspiration. She had mild shortness of
breath but no distinct chest pain. She denied any recent
viral or URI illnesses. She denied any recent travel. She
stated that she was thirsty. There was a question of some
sort of an insect bite 1 to 1 1/2 weeks ago but it was
unlikely that it was a tick.
PRENATAL COURSE:
1. EDC [**2176-8-10**].
2. Her prenatal laboratories revealed that she is Rh
negative, status post a RhoGAM injection on [**2176-5-23**].
3. Bilateral choroid plexus cyst with a marginally enlarged
nuchal fold but an amniocentesis that was within normal
limits.
OB HISTORY: On [**2175-3-16**], she had a primary low-transverse
cesarean section at term of a 7 pound, 9 ounce male after 24
hours of labor and an arrest of dilation at 4 cm.
GYN HISTORY: She has regular 28 day cycles. She had no
abnormal Pap smears, no GYN surgeries, and no STDs.
PAST MEDICAL/SURGICAL HISTORY: Significant for an
appendectomy in [**2167**] and a cesarean section in [**2174**].
ADMISSION MEDICATIONS: The patient was on no medications
upon admission.
ALLERGIES: The patient has no known drug allergies.
PSYCHOSOCIAL HISTORY: She denied any tobacco, alcohol, or
drug use. She is married and lives at home with her husband
and son.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.7, pulse 113, respirations [**12-3**]. Her blood pressure was
96/64 and her 02 saturation 96% on 2 liters nasal cannula.
General: The patient appeared uncomfortable but in no acute
distress. HEENT: Benign. Neck: No lymphadenopathy.
Lungs: Clear to auscultation bilaterally except for some
decreased breath sounds in the left lower lung base.
Cardiac: Regular rate and rhythm but tachycardiac. Abdomen:
Benign. Extremities: Unremarkable. GYN: Her sterile
vaginal examination was long, closed, and posterior. Her
ultrasound showed an SIUP that was vertex, BPP [**7-26**], AFI of
18.
HOSPITAL COURSE: The patient was thus admitted as a transfer
patient with the diagnosis of pericarditis with pericardial
fluid. The Cardiology Service was consulted from the start
of this hospitalization. A repeat echocardiogram on [**2176-6-12**]
showed an EF greater than 60% that was within normal limits.
There was no aortic or mitral regurgitation and a
structurally normal aortic and mitral valve. There was a
small to moderate sized pericardial effusion and left pleural
effusion. There was no ultrasound evidence of a cardiac
tamponade.
After transfer, the patient was initially kept in the ICU for
closer monitoring given the pericardial effusion. At the
outside hospital, she had been started on ceftriaxone,
Phenergan, and Dilaudid p.r.n. The ceftriaxone was
continued. The patient was placed on a Dilaudid PCA for
better pain control with a basal rate. A lupus, thyroid, and
hemolysis workup were all unremarkable. Her ESR was 82. The
patient's white count on [**2176-6-13**] was 11.9 with 0 bands. Her
electrolytes were within normal limits and her LFTs were also
within normal limits. Her initial set of cardiac enzymes
were negative. Her TIBC was 304. Her B12 was 500. Her
folate was 14.0. Her ferritin was 79 and her TRF was 234.
Her hematocrit was 26.0 and her platelets 391,000. The
patient was simply maintained on continuous telemetry with no
evidence on telemetry during the ICU admission and during the
floor admission.
On hospital day number two, the patient was called out from
the Intensive Care Unit and admitted to the Antepartum
Service. Her blood pressures were stable throughout the
hospitalization as were the rest of her vital signs. On
hospital day number three, her 02 saturations were weaned and
by [**2176-6-16**], she was off of supplemental 02 while still
maintaining her 02 saturation of greater than 95% on room
air. The patient was also given an incentive spirometer and
instructed on how to use it. From a cardiac standpoint, she
received two more echocardiograms, one on [**2176-6-14**] and
another one on [**2176-6-17**]. The echocardiogram on [**2176-6-14**] was
stable compared to the one on [**2176-6-12**] and the echocardiogram
on [**2176-6-17**] showed an EF of greater than 55% and slightly
smaller pericardial effusion compared to her previous
echocardiograms. Again, there was no evidence of tamponade
and there was a mild (1+) mitral regurgitation and tricuspid
regurgitation.
The patient received a physical therapy consultation during
this hospitalization but by the time of discharge she was
able to ambulate with minimal assistance. The patient was
started on a course of prednisone during the hospitalization
for the pericarditis. She received 30 mg p.o. starting on
[**2176-6-15**]. She received 30 mg p.o. q.d. for three days and on
the day of discharge she will go on a three day taper, 20 mg
on [**2176-6-18**], 10 mg on [**2176-6-19**] and [**2176-6-20**], and nothing on
[**2176-6-21**]. The patient, on the day of discharge, had
excellent pain control with only Tylenol p.r.n. She is no
longer on any narcotics. Her fetal testing has been
reassuring throughout this hospitalization.
On [**2176-6-15**], the patient had a bowel regimen given her lack
of bowel movement in several days. The patient had multiple
bowel movements on [**2176-6-16**] and reported good relief of her
symptoms. The chest pressure and the pain in her left
shoulder was completely resolved by [**2176-6-15**] and on the day
of discharge [**2176-6-17**], the date of discharge, her chest and
shoulder pain are completely gone and her abdominal pain
which had started on [**2176-6-14**] was also completely resolved.
On [**2176-6-17**], the patient had an ultrasound which showed a BPP
of [**7-26**], an AFI of 12.8 and the fetus was vertex.
From a cardiac standpoint, she is considerably improved
clinically. She will follow-up with Dr. [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] at
[**Hospital3 **] Hospital, a cardiovascular specialist. The
telephone number is [**Telephone/Fax (1) 34149**] and fax number [**Telephone/Fax (1) 41167**]
on Monday, [**2176-6-24**] at 1:30 p.m. The patient has been
instructed to call Dr. [**Last Name (STitle) 2472**], her primary OB/GYN on
Thursday morning. She was also given our phone number and
instructed to call with any recurrences of her chest pain or
any other symptoms.
The patient is discharged to home on a three day rapid taper
of prednisone and iron supplements. She has received six
days of ceftriaxone while here at the [**Hospital6 649**]. She had a PPD that was read negative on
[**2176-6-15**].
CONDITION ON DISCHARGE: Good. She is discharged to home
with close follow-up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 50722**]
Dictated By:[**Name8 (MD) 4872**]
MEDQUIST36
D: [**2176-6-17**] 05:37
T: [**2176-6-17**] 22:59
JOB#: [**Job Number 51090**]
|
[
"648.63",
"648.23",
"280.9",
"397.0",
"423.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4169, 8812
|
3256, 3367
|
160, 3232
|
3527, 4151
|
3384, 3512
|
8837, 9154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,879
| 166,554
|
27446
|
Discharge summary
|
report
|
Admission Date: [**2137-6-19**] Discharge Date: [**2137-7-15**]
Date of Birth: [**2075-10-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE and dyspnea after dialysis
Major Surgical or Invasive Procedure:
cabg x5 on [**2137-6-19**] (LIMA to LAD, SVG to OM1, sequenced to OM2,
sequenced to OM3; SVG to PDA)
exploratory laparotomy [**2137-6-24**]
History of Present Illness:
61 yo male first seen on [**2137-4-10**] for DOE, and dyspnea after
dialysis. He has had routine echos to follow his worsening EF.
Echo in [**2-15**] showed EF 25% , mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. Cath done in [**4-15**]
showed 30% ostial LM, 95% ostial CX, 90% LAD, PAP 71/31, LVEDP
37, 70% ostial RCA, EF 19%. Referred for surgical
revascularization after re-evaluation in late [**5-16**]. Pre-op vein
mapping showed bilat. severe reflux in greater saphs above knees
and mult. varicosities bilat. calves, no thrombosis. Carotid US
[**5-16**] showed no significant stenoses with bilat. antegrade
vertebral flow.
Past Medical History:
CRF with HD (T-TH-Sat)
elev. chol.
cardiomyopathy
retinopathy
IDDM
HTN
left forearm AV fistula
right subclavian dialysis catheter
large right inguinal hernia
diverticulosis with GI bleed 4 years ago
appendectomy
tonsillectomy
ORIF right femur 2 years ago
cataract surgery
laser eye surgery
Social History:
retired maintenance worker for the military
lives with wife
smokes [**Name2 (NI) **]. cigar
rare ETOH
Family History:
grandfather died of MI at age 50
Physical Exam:
ambulates with walker; very weak
HR 78 RR 14 124/79 6'1" 175#
fatigued, NAD
keratoses anterior chest
PERRL, EOMI, OP benign, poor dentition
neck supple with no JVD or carotid bruits, full ROM
RRR no murmur
abd soft, NT, ND with large inguinal hernia
left forearm fistula in place
rubor bilat. [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **], well-perfused with no edema and bilat. varicosities
neuro grossly intact
right-handed
1+ bilat. DP/PT/radials
1+ right femoral, 2+ left femoral
Pertinent Results:
[**2137-7-15**] 02:12AM BLOOD WBC-13.5*# RBC-2.83* Hgb-8.2* Hct-25.4*
MCV-90 MCH-29.1 MCHC-32.4 RDW-16.9* Plt Ct-185
[**2137-7-15**] 03:47PM BLOOD Hgb-7.8* Hct-23.4*
[**2137-7-15**] 02:12AM BLOOD PT-13.2* PTT-30.2 INR(PT)-1.2*
[**2137-7-15**] 02:12AM BLOOD Plt Ct-185
[**2137-7-15**] 02:12AM BLOOD Fibrino-440*
[**2137-7-15**] 02:12AM BLOOD Glucose-65* UreaN-14 Creat-1.7* Na-136
K-4.2 Cl-99 HCO3-24 AnGap-17
[**2137-7-15**] 02:12AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2
[**2137-7-15**] 02:12AM BLOOD Vanco-22.6*
[**2137-7-15**] 04:01PM BLOOD Type-ART pO2-121* pCO2-47* pH-7.37
calTCO2-28 Base XS-1
[**2137-7-15**] 04:01PM BLOOD freeCa-0.91*
Brief Hospital Course:
Admitted [**6-19**] and underwent cabg x5 with Dr. [**Last Name (STitle) 914**].
Transferred to the CSRU in stable condition on epinephrine,
neosynephrine and propofol drips. Seen by renal service for
management of HD issues. Extubated on POD #2 and off all drips.
Transferred to the floor to begin to increase his activity
level. Suffered an acute respiratory arrest on the morning of
POD #3 and reintubated and transferred back to the CSRU with
continued hypotension. Bedside echo done urgently which
confirmed cardiac arrest. ACLS protocol done and pressor
support/steroids given.Ruled out for PE by CT scan when
stabilized with suggestion of right heart failure. Bilat.
atelectasis and severely elevated PA pressures treated per Dr.
[**Last Name (STitle) **]. General surgery consulted on POD #4 for GNR serratia
sepsis, and probable shock liver due to hypotension. Exploratory
lap done by general surgery on POD #5 for ? mesenteric ischemia.
ID and neurology consults done with noted probable anoxic
insult.
CVVH, epinephrine, pitressin and milrinone added for further
support. On vancomycin, meropenem, and flagyl for coverage.
Cardioverted for Afib multiple times on amiodarone. He remained
critically ill with marginal CO/CI. Clinical nutrition consulted
as pt. could not tolerate tube feeds. Chest tubes and pacing
wires removed on POD #13/8. Flagyl stopped on [**7-3**] as C. diff.
negative. CT scan showed mediastinal /retrosternal fluid
collection,pleural effusion and loculated left
hydropneumothorax. Head CT was negative. Pericardial drain
placed and 500 cc of old blood removed.Heparin was held as
indicated. Bronchoscopy done on [**7-4**] which revealed RML and RLL
thick secretions. Swan removed and CVL changed on POD #17/12.
Re- bronchoscopied on [**7-10**] with clear right lung, and thick
secretions from LUL.
MRI and EEG done which were both consistent with severe diffuse
anoxic injury.
Renal, ID, and neuro services followed the pt. daily.
On [**7-12**],social work team consulted with family and Dr. [**Last Name (STitle) 914**]
regarding the pt's poor prognosis. DNR/DNI order in effect on
[**7-13**]. Comfort measures only instituted on [**7-13**]. Stroke attending
neurologist consulted on [**7-15**] for second opinion on prognosis and
confirmed extremely poor prognosis for a meaningful neurological
recovery. Family discussion had with team, and they elected to
have him extubated. Pt. expired in the CSRU at 8:08 PM on [**7-15**].
Medications on Admission:
coreg 25 mg [**Hospital1 **]
nephrocaps one daily
cortef 10 qAM, 5 qPM
lisinopril 40 mg daily
folate daily
lovastatin 20 mg daily
phoslo 662 TID
flomax 0.4 mg daily
omeprazole 20 mg daily
fludrocortisone 0.1 [**Hospital1 **]
gemfibrozil 600 mg [**Hospital1 **]
lantus 12 units qPM
ASA 81 mg daily
epogen at dialysis
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p cabg x5 [**6-19**]
s/p exploratory laparotomy [**6-24**]
IDDM
ESRD/CRF on HD
cardiomyopathy
HTN
BLE varicosities
cardiopulmonary arrest
elev. chol.
diverticulosis with GI bleed 4 years ago
retinopathy
Discharge Condition:
expired
Completed by:[**2137-8-16**]
|
[
"423.0",
"403.91",
"427.31",
"427.5",
"250.40",
"550.12",
"995.92",
"482.83",
"348.1",
"V64.41",
"428.0",
"414.01",
"707.05",
"518.5",
"585.6",
"V58.67",
"038.44"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.44",
"88.72",
"99.60",
"33.24",
"96.04",
"96.72",
"96.6",
"00.17",
"36.14",
"89.64",
"88.42",
"39.61",
"37.0",
"39.95",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
5684, 5693
|
2848, 5317
|
352, 494
|
5945, 5983
|
2185, 2825
|
1615, 1649
|
5714, 5924
|
5343, 5661
|
1664, 2166
|
282, 314
|
522, 1167
|
1189, 1480
|
1496, 1599
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,061
| 108,735
|
4181
|
Discharge summary
|
report
|
Admission Date: [**2153-8-23**] Discharge Date: [**2153-9-2**]
Date of Birth: [**2083-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
ventricular fibrillation - cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2153-8-23**]
Cornary artery bypass graft x2 (Left internal mammary artery >
Left anterior descending artery, saphenous vein graft >
Posterior descending artery) [**2153-8-11**]
History of Present Illness:
70 year old male transferred from [**Hospital3 3583**] for emergent
therapeutic catheterization. He was playing basketball yesterday
with some friends. [**Name (NI) **] after he was done playing, he sat on the
bench to rest and watch other players running by him. He then
felt slightly dizzy, and the other players appeared blurry and
fuzzy, and then he lost consciousness. He had no palpitations or
chest pain. He was later told by witnesses that he fell from the
bench, hit his head on the ground. He was found to be in VF
arrest, was out for about 2 minutes before the EMTs started CPR,
and he was shocked 3 tmes with AED before his pulses came back.
He woke up in the ambulance, confused about where he was and was
initially very combative. He arrived at [**Hospital3 3583**] awake
and alert and oriented in NSR.
Past Medical History:
Hypertension
metastatic renal cell CA to cerv. nodes [**2139**]
Elevated lipids
Chronic kidney disease
metastatic renal cell cardinoma (to cervical lymph nodes
[**2138**])
s/p neck [**Doctor First Name **]
Gout
Cataracts
s/p left nephrectomy
s/p cervical lymph node dissection [**2139**]
Social History:
He is a father of 2 adult daughters, 6 [**Name2 (NI) 18198**].
retired limo driver and cares for his grandchildren several days
a week
No alcohol.
Tobacco history: He smoked 2 packs a day for 40 years, quit at
the diagnosis of renal cell cancer.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. His mother died of cervical cancer. He
is estranged from his father.
Physical Exam:
VS: temperature not recorded. 120/60, 48, 20
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: bradycardic. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
CATH SITES: c/d/i. Nontender to palpation.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Brief Hospital Course:
Transferred in for cardiac evaluation and underwent cardiac
catherization that revealed coronary artery disease.
Electrophysiology was consulted due to ventricular fibrillation.
Echocardiogram revealed decreased left ventricular function and
underwent preoperative workup for cardiac surgery. On [**8-28**] he
was brought to the operating room and underwent coronary artery
bypass graft surgery. See operative report for further details.
He received vancomycin for perioperative antibiotics. He was
transported to the intensive care unit for hemodynamic
management. Mr. [**Known lastname 18199**] was weaned and extubated from the
ventilator on the eve of POD 0. On POD#1 he was started on
betablockers, diuretics, and statin therapy and was transferred
from the ICU to the floor. His chest tubes and wires were
removed per protocol. He was evaluated and treated by physical
therapy and was cleared for discharge to home on POD#5.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
Metoprolol succinate - 25mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Primary diagnoses:
- Coronary artery disease
- Ventricular fibrillation
Secondary diagnoses:
- Hypertension
Discharge Condition:
Stable, afebrile, ambulating.
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 to schedule
wound check as arranged by [**Hospital Ward Name 121**] 6 nurses [**Telephone/Fax (1) 170**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-2-12**] 4:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2153-9-11**] 9:20
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 18200**], MD (PCP) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-9-12**] 1:45
Completed by:[**2153-9-2**]
|
[
"427.41",
"585.9",
"414.01",
"274.9",
"V10.52",
"403.90",
"427.5",
"277.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"40.11",
"38.93",
"36.15",
"36.11",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
4953, 4987
|
3029, 3966
|
361, 569
|
5140, 5172
|
5683, 6308
|
2008, 2167
|
4163, 4930
|
5008, 5081
|
3992, 4140
|
5196, 5660
|
2182, 3006
|
5102, 5119
|
280, 323
|
597, 1415
|
1437, 1727
|
1743, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,464
| 107,848
|
26860
|
Discharge summary
|
report
|
Admission Date: [**2127-2-27**] Discharge Date: [**2127-3-17**]
Date of Birth: [**2061-4-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Staph bacteremia, lead extraction
Major Surgical or Invasive Procedure:
[**2127-3-6**] ICD Lead Extraction and ASD closure via right
thoracotomy
[**2127-3-6**] Removal of Port-A-Cath
[**2127-3-4**] Cardiac Catheterization
[**2127-3-10**] Insertion of PICC Line
History of Present Illness:
65 yo M with CAD s/p CABG, ischemic cardiomyopathy with EF 25%
s/p ICD in [**2125**], admitted to [**Hospital6 33**] in [**Month (only) 956**]
with MSSA bacteremia. Port-a-cath was placed and he completed a
4 week course of Cephazolin (d/c'd 1 week PTA). He was scheduled
to have his port-a-cath removed as an outpatient, but developed
fevers to 103, nausea and vomiting. He was readmitted to [**Hospital1 34**] on
[**2-24**] and was found to be bacteremic with Staph and in mild CHF.
He was diuresed and started on Oxacillin Q4H. TEE was performed
which was significant for a vegetation on an ICD lead. INR was
2.8. Pt was given 5 mg vitamin K sc x 1. He was transferred to
the [**Hospital1 18**] for lead extraction and device removal.
ROS: +Fevers/N/V. No CP. +SOB, HA. No neck stiffness.
+rhinorrhea, no ST. Minimal cough. No abd pain, changes in
urination or bowel movements. No orthopnea/PND.
Past Medical History:
1. Ischemic CM 25%
2. CAD s/p CABG [**40**] y ago, left ventricular apical aneurysm
3. s/p AICD placement in [**2125**] ([**Company 1543**] Maximow VR single
chamber ICD)(last fired in [**Month (only) 956**])
4. s/p embolic CVA in [**2113**] with mild expressive aphasia and
right hemiparesis on coumadin
5. Hypothyroidism/h/o [**Doctor Last Name 933**] disease s/p radioactive iodine
ablation
6. DMII
7. MSSA bacteremia [**1-13**] treated with 4 weeks of abx
8. HTN
9. High Cholesterol
Social History:
Lives with his wife, disabled truck driver, quit smoking in [**2112**]
(80 py history), no ETOH or illicit drugs
Family History:
Father with prostate ca, grandparents with CAD in their 50s.
Physical Exam:
VS: 97.0, 104/60, 79, 20, 95RA
GEN: A+O x 2 (not to place), pleasant gentleman in NAD
HEENT: PERRLA, EOMI, OP clear +dentures
CV: RRR, I/VI diastolic murmur at LLSB
LUNGS: +crackles [**12-9**] way up bilaterally
ABD: soft, NTND, +BS
EXT: no edema, decreased pulses bilaterally, amputated 2nd toe
on right foot
NEURO: 3/5 strength right arm, [**4-11**] in legs and left arm
Pertinent Results:
[**2127-3-14**] 03:35AM BLOOD Hct-29.6*
[**2127-3-13**] 05:12AM BLOOD WBC-11.1* RBC-3.09* Hgb-9.7* Hct-27.3*
MCV-88 MCH-31.4 MCHC-35.5* RDW-18.1* Plt Ct-280
[**2127-2-27**] 08:52PM BLOOD WBC-9.1 RBC-3.44* Hgb-10.7* Hct-31.0*
MCV-90 MCH-31.1 MCHC-34.5 RDW-15.0 Plt Ct-258
[**2127-3-17**] 04:40AM BLOOD PT-24.6* INR(PT)-2.5*
[**2127-3-17**] 09:40AM BLOOD UreaN-33* Creat-1.7* K-4.4
[**2127-3-15**] 05:39AM BLOOD UreaN-39* Creat-1.8*
[**2127-3-14**] 03:35AM BLOOD UreaN-44* Creat-2.0* K-3.7
[**2127-2-27**] 08:52PM BLOOD Glucose-283* UreaN-40* Creat-1.8* Na-137
K-4.3 Cl-98 HCO3-27 AnGap-16
[**2127-3-13**] 05:12AM BLOOD Calcium-7.9* Phos-5.1* Mg-2.8*
[**2127-3-10**] 04:59AM BLOOD Digoxin-1.2
Brief Hospital Course:
Mr. [**Known lastname 66100**] was admitted and remained on Oxacillin for his MSSA
bacteremia. Repeat blood cultures remained negative. Warfarin
continued to be held. As his INR dropped below 2.0, intravenous
Heparin was initiated. He otherwise remained stable on medical
therapy. A transesophogeal echocardiogram on [**3-3**] was
notable for a large secundum atrial septal defect and
approximately a 7 millimeter vegetation on the right ventricular
lead. There was continuous flow across the atrial septal defect.
The ASD was a new finding, as it was not documented on outside
echocardiogram. Due to the ASD, blind extraction of the RV lead
and port-a-cath was not recommended as there was substantial
risk for paradoxical embolism. Cardiac surgery was there for
consulted for surgical intervention. Prior to surgical
intervention, cardiac catheterization was performed. Coronary
angiography showed native three vessel disease, with a patent
LIMA to LAD. No patent vein grafts were visualized and left
ventriculography was deferred. Preoperative carotid noninvasive
studies revealed no stenosis in the right internal carotid
artery with an insignificant stenosis of less than 40% in the
left internal carotid artery. On [**3-6**], Dr. [**Last Name (STitle) 914**]
performed a surgical repair of his atrial septal defect and ICD
lead extraction under cardiopulmonary bypass while Dr.
[**Last Name (STitle) **] performed concomitant removal of his port-a-cath.
Operative cultures were obtained. The operation was otherwise
uneventful and he was brought to the CSRU for monitoring. Within
24 hours, he was extubated. He remained at his neurologic
baseline. Due to incisional discomfort, he was started on a
Dilaudid PCA. He remained in a junctional rhythm with rate 50-70
but otherwise maintained stable hemodynamics. He transferred to
the SDU on postoperative day two. Oxacillin was continued and
Warfarin anticoagulation was resumed. Low dose beta blockade was
resumed for periods of atrial fibrillation which he tolerated
well. On [**3-10**], a left basilic vein PICC line was placed
without complication for long term antibiotics. Over several
days, he was noted to have periods of bradycardia and conversion
pauses, with periods of atrial tachycardia/fibrillation on
telemetry. He was concomitantly noted to have a decline in renal
function. His creatinine peaked to 2.5. The ACE inhibitor was
therefore discontinued. Due to the potential for temporary
pacing wire secondary to bradycardia, Warfarin was temporarily
stopped and Heparin was utilized for anticoagulation. With close
consultation with the EP service, all nodal agents were titrated
accordingly. Over several days of adjusted medical therapy, his
heart rate and rhythm improved. Warfarin was eventually resumed
as was beta blockade for rate control. He continued to
experience bouts of atrial fibrillation. Due to suboptimal
control of his diabetes mellitus, the [**Last Name (un) **] Center was
consulted to assist in the management of his blood sugars. The
remainder of his hospital course was unremarkable. His renal
function gradually improved. Due to explantation of his ICD
system, he was fitted for the LifeVest external defibrillator
system prior to discharge. He will continue to require
intravenous antibiotics for an additional four weeks and then
return for an AICD in six weeks.
Medications on Admission:
MEDS (on Transfer):
- Oxacillin 2gm q 4 hours (has peripheral 22 g. IV in hand, poor
access, port a cath)
- Lasix 80mg IV daily
- Lisinopril 20mg daily
- Procardia XL 30mg daily
- Digoxin .25 daily
- Zocor 40 daily
- Protonix 40 daily
- KCL 20 meq daily
- Lopressor 25mg twice daily
- Doxepin 200 mg qhs
- Sliding scale insulin
- NPH 50 units QAM, 40 u QPM
- Vicodin prn
- Phenergan prn
- Ambien prn
- Ativan 1mg prn
- Tylenol prn
- Nitroglycerin 1 inch Q6H
.
MEDS (OP)
- Lasix, Zestril, Coumadin, Procardia, Lanoxin, Insulin,
Doxepin, Zocor, Prevacid, KCL, Lopressor (wife to bring in med
list)
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxacillin 10 g Recon Soln Sig: Two (2) grams Injection Q4H
(every 4 hours): 4 weeks - last dose [**2127-4-11**].
Disp:*QS 1 month* Refills:*0*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO once a
day: take three tabs for a total of 225 mcg/day.
Disp:*90 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Doxepin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
Disp:*60 Capsule(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QPM: Take daily
Disp:*60 Tablet(s)* Refills:*2*
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 52 QAM
and 40 QPM units Subcutaneous once a day: take as directed.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
MSSA bacteremia/ICD lead vegetation/Atrial Septal Defect - s/p
ASD closure and ICD and Port-a-cath removal, Coronary artery
disease - s/p CABG [**40**] years ago, left Ventricular Apical
Aneurysm, Ischemic Cardiomyopathy, Diabetes Mellitus, s/p AICD
placement in [**2125**] ([**Company 1543**] Maximow VR single chamber ICD)(last
fired in [**Month (only) 956**]), s/p embolic CVA in [**2113**] with mild expressive
aphasia and right hemiparesis on coumadin, Hypothyroidism/h/o
[**Doctor Last Name 933**] disease s/p radioactive iodine ablation, Hypertension,
High Cholesterol, Renal Insufficiency
Discharge Condition:
Good
Discharge Instructions:
1)Please be sure to take all medications as directed.
2)You will need to take your Oxacillin antibiotic through your
PICC line - last doses will be on [**2127-4-11**].
3)You should continue taking your coumadin as previously, and
have your blood drawn at your usual coumadin lab to adjust your
dose. INR should be checked within 72 hours of discharge.
4)If you have chest pain, shortness of breath, changes in your
speech or new weakness, or fever or chills please call your
doctor or come to the emergency room.
5)Have thyroid function tests checked in 2 weeks following
discharge. You should contact your PCP for appropriate blood
draw.
6)Please checky lytes, BUN and Cr weekly - arrange with VNA or
local PCP.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 914**] - call for appt([**Telephone/Fax (1) 170**])
EP service, Dr. [**Last Name (STitle) **] in 4 weeks, call for appt([**Telephone/Fax (1) 14967**])
PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 14966**] in 2 weeks, call for appt([**Telephone/Fax (1) 14967**])
Completed by:[**2127-5-1**]
|
[
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"428.0",
"997.1",
"414.8",
"427.31",
"438.11",
"790.7",
"V45.81",
"041.11",
"414.01",
"244.1",
"996.62",
"438.20",
"250.00",
"421.0",
"429.71",
"401.9",
"272.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.07",
"88.44",
"39.61",
"88.56",
"35.71",
"88.72",
"37.99",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
9114, 9165
|
3283, 6643
|
319, 510
|
9806, 9813
|
2568, 3260
|
10574, 10925
|
2097, 2159
|
7289, 9091
|
9186, 9785
|
6669, 7266
|
9837, 10551
|
2174, 2549
|
246, 281
|
538, 1439
|
1461, 1950
|
1966, 2081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,722
| 102,572
|
3118
|
Discharge summary
|
report
|
Admission Date: [**2176-9-26**] Discharge Date: [**2176-10-4**]
Date of Birth: Sex: M
Service: ORTHOPEDIC
The patient was initially on the Service of Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] of
Orthopedics.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 14782**] is a 50 year old
male with a past history significant for hepatitis C,
depression, childhood asthma, chronic low back pain status
post fall to the low back three months prior to admission,
anxiety, history of suicide attempt times two with last in
[**2176-7-10**], status post penile implant, and status post
left rotator cuff in [**2173**]. The patient was admitted to the
hospital under the Orthopedics Service and taken to the
Operating Room on [**2176-9-26**], where the patient underwent
uncomplicated L5-S1 decompression/fusion with right ICBG
placement for noted lumbar spondyloses.
The patient initially tolerated the procedure well without
complication. The patient was transferred to the Floor on
[**2176-9-27**]. The patient was noted to exhibit increasing
confusion. The patient's epidural catheter was discontinued
on postoperative day number one and the patient was started
on PCA pain control.
On [**2176-9-28**], postoperative day number two, the Orthopedics
Service notes the patient increasingly confused and now
agitated. Psychiatry is consulted. Conclusions of
Psychiatry consult are the following: History and
presentation of agitation, somnolence and disorientation
consistent with delirium, although patient has denied recent
alcohol use, his past history would strongly suggest alcohol
withdrawal. Psychiatry Service suggests alcohol withdrawal
prophylaxis with Ativan, continuation with one-to-one sitter
for patient's safety.
On [**2176-9-29**], the patient was noted to be increasingly
agitated, fever of 100.5 F., is noted; tachycardia to 110
beats per minute noted. Orthopedics Service continuing with
alcohol withdrawal prophylaxis, Ativan and normal saline drip
for decreased sodium and chloride in the likely setting of
volume depletion.
On [**2176-9-30**], Orthopedics Service is called to see patient
for increasing tachypnea, tachycardia and general agitation.
A fever is noted at 101.3 F.; heart rate between 110s and
120s. EKG is notable for sinus tachycardia. A portable
chest x-ray is notable for poor inspiration. Left lateral
lung parenchymal margin not captured; patchy asymmetric
vascular congestion, greatest in right middle lobe. Right
upper lobe and left lower lobe with hilar fullness. Cannot
rule out right middle lobe infiltrate with normal cardiac
silhouette.
On [**2176-9-30**], postoperative day number four, a Medical
consultation is obtained for the above symptomatology.
Recommendations are to discontinue intravenous fluid in
likely setting of volume overload, position the patient
upright, cycle CK and troponin to rule out myocardial
infarction in the setting of congestive heart failure. Begin
Levaquin 500 intravenously q. day as treatment for likely
pneumonic process. Recommending CT angiogram to rule out
pulmonary embolism in the setting of immobility and recent
surgery.
On [**2176-9-30**], the Medical Service accepted the patient from
the Orthopedic Service for further treatment for complicating
issues.
On [**2176-9-30**], while in the service of the Medical Team, the
patient underwent CT angio of the chest to rule out pulmonary
embolism which was noted as negative. Mental status change
continued in the setting of delirium; alcohol withdrawal was
suspected. Haldol for p.r.n. agitation was continued while
QTC interval was monitored. Antibiotic regimen was changed
from Levaquin to Ceftriaxone and Flagyl for possible
aspiration pneumonia coverage.
On [**2176-10-1**], postoperative day number five, medical
cross-coverage was called to see the patient for increasing
respiratory rate from 34 to 50 per minute and [**Doctor Last Name 688**] mental
status, now notable to be unresponsive to sternal rub or
painful stimuli. On physical examination, it was noted the
patient's pupils were fixed and dilated with only minimal to
sluggish responsiveness.
Chest x-ray was noted for increasing right middle lobe
infiltrate and right middle lobe opacity. On [**2176-10-1**], in
the morning, at around 09:15, an Anesthesia Code was called.
Anesthesia Team responded to the bed of Mr. [**Known lastname 14782**] and noted
unresponsiveness and agonal breathing. The patient was
intubated successfully with the use of Atonomate 10 mg,
succinyl choline 100 mg. A MAC 3 blade was used without
complications and an 8.0 endotracheal tube was used. Good
breath sounds were noted bilaterally and a right femoral vein
line was inserted at that time.
On [**2176-10-1**], postoperative day number five, the patient was
transferred to the Service of the Medical Intensive Care
Unit-[**Location (un) **] Team. Initial thoughts on accepting the patient
Mr. [**Known lastname 14782**] by the Medical Intensive Care Unit Team: From a
respiratory standpoint the patient demonstrated a large
pneumonic process on chest x-ray with [**Doctor Last Name 688**] mental status
necessitating intubation. The plan was for pressure support,
ventilation, and treatment with Ceftriaxone, Levofloxacin,
Flagyl and aggressive pulmonary toilet.
From a neurological standpoint, differential included alcohol
withdrawal versus metabolic versus infectious, although the
patient had denied alcohol use since [**2176-2-8**]. From a
neurological standpoint, head CT scan the prior evening on
[**2176-9-30**], was noted as negative for acute process.
On [**2176-10-1**], the patient was procedurized with a right
radial arterial line and a left subclavian Cordis
PA-catheter, both without complications. Initial readings of
PA-pressure are 25/10, wedge was 5. The patient was noted to
have a fever of 108.0??????F. Aggressive use of ice packs and
cooling blankets were utilized. Surgery was consulted which,
on [**2176-10-1**], placed a right chest tube, #36 French, without
complication with infusion of one liter of cold sterile
water.
On [**2176-10-2**], the patient was noted to be hyperthermic to a
temperature maximum of 108.0 F., despite cooling blankets, OT
lavage and placement of chest tube. Dantrolene was given,
100 mg intravenously times one for fear of malignant
hyperthermia secondary to succinyl choline versus Haldol use.
Arterial blood gas notable for severe acidosis. Started on a
bicarbonate drip. The patient was noted to be persistently
hypotensive despite aggressive fluid resuscitation and
continuing use of Neo-Synephrine, Levophed and vasopressin
drips.
Acute renal failure was noted to be worsening on [**2176-10-2**].
The Renal Service was consulted which noted a rise in CK to
initially 13,500. Renal dysfunction thought secondary to
hypoperfusion/rhabdomyolysis. Urine output was noted to be
minimal. As such, Renal Service proceeded with CVVH
treatments via left femoral Quinton placement without
complications.
On [**2176-10-3**], it was noted that the patient's CPK levels
were 49,305, consistent with a picture of rhabdomyolysis.
BUN and creatinine indicating worsening renal function.
Lactate worsening to 11.3. The patient was started on CVA
with citrate anti-coagulation on [**2176-10-3**]. Temperature
maximum noted on [**2176-10-3**], was 102.0??????F.
On [**2176-10-3**], postoperative day number seven, in the Medical
Intensive Care Unit, the patient's white count was noted to
be 33.1 despite aggressive antibiotic therapy including
Levofloxacin, Flagyl, Ceftriaxone and Vancomycin for question
of central nervous system process.
On [**2176-10-4**], at 01:15 a.m., Medical Intensive Care Unit
cross cover intern was called to see patient for lack of
respirations. On examination, the patient did not respond to
verbal or noxious stimuli. Pupils were fixed and dilated.
There were no peripheral pulses. Auscultation of the chest
for two minutes revealed no breath sounds and no heart
sounds. The patient was pronounced dead at 12:55 a.m. on
[**2176-10-4**].
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Last Name (NamePattern1) 14783**]
MEDQUIST36
D: [**2177-5-9**] 14:54
T: [**2177-5-9**] 17:33
JOB#: [**Job Number 14784**]
|
[
"997.3",
"584.9",
"721.3",
"518.5",
"496",
"070.54",
"038.9",
"507.0",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"03.09",
"38.91",
"81.08",
"77.79",
"34.04",
"96.04",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
291, 8343
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,788
| 187,663
|
3547
|
Discharge summary
|
report
|
Admission Date: [**2167-6-16**] Discharge Date: [**2167-7-2**]
Date of Birth: [**2124-12-16**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 16229**] is a
42-year-old male with end-stage renal disease secondary to
FK506 toxicity with IGA nephropathy who has been on
hemodialysis three times a week through a left AV fistula.
He is status post liver transplant from [**2156**] and has had
excellent liver graft function. The patient presented on [**2167-6-16**] for a living related kidney transplant from his
sister.
PAST MEDICAL HISTORY:
1. Status post liver transplant in [**2156**] secondary to chronic
hepatitis B.
2. Hypertension.
3. End-stage renal disease secondary to FK506 toxicity/IgA
nephropathy.
4. Rheumatoid arthritis.
5. Depression.
6. GERD.
7. Status post hernia repair times two.
8. Status post AV fistula in [**2166-12-31**].
ALLERGIES: Penicillin.
ADMISSION MEDICATIONS:
1. Neurontin 300 mg q.o.d.
2. Zoloft 200 mg q.a.m.
3. Wellbutrin 200 mg q.a.m., 100 mg p.m.
4. Bactrim one tablet three times a week.
5. Renagel 400 mg t.i.d.
6. Prednisone 25 mg q.d.
7. Prograf 1 mg.
8. Diovan 80 mg q.d.
9. Plaqueril 200 mg b.i.d.
10. Metoprolol 100 mg q.d.
11. ............. 0.1 mg q.d.
12. Oxycontin 20 mg b.i.d.
13. Lorazepam 0.5 mg p.r.n.
14. Protonix 20 mg q.d.
15. Lasix 20 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vitals signs: 97.8,
blood pressure 117/64, heart rate 72, respiratory rate 18,
oxygen saturation 97% on room air. General: The patient was
a well-developed, well-nourished, very pleasant man in no
acute distress. HEENT: Normocephalic, atraumatic. Sclerae
were anicteric. The pupils were equal, round, and reactive
to light and accommodation. Extraocular movements intact.
Neck: Supple, no lymphadenopathy, no thyromegaly. Chest:
Clear to auscultation bilaterally. The patient was noted to
have two puncture sites that were well healed at the right
upper chest from prior Perma-Cath placements. Cardiac:
Normal S1, S2, regular rate and rhythm. Abdomen: Soft,
nontender. The liver was not palpable. There was a large
well healed scar from his transplant. Extremities: Without
edema, 2+ PT pulses bilaterally, 1+ palpable radial on the
left. There was a left AV fistula with bruit and thrill.
LABORATORY/RADIOLOGIC DATA: White count 15.2, hematocrit
34.9, platelets 409,000, INR 1.0. Sodium 142, potassium 4.4,
BUN 20, creatinine 5.4, AST 15, ALT 15, alkaline phosphatase
68, T bilirubin 0.2, TSH 0.78, albumin 3.4, calcium 9.1,
phosphate 5.4.
Preoperative chest x-ray indicated no cardiopulmonary
process. A Persantine study in [**2167-1-31**] indicated no
angina or ischemic EKG changes. A MIBI study was without
perfusion defects and indicated a 46% ejection fraction.
An echocardiogram in [**2167-1-31**] showed a left atrial
dilation, mild LVH, left ventricular function was low normal.
Laboratories were normal. There was mild dilatation of the
aortic arch.
HOSPITAL COURSE: The patient is a 42-year-old male status
post liver transplant in [**2156**] secondary to hepatitis B
cirrhosis who now presented to the [**Hospital6 649**] on [**2167-6-16**] with end-stage renal disease
secondary to either FK506 toxicity or IgA nephropathy. He
also has hypertension.
He underwent a living related kidney transplant on [**2167-6-16**] from his sister. The procedure was uncomplicated. His
initial postoperative course was unremarkable. By
postoperative day number three, he was 7 liters positive.
His creatinine was down to 6.2 from 8 at admission. Later
that day, he developed increasing shortness of breath and he
dropped his oxygen saturations to 92%. He demonstrated a P02
of 62. A chest x-ray was obtained at that time which
demonstrated pulmonary edema. An EKG and cardiac
echocardiogram was negative.
He was transferred to the Intensive Care Unit and placed on a
nitroglycerin drip, CPAP and Lasix. Over the next 24 hours,
he was aggressively diuresed despite being negative by 2
liters for 24 hours. His symptoms did not improve. He was
empirically started on broad spectrum antibiotics. An
echocardiogram at that time obtained demonstrated normal
ejection fraction. No valvular abnormalities and normal left
ventricular wall thickness. Despite antibiotics and
aggressive diuresis, he required intubation on postoperative
day number five. Bronchoscopy at that time showed thick
secretions.
Over the next five days, he was diuresed and supported until
he was extubated on postoperative day number nine. At that
point, he remained extubated in the ICU and his creatinine
had decreased to 2.7. Psychiatry had consulted on the
patient for agitation which eventually resolved. A head CT
at the time was obtained which was normal. The patient had
hypernatremia with a free water deficit of around 4 liters
for which he was given D5W and it eventually resolved. The
patient was transferred to the floor on postoperative day
number 18. He had a slight increase in his creatinine from
2.6 to 2.9 for which a biopsy was performed which was read as
as noted which is consistent with acute failure rejection.
However, the granulomatous inflammation was not typical of
failure rejection and its significant was unclear. The team
thought that he was clear for discharge with adequate
follow-up by Dr. [**Last Name (STitle) **] from the Renal Department.
By postoperative day number 16, the patient was ambulating,
tolerating solids, and was stable for discharge. The patient
did leave the hospital before discharge papers were
finalized. However, we contact[**Name (NI) **] the patient and the patient
returned to review discharge medications and discharge
instructions as well as follow-up visits.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS:
1. End-stage renal disease secondary to FK506 toxicity/IgA
nephropathy, status post living related kidney transplant on
[**2167-6-16**] for which he has had excellent graft function.
2. Postoperative pulmonary edema requiring reintubation.
3. Hyponatremia.
4. Status post liver transplant, excellent liver graft
function, in [**2156**].
5. Hypertension.
6. Depression/anxiety.
DISCHARGE MEDICATIONS:
1. Bactrim one tablet p.o. q.d.
2. Tylenol p.r.n.
3. Gabapentin 300 mg tablet p.o. q.o.d.
4. Valcyte 400 mg p.o. q.o.d.
5. Amlodipine 5 mg tablet, two tablets p.o. q.d.
6. Metoprolol 50 mg tablet, one tablet p.o. b.i.d.
7. CellCept 1,000 mg p.o. b.i.d.
8. Reglan 10 mg tablet p.o. q.i.d.
9. Prednisone 20 mg tablet p.o. q.d.
10. Wellbutrin 100 mg tablet, two tablets p.o. q.d.
11. Sertraline 100 mg tablet p.o. q.d.
12. Tacrolimus 6 mg p.o. b.i.d.
13. Percocet one to two tablets p.o. q. four to six hours for
one week.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2167-7-6**] at 3:40 p.m., at the Transplant
Center, phone number [**Telephone/Fax (1) 673**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
the [**Last Name (un) 2577**] Building Transplant Center, [**Telephone/Fax (1) 673**], on [**2167-7-14**] at 10:40 a.m. as well as the Bone Density Center at
the [**Hospital Ward Name 23**] Center on [**2167-7-14**] at 1:20 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 12360**]
MEDQUIST36
D: [**2167-8-1**] 01:27
T: [**2167-8-8**] 20:24
JOB#: [**Job Number 16230**]
|
[
"403.91",
"311",
"583.89",
"E933.1",
"518.81",
"V42.7",
"276.1",
"293.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"38.93",
"38.91",
"96.71",
"55.69",
"96.04",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
6225, 7548
|
5818, 6202
|
3029, 5797
|
964, 1408
|
1423, 3011
|
601, 941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,313
| 107,306
|
19064
|
Discharge summary
|
report
|
Admission Date: [**2139-12-4**] Discharge Date: [**2139-12-13**]
Date of Birth: [**2081-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable Angina
Major Surgical or Invasive Procedure:
[**2139-12-8**] Coronary Artery Bypass Graft x 4 (Lima to LAD, SVG to
OM, SVG to Ramus, SVG to PDA)
[**2139-12-4**] Cardiac Catheterization
History of Present Illness:
58 y/o male with mulitple cardiac risk factors who presented to
outside hosptial with unstable angina/bilateral arm pain. ECG
showed small ST depressions, but was ruled out for an MI. He
then had a stress MIBI which was postive for symptoms and ST
depressions. Also revealed small reversible inferior defect and
old fixed defect. Patient was then transferred to [**Hospital1 18**] for
cardiac cath. Cath revealed three vessel coronary artery
disease, 80% distal left main stenosis, and 70-80% instent
restenosis of the RCA. Cardiac surgery was then consulted for
surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p s/p NSTEMI w/ PTCA/Stenting to RCA
in [**2136**] and again in [**2138**]
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Peripheral Neuropathy
Chronic Renal Insufficiency
Social History:
Lives with wife. Retired, previously worked as electrical
lineman. Now runs catering service. Previous 15 pack year
smoker, quit 30 years ago. ETOH: [**1-23**] drinks [**11-23**] time per week.
Family History:
CAD in Sister and Father
Physical Exam:
VS: 60 140/80
HEENT: EOMI, PERRL, NC/AT, OP Benign
Neck: Supple, FROM, -JVD
Lungs: CTAB -w/r/r
Heart: RRR, +S1/S2, -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, 2+ pulses, -Edema
Neuro: A&O x 3, MAE, Non-focal
Pertinent Results:
Cardiac Cath [**2139-12-4**]: 1. Coronary angiography revealed a right
dominant system status post RCA stenting. The LMCA showed a
complex 80% distal stenosis with involvement of the LAD and LCX
ostia. The LAD showed a 70% ostial stenosis with 70% stenosis of
the D1. The LCX showed an ostial 80% stenosis with diffuse
disease, including a 50% midsegment stenosis. The RCA showed
sequential 80% and 70% instent restenoses within the most
proximal RCA stent, with milder 20-30% restenosis of the mid and
distal stents.
Echo [**2139-12-7**]: Overall left ventricular systolic function is
normal (LVEF>55%). The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen in suboptmal views
(cannot exclude). There is a trivial/physiologic pericardial
effusion.
Head CT Scan [**2139-12-10**]: There is no evidence of intra- or
extra-axial hemorrhage. The ventricles, cisterns, and sulci are
unremarkable, without effacement. There does seem to be a slice
through the suprasellar cistern, which is missing, limiting
evaluation but the other slices suggest no abnormality. There is
no mass effect, hydrocephalus, or shift of the normally midline
structures. The [**Doctor Last Name 352**]-white matter differentiation appears
preserved.
Carotid Ultrasound [**2139-12-11**]: Significant amount of plaque at the
origins of the bilateral internal carotid arteries, associated
with luminal narrowing estimated between 80 and 99% in diameter
on both sides.
EEG [**2139-12-11**]: Abnormal EEG due to the presence of diffuse
background
slowing and superimposed bursts of generalized mixed frequency
delta and
theta slowing. No focal or epileptiform features were seen.
Common
causes of encephalopathy include medications, metabolic causes,
and
infectious processes.
Brain MRI [**2139-12-12**]: The diffusion images demonstrate subtle areas
of slow diffusion in the right frontal cortical region with a
small area of subcortical acute infarct in the right frontal
lobe. A similar small area of signal abnormality is seen on
diffusion images in the left parietal cortical region. The
findings are suggestive of acute infarcts. There is no mass
effect, midline shift, or hydrocephalus seen. There are no
chronic territorial infarcts visualized. There is no evidence of
significant subcortical white matter ischemic disease seen.
[**2139-12-13**] 06:00AM BLOOD WBC-7.1 RBC-3.09* Hgb-9.9* Hct-28.0*
MCV-90 MCH-31.9 MCHC-35.3* RDW-14.1 Plt Ct-167
[**2139-12-13**] 06:00AM BLOOD Glucose-122* UreaN-34* Creat-1.9* Na-140
K-4.0 Cl-101 HCO3-28 AnGap-15
[**2139-12-7**] 09:35AM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE
[**2139-12-4**] 06:00PM BLOOD Triglyc-235* HDL-35 CHOL/HD-3.8
LDLcalc-52
Brief Hospital Course:
As mentioned in the HPI, patient was transferred from OSH for
cardiac catheterization. After cardiac catheterizaion - see
above results, cardiac surgery was consulted for surgical
revascularization. Patient had usual work-up along with an
echocardiogram - see above results. Plavix was stopped on [**12-4**].
Patient was consented for surgery and brought to the operating
room on [**2139-12-8**]. He underwent a coronary artery bypass graft x
4. Please see op note for surgical details. Following surgery
patient was transferred to the CSRU in stable condition on a
Neo-synephrine drip. Within 24 hours, he awoke neurologically
intact. Mechanical ventilation was weaned and patient was
extubated. Beta blockers and diuretics were initiated. Patient
was gently diuresed towards pre-op weight. His creatinine peaked
to 2.3 on postoperative day two. He required foley reinsertion
at that time for urinary retention but did not become oliguric.
Mr. [**Known lastname 52049**] [**Last Name (Titles) 52050**] experienced altered mental status, along
with fluctuations in level of alertness and incoherent speech.
The neurology service was consulted to evaluate for potential
embolic etiology and/or seizure. A head CT scan on [**12-10**]
showed no evidence of intracranial hemorrhage or of acute
territorial infarction. Carotid ultrasound was notable for
bilateral carotid disease, report stating that there was a
significant amount of plaque at the origins of the bilateral
internal carotid arteries, associated with luminal narrowing
estimated between 80 and 99% in diameter on both sides. An EEG
on [**12-11**] was deemed abnormal due to the presence of
diffuse background slowing and superimposed bursts of
generalized mixed frequency delta and theta slowing. No focal or
epileptiform features were seen. Findings were suggestive of an
encephalopathy. Narcotics were avoided and blood sugar managment
was optimized. He was also transfused to maintain hematocrit
near 30%. MRI imaging of the brain on [**12-12**] was notable
for findings suggestive of small acute cortical and subcortical
infarcts in the right frontal lobe and possibly in the left
parietal lobe. There was no evidence of mass effect or
hydrocephalus. There was no indication for Warfarin
anticogulation. Over several days, his neurological symptoms
improved as did his renal function. He continued to make
clinical improvements with medical therapy and made steady
progress with physical therapy. He remained in a normal sinus
rhythm. He responded nicely to diuresis and was tolerating room
air by discharge. He was cleared for discharge to home on
postoperative day five. At discharge, his BP was 130/70 with a
HR in the 80's. Room air saturations were 99% and all wounds
were clean, dry and intact. Given his carotid disease, his goal
SBP was between 120-140 to ensure adequate cerebral perfusion.
Also at discharge, he was voiding without difficulty.
Medications on Admission:
ASA 325mg qd
Plavix 75mg qd
Lipitor 20mg qd
Lisinopril 20mg qd
Lopressor 25mg [**Hospital1 **]
Glyburide 2.5mg qd
Glucophage 1000mg [**Hospital1 **]
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:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Services
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery bypass Graft x 4
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Acute on Chronic Renal Insufficiency
Postoperative Stroke with ?encephalopathy
Bilateral Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with water [**Doctor Last Name **] gentle soap.
Gently pat dry. Do not apply lotions, creams, or ointments to
incisions.
Do not bath.
Do not drive for 1 month.
Do not loft greater than 10 pounds for 2 months.
Make follow-up appointments and take all medications.
If you notice any redness or drainage from incisions, please
contact office immediately
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) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5315**] Follow-up
appointment should be in 3 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 52051**] Follow-up appointment
should be in 2 weeks
Completed by:[**2140-1-6**]
|
[
"357.2",
"997.09",
"V45.82",
"996.72",
"V17.3",
"272.0",
"V15.82",
"412",
"414.01",
"593.9",
"401.9",
"433.10",
"411.1",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.56",
"37.22",
"99.04",
"36.15",
"89.60",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8593, 8662
|
4548, 7469
|
338, 479
|
8923, 8929
|
1834, 4525
|
9360, 9843
|
1552, 1578
|
7668, 8570
|
8683, 8902
|
7495, 7645
|
8953, 9337
|
1593, 1815
|
283, 300
|
507, 1099
|
1121, 1325
|
1341, 1536
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,401
| 198,143
|
50514
|
Discharge summary
|
report
|
Admission Date: [**2167-4-30**] Discharge Date: [**2167-5-29**]
Date of Birth: [**2105-6-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
hand weakness
Major Surgical or Invasive Procedure:
C6 corpectomy and ACDF C7T1 with allograft and plate
tracheostomy
PEG
lumbar drain placements
History of Present Illness:
62-year-old woman who presents with cervical spondylitic
myelopathy. She reports difficulty with buttoning her blouse
and repeatedly dropping things. This has become progressively
more severe over the last several months, but dates back at
least a year or more. She has paravertebral spasm, which
migrates to the shoulders, but to no real radiculopathy. She
denies difficulty with bowel, bladder, or gait.
Past Medical History:
hypertension
Social History:
She smokes approximately a third of a pack per day.
Family History:
nc
Physical Exam:
On examination, her motor strength is [**6-11**] in the deltoid,
biceps, triceps, and hand intrinsics bilaterally. There may
have been some mild weakness of the triceps and deltoid on the
left, but this may have been effort dependent as well. The
lower extremity strength is normal. She is able to stand out of
a chair without using her arms. Her sensory examination showed
a decreased appreciation of light touch in the hands
bilaterally. It does not follow a dermatomal pattern. Her hand
intrinsics were diminished and graded [**5-12**] bilaterally. There
was no clonus. Lhermitte's phenomenon was absent. Hoffmann's
reflex was absent.
Exam on discharge: Awake and alert. Follows commands. Moving L
bicep and deltoid with 5-/5 strength. Moves R bicep 4-/5 and R
deltoid 5-/5. No movement in lower extremities.
Pertinent Results:
An MRI of the cervical spine on [**2166-12-5**] demonstrated normal
alignment. There were degenerative changes throughout with
significant compression at both C5-6 and C6-7 and compression
behind the body of C6 as well. There
was less severe, but still significant compression at the C7-T1
disc.
MRI C SPINE [**4-30**]
The patient is status post C6 corpectomy and partial resection
of a heavily
calcified PLL. There is extensive signal intensity abnormality
in the spinal cord, new since the study of [**2166-12-5**]. The
spinal cord is poorly defined at the level of surgery, which may
reflect, singly or in combination, contusion,infarction, or
direct mechanical injury. There appears to be intramedullary
hemorrhage inferior to the surgical site, again difficult to
characterize
Chest X ray [**5-6**]
Left lower lobe retrocardiac opacity has improved consistent
with improving atelectasis. Right middle lobe consolidation is
unchanged. There is evidence of loss of volume in the right
chest with tenting of the hemidiaphragm. This loss of volume is
most likely due to atelectasis in the right middle lobe. There
is no pneumothorax or large pleural effusion. Left PICC remains
in place. NG tube tip is out of view below the diaphragm. ET
tube is seen in standard position.
MRI brain [**2167-5-8**]
No acute intracranial abnormality. Paranasal sinus mucosal
reaction with fluid-fluid levels in the sphenoidal sinuses and
mastoid
opacification. This may be secondary to intubation.
MR [**Name13 (STitle) 2853**] [**2167-5-8**]
LUE Doppler [**2167-5-8**]
Non-occlusive DVT extending from the left axillary vein to the
subclavian vein. Complete thrombosis of the left basilic vein.
Chest X ray [**5-14**]
Unchanged moderate cardiomegaly with areas of atelectasis at
both the right and the left lung base. No newly appeared focal
parenchymal opacities. No larger pleural effusions. No
pneumothorax.
Echo [**5-18**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or 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 high normal.
There is an anterior space which most likely represents a
prominent fat pad.
Brief Hospital Course:
Pt was admitted electively to hospital, went to OR where under
general anesthesia underwent C6 corpectomy and C7T1 ACDF with
plate. She tolerated the procedure well, was extubated, and
post op was found to have poor motor exam. She underwent
emergent MRI which showed no hematoma or cord compression. She
was monitored in ICU with MAP>80 to promote cord perfusion. She
was also started on high dose steroids. She had slight
improvement in UE strength in morning but still no movement of
lower extremities. She was maintained at flat bedrest for dural
leak from OR but then activity liberalized [**2167-5-2**]. Steroids
were slowly tapered. She had slight improvement in UE motor
function. On [**5-4**] early morning she required intubation for
respiratory decline. She had a bronchoscopy that revealed
copious clear secreation. Repeat bronchoscopy was performed the
same day and more secretions were suctioned and the airway was
mildly erythematous.
On [**2167-5-5**] an additional repeat bronchoscopy was performed with
brochoalveleolar lavage of the left lower lobe. She continued to
require pressors to maintain a MAP above 80. Aterial line
placement for blood pressure monitoring failed. She also spiked
a fever to 102.8 and a fever workup was sent.
On [**5-6**] goal MAP of greater than 80 was deemed no longer
necessary, though the patient could not be weaned off pressurs.
Given the patients tenous respiratory status, secretion
production, and fevers, therapy for ventilator associated
pneumonia was initiated with vancomycin/cefepime/ciprofloxacin.
The BAL samples speciated to H.influenzae.
On [**5-7**] she continued to be febrile and a planned trach/PEG was
delayed. She remained consistently febrile overnight and on [**5-8**]
a.m she was transistioned to high dose ceftriaxone for better
coverage of H. Flu in her sputum. An MRI of the cervical spine
was ordered as part of fever workup and this showed an increase
in pseudomeningoceal but cord comprssion was not suspected. She
was febrile on [**5-9**] and antibiotic dosing was increased per ID.
She was found to have a DVT at her Left PICC site and a Heparin
drip was started when cleared by Neurosurgery.
[**Date range (1) 105207**] Heparin drip remained on with a goal PTT of 45-60 for
the treatment of her DVT. She remained febrile with a rising WBC
count and ID changed her abx regimen to ceftriaxone and
linezolid. On [**5-12**] a tracheostomy was attempted but was aborted
when a CSF collection was encountered. A JP drain was placed at
the site of the fluid collection and she was transferred back to
the ICU. CSF was sent for culture at that time. The JP drain
continued with drainage of CSF and on [**5-14**] she underwent
uncomplicated placement of lumbar drain, her JP drain was
removed and a stitch was placed on the site.
[**5-15**]- Pt underwent tracheostomy and PEG tube placement. Her
lumbar drain continued to drain and her neck remained soft
without any palpable fluid collection. Her JP site had no active
drainage. Her abx continued per ID recs.
[**Date range (1) 52620**]- Her WBC count continued to trend down over the weeknd
and she remained on abx treatment for hospital aquired PNA with
H.Flu and MRSA. Her lumbar drain stopped functioning on [**5-17**] and
it was pulled without complication. Her Heparin GTT was held
overnight in preparation for lumbar drain placement on [**5-18**].
[**5-18**]- Pt underwent placement of two lumbar drains and tolerated
this procedure very well. Both drains were functioning well and
she was draining a total of 15-20cc of CSF per hour.
[**5-19**]- Pt had small amount of serosanguinous drainage at the
lumbar drain sites that was insignificant. Her glycopyrolate was
increased. On physical examination it was noted she had some
thrush and fluconazole was started. She was weaned off of neo.
[**5-20**]: She was switched to cefazolin Q8H for drain prophylaxis
after finishing her course of antibiotics for ventilator
associated pneumonia. She was switched hydrocortisone from to
prednisone to further wean off of steroids.
She continued to have lumbar drain in place. CSF was cultured
for surveillance which revealed no growth. She continued to
have hypotension but remained aymptomatic. She was started on
Glycopyrrolate to improved her pressures on [**5-21**]. On Sunday,
[**5-24**], her LD was removed and sutures were placed which should be
removed 7-10 days. On [**5-25**], patient was stable on examination.
No drainage was observed at the trach site or around lumbar
drain sites. Her PTT was at goal and coumadin 5mg QD was started
and was therapeutic at INR 2.4 [**2167-5-26**] and heparin drip was
discontinued. She will need to remain on coumadin for [**4-12**]
months for treatment of left arm DVT. Her exam remained stable
with trapezious full, deltoid/bicep 5-/4+ and no
triceps/grip/LE. Wound clean and dry.
Medications on Admission:
albuterol,esidrix 12.5, lipitor80, toprol XL 50,lisinopril
10,MVI, NTG prn
Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
3. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4
hours) as needed for pain.
10. midodrine 2.5 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
goal INR 2.5 - 3.0.
12. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever.
13. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for thick
secretions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
cervical spondylotic myelopathy
Hospital aquired pneumonia
quadraplegia
Pseudomeningocele
Upper extremity DVT
CSF leak
Sepsis
Pneumonia
MRSA
Respiratory failure
Post-op Fever
Delirium
dysphagia
Transient transaminitis
Adjustment disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Keep wound clean
?????? Take medication as instructed.
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote
bony fusion. Please use bone stimulator per instructions from
vendor.
**Remove lumbar drain sutures [**2167-6-3**]***
Followup Instructions:
YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN
UNTIL THE FOLLOW UP APPOINTMENT
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED AP AND LATERAL C SPINE XRAYS PRIOR TO YOUR
APPOINTMENT
Completed by:[**2167-5-28**]
|
[
"293.0",
"E878.1",
"112.0",
"305.1",
"349.2",
"997.31",
"401.9",
"041.5",
"349.31",
"518.5",
"E879.8",
"E870.0",
"309.9",
"336.1",
"721.1",
"344.00",
"250.00",
"453.84",
"453.81",
"041.12",
"V45.82",
"997.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.59",
"03.09",
"43.11",
"81.02",
"96.6",
"81.63",
"80.99",
"31.1",
"33.24",
"86.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10767, 10837
|
4428, 9299
|
322, 418
|
11119, 11119
|
1838, 4405
|
11644, 11959
|
978, 982
|
9424, 10744
|
10858, 11098
|
9325, 9401
|
11295, 11621
|
997, 1643
|
269, 284
|
446, 857
|
1662, 1819
|
11134, 11271
|
879, 893
|
909, 962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,083
| 119,635
|
22865
|
Discharge summary
|
report
|
Admission Date: [**2134-3-22**] Discharge Date: [**2134-3-30**]
Date of Birth: [**2069-7-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 29055**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
History of Present Illness:
64-year-old male with PMHx of CAD s/p DES to prox LAD in [**1-23**] &
[**7-23**], HTN, HLD & paroxysmal atrial fibrillation s/p PVI [**3-22**] who
presents with acute CHF exacerbation secondary to excessive
fluid resuscitation during PVI today. Patient received 3.3L of
fluid during procedure and urine output was only 300ml. He
received lasix IV 40mg x 2 with minimal effect. Given patient's
borderline hypotension, he was transferred to the CCU for
diuresis and close monitoring.
Patient complains of worsening DOE & orthopnea (two pillows at
baseline; now sleeping basically upright) over the past 2 days
prior to admission. Of note, he reports that he was instructed
to stop taking his metolazone 2-3 weeks ago for poor renal
function, but continued taking furosemide 80mg [**Hospital1 **]. Denies any
recent dietary indiscretion and states that he has been
compliant with his medications.
.
On review of systems,
(+): Per HPI, intermittent lightheadedness, completed a course
of antibiotics for pneumonia about 3 weeks prior to admission
(-): He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope.
.
In the PACU, initial VS were BP 96/59, HR 72, 93% on shovel
mask. Patient was still mildly sedated, but able to carry on a
conversation
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: (see below)
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to prox LAD in [**1-23**]
and DES to prox LAD in [**7-23**]
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
CAD s/p DES to prox LAD in [**1-23**] and DES to prox LAD in [**7-23**]
Paroxysmal atrial fibrillation s/p DCCV [**10-28**] & [**11-27**] with early
reversion to atrial fibrillation
Nonsustained ventricular tachycardia noted on Holter [**2-24**]
CHF - (LVEF 60% in [**10-28**] - 29% since [**2134-2-9**])
Hypertension
Hyperlipidemia
Obstructive Sleep apnea - does not use cpap
Gout
Dysphasia (per Dr.[**Name (NI) 59117**] [**2134-2-10**] note)
[**1-22**]: Left wrist fx w/external fixation
Cough syncope (per Dr.[**Name (NI) 59117**] [**2134-2-10**] note)
Social History:
Patient is disabled and married, and has 2 grown children.
-Tobacco history: Denies.
-ETOH: 2 beers/week.
-Illicit drugs: Denies.
Family History:
His brother died of an MI at age 50. Another brother has
hypertension. His father had a stroke at age 75. No 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 *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2134-3-22**] 07:00AM PT-26.1* INR(PT)-2.5*
[**2134-3-22**] 07:00AM PLT COUNT-238
[**2134-3-22**] 07:00AM NEUTS-77.7* LYMPHS-15.9* MONOS-3.8 EOS-2.1
BASOS-0.5
[**2134-3-22**] 07:00AM WBC-12.7* RBC-5.45 HGB-16.7 HCT-48.0 MCV-88
MCH-30.7 MCHC-34.8 RDW-14.8
[**2134-3-22**] 07:00AM GLUCOSE-141* UREA N-55* CREAT-2.5* SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-19
[**2134-3-22**] 07:50AM SODIUM-140 POTASSIUM-3.9 CHLORIDE-101
[**2134-3-22**] 12:37PM freeCa-1.09*
[**2134-3-22**] 12:37PM HGB-14.7 calcHCT-44
[**2134-3-22**] 12:37PM GLUCOSE-171* LACTATE-1.5 NA+-138 K+-5.3
[**2134-3-22**] 12:37PM TYPE-CENTRAL VE O2-76 PO2-25* PCO2-68*
PH-7.23* TOTAL CO2-30 BASE XS--1 INTUBATED-INTUBATED
[**2134-3-22**] 08:04PM PT-32.0* PTT-27.4 INR(PT)-3.2*
[**2134-3-22**] 08:04PM PLT COUNT-192
[**2134-3-22**] 08:04PM NEUTS-88.9* LYMPHS-6.6* MONOS-3.9 EOS-0.3
BASOS-0.4
[**2134-3-22**] 08:04PM WBC-15.0* RBC-5.00 HGB-15.4 HCT-45.2 MCV-90
MCH-30.8 MCHC-34.0 RDW-15.2
[**2134-3-22**] 08:04PM CALCIUM-9.0 PHOSPHATE-4.8* MAGNESIUM-2.1
[**2134-3-22**] 08:04PM CK-MB-6 cTropnT-0.48*
[**2134-3-22**] 08:04PM CK(CPK)-219
[**2134-3-22**] 08:04PM GLUCOSE-109* UREA N-57* CREAT-3.1* SODIUM-143
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-29 ANION GAP-15
Imaging:
ECHO [**2134-3-24**]
The left atrium is moderately dilated. The right atrium is
markedly dilated. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is top normal/borderline
dilated. There is severe global left ventricular hypokinesis
(LVEF = 20 %) with relative preservation of the basal
inferolateral wall. No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is moderately dilated
with depressed free wall contractility. 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. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction.
Moderate right ventricular dilation and dysfunction. Moderate
mitral and tricuspid regurgitation. Moderate pulmonary
hypertension.
CHEST XRAY PA/L
[**2134-3-27**]
Moderate cardiomegaly is unchanged since [**2134-3-27**]. There is no
evidence of pleural effusion. Bilateral apical pleural
thickening is mild.
Brief Hospital Course:
64-year-old male with PMHx of CAD s/p DES to prox LAD in [**1-23**] &
[**7-23**], HTN, HLD & paroxysmal atrial fibrillation s/p PVI [**3-22**] who
presents with acute CHF exacerbation secondary to excessive
fluid resuscitation and ineffective diuresis during PVI today.
.
# PUMP/Acute decompensated CHF: LVEF decreased significantly
from 55-60% ([**October 2133**]) to 29% ([**January 2134**]). No evidence of ischemia on
EKG and patient denies any chest pain. Worsening of LV function
likely secondary to tachycardia-induced cardiomyopathy in the
context of persistent atrial fibrillation. Current CHF
exacerbation most likely triggered by fluid overload from IVF
during pulmonary vein isolation in the context of already
worsening CHF since prior to admission (after stopping
metolazone for 2 weeks). Last CHF exacerbation was [**1-29**]. Patient
denies any dietary indiscretion or medication non-compliance. He
was diuresed with furosemide gtt and metolazone which was
eventually switched to PO torsemide. His creatinine continued to
trend down in this setting. He was discharged on 40 mg
torsemide daily.
.
# CORONARIES/CAD: Patient has had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to proximal LAD, in
[**January 2128**] and [**July 2128**]. He denies any recent chest pain or ACS. No
changes on EKG suggestive of ischemia. Continue aspirin 81mg,
simvastatin 20mg. Started on spironolactone. His metoprolol was
restarted and uptitrated to control his rapid Afib.
.
# RHYTHM: H/o paroxysmal atrial fibrillation s/p failed DCCV
[**10-28**] & [**11-27**] with early reversion to atrial fibrillation (2
days). Had pulmonary vein isolation [**3-22**] with successful
conversion to sinus rhythm. He has failed sotalol and
amiodarone. Has been on atenolol in the past. Metoprolol and
amiodarone were restarted and he was cardioverted but this did
not last more than 20 secs. Given a transaminitis, the
amiodarone was stopped. He continued in rapid Afib for several
days. Metoprolol then uptitrated to 100mg TID, however he
continued with high heart rates. He was restarted on Amiodarone
for rate and rhythm control. He was started on warfarin 2 mg
daily for anticoagulation with INR check scheduled for [**4-1**].
.
# Leukocytosis: Patient recently completed antibiotic course for
infiltrate on CXR. Currently with no clinical signs of
infection; no cough, dysuria, fevers or chills. He did not
reveal signs of infection. We did start him on a combivent
inhaler PRN for shortness of breath.
# PND/Orthopnea: patient noticed increasing symptoms of PND and
Orthopnea despite diuresis noting that he frequently began
waking up at night with SOB. A chest xray was performed that
revealed resolution of pulmonary edema. We did start him on a
combivent inhaler PRN for shortness of breath.
.
# HTN: Patient is currently relatively hypotensive, so
metoprolol and diltiazem were being held on admission while he
was being diuresed. Diltiazem was discontinued at time of
discharge, and he was restarted on 150 mg metoprolol daily.
.
# Hyperlipidemia: Continued simvastatin & fish oil. Fenofibrate
held as not on formulary.
.
# Gout: Not currently an issue. Patient takes colchicine as
needed. Tolmetin was discontinued given renal failure. PCP may
consider starting allopurinol given > 4-5 episodes of gout per
year.
.
FEN: no IVF, replete electrolytes prn, low sodium/heart healthy
Medications on Admission:
COLCHICINE [COLCRYS] - ([**Month/Year (2) **] by Other Provider) - 0.6 mg
Tablet - 1 Tablet(s) by mouth once daily as needed for gout
DILTIAZEM HCL - ([**Month/Year (2) **] by Other Provider) - 360 mg
Capsule,
Extended Release - 1 Capsule(s) by mouth once daily
FENOFIBRATE MICRONIZED - ([**Month/Year (2) **] by Other Provider) - 134
mg
Capsule - 1 Capsule(s) by mouth once daily
FUROSEMIDE - ([**Month/Year (2) **] by Other Provider) - 40 mg Tablet - 2
Tablet(s) by mouth twice daily
METOLAZONE [ZAROXOLYN] - ([**Month/Year (2) **] by Other Provider) - 5 mg
Tablet - 1 Tablet(s) by mouth once daily
METOPROLOL TARTRATE - ([**Month/Year (2) **] by Other Provider) - 25 mg by
mouth twice daily
POTASSIUM CHLORIDE - ([**Month/Year (2) **] by Other Provider) - 60 mEq
Capsule, Extended Release twice daily
SIMVASTATIN - ([**Month/Year (2) **] by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once daily
TADALAFIL [CIALIS] - ([**Month/Year (2) **] by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth as needed
TOLMETIN - ([**Month/Year (2) **] by Other Provider) - 400 mg Capsule - 1
Capsule(s) by mouth once daily for gout as needed
WARFARIN - ([**Month/Year (2) **] by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once daily or as directed
Medications - OTC
ASPIRIN - ([**Month/Year (2) **] by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth once daily
OMEGA-3 FATTY ACIDS [FISH OIL] - ([**Month/Year (2) **] by Other Provider)
- 1,000 mg Capsule - 1 Capsule(s) by mouth once daily
.
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for gout.
2. fenofibrate Oral
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cialis 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
5. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for SOB, anxiety.
Disp:*60 Tablet(s)* Refills:*0*
10. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
11. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
14. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
15. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check Chem-7 on [**4-1**] with results to Dr. [**Last Name (STitle) 8049**]
17. Spacer
Please provide spacer x1 to use with inhaler
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation s/p PVI
Heart Failure - systolic dysfunction
Coronary Artery Disease
Hypertension
Dyslipidemia
OSA - intolerant to CPAP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pulmonary vein isolation for recurrent atrial
fibrillation. This procedure went well but it took a few days
for the rhythm to convert to a normal sinus rhythm. In the
meantime, you were restarted on amiodarone and your medicines
were adjusted. You were having trouble breathing and we gave you
diuretics to remove extra fluid in your lungs. You now weigh 208
pounds and this should be considered yoour ideal or "dry"
weight. Please weigh yourself every day and talk to Dr. [**Last Name (STitle) 20222**]
if you notice your weight increases more than 3 pounds in 1 day
or 5 pounds in 3 days. Dr. [**Last Name (STitle) 20222**] can then go up or down on
your diuretic dose. At this point, we feel that your shortness
of breath is not cardiac related and you should talk to Dr. [**Last Name (STitle) 8049**]
about repeating the pulmonary function tests. You will go home
on an inhaler and a sleeping pill to help you at night.
We made the following changes to your medicines:
1. START Warfarin 2mg daily to prevent blood clots after your
ablation. Please get your INR checked on Thursday [**4-1**] at Dr. [**Name (NI) 59118**] office.
2. START taking amiodarone to keep you in a normal sinus rhythm.
You will need to have your liver function tests, your pulmonary
tests and thyroid tests followed regularly when you are on this
medicine.
3. START taking Lorazepam as needed for shortness of breath. The
pulmonologists here suggest that you use your CPAP as much as
possible and follow up with the doctor [**First Name (Titles) **] [**Last Name (Titles) 2875**] the CPAP.
You should also get pulmonary function tests through Dr. [**Last Name (STitle) 8049**].
4. Increase your Metoprolol to 150 mg daily
5. START a Combivent inhaler to prevent your shortness of breath
6. Stop taking Furosemide, take Torsemide 40 mg instead
7. STart taking spironolactone to help keep the fluid off.
8. Stop taking Diltiazem, metolazone, Tolmetin, and potassium.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 488**] J.
Location: [**Hospital **] MEDICAL GROUP
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 59119**]
Phone: [**Telephone/Fax (1) 8036**]
When: Thursday, [**4-1**], 2:30PM
Name: [**Last Name (LF) 5051**], [**First Name7 (NamePattern1) **] [**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**]
When: [**Last Name (LF) 2974**], [**4-2**], 3:30PM
|
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"428.0",
"428.23",
"414.01",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"99.61",
"37.34"
] |
icd9pcs
|
[
[
[]
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|
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|
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|
2048, 2119
|
2889, 3020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,261
| 152,135
|
50921
|
Discharge summary
|
report
|
Admission Date: [**2158-3-17**] Discharge Date: [**2158-3-23**]
Date of Birth: [**2082-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Severe bradycardia
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
75y/o M w/ h/o a flutter s/p non-Q-wave MI, and 3 ablations done
at [**Hospital1 18**], been maintained on meds and no anticoagulation for the
past few years. Was increased to 400mg amiodaron since 200mg was
not enough to suppress AF. No recent dose change. Was in usual
state of health until yesterday when he felt very fatigued. Day
of admission, he was feeling well. He hosted a banquet for his
bowling league and made a speech. After arriving home around
3pm, he started to feel "woozy" and had double vision. He
complained of SOB, no n/v/CP or diaphoresis. He presented to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation.
.
At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], found to be brady in the 20s. EKG showed narrow
complexes, no visable P waves. Patient initially normotensive,
then dropped his pressures to SBP 70's after being given valium.
He was then transcutaneously paced, though per report, pacing
was not working well. He was transiently hypertensive during
this pacing. He was given one dose of Atropine 0.5mg IV and
transferred to [**Hospital1 18**] for further management. Baseline HR is in
the 40s-60s. He recently started synthroid for hypothyroidism.
Of note, his HR increases with movement.
.
Patient was doing well up until 5am when he had several 6 second
pauses. He was transferred to the CCU for nursing concern.
Patient w/o any c/o this am. No chest pain/pressure, no SOB, no
LH/dizzyness.
Past Medical History:
1. A flutter s/p Non-Q wave MI, 3 ablations for AF
2. WPW
3. Cellulitis
4. Colon Cancer s/p resection [**2149**]
5. DVT in [**2144**]
6. Htn
7. s/p appy
8. L hand tendon repair
9. BPH
Social History:
Quit tob 28 years ago. Drinks 2 EtOH beverages daily, last
drink was day of admission. Lives with his wife. 7 children.
Family History:
NC
Physical Exam:
T: 98.3 P: 36 BP: 113/54 R: 16 O2: 98% RA
Gen: obese male, awake, lying in bed, NAD
HEENT: NC/AT, PERRL, EOMI, MM dry
Neck: thick neck, unable to appreciate JVD
Heart: brady, regular, distant heart sounds, no m/r/g
Chest: bibasilar crackles at bases, o/w CTA supriorly
Abd: soft, NT/ND, +BS
Extr: warm, 2+ DP/PT pulses bilaterally, no E/C/C
Neuro: A, OX3, no focal deficits
Pertinent Results:
OSH labs: Trop I 0.02; Cr 1.6 (6 years ago Cr baseline was 1.0),
K 4.6, Ca 8.5; Hct 36.1
.
.
EKG: Brady 29 bpm, LAD, junctional rhythm, no STE or Depressions
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2158-3-22**] 06:50AM 6.6 3.72* 12.2* 35.6* 96 32.7* 34.2 13.3
107*
[**2158-3-21**] 06:20AM 6.6 4.13* 13.3* 39.2* 95 32.2* 34.0 13.3
102*
[**2158-3-20**] 05:01AM 5.5 3.93* 12.6* 37.8* 96 32.2* 33.4 13.6
114*
[**2158-3-19**] 06:20AM 6.1 3.96* 12.8* 38.1* 96 32.3* 33.5 13.4
109*
[**2158-3-18**] 05:46AM 6.9 3.81* 12.3* 36.5* 96 32.3* 33.8 13.7
113*
[**2158-3-17**] 09:35PM 5.9 3.79* 12.5* 36.4* 96 33.0* 34.4 13.6
123
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2158-3-22**] 06:50AM 95 24* 1.1 139 4.0 106 24 13
[**2158-3-21**] 06:20AM 100 27* 1.3* 143 4.2 109* 24 14
[**2158-3-20**] 05:01AM 91 29* 1.2 140 4.3 107 25 12
[**2158-3-19**] 06:20AM 96 34* 1.4* 140 4.9 106 25 14
[**2158-3-19**] 12:04AM 87 37* 1.5* 142 4.7 108 24 15
[**2158-3-18**] 05:46AM 108* 43* 1.7* 140 5.5* 109* 20* 17
[**2158-3-17**] 09:35PM 89 40* 1.6* 140 5.1 108 21* 16
.
CK(CPK)
[**2158-3-19**] 06:20AM 632*
[**2158-3-19**] 12:04AM 712*
[**2158-3-18**] 04:28PM 639*
[**2158-3-18**] 05:46AM 632*
[**2158-3-17**] 09:35PM 655
.
CK-MB MB Indx cTropnT
[**2158-3-19**] 06:20AM 33* 5.2
[**2158-3-19**] 12:04AM 34* 4.8 0.27*
[**2158-3-18**] 04:28PM 33* 5.2 0.20*
[**2158-3-18**] 05:46AM 33* 5.2 0.29
[**2158-3-17**] 09:35PM 41* 6.3* 0.22
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2158-3-19**] 06:20AM [**Telephone/Fax (1) 105833**] 43 3.6 85
.
AMIODARONE AND DESETHYLAMIODARONE METHYLMALONIC ACID
[**2158-3-19**] 08:55PM PND
[**2158-3-17**] 09:35PM PND
.
**FINAL REPORT [**2158-3-20**]**
RAPID PLASMA REAGIN TEST (Final [**2158-3-20**]):
NONREACTIVE.
Reference Range: Non-Reactive.
.
VitB12
[**2158-3-19**] 06:20AM 204
.
TSH
[**2158-3-17**] 09:35PM 2.7
IMMUNOLOGY CRP
[**2158-3-19**] 06:20AM 15.6
.
.
[**3-18**] Head CT
FINDINGS: There is no evidence of intra- or extra-axial
hemorrhage. There is no mass effect, hydrocephalus or shift of
the normally midline structures. There is a subcentimeter
hypodensity in the right frontal lobe perhaps a prior lacunar
infarct, but the [**Doctor Last Name 352**]-white matter differentiation appears
intact. The osseous structures are unremarkable.
IMPRESSION: No evidence of acute intracranial process or
hemorrhage.
.
[**2158-3-19**] CTA Head and Neck
IMPRESSION:
1. No evidence for obstruction, stenosis, or aneurysm of the
anterior or posterior circulations in the neck and head.
2. Mediastinal lymphadenopathy.
.
[**2158-3-19**] ECG:
Probable ventricular pacing with occasional conducted QRS with
long P-R
interval. Premature ventricular contractions or aberrant
ventricular conduction. Conducted beats are left axis deviation,
intraventricular conduction delay. Consider atrial sensing
abnormality. Since previous tracing of [**2152-4-25**], atrial flutter
not seen, ventricular paced new.
.
[**2158-3-20**] ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 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: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.43 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.78
Mitral Valve - E Wave Deceleration Time: 270 msec
Pulmonic Valve - Peak Velocity: 0.8 m/sec (nl <= 1.0 m/s)
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal biventricular systolic function.
.
[**2158-4-18**] CXR:
FINDINGS: Compared with 5/1, a dual lead AV left subclavian
pacemaker has been placed. The leads appear in unremarkable
positions. No pneumothorax or other acute process.
Brief Hospital Course:
A/P: 75 yo M p/w symptomatic bradycardia on amio 400mg daily and
atenelol for [**Last Name (un) **].
.
Rhythm
# Bradycardia: At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], found to be brady in the 20s. EKG
showed narrow complexes, no visable P waves. Patient initially
normotensive, then dropped his pressures to SBP 70's after being
given valium. He was then transcutaneously paced, though per
report, pacing was not working well. He was transiently
hypertensive during this pacing. He was given one dose of
Atropine 0.5mg IV and transferred to [**Hospital1 18**] for further
management. While at [**Hospital1 18**] pt was not hypotensive. Pt with sinus
node dysfunction s/p temp pacer on [**3-18**] he was maintained on bed
rest, IV ancef, daily pacer check. Pt remained stable s/p temp
pacer without hypotension, however following temp pacer
developed mental status changes with garbled speech. Neurology
was consulted and thought to be transient brainstem ischemia in
setting of transient episode of hypotension at OSH. His
dysarthria resolved without intervention. He did not have any
dysrhythmias, no CP/Palpitations/SOB post pacer. No bleeding or
hematoma devloped. Pt underwent permanent Pacer placement on
[**2158-3-21**] wihtout any complications. Pt's home atenolol was
restarted at a lower dose on last day of admission, given his BP
started to increase 120-130s.
.
#.CAD: Pt had elevated Tn, in setting of severe bradycardia, HR
17-20s. No EKG elevations or depressions to suggest ischemia. Pt
was started on ASA 325, statin 80mg, and low dose BB.
.
Pump: Pt was initially diuresed gently on presentation. He
remained euvolemic. His ECHO was normal , normal EF, normal
biventriclar systolic function.
.
# Htn: In setting of episode of hypotension, all
antihypertenisve meds were held intially held. His BP remained
well controlled and stable at SBP 120s without BB. His home
Atenolol was restarted on [**2158-3-22**] at a lower dose 12.5mg daily
for BP increasing to 130s. He was sent home with 12.5mg Atenolol
daily.
.
#. Mental Status changes/Dysarthria: Pt developed dysarthria and
confusion s/p temp pacer placement. Neurology was consulted and
felt it may have been a transient episode of poor perfusion to
brainstem (ischemia) related to severe bradycardia. Pt's
dysarthria resolved the following day. Per nuerology and
Negative CTA Head/Neck no acute stroke and did not require any
further work up or monitoring. Pt will f/u with Neurology as
outpt. Prior to discharge, dysarthria completely resolved as
well as confusion.
.
# BPH: Continued home dose of tamsulosin
.
#. Hypothyroidism: TSH normal. Continued home dose of synthroid.
.
# OSA: on CPAP with full face mask at home, pressure 7.
Continued CPAP
.
# Chronic Alcohol use - need to monitor on CIWA scale, but
caution with ativan as pt became dysarthric and confused after 1
dose, however etiology most likely brainstem ischemia as noted
above. Pt was on a CIWA scale, MVI, Thiamine, folate. He
received 1 dose of Ativan but did not require any further
throughout his hospital course.
.
# ARF: likely [**12-22**] poor perfusion, his Cr trended down to
baseline. On day of discharge Cr. 1.1
.
#. Unsteady gait: Pt was evaluated by PT prior to d/c home on
[**2158-3-22**] as he had been bed bound for 5 days during this
admission. Per Physical therapy pt too unsteady for d/c home on
[**2158-3-22**]. He was kept in house 1 more day for further monitoring
of gait prior to d/c home. PT cleared the patient the following
day without any need for services at home.
.
# Code: Full
.
Medications on Admission:
1. Atenolol 25 [**Hospital1 **]
2. Amio 200 [**Hospital1 **]
3. Zestril 10mg Daily
4. Vitamin C
5. MVI
6. Synthroid 100mcg
7. Triam/Hctz one tab daily
8. Flomax
9. PenVK daily (for cellulitis proph)
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: [**11-21**] Tablet PO DAILY (Daily): take
[**11-21**] tablet daily.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as directed and keep your
follow up appointments.
.
If you have chest pain, palpitations, shortness of breath,
lightheadedness, dizziness, mumbled speech or any other
concerning symptoms call your physician and go to the emergency
room.
.
Please note your medication changes:
-You will continue to take Cephalexin (Antibiotic) for 1 day
-Your atenolol was decreased to 12.5mg daily
-Your Triam/Hctz one tab daily was discontinued
-Your amiodorone was discontinued
-Your were started on Aspirin 325mg and Atorvastatin 80mg daily
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13534**] at
[**Telephone/Fax (1) 105834**] or Dr. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Last Name (un) 39288**] at [**Telephone/Fax (1) 4475**] for a
follow up appointment within the next week.
.
You have a Nuerology Follow Up appointment with Provider: [**Name10 (NameIs) 5005**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2158-5-19**] 2:00 at
the [**Hospital Ward Name 23**] Center on the [**Location (un) **].
.
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 147**] SPEC SURGERY- [**Doctor Last Name **] [**Doctor First Name 147**] SPEC (NHB)
Date/Time:[**2158-3-27**] 3:30
Completed by:[**2158-3-24**]
|
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icd9cm
|
[
[
[]
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[
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"37.83",
"37.72"
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icd9pcs
|
[
[
[]
]
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12185, 12191
|
7638, 11219
|
333, 354
|
12247, 12254
|
2632, 7615
|
12864, 13710
|
2219, 2223
|
11468, 12162
|
12212, 12226
|
11245, 11445
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12278, 12567
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2238, 2613
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12587, 12841
|
275, 295
|
382, 1858
|
1880, 2065
|
2082, 2203
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,514
| 165,536
|
44737
|
Discharge summary
|
report
|
Admission Date: [**2104-6-6**] Discharge Date: [**2104-6-23**]
Date of Birth: [**2054-10-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
New onset abdominal pain and workup found him to have evidence
of a perforated diverticulum in his left colon.
Major Surgical or Invasive Procedure:
Hartmann's procedure (sigmoid resection with
end-colostomy)[**2104-6-7**].
History of Present Illness:
This 49-year-old gentleman has been treated for HIV disease for
over 20 years. He is a relatively healthy man. He has a low
viral load and a good CD-4 count at
this point in time. He presents with a new onset abdominal pain
and workup found him to have evidence of a perforated
diverticulum in his left colon. Initial CT scan imaging when he
was stable showed this to be a contained retroperitoneal
perforation on the left side. We admitted him and through the
course of the next six to eight hours, he progressively worsened
his clinical picture. He became tachycardiac and required
intubation. It was very clear that he had a progressive problem
and we therefore he was taken to the operating room first thing
on the morning of [**2104-6-7**]. Informed consent was obtained
from his family.
Past Medical History:
1. HIV diagnosed in [**2092**] on HAART therapy - last CD4+ 700's and
no hx of AIDS defining illness per family
2. Hypertension
3. Hypercholesterolemia
4. Grave's disease - treated with iodine ablation in [**2096**]
5. Depression/Anxiety
6. ?Complex partial seizures in [**2099**] - normal work-up including
MRI and EEG; seen per Dr. [**First Name (STitle) **] [**Name (STitle) 2340**]
7. hx of EtOH/polysubstance abuse - no hx of withdrawal seizures
8. hx of bitemporal throbbing
Social History:
Lives alone - same partner for many years. Works as a
restaurant manager in [**Location (un) 86**]. Quit smoking 9 yrs ago (10 pack
years) and no EtOH since [**1-20**] after hx of EtOH abuse. Also hx
of polysubstance abuse.
Family History:
Non-contributory
Physical Exam:
On Admission:
97.9 90 146/68 16 96%RA
A+Ox3. In NAD.
Tanned, not jaundiced.
Sclerae anicteric. O-P clear.
RRR; nl S1/S2 w/o m/c/r.
CTA b/l
LLQ>RLQ mod tender with localized peritonitis. Soft, mildly
distended.
No edema.
Pertinent Results:
[**2104-6-6**] 11:32PM GLUCOSE-138* UREA N-20 CREAT-1.1 SODIUM-143
POTASSIUM-5.7* CHLORIDE-109* TOTAL CO2-26 ANION GAP-14
[**2104-6-6**] 11:32PM CK(CPK)-216*
[**2104-6-6**] 11:32PM CK-MB-6 cTropnT-<0.01
[**2104-6-6**] 11:32PM CALCIUM-8.4 PHOSPHATE-6.3*# MAGNESIUM-1.7
[**2104-6-6**] 11:32PM WBC-12.2* RBC-5.56 HGB-17.2 HCT-52.5* MCV-94
MCH-30.8 MCHC-32.7 RDW-13.4
[**2104-6-6**] 11:32PM PLT COUNT-410
[**2104-6-6**] 05:38PM LACTATE-2.8*
[**2104-6-6**] 02:14PM LACTATE-4.3*
[**2104-6-6**] 01:40PM GLUCOSE-119* UREA N-23* CREAT-1.1 SODIUM-139
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19
[**2104-6-6**] 01:40PM ALT(SGPT)-55* AST(SGOT)-46* ALK PHOS-74 TOT
BILI-0.4
[**2104-6-6**] 01:40PM LIPASE-30
[**2104-6-6**] 01:40PM ALBUMIN-4.4
[**2104-6-6**] 01:40PM WBC-20.3*# RBC-5.66 HGB-17.1 HCT-51.2 MCV-90
MCH-30.2 MCHC-33.4 RDW-13.2
[**2104-6-6**] 01:40PM NEUTS-83.5* LYMPHS-13.3* MONOS-1.9* EOS-1.0
BASOS-0.3
[**2104-6-6**] 01:40PM PLT COUNT-331
.
[**2104-6-6**] Abd/Pelvic CT:
1. Perforated sigmoid diverticulitis with intra- and
retroperitoneal free gas and left hemipelvic extraluminal
collection of air with possible extraluminal leak of fecal
material. Please note that while no definite mass is visualized
at this site, this not excluded on the basis of this study and
would recommend correlation with colonoscopy when the patient is
clinically stable.
2. Indeterminant left adrenal gland nodule. Recommend evaluation
with MRI
when clinically stable.
3. Multilevel degenerative change in the lumbar spine as
detailed above.
.
[**2104-6-12**] Pathology:
SPECIMEN SUBMITTED: Sigmoid Colon.
DIAGNOSIS:
Sigmoid colectomy specimen:
Perforated colonic diverticulum with associated serositis.
Unremarkable colonic margin.
2 lymph nodes, no diagnostic abnormalities recognized.
Clinical: Peritoneal sigmoid diverticulitis.
Gross:
The specimen is received fresh in a container labeled with the
patient's name, "[**Known lastname 95708**], [**Known firstname **]", the medical record number
and additionally labeled "sigmoid colon". It consists of a
segment of colon measuring 9 cm in length and up to 7 cm in
diameter. A portion of mesentery is attached to the colon that
measures 7 x 2 x 2 cm. The specimen is not oriented. Both ends
are opened. The serosa of the bowel is unremarkable other than a
perforation measuring 1 x 1 cm. The mesentery surrounding this
perforation is dark brown and hemorrhagic. The remainder of the
mesentery is unremarkable. The specimen is opened along the
antimesenteric surface to reveal an empty lumen. The mucosa is
tan with normal folds. No masses or polyps are identified. The
bowel wall is unremarkable and measures up to 0.9 cm in
thickness. Within the mesentery, no lymph nodes are identified.
The specimen is represented as follows: A-B=colonic perforation,
C=peripheral margins, D-E=section of normal bowel, F-L=mesocolic
fat with possible lymph nodes.
.
[**2104-6-8**] Head CT:
1. No acute intracranial process. CT has limited sensitivity for
detection
of acute stroke for which MR is a better modality.
2. Mucosal thickening and air-fluid level in the paranasal air
sinuses could reflect sinusitis. Clinical correlation is
recommended.
.
[**2104-6-20**] Abd/Pelvic CT with contrast:
1. Findings are not significantly changed from [**6-13**]. There is
fluid
localized around the spleen, as before, and fluid again
localized in the left paracolic gutter of the abdomen. Fluid
about the spleen was sampled on [**6-13**].
2. The previously described punctate foci of air in the anterior
intraabdominal midline have resolved. Bowel loops in this area
are not
opacified with oral contrast.
3. Decreased gallbladder distention.
4. Small bilateral pleural effusions and associated atelectasis.
5. Unchanged indeterminate left adrenal nodule, for which
characterization is recommended with MRI once the patient's
clinical condition permits.
Brief Hospital Course:
[**6-6**]: admitted, CT scan: perforated sigmoid diverticulitis.
Became hypotensive; intubated.
[**6-7**]: OR 2500mL LR, 750mL albumin 5%, UOP 135, EBL 100
[**6-8**]: question of seizure like activity; CT head performed
[**6-10**]: Overnight became hypotensive, MAP 50s -> Levophed, stopped
lasix gtt
[**6-11**]: Still intubated, weaning to extubate. Back on Lasix gtt
(goal -1L). Came off prop/fent, but became agitated; started on
Precedex/Dilaudid -> became agitated/aggressive again; back on
propofol.
[**6-12**]: Started TFs. Abd wound cx sent. Spiked fever to 102.7 at
1600; pan cx'd.
[**6-13**]: started clonidine & Effexor, CT torso, L pleural effusion
drained (650cc), perisplenic fluid [**Last Name (un) **] drained, changed TF to
more concentrated, cont diuresis, febrile
[**6-14**]: 1.6L neg
[**6-15**]: started aldactone, Reglan
[**6-16**]: d/c'd Lasix gtt, started Diamox, extubated, sips
[**6-17**]: Stopped TFs. Advanced from sips to clears. Started Tobra x1
dose.
[**6-19**]: Foley discontinued. Transferred to floor. Started Tobra.
Overnight fell and hit head; head CT negative.
[**6-20**]: Elevated WBC 12->15.6; CT abd/pelvis done with no
significant change.
[**6-21**]: Fever; CXR done with mild bilateral pleural effusion, but
no pneumonia.
[**6-22**]: Started all home PO meds.
[**6-23**]: Discharged home with [**Month/Year (2) 269**] for ostomy care, incision wound
care, PICC care, and IV antibiotic infusion. Follow-up
instructions and appointments given.
Medications on Admission:
Effexor XR 150am/75pm, wellbutrin 100mg daily, diovan 80mg
daily, lipitor
40mg daily, levoxyl 112mcg daily, viread 300mg Po daliy, Epivir
300mg PO daily, viramune 20mg PO BID
Discharge Medications:
1. Outpatient Lab Work
Please check a Chem7 (electrolytes, BUN, creatinine, glucose),
CBC, ALT, AST, T.bili, D. bili, Alk Phos, albumin weekly on
mondays. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7991**] at
([**Telephone/Fax (1) 74533**] care of [**Last Name (un) 95709**]. Thank you.
2. Outpatient Lab Work
Please check a Vancomycin level before the fourth IV Vanco dose.
Fax result to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7991**] at ([**Telephone/Fax (1) 74533**] care of
[**Last Name (un) 95709**]. Thank you.
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Epivir 300 mg Tablet Sig: One (1) Tablet PO once a day.
5. Nevirapine 50 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation four times a day as needed for shortness
of breath or wheezing.
Disp:*1 HFA* Refills:*2*
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO QAM (once a day (in the
morning)).
8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO QPM (once a day (in the
evening)).
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Aldactone 50 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
12. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ertapenem 1 gram Recon Soln Sig: One (1) gram Recon Soln
Injection once a day for 14 days.
Disp:*14 gram Recon Soln(s)* Refills:*0*
17. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
18. Medication:
Vancomycin 1250mg IV Q8HOURS x 14 days
Disp: QS
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Priamry: Perforated diverticulitis
Secondary: HIV Disease
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry. Incision wound
dressing changes should be changed after showering.
*If you have staples, they will be removed at your follow-up
appointment.
*Wet-to-dry dressings changes along incision to be performed by
[**Month/Year (2) 269**] Nurse.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
Monitoring Ostomy Output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, contact your MD [**First Name (Titles) **] [**Last Name (Titles) 269**] Nurse.
Followup Instructions:
Please call ([**Telephone/Fax (1) 95710**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 7991**] (PCP) 1 week.
Please call ([**Telephone/Fax (1) 2828**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in 2 weeks.
Completed by:[**2104-6-25**]
|
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|
1842, 2071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,532
| 114,898
|
37456
|
Discharge summary
|
report
|
Admission Date: [**2105-12-26**] Discharge Date: [**2106-1-7**]
Date of Birth: [**2082-3-9**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Paralysis of bilateral legs
Major Surgical or Invasive Procedure:
T4-T8 laminectomy with excision of dorsal epidural abscess.
History of Present Illness:
Patient is a 23 y/o F IVDA, who noted four days worth of back
pain prior to presentation. She presented to the emergency room
on [**2105-12-26**] with paralysis of her bilateral lower extremities,
MRI showed an epidural abscess in her T spine and was taken
urgently to the OR.
Past Medical History:
IVDA
Physical Exam:
Afebrile
BUE: [**4-14**] deltoid, biceps, triceps, WF, WE, FF, FAb
BUE: SILT C4-T1
BLE: no motor below T9
BLE: no sensation BLE T9-S1.
incontinent of bowel and bladder, foley catheter dependent
poor rectal tone
Pertinent Results:
[**2105-12-26**] 03:55PM WBC-18.7* RBC-3.28* HGB-10.0* HCT-29.0*
MCV-88 MCH-30.6 MCHC-34.6 RDW-12.6
[**2105-12-25**] 10:57PM CRP-GREATER TH
[**2105-12-25**] 10:57PM WBC-19.8* RBC-4.22 HGB-12.8 HCT-36.6 MCV-87
MCH-30.3 MCHC-34.9 RDW-12.5
[**2105-12-25**] 10:57PM SED RATE-75*
[**2105-12-25**] 10:57PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2105-12-25**] 10:57PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2105-12-25**] 10:57PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
Brief Hospital Course:
The patient was taken emergently to the operating room on the
day of presentation. She underwent a decompression from T5-T8
(Laminctomies). Frank pus was removed from the epidural space
which was shown to be + for MRSA. She was taken to the SICU
immediately after surgery. Her SICU course was uneventful and
she was discharged to the floor. She was given a PICC line for a
total of a 10 week course of vancomycin to be followed by
infectious disease. See discharge instructions for follow-up
information. She was discharged to a spinal cord rehabilitation
facility once her insurance company provided approval.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever > 100.4, pain.
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for if no BM in > 24 hours.
9. Hydromorphone 4 mg Tablet Sig: 1 [**12-12**] to 2 [**12-12**] Tablet PO Q3H
(every 3 hours) as needed for pain.
10. Methadone 10 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8
Hours): Methadone is being for pain management as per the
recommendation of chronic pain management services.
11. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
12. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
13. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed for rash/itching.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Vancomycin 500 mg Recon Soln Sig: 2 [**12-12**] Recon Solns
Intravenous Q 8H (Every 8 Hours).
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Thoracic epidural abscess from T4-T8
Discharge Condition:
Stable.
Tolerating oral diet.
Alert and oriented.
Discharge Instructions:
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
- 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 or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
-For your vancomycin, please have a weekly CBC with
differential, ESR, CRP, and vancomycin trough faxed to the
Infectious Disease clinic at [**Telephone/Fax (1) 1419**] attention Dr. [**Last Name (STitle) **]
[**Name (STitle) 84167**]
Physical Therapy:
OOB to chair,
Passive ROM in ankle, knee and hip joints.
Wheelchair mobilization.
Treatments Frequency:
IV antibiotics through the PICC line.
Physical therapy in the form of OOB to chair.
Removal of staples in 3 weeks.
Followup Instructions:
Follow up in 6 weeks with Dr [**Last Name (STitle) 1007**]. Please call [**Telephone/Fax (1) 9769**] to
make an appointment.
Follow up in Six weeks at the infectious disease clinic at [**Hospital1 1535**] [**Hospital Ward Name 516**]. Please follow-up in
six weeks. Please call office to schedule an appoinement.
Follow-up with the Chronic Pain service, Dr. [**Last Name (STitle) 13284**], [**Hospital1 1535**], in four to six weeks. Please
call his office to schedule an appointment.
Completed by:[**2106-1-7**]
|
[
"304.01",
"324.1",
"344.1",
"616.10",
"305.1",
"336.1",
"041.12",
"111.9",
"790.7",
"788.29",
"730.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.39",
"03.4",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
3989, 4086
|
1598, 2210
|
346, 408
|
4167, 4219
|
988, 1575
|
6941, 7458
|
2233, 3966
|
4107, 4146
|
4243, 4243
|
757, 969
|
6698, 6780
|
6802, 6918
|
5959, 6680
|
4277, 4471
|
279, 308
|
4953, 5947
|
436, 714
|
736, 742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,458
| 150,816
|
3084
|
Discharge summary
|
report
|
Admission Date: [**2206-5-30**] Discharge Date: [**2206-6-10**]
Date of Birth: [**2152-7-13**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Valium / Allopurinol
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
.
CC:[**CC Contact Info 14653**]
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Pt is a 53 yo female with HTN, ESRD on HD TThS, atrial
fibrillation s/p DCCV, CHF with preserved EF, PVD s/p R fem-[**Doctor Last Name **],
pulmunary HTN, and COPD who presented to the ED with increasing
facial swelling over the course of one month and dizziness,
particularly when lying down. Also, pt reports some difficulty
swallowing due to sensation of swelling in her throat. She
states it began after her last surgery to retrieve retained
graft in left arm late in [**Month (only) 958**]. She states her diet and fluid
status are unchanged. No major medication changes during the
past 1-2 months except decreases in the dose of hypertension
meds. Last dialysis was in the AM of [**2206-5-29**]. Pt also notes mild
increasing abdominal distention.
Of note pt had a infected graft which was removed [**2206-5-2**].
In the ED, concern for SBPs 70-90s. The pt was initially going
to be admitted to the floor but then became hypotensive and was
sent for further evaluation and monitoring in the MICU. Pt
arrived to the MICU hemodynamically stable with SBPs 120-140s so
was called-out to the floor.
ROS: + eye watering, + facial "tightness" with mild HA
especially upon changing positon. Also feels light-headed upon
changing position. No recent F/C. No N/V/D or abodminal pain.
No SOB or CP. No urinary symptoms.
Past Medical History:
1. HTN
2. ESRD ([**3-7**] HTN), on HD since [**5-/2205**]
3. Atrial fibrillation s/p DCCV (dx 2 years ago)
4. Diastolic CHF with preserved EF, PCWP 32 on cath [**2201**]
(followed by Dr. [**First Name (STitle) 437**]
5. PVD s/p B/L fem-[**Doctor Last Name **]
6. Pulmunary HTN
7. Small secundum type atrial septal defect
8. COPD
9. Gout
10. Complicated left parapneumonic effusion s/p VATS drainage
[**2205**]
11. h/o Right-sided ovarian teratoma (s/p resection)
12. h/o Splenic Infarct
13. s/p BTL [**2179**]
14. h/o PPD+ (per old discharge summary)
15. h/o MRSA line infection
16. s/p fibroid resection
Line history:
s/p RSC X 3
s/p LSC X 2
s/p resection of infected graft in L arm
s/p fistula placement in L arm (still maturing)
Social History:
Works as a school bus monitor, lives with her husband in [**Name (NI) **],
has 5 kids. 75 pack yr smoking hx, quit 7 yrs ago. [**2-4**] glasses
of wine/day, no injection drugs. H/o cocaine use in the 80s.
Family History:
Mother had MI at age 25, died at 26. Father died of renal
disease [**3-7**] HTN. Mother of 5. One son was murdered. Another
son in jail. Her daughter (36) has depression. Her son (32)
and daughter (30) are healthy.
Physical Exam:
T 98 BP 129/68 HR 79 RR 21 100%RA
General: Comfortable, NAD, sleeping.
HEENT: NC/AT. PERRLA. EOMI. Sclera anicteric. MM dry. OP clear.
Mild diffuse facial swelling.
NECK: No bruits, normal pulses, no LAD, multiple scars from
previous neck lines. Mild left-sided swelling.
CV: S1, S2 with a Grade II/VII systolic murmur over RUSB. No
r/g.
Pulm: CTAB without wheezes or crackles.
Abd: Lower abd vertical scar, mildly obese, soft, NT, ND with
normoactive BS.
Ext: No edema, weak DP pulses, warm ext. Scars over both lower
extremities following venous pattern.
NEURO: A & O x3. CNs II-XII grossly intact.
Pertinent Results:
[**2206-5-29**] 01:30PM BLOOD WBC-8.5 RBC-4.30 Hgb-12.3 Hct-37.9 MCV-88
MCH-28.6 MCHC-32.4 RDW-16.9* Plt Ct-185
[**2206-5-29**] 01:30PM BLOOD Neuts-74.3* Lymphs-15.6* Monos-6.1
Eos-3.0 Baso-1.1
[**2206-5-29**] 01:30PM BLOOD PT-15.6* PTT-62.8* INR(PT)-1.4*
[**2206-5-29**] 01:30PM BLOOD Glucose-87 UreaN-23* Creat-5.4*# Na-141
K-3.2* Cl-97 HCO3-32 AnGap-15
[**2206-5-29**] 01:30PM BLOOD ALT-11 AST-24 CK(CPK)-61 AlkPhos-108
Amylase-203* TotBili-0.4
[**2206-5-29**] 01:30PM BLOOD CK-MB-NotDone proBNP-649*
[**2206-5-29**] 07:30PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2206-5-29**] 01:30PM BLOOD TotProt-8.5* Calcium-9.9 Phos-2.7# Mg-2.0
.
[**5-29**] Left upper ext ultrasound:
FINDINGS: [**Doctor Last Name **] scale, color and pulse Doppler son[**Name (NI) 867**] was
performed of the subclavian, axillary, brachial, cephalic and
basilic veins. Normal flow, compression, augmentation and
waveforms were demonstrated. Of note, the left internal jugular
vein was not well demonstrated on this study although an
adjacent venous structure is identified with normal flow and
compressibility.
IMPRESSION: No evidence of left upper extremity DVT.
Of note, the left internal jugular vein was not well
demonstrated although an adjacent venous structure was noted to
be patent without clots. This may represent an anatomic
variant.
[**2206-5-30**] CXR
CHEST, PA AND LATERAL: Cardiac, mediastinal, and hilar contours
are stable. Pulmonary vasculature is unremarkable. There is
linear left lower lung atelectasis. The lungs are otherwise
clear. There are no pleural effusions. Right IJ dialysis
catheter tip is in the distal SVC. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: Linear left lower lung atelectasis. No evidence of
pulmonary edema.
[**2206-5-30**] CTA
IMPRESSION:
1. Short segment occlusion of the SVC secondary to fibrin
sheath or thrombus around the dialysis catheter. Numerous large
collateral veins in the upper chest and neck are observed and
the SVC reconstitutes inferiorly through the azygos vein.
2. Discontinuity of flow through the right subclavian vein
could be secondary to thrombosis or could be related to arm
positioning.
3. No evidence of PE.
.
SVC gram 4/30/07-1. Venogram confirms occlusive thrombus from
the right brachiocephalic through mid SVC.
2. Catheter placed for overnight TPA infusion, per rate
specified in post
procedure orders (0.5 mg/hour).
3. Repeat venogram and potential balloon dilation planned for
the following day.
.
CTA [**2206-6-7**]:
1. No evidence of pulmonary embolus.
2. New ground-glass opacities in the right upper lobe that could
represent a combination of asymmetric pulmonary edema and
infection.
3. New small bilateral pleural effusions.
4. Interval resolution of multiple collaterals in the right
upper chest and neck suggesting that the previous SVC
obstruction has resolved.
.
Head CT [**2206-6-9**]:
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, or major vascular territorial
infarct. [**Doctor Last Name **]-white matter differentiation is preserved. There
is no hydrocephalus. The visualized paranasal sinuses and
mastoid air cells are clear. Osseous structures and soft tissues
are unremarkable.
Brief Hospital Course:
A/P: 53 y/o female with ESRD on HD, HTN, and COPD who presents
with left facial swelling x 1 month along with intermittent
hypotension in the ED.
#SVC syndrome: The patient had facial swelling/edema likely [**3-7**]
SVC syndrome. She had a CTA revealing short segment occlusion of
the SVC [**3-7**] to fibrin sheath or thrombus around the HD catheter.
Patient had an interventional [**Month/Day (2) **] evaluation by venogram.
It confirmed occlusive thrombus from the right brachiocephalic
through mid SVC. A catheter was placed in IR and TPA was
administered overnight in addition to heparin gtt. Laboratory
values including frequent platelet counts, coagulation, and
fibrogren were checked and remained within normal values. The
patient underwent thrombectomy and dilatation of the SVC the
next day, which was HD 5. It preserved flow through the SVC,
although some clot remains. The TPA was d/cd and heparin gtt was
continued until she was therapeutic x24 hours on coumadin.
# Intermittent hypotension- Initially a concern but then
resolved. SBPs 120-140s upon arrival to MICU. Her carvedilol,
amlodipine and lisinopril and were d/cd. Her BP normalized.
After her HD session on day of discharge SBP was ~130. She was
restarted on carvediolol at discharge. The rest may be added
back on as blood pressure allows as outpatient.
# ESRD We continued sevelamer and nephrocaps. Calcium carbonate
was discontinued per renal. Renal followed when patient was
inhouse. She was dialyzed after her thrombectomy procedure on
her tue, thurs, sat schedule.
# Atrial fibrillation: Currently in sinus rhythm. Propafenone
was restarted and pt was on heparin gtt until therapeutic on
coumadin.
# Headache - patient complained of persistent headache. Patient
without any focal neuro signs/sxs. Patient had CT that was
negative for bleed or other acute process. Treat conservatively
and recommend outpatient follow up.
# Pneumonia - Patient had congestion, hypoxia, SOB. CXR showed
infiltrate. She will complete a 7 day course of ciprofloxacin.
# Diastolic CHF with preserved EF - Euvolemic. She will follow
up with Dr. [**First Name (STitle) 437**].
# PVD s/p B/L fem-[**Doctor Last Name **] - Warm extremities. Stable
# COPD - continued advair and albuterol and ipratropium
# anemia - recommend outpatient colonoscopy.
# [**Name (NI) 1623**] Pt was NPO for procedures and then resumed a cardiac,
renal diet.
# Code- Full Code
Medications on Admission:
ADVAIR DISKUS 100-50 mcg/Dose--1 puff inh twice a day
AMBIEN 5 mg--1 tablet(s) by mouth at bedtime as needed for
insomnia
ARANESP 25MCG/0.42--Inject one s/c weekly
Amlodipine 5 mg--1 tablet(s) by mouth once a day per cardiology
Atorvastatin 20 mg--1 tablet(s) by mouth once a day
CALCIUM CARBONATE 500 mg--1 tablet(s) by mouth three times a day
CARVEDILOL 12.5 mg--1 tablet(s) by mouth twice a day per
cardiology
HYDROXYZINE HCL 25 mg--[**2-4**] tablet(s) by mouth at bedtime as
needed for prn itch
LAC-HYDRIN 12 %--use [**Hospital1 **] as noted twice a day
LISINOPRIL 5 mg--1 tablet(s) by mouth once a day per cardiology
PERCOCET 5 mg-325 mg--[**2-4**] tablet(s) by mouth every six (6) hours
as needed for pain
PREDNISONE 10 mg--4 tablet(s) by mouth once a day taper as
instructed (for gout flairs)
PROPAFENONE 225MG--One tablet(s) by mouth three times a day
PROTONIX 40 mg--1 tablet(s) by mouth once a day
RENAL CAPS 1 mg--1 (one) capsule(s) by mouth once a day
WARFARIN 5 mg------ tablet(s) by mouth daily take as directed by
coumadin clinic [**Telephone/Fax (1) 10844**] (usually on [**6-12**] mg)
Folate
Discharge Disposition:
Home
Discharge Diagnosis:
Superior Vena Cava Syndrome
Hypotension
Hypertension
Urinary tract infection, bacterial
Pneumonia
anemia
ESRD on HD
Atrial fibrillation
Diastolic Heart Failure
Peripheral Vascular Disease
COPD
Headache
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
Adhere to 2 gm sodium diet
.
You were admitted with superior vena cava syndrome.
.
Please seek medical attention immediately if you develop fever,
chills, shortness of breath, chest pain or any other concerning
symptoms.
Followup Instructions:
Please make a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] within the
next 2 weeks. Tel [**Telephone/Fax (1) 250**].
.
If you have any concerns contact the Renal office and ask for
Dr. [**Last Name (STitle) 7143**]. ([**Telephone/Fax (1) 773**]
.
Please follow-up with Dr. [**Last Name (STitle) **] as directed.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2206-6-19**] 1:40
.
|
[
"496",
"486",
"459.2",
"443.9",
"427.31",
"416.9",
"453.8",
"784.0",
"585.6",
"403.91",
"996.73",
"E849.0",
"285.9",
"E879.1",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"39.95",
"39.50",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
10477, 10483
|
6881, 9312
|
401, 416
|
10729, 10767
|
3619, 6858
|
11036, 11562
|
2762, 2982
|
10504, 10708
|
9338, 10454
|
10791, 11013
|
2997, 3600
|
255, 363
|
444, 1766
|
1788, 2522
|
2538, 2746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,138
| 175,754
|
4234
|
Discharge summary
|
report
|
Admission Date: [**2124-6-19**] Discharge Date: [**2124-6-20**]
Date of Birth: [**2081-10-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Tegretol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unresponsive, overdose
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Patient is a 42year old female with history of depression,
anxiety, suicide attempts who was brought in by EMS
unresponsive, found to have toxocology screen positive for
benzodiazepines and amphetamines and intubated for airway
protection.
Per report, the patient's neighbor heard a crash, and to the
patients apartment to check up on her and found her flailing
around. EMS was called. She was brought to the [**Hospital1 18**] ED
unresponsive.
Her vitals on admission to the ED were T97.4, BP 104/64, RR 16,
O2 sat 98% NRB She was given narcan 0.4mg x2. She was not
responsive to pain, and had a minimal gag and was intubated. She
was initially given versed, did not tolerated CT scan, as she
was thrashing around, and then was given a dose of vecuronium.
After the CT scan she got ativan, and is now sent to the ICU on
a propofol drip.
On admission to the ICU, she was intubated and sedated, but
following commands
Past Medical History:
Suicide attepts
over 20 psych admissions
Depression
Axiety
Iron deficiency anemia
Cervical dysplasia
Anorexia
Dissociative disorder
Etoh abuse
Borderline Personality Disorder
ADHD
[**Doctor First Name 147**] HX:
chest tube
facial surgery at age 21 due to trauma from abuse
Social History:
Social History: unable to obtain as is intubated
Per history: estranged from family as was abused growing up.
smoking history and hx of ETOH abuse. multiple psych admissions.
Family History:
Family history: per PCP note from [**1-10**]
Not able to give much details of her family's hx as estranged
from most of them.
Mother: 65 yo
Father: d. in prison in his 60s
Siblings: 6 B 2 sisters - she talks to one of her sisters.
Physical Exam:
Physical Exam:
Vitals: T: 97.5 BP: 126/88 P: 75 RR: 14 O2Sat: 100%
Gen: intunbated, sedated, follows commands
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions, multiple healed scars on b/l wrists
Pertinent Results:
[**2124-6-19**] 03:40PM WBC-7.2 RBC-4.56 HGB-14.7 HCT-42.8 MCV-94
MCH-32.2* MCHC-34.3 RDW-13.8
[**2124-6-19**] 03:40PM ASA-NEG ETHANOL-220* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2124-6-19**] 03:52PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
.
[**2124-6-19**] CT C Spine: prelim: no acute fractures or dislocations
of the cervical spine
.
[**2124-6-19**] CT Head: prelim: no acute intracranial process.
.
[**2124-6-19**] CXR: no acute process
.
DISCHARGE LABS:
[**2124-6-20**] 06:09AM BLOOD WBC-10.8 RBC-4.82 Hgb-15.5 Hct-45.5
MCV-94 MCH-32.0 MCHC-34.0 RDW-13.7 Plt Ct-284
[**2124-6-20**] 06:09AM BLOOD Glucose-77 UreaN-3* Creat-0.6 Na-143
K-3.6 Cl-109* HCO3-26 AnGap-12
[**2124-6-19**] 03:40PM BLOOD ALT-23 AST-41* LD(LDH)-147 AlkPhos-42
Amylase-48 TotBili-0.2
[**2124-6-20**] 06:09AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
Brief Hospital Course:
Patient is a 42 year old female with a history of anxiety,
posttraumatic stress disorder, abuse, anorexia, ETOH abuse
admitted unresponsive, intubated, with urine toxicology notable
for positive benzodiazepines, positive amphetamines, ETOH of
220. The patient was initially unresponsive and was intubated
for airway protection. Unresponsiveness was attributed to
multiple drugs on urine toxicology. As propofol sedation was
weaned and as medications cleared from her system, the patient
became more responsive. The patient was successfully extubated.
Trauma was ruled out as cause of the altered mental status as
per negative CT head, spine. There was concern that the drug
overdose was related to a suicide attempt and the patient was
Section 12'ed when she tried to leave AMA. Code purple was
called and security had to restrain the patient. Valium was
given as per CIWA scale and home dose medications given to
reduce withdrawals. Patient refused most of her medications.
Psychiatry evaluated the patient who felt that she would benefit
from an inpatient psychiatric stay. With the resolution of the
patient's active medical issues, namely her altered mental
status, the patient was cleared for transfer to psychiatric
care.
The patient has been admitted to [**Hospital1 **] 4 at [**Hospital1 18**] for
further care.
Medications on Admission:
Medications on Admission:
unclear, but per EMS on antabuse, valium and trazadone. no note
in chart.
Discharge Medications:
1. Valium 10 mg Tablet Sig: 1-2 Tablets PO three times a day: 20
mg in am
10mg in afternoon
20mg qhs.
2. Haldol Decanoate 50 mg/mL Solution Sig: Five (5) mg
Intramuscular TID:PRN as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
Deconesse 4
Discharge Diagnosis:
Drug overdose: benzodiazepines, amphetamines, EtOH
Discharge Condition:
stable
Discharge Instructions:
You were admitted due to a change in your mental status which
has resolved and was felt to be due to trouble taking your
medications. You have a need to be in an inpatient psychiatric
facility for further care at this time.
Please continue to see your psychiatist and go to the emergency
room if you have any suicidal or homicidal idealations.
You are strongly encouraged to speak with your psychiatrist
about additions and treatment counseling.
If you develop fevers, chills, nausea, vomiting, chest pain,
shortness of breath or any other concerning symptom please
notify your primary care provider or go to the emergency room.
Followup Instructions:
Please follow up with your PCP and outpatient psychiatrist
|
[
"E849.0",
"280.9",
"309.81",
"E950.3",
"305.00",
"969.7",
"300.15",
"305.1",
"969.4",
"301.83",
"314.01",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5024, 5062
|
3320, 4644
|
303, 326
|
5156, 5164
|
2414, 2831
|
5844, 5906
|
1799, 2016
|
4795, 5001
|
5083, 5135
|
4696, 4772
|
5188, 5821
|
2937, 3297
|
2046, 2395
|
241, 265
|
354, 1276
|
2840, 2921
|
1298, 1573
|
1605, 1767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,952
| 199,209
|
22258
|
Discharge summary
|
report
|
Admission Date: [**2190-7-20**] Discharge Date: [**2190-9-2**]
Date of Birth: [**2129-7-9**] Sex: F
Service: GYN
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
vulvar infection
Major Surgical or Invasive Procedure:
s/p radical vulvectomy with groin lymph node dissection
s/p left groin debridements x 2
History of Present Illness:
61 yo female who presented with a vulvar lesion on [**2190-7-15**]. Dr.
[**First Name (STitle) 1022**] performed a biopsy, which revealed high-grade atypia most
suggestive of squamous cell carcinoma. She was admitted [**7-20**]
with a complaint of lower extremity erythema and swelling
consistent with cellulitis.
Past Medical History:
had not been to the doctor for many years
Social History:
from [**Male First Name (un) 1056**], was staying with her niece. No T/E/D
Family History:
non-contributory
Brief Hospital Course:
On [**2190-7-27**], the patient underwent a D&C for postmenopausal
bleeding. This was following imaging studies including an MRI on
[**2190-7-23**] that revealed highly suspicious necrotic lymph nodes
along bilateral pelvic nodal chain along with a two-cm mass with
papillary surface projecting into the bladder lumen from the
right bladder wall highly suspicious for transitional cell
carcinoma. On [**2190-7-27**], Dr. [**Last Name (STitle) 9125**] performed cystoscopy and she
was found to have a two-cm superficial papillary bladder tumor
lateral to the right ureteral orifice, which was biopsied and
consistent with papillary urothelial carcinoma, low-grade. The
endometrial curettage showed no evidence of malignancy. A left
vulvar biopsy, however, revealed invasive squamous cell
carcinoma, moderately differentiated.
On [**2190-7-30**], the patient underwent radical vulvectomy and
bilateral groin lymphadenectomy with 3/6 right groin nodes
positive for metastatic carcinoma ans 12 of 13 lymph nodes in
the left groin were positive for metastatic squamous cell
carcinoma with extensive extracapsular extension and
obliteration of nodal architecture.
On [**2190-8-11**], the patient with taken back to the OR for a
nonhealing left groin wound and underwent debridement and
placement of a vacuum dressing. The left groin excision revealed
squamous cell carcinoma as well along with acute and chronic
inflammation. Wound culture from that procedure revealed mixed
bacterial types. On [**8-20**] she was taken to the OR for further
debridement with Plastics surgery, followed by a placement of
vacuum dressing since the tissue felt to be too necrotic for a
flap. The dressing was removed on [**8-27**] and the wound has been on
wet to dry dressings since. A large amount of lymph fluid drains
from this, with increased pitting edema in her left lower
extremity greater than the right. She is able to ambulate. The
rest of her incision remains clean dry and intact.
Further issues:
1. Vulvar carcinoma: a CXR on [**8-11**] showed some hilar fullness, so
a CT scan was done and showed pulmonary nodules c/w metastatic
disease. A repeat CT on [**8-28**] showed increased number and size of
pulmonary nodules. After discussion with the pt and her family,
it was decided not to pursue further treatment for this
(including further debridement or debulking, or palliative
chemotherapy).
2. ID: pt has persistent low grade fevers throughout her
hospitalization, all cultures (blood, urine, deep tissue, PPD
and fungal/myco) have been negative. It is not clear if this is
merely tumor fever or if there is a superimposed infection
despite different antibiotic regimens for more of her
postoperative course, including Unasyn, Levofloxacin, Vancomycin
and Zosyn. Strongyloides, histoplasmosis studies are still
pending but very unlikely. Her WBC remains elevated (had peaked
at 47 after her vac dressing was removed). However, pt remains
asymptomatic. Her antibiotic regimen on discharge is Augmentin,
Flagyl and Fluconazole PO.
3. Hypercalcemia: The patient also developed hypercalcemia twice
this admission. On admission, her calcium was 10.7, but climbed
to 15.6. She received pamidronate [**8-17**] with good response, but
then her calcium again began to rise until she received another
dose of pamidronate on [**9-1**]. This is presumably caused by bony
metastases; it was felt that doing a bone scan, however, would
not yield any information that would change her management. Pt
will get electrolytes checked q week after d/c and repleted prn.
4. Heme: Anemia: likely due to chronic infection. She received a
total of 4 units of PRBC with good effect.
Thrombophlebitis of L superficial femoral vein: noted on [**8-28**] CT
scan. Will continue Heparin 5000 units SC TID.
5. Pain control: pt complained of increased pain toward the end
of her hospitalization, but adequate control was obtained with
MS contin 100 mg PO q12hrs, with morphine IR 15-30mg PO q4-6hrs.
6. Code: After extensive discussion with the pt and family, she
is DNI only. She does request resuscitation.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000 units/ml Injection TID (3 times a day).
Disp:*90 5000 units/ml* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*1 ML(s)* Refills:*1*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*2*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*120 Tablet(s)* Refills:*1*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
10. Morphine Sulfate 100 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours).
Disp:*60 Tablet(s)* Refills:*2*
12. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*60 Tablet(s)* Refills:*1*
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous QD (once a day) as needed.
Disp:*60 ML(s)* Refills:*1*
14. Phenergan 12.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for nausea.
Disp:*60 Tablet(s)* Refills:*1*
15. Reglan 10 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
Disp:*60 Tablet(s)* Refills:*1*
16. Aquacel Hydrofiber Packing Bandage Sig: Two (2) 6x6 inch
bandages Topical twice a day: Please place at base of wound.
Disp:*10 boxes* Refills:*2*
17. Aquacel Hydrofiber Packing Bandage Sig: Two (2) 4x4 inch
Topical twice a day: Please put at base of wound.
Disp:*10 boxes* Refills:*2*
18. MSIR 20 mg/mL Solution Sig: 2-20 mg PO q1hr PRN as needed
for pain: for emergency kit.
Disp:*150 cc* Refills:*0*
19. Gauze Pad Bandage Sig: Five (5) 4x4in Topical twice a
day.
Disp:*10 boxes* Refills:*2*
20. super absorbant dressing Sig: Five (5) dressing twice a
day.
Disp:*10 boxes* Refills:*2*
21. ABD pads Sig: Three (3) pads twice a day.
Disp:*10 boxes* Refills:*2*
22. Kerlix Bandage Sig: Four (4) rolls Topical twice a day.
Disp:*10 boxes* Refills:*2*
23. [**Location (un) **] straps Sig: One (1) pair once a week.
Disp:*10 pairs* Refills:*2*
24. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 1-2 tabs
Sublingual every 4-6 hours as needed for increased upper airway
secretions: for emergency kit.
Disp:*10 cc* Refills:*0*
25. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed: for emergency kit.
Disp:*30 Tablet(s)* Refills:*0*
26. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch
Transdermal q72hrs as needed for nausea: for emergency kit.
Disp:*1 box* Refills:*0*
27. Zometa 4 mg/5 mL Solution Sig: Four (4) mg Intravenous once
as needed for for Calcium>10: Infuse over 15 minutes.
Disp:*1 bags* Refills:*5*
28. Outpatient Lab Work
Please check Calcium level once a week; if Calcium > 10, please
infuse Zometa, 4 mg IV over 15 minutes.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2188**]
Discharge Diagnosis:
vulvar carcinoma, Stage IV
Discharge Condition:
stable
Discharge Instructions:
Please ambulate and use your incentive spirometer.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule
appointment prn.
|
[
"682.2",
"038.9",
"995.91",
"184.4",
"197.0",
"998.83",
"188.2",
"196.5",
"451.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"71.5",
"83.32",
"69.09",
"71.11",
"57.49",
"83.39",
"40.54"
] |
icd9pcs
|
[
[
[]
]
] |
8574, 8624
|
973, 5054
|
325, 415
|
8695, 8703
|
8802, 8930
|
931, 949
|
5077, 8551
|
8645, 8674
|
8727, 8779
|
269, 287
|
443, 758
|
780, 823
|
839, 915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,506
| 136,552
|
22814
|
Discharge summary
|
report
|
Admission Date: [**2201-5-1**] Discharge Date: [**2201-5-5**]
Date of Birth: [**2121-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
ICU stay
History of Present Illness:
Patient is 79 y/o male with Hx significant for CAD, stroke,
several toe amputations, and DM, who admitted to OSH after a
witnessed fall. Pt does not remember the event, but wife
described her husband walking from the bedroom into the living
room and falling forward without warning or without tripping.
She said that he was making odd sounds but no LOC, no loss of
bowel/bladder. Per intake report, no chest pain, palpitation,
shortness of breath, or lightheadedness ED course: repeat CT
showed unchanged SDH and intraparenchymal hemorrhage (from CT on
OSH). neurosurgery consulted who recommended holding aspirin
plavix and repeat CT, Q 2 hour neuro-checks, SBP < 160. He was
admitted to the MICU for frequent neuro checks; he was given
hydralazine IV on a PRN basis to keep BP goal< 160.
Past Medical History:
CAD, normal stress and ECHO [**2198**], Cath [**2200**], no stents per wife
Stroke s/p R CEA [**2187**]
DM2, hyperllipdemia, hypertension
basal cell carcinoma [**2198**],
?incomplete LBBB,
CKD, baseline creatinine of 1.4
Wenckabach-negative stress
depression
Social History:
married
nonsmoker
non drinker
Lives at home with wife
Family History:
unknown
Physical Exam:
PE: T 99.2 BP 162/58 HR 60 RR 18 O2Sat95
General: mildly confused and agitated male, AOx1
HEENT: COP, mmm
Neck: supple, flat jvp
Lungs: CTA bl
Heart: RRR, S4
Abdomen: soft, nt, nd
Extremities: no edema , s/p toe amputation x8
Skin: no rash
Neuro: CNII-XII grossly intact with the exception of left
shoulder which pt can't move upward however
Strength 5/5 in upper and lower extremities
Sensation preserved and equal
Pertinent Results:
HEMATOLOGY
[**2201-5-1**] 01:55PM BLOOD WBC-11.9* RBC-4.00* Hgb-11.1* Hct-33.9*
MCV-85 MCH-27.8 MCHC-32.7 RDW-14.7 Plt Ct-242
[**2201-5-2**] 03:50AM BLOOD WBC-9.2 RBC-3.63* Hgb-10.4* Hct-30.9*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.8 Plt Ct-236
[**2201-5-5**] 05:17AM BLOOD WBC-7.6 RBC-3.88* Hgb-10.6* Hct-32.2*
MCV-83 MCH-27.5 MCHC-33.0 RDW-15.0 Plt Ct-268
[**2201-5-1**] 01:55PM BLOOD Neuts-78.3* Lymphs-14.6* Monos-5.5
Eos-1.1 Baso-0.4
COAGS
[**2201-5-1**] 01:55PM BLOOD PT-12.8 PTT-30.1 INR(PT)-1.1
[**2201-5-2**] 03:50AM BLOOD PT-13.6* PTT-30.2 INR(PT)-1.2*
CHEM
[**2201-5-1**] 01:55PM BLOOD Glucose-134* UreaN-22* Creat-0.9 Na-141
K-4.5 Cl-105 HCO3-24 AnGap-17
[**2201-5-2**] 03:50AM BLOOD Glucose-107* UreaN-19 Creat-0.9 Na-139
K-4.2 Cl-105 HCO3-24 AnGap-14
[**2201-5-5**] 05:17AM BLOOD Glucose-150* UreaN-22* Creat-0.7 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-15
CK/TROP
[**2201-5-1**] 01:55PM BLOOD CK(CPK)-81
[**2201-5-1**] 08:00PM BLOOD CK(CPK)-84
[**2201-5-1**] 01:55PM BLOOD cTropnT-0.02*
[**2201-5-1**] 08:00PM BLOOD CK-MB-NotDone cTropnT-0.02*
MAX/SINUS CT
FINDINGS: There is a small air-fluid level in the left maxillary
sinus, consistent with layering hemorrhage. There is a small,
minimally displaced fracture of the anterior wall of the left
maxillary sinus. There is minimal subcutaneous stranding and air
in this region. There is a small left periorbital hematoma.
There is evidence of bilateral lens replacements. The globes
appear intact. The lateral masses of C1 are well apposed on C2.
No retroorbital hematoma is identified.
IMPRESSION:
1. Minimally displaced fracture of the anterior wall of the left
maxillary sinus with a small amount of hemorrhage within the
sinus.
2. Small periorbital hematoma.
HEAD CT
The extracalvarial soft tissues are unremarkable aside from
vascular calcifications. No acute fractures are identified.
There is a small fluid level within the left maxillary sinus.
There is heavy vascular calcification of the vertebral arteries
and cavernous carotid arteries.
There is intraventricular hemorrhage with blood products
layering in the occipital horns. A tiny extra-axial collection
consistent with a subdural hematoma measuring 3 mm in greatest
width and layers along the left frontal convexity with minimal
extension into the left middle cranial fossa. There is minimal
sulcal effacement of the subjacent gyri. No intracranial
herniation or shift is apparent.
There is moderate confluent periventricular hypoattenuation
consistent with chronic microvascular infarction. A focal region
of hypoattenuation within the right parietal lobe extending to
the cortical surface likely represents encephalomalacia from
previous infarction. There is a foci of calcification within the
right sylvian fissure, likely vascular in origin. Coarse
calcification is noted along the tentorium.
IMPRESSION:
1. Acute intraparenchymal hemorrhage with surrounding edema in
the left frontal lobe without significant mass effect consistent
with a hemorrhagic contusion.
2. Tiny acute subdural hematoma along the left frontal cerebral
convexity, with minimal extension into the middle cranial fossa.
3. Intraventricular hemorrhage. No significant change in
appearance since comparison study approximately three hours
previous.
ECHOCARDIOGRAM
The left atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
10-15mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50%).
Right ventricular chamber size and free wall motion are normal.
The right ventricular cavity is mildly dilated with borderline
normal free wall function. The aortic root is mildly dilated at
the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and low normal global biventricular systolic
function. Moderate pulmonary artery systolic hypertension. No
definite cardiac source of embolism identified.
Brief Hospital Course:
INTRAPARENCHYMAL HEMORRHAGE
Acute IPH seen with small SDH and intraventicular hemorrhage
without significant mass effect. Seen and followed by
neurosurgery, managed non-operatively. He was initially treated
with hydralazine to keep SBP < 160, but on the floor rarely
required intervention. If he has sustained hypertension this
follow-up in 4 weeks after discharge with Dr. [**First Name (STitle) **], with CT
prior. That phone number is [**Telephone/Fax (1) 58980**].
Aspirin and plavix held for 10 days. These can be restarted on
[**2201-5-12**].
MAXILALRY SINUS FRACTURE
Evaluated by trauma surgery, was non-displaced, non-operative
management.
Can be re-referred to OMFS if needed.
FALL
Witnessed by wife but circumstances are unclear as to why he
fell. Wife did not think he had LOC, and pt does not remember
event. Echo showed no siginifant valvular lesions to account for
sx, and pt had occasional bradycardia on telemetry without
significance thought to be in Wenkebach.
UTI
Pt with relatively resistant U/A.
Started on nitrofurantoin based on sensitivities.
MENTAL STATUS
Alert, coooperative, oriented to person and place.
DIABTES
placed on sliding scale instaed of home medications. should be
changed prior to d/c home.
Medications on Admission:
Aspirin 81 mg daily
Plavix 75 mg daily
Actos 45 mg daily
Glyburide 5 mg [**Hospital1 **]
Zocor 20 mg daily
Flomax 0.4mg SR 2 caps QD
Zoloft 150mg daily
Glucotrol 2.5mg [**Hospital1 **]
Zantac 75 2 tabs [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 4 days.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale
units Injection ASDIR (AS DIRECTED).
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: HOLD
until [**2201-5-12**].
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: HOLD
until [**2201-5-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Minimally displaced fracture of the anterior wall of the left
maxillary sinus
Acute intraparenchymal hemorrhage
Urinary Tract Infection
Secondary:
Depression
Diabetes
Stroke
Coronary Artery Disease
Discharge Condition:
Stable. Oriented to person, place, not perfect with date/time.
Discharge Instructions:
You were admitted with fall. You had a left facial fracture and
intracranial head bleed. Both of these do not require surgical
intervention and are stable.
Please review your dicharge medication list.
If you develop neurologic changes, worsening confusion, fever,
or other concerning symptoms, please return to the ED
Followup Instructions:
Please follow-up with neurosurgery Dr. [**First Name (STitle) **] in 4 weeks. His
number is [**Telephone/Fax (1) 58980**].
Please call your PCP when discharged from rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 13312**]
|
[
"311",
"414.01",
"599.0",
"801.31",
"E885.9",
"427.31",
"250.00",
"V12.54",
"272.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8794, 8864
|
6483, 7720
|
316, 327
|
9116, 9181
|
1979, 6460
|
9549, 9804
|
1518, 1527
|
7990, 8771
|
8885, 9095
|
7746, 7967
|
9205, 9526
|
1542, 1960
|
272, 278
|
355, 1146
|
1168, 1430
|
1446, 1502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,236
| 171,943
|
20197
|
Discharge summary
|
report
|
Admission Date: [**2150-3-11**] Discharge Date: [**2150-3-23**]
Date of Birth: Sex:
Service:
ADMITTING DIAGNOSIS: Stage 3-A lung cancer.
HISTORY OF PRESENT ILLNESS: The patient is a delightful 62
year old woman with a 90 pack year history of smoking. She
presented with chronic cough, worse for a 15 month duration,
and a 13 pound weight loss. She was found to have a poorly
differentiated non small cell lung cancer in the left upper
lobe, emanating from the lobar bronchus. It measured 3 by
2.6 cm and was associated with bulky mediastinal adenopathy.
An otolaryngology examination confirmed the presence of vocal
cord paralysis. Her chest CT scan showed no evidence of
liver or mediastinal involvement. Bone scan was negative.
PET scan reportedly showed no evidence of metastatic
involvement in the periphery. She was initially deemed
unresectable due to her bulky N2 disease and was started on
definitive chemoradiotherapy with Carboplatinum and Taxotere.
She did well and a recent CT scan showed a dramatic response
to the primary tumor as well as mediastinal lymph nodes.
Because of the significant reduction in mass, she was
discussed in the thoracic oncology multi-disciplinary center
and the consensus of the group was to move forward with an
attempt at surgical resection given her age and good health.
She was, therefore, admitted to the hospital for surgery.
DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room on [**2150-10-11**] and underwent a left
thoracotomy. During the operation, she had severe damage to
her left lung from radiation therapy and her left lung became
extremely edematous and she developed hemorrhage into her
airways. Because of the inability to oxygenate her, we
rapidly converted her over to a median sternotomy and
prepared for cardiopulmonary bypass. In the end, this turned
out not to be necessary and we completed the operation
through the median sternotomy and then converted it back to
the thoracotomy for the final portions of it, which included
the latissimus dorsi flap. She had initially difficult
postoperative course but eventually was discharged in
relatively good condition. She left against medical advice
due to the fact that her son had committed suicide the day
before. When she found out that this had happened, she left
against medical advice but she was in reasonably good health
at that time.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern4) 54269**]
MEDQUIST36
D: [**2150-12-24**] 17:12:32
T: [**2150-12-24**] 17:46:38
Job#: [**Job Number 54270**]
|
[
"998.11",
"287.4",
"293.0",
"458.29",
"427.0",
"162.3",
"997.1",
"V15.82",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"34.22",
"99.04",
"86.74",
"32.5"
] |
icd9pcs
|
[
[
[]
]
] |
198, 2692
|
145, 169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,477
| 153,210
|
11573+56251
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-5-4**] Discharge Date: [**2187-5-11**]
Date of Birth: [**2107-11-8**] Sex: M
Service: MEDICINE
Allergies:
Actos / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
xxxxxx
History of Present Illness:
79 yo M with history of CABG in [**2176**], DM, renal insufficiency
with baseline Cr ~1.7 reportedly, post polio syndrome who was
initially admitted to [**Hospital3 **] [**5-2**] with SOB x2days and
chest heaviness. Thought to be CHF/COPD exac with BNP was 1150,
and he ruled in for NSTEMI with troponin of 0.37 He was started
on heparin ggt with plan for transfer to [**Hospital1 18**] for likely cath.
No plavix given [**1-11**] previous "adverse rxn". He is also receiving
lasix 20mg IV BID but is running even with I/Os. CXR at OSH
revealed no consolidation. Pt has continued to smoke. P/w severe
congestion x 3 days, and SOB w/ productive cough and some chills
as well as urinary frequency. Also reported he could not lay
flat at night [**1-11**] SOB prior to OSH admission. Stopped plavix
within past few months [**1-11**] GIBleed. ?diverticular,
.
For his COPD exac vs. atypical PNA, he was given started on
azithromycin 250mg POx 5 days, given duonebs and solumedrol 60mg
q8 IV. Given lasix 20mg IV BID for possible CHF exac dc/'d on
[**2187-5-4**].
For his [**Last Name (un) **], baseline apparently 1.7 with peak ~2.5. U/A neg.
EKG [**5-2**], sinus rhyth, NA, Qtc 440, QRS 112, ~1mm STE in V2.
.
REVIEW OF SYSTEMS: otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: 3V CABG [**2176**]
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-DM2
-S/P nephrectomy as child
-renal insufficiency with baseline Cr in the 2's
-post polio syndrome
-Asthma
-s/p APPY
.
Social History:
2ppd smoker for many years. Occ ETOH. Denies drugs. Lives w/
grandson.
Family History:
Dad and sister died of pancreatic CA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 150/75 45 22 92 RA Wt: 164 lbs
GENERAL: NAD
NECK: Supple with JVP around level of lower neck
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: scattered wheezes and crackles at bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
DISCHARGE PHYSICAL EXAM:
VS: 98.0, BP 151/76, HR 92, RR 20, O2 99% RA
GENERAL: elderly man lying in bed in NAD, in good spirits
NECK: Supple with JVP around level of lower neck
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Poor air movement, prolonged expiratory phase. Diffuse
rhonchi and scattered wheezes, no rales.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
Pertinent Results:
LABS:
On admission:
[**2187-5-4**] 05:00PM PT-11.8 PTT-91.8* INR(PT)-1.1
[**2187-5-4**] 05:00PM PLT COUNT-276
[**2187-5-4**] 05:00PM TRIGLYCER-93 HDL CHOL-58 CHOL/HDL-5.1
LDL(CALC)-221* LDL([**Last Name (un) **])-236*
[**2187-5-4**] 05:00PM TRIGLYCER-93 HDL CHOL-58 CHOL/HDL-5.1
LDL(CALC)-221* LDL([**Last Name (un) **])-236*
[**2187-5-4**] 05:00PM ALBUMIN-4.3 CALCIUM-10.5* PHOSPHATE-4.3
MAGNESIUM-2.1 CHOLEST-298*
[**2187-5-4**] 05:00PM CK-MB-6 cTropnT-0.15*
[**2187-5-4**] 05:00PM CK(CPK)-104
[**2187-5-4**] 05:00PM estGFR-Using this
[**2187-5-4**] 05:00PM GLUCOSE-141* UREA N-65* CREAT-2.7*#
SODIUM-142 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-22*
[**2187-5-4**] 08:38PM URINE MUCOUS-RARE
[**2187-5-4**] 08:38PM URINE HYALINE-8*
[**2187-5-4**] 08:38PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2187-5-4**] 08:38PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2187-5-4**] 08:38PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
Cardiac enzymes:
[**2187-5-4**] 05:00PM BLOOD CK-MB-6 cTropnT-0.15*
[**2187-5-5**] 06:22AM BLOOD CK-MB-5 cTropnT-0.20*
[**2187-5-5**] 01:01PM BLOOD CK-MB-6 cTropnT-0.22*
[**2187-5-6**] 07:08AM BLOOD CK-MB-5 cTropnT-0.15*
[**2187-5-6**] 01:20PM BLOOD CK-MB-5 cTropnT-0.12*
[**2187-5-9**] 10:49PM BLOOD CK-MB-52* MB Indx-7.6*
[**2187-5-10**] 12:49PM BLOOD CK-MB-48*
Hematocrit trend:
[**2187-5-4**] 05:00PM BLOOD Hct-39.7*#
[**2187-5-5**] 06:22AM BLOOD Hct-37.2*
[**2187-5-6**] 07:08AM BLOOD Hct-38.8*
[**2187-5-7**] 06:26AM BLOOD Hct-30.9*
[**2187-5-7**] 11:00AM BLOOD Hct-27.4*
[**2187-5-7**] 07:25PM BLOOD Hct-36.8*#
[**2187-5-8**] 06:59AM BLOOD Hct-33.5*
[**2187-5-8**] 03:00PM BLOOD Hct-33.6*
[**2187-5-8**] 10:10PM BLOOD Hct-32.1*
[**2187-5-9**] 07:42AM BLOOD Hct-34.4*
[**2187-5-9**] 05:01PM BLOOD Hct-30.5*
[**2187-5-9**] 10:49PM BLOOD Hct-27.2*
[**2187-5-10**] 08:46AM BLOOD Hct-33.9*
[**2187-5-10**] 12:49PM BLOOD Hct-32.9*
[**2187-5-10**] 06:52PM BLOOD Hct-36.1*
[**2187-5-11**] 06:02AM BLOOD Hct-31.2*
[**2187-5-11**] 04:00PM BLOOD Hct-31.5*
Misc labs:
[**2187-5-4**] 05:00PM BLOOD %HbA1c-8.0* eAG-183*
[**2187-5-4**] 05:00PM BLOOD Triglyc-93 HDL-58 CHOL/HD-5.1
LDLcalc-221* LDLmeas-236*
On discharge:
[**2187-5-11**] 06:02AM BLOOD WBC-5.8 RBC-3.51* Hgb-10.4* Hct-31.2*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.0 Plt Ct-207
[**2187-5-11**] 06:02AM BLOOD Glucose-192* UreaN-43* Creat-2.0* Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2187-5-11**] 06:02AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8
MICRO:
[**2187-5-4**] 8:38 pm URINE Source: CVS.
**FINAL REPORT [**2187-5-5**]**
URINE CULTURE (Final [**2187-5-5**]): NO GROWTH.
[**2187-5-5**] 4:09 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2187-5-7**]**
GRAM STAIN (Final [**2187-5-5**]):
[**10-4**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2187-5-7**]):
MODERATE GROWTH Commensal Respiratory Flora.
STUDIES:
[**2187-5-4**] CXR:
CHEST, AP UPRIGHT: Lungs are clear. Changes of median
sternotomy, with
mediastinal clips and coronary artery bypass grafting. Heart
size is top
normal. Aorta is tortuous and calcified. There are no
significant pleural
effusions, pneumothorax, or pneumomediastinum.
IMPRESSION: No acute cardiopulmonary process.
[**2187-5-5**] ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior and
infero-lateral hypokinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. 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. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
[**2187-5-5**] RENAL U.S.
Right kidney surgically absent. No evidence of left
hydronephrosis.
[**2187-5-9**] C.CATH
Findings
ESTIMATED blood loss: <40 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: Distal 90% with total occlusion of the LAD after small
diagonal supplied
LAD: Total occlusion. Fills via LIMA with diffuse disease
distal to the touchdown with 60% stenosis in the mid vessel and
distal 50-60% stenosis in the distal 2.0 mm segment
LCX: Total occlusion ostial.
RCA: Total occlusion 90% proximal and mid vessel total occlusion
SVG-Diagonal-OM: Ulcerated thrombotic mid segment 80% occlusion
in the jump graft segment to the OM
LIMA-LAD: Widely patent to the LAD
Angiography of the SVG to PDA showed diffuse, serial 50-70%
lesions in the body of the graft. No visible thrombus or
ulceration.
Interventional details
Change for 6 French JR4 guide. Crossed with a Prowater wire and
exchanged for a 5.0 mm Spider distal protection device. Deployed
a 5.0 x 16 mm Ultra stent. Angiography revealed a focal
perforation. A 4.5 mm balloon was inflated to occlude flow.
Access was obtained in the left common femoral artery. A 7
French JR4 guide was used to access the SVG graft after the 4.5
mm balloon was deflated, the Spider device was retrieved and the
6 French guide removed. A 4.0 x 19 mm Graftmaster covered stent
was deployed after prolonged balloon inflation did not seal the
perforation. The 4.0 mm stent did not seal the perforation and
was postdilated to 4.5 mm, but this did not seal the
perforation.
A second 4.5 x 26 mm Graftmaster stent was deployed in a more
proximal overlapping fashion and this did not seal the
perforation. Further postdilation with a 4.5 mm balloon sealed
the peforation completely and this was confirmed in multiple
views. Final angiography revealed normal flow, no dissection and
0% residual stenosis in the stents. The patient tolerated the
procedure well and left the laboratory in stable condition.
1. Secondary prevention CAD
2. Plavix 75 mg PO QD x 1 month, preferably longer given
Graftmaster stents and NSTEMI
3. Planned PCI of SVG to PDA if patient can tolerate
drug-eluting
stent with dual antiplatelet therapy.
[**2187-5-10**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild elevation of the right hemidiaphragm, no evidence
of pneumonia or other parenchymal pathology. Borderline size of
the cardiac silhouette. Coronary stent in situ. Unchanged
alignment of the sternal wires.
Brief Hospital Course:
79 yo M with history of CABG in [**2176**], DM, renal insufficiency
with baseline Cr ~1.7 reportedly, post polio syndrome who was
initially admitted to [**Hospital3 **] [**5-2**] with SOB found to
have peak troponin to 0.37, treated for NSTEMI w/ ASA, Heparin
GTT, as well as for acute congestive heart failure exacerbation
+ COPD exacberation + [**Last Name (un) **] and transferred to [**Hospital1 18**] for further
managment. His course was complicated by GI bleed during medical
managment and perforated SVG graft during PCI on [**2187-5-9**]. He was
transferred to the CCU following cathterization on [**2187-5-9**],
monitored overnight, and stable for transfer back to the
cardiology floor the following day
ACTIVE ISSUES BY PROBLEM:
# NSTEMI: He was plavix loaded and placed on heparin gtt, but
developed slow GI bleed (see below). Heparin gtt and plavix were
stopped on [**5-7**], however plavix was restarted the following day.
Cardiac catheterization was delayed until the bleeding
stabilized on [**5-9**]. Cath showed thrombus in SVG->OM3, so BMS was
deployed, but procedure was complicated by perforation of vein
graft. Perforation was controlled with GRAFTMASTER covered stent
and patient was transferred to CCU for further monitoring
overnight. He developed no further complications from the
perforation. He had additional diffuse disease in the SVG->PDA
graft which was not intervened upon, but would likely benefit
from stenting. Rather than return to the cath lab this
admission, the patient preferred to follow up with Dr.
[**Last Name (STitle) 1911**] as an outpatient and decide at that time about
elective catheterization for PCI. He was discharged on aspirin,
metoprolol, lisinopril, plavix (for at least 1 month) and
atorvastatin (low dose, given questionable allergy). He will
follow up with his cardiologist in the next 2-3 weeks and will
continue to monitor for signs of bleeding as a result of his
plavix therapy.
# GI bleed: Developed bloody stools on [**5-6**] while on heparin gtt
and plavix. Of note, he had had a GI bleed this past fall while
using plavix, however the source was never identified. He was
tranfused 2 units PRBCs with appropriate hct bump. GI consulted
and thought likely diverticular vs. AVM c/b plavix + heparin.
Both were stopped on [**5-7**], but plavix was restarted on [**5-8**].
Prior to catheterization patient was still having small stools
streaked with maroon. Following tranfer to CCU, patient was
noted to have at least 3 moderate sized maroon stools. He had no
nausea, vomiting, or abdominal pain. He remained hemodynamically
stable and was started on 40mg IV pantoprazole q12 hours. HCT
was trended and patient received another 2units pRBC after HCT
dropped to 27.2 the evening of [**5-9**]. He had appropriate increase
in HCT, which was stable for transfer back to the cardiology
service. He had no further episodes of blood in his stool and
hematocrit was stable on discharge. We had planned on doing a
colonoscopy and EGD as an inpatient, however the patient
preferred to be discharged and follow up with his GI doctor [**First Name (Titles) **] [**Location (un) 36805**] (Dr. [**Last Name (STitle) **] for follow up and possible elective
scope. He has an appointment for follow up with him on [**2187-5-14**].
# Acute on chronic renal insufficiency: baseline reportedly
1.7, elevated to 3.1 at peak, thought to be due to overdiuresis
at OSH. FEUrea 34%, renal u/s without evidence of obstruction.
His Cr trended back down to baseline with fluids.
# COPD: Shortness of breath at OSH treated as COPD exacerbation
with prednisone burst of 40 mg daily x5 days and course of
azithromycin x5days. He was also treated with duonebs as an
inpatient and started on tiotropium and albuterol inhalers at
discharge. He will follow up with his PCP to assess his
pulmonary symptoms, would recommend considering PFTs and
pulmonary referral, if necessary.
# HTN: BP meds were held intermittently throughout his
hospitalization given GI bleed. He was started on metoprolol (in
place of atenolol) and lisinopril. He should follow up with his
PCP for follow up chem panel and BP check in the next 1-2 weeks.
# Hyperlipidemia: on gemfibrozil as an outpatient, so this was
continued and ezetimibe was added, given his statin "allergy"
(patient is not sure about this allergy). On discussion with
his primary cardiologist, however, we stopped his gemfibrozil
and started him on atorvastatin 10mg and continued ezetimibe on
discharge. He should have LFTs checked in [**3-16**] weeks.
# Tobacco abuse: expressed a desire to quit smoking, so he was
given a prescription for nicotine patches on discharge.
INACTIVE ISSUES BY PROBLEM:
# Chronic Systolic CHF: EF 45% on TTE this admission. His
shortness of breath at the OSH was initially thought to be due
to a CHF exacerbation, so he was diuresed aggressively, however
on arrival at [**Hospital1 18**] he appeared euvolemic to dry. He was not
diuresed any further during this hospital stay.
# Diabetes: on sitaglipin and glipizide as an outpatient. These
were held while inpatient, and he was started on insulin sliding
scale. A1c found to be 8. He was restarted on his oral DM
medications on discharge. He would likely benefit from addition
of insulin to his regimen, given his A1c of 8, however will
defer to his PCP.
TRANSITIONS OF CARE:
- NSTEMI/CAD: had covered stent placed and needs at least 1
month of plavix for this. He ideally should return for elective
placement of DES to diseased SVG to PDA, however this would
require longterm plavix, which he may not tolerate. Will follow
up with Dr. [**Last Name (STitle) 1911**] in clinic in the next 2-3 weeks.
- GI Bleed: will follow up with with primary GI Dr. [**Last Name (STitle) **] on
[**2187-5-14**] for possible c-scope and/or EGD. Hematocrit should be
checked at follow up appt with PCP [**Last Name (NamePattern4) **] [**2187-5-15**] to ensure stability
- HTN: started on lisinopril in addition to metoprolol. Should
have chem panel checked in [**12-11**] weeks
- Hyperlipidemia: started low-dose atorvastatin per Dr. [**Name (NI) 36806**] recs, will need to monitor LFTs in [**3-16**] weeks
- COPD: started on tiotropium and albuterol inhalers. Would
benefit from PFTs and possible pulmonary referral
- FULL CODE this admission
Medications on Admission:
MEDICATIONS (HOME)
Aspirin 81mg PO dialy
atenolol 50mg PO daily
gemfibrozil 600mg PO BID
Glipizide 5mg [**Hospital1 **]
Omeprazole 20mg PO daily
Sitagliptin 50mg PO daily
.
MEDICATIONS ([**Hospital3 **])
nicotine patch 21mg daily
azithromycin 250mg po daily x5 days (stopped prior to transfer)
ISS
Heparin ggt
aspirin 81mg PO daily
atenolol 50mg PO BID
gemfibrozil 600mg PO BID
glipizide 5mg PO BID
omeprazole 20mg PO daily
Januvia 50mg PO daily
Duonebs q4h PRN SOB
Prednisone taper: 60 60 40 40 20 20 10 10 off
solumederol 60mg IV TID(stopped and changed to prednisone taper
as above)
lasix 20mg IV BID (stopped prior to transfer)
.
Discharge Medications:
1. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
3. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 14 days: Do not smoke while using.
Disp:*14 Patch 24 hr(s)* Refills:*0*
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 7 days: Do not smoke while using.
Disp:*7 patch* Refills:*0*
8. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 7 days: Do not smoke while using.
Disp:*7 patches* Refills:*0*
9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Dr. [**Last Name (STitle) 1911**] will decide when it is safe to stop
this.
Disp:*30 Tablet(s)* Refills:*0*
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
15. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation once a day.
Disp:*30 capsules* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary:
Non-ST segment elevation mycardial infarction
Gastrointestinel Bleed
Acute on chronic renal failure
Hypertension
Hyperlipidemia
Secondary:
Chronic Obstructive Pulmonary Disease
Diabetes mellitus
Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 36803**]
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital for a small heart attack in the setting
of a COPD exacerbation. You also had some signs of worsening
kidney function, which improved after getting fluids.
A narrowing in your bypass graft was found in the cath lab and
then was stented. Unfortunately during the procedure, a small
hole was pokes in your graft, however this was closed and you
did very well afterward. There are some areas of your heart
where more blockages were seen, so you may need to go back for
more stenting if Dr. [**Last Name (STitle) 1911**] feels that this would be
beneficial.
You were started on plavix for your heart attack, and
unfortunately this caused some bleeding in your gastrointestinal
tract. The bleeding appears to have stopped now, but it is
essential that you follow up with Dr. [**Last Name (STitle) **] (your GI doctor)
on Monday [**5-14**] for evaluation and possible
colonoscopy/endoscopy to look for the source of bleeding.
We have made a number of changes to your medication regimen
Medications STARTED that you should continue:
Atorvastatin 10mg for cholesterol
Plavix 75 mg daily for your heart and new stent (for at least
one month)
Metoprolol succinate 25 mg daily for your heart
Nicotine patches to help quit smoking
Ezetimibe 10mg daily for cholesterol
Tamsulosin 0.4mg nightly for your prostate
Lisinopril 10mg daily for your blood pressure
Albuterol inhaler 1-2 puffs as needed for shortness of breath
Tiotropium (spiriva) inhaler 1 puff daily
Medications STOPPED this admission:
Atenolol
Gemfibrozil
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Please ensure to stop smoking cigarettes. This is incredibly
important to help you stay healthy and protect your heart and
lungs.
Followup Instructions:
Follow up with your PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) **]
Tuesday, [**5-15**] @ 11:30am
Please follow up with your GI specialist for follow up of your
gastrointestinal bleed:
Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) **]
[**5-14**], 1:15 PM
([**Telephone/Fax (1) 36807**]
Please call Dr.[**Name (NI) 1912**] office to make an appointment to
be seen in the next 2-3 weeks to see how you are doing after
your heart attack.
Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**]
[**Telephone/Fax (1) 11767**]
Name: [**Known lastname 6553**],[**Known firstname **] Unit No: [**Numeric Identifier 6554**]
Admission Date: [**2187-5-4**] Discharge Date: [**2187-5-11**]
Date of Birth: [**2107-11-8**] Sex: M
Service: MEDICINE
Allergies:
Actos / Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 1845**]
Addendum:
Major Surgical or Invasive Procedure:
[**2187-5-9**] cardiac catheterization
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1850**] MD [**MD Number(2) 1851**]
Completed by:[**2187-5-13**]
|
[
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"288.60",
"414.02",
"578.9",
"250.00",
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"997.1",
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"E879.0",
"138",
"585.9",
"285.9",
"414.12",
"428.0",
"493.22",
"584.9",
"276.7",
"305.1",
"414.01",
"428.22",
"E934.8",
"272.4",
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icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.47",
"00.66",
"37.22",
"88.56",
"36.06",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
22470, 22695
|
10053, 15396
|
22406, 22447
|
19311, 19311
|
3118, 3125
|
21424, 22368
|
2041, 2081
|
17065, 18957
|
19069, 19290
|
16406, 17042
|
19494, 21401
|
2121, 2550
|
1703, 1784
|
5385, 10030
|
1578, 1599
|
4187, 5371
|
265, 274
|
349, 1559
|
3139, 4170
|
19326, 19470
|
15417, 16380
|
1815, 1937
|
1621, 1683
|
1953, 2025
|
2575, 3099
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,667
| 139,836
|
28077
|
Discharge summary
|
report
|
Admission Date: [**2118-7-27**] Discharge Date: [**2118-7-28**]
Date of Birth: [**2040-4-17**] Sex: F
Service: MEDICINE
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Right Carotid Artery Stenosis
Major Surgical or Invasive Procedure:
1. Cardiac cath with stent placement placement to the right
carotid artery.
History of Present Illness:
Ms. [**Known lastname 68297**] is a 78 year-old female with a history of
hypertension, hyperlipidemia and diabetes who presents for
referred for right carotid artery angiography and possible
revascularization.
.
Recently noted to have a right carotid bruit on routine exam in
[**2118-4-5**]. On [**2118-6-9**], she had a carotid duplex at the
[**Hospital1 18**]-[**Location (un) 620**] which revealed a critical, 90% stenosis of the
right internal carotid artery. No significant abnormalities were
noted on the left side. She has had mild intermittent dizziness
for the past few years. She also reports some positional
lightheadedness in the morning, but otherwise has been
asymptomatic from a neurological stanpoint. She has no history
of stroke or TIA. She specifically denies any motor or sensory
changes, or amaurosis fugax. She does report numbness and
tingling in her feet for the last several years.
.
The patient had her pre-carotid neurological assessment on
[**2118-7-25**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Of note, her blood pressure
during her visit with Dr. [**First Name (STitle) **] was over 200 systolic.
.
From a cardiovascular standpoint, she does report having some
exertional dyspnea. This occurs with activity such as walking
one block. She denies any chest pain, PND or orthopnea. She also
denies lower extremity edema and claudication. Due to her
multiple risk factors, she was referred for a Persantine MIBI.
.
Currently, the patient feels well with no chest pain or
shortness of breath.
Past Medical History:
1) Carotid bruit--->stenosis
2) HTN
3) DMII-HgAlc 6.1% on [**2118-6-13**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC. Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**1-7**] breast ca
[**22**]) Chronic renal insufficency-Baseline Cr of 2.0. At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.
Social History:
Social history is significant for the absence of current tobacco
use; 25 pack-year history, but quit 25+ years ago. There is no
history of alcohol abuse. Widow. Has 4 children. Lives with one
of her sons. Currently retired and has no car. Relies on ??????The
Ride?????? for transportation for medical care. Her son [**Name (NI) **] can be
reached at [**Telephone/Fax (1) 68298**] (cell).
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had a pacemaker, father died of an MI in
his early 80??????s.
Physical Exam:
Ht: 5 feet 3.5 inches
Wt 138 lbs
.
Blood pressure was 112/71 mm Hg while lying flat. Pulse was 108
beats/min and regular, respiratory rate was 12 breaths/min and
she was satting 99% on room air. Weight 138 lbs and 63.5 inches.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 2-3cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Examination of the heart revealed no thrills, lifts or palpable
S3 or S4. The heart sounds revealed a normal S1 and the S2 was
normal. There was a soft II/VI systolic murmur at the left lower
sternal border.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Neurologic exam showed CN II-XII to be intact. Strength was [**4-9**]
in the upper and lower extremities BL and sensation was grossly
intact in all four extremities. Gait was not assessed.
.
Pulses:
Right: Carotid 1+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 1+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2118-7-27**] 04:54PM GLUCOSE-146* UREA N-9 CREAT-0.5 SODIUM-140
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2118-7-27**] 04:54PM estGFR-Using this
[**2118-7-27**] 04:54PM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-1.9
[**2118-7-27**] 04:54PM WBC-9.3 RBC-3.27* HGB-11.1* HCT-30.9* MCV-94
MCH-33.9* MCHC-35.9* RDW-13.5
[**2118-7-27**] 04:54PM PLT COUNT-185
CATH [**2118-7-27**]
PTCA COMMENTS: Initial angiography revealed a severe 90%
stenosis of
the right ICA. We planned to treat this with PTA and stenting.
Heparin
was commenced prophylactically. A 6F Shuttle sheath was advanced
to the
Right CCA. An Accunet filter device failed to deliver due to
severe
tortuosity. The lesion was therefore crossed with a Wizdom
supersoft
wire and exchanged for a 6.0mm Spider filter without difficulty.
The
lesion was dilated with a 2.5mm balloon to 16atms. Stenting was
performed with a [**5-13**] x40mm AccuLink stent postdilated with a
4.5mm
balloon to 12 atms. Excellent result with normal flow down
vessel and
10% residual. Patient remained hemodynamically stable with no
neurologically symptoms. Patient discharged from cath lab in
stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = minutes.
Arterial time =
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol ml
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Cardiac Cath Supplies Used:
- CORDIS, WIZDOM SS 300
- [**Company **], QUANTUM MAVERICK RX 20MM
- [**Company **], QUANTUM MAVERICK RX 20MM
- ALLEGIANCE, CUSTOM STERILE PACK
5 CORDIS, BER, 100
- CORDIS, BER, 100
- COOK, SHUTTLE SHEATH
- GUIDANT, LO PRESSURE INFLATION DEVICE
- [**Doctor Last Name **], EMBO SHIELD
COMMENTS:
1. Abdominal aorta - Type 1 arch without critical lesions
2. Left carotid - The LCCA is normal. The ICA has mild disease
without
critical lesions. The ICA fills the ipsilateral ACA and MCA with
noted
fetal origin PCA. There is minimal cross filling of
contralateral ICA.
3. Right carotid - The CCA is normal. The ICA has a tubular 90%
lesion.
The ICA fills ipsilateral ACA and MCA.
4. Successful Stenting of right ICA with a [**5-13**] x 40mm Acculink
stent
posdilated with a 4.5mm balloon. Excellent result with 10%
residual.
Patient left cathlab in stable condition.
FINAL DIAGNOSIS:
1. Right 90% ICA stenosis
2. Successful stenting of right ICA with a bare metal stent.
Brief Hospital Course:
1. [**Country **] stenosis: After stenting with no complications (see
cath report above), the patient underwent serial neurological
assessment that demonstrated normal neurological function. She
was put on Plavix for 12 months and aspirin. Systolic Blood
Pressure was maintained at above> 100 without the need for
boluses or pressors.
.
2. Diabetes:
- Continued home insulin regimen
.
3. Hypertension:
- Continued lisinopril. Amlodipine was added for better blood
pressure control
.
---FEN: Diabetic diet
---Received subcutaneous heparin for DVT prophylaxis.
Medications on Admission:
1. Lisinopril 5mg daily
2. Synthroid 75mcg daily
3. NPH 35 units QAM
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
Five (35) units Subcutaneous once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Right internal carotid artery stenosis
Secondary: Hypertension, hyperlipidemia
Discharge Condition:
Hemodynamically stable.
Neurologically intact.
Discharge Instructions:
You were admitted and had a stent placed in your right carotid
artery. It will be extremely important for you to continue
takingall your medications, as prescribed. Please note the
following changes:
1. Plavix - In addition to aspirin, this helps to thin the blood
and keep your new stent open. This must be taken, every day,
without exception.
2. Amlodipine - This is an additional blood pressure medication.
Followup Instructions:
Please be sure to follow-up with Dr. [**First Name (STitle) **] in 2 weeks time
([**Telephone/Fax (1) 4022**]).
|
[
"593.9",
"V10.3",
"250.00",
"272.4",
"433.10",
"244.0",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"00.61",
"00.45",
"00.40",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
8614, 8672
|
7364, 7926
|
303, 381
|
8806, 8854
|
4824, 5993
|
9316, 9431
|
2913, 3064
|
8046, 8591
|
8693, 8785
|
7952, 8023
|
7252, 7341
|
8878, 9293
|
3079, 4805
|
6012, 7235
|
234, 265
|
409, 1964
|
1986, 2492
|
2508, 2897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,682
| 132,878
|
45234
|
Discharge summary
|
report
|
Admission Date: [**2148-1-10**] Discharge Date: [**2148-1-17**]
Date of Birth: [**2065-4-28**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Milk
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
[**2148-1-11**] Left hip hemiarthroplasty with [**Doctor Last Name 3389**] components, #9
press-fitted stem, 46-mm head, -3-mm neck.
[**2148-1-11**] IVC filter placement
[**2148-1-15**] Right AC PICC
History of Present Illness:
Patient is an 82 year old female who fell down while ambulating
unwitnessed today hit the left side of her body causing a left
hip fracture. Did not lose
consciousness according to 24 hour caregiveer
Past Medical History:
PMH
1. Atrial fibrillation
2. Hypercholesterolemia
3. GERD
4. Depression
5. Osteoporosis
6. Retroperitoneal bleed [**4-17**]
7. Diastolic heart failure
PSH
1. S/P MVR with mechanical valve [**2145**]
2. S/P L4-5 laminectomy [**12-17**]
Social History:
Patient lives with a 24 hour aide and is able to do ADLs with
help from aide. She is a Holocaust survivor. Her son, [**Name (NI) **], is
very involved in her medical care and is her HCP.
[**Name (NI) 1139**]: Non-smoker
EtOH: none
Illicits: none
Family History:
Non-contributory
Physical Exam:
O: T:100.4 BP:144/49 HR:98 R 24 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 min reactive EOMs full
Neck: In collar
Chest CTAB pinpoint tenderness to L parasternal area
Cor RRR
Abd s/nd with LLQminimal tenderness, spine tender to lumbar
region (baseline per
patient)
Ext moves all extremities, tender over left shoulder w/o
deformity or crepitus, tender to L hip, otherwise extremities
well perfused with intact range of motoin and sensatoin
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and [**2139-3-12**] but
realized [**Holiday 1451**] just occured. Aware of hip fracture and
possible surgery
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2.5 min reactive
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-13**] throughout did not test left
leg
though wiggles toes. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Pertinent Results:
[**2148-1-10**] 12:10PM WBC-12.1* RBC-4.07* HGB-12.6 HCT-38.7 MCV-95
MCH-30.8 MCHC-32.5 RDW-15.6*
[**2148-1-10**] 12:10PM NEUTS-90.8* LYMPHS-6.5* MONOS-2.2 EOS-0.3
BASOS-0.1
[**2148-1-10**] 12:10PM PLT COUNT-187#
[**2148-1-10**] 12:10PM PT-25.9* PTT-28.4 INR(PT)-2.5*
[**2148-1-10**] 12:10PM GLUCOSE-94 UREA N-18 CREAT-0.6 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
[**2148-1-10**] Head CT : Acute subdural hemorrhage overlying the left
temporal lobe extending to overly the left frontal lobe, with
some effacement of the left temporal lobe. No significant
midline shift.
[**2148-1-10**] CT C spine :
1. No evidence of acute fracture.
2. Multilevel degenerative disease. Minimal anterolisthesis of
C5 over C6. If continued clinical concern for spinal cord or
ligamentous injury, MRI is more sensitive.
3. 5 mm right upper lobe nodular density. Follow up chest CT is
indicated in [**7-21**] months if patient is high risk (incl history
of smoking or malignancy) or in 12 months if patient is low
risk.
4. Mild septal thickening in visualized portions of bilateral
lung apices, may be due to mild edema.
[**2148-1-10**] Left hip fracture : Subcapital fracture of the proximal
left femur.
[**2148-1-10**] CT Torso :
1. Multiple pulmonary nodules stable since [**2142**]. Largest
preexisting nodule, in the right upper lobe, is smaller and
retracted, consistent with scar.
2. New left anterior third rib fracture.
3. Small bilateral pleural effusions probably due and mild
pulmonary edema.,
4. Concurrent conventional PA and Lateral upright radiographs
recommended to evaluate possible right lower lobe lesion
(rounded atelectasis or abscess, less likely tumor) or fissural
fluid loculation. If the abnormality is verified it can be
followed with subsequent conventional films.
5. Possible pulmonary arterial hypertension.
6. Calcification of the coronary arteries, aortic valve and
aorta extending into the brachiocephalic trunk.
[**2148-1-10**] Head CT : 1. Small left subdural hematoma, unchanged in
size. Subdural blood layers along the falx and tentorium.
2. Right frontal hyperdensity which is equivocal for a small
focus of
subarachnoid hemorrhage and can be reassessed on followup
studies (2:23).
NOTE ADDED AT ATTENDING REVIEW: There is not evidence of
subdural hemorrhage along the falx or tentorium. These
structures are dense due to enhancement from prior
administration of contrast material for the abdominal CT study.
Otherwise I agree with this interpretation.
[**2148-1-11**] Head CT : 1. Little change in the 3 mm left subdural
hematoma.
2. Right frontal lobe hyperdensity is no longer identified.
3. Possible subtle hypodensity of the left temporal lobe. If
there is
concern for acute or subacute infarct, MRI is recommended.
[**2148-1-12**] Head CT : 1. Unchanged 4-mm left subdural hematoma.
2. 2-mm hyperdense focus in the left frontal lobe equivocal for
small focus of subarachnoid hemorrhage. Attenation to this
finding is recommended on follow-up studies.
3. Unchanged left temporal lobe hypodensity can be due to
contusion. If
there is concern for acute infarct, MRI is recommended.
[**2148-1-13**] MRI Brain : No acute infarct identified. The CT
demonstrated hypodensity in the left temporal region likely is
secondary to artifacts as well as some associated changes of
brain contusion and extra-axial blood. A small left- sided
subdural is again identified. Severe changes of small vessel
disease and moderate ventriculomegaly and sulcal prominence due
to atrophy is identified.
[**2148-1-16**] EEG: no seizure activity
[**2148-1-17**] Non invasive carotid studies : No significant stenoses
bilat. ICA's
Brief Hospital Course:
Mrs. [**Known lastname **] was evaluated in the Emergency Room by the Trauma
Service and all scans were reviewed. Based on her small SDH she
was transferred to the Trauma ICU for close monitoring and
frequent neuro checks. Her admission INR of 2.5 was corrected
with 2 units of fresh frozen plasma which normalized her INR
along with some Vitamin K. Following a temperature spike of 101
she was fully cultured. She remained stable and on [**2148-1-11**] was
taken to the Operating Room for repair of her left hip fracture
and placement of an IVC filter. She tolerated this well and
subsequently underwent repeat Head CT's which showed no
progression of the SDH. She was transferred to the Trauma floor
for further management. She was transfused with 2 units of
packed red blood cells post op for a hematocrit of 24.
Forty eight hours after an unchanged Head CT she began
anticoagulation with Heparin for her mechanical valve and atrial
fibrillation. About 3-4 hours after the heparin started she
developed left sided weakness and seemed more somnolent. She
also had rapid atrial fibrillation. This prompted transfer back
to the ICU. A repeat head CT showed no increase in the SDH and
she was seen by the Stroke service for full evaluation. An MRI
of the head was recommended and showed no acute stroke, a stable
SDH and small vessel disease. The hypodense area at the left
temporal lobe was artifact. Her mental status continued to wax
and wane between sleepy to alert and conversant. ( Her primary
language is Polish but she can speak and understand a little
English.) Her left sided weakness resolved and she was improving
daily. Carotid studies were negative and an EEG showed no
evidence of seizure activity. She was on prophylactic Dilantin
for her SDH which ended today.
Currently she remains on IV heparin and her [**Date Range 197**] was started
2 days ago ( 2 mg each day). Her INR today is 1.7 and she
should receive another 2 mg. tonight. Her heparin is at 1100
units an hour. Her last PTT was 100 which reflected 1150 units
an hour. Her PTT should be checked every 6 hours. Her heparin
can be discontinued when her INR is 2.2.
From a surgical standpoint, her left hip incision has a small
amount of serous drainage on the dressing and is changed [**Hospital1 **].
She has not been febrile and there is no wound erythema. Her
weight bearing status is full weight bearing left lower
extremity.
Mrs. [**Known lastname **]' appetite is slowly improving. She has no trouble
swallowing and her best meal is breakfast. She's also willing
to take supplements. Calorie counts will need to continue.
Following a prolonged hospital stay she was discharged to rehab
today for more intense physical therapy and continued adjustment
of her [**Known lastname 197**] with the hope that she will be able to return
home with her caregiver.
Medications on Admission:
1. Mirtazapine15 mg PO Qhs
2. Folate 1 mg PO Daily
3. Methotrexate 12.5 mg Qweek
4. Lopressor 25 mg PO BID
5. Prednisone 4 mg PO Daily
6. Simvastatin 20 mg PO Daily
7. [**Known lastname 197**] 2 mg PO Daily
8. Cymbalta
9. Vicodin 5/500 mg PO Q4 hours prn pain
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO tonight.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12 () as needed for
pain.
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: 0.5 Tablet PO Q6H
(every 6 hours).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Heparin (Porcine) in D5W 12,500 unit/250 mL Parenteral
Solution Sig: 1100 (1100) units per hour Intravenous continuous.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis
S/P fall
1. 4mm SDH
2. Left hip fracture
3. Left anterior 3rd rib fracture
4. Acute blood loss anemia
Secondary diagnoses
1. Atrial fibrillation
2. Hypercholesterolemia
3. GERD
4. Depression
5. Osteoporosis
6. Retroperitoneal bleed [**4-17**]
7. Diastolic heart failure
8. S/P MVR with mechanical valve [**2145**]
9. S/P L4-5 laminectomy [**12-17**]
Discharge Condition:
Stable, has some periods of sleepiness but wakes up and is alert
and oriented. Appetite waxes and wanes, needs some assistance
and calorie counts
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications. These medications include but are not
limited to: narcotics and benzodiazepines. Use extreme caution
when combining these substances with each other, alcohol, or
other central nervous system depressants.
Take all medications as directed.
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 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.
Activity:
Full weight bearing left lower extremity.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Staples will be removed on [**2148-1-25**]
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**]
Date/Time:[**2148-2-27**] 11:45
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment 2 weeks after you are discharged from rehab
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] for a follow up appointment in 2
weeks
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2148-1-17**]
|
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icd9cm
|
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[
[]
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[
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"81.52",
"38.93"
] |
icd9pcs
|
[
[
[]
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] |
10823, 10889
|
6492, 9352
|
287, 489
|
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|
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1260, 1278
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|
517, 720
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|
742, 980
|
996, 1244
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,909
| 110,349
|
3025
|
Discharge summary
|
report
|
Admission Date: [**2136-3-13**] Discharge Date: [**2136-3-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Lightheadeness, Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
Blood transfusions
History of Present Illness:
Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status
post repair, MVR s/p porcine valve placement, atrial
fibrillation on coumadin, and diverticulosis who presented with
lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He
admits to feeling weak one day prior and his wife reports he has
had increased fatigue throughout the week prior to presentation.
He notes he woke up early on morning of admission feeling very
dizzy and "woozy." His wife reports he has had bloody stools for
at least a week. He also has had relatively severe nosebleeds
and had excessive bleeding from a cut on his hand over the past
week. He denies any changes to his coumadin doses or other
changes in his medications recently.
In the ED, initial vs were: T 97.3, P 78, BP 122/60, R 16, O2
sat 98% on RA. A foley was placed and per report approximately
200 cc of urine drained. He was found to have a 12 point Hct
drop from his prevoius value taken last summer and INR greater
than assay as well as acute renal failure. Patient was given 1 L
of NS, vitamin K 5 mg PO x1, protonix 40 mg IV x1 and 2 units of
PRBCs and 4 units of FFP were ordered. Additionally, patient got
up in the ED to urinate and fell. He was possibly unresponsive
mom[**Name (NI) 11711**]. CT head was negative. He did sustain bilateral knee
hematomas at the time.
He denies any recent changes in his coumadin dose and has been
on coumadin for about two years. He reports taking some
supplements but mostly vitamins and melatonin. His last
colonoscopy was in [**11/2131**] and showed diverticulosis of the
sigmoid colon. EGD at that time showed a large hiatal hernia and
gastritis with normal biopsies.
In the MICU, the patient reports feeling well and denies ever
having chest pain, shortness of breath, abdominal pain, or
nausea and vomiting. His greatest concern on transfer to the
floor is that his urine appeared quite bloody.
Review of Systems: The patient denied any fevers, chills, weight
loss, or recent illnesses. No nausea, vomiting, abdominal pain,
or melena. He denied any chest pain, shortness of breath, or
palpitations. He did report some worsened urinary hesitancy and
feeling of being unable to void fully on the day prior to
presentation.
Past Medical History:
-Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD,
SVG to PDA)
-Ascending Aortic Aneurysm s/p repair in [**2134**]
-Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**]
-Atrial fibrillation
-Diabetes Mellitus
-Hypertension
-Benign Prostatic Hypertrophy
-Obesity
-Hiatal hernia
-S/p pacemaker in [**2129**]
-S/p left knee surgery
-Splenic hypodensity
-Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood)
Social History:
He is a retired optometrist and a veteran of WWII. He smoked
while he was in the Air Force and has not smoked since leaving
the army in the [**2067**]'s. Extremely rare alcohol use. He lives
at home with his wife.
Family History:
Non-contributory
Physical Exam:
Vitals: T:97.1 BP: 119/47 P: 60 R: 16 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: large hematoma on L knee
Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-10.6# RBC-3.23*# Hgb-9.2*# Hct-28.1*# MCV-87 RDW-15.8* Plt
Ct-182
----Neuts-85.9* Lymphs-9.0* Monos-4.7 Eos-0.2 Baso-0.1
PT->150* PTT-68.5* INR(PT)->21.8*
Glucose-271* UreaN-40* Creat-2.6*# Na-137 K-4.8 Cl-101 HCO3-23
Calcium-9.1 Phos-4.6* Mg-2.9*
On Discharge:
WBC-6.7 RBC-3.76* Hgb-11.2* Hct-32.4* MCV-86 RDW-16.3* Plt
Ct-192
PT-18.7* PTT-29.0 INR(PT)-1.7*
Glucose-86 UreaN-14 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-25
Cardiac Enzymes:
CK 258 -- 256 -- 276
CK-MB: 4-- 4 -- 4
TropT 0.03 -- 0.02 -- 0.03
OTHER STUDIES
===============
CT head [**2136-3-13**]:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Possible remote infarct in the left cerebellar hemisphere.
3. Diffuse pagetoid changes of the calvarium. Clinical
correlation
recommended.
4. Maxillary and ethmoid sinus disease, likely chronic in
nature. Clinical correlation recommended.
Chest Radiograph [**2136-3-13**]:
IMPRESSION: Interval improvement in lung aeration with band-like
atelectasis at the left lung base. Hiatal hernia. Mildly
prominent small bowel loops in the upper abdomen. Recommend
correlation with abdominal radiographs if there is need for
further evaluation.
ECG [**2136-3-14**]:
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to the previous tracing pacing is now more consistent.
Brief Hospital Course:
88 year old man with significant cardiac history admitted with
significant coagulopathy, acute renal failure and a GI bleed.
1) Gastrointestinal bleed: On presentation the patient had 12
point hematocrit drop from baseline and this was presumed to
have taken place over the previous week when he had been having
bleeding events. He never evidenced any signs of hemodynamic
instability though his tachycardic response could be blunted by
his beta blockade. At presentation he had guiac positive brown
stool but no hematochezia or melena. His coagulopathy was
corrected and he was transfused. Given overall he appeared
quite stable the decision was made to postpone endoscopy until
hematocrit was between 1.5 and 1.7. Given the patient's history
of divericulosis this was considered the most likely cause of
bleeding and gastritis or upper source was considered much less
likely given he had not had melena. Eventually, the patient
underwent upper and lower endoscopy of [**2136-3-16**], which showed no
active source of bleeding but erythema and congestion in the
lower part of the stomach with a small AVM. Presumed source of
bleeding was this gastritis in the context in his initial severe
coagulopathy. The patient was discharged on [**Hospital1 **] PPI therapy to
follow up with GI as an oupatient. At the time of discharge his
hematocrit had been stable around 32 for >48 hours.
2) Coagulopathy: The etiology of the patient's coagulopathy is
unclear. [**Name2 (NI) **] typically has had his INR checked monthly and
review of records by his [**Hospital3 **] reveals he has
been stable with INR's between 2 and 2.5 for a long time. No
antibiotics, illnesses, or diet change. On holding his coumadin
and reversal with vitamin K and FFP this quickly corrected. He
was discharged on half of his usual coumadin dose with close
follow up in his [**Hospital3 **]. They will also inspect
his most recent set of coumadin pills to make sure he had not
received pills of a different dosage in error. He was also
counseled to stop his supplements for the moment as these could
possibly interfere with his coumadin metabolism. The patient
was also restarted on his aspirin prior to discharge.
3) Acute Kidney Injury: On presentation the patient's Cr was
increased at 2.6. This quickly corrected with volume
resuscitation and transfusions, which suggests this was due to
pre-renal kidney injury due to his blood loss. At the time of
discharge Cr was less than one.
4) Bilateral knee hematomas: These occurred after traumatic fall
in the ED. He was seen by orthopedics who were confident that
this was superficial bleeding in the pre-patellar bursae with no
other major pathology. This was observed and no further
management was instituted.
5) Coronary Artery Disease: The patient never had chest pain or
signs of active ischemia though he did have TWI that resolved in
the ED. Three sets of cardiac enzymes remained stable
suggesting no demand infarction. He was continued on his statin
and restarted on ACEi and beta blocker prior to discharge.
6) Aortic aneurysm s/p repair: Given lack of significant
abdominal pain and the patient's rapid improvement with volume
replacement no particular management for his history of aneurysm
repair was considered necessary.
7) Benign Prostatic Hypertrophy: The patient was continued on
his home finasteride and terazosin in the hospital. Given
complaints of increased difficulty with urination he initially
had a foley catheter placed. This was discontinued after he
left the ICU without difficulties with urination. He did have
some hematuria while the catheter in place but this resolved
after removal and was thought most likely due to foley trauma in
the context of coagulopathy.
8) Diabetes Mellitus type 2: The patient was continued on his
home insulin regimen with some reduction in his standing doses
while NPO. Reasonable control of his blood pressures was
obtained with this regimen.
9) Hypertension: The patient was nevery hypotensive. Initially,
all of his home anti-hypertensives and diuretics were held.
Eventually his metoprolol, furosemide, and ACEi were restarted
but his calcium channel blocker continued to be held as he was
normotensive without it.
He received [**Hospital1 **] IV and then PO PPI for his GI bleed. He had
pneumoboots for DVT prophylaxis. He was full code. Prior to
discharge he was tolerating a full diet.
Medications on Admission:
Felodipine SR 10 mg daily
Finasteride 5 mg qam
Furosemide 20 mg daily
Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8
units qpm
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg daily
Simvastatin 40 mg QHS
Terazosin 5 mg QHS
Aspirin 325 mg qam
Coumadin 5 mg 5 days, 10 mg 2 days
Benefiber
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 5 in the
morning, 8 in the evening units Subcutaneous twice a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please follow up with your primary care provider. [**Name10 (NameIs) 2172**] dose may
need to be adjusted according to your blood work.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*3 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
GI Bleed
Supratherapeutic INR
Hiatal hernia
Arterio-venous malformations
Discharge Condition:
Vital signs stable, HCT 33, INR 1.6
Discharge Instructions:
You were admitted because you were bleeding from your GI tract.
This was most likely due to your blood being much too thin from
your coumadin. The gastroenterologists looked and they only saw
some small foci of disordered vessels as a source of bleeding.
You seemed to stop bleeding once your blood was clotting
appropriately again but the gastroenterologists coagulated the
probable site of bleeding just in case. It is unclear why your
blood was so much thinner than it has been. It is possible you
got an incorrect prescription or somehow doses were confused.
You will need close monitoring of your coumadin over the next
weeks until your INR is stable once again.
Your medications have been changed. You have been started on
OMEPRAZOLE, a medication to help stop further bleeding from the
AVM. You should also stop taking the Warfarin you have and fill
a new prescription (you were given this). You will start taking
2.5 mg/day and follow up with the [**Hospital 2786**] clinic at
[**Location (un) 620**] early next week. Your FELODIPINE has been held as you
were not on this medication in the hospital and you had no high
blood pressure. You should discuss with your regular doctor,
Dr. [**Last Name (STitle) 2204**], whether you need this medication.
We have stopped 1 of your hypertension (high blood pressure)
medications. We have stopped your felodipine. You should
continue with your metoprolol, lasix, and lisinopril. Your
blood pressure has been fine while in the hospital. Please
follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] to see
if this medication needs to be re-added.
Please return to the hospital or call your doctor if you have
chest pain, shortness of breath, fevers or chills, or any other
concerning changes in your health.
Followup Instructions:
You have a follow up scheduled in [**Location (un) 620**] anticoagulation clinc
on Tuesday at 1:00 pm. They would like you to bring the
coumadin pills you were taking prior to this in order to make
sure these were the appropriate dose.
You also have a follow up appointment with stomach and colon
specialist Dr. [**Last Name (STitle) 1940**] on [**2136-5-11**] at 3PM. Please confirm this
with his clinic. The clinic number is [**Telephone/Fax (1) 463**].
Please follow-up with Dr. [**Last Name (STitle) 2204**] next week. His office number
is [**Telephone/Fax (1) 2205**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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76,594
| 136,689
|
52589
|
Discharge summary
|
report
|
Admission Date: [**2147-2-17**] Discharge Date: [**2147-2-21**]
Date of Birth: [**2080-10-31**] Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing / Keflex / Codeine / Isoniazid /
Indocin
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Melena and hypotension.
Major Surgical or Invasive Procedure:
1. Nasogastric lavage
History of Present Illness:
66 yo female with pmh significant for DM I, lupus, ESRD on HD
(Tues, [**Last Name (un) **], Sat), Afib on coumadin who is admitted for melena x
2 days and hypotension. Pt states that she developed mild abd
discomfor and nausea on Sun (5 days prior to admission). She
then developed abd bloating and had one episode of melena on
Wed. She describes as 100cc of black tarry stool. She had
another small episode of dark stool on [**Last Name (un) **] and had dark
semi-formed stool today. She had one prior episode of melena
many years ago due to diverticulitis that self resolved. She had
EGD and colonoscopy ~ 1 year ago which showed gastritis and she
had polyps that were biopsy and "pre-cancerous". She denies
having any fever or chills. She states that some people had the
"stomach flu" at her HD unit, but denies having any sick
contacts. [**Name (NI) **] other episodes of emesis, no hematemesis. She is
drinking and eating without any problems. On her HD yesterday
her BP was lower than at her baseline of 120s/50s-60s as she was
coming off. So, she was given 1.5L to get her to her dry weight.
Her Hgb was found to be 11 and her INR 3.9. She continued to
feel unwell today and her PCP recommended that she come in to
the ED. She also had one episode of fall on Monday when she lost
balance and hit her head on the floor. She denies loosing
conscious. No HA, no changes in vision, no weakness noted, or
lethargy. She has a small lump on the right side of her head.
.
In the ED, initial vs were: T 97.8, 111/51, 20, 96% on RA. Her
BP dropped to 84/50 after pt has taken her morning meds
including 360mg of dilt and her 200mg of metoprolol for her
A-fib. She was given 1 L of IV fluids and her BP responded
97/69. Her labs were notable for Hct 34.4, Hgb 11.6 which is
unchanged from yesterday. INR of 3.8. Patient had NG Lavage with
120 CC clear fluid. A foley was placed, but no urine return. Pt
states that she is oliguric at baseline and had recent hx of UTI
with E.coli for which she was treated with cipro. Prilosec 40 mg
IV given, dilt 120mg (home dose), GI consulted they will follow.
.
On arrival to the ICU, pt is comfortable in NAD. Her vitals
afebrile, HR in 110s, BP 100/63, sating 94% on RA.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- DMI
- ESRD, on HD since [**2146-8-14**]
- Chronic anemia
- Gastritis
- Afib on coumadin, metoprolol and dilt
- Pace maker in place
- Lupus, + anti-phospholipid antibody
- Recurrent UTIs with E.coli
- Arthritis with spinal stenosis
- Cholecystitis
Social History:
Patient is a retired nurse who lives by herself. She denies
smoking, drinking or using ilicits drugs.
Family History:
Sister with breast CA [**79**] yo. Father with [**Name2 (NI) 499**] CA and brother
who died of esophageal CA.
Physical Exam:
Upon admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, tachy, no murmurs, rubs, gallops
Abdomen: soft, obese, mildly tender on epigastric area, and
diffusely tender on bil lower quads, non-distended, +
hyperactive bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. + 1
bil LE pitting edema of LE. venous stasis of bil LE. Fistula on
R arm with + bruit and thrill. Old fistula on L arm
Skin: dry and [**Doctor Last Name **], ecchymotic area around fistula on righ
arm, no hematoma
Neuro: CN II-XII, EOM intact, PERRLA, symmetrical strength on
bil UE/LE.
.
At discharge:
General: Alert, oriented, no acute distress, sitting in chair
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Abdomen: soft, obese, nontender, non-distended, + bowel sounds,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
LE edema with compression stockings on. venous stasis of bil LE.
Fistula on R arm with + bruit and thrill. Old fistula on L arm.
Large hematoma on left forearm with newly placed PIV.
Skin: dry and [**Doctor Last Name **], ecchymotic area around fistula on right
arm, no hematoma
Neuro: CN II-XII
Pertinent Results:
ADMISSION LABS:
[**2147-2-17**] 11:20AM WBC-9.5 RBC-3.71* HGB-11.6* HCT-34.4* MCV-93
MCH-31.3 MCHC-33.6 RDW-15.1
[**2147-2-17**] 11:20AM NEUTS-83.4* LYMPHS-8.9* MONOS-4.9 EOS-2.4
BASOS-0.3
[**2147-2-17**] 11:20AM PLT COUNT-221
[**2147-2-17**] 11:20AM PT-37.0* PTT-59.7* INR(PT)-3.8*
[**2147-2-17**] 11:20AM GLUCOSE-148* UREA N-43* CREAT-6.0* SODIUM-138
POTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-23 ANION GAP-31*
[**2147-2-17**] 11:20AM ALT(SGPT)-32 AST(SGOT)-74* ALK PHOS-149* TOT
BILI-0.7
[**2147-2-17**] 11:20AM LIPASE-51
[**2147-2-17**] 11:20AM ALBUMIN-3.8 CALCIUM-9.1 PHOSPHATE-7.1*
MAGNESIUM-2.3
[**2147-2-17**] 11:20AM cTropnT-0.08*
[**2147-2-17**] 11:30AM LACTATE-2.9* K+-4.2
[**2147-2-17**] 09:48PM CK-MB-4 cTropnT-0.07*
LABS PRIOR TO DISCHARGE:
[**2147-2-21**] 07:45AM BLOOD WBC-4.9 RBC-3.21* Hgb-10.2* Hct-30.0*
MCV-94 MCH-31.8 MCHC-34.1 RDW-14.8 Plt Ct-207
[**2147-2-18**] 06:41AM BLOOD PT-37.4* PTT-57.4* INR(PT)-3.9*
[**2147-2-19**] 06:20AM BLOOD PT-36.7* PTT-57.4* INR(PT)-3.8*
[**2147-2-20**] 09:30AM BLOOD PT-28.8* PTT-46.3* INR(PT)-2.8*
[**2147-2-20**] 05:40PM BLOOD PT-24.3* INR(PT)-2.3*
[**2147-2-21**] 07:45AM BLOOD PT-19.2* PTT-36.8* INR(PT)-1.8*
[**2147-2-21**] 07:45AM BLOOD Glucose-147* UreaN-39* Creat-6.4* Na-140
K-3.9 Cl-98 HCO3-26 AnGap-20
[**2147-2-21**] 07:45AM BLOOD Calcium-8.6 Phos-5.2* Mg-2.1
MICRO:
[**2147-2-17**] blood culture pending
[**2147-2-18**] urine culture pansensitive klesiella
[**2147-2-18**] urinalysis: contaminated specimen with >50 epithelial
cells
Brief Hospital Course:
66 yo female with pmh significant for DM I, lupus, ESRD on HD
(Tues, [**Last Name (un) **], Sat), and afib on coumadin who is presented with
melena x 2 days and hypotension concerning for upper GI bleed in
the setting of a supratherapeutic INR. While waiting for the
INR to trend down, her hospital course was complicated by afib
with RVR and difficult IV access.
.
# GI bleed: Pt presented with 2 day history of melena in the
setting of epigastric pain and prior EGD findings most likely
upper GI bleed secondary to gastritis. She had a negative NG
lavage and brown guaiac positive stool in the rectal vault.
Patient was monitored overnight in the MICU where her vitals and
hematocrit remained stable. INR was not reversed in the setting
of her stable hct and no active bleeding, though coumadin was
held. She was put on PPI [**Hospital1 **]. Her diltiazem was continued but
her metoprolol was held to avoid hypotension. She has a history
of gastritis and diverticulitis seen on EGD and colonoscopy 1
year ago. GI was consulted and recommended endoscopy. She had a
brown bowel movement prior to transfer from the MICU to the
floor. She had only one peripheral IV and a request for a power
PICC was placed, but the patient refused PICC placement. Her
diet was advanced as she remained stable. Her INR drifted down
as her warfarin was held. She was ordered for a heparin drip
once her INR was less than 2.5, but she lost IV access at this
time. A peripheral IV was placed after many attempts. At that
point, the patient refused the heparin drip despite
acknowledging the risk of significant and possibly fatal clot
when off anticoagulation. EGD was planned for the afternoon on
the day of discharge as her INR was 1.8 that morning. Prior to
the procedure she lost IV access, and refused further peripheral
or central access. GI was unable to proceed with an EGD. As
she had recently been stable, she was discharged to follow up
with GI as an outpatient. She will take Lovenox as a bridge to
a therapeutic INR of 2.5-3 which she has previously done and is
comfortable with.
.
# Afib with RVR: Pt has hx of A-fib on metoprolol/diltiazem with
a pacemaker for rate control. She was given a lower dose of
dilt in the ED and HR tachy on admission. She was continued on
diltiazem given her hemodynamic stability, but held her
metoprolol 200 mg [**Hospital1 **]. She had one episode of afib with RVR
without hemodynamic instability. Her metoprolol was restarted
and uptitrated to her home dose. Given her CHADS2 score of 2,
she is anticoagulated with warfarin at home. Her goal INR is
2.5 to 3 given her history of antiphopholipid antibody syndrome.
Her coumadin was held given concern for possible bleed, but
restarted at 4.5mg per day per her [**Hospital3 **] upon
discharge.
.
# ESRD: Pt receives HD on T, TH, Sat. Renal was notified about
the patient's admission and arrangements were made for dialysis
the following morning. She was ultrafiltrated during the first
session given concern for hypotension in the setting of UGIB.
She was continued on home nephrocaps and sevelamer and underwent
a normal dialysis session on the day of discharge.
.
# Lupus: Continued home plaquenil 200mg 3x week.
.
# Back pain: Continued on gabapentin.
.
# S/p fall: Pt had fall on Monday and hit head on floor with
subsequent small lump on the side of her head. Given her
elevated INR, this is concerning for subdural hematoma. However
given that her neuro exam was normal and there was no HA or any
neurologic c/o, did not image with CT. Neurologic exam and MS
was monitored and wnl.
.
#Contaminanted UA: Patient reported symptoms of bladder spasm
and dysuria and culture grew GNR's but specimen was contaminated
with >50 epi's. She is on HD so likely has colonization of her
bladder. Repeat UA improved but still with leuk est, bact, and
WBC, however at this point her symptoms improved.
.
# Transaminitis: AST elevated on admission due to hemolysis, but
was subsequently normal. Alk phos elevated, bilirubin normal.
Patient has history of cholithisis but was without fever,
chills, or RUQ pain to suggest acute cholecystitis.
.
# DM: Diabetic diet, continued on insulin sliding scale only.
Sugars well controlled.
.
# Code Status: During this admission, the patient was full
code.
Medications on Admission:
-Coumadin 5mg
-dilt 360mg PO TID
-Epogen 3x per week on HD days
-Ferrous sulfate
-gabapentin 300mg Qday
-plaquenil 200mg 3x week
-Toprol XL 200mg [**Hospital1 **]
-omeprazole 20mg [**Hospital1 **]
-Nephrocaps
-Sertraline 100mg Daily
-Sevelamer 1600mg TID
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
(Of note: the [**Hospital 228**] [**Hospital3 **] advised a dose of
4.5mg daily after the patient received her discharge papers.
The patient was understood these instructios.)
2. diltiazem HCl 360 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO three times a day.
3. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
QMOWEFR (Monday -Wednesday-Friday).
6. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/insomnia.
12. Lovenox 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous
once a day: Please use daily until your INR <2.5.
13. Epogen Injection
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis: Upper GI bleed, Atrial fibrillation with
Rapid Ventricular Rate, Anticardiolipin antibody syndrome
(Of note: this is an error recorded in the discharge paperwork.
She has antiphospholipid antibody syndrome, not anticardiolipin
antibody syndrome.)
Secondary Diagnosis: Diabetes Mellitus, End stage renal disease
on Hemodialysis
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 during your stay here at
[**Hospital1 18**].
You were admitted for an upper GI bleed in the setting of an
elevated INR. Your warfarin was held to let your INR fall. An
EGD was planned once your INR was low enough to minimize the
risk of rebleeding. However, due to access issues, they were
not able to proceed. You decided instead to use conservative
management with watchful waiting for this issue. You understand
the risk for this approach which include rebleeding, falls,
fainting, and death, especially while on anticoagulation.
During your stay your medications for afib were held to avoid
low blood pressures if your bleeding continued. You had one
episode of fast afib which quickly responded to your home
medications.
Please continue to have your INR checked at each dialysis
session. These results should be faxed to Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
office.
The following changes were made to your medication regimen:
START lovenox daily until your INR is 2.5
RESTART coumadin tomorrow
Followup Instructions:
The following appointments were made for you:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**]-[**Hospital1 **]
Address: [**Hospital1 34796**], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 2573**]
Appointment: Thursday [**2147-3-2**] 3:00pm
We would recommend that you follow up with a gastroenterologist
to evaluate the location and the cause of your bleeding. Please
call ([**Telephone/Fax (1) 451**] to schedule an appointment.
|
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80,429
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2900
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Discharge summary
|
report
|
Admission Date: [**2132-12-12**] Discharge Date: [**2132-12-19**]
Date of Birth: [**2056-11-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
blood transfusions
Colonoscopy
EGD
History of Present Illness:
76 y/o man with PMH notable for gastric cancer s/p gastrectomy
([**2116**]) who presents with several episodes of bright red blood
per rectum. The patient was at home and felt well yesterday. He
then had vague abdominal pain last night and had [**5-20**] grossly
bloody stools starting at about 9 pm. After several bloody
stools, he noted dizziness with sitting up and standing. On his
way to the bathroom, he fell and may have briefly lost
consciousness. His girlfriend then found him passed out in a
pool of blood on the floor before making it to the bathroom. He
does not believe he struck his head but cannot recall exactly
what happened. He then came to the emergency room at about 1 am;
his last episode of BRBPR was at home.
.
In the ED, initial vitals were T 96.8, HR 70, BP 123/70, RR 16,
99% on RA. He had bright red blood on rectal examination but no
obvious hemorrhoids. The patient was treated with 80 mg IV
protonix and 4 mg IV zofran for nausea. His hematocrit was found
to be 21.6 (baseline ~ 40) and he was given 2 U PRBCs as well as
2 L NS. He did not undergo NG lavage due to h/o gastrectomy. GI
was contact[**Name (NI) **] and will see the patient this morning. He had a CT
of his abdomen/pelvis which showed diverticulosis without
diverticulitis as well as evidence of prior gastrectomy and ?
roux-en-y anastomosis.
.
On arrival to the ICU, the patient reports that his abdominal
pain has resolved. He has not had any further BRBPR since
arrival at the ED. He denies any recent aspirin or coumadin use
though he does take motrin about once per day on average for
arthritis. He drinks beer occasionally, perhaps a few drinks
yesterday during the holiday. He had some nausea with dry heaves
at home but no vomiting or hematemesis. When the diarrhea
started, he also had diffuse vague abdominal pain but this
resolved in the ED. No headache, chest pain, difficulty
breathing, or urinary symptoms. He denies any current nausea or
dizziness. He has never had bleeding like this in the past. He
had gastric cancer resected in [**2116**] at the [**Hospital1 756**] but tells me
he is not followed there any more.
Past Medical History:
* h/o hypertension (not on meds)
* h/o stage I gastric adenocarcinoma, diagnosed following
melenotic stools in [**2116-1-15**]
- s/p antrectomy & Bilroth I gastrojejunostomy in [**1-/2116**]
- completion total gastrectomy in [**2-/2116**] due to findings of
T1 adenocarcinoma
* h/o diverticulosis (last colonoscopy [**4-/2131**] at [**Hospital1 18**])
* h/o left rotator cuff tear
* h/o gout
* h/o prostate cancer
Social History:
Widowed and retired. Former smoker but quit 30 years ago. Drinks
a few beers per week.
Family History:
+ for gout
Physical Exam:
BP: 153/72 HR: 90 RR: 12 O2 99% RA
Gen: Pleasant, well appearing elderly African American male in
no distress, lying in bed
HEENT: Slight conjunctival pallor. No scleral icterus. MMM. OP
clear.
NECK: Supple, No LAD. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs appreciated.
LUNGS: clear bilaterally, no wheezing
ABD: slightly distended but soft, hypoactive bowel sounds,
diffuse mild tenderness to palpation without guarding or rebound
Rectal: Small amount of thin bright red blood on perianal area,
no rectal fissure appreciated
EXT: warm, no peripheral edema, DP pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. Face symmetric and speech clear,
moving all extremities without difficulty.
Pertinent Results:
[**2132-12-15**] Colonoscopy
Multiple non-bleeding diverticula with wide-mouth openings were
seen in the whole colon.Diverticulosis appeared to be severe.
Impression: Severe diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
Recommendations: Bleeding likely secondary to diverticulosis.
Routine post-procedure orders
[**2132-12-15**] EGD
Previous gastrectomy with roux en y anastomosis of the stomach
Benign appearing polyp in the stomach
Otherwise normal EGD to third part of the duodenum
Recommendations: Routine post-procedure orders.
No etiology of bleeding found.
[**2132-12-12**] CTabd/pelvis
1. Pancolonic diverticulosis with no evidence of diverticulitis.
2. Unchanged appearance of multiple hypodense liver lesions
which were
previously characterized as hemangioma and simple cysts.
3. Status post gastrectomy and esophageal jejunostomy for a
gastric cancer.
This study is not able to evaluate tumor recurrence at
anastomosis
[**2132-12-17**] GIB study
INTERPRETATION: Following intravenous injection of autologous
red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for minutes
were obtained. A left lateral view of the pelvis was also
obtained.
Blood flow images show no evidence of active tracer
extravasation.
Dynamic blood pool images show no pooling of tracer uptake to
suggest active
bleeding. Tracer activity inferior to the bladder is within the
penis.
IMPRESSION:
No evidence of active intraluminal extravasation of tagged
RBC's.
[**2132-12-12**] 03:00AM BLOOD WBC-9.9# RBC-2.13*# Hgb-7.1*# Hct-21.6*#
MCV-102* MCH-33.6* MCHC-33.1 RDW-14.4 Plt Ct-113*
[**2132-12-13**] 04:37AM BLOOD WBC-7.6 RBC-2.48* Hgb-8.4* Hct-22.9*
MCV-92 MCH-33.8* MCHC-36.7* RDW-16.9* Plt Ct-104*
[**2132-12-14**] 06:55AM BLOOD WBC-9.7 RBC-3.16*# Hgb-10.1* Hct-28.6*
MCV-90 MCH-32.0 MCHC-35.4* RDW-16.7* Plt Ct-113*
[**2132-12-15**] 06:58AM BLOOD WBC-6.7 RBC-3.09* Hgb-9.8* Hct-26.7*
MCV-86 MCH-31.6 MCHC-36.6* RDW-17.6* Plt Ct-111*
[**2132-12-16**] 06:25AM BLOOD WBC-6.5 RBC-3.11* Hgb-9.9* Hct-28.1*
MCV-90 MCH-31.8 MCHC-35.2* RDW-17.9* Plt Ct-133*
[**2132-12-17**] 06:10AM BLOOD WBC-6.4 RBC-3.26* Hgb-10.3* Hct-29.0*
MCV-89 MCH-31.5 MCHC-35.3* RDW-17.6* Plt Ct-142*
[**2132-12-18**] 07:10AM BLOOD WBC-7.0 RBC-3.99* Hgb-12.2* Hct-34.4*
MCV-86 MCH-30.6 MCHC-35.5* RDW-17.4* Plt Ct-174
[**2132-12-19**] 07:05AM BLOOD WBC-6.2 RBC-3.91* Hgb-12.5* Hct-35.0*
MCV-90 MCH-32.0 MCHC-35.8* RDW-17.6* Plt Ct-194
[**2132-12-12**] 03:00AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3*
[**2132-12-15**] 06:58AM BLOOD PT-13.0 PTT-27.0 INR(PT)-1.1
[**2132-12-12**] 03:00AM BLOOD Glucose-196* UreaN-45* Creat-1.8* Na-140
K-5.2* Cl-116* HCO3-15* AnGap-14
[**2132-12-19**] 07:05AM BLOOD Glucose-92 UreaN-20 Creat-1.3* Na-141
K-4.4 Cl-108 HCO3-25 AnGap-12
[**2132-12-12**] 03:00AM BLOOD ALT-34 AST-23 LD(LDH)-163 CK(CPK)-85
AlkPhos-57 TotBili-0.2
[**2132-12-12**] 03:00AM BLOOD Lipase-48
[**2132-12-12**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2132-12-12**] 12:03PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2132-12-12**] 03:00AM BLOOD TotProt-4.2* Albumin-2.5* Globuln-1.7*
[**2132-12-12**] 12:03PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
[**2132-12-19**] 07:05AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.2
[**2132-12-13**] 04:37AM BLOOD VitB12-281 Folate-19.8
[**2132-12-14**] 07:04AM BLOOD %HbA1c-5.9
Brief Hospital Course:
Mr. [**Known lastname 634**] is a 76 year old man with PMH notable for gastric
CA s/p gastrectomy admitted with massive BRBPR.
# LGIB: Pt. was initially kept in MICU for close monitoring and
repeatedly needed transfusions after having episodes of BRBPR.
He had a colonoscopy which showed diverticulosis, but no
bleeding source. Bleeding scan was attempted after an episode of
BRBPR but was non localizing. His Hct stabilized and he did not
have anymore episodes of BRBPR so he was d/c'd w/ instructions
to call 911 immediately if he developed BRBPR
.
# Acute on chronic renal insufficiency: Cr returned to baseline
after resucitation.
.
# Hyperglycemia: No history of diabetes per patient. Pt. had
several finger sticks greater than 200 so Dx w/ DM. Pt. was told
to F/u w/ his PCP RE Tx.
# Hypoalbuminemia: Likely related to prior gastrectomy and
possibly diet. Nutrition consulted and started on a
multivitamin with minerals and Ensure TID.
.
# CODE: full, confirmed with patient
# COMM: With patient and girlfriend, [**Name (NI) **] [**Name (NI) 174**],
[**Telephone/Fax (1) 14024**]
Medications on Admission:
travoprost eye gtt
motrin prn (once daily)
tylenol prn arthritis
Allopurinol 300mg PO QD
Indocin
Cyproheptadine 4mg
Viagra 100mg PRN
Discharge Medications:
1. Travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
6. Outpatient Lab Work
Please have a complete blood count drawn at Dr.[**Name (NI) 14025**] office.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Viagra 100 mg Tablet Sig: One (1) Tablet PO as needed as
needed for Erection.
9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Indocin Oral
11. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO once a
day: We did not change this, take whatever you did before.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Diverticulosis
Lower gastrointestinal bleed
Secondary
Diabetes Mellitus type II
Hypertension
Discharge Condition:
Stable, not bleeding
Discharge Instructions:
You have been diagnosed with diverticulosis and lower GI bleed.
You lost a significant amount of blood before comming to the
hospital and you required several blood transfusions. You need
to take one iron supplement pill daily for the next month. We
are also starting you on colace to help you have softer bowel
movements. We also started you on an acid pill to prevent your
gastrointestinal tract from bleeding. We also gave you a vitamin
B12 shot and a pneumonia vaccine.
While you were here you were also diagnosed with diabetes but
your blood sugars remained well controlled most of the time. You
should talk to Dr. [**Last Name (STitle) 1789**] about whether you should start taking
medication for this or whether it can be controlled with diet
and excercise.
You need to get your blood drawn at Dr.[**Name (NI) 14025**] office at 2:00
p.m. on Monday [**12-22**].
You should eat a diet high in fiber (you can see the amount of
fiber in the nutrition information on the box). You should also
avoid seeds and whole nuts, peanut butter is fine. You should
not consume more than one or two alcoholic beverages per night.
Please follow the diet instructions included in the included
information.
Please take all of your medications exactly as prescribed.
If you have ANY rectal bleeding, black tarry stools, shortness
of breath, fainting, chest pain, confusion or any other
concerning symptoms please call your doctor immediately or go to
the emergency department.
Followup Instructions:
You need to get your blood drawn at Dr.[**Name (NI) 14025**] office at 2:00
p.m. on Monday [**12-22**].
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2132-12-25**]
1:30
Provider [**Name9 (PRE) **] GATES, [**Name9 (PRE) 280**] MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2133-1-6**] 11:30
Dr. [**Last Name (STitle) 1789**] Thursday [**2132-12-25**] 12:00 call [**Telephone/Fax (1) 1792**] w/
questions.
Have your blood drawn at Dr.[**Name (NI) 14025**] on monday [**12-22**] at
2:00p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2132-12-24**]
|
[
"250.00",
"V10.04",
"403.90",
"285.9",
"584.9",
"562.12",
"287.5",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9681, 9687
|
7234, 8332
|
345, 382
|
9833, 9856
|
3882, 7211
|
11375, 12094
|
3104, 3117
|
8516, 9658
|
9708, 9812
|
8358, 8493
|
9880, 11352
|
3132, 3863
|
278, 307
|
410, 2539
|
2561, 2983
|
2999, 3088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,202
| 171,657
|
9952
|
Discharge summary
|
report
|
Admission Date: [**2110-10-31**] Discharge Date: [**2110-11-6**]
Date of Birth: [**2065-5-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
fever, shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy with bronchoalveolar lavage
History of Present Illness:
Patient is a 45M with HIV (CD4 count of 7 in [**2-17**]) off his ARVs
for 2 weeks who presented with respiratory distress. The patient
reports a 10 days of fevers (up to 37C), chills, productive
cough of small amounts of white phlegm, SOB, and R-sided
pleuritic chest pains. He is SOB to the point where he cannot
climb a flight of stairs. He also has a mild frontal headache.
No sinus problems, rhinorrhea. [**Name2 (NI) **] went to his PCP [**Name Initial (PRE) 3011**]. His O2
sat was noted to be 93% and desatted to 71% with ambulation. His
RR was in the 30s. He was referred to [**Hospital1 **] [**Location (un) 620**]. Of note, he
had run out of his medications for the past 2 weeks and have not
been taking any.
.
There he had a CXR that showed diffuse, interstitial bilateral
pnuemonia. He received vanc, zosyn, and steroids. He did not
receive bactrim. And, he was transferred to [**Hospital1 18**] [**Location (un) 86**].
.
In the ED, initial VS: 98.4 93 140/90 32 100. Lactate was 1.
Labs were sig. for WBC of 2.3, Cr 1.8, and LDH 590. He received
Bactrim. His current vital signs are now: HR 90, 125/75, RR 47,
98% 12L NRB.
.
ROS: Denies vision changes, rhinorrhea, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria.
Past Medical History:
HIV, CD4 count of 7, viral load of 223,000 copies/ml in [**2-17**]
Social History:
Patient moved from [**Country 15800**] 8 years ago. He lives alone. He works
as a cashier. No sick contacts. [**Name (NI) **] recent travel. Quit tobacco 3
years ago, previously smoked 3 cig/day x 15 years. 1 alcoholic
drink/week. No IVDU.
Family History:
Non contributory
Physical Exam:
On admission;
VITALS: T 97.8 BP 113/70 HR 69 RR 35 O2 94% 3L NC
GEN: well developed adult male in NAD.
HEENT: [**Last Name (un) **], MMM, EOMI, + oral thrush, no mucocutaneous lesions
NECK: supple, No LAD, no thyromegally
CV: RRR, no murmurs, gallops or rubs, no s3 or s4
LUNGS: tachypnic. occasional crackle at left lower lung base,
otherwise CTA bilaterally, no rhonchi or wheezes noted. no use
of accessory muscles.
ABD: soft, NT/ND, +BS, no HSM noted. no rebound tenderness, no
gaurding
EXT: no c/c/e, radial and DP pulses palapable bilaterally
NEURO: CN II-XII intact, stregth [**5-13**] in all 4 extremities,
sensation intact throughout,
PSYCH: interactive, pleasant
SKIN: + papular rash on extremities and abdomen, some with
superficial scabbing. + warts on bilateral fingers.
On discharge:
vs 97.9 118/82 68 24 96 on 2L NC
Gen: NAD, breathing comfortably, sitting upright
CV: RRR. Nl S1 and S2. No murmur.
Lungs: tachypneic, improved breath sounds, no crackles or
wheezes
Abd: soft, non distended, non tender, active BS, no
organomegally
Ext: no clubbing, cyanosis, or edema
Skin: multiple hyperpigmented ciruclar, papules with central
scaling, 1cm in diameter, raised 1/2 cm. Multiple firm, raised,
plaque dark with defined borders and violaceous hue, surrounding
erythema. Bandage over site of biopsy on left posterior thigh
.
Pertinent Results:
[**2110-10-31**] 09:25AM BLOOD
WBC-2.3* RBC-4.75 Hgb-14.4 Hct-44.5 Plt Ct-236
Neuts-62.4 Lymphs-23.0 Monos-4.8 Eos-9.6* Baso-0.3
WBC-2.3* Lymph-23 Abs [**Last Name (un) **]-529 CD3%-53 Abs CD3-280* CD4%-1 Abs
CD4-7* CD8%-41 Abs CD8-218 CD4/CD8-0.03*
UreaN-23* Creat-1.8* Na-137 K-4.1 Cl-102
ALT-16 AST-40 LD(LDH)-525* AlkPhos-72 TotBili-0.3
Calcium-9.7
[**2110-11-1**] 02:01AM BLOOD Type-ART pO2-86 pCO2-31* pH-7.43
calTCO2-21 Base XS--2
HIV Viral Load 453,000 copies/ml.
Legionella negative
RSV and Influenza negative
Cryptococcal Ag negative
BAL:
GRAM STAIN (Final [**2110-11-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2110-11-6**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2110-11-10**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2110-11-4**]):
POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Virus isolated so far.
ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) 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. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
CT Chest -
1. Diffuse ground-glass opacification spread throughout both
entire lung
fields that in history provided of AIDS is most suggestive of
with PCP
pneumonia, however, other infectious etiologies are not
excluded. Multiple
associated subcentimeter mediastinal and axillary lymph nodes,
likely reactive in nature.
2. No focal areas of parenchymal consolidation that would be
concerning for a superimposed focal infection.
CXR:
The cardiomediastinal silhouette is normal. Bilateral perihilar
and infrahilar opacities have increased in extent. There is no
pleural
effusion, pneumothorax or pulmonary edema.
Skin, posterior thigh, biopsy:
Immunohistochemical stains reveal lesional cells to be positive
for D2-40, subset positive for CD31, and weakly positive for
HHV8. MIB-1 (Ki-67) reveals up to 20% positive cells.
Brief Hospital Course:
45 year old male with past history of HIV (CD4 count of 7 in
[**2-17**]) non-compliant with his HIV medications, admitted for
respiratory distress from an atypical PNA. Currently being
treated for PCP pneumonia, possible bacterial pneumonia and
histoplasma pending culture results.
.
# Respiratory Distress - Started empirically on vanc/cefepime
for nosocomial PNA, bactrim and solumedrol for PCP, [**Name10 (NameIs) **] ambisome
for empiric coverage of histoplasmosis. Tamiflu and droplet
precautions discontinued when respiratory Viral antigen screen
returned negative. Chest CT [**11-2**] showed diffusely scattered
ground-glass opacifications throughout the entire lung fields,
most compatible with PCP [**Name Initial (PRE) 1064**]. Solumedrol changed to
prednisone 40 mg [**Hospital1 **] on [**11-2**]. Ambisome changed to itraconazole
at the recommendation of the consulting ID team. Weekly
azithromycin was started for MAC prophylaxis. HAART was not
restarted at the recommendation of his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Induced
sputum negative for PCP x2, followed up with BAL per ID
recommendation. BAL was positive for PCP. [**Name10 (NameIs) 33336**] viral screen
negative. History of disseminated histoplasmosis, now negative.
Cryptococcal antigen negative. Upon confirmation of PCP
pneumonia, Cefepime and Vancomycin were discontinued. He was
continued on PCP treatment and fungal and MAC prophylaxis. His
symptoms imiproved daily. On the day of discharge he was
breathing comfortably on room air. He denied dysnpea. He was
discharged on treatment doses of Bactrim and steroid taper. He
should have his CBC checked to ensure no worsening of his
leukopenia given he is on immunosuppressive therapy and Bactrim.
# HIV - Pt has history of HIV, CD4 count during this
hopspitalization was again 7. He states he has been
noncompliant with his medications because he runs out of [**Name10 (NameIs) 33337**]
and doesn't have reliable transportation from [**Location (un) 47**] to
[**Location (un) 86**] to pick up his [**Location (un) 33337**]. He does not want to pick up his
[**Location (un) 33337**] at a pharmacy close to his home due to concern that his HIV
status will be revealed. He had been noncompliant with his HIV
medications for two weeks prior to admisssion per his report.
Per the pharmacy, he had not filled a prescription of his
antiretroviral medications since [**Month (only) 956**] of this year. He was
restarted on his antiretrovirals per Dr. [**Last Name (STitle) **], his PCP. [**Name10 (NameIs) **]
were arranged to be delivered to his home so transportion would
not be a barrier to access.
.
#Skin lesions/[**Name (NI) 33338**] Sarcoma - Pt has multiple skin lesions,
including multiple papules 1cm with scaling and excoriation,
considered to be eosinophilic folliculitis. He also has
violaceous lesions with an erythemetous border which were
concerning for Kaposi's sarcoma. Dermatology was consulted and
a lesion on his left posterior back was biopsied. He was
started on steroid cream. Preliminary biopsy results were
positive for KS. He was discharged with follow-up with
dermatology.
.
#Acute on Chronic Renal Failure- Baseline Cr = 1.5. He was
briefly noted to have acute on chronic failure likely due to
brief exposure to amphotericin. He was given IVF and his renal
function improved.
.
Medications on Admission:
-Atazanavir [Reyataz] 400 mg qday with ritonavir
-Azithromycin - 1200 mg qweekly
-Betamethasone Dipropionate 0.05 % Cream qd prn
-Fluocinonide - 0.05 % Cream apply affected areas on arms [**Hospital1 **]
prn
-Itraconazole - 200 mg twice a day
-Ranitidine HCL - 150 mg Tablet twice a day
-Ritonavir [Norver] - 100 mg qd with Atanazavir
-Tenofovir Disoproxil Fumarate [Viread] - 300 mg once a day
-Bactrim - 800 mg-160 mg once a day
-Zidovudine - 300 mg twice a day
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day:
daily for five days, then take 1 tablet daily for 11 days. .
Disp:*21 Tablet(s)* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*500 ML(s)* Refills:*0*
3. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QSUN (every
Sunday).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day): On [**11-21**] Please reduce
dose to one tablet daily.
Disp:*45 Tablet(s)* Refills:*0*
5. Betamethasone Dipropionate 0.05 % Cream Sig: One (1) cm
Topical twice a day as needed for itching: Please avoid face,
neck and genitals.
6. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*2*
8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Zidovudine 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: PCP pneumonia, advanced AIDS
secondary: eosinophilic folliculitis, rash unspecified
Discharge Condition:
stable, afebrile, on room air
Discharge Instructions:
You were admitted for evaluation and treamtent of low oxygen
levels and fever. You were found to have PCP pneumonia which is
a type of pneumonia commonly found in patients with advanced
HIV/AIDS. Your CD4 count is 7 and your viral load is 453,000.
You MUST continue treatment for your pneumonia, last day for
treatment dosing of Bactrim is [**11-20**]. On [**11-21**]
you must start prophylactic dosing to prevent another infection
with the PCP [**Name Initial (PRE) **]. You also have your HAART therapy and
antibiotics ready to pick up at your pharmacy, please confirm
your address there for mail order of your prescriptions so they
can be sent to your home next month.
You should keep your biopsy site clean and dry, covered with
vaseline and a bandaid for 2 weeks.
Medications changed during this hospitalization:
- It is essential that you continue you continue taking
Ritonavir, Tenofovir, Zidovudine, and Atazanavir.
- Please continue taking Bactrim - 1 double strength tabs three
times daily, last day is [**11-20**].
- On [**11-21**], please decrease your bactrim
(Trimethoprim-Sulfamethoxazole) to 1 double strength tab daily
to prevent recurrent PCP [**Name Initial (PRE) 2**].
- Stop taking Ranitidine.
- Please continue taking Itraconazole 200mg twice daily
- Please continue taking Azithromycin 1200mg once weekly
- Please take the Nystatin liquid as directed to treat fungal
infection in the back of the mouth.
Please call your doctor or return to the ED if you develop
worsening shortness of breath, new fevers, chest pain, or any
other concerning symptom.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Location (un) **] Office on Friday
[**11-14**] at 11:30am. Phone [**Telephone/Fax (1) 4775**]
Please follow up with Dr [**Last Name (STitle) **] on Monday [**12-29**] at 11:30
AM.
Please follow up with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] in [**Hospital Ward Name 23**] Bldg on the [**Location (un) 1385**] on Thursday [**11-13**] at 11AM. Phone [**Telephone/Fax (1) 1971**].
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Completed by:[**2110-11-11**]
|
[
"585.9",
"423.9",
"782.1",
"112.0",
"V15.81",
"136.3",
"704.8",
"799.02",
"584.9",
"518.81",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
11089, 11095
|
6025, 9407
|
352, 395
|
11232, 11264
|
3453, 4458
|
12893, 13529
|
2062, 2080
|
9922, 11066
|
11116, 11211
|
9433, 9899
|
11288, 12870
|
2095, 2880
|
4491, 6002
|
2894, 3434
|
286, 314
|
423, 1699
|
1721, 1789
|
1805, 2046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,475
| 113,996
|
26282
|
Discharge summary
|
report
|
Admission Date: [**2164-6-8**] [**Month/Day/Year **] Date: [**2164-6-16**]
Date of Birth: [**2088-11-20**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Nexium
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI bleed, Altered Mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 yo M with cirrhosis [**1-26**] NASH and likely EtOH use c/b portal
hypertension, gastric varices, recurrent UGIB requires TIPS
placement in [**2158**] and revision in [**2160**], encephalopathy, and
other medical issues, now transferred from [**Hospital6 5016**]
for fresh hemetemesis and coffee ground on NG lavage.
Per patient's wife, he was at his usual state of health until
[**6-7**]. He woke up feeling unwell, and his wife saw him sitting
at the edge of the bed with a wastebasket that had about 2 cups
of red-brown blood. She flushed it, and he dry-heaved and
vomited up another cup of blood. He was taken to [**Hospital3 **]. According to the wife, patient was A&Ox3. She firmly
stated that he has not touched alcohol since [**2150**].
Per Dr. [**Last Name (STitle) 65072**] at [**Hospital6 5016**], patinet was admitted to
the ICU on [**2164-6-7**] with hematemesis. Exam was notable for
clear lungs, mild tachycardia, asterixis, alert, and awake. His
initial Hgb was 10.9 but then subsequently dropped to 8.8. It
was reported that his hemodynamics were stable. He received 2
units of pRBC and 2 units of FFP. He was started on octreotide
and protonix gtt. He was also given 5 mg po vitamin K daily.
Patient was apparently alert and oriented at the time of the
admission. He became agitated (pulled out IV & punched a nurse)
and hallucinated overnight and received IV Ativan (3 mg) and ?
haldol for concern of EtOH withdrawal although patient and his
wife denied EtOH ingestion. On the day of transfer, patient
underwent EGD with banding. Per verbal report, it seemd that he
had gastric varices that was no longer actively bleeding. He
received another unit of pRBC for Hgb of 9.1 and 2 more FFP. He
was thought to be more sedated, possibly from hepatic
encephalopathy and medication (lorazepam), only arousable to
painful stimuli. Dr. [**Last Name (STitle) 65072**] stated that patient's VS were
stable at the time of transfer and did not think patient would
require intubation. He was continued on lactulose and
rifaximin. He was also given ceftriaxone prophylactically given
the GIB. VS upon transfer were 98.6F, pulse 69, resp 14, BP
136/85, O2Sat 100%.
[**Name (NI) **] wife wants him to receive the remaining of his care
here at [**Hospital1 18**].
On arrival to the MICU, patient's VS were 97.7F, 74, SBP 137, RR
22, O2Sat 96% RA. Patient mumbled.
Review of systems:
(+) Per HPI
(-) Unable to obtain
Past Medical History:
- cirrhosis [**1-26**] NASH and likely EtOH c/b portal hypertension,
varices, encephalopathy
- h/o EtOH abuse
- h/o recurrent variceal bleeds s/p TIPS placement in [**5-/2159**] and
TIPS revision [**2-/2161**]
- gastric varices
- Diverticulosis
- GERD
- Barrett's esophagus
- h/o rheumatic fever
- h/o thrombocytopenia
- cataracts, s/p bilateral cataract surgeries, last one was 2
weeks ago
- h/o right humerus fx, s/p reverse shoulder surgery in [**2161**]
- CAD (per OMR, but wife is not aware of this)
Social History:
- ex-smoker, quit in [**2120**], ~ 37.5 pack year
- h/o heavy EtOH, quit [**2150**]
- part time plumber
- lives with wife
- 2 adult children
- no illicit drug use
Family History:
- no family history of CAD, DM, cancer
- no family history of liver disease
- mother died of old age
- father died of lung disease
Physical Exam:
ADMISSION EXAM
General: lethargic, oriented to self, does not appear to be in
acute distress
HEENT: sclera anicteric, mucous membrane dry, OP clear,
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly bilaterally, no wheezes,
rales, ronchi
Abdomen: soft, mildly distended, non-tender, no rebound or
guarding
GU: + foley, yellow urine
Rectal: dark tarry liquid stool
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema
Neuro: PERRLA, EOMi, oriented to self, but not oriented to place
or time, + asterixis, move all 4 extremities, gait deferred.
.
[**Year (4 digits) **] Exam:
VS: T 98 BP 100-120/40-50s HR 70s RR 18 O2 100 RA
GENERAL: Well appearing, NAD, AOX3.
HEENT: Sclera icterus noted. MMM.
CARDIAC: RRR with m/r/g noted
LUNGS: Lungs clear b/l without wheeze.
ABDOMEN: Soft, mildly distended, no tenderness to palpation.
(-) HSM.
EXTREMITIES: mild edema b/l. Warm and well perfused, no
clubbing or cyanosis.
NEUROLOGY: no asterixis, mild tremor
Pertinent Results:
ADMISSION LABS
[**2164-6-8**] 10:02PM BLOOD WBC-10.2 RBC-3.45* Hgb-10.6* Hct-32.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.9 Plt Ct-110*
[**2164-6-8**] 10:02PM BLOOD PT-14.4* PTT-32.0 INR(PT)-1.3*
[**2164-6-8**] 10:02PM BLOOD Glucose-158* UreaN-30* Creat-0.8 Na-146*
K-4.4 Cl-115* HCO3-24 AnGap-11
[**2164-6-8**] 10:02PM BLOOD ALT-18 AST-34 LD(LDH)-232 AlkPhos-64
TotBili-1.9*
[**2164-6-8**] 10:02PM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.4*
Mg-2.1
.
URINE STUDIES
[**2164-6-8**] 10:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2164-6-8**] 10:02PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2164-6-8**] 10:02PM URINE RBC-67* WBC-16* Bacteri-FEW Yeast-NONE
Epi-0 RenalEp-<1
.
MICROBIOLOGY
URINE CULTURE (Final [**2164-6-10**]): NO GROWTH.
Blood culture- pending
.
IMAGING
CXR [**2164-6-8**]
Heart size is upper limits of normal. There is tortuosity of
the thoracic
aorta. The lungs are relatively clear without signs for overt
pulmonary edema or focal consolidation. No pneumothoraces are
identified.
.
ABDOMINAL US [**2164-6-9**]
Limited study as above with patent TIPS, main portal vein and
left portal vein.
.
TIPS Study [**2164-6-15**]:
1. Mild-to-moderate focal stenosis was demonstrated at the
distal
shunt-hepatic vein junction. This was confirmed with the
pressure jump across the area of stenosis.
2. Angioplasty was performed with a 10 mm x 4 cm balloon.
3. Post-angioplasty venogram did not demonstrate the area of
stenosis. The gradient had also normalized across the area of
interest.
4. Pre-angioplasty portosystemic gradient was 8 mmHg and
post-angioplasty portosystemic gradient was 7 mmHg.
MRI abdomen w/ and w/o contrast:
1. Patent portal vein, TIPS and splenic vein.
2. Non-occlusive thrombus in the SMV, slightly more extensive
than on the [**2161**] MRI.
3. No large concerning hepatic lesion although assessment is
limited by non-breath-hold technique.
EGD [**2164-6-12**]:
Normal mucosa in the esophagus (no varices noted)
Normal mucosa in the duodenum
Abnormal vascularity and mosaic appearance in the body and
fundus compatible with mild portal hypertensive gastropathy
Erythema and petechiae in the antrum compatible with moderate
GAVE
Food in the stomach
Small gastric varices with prior bands in place
A focal area of erythema in the body which may be from prior NG
tube trauma
Otherwise normal EGD to third part of the duodenum
.
Labs on [**Month/Day/Year **]:
[**2164-6-16**] 10:00AM BLOOD WBC-3.2*# RBC-2.96* Hgb-9.4* Hct-28.4*
MCV-96 MCH-32.0 MCHC-33.3 RDW-15.3 Plt Ct-63*
[**2164-6-16**] 10:00AM BLOOD PT-15.1* PTT-31.4 INR(PT)-1.4*
[**2164-6-16**] 10:00AM BLOOD Glucose-118* UreaN-5* Creat-0.8 Na-141
K-4.2 Cl-111* HCO3-24 AnGap-10
[**2164-6-16**] 10:00AM BLOOD ALT-18 AST-32 AlkPhos-73 TotBili-1.1
[**2164-6-16**] 10:00AM BLOOD Calcium-7.4* Phos-2.6* Mg-1.8
Brief Hospital Course:
75 yo M with cirrhosis [**1-26**] NASH and possibly history of heavy
EtOH use c/b portal hypertension, gastric varices, recurrent
UGIB requires TIPS placement in [**2158**] and revision in [**2160**],
encephalopathy, and other medical issues, transferred to [**Hospital1 18**]
MICU from [**Hospital6 5016**] for upper GI bleed and delirium.
# UGIB. Most likely [**1-26**] gastric varices given his history of
variceal bleeding, though also could be secondary to gastric
angioectasias. Unclear what the precipitant was given this
occurred quite suddenly. Per wife, he was taking all of his
medications as prescribed and that he has not had any alcohol
since [**2150**]. RUQ US showed patent TIPS. Patient underwent EGD at
OSH with banding of non bleeding gastric varicies. Patient
received a total of 3 u pRBC and 4 of FFP at OSH. On arrival to
[**Hospital1 18**] MICU he was continued on an octreotide drip and [**Hospital1 **] IV
PPI. His home nadolol was initially held. He was further started
on ceftriaxone for SBP prophylaxis. Hepatology was consulted
and recommended starting carafate. HCT remained stable and he
was transferred to the liver service.
On the hepatology floor, RUQ US demonstrated patent TIPS, but
still had concern for malfunction of TIPS given the bleed. Pt
had MRI to evaluate for portal or SMA thrombus, which was
negative. TIPS study completed [**6-15**] which demonstrated focal
stenosis at distal shunt-hepatic vein junction. An angioplasty
was performed and the pressure gradient was reduced from 8mmHg
to 7mmHg. A post-procedure venogram did not show the area of
stenosis. Of note, hct trended down very slowly from 30 to ~26
while on the floor, Did not suspect bleed, but will have labs
re-checked on [**Month/Year (2) **].
# Encephalopathy, NOS. Based on history, patient initially was
alert and oriented at the time of initial admission to OSH. His
mental status deteriorated in the setting of UGIB and possibly
result of benzodiazepine +/- antipsychotics. It is not clear if
he received antipsychotics based on OSH record. It is also
unclear how frequently he was receiving lactulose for his
underlying hepatic encephalopathy. Infectious work-up including
CXR,UA, and blood cultures were negative for infection. He was
continued on lactulose and rifaxamin. Sedating medications were
avoided. MS improved. The patient did not exhibit signs or
symptoms of withdrawal.
# Cirrhosis [**1-26**] NASH/EtOH. Appears to be compensated based on
recent labs. MELD score per OSH labs was 15 on arrival. His
home spironolactone and lasix were held in the setting of a
mildly elevated Cr but re-started on [**Month/Day (2) **].
# Cataract, s/p surgery 2 weeks ago. He was continued on his
home eyedrops.
TRANSITIONAL ISSUES
- will f/u in liver clinic
- will have labs checked on [**6-18**] and faxed to liver clinic
(particularly CBC)
- Patient was full code throughout this admission
Medications on Admission:
Home medications: per wife
- [**Name (NI) 65073**] 550 mg po BID
- omeprazole 20 mg [**Hospital1 **]
- magnesium oxide 250 mg [**Hospital1 **]
- aldactone 25 mg QD (down from [**Hospital1 **] since last hepatology visit)
- lasix 40 mg daily
- lactulose 2 tablespoons [**Hospital1 **]
- iron 240 mg [**Hospital1 **]
- a medication for the bones- "Osteo---" daily
- ? neo-poly-dex eye drops 1 drop in right eye QID
- ? ketorolac 1 drop in right eye QID
Medications upon transfer:
- folic acid 1 mg daily
- ketorolac 0.5% ophth solution right eye, QID
- lactulose 20 g TID
- MVI daily
- nadolol 20 mg daily
- neomy/polymyx/dexam ophth susp right eye, QID
- octreotide 25 mcg/hr gtt
- protonix 40 mg daily
- phytonadione 5 mg daily
- rifaximin 550 mg [**Hospital1 **]
- thiamine 100 mg daily
- Ceftriaxone 1 g daily
- ativan 1-2 mg IV q2-4hr prn for agitation
- NS 75 ml/hr
[**Hospital1 **] Medications:
1. Outpatient Lab Work
Please check chem10, CBC, LFTs, coags and fax to:
Liver transplant clinic
[**Telephone/Fax (1) 24156**]
2. Rifaximin 550 mg PO BID
3. Nadolol 20 mg PO DAILY
pls hold for sbp<100 or hr<60
4. Lactulose 30 mL PO TID
5. Ferrous Sulfate 240 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Magnesium Oxide 250 mg PO BID
9. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 Capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
[**Telephone/Fax (1) **] Disposition:
Home
[**Telephone/Fax (1) **] Diagnosis:
Gastric variceal bleed
Hepatic encephalopathy
TIPS occlusion
[**Telephone/Fax (1) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Telephone/Fax (1) **] Instructions:
Dear Mr. [**Known lastname 931**],
You were admitted to another hospital initially because you were
having a lot of bleeding from some blood vessels in your
stomach. There, the bleeding was stopped and you were
transferred to [**Hospital3 **] Medical Center. Here, you did not
have any more bleeding. You had another endoscopy which
confirmed you did not have any bleeding. We were concerned that
your TIPS was not open. An MRI and ultrasound were normal. You
then had a dedicated TIPS study which did show a narrowing which
was dilated successfully. We have made sure your kidney function
was normal after the procedure.
You were a bit confused initially during the admission. Please
make sure to take your lactulose regularly, goal of [**2-26**] bowel
movements daily.
Your blood counts were a little bit low, so we would like you to
have them checked after the weekend.
We have made the following changes to your medications:
- INCREASE omeprazole to 40mg twice per day
- INCREASE lactulose to 30mL 3 times per day, goal of [**2-26**] bowel
movements daily
On [**Date Range **], please call Dr.[**Name (NI) 6670**] office to schedule a
follow up appointment at [**Telephone/Fax (1) 24157**] in the next 1-2 weeks.
Please have your labs checked on [**Last Name (LF) 766**], [**6-18**] and faxed to
the liver clinic. Prescription included below.
Followup Instructions:
Department: RADIOLOGY
When: THURSDAY [**2164-11-8**] at 10:00 AM
With: ULTRASOUND [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: LIVER CENTER
When: THURSDAY [**2164-11-8**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2164-6-18**]
|
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icd9cm
|
[
[
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[
"88.65",
"45.13",
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icd9pcs
|
[
[
[]
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7676, 10603
|
322, 328
|
4767, 7653
|
13740, 14295
|
3530, 3663
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10629, 10629
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3678, 4748
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10647, 11502
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2769, 2804
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,275
| 159,855
|
53861
|
Discharge summary
|
report
|
Admission Date: [**2104-4-21**] Discharge Date:
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
female with a history of a large cell lymphoma status post
CHOP as well as Chlorambucil off therapy for several years,
lymphoma complicated by hypogammaglobulinemia for which the
was seen in [**Hospital 191**] clinic with complaints of right arm and neck
swelling and was referred to the Emergency Room for
evaluation. The patient had right sided porta-cath in place
for several years by report which has not been flushed in
several months. In the Emergency Room a neck CT with
contrast was performed revealing a right subclavian thrombus
extending into the SVC around the patient's porta-cath. Per
yesterday. The patient's main complaint is pain and
swelling. She has had some shortness of breath with vigorous
movement. She has not been doing any unusual activities,
simply doing her usual housework.
PAST MEDICAL HISTORY: Carcinoma of the cecum, large cell
lymphoma, zoster, gastroesophageal reflux disorder.
MEDICATIONS: On admission are none by her son's report.
ALLERGIES: Include Morphine which causes nausea and
vomiting.
PHYSICAL EXAMINATION: On admission temperature 98.8, heart
rate in the 80's, blood pressure 120/60. In general she is
alert, pleasant, elderly female. HEENT: She has a distended
right internal jugular, 1+ carotid pulses, no palpable
cervical lymphadenopathy or subclavian lymphadenopathy. She
has an enlarged right side of her face and the right lateral
aspect of her neck is also enlarged. Her lungs are clear to
auscultation bilaterally. Heart is regular rate and rhythm,
normal S1 and S2, no murmurs, rubs or gallops. Abdomen soft,
nontender, non distended, no rebound, guarding, no
hepatosplenomegaly. Extremities, she has scattered abrasions
on her left lower extremity, 1+ chronic edema.
Neurologically she is alert, speech seems fluent, cranial
nerves are intact, strength 5/5 in left biceps and left
triceps, 4+/5 in right biceps and [**6-1**] in the right triceps.
Rectal is guaiac negative. EKG shows normal sinus rhythm, no
ischemic ST-T changes.
LABORATORY DATA: On admission, white count 8.2, hematocrit
36.2, platelet count 238,000, sodium 142, potassium 4,
chloride 107, CO2 26, BUN 10, creatinine .5, glucose 78.
Urinalysis, specific gravity 1.001, there is small blood, no
nitrites, no protein, 6 reds, 2 whites, occasional bacteria.
Neck CT shows right porta-cath thrombus around catheter in
the right subclavian vein extending into the SVC. There was
good collateralization and no evidence of lymphadenopathy.
Head CT showed calcified meningioma.
HOSPITAL COURSE:
1. Superior vena cava syndrome: The patient was diagnosed
with superior vena cava syndrome based on neck CT and
clinical findings. She was initially started on Heparin to
keep her PTT between 60 and 80. The patient received
directed TPA by the interventional radiology service on
hospital day #2 with no consequence. Her SVC syndrome
subsequently improved, face became less swollen, neck became
less swollen, her porta-cath was discontinued at that time.
She has been continued on Heparin and will be transitioned to
Coumadin as an outpatient.
2. The patient has had pleuritic chest pain during this
admission. She was ruled out for pulmonary embolus by CTA on
hospital day #1. Her pleuritic chest pain may be related to
a small effusion that is present in the left lower lobe. She
has a right lower lobe pulmonary nodule which has reportedly
not been worked up in the past.
3. Meningioma which is a [**Last Name **] problem. She will require
work-up for the meningioma and appropriate treatment.
4. Pain control: The patient received Fentanyl patch for
pain control. She also received OxyContin for breakthrough
pain.
DISCHARGE MEDICATIONS: Protonix 40 mg po q d, Heparin drip
per protocol, Coumadin 5 mg po q h.s., Erythromycin ointment
to eyes, Colace 100 mg po bid, OxyContin 20 mg po q 12 hours,
Senna two tablets po q h.s., normal saline for one liter.
Patient's discharge is pending her becoming therapeutic on
Coumadin. Patient will follow-up with her PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] as an outpatient.
DISCHARGE DIAGNOSIS:
1. SVC syndrome.
2. Meningioma.
The patient is currently in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], M.D. [**MD Number(1) 94909**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2104-4-27**] 22:24
T: [**2104-4-28**] 19:52
JOB#: [**Job Number 110506**]
|
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icd9cm
|
[
[
[]
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[
"88.44",
"86.05",
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icd9pcs
|
[
[
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3815, 4257
|
4278, 4642
|
2655, 3791
|
1181, 2638
|
85, 925
|
948, 1158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,193
| 154,478
|
53467
|
Discharge summary
|
report
|
Admission Date: [**2110-1-5**] Discharge Date: [**2110-1-8**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo female with h/o stroke, DM2, GERD, GOUT who presented wtih
SOB. She reports that she felt lightheaded and SOB at home. She
felt fatigued and had a non-productive cough for several days.
Denies chest pain, nause or vomiting. Today she felt more
lightheaded and SOB. She called her daughter and then 911. In
the ED, she was found to be in a.flutter with 2:1 block rate
140s, SBP 78/53. She was given IV diltiazem and placed on a dilt
gtt at 5mg/hr. She was given IVF and preppred with versed and
fentanyl for cardioversion. The SBP dropped to 50s systolic. She
was shocked with 100J and then 150J with no effect. A femoral
line was placed urgently and neosynepherine was started. Her BP
improved to 120-140 range systolic. In total she received 5L
IVF. Her rectal temp was 100.6 and CXR suggested RLL infiltrate;
therefore, she was given vancomycin and levofloxacin. She also
had a CTA chest to rule out PE which was negative. She
spontaneously converted to sinus rhythm in the 80s and felt much
better. She is admitted to the ICU for further care.
On review of systems, she denies fevers/chills, N/V, abdominal
pain, palpitations, dysuria or frequency. Denies PND or
orthopnea.
Past Medical History:
- CAD
- HTN
- DM, type 2
- h/o Gout and pseudogout
- s/p right knee replacement [**2099**]
- osteoporosis
- OA
- GERD
- Aortic Regurg/MR/TR
- h/o TIA
- s/p right rotator cuff injury with partial shoulder
replacement
- spinal stenosis
- h/o right Colles' fx
Social History:
Lives independently in apartment with help from Home Health
Aide 2-3 times per week, but performs most ADLs. Remote smoking
history. Occasional EtOH. Dr. [**Known lastname **] is her daughter. [**Name (NI) 6934**]
at baseline with walker in apartment and in wheelchair when out
of house [**3-16**] chronic arthritis.
Family History:
No family history of early MI.
Physical Exam:
VS: 98.1, 87, 136/79, 17, 98%2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: No JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR w/o m
LUNGS: Crackles in lower lung fields.
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c. +1 LE edema.
SKIN: LE with chronic changes. LLE Warm and erythematous, with
scabbed lesions.
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:
[**2110-1-7**] 12:00AM BLOOD WBC-6.5 RBC-4.06* Hgb-11.6* Hct-33.5*
MCV-83 MCH-28.6 MCHC-34.7 RDW-14.9 Plt Ct-148*
[**2110-1-5**] 12:40PM BLOOD Neuts-84.7* Lymphs-9.6* Monos-5.1 Eos-0.4
Baso-0.2
[**2110-1-7**] 12:00AM BLOOD PT-13.6* PTT-26.7 INR(PT)-1.2*
[**2110-1-7**] 12:00AM BLOOD Glucose-160* UreaN-22* Creat-0.6 Na-136
K-3.5 Cl-100 HCO3-27 AnGap-13
[**2110-1-5**] 12:40PM BLOOD ALT-22 AST-17 CK(CPK)-58 AlkPhos-77
TotBili-0.7
[**2110-1-7**] 09:15AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2110-1-5**] 12:40PM BLOOD CK-MB-NotDone proBNP-1172*
[**2110-1-7**] 12:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0
[**2110-1-5**] 01:03PM BLOOD Lactate-2.2*
[**2110-1-5**] 06:25PM BLOOD Lactate-1.1
[**2110-1-5**] 02:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2110-1-5**] 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Urine Cx [**1-5**]: Negative
Blood Cx [**1-5**]: NGTD
CXR [**1-5**]:
1. Decreased lung volumes. Patchy opacities in both lower lobes
could
represent a combination of asymmetric pulmonary edema,
atelectasis, and/or
infection.
2. Crescents of gas noted beneath both diaphragms. Air under
left diaphragm could represent air within a loop of bowel, as
previously seen. If there is concern for free air within the
abdomen, lateral decubitus radiographs of the abdomen could be
obtained.
CTA [**1-5**]:
1. No evidence of pulmonary embolism or dissection.
2. Sub-5-mm nodules in the left upper lobe as described above.
Followup in
three-to-six months is recommended to document stability if
clinically
indicated.
3. Findings in the right lung base may represent atelectasis
versus
consolidation.
4. Mediastinal and hilar lymph node calcifications, and splenic
calcificaions, consistent with prior granulomatous disease.
5. Degenerative changes of the left shoulder with large joint
effusion.
ECHO [**1-6**]:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). The right ventricular cavity is mildly dilated
with normal free wall contractility. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2108-6-14**], the
aortic valve velocity has slightly increased. The right
ventricular cavity was mildly increased on review of the prior
study.
Brief Hospital Course:
89 yo F with PMH of DM2, diastolic CHF, gout and presented with
sudden onset of SOB and found to be in atrial flutter and then
atrial fibrillation.
# RHYTHM: Pt initially failed 2 attempts at cardioversion from
presumed new onset atrial flutter, but converted spontaneously
to normal sinus rhythm with volume resuscitation. Based on CXR
and CTA, possible pneumonia may have been the inciting factor
for this new arrhythmia. She was ruled out for other etiology
including PE (neg CTA), ischemia (CE negative x3), and sepsis
(blood cultures NGTD). An echo showed no obvious etioloty of the
atrial flutter with no wall motion abnormalities or dilitation.
Pt's home regimen of diltiazem was initially held, then
restarted IV and transitioned to PO extended release. She was
continued on ASA at an increased dose but was poor candidate for
anticoagulation with coumadin. Patient and daughter are in
agreement of not anticoagulating. Pt was monitored closely on
telemtry without any furthur arrhythmic episodes.
# Hypotension: On presentation pt required pressors to maintain
adequate blood pressure. This was thought to be due to rapid
rate vs sepsis. Blood cultures were drawn and were NGTD at time
of discharge and pt quickly was able to wean off pressors with
control of heart rate. Diltiazem was initially held but
restarted for rate control. Pt's lactate initially was 2.2,
improved on repeat. Lasix from home regimen was also held and
restarted prior to discharge.
# Pneumonia: Pt with RLL pneumonia on CXR and was treated with
continue levofloxacin for community acquired pneumonia. Pt was
initially on Vancomycin for a questionable cellulitis of lower
extremities but discontinued when clarified that this is
chronic. An ultrasound of the lower extremities was refused by
the patient to rule out DVT, although clinical suspicion was
low. All cultures were negative or pending at time of
discharge.
# Chronic Diastolic CHF: Pt received 5L of IVF in ED and since
then appeared euvolemic. BP control with diltiazem was initially
held and restarted once stable.
Prior to discharge, home regimen of lasix was restarted.
# Diabetes type 2: Oral agents were held and blood sugars were
treated with insulin sliding scale. Will resume oral agents.
# Gout: Pt was continued on allopurinol and colchicine
# Osteoporosis: Pt was continued on calcium and vitamin D
Pt was DNR/DNI throughout admission.
Medications on Admission:
-lasix 80mg daily
-pantoprazole 20mg [**Hospital1 **]
-allopurinol 300 mg daily
-colchicine 0.6 every other day
-dilt 120mg daily
-asa 81
-MVI
-calcium and vit D
-glyburide 2.5mg daily
-KCl 40mg daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QOD ().
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Four
(4) Tablet Sustained Release PO once a day.
9. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
10. Multiple Vitamins Daily Tablet Sig: One (1) Tablet PO
once a day.
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for pain.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: one Tab
Sublingual every 5 minutes x3 as needed for chest pain.
15. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Atrial Flutter
Community Aquired Pneumonia
Diabetes Mellitus
Chronic Diastolic Dysfunction
Peripheral Vascular Disease
Patient is DNR/DNI
Discharge Condition:
stable
BUN= 22
Creat=0.6
K=3.4 (repleted)
Na=140
INR= 1.2
Discharge Instructions:
You had rapid atrial fibrillation and a low blood pressure that
was controlled with intravenous Diltiazem, then changed to oral
diltiazem. You had a cardioversion that converted your rhythm
into a normal sinus rhythm. It is not recommended at this time
that you take Warfarin (coumadin) but your aspirin was increased
to 325mg. You also had a possible pneumonia. You were started on
a 5 day course of antibiotics to treat this.
Medicine changes:
1. Increase aspirin to 325mg
2. Levofloxacin: antibiotic to treat pneumonia
.
Please call your provider at [**Hospital 100**] Rehab if you have any
palpitations, chest pain, trouble breathing, increasing cough,
swelling or any other unusual symptoms.
Followup Instructions:
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 608**] Date/Time: Please call after
you get out of rehabilitation.
.
Cardiology:
Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**] Phone: [**Pager number **]=[**Telephone/Fax (1) **] Date/time: [**1-30**] at
1:00pm.
Completed by:[**2110-1-8**]
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"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
9503, 9576
|
5542, 7949
|
246, 252
|
9758, 9818
|
2678, 5519
|
10563, 10938
|
2098, 2130
|
8201, 9480
|
9597, 9737
|
7975, 8178
|
9842, 10540
|
2145, 2659
|
187, 208
|
280, 1466
|
1488, 1747
|
1763, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,580
| 110,974
|
6612
|
Discharge summary
|
report
|
Admission Date: [**2130-1-3**] Discharge Date: [**2130-1-6**]
Date of Birth: [**2077-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 52 yo m with recent hypercarbic hypoxic failure s/p
tracheostomy on mechanical ventilation, insulin dependent
diabetes, hypertension, obstructive sleep apnea, and chf who
presents with fever x 2-3 days with no obvious source.
Patient was recently admitted with hypercarbic hypoxic
respiratory failure requiring intubuation and subsequent
tracheostomy. Found to have MRSA pna refractory to 24 d of
treatment-- then switched to linezolid. During his last
hospital course, he was found to be in renal failure thought to
be from ATN as it improved with improved bp. He was discharged
on linezolid, and continued at rehab ([**12-28**])scheduled to end
[**1-4**]. Of note, picc line was changed to midline [**12-31**] with
picc line tip cx negative. He was started on cefepime, iv
flagyl, po vanco, in addition to the linezolid all during the 5
day rehab stay.
Past Medical History:
Past Medical History:
1. Morbid obesity.
2. Hypertension.
3. Obstructive sleep apnea on CPAP 12 with 2 liters of
supplemental O2 (not currently using). On 5L nC at home.
4. Insulin-dependent diabetes (Followed at [**Last Name (un) **]. Seen by an
ophthalmologist once a year. He has not seen a podiatrist in
over two years. [**4-21**]: Hemoglobin A1c 8.6, urine albumin to
creatinine 31.6).
5. CHF (EF indeterminate on most recent Echo).
6. Polycythemia.
7. ? h/o COPD (he has never had pulmonary function testing).
8. Degenerative disc disease.
9. Diabetic neuropathy.
10. Venous stasis/leg ulcers.
11. Right knee with torn cartilage (?meniscal injury).
12. History of left hip pain status post fall one year ago using
Lidoderm patches.
13. Hyperlipidemia (Last cholesterol [**4-21**]: TC 157, TG 238, HDL
45, LDL 76)
.
Past Surgical History:
1. Status post splenectomy secondary to motor vehicle accident
(he is unclear of his vaccination status, he is not sure when he
last received the Pneumovax).
2. Status post vascular repair of his right groin (details
unclear).
3. Tracheostomy
Social History:
He is married, but is estranged from his wife. [**Name (NI) **] works
part-time for a property management company. He walks with a
cane at baseline He denies current tobacco use. He smoked
briefly for 2 years, however quit over 10 years ago. He drinks
EtOH occasionally. He has never been a heavy drinker. He denies
illicit drug use.
Family History:
Family History: His mother has hypertension. His father died
from complications of diabetes and hypertension. He did not have
coronary artery disease. He has four brothers, all which are
healthy. He has 2 boys aged 21 and 27, both healthy. His uncle
is status post heart transplant (details unknown).
Physical Exam:
v/s T 101 BP 140/80 P 85, 300 cc of yellow clear urine in foley
catheter
vent setting: AC 12, TV 550, Peep 5, FIO2 of 45% sat 93%
GEN: trached, rigoring
HEENT: OP clear, stage 2, dime sized ulcer, no drainage,
tracheostomy site clean
LUNGS: difficult lung exam, CTA x 2
HEART: s1 s2 no m/r/g
ABDOMEN: soft, obese, vertical scar and scar on RLQ, +bs, foley
in place
EXTREMITIES: venous stasis changes b/l, good pt/dp pulses
NEURO: able to follow simple commands, squeezes hand for
responses
Pertinent Results:
Prior culture data:
urine cx- enterococcus [**Last Name (un) 36**] to vanc
respiratory cx [**2129-12-22**]- mrsa
catheter tip culture neg from [**12-31**]
blood cx [**12-29**]- NGTD
OSH: wbc 15.2, hct 48, na 153, co2 33, ldh 343
Brief Hospital Course:
Patient is a 52 yo m with recent hypercarbic hypoxic failure s/p
tracheostomy on mechanical ventilation, insulin dependent
diabetes, hypertension, obstructive sleep apnea, and chf who
presents with fever x 2 days.
Respiratory failure - did well on SBT and able to last 2 hours
on trach mask. Did well on passy muir valve and able to eat
regular diet while on valve. Should continue to wean off vent
while at [**Hospital **] rehab.
Fever - Resolved while patient was hospitalized. Not on
antibiotics. Stool was negative for c diff x 2. Blood cultures
NGTD. CXR without signs of pneumonia.
Hypernatremia - got free water boluses through NG tube. Na was
146 at the time of discharge. Should be checked again over the
weekend and twice a week after that.
Elevated CPK- neg mb fraction and mildly elevated troponin,
denied chest pain. Troponins trended down during admission.
Diabetes- insulin dependent diabetes, baseline lantus 75 [**Hospital1 **] and
humalog sliding scale.
CODE Status- full
Medications on Admission:
atorvastatin 40'
asa 81'
ipratrop/albut
fluticasone
docusate
heparin sc
lactulose
tylenol prn
miconazole powder
biscodyl
senna
linezolid
insulin sliding scale
fentanyl patch 100 mcg/hr q72 (weaned by 25 mcg)
lasix 40'
naloxone for constipation
metoprolol 25'''
captopril 25'''
haldol prn [**3-20**] iv prn
famoditine
oxymetazoline nasal spray
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Respiratory Failure
Fevers
Discharge Condition:
Fair; tolerating trach mask for 2 hours periods
Discharge Instructions:
--Continue to wean ventilation at rehab.
--When you are on trach mask and have the passy muir valve on
you can eat regular food.
--please check sodium twice a week and give free water boluses
as needed for hypernatremia
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2130-2-23**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2130-2-23**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] / DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2130-2-23**] 2:30
|
[
"V58.67",
"459.81",
"780.6",
"428.0",
"707.09",
"276.0",
"518.83",
"250.60",
"357.2",
"278.01",
"401.9",
"327.23",
"V44.0",
"238.4",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5193, 5259
|
3792, 4799
|
317, 323
|
5330, 5380
|
3537, 3769
|
5648, 6077
|
2724, 3011
|
5280, 5309
|
4825, 5170
|
5404, 5625
|
2093, 2339
|
3026, 3518
|
272, 279
|
351, 1226
|
1270, 2070
|
2355, 2692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,825
| 154,246
|
20828
|
Discharge summary
|
report
|
Admission Date: [**2200-1-3**] Discharge Date: [**2200-1-16**]
Date of Birth: [**2140-12-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
blood in stool
Major Surgical or Invasive Procedure:
Endoscopic Gastroduodenoscopy x2
Endoscopic Ultrasound
Colonoscopy
Right internal jugular central venous line placement
History of Present Illness:
59 year old woman s/p MV replacement (St. [**Male First Name (un) 923**] mechanical), TVR
([**Doctor Last Name **] ring) and ASD [**2199-7-10**] with postoperative Atrial
fibrillation presenting with melena for 1 day. She noticed that
her stool this morning was soft but black. She had four similar
stools today. She went to her PCP who sent her in to ED for
evaluation. She denies recent nausea, vomiting, or BRBPR. She
had a similar episode in [**2197**], but otherwise has not had recent
bleeding. She was started on a ten day course of augmentin for
ear pain two weeks ago and was started on amiodorone for atrial
fibrillation on [**12-25**]. Two days ago she had transient
orthostasis, but otherwise has not had pre-syncope or
lightheadedness.
In the ED, initial VS: HR 89 BP 135/66. She compained of SOB and
weakness and ST depressions and was consented via interpreter
for transfusion. She had guiac positive black stools. An NG
lavage was negative for blood. Her Hct was 27.3, from a baseline
27-29%, but per her PCP's last record, her Hct was 34. She was
given 2L IVF and 1U PRBC en route to the ICU. Prior to transfer,
her VS: 98.3 76 111/55 16 100/RA.
Past Medical History:
s/p Mitral Valve Replacement (#27mm St.[**Male First Name (un) 923**]
Mechanical)/Tricuspid Valve repair (#28mm [**Doctor Last Name **] ring)/Atrial
Septal Closure-[**2199-7-10**]
-Unsuccessful electrical cardioversion of atrial fibrillation in
[**12-25**]
-Hypertension
-Hyperlipidemia
-Rheumatic fever as a child
-Atrial fibrillation
-Diabetes Type II
-Tubal ligation
-Arthritis
-Mitral stenosis s/p mitral valvuloplasty
-Trisuspid regurgitation
-Pulmonary hypertension
-Arthritis
-Gastric ulcer [**2197**]-GI bleed per pt
Social History:
married and living with her spouse, denied smoking ETOH, and
IVDA
Occupation:retired
Last Dental Exam - edentulous
Lives with: spouse
[**Name (NI) **] Asian
Tobacco:denies
ETOH denies
Family History:
mother - stroke and MI in her 50s, died in her 70s
Physical Exam:
VS: 98.4 (101.3) 97/48 (97-129/48-72), 61-81, 20 (16-20) 98 on
1.5L
GENERAL: NAD, comfortable. A&O
HEENT: O/P clear, MMM
CARDIAC: regular [**Last Name (un) 3526**], mecanical S1 with occasion split s2
LUNG: CTAB with crackles at left base
ABDOMEN: S NT ND
EXT: WWP, 2+ pulses, tr LE edema
Pertinent Results:
Admission
[**2200-1-3**] 03:05PM BLOOD WBC-8.0 RBC-3.70* Hgb-8.0* Hct-27.3*
MCV-74*# MCH-21.7*# MCHC-29.3* RDW-17.0* Plt Ct-299
[**2200-1-3**] 03:05PM BLOOD Neuts-67.5 Lymphs-27.4 Monos-3.7 Eos-1.1
Baso-0.4
[**2200-1-3**] 04:22PM BLOOD PT-47.5* PTT-41.2* INR(PT)-5.1*
[**2200-1-3**] 03:05PM BLOOD Glucose-75 UreaN-37* Creat-0.7 Na-136
K-4.5 Cl-103 HCO3-24 AnGap-14
[**2200-1-4**] 04:32AM BLOOD ALT-21 AST-28 CK(CPK)-83 AlkPhos-88
TotBili-0.7
IRON STUDIES
[**2200-1-3**] 03:05PM BLOOD Iron-19*
[**2200-1-3**] 03:05PM BLOOD calTIBC-512* Ferritn-15 TRF-394*
CARDIAC ENZYMES
[**2200-1-6**] 11:49PM BLOOD CK-MB-2 cTropnT-<0.01
[**2200-1-4**] 04:32AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2200-1-3**] 03:05PM BLOOD cTropnT-<0.01
Discharge Labs:
Radiology:
CXR [**1-6**]
There is no evidence of free air. Severe cardiomegaly is
unchanged. Sternal wires are aligned. Right IJ catheter tip is
in the lower SVC. Bilateral pleural effusions are small. New
opacities in the left upper lobe are worrisome for aspiration.
There is no pneumothorax.
CXR [**1-8**]
Interval resolution of a previously seen left upper lobe
opacity,
compatible with resolved aspiration pneumonitis given the rapid
time course.
EGD Reports:
[**1-4**]
Findings: Esophagus: Normal esophagus.
Stomach: Protruding Lesions A fungating and ulcerated
non-bleeding 2-3 cm mass of malignant appearance was found at
the antrum. The scope traversed the lesion. A fungating and
ulcerated 1 cm mass with stigmata of recent bleeding of
malignant appearance was found at the antrum. The scope
traversed the lesion. Duodenum: Normal duodenum. Impression:
Mass in the antrum. Mass in the antrum. Otherwise normal EGD to
third part of the duodenum
[**1-6**] (EUS):
EUS
findings: EUS was performed using a linear echoendoscope at 7.5
MHz frequency: The polyps were first identified endoscopically
in the antrum and then imaged with EUS. The larger polyp
measured 1.2 cm X 1.0 cm. Shape of the polyp was round.
Echotecture of the polyp was hypoechoic and homogenous. The
polyp appeared to arise from the superficial layer [EUS layers 1
and 2]. An intact submucosal layer ahd muscularis [layers 3 and
4] was noted along the entire lesion. No adjacent lymph
adenopathy was found. No peri-gastric ascites was noted.
Impression: 2 polyps seen in the antrum - endoscopic appearance
was suggestive of hyperplastic/inflammatory polyps EUS: The
polyps appeared to arise from the superficial gastric layers.
12/23
Esophagus: Normal esophagus.
Stomach: Protruding Lesions Two polyps were found in the
antrum. The larger polyp had a stalk and measured about 20mm.
There was a ulceration at the tip of the polyp. The smaller
polyp measured about 8mm. There was no active bleeding.A
single-piece polypectomy was performed using a hot snare and
both the polyps were removed. The polyps were retrived using a
[**Doctor Last Name **] net and sent for pathology. 2 clips were applied at the
site of the smaller polyps to prevent post-polypectomy bleed.
Duodenum: Normal duodenum. Impression: Two polyps were found in
the antrum. The larger polyp had a stalk and measured about
20mm. There was a ulceration at the tip of the polyp. The
smaller polyp measured about 8mm. There was no active bleeding.
A single-piece polypectomy was performed using a hot snare and
both the polyps were removed. The polyps were retrived using a
[**Doctor Last Name **] net and sent for pathology. 2 clips were applied at the
site of the smaller polyps to prevent post-polypectomy bleed.
Colonoscopy: [**1-9**]
Findings: Protruding Lesions Small non-bleeding grade 1
internal hemorrhoids were noted. Impression: Grade 1 internal
hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: Sugarless metamucil [**1-18**] teaspoons daily in
glass of water
High Fiber DietColonoscopy in 10 years as per the recommendation
of Medicare.
Brief Hospital Course:
59 year old woman with mechanical St. [**Male First Name (un) 1525**] mitral valve,
tricuspid valve replacement ([**Doctor First Name 7624**] ring), atrial fibrillation
on coumadin and aspirin presenting with melana in the setting of
a supratherapeutic INR and new diagnosis of antral gastric
polyps.
Hospital Course by Problem:
# GI Bleed: Patient with upper GI bleed in the setting of a
supratherapeutic INR, recent weight loss, and chronic iron
deficiency anemia. She was initially admitted to the Medical
ICU for close monitoring of her hematocrit. 4 U of packed red
blood cells was required during admission from [**Date range (1) 5197**].
Serial hematocrits were checked, and hematocrit remained stable
at 32-34. Patient had central line placed for access, which was
removed once her hematocrit remained stable. She was
subsequently called out to the medical floor: EGD and EUS
revealed 2 antral gastric polyps removed via endoscopic
polypetomy. Colonoscopy only significant for grade I hemorroids.
Pathology of polyps showed granulation tissue and inflammation,
but no evidence of adenocarcinoma. Surgery recommended no
surgery at this time. Patient should no longer take any
ibuprofen or aspirin. Her hematocrit remained stable (38-40)
for latter five days of her hospitalization.
# Anticoagulation: Patient has significant stroke risk given
mechanical mitral valve and atrial fibrillation. Goal INR
2.5-3.5 but wanted reversible anticoagulation for required
diagnostic and therapeutic procedures. Due to risk of rebleeding
s/p polypectomy, heparin gtt was initiated and then held for 48
hours after polypectomy. This decision was discussed and agreed
upon with both cardiology and GI prior to implementation. Once
all GI endoscopic and colonoscopy procedures were completed,
heparin gtt bridge was restarted and she was transitioned back
to coumadin (goal INR 2.5-3.5) prior to discharge. Her final day
of discharge, her INR was 3.0. She was discharged on 5 mg of
warfarin with close follow-up with her PCP for further
monitoring.
# Aspiration Pneumonitis: Noted a LUL opacity on CXR after
patient spiked fever and had elevated leukocytosis. Patient was
briefly placed on Vancomycin/Cefepime for hospital acquired
pneumonia coverage. Repeat CXR 24 hours later showed resolution
of opacity, consistent with aspiration pneumonitis. Repeat
leukocytosis occurred a few days later, repeat CXR showed no
acute process. All blood and urine cultures were negative to
date. Her leukocytosis resolved and she remained afebrile with
no complaints through the course of her hospital stay. She was
observed eating her meals and there was no concern for
aspiration.
# Atrial fibrillation/Flutter: Decreased metoprolol to 25 mg
daily and added amiodarone 200 mg [**Hospital1 **]. Patient remained rate
controlled and hemodynamically stable. Anticoagulation was
maintained on heparin gtt as listed above, and she was
transitioned back to coumadin.
# H. pylori infection: During her GI work-up, she was found to
have positive serology for H. pylori. She was started on triple
therapy with Amoxacillin, Flagyl, and Pantoprazole. She will
take antibiotics for 10 days total, with last dose [**2200-1-17**]. She
was also given a prescription for pantoprazole 40 mg [**Hospital1 **]
standing upon discharge.
# Hypertension: Continued home anti-hypertensives (metoprolol,
lisinopril).
# Diabetes: Stable throughout admission. On Insulin sliding
scale throughout admission and transitioned back to home
medications upon discharge.
Medications on Admission:
AMOXICILLIN-POT CLAVULANATE 875 mg-125 mg twice daily for 10
days
FOLIC ACID 1 mg DAILY
GLIPIZIDE 5 mg by mouth qam
IBUPROFEN 400 mg by mouth as needed for q 4 to 6 hours PRN
LISINOPRIL 20 mg by mouth once a day
METOPROLOL TARTRATE 50 mg by mouth twice a day
PANTOPRAZOLE 40 mg by mouth twice a day
PRAVASTATIN [PRAVACHOL] 80 mg by mouth qpm
WARFARIN tues, thurs, sat and sunday she takes 7mg total, and
mon, wed, fri she takes 6mg total.
amiodarone 200mg [**Hospital1 **]
ASPIRIN 81 mg by mouth DAILY
Discharge Medications:
1. Pravastatin 20 mg [**Hospital1 8426**] Sig: Four (4) [**Hospital1 8426**] PO HS (at
bedtime).
2. Amiodarone 200 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
3. Lisinopril 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
4. Pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
5. Glipizide 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO QAM.
6. Warfarin 5 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Once Daily at 4
PM.
Disp:*5 [**Hospital1 8426**](s)* Refills:*2*
7. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 3 doses.
Disp:*12 Capsule(s)* Refills:*0*
8. Metronidazole 500 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2
times a day) for 3 doses.
Disp:*3 [**Hospital1 8426**](s)* Refills:*0*
9. Metoprolol Succinate 25 mg [**Hospital1 8426**] Sustained Release 24 hr
Sig: One (1) [**Hospital1 8426**] Sustained Release 24 hr PO once a day.
Disp:*30 [**Hospital1 8426**] Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Upper Gastrointestinal Bleed
Secondary Diagnosis
Atrial fibrillation
Mitral valve replacement
Discharge Condition:
Mental status: alert and oriented x3
Ambulatory status: independently walks
Discharge Instructions:
You were admitted with bleeding from your GI tract. You were
found to have some gastric polyps that were removed
endoscopically. The tissue diagnosis of those polyps showed no
evidence of cancer. You were also noted to have an infection of
the stomach called 'Helicobacter pylori', and you will require
treatment for this infection. You should no longer take an
ibuprofen or aspirin, and you should have your INR levels
followed closely as an outpatient by your primary care
physician.
Please take the following medications as directed:
START: Protonix 40 mg by mouth twice a day (ongoing)
START: Amoxicillin 1 gram by mouth twice a day for 10 days
total. You will take three more pills. Stop [**2200-1-18**].
START: Flagyl 500 mg by mouth twice a day for 10 days total. You
will take three more pills. Stop: [**2200-1-18**].
START: Amiodarone 200 mg by mouth twice a day
STOP: Ibuprofen and Aspirin
DECREASE: Metoprolol from 50 mg to 25 mg daily
Continue to take Lisinopril, Pravastatin and your diabetic
medications as you were doing prior to your hospitalization.
You should contact your primary care doctor or go to the
emergecny room if you experience chest pain, palpitations, tarry
or bloody stools, vomiting blood, severe abdominal pain or any
other symptom that is concerning to you.
Followup Instructions:
You are scheduled to have your coumadin checked:
Monday [**1-20**]: 11:00 am at Dr.[**Doctor Last Name 55497**] office
You are scheduled to see your primary care physician
[**Last Name (NamePattern4) **]: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Primary Care
Date/ Time: Wednesday, [**1-22**] at 3:45pm
Location: [**Hospital3 **] Community Health Ctr, [**State 55498**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 8236**]
You are scheduled to see your Cardiologist:
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2200-1-24**] at 10:20
(Phone:[**Telephone/Fax (1) 62**])
|
[
"507.0",
"250.00",
"V58.61",
"401.9",
"416.8",
"V43.3",
"211.1",
"272.4",
"455.0",
"427.31",
"427.32",
"041.86",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"43.41",
"45.13",
"38.93",
"88.74",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12012, 12018
|
6672, 6974
|
330, 452
|
12175, 12175
|
2789, 3515
|
13596, 14260
|
2412, 2464
|
10753, 11989
|
12039, 12154
|
10226, 10730
|
12277, 13573
|
3532, 6649
|
2479, 2770
|
276, 292
|
7003, 10200
|
480, 1645
|
12190, 12253
|
1667, 2194
|
2210, 2396
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,134
| 173,533
|
4395+4396
|
Discharge summary
|
report+report
|
Admission Date: [**2124-11-30**] Discharge Date: [**2124-12-7**]
Date of Birth: [**2050-11-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74 -year-old
woman with a history of severe O2 dependent chronic
obstructive pulmonary disease (FEV1 0.65), recurrent
pneumonia, who transferred from [**Hospital **] Hospital for further
evaluation and treatment of a chronic obstructive pulmonary
disease pneumonia. The patient was recently admitted to this
hospital on [**8-1**] with a right lower lobe pneumonia and
she was treated with azithromycin, ceftriaxone, and then
discharged home on Ceftin. A follow up chest x-ray in the
morning showed resolution of this right lower lobe pneumonia,
but the patient continued to have sputum production, so she
was treated with one week of Levaquin. The patient was also
subsequently on dicloxacillin for a non-healing wound on her
left leg and left lower extremity cellulitis.
The patient was doing quite well until the evening prior to
admission when she developed sudden onset of chills, fever,
and shortness of breath and vomiting. The patient described
that she could not fill her lungs with air. She complains of
only minimal cough which is productive of yellow sputum. She
denies hemoptysis and chest pain. The patient took her
metered dose inhalers without improvement, then called her
visiting nurse, who had her taken to [**Hospital **] Hospital.
At [**Location (un) **], her temperature was 101.6 F and her white blood
cell count was 30. Chest x-ray showed a left lower lobe
infiltrate. She was given 125 mg of IV Solu-Medrol and a
dose of cefuroxime and Biaxin, as well as Albuterol
nebulizers. The patient was referred to [**Hospital3 **] -
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] at the request of the family and
patient.
At baseline, the patient does a treadmill for thirty minutes
a day with four liters of O2. She has baseline orthopnea and
occasional paroxysmal nocturnal dyspnea, but denies recent
worsening of these symptoms. She had recently been on Lasix
for increased shortness of breath and lower extremity edema,
but this was recently discontinued. She denies sick contacts
or travel.
REVIEW OF SYSTEMS: No nausea, positive vomiting, no
abdominal pain. No urinary symptoms. No headaches or visual
changes. She complains of post nasal drip.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease - O2 dependent,
baseline two liters with saturations from 95% to 96%. In
[**2121**] she required prolonged mechanical ventilation /
tracheostomy, which was subsequently reversed. She has a
history of frequent pneumonias, the last pneumonia was [**8-9**].
Last steroid use was in [**Month (only) 359**]. Pulmonary function test
from [**2124-10-19**]: FEV1 0.65 (35%), FEC 2.15 (81%), ratio 43%.
The patient also with a history of bronchiectasis by chest CT
scan.
2. Anxiety.
3. Osteoporosis.
4. Urge incontinence.
5. Gastroesophageal reflux disease.
6. Status post total abdominal hysterectomy.
ALLERGIES: No known drug allergies.
ADMITTING MEDICATIONS: Prilosec 20 mg once a day, Premarin
0.625 mg once a day, Ativan 0.5 mg [**Hospital1 **] and prn anxiety,
multivitamin one a day, Flovent 220 mcg six puffs [**Hospital1 **],
Atrovent four puffs qid, Serevent two puffs [**Hospital1 **], Albuterol
two puffs q four hours prn.
SOCIAL HISTORY: The patient lives with her husband in a
retirement community. Her son is Dr. [**First Name8 (NamePattern2) **] [**Known lastname 18920**]. She
smoked one pack a day for forty years, but quit twenty years
ago. She denies alcohol use or drug use.
PHYSICAL EXAMINATION: On admission, temperature 98.8 F,
blood pressure 116/70, pulse 100, respiratory rate 28, O2
saturation 95% on three liters. General appearance: the
patient is a thin, elderly woman with tachypnea and shortness
of breath, with approximately five word sentences. Head,
eyes, ears, nose, and throat: Pupils are equal, round, and
reactive to light, sclerae anicteric, oropharynx clear, and
noticeable use of accessory muscles for breathing. Neck: no
lymphadenopathy, no jugular venous distention, supple.
Respiratory: decreased breath sounds with left basilar
crackles and rhonchi, positive egophony in the left lower
lobe. Her I/E ratio is approximately 1:3 without wheezes.
Cardiovascular: tachycardic, regular rhythm, normal S1, S2,
no murmurs, rubs, or gallops. Abdomen: bowel sounds present,
abdomen is soft and nontender, nondistended, with no
hepatosplenomegaly. Extremities: 1+ edema in the left lower
extremity with 1.0-2.0 cm ulcer with granulation tissue at
the base without surrounding erythema or cellulitic changes.
Neurologic: alert and oriented times three, cranial nerves II
through XII intact. Strength and sensation grossly intact.
ADMISSION LABORATORY DATA: White count 42, hematocrit 38,
platelets 297,000. Sodium 138, potassium 3.9, chloride 99,
CO2 25, BUN 12, creatinine 0.5, glucose 132. Arterial blood
gas: 7.43 / 41 / 61, saturating 92% on two liters nasal
cannula. Calcium 8.7, phosphorus 2.8, magnesium 1.2.
Chest x-ray showed left lower lobe infiltrate, hyperexpanded
lungs, and air bronchogram. Electrocardiogram was without
change from prior electrocardiogram from [**Month (only) 216**].
HOSPITAL COURSE:
1. Pulmonary: Pneumonia - the patient was admitted for a
left lower lobe pneumonia as evidenced upon x-ray and
examination. She was treated with Levaquin 500 mg once a day
to which she responded. She was also treated with chest
physical therapy, suction, and Albuterol and Atrovent
nebulizers q two to four hours prn.
Chronic obstructive pulmonary disease - on admission, the
patient had an increased O2 requirement from her baseline,
poor air movement, tachypnea, and increased work of
breathing. Her initial saturations were about 92% on three
liters. She was treated with a second dose of IV Solu-Medrol
125 mg and then 100 mg q eight hours times one day, and then
a prednisone taper.
On hospital day two in the evening, the patient required
transfer to the Intensive Care Unit for noninvasive pressure
ventilation due to patient tiring. The patient tolerated
this well with improved O2 saturations. She was transferred
back to the regular floor on hospital day five. The
prednisone taper was continued, as was Levaquin. The patient
continued to improve back to her baseline O2 requirement of
approximately two liters at rest. However, she continued to
have decreased exercise tolerance.
It was felt that the patient would benefit from pulmonary
rehabilitation due to the frequency of her recent pulmonary
infections and her decreased exercise capacity. The patient
also continued to have a bronchospastic cough, but had
resolution of pneumonia. The patient will be continued on
Levaquin for a fourteen day course and a steroid taper.
2. Fluids, electrolytes, and nutrition: The patient had
decreased po intake during the first part of her
hospitalization. She was started on Boost with meals to
supplement her intake. She also took a multivitamin once a
day.
3. Skin: On admission, the patient had a 1.0-2.0 cm ulcer
on her left lower extremity. Treatment with Santyl ointment
and dry sterile dressing changes were continued. The patient
underwent evaluation by wound care nurse who recommended
continuation of the Santyl ointment as well as [**Male First Name (un) **]
compression stockings to bilateral lower extremities.
CODE STATUS: The patient was initially do not resuscitate /
do not intubate on admission. However, after successful
treatment with noninvasive pressure ventilation, the patient
changed her status to do not resuscitate with intubate if
condition was felt to be reversible with the condition of
extubating after three to five days. Suggested on further
admission that the topic of intubation status be addressed
with the patient in the context of her presentation at that
time.
DISCHARGE STATUS: To pulmonary rehabilitation.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Chronic obstructive pulmonary disease exacerbation.
3. Anxiety.
DISCHARGE MEDICATIONS: Albuterol and Atrovent nebulizers qid
and prn, prednisone 20 mg po q day times five days, then 10
mg po times three days, then stop, levofloxacin 500 mg po q
day times seven more days, Ativan 0.5 mg po bid and prn for
anxiety, Milk of Magnesia 30 mL po prn, omeprazole 20 mg po q
day, multivitamin one tablet po q day, guaifenesin 400 mg q
four to six hours prn cough, Boost with meals, Santyl
ointment [**1-17**] inch to left leg ulcer q day with dry sterile
dressing changes, Flovent 220 mcg six puffs [**Hospital1 **], Atrovent
four puffs qid, Serevent two puffs [**Hospital1 **], Albuterol two puffs q
four hours prn, nasal cannula O2 at two liters, [**Male First Name (un) **]
compression stockings to bilateral lower extremities.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2124-12-7**] 07:45
T: [**2124-12-7**] 08:42
JOB#: [**Job Number 18921**]
Admission Date: [**2124-11-30**] Discharge Date: [**2124-12-7**]
Date of Birth: [**2050-11-25**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a 74 -year-old
woman with a history of severe O2 dependent chronic
obstructive pulmonary disease (FEV1 0.65), recurrent
pneumonia, who transferred from [**Hospital **] Hospital for further
evaluation and treatment of a chronic obstructive pulmonary
disease pneumonia. The patient was recently admitted to this
hospital on [**8-1**] with a right lower lobe pneumonia and
she was treated with azithromycin, ceftriaxone, and then
discharged home on Ceftin. A follow up chest x-ray in the
morning showed resolution of this right lower lobe pneumonia,
but the patient continued to have sputum production, so she
was treated with one week of Levaquin. The patient was also
subsequently on dicloxacillin for a non-healing wound on her
left leg and left lower extremity cellulitis.
The patient was doing quite well until the evening prior to
admission when she developed sudden onset of chills, fever,
and shortness of breath and vomiting. The patient described
that she could not fill her lungs with air. She complains of
only minimal cough which is productive of yellow sputum. She
denies hemoptysis and chest pain. The patient took her
metered dose inhalers without improvement, then called her
visiting nurse, who had her taken to [**Hospital **] Hospital.
At [**Location (un) **], her temperature was 101.6 F and her white blood
cell count was 30. Chest x-ray showed a left lower lobe
infiltrate. She was given 125 mg of IV Solu-Medrol and a
dose of cefuroxime and Biaxin, as well as Albuterol
nebulizers. The patient was referred to [**Hospital3 **] -
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] at the request of the family and
patient.
At baseline, the patient does a treadmill for thirty minutes
a day with four liters of O2. She has baseline orthopnea and
occasional paroxysmal nocturnal dyspnea, but denies recent
worsening of these symptoms. She had recently been on Lasix
for increased shortness of breath and lower extremity edema,
but this was recently discontinued. She denies sick contacts
or travel.
REVIEW OF SYSTEMS: No nausea, positive vomiting, no
abdominal pain. No urinary symptoms. No headaches or visual
changes. She complains of post nasal drip.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease - O2 dependent,
baseline two liters with saturations from 95% to 96%. In
[**2121**] she required prolonged mechanical ventilation /
tracheostomy, which was subsequently reversed. She has a
history of frequent pneumonias, the last pneumonia was [**8-9**].
Last steroid use was in [**Month (only) 359**]. Pulmonary function test
from [**2124-10-19**]: FEV1 0.65 (35%), FEC 2.15 (81%), ratio 43%.
The patient also with a history of bronchiectasis by chest CT
scan.
2. Anxiety.
3. Osteoporosis.
4. Urge incontinence.
5. Gastroesophageal reflux disease.
6. Status post total abdominal hysterectomy.
ALLERGIES: No known drug allergies.
ADMITTING MEDICATIONS: Prilosec 20 mg once a day, Premarin
0.625 mg once a day, Ativan 0.5 mg [**Hospital1 **] and prn anxiety,
multivitamin one a day, Flovent 220 mcg six puffs [**Hospital1 **],
Atrovent four puffs qid, Serevent two puffs [**Hospital1 **], Albuterol
two puffs q four hours prn.
SOCIAL HISTORY: The patient lives with her husband in a
retirement community. Her son is Dr. [**First Name8 (NamePattern2) **] [**Known lastname 18920**]. She
smoked one pack a day for forty years, but quit twenty years
ago. She denies alcohol use or drug use.
PHYSICAL EXAMINATION: On admission, temperature 98.8 F,
blood pressure 116/70, pulse 100, respiratory rate 28, O2
saturation 95% on three liters. General appearance: the
patient is a thin, elderly woman with tachypnea and shortness
of breath, with approximately five word sentences. Head,
eyes, ears, nose, and throat: Pupils are equal, round, and
reactive to light, sclerae anicteric, oropharynx clear, and
noticeable use of accessory muscles for breathing. Neck: no
lymphadenopathy, no jugular venous distention, supple.
Respiratory: decreased breath sounds with left basilar
crackles and rhonchi, positive egophony in the left lower
lobe. Her I/E ratio is approximately 1:3 without wheezes.
Cardiovascular: tachycardic, regular rhythm, normal S1, S2,
no murmurs, rubs, or gallops. Abdomen: bowel sounds present,
abdomen is soft and nontender, nondistended, with no
hepatosplenomegaly. Extremities: 1+ edema in the left lower
extremity with 1.0-2.0 cm ulcer with granulation tissue at
the base without surrounding erythema or cellulitic changes.
Neurologic: alert and oriented times three, cranial nerves II
through XII intact. Strength and sensation grossly intact.
ADMISSION LABORATORY DATA: White count 42, hematocrit 38,
platelets 297,000. Sodium 138, potassium 3.9, chloride 99,
CO2 25, BUN 12, creatinine 0.5, glucose 132. Arterial blood
gas: 7.43 / 41 / 61, saturating 92% on two liters nasal
cannula. Calcium 8.7, phosphorus 2.8, magnesium 1.2.
Chest x-ray showed left lower lobe infiltrate, hyperexpanded
lungs, and air bronchogram. Electrocardiogram was without
change from prior electrocardiogram from [**Month (only) 216**].
HOSPITAL COURSE:
1. Pulmonary: Pneumonia - the patient was admitted for a
left lower lobe pneumonia as evidenced upon x-ray and
examination. She was treated with Levaquin 500 mg once a day
to which she responded. She was also treated with chest
physical therapy, suction, and Albuterol and Atrovent
nebulizers q two to four hours prn.
Chronic obstructive pulmonary disease - on admission, the
patient had an increased O2 requirement from her baseline,
poor air movement, tachypnea, and increased work of
breathing. Her initial saturations were about 92% on three
liters. She was treated with a second dose of IV Solu-Medrol
125 mg and then 100 mg q eight hours times one day, and then
a prednisone taper.
On hospital day two in the evening, the patient required
transfer to the Intensive Care Unit for noninvasive pressure
ventilation due to patient tiring. The patient tolerated
this well with improved O2 saturations. She was transferred
back to the regular floor on hospital day five. The
prednisone taper was continued, as was Levaquin. The patient
continued to improve back to her baseline O2 requirement of
approximately two liters at rest. However, she continued to
have decreased exercise tolerance.
It was felt that the patient would benefit from pulmonary
rehabilitation due to the frequency of her recent pulmonary
infections and her decreased exercise capacity. The patient
also continued to have a bronchospastic cough, but had
resolution of pneumonia. The patient will be continued on
Levaquin for a fourteen day course and a steroid taper.
2. Fluids, electrolytes, and nutrition: The patient had
decreased po intake during the first part of her
hospitalization. She was started on Boost with meals to
supplement her intake. She also took a multivitamin once a
day.
3. Skin: On admission, the patient had a 1.0-2.0 cm ulcer
on her left lower extremity. Treatment with Santyl ointment
and dry sterile dressing changes were continued. The patient
underwent evaluation by wound care nurse who recommended
continuation of the Santyl ointment as well as [**Male First Name (un) **]
compression stockings to bilateral lower extremities.
CODE STATUS: The patient was initially do not resuscitate /
do not intubate on admission. However, after successful
treatment with noninvasive pressure ventilation, the patient
changed her status to do not resuscitate with intubate if
condition was felt to be reversible with the condition of
extubating after three to five days. Suggested on further
admission that the topic of intubation status be addressed
with the patient in the context of her presentation at that
time.
DISCHARGE STATUS: To pulmonary rehabilitation.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Chronic obstructive pulmonary disease exacerbation.
3. Anxiety.
DISCHARGE MEDICATIONS: Albuterol and Atrovent nebulizers qid
and prn, prednisone 20 mg po q day times five days, then 10
mg po times three days, then stop, levofloxacin 500 mg po q
day times seven more days, Ativan 0.5 mg po bid and prn for
anxiety, Milk of Magnesia 30 mL po prn, omeprazole 20 mg po q
day, multivitamin one tablet po q day, guaifenesin 400 mg q
four to six hours prn cough, Boost with meals, Santyl
ointment [**1-17**] inch to left leg ulcer q day with dry sterile
dressing changes, Flovent 220 mcg six puffs [**Hospital1 **], Atrovent
four puffs qid, Serevent two puffs [**Hospital1 **], Albuterol two puffs q
four hours prn, nasal cannula O2 at two liters, [**Male First Name (un) **]
compression stockings to bilateral lower extremities.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2124-12-7**] 07:45
T: [**2124-12-7**] 08:42
JOB#: [**Job Number 18921**]
|
[
"491.21",
"733.00",
"707.12",
"486",
"300.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
17205, 17290
|
17314, 18328
|
14501, 17184
|
12851, 14484
|
11419, 11559
|
9332, 11399
|
11581, 12562
|
12579, 12828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,425
| 174,834
|
7301
|
Discharge summary
|
report
|
Admission Date: [**2110-10-8**] Discharge Date: [**2110-10-27**]
Date of Birth: [**2054-1-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Shortness of Breath/Dyspnea on exertion
Major Surgical or Invasive Procedure:
Tracheostomy
PEG placement
Central line placement - right subclavian
Arterial line placement
PICC line placement
History of Present Illness:
This 56 year old female with history of interstitial pulmonary
fibrosis on 2L home O2 chronically presents with cough and chest
pain. She stated that the cough and chest pain began one week
prior. She also reported some nasal congestion and fevers. Her
cough was productive of green sputum and was accompanied by
right sided sub sternal chest pain. The pain is intermittent in
nature, sharp, it doesn't radiate. She reported no sick
contacts, no hemoptysis. No abdominal pain, no N/V/D. Her
daughter said that she was sick last weekend, felt a little
better over the weekend, sounded a lot better the day prior to
admission. She presented to [**Company 191**] where she was seen by Dr.
[**Last Name (STitle) 1538**] and was found to have decreased O2 sats, she was sent
to the ED for evaluation.
At baseline she is on home O2 2L, 3-4 liters at night. In the
ED she was found to have decreased BS at the bases with wheezes.
Her CXR showed rt pleural effusion, ? of pneumonia. She was
treated with combivent, solumedrol, Ceftazadime, and Zithromax.
She was reassessed and found to be somnolent, tachypneic with
very little air movement. The decission was made to intubate
her based upon these symptoms and she was intubated. A chest CT
was performed and she was transferred to the MICU.
Past Medical History:
1. Pulmonary fibrosis thought [**2-5**] old Tb (on right side), on 2L
O2 at home at baseline, unchanged x 5 yrs
2. Pulmonary HTN
3. Osteoporosis
4. DJD R knee
5. Thalassemia trait
6. Depression
7. Anemia
8. Tuberculosis, treated in [**2079**] and [**2081**] x 6 months
9. Attention deficit disorder
10. Hx pseudomonal pna [**2104**], requiring intubation x 3 weeks
Social History:
No EtOH, no tobacco
Lives in [**Hospital1 **], on disability
Family History:
Mother died of colon CA
Physical Exam:
Vitals Temp 99.5, HR 90, BP 102/57, RR 38, sat 98% on A/C
400X18, FIO2 100%, PEEP 5
Gen: sedated, intubated female in NAD
HEENT: PERRL, MMM, OP with ET tube in place
Neck: no JVD, no lymphadenopathy
Lungs: diffuse rhonchi, more air movement on left than right,
also with intermittent wheezes
CV: RRR, nl S1S2, no murmers
Abd: soft, NT, ND, positive BS
Ext: no edema
Skin: no rashes
Pertinent Results:
Admission Labs:
[**2110-10-8**] 01:45PM WBC-10.0# RBC-3.45* HGB-10.3* HCT-33.2*
MCV-96 MCH-29.8 MCHC-31.0 RDW-13.0
[**2110-10-8**] 01:45PM NEUTS-84.4* BANDS-0 LYMPHS-7.9* MONOS-7.1
EOS-0.4 BASOS-0.3
[**2110-10-8**] 01:45PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2110-10-8**] 01:45PM PLT SMR-NORMAL PLT COUNT-167
[**2110-10-8**] 01:45PM PT-14.3* PTT-27.3 INR(PT)-1.4
[**2110-10-8**] 06:39PM TYPE-ART TEMP-34.8 RATES-15/0 TIDAL VOL-450
PEEP-8 O2-100 PO2-489* PCO2-62* PH-7.48* TOTAL CO2-47* BASE
XS-19 AADO2-187 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED
[**2110-10-8**] 06:39PM O2 SAT-98
[**2110-10-8**] 01:48PM LACTATE-0.8
[**2110-10-8**] 01:45PM GLUCOSE-123* UREA N-8 CREAT-0.4 SODIUM-140
POTASSIUM-4.6 CHLORIDE-90* TOTAL CO2-44* ANION GAP-11
Additional pertinent labs/studies:
.
[**2110-10-8**] CXR: Interval increase in amount of air in the bullae
in the right hemithorax. CT recommended.
[**2110-10-8**] CT Chest: 1. Severe bronchiectasis and volume loss in
the right lung which is probably of minimal or no function.
Moderate-to-severe left lower lobe bronchiectasis slightly
improved when compared to [**9-2**] without new focal
consolidation.
2. Interval increase in right lung base bulla when compared to
the prior
study.
3. Chronic fibrotic changes with calcifications in the left
upper lobe,
likely related to prior granulomatous disease.
4. Severe, chronic pulmonary hypertension.
5. There are no pleural effusions.
6. Enlarged pulmonary arteries, likely due to pulmonary artery
hypertension.
7. In the axial images, the ET tube appears to be at the level
of the carina. Withdrawal of 1 cm should be prudent.
8. Small tracheal diverticulum.
[**2110-10-13**] ECHO: The left atrium is elongated. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Preserved global biventricular systolic function.
Compared with the prior report (tape unavailable for review) of
[**2105-4-10**], the findings are similar.
[**2110-10-13**] CXR: 1. Worsening multifocal opacities within the left
lung, most likely due to worsening multifocal pneumonia
superimposed upon chronic bronchiectasis.
2. Stable appearance of chronic bronchiectasis and volume loss
in the right lung as well as a large right lung bulla.
[**2110-10-19**] CXR: The previously identified edema in the left lung
has been increased. There is continued fibronodular opacity in
the left upper lobe as described.
[**2110-10-23**] CXR: 1) Status post tracheostomy tube placement with
interval removal of NG tube, and interval placement of a PICC.
The distal tip of the PICC is difficult to ascertain, but may
terminate in the right atrium.
2) Apparent lucency below the right hemidiaphram worrisome for
free air. This was discussed with Dr. [**Last Name (STitle) 26969**] at the time of
interpretation of the study. (Note that this was not present in
the initial preliminary report).
[**2110-10-26**] CXR: Tracheostomy tube and right PICC line remain in
place, with the PICC line terminating in the expected location
of the right atrium. There is volume loss in the right
hemithorax with collapse of majority of the right lung with
associated bronchiectasis. A large bulla is noted in the right
lower lung zone. Within the left lung, there are diffuse
bronchiectatic changes, with interval increase in
peribronchiolar opacities, particularly within the left lower
lobe. Finally, note is made of free intraperitoneal air within
the abdomen, which has decreased in severity in the interval.
.
IMPRESSION:
1. Decrease in amount of free intraperitoneal air.
2. Slight worsening of peribronchiolar opacities, especially in
the left lower lobe. This may represent progressive infection in
this patient with underlying bronchiectasis.
Discharge Labs:
.
[**2110-10-27**] 03:06AM BLOOD Hct-27.3*
[**2110-10-9**] 01:46AM BLOOD Neuts-88.9* Lymphs-7.9* Monos-3.0 Eos-0
Baso-0.1
[**2110-10-27**] 03:06AM BLOOD Glucose-122* UreaN-9 Creat-0.3* Na-139
K-3.8 Cl-98 HCO3-35* AnGap-10
[**2110-10-27**] 03:06AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.4*
Brief Hospital Course:
56 year old female with history of pulmonary fibrosis probably
from TB presenting with respiratory distress, with worsening CXR
and lung CT, intubated for respiratory support with difficulty
weaning off the vent now s/p course of levofloxacin for
Pseudomonal PNA sensitive to FQ and s/p trach.
1. Respiratory distress - On admission we considered that Mrs.
[**Known lastname 16905**] could have worsening brochiectasis vs. pneumonia with
underlying lung disease. She has relatively [**Name2 (NI) 26970**] respiratory
function at baseline due to her history of TB, pulmonary
fibrosis, and having only one functional lung. She is on 2L O2
by NC at home at baseline, with 3-4L at night, and a recent
diagnosis of OSA requring nightime BIPAP. She also has a prior
history of pseudomonal pneumonia with [**Hospital Unit Name 153**] stay a year ago
requiring intubation. On that stay she responded to Levofloxacin
and Ceftazidime and the pseudomonas was sensitive to these
antibiotics. Sputum during this hospitalization grew strep
pneumococcus and pseudomonas, both pan-sensitive. She was
initially treated with Levofloxacin and Ceftazidime until the
sensitivities returned, and then the ceftazidime was
discontinued. She completed a ten day course of levofloxacin,
with no recurrence of fevers or elevation of WBC count after
treatment was completed. CT of the chest did show worsened
bronchietasis as well. She was also treated with standing
nebulizer treatments. Initial attempts to wean the ventilator
support were moderately sucessful, and she was extubated
[**2110-10-16**]. However, she became hypercarbic with PaCO2 in the high
90's, and became more confused. Therefore she was reintubated.
Following this repeated attempts to wean the ventilatory support
were unsuccessful, with repeated hypercarbia (PaCo2 up to the
100's). Therefore on [**2110-10-23**] a tracheostomy was performed to
allow a slower wean from the ventilator. A PEG was placed at the
same time for nutritional support during her wean. Of note: she
is a CO2 retainer with baseline HCO3 of 40's. Her outpatient
pulmonologist is Dr. [**Last Name (STitle) **], and he was notified of her
admission, and updated on her course. The patient has since
completed her course of antibiotics. Although the patient
continues to look well clinically, remains afebrile without
increased secretions, a repeat chest film performed yesterday,
[**2110-10-26**], demonstrated slight worsening of peribronchioloar
opacities, especially in the left lower lobe, which was
interpreted as possibly consistent with progressive inefection.
However, as the patient looks clinically well as above, the
decision is being made to have patient continue discharge to
vent rehab without an additional course of antibiotics. She will
need to be followed closely clinically to distinquish between
colonization and true infection.
2. Cardiovascular: Mrs. [**Known lastname 16905**] [**Name (STitle) **] had some hypotensive
episodes with low urine output, and briefly required Levophed
(less than 24 hours). However, this was quickly weaned off, and
she was hemodynamically stable. On admission she had a right
subclavian TLC and an A-line placed on admission. The central
line was discontinued after approximately a week when CVP
monitoring was deemed no longer necessary, and her A-line was
changed twice - maintained to follow ABGs for ventilator
weaning. She had an ECHO which showed a normal EF and moderate
pulmonary artery systolic hypertension. Her CXR did appear to
show signs of mild failure, and she was diuresed a small amount.
This did not significantly improve her respiratory function, and
it was not felt that cardiovascular function was at the root of
her decreased respiratory function.
3. Anemia: Mrs.[**Known lastname 16906**] hematocrit is 33 at baseline. Early
in her admission she received one unit pRBCs for a hematocrit of
23.5. She raised her hematocrit appropriately to this treament,
and was stable thereafter.
4. GERD: Mrs. [**Known lastname 16905**] was continued on protonix as per her home
regimen for GERD.
5. FEN: Mrs. [**Known lastname 16905**] was NPO with tubefeeds via her OG tube,
which she tolerated well. Post placement of her PEG, she resumed
tubefeeds via her PEG. A small amount of free air was present
after her PEG placement, a common event post-PEG placement.
Thoracic surgery followed ,a nd serial abdominal exams were
benign. She was also given intermitant IV fluid boluses to
maintain urine output. However, caution was used to avoid fluid
overload as she has only one functional lung, and her CXR did
show signs of mild congestive failure, and we did not want to
worsen her respiratory status.
6. Prophylaxis: Mrs. [**Known lastname 16905**] was on subcutaneous Heparin for
DVT prophylaxis and protonix for ulcer prophylaxis.
7. Access: Mrs [**Known lastname 16905**] initially had a R SC TLC and L A-line.
The A-line was changed twice, and she was maintained with PIVs
after the central line was discontinued approximately one week
into her stay. A PICC line was placed [**2110-10-22**] for more
long-term access while she is weaning off the ventilator.
8. Mrs. [**Known lastname 16905**] is FULL code
9. Communication: We communicated frequently with Mrs. [**Known lastname 16905**]
about her progress and her plan, and talked with her daughter
[**Name (NI) 11556**] as well, who is her health care proxy. Mrs. [**Known lastname 16905**]
consented for her own procedures.
10. Dipso: Mrs. [**Known lastname 16905**] was discharged to [**Hospital3 **]
for further management of ventilatory support and
rehabilitation.
Medications on Admission:
1. Protonix
2. Fosamax
3. Combivent
4. Advair
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Midazolam 1 mg/mL Solution Sig: 1-2 mg Injection Q6H (every 6
hours) as needed for anxiety.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
10. fentanyl Sig: 12.5 mg Intravenous (only) every six (6)
hours as needed for pain.
11. Colace 150 mg/15 mL Liquid Sig: Ten (10) ml PO twice a day.
12. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]--[**Hospital1 **]
Discharge Diagnosis:
Primary:
pseudomonal pneumonia
Secondary:
Pulmonary fibrosis
Pulmonary HTN
Osteoporosis
DJD R knee
Thalassemia trait
Depression
Anemia
history of tuberculosis
Attention deficit disorder
Discharge Condition:
Stable, with tracheostomy and on ventilator PS 15/5 w/ 40% FiO2,
with PEG for nutrition (tolerating tube feeds)
Discharge Instructions:
Please notify your caregivers if you have any trouble breathing,
feel feverish, nauseated, or are vomiting, or have any other
health concern.
Followup Instructions:
Please call your primary care doctor for an appointment within
7-10 days of discharge from rehab.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **],MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2110-12-24**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2111-1-27**] 12:00
Completed by:[**2110-10-27**]
|
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"282.49",
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"137.0",
"530.81",
"715.96",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"31.1",
"46.32",
"38.93",
"96.72",
"96.6",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14167, 14228
|
7444, 13060
|
356, 471
|
14459, 14573
|
2727, 2727
|
14763, 15170
|
2284, 2309
|
13156, 14144
|
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|
13086, 13133
|
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|
7138, 7421
|
2324, 2708
|
277, 318
|
499, 1801
|
2743, 7122
|
1823, 2189
|
2205, 2268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,949
| 107,589
|
7792
|
Discharge summary
|
report
|
Admission Date: [**2163-12-8**] Discharge Date: [**2163-12-16**]
Date of Birth: [**2102-12-3**] Sex: F
Service: MEDICINE
Allergies:
Nickel / Aspirin / Plavix
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
abdominal pain and weakness
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is a 61-yo woman with PMHx of PUD, diverticulitis, s/p CCY,
CAD s/p CABG, DM2, PVD, intestinal vascular insufficiency,
chronic kidney disease, presenting with weakness and abdominal
pain. She had been having left-sided abdominal pain since Friday
and had not been able to eat or drink anything. Pain was similar
to the diverticulitis and ulcer pain that she has had in the
past, which she described as crampy and waxing / [**Doctor Last Name 688**]. The
pain then developed into constant peri-umbilical and epigastric
pain. She had also been feeling very weak, lightheaded, and
confused, with multiple falls at home. She noted some nausea and
loose stools, and a dark bowel movement at home, but denied any
subjective fevers. She is currently being treated with Bactrim
for a left middle toe infection.
.
In the ED at OSH: VS - Temp 95F, SBP 60s. Labs significant for
WBC >40, K 7.5, Cr 5.0 (baseline 1.3), and elevated LFTs (ALT
114, AST 163, Alk Phos 158, T.Bili 0.1), amylase (382), lipase
(1665), and lactic acid (6.7). CVL was placed, she was
resuscitated with 4L crystalloid and started on Levophed.
Hyperkalemia was treated with Calcium gluconate, Kayexelate,
Dextrose, and Insulin. CT Abd/Plv showed early pericolonic
inflammatory changes [**1-14**] diverticular disease without abscess
formation in the rectosigmoid, and associated small bowel ileus.
RUQ US was done to eval for cholangitis, which showed dilated
extrahepatic bile ducts (12mm). The patient was started on
Levofloxacin, Flagyl, and Zosyn, and admitted to the SICU
(again, still at the OSH). In the SICU, she improved and was
able to be weaned off pressors. She was evaluated by GI, who
felt that ERCP would be necessary given the suspicion of
gallstone pancreatitis and ascending cholangitis. She was
further stabilized and was transferred to [**Hospital1 18**] for ERCP.
.
On arrival to the floor, the pt was hypotensive and lethargic.
She had been given Dilaudid just prior to transfer, so her
pressures initially responded to fluids, but she then developed
atrial fibrillation with rapid ventricular response and she
became hypotensive again. She was given fluids and started on
Neosynephrine and Diltiazem drips for stabilization after she
did not respond to metoprolol or digoxin. She was then
transitioned to Amiodarone for her atrial fibrillation, and
transiently required both Neosynephrine and Levophed pressors
for hypotension. After discussion with the ERCP team, the
Surgical consult team, and referring SICU team at [**Hospital3 **], it was determined that the patient was at risk for
ischemic colitis and would be treated as such.
Past Medical History:
Hypothyroidism
Hypertension
Diabetes Mellitus Type II, c/b neuropathy
Hyperlipidemia
Hypertensive cardiomyopathy
Coronary artery disease s/p CABG [**2154**]
h/o V-fib arrest s/p pacemaker/AICD placement [**2154**]
h/o Atrial fibrillation
Peripheral vascular disease
Mitral valve disorder
Gastritis
Duodenal ulcer [**2-17**] despite being on high-dose PPI
Gastroparesis
Diverticulitis
Intestinal vascular insufficiency
Chronic kidney disease (baseline 1.3)
Hydronephrosis
Iron-deficiency anemia
s/p AAA repair / aorto-bifemoral bypass grafting
s/p Right Fem-[**Doctor Last Name **] Bypass
s/p Left Fem-[**Doctor Last Name **] Bypass
s/p Cholecystectomy
s/p Hysterectomy
Arthropathy
Social History:
Lives at home with husband, non-[**Name2 (NI) 1818**], denies EtOH.
Family History:
Non-contributory
Physical Exam:
On arrival to MICU:
VS - Temp 97.2F, BP 103/44, HR 102, R 28, O2-sat 91% 4L NC, Ht
5'2", Wt 250lbs
GENERAL - ill-appearing woman, appears uncomfortable
HEENT - NC/AT, PERRL, sclerae anicteric, dry MM
NECK - supple, unable to assess JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - decreased BS, soft/obese, +TTP over left abdomen and
epigastrium, +guarding, no rebound, unable to assess for
organomegaly
EXTREMITIES - WWP, no c/c/e, faint Dopplerable peripheral pulses
(radials, DPs)
NEURO - lethargic, somewhat responsive, MAE although weak
Pertinent Results:
[**2163-12-8**] 11:55AM ALT(SGPT)-125* AST(SGOT)-176* LD(LDH)-310*
CK(CPK)-1305* ALK PHOS-127* AMYLASE-63 TOT BILI-0.2
[**2163-12-8**] 11:55AM LIPASE-26
.
[**2163-12-8**] 09:01PM ALT(SGPT)-137* AST(SGOT)-235* LD(LDH)-356*
CK(CPK)-3298* ALK PHOS-124* AMYLASE-37 TOT BILI-0.2
.
[**2163-12-8**] 11:55AM WBC-31.7* RBC-3.23* HGB-8.7* HCT-27.7* MCV-86
MCH-27.0 MCHC-31.5 RDW-15.7*
[**2163-12-8**] 11:55AM NEUTS-73* BANDS-22* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2163-12-8**] 11:55AM PT-17.9* PTT-33.3 INR(PT)-1.6*
[**2163-12-8**] 11:55AM FIBRINOGE-746* D-DIMER-4921*
[**2163-12-8**] 11:55AM CK-MB-23* MB INDX-1.8 cTropnT-<0.01
[**2163-12-8**] 11:55AM GLUCOSE-183* UREA N-53* CREAT-2.3*
SODIUM-148* POTASSIUM-3.7 CHLORIDE-120* TOTAL CO2-16* ANION
GAP-16
.
[**2163-12-8**] 05:57PM LACTATE-2.5*
[**2163-12-8**] 09:01PM WBC-39.0* RBC-3.40* HGB-9.2* HCT-28.8* MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9*
[**2163-12-8**] 09:01PM NEUTS-93* BANDS-4 LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2163-12-8**] 09:01PM CORTISOL-51.8*
[**2163-12-8**] 10:00PM CORTISOL-53.1*
[**2163-12-8**] 10:38PM CORTISOL-52.9*
.
[**2163-12-8**] 03:20PM TYPE-ART PO2-102 PCO2-35 PH-7.28* TOTAL
CO2-17* BASE XS--9
[**2163-12-8**] 09:20PM TYPE-ART TEMP-37.2 RATES-[**11-24**] TIDAL VOL-550
PEEP-5 O2-50 PO2-110* PCO2-33* PH-7.29* TOTAL CO2-17* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2163-12-14**] 7:34 am SWAB Source: L 3rd toe.
GRAM STAIN (Final [**2163-12-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
#. Sepsis -
When pt arrived, appeared to have septic picture but resolved
during stay and by the time of her ERCP she was afebrile, stable
hemodynamics, and without elevated white count. She had been on
Zosyn, PO Vanc and Flagyl, with the latter two being for concern
for C. diff, and the former being coverage for bowel organisms
because of a high suspicion for diverticulitis as the source.
She was C. diff negative x3 now, and had relatively small amount
of stool output, and her white count is stable. She did have a
positive UA at the OSH as well as chronic hydronephrosis. We
discontinued Vancomycin and Flagyl, which had been covering C.
diff. We continued Zosyn for coverage of GI/GU organisms given
earlier septic presentation; although we do not have clear
evidence for what we are treating it is reasonable to think we
have treated something given her clinical course.
.
#. Altered mental status -
Pt presented from OSH lethargic and hypotensive, in the setting
of initial concern for infection / sepsis as described above. By
the time of ERCP she was able to express her dissatisfaction
with her circumstances but in a focused and oriented manner, and
was certainly interactive. This issue appeared to be resolving
or resolved.
.
#. Atrial fibrillation with rapid ventricular response -
After amiodarone loading she eventually remained in sinus. She
should go down to maintenance dose starting [**2162-12-16**]. She remains
stable but given rapid RVR, she may be best served by tele on
the floor for wherever she is transferred.
.
#. Acute on chronic renal failure - Pt with known h/o chronic
kidney disease, baseline Cr 1.3 per OSH records. On arrival to
OSH, the Cr wa 5.0 but recovered to baseline (~1.2). Original
insult was likely pre-renal given sepsis / hypotension. Pt has
known history of hydronephrosis, presumed to be contributing to
her chronic kidney disease, and likely due to fibrotic
post-surgical changes in her abdomen from her numerous vascular
surgeries. We hydrated and avoided nephrotoxins, apparently to
good effect.
.
#. Pancreatitis - The patient was noted to have elevated amylase
and lipase at OSH as evidence of pancreatitis, but on admission
did not have any evidence on CT-scan. Pancreatic enzymes were
trending down and were normal by arrival at [**Hospital1 18**]. However, they
were then increasing theraafter, while [**Hospital1 **] resolved
while pancreatic enzymes were continuing to increase. This was
consistent with an evolving blockage and ERCP was performed and
included stone removal. A summary description of the procedure
was as follows: "Biliary dilation was noted. Given h/o gallstone
pancreatitis and acute cholangitis, a biliary sphincterotomy was
performed. Moderate dilation of pancreatic duct in the head of
the pancreas was noted. (Sphincterotomy, stone extraction.)"
.
#. [**Name (NI) 5779**] - Pt noted to have a [**Name (NI) **] at OSH,
which has since resolved here. Original elevation in AST > ALT,
suggestive of alcohol as a possible cause of [**Name (NI) **] and
pancreatitis; however this would not entirely explain resolution
of [**Name (NI) **] with increase in pancreatitis. More likely this
has been an evolving blockage, perhaps from a migrating stone or
transient contractions/strictures. This should continue to be
followed.
.
#. GI bleeding - By the time of transfer there was no current
evidence for GI bleed; C diff and ischemic colitis were in
differential as well for guiaic-positive diarrhea, but C diff
was negative and clinical course was not consistent with
worsening ischemic colitis. A rectal tube continued to drain
liquid stool.
.
#. Coagulopathy - Pt was noted to have elevated INR to 3.0 at
the OSH, INR down to 1.7 on arrival, and was continuing to
decline. This may be secondary to temporary liver function
decline, now resolving; or from sepsis earlier in her course.
Should be continued to be followed.
.
#. Toe infection. Arrived with 3rd toe infection of L foot.
Podiatry saw, noted that they further debrided the HPK, tract
probed to bone, applied W-D dressing to toe. They recommended
that she will need ulcer excision and removal of distal phalanx
when stable. Her wound culture is pending as of this dictation
but it appears to be growing coag + staph aurues. She will be
discharged to [**Hospital3 2568**] on zosyn and vancomycin. A vancomycin
level should be checked in 3 days given her previous ARF. She
will need podiatry follow-up after transfer; we deferred this
given her other issues and imminent transfer.
#. Diabetes mellitus type II - We kept her on ISS and QACHS
fingersticks. Her glucose control was evolving given times on
and off NPO and likely her scales will need to be adjusted
further.
.
#. Hypothyroidism - Pt maintained on PO levothyroxine as
outpatient. We continued IV levothyroxine maintenance.
.
#. FEN - NPO, IVF, replete lytes PRN
.
#. Access - LIJ, A-line [**12-8**]. We had kept A-line because of
some difficulty getting blood pressures earlier; this seems to
have resolved and if she continues to have uneventful post-ERCP
course this should be able to be pulled.
.
#. PPx - venodynes, no heparin because of GI bleeding though if
course continues well, could revisit this; no bowel regimen
given diarrhea but if stool output continues to reduce in
quantity could consider gentle restart.
.
#. Code - FULL CODE
.
#. Dispo - to [**Hospital3 2568**] (pt requesting transfer).
.
#. IMPORTANT FOLLOW-UP NOTES
-- if continued on amiodarone will need PFTs
-- continue Zosyn for total of [**9-25**] days
-- -- needs podiatry follow-up
Medications on Admission:
HOME MEDICATIONS:
Cymbalta 60mg daily
Lyrica 100mg TID
Avapro 300mg [**Hospital1 **]
Aldactone 25mg [**Hospital1 **]
Zetia 10mg daily
Crestor 40mg daily
Levothyroxine 200mcg daily
Folate 1mg daily
Lasix 40mg daily
Omeprazole 40mg ACB
Prilosec 20mg AD
Bactrim DS [**Hospital1 **]
.
Tx Meds
Levothyroxine Sodium 200 mcg PO DAILY
Acetaminophen (Liquid) 650 mg PO Q6H:PRN
Lidocaine Viscous 2% 20 ml PO TID:PRN perianal pain
Amiodarone 200 mg PO BID Duration: 7 Days Start: In am
Metoprolol 12.5 mg PO TID
Desitin 1 Appl TP PRN
Miconazole Powder 2% 1 Appl TP TID:PRN
Haloperidol 0.5 mg IV Q4H:PRN agitation
OxycoDONE Liquid 5 mg PO Q4H PRN
Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain
Pantoprazole 40 mg PO Q24H
Insulin SC (per Insulin Flowsheet)
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Discharge Disposition:
Extended Care
Facility:
Mt. [**Hospital 28202**] Hospital
Discharge Diagnosis:
Pancreatitis/[**Hospital **]
Discharge Condition:
Stable
|
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icd9cm
|
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icd9pcs
|
[
[
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12561, 12621
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6157, 11725
|
315, 321
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12693, 12702
|
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3695, 3764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,476
| 154,615
|
50458
|
Discharge summary
|
report
|
Admission Date: [**2107-3-6**] Discharge Date: [**2107-3-17**]
Date of Birth: [**2028-12-15**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Penicillins / Percocet / Meropenem / Ativan /
Depakote
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Lethargy/SOB
Major Surgical or Invasive Procedure:
PICC line placement
G-Tube placement
History of Present Illness:
Ms. [**Known lastname 8320**] is a 78 year old woman with a history of HTN and PVD
s/p CVA (unclear deficits), bipolar who presents after mental
status changes, anorexia, & progressive lethargy. Per her
physician referral, the patient was not eating or drinking at
her NH and was found to be lethargic and poorly responsive with
oxygen saturations in the upper 80's on room air. There was some
concern that was dehydrated. She was then brought to the
emergency room. Initial ED VS, initial vital signs were: T 97.5,
HR 115, BP 133/79, RR 18, POx 95 O2 sat (unclear O2), hypoxic to
77 on RA. Physical exam notable for clear lung sounds on
inspiration with upper airway noise on expiration with decreased
BS in bases. Patient was placed on NRB. Per ED resident, he
confirmed DNR/DNI w/ patient. Mental status worsened. She then
got a head CT, this showed no ICH. ABG 7.14/119/252. NRB was
removed and mental status improved. She was then placed on BIPAP
but reportedly did not tolerate well, was only getting in about
150cc Vt. Per ED resident, she was fairly lethargic the whole
time but not requiring sternal rub to become alert. CXR with
infiltrates vs consolidation at the bases. Also with decreased
breath sounds at the bases. Both Pen/Cipro allergic so getting
Vanc/Cefepime/Gent. VS on transfer 96.7, 100, 140/80, 24 and
86%/4L.
.
On the floor, patient with BiPAP in place. Wakens to loud voice.
Denies any pain or localizing symptom. Breathing mildly
difficult. Agrees that she does not want to be intubated or
resuscitated.
.
Review of sytems:
(+) Per HPI
(-) Minimally able to obtain given BiPAP. Patient denies fever,
chills or localizing pain. No recent dysuria.
Past Medical History:
Peripheral vascular disease
Hypertension
Bipolar disorder
s/p CVA (details unknown)
Degenerative joint disease
Obesity
Diverticulosis
Lower GI bleed, [**2104**]
Renal insufficiency
Incontinence
S/p tracheostomy in [**4-/2096**] [**2-1**] incarcerated hernia repair and
failure to wean
Venous stasis changes in LE b/l (Incanthosis)
Social History:
She is divorced. She lives in an [**Hospital3 **] facility. She
has no history of tobacco use. She drinks alcohol socially.
Family History:
Her mother died of a myocardial infaraction at age 63. Her
father died of cancer of unclear type. There is no family
history of colon cancer per patient.
Physical Exam:
Vitals: T: 95.5 BP: 180/96 P: 79 R: 18 O2: FIO2 35%, PSV 12/PEEP
8
General: Sedated, awakens to loud voice, nodding yes and no.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
[**2107-3-6**] 03:45PM BLOOD WBC-5.5 RBC-5.57*# Hgb-15.0# Hct-49.9*#
MCV-90 MCH-26.9* MCHC-30.0* RDW-15.6* Plt Ct-153
[**2107-3-6**] 03:45PM BLOOD Neuts-58.3 Lymphs-27.3 Monos-8.5 Eos-1.7
Baso-4.2*
[**2107-3-6**] 03:45PM BLOOD Plt Ct-153
[**2107-3-6**] 03:45PM BLOOD Glucose-97 UreaN-21* Creat-0.7 Na-142
K-6.9* Cl-97 HCO3-38* AnGap-14
[**2107-3-6**] 03:45PM BLOOD ALT-14 AST-68* LD(LDH)-812* CK(CPK)-116
AlkPhos-57 TotBili-0.3
[**2107-3-6**] 03:45PM BLOOD CK-MB-5 cTropnT-0.04* proBNP-1704*
[**2107-3-6**] 03:45PM BLOOD Albumin-3.9 Calcium-9.2 Phos-5.0* Mg-2.3
[**2107-3-6**] 05:52PM BLOOD Type-ART pO2-252* pCO2-119* pH-7.14*
calTCO2-43* Base XS-6 Intubat-NOT INTUBA
[**2107-3-6**] 03:55PM BLOOD Glucose-98 Lactate-1.1 K-6.7*
[**2107-3-6**] 09:32PM BLOOD Hgb-14.7 calcHCT-44 O2 Sat-89
[**2107-3-6**] 09:32PM BLOOD freeCa-1.21
[**2107-3-6**] 04:25PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.021
[**2107-3-6**] 04:25PM URINE Blood-LG Nitrite-POS Protein-150
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2107-3-6**] 04:25PM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-NONE
Epi-[**3-4**]
[**2107-3-7**] 05:49AM BLOOD Valproa-21*
BLOOD GASES:
[**2107-3-6**] 05:52PM BLOOD Type-ART pO2-252* pCO2-119* pH-7.14*
calTCO2-43* Base XS-6 Intubat-NOT INTUBA
[**2107-3-6**] 06:45PM BLOOD Type-ART O2 Flow-5 pO2-73* pCO2-114*
pH-7.18* calTCO2-45* Base XS-9 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2107-3-6**] 08:42PM BLOOD Type-ART O2 Flow-10 pO2-75* pCO2-121*
pH-7.11* calTCO2-41* Base XS-4 Intubat-NOT INTUBA
Comment-NEBULIZER
[**2107-3-6**] 09:32PM BLOOD Type-ART pO2-66* pCO2-100* pH-7.17*
calTCO2-38* Base XS-4
[**2107-3-7**] 05:50AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-95* pH-7.24*
calTCO2-43* Base XS-8
[**2107-3-7**] 02:36PM BLOOD Type-[**Last Name (un) **] Temp-36.7 FiO2-40 pO2-63*
pCO2-65* pH-7.21* calTCO2-27 Base XS--3 Intubat-NOT INTUBA
[**2107-3-7**] 05:17PM BLOOD Type-ART pO2-57* pCO2-107* pH-7.18*
calTCO2-42* Base XS-7 Intubat-NOT INTUBA
[**2107-3-7**] 07:15PM BLOOD Type-ART Rates-/26 PEEP-5 FiO2-35 pO2-62*
pCO2-78* pH-7.29* calTCO2-39* Base XS-7 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2107-3-7**] 11:18PM BLOOD Type-ART pO2-68* pCO2-87* pH-7.22*
calTCO2-38* Base XS-4
[**2107-3-8**] 02:28AM BLOOD Type-ART pO2-67* pCO2-77* pH-7.32*
calTCO2-42* Base XS-9
[**2107-3-8**] 10:46AM BLOOD Type-ART FiO2-50 pO2-61* pCO2-77*
pH-7.28* calTCO2-38* Base XS-5 Intubat-NOT INTUBA
[**2107-3-8**] 03:51PM BLOOD Type-ART Temp-36.4 O2 Flow-50 pO2-75*
pCO2-91* pH-7.27* calTCO2-44* Base XS-10 Intubat-NOT INTUBA
Comment-SIMPLE FAC
[**2107-3-8**] 06:35PM BLOOD Type-ART Temp-36.1 Tidal V-260 FiO2-35
pO2-64* pCO2-65* pH-7.35 calTCO2-37* Base XS-6 Intubat-NOT
INTUBA
[**2107-3-9**] 02:24AM BLOOD Type-ART pO2-78* pCO2-68* pH-7.33*
calTCO2-37* Base XS-6
[**2107-3-9**] 12:43PM BLOOD Type-ART pO2-95 pCO2-86* pH-7.14*
calTCO2-31* Base XS--2
[**2107-3-9**] 11:06PM BLOOD Type-ART Temp-35.5 Rates-/27 Tidal V-250
PEEP-8 FiO2-35 pO2-64* pCO2-70* pH-7.32* calTCO2-38* Base XS-6
Intubat-NOT INTUBA Vent-SPONTANEOU
[**2107-3-10**] 08:16AM BLOOD Type-CENTRAL VE Temp-36.9 Rates-/23
PEEP-8 FiO2-35 pO2-46* pCO2-63* pH-7.35 calTCO2-36* Base XS-6
Intubat-NOT INTUBA Vent-SPONTANEOU Comment-PS 12
[**2107-3-10**] 06:13PM BLOOD Type-CENTRAL VE Temp-36.5 Rates-/28
FiO2-35 pO2-54* pCO2-81* pH-7.29* calTCO2-41* Base XS-9
Intubat-NOT INTUBA Vent-SPONTANEOU Comment-COOL MIST
[**2107-3-11**] 04:47AM BLOOD Type-ART pO2-79* pCO2-67* pH-7.39
calTCO2-42* Base XS-11
[**2107-3-11**] 01:01PM BLOOD Type-ART pO2-92 pCO2-105* pH-7.17*
calTCO2-40* Base XS-5
[**2107-3-11**] 02:53PM BLOOD Type-ART pO2-89 pCO2-81* pH-7.32*
calTCO2-44* Base XS-11
[**2107-3-12**] 03:27AM BLOOD Type-ART pO2-79* pCO2-72* pH-7.32*
calTCO2-39* Base XS-7
[**2107-3-12**] 06:53AM BLOOD Type-ART pO2-86 pCO2-78* pH-7.32*
calTCO2-42* Base XS-9
[**2107-3-13**] 04:03AM BLOOD Type-ART Temp-36.4 pO2-79* pCO2-73*
pH-7.33* calTCO2-40* Base XS-8
LABS ON DISCHARGE:
MICRO:
[**2107-3-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2107-3-9**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2107-3-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST} INPATIENT
[**2107-3-7**] URINE URINE CULTURE-FINAL INPATIENT
[**2107-3-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2107-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2107-3-6**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
AMMONIA LEVELS
[**2107-3-8**] 02:13AM BLOOD Ammonia-122*
[**2107-3-11**] 04:29AM BLOOD Ammonia-26
Brief Hospital Course:
78F HTN, CVA c R hemiplegia, PVD, bipolar d/o admitted with
acute-on-chronic hypercarbic respiratory failure and probable
UTI, PNA with increasingly productive cough, on NPPV much of the
time.
# Hypercarbic Respiratory Failure: Multifactorial, acute on
chronic. Chronic hypercarbia at baseline (baseline HCO3 ~30)
with contributions from COPD, OSA and likely OHS. Acute
component of respiratory failure due to primarily to aspiration
pneumonia. No evidence of PE on CTA. Fluid status difficult to
assess but appears to not have been significant driver of
respiratory failure. Patient with history of difficulty weaning
with a prior tracheostomy in [**2095**] in the setting of an
incarcerated hernia repair and failure to wean.
# PNA, Aspiration:
-Treated with course of linezolid and aztreonam.
# Nutritional Status: Failed repeat speech and swallow
evaluations including a video eval. Patient stated express
desire to not have any nasal or oral feeding tube, but
- f/u PEG placement with general surgery
# Lethargy/AMS: Intermittently somnolent and disoriented but
consistently arousable. Overall mental status improved across
admission. Original AMS likely multifactorial including
infectious, hypercarbic. Now resolved. High ammonia level on
admission thought [**2-1**] depakote, resolved with stopping of
medication. Overall mental status improved with improvement in
respiratory status.
- Continue Zydis; will not give Ativan.
- Continue home risperdal dose given occasional anxiety
- Continue to hold depakote given MS changes and elevated
ammonia level
- DC ativan and added to allergy list
# Atrial Fibrilation: new AF v. PACs on [**3-10**] on telemetry
although not captured on EKG. No history of AF per
documentation. On IV dilt 10 q6 if HR > 160 prn. Was given
lopressor, however may have contributed to worsening respiratory
status. CE negative. TSH normal. No observed recurrances. Of
note, briefly started on beta blocker but appeared to have
increased SOB. CHADS = 5 (previous CVA, no documented CHF).
- plan to restart PO dilt once PEG tube in place
- Given history of strokes, consider anticoagulation, holding
off in context of lack of PO access
# UTI/Hematuria: Hematuria had improved, but now continues.
Completed antibiotic course. Likely needs outpatient follow up
for work up of possible urinary malignancy
- f/u urine cytology
- potential outpatient workup
# Low urine output: Patient had tntermittent low urine output
initially thought [**2-1**] hypovolumia but relatively unresponsive to
fluid boluses but consistently responsive to lasix.
# Rash: Patient developed a diffuse erythematous rash across her
upper torso during her admission which was felt likely a drug
reaction. The time course was most consistent with her use of
meropenem. This was stopped and added to her drug allergy list.
Of note, her rash resolved completely within 4-5 days of
stopping her meropenem.
# Hypertension: On diltiazem as outpatient, initially held on
admission, and then held with concern for aspiration with
intermittent use of a dilt gtt in the setting of AF as
previously described.
- restart PO dilt once PEG tube is in
# Peripheral vascular disease: Patient known chronic venous
stasis changes and proteus wound infections in lower
extremities. LE wounds were treated with moisturizing lotion [**Hospital1 **]
and improved during admission.
# Bipolar disorder: Admitted on Risperdal and Depakote as
outpatient. Depakote stopped due to concern for high ammonia
levels and added to her allergy list. Intermittent agitation
managed with Zydis (SL zyprexa) prn.
# Diverticulosis: Patient h/o LGIB in [**2104**]. No c/o of pain at
this time to indicate inflammation, no e/o LGIB during this
admission.
# s/p CVA: Per family, unable to move R arm and not ambulatory.
Neuro exam limited to known deficits.
# Urinary Incontinence: At baseline.
***On [**3-15**] she had been weaned successfully to 3-4 L NC, however
on the evening of [**3-16**] she had worsening saturations and was
placed back on BiPap with good effect. Over the course of [**3-17**]
she continued to have desaturations that were not improved with
BiPap. She alternated between the Bipap and NRB and her
tachypnea continued to increase to 40s and 50s. Her symptoms
improved for several hours on morphine and lasix drip. Her
tachypnea returned at about 17:30 and her O2 sat dropped into
the 70s despite BiPap, she became unresponsive and efforts to
suction and assist her with BVM and high flow O2 remained
unsuccessful. She was DNR/DNI and expired at 18:20
Medications on Admission:
ASA 81 mg daily
Diltiazem CR 180 mg daily
Risperidone 0.25 qam, 0.5 qpm
Lasix 20 mg qam, 40 mg qpm
Loratadine 10 mg Qday
Loperamide 2mg [**Hospital1 **] prn loose stool
Calcium carbonate 1200 daily + 800U Vitamin D
Salsalate 500 [**Hospital1 **]
Tylenol prn
Multivitamin with minerals
Depakote 250 mg [**Hospital1 **]
Ferrous sulfate 1 tab po daily
Discharge Medications:
Pt. expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hyperarbic Respiratory Failure
Discharge Condition:
Pt. expired
Discharge Instructions:
Pt. expired
Followup Instructions:
Pt. expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"327.23",
"438.21",
"507.0",
"V12.51",
"E930.8",
"562.10",
"599.70",
"496",
"599.0",
"783.0",
"427.31",
"443.9",
"401.9",
"296.89",
"518.84",
"693.0",
"276.52",
"788.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12950, 12959
|
7956, 12514
|
344, 382
|
13033, 13046
|
3340, 3345
|
13106, 13212
|
2599, 2755
|
12914, 12927
|
12980, 13012
|
12540, 12891
|
13070, 13083
|
2770, 3321
|
292, 306
|
7327, 7933
|
1961, 2085
|
410, 1943
|
3360, 7307
|
2107, 2440
|
2456, 2583
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,728
| 104,025
|
40296
|
Discharge summary
|
report
|
Admission Date: [**2101-1-14**] Discharge Date: [**2101-1-26**]
Date of Birth: [**2031-1-31**] Sex: F
Service: SURGERY
Allergies:
Shellfish Derived / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
RUQ pain, portal vein thrombus, leukocytosis, rigors
Major Surgical or Invasive Procedure:
[**2101-1-14**]: CTA Abdomen
[**2101-1-14**]: IJ line placement
[**2101-1-17**]: Thrombolysis via TPA infusion catheter via the left
portal venous branch
[**2101-1-18**]: AngioJet assisted clot lysis
[**2101-1-21**]: Sigmoidoscopy; removal of foreign body
History of Present Illness:
69 year-old female presenting with a 1-week history of diffuse
abdominal pain, chills and subjective fevers. Initially her pain
started epigastric and after 2-3 days it radiated to her entire
abdomen. She denies any nausea or vomiting, has been mildly
constipated lately, but her last bowel movement was yesterday
and it was normal. She is being transferred from [**Hospital3 4107**]
with a RUQ U/S suspicious for PV thrombosis. She had a WBC of
20.8 and was having rigors in the [**Last Name (LF) **], [**First Name3 (LF) **] received 3g of Unasyn
for concerns for cholangitis.
Past Medical History:
None
.
Past Surgical History:
tubal ligation 40 years ago
Social History:
Lives at home with ill husband, Smokes 1PPD for >50 years.
Denies any Alcohol
Family History:
Father died of bladder cancer
Physical Exam:
VS 101.4 107 108/66 22 91% RA
General: No acute Distress
Neuro: Awake, alert, cooperative with exam, normal affect,
oriented to person, place and date.
Lungs: Clear to Auscultation bilaterally
Cardiac: Regular rate and rhythm, S1/S2
Abd: Soft, nondistended, very mildly tender on the RUQ. No
guarding or [**Doctor Last Name **] sign.
Extrem: Warm, well-perfused, no edema
Pertinent Results:
On Admission: [**2101-1-13**]
WBC-19.0* RBC-3.61* Hgb-11.4* Hct-33.2* MCV-92 MCH-31.5
MCHC-34.2 RDW-14.3 Plt Ct-285
PT-14.4* PTT-35.9* INR(PT)-1.3* Fibrino-673*
Glucose-91 UreaN-31* Creat-1.1 Na-126* K-7.9* Cl-93* HCO3-20*
AnGap-21*
ALT-36 AST-84* AlkPhos-191* TotBili-1.9* Lipase-22
Albumin-3.0* Calcium-8.6 Phos-3.7 Mg-2.4
[**2101-1-14**] HBsAg-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2101-1-16**] CEA-4.9* AFP-1.6 CA [**09**]-9 33
WBC trend:
[**2101-1-14**] WBC-11.5*
[**2101-1-17**] WBC-16.2*
[**2101-1-19**] WBC-24.5*
[**2101-1-20**] WBC-20.7*
[**2101-1-21**] WBC-25.8*
[**2101-1-24**] WBC-20.0*
[**2101-1-25**] WBC-27.4*
[**2101-1-26**] WBC-14.8*
Brief Hospital Course:
69 y/o female who presents from OSH with evidence of portal vein
thrombus on ultrasound. An ultrasound was performed on admission
to [**Hospital1 18**] showing thombosed left portal vein. Main portal and
right portal veins are patent. there is a normal gallbladder
with no gallstones. The liver is diffusely echogenic compatible
with fatty infiltrate. A CTA was then obtained to further
delineate the extent of thrombus, which showed the left portal
and anterior right portal vein thrombosis. Small thrombus
extends into the main portal vein. The posterior right portal
vein remains patent. The SMV and the splenic veins are patent.
No discrete pancreatic
mass. There is also a 6 mm left lower lobe pulmonary nodule
which would be concerning due to patients 50 pack year history
of smoking.
The patient was immediately started on a heparin drip and was
given 2 days of Unasyn due to concerns for cholangitis. Blood
and urine cultures taken on admission have been finalized with
no growth. In the meantime coverage was broadened to Vanco and
Levaquin. An echo was performed showing no evidence of
vegetations and an EF > 65%.
She was noted to have worsening abdominal pain, and on [**1-16**], a
repeat abdominal CT was obtained showing progression of the
previously noted portal vein thrombosis, which now involved the
posterior right portal vein. There was marked delayed periportal
enhancement without biliary dilatation, with findings concerning
for septic thrombophlebitis. Perforation of sigmoid colon by an
intraluminal foreign body is suggested as etiology by the
imaging findings; as there is no provided
history of any hepatobiliary stenting, there is the possibility
of an ingested foreign body.
On [**2101-1-17**] the patient underwent attempted thrombolysis. Portal
venogram demonstrating completely occluded left portal vein.
Partial filling defect noted in a branch of the right portal
vein suggestive
of partial thrombus. She had successful placement of a TPA
(Alteplase) infusion catheter via the left portal venous branch
for overnight thrombolytic infusion and was transferred to the
SICU overnight for monitoring. On [**1-18**] a pre-procedure venogram
showed no decrease in the clot. She then had a Post-AngioJet
clot lysis venogram demonstrating total clot lysis in the
branches of the right portal vein. Residual clot is still noted
in the left portal vein. The left portal vein appears small in
caliber, with little forward flow. The heparin drip was
restarted and she was able to be transferred back to the regular
surgical floor.
The thrombus remnant was sent for culture, there was no growth
obtained from this specimen.
On [**1-19**] the antibiotic coverage was changed, the levaquin was
d/c'd and Zosyn was started.
Her respiratory status was worsening, she had developed
inspiratory and expiratory wheezes, and chest xrays indicated
concern for new bilateral opacities, likely pneumonia with para
pneumonic effusions, right greater than left. Lasix was started.
Over the next few days her respiratory status improved and on
[**1-25**] a chest xray was obtained showing there is some decrease
in the still present bilateral pleural effusions with
compressive atelectasis at the bases. The pulmonary vascularity
has returned to an almost normal state.
Another CT of the abdomen was done on [**1-25**] showing increased
perihepatic and perisplenic ascites. Since [**2101-1-16**], there has
been interval removal/resolution of thrombi at the distal main
portal vein and the proximal right posterior branch, the right
posterior portal vein is now widely patent and the left portal
vein and anterior branches of the right portal vein are not
opacified with IV contrast and likely thrombosed. This is
unchanged since [**2101-1-16**].
As the patient was having persistently elevated WBC, with all
negative blood and urine cultures as well as the thrombus, the
central line was removed, and she was also switched to PO
Augmentin which should continue for an additional two weeks. The
WBC came down to 14.8 and she remained afebrile.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) VIAL Inhalation Q6H (every 6 hours).
5. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day:
PLEASE CHECK INR EVERY 2 DAYS UNTIL INR STABLE. THEN PER
ROUTINE.
.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Portal vein thrombosis
Pneumonia
Diverticulitis
Foreign body removal from colon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). With oxygen requirement
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarhea, constipation, signs of bleeding to
include nosebleed, dark/tarry stool or bright red blood per
rectum or easy bruising, inability to take or keep down food,
fluids or medications, increased abdominal pain or any other
concerning symptoms. Be on lookout for worsening pulmonary
status
Monitor the INR at least twice a week until stable, patient will
need anticoagulation for the foreseeable future, and will need
follow up with a coumadin clinic or her PCP once discharged to
home
No heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2101-2-9**]
10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2101-1-26**]
|
[
"562.10",
"511.9",
"789.59",
"518.89",
"936",
"576.1",
"305.1",
"486",
"E915",
"452"
] |
icd9cm
|
[
[
[]
]
] |
[
"98.04",
"88.64",
"45.24",
"99.10",
"39.79",
"38.97",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7582, 7625
|
2535, 6591
|
357, 614
|
7749, 7749
|
1854, 1854
|
8606, 8925
|
1415, 1446
|
6646, 7559
|
7646, 7728
|
6617, 6623
|
7956, 8583
|
1274, 1304
|
1461, 1835
|
265, 319
|
642, 1222
|
1868, 2512
|
7764, 7932
|
1244, 1251
|
1320, 1399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,597
| 145,740
|
53983
|
Discharge summary
|
report
|
Admission Date: [**2122-8-6**] Discharge Date: [**2122-8-11**]
Date of Birth: [**2070-2-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
[**8-6**] left subclavian central venous line (has been removed)
[**8-11**] PICC placement
History of Present Illness:
52 year old male with past medical history of anoxic brain
injury, unresponsive at baseline and trach at baseline with
G-tube and Foley. Patient presents with fever to 102 today from
nursing home. He also has a history of a G-tube site deep space
infection. He was given Tylenol at his nursing home and sent to
[**Hospital1 18**].
In [**Hospital1 18**] ED, initial VS were 158 81/55 97% on vent. Evaluation
was significant for leukocytosis to 25.9, lactate of 4.3 and
grossly positive UA. He received Tylenol PR, Vancomycin and
cefepime. Potassium was 6.3 for which he received calcium,
insulin and dextrose. Repeat potassium which was checked prior
to latter therapy was normal. CXR and CT abdomen were completed
and showed cystitis. Wetread was read as mild hydronephrosis but
upon [**Location (un) 1131**] with radiology attending there was no concern for
hydronephrosis and was likely dilatation of ureter due to
kinking of foley. He was started on norepi for hypotension while
left subclavian line was placed. He received 6LNS in the ED.
Patient was then admitted to MICU for further management.
On arrival to the MICU, he could not voice any concern due to
his baseline mental status.
Review of systems: unable to obtain
Past Medical History:
- TBI secondary to anoxia during substance overdose
- s/p Tracheostomy and PEG placement [**1-/2122**]
- Sepsis secondary to acute cholecystitis with placement of
drain [**4-/2122**]
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1003**] G tube placement [**2122-4-18**]
- s/p exploratory G tube tract incision and drainage of the
retro-rectus/peri-rectus space and drain placement [**2122-4-14**]
- multiple highly resistent urinary tract infections
Social History:
according to guardian
- from [**Name (NI) **]
- h/o substance abuse, was on methadone
- unclear if used EtOH or smoked
- no kids
Family History:
could not obtain
Physical Exam:
ADMISSION EXAM
General: non-responsive, not obeying commands
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
anisocoric R > L
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: PERRL, does not obey commands, toes upgoing bilaterally,
decorticate posturing, no withdrawl to painful stimuli though
winced to painful stimulus of RUE, no hyperreflexia
SKIN: erythemetous macular rash of back confuent on upper back
and more macular further down
DISCHARGE EXAM
Vitals: T98.4/98.4, 122/88 (120s-130s/80s), p93, 100 Trach
Wgt (current): (admission): 94 kg
Height: 70 Inch
General: Awake, minimally-responsive, not obeying commands,
shakes head intermittently
HEENT: MMM, oropharynx clear, closes eyes tightly on exam
Neck: JVP not elevated, soft, nontender, L subclavian line in
place, area erythematous
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Upper airways sounds heard throughout lung fields.
ABD: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding,
- G tube in place, covered by dressing, no erythema/exudate seen
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Does not obey commands, toes upgoing bilaterally,
decorticate posturing, no withdrawl to painful stimuli though
winced to painful stimulus of RUE, no hyperreflexia
SKIN: erythemetous macular rash of back confuent on upper back
and more macular further down, L elbow ulcer, R heel ulcer,
sacral ulcer
Pertinent Results:
ADMISSION LABS
[**2122-8-6**] 10:10AM BLOOD WBC-25.9*# RBC-5.41# Hgb-17.1# Hct-52.5*#
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.0 Plt Ct-653*#
[**2122-8-6**] 10:10AM BLOOD Neuts-87.7* Lymphs-5.9* Monos-6.0 Eos-0
Baso-0.4
[**2122-8-7**] 05:22AM BLOOD PT-14.4* PTT-29.5 INR(PT)-1.3*
[**2122-8-6**] 10:10AM BLOOD Glucose-168* UreaN-50* Creat-1.3* Na-139
K-6.5* Cl-104 HCO3-21* AnGap-21*
[**2122-8-6**] 10:10AM BLOOD ALT-77* AST-43* AlkPhos-76 TotBili-0.8
[**2122-8-6**] 05:18PM BLOOD Calcium-7.7* Phos-4.0 Mg-2.2
[**2122-8-6**] 10:01AM BLOOD Lactate-4.3*
[**2122-8-7**] 05:40AM BLOOD Lactate-0.8
==============================
DISCHARGE LABS
[**2122-8-10**] 06:00AM BLOOD WBC-6.3 RBC-3.58* Hgb-11.6* Hct-33.9*
MCV-95 MCH-32.2* MCHC-34.1 RDW-13.8 Plt Ct-342
[**2122-8-9**] 06:10AM BLOOD PT-11.0 INR(PT)-1.0
[**2122-8-10**] 06:00AM BLOOD Glucose-103* UreaN-14 Creat-0.3* Na-135
K-4.5 Cl-99 HCO3-27 AnGap-14
[**2122-8-10**] 06:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0
[**2122-8-7**] 05:40AM BLOOD Lactate-0.8
==============================
URINALYSIS
[**2122-8-6**] 10:10AM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
[**2122-8-6**] 10:10AM URINE Blood-NEG Nitrite-POS Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
[**2122-8-6**] 10:10AM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.010
==============================
[**2122-8-8**] 5:20 pm CATHETER TIP-IV Source: left subclavian.
**FINAL REPORT [**2122-8-10**]**
==============================
[**2122-8-6**] 10:24 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2122-8-9**]**
GRAM STAIN (Final [**2122-8-6**]):
[**11-5**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2122-8-9**]):
HEAVY GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
==============================
[**2122-8-6**] 10:10 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2122-8-9**]**
URINE CULTURE (Final [**2122-8-9**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefepime sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 1 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
==============================
[**2122-8-6**] 10:10 am BLOOD CULTURE x2 - PENDING
==============================
ECG [**2122-8-6**] 9:46:10 AM
Sinus tachycardia with non-specific repolarization
abnormalities. Probable limb lead misattachment. Compared to the
previous tracing of [**2122-5-14**] the heart rate is further increased.
==============================
CHEST (PORTABLE AP) [**2122-8-6**] 9:56 AM
1. No acute cardiopulmonary process.
2. Stable bibasilar atelectasis or scarring.
==============================
CT ABD & PELVIS WITH CONTRAST [**2122-8-6**] 11:42 AM
1. Bladder wall thickening and mucosal hyperenhancement with
surrounding inflammatory changes is concerning for severe
cystitis. Recommend correlation with urinalysis.
Calcifications adjacent to the Foley catherter balloon are of
unclear significance, but may be related to the chronic
indwelling catheter.
2. New mildly dilated extrarenal pelvises and ureters without
definite hydronephrosis. No evidence of pyelonephritis or
perinephric fluid collection.
3. G-tube in proper position within the stomach. No evidence
of bowel obstruction.
Brief Hospital Course:
Mr. [**Known lastname 110682**] is a 52y/o gentleman with h/o anoxic brain injury
attributed to drug abuse/overdose, s/p trach/PEG/chronic foley
with recent cholecystitis s/p cholecystotomy tube placement,
recent Gtube infection and abscess, multiple decub ulcers, and
MDR UTIs, who was admitted with urosepsis. His UTI was treated
and he was discharged to rehab.
#. Goals of care: DNR/DNI, will pursue comfort-focused care in
the near future.
Patient has a court-appointed guardian. [**Name (NI) **] a friend and a
sister, but neither has returned his guardian's phone calls
regarding the patient's care. Per discussion with guardian,
patient is now DNR/DNI. Ongoing discussion regarding goals of
care for this gentleman who is non-communicative and minimally
responsive is encouraged. Guardian is strongly considering
transitioning him to "comfort-focused care" which is appropriate
given his poor quality of life. This would include stopping
tube feeds but continuing comfort measures including appropriate
foley care, antibiotics for his current UTI, and wound care for
his decubitus ulcers. This should be discussed with guardian
upon arrival to rehab.
#. Proteus mirabilis urosepsis: resolved.
Along with IV fluid resuscitation, he was initially treated with
Vancomycin/Gentamycin/Meropenem given his prior sensitivities,
but his urine culture returned sensitive to Meropenem. He was
promptly able to be transitioned from the MICU to the medical
floor. Blood cultures remained negative. A PICC line was
placed and he will complete a course for complicated UTI
([**Date range (1) 40312**]/12).
#. Pseudomonas in sputum: likely a contaminiant.
He was not noted to have a cough or fever; chest x-ray was
clear. The Meropenem he received wil adeqetely treat this as
well.
#. Decubitus ulcers: stage III-IV.
Significant stage IV on his coccyx, stage III on his left elbow,
and right heel ulcer were present on admission and not obviously
infected. wound care was consulted (see recs in the Page 1).
He is in need of Podiatry as well to trim his toenails.
#. [**Last Name (un) **]: Resolved.
Cr was 1.3 on admission but decreased to 0.3 upon discharge.
Was likely due to volume depletion in the setting of sepsis and
resolved with volume repletion (9 liters in the MICU).
#. Sinus tachycardia: improved.
Initial tachycardia above baseline was likely related to volume
depletion but he remains mildly tachycardic at baseline.
Persistent from previous admissions since earlier this year.
Most likely due to autonomic instability. He continues on
Metoprolol 50mg q6h
#. Transaminitis: Around his baseline. HepB negative. HepC
positive.
Viral load of 250,000 in 04/[**2122**]. Liver US and CT abdomen in the
past few months were normal. No AFP checked. LFTs trended down
(ALT 43, AST 20). This should be followed up as an outpatient.
#. Transitional issues
-code status: DNR/DNI
-guardian: [**Name (NI) **] [**Name (NI) 8215**] [**Telephone/Fax (1) 110688**]
-suggest ongoing discussion about goals of care
-wound care recs included in page 1
-please remove PICC after IV antibiotics are finished
Medications on Admission:
. Information was obtained from .
1. Docusate Sodium 250 mg PO BID
2. Heparin 5000 UNIT SC TID
3. Ascorbic Acid 250 mg PO DAILY
4. Famotidine 20 mg PO BID
5. Metoprolol Tartrate 50 mg PO QID
Discharge Medications:
1. Famotidine 20 mg PO BID
2. Heparin 5000 UNIT SC TID
3. Metoprolol Tartrate 50 mg PO QID
4. Ascorbic Acid 250 mg PO DAILY
5. Docusate Sodium 250 mg PO BID
6. Meropenem 500 mg IV Q6H
This is a new medication to treat your infection. 10-day course
is from [**Date range (1) 40312**].
7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
urosepsis
sacral decubitus ulcers
SECONDARY
hypoxic brain injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were brought to [**Hospital1 18**] because of sepsis that was due to a
UTI. You were admitted to the MICU where your foley was changed
and you were given antibiotics for your infection. You improved
and were transferred to a Medicine floor where a PICC line was
placed. You are being discharged to rehab to finish your
antibiotics.
In addition, you were found to have severe skin breakdown.
Wound recommendations have been included in the Page 1.
We made the following changes to your medications:
-START Meropenem (ten day course ends [**8-16**])
Followup Instructions:
You will be followed by healthcare providers at rehab.
|
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[
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[]
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27,486
| 186,240
|
51100
|
Discharge summary
|
report
|
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-7**]
Date of Birth: [**2082-11-2**] Sex: F
Service: MEDICINE
Allergies:
Ancef / Keflex / ciprofloxacin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
Ms. [**Known lastname 18734**] is a 67 year-old woman with RA, HTN, asthma and a
history of severe PNA's including an episode of necrotizing PNA
in [**2144**] requiring left lower lobectomy presents with increased
wheezing, dyspnea and coughing since early this morning, which
she says is consistent with previous asthma exacerbations. She
denies any chest pain.
Initial vitals in the ED were 97.3 60 154/129 24 95%. Labs in
the ED were notable for WBC 11.2 92.8%N, HCT 36.6, Na 130, K
3.1, Latate 5.1. Initial evalution in the ED revealed tachypnea
to the 40s with diffuse wheezes and rhonchi bilaterally. CXR
identified multifocal PNA. Patient received duonebs x3 as well
as 2g IV Magnesium Sulfate, 125mg IV methylprednisolonem, 750 mg
IV levofloxacin 750mg, 1g IV vancomycin in the ED. Vitals on
transfer were 98.6 130/88 105 28 95%RA.
On the MICU floor, the patient is breathing comfortably and
speaking in full sentences.
Past Medical History:
# necrotizing pneumonia s/p L lower lobectomy
# history of left empyema
# Asthma
# Rheumatoid arthritis
# Kyphoscoliosis s/p multiple fusion/rods
# Hypertension
# Anxiety
# Pyloric stenosis s/p loop gastrojej [**2117**]'s s/p Roux-en-Y [**2140**]
# Multiple Pneumonias [**11-11**], [**3-13**], [**5-14**]
# Migraines
# Hiatal hernia
Social History:
Never smoked but was exposed to cigarrette smoke via both
parents, no etoh. Lives w/ husband. 3 dogs, no children. Hasn't
worked since [**74**] when she fell and needed lower back surgery.
Family History:
Mother with [**Name (NI) 5895**]. Father died from complications of
alcoholism. Positive FHx of GAD, DM. No h/o lung disease.
Physical Exam:
ADMISSION EXAM:
VS T 98.1 104 116/97 rr 17 SpO2: 98%/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral crackles in right lung zones. LUL with crackles
and decreased breath sounds on left lower fields.
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
DISCHARGE EXAM:
97.8(98.2) 98(80-90) 119/65(110-140/60-80) 20 97/RA
GEN: Asleep in bed, NAD. Awakens to voice.
HEENT: NCAT. MMM.
COR: +S1S2, [**Name (NI) 8450**], no m/g/r.
PULM: Absent BS at L base. Faint rhonci in LUL. Crackles
diffusely in right lung field.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND.
EXT: WWP, no c/w/r.
NEURO: MAEE.
Pertinent Results:
ADMISSION LABS
[**2150-4-3**] 02:15PM BLOOD WBC-11.2* RBC-3.81* Hgb-11.1* Hct-36.6
MCV-96# MCH-29.1 MCHC-30.3* RDW-18.3* Plt Ct-208#
[**2150-4-3**] 02:15PM BLOOD PT-11.9 PTT-23.9* INR(PT)-1.1
[**2150-4-3**] 02:15PM BLOOD Glucose-196* UreaN-14 Creat-0.9 Na-130*
K-3.1* Cl-93* HCO3-22 AnGap-18
[**2150-4-3**] 02:22PM BLOOD Lactate-5.1*
DISCHARGE LABS
[**2150-4-6**] 05:35AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.6* Hct-34.1*
MCV-96 MCH-29.9 MCHC-31.0 RDW-19.1* Plt Ct-218
[**2150-4-6**] 05:35AM BLOOD Glucose-92 UreaN-11 Creat-0.5 Na-141
K-4.1 Cl-105 HCO3-26 AnGap-14
[**2150-4-6**] 05:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9
MICRO
[**2150-4-3**] URINE Legionella Urinary Antigen -FINAL NEGATIVE
[**2150-4-3**] URINE CULTURE-PENDING
[**2150-4-3**] MRSA SCREEN-PENDING
[**2150-4-3**] BLOOD CULTURE -PENDING
[**2150-4-3**] BLOOD CULTURE -PENDING
IMAGING
[**2150-4-3**] FRONTAL AND LATERAL CHEST RADIOGRAPHS:
There are new right mid and upper zone opacities since [**1-14**], [**2149**],
concerning for infection. Again seen is severe left hemithorax
volume loss secondary to prior left lobectomy, with unchanged
associated leftward mediastinal shift. There is decreased
aeration of the left lung apex as compared to the prior study.
There is no right pleural effusion or right pneumothorax. Severe
osteopenia and multiple severe wedge compression deformities
throughout the lower thoracic and upper lumbar spine are again
seen.
IMPRESSION:
1. Multifocal pneumonia.
2. Chronic left lobectomy volume loss with leftward mediastinal
shift, and interval mild decrease in aeration of the left lung
apex.
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
67F with hx RA, HTN, asthma and recurrent severe PNA p/w
dyspnea, found to have multifocal PNA.
ACUTE:
# PNA: On admission pt had evidence of multifocal PNA with
involvement of RML and RUL. Poor pulmonary reserve noted, with
hx left lower lobectomy during complicated pneumonia in the
past. Initially required several L supplemental O2 in the ED but
was weaned to 2L prior to floor transfer, and further weaned to
RA overnight (within 12h). She was started empirically on
vanc/levo in the ED. Also received duonebs and IV
methylprednisolone with improvement in dyspnea. Given history of
severe PNA, the ED elected to admit the patient to the MICU for
closer monitoring. She received 1 dose aztreonam in the ICU
because of hospital policy of double coverage for pseudomonal
PNA in pts requiring ICU admission and pt's documented allergy
to cephalosporin (Aztreonam not continued thereafter).
Legionella antigen negative. Given her clinical appearance &
CXR findings, she was not felt to have an MRSA PNA. Pt was
eventually transitioned from vancomycin & IV levofloxacin to PO
moxifloxacin, which she will continue to complete a 14-day
course.
CHRONIC:
# Asthma: Patient is on combivent at home. Not on inhaled
steroid at home, but did receive 125mg IV solumedrol in ED. No
additional steroids administered given clinical stability.
Nebulizers were continued on the floor and the patient was
discharged on her home inhalers.
# Hypertension: The patient was normotensive on admission. Home
verapamil was continued.
# Anxiety: Continued home regimen of amitryptiline and
klonopin.
# Migraines: Continued home regimen of amitriptyline.
Medications on Admission:
- Celecoxib 200 mg [**Hospital1 **]
- Escitaopram 10 mg daily
- Pravastatin 40 mg daily
- Clonazepam 1 mg TID
- Omeprazole 40 mg daily
- Cyclobenzaprine 10 mg TID
- Amitriptyline 75 mg HS
- Dicyclomine 20 mg QID:PRN stomach pain
- Lidocaine 5 %(700 mg/patch) x3 daily
- Combivent 18-103 mcg/Actuation 2 Puffs Q4H:PRN SOB or Wheeze
- Verapamil 120 mg daily
- Vitamin D 50,000 unit Q2W
- Reclast 5 mg/100 mL Yearly in [**Month (only) **]
Discharge Medications:
1. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back spasm.
6. amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day) as needed for stomach pain.
8. celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
11. Medication
Vitamin D 50,000 unit Q2W
12. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Medication
Reclast 5 mg/100 mL Yearly in [**5-21**]. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 18734**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital because you
experienced some shortness of breath. While you were here we
determined that you had a pneumonia in your lungs. You were
initially treated with antibiotics through your IV and you
improved. You will continue to take antibiotics by mouth as
directed below.
MEDICATION INSTRUCTIONS:
- Medications ADDED:
----> Please take moxifloxacin 400 mg daily through [**2150-4-16**]
- Medications STOPPED: None.
- Medications CHANGED: None.
Followup Instructions:
Please call your primary care doctor for a follow up appointment
within 1-2 weeks of leaving the hospital:
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
In additional to scheduling an appointment with your primary
care doctor, you have additional follow up appointments:
Department: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD
When: WEDNESDAY [**2150-4-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD [**Telephone/Fax (1) 11262**]
Building: [**Last Name (NamePattern1) 14648**] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: None
Department: PULMONARY FUNCTION LAB
When: FRIDAY [**2150-7-24**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2150-7-24**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"V45.76",
"V45.4",
"530.81",
"486",
"401.9",
"493.90",
"300.00",
"346.90",
"V12.04",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7950, 7956
|
4525, 6197
|
297, 307
|
8050, 8050
|
2908, 4502
|
8812, 9199
|
1844, 1971
|
6684, 7927
|
7977, 7977
|
6223, 6661
|
8201, 8615
|
1986, 2542
|
2558, 2889
|
250, 259
|
9224, 10341
|
335, 1266
|
7996, 8029
|
8640, 8789
|
8065, 8177
|
1288, 1622
|
1638, 1828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,332
| 112,147
|
30313
|
Discharge summary
|
report
|
Admission Date: [**2120-12-24**] Discharge Date: [**2121-1-10**]
Date of Birth: [**2055-4-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
SOB/fever
Major Surgical or Invasive Procedure:
Doboff tube placed by interventional radiology
PICC Placement on Right arm
Left sided thoracentesis
History of Present Illness:
Pt is a 65 y.o male with h.o esophageal ca s/p surgical
intervention, chemo/radiation, MI, HTN, HL who presents with
SOB/fever/orthopnea. Pt is a transfer from OSH where CTA
performed showed a large R.sided consolidation with b/l effusion
R>L. D-dimer 1.63, WBC 8.9, given 300CC NS, 40mg IV lasix. BNP
326. CK 33, CKMB 2.8, Trop 0.03
.
In the ED at [**Hospital1 18**] initial vitals demonstrated T 99, HR 108, BP
125/85, RR 24 sat 95%. Due to BNP and CXR findings pt was given
vanco/levo/ctx for PNA.
.
Vitals prior to transfer to ICU. HR 100-110, BP 149/70, RR 24,
sat 91% on 5L
.
Pt reports 2 days of SOB, orthopnea, cough (acute on chronic,
non-productive), +subjective fever, +sick contacts URI at home,
-CP. Otherwise denies headache/lh/dizziness/blurred
vision/+palpit chronic, -abd pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, joint pain/skin rash, +poor po intake.
Reports sometimes difficulty with swallowing, unsure if
chokes/coughs during eating.
.
Past Medical History:
esophageal ca s/p esophagectomy [**8-5**], radiation+chemo
weight loss
HTN
HL
MI [**2109**]
s/p CCY
Social History:
He is married. He has four children in their 20s. He lives in
[**Location 5110**] with his wife. [**Name (NI) **] is retired from the meat cutting
industry. He does not smoke cigarettes nor has he in the past.
He drinks alcohol rarely about a six-pack per summer.
Family History:
His mother is alive at age 88 with breathing difficulties and
memory loss and heart problems.
His father is alive at age [**Age over 90 **] and was just recently diagnosed
with gastric
cancer.
He has a sister who died at age 61 of pancreatic cancer and a
sister who is alive at age 54.
There is no other family history of breast, ovarian, uterine, or
colon cancer.
Physical Exam:
Vitals: T. 97.6, BP 131/81 HR 101, RR 11 sat 98%
GEN:cachetic, ashen, frail, cooperative, alert
HEENT: nc/at, PERRLA, EOMI, anicteric.
neck: +JVP to thyroid cartilage, supple no LAD
chest: b/l ae, poor effort, decreased breath sounds RML/RLL,
also LLL. No w/c
heart:s1s2 rrr 2/6 systolic flow murmur, no r/g
abd:cachetic, +bs, soft, NT, ND, well healed surgical scars.
ext: thin, no c/c/e 2+pulses, warm
Pertinent Results:
Admission labs:
[**2120-12-24**] 12:30AM
PT-13.7* PTT-30.7 INR(PT)-1.2*
PLT COUNT-245#
NEUTS-94.2* LYMPHS-2.7* MONOS-3.1 EOS-0 BASOS-0
WBC-9.9# RBC-4.60# HGB-14.3#
HCT-39.1*# MCV-85 MCH-31.0 MCHC-36.5*# RDW-14.2
proBNP-5268*
GLUCOSE-139* UREA N-16 CREAT-0.8
SODIUM-142 POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-26 ANION GAP-19
LACTATE-1.7
[**2120-12-24**] 01:06AM URINE
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2120-12-24**] 07:02AM
ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-1.8 IRON-19*
CK-MB-3 cTropnT-<0.01
ALT(SGPT)-40 AST(SGOT)-29 LD(LDH)-133
CK(CPK)-23* ALK PHOS-143* AMYLASE-55 TOT BILI-0.8
LACTATE-1.4
TYPE-ART PO2-112* PCO2-41 PH-7.50* TOTAL CO2-33* BASE XS-8
[**2120-12-24**] 04:51PM CK(CPK)-24*
.
ECHO [**12-24**]:
Compared with the findings of the prior study (images reviewed)
of [**2119-9-25**], anteroseptal hypokinesis with focal apical
akinesis is now present.
.
CT ABDOMEN W/O CONTRAST Study Date of [**2120-12-24**] 3:38 PM
IMPRESSION:
1. Bilateral pleural effusions that are increased compared to
[**2120-7-30**].
2. Compressive atelectasis of the right lower lobe with possible
superinfection.
3. ALthough limited by lack of contrast, esophageal-gastric
anastomosis
appears intact. Collapse of the distal esophagus and stomach,
which precludes evaluation for mass. Small amount of simple
fluid just distal to the anastomosis of uncertain clinical
significance.
4. No evidence of intra-abdominal fluid collection or abscess.
Interval loss of the subcutaneous fat plane in the left mid
abdomen.
.
[**2121-1-1**] CTA Chest:
IMPRESSION:
1. Negative examination for pulmonary embolism.
2. Moderate pleural effusions, left greater than right. The left
effusion is slightly smaller. The right pleural effusion is
unchanged with persistent loculation laterally.
3. Unchanged right lower lobe consolidation.
4. Limited evaluation of the gastroesophageal pull-through and
of the upper abdomen. Specifically, evaluation for upper
abdominal lymphadenopathy is suboptimal.
Thoracentesis:
[**2120-12-30**] 12:37PM PLEURAL WBC-50* RBC-[**Numeric Identifier **]* Polys-6* Lymphs-83*
Monos-10* Macro-1*
[**2120-12-30**] 12:37PM PLEURAL TotProt-2.7 Glucose-84 LD(LDH)-84
Albumin-1.7
Pleural fluid cytology: NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
The patient is a 65 year old man with a history of hypertension,
hyperlipidemia and esophageal ca s/p surgerical
intervention/chemo/radiation, admitted to the ICU with SOB,
fever, orthopnea.
.
#SOB/fever: CXR on admission with bibasilar opacities; left side
noted to be chronic. CT chest from OSH and CT torso from
admission reviewed with unchanged pleural effusion, new RLL and
RML infiltrates. Also, difficult to track esophagus but still a
question of fistula or obstruction. Additionally, BNP elevated
on admission and CHF was also considered (see below). Patient
was initially started on VANC/levo/flag then switched to
Levo/flagyl to cover for aspiration pneumonia.
.
A thoracentesis was performed to alleviate some of his SOB/O2
requirement and assess for a malignant effusion. Pleural fluid
was negative for malignancy, but recurrence was still highly
suspected with elevated CEA and continued weight loss. A trial
of prednisone was started for his SOB and appetite. He did well
and will continue a taper. He currently requires 3L O2.
.
Given tenuous status and discussion with Dr. [**Last Name (STitle) 3274**] about
likely cancer recurrence, patient decided to shift goals of care
to comfort oriented care. He was given morphine as needed for
SOB. Still prescribing meds for comfort. He decided to work
toward hospice.
.
#CAD- BNP elevated on admission. ECHO showed interval change
from previous with
moderately-to-severely depressed (ejection fraction 30 percent).
Cardiac enzymes were negative.
.
#Esophageal ca: Paitent reported extensive weight loss and
diminished appetite. Oncology was consulted; CEA noted to be
elevated at 90. Given concern for possible malignant
recurrance, pt was transferred to the oncology service once
stable.
.
# Nutrition: Speech and swallow felt he was too ill for inital
evaluation. He was made NPO for concern of aspiration risk.
Dobhoff tube was placed via IR due to anatomy of his espohagus.
Pt was started on tube feeds. Speech and swalloe re-evaluated
on floor and clear patient for full diet. The dobhoff tube was
pulled. Nutrition recomended calorie counts and ensure
suplements.
.
# Acute likely systolic CHF: Patient with new diagnosis of CHF
with pleural effusion and EF of 30%. He was diuresed until his
Cr elevated slightly, but his effusions remained. He was then
only diuresed for symtom management.
.
# Anemia: Iron studies consistent with ACD
.
# Goals of care: as noted above, Dr. [**Last Name (STitle) 3274**] discussed
likelyhood of recurrence of cancer given elevated CEA and
continued loss of appetite and weight. The patient decided to
be DNR/DNI and to move towards hospice. He will be discharged
to [**Last Name (un) 72158**] house.
.
Medications on Admission:
lexapro 20mg daily
lipitor 5mg daily
megestrol 625mg/5ml, 5ml po daily ?
metoprolol 50mg [**Hospital1 **]
asa 325mg
colace
omeprazole 20mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
3. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 3 days.
4. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 5 days: Start after last 20 mg dose.
5. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
for 5 days: Start after last 20 mg dose.
6. Morphine Concentrate 20 mg/mL Solution [**Hospital1 **]: 10-20 mg PO Q1hrs
as needed: for respiratory distress.
7. Lexapro 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Aspiration Pneumonia
weight loss
Esophogeal cancer
Discharge Condition:
Feeling well, on 3L O2, comfortable.
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. You initially went to the intensive care unit because
of your need for oxygen. You recieved IV antibiotics and had a
tube placed in your nose to recieve nutrition. You were stable
to leave the intensive care unit and go to the oncology floor.
You were seen by speech and swallow team who said you were safe
to eat and so the tube was pulled. While a tap of fluid around
your lung did not show malignancy, we continue to suspect that
you have a cancer recurrence. After discussion with Dr.
[**Last Name (STitle) 3274**] about signs that indicate cancer recurrence, it was
decided to shift goals of care to comfort oriented care. You
were given morphine as needed for SOB and other meds as needed
for comfort. You will be dischaged to hospice.
.
All of your medications have been changed. Please take as
prescribed.
.
Please call your doctor or your hospice care if you have
concerns.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 3274**] at ([**Telephone/Fax (1) 3280**] as needed for an
appointment.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2121-1-10**]
|
[
"428.0",
"428.21",
"511.9",
"707.03",
"285.22",
"507.0",
"V87.41",
"783.0",
"799.4",
"783.21",
"272.4",
"V15.3",
"707.21",
"V15.29",
"412",
"401.9",
"V66.7",
"150.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8749, 8849
|
5102, 7828
|
326, 428
|
8944, 8983
|
2648, 2648
|
9986, 10237
|
1841, 2208
|
8024, 8726
|
8870, 8923
|
7854, 8001
|
9007, 9963
|
2223, 2629
|
277, 288
|
456, 1419
|
2664, 5079
|
1441, 1543
|
1559, 1825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,983
| 159,334
|
18324
|
Discharge summary
|
report
|
Admission Date: [**2142-11-9**] Discharge Date: [**2142-11-19**]
Date of Birth: [**2066-6-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76-yaer-old
gentleman who presented with mild dysphagia and cough. He
underwent esophagogastroduodenoscopy which diagnosed with
Barrett's Esophagus. In the one year follow-up there seemed
to be progression of the lesion. The patient had a biopsy
which confirmed a T1 lesion. No fever, no chill, no other
complications although he has some dysphagia he is able to
tolerate food okay.
PAST MEDICAL HISTORY: Status post prostatectomy in [**2133**],
status post radiation therapy for testicular cancer at the
age of 33. No abdominal surgeries. Hyperthyroidism.
MEDICATIONS:
1. Synthroid 25 mcg q day.
2. BPI.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Pleasant, cooperative in no acute
distress. Regular rate and rhythm. Neck is supple. Lungs
clear to auscultation bilaterally. Abdomen soft, nontender,
nondistended. Extremities: Warm and well perfused.
HOSPITAL COURSE: The patient was taken to an operating room
on [**2142-11-9**] where [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Esophagectomy was performed. The
patient tolerated procedure well and was transferred to CSIU
in stable condition. Please see op notes for details. Over
the next couple of days the patient became very agitated,
once pulled out his nasogastric tube which was replaced,
confused, required scheduled Ativan sedation and restraints.
His tube feeds were started on postop day two and were
advanced the goal on postop day three and four. On postop
day three his Ativan was decreased, the patient seemed to be
more calm, following commands, he is cooperative and
oriented. Postop day four and five, the patient is afebrile,
vital signs are stable. He is alert, oriented, following
commands. Pain is well controlled. Tube feeds are at goal.
He is starting to ambulate with help. On postop day seven
the patient underwent swallow study which was normal and he
had no leak. His nasogastric tube was removed. The patient
was started on clears. After that his chest tube was removed
without complication. The patient is tolerating with
physical therapy, tolerating clears well. Postop day ten,
the patient is afebrile, vital signs stable. His wounds are
clean, dry and intact. He is ambulating with help. His tube
feeds switched to cycle. No concerns now, no active issues
at this time.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged to rehabilitation.
The patient will continue on cycle tube feeds for 12 hours at
night. Please see attached sheet. The patient has to stay
on clears until seen in the office by Dr. [**Last Name (STitle) 952**]. Ambulate
with physical therapy was a goal of independent ambulation.
Wound check q day. Please contact Dr.[**Name (NI) 1816**] office for
follow-up in two weeks.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. twice a day.
2. Levothyroxine 100 mcg p.o. q day.
3. Simvastatin 40 mg p.o. q day.
4. Tylenol.
5. Roxicet elixir 10 cc's q 4 to 6 hours p.r.n. for pain.
6. Prophenazine 100 mg in 5 cc's q four hours p.r.n. for
cough.
DISCHARGE DIAGNOSIS
1. Esophageal neoplasm.
2. Prostate cancer.
3. Testicular cancer.
4. Hypothyroidism.
5. Postoperative Intensive Care Unit psychosis.
6. Failure to thrive.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2142-11-19**] 14:25
T: [**2142-11-19**] 15:40
JOB#: [**Job Number 50495**]
|
[
"293.0",
"V10.47",
"V15.3",
"196.1",
"244.9",
"150.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.41",
"42.52",
"96.6",
"99.04",
"40.3",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
2984, 3681
|
1083, 2508
|
856, 1065
|
161, 566
|
589, 833
|
2533, 2958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,646
| 114,764
|
18220
|
Discharge summary
|
report
|
Admission Date: [**2143-10-29**] Discharge Date: [**2143-11-11**]
Date of Birth: [**2068-2-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 75-year-old white male has
a history of coronary artery disease, chronic renal
insufficiency, and anemia, and had been complaining of
shortness of breath. He presents to an outside hospital in
pulmonary edema. He denied chest pain. He had a 68% sat on
room air, and his respiratory rate was 38. He received
Lopressor, Lasix, nitroglycerin drip, and Heparin drip, and
was intubated. His EKG revealed ST depressions in V4 through
V6, and he is transferred here to [**Hospital1 190**] for further management.
PAST MEDICAL HISTORY:
1. History of anemia.
2. History of peripheral vascular disease.
3. History of coronary artery disease; he had a positive
stress test in [**March 2143**] and had a cardiac catheterization in
[**2138**], and an echocardiogram in [**3-25**] which revealed
concentric left ventricular hypertrophy, normal left
ventricular size and function with an EF of 60%, moderate
aortic insufficiency, a thickened mitral valve with
mild-to-moderate MR, LA enlargement, and moderate pulmonary
hypertension.
4. He also has a history of chronic renal insufficiency with
a baseline creatinine of 2.4 to 2.6.
5. Hypertension.
6. History of necrotic kidney and only has one kidney.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Xalatan.
2. Cardura 1 mg p.o. q.d.
3. Hydrochlorothiazide 12.5 mg q Monday.......... Friday.
4. Norvasc 10 mg p.o. q.d.
5. Nitroglycerin prn.
6. Aspirin 325 mg p.o. q.d.
7. Imdur 60 mg p.o. q.d.
8. Lipitor 20 mg p.o. q.d.
9. Folate 2 mg p.o. q.d.
10. Vasotec 20 mg p.o. b.i.d.
11. Nadolol 120 mg p.o. q.d.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: On physical exam, he is an elderly
white male intubated. His temperature was 99.8, heart rate
75, blood pressure 136/60. O2 saturation was 88% on 100%
FIO2, 15 of PEEP, and 16 of IMV. Neck was supple, full range
of motion, and no lymphadenopathy, thyromegaly. Carotids are
2+ and equal bilaterally without bruits. Lungs had coarse
breath sounds diffusely up to the mid chest. Cardiovascular
examination: Regular, rate, and rhythm, normal S1, S2, no
murmurs, rubs, or gallops. Abdomen is soft and nontender
with positive bowel sounds, no masses or hepatosplenomegaly.
Extremities had 1+ bilateral pitting edema. Neurologic
examination: He was sedated.
He was admitted to the CCU and he was diuresed. Renal was
consulted. They recommended holding his ACE inhibitor. He
ruled in for a MI with a peak troponin of 3.24, peak CPK of
934 with 37% MB. He was diuresed with Lasix drip and he was
started on CVVH as a therapy prior to cardiac
catheterization.
On [**10-31**], he underwent cardiac catheterization which revealed
a 70% distal left main stenosis, 80% ostial proximal left
anterior descending artery stenosis, 70% long proximal left
circumflex stenosis, and a 90% OM-3 stenosis. RCA had a
proximal occlusion.
Dr[**Last Name (Prefixes) 4558**] was consulted, and the patient was continued
on CVVH. The patient continued to improve, was extubated.
His creatinine was up to 3.3 and came back down to 2.4 with
CVVH. He was transferred to the floor on [**11-2**],
hospital day four, and continued to progress and on [**11-5**], he
underwent a CABG x3 with PDA endarterectomy. He had a
saphenous vein graft to the PDA to the distal LAD and a LIMA
to the diagonal with a cross clamp time was 99 minutes.
Total bypass time was 117 minutes. He was transferred to the
CSRU in stable condition, and was only on propofol.
He was extubated postoperative night and his creatinine was
2.8 on postoperative day #1. He had good urine output. He
was A-paced for blood pressure support. His creatinine on
postoperative day two went up to 3.6, and we continued to
monitor this.
On postoperative day three, it came down to 3.6, and he was
transferred to the floor in stable condition. He was started
on Plavix immediately postoperatively for his endarterectomy
and chest tubes D/C'd on postoperative day #2. He continued
to progress. Had his epicardial pacing wires D/C'd on
postoperative day #4, and Renal continued to follow him. His
creatinine remained around 3, and on postoperative day #6, he
was discharged to home in stable condition.
LABORATORIES ON DISCHARGE: Hematocrit is 28.8, white count
7,300, platelets 357. Sodium 134, potassium 4.8, chloride
98, CO2 26, BUN 79, creatinine 3.0, blood sugar 107.
MEDICATIONS ON DISCHARGE:
1. Percocet 1-2 tablets p.o. q.4-6h. prn pain.
2. Plavix 75 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Imdur 30 mg p.o. q.d.
5. Iron 150 mg p.o. q.d.
6. Vitamin C 500 mg p.o. b.i.d.
7. Epogen 5,000 units subQ two times a week.
8. Calcium 1334 mg p.o. t.i.d. with meals.
9. Lipitor 20 mg p.o. q.d.
10. Eyedrops one drop O.U. q.h.s.
11. Lopressor 50 mg p.o. b.i.d.
12. Lasix 40 mg p.o. b.i.d.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He will be followed by Dr. [**First Name (STitle) **] in
[**1-24**] weeks and Dr. [**Last Name (STitle) **], his renal doctor in one week, and
an appointment with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3116**]
MEDQUIST36
D: [**2143-11-11**] 13:07
T: [**2143-11-11**] 13:10
JOB#: [**Job Number 50327**]
|
[
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"285.9",
"584.9",
"410.71",
"403.91"
] |
icd9cm
|
[
[
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]
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[
"88.56",
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"36.12",
"39.95",
"37.23",
"39.61",
"96.71",
"38.95",
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icd9pcs
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[
[
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1760, 1775
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4553, 5467
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1433, 1743
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1798, 4367
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4382, 4527
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161, 678
|
700, 1407
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,582
| 180,711
|
44498+58725
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-1-11**] Discharge Date: [**2169-1-24**]
Date of Birth: [**2102-1-19**] Sex: M
Service: MEDICINE
Allergies:
Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
fever, hypoxia
Major Surgical or Invasive Procedure:
mechanical ventilation (already had a trach)
Central Line placement
PICC placement
History of Present Illness:
This is a 66 y.o. man, with complicated recent medical history
(detailed below), DM2, HTN, PD, tracheostomy, PEG, who presents
from [**Hospital 100**] rehab. He was noted to have a fever of 101.6,
beginning evening of [**2169-1-7**]. He was already on Imipenem (only)
for ESBL Klebsiella in the sputum grown on [**2168-12-20**]. B/c of the
fever, IV vanco 750mg Q12 was started. Also had elevated CO2
and respiratory distress, so was placed back on the ventilator.
CXR showed RLL pna per rehab notes. Cultures were drawn [**2169-1-8**],
which eventually grew GNRs. At this point, the most recent
culture data from [**2169-1-4**] showed acinetobacter in the sputum,
sensitive only to Amikacin. Treatment had not been given for
this acinetobacter up until this point b/c patient looked well.
Fever persisted up to 103, and on [**2169-1-10**] Amikacin was started.
Despite this, his fever rose to 103.6 on [**2169-1-11**]. He was
transferred to [**Hospital1 18**] ED.
.
Of note, he had recent pneumonia with ESBL Klebsiella (early [**Month (only) **]
[**2168**], treated with 12 days Meropenem), and Acinetobacter
(treated with Unasyn/Tobramycin, completed [**2168-12-26**]).
.
In the ED, initial VS were: T 103, 127/66, HR 110, O2 100% on
ventilator. He was given tylenol. CXR suspicious for LLL
infiltrate. ID curbsided (they follwed during previous
admissions) and recommended covering broadly for HAP with
vanco/meropenem/tobramycin, which were ordered, but only
vancomycin given prior to his ICU transfer. He transiently
became hypotensive and 2 L normal saline given. R IJ catheter
placed. BP stabilized and he never needed pressors. Admitted
to MICU.
Past Medical History:
- Morbid obesity
- DM type 2 poorly controlled with complications
- Chronic renal insufficiency (new baseline as of [**12-12**] - Cr
1.6-2)
- HTN
- reactive airways disease
- h/o asbestos exposure with pleural plaques
- GERD
- Parkinson's disease
- detrusor instability
- gout
- hypothyroidism
- aortic stenosis, valve area 0.9cm2, peak gradient 24, median
gradient 48
- Anemia
- h/o nephrolithiasis
- Fall in [**8-12**] w/ R subdural hematoma, s/p strep bovis
bacteremia and endocarditis and received 6 wks Ceftriaxone. He
then developed bacteremia with MRSA and enterococcus from a PICC
line infection. The line was removed, he was treated with Vanco.
After vanco d/c'd, he had negative bloood cx x 3 days. On
[**2168-11-4**], he was febrile, and blood cxs + enterococcus, [**Last Name (un) 36**] to
PCN and Vanc. got Vancomycin from [**11-4**]/-[**2168-11-14**] due to PCN
allergy.
.
- Re-admitted [**Date range (3) 95357**] for altered mental status, found
to have pneumonia, NSTEMI (medically managed, wall motion abn on
echo), embolic CVA (thought not contributing to mental status
and no focal motor deficit) and aortic valve endocarditis with
vanco-sensitive enterococcus (course of vanco was to complete
[**2168-12-21**]). Was intubated in the ED with difficult to wean vent
felt. Eventually exctubated on [**11-28**]. Acinetobacter in sputum (?
colonization versus VAP), treated with tobramycin and unasyn
(plan was to d/c on [**12-1**]). Also diuresed with lasix gtt for
volume overload.
.
- Re-admitted [**Date range (3) 95358**], one day after discharge from
MICU, again with respiratory failure, and was re-intubated.
Found to have ESBL Klebsiella and treated with Meropenem x 12
days. Tracheostomy performed due to copious secretions,
aspiration with inability to protect airway, and recent
prolonged intubation with difficult wean. Sputum later grew
Acinetobacter on [**2168-12-10**], treated with Unasyn and Tobramycin
initiated [**2168-12-12**] which was to complete [**2168-12-26**]. The patient
improved and was weaned to trach mask. His hospital course was
complicated by HIT, acute on chronic renal failure, and
hypotension, felt [**2-6**] medications used for intubation. He was
discharged on [**2168-12-16**] on vanco for endocarditis from prior
hosptialization (to complete [**2168-12-21**]), and Unasyn/Tobramycin
for acinobacter HAP to complete [**2168-12-26**].
Social History:
no alcohol or tobacco use, currently resides at [**Hospital 100**] Rehab,
formerly owned pizzaria restuarants
Family History:
non-contributory
Physical Exam:
GEN: responds to voice but does not follow commands
HEENT: PERRL, anicteric sclera
LUNGS: Diminished BS at bases. Bilateral rhonchi
HEART: Soft HS. Nl S1S2, no m/r/g
ABD: hypoactive BS. Soft, ND/NT
EXT: trace LE edema b/l
NERUO: responds to voice. does not follow commands
PULSES: 2+ radial and DP bilaterally
Pertinent Results:
ADMISSION LABS:
[**2169-1-11**] 12:44PM URINE GRANULAR-0-2 HYALINE-0-2
[**2169-1-11**] 12:44PM URINE RBC-21-50* WBC-[**11-24**]* BACTERIA-FEW
YEAST-OCC EPI-0-2
[**2169-1-11**] 12:44PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-TR
[**2169-1-11**] 12:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2169-1-11**] 12:44PM PLT COUNT-198
[**2169-1-11**] 12:44PM NEUTS-77.9* LYMPHS-17.5* MONOS-3.7 EOS-0.7
BASOS-0.2
[**2169-1-11**] 12:44PM WBC-9.3 RBC-3.63* HGB-10.1* HCT-30.9* MCV-85
MCH-27.8 MCHC-32.6 RDW-19.1*
[**2169-1-11**] 12:44PM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-4.2
MAGNESIUM-2.1
[**2169-1-11**] 12:44PM ALT(SGPT)-16 AST(SGOT)-34 ALK PHOS-109 TOT
BILI-0.5
[**2169-1-11**] 12:44PM estGFR-Using this
[**2169-1-11**] 12:44PM GLUCOSE-80 UREA N-43* CREAT-1.3* SODIUM-145
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-40* ANION GAP-10
[**2169-1-11**] 01:11PM LACTATE-0.9
[**2169-1-11**] 01:11PM COMMENTS-GREEN TOP
[**2169-1-11**] 05:32PM TYPE-ART TEMP-38.2 RATES-12/ TIDAL VOL-500
PEEP-5 O2-50 PO2-174* PCO2-50* PH-7.43 TOTAL CO2-34* BASE XS-8
-ASSIST/CON INTUBATED-INTUBATED
MICROBIOLOGY DATA at [**Hospital 100**] Rehab:
-- Sputum [**12-20**]: ESBL Klebsiella - sensitive to imipenem,
tetracycline, cefotetan, cefoxitin
-- Sputum [**1-4**]: Acinetobacter - sensitive only to Amikacin
-- Sputum [**2169-1-8**]: pseudomonas (light growth), sensitivities
pending
-- Sputum [**2169-1-10**]: GNRs (3 species)
-- Blood [**2169-1-10**]: NGTD
-- Urine [**2169-1-8**]: No growth (final)
-- Blood (2 sets) [**2169-1-8**]: NGTD
-- Cdiff [**1-4**]: Negative
-- Blood 12/28: No growth (final)
.
MICROBIOLOGY DATA at [**Hospital1 18**]
BLOOD CULTURES from [**2169-1-11**] x 2, [**1-13**], [**1-15**] x 2, [**1-17**] x 2, [**1-18**] x
2, [**1-22**] x 2: negative
URINE CULTURES from [**1-11**], [**1-15**], [**1-17**], [**1-18**], [**1-22**]: all growing
yeast (foley changed on multiple occassions)
[**2169-1-11**] SPUTUM & BAL:
ACINETOBACTER BAUMANNII COMPLEX
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- =>64 R 32 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R 2 I
GENTAMICIN------------ =>16 R 8 I
IMIPENEM-------------- 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ 4 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2169-1-15**] SPUTUM:
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 8 S =>64 R
CEFEPIME-------------- 16 I =>64 R
CEFTAZIDIME----------- 32 R =>64 R
CIPROFLOXACIN--------- 2 I 2 I
GENTAMICIN------------ 4 S =>16 R
MEROPENEM------------- 8 I =>16 R
PIPERACILLIN---------- 32 S =>128 R
PIPERACILLIN/TAZO----- 64 S =>128 R
TOBRAMYCIN------------ <=1 S 2 S
[**2169-1-17**] SPUTUM:
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
[**2169-1-22**] SPUTUM:
GRAM STAIN (Final [**2169-1-22**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING at time of
discharge.
[**2169-1-21**] C. DIFF: negative
IMAGING:
[**2169-1-11**] CXR:
There are interval increase of bibasilar opacities, likely a
combination of increased bilateral pleural effusions and
bibasilar infiltrates. There is an unchanged opacity in the
right mid lung, stable compared to the [**Month (only) 1096**] study. The
tracheostomy and endotracheal stump are essentially unchanged,
allowing the difference of patient's position. There is no
evidence of pneumothorax. There is unchanged appearance of
bibasilar pleural calcification. No acute fracture is seen.
IMPRESSION:
Interval increase of bibasilar opacities, likely representing
effusion and
infiltrates, concerning for pneumonia.
[**2169-1-11**] BRONCHOSCOPY: frank pus in airways of left lower lobe
[**2169-1-16**] RENAL US:
1. No hydronephrosis.
2. Small non-obstructing renal stones bilaterally.
3. Two stable simple left renal cysts.
.
[**1-24**] CXR
Left PICC line can be traced to the low right atrium, although
the tip is
indistinct, at least 8 cm beyond the superior cavoatrial
junction. Extensive pleural parenchymal scarring in both lungs
is essentially unchanged at least since [**2168-2-11**],
including heavy pleural calcification. Moderate cardiomegaly is
stable. Tracheostomy tube in standard placement. No pneumothorax
or new pleural effusion.
Brief Hospital Course:
Hospital course by problem:
.
Multidrug Resistent PNEUMONIA (ACINETOBACTER, PSEUDOMONAS,
KLEBSIELLA)
Mr. [**Known lastname **] was admitted from rehab with a tracheostomy (placed
[**12-12**]) and culture-documented MDR pneumonia from ESBL
Klebsiella, Acinetobacter and Pseudomonas. He had been followed
by the division of ID at [**Hospital 100**] Rehab. The infectious disease
service was consulted and followed Mr. [**Known lastname **] throughout his
hospital course. On arrival, he was started on vanocmycin &
meropenem for broad coverage. Bronchoscopy was performed on
admission on [**2169-1-11**] and frank pus and sputum was collected by
BAL for quantitative culture. Fevers persisted, and ID
recommended starting amikacin and colistin IV to cover the
resistent Acinetobacter cultured from sputum on [**2169-1-4**] at
[**Hospital 100**] Rehab. As his Cr increased (likely from IV colisitin -
renal sono negative, urine lytes unrevealing, positive [**Last Name (un) **]
eosinophils), his colistin was changed from IV to inhaled
formulation to reduce the risk of systemmic side effects. He
remained intermittently febrile throughout the admission wihtout
clear source (lines were changed and then d/c'ed; culture data
were negative aside from serial sputums); vancomycin was added
on [**2169-1-18**] to broaden coverage, though it was discontinued on
[**2169-1-21**] because no further culture data was positive. His Foley
was changed on [**1-23**] due to moderate growth of yeast. Per ID, he
should contiune on a 21 day course of amikacin/colistin, to be
completed [**2169-2-1**] (day 1 was [**2169-1-12**]). Mr. [**Known lastname **] was initially
on a mechanical ventillator; he was weaned to trach collar by
[**2168-1-21**] and discharged on 35% trach collar.
ACUTE RENAL FAILURE:
Renal function declined throughout the admission thought to be
related to AIN from colistin exposure. Cr was on admission 1.4
(improved to 1.1 with hydration initially) and then peaked to
2.6-2.8 (where it has been stably since [**2169-1-20**]). Urine output
remained good. Renal US was negative for obstruction; urine
eosinophils were present, consistent with AIN. Although there
was no acute need for hemodialysis, the possibility was
discussed with the family, who felt the patient would NOT want
hemodialysis. This is not an option in the future.
YEAST GROWING IN URINE:
Mr. [**Known lastname **] has a chronic indwelling catheter. Urine cultures
grew yeast on multiple cultures, and the foley was changed in
repsonse to these cultures.
HISTORY OF HIT:
Mr. [**Known lastname **] [**Last Name (Titles) 35325**] DVT prophylaxis with Fondaparinux.
PARKINSON's DISEASE:
He was continued on Sinemet and Ropinirole.
HYPOTHYROIDISM:
He was continued on his home dose of levothyroxine.
ANEMIA
Chronic per records. Hct was above baseline on admission, but
with hydration came down to midi-20s which is baseline. He was
monitored withouth evidence of bleeding. He was guaiac negative.
HYPERTENSION:
Mr. [**Known lastname 63572**] blood pressures were lower than baseline; home
hypertension medicines were held.
DIABETES:
He was continued on Glargine and SSI while in house.
VENOUS ACCESS:
A PICC was laced on [**2169-1-24**] due to poor peripheral access.
NUTRITION:
He was fed via tube feeds with Replete with fiber at 75 cc/hr,
receiving free water flushes 250 cc Q4 hours.
.
SPEECH AND SWALLOW eval on [**1-24**]:
Pt tolerated PMV placement. He may wear it w/ RN supervision, w/
Yankauer suctioning as needed, as he has a productive cough.
RECOMMENDATIONS:
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
2. Monitor O2 Sats / respiration while valve is in place.
3. Do not allow the patient to sleep with the valve in place.
4. PMV wear schedule is up to the discretion of the
nurse and/or respiratory therapist.
.
(2) Please continue to trend renal function. BUN was 59 and Cr
2.8 at discharge; UOP was good. His ARF is thought to be
related to colistin toxicity. There was no acute need for
hemodialysis, though the possibility was discussed with the
patient's family (wife & daughters). They felt he would NOT
want to pursue dialysis if needed.
(3) Please continue amikacin & inhaled colistin for his MDR
pneumonia through [**2169-2-1**] to complete a 21 day course. goal
amikacin trough is < 8.
.
.
.
PLEASE NOTE
******* Per discussions with family, patient is DNR (has trach;
ventilation ok), and he is being discharged to rehab with
intention for NO REPEAT HOSPITALIZATION. If patient worsens
clinically requiring hospitalization, the family should be
consulted and the possibility of hospice discussed. *******
Medications on Admission:
MEDICATIONS ON TRANSFER FROM [**Hospital **] REHAB TO [**Hospital1 18**]:
Vancomycin 750mg IV Q12, most recent trough [**2169-1-10**] - 13.2
Imipenem 500mg IV Q6H
Amikacin 650mg IV Q12
Aspirin 81mg Daily
Mucomyst 200mg IH [**Hospital1 **]
Albuterol- 6 puffs IH Q6H
Ipratropium IH Q6H
Cabidopa/Levodopa (25/250), 1 tab Q4H
Insulin Glargine 34 units QHS
Insulin regular insulin SS -- start at gluc 181 with four units,
gluc 241 six units, gluc 321 eight units, gluc > 400 ten units
Levothyroxine 88 mcg daily
Lidoderm patch 5%, 12 hours on, 12 hours off
Metoprolol 37.5 Q6H
MV
Omeprazole 20mg Daily
Ropinirol 3mg QID
Tylenol 950mg Q6H
Colace 100mg [**Hospital1 **]
Bisacodyl 10mg PR Daily PRN
Epiniphrine - 10 drops in saline via nebulizer q2H PRN
Miconazole powder PRN
Chlorhexidine rinse 5ML [**Hospital1 **], swish and spit
Vitamin D 1000 units daily
Calcium Carbonate 650mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Carbidopa-Levodopa 25-250 mg Tablet [**Hospital1 **]: One (1) Tablet PO
Q4H (every 4 hours).
6. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Ropinirole 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO QID (4 times
a day).
9. Amikacin 250 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg
Injection Q48H (every 48 hours) for 8 days: course ending
[**2169-2-1**].
10. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
11. Colistimethate Sodium 150 mg Recon Soln [**Month/Day/Year **]: Seventy Five
(75) mg Recon Soln Injection Q 8H (Every 8 Hours) for 8 days:
75mg inhaled q8h with course to end [**2169-2-1**].
12. Simvastatin 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY
(Daily).
13. Fondaparinux 2.5 mg/0.5 mL Syringe [**Month/Day/Year **]: 2.5 mg Subcutaneous
Q48H (every 48 hours).
14. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical QID
(4 times a day) as needed.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Four (4)
Puff Inhalation Q4H (every 4 hours).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day/Year **]:
Two (2) Puff Inhalation Q8H (every 8 hours): please give 15
mintues prior to each inhaled colistin dose .
17. Morphine 2 mg/mL Syringe [**Month/Day/Year **]: One (1) mg Injection Q4H
(every 4 hours) as needed for pain.
18. insulin
please continue to administer insulin as follows:
insulin glargine 34 units at bedtime; Humalog insulin sliding
scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
multi-drug resistent multi-organism pneumonias
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a multidrug resistant
pneumonia caused by several different bacteria. You were put on
very strong antibiotics to fight these infections. You are being
discharged back to rehab, where you will finish a course of
these antibiotics.
.
Please continue to take all of your medications as prescribed.
Per discussion with your family, the decision has been made to
not re-hospitalize you in the event of a worsening of your
condition, and to defer treatment to either your rehabilitation
institution or a hospice.
Followup Instructions:
you will continue to be seen by our infectious disease
specialists at [**Hospital **] rehab. You may also follow up with your
PCP: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**], at your earliest
convenience.
Name: [**Known lastname 12032**],[**Known firstname **] A Unit No: [**Numeric Identifier 15102**]
Admission Date: [**2169-1-11**] Discharge Date: [**2169-1-24**]
Date of Birth: [**2102-1-19**] Sex: M
Service: MEDICINE
Allergies:
Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents
Attending:[**First Name3 (LF) 8956**]
Addendum:
PLEASE NOTE
******* Per discussions with family, patient is DNR (has trach;
ventilation ok)**************
.
ALSO, the family is currently deciding whether or not they would
like Mr. [**Known lastname **] to be re-hospitalized should his clinical status
worsen. He is being discharged to rehab with this decision still
pending. If patient worsens clinically requiring
hospitalization, the family should be consulted and the
possibility of hospice discussed. *******
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 8958**] MD [**MD Number(1) 8825**]
Completed by:[**2169-1-24**]
|
[
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"250.90",
"244.9",
"412",
"117.9",
"530.81",
"285.29",
"493.90",
"276.3",
"596.59",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"33.24",
"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
19847, 20072
|
10139, 10139
|
337, 421
|
18087, 18096
|
5051, 5051
|
18690, 19824
|
4685, 4703
|
15741, 17907
|
18017, 18066
|
14824, 15718
|
18120, 18667
|
4718, 5032
|
8758, 10116
|
283, 299
|
10167, 14798
|
449, 2121
|
5067, 8720
|
2143, 4542
|
4558, 4669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,087
| 145,722
|
26288
|
Discharge summary
|
report
|
Admission Date: [**2139-4-10**] Discharge Date: [**2139-4-15**]
Date of Birth: [**2093-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13024**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement
PICC line placement
History of Present Illness:
45 year old male with hx of HIV/AIDS on truvada only, hx of
lymphoma with baseline LE edema, who presented to the ED with
fevers and increased swelling in his LLE. Patient was in USOH
until this morning when left leg started swelling above
baseline. Later in the morning he developed diarrhea followed by
fever and shaking chills, at which point he came home from work.
Continued to feel unwell and brought in by EMS. In the ED,
initial vs were T 102.5, p 100, bp 84/50, r 2O, 99%. Noted to
look unwell and have significant LE edema from feet to groin
L>R. CT scan in the ED showed widespread edema without gas.
While in ED patient developed significant abdominal pain.
Patient was given vanco, zosyn and clindamycin in the ED; also 2
mg of morphine. Had R IJ placed in the ED. Received 4L of NS
initially. Levofed was started for hypotension.
On the floor, 134/65, 26, 88, levofed at 0.2mg/kg/min. 98% on
RA.
Past Medical History:
- HIV/AIDS - diagnosed [**2134**], currently on HAART
(Truvada/Kaletra), last CD4 540, VL undetectable ([**11-24**]).
- Kaposi Sarcoma, treated with Doxil and Taxol, last treatment
[**9-/2136**], in inguinal nodes causing chronic LE edema.
- +RPR (1:128) [**4-23**], tx'ed with penicillin
- h/o Steptococcus Mitis infection, [**2135**], tx'ed at [**Hospital1 2025**]
Social History:
From [**Country **] but much of family is from [**Country 7192**].
Tob - prior use <1 pack year
Etoh - rare; Drugs - none
Family History:
GM with DM. Parents/siblings healthy.
Physical Exam:
Vitals: T 102 BP 113/63 P 88 R 22 O2
General: Alert, oriented, moderate distress
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: tense 3+ edema, L > R, distal pulses intact, mildly
erythematous, no lesions, WWP
Pertinent Results:
Admission Labs:
[**2139-4-10**] 05:40PM WBC-1.0*# RBC-3.95* HGB-12.2* HCT-35.4*
MCV-90 MCH-31.0 MCHC-34.6 RDW-13.4
[**2139-4-10**] 05:40PM NEUTS-16* BANDS-8* LYMPHS-74* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2139-4-10**] 05:40PM PLT SMR-NORMAL PLT COUNT-239
[**2139-4-10**] 05:40PM CK-MB-NotDone cTropnT-<0.01
[**2139-4-10**] 05:40PM LIPASE-15
[**2139-4-10**] 05:40PM ALT(SGPT)-11 AST(SGOT)-16 CK(CPK)-44* ALK
PHOS-38* TOT BILI-1.6*
[**2139-4-10**] 05:40PM GLUCOSE-104* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-18* ANION GAP-14
[**2139-4-10**] 08:51PM LACTATE-2.4*
CT Torso [**2139-4-11**]:
1. Enlarged gallbladder with no CT evidence of acute
cholecystitis. Mild
intrahepatic biliary dilatation. Given history of AIDS, AIDS
holangiopathy is a consideration, although no specific imaging
findings are present. If
indicated, correlate with ERCP or MRCP.
2. No subcutaneous air. No evidence of lower extremity DVTs.
Extensive soft tissue edema in lower extremities bilaterally.
RIGHT UPPER QUADRANT ULTRASOUND [**2139-4-11**]: There is mild
intrahepatic biliary ductal dilatation with echogenic appearance
of intrahepatic duct. The gallbladder is severely distended and
contains tiny stones or polyps in dependent portion. There is no
gallbladder wall thickening. There is a small amount of fluid
adjacent to the gallbladder. Portal vein is patent. Common duct
is not dilated and measures up to 3 mm. Imaged pancreatic head
is grossly unremarkable. IMPRESSION: 1. Distended gallbladder
with tiny stones or polyps in the dependent portion and small
amount of pericholecystic fluid. Acute cholecystitis cannot be
excluded. In case of continued clinical concern, a HIDA scan can
be obtained. 2. Mild intrahepatic biliary ductal dilatation and
echogenic appearance of the intrahepatic biliary duct may
represent HIV cholangiopathy. Clinical
correlation is recommended.
Chest xray [**2139-4-13**]: The right internal jugular line tip is at
the level of mid SVC. Cardiomediastinal silhouette is stable.
Lungs are slightly hyperinflated but essentially clear. There is
no evidence of pneumothorax or interval development of pleural
effusion.
ECG [**2139-4-12**]: Sinus rhythm. Complete right bundle-branch block.
Compared to the previous tracing of [**2136-4-10**] heart rate is not as
fast and the QRS axis is somewhat more vertical.
Discharge Labs:
[**2139-4-15**] 06:15AM BLOOD WBC-7.7 RBC-4.11* Hgb-12.4* Hct-36.7*
MCV-89 MCH-30.2 MCHC-33.9 RDW-13.6 Plt Ct-317
[**2139-4-15**] 06:15AM BLOOD Plt Ct-317
[**2139-4-15**] 06:15AM BLOOD Glucose-84 UreaN-11 Creat-1.0 Na-136
K-4.4 Cl-100 HCO3-27 AnGap-13
[**2139-4-15**] 06:15AM BLOOD ALT-13 AST-15 AlkPhos-193* TotBili-1.4
[**2139-4-15**] 06:15AM BLOOD Calcium-8.4 Phos-1.4* Mg-2.3
Brief Hospital Course:
45yo M with HIV (dx [**2134**], last CD4 212, VL undetectable) on
truvada and kaletra with h/o karposi lymphoma of inguinal lymph
nodes with lymphadema in the lower extremities, admitted with
neutropenic fever, biliary obstruction, and sepsis.
#. Sepsis/Cholecystitis: He was initially hypotensive with
neutropenic fever and hypotension. He was admitted to the MICU.
A central line was placed and he was started on levophed. Lower
extremity cellulitis was initially thought to be the source.
However he began to complain of abdominal pain, had elevated
liver function tests in an obsructive pattern with a RUQ
ultrasound showing an enlarged gallbladder. Blood cultures were
drawn and remained negative. He was initially treated with
Vancomycin and Zosyn. He underwent percutaneous cholecystostomy
drain placememt by interventioal radiology with significant
improvement in his abdominal pain. His blood pressure improved
and he was weaned off pressors on [**4-13**]. Vancomycin was
stopped due to continued negative culture results. PICC line
was inserted on [**2139-4-14**], and his right IJ CVL was subsequently
removed. He should have the chole tube in place for at least 3
weeks until his follow-up with Dr. [**First Name (STitle) **] in surgery.
#. Chest Pain: He complained of left-sided chest pain after his
percutaneous cholen drain placement. ECG and chest xray were
unchanged from baseline. His pain was initially treated with IV
and then po Dilaudid and his pain eventually improved. It was
felt that it may have been related to his percutaneous chole
drain placement.
#. LE Edema: He had significant LE edema, L>R, from feet to
groin. CT scan showed widespread edema. There was no
subcutaenous air to suggest necrotizing fasciitus and no
evidence of DVT. His edema decreased significant after
auto-diuresis after aggressive fluid resuscitation during
sepsis. There was some concern for cellulitis on presentation
but the erythema was bilateral and it was felt that his initial
presentation was due to sepsis from cholecystitis.
#. HIV: His HAART was continued per infectious disease
recommendations.
#. Anxiety: Continued his home Xanax.
#. Neutropenia: He was neutropenic on admission that was
ultimately felt to be due to sepsis.
#. Code Status: He was full code during this admission.
Medications on Admission:
Viagra 50 mg PO prn
Emtricitabine-Tenofovir (Truvada) 200 mg-300 mg PO Daily
Xanax 0.5-1 mg PO Daily prn anxiety
Ofloxacin 0.3 % Eye drops two drops each eye every 4 hours
Discharge Medications:
1. Zosyn 4.5 gram Recon Soln Sig: 4.5 gram Intravenous every
eight (8) hours for 10 days: Last dose [**2139-4-23**].
Disp:*30 doses* Refills:*0*
2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Alprazolam 0.5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for anxiety.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. Viagra 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for ED: Please take as you were prior to hospitalization.
7. Ofloxacin 0.3 % Drops Sig: Two (2) Drops Each Eye Ophthalmic
every four (4) hours: Take as you were prior to hospitalization.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
Acute cholecystitis
Sepsis
Secondary Diagnosis:
HIV
History of Kaposi's sarcoma
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
With cholecystostomy tube place
Discharge Instructions:
You were admitted to the hospital after you exerienced fevers
and increased swelling in your legs. Since your blood pressure
was low and you had a fever, there was a concern you had sepsis,
which is an infection of the blood stream. Since you had
increased abdominal pain and an ultrasound of your abdomen
suggested you had an infection in your gallbladder (acute
cholecystitis), it is most likely that this was causing your
sepsis. A tube (cholecystotomy) was placed in your gall bladder,
which will likely be removed in [**3-19**] weeks by surgery. You
should discuss with the surgeons if you need to have your gall
bladder removed.
You were started on antibiotics which you will continue to
receive for a total of 14 days (with your last day on [**2139-4-23**])
through the intravenous central line placed in your left arm.
The intravenous central line will then be removed.
While in the hospital, you also had left sided chest pain -
chest x-rays were all normal, and it was thought the pain could
be pain caused by your gall bladder tube. If you develop a rash
in this area, you should call your PCP immediately as this may
be Shingles.
The following changes were made to your medications while in the
hospital:
Start Zosyn (antibiotic) 4.5g IV every 8 hours for a 14 day
course to end on [**2139-4-23**].
Start oxycodone 5mg every 4 hours as needed for pain
It is important that you follow up with your PCP, [**Name10 (NameIs) **] Dr. [**First Name (STitle) **]
of surgery (these appointments have been made for you, see
below).
Followup Instructions:
You have the following appointments scheduled:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Appt: Tuesday, [**4-21**], 11am
Location: [**Location (un) **] ASSOCIATES OF [**Hospital6 5242**]
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2139-4-27**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES with Dr. [**First Name (STitle) **]
When: FRIDAY [**2139-5-1**] at 9:00 AM [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,633
| 166,411
|
47074
|
Discharge summary
|
report
|
Admission Date: [**2104-12-19**] Discharge Date: [**2104-12-26**]
Date of Birth: [**2027-11-11**] Sex: M
Service: MEDICINE
Allergies:
Tetanus / Azithromycin
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
chest pain, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo male with history of coronary artery disease, PBH, recent
prostate biopsy and recent dental work presented with substernal
chest pain, with ED course complicated by hypotension.
.
Chest pain began last night after eating an apple. Worse with
movement and with inspiration, radiates to his neck, associated
with dyspnea and nausea, but no vomiting. No diaphoresis. The
pain does not radiate to his back. He is unsure if this pain is
same as his prior cardiac pain. His wife gave him simethicone-
the pain persisted, and given his history, she gave him aspirin
and sublingual nitroglycerin, without change in pain. He was
then transferred to [**Hospital1 18**] ED via ambulance.
.
Of note, his PCP recently check his PSA, which was elevated at
5.7. He saw Dr. [**Last Name (STitle) **], who performed a TURP about five years ago.
The patient has recently had a prostate biopsy within the past
two weeks, which showed localized prostate cancer. Next
management steps were to be discussed on [**2104-12-23**].
.
He also reports having recent dental work in the past two weeks,
and has an implanted piece of gold in his upper teeth. Prior to
dental work, he was pretreated with one dose of amoxicillin.
.
In the ED, initial VS were: 99.7 70 102/54 18 97% RA
[x] EKG - sinus rhythm at 65, normal intervals, TWI in III is
old, other NSST changes unchanged from prior
[x] bedside echo no effusion
Rectal exam- no blood, non-tender prostate
.
Patient was ready to be admitted to floor, and vitals were:
100.9 76/40 61 18
CVL placed, 3 liters total, CVP 8-9, and was started on
noripenephrine to maintain MAP > 60. He received pip/tazo 4.5
grams x 1 anc vanc 1 gram x 1. UOP 500 cc.
.
On arrival to the MICU, patient reported chronic neck, back and
leg pain. He reported some gassy pain, relieved with belching.
.
Review of systems:
(+) Per HPI
(-) Denies recent fevers, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. He does endorse chroinc arthralgias related to
arthritis. Denies rashes or skin changes.
Past Medical History:
CAD, status post previous CABG [**2085-10-13**] status post PTCA/stent
of distal LCX and mid LCX [**2096-10-12**]. Recurrent atypical chest,
with normal p-mibi in [**7-/2104**]
Recent prostate biopsy, which showed prostate cancer ->
subsequent PET CT did not show evidence of metastatic disease
BPH s/p TURP about five years ago
hypertension
hyperlipidemia
obesity
complicated gallbladder surgery
chronic back pain
gout
Social History:
Patient lives in [**Location 1268**] with his wife. Originally from
[**Location (un) 20338**], [**Country 2559**]. Worked as a cabinet maker. Smokes [**3-20**] pipes of
tobacco a day. Glass of wine daily.
Family History:
Sister died from CVA, father died at 54 from MI, brother with MI
at 80
Physical Exam:
Vitals: T 97.8 HR 54 BP 115/51 95 % 2 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Dentures in upper teeth, with gold piece in right upper teeth.
Neck: supple, JVP not elevated, no LAD. Right IJ in place.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar rales that clear with inspiration. No wheezes,
rales, ronchi
Abdomen: soft, non-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, gait deferred.
Pertinent Results:
Admission Labs:
[**2104-12-19**] 05:00AM BLOOD WBC-7.0 RBC-3.71* Hgb-12.2* Hct-36.0*
MCV-97 MCH-32.8* MCHC-33.8 RDW-13.2 Plt Ct-194
[**2104-12-19**] 05:00AM BLOOD Neuts-52.7 Lymphs-39.0 Monos-4.5 Eos-3.1
Baso-0.7
[**2104-12-19**] 05:00AM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2104-12-19**] 05:00AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-136
K-4.2 Cl-99 HCO3-29 AnGap-12
[**2104-12-19**] 05:00AM BLOOD ALT-6 AST-16 LD(LDH)-126 AlkPhos-77
TotBili-0.3
[**2104-12-19**] 05:00AM BLOOD Lipase-23
[**2104-12-19**] 05:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.6
[**2104-12-19**] 05:00AM BLOOD cTropnT-<0.01
[**2104-12-19**] 05:59PM BLOOD cTropnT-<0.01
[**2104-12-19**] 05:31AM BLOOD Lactate-0.6
[**2104-12-19**] 07:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.033
[**2104-12-19**] 07:20AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2104-12-19**] 07:20AM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2104-12-19**] 07:20AM URINE CastHy-9*
.
Discharge Labs:
[**2104-12-24**] 06:55AM BLOOD WBC-4.8 RBC-3.49* Hgb-11.0* Hct-33.4*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.3 Plt Ct-209
[**2104-12-25**] 06:53AM BLOOD Glucose-85 UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-99 HCO3-31 AnGap-11
[**2104-12-22**] 07:30AM BLOOD Cortsol-2.6
[**2104-12-23**] 01:30PM BLOOD Cortsol-2.4
[**2104-12-23**] 02:10PM BLOOD Cortsol-11.0
[**2104-12-24**] 04:05PM BLOOD Cortsol-5.9
[**2104-12-24**] 05:18PM BLOOD Cortsol-22.5*
.
PENDING LABS: ACTH, Free Cortisol, Renin, Aldosterone from
[**2104-12-24**]
.
Microbiology:
Blood Cultures 11/4 and [**12-21**]: No growth (final)
Urine Culture [**12-19**]: No growth (final)
Catheter Tip culture [**12-21**]: No growth (final)
Influenza DFA [**12-19**]: Negative
.
IMAGING:
CTA Chest [**2104-12-19**]: The thyroid gland is unremarkable. There is
no axillary or mediastinal
lymphadenopathy by CT size criteria. The heart and greater
vessels are
unremarkable. There is mild coronary artery calcifications. No
pericardial
effusions are present. The pulmonary arteries are patent down to
the
subsegmental level. The lungs show minimal bibasilar atelectasis
and a small
focus of scarring in the left upper lobe, unchanged since [**2097**].
A 2 mm and 4
mm nodule in the right upper lobe is unchanged since the
previous examination.
No other nodules, effusions or consolidations are present. The
patient is
status post a coronary artery bypass grafting.
Although this examination was not intended for subdiaphragmatic
evaluation,
the partially imaged abdomen shows a granuloma in the right lobe
of the liver
and a calcified right adrenal nodule, unchanged. The patient is
status post
cholecystectomy.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or
blastic lesions or
fractures. There is mild scoliosis of the thoracic spine.
IMPRESSION:
No acute intrathoracic process.
.
CT Abd/Pelvis [**2104-12-19**]: 1. No acute intra-abdominal process.
2. Diverticulosis, but no diverticulitis.
3. Atherosclerotic disease of the coronary arteries and
intra-abdominal
aorta.
4. Scoliosis and degenerative changes of the lumbar spine.
.
TTE [**2104-12-22**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly 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. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild aortic
regurgitation. Pulmonary artery hypertension. Dilated ascending
aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2096-10-12**], the ascending aorta is slightly larger
and mild PA systolic hypertension is now identified. The other
findings are similar.
CLINICAL IMPLICATIONS:
Based on [**2100**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
CXR [**2104-12-24**]: In comparison with the study of [**12-19**], the cardiac
silhouette is
less prominent and the pulmonary vascularity is substantially
improved. Mild
atelectatic changes are seen at the bases.
Brief Hospital Course:
Mr. [**Known lastname 99802**] is a 77 yo M with a hx of CAD s/p CABG, HTN, HL,
recent diagnosis of prostate cancer who presented to the MICU
with chest pain and hypotension.
.
# Hypotension: Initially, the patient's hypotension in the
setting of low grade fevers was concerning for a septic
etiology. However, he only required pressors transiently, and
his blood pressure improved significantly with fluid
resuscitation. He was started on Unasyn, as possible sources of
infection were thought to be GU and oropharyngeal (patient had
recent prostate biopsy and dental work). Unasyn was stopped
when infectious workup remained unrevealing. He was ruled out
for an MI and a PE. After transfer to the medicine floor, the
patient's BP remained low but stable. A morning cortisol was
low, as was a cortisol stimulation test, raising concern for
adrenal insufficiency. The endocrinology service was consulted,
and performed another cortisol stimulation test; several
portions of this test were pending at discharge, and the patient
planned to follow up in endocrine clinic in several weeks. He
was started on hydrocortisone 15 mg in the AM and 5 mg in the PM
for presumed partial adrenal insufficiency, with a plan for
endocrine to taper steroids after the patient is seen in clinic.
.
# Fevers: During his stay in the MICU, the patient had low grade
fevers. However, no sources of infection were found. Workup
included urine culture, blood cultures, influenza DFA, CT
abdomen and pelvis and CTA chest. Additionally, the patient
underwent TTE to evaluate for culture negative endocarditis, and
no vegetations were seen. His fevers resolved several days
after admission, and he had been afebrile > 72 hours at the time
of discharge.
.
# Chest pain: The patient initially presented with chest pain,
which persisted throughout his hospitalization. He was ruled
out for PE, and cardiac enzymes were negative. He did have
subtle ECG changes when he was hypotensive on admission, and he
might benefit from repeat stress testing with imaging as an
outpatient.
.
# Anemia - The patient had a Hct drop from 36 to 31; this was
felt to be multifactorial from dilution after fluid
resuscitation, phlebotomy and ongoing hematuria related to
prostate cancer and recent prostate biopsy.
.
# Hypoxia - After fluid resuscitation the patient had a small
oxygen requirement. CXR showed interstitial edema and he
received several doses of oral furosemide with good urine
output. At discharge, his oxygen requirement had resolved and
his ambulatory O2 saturation was in the mid-90s.
.
# Prostate Ca - Patient reported a recent diagnosis of prostate
cancer, with a plan to follow-up with Dr. [**Last Name (STitle) 365**] as an outpatient.
.
# HTN - Anti hypertensives were initially held secondary to the
patient's hypotension, but low dose metoprolol was restarted on
discharge.
.
# CAD - Patient was continued on ASA. Metoprolol initially
held, but restarted on discharge.
.
# Spinal Stenosis: Continued on home oxycontin and prn
oxycodone.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet daily
FLUOXETINE - 20 mg Capsule daily
METOPROLOL SUCCINATE 25 mg daily
NITROGLYCERIN - 2.5 mg Capsule, Extended Release - 1 Capsule(s)
by mouth every 12 hours
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes up to 3 tablets for chest pain
OXAZEPAM 10 mg Capsule - 2 Capsule(s) by mouth at bedtime
OXYCODONE - 5 mg Tablet - Q 4-6 hours PRN pain
OXYCODONE [OXYCONTIN] - 10 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily in the morning and 1 at night
PRIMIDONE - 50 mg Tablet daily
SIMVASTATIN - 40 mg daily
SUCRALFATE 2 grams by mouth QAM and HS
URSODIOL - 300 mg Capsule - two Capsule(s) [**Hospital1 **]
VALSARTAN 40 mg Tablet daily
ASPIRIN 325 mg Tablet daily
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Tablet daily
OMEGA-3 FATTY ACIDS-FISH OIL
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. sucralfate 1 gram Tablet Sig: Two (2) Tablet PO twice a day.
10. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
11. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
Disp:*90 Tablet(s)* Refills:*2*
12. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Partial Adrenal Insufficiency
Hypotension
Acute pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 99802**],
You were admitted to the hospital with low blood pressure and
chest discomfort. Your blood pressure medications were held,
you were given IV fluids and your blood pressure improved. You
were seen by endocrinology while in the hospital, and they think
that you may have a partial deficiency in cortisol. You have an
appointment to see endocrinology in clinic to discuss whether
you will need any treatment for this condition.
.
We made the following changes to your home medications:
STOP Nitroglycerin
STOP Ursodiol
STOP Valsartan
START Hydrocortisone, 15 mg in the morning and 5 mg in the PM
around 2pm
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2104-12-29**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: MEDICAL SPECIALTIES-Endocrinology
When: MONDAY [**2105-1-12**] at 4:20 PM
With: DR. [**Last Name (STitle) **] & ZHIHENG [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
[
"518.4",
"414.00",
"401.9",
"272.4",
"285.9",
"V70.7",
"255.5",
"185",
"V45.81",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
14086, 14143
|
8877, 11914
|
311, 318
|
14251, 14251
|
4140, 4140
|
15103, 15841
|
3337, 3410
|
12826, 14063
|
14164, 14230
|
11940, 12803
|
14434, 14940
|
5173, 8379
|
3425, 4121
|
14958, 15080
|
8402, 8854
|
2175, 2656
|
248, 273
|
346, 2156
|
4156, 5157
|
14266, 14410
|
2678, 3099
|
3115, 3321
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,250
| 173,753
|
47023
|
Discharge summary
|
report
|
Admission Date: [**2200-10-1**] Discharge Date: [**2200-10-8**]
Date of Birth: [**2132-5-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
recurrent palate abscess, headache
Major Surgical or Invasive Procedure:
Formal Cerebral angiogram via the right groin.
History of Present Illness:
68F with recurrent palate abscess. The initial episode occurred
in [**10-14**] after pt had pain and swelling of her palate after
dental work. She had the lesion drained at that time resulting
in complete resolution of swelling and symptoms. Her symptoms
recurred with dental work in [**1-15**]. The lesion was again drained
and treated with penicillin with complete resolution of signs
and symptoms. Her symptoms returned again last week which also
included a fever. She had her lesion lanced and was treated
with clindamycin. The following morning she woke with a
mouthful of blood, which ceased after compression. It was noted
then that the patient was complaining of headache. She had
vomited twice and a head CT showed diffuse frontal subarachnoid
hemorrhage and enlarged pituitary.
Past Medical History:
OSA - requiring CPAP at 8 cm
HTN - on norvasc, metoprolol and lisinopril
MI - in the [**2175**].
Bilateral cataract operations
Chronic bronchitis
CVA [**1-15**]
Goiter
Partial hysterectomy
Social History:
90 pack years, has quit. No alcohol. Used to work as a nurse.
Lives alone, sister is upstairs. Never married, no kids.
Retired RN.
Family History:
Mother had a stroke in her 70s.
Physical Exam:
Exam:
Gen:pleasant woman lying in bed NAD
HEENT:No Carotid bruits, neck supple, R hard palate bleed
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: oriented to person, place, and date
Attention: able to due serial substractions
Recall: [**3-13**] at 5 minutes
Language: fluent with good comprehension and repetition; naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect
[**Location (un) **] intact
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
No pronator drift
Sensation: Intact to light touch.
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements normal, heel to shin also normal
Gait was not assessed this time.
Pertinent Results:
[**2200-10-7**] 05:55PM BLOOD WBC-11.8* RBC-3.66* Hgb-12.2 Hct-35.7*
MCV-97 MCH-33.3* MCHC-34.2 RDW-13.7 Plt Ct-393
[**2200-10-1**] 12:45PM BLOOD WBC-9.6 RBC-3.87* Hgb-12.5 Hct-37.8
MCV-98 MCH-32.3* MCHC-33.0 RDW-12.7 Plt Ct-332
[**2200-10-7**] 05:55PM BLOOD Plt Ct-393
[**2200-10-6**] 03:12AM BLOOD PT-13.5* PTT-21.6* INR(PT)-1.2
[**2200-10-1**] 12:45PM BLOOD Plt Ct-332
[**2200-10-1**] 12:45PM BLOOD PT-21.7* PTT-30.2 INR(PT)-3.4
[**2200-10-8**] 06:25AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-134
K-4.0 Cl-100 HCO3-26 AnGap-12
[**2200-10-1**] 12:45PM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-135
K-5.2* Cl-98 HCO3-22 AnGap-20
[**2200-10-8**] 06:25AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
[**2200-10-2**] 03:07AM BLOOD Calcium-10.4* Phos-3.7 Mg-1.7
[**2200-10-7**] 03:04AM BLOOD Phenyto-6.1*
[**2200-10-3**] 02:53AM BLOOD Phenyto-6.1*
[**2200-10-4**] 03:31AM BLOOD Type-ART pO2-100 pCO2-45 pH-7.46*
calHCO3-33* Base XS-6
[**2200-10-1**] Head CT:
1. Subarachnoid hemorrhage in the distribution of the anterior
cerebral
artery.
2. No evidence of hydrocephalus or shift of normally midline
structures or
mass effect.
3. Right maxillary sinus opacification, which may be related to
right hard
palate abnormality. Would recommend dedicated facial bone scan
with contrast if clinically indicated to further evaluate this
lesion.
[**2200-10-2**] head CT:
1. Unchanged subarachnoid hemorrhage in the distribution of the
anterior
cerebral arteries.
2. Small hyperdensity in the right trigone consistent with small
amount of
intraventricular hematoma.
3. Right maxillary sinus opacification of unclear etiology.
Recommend
dedicated facial bone scan with contrast if clinically indicated
to further
evaluate this lesion.
[**2200-10-3**] Head CT:
IMPRESSION: No significant interval change in subarachnoid
hemorrhage and
likely small intraventricular hemorrhage compared to study of
one day prior.
[**2200-10-3**] EKG: Sinus rhythm. Diffuse non-specific ST-T wave
changes. Compared to the previous tracing of [**2200-1-30**] the rate
has increased.
[**2200-10-3**] CXR: IMPRESSION: Mild congestive heart failure with
cardiomegaly and small bilateral pleural effusion. Bibasilar
patchy atelectasis.
[**2200-10-4**] Head CT: IMPRESSION: Stable appearance of subarachnoid
and intraventricular hemorrhage.
[**2200-10-6**] cerebral angiogram:
IMPRESSION: No evidence of intracranial aneurysm or arterial
vascular
malformation. No cause for subarachnoid hemorrhage identified.
The left
anterior cerebral artery territory was supplied by the right
anterior cerebral artery by way of the anterior communicating
artery. Again seen is a small infundibulum at the origin of the
right posterior communicating artery.
Brief Hospital Course:
68F with SAH on CT s/p palate abscess drainage. She was
admitted to the neuro ICU for qhr checks. Her INR was reversed
with FFP, platelets and vitamin K. She was given Nimodipine to
maintain her SBP between 100 and 130. She was given dilantin as
seizure prophylaxis. Her repeat head CT's during her hospital
course showed that the hemorrhage was stable in appearance. Her
clindamycin was continued for a course of total 7 days. ENT was
consulted for her palate abscess. They recommended follow-up
with Dr. [**Last Name (STitle) 99691**] in 2 weeks. On HD6 pt received a cerebral
angiogram that showed no evidence of aneurysm. She was
transferred to the floor on HD7. PT and OT were consulted and
recommended rehab secondary to poor functional status. She was
discharged to rehab in stable condition on [**2200-10-8**].
Medications on Admission:
ALBUTEROL 17 GM--Two puffs up to four times a day as needed
AMBIEN 5 mg--1 tablet(s) by mouth at bedtime as needed for
insomnia
ASA 81 MG--One tablet every day
COLACE 100MG--One tablet twice a day - tid, as needed
COUMADIN 1MG--one tablet(s) by mouth once a day
COUMADIN 5MG--one tablet(s) by mouth once a day
DETROL LA 4MG--Take one by mouth every day
FLUOXETINE HCL 40 mg--1 capsule(s) by mouth once a day
HYDROCHLOROTHIAZIDE 25 MG--Take one by mouth every day
LISINOPRIL 40 mg--1 tablet(s) by mouth once a day
LOPRESSOR 50 mg--1 (one) tablet(s) by mouth twice a day
LOVASTATIN 20 mg--1 tablet(s) by mouth once a day
ULTRAM 50MG--One tablet tid, prn, pain
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**1-12**]
Tablets PO Q4-6H (every 4 to 6 hours) as needed.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO ONCE (once) for 1 doses.
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. HydrALAZINE HCl 20 mg IV Q6H PRN SBP>150
hold for SBP<110
give for SBP>150
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P subarrachnoid hemorrhage - No aneurysm identified on
angiogram.
Discharge Condition:
neurologically stable - awake alert oriented. Follows commands.
speech clear - requires balance and mobility training.
Discharge Instructions:
please call Dr [**Last Name (STitle) **] for any mental status changes,
neurological deterioration - if you cannot reach him - please go
to the nearest emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 9977**] Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2200-10-28**] 10:45
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2201-1-2**]
11:00
Provider: [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2201-3-13**] 11:30
Provider: [**Name10 (NameIs) **] up with Dr. [**Last Name (STitle) **] in one month - Neurology
call for appointment [**Telephone/Fax (1) 2574**].
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66323**] in 2 weeks - ENT [**Telephone/Fax (1) 41**] for
follow up of palate abcess..possible MRI for follow up of palate
and thyroid.
Completed by:[**2200-10-8**]
|
[
"430",
"780.57",
"241.0",
"412",
"491.9",
"401.9",
"438.89",
"526.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.41",
"99.05",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8756, 8826
|
5768, 6600
|
354, 402
|
8937, 9058
|
3045, 3980
|
9274, 10192
|
1606, 1639
|
7308, 8733
|
8847, 8916
|
6626, 7285
|
9082, 9251
|
1654, 1842
|
280, 316
|
430, 1228
|
2234, 3026
|
5260, 5745
|
1881, 2218
|
1866, 1866
|
1250, 1441
|
1457, 1590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,755
| 138,100
|
39974
|
Discharge summary
|
report
|
Admission Date: [**2138-11-7**] Discharge Date: [**2138-11-24**]
Date of Birth: [**2066-10-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
hepatocellular carcinoma
Major Surgical or Invasive Procedure:
right hepatic lobectomy
History of Present Illness:
Patient is a 72-year-old Chinese-speaking male with chronic HBV
and who in the past has had an undetectable viral load. He notes
a recent history of right upper quadrant abdominal pain for the
past six to eight weeks. This is
relatively constant and there is no exacerbating or alleviating
factors. On [**2138-10-10**], he underwent a CT scan of the
abdomen that demonstrated multiple cysts throughout the liver.
However, in the right lobe, there is a less well-defined
multicentric low density and it was unclear by report whether
this was a cystic or solid, and an MRI was recommended. An MRI
on [**2138-10-24**] demonstrated again multiple cysts throughout the liver
measuring up to 2.7 cm in diameter. There was a multifocal
solid
mass in the right lobe of the liver measuring 3.3 x 4.8 cm.
There is less than 1.5 cm arterial enhancing focus in the right
lobe of the liver. This was thought to be a tumor thrombus in a
branch of the right portal vein, but the main right, right
anterior, and right posterior portal veins are patent. His
hepatitis A antibody was positive. His hepatitis B core
antibody was positive, hepatitis B surface antigen positive and
HBV quantitative was 17,433,484 and AFP on [**2138-10-28**], was
110. He currently is doing well clinically. He is eating and
tolerating a regular diet, having normal formed bowel movements,
and remains fully active in spite of his discomfort.
Past Medical History:
PMHx
1. hepatocellular carcinoma
2. hepatitis B
3. benign prostatic hypertrophy, elevated PSA
4. chronic obstructive pulmonary disease
5. obstructive sleep apnea on CPAP
PSurgHx
1. appendectomy
Social History:
He is married with 2 children. He is a retired cook. He has a
history of drinking one beer per day for 10 years, but quit
several months ago. He has a history of smoking half pack of
cigarettes per day for 20
years, but quit 30 years ago. He has no history of IV drug use,
marijuana use, tattoos, or piercing. He has had blood
transfusions 40 years ago.
Family History:
His mother committed suicide at age 60, and his father was
murdered in [**Name (NI) 651**] at
age 40.
Physical Exam:
post-op exam:
T 97.1 HR 112, BP 96/61, RR 23, SpO2 96% on 3L NC
gen: drowsy but awake, oriented X3
neck: supple
chest: CTAB
cardiac: nl S1S2, no murmurs, rubs, or gallops
abdomen: soft, appropriately tender without rebound; dressings
clean, serosanguinous fluid in JP
ext: wwp, no edema
Pertinent Results:
[**2138-11-7**] 01:29PM PT-16.0* PTT-38.2* INR(PT)-1.4*
[**2138-11-7**] 01:29PM PLT COUNT-138*
[**2138-11-7**] 01:29PM WBC-16.4*# RBC-3.74* HGB-11.8* HCT-34.3*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.6
[**2138-11-7**] 01:29PM CALCIUM-7.1* PHOSPHATE-3.9 MAGNESIUM-2.4
[**2138-11-7**] 01:29PM ALT(SGPT)-328* AST(SGOT)-405* ALK PHOS-59 TOT
BILI-3.1*
[**2138-11-7**] 01:29PM GLUCOSE-120* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-19* ANION GAP-21*
[**2138-11-7**] liver biopsy: grade 2 inflammation, grade 3 fibrosis
[**2138-11-7**] resection specimen: pT3 G3 6.4 X 4.0 X 3.0 HCC
[**2138-11-8**] liver U/S: multiple cysts in remaining left lobe,
normal vascular flow
[**2138-11-9**] CXR: bilateral pleural effusions
[**2138-11-10**] liver U/S: patent portal and hepatic veins
[**2138-11-14**] CXR; Persistent moderately large right posteriorly
layering pleural effusion. Mild left lower lobe atelectasis and
small left pleural effusion.
[**2138-11-24**] abdominal U/S: small pockets of abdominal fluid were
identified in the left lower quadrant and lower central abdomen.
A small
pocket of fluid is seen along the superior margin of the liver.
Not enough fluid to drain.
Brief Hospital Course:
Patient was admitted on [**2138-11-7**] for right hepatectomy for
hepatocellular carcinoma (please refer to Dr.[**Name (NI) 1369**] operative
note from [**2138-11-7**]). Surgery was without complication: estimated
blood loss was 1500 mL, for which patient received 2 units
pRBCs; pathology demonstrated HCC with > 1 cm margins. Patient
was transferred extubated to the PACU in stable condition. Pain
control was maintained with intrthecal morphine by Acute Pain
Service. While in the PACU, patient required multiple fluid
boluses (5.5 L) and 25% albumin for hypotension, tachycardia,
and low urine output, which responded, but was kept in the PACU
overnight for observation. An EKG and cardiac enzymes were
obtained for chest pain and were negative.
[**11-8**]: transferred to the floor. Triggered for dizziness on
getting out of bed. Recovered after lying down with stable BP.
[**11-9**]: Triggered for tachycardia (143), low sat (90-93% on
3LNC), and low urine output (100 cc frank blood). Respiratory
distress attributed to pulmonary edema. Patient was transferred
to the SICU and a urology consult was obtained for hemorrhage
into Foley. Cystoscopy demonstrated uretral tear and prostatic
bleeding: 3-way Foley placed and bladder irrigated. Started on
neosynephrine for hypotension. Intubated for respiratory
acidosis. Ultrasound demonstrated normal bloodflow to liver
remnant. Started on rifaximin and lactulose.
[**11-10**]: Weaned off pressors, but required fluid boluses to
maintain pressure. Received 2 u pRBCs for HCT of 20.8
[**11-11**]: Started on TPN.
[**11-12**]: Extubated and Swan removed. Tachycardic to 140s and
hypertensive.
[**11-14**]: Gentle diuresis with Lasix. NG tube out. Confused. Passed
swallow eval.
[**11-15**]: antibiotics discontinued. Tolerated clears.
[**11-16**]: Transferred to floor. Mental status improved after
narcotics discontinued.
[**11-17**]: Tolerated regular diet. TPN discontinued.
[**11-18**]: Foley removed. Initially incontinent but later voiding
normally.
[**11-19**]: JP discontinued. Peritoneal fluid sent: no evidence of
spontaneous bacterial peritonitis (WBC 233, RBC 478, negative
gram stain and culture).
[**11-20**]: Started on Lasix and aldactone for edema/ascites and
Cipro for SBP prophylaxis. Suture placed at drain site for fluid
leakage.
[**11-22**]: Central venous access discontinued. Staples removed from
wound. Ascitic leakage from incision and drain site.
[**11-24**]: Ultrasound obtained showing minimal ascites. Sutures
placed at drain site and incision with cessation of fluid
leakage. Pain controlled on Tylenol and oxycodone. Tolerating
regular diet. Vital signs stable. Edema improved. Consequently,
discharged home.
Medications on Admission:
1. Viread 300 mg daily
2. Albuterol prn wheezing
3. calcium
4. glucosamine
5. vitamin E
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
3. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q 12H
(Every 12 Hours).
Disp:*900 ML(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as
needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*0*
8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Glucosamine Oral
11. vitamin E Oral
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hepatocellular carcinoma s/p R hepatic lobectomy
urethral injury from Foley insertion
HBV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
VNA has been set up to assist you at home.
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, constipation, inability to take or
keep down food, fluids or medications.
Monitor the incision for redness, drainage or bleeding. You
should change your wound dressing regularly. The drainage should
decrease with time.
No heavy lifting
No driving if taking narcotic pain medication
Followup Instructions:
Call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] to make an appointment to
be seen on Wednesday, [**12-3**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"600.00",
"789.59",
"998.2",
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"070.32",
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"327.23",
"155.0",
"348.30",
"276.69",
"573.8",
"790.93",
"518.81",
"514",
"276.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"50.11",
"99.15",
"89.64",
"57.32",
"50.3",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7971, 8028
|
4070, 6777
|
340, 366
|
8161, 8161
|
2841, 4047
|
8783, 9039
|
2415, 2519
|
6915, 7948
|
8049, 8140
|
6803, 6892
|
8312, 8760
|
2534, 2822
|
276, 302
|
394, 1807
|
8176, 8288
|
1829, 2025
|
2041, 2399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,181
| 188,047
|
33616
|
Discharge summary
|
report
|
Admission Date: [**2200-5-25**] Discharge Date: [**2200-7-10**]
Date of Birth: [**2126-10-4**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**Known firstname 148**]
Chief Complaint:
Pancreatic head necrosis
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Retroperitoneal exploration and drainage of abscess.
3. Open cholecystectomy.
4. Duodenostomy tube placement.
5. G-tube placement.
6. J-tube placement.
7. Tracheostomy
8. Incision, drainage and debridement of right inguinal canal
and the suprapubic space.
9. Incision and drainage of scrotum.
History of Present Illness:
73M transferred from [**Hospital3 **] Hospital for necrosis of pancreas
seen on CT s/p emobolization of pancreaticoduodenal artery 2
days ago for upper GI bleed. He was in usual health 4 days ago
when he had two episodes of bright red blood per rectum with
associated light headedness, no CP or SOB. Was seen in ED
and admitted to medicine service. Tagged RBC showed possible
bleeding proximal transverse colon but EGD 2 days ago revealed
"welling up" of blood in 2nd portion of duodenum with no
identification of source. IR was consulted and embolization of
the duodenal portion of the pancreaticoduodenal artery was
performed the same day [**2200-5-23**]. Patient has not had any
subsequent episodes of BRBPR. CT today was significant for
ileus and low attenuation of head of pancreas worrisome for
ischemia/necrosis and thickening of wall of duodenum. Patient
was tranferred to [**Hospital1 18**] for evaluation and care.
During hospitalization patient received a total of 5 units PRBC
with 2 of those units being transfused overnight of [**5-24**]. He
had an NGT placed prior to transfer to [**Hospital1 18**]. Colonoscopy was
never performed to evaluate proximal transverse colon.
Past Medical History:
PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal
ulcers, Gout, Neuropathy, Back pain, h/o carpal tunnel, cervical
radiculopathy
Social History:
Married, smokes 2 ppd, retired reader's digest editor
Family History:
nc
Physical Exam:
Vitals: 98.3, 76, 130/61, 24, 93RA
A&Ox3, NAD
NC/AT
NGT to low wall suction putting out thick light green fluid, no
blood
CV: RRR with 3/6 systolic murmur best heard LUSB
Pulm: lungs clear to auscultation bilaterally
GI: Distended, +BS, TTP in epigastrium and in RLQ. + tympany,
soft, no guarding or rebound tenderness, Rectal exam with
melanic
stool guiac +
GU: no foley
Ext: warm and dry
Pertinent Results:
[**2200-5-26**] 12:18AM BLOOD WBC-13.5* RBC-3.84* Hgb-12.5* Hct-34.7*
MCV-90 MCH-32.6* MCHC-36.0* RDW-17.4* Plt Ct-160
[**2200-5-26**] 08:30AM BLOOD WBC-11.5* RBC-3.53* Hgb-11.1* Hct-32.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-17.3* Plt Ct-143*
[**2200-5-26**] 12:18AM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-104 HCO3-20* AnGap-16
[**2200-5-26**] 12:18AM BLOOD ALT-29 AST-37 LD(LDH)-290* AlkPhos-64
Amylase-158* TotBili-1.9*
[**2200-5-26**] 12:18AM BLOOD Lipase-92*
[**2200-5-26**] 12:18AM BLOOD Albumin-3.0* Calcium-9.9 Phos-1.9*
Mg-1.2*
.
CT HEAD W/O CONTRAST [**2200-5-26**] 4:17 AM
IMPRESSION: No acute intracranial process.
.
CTA ABD W&W/O C & RECONS [**2200-5-29**] 2:01 AM
IMPRESSION:
1. Large gas- and fluid-containing retroperitoneal collection
extending from the region of the second portion of the duodenum
and pancreatic head, along the right flank, through the right
inguinal canal into the right scrotum. The findings are
consistent with duodenal perforation, likely related to reported
recent embolization.
2. Necrosis of the pancreatic head, largely replaced by a gas-
and fluid- containing collection. No pancreatic ductal dilation.
3. 11-mm cystic lesion in the uncinate process of the pancreas.
This could possibly relate to the patient's acute syndrome, as
in the case of focal pancreatic necrosis, versus a primary
cystic lesion of the pancreas or dilation of the uncinate
process duct. If this lesion is not resected, further followup
will be required after the patient's acute process has resolved.
4. Massive scrotal edema and right-sided hydrocele directly
extending from the retroperitoneal collection. The marked
enhancement about the periphery of the collection and marked
scrotal edema are consistent with inflammatory process.
5. Bilateral hypodense renal lesions, too small to characterize.
6. Probable gallbladder adenomyomatosis.
.
SCROTAL U.S. [**2200-5-29**] 1:58 PM
TESTICULAR ULTRASOUND: Comparison was made with the CT scan
performed on the same day dated [**2200-5-29**]. Right testicle
measures 2.8 x 2.6 x 3.6 cm. Left testicle measures 2.8 x 2.2 x
3.5 cm. The vascularity to the testicles is preserved without
evidence of focal lesion. Echotexture of the testicles is
normal. Within the bilateral scrotum in extratesticular
location, there is markedly heterogeneous and echogenic complex
fluid, due to extension of the pancreatic fluid tracking down in
the retroperitoneum as seen on the CT study. The skin is
thickened; however, there is no evidence of subcutaneous air.
IMPRESSION: Heterogeneous complex material and fluid within the
scrotum bilaterally in extratesticular location, due to tracking
and accumulation of the pancreatic fluid seen on CT study.
Normal testicles with preserved flow without focal lesion. The
findings were discussed with the referring physician.
.
ECHO
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of mild to moderate ([**2-12**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT ABDOMEN W/O CONTRAST [**2200-6-1**] 10:23 AM
CONCLUSION:
1. Interval improvement in the patient's right flank
retroperitoneal collection, status post surgery. Multiple drains
are identified in situ. No evidence of intraperiotneal spillage
of contrast pd connection with the residual collection .
2. There has been dramatic interval worsening in the patient's
pulmonary status and consideration towards a formal chest CT to
further evaluate these is made. There is a wide differential
including pulmonary edema, infection and ARDS.
.
CHEST (PORTABLE AP) [**2200-6-5**] 4:24 AM
FINDINGS: As compared to the previous radiograph, there is a
slight improvement. The extent of the left-sided pleural
effusion has decreased, the right lung has increased in
transparency. There are still moderate opacities at the right
lung base and extensive retrocardiac atelectasis. The size of
the cardiac silhouette is unchanged. Also unchanged are the
positions of the monitoring and support devices. There is no
evidence of newly occurred parenchymal opacities.
.
CT PELVIS W/CONTRAST [**2200-6-13**] 1:01 PM
IMPRESSION:
1. Interval development of large amount of air and fluid within
the right scrotum, which extends into the right lower anterior
abdominal wall. A catheter is identified extending from the
right retroperitoneal flank into the right inguinal canal.
2. Splenic hypodensity and renal hypodensities, too small to
characterize.
3. Interval improvement in bilateral patchy opacities at the
lung bases.
4. Unchanged appearance of bilateral pleural effusions.
.
CHEST (PORTABLE AP) [**2200-6-25**] 3:51 PM
As compared to the previous radiograph, the intrathoracic tube
has been exchanged for a tracheal tube. The left-sided central
venous access line has been removed. Increase in extent of the
left-sided pleural effusion. Unchanged extent of the
retrocardiac atelectasis. Unchanged extent of moderate pulmonary
edema, there is no evidence of newly occurred focal parenchymal
opacities suggestive of pneumonia.
.
CT ABDOMEN W/CONTRAST [**2200-7-3**] 2:46 PM
IMPRESSION:
1. Interval decrease in large amount of air and fluid collection
within the right lower anterior abdominal wall extending to the
right scrotum.
2.Catheter is identified near the medial portion of the duodenum
at the site of perforation. Small fluid collection measuring 1.5
cm is noted near the third portion of the duodenum.
3. Bilateral pleural effusions.
.
CHEST (PORTABLE AP) [**2200-7-5**] 4:22 AM
Tracheostomy tube and right subclavian catheter remains in
place. A small right and moderate left pleural effusion have
increased in the left side. There has been mild interval
worsening of moderate-to-severe pulmonary edema. There has been
interval increase in left lower lobe retrocardiac atelectasis.
The left cardiac border is obscured by the pleuroparenchymal
opacities.
.
Brief Hospital Course:
This is a 73 yo M with pancreas necrosis based on CT finding
from [**Hospital3 **]
hospital related to embolization of Pancreaticoduodenal artery
on [**5-23**]. Since then his GI bleed has stabilized without any
additional events of BRBPR or melena. However a colonoscopy to
evaluate tagged RBC scan findings of proximal transverse colon
was not done. He was transferred to the ICU on [**5-30**] for CHF,
respiratory distress.
CV: Murmur, on cardizem at home, will give IV metop. He had an
episode of A-fib on HD 5. This was a transient episode that
resolved with IV Lopressor.
ON HD 6, he had an episode of CHF, Respiratory distress and was
transferred to the ICU. His BNP was 1072. [**6-23**] Echo: EF>65%, 2+
MR (eccentric), stable c/w [**2200-5-30**]. On [**6-24**] he another bout of
AFIB. Upon discharge, the patient is in normal sinus rhythm.
GI: GI bleed/necrosis pancreas/ileus - NGT to suction, NPO,
Protonix [**Hospital1 **], serial abdominal exams. T-bili was slightly
elevated at 1.9 on admission. Amylase and Lipase were also
elevated.
His CAT scan revealed a gross amount of retroperitoneal air and
this tracked down into the right testicular region and was
entirely consistent with pancreatic necrosis gone afoul. The
patient suffered signs of sepsis including atrial fibrillation
and respiratory distress in the day prior to this operation and
he underwent exploration for management.
He went to the OR on [**2200-5-30**] for:
1. Exploratory laparotomy.
2. Retroperitoneal exploration and drainage of abscess.
3. Open cholecystectomy.
4. Duodenostomy tube placement.
5. G-tube placement.
6. J-tube placement.
He went to the OR on [**2200-6-16**] for:
1. Incision, drainage and debridement of right inguinal canal
and the suprapubic space.
2. Incision and drainage of scrotum.
He went for EGD on PPD 5 and this showed a single ulcer large
ulcer was found in the duodenum on the medial wall extending
from the duodenal bulb to the second portion of the duodenum.
The ulcer was partially obscured by debris and necrotic material
but there was a suggestion of ischemia with no obvious mass and
no bleeding.
He was also complaining of right inguinal pain. An US showed no
evidence of pseudoaneurysm. Loops of bowel corresponding to
point of patient's maximal tenderness. He was noted to have
progressive scrotal swelling. A CT the next day showed a right
hydrocele. A repeat CT scan demonstrated evidence of fluid
tracking through the inguinal canal from a retroperitoneal
collection into the scrotum. It was determined that he needed to
go to OR for washout and drainage. The wound was packed with
WTD dressings and we intermittently used a wound vac to help
with healing.
Repeat Abd CT on [**7-3**] showed gastric contrast appears to have
traversed duodenum with a decrease collection w/in R abd
wall-->R scrotum.
Upon discharge, the patient's wound is healing very nicely, and
we are continuing with [**Hospital1 **] WTD dressing changes.
H.pylori was negative.
Delerium: Possibly related to EtOH withdrawl. He had one
unwitnessed fall when trying to get out of bed. He had family at
the bedside during the day for reorientation and sitter at
night. Geriatrics was consulted for the delirium and
recommendations followed
FEN: A PICC was placed on [**5-27**] and TPN initiated. TPN was
discontinued [**6-11**] and the patient's tube feeds were advanced to
65cc/hr. Upon discharge, the patient's tube feeds were Replete
with fiber full strength at a rate of 70cc/hr with q4h 30cc
water flushes.
Respiratory: On [**2200-6-12**]: He received a tracheosotmy. On [**6-26**] the
trach was downsized. The patient was on and off of the vent and
required a continued stay in the ICU. Upon discharge, the
patient had been off of the vent for ~4-5 days without signs of
respiratory distress.
Infectious diseases:
MICRO:
[**6-29**]:C diff neg
[**6-29**] BAL: NG
[**6-20**] Peritoneal Cx: Enterobacter x2
[**6-16**] Inguinal Canal OR swab : Enterobacter x2
[**6-9**] Sp Cx: enterobacter cloacae
[**5-30**] RP tissue: Prevotella Beta lactam neg. and Strep Viridans
[**5-30**] RP fluid: GNR, GPC, strep viridans
[**5-26**] Hpylori: Neg
Upon discharge, the patient is in stable condition, has been off
of the vent for > 4 days, is afebrile with all vitals stable,
tolerating tube feeds well, and with pain controlled.
Medications on Admission:
atenolol 50', Cartia 120', Lisinopril 40', Prednisone 5'',
Naproyn 500'', Zocor 40', Nexium 40', Cochicine .6', ASA 81',
MVI', Vit B12, Vit D
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
2. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: 2.5 Tablets PO TID (3
times a day).
3. Lisinopril 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
4. Quetiapine 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every 12
hours) as needed for agitation, insomnia.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) unit
Injection ASDIR (AS DIRECTED): Fingerstick QACHS, Q6HInsulin SC
Fixed Dose Orders
Breakfast Dinner
NPH 5 Units NPH 5 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime Q6H
Regular Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
Insulin Dose
0-60 mg/dL [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**]
amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 2
Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units 4
Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units 6
Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units 8
Units
281-320 mg/dL 10 Units 10 Units 10 Units 10 Units 10
Units
321-360 mg/dL 12 Units 12 Units 12 Units 12 Units 12
Units
361-400 mg/dL 14 Units 14 Units 14 Units 14 Units 14
Units
Notify M.D.
.
8. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: 4-8 Puffs
Inhalation Q4-6H () as needed.
10. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 4-8 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Octreotide Acetate 100 mcg/mL Solution [**Month/Day (2) **]: One Hundred
(100) mcg Injection Q8H (every 8 hours).
12. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).
13. Amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
14. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day (2) **]: Three [**Age over 90 1230**]y
(350) mg PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
Ischemic pancreatic head
Retroperitoneal ulcer with duodenal ulcer and perforation.
Sepsis.
Delerium
Acute CHF
Respiratory Failure
Inguinal and scrotal sepsis on the right side.
Discharge Condition:
Stable off vent
Continue drain care
Continue wound care
PT
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.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.
You have a right groin wound that will be changed twice a day
with wet to dry gauze packings
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1231**] Call to schedule
appointment
|
[
"575.11",
"567.22",
"E878.8",
"427.31",
"567.38",
"998.59",
"997.4",
"518.81",
"608.4",
"603.1",
"293.0",
"305.1",
"428.0",
"287.5",
"584.9",
"577.0",
"532.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"51.22",
"54.4",
"52.22",
"61.0",
"38.93",
"96.6",
"33.24",
"45.16",
"99.15",
"43.19",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
15938, 16004
|
8938, 13284
|
320, 646
|
16226, 16287
|
2554, 8915
|
17838, 17987
|
2124, 2128
|
13476, 15915
|
16025, 16205
|
13310, 13453
|
16311, 17815
|
2143, 2535
|
255, 282
|
674, 1870
|
1892, 2037
|
2053, 2108
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,503
| 152,555
|
14022
|
Discharge summary
|
report
|
Admission Date: [**2142-9-23**] Discharge Date: [**2142-9-27**]
Date of Birth: [**2065-9-26**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Codeine / Ticlid / Atorvastatin /
Lipitor / Crestor / albuterol
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75F PMHx polycythemia [**Doctor First Name **], Afib on coumadin s/p cardioversion
in [**10-4**], chronic CHF (EF 45%), CAD s/p CABG s/p multiple PCIs,
COPD, hx of thoracic aortic aneurysm, Barrett's esophagus,severe
PVD s/p femoral stenting b/l renal artery stenosis s/p right
stent placed [**11-28**], and LLL wedge resection for stage 1A squamous
cell CA presenting from BIDN with AFib with RVR and unstable
angina. Patient initially presented to BIDN on [**9-21**] with
several days worth of worsening SOB, CXR showed lower lobe
consolidation, and she was started on levofloxacin as well as
steroids and nebulizers for COPD.
.
She then started to have continued runs of AFib with RVr into
the 120s, with subseuqent jaw pain (her anginal equivalent), and
anterior ST depressions. The jaw pain would resolve with SL
Nitro, then return intermittently and she was thus started on a
nitro gtt, as well as a dilt gtt for rate control. Also of
note, her Hct had decreased from 28 to 22 with no obvious
bleeding source, INR 3.5. She was given 10 mg VitK, 2 units
PRBCs prior to transfer. She is being transferred for possible
cath, on a nitro gtt, dilt gtt.
.
The patient has a history of CAD s/p MI, PTCA and CABG in '[**17**].
Pt's anginal equivalent is jaw pain; pMIBI in [**2139**] showed
reversible moderate in severity ischemic defect in the distal
anterior wall and apex. Hypokinesis of the distal anterior wall
and apex.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CAD s/p CABG [**2117**], stent [**2128**]
HTN
COPD
bilateral renal artery stenosis s/p right stent placed [**11-28**]
Right femoral aa stent placed ([**2134**]?)
Left femoral aa angioplasty
thoracic aortic aneurysm medically managed
atrial fibrillation
anxiety
Barrett's esophagus seen on last EGD [**2134**]- but not on bx
s/p LLL wedge resection [**2140**] for Stage 1A squamous cell
carcinoma
s/p cholecystectomy
s/p appendectomy
s/p oophrectomy
h/o GIB- 2yr ago, EGD/colonoscopy at OSH
Social History:
Lives alone in [**Location (un) 1411**] with a cat, used to work as a MA in
nursing, now collects
SSI. Has four children. Son [**Name (NI) **] and [**Name2 (NI) 41859**] [**Doctor First Name 8513**] are
closely involved with her care. 60pk-yr tobacco history,
stopped [**1-/2141**]; denies etoh, illicits
Family History:
mother, grandmother - liver cancer.
Father/Brother "heart disease" (deceased)
Physical Exam:
ADMISSION
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple, JVP to edge of mandible
CARDIAC: irregular rhythm, S1, S2, no murmurs/rubs/gallops
appreciated
LUNGS: crackles throughout lower [**11-26**] of lung fields bilaterally,
some improvement with coughing
ABDOMEN: Soft, nontender, nondistended, +BS
rectal: guaic negative, brown stool in the rectal vault
EXTREMITIES: warm, well-perfused, 2+ DP pulses, some bruising on
UE b/l, no bruising of thighs/back
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
DISCHARGE
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple, could not appreciate JVP
CARDIAC: irregular rhythm, S1, S2, no murmurs/rubs/gallops
appreciated
LUNGS: bibasilar inspiratory crackles, much improved from
yesterday, bronchial breath sounds throughout, no wheezes
appreciated
ABDOMEN: Soft, nontender, nondistended, +BS
EXTREMITIES: warm, well-perfused, 2+ DP pulses, some bruising on
UE b/l, no bruising of thighs/back
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:
ADMISSION:
[**2142-9-23**] 09:22PM GLUCOSE-168* UREA N-41* CREAT-1.6* SODIUM-139
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-21* ANION GAP-15
[**2142-9-23**] 09:42PM PT-35.5* PTT-30.3 INR(PT)-3.6*
[**2142-9-23**] 09:22PM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-2.3
[**2142-9-23**] 09:22PM WBC-24.0* RBC-3.48* HGB-9.0* HCT-28.5* MCV-82
MCH-25.9* MCHC-31.6 RDW-15.4
.
DISCHARGE:
[**2142-9-27**] 05:48AM BLOOD Glucose-109* UreaN-44* Creat-1.3* Na-140
K-3.7 Cl-105 HCO3-28 AnGap-11
[**2142-9-27**] 05:48AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.3
[**2142-9-27**] 05:48AM BLOOD WBC-14.4* RBC-3.65* Hgb-9.5* Hct-30.1*
MCV-83 MCH-26.2* MCHC-31.7 RDW-15.7* Plt Ct-266
.
Sputum Culture:
GRAM STAIN (Final [**2142-9-25**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
MOLD. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- 2 S
.
IMAGING:
FINDINGS: Bilateral lungs are hyperexpanded, suggestive of COPD.
Since
[**2142-9-22**], bilateral lower lung opacities have worsened
concerning for an aspiration. Minimal left pleural effusion is
unchanged. Both upper lungs are clear. Top normal size heart,
mediastinal and hilar contours are normal. Left PICC line ends
at mid SVC. Patient is status post median sternotomy and sternal
sutures are intact. Atherosclerotic calcifications seen at the
aortic arch and descending thoracic aorta.
.
IMPRESSION: Since [**2142-9-22**], new bilateral lower lung
opacities are
concerning for aspiration and mild left pleural effusion is
unchanged.
Brief Hospital Course:
ASSESSMENT AND PLAN:
75F PMHx Afib on coumadin chronic CHF (EF >55%), CAD s/p CABG,
severe COPD on 3L home O2, stage 1A squamous cell lung ca who
presented with aFib with RVR in the setting of a pnuemonia and
COPD exacerbation, now rate controlled and treated, being
discharged to rehab.
.
ACTIVE ISSUES:
#Atrial Fibrillation: Transfered from [**Hospital1 **] [**Location (un) 620**] with Afib with
RVR and jaw pain thought to be from rate related ischemia. She
was rate controlled with IV agents, with resolution of her jaw
pain. Patient transitioned to PO diltiazemn 360 daily and
metoprolol 100 daily. Her warfarin was briefly held on
admission, then restarted at her home dose of 2.5mg daily (at
discharge INR was 1.2, not bridging).
.
#Pneumonia: Patient w bilateral lower lung opacities in setting
of increased O2 requirement and leukocytosis. She was started
on broad spectrum abx [**2142-9-21**], though on [**2142-9-27**], sputum
cultures grew strenotrophomonas, necessitating switching patient
to Bactrim DS 2 tabs TID for 14 days (first day [**2142-9-27**]).
.
# COPD Exacerbation: O2 requirment up to 4L on admission from
baseline 3L; she was given IV steroids, ipratropium nebulizers
and treatment of PNA as above; later switched to PO prednisone
with the plan for slow taper given severe underlying lung
disease; at discharge, plan to receive one more day of 40mg po
prednisone followed by 5 days of 20 mg po prednisone then stop.
She should continue tiotropium and advair. Albuterol was avoided
as she has a history of tachycardia following albuterol use.
.
# Chronic Diastolic CHF / Volume overload: Pt received 2U PRBC
at OSH and was volume overloaded which may have been
contributing to her SOB. She was diuresed with IV lasix and was
net negative >7L on discharge.
.
# CAD: Has h/o CABG and multiple PCIs. Has known reversible
ischemia from stress on 4/[**2139**]. Jaw pain most likely from rate
related demand ischemia versus ACS. Jaw pain resolved with rate
control. Cardiac enzymes were negative.
.
# HTN: Started lisinopril 10mg. The lisinopril was added during
this hospitalization so renal function and potassium should be
followed for a short period of time.
.
CHRONIC ISSUES:
# PAD: Severe PVD s/p femoral stenting b/l renal artery stenosis
s/p right stent placed [**11-28**]. Not on plavix, continued Asa 81mg
daily, and pravastatin 80mg daily.
.
# HLD: Continued pravastatin 80 mg daily
.
# Barrets esophagus/GERD: Continued omeprazole 20mg daily.
.
# Lung cancer: s/p LLL wedge resection for stage IA SCC lung
[**2-/2141**] with several small pulmonary nodules that continue to
warrant follow-up.
.
# Anxiety: Continued home ativan 0.5 mg b.i.d. p.r.n.
.
Transitional Issues:
# Started lisinopril: She will need monitoring of her renal
function and potassium for a short time.
.
#Prednisone Taper: She should take one day of preednisone 40 mg,
then tyake prednisone 20 mg for 5 days, then stop (last day
[**2142-10-3**]).
.
#Pneumonia: Her sputum cultures grew strenotrophomonas so
Bactrim was started [**2142-9-27**] with the plan to treat her with 2
DS tabs TID for 14 days (first day [**2142-9-27**]).
.
#Anticoagulation: Warfarin was held in setting of HCT drop.
Restarted warfarin after stable HCT. Please monitor INR to
ensure adequate aticoagulation.
Medications on Admission:
1. Toprol XL 100 mg daily.
2. Diltiazem CD 180 mg daily.
3. Advair [**3-/2081**] b.i.d.
4. Coumadin 2.5 mg daily take as directed.
5. Ativan 0.5 mg b.i.d. p.r.n.
6. Colace 100 mg daily.
7. Atrovent as needed.
8. Pravachol 80 mg daily.
9. Singulair 10 mg daily.
10. Multivitamin 1 tablet daily.
11. Prilosec 20 mg daily.
12. Aspirin 81 mg daily.
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO TID (3 times a day) for 14 days.
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Prednisone
Prednisone 40 mg for one day, then 20 mg for five days, then
stop
10. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for Cough.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Pneumonia
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires [**Location (un) 11807**] or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 784**],
Thank you for coming to the [**Hospital1 1170**]. It was a pleasure taking care of you. You were in the
hospital because you had a fast heart rate from atrial
fibrillation, pneumonia, and temporary worsening of your COPD.
Your heart rate has been controlled by increasing the dose of
your diltiazem. Your pneumonia has been treated with antibiotics
but you will need to continue this medication (BACTRIM DS) three
times a day for 14 days. Your COPD exacerbation was treated with
ipratropium nebulizers, montelukast, and prednisone. You should
continue the prednisone for 6 more days (see below).
.
Medication summary:
Please take Diltiazem extended release 360 mg daily
Please take metoprolol extended release 100 mg daily
Please take Lisinopril 20 mg daily
Please continue to take warfarin 2.5 mg daily
Please continue advair 500/50 twice a day
Please take tiotropium daily
Please stop ipratropium
Please continue Montelucast 10 mg daily
Please take prednisone 40mg for one day the take 20 mg for five
days then stop
Please take Bactrim (trimethoprim/sulfamethoxazole) two double
strength tablets three times a day for two weeks (first day
[**2142-9-27**])
Please continue guifenesin [**4-3**] ml by mouth as often as four
times per day as needed
Please continue omeprazole 20mg daily
please continue pravastatin 80 mg daily
please continue lorazepam(ativan) 0.5 mg twice a day as needed
please continue any other medications as you have been
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please schedule an apointment with your primary care doctor
within one week of leaving the rehabilitation facility.
.
Please schedule an appointment with your cardiologist within 2
weeks of leaving the reahbilitation facility.
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2143-1-24**] at 4:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2142-9-28**]
|
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"414.00",
"238.4",
"300.00",
"443.9",
"584.9",
"428.0",
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"427.31",
"V45.81",
"441.2",
"428.33",
"V58.61",
"272.4",
"162.8",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11894, 11979
|
6696, 6986
|
371, 377
|
12103, 12103
|
4522, 5519
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13895, 14437
|
3044, 3123
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5560, 6673
|
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|
312, 333
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7001, 8890
|
405, 2014
|
12118, 12277
|
2213, 2704
|
8906, 9388
|
2036, 2101
|
2720, 3028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,210
| 111,757
|
34190
|
Discharge summary
|
report
|
Admission Date: [**2140-4-28**] Discharge Date: [**2140-5-7**]
Date of Birth: [**2080-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
angiogram
History of Present Illness:
HPI: This is a 57 y/o male transferred from an OSH where CT scan
demonstrated subarachnoid hemorrhage. At approximately 10AM on
[**2140-4-26**], the patient experienced an electric shock sensation
travelling up his spine to his head while at work. The sensation
was not debilitating, but over the next several hours the
patient
developed a progressively severe headache to the point where he
had to leave work. He also began to have nausea and vomiting
that
continued throughout the day. Pt describes the headache as [**6-21**]
out of 10. He presented to his PCP [**Last Name (NamePattern4) **] [**2140-4-27**] who ordered a head
CT at the [**Hospital1 882**] ER. CT demonstrated a SAH, thus the patient
was transferred to [**Hospital1 18**] for neurosurgical evaluation. Currently
the patient notes a bifrontal headache.
Past Medical History:
PMHx: s/p cardiac stenting [**6-/2132**], s/p CABG x 2 [**10/2132**]
Social History:
Social Hx: works as an attorney, lives with wife, [**Name (NI) **] EtOH, no
tobacco
Family History:
Family Hx: multiple CVAs (sister at age 39, father in 70s,
mother
in 70s), denies family history of polycystic kidney disease,
Marfan's syndrome, or Ehlers Danlos syndrome
Physical Exam:
PHYSICAL EXAM:
O: T: 99.4 BP: 161/67 HR: 56 R: 17 98% on RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 mm B/L intact EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-15**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-18**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 3+ throughout
Left 3+ throughout
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger and heel to shin
Pertinent Results:
head CT from OSH at 6PM: subarachnoid hemorrhage
head CT and CTA: hyperdensity anterior to brainstem, small
degree
of hydrocephalus, no obvious aneurysm or AVM, no midline shift
[**2140-4-27**] 08:30PM GLUCOSE-98 UREA N-14 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2140-4-27**] 08:30PM WBC-8.9 RBC-3.73* HGB-12.4* HCT-34.8* MCV-93
MCH-33.2* MCHC-35.6* RDW-13.2
[**2140-4-27**] 08:30PM NEUTS-75.2* LYMPHS-17.8* MONOS-6.2 EOS-0.4
BASOS-0.3
[**2140-4-27**] 08:30PM PLT COUNT-190
[**2140-4-27**] 08:30PM PT-13.0 PTT-24.5 INR(PT)-1.1
[**2140-4-28**]:
FINDINGS:
RIGHT COMMON CAROTID ARTERY: There is prompt flow of contrast
into the right internal and external carotid arteries. There is
normal appearance of the distal cervical, petrous, cavernous,
and supraclinoid segments of the right internal carotid artery.
The anterior and middle cerebral arteries are within normal
limits. There is no evidence of aneurysms or vascular
malformations. Evaluation of the origin of the right internal
carotid artery and distal common carotid artery is not included
on this film.
RIGHT EXTERNAL CAROTID ARTERY: There is prompt flow of contrast
through the external carotid artery and its major branches.
There is no evidence of an arteriovenous malformation.
LEFT VERTEBRAL ARTERY: The distal left vertebral artery appears
normal. There is reflux of contrast into the right vertebral
artery. The visualized basilar artery and posterior cerebral
arteries are normal. The posterior-inferior cerebellar arteries
and anterior-inferior cerebellar arteries as well as the
superior cerebellar arteries are also normal.
RIGHT VERTEBRAL ARTERY: The visualized right vertebral artery is
within normal limits. There is no evidence of stenosis. There is
prompt flow of contrast into the basilar artery and posterior
cerebral arteries which also appear normal.
LEFT EXTERNAL CAROTID ARTERY: The visualized left external
carotid artery appears within normal limits. The major branches
are also unremarkable. There is no evidence of arteriovenous
malformation or dural venous fistula
_____The distal cervical, petrous, cavernous and supraclinoid
segments of the left internal carotid arteries are normal. There
is prompt flow of contrast into the anterior and middle cerebral
arteries which demonstrate no aneurysm or vascular
malformations.
LEFT COMMON CAROTID ARTERY: The distal common carotid artery as
well as the origin of the left internal and external carotid
arteries are within normal limits.
RIGHT COMMON FEMORAL ARTERY: The visualized right common femoral
artery demonstrates no stenosis or dissection.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] was present during the entire procedure.
Moderate sedation achieved utilizing 1.5 mg of Versed and 75 mcg
of Fentanyl.
IMPRESSION: Mr. [**Known firstname **] [**Known lastname 1637**] underwent a cerebral
angiogram which demonstrate no aneurysm or vascular
malformation.
[**2140-5-5**]:
CT HEAD: Compared to the CT of [**2140-4-27**], there has been interval
resolution of hyperdense blood in the prepontine cistern. There
is no new focus of hemorrhage seen. Mild prominence of the
ventricles is unchanged. There is no shift of normally midline
structures, or evidence of acute major vascular territorial
infarction. No fracture or bony destruction is seen within the
visualized calvarium. The paranasal sinuses and mastoid air
cells are well aerated.
CTA: Compared to the CTA of [**2140-4-27**], there is apparent diffuse
decrease caliber throughout the anterior and posterior
circulation. In the absence of subarachnoid hemorrhage, this
appearance is felt to be likely due to technical issues rather
than due to diffuse vasospasm. No focal narrowing is noted.
IMPRESSION:
1. Interval resolution of prepontine subarachnoid hemorrhage,
without interval development of new intracranial hemorrhage.
2. CTA demonstrates diffuse decreased caliber throughout the
intracranial arteries. In the absence of a subarachnoid
hemorrhage, this is felt to be due to technical factors rather
than representing diffuse vasospasm. If there is concern for
vasospasm, angiography would be recommended for further
evaluation.
Brief Hospital Course:
The patient was admitted after having a spontaneous SAH. He had
been on aspirin prior to admission so he had a platelet
transfusion on the day of admission. He had an angio by [**Doctor Last Name **]
which was neg for aneurysm. The patient continued to have
headaches while he was in the ICU but remained neurologically
stable the entire time. On [**2140-5-1**] he had a low grade temp of
100.8 and developed a fever of 101.5 on [**2140-5-4**]. He had blood
cultures sent which were still pending at the time of discharge.
The urine culture from the same day was negative. On [**2140-5-3**] the
patient had an MRI of the C/T spine which was negative for AVM
but there was spinal stenosis - discussed finding with the
patient.
Mr. [**Known lastname 1637**] was transferred to the floor after being in the ICU
for several days. He continued to be neurologically stable. On
[**2140-5-6**] he had a CTA which showed "technical vasospasm" but the
SAH was resolving and clinically he had no signs of spasm. He
was afebrile, ambulating without difficulty, and his pain was
well controlled prior to discharge. Dr. [**Last Name (STitle) **] felt that he did
not need to be sent home with dilantin since he had no seizures
and since his head CT showed resolving SAH prior to discharge.
His pharmacy was notified that he needed 10 more days of
nimodipine. Mr. [**Known lastname 1637**] was neurologically intact on the day of
discharge.
Medications on Admission:
Medications prior to admission: lopressor 12.5 mg [**Hospital1 **], lipitor
10', ASA 325', lisinopril 20, fish oil 1000 mg, MVI
Discharge Medications:
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4-6H () as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: No driving while on narcotics.
Disp:*40 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 10 days: You need to continue for 10 more days.
Disp:*120 Capsule(s)* Refills:*0*
9. Outpatient Physical Therapy
Please allow this patient to have therapy for bilateral
tightening of his hamstrings.
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SUBARACHNOID HEMORRHAGE
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? 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.
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
Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] on Tuesday to schedule an appointment
with Dr. [**First Name (STitle) **] for an angiogram in about 4 weeks.
If you have any concerns please call Dr.[**Name (NI) 9034**] office
[**Telephone/Fax (1) 1669**].
Completed by:[**2140-5-7**]
|
[
"V17.1",
"V45.82",
"401.9",
"V45.81",
"430",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
9790, 9796
|
7194, 8623
|
327, 338
|
9844, 9868
|
2961, 5948
|
10641, 10919
|
1400, 1573
|
8801, 9767
|
9817, 9823
|
8649, 8649
|
9892, 10618
|
1603, 1859
|
8681, 8778
|
279, 289
|
366, 1190
|
2152, 2942
|
5957, 7171
|
1874, 2136
|
1212, 1283
|
1299, 1384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,162
| 106,377
|
49402
|
Discharge summary
|
report
|
Admission Date: [**2137-6-6**] Discharge Date: [**2137-6-19**]
Date of Birth: [**2071-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxacillin / Ciprofloxacin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain/Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2137-6-6**] Cardiac Cath
[**2137-6-10**] Aortic Valve Replacement with 23mm St. [**Male First Name (un) 923**] Regent
Mechanical Valve
History of Present Illness:
66-year-old male with aortic stenosis, atrial fibrillation,
coronary artery disease and type II diabetes who was admitted
for cardiac catheterization following an abnormal stress test.
He had been doing well until [**2137-5-1**] at which time he developed
chest burning and dypnea on exertion. He was admitted and
underwent nuclear stress test on [**2137-5-2**] where he was able to
exercise 6 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and stopped due to
fatigue. Nuclear images revealed a new partially reversible
inferolateral wall perfusion defect and a fixed inferior wall
defect. He was referred for cardiac catheterization. In the cath
lab he was found to have single vessel coronary disease as
previously but his aortic valve area was 0.68 cm2. He is being
admitted for aortic valve replacement.
Past Medical History:
Aortic Stenosis, Diabetes Mellitus, Atrial Fibrillation, Chronic
Diastolic Heart Failure, Chronic Kidney Disease, Chronic back
pain, Gout, s/p Tonsillectomy
Social History:
He is married and works as a French and Spanish teacher in a
high school. He does not smoke or drink. He has two daughters.
Family History:
His mother had CABG @ age 80. Father died of Lung ca (smoker).
HTN and DM in family.
Physical Exam:
T: 97.9 BP: 117/73 HR: 83 RR: 18 O2: 97% on RA
General: Well appearing male, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, s1 + s2, II/VI SEM radiating throughout
Resp: clear to ausculation bilaterally, no wheezes, rales,
ronchi
GI: obese, soft, non-tender, non-distended, +BS
GU: no foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Skin: No rashes
Pulses: DP and PT pulses palpable bilaterally
Pertinent Results:
ECG ([**6-6**]): Atrial fibrillation at a rate of 82. ST-T wave
abnormalities.
Cardiac Catheterization ([**6-6**]): 1. Selective coronary
angiography of this right dominant system demonstrated single
vessel coronary artery disease. The left main demonstrated no
angiographically apparent flow limiting disease. The left
anterior descending artery demonstrated mild diffuse disease
throughout without any significant stenosis. The left
circumflex demonstrated a totally occluded obtuse marginal
filling via right to left collaterals. The right coronary
artery demonstrated no angiographically apparent disease. 2. LV
ventriculography was deferred. 3. Limited resting hemodynamics
demonstrated normal right (RVEDP 7 mm hg) and left (LVEDP 7 mm
Hg) heart filling pressures. The cardiac index calculated via
the Fick method was preserved at 2.0 L/min/m2. 4. The mean
pressure gradient across the aortic valve was 47 mm Hg and a
peak of 60 mm Hg. The calculated aortic valve area of 0.68 cm2.
The aortic valve was heavily calcified.
Echo ([**6-10**]): PRE-BYPASS: 1. The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s). 2. The right atrium is dilated. No atrial septal
defect is seen by 2D or color Doppler. 3. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is lateral wall hypokinesis of the
mid to the apical segments ). Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %). 4. Right ventricular
chamber size and free wall motion are normal. 5. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. 6. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(area <0.8cm2). Mild (1+) aortic regurgitation is seen. 7. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. Due to co-existing aortic regurgitation,
the pressure half-time estimate of mitral valve area may be an
OVERestimation of true mitral valve area. 8. There is no
pericardial effusion. POST-BYPASS: For the post-bypass study,
the patient was receiving vasoactive infusions including
phenylephrine and is being AV paced. 1. A well-seated bileaflet
valve is seen in the aortic position with normal leaflet motion
and gradients (mean gradient = 15 mmHg). No aortic regurgitation
is seen. 2. Left ventricular systolic function is low normal
(LVEF 45%). 3. Right ventricular systolic function is normal. 4.
Aortic contours are intact post decannulation.
Brief Hospital Course:
As mentioned in the HPI Mr. [**Known lastname **] was admitted following his
cardiac cath which revealed Aortic Stenosis and single vessel
coronary artery disease. He received medical management for
several days and underwent pre-operative work-up while awaiting
for surgery. On [**6-10**] he was brought to the operating where he
underwent a aortic valve replacement. Please see operative
report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-operative day one
his chest tubes were removed. He was started on beta blockers
and diuretics and gently diuresed towards his pre-op weight.
Also on this day he was started on Coumadin with Heparin bridge
for mechanical valve. Coumadin was titrated. On post-op day two
his epicardial pacing wires were removed and his was transferred
to the telemetry floor for further care. Cleared for discharge
to rehab on POD #11 Target INR is 2.5-3.0 for mechanical valve.
INR in uptrend on DC 2.1.
Medications on Admission:
Medications at Home: Niacin 1000 mg daily, KCL 10 mEq [**Hospital1 **], Lasix
80 mg 1-2 tabs daily prn, Zocor 20 mg 1 tab daily, Coumadin 2.5
mg 1 tab for 6 days and 3.75 every Saturday LD [**2137-6-2**], Ativan 1
mg qhs prn, Xanax 0.25 mg [**Hospital1 **] prn, Aldactone 25 mg daily, ASA 81
mg, 2 tablets daily, Lisinopril 10 mg daily, Metoprolol tartrate
100 mg [**Hospital1 **], Nitroglycerin 0.4 mg 1 tab sl q 5 min prn chest
pain, Novolog 70/30 40 Units [**Hospital1 **], Magnesium Oxide 400 mg 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).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days: 7 days.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once):
goal is 2.5 - 3.
11. INSULIN
Insulin SC Fixed Dose Orders
Breakfast Dinner
70 / 30 40 Units 70 / 30 40 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 6 Units
12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): until gouty flare up resolves then DC.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Diabetes Mellitus, Atrial Fibrillation, Chronic Diastolic
Heart Failure, Chronic Kidney Disease, Chronic back pain, Gout,
s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Dr. [**First Name (STitle) **] will be following your INR and adjusting your
Coumadin for a goal INR of 2.5-3 when you are discharged from
rehab.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 73**] in [**2-24**] weeks
Dr. [**First Name (STitle) **] in [**1-23**] weeks
Dr. [**First Name (STitle) **] will be following your INR and adjusting your
Coumadin for a goal INR of 2.5-3. Rehab: please contact Dr.
[**First Name (STitle) **] prior to his discharge from rehab. Daily INRs while at
rehab.
Completed by:[**2137-6-16**]
|
[
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"428.0",
"726.60",
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"414.01",
"403.90",
"427.31",
"413.9",
"726.33",
"338.29",
"274.89",
"585.3",
"250.00",
"724.2",
"458.29",
"278.01",
"428.32",
"427.41",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.72",
"81.91",
"39.64",
"88.56",
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
8731, 8798
|
4896, 5996
|
322, 461
|
9031, 9037
|
2228, 4873
|
9502, 9931
|
1675, 1761
|
6552, 8708
|
8819, 9010
|
6022, 6022
|
9061, 9479
|
6043, 6529
|
1776, 2209
|
252, 284
|
489, 1338
|
1360, 1518
|
1534, 1659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,464
| 176,257
|
22679
|
Discharge summary
|
report
|
Admission Date: [**2168-1-10**] Discharge Date: [**2168-1-13**]
Date of Birth: [**2123-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
urosepsos; bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 44 yo M with h/o htn, ? prior strokes, transfer from prison
for syncope. Prior to syncopal event, reports SSCP x 15 min, no
radiation, but diaphoretic with nausea. Pt. then noticed his
hearing going before blacking out.
Pt. recently had his atenolol increased from 50 to 100mg qd.
Pt. also reports having dysuria 4-5 days ago, 1 week of a L
sided headache, mild photophobia, and 3 days of fatigue, but no
fevers. Around the same time, noticed hand numbness when
getting into bed.
Brought to [**Hospital 46**] Hosp. There, pt. had bradycardic arrest,
asystolic x 12 sec, got epi and atropine. HR increased from
25 to 160, thought to be in SVT, received adenosine(6mg, then
12mg). Then, hypotensive, started on dopamine. CT
head/chest/abd negative. Transferred to [**Hospital1 18**].
On transfer, temp of 102F, sbp in 80s, lactate 3.2. After 3 L,
sbp still in 80s. Code sepsis called. Sepsis line placed.
Fluid CVP came up to [**10-19**]. Started on levophed. Pt. received
unasyn and vanc. EKG without abnormalities, but troponin came
back at 0.70. ABG - 7.43/32/295. Lactate decreased from 3.2 to
1.1. U/A grossly positive. Labs also notable for elevated Cr.
(baseline unknown). Received vanc and Unasyn in ED.
Patient admitted to MICU, IVF resuscitated and weaned off of
levophed, and subsequently transferred to 12R.
Past Medical History:
PMH: htn, ? past strokes, h/o cocaine use;; patient reports h/o
CAD (no records available)
Social History:
SH: Incarcerated x 1 mo. + tob use. Prior ETOH, none recently.
Injected cocaine 1-2 months ago. Last sexually active 1 mo. ago
- partner is female, not known to have STDs
Family History:
Non-contributory
Physical Exam:
PE: 97.5, tmax-102, 78, 132/70, 18, 94%RA
gen - NAD
HEENT - MM dry, PERRLA - no photophobia
neck - supple, some post. midline tenderness
c/v - RRR, no m/g/r
abd - s/nt/nd, NABS
rectal - boggy prostate, tender to palp (per OMR)
groin - R inguinal tenderness without LAD - no hernia palpated
lungs - b/basilar crackles
back - paraspinal and midline lumbar tenderness
extr - no c/c/e
neuro - A+Ox3, mild facial weakness (baseline per patient), MAE
Pertinent Results:
[**2168-1-10**] 11:31PM URINE HOURS-RANDOM CREAT-89 SODIUM-66
[**2168-1-10**] 11:31PM URINE RBC-[**3-12**]* WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2168-1-10**] 11:19PM LACTATE-1.1
[**2168-1-10**] 09:00PM PT-14.3* PTT-54.5* INR(PT)-1.3
[**2168-1-10**] 08:13PM freeCa-1.11*
[**2168-1-10**] 07:50PM GLUCOSE-115* UREA N-30* CREAT-2.3* SODIUM-137
POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2168-1-10**] 07:50PM ALT(SGPT)-19 AST(SGOT)-12 CK(CPK)-55 ALK
PHOS-99 AMYLASE-79 TOT BILI-0.5
[**2168-1-10**] 07:50PM LIPASE-38
[**2168-1-10**] 07:50PM cTropnT-0.70*
[**2168-1-10**] 07:50PM CORTISOL-47.6*
[**2168-1-10**] 07:50PM CALCIUM-8.6 MAGNESIUM-1.8
[**2168-1-10**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-1-10**] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2168-1-10**] 07:50PM WBC-11.3* RBC-3.66* HGB-13.3* HCT-37.3*
MCV-102* MCH-36.4* MCHC-35.7* RDW-12.7
[**2168-1-10**] 07:50PM NEUTS-90.6* BANDS-0 LYMPHS-5.9* MONOS-3.3
EOS-0.1 BASOS-0.1
[**2168-1-10**] 07:50PM PLT SMR-NORMAL PLT COUNT-255
CXR: no acute process
EKG:NSR ar 90bpm, nlaxis/nl int twi AvL
Nuclear stress test-normal perfussion and wall motion. EF> 55%
Brief Hospital Course:
A/P 44 yo M with h/o htn p/w with new chest pain, syncope,
hypotension, in setting of prostatitis c/b urosepsis and same
day change in beta-blocker dose. The stress of infection in
addition to bradycardia from increased atenolol likely led to
unstable angina and syncope.
.
#hypotension - the cause of patient's arrest was never clear.
Our theory was that he was becoming septic from a urinary tract
pathogen, possibly related to prostatitis. Pt likely had a
bradycardic arrest in the setting of this septic picture plus
the recent increased dose of his beta blocker. Pt's blood
pressure was high-normal at discharge and he was able to
tolerate the equivalent of 50 [**Hospital1 **] of lopressor. We felt this
was a better drug than atenolol for this pt in light of his
renal dysfunction (mild arf at presentation that cleared up with
hydration).
#urosepsis/prostatitis - positive U/A, likely related to
prostatitis - STD ruled out by urethral swab. Pt probably
became septic with foley insertion. Less likely from renal stone
given nl CT abd. Will rx with 500 mg po levaquin for 4 weeks
total for acute prostatitis. Abd/Pelvis CT negative for
prostatic abscess.
#bradycardia - probably has been going on for days as the
patient has been feeling very fatigued x 3d. Brady likely from
combination of increased atenolol plus vasovagal from the pain
of the prostatitis.
.
#troponin leak -Pt had + troponin but negative CK at
presentation which subsequently improved. It is unclear if
related to the bradycardia or if from epinephrine during brady
arrest or from CPR given in ER. No evidence of new coronary
event on EKG. Pt. denies cocaine use, none seen in tox screen.
Pt was seen by cardiology and had a negative stress mibi which
also revealed normal ejection fraction.
.
#ARF - no known h/o renal failure. This was related to arrest
vs hypotension of sepsis and dehydration. No hydronephrosis or
perinephric abscess seen on abd/pelvic CT scan. Pt's renal fx
improved with hydration.
Medications on Admission:
ASA
ciprofloxacin 500mg [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis-no pathogen found.
Bradycardia related to medication side-effect.
Prostatitis.
Coronary Artery Disease
Discharge Condition:
Good
Discharge Instructions:
You have been evaluated for possible prostatitis and chest pain.
Please take all your medications as prescribed. We have ruled
out a heart attack as the cause of your low blood pressure and
feel that you likely had an infection that caused your symptoms.
Please page Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 8717**] for questions you or your
doctor may have about your care during this hospitalization.
Please talk to your doctor if you develop chest pain, fevers or
other problems.
Followup Instructions:
You should be evaluated by a doctor in [**2-12**] days to check your
vital signs and perform orthostatic blood pressure checks.
Please follow-up with a cardiologist in [**4-13**] weeks.
|
[
"E942.9",
"786.59",
"584.9",
"276.5",
"601.0",
"401.9",
"995.92",
"593.9",
"427.89",
"038.9",
"785.52",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5901, 5907
|
3812, 5810
|
337, 343
|
6061, 6067
|
2532, 3789
|
6616, 6806
|
2034, 2052
|
5928, 6040
|
5836, 5878
|
6091, 6593
|
2067, 2513
|
275, 299
|
371, 1715
|
1737, 1829
|
1845, 2018
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,560
| 104,680
|
29695
|
Discharge summary
|
report
|
Admission Date: [**2150-1-3**] Discharge Date: [**2150-2-7**]
Date of Birth: [**2069-1-30**] Sex: M
Service: SURGERY
Allergies:
Plavix
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Free air
Major Surgical or Invasive Procedure:
Trach and peg
History of Present Illness:
Mr. [**Known lastname **] is an 80 yo M with treatment refractory ITP on
long-term high dose steroids s/p lap splenectomy on [**2149-12-24**],
discharged to home on [**2149-12-28**]. The next day, his visiting nurse
noted that he was unable to rise from the couch. He presented to
[**Hospital3 **] ED and was diagnosed with steroid induced
myopathy and discharged to a rehab facility. At that rehab, he
had a KUB showing an ileus. He then represented to [**Hospital3 **] last night with marked abdominal distention. Repeat
imaging at that time showed free air on CXR and he had a CT
which
showed a large amount of free air, small fluid collection in
LLQ,
marked bowel distention ? SBO vs ileus, and RLL PNA. He was
started on vanc/cipro/flagyl and a surgery consult was obtained.
The surgeons at the outside hospital recommended transfer back
to
[**Hospital1 18**] for management under the patient's recent surgeon at
[**Hospital1 18**],
Dr. [**First Name (STitle) 2819**].
Past Medical History:
PMH:
ITP
A-Fib
CAD-EF 35%
Bullous dermatitis
HTN
Hyperlipidemia, BPH
macular degeneration, degenerative joint disease
Perineal abscess s/p ID
Hyperglycemia 2nd to steroids
PSH:
RCA stent [**2146**]
Hernia repair
Social History:
SH: Live with brother, never married, no children, +tobacco in
20's quite, occasion EtOH, no drugs
Family History:
FH: CAD
Physical Exam:
[**2150-2-2**] 07:04 AM
Vital signs
Tmax: 37.4 ??????C (99.4 ??????F)
T current: 36.4 ??????C (97.6 ??????F)
HR: 83 (83 - 98) bpm
BP: 135/62(90) {135/62(90) - 170/78(115)} mmHg
RR: 15 (14 - 27) insp/min
SPO2: 91%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 97.9 kg (admission): 89 kg
CVP: 9 (1 - 10) mmHg
Total In:
2,080 mL
483 mL
Tube feeding: 960 mL/ 273 mL
IV Fluid: 600 mL/ 50 mL
Total out:
2,355 mL
745 mL
Urine:
2,355 mL
745 mL
Balance:
-275 mL
-262 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 729 (553 - 865) mL
PS : 5 cmH2O
RR (Set): 8
RR (Spontaneous): 13
PEEP: 5 cmH2O
FiO2: 40%
RSBI: 19
PIP: 11 cmH2O
SPO2: 91%
ABG: 7.45/35/91.[**Numeric Identifier 71132**]/27/0
Ve: 9.7 L/min
PaO2 / FiO2: 230
Physical Examination
General Appearance: Cachectic
HEENT: PERRL
Cardiovascular: (Rhythm: Irregular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous : bilateral)
Abdominal: Soft, Bowel sounds present, Tender: Upper quadrants,
Mild distension
Left Extremities: (Edema: 3+), (Temperature: Warm)
Right Extremities: (Edema: 3+), (Temperature: Warm)
Skin: (Incision: Erythema)
Neurologic: (Responds to: Tactile stimuli, Noxious stimuli)
Brief Hospital Course:
Pt is an 80 Y M with ITP on steroids who had un uncomplicated
lap splenectomy on [**12-24**] who was readmitted on [**12-28**] to OSH for
what was thought to be steroid induced myopathy. Readmitted to
[**Hospital1 18**] on [**1-2**] from OSH for abd distention. Imaging at that time
showed free air on CXR and he had a CT which showed a large
amount of free air, small fluid collection in LLQ, Treated for
diverticulitis with bowel rest and NPO. Pt was transfered to
the TICU for resp distress, and subsequent B/L aspergillus PNA,
VRE, ATN and acute renal failure, possible PE, most recently a
retroperitoneal hematoma.
.
Events:
.
[**12-24**] readmitted with diverticulitis,
[**1-8**] CTA chest: No PE. likely a predominantly right upper lobe
pneumonia, CXR: the pre-existing right upper lobe pneumonia
markedly decreased
- doing well. A&O. on 4L NC, sats in high 90s. gentle
diuresis. lasix 20mg once. hct 28-->26-->25-->24. GI consult:
possible infected diverticuli with perf with 2ndary partial SBO
or ischemic colon with perf. no emergent intervention/scope at
this time. conservative treatment with hydration and IV abx,
serial hcts. this AM, pt started to have increased WOB and
tachypnea. another lasix 20mg. pt improved. febrile to 101. pan
cx. APAP PR. s/p splenectomy and chronic steroids thus with
increased risk of infections. last night febrile to 101. APAP
PR. pan cx. primary team wants to consider adding fluconzole
and ID consult. currently on Vanc/Zosyn, to cover HAP and
diverticulitis.
[**1-9**] Fluconazole added, d/w ID. ID also recommended consider add
cipro if continues to spike fevers for double gram neg coverage.
[**1-9**] HCT dropped slightly at noon to 23.6 from 24.6, but was
stable for 9 hours at 23.0. Had another episode of blood per
rectum (red/maroon/clot) at 10pm. Repeat HCT to be checked at
2am.
[**1-10**] 2am HCT drop again to 21.7 w/another bloody/marroon BM,
given dropping hct and active bleeding, transfused x1units
PRBCs, electrolyte abnormalities suggested labs drawn from PICC
contaminated by TPN. Repeat HCT stable at 23.7. Pt intubated for
respiratory distress. Another maroon colored stool, hct stable,
INR 1.5. Bronchoscopy showing purulent fluid in RUL and LLL and
LUL/lingula.
[**1-11**]: started runs of [**7-6**] beats of vtach --> cont vtach. BP
stable. ECG, electrolytes, trops. lidocaine 100mg, Mag 2gms,
lidocaine 100mg, midazolam 2mg, percedex gtt, back on AC on
vent.
[**1-12**] lasix 20mg overnight, to diurese to even. Net -91cc.
[**1-13**]: Febrile in AM, pancx, NGT placed and TF started, failed
decrease in PSV, unable to wean
[**1-14**]: aline. PM Hct 25.3. CT torso per primary team. failed wean
overnight. CT torso: Multiple lower abdominal pelvic air and
fluid collections appear somewhat more organized and slightly
smaller than prior exam. Left lower lobe pneumonia, new since
prior exam.
[**1-15**]: failed weaning
[**1-15**]: ID consult: see below for recs
[**1-16**]: Started Voriconazole, CT chest worse, CT head done (WNL),
unable to wean off vent, needed to increase PSV, HCP consented
for trach/peg in future
[**1-17**]: spiked to 102.1. pan cx. requiring increased vent
support. d/c'd fluconazole. tracheal asp sent for PCP. 2 doses
of lasix to keep him even. minimal output, increased Cr.
intermittent runs of V-tach. BPs stable. today: trach bedside,
peg by IR.
[**1-18**] attempted PICC line placement, but failed. Placed L IJ for
access.
[**1-18**] Bcx from [**1-17**] grew out GPCs in pairs and short chains.
[**1-19**] bedside trach/peg converted to open trach/peg in OR, +VRE,
antibiotics changed, increasing Cr, hypotensive --> neo gtt
started, mixed respiratory and metabolic acidosis unresponsive
to vent changes and cis gtt. bicarb gtt started. hcp passed
away.
[**1-20**]: dead space 74%. started on heparin gtt for persumed PE. no
read on LE U/S. trach with cuff leak. Hct this AM 22. transfused
1 unit. TTE: RV mod dilated, mod [**Last Name (LF) 71133**], [**First Name3 (LF) **] > 55%. UOP improving
slightly, but Cr and lytes worsening. legionella/norcadia urine
Ag neg, Cx pending. increased fats and decreased Dex in TPN.
residuals in the 300s. TFs stopped. reglan given. family meeting
on thursday 1pm with brother.
[**1-21**]: 2 units PRBC for Hct 22. Renal C/s for volume overload,
ATN
[**1-22**]: HD catheter placed, cosyntropin test (initial cortisol
WNL, but poor response to test), started hydrocort 100 IV TID,
TPN stopped, plan to advance TFs, family mtg - DNR/DNI. no CPR,
no shock, no HD, no vasopressors. continue current medical
mgmt, DC coumadin.
[**1-23**]: had another large maroon BM. stat hct 23.3. no change in
mgmnt. TFs held again [**12-30**] high residuals. per ID, d/c'd cipro.
[**1-24**] Transfused 2u PRBc w/ bump from 23.7 to 26.4. Put back on
PSV, tolerating well.
[**1-26**]: Switched to SIMV, Prednisone taper started
[**1-27**] family meeting, continue DNR (no shocks, no compression), no
dialysis, no escalation of care, but continue w/treatment/
abx/medications.
[**1-29**]: resolved metabolic acidosis with normal ABG, family
meeting: no change in care plan.
[**1-30**] stopped heparin given HCT drop and bleeding from PEG site,
CT-torso showed large abdominal ?retroperitoneal bleed. CT-chest
w/ worsening ground-glass opacities/consolidation.
[**2-2**]: US: superficial DVT in cepahlic vein RUE noted
.
Current assessment and Plan:
NEURO: Declined when became azetemic, BUN was up to 170. As his
renal function improved making eye contuct moving extremities,
no priary neurological event
Currently: Mental status poor despite minimal sedation, mild
improvement with resolving uremia. HD CT [**1-16**] neg. Neuro checks
Q4H, Intermittent Haldol/Dilaudid for agitation/pain control.
.
CV: During his VRE bacteremia, hypotensive and requred -pressor
during his course, but as his infection improved he has been
normo tensive and now needs home BP medicaiton. 75 TID of
lopressor tolerating well. Quite a bit of ectomy with runs of
VTACH no hymodynamic instibiliti. He is DNR so if he goes into
lethal run can ot convert out. Was treated with lidocaine.
Currently: Pt has Chronic a-fib - rate controlled with lopressor
increased to 37.5 PO TID, continues to have ectopy and short
runs of VTAC, but remains hemodynamically stable. Holding off on
anticoagulation due to slow drop in Hct
.
PULM: Aspirgillis pneumonia with vorticonizol, On PO fluconazole
which is not neurotoxic. Tached in the OR, remained ventilator
dependent. Currnently:
-Possible PE based on TTE [**1-20**]: RV mod dilated, mod [**Month/Year (2) 71133**]. 75%
calculated dead space. Heparin stopped [**1-30**] due to HCT drop,
active bleeding from PEG site and CT showing retroperitoneal
hematoma.
-Respiratory failure - s/p trach. Daily CXRs. On CPAP 5/5. ABGs
improving. Oxygenating well. Although CT chest on [**1-30**] read as
worsening infection, will continue to assess clinically.
-HAP/VAP: treating with Voriconazole (day 16-on [**1-31**]) for
aspergillius PNA
-Most recent sputum cultures from [**1-31**] and [**2-3**] showed yeast
with gpc which were c/w commensal flora. They were not
enterococcus.
.
GI: During his course pt recieved a PEG and now is on tube
feeds. Currently:
- Abd intermittently diffusely tender as pt occasionally
grimaces to exam. Could be [**12-30**] retroperitoneal hematoma (no
evidence of diverticulitis from CT [**1-30**])
- TFs restarted and tolerating at goal, flexiseal for stool
management, C diff negative so far.
.
RENAL:
-Resolving ARF/ATN with Cr normalizing though pt is uremic
despite adequate urine output, still w/anasarca, grossly volume
overloaded. no dialysis per family mtg. His renal failure has
resolved with his creatinine down to 1.1. Over the last few
days his sodium had increased to 153 but this has improved with
D5W running at 100cc/hr.
HEME:
- Possible PE: Heparin gtt stopped [**12-30**] HCT drop and bleeding.
- Anemia: HCT slowly dropping, checking seral HCT [**Hospital1 **] and
transfusing when clinically indicated. Stool currently brown
though heme positive in past.
.
ENDO: RISS. Restarted steroids; Now on pre-splenectomy
prednisone PO dose.
.
ID: .
-PNA: BAL [**1-15**]: Aspergillus: On Voriconazole (day 16, [**1-31**]).
CT-Chest on [**1-30**] worsening infection, ? radiologic lag vs
evolving infection.
-Bacteremia: BCx [**1-19**] Negative, Surveillance culture [**1-27**] still
NGTD. Blood Cx: [**1-17**] VRE, treated with linezolid for 14 days,
stopped on [**2-1**]. Testing for legionella, PCP, [**Name10 (NameIs) 13607**], all
negative. Continue to f/u BCx.
-ID recs repeat B-glucan/galactomanan to assess treatment.
Voriconazole level 6.78 (therapeutic).
-From [**1-29**] to the 10th he had a rising white count from 10 to
19. He had completed his two week course of linezolid for the
VRE in his blood. However given the gpc in his sputum the
linezolid was continued. It should be continued for another 10
days. He his count has come back down to 15 from 19 and he has
been afebrile during this time.
Medications on Admission:
warfarin 2.5 alternating with 1.5 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, proscar 5
qd, lasix 40 qd, lantus 7 units qPM, RISS, isosorbide
mononitrate
90 qd, lactinex two pills [**Hospital1 **], toprol XL 50 qd, prednisone 40 qd
(recently reduced from 50 qd), zocor 40 qd, prednisone forte eye
drops one drop OD qd, Vit B3 [**Numeric Identifier 1871**] qweek, MVI qd, dulcolax &
colase qd
Discharge Medications:
1. Prednisolone Acetate 1 % Drops, Suspension [**Numeric Identifier **]: One (1) Drop
Ophthalmic DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Numeric Identifier **]: One (1) PO BID (2
times a day).
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Numeric Identifier **]:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
4. Voriconazole 200 mg Tablet [**Numeric Identifier **]: 1.5 Tablets PO Q12H (every 12
hours).
5. Prednisone 20 mg Tablet [**Numeric Identifier **]: 1.5 Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Haloperidol 1-2 mg IV Q4H:PRN agitation
11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. Linezolid 600mg iv q12
14. Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing
15. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
intubated
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,
AIRWAY CLEARANCE, COUGH), ACIDOSIS, METABOLIC, .H/O
GASTROINTESTINAL BLEED, LOWER (HEMATOCHEZIA, BRBPR, GI BLEED,
GIB), VENTRICULAR PREMATURE BEATS (VPB, VPC, PVC), RESPIRATORY
FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **]), ALTERED MENTAL STATUS (NOT
DELIRIUM), [**Last Name **] PROBLEM - ENTER DESCRIPTION IN COMMENTS,
IMPAIRED SKIN INTEGRITY, CARDIOMYOPATHY, OTHER, PNEUMONIA,
OTHER, RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF),
DIVERTICULITIS
Neurologic: Mental status poor despite minimal sedation, mild
improvement with resolving uremia. HD CT [**1-16**] neg. Neuro checks
Q4H, Intermittent Haldol/Dilaudid for agitation/pain control.
Add Tylenol, wean dilaudid as tolerated
Cardiovascular: Chronic a-fib - rate controlled with lopressor
increased to 50 PO TID advance to 75 TID, continues to have
ectopy and short runs of VTAC, but remains hemodynamically
stable.
Pulmonary: Trach, (Ventilator mode: CPAP + PS), Possible PE
based on TTE [**1-20**]: RV mod dilated, mod [**Month/Year (2) 71133**]. 75% calculated dead
space. Heparin stopped [**1-30**] due to HCT drop, active bleeding from
PEG site and CT showing retroperitoneal hematoma.
-Respiratory failure - s/p trach. Daily CXRs. On CPAP 5/5. ABGs
improving. Oxygenating well. Although CT chest on [**1-30**] read as
worsening infection, will continue to assess clinically.
-HAP/VAP: treating with Voriconazole (day 16-on [**1-31**]) for
aspergillius PNA
Gastrointestinal / Abdomen: Abd soft,
- TFs restarted and tolerating at goal, flexiseal for stool
management, C diff negative
Nutrition: Tube feeding
Renal: Foley, -Resolving ARF/ATN with Cr normalizing though pt
is uremic despite adequate urine output, still w/anasarca,
grossly volume overloaded. no dialysis per family mtg. [**Month (only) 116**] need
some hydration with elevated BUN and serum Sodium and creatinine
is almost reached baseline.
Hematology: - stable anemia. 1 unit for Hct=22
- Anemia: HCT slowly dropping, checking seral HCT [**Hospital1 **] and
transfusing when clinically indicated. Stool currently brown
though heme positive in past.
Endocrine: RISS, RISS. Restarted steroids; Now on
pre-splenectomy prednisone PO dose.
Infectious Disease: -PNA: BAL [**1-15**]: Aspergillus: On Voriconazole
(day 16, [**1-31**]). CT-Chest on [**1-30**] worsening infection, ? radiologic
lag vs evolving infection.
-Bacteremia: BCx [**1-19**] Negative, Surveillance culture [**1-27**] still
NGTD. Blood Cx: [**1-17**] VRE, treated with linezolid for 14 days,
stopped on [**2-1**]. Testing for legionella, PCP, [**Name10 (NameIs) 13607**], all
negative. Continue to f/u BCx.
-ID recs repeat B-glucan/galactomanan to assess treatment.
Voriconazole level 6.78 (therapeutic).
.
Wound: Stage 1-2 wound. wound care per nursing.
Lines / Tubes / Drains: Trach, PEG, Foley, right axillary
a-line, LIJ CVL
Wounds:
Imaging:
Fluids: KVO
Consults: General surgery, ID dept
Billing Diagnosis: (Respiratory distress: Failure), Post-op
hypotension, Acute renal failure
Discharge Condition:
Poor
Discharge Instructions:
N: Follow mental status
CV: beta-blockade for rate controlled afib and runs of v-tach.
Resp: Vent - currently requiring minimal support, wean to trach
collar, 2 weeks linezolid for gpc in sputum. Airway and mouth
care.
GI: NovaSource Renal (Full) - [**2150-1-31**] 06:13 PM 40 mL/hour
GU: renal failure resolved, watch creatinine
Glycemic Control: Regular insulin sliding scale
Heme: no anticoagulation for afib secondary to retroperitoneal
hematoma.
ID: prolonged voriconzole and 10 days of linezolid.
Lines:
Multi Lumen - [**2150-1-18**] 06:30 PM
Arterial Line - [**2150-1-19**] 06:09 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Code status: DNR (do not resuscitate)
Followup Instructions:
Follow with Dr. [**First Name (STitle) 2819**] in 3 weeks. Office number ([**Telephone/Fax (1) 10058**]
Completed by:[**2150-2-7**]
|
[
"V09.81",
"567.21",
"600.00",
"362.50",
"359.4",
"415.19",
"707.22",
"V45.82",
"287.31",
"560.1",
"707.03",
"707.09",
"484.6",
"276.0",
"707.05",
"416.8",
"E932.0",
"276.4",
"V58.61",
"427.31",
"715.90",
"428.0",
"518.81",
"414.8",
"401.9",
"997.31",
"584.5",
"995.92",
"427.1",
"518.1",
"568.81",
"562.13",
"518.89",
"414.01",
"E878.1",
"038.0",
"453.81",
"117.3",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"33.24",
"96.04",
"43.11",
"38.91",
"99.15",
"96.6",
"38.93",
"38.95",
"96.72",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
13814, 13914
|
2990, 12004
|
273, 288
|
17044, 17050
|
17844, 17977
|
1661, 1671
|
12457, 13791
|
13935, 17023
|
12030, 12434
|
17074, 17821
|
1686, 2967
|
225, 235
|
316, 1291
|
1313, 1528
|
1544, 1645
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,052
| 194,335
|
4089
|
Discharge summary
|
report
|
Admission Date: [**2139-12-17**] Discharge Date: [**2139-12-27**]
Date of Birth: [**2090-12-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Called out from MICU after normal workup for pseudoseizure.
Major Surgical or Invasive Procedure:
Cardiac catheterization, no intervention required.
History of Present Illness:
48 y/o m with h/o chronic CP with multiple prior cardiac
caths (last [**1-22**] here showing just 50% RCA) and thrombolysis for
ST elev in V1 V2 (thought to be Brugada pattern EKG) was ruled
out for MI at OSH, has been having CP for 5 days without any
bump in CE, was transferred here for cath for persistent CP. CP
usually not responsive to SLNTG, only morphine. Some concern for
drug seeking/malingering behavior per psych consult from OSH.
Also c/o L sided weakness for 2 days. MRI/A neg at OSH, neuro
consulted, psych consulted and concern fdor malingering. Also
has episode of unresponsiveness while in MRI scanner at OSH. Has
had prior negative EEGs, neuro concerned for pseudoseizures. On
arrival here CP was felt to be unlikely cardiac as negative
enzymes and no new EKG changes. Plan for MIBI on Monday.
Past Medical History:
EtOH abuse
Tobbaco use
Chronic Chest pain, ruled out for MI
?Pseudoseizures
Htn
Social History:
Smokes 50 pack-years, now 3ppd h/o heavy EtOH use, no IVDU
Family History:
1. MI: father died at 57
2. CAD: sister at 33
Physical Exam:
T 97.3 HR 68 BP 110/70 R 20 sat 98% on 2L
gen NAD A+OX3
HEENT mmm, no JVD, no bruits
CV RRR no m/r/g
pulm CTAb
abd s/nt/nd +BS
extr no edema
neuro CN 2-12 intact bilat, sensation intact, poor effort in L
extr but strength 5/5 bilat, DTRs [**1-20**] bilat
Pertinent Results:
[**2139-12-17**] 10:05PM GLUCOSE-94 UREA N-18 CREAT-0.9 SODIUM-143
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2139-12-17**] 10:05PM CK(CPK)-42
[**2139-12-17**] 10:05PM CK-MB-NotDone cTropnT-<0.01
[**2139-12-17**] 10:05PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2139-12-17**] 10:05PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2139-12-17**] 10:05PM WBC-8.3 RBC-4.70 HGB-14.9 HCT-43.6 MCV-93
MCH-31.6 MCHC-34.1 RDW-13.4
[**2139-12-17**] 10:05PM PLT COUNT-205
[**2139-12-17**] 10:05PM PT-13.3 PTT-27.5 INR(PT)-1.1
CXR: Compared with a portable AP chest of two days ago, as well
as portable chest from [**2135-7-19**], no consolidating pulmonary
infiltrates or definite acute process seen.
EKG: Sinus rhythm, rate 85. Poor R wave progression. ST segment
elevation in leads VI-V3 with associated T wave inversion.
Consider anteroseptal injury current. Compared to the previous
tracing of [**2139-12-23**] ST segments are less elevated in lead V2 and
are newly elevated in lead V3. T waves are inverted in leads VI
and V3. This may represent lead placement but is also consistent
with evolution of an anteroseptal injury process
Cardiac cath:
COMMENTS:
1. Hemodynamic evaluation revealed a normal central aortic
pressure of
118/69 mmHg and a normal LVEDP of 12 mmHg. There was no
gradient across
the aortic valve on pullback of the angled pigtail cathter from
the left
ventricle to the ascending aorta.
2. Left ventriculography revealed a borderline normal ejection
fraction
of 51%. There were no wall motion abnormalities. There was no
mitral
regurgitation.
3. Selective coronary angiography of this right-dominant
system
revealed no significant disease. The LMCA, LAD, and LCX as well
as
their branches were free of flow-limiting stenoses. The RCA had
a mid
30% stenosis.
4. Successful angioseal of the right femoral arteriotomy site.
FINAL DIAGNOSIS:
1. Coronary arteries without significant disease.
2. Borderline ventricular function.
3. Successful angioseal.
Brief Hospital Course:
1. Chest pain:
48yo man with history of chronic chest pain and Brugada type [**Hospital **]
transferred from outside hospital with chest pain. He ruled out
for myocardial infarction by cardiac enzymes. He underwent a
p-MIBI
stress test, which was significant for a moderate reversible
perfusion
defect in the inferior wall with no wall motion abnormalities.
He subsequently
underwent cardiac catheterization, which was only significant
for a 30% RCA lesion.
This was without complication. He was maintained on his ASA and
amlodipine,
and the amlodipine was changed to low dose atenolol before
discharge.
He was given NTG prn for pain. Otherwise, his lipids were
significant for
LDL at 76. His triglycerides were elevated at 251; this will
need to
addressed as an outpatient.
2. Pseudoseizures:
Has history of pseudoseizures with previous negative EEG
studies. He was evaluated by Neurology, who felt that this was
pseudoseizure. Psychiatry concurred with this diagnosis.
Additionally, he had a 24hour EEG, which captured only a
pseudoseizure and no evidence of epileptiform activity.
3. Fever:
Hospital course significant for intermittent fevers with no
localizing
source, and no abnormalities on UA or chest xray. He was
systemically well
and afebrile upon discharge.
4. HTN:
This was well controlled on amlodipine during his hospital
course; it
was changed to low dose atenolol before discharge. He will f/u
with
Cardiology for further management.
5. L sided weakness: poor effort on exam but intact strength
bilat, concern for malingering, MRI/A negative at OSH, psych
consulted for malingering.
6. stuttering/slurred speech: not c/w any neuro lesion as
alternates stuttering and slurred speech with intermittent
resolution of both, no defect of word finding or repitition or
comprehension, pt R handed
7. Dispo:
Patient will be discharged to home, no services required.
He was to be seen by PT for gait/steadiness, as he had
complained
of some lightheadedness with ambulating. He was observed by his
nurse
[**First Name (Titles) 151**] [**Last Name (Titles) 17981**] before discharge, and he had no symptoms of
lightheadedness
or gait instability.
He will f/u with his PCP as well as Dr. [**Last Name (STitle) **] in Cardiology
for further care.
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, ruled out for MI
? Pseudoseizures
Tobbaco use
EtOH abuse
Discharge Condition:
stable
Discharge Instructions:
Please continue your medications as listed below. Please follow
up with your cardiologist and your PCP.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2140-1-5**] 2:30
2. Please follow up with your PCP in the next 2weeks.
|
[
"780.39",
"496",
"305.00",
"786.59",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6110, 6116
|
3809, 6087
|
335, 388
|
6229, 6237
|
1772, 3653
|
6389, 6645
|
1428, 1475
|
6137, 6208
|
3671, 3786
|
6261, 6366
|
1490, 1753
|
236, 297
|
419, 1233
|
1255, 1336
|
1352, 1412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,832
| 183,233
|
38567+58227
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-8-13**] Discharge Date: [**2106-8-28**]
Date of Birth: [**2029-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left upper lobe pulmonary nodule
Major Surgical or Invasive Procedure:
[**2106-8-13**] Left video-assisted thoracoscopic surgery, left upper
lobectomy
History of Present Illness:
This is a 77 years old male with history of DVT and Atrial
fibrillation (on anticoagulation) who presented in [**4-/2106**] with
incidental finding of left
upper lung mass on chest x-ray during fever work at the
beginning of [**2105-3-29**]. CT scan described a 2.8 x 2.9 cm LUL
nodule crossing the major fissure into the superior segment of
the left lower lobe--which is positive on PET scan. A 2 mm
ground glass nodule on was noted in the right lower lobe, and a
7x10 mm nodule in the subpleural region of the right lower lobe
and calcified granuloma on the left lung base. No FDG avidity
was noted on PET scan. He had flexible bronchoscopy/BAL and
transbronchial biopsy that were negative, but concerning for
malignancy on [**2106-6-2**]. The patient had flexible bronchoscopy
and mediastinoscopy performed on [**2106-7-2**] which revealed 4L, 4R
and 7 lymph nodes which were negative for malignancy. He denied
any respiratory symptoms, cough, or constitutional symptoms like
fever, chills, nightsweats and weight loss.
Patient was admitted on [**2106-8-13**] for left upper lobe
video-assisted thoracoscopic surgery, left upper lobectomy.
Past Medical History:
- Atrial fibrillation
- Anemia
- Osteoarthritis, s/p total L hip replacement, s/p total R knee
replacement
- h/o tibial fracture
- spondylosis of the lumbosacral spine
- h/o Gastric ulcer
- h/o TIA
- colonic adenoma
- hypothyroidism
Social History:
10 pack year history many years ago. Denies current alcohol use,
illicit substance use.
Family History:
No family history of lung cancers, prostate cancers or clotting
disorders.
Physical Exam:
on discharge:
VS: 98.2 66 122/69 20 96% RA
gen: WA/WD, NAD
CV: irregularily irregular
pulm: CTA b/l
abdomen: soft, NT/ND, +BS
extremities: no edema
Pertinent Results:
[**2106-8-25**] WBC-8.8 RBC-3.23* Hgb-10.0* Hct-29.7 Plt Ct-389
[**2106-8-24**] WBC-7.7 RBC-3.37* Hgb-10.4* Hct-31.2 Plt Ct-374
[**2106-8-23**] WBC-9.9 RBC-3.49* Hgb-10.7* Hct-32.8 Plt Ct-393
[**2106-8-19**] WBC-7.3 RBC-3.16* Hgb-9.8* Hct-29.5 Plt Ct-297
[**2106-8-25**] Glucose-128* UreaN-15 Creat-0.8 Na-141 K-4.1 Cl-102
HCO3-32
[**2106-8-24**] Glucose-256* UreaN-14 Creat-0.8 Na-137 K-4.1 Cl-100
HCO3-31
[**2106-8-22**] Glucose-135* UreaN-16 Creat-0.9 Na-140 K-4.1 Cl-99
HCO3-34*
[**2106-8-13**] Glucose-149* UreaN-12 Creat-0.7 Na-140 K-3.8 Cl-105
HCO3-30
[**2106-8-25**] Calcium-8.3* Phos-3.7 Mg-2.1
[**2106-8-28**] INR(PT)-2.7*
[**2106-8-27**] INR(PT)-2.4*
[**2106-8-26**] INR(PT)-2.4*
[**2106-8-25**] INR(PT)-2.2*
[**2106-8-24**] INR(PT)-1.8*
[**2106-8-23**] INR(PT)-1.4*
[**2106-8-22**] INR(PT)-1.3*
[**2106-8-21**] INR(PT)-1.1
CXR:
[**2106-8-24**] CHEST RADIOGRAPH, AP SEMI-UPRIGHT: Left
hydropneumothorax is redemonstrated, with decrease in basilar
pleural effusion and possible increase in apical pneumothorax
compared to one day prior. There is left basilar lung opacity,
but the right lung remains clear.
CCT
[**2106-8-15**]: IMPRESSION: Left chest tube is surrounded by hematoma
and small air-fluid level, so that parenchymal laceration by the
tube might be present. Otherwise normal postoperative aspect of
the recent left upper lobectomy. The stump is unremarkable,
there is no evidence of larger pulmonary emboli. No
abnormalities at the stump.
Moderate fluid or pneumothorax and subcutaneous gas collections.
Uncharacteristic right upper lobe parenchymal opacities, mild
right lower lobe atelectasis. Calcified gallstone, mild
compression fracture of T6.
Brief Hospital Course:
CARDIOVASCULAR: He remained hemodynamically stable with few PACs
post-op, but he always remained asymptomatic and EKG tracing was
unremarkable. He was monitored on telemetry and we continued his
home doses of Digoxin 0.125 mg PO daily and Metoprolol 75 mg PO
daily. On [**2106-8-15**] he had intermittent A.fib with RVR.
Cardiology was consulted and recommended IV diltiazem converted
to dilitiazem 60 mg QID, increased his digoxin dose to 0.375 and
beta-blocker 100 mg [**Hospital1 **]. He converted to sinus rhythm 50-70's
with brief burst of atrial fibrillation. Please monitor his
digoxin level.
RESPIRATORY: Patient is s/p VATS [**Doctor Last Name **] lobectomy. He had a left
side chest tube placed intra-operatively. In the immediate
post-op period, it only drained 75-100 mL of serosanguinous
fliud. His chest tube was placed on low continuous suction and
has mild evidence of airleak. His post-op film showed moderate
pneumothorax with left upper lobe collapse. The patient remained
asymptomatic with oxygen saturations greater than 94% on nasal
cannula. Chest tube was removed on [**8-18**]. Patient tolerated it
well and at the time of discharge his oxygen saturation is > 92%
on RA.
FEN/GI: Post-operatively, normal saline at 75 cc/hr was given
for maintenance fluid, and we HLIV when the patient began
tolerating clear liquids. He was advanced to regular diet when
appropriate. He tolerated diet well.
GENITOURINARY: A Foley catheter was placed intra-operatively,
and he maintained adequate urine output throughout. His BPH
medication was restarte his foley was removed and he voided
without difficulty.
HEME/ID: Peri-operative antibiotics were given. His WBC was 11.8
and his hematocrit post-op was 30.5 which was appropriate. He
remained afebrile and without evidence of infection. His
Lovenox was restarted with bridge to Warfarin. Once his INR was
2.0 the Lovenox was discontinued. He received Warfarin 7.5 mg at
the time of discharge, his INR was 2.7.
ENDOCRINE: No active issues of note.
PROPHYLAXIS: Heparin 5000 units SQ TID for DVT prophylaxis.
NEURO: Geriatric service was consulted to assist with managment
of his dilirium and delusion. They recommended Seroquel 12.5
Q6PM and prn until his delirium improved
Medications on Admission:
Digoxin
125 mcg Tablet
One (1) Tablet by mouth DAILY (Daily).
Docusate Sodium
100 mg Capsule
One (1) Capsule by mouth twice a day: hold to loose stools.
Doxycycline Hyclate
100 mg Capsule
One (1) Capsule by mouth every twelve (12) hours for 6 days.
Enoxaparin
120 mg/0.8 mL Syringe
One (1) injection Subcutaneous every twelve (12) hours: hold on
[**5-26**] am prior to bronchoscopy.
Metoprolol Tartrate
50 mg Tablet
1.5 Tablets by mouth twice a day.
Tamsulosin
0.4 mg Capsule, Sust. Release 24 hr
One (1) Capsule, Sust. Release 24 hr by mouth HS (at bedtime).
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE (Once) as needed for agitation.
4. Digoxin 125 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
10. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: Maintain INR 2.0-3.0.
11. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO Daily as needed
for agitation.
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO BID (2 times a day).
13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO four times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
Left upper lobe nodule
Atrial fibrillation on coumadin
Hyperlipidemia
BPH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-You may shower. No tub bathing or swimming until incision
healed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2106-9-7**] 10:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Chest X-Ray [**Location (un) **] Radiology 30 minutes before your
appointment
Completed by:[**2106-8-28**] Name: [**Known lastname 1028**],[**Known firstname 422**] Unit No: [**Numeric Identifier 13604**]
Admission Date: [**2106-8-13**] Discharge Date: [**2106-8-28**]
Date of Birth: [**2029-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1999**]
Addendum:
The following additional changes were made to the discharge
medications prior to discharge per request of geriatrics:
diltiazem 60 mg PO qid - discontinued
metoprolol XR 75 mg PO bid - discontinued
diltiazem ER 240 mg once daily - started
metoprolol 75 mg PO bid - started
The digoxin level was drawn prior to discharge. We will contact
the facility if the level is not within normal limits.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1785**] Care & Rehab Center - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2106-8-28**]
|
[
"721.3",
"511.9",
"V43.65",
"V58.61",
"788.20",
"512.1",
"518.0",
"272.4",
"162.3",
"V43.64",
"244.9",
"293.0",
"E878.6",
"600.00",
"427.31",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"32.41"
] |
icd9pcs
|
[
[
[]
]
] |
9799, 10049
|
3952, 6200
|
353, 434
|
8252, 8252
|
2248, 3929
|
8641, 9776
|
1985, 2061
|
6817, 8018
|
8155, 8231
|
6226, 6794
|
8362, 8618
|
2076, 2076
|
2090, 2229
|
281, 315
|
462, 1607
|
8267, 8338
|
1629, 1864
|
1880, 1969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,772
| 110,438
|
17132
|
Discharge summary
|
report
|
Admission Date: [**2182-8-29**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2124-3-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
s/p Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical)[**9-5**]
s/p Cardiac [**Month/Year (2) **] [**8-30**]
History of Present Illness:
58 yo F with PMH of CAD s/p PCI x3 presents with chest and left
arm discomfort, along with SOB, for the past 1 week.
Past Medical History:
Coronary Artery Disease s/p Multiple PCI's (stent LAD [**2171**], [**Year (4 digits) **]
[**2179**], [**2182**])
Congestive Heart Failure
Hypertension
Hypercholesterolemia
Fibromyalgia
Chronic Obstructive Pulmonary Disease
Asthma
Chronic Renal Insufficiency(1.3)
Lower back pain
Hiatal hernia
PSH:
Ectopicx2 in [**2155**],79
Social History:
50 pack year h/o smoking (quit in [**2179**])
does not drink alcohol
Family History:
not contributory
Physical Exam:
Afebrile, HR 80, BP 140/52 RR 22 5'3" 126kg
Gen: Sleepy but arousable, AAOx3
HEENT: no lymphadenopathy, no carotid bruits
Neck: JVP around [**8-21**] cms
Heart: S1 S2, RRR, 3/6 SEM
Lungs: BS w/ rales 1/2 up
Abd: soft/NT/ND, BS+
Ext: 1+ edema, warm, well-perfused
Neuro: no focal deficits, MAE
Pertinent Results:
TTE [**8-30**]: Severe mitral regurgitation with probably rheumatic
mitral valve disease. Moderate to severe pulmonary artery
systolic hypertension. Left ventricular cavity enlargement with
regional dysfunction c/w CAD
[**Month/Year (2) **] [**8-30**]: 1. One vessel coronary artery disease.2. Severe
diastolic ventricular dysfunction.3. Moderate precapilary
pulmonary hypertension.4. Successful deployment of a Cypher
drug-eluting stent in the distal RCA
Carotid U/S [**9-4**]: Moderate plaque with bilateral 40-59% carotid
stenosis. Of note, both of the stenoses will fall into the lower
end of the range.
[**2182-8-29**] 04:30PM BLOOD WBC-13.2* RBC-4.62 Hgb-11.8* Hct-36.5
MCV-79* MCH-25.5* MCHC-32.2 RDW-16.4* Plt Ct-390
[**2182-9-4**] 07:50AM BLOOD WBC-12.3* RBC-4.52 Hgb-11.8* Hct-36.4
MCV-81* MCH-26.1* MCHC-32.4 RDW-17.3* Plt Ct-352
[**2182-9-12**] 01:23AM BLOOD WBC-19.0* RBC-3.78* Hgb-10.0* Hct-30.8*
MCV-82 MCH-26.4* MCHC-32.4 RDW-18.6* Plt Ct-354
[**2182-9-19**] 06:21AM BLOOD WBC-12.8* RBC-3.11* Hgb-8.4* Hct-26.9*
MCV-87 MCH-27.0 MCHC-31.2 RDW-20.6* Plt Ct-508*
[**2182-8-30**] 01:00AM BLOOD PT-13.9* PTT-45.1* INR(PT)-1.3
[**2182-9-13**] 02:24AM BLOOD PT-27.6* PTT-39.4* INR(PT)-5.0
[**2182-9-20**] 12:30AM BLOOD PT-17.3* PTT-54.8* INR(PT)-2.0
[**2182-8-29**] 04:30PM BLOOD Glucose-120* UreaN-26* Creat-1.3* Na-141
K-4.1 Cl-100 HCO3-27 AnGap-18
[**2182-9-19**] 06:21AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
[**2182-9-14**] 08:49AM BLOOD ALT-178* AST-96* LD(LDH)-516*
AlkPhos-127* Amylase-66 TotBili-1.7*
[**2182-9-18**] 05:37PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018
[**2182-9-18**] 05:37PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2182-9-18**] 05:37PM URINE RBC-[**12-1**]* WBC-[**3-16**] Bacteri-MOD Yeast-NONE
Epi-[**6-21**]
Brief Hospital Course:
Pt. was admitted on [**8-29**] and then underwent both a Cardiac Echo
and [**Month/Year (2) **] on [**8-30**]. The Echo revealed severe MR [**First Name (Titles) **] [**Last Name (Titles) **] showed 1
vessel CAD and a stent was placed in the distal RCA. Cardiac
surgery was consulted following these procedures for
replacement/repair of her mitral valve. But pt needed to be
aggressively diuresed before surgery d/t CHF (pt was SOB and
fluid overloaded-Edema & bilat pleural effusions). Please see
medical records for CXR reports. She continued to be followed by
us along with medicine and cardiology (see notes in medical
records). PT. underwent a carotid u/s on [**9-4**] along with a
dental consult and was cleared for surgery pending her WBC(12).
On [**9-5**] pt was brought to the operating room where she underwent
a mitral valve replacement with a mechanical valve. She
tolerated the procedure well with no complications. Please see
op note for surgical details. She was transferred to CSRU in
stable condition on a Propofol gtt. Later on op day pt was
weaned from mechanical ventilation and propofol and was
extubated. She was MAE, following commandes, and A&O. On POD #1
pt appeared somewhat hypoxic w/ CXR showing CHF. Albuterol MDI,
along with Diuresis, Oxygen via face tent and NC was started.
Heparin was being given and Coumadin would be started later that
night until target INR/PT/PTT was reached. POD #2 pt was stable
and being diuresed with increased pulmonary toilet. Chest tubes
and Swan-Ganz catheter were removed. On POD #3 Levofolx was
started for increased WBC and yellow sputum. Sputum was
cultered. She also received a blood transfusion b/c HCT was 24.
Pt. remained in the CSRU until POD #12 and was then transferred
to step-down unit. During that time (POD #[**4-23**]) she continued to
have pulm symptoms and required aggressive pulm toilet w/ high
flow oxygen. Pt. was encouraged to get OOB and ambulate.
Pulmonary eventually was consulted. Also during this time pt's
heart rhythm went into atrial flutter (EP followed pt).
Amiodarone and Verapamil were started. Pt. also experienced a
rise in her WBC while in the CSRU, multiple cultures were
performed and appropriate antibiotics coverage was given. From
POD #13 to 15 her oxygen was slowly weaned down. Also during
here entire post-op period her Coumadin and Heparin were
adjusted to reach a goal INR of 2.5 to 3 d/t her mechanical
valve. Physical therapy followed pt during post-op period as
well. She was transferred to rehab on POD #15 in stable
condition and will have her INR followed and coumadin adjusted
until goal is reached. She will also make appropriate f/u's with
physicians.
Medications on Admission:
1. Atenolol 50mg qd
2. Plavix 75mg qd
3. Protonix 40mg qd
4. Lasix 40mg [**Hospital1 **]
5. ASA 325mg qd
6. Folic Acid
7. KCL
8. Lipitor 40mg qd
9. Nitro
10. Atrovent
11. Flovent
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
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.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: Then 200mg qd for 1 month.
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
Inhalation twice a day.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): to maintain target INR 2.5-3.
15. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Mitral Regurgitation S/P Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
mechanical)[**9-5**]
PMH:Coronary Artery Disease s/p Multiple PCI's
Congestive Heart Failure
Hypertension
Hypercholesterolemia
Fibromyalgia
Chronic Obstructive Pulmonary Disease
Asthma
Chronic Renal Insufficiency(1.3)
Lower back pain
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Take all of your medications as directed.
Please seek medical attention immediately if you feel any chest
pain, shortness of breath, or any otehr concerning symptoms.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
Can take shower. Wash incision with warm water and gentle soap.
Gently pat dry. Do not take bath or go swimming.
Do not apply lotions, creams, ointments or powders to incision.
Followup Instructions:
Dr. [**Last Name (STitle) 48108**] 2-3 weeks.
Dr. [**Last Name (STitle) **] in 4 weeks.
Completed by:[**2182-9-20**]
|
[
"411.1",
"427.32",
"593.9",
"401.9",
"272.4",
"997.1",
"996.72",
"V15.82",
"412",
"729.1",
"394.1",
"285.9",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"36.01",
"39.61",
"99.20",
"35.24",
"89.60",
"88.56",
"37.23",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
7596, 7675
|
3312, 5984
|
316, 481
|
8071, 8079
|
1423, 3289
|
8643, 8761
|
1077, 1095
|
6213, 7573
|
7696, 8050
|
6010, 6190
|
8103, 8620
|
1110, 1404
|
260, 278
|
509, 627
|
649, 975
|
991, 1061
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,015
| 140,735
|
32890
|
Discharge summary
|
report
|
Admission Date: [**2138-12-3**] Discharge Date: [**2138-12-10**]
Date of Birth: [**2066-3-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Heart failure and mitral regurgitation
Major Surgical or Invasive Procedure:
TEE
PICC
Coronary Angiography
History of Present Illness:
72 F w/ pmh of HTN, p/w slurred speech and weakness X 5-6 days.
Complained of feeling "weak in the legs", progressively worse
over the week prior to presentation. Sons also noted that her
speech was slurred and thinking was slowed. Otherwise, no
CP/N/V/LH/SOB or fever, though sons note that she is stoic and
does not often tell them even if she is experiencing symptoms.
On morning of presentation, she was still in bed at 11 am which
was unusual for her so sons brought her in to [**Name (NI) **].
.
In the ED, noted to be in sinus brady in the 30s, with BP as low
as 83/65 so received calcium and atropine w/o change so received
temp wire. Also hypothermic to 89.8. Admitted to ICU.
.
Total CKs were 259->215->136, with CK-MB 56->51->40 and Trop T
0.09->0.08->0.10. Heparin gtt was initiated. At some point
during her stay, she became hypotensive and had low UOP and was
given 3.5L IVF, and briefly on dopamine gtt. In setting of
volume resuscitation, had pulmonary edema and respiratory
failure requiring NRB. CHF by CXR.
ECHO showed w/ [**2-10**]+ TR and [**2-10**]+ MR (mild thickening) and EF
60-65%. Pulm pressure 26.
.
Transferred to [**Hospital1 18**] for catheterization for NSTEMI and possible
mitral valve surgery.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. She has chronic lower
extremity edema and scaling for which she wears compression
stockings.
Past Medical History:
HTN
LE edema, chronic
Social History:
Quit smoking 20 yrs ago, w/ 1.5 ppd prior. 3-4 beers per day.
Lives independently alone. Independent w/ ADLs.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.0, BP 141/58, HR 80, RR 19, O2 95% on NRB
Gen: Elderly female in NAD, resp or otherwise. Speaking in full
sentences. Oriented x3. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 15 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2-3/6 syst mur @ apex
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Marked bilat crackles
1/2 up.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Bilateral erythema with scaling.
Pertinent Results:
Echo:
IMPRESSION: Moderate tricuspid regurgitation. Mild-moderate
mitral regurgitation with with some variation (increase) with
paced vs. native conduction. Low normal left ventricular
systolic function. Pulmonary artery systolic hypertension.
.
CTA:
CONCLUSION:
1. No central or segmental pulmonary embolism, however, due to
atelectasis
and bibasal effusions, small subsegmental peripheral pulmonary
emboli cannot
be excluded in the lower lobes.
2. Background emphysema with scattered ground-glass opacities
and multifocal
fibrosis likely is a combination of interstitial lung disease,
consolidation,
and fluid overload.
.
Cardiac catheterization:
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function
[**2138-12-3**] 05:00PM GLUCOSE-87 UREA N-23* CREAT-1.3* SODIUM-139
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2138-12-3**] 05:00PM estGFR-Using this
[**2138-12-3**] 05:00PM ALT(SGPT)-40 AST(SGOT)-72* CK(CPK)-965* ALK
PHOS-77 TOT BILI-0.3
[**2138-12-3**] 05:00PM CK-MB-23* MB INDX-2.4 cTropnT-0.18*
[**2138-12-3**] 05:00PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.4*
CHOLEST-220*
[**2138-12-3**] 05:00PM WBC-8.4 RBC-3.22* HGB-10.3* HCT-29.5* MCV-92
MCH-32.0 MCHC-35.0 RDW-15.4
[**2138-12-3**] 05:00PM PLT COUNT-130*
[**2138-12-10**] 05:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.4* Hct-25.2*
MCV-96 MCH-31.9 MCHC-33.2 RDW-15.2 Plt Ct-322
[**2138-12-7**] 06:30AM BLOOD Neuts-85.5* Lymphs-9.7* Monos-4.1 Eos-0.5
Baso-0.2
[**2138-12-10**] 05:55AM BLOOD Plt Ct-322
[**2138-12-9**] 06:00AM BLOOD Plt Ct-308#
[**2138-12-10**] 05:55AM BLOOD Glucose-96 UreaN-22* Creat-1.3* Na-148*
K-3.6 Cl-113* HCO3-27 AnGap-12
[**2138-12-9**] 06:00AM BLOOD Glucose-116* UreaN-24* Creat-1.3* Na-149*
K-2.9* Cl-111* HCO3-26 AnGap-15
[**2138-12-10**] 05:55AM BLOOD ALT-30 AST-29 LD(LDH)-261* AlkPhos-78
Amylase-193* TotBili-0.4
[**2138-12-4**] 05:00AM BLOOD CK-MB-12* MB Indx-2.2 cTropnT-0.19*
[**2138-12-3**] 05:00PM BLOOD CK-MB-23* MB Indx-2.4 cTropnT-0.18*
[**2138-12-7**] 06:30AM BLOOD calTIBC-183* VitB12-822 Folate-14.7
Ferritn-837* TRF-141*
[**2138-12-6**] 02:53AM BLOOD Hapto-233*
Brief Hospital Course:
#)Bacteremia:
Patient intially presented to OSH with severe hypothermia,
bradiacardia and hypotension. At that time she had a temporary
pacing wire placed and was given significant IV hydration for
her hypotension. On transfer to [**Hospital1 18**] she was noted to have [**5-15**]
positive blood cultures for MSSA. Surveillance cultures have
been negative to date. The source of her infection is unclear.
One possible source is the multiple cuts on her fingers, another
possible source is the central line placed at the OSH. It is
believed that an infection/sepsis picture is responsible for her
initial presentation with slurred speach and weakness. TEE
performed did not show any evidence of vegitations. She will
need a total of three weeks of IV antibiotics.
.
#)History of Slurred Speech:
She was initially seen by neurology consult at OSH and they were
concerned for thromboembolic stroke in setting of Atrial
fibrillation. Unclear history of atrial fibrillation as we only
have mention of afib on an EKG discussing previous EKGs. MRI/MRA
done did not show any evidence of ischemic insult. Neuro consult
in house believed the infection most likley caused the
difficulty speaking. She is no without symptoms. Unclear
documentation of Afib, but even so, her chads2 score is 2 and at
this time we would not favor anticoagulation because of known
aneurysm. This will need to be readdressed in the future by her
PCP after evaluation of the aneurysm by neurosurgery. She was
continued on ASA 325mg daily
.
#)11-mm right posterior communicating artery aneurysm - will
need evalutation as outpatient with a neuro surgeon
.
#)Acute systolic and diastolic heart failure:
Patient initially admitted to CCU with acute pulmonary edema.
Repeat Echo showed only mild to moderate MR and low normal
ejection fraction. Her shortness of breath was attributed to
pulmonary edema from volume repletion in the OSH and she was
diuresed. Patient went for cardiac catheterization which did not
show any significant coronary artery disease. Temporary wire
pacing was initiated for bradycardia and home dose of atenolol
was held. Bradycardia resolved. CTA performed which was negative
for PE. At the time of discharge she seemed dry and lasix were
not continued.
.
# CAD/Ischemia:
There were elevated cardiac biomarkers on presentation, cardiac
catheterization on [**12-5**] with clean coronary arteries.
Elevation likely secondary to stretched myocardium from fluid
overload.
.
# Rhythm:
She presented with bradycardia in the 30s. She required a
temporary pacer temporarily though this was discontinued after
the bradycardia resolved.
.
#)Anemia:
Unclear baseline HCT, 30 at OSH, slowly trended down initially
during this hospitalization. [**Month (only) 116**] be from frequent blood draws.
Hemolysis labs negative. Iron studies not consistenet with iron
deficiency, likley be anemia of chronic (or acute) disease from
acute infection. Her HCT should be followed by her PCP
.
#)Hypertension:
Her atenolol was stopped and she was switched to lisinopril for
BP control. If needed, her HCTZ or norvasc can be restarted as
an outpatient.
.
#)Rash:
Patient with chronic rash on lower extremities. She is followed
by an outpatient dermatoligist for this compliant.
Medications on Admission:
ASA 325
HCTZ 25
Norvasc 5
Atenolol 75
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
3. Nafcillin in D2.4W 2 gram/50 mL Piggyback Sig: Two (2) grams
Intravenous every six (6) hours: Last dose to be given on
[**2138-12-27**].
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Outpatient Lab Work
Please have weekly basic metabolic panel while you are receiving
nafcillin.
6. Outpatient Lab Work
Surveillance blood cultures to be checked within 2-3 days after
completing your course of antibiotics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare center
Discharge Diagnosis:
Primary:
Hypothermia
Acute diastolic heart failure.
Bradycardia s/p temporary pacing wire
MSSA Bacteremia/Septicemia.
Non-thrombotic troponin elevation
Altered mental status NOS
11-mm right posterior communicating artery aneurysm.
Extensive cerebral small vessel ischemic changes
Emphysema/Interstitial lung disease NOS
Anemia of chronic inflammation / Chronic kidney disease
Lower extremity petechial rash NOS
Anemia of chronic inflammation
Discharge Condition:
Stable, comfortable on room air and without shortness of breath
Discharge Instructions:
You were seen in the hospital for an infection of your blood.
Initially you were in the intensive care unit because of volume
overload. The fluid was removed and your breathing improved.
You will need a prolonged course of IV antibiotics to treat your
blood infection.
Followup Instructions:
Please plan to follow up with your primary care physician [**12-10**]
weeks after hospital discharge. Please call Dr. [**Last Name (STitle) 3306**]'
office to establish this appointment. The phone number is
[**Telephone/Fax (1) 14751**].
.
You will need to have bloodwork checked once a week for basic
metabolic panel while you are being treated with nafcillin.
.
You will also need to follow up with neurosurgery for the
aneurysm seen on your MRI. You have an appointment scheduled
with Dr. [**First Name (STitle) **] in neurosurgery on Thursday [**2139-1-1**] at 1pm.
Please call [**Telephone/Fax (1) 1669**] if you have any questions. The office
is in the [**Hospital Unit Name **], [**Location (un) 470**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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"782.3",
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"585.9",
"437.3",
"038.11",
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icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"88.56",
"39.64",
"38.93",
"89.68"
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icd9pcs
|
[
[
[]
]
] |
9294, 9354
|
5329, 8584
|
354, 386
|
9840, 9906
|
3192, 3843
|
10225, 11031
|
2448, 2531
|
8673, 9271
|
9375, 9819
|
8610, 8650
|
3860, 5306
|
9930, 10202
|
2546, 3173
|
276, 316
|
414, 2258
|
2280, 2304
|
2320, 2432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,949
| 153,600
|
15425
|
Discharge summary
|
report
|
Admission Date: [**2112-2-12**] Discharge Date: [**2112-2-25**]
Date of Birth: [**2040-6-19**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 71 year-old
male with a history of end stage renal disease on
hemodialysis and a history of gastrointestinal bleed, recent
myocardial infarction and hypotension. The patient went to
an outside hospital one week ago. He had been in his usual
state of health, but had chest pain, twice went to the
Emergency Department, but left AMA. On [**2112-2-10**] he noticed
bright red blood per rectum. His INR was found to be
supratherapeutic at 3.8. The patient went to the Emergency
Department with chest pain and received po and intravenous
vitamin K, fresh frozen platelets and INR dropped to 1.0.
Hematocrit at that time was found to drop from 37 to 27. The
patient was given 2 units of packed red blood cells. The
patient had vague intermittent chest pain throughout
admission to the outside hospital for which he received
morphine and sublingual nitroglycerin. CKs were negative,
but troponin was .63 with an unknown baseline value. The
patient was transferred to [**Hospital1 188**] for the catheterization. Upon being admitted to the
[**Hospital Unit Name 196**] Service and sent for catheterization the patient was
found to have maroon stool preprocedure. Systolic blood
pressure went from 105 down to 85. He received 250 cc bolus
and blood pressure increased to 95. The patient was sent for
the Medical Intensive Care Unit for further monitoring of
hypotension.
PAST MEDICAL HISTORY:
1. End stage renal disease on hemodialysis. The patient's
sees Dr. [**Last Name (STitle) 44753**]. The patient is aneuric and has an AV
fistula ni the left forearm with a history of clot.
2. Hypercalcemia secondary to end stage renal disease and
hyperparathyroidism with a PTH of 491 in [**2110-11-11**].
3. Hypertension.
4. Coronary artery disease with history of myocardial
infarction in the anteroseptal region unclear when.
5. Obstructive sleep apnea.
6. Cerebrovascular accident in [**2111-11-11**] and left
hemiplegia.
7. History of atrial fibrillation and rapid ventricular rate
and primary AV delay in [**2110-11-11**]. The patient was in
normal sinus rhythm on Coumadin after discharge.
8. Catheterization [**2110-11-11**] revealed one vessel
disease in left anterior descending coronary artery disease
approximately 50% stenosis of the left circumflex, impaired
ejection fraction at 40% and 1+ aortic regurgitation and 3+
mitral regurgitation.
9. History of OB positive stool in [**2110-11-11**].
10. Diabetes type 2 diagnosed in [**2110-11-11**] during
inpatient admission, but no medical treatment.
11. Right middle lobe pneumonia, history of aspiration.
12. History of left subclavian vein stenosis status post
stenting.
ALLERGIES: Intravenous contrast requiring steroid use.
SOCIAL HISTORY: He lives with his wife whose name is [**Name (NI) **]
who care for each other although the patient is not mobilized
well given his left hemiplegia. The patient has a history of
alcohol use unclear when. Tobacco use of cigars on a regular
basis. No illicit substance use.
MEDICATIONS ON ADMISSION:
1. Coumadin 3 mg h.s.
2. Nephrocaps daily.
3. Renagel daily.
4. Prevacid 30 mg q day.
5. Atenolol 50 mg q day.
6. Amiodarone 200 mg q day.
7. Isosorbide 20 mg t.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs afebrile.
Heart rate 74. Blood pressure 90/54. Respirations 18. 99%
saturation on 2 liters nasal cannula as well as on room air.
In general, he was a cranky thin man laying at 45 degrees.
HEENT he had moist mucous membranes. No elevation in JVP or
JVD. Cardiovascular regular rate, 3 out of 6 systolic
murmur. No rubs. Question of an S3. Radial and dorsalis
pedis pulses were 1+ bilaterally. Lungs were clear to
auscultation throughout. Abdomen was soft, nontender,
nondistended with positive bowel sounds. Extremities were
cool with no edema.
PERTINENT LABORATORY STUDIES: Anemia with a hematocrit of
30.7, white blood cell count of 13.6 with 95% neutrophilia.
Electrolytes significant for bicarb of 27, BUN 37, creatinine
6.3, and a potassium of 6.3. Electrocardiogram revealed
normal sinus rhythm at 60 beats per minute with lateral T
wave inversions. Electrocardiogram revealed no R wave
progression and no R wave despite changes in lead placement.
Notably electrocardiogram sent from outside hospital taken on
[**2-10**] three days prior revealed normal R wave and
normal R wave progression throughout all precordial leads.
IMPRESSION: Our impression was that this is a 71 year-old
man with a gastrointestinal bleed and hypotension whose
treatment was complicated by end stage renal disease
requiring hemodialysis and the patient having a history of
congestive heart failure and systolic dysfunction and 3+
mitral regurgitation. The patient's hypotension was presumed
stable and all antihypertensive medications were held. He
received 1 liter intravenous fluid bolus and 1 unit of packed
red blood cells. Blood pressure was increased in maps were
maintained 60 to 65. Over the first night of admission the
patient had 10 out of 10 chest pain in the substernal area
with burning decreased with two sublingual nitroglycerin. No
hypotension throughout event and no electrocardiogram changes
from his baseline. The patient slept well that night without
event and used CPAP throughout the night. The patient
persistent refused arterial blood gas and blood draws. The
patient also had esophagogastroduodenoscopy to investigate
source of gastrointestinal bleeding. Bile was seen in the
stomach and the esophagogastroduodenoscopy was normal to the
third part of the duodenum and colonoscopy was recommended.
The patient received additional bolus of intravenous fluids
with no change in saturations. Blood pressure was stable and
the patient was transferred to the floor. CKs were cycled
after initial event of chest pain and were positive with an
MB index of 12.3. Cardiology consult was called and they
recommended medical management and catheterization when the
patient could tolerate anticoagulation.
The patient was transferred to the floor when he was
normotensive. Hematocrits were followed carefully. The
patient persistently refused drawing of blood despite the
presence of triple lumen catheter in his right groin. The
patient was given GoLYTELY for colonoscopy prep and had
persistent maroon stool. Hematocrit continued to drop. The
plan of care was frequently complicated by patient's
inability to recall conversations with the team over the
course of his stay and he was repeatedly reoriented and
reminded of why he was there and assured that care was being
done in his best interest. The patient received additional
one unit of packed red blood cells when hematocrit dropped
again to 30%. The patient had second hemodialysis without
event. Given the patient's change in mental status and
frequent memory impairment he had a head CT to rule out
subdural hemorrhage and there was no evidence of bleeding.
Colonoscopy on [**2-17**] revealed two ulcerations that were
thought to be the probable sources of his gastrointestinal
bleed. The patient had a polypectomy and there was another
ulcer in the hepatic flexure consistent with ischemic colitis
after hypotension. On [**Month (only) 404**] the patient spiked to 102
temperature. Blood cultures were sent from his right femoral
groin line. Fem line was discontinued and the tip culture
was sent and line was resighted to the left femoral vein with
interventional radiology's assistance. The line placement
was extremely difficult given that he had multiple clots in
multiple regions including the subclavians bilaterally and
very narrow vessels in the femoral region bilaterally not
allowing for the normal J wire to be passed through.
After being febrile the patient had persistent rigors and was
found to have gram negative rods grow in his blood cultures.
The patient was covered with Vancomycin and Levofloxacin. The
following day the patient spiked again to 102. Four out of
four blood cultures were found to be positive for gram
negative rods. The patient was started on Cipro and Zosyn
for double pseudomonal coverage. The following day the
patient was noted to be bleeding from his AV fistula site
that was oozing stopping with pressure dressings applied.
Antibiotics were changed to Levofloxacin po given
sensitivities found on the gram negative rods. Fistula
stopped working. On [**2-19**] repair was attempted with
fistulogram. Tissue plasminogen activator injection was done
with no effect and fistula site persistently oozed.
Hematocrits were monitored carefully and were stable. The
patient was sent to the Operating Room with Vascular Surgery
to have fistula repaired without difficulty. Final
sensitivities of gram negative rods revealed Enterococcus
faecalis and Salmonella. Salmonella was susceptible to
Levofloxacin. Vancomycin was continued for faecalis to be
continued renally dosed for two weeks of treatment.
HOSPITAL COURSE: Gastrointestinal bleeding and hypotension
secondary to ulcerations in the ulcerations in the colon due
to ischemic colitis secondary to hypotension as well as
polyp. Pathology of polyp on [**2112-2-17**] found in the descending
colon revealed adenoma with high grade dysplasia. The
patient was instructed to follow up with gastrointestinal as
an outpatient for additional colonoscopies and management of
this potentially cancerous condition.
For non ST elevation myocardial infarction that occurred on
[**2112-2-13**] the patient was maintained on beta-blockers
by mouth and nitroglycerin prn for medical management to
follow up with cardiology a full two weeks after having his
polypectomy at which time it was presumed that
anticoagulation would be safe.
For end stage renal disease on hemodialysis the patient had a
left AV fistula that clotted and led to excessive bleeding
after tissue plasminogen activator use and then with repair
in vascular surgery. The fistula was highly functional at the
time of discharge and was used by dialysis on the day of
discharge without any problems. The patient has
hypercalcemia due to hyperparathyroidism. The patient was
followed throughout his stay by renal consult and had
hemodialysis three times weekly. The patient was maintained
on Sevelamer and calcium acetate and aluminum hydroxide to
keep his calcium phosphate less then 70. He was maintained
on Nephrocaps and a renal diet and lytes were monitored
carefully.
The patient had a history of atrial fibrillation. He was in
normal sinus rhythm throughout his stay and was maintained on
Amiodarone and anticoagulation was held despite concerns for
subsequent cerebrovascular accidents.
For fever and bacteremia, this was presumed due to femoral
line. The patient had gram negative rods four out of four
cultures that was Salmonella sensitive to Levaquin. The
patient also had gram positive anaerobic rod in one bottle
that was Enterococcus faecalis managed on
Vancomycin for a two week course renally dosed.
Diabetes, the patient had no home treatment. He was
maintained on a diabetic diet and glucose levels were less
then 200 throughout his stay.
Obstructive sleep apnea, the patient was maintained on BIPAP
each night. He had no home oxygen requirement and had no
desaturations throughout his stay.
Dementia, this was presumed to be some baseline level of
dementia without any evidence for reversible causes present
as well as due to his history of cerebrovascular accident and
left hemiplegia. The patient was managed with Olanzapine prn
and frequent reorientation.
Poor musculoskeletal strength and deconditioning, the patient
was unable to care for self or transfer. He had physical
therapy and occupational therapy assistance. The patient
refused to go to rehab. The patient agreed to have home VNA
as condition for discharge with medical advice and he was set
up for physical therapy and occupational therapy at home and
he was able to transfer and ambulate with walker at the time
of discharge.
DISCHARGE DIAGNOSES:
1. Bacteremia.
2. Diabetes type 2 with nephropathy uncontrolled.
3. Renal failure chronic.
4. Coagulation disorder not otherwise specified.
5. Obstructive sleep apnea.
6. History of cerebrovascular accident.
7. Left hemiparesis.
8. Hypercalcemia.
9. Subclavian stenosis.
10. Anemia due to blood loss.
11. Atrial fibrillation, paroxysmal.
12. Myocardial infarction, non Q wave myocardial infarction.
13. Gastrointestinal bleeding.
14. Hypokalemia.
15. Hyperkalemia.
16. Hypomagnesemia.
17. Bacteremia.
18. Fistula clot.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg po q.d.
2. Lipitor 20 mg po q.d.
3. Amiodarone 200 mg po q.d.
4. Multivitamin po q.d.
5. Nitroglycerin prn.
6. Calcium acetate two tablets po t.i.d. with meals.
7. Trazodone 25 mg h.s. prn.
8. Sevelamer 1600 mg po t.i.d.
9. Levofloxacin 250 mg po q 48 hours for a 14 day course.
10. Tylenol prn.
11. Lisinopril 2.5 mg po q.d.
12. Aspirin 81 mg q.d.
13. The patient was instructed to not take Coumadin until he
discussed it with his physician and discussed the benefits
and drawbacks of anticoagulation given his multiple
illnesses.
14. Vancomycin 1 gram at hemodialysis for a total of a 14
day course.
The patient was instructed to see his primary care physician
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] on the day after admission. The patient was
instructed to have an echocardiogram. The patient was
instructed to see a cardiolgoist for a myocardial perfusion
study or catheterization to prevent additional myocardial
infarctions. The patient was instructed to have a
colonoscopy on [**2112-8-12**] to evaluate for new polyps. VNA
was instructed to check the patient's blood pressure, monitor
medication use and to help the patient ambulate with walker
and transfer.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2112-4-25**] 04:57
T: [**2112-4-26**] 11:35
JOB#: [**Job Number 44754**]
|
[
"790.7",
"250.40",
"280.0",
"557.9",
"996.73",
"410.71",
"427.31",
"578.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"99.03",
"39.95",
"39.50",
"45.13",
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"93.90",
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] |
icd9pcs
|
[
[
[]
]
] |
12146, 12684
|
12710, 14213
|
3217, 3412
|
9101, 12125
|
177, 1570
|
3427, 9083
|
1592, 2899
|
2916, 3191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,401
| 127,245
|
50368
|
Discharge summary
|
report
|
Admission Date: [**2148-7-8**] Discharge Date: [**2148-7-20**]
Date of Birth: [**2086-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Meperidine / Oxycodone/Acetaminophen / Darvon /
Dilaudid
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/SOB
Major Surgical or Invasive Procedure:
[**2148-7-8**] Redosternotomy/MVR with #29 SJM Mechanical valve
History of Present Illness:
61 yo female who underwent MV repair and cabg x2 in [**2144**] after
having a GI bleed and cardiogenic shock. Followed by serial
echos for LVOT obstruction, LVH and TR and SOB since [**11-5**].
Hospitalized in [**9-5**] one night for neck pain. Ultimately
diagnosed with a pinched nerve and r/o for MI at that time. Now
presents for surgical replacement of MV with Dr. [**Last Name (STitle) 1290**].
Past Medical History:
MVrepair/cabg x2 [**2144**] (26 mm [**Doctor Last Name 405**] band, SVG to OM, SVG to
PDA)
GI bleed
pulm. HTN
bil. carpal tunnel syndrome
basal cell skin Ca
HOCM/LVOT obstruction
fibromyalgia
IBS
Afib
bladder Ca
HTN
asthmatic bronchitis
elev. chol.
OA
right breast Ca with lumpectomy and XRT
hypothyroidism
obesity
bil. cataracts
tonsillectomy
left ovarian cystectomy
Social History:
currently not working ( employed by [**Hospital1 18**])
lives with husband
no [**Name2 (NI) 50923**]. drugs
quit smoking in [**2144**]/ 30pack/year Hx
very rare ETOH
Family History:
mother with mult. MIs and died at 54
Physical Exam:
HR 76 right 138/76 left 142/78 5'4' 201#
NAD, obese
PERRLA, EOMI, anicteric, OP benign
squat neck, no JVD, supple
CTAB, with well-healed sternotomy
RRR 4/6 SEM throughout precordium and neck
soft, NT, ND, no HSM/CVA tenderness
warm, well-perfused with no edema
no varicosities on left, right LE EVH/OVH sites well-healed
neuro grossly intact , nonfocal exam, MAE, [**4-5**] strengths
bil. 1+ fem/DP/PT, left radial
non-palp. right radial
Pertinent Results:
[**2148-7-18**] 05:38AM BLOOD WBC-8.3 RBC-3.37* Hgb-9.6* Hct-28.9*
MCV-86 MCH-28.5 MCHC-33.3 RDW-15.1 Plt Ct-410
[**2148-7-18**] 05:38AM BLOOD PT-18.9* PTT-106.6* INR(PT)-1.8*
[**2148-7-18**] 05:38AM BLOOD Plt Ct-410
[**2148-7-18**] 05:38AM BLOOD Glucose-94 UreaN-15 Creat-1.2* Na-140
K-4.2 Cl-102 HCO3-31 AnGap-11
[**Numeric Identifier 104982**] - CCC *** PRELIMINARY ***
PROCEDURE DATE: [**2148-6-21**]
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, valvular heart disease. Prior CABG
.
FINAL DIAGNOSIS:
1. Native coronary arteries and grafts do not show flow-limiting
disease.
2. Severe resting left ventricular outflow tract obstruction.
3. Severe mitral regurgitation.
4. Normal ventricular function.
COMMENTS:
1. Resting hemodynamic measurement demonstrates LVOT gradient
of 120mmHg. Left sided filling pressure is elevated with no
evidence of
mitral stenosis. There is moderate pulmonary hypertension (wedge
tracing is confirmed by obtaining oxygen saturation).
2. Selective angiography of this right dominant system reveals
that the
left main coronary artery, the left anterior descending artery,
the left
circumflex artery, and the right coronary artery did not show
flow-limiting obstruction.
3. Graft angiography reveals patent grafts to OM1 and RCA with
competitive flow.
4. Left ventriculogarphy demonstrates normal LV function with an
EF of
55%. There is 3+ MR.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 8 minutes.
Arterial time = 0 hour 43 minutes.
Fluoro time = 17.8 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 100 ml,
Indications - Renal
Premedications:
Fetanyl 100mcg
Versed 1.5mg
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Cardiac Cath Supplies Used:
150CC MALLINCRODT, OPTIRAY 150CC
100CC MALLINCRODT, OPTIRAY 100CC
- ALLEGIANCE, CUSTOM STERILE PACK
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104983**]Portable TTE
(Complete) Done [**2148-7-11**] at 3:22:24 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-10-17**]
Age (years): 61 F Hgt (in): 64
BP (mm Hg): 98/66 Wgt (lb): 200
HR (bpm): 120 BSA (m2): 1.96 m2
Indication: Evaluate LVEF s/p MVR.
ICD-9 Codes: V43.3, 424.0
Test Information
Date/Time: [**2148-7-11**] at 15:22 Interpret MD: [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West [**Hospital Ward Name 121**]
[**1-5**]
Contrast: None Tech Quality: Suboptimal
Tape #: 2006W032-1:26 Machine: Vivid [**6-7**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *7.0 cm <= 4.0 cm
Left Ventricle - Ejection Fraction: >= 70% >= 55%
Aorta - Valve Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - E Wave: 1.3 m/sec
TR Gradient (+ RA = PASP): 15 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Dilated LA.
LEFT VENTRICLE: Symmetric LVH. Small LV cavity. Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal
MVR gradient.
TRICUSPID VALVE: Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes. Resting tachycardia (HR>100bpm).
Conclusions
The left atrium is dilated. There is symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small (may
be underfilled). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. A bileaflet
mitral valve prosthesis is present. The transmitral gradient is
normal for this prosthesis. The estimated pulmonary artery
systolic pressure is normal. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade
(however no subcostal views obtained).
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD, Interpreting physician
FINAL REPORT
INDICATION: Status post mitral valve replacement, evaluate
pleural effusion.
COMPARISON: [**2148-7-11**].
PA AND LATERAL CHEST X-RAY: Stable moderate cardiomegaly.
Mediastinal and
hilar contours are within normal limits. There is a small left
pleural
effusion. There is subsegmental atelectasis in the left lung.
Median
sternotomy wire and prosthetic mitral valve are unchanged in
position.
IMPRESSION: Small left pleural effusion but otherwise stable
postoperative
chest.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2148-7-17**] 8:56 AM
Procedure Date:[**2148-7-16**]
?????? [**2144**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted on [**7-8**] and underwent redo MVR with Dr. [**Last Name (STitle) 1290**].
Transferred to the CSRU in stable condition on neosynephrine and
propofol drips. Extubated and off all drips on POD #1. Chest
tubes removed, beta blockade started, and transferred to the
floor to begin increasing her activity level.Coumadin started on
POD #2 and PICC inserted for access. Renal consult also done for
rise in creatinine to 2.1 ( non-oliguric ATN). Went into rapid
AFib on POD #3, heparin continued , and amiodarone drip
started.Cardiology/EP consult done and diltiazem drip started.
This was stopped on POD #7 and DC cardioversion done. Converted
to SR and had a 6 beat run of SVT on POD #9. Discharged to home
with VNA services on POD #12 when INR therapeutic in target
range of 2.5-3.5. First blood draw on [**7-22**] with INR/coumadin
follow-up with Dr. [**Last Name (STitle) **].
Medications on Admission:
toprol XL 200 mg daily
lisinopril 5 mg daily
ASA 81 mg daily
amitriptyline 30 mg daily
levoxyl 0.1 mg daily
lipitor 40 mg daily
lasix 20 mg daily
arimidex 1 mg daily
folic acid 1 mg daily
clindamycin prn dental
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
Tablet(s)
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400 mg (2 tablets) daily x 1 week, then 200 mg (1 tablet)
ongoing.
Disp:*60 Tablet(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
MR/LVOT obstruction
UGI bleed
Bilat. carpal tunnel
Pulmonary hypertension
basal cell skin ca
oa
MV repair & CABG x 2 [**2144**]
Atrial fibrillation
bladder ca
asthma, bronchitis
IBS
HTN
hypercholesterolemia
hypothyroid
R breast ca s/p XRT
obesity
fibromyalgia
bilateral cataracts
sinus bradycardia
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds for 10 weeks
or driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
First blood draw on ................
Coumadin/ INR follow up with .................
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2148-7-22**]
|
[
"414.01",
"425.1",
"997.1",
"424.0",
"V15.82",
"V15.3",
"272.0",
"584.5",
"401.9",
"V45.81",
"997.5",
"244.9",
"729.1",
"V10.3",
"V17.3",
"V10.51",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"35.24",
"99.04",
"39.61",
"99.61",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
10097, 10146
|
7845, 8732
|
345, 411
|
10488, 10496
|
1952, 2358
|
1431, 1469
|
8995, 10074
|
10167, 10467
|
8758, 8972
|
2470, 3340
|
10520, 10870
|
10921, 11068
|
1484, 1933
|
3359, 7822
|
2391, 2453
|
298, 307
|
439, 840
|
862, 1231
|
1247, 1415
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,648
| 147,446
|
4303
|
Discharge summary
|
report
|
Admission Date: [**2188-6-13**] Discharge Date: [**2188-6-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted from outside hospital with possible small bowel
obstruction.
Major Surgical or Invasive Procedure:
Status Post bilateral femoral hernia repair.
History of Present Illness:
Ms. [**Known lastname **] is nearly [**Age over 90 **]-year-old
woman who presented to [**Hospital3 1196**] on [**2188-6-6**]
apparently with respiratory symptoms and pneumonia. She was
noted the following day to have abdominal distention and emesis.
She underwent a CAT scan, which demonstrated a small-bowel
obstruction. A surgical consultation was obtained and they
elected to treat nonoperatively due to her age and comorbidity.
The thought was that she was at very high risk for complications
and that her outcome would at best entail a difficult and
prolonged recovery. There was evidently a recommendation that
she be transferred to hospice. Per the family's wishes, she was
transferred to [**Hospital1 69**] for
potential
surgical treatment.
Past Medical History:
1. CAD s/p MI in [**2181**] with RCA - EF 40%.
2. Hypertension.
3. Arthritis.
4. Vertigo.
5. Bilateral cataracts.
6. Hyperlipidemia.
7. NSAID gastritis.
8. Depression.
9. Anxiety.
10. SBO s/p lysis of adhesions, small bowel resection, 01/[**2183**].
Social History:
Patient lives in nursing home in [**Location (un) 1887**], she is very hard of
hearing. She has 2 sons and a daughter that are very involved
with her care.
Family History:
Non contributory
Physical Exam:
VITAL SIGNS: On examination here temperature is 97.9, pulse 76,
blood pressure 122/68, and room air oxygen saturation is 96%.
GENERAL: She is alert, hard of hearing, does answer questions,
complains of being hungry. Sclerae are anicteric. She is
frail,
elderly and extremely thin. Oropharynx is clear.
NECK: Supple without lymphadenopathy, jugular venous
distention,
bruits, thyromegaly, or nodules. Trachea is midline.
LUNGS: Clear bilaterally apart from a few crackles.
HEART: Regular.
ABDOMEN: Distended, she does have bowel sounds. I believe I am
actually able to palpate intestinal loops. She is completely
nontender. I am unable to palpate any femoral or inguinal
hernias. Howship-Romberg is negative. Examination of perineum
reveals diffuse erythema and no skin breakdown per se. She does
have dermatitis in both femoral folds without skin breakdown.
RECTAL: Reveals no masses. There is not much in the way of
tone. There is soft green stool. No gross blood. Several skin
tags.
BACK: No costovertebral or obvious spinal tenderness.
EXTREMITIES: Examination of her extremities reveal 1+ edema.
She does have a fair amount of fluctuance or fluid around her
left knee. Femoral pulses are 1+. Feet are warm and appear
perfused.
NEUROLOGICAL: She is moving all extremities.
Pertinent Results:
[**2188-6-13**] 07:50PM BLOOD WBC-13.4*# RBC-4.03* Hgb-11.3*# Hct-35.1*
MCV-87 MCH-28.1 MCHC-32.3 RDW-13.5 Plt Ct-355
[**2188-6-16**] 02:22AM BLOOD WBC-12.3* RBC-3.11* Hgb-9.1* Hct-26.7*
MCV-86 MCH-29.1 MCHC-33.9 RDW-13.7 Plt Ct-394
[**2188-6-21**] 02:00PM BLOOD WBC-11.9* RBC-3.76* Hgb-10.9* Hct-32.3*
MCV-86 MCH-28.9 MCHC-33.8 RDW-13.9 Plt Ct-531*
[**2188-6-13**] 07:50PM BLOOD PT-15.8* PTT-33.7 INR(PT)-1.4*
[**2188-6-15**] 02:17AM BLOOD Plt Ct-400
[**2188-6-21**] 02:00PM BLOOD Plt Ct-531*
[**2188-6-13**] 07:50PM BLOOD Glucose-111* UreaN-8 Creat-0.7 Na-142
K-3.2* Cl-109* HCO3-22 AnGap-14
[**2188-6-17**] 05:50AM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-136 K-3.4
Cl-103 HCO3-26 AnGap-10
[**2188-6-23**] 05:35AM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-25 AnGap-12
[**2188-6-13**] 07:50PM BLOOD Albumin-2.8* Calcium-7.8* Phos-2.8 Mg-1.8
[**2188-6-15**] 04:30PM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.4 Mg-2.1
[**2188-6-23**] 05:35AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.8
[**2188-6-13**] CT
1. High-grade small-bowel obstruction, with likely transition
point in small
right inguinal hernia.
2. Large bilateral pleural effusions, and adjacent atelectasis.
3. Small volume of ascites.
4. Cholelithiasis, without evidence of cholecystitis.
5. Progression of compression deformity of T11 vertebral body.
Brief Hospital Course:
Patient underwent an Exploratory laparotomy, Lysis of adhesions
and Preperitoneal and bilateral femoral hernias with prosthetic
mesh. She tolerated the procedure very well. Immediately
postoperatively she was transferred to the surgical ICU for
monitoring. She had low urine output for the first couple of
days and was given blood as well as fluids. Her urine output
responded well. She also developed fever. Chest x-ray confirmed
atelectasis and she was encouraged to cough and deep breathe and
she was gotten out of bed daily. Patient complained of nausea
that resolved after several days. She was incontinent of stool
and several specimens were sent to lab to rule out c. diff. She
was progressed from a clear liquid diet to ground diet with
prethickened liquids after she was evaluated by speech and
swallow. It was determined that she is at risk for aspiration
and would not tolerate thin liquids and needs supervision with
eating. Despite encouragement from family and staff the patient
did not eat or drink very much. Family confirmed that this was
consistent with her preoperative state. Staff discussed with
family options regarding feeding of patient. Options discussed
were feeding tube and intravenous hydration. Family and patient
have decided to defer these options at this time. She will be
discharged back to her nursing home with hopes to rehabilitate
to previous level as tolerated and per patient and family
wishes.
Medications on Admission:
reglan 10 q6h, SQH 5000U [**Hospital1 **], senokot 2 tab [**Hospital1 **], colace 100'',
rocephin 1g IV q24, albuterol prn, aricept 5', timolol 0.5% eye
drops (1 drop both eyes daily), zoloft 50', calcium/vitamin D
250', multivitamin 1 cap daily, lidoderm patch 5% topically
daily, lasix 20', ASA 81'
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Megestrol 400 mg/10 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day) as needed for constipation.
7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Bilateral femoral hernias
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.
Activity:
No heavy lifting of items [**9-10**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please remove staples on [**6-27**].
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please feel free to call Dr. [**Last Name (STitle) **] if you have any problems
related to your recent surgery. His number is [**Telephone/Fax (1) 3201**].
Completed by:[**2188-6-23**]
|
[
"552.02",
"401.9",
"272.4",
"414.01",
"486",
"V45.82",
"331.0",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"53.31",
"38.93",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
6805, 6893
|
4338, 5775
|
339, 386
|
6963, 6973
|
2989, 4315
|
8229, 8416
|
1633, 1651
|
6126, 6782
|
6914, 6942
|
5801, 6103
|
6998, 7929
|
1666, 2970
|
222, 301
|
7941, 8206
|
414, 1171
|
1193, 1444
|
1460, 1617
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,050
| 133,652
|
13099
|
Discharge summary
|
report
|
Admission Date: [**2129-5-29**] Discharge Date: [**2129-6-9**]
Date of Birth: [**2065-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hematemesis.
Major Surgical or Invasive Procedure:
EGD
Bronchoscopy
History of Present Illness:
The patient is a 63 year old male with a history of prostate
cancer with bony metastases, atrial fibrillation on coumadin,
[**First Name3 (LF) 18048**] s/p renal transplant, lung cancer s/p resection and h/o
prior GIB (per patient) who presented to the ED on [**2129-5-29**] after
having large volume brown, guaiac positive emesis at his [**Hospital1 1501**] the
morning of presentation. The patient states that he has vomited
4-5 times on the day of admission. He denied any hemetemesis,
hematochezia, or melena although he cannot recall what color his
stool is. He admitted to having had "coffee ground" emesis prior
to this admission. The patient denied any abdominal pain,
lightheadedness or dizziness.
He did admit to a cough with brownish sputum for the "past hour"
prior to admission but denied any shortness of breath or chest
pain. He denied any orthopnea or back pain.
In the ED, the patient was found to have a fever of 103.8 with a
SBP of 75/53 with a HR in the 140-160s. He was given 5 liters of
NS in the ED with SBP 102/50 and a drop in his HR to 110-130. He
was found to have a Hct of 24.8 with a WBC of 7.7 and no bands.
He also had an INR of 3.3 on coumadin for afib. The patient was
found to be guaiac positive rectally. Therefore, the patient was
transfused 2 units PRBC in the ED. His CXR showed a bibasilar
opacities concerning for pneumonia. The patient was started on
decadron 6 mg IV for presumed sepsis, CTX/flagyl/vanco which was
switched to zosyn/vanco and bibasilar pneumonia with a lactate
of 3.2. Two peripheral IVs were placed and he was transferred to
the MICU.
Past Medical History:
-Prostate carcinoma with lumbar metastases
-Paroxysmal atrial fibrillation on coumadin
-Lung cancer s/p RUL resection x2 and LLL biopsy
-Polycystic kidney disease s/p right renal cadaveric transplant
[**2112**]
-liver cysts (discovered on CT in [**2127**])
-peripheral neuropathy
-H/O recurrent urosepsis, had been on prophylactic gatifloxacin
for approximately 2 years (?stopped one year PTA)
-HTN
-hyperlipidemia
-s/p Cholecystectomy
-H/O diverticulitis with pericolic abscess and partial colectomy
in [**2117**]
-Peripheral neuropathy leading to bilateral 1st toe amputations
-H/o TIAs
-H/o GIB per patient
-h/o pancreatitis
-multiple episodes of MRSA osteomyelitis leading to bilateral
great toe amputations and s/p right hip arthroplasty for
osteomyelitis
Social History:
The patient is a former smoker 1 ppd x 20 years and quit in
[**2112**]. He also has a history of heavy EtOH use ("as much as I
can") with his last alcoholic drink in [**2103**]. He denies any
history of IV or other illicit drug use.
Family History:
Son with [**Name2 (NI) 18048**]
Divorced
Physical Exam:
Tc = 99.0 P=103 BP=113/64 RR=16 96% on RA3 liters O2
Gen - NAD, AOX2 ( thinks year is [**2089**] but is able to name the
president of the U.S)
Heart - Irregular rate and rhythm, no M/R/G
Lungs - Bibasilar decreased breath sounds, no wheezes, rhales,
rhonchi
Abdomen - Right flank palpable kidney, no abdominal
tenderness/distention, positive splenomegaly (nontender), mild
ecchymoses on skin
Ext - SCD bilaterally, 1st toes bilaterally amputated, +1 d.
pedis bilaterally
Skin: scattered ecchymoses
Neurologic:
CN II-XII intact
Sensation diminished to light touch over BLE to mid-tibial
region.
Motor: 3-5Hz, low amplitude tremor at rest.
Delt [**Hospital1 **] Tri Wr.Ext. IO IP Quad Ham TA gastroc
R 4+ 4+ 4+ 5 5 1 2 2 5 5
L 5 5 5 5 5 4+ 4+ 4+ 5 5
DTRs: [**Name2 (NI) 40022**] (1+) biceps, triceps, brachioradialis, patellar,
Achilles jerks bilaterally.
Pertinent Results:
CHEST (PORTABLE AP) [**2129-5-29**] 5:50 AM, on admission
IMPRESSION: Questionable opacity in the right lower lobe versus
patient positioning.
CHEST (PA & LAT) [**2129-5-29**] 8:06 AM
IMPRESSION:
1) Right lower lobe pneumonia, and subtle opacity in the left
lower lobe, which may represent early infiltrate versus
atelectasis.
2) Right-sided volume loss of unknown etiology.
Labs on admission:
[**2129-5-29**] 05:40AM BLOOD WBC-7.7 RBC-2.98* Hgb-8.2* Hct-24.8*
MCV-83 MCH-27.5 MCHC-33.1 RDW-20.8* Plt Ct-111*
[**2129-5-29**] 05:40AM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2129-5-29**] 05:40AM BLOOD PT-22.2* PTT-30.1 INR(PT)-3.3
[**2129-5-29**] 05:40AM BLOOD Glucose-110* UreaN-32* Creat-1.0 Na-136
K-4.0 Cl-101 HCO3-24 AnGap-15
[**2129-5-29**] 01:30PM BLOOD ALT-16 AST-22 LD(LDH)-466* CK(CPK)-44
AlkPhos-137* Amylase-29 TotBili-1.5
[**2129-5-29**] 01:30PM BLOOD CK-MB-4 cTropnT-0.03*
[**2129-5-29**] 05:40AM BLOOD Iron-31*
[**2129-5-29**] 05:40AM BLOOD calTIBC-146* Ferritn-658* TRF-112*
[**2129-5-29**] 05:46AM BLOOD Lactate-3.2*
Brief Hospital Course:
MICU course:
In the MICU, the pt's hematocrit remained stable after the 2
units of PRBCs given in the ED. The gastroenterology service
was consulted for EGD and colonoscopy which are planned. He was
kept NPO. His hypotension was felt to be secondary to
hypovolemia and his blood pressure responded to IVF
resuscitation. His lopressor and cardizem were held. He was
also placed on stress-dose steroids. The patient presented with
atrial fibrillation with rapid ventricular rate to the 140-160s
which responded well to IVF to the 100s. It was felt that his
rapid rate was either precipitated by his hypotension or the
cause of it. The patient was on digoxin 0.125 mg daliy for rate
control. He was taking coumadin as an outpatient with a
supratherapeutic INR of 3.3. His coumadin is currently being
held and he was given 10 mg SC of vitamin K in the ED. Despite
this, his INR was 4.1 on the morning of transfer. He was found
to have a bibasilar pneumonia and was started on on Zosyn and
Vancomycin (1st dose 5-15). Blood cultures were obtained on
[**5-29**] and are pending.
The following issues were addressed after transfer to the floor:
1. UGIB/Hematemesis: The pts hematocrit was cycled q12 hours and
was stable in the 27-29 range, requiring no further
transfusions. An EGD was performed on hospital day three. It
revealed an arteriovenous malformation in the gastric antrum
which was cauterized. He was maintained on an intravenous PPI.
He did have an episode of BRBPR and a small blood clot in his
stool on hospital day 4. His hematocrit remained stable but he
received one unit of PRBCs on hospital day six to support his
volume.
2. Bibasilar pneumonia: As part of the pt's overall workup a CT
scan of the torso was performed on hospital day 3. This
revealed, amongst other findings, a near total collapse of the
right lung. The pulmonary service was consulted and performed a
bronchoscopy on hospital day five. They noted that the right
lung had re-inflated. They took bronchial biopsies of
irregularly-appearing mucosa. The pt. did spike fevers on the
antibiotics. Once the pt. was made CMO, antibiotics were
discontinued.
3. Atrial fibrillation: The patient was placed on digoxin 0.125
mg for rate control as cardizem and lopressor held secondary to
hypotension on admission. His anticoagulation with warfarin was
discontinued. He developed RVR with heart rates into the 180's.
Metoprolol was started at a low dose and slowly titrated up
with effect. The pt. did require intravenous pushes of
metoprolol and diltiazem on hospital days three, four and five
for RVR into the 180's. After these interventions, his heart
rate would decrease and remain relatively stable into the
90-100's for the next 24 hours. Even after the pt. was made
CMO, oral metoprolol was continued to help control palpitations.
4. [**Month/Year (2) 18048**] s/p renal transplant
The pt. was transferred to the floor on azathioprine 50 mg and
prednisone 60 mg (increased from 30 mg at [**Hospital1 1501**]). A renal
transplant consult was called on hospital day 3. They
recommended tapering the prednisone down to 5mg po daily and
increasing the azathioprine to 100mg po daily. The pt's
creatinine remained stable even despite a CT torso with
intravenous contrast (he was prehydrated with HCO3).
Immunosuppressants were discontinued once CMO status was
instituted.
5. ? CAD/myocardial ischemia:
Pt's EKG on presentation showed nonspecific ST depressions in
the lateral leads with a prior EKG report noting nonspecific ST
changes in the lateral leads as well but CE not elevated. Repeat
EKG on hospital day 2 showed resolution of ST depression. The
changes on admission were felt to be due to demand ischemia in
setting of UGIB.
6. Metastatic prostate and lung cancer/pain control/overall
goals of care: The pt's CT of the chest showed a new mass
consistent with metastatic lung cancer. A family meeting was
held with the [**Hospital **] health care proxy, his ex-wife [**Name (NI) 7279**] and it
was decided that the goals of care would shift to comfort. Four
days before his expiration the patient was taken off all
antibiotics, anti-coagulants and immunosuppressants and
maintained on morphine and ativan for comfort. On [**2129-6-9**] at
8:00am, the pt died peacefully with [**Doctor First Name **] at his side. The
family declined a post-mortem exam.
Medications on Admission:
Lopressor 75 mg PO Q6
Cardizem 30 mg PO Q6
Fosamax 70 mg PO Qweek
Epogen 40,000 units Qweek
Prednisone 30 mg PO QD
Digoxin 0.125 mg PO QD
Neurontin 600 mg PO TID
Imuran 50 mg PO QD
Protonix 40 mg
Percocet prn
Neutrophos TID
Ativan QHS prn
Niferex forte 150 mg PO BID
Mscontin 15 mg PO BID
Coumadin 1 mg PO QD
Discharge Disposition:
Expired
Discharge Diagnosis:
Death
Discharge Condition:
Dead
|
[
"401.9",
"V12.59",
"537.83",
"185",
"753.12",
"453.42",
"198.5",
"287.5",
"V66.7",
"285.1",
"162.4",
"427.31",
"V42.0",
"038.9",
"276.5",
"486",
"443.9",
"V49.71",
"995.92",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9838, 9847
|
5102, 9478
|
326, 344
|
9896, 9903
|
3995, 4380
|
3021, 3064
|
9868, 9875
|
9504, 9815
|
3079, 3976
|
274, 288
|
372, 1971
|
4395, 5079
|
1993, 2755
|
2771, 3005
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,078
| 148,321
|
6538
|
Discharge summary
|
report
|
Admission Date: [**2195-3-14**] Discharge Date: [**2195-3-23**]
Date of Birth: [**2144-5-7**] Sex: M
Service: SURGERY
Allergies:
Actos
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Swollen tongue and neck, Airway compromise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 y/o diabetic male s/p kidney transplant presents with
tongue swelling after biting his tongue 2 days prior to
admission, although he
initially came to the [**Hospital1 18**] ED for treatment of a L foot ulcer.
EENT were consulted to assess airway. He has been unable to
tolerate POs and has been unable to speak or move his tongue for
2 days.
Past Medical History:
1. DM type 2
2. HTN
3. CRI progressing to ESRD, now s/p renal transplant
4. Neuropathy
5. Depression
Social History:
smoker, truck driver, lives in [**Location 4310**]
Family History:
non-contributory
Physical Exam:
Admission PE:
98.6 110 171/88 18 100% RA
General: working to breathe, unable to swallow secretions
Oral cavity: large hematoma in floor of mouth, unable to see
soft
palate,tongue not mobile
OP: unable to assess
Neck: erythema of submentum w/ecchymoses, submental
edema,crycoid
palpable above sternal notch
Today's PE:
VS: BP 138/76 P 92 O2 sat 98% on RA
Gen: AAOx3, NAD
HENT: wnl, breathing with ease
Lungs: CTA, B/L
Heart: RRR, S1S2
Abd: obese, non-tender
Ext: L heel has an ulceration with some yellowish drainage
R BKA
Pulses: Left palp fem / dop dp left / no pt left
Right palp fem
Pertinent Results:
[**2195-3-23**] 11:10AM BLOOD WBC-13.9* RBC-5.05 Hgb-11.2* Hct-34.3*
MCV-68* MCH-22.1* MCHC-32.6 RDW-19.6* Plt Ct-654*
[**2195-3-23**] 11:10AM BLOOD Plt Ct-654*
ANKLE (2 VIEWS) LEFT [**2195-3-14**] IMPRESSION: No osseous erosion or
destruction identified to suggest osteomyelitis.
CHEST PORT. LINE PLACEMENT [**2195-3-17**] 11:24 IMPRESSION: Right
basilic PICC terminating in distal SVC. Endotracheal tube
terminating at the upper border of the clavicles, 7 cm above the
carina. Unchanged bibasilar opacities could reflect atelectasis
or aspiration.
RENAL TRANSPLANT U.S. [**2195-3-22**] 9:43 FINDINGS: The transplanted
kidney is again identified measuring 13.8 cm. There has been
interval decrease in the previously seen hydronephrosis which is
mild. No perinephric fluid collection identified. Doppler
interrogation of the kidney demonstrates arterial waveforms in
the upper, mid and lower poles, with resistive indices elevated
compared to the prior study, ranging from 0.81-0.87.
CT NECK W/CONTRAST (EG:PAROTIDS) [**2195-3-14**] IMPRESSION: 1.
Massive sublingual hematoma producing elevation of the tongue
base and floor and mouth with severe compromise of the upper
airway.2. Complete opacification of the right sphenoid sinus.3.
Periodontal disease.
Brief Hospital Course:
The patient is a 50-year-old male who presented to [**Hospital1 18**] ED on
[**2195-3-13**] with Ludwigs
angina from hematoma [**3-7**] biting tongue in his sleep 2 days ago.
Also w/ bleeding of left heel while supratherapeutic on coumadin
(>22 on [**Month/Day (2) 269**] check). INR on admission 22.8. Pt states his mouth
has been getting
progressively swollen since he bit it apparently while sleeping.
Has been bleeding as well. No c/o SOB, has been unable to take
POs although has taken a select couple of meds. LE heel wound
is
a chronic problem that he has been followed by Dr. [**Last Name (STitle) **] and
[**Doctor Last Name 12636**] for. Pt complains of continuous oozing from the wound.
Patient was intubated under Fiberoptic bronchoscopic guidance
and mild
sedation by ENT. Patient was admitted to the ICU/ENT service. In
the ICU patient was on tube feedings for nutrition. Remained
intubated, [**2195-3-20**] he was successfully weaned and extubated. NGT
and tube feedings were also discontinued, diet started and
tolerating well, no bowel problems.
[**Name (NI) **] also came in on DKA, blood sugar on admission 355,
patient was placed on insulin drip in the ICU, blood sugar
stablelized on Glargine and is being covered with regular
insulin per sliding scale.
[**2195-3-14**] ID: Patient was placed on his home prophylactic meds of
Bactrim.
[**2195-3-15**] wound culture, came back + for STAPH AUREUS COAG +
MODERATE GROWTH, started on Vanco and Flagyl. Vanco levels were
elevated, Vanco held since [**3-20**].
[**2195-3-23**] discharged on Linezolid/Bactrim/Flagyl.
[**2195-3-15**] Patient was transfused with for a total 4 unit red
cells and 6 units plasma to for low Hct and elevated INR, HCT
and INR stablelized.
[**2195-3-17**] Right basilic PICC line was placed in interventional
radiology, placement confirmed by X-ray.
[**3-20**] Renal- Renal transplant consulted- switched Rapamune to
Prograf.
[**3-22**] Creatinine rose to 2.4 from 1.3 on [**3-21**], repeat [**3-23**] 2.6
renal transplant service (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25064**]) consulted and came
to see patient, will follow outpatient with Dr. [**Last Name (STitle) **].
[**3-21**] Patient was transferred to [**Hospital Ward Name 121**] 5 VICU Vascular Sugery
service on telemetry. Telemetry discontinued [**1-20**]. Patient's
vital signs have been stable during his post [**Hospital **] hospital stay.
Wound: L heel ulcer was dressed with DSD and ace since
admission, will discharge with [**Hospital 269**] for wound care.
Medications on Admission:
Lopressor 50 TID, MMF 500"', Sacrolimus 2, Insulin 70/30 (34U
[**Hospital1 **]), Humulog SSI QID, lisinopril 5', bactrim 4000/80', lipitor
20', Clindamycin 300 "', Hydralazine 25', Coumadin (INR goal is
[**3-8**])
Discharge Medications:
1. Linezolid 600 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO every twelve
(12) hours for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (3) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (3) **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Amlodipine 5 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable [**Month/Day (3) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
10. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
12. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
TID (3 times a day).
14. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Ludwigs angina requiring intubation
Left heel ulcer
IDDM
HTN
ESRD s/p CRT (CR 1.2-1.6)
Neuropathy
Depression
BKA
Discharge Condition:
Stable
Discharge Instructions:
[**Hospital1 69**]
Division of Vascular and Endovascular Surgery
Discharge Instructions
- Your angiogram was deferred due to your Creatinine rising.
- You may resume your regular diet and all your activities prior
to
your hospitalization.
- Please call Dr.[**Name (NI) 1720**] office at [**Telephone/Fax (1) 1241**] to set up an
appointment for your angiogram in 2 weeks.
- Take all your medications as prescribed.
- You have lab works that need to be done weekly. Results need
to be
faxed to Dr.[**Name (NI) 1720**] office at ([**Telephone/Fax (1) 25065**]
- Home care services will come to evaluate your wound and go
over
treatment with you and your spouse.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call to schedule
appointment [**Telephone/Fax (1) 1241**]
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Phone: ([**Telephone/Fax (1) 3626**], please call her
office to set up an appointment in 2 weeks.
Completed by:[**2195-3-23**]
|
[
"790.92",
"528.3",
"707.14",
"V49.75",
"285.9",
"401.9",
"250.62",
"357.2",
"440.23",
"996.81",
"250.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"99.04",
"38.93",
"96.72",
"86.28",
"99.07",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7225, 7324
|
2860, 5416
|
308, 315
|
7481, 7490
|
1571, 2837
|
8212, 8526
|
906, 924
|
5680, 7202
|
7345, 7460
|
5442, 5657
|
7514, 8189
|
939, 1552
|
226, 270
|
343, 691
|
713, 821
|
837, 890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,167
| 167,203
|
33822
|
Discharge summary
|
report
|
Admission Date: [**2122-4-29**] Discharge Date: [**2122-5-1**]
Date of Birth: [**2078-12-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
Exploratory Laporotomy with repair of small bowel laceration and
grade 1 liver laceration. L foream venous injury
repaired/closed by Vascular surgery.
History of Present Illness:
43 yo M brought in by ambulance s/p assault with stab wounds to
abdomen and LUE.
Past Medical History:
Denies
Social History:
Married. 3 children. Lives with wife and 3 children.
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
T 101.3 131 130/92 20 992L
NAD, comfortable
HEENT: NC/AT
Chest: CTAB
Cardio: Tachycardic, no M/R/G
Abdomen: Central Exlap incision with staples in place, healing
well, dressing with small amount of serosanguineous oozing. 4
stab wounds with skin edges loosely approximated, no signs of
infection: minimal erythema, no purulent drainage
Ext: LUE bandaged, minimal drainage on dressing, nl
sensation/motor function. 5/5 strength diffusely
Neuro: a&o x3.
Psych: flat affect
Pertinent Results:
[**2122-4-29**] 07:54PM GLUCOSE-138* UREA N-11 CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
[**2122-4-29**] 07:54PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2122-4-29**] 07:54PM WBC-15.6* RBC-4.07* HGB-12.0* HCT-34.7*
MCV-85 MCH-29.5 MCHC-34.5 RDW-14.4
[**2122-4-29**] 07:54PM PLT COUNT-235
[**2122-4-29**] 06:11PM GLUCOSE-232* LACTATE-7.3* NA+-138 K+-3.9
CL--99* TCO2-22
[**2122-4-29**] 06:05PM UREA N-11 CREAT-0.9
[**2122-4-29**] 06:05PM estGFR-Using this
[**2122-4-29**] 06:05PM AMYLASE-51
[**2122-4-29**] 06:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-4-29**] 06:05PM WBC-11.5* RBC-4.93 HGB-14.1 HCT-41.1 MCV-83
MCH-28.6 MCHC-34.3 RDW-14.6
[**2122-4-29**] 06:05PM PLT COUNT-304
[**2122-4-29**] 06:05PM PT-10.8 PTT-18.2* INR(PT)-0.9
[**2122-4-29**] 06:05PM FIBRINOGE-193
TRAUMA #3 (PORT CHEST ONLY) [**2122-4-29**] 5:55 PM
TRAUMA #3 (PORT CHEST ONLY)
Reason: TRAUMA
CHEST RADIOGRAPH PERFORMED ON [**2122-4-29**]
COMPARISON: None.
CLINICAL HISTORY: Trauma.
FINDINGS: Portable supine AP chest radiograph is obtained. The
lungs are clear bilaterally demonstrating no evidence of
airspace consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette is unremarkable. The visualized
osseous structures appear intact.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
43 yo M BIBA s/p assault and stab wounds to abdomen and LUE. In
trauma bay patient had IV access obtained, tachycardic but VSS.
After initial resuscitation patient was brought immediately to
the Operating Room for exploratory laporotomy given his
abdominal stab wounds.
Operative note will be faxed when transcribed: summary of op
note: patient was found to have a grade 1 liver laceration and
an extremely small small bowel laceration which was sewn. The
bowel was run and no other injuries were found. Additionally pt
had a eleft arm injury (see vascular note) which has been
repaired and requires dressing changes only.
Pt spent the night ([**Date range (1) 52620**]) in the PACU for pain control
issues: respiratory rate was dropping to 8 with adequate IV pain
medication. The acute pain service was consulted and placed an
epidural for pain relief. Pt was subsequently transferred to
the floor for further care and respiratory rate has been stable
and normal.
While on the floor the patient has remained tachycardic in the
120 to 130s, attributed to pain. An Ekg was performed
confirming sinus tachycardia. He spiked a fever on [**4-30**]
overnight to 101.3 and 101.2 on [**5-1**], the fever has been
responsive to tylenol and is more then likely due to atelectasis
as pt has not been compliant with incentive spirometry or
getting OOB. Pt encouraged to use incentive spirometer and
assisted out of bed.
Pt was started on sips [**5-1**] but further advancement of diet is
pending return of bowel function. Pt has not yet had flatus and
did have significant bowel manipulation during surgery (his
bowel was run).
Psychiatry has been following the patient since admission (see
psych note). psych requested that an EEG be performed, this has
not yet occurred at the time of transfer.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed. Tablet(s)
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO CIWA () as
needed for per ciwa protocol.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. IV care
Peripheral IV flushes: Sodium Chloride 0.9% Flush 3 mL IV
DAILY:PRN
7. PCA
HYDROmorphone (Dilaudid) 0.25 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 2.5 mg(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p Assault
Discharge Condition:
Stable
Discharge Instructions:
PT BEING TRANSFERRED TO [**Hospital **] HOSPITAL LOCKED FACILITY
Followup Instructions:
Please follow up with the Trauma clinic. Call [**Telephone/Fax (1) 11173**] to
make your appointment.
|
[
"298.9",
"903.1",
"305.50",
"863.39",
"305.60",
"518.0",
"427.89",
"E956",
"864.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"54.63",
"50.61",
"46.73"
] |
icd9pcs
|
[
[
[]
]
] |
5238, 5311
|
2657, 4457
|
326, 480
|
5367, 5376
|
1261, 2634
|
5489, 5595
|
707, 725
|
4512, 5215
|
5332, 5346
|
4483, 4489
|
5400, 5466
|
740, 740
|
275, 288
|
508, 590
|
612, 620
|
636, 691
|
765, 1242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,406
| 193,186
|
46972
|
Discharge summary
|
report
|
Admission Date: [**2170-3-25**] Discharge Date: [**2170-4-20**]
Date of Birth: [**2107-10-30**] Sex: F
Service: Fenard Intensive Care Unit
CHIEF COMPLAINT: Respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a 62-year-old woman with
multiple medical problems with a recent admission complicated
by PEA arrest x2, Intensive Care Unit admission, respiratory
arrest, who presented on [**3-25**] after being intubated at
[**Hospital3 672**] Hospital. The patient reported increasing
shortness of breath starting on [**3-23**]. Initially, she
had received an increasing Lasix dose and was later found to
have pneumonia with a sputum culture which was showing both
gram-positive cocci and gram-negative rods at the outside
hospital.
By [**3-24**], she was requiring increasing oxygen and
attempts at BiPAP were unsuccessful. Therefore, she was
intubated secondary to respiratory failure and was then
transferred to the [**Hospital1 69**]. On
arrival here, arterial blood gas showed 7.27/52/93. She was
given azithromycin, ceftriaxone, and Flagyl in the Emergency
Department. She had a left subclavian line placed in the
Emergency Department, and then was transferred to the
Intensive Care Unit for further management.
MEDICATIONS ON TRANSFER:
1. Lasix 120 mg [**Hospital1 **].
2. Lopressor 150 mg [**Hospital1 **].
3. Aspirin 81 mg q day.
4. NPH insulin 95 units q am, 30 units q pm.
5. Erythromycin eyedrops.
6. Nystatin swish and swallow.
7. Protonix 40 mg q day.
8. Amiodarone 400 mg q day.
9. Diltiazem 120 mg qid.
10. Regular insulin-sliding scale.
11. Zinc.
12. Albuterol and Atrovent nebulizers.
13. One day's worth of levofloxacin and Flagyl.
ADMISSION PHYSICAL EXAMINATION: Vitals: Temperature 102,
heart rate 86, blood pressure 88/palp. She was intubated and
sedated, with response to painful stimuli. Markedly obese.
Injected sclerae. ETT in place. Neck is supple. Coarse
rhonchi bilaterally. Heart rate irregularly, irregular, S1,
S2, with no murmurs appreciated. Obese abdomen, soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities showed bilateral 2+ pitting edema.
ADMISSION LABORATORIES: Chem-7 shows a sodium of 135,
potassium 5.6, chloride 98, bicarb 21, BUN 41, creatinine
1.5, glucose 270. Calcium 8.4, magnesium 1.8, phosphorus
5.4. Complete blood count shows a white count of 16.7,
hematocrit of 29.5, platelets of 386. Differential shows 78%
segs, 12 bands, 7 lymphocytes, and 1 monocyte. Initial coags
show an INR of 1.6 and a PTT of 30.5. CK of 69 with a
troponin of less than 0.3.
ELECTROCARDIOGRAM: Showed atrial fibrillation at a rate of
96 beats per minute with T-wave inversions in II, III, and F
which were new compared to prior study from [**2170-3-10**].
HOSPITAL COURSE: The patient was brought to the Intensive
Care Unit and treated for respiratory failure secondary to
presumed aspiration pneumonia that required intubation. Her
course thereafter was most notable for persistent and
progressive anasarca and pulmonary edema, which failed to
respond to aggressive treatment with diuretics and titration
of her cardiac medications. Her course was then complicated
by persistent worsening of renal failure.
When she failed to significantly improve, she initially
underwent tracheostomy. However, when she continued to show
no signs of improvement, appear to be in significant pain,
and had a slim chance for meaningful recovery in a way that
would be consistent with her previously expressed wishes for
her care, a series of family meetings were held. Finally, on
[**2170-4-19**], the patient's family was in agreement that the
patient would not want to undergo prolonged suffering given
the slim chances for meaningful recovery. At that time, the
decision was made to remove mechanical ventilatory support.
The patient expired the next day on [**2170-4-20**] at 2:10 pm.
The patient's family consented to autopsy.
DISCHARGE STATUS: Deceased.
DISCHARGE DIAGNOSES:
1. Respiratory failure secondary to pneumonia due to
methicillin-resistant Staphylococcus aureus and Klebsiella.
2. Acute renal failure.
3. Atrial fibrillation.
4. Diabetes mellitus.
5. Severe sacral decubitus ulcers in multiple locations.
6. Anasarca.
7. Hypoalbuminemia.
8. Hypotension.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 19919**]
MEDQUIST36
D: [**2170-5-21**] 17:15
T: [**2170-5-25**] 07:26
JOB#: [**Job Number 56703**]
|
[
"518.81",
"482.0",
"707.0",
"507.0",
"427.31",
"038.9",
"584.9",
"428.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"33.21",
"38.93",
"38.91",
"96.72",
"31.1",
"96.6",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
3975, 4526
|
2773, 3954
|
1712, 2755
|
174, 196
|
225, 1245
|
1270, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
798
| 167,367
|
30080
|
Discharge summary
|
report
|
Admission Date: [**2151-2-11**] Discharge Date: [**2151-3-3**]
Date of Birth: [**2083-4-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2151-2-11**] Cardiac catheterization.
AVR (#25 CE pericardial), CABG X 4 (LIMA>LAD, SVG>Diag>OM,
SVG>PDA) on [**2151-2-18**]
History of Present Illness:
67 yoM progressively DOE on exertion for one week with
associated chest pressure. The patient presented to podiatry,
and was found to be in HF. Referred to OSH ED for evaluation
which found HF and NSTEMI. Transferred to [**Hospital1 18**] for further
cardiac evaluation.
Past Medical History:
DM II
PAD
HTN
Dyslipidemia
Smoking history
Spinal stenosis
DJD
Peripheral neuropathy
OSA, not on CPAP
Social History:
quit smoking 25 years ago. Prior 3ppdx 15-20 years. ETOH [**1-16**]/wk.
No other drugs.
Family History:
CAD in father in mid 60s. No DM. No SCD.
Physical Exam:
Exam: 90% on nonrebreather
JVP 10cm
crackles 1/3 up bilaterally
+ 1 LE edema
Discharge
Vitals 98.6 SR 71 105/53 22RR, RA sat 90-92% wt 84kg
Neuro A/ox3 non focal MAE rleg 5/5 l leg [**3-18**]
Pulm Fine crackles bilat bases
Cardiac RRR no murmur/rub/gallop
GI Abd soft, NT, ND, +BS bm [**3-2**]
Ext Warm pulses palpable +1 edema
Incision Sternal healing no erythema/drainage sternum stable,
steris
Left leg - EVH steris healin no erythema/drainage
Pertinent Results:
[**2151-3-1**] 05:55AM BLOOD WBC-11.3* RBC-3.36* Hgb-9.9* Hct-29.7*
MCV-89 MCH-29.5 MCHC-33.3 RDW-14.0 Plt Ct-391
[**2151-2-11**] 06:15PM BLOOD WBC-10.2 RBC-3.49* Hgb-10.8* Hct-31.9*
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.5 Plt Ct-265
[**2151-2-17**] 07:00AM BLOOD Neuts-75.7* Lymphs-15.4* Monos-4.7
Eos-3.6 Baso-0.5
[**2151-3-2**] 06:15AM BLOOD PT-20.8* INR(PT)-2.0*
[**2151-3-1**] 05:55AM BLOOD Plt Ct-391
[**2151-2-11**] 06:15PM BLOOD PT-13.6* PTT-26.2 INR(PT)-1.2*
[**2151-2-11**] 06:15PM BLOOD Plt Ct-265
[**2151-3-1**] 05:55AM BLOOD PT-18.6* PTT-29.9 INR(PT)-1.8*
[**2151-2-28**] 10:15AM BLOOD PT-19.6* PTT-29.1 INR(PT)-1.9*
[**2151-2-27**] 12:00PM BLOOD Plt Ct-431
[**2151-2-27**] 12:00PM BLOOD PT-17.6* PTT-27.8 INR(PT)-1.6*
[**2151-2-26**] 03:55AM BLOOD PT-15.8* PTT-26.6 INR(PT)-1.4*
[**2151-3-2**] 06:15AM BLOOD Creat-1.6* K-4.5
[**2151-3-1**] 05:55AM BLOOD Glucose-47* UreaN-28* Creat-1.4* Na-140
K-4.5 Cl-104 HCO3-29 AnGap-12
[**2151-2-11**] 06:15PM BLOOD Glucose-131* UreaN-35* Creat-1.3* Na-140
K-4.0 Cl-108 HCO3-21* AnGap-15
[**2151-2-27**] 12:00PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.5
[**2151-2-12**] 07:47AM BLOOD calTIBC-238* VitB12-542 Folate-GREATER TH
Ferritn-421* TRF-183*
[**2151-2-11**] 06:15PM BLOOD %HbA1c-6.7* [Hgb]-DONE [A1c]-DONE
[**2151-2-12**] 07:47AM BLOOD Triglyc-120 HDL-49 CHOL/HD-3.8
LDLcalc-112
EKG [**3-2**]
Sinus rhythm
Right bundle branch block
Consider septal myocardial infarction, age indeterminate
ST-T wave abnormalities - cannot exclude in part ischemia -
clinical
correlation is suggested
Since previous tracing of [**2151-2-25**], no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 178 140 [**Telephone/Fax (2) 71728**] 37 110
CXR [**2151-3-1**]
CHEST (PA & LAT) [**2151-3-1**] 9:13 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
67 year old man with NSTEMI, CHF, fever.
REASON FOR THIS EXAMINATION:
r/o inf, eff
INDICATION: CHF, fever. Rule out infiltrate or effusion.
COMPARISON: Multiple x-rays from [**2151-2-16**] to [**2151-2-25**].
PA AND LATERAL RADIOGRAPHS OF THE CHEST: There has been slight
improvement to the bilateral perihilar airspace opacities.
Underlying cystic lucencies are becoming more prominent, which
may be due to pre-existing emphysema or pneumatoceles from
recent barotrauma. Loculated left pleural effusion is unchanged.
The patient is status post median sternotomy, CABG, and AVR.
IMPRESSION: Slight improvement in bilateral interstitial
opacities which may represent asymmetrical edema, though with a
new history of fever, infection is also a possibility.
Underlying cystic lucencies may represent pre-existing emphysema
or pneumatoceles from recent barotrauma.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2151-3-1**] 1:13 PM
TEE
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. H/O cardiac surgery. Left
ventricular function. Valvular heart disease.
Height: (in) 69
Weight (lb): 198
BSA (m2): 2.06 m2
BP (mm Hg): 146/59
HR (bpm): 86
Status: Inpatient
Date/Time: [**2151-2-22**] at 13:18
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W018-1:03
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 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: *5.8 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 20% to 25% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.38
Mitral Valve - E Wave Deceleration Time: 213 msec
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2151-2-12**].
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Severely
depressed LVEF. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated,
normal leaflet/disc motion and transvalvular gradients. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**12-15**]+)
MR. Eccentric MR jet.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated.
Overall left ventricular systolic function is severely depressed
with global
hypokinesis. There is no ventricular septal defect. There is
moderate global
right ventricular free wall hypokinesis. A bioprosthetic aortic
valve
prosthesis is present (not well seen, but by op note, a Magna
tissue valve was
placed on [**2151-2-18**]). The aortic prosthesis appears well seated
with normal
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-15**]+) mitral
regurgitation is
seen. The mitral regurgitation jet is eccentric. The tricuspid
valve leaflets
are mildly thickened. There is no pericardial effusion.
Compared to the prior study dated [**2151-2-12**], the LVEF and RVEF
are now lower.
By report (not well seen) an aortic valve bioprosthesis is now
present. The
degree of mitral regurgitation is similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2151-2-22**] 15:06.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **]
Brief Hospital Course:
Cardiac catheterization here showed severe 3 VD. Cardiac surgery
was consulted and he underwent preoperative workup and awaited
diuresis and plavix washout. He was also placed on levofloxacin
for presumes pneumonia. On [**2-18**] he was taken to the operating
room where he underwent a CABGx4 and AVR with tissue valve. he
was transferred to the ICU in critical but stable condition on
milrinone and levophed. He was extubated and weaned from his
vasoactive srips on POD #1. He was started on amiodarone on POD
#2 for intermittent atrial fibrillation. He became bradycardic,
and was seen by electrophysiology who recomended contining PO
amio and using lopressor instead. He should also follow up with
Dr. [**Last Name (STitle) **] in 6 weeks for an ICD evaluation given his ventricular
ectopy. He was also started on coumadin for his a fib. He was
transferred to the floor on POD #5. ON POD #7 he was transferred
back to the ICU for hypotension after his ACE inhibitor and beta
blocker were increased aggreseively. His doses were decreased,
his blood pressure improved and he was transferred back to the
floor on POD #8. Pulmonary was consulted and will follow up with
him as an outpatient. He continued to progressed and was ready
for discharge to rehab on POD 12 with [**Doctor Last Name **] of hearts monitor.
Medications on Admission:
Labetalol 200 mg QD
Norvasc 10 mg QD
Actos 30 mg QD
Glipizide 10 mg QD
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:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*0*
4. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day:
400 [**Hospital1 **] x 1 week, then 200 mg daily for three weeks.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please take [**3-2**] and [**3-3**] - check INR [**3-4**].
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
AS
CAD
DM
HTN
DJD
sleep apnea
peripheral neuropathy
Discharge Condition:
good
Discharge Instructions:
[**Doctor Last Name **] of Hearts monitor - twice a day readings to holter lab at
[**Hospital1 18**]
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 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
Followup Instructions:
with Dr. [**Last Name (STitle) 10543**] after discharge from rehab [**Telephone/Fax (1) 4475**]
with Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 18323**] after discharge from rehab
Dr. [**Last Name (STitle) **] (EP) please call to schedule ([**Telephone/Fax (1) 5862**]
Please call to schedule all appointments
[**Doctor Last Name **] of hearts monitor - holter lab ([**Telephone/Fax (1) 33989**] - Dr [**Last Name (STitle) **] to
follow Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2151-4-8**] 2:30
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2151-4-8**] 2:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] /DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-4-8**] 3:30
PT/INR as needed first draw [**3-4**] goal INR 2.0-2.5 for atrial
fibrillation
Sleep study to evaluate for sleep apnea after recovery from
surgery
Completed by:[**2151-3-2**]
|
[
"250.00",
"433.10",
"327.23",
"410.71",
"V58.61",
"585.9",
"356.9",
"V17.3",
"414.01",
"486",
"427.31",
"398.91",
"584.9",
"401.9",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"99.04",
"35.21",
"36.11",
"37.23",
"88.56",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
10643, 10732
|
7778, 9093
|
339, 469
|
10828, 10835
|
1543, 3396
|
11402, 12492
|
1017, 1059
|
9215, 10620
|
3433, 3474
|
10753, 10807
|
9119, 9192
|
10859, 11379
|
4599, 7672
|
1074, 1524
|
280, 301
|
3503, 4573
|
497, 770
|
7704, 7755
|
792, 896
|
912, 1001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,603
| 103,656
|
53838
|
Discharge summary
|
report
|
Admission Date: [**2123-7-21**] Discharge Date: [**2123-7-26**]
Date of Birth: [**2060-6-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2123-7-22**] AVR(21 [**Doctor Last Name **] Pericardial)/Septal myomectomy
History of Present Illness:
62 year old female with known bicuspid aortic valve and
aortic stenosis. She has a history of a coarctation of the aorta
repair by way of an end to end anastomosis at the age of 12.
Over
the past couple years, she has been followed by serial
echocardiograms which have shown progression of her aortic
stenosis. Over the last 6 months, she has noted mild dyspnea on
exertion. She denies chest pain, syncope, pre-syncope,
orthopnea,
PND and pedal edema. Given her most recent echocardiogram
findings, she has been referred for cardiac surgical evaluation.
Past Medical History:
Past Medical History:
- Bicuspid aortic valve, Aortic stenosis
- Dyslipidemia
Past Surgical History:
- Coarctation repair at age 12 via left thoracotomy
- Tonsillectomy
Past Cardiac Procedures:
- Coarctation repair at age 12 via left thoracotomy at [**Hospital1 1872**]
in [**Location (un) 6482**]
Social History:
Race: Caucasian
Last Dental Exam: Every 6 months
Lives: In [**Location (un) 17566**] with brother who is somewhat dependent,
has social supports/friends in area
Occupation: Teacher
Cigarettes: Very rarely, in distant past
ETOH: Rare
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Admission:
Vital Signs
BP: 152/82 Heart Rate: 84 Resp. Rate: 16
O2 Saturation%: 100.
Height: 5'2" Weight: 133 lbs
General: WDWN in NAD
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA, EOMI, sclera anciteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:1
Radial Right:2 Left:2
Carotid Bruit - Transmitted vs. Bruit
Discharge:
VS T 98.2 HR 84 BP 97/62 RR 18 O2sat 97%-RA
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
CV: RRR, no M/R/G. Sternum stable-incision CDI
Pulm: CTA-bilat
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. trace edema bilat
Pertinent Results:
Admission labs:
[**2123-7-21**] 12:38PM PT-12.8* INR(PT)-1.2*
[**2123-7-21**] 12:38PM PLT COUNT-208
[**2123-7-21**] 12:38PM NEUTS-65.7 LYMPHS-30.2 MONOS-3.7 EOS-0.2
BASOS-0.3
[**2123-7-21**] 12:38PM WBC-6.6 RBC-3.58* HGB-11.9* HCT-35.4* MCV-99*
MCH-33.2* MCHC-33.6 RDW-12.5
[**2123-7-21**] 12:38PM TRIGLYCER-29 HDL CHOL-60 CHOL/HDL-2.7
LDL(CALC)-97
[**2123-7-21**] 12:38PM %HbA1c-5.5 eAG-111
[**2123-7-21**] 12:38PM VIT B12-551
[**2123-7-21**] 12:38PM ALBUMIN-3.7 CHOLEST-163
[**2123-7-21**] 12:38PM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-58
AMYLASE-19 TOT BILI-0.4
[**2123-7-21**] 12:38PM GLUCOSE-85 UREA N-15 CREAT-0.5 SODIUM-138
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
Discharge labs:
[**2123-7-26**] 05:50AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.4* Hct-28.5*
MCV-100* MCH-32.9* MCHC-33.0 RDW-12.6 Plt Ct-117*
[**2123-7-26**] 05:50AM BLOOD Plt Ct-117*
[**2123-7-22**] 11:50AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.3*
[**2123-7-26**] 05:50AM BLOOD Na-141 K-4.0 Cl-103
Radiology Report CHEST (PA & LAT) Study Date of [**2123-7-25**] 11:21
AM
Final Report: In comparison with the study of [**7-24**], there is
continued
opacification in the retrocardiac region and obscuring the
costophrenic sulcus on the left. Again, this is consistent with
pleural effusion and substantial volume loss in the left lower
lobe. A small apical pneumothorax on the right is again seen.
IMPRESSION: Little overall change.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Indication: Aortic valve disease. Congenital heart disease. Left
ventricular function. Prosthetic valve function. Right
ventricular function. Valvular heart disease.
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *51 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild 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.
AORTIC VALVE: Severe AS (area 0.8-1.0cm2).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is severe aortic valve stenosis (valve area 0.8-1.0cm2). The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Preserved biventricular systolci function
2. Bioproshtetic valve in aortic position. Well seated and good
leaflet excursion.
3. No AI, Peak Gradient = 30 mm Hg,
4. Intact aorta and no other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2123-7-22**] 10:21
Brief Hospital Course:
Ms [**Known lastname **] was admitted one day prior to scheduled surgery for
cardiac catheterization. the catheterization revealed: no
angiographically-apparent flow-limiting stenoses.
She was brought to the operating room on [**7-22**] for planned heart
suregry, please see operative report for details in summary she
had: Aortic Valve Replacement with 21 [**Doctor Last Name **] Pericardial and
Septal myomectomy. Her bypass time was 63 minutes with a
crossclamp time of 49 minutes. She tolerated the operation well
and post operatively was transferred to the cardiac surgery ICU
in stable condition. She remained stable in the immedicate
post-op period and within hours of leaving the OR woke
neurologically intact was weaned from the ventilator and
extubated. She weaned off all pressors over the next 12 hours
and on POD1 was transferred to the stepdown floor for continued
care and recovery. All tubes lines and drains were removed per
cardiac surgery protocol. She worked with nursing and PT to
increase strength and endurance.
The remainder of her hospital course was uneventful. On POD 4
she was discharged home with visiting nurses. She is to folllow
up in wound clinic in 1 week and with Dr [**Last Name (STitle) **] in 1 month.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. biotin *NF* 1 mg Oral daily
3. Glucosamine-Chondroitin Complx *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosam-chondroitin-vit
C-Mn;<br>glucosamine-chondroit-vit C-Mn) Oral daily
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY Duration: 10 Days
5. Ibuprofen 400 mg PO Q8H:PRN pain
6. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
7. Oxycodone-Acetaminophen (5mg-325mg) [**11-16**] TAB PO Q4H:PRN pain
8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
9. biotin *NF* 1 mg Oral daily
10. Glucosamine-Chondroitin Complx *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosam-chondroitin-vit
C-Mn;<br>glucosamine-chondroit-vit C-Mn) 0 ORAL DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p AVR(21 [**Doctor Last Name **] Pericardial)/Septal myomectomy [**2123-7-22**]
PMH:
Bicuspid aortic valve
Aortic stenosis
Dyslipidemia
Coarctation repair at age 12 via left thoracotomy [**Hospital1 13696**]([**Location (un) 6482**])
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- trace bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound check: [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2123-8-3**] @10:30
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time: [**2123-8-18**] 1:15
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2123-9-11**] @10:50AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 85715**],[**Last Name (un) **] F. [**Telephone/Fax (1) 85716**] in [**2-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2123-7-26**]
|
[
"433.30",
"272.4",
"433.10",
"V12.59",
"746.4",
"429.3",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"39.61",
"35.21",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9725, 9774
|
7359, 8601
|
331, 411
|
10054, 10279
|
2605, 2605
|
11166, 11942
|
1609, 1652
|
9033, 9702
|
9795, 10033
|
8627, 9010
|
10303, 11143
|
3323, 6175
|
1118, 1317
|
6219, 6954
|
1667, 2586
|
272, 293
|
439, 995
|
2621, 3306
|
1039, 1095
|
1333, 1593
|
6964, 7336
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,827
| 135,650
|
22002
|
Discharge summary
|
report
|
Admission Date: [**2166-4-1**] Discharge Date: [**2166-4-12**]
Date of Birth: [**2105-10-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Cough and Malaise
Major Surgical or Invasive Procedure:
Lumbar Puncture
Bone Marrow Biopsy
Bronchoscopy with Bronchoalveolar Lavage
Hemodialysis
History of Present Illness:
60 M with a history of Hepatitis C, HIV (last CD4 of 137 on
[**2166-3-18**]) brought to the ED by his friends after the patient had
been complaining of generalized malaise and cough x 1 week, as
well as diffuse joint pains. He initially denied having a cough,
but then stated it had been on-going for a week. On ROS, the
patient denied any fevers, chills, chest pain, abdominal pain,
nausea or vomiting, back pain, dysuria, dysphagia, or
odynophagia. He denied pain around the tunneled catheter HD
line, denied recent Tylenol use, or accidental ingestions.
.
Of note, the patient was recently discharged from [**Hospital1 18**] on [**3-25**].
At that time, the patient was admitted with acute on chronic
renal insufficiency, started on hemodialysis which was continued
as an outpatient, and was diagnosed with a RML/RLL PNA and
completed a course of CTX/Azithromycin. The patient's HAART
therapy had been held earlier in [**Month (only) 956**] due to concern
regarding potential medication related ARF, and has been on hold
since. The patient's renal function progressively declined and
HD was started on [**3-20**].
.
In the ED the patient's initial V/S were: 97.5, 117/71, 80, 98%
RA. However, while still in the ED, the patient was found to be
transiently hypotensive to 79/50, HR 80, T 98.9, and still
satting 99% on RA. He was given 1L IVF with improvement in his
BP to 106/63. Given concern for PNA with a leukocytosis and
symptoms of a productive cough, and rhonchi noted on exam, the
patient was given CTX and azithro for a possible CAP. However,
Abx coverage was broadened to include Vanco and Flagyl for a
possible biliary source of infection after the patient was found
to also have a new transaminitis. He underwent an CT abd/pel
which showed fluid filled loops of colon and an atrophic left
kidney but no intrabiliary pathology.
Past Medical History:
1) HIV dx in [**2153**]. Most recent CL [**2166-2-6**] nondetectable, with
decreasing CD4 count since he was taken off ARV most recent
[**2166-4-1**] 132 (acute illness), [**2166-3-18**] 137 (acute illness), [**2166-2-6**]
261. Home ARV regimen was discontinued on [**2166-2-24**]: Atazanavir
300mg Qdaily, Ritonovir 100mg Qdaily, Truvada 1 tab qdaily, and
bactrim ppx. No hx of OI.
2) Hep C dx in [**2153**]. Most recent bx [**11-21**] with no cirrhosis,
grade 1. No hx of treatment.
3) COPD
4) GI bleed/ shock [**9-22**]
Workup notable for CMV esophogitis s/p valganciclovir, Cdiff
positive s/p po vancomycin.
5) Blindness R eye since [**2152**], unclear etiology
6) HTN
7) Polysubstance abuse
8) Diverticulitis s/p resection [**2150**]
9) Hypoplastic L kidney
10) CRF with concern for medication induced AIN/ATN as noted
above
11) Tobacco Abuse
Social History:
The patient is a widower, he currently lives in [**Hospital1 392**] with his
sister. [**Name (NI) **] reports he has a daughter and 2 cats The patient was
previously employed as a bricklayer, now unable to work. The
patient reports his Sister [**Name (NI) **] [**Name (NI) **] to be his HCP
[**Name (NI) 1139**]: 2 PPD
ETOH: Reports prior heavy use, none current
Illicits: History if IV Heroin and Cocaine, last documented use
[**2153**]
Family History:
Mother: [**Name (NI) **] CA
Father: CAD
Physical Exam:
VS: Afebrile 140/60 60s 95% RA
GEN: Severely cachetic male with buccal lipoatrophy, awake,
opens and closes eyes intermittently, oriented to person, place,
year, date, month, situation
HEENT: EOMI, right [**Doctor First Name 2281**] and pupil occluded with scarring, sclera
anicteric, conjunctivae clear, MMM but intact, no thrush, poor
dentition
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. Few
scattered wheezes
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
NEURO: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII grossly intact. Deferred gait
exam until am given reported instability.
Pertinent Results:
[**2166-3-31**] 09:00PM PT-15.3* PTT-27.8 INR(PT)-1.3* PLT COUNT-77*#
NEUTS-87.4* LYMPHS-9.2* MONOS-3.3 EOS-0.1 BASOS-0 WBC-13.3*#
RBC-2.75* HGB-8.8* HCT-26.5* MCV-96 MCH-31.8 MCHC-33.0 RDW-16.0*
AMMONIA-27 LIPASE-77*
.
[**2166-3-31**] 09:00PM ALT(SGPT)-361* AST(SGOT)-429* ALK PHOS-121*
TOT BILI-0.2 GLUCOSE-88 UREA N-58* CREAT-6.3*# SODIUM-138
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-26 ANION GAP-21*
LACTATE-1.8
.
[**2166-4-1**] 05:54AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS; SERUM ASA-NEG ETHANOL-NEG
ACETMNPHN-NEG
.
[**2166-4-1**] 07:00AM RET AUT-5.9* WBC-12.1* LYMPH-14* ABS
LYMPH-1694 CD3-91 ABS CD3-1547 CD4-8 ABS CD4-132* CD8-80 ABS
CD8-1348* CD4/CD8-0.1* PT-15.3* PTT-28.1 INR(PT)-1.3* PLT
COUNT-65* HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+
MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ STIPPLED-1+
TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL
.
[**2166-4-1**] 07:00AM WBC-12.1* RBC-2.27* HGB-7.6* HCT-22.4*
MCV-99* MCH-33.4* MCHC-33.9 RDW-16.3*
.
[**2166-4-1**] 07:00AM IgM HAV-NEGATIVE calTIBC-256* VIT B12-1409*
HAPTOGLOB-125 FERRITIN-1238* TRF-197* CALCIUM-6.9*
PHOSPHATE-6.5* MAGNESIUM-1.9 IRON-11* ALT(SGPT)-255*
AST(SGOT)-217* LD(LDH)-293* ALK PHOS-93 TOT BILI-0.2
GLUCOSE-79 UREA N-55* CREAT-6.1* SODIUM-139 POTASSIUM-3.7
CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
.
[**2166-4-1**] 12:06PM STOOL BLOOD-NEGATIVE
.
[**2166-4-1**] 07:05PM PT-13.4 PTT-33.5 INR(PT)-1.2* PLT COUNT-55*
WBC-10.2 RBC-2.68* HGB-8.5* HCT-26.3* MCV-98 MCH-31.7 MCHC-32.3
RDW-16.2*
.
[**2166-4-1**] 07:46PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0 BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-150 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG COLOR-Straw
APPEAR-Clear SP [**Last Name (un) 155**]-1.005
.
CXR PA and Lat [**3-31**]: Interval improvement in multifocal right
lung patchy opacities which could represent a resolving
infectious process.
.
CT A/P [**3-31**]: 1. Limited non-contrast evaluation of the hepatic
parenchyma is unremarkable without evidence of significant
intrahepatic biliary ductal dilation. The CBD measures up to 1
cm, within limits in setting of cholcystectomy. 2. There are
diffusely prominent fluid-filled loops of bowel without evidence
of mechanical obstruction. [**Month (only) 116**] represent an infectious process.
.
CT head (non-contrast) [**4-2**]: 1. No evidence of space-occupying
lesion within the brain. 2. Fluid opacification of the maxillary
sinuses bilaterally, right greater than left. Aerosolized
secretions in the right maxillary sinus could suggest a
component of acute sinusitis. 3. Calcifications in the right
globe. Correlate clinically, with history of
prior trauma or infection, particularly cytomegalovirus
infection given the patient's HIV status.
.
CSF [**4-6**]: NEGATIVE FOR MALIGNANT CELLS. Many lymphocytes, some
with reactive changes, monocytes and macrophages. Note: If
clinically suspicious for a lymphoproliferative process,
additional sampling for flow cytometry is suggested.
.
CT chest (non-contrast) [**4-8**]: 1. Extensive centrilobular and
panlobular emphysema.
2. Nodular peripheral parenchymal lesion in the right lower
lobe, accompanied by a satellite lesion, parenchymal
consolidation and a moderate pleural effusion. This lesion is
suggestive of recent infection, most likely fungal or bacterial.
3. Disseminated subpleural nodules that are most likely
post-infectious in
origin. These nodules predominate in the right lung.
4. Right lung predominant bronchiolar nodules of varying
density, suggesting recurrent bronchiolar infection.
5. Tracheal widening with tracheal sputum level.
6. Moderately enlarged mediastinal lymph nodes.
7. Partial fissural distortions caused by scarring.
.
Bone Marrow [**4-9**]:
Pathology - Hypercellular bone marrow with megakaryocytic
hyperplasia. No lymphoid aggregates are seen on the core biopsy
and corresponding flow cytometric analysis of the marrow
aspirate showed a T cell predominant population. Overall,
diagnostic features of lymphoma are not seen.
Although dyserythropoeisis is seen, similar changes can be seen
in HIV associated myelopathy. Please correlate with clinical
and cytogenetic findings. MICROSCOPIC DESCRIPTION - Peripheral
Blood Smear: The smear is adequate for evaluation. Erythrocytes
show mild anisopoikilocytosis with macrocytes, dacrocytes, and
rare schistocytes. The white blood cell count appears normal.
Neutrophils with toxic granulation seen. Lymphocytes include
large granular lymphocytes and lymphoplasmacytic lymphocytes.
Platelet count appears decreased; large forms are seen; giant
forms are not present. Differential count shows 62%
neutrophils, 11% monocytes, 24% lymphocytes, 1% eosinophils, 2%
basophils, 1% blast. Rare myelocyte as well as a rare blast is
seen on scan. Aspirate Smear: The aspirate material is adequate
for evaluation and consists of multiple cellular spicules. The
M:E ratio is 1.3:1. Erythroid precursors are present with
overall normoblastic maturation; forms with mild nuclear
membrane irregularities, occasional asymmetric nuclear budding,
as well as occasional megablastoid forms are seen. Myeloid
precursors appear normal in number and show full spectrum
maturation. Megakaryocytes are present in increased numbers and
include hypolobated forms. Differential shows: 3% Blasts, 5%
Promyelocytes, 7% Myelocytes, 11% Metamyelocytes, 26%
Bands/Neutrophils, 1% Plasma cells, 12% Lymphocytes, 36%
Erythroid.
Clot Section and Biopsy Slides: The biopsy material is adequate
for evaluation and shows hypercellular marrow with overall
cellularity of approximately 70%. The M:E ratio estimate is
normal. Erythroid precursors are normal in number and exhibit
megaloblastic maturation. Myeloid elements are normal in number
and exhibit full spectrum of maturation. Megakaryocytes are
present in increased numbers and focally in clusters. Marrow
clot section is not submitted. Touch prep is not submitted.
ADDENDUM:
Special stains for infectious organisms (AFB, GMS) performed at
the request of Dr. [**Last Name (STitle) **] were negative for acid-fast and/or
fungal organisms.
.
Immunophenotyping - Three color gating is performed (light
scatter vs. CD45) to optimize lymphocyte yield. B cells comprise
4% of lymphoid-gated events and do not express aberrant
antigens. Clonality could not be reliably assessed due to
non-specific staining by surface immunoglobulin antibodies
(cytophilic staining pattern). T cells comprise 85% of lymphoid
gated events, express mature lineage antigens. INTERPRETATION:
Non-specific T cell dominant lymphoid profile. B-cells are 4% of
lymphoid gated events, however B-cell clonality could not be
reliably assessed due to non-specific staining of B-cells by
surface immunoglobulin light chain antibodies. Correlation with
clinical findings and morphology (see S09-[**Numeric Identifier 35359**]; ) is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.
.
Cytogenetics - KARYOTYPE: 46,XY[CP20] INTERPRETATION:
No clonal cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen. This
normal result does not exclude a neoplastic proliferation.
.
Bronchial Washings [**4-10**]: Bronchial lavage (right lower lobe):
ATYPICAL.
Few atypical squamous cells in a background of neutrophils, few
macrophages and few bronchial cells, (see note.) Note: The
squamous cells may represent oral contamination.
.
HCV VIRAL LOAD (Final [**2166-4-2**]):
548,000 IU/mL.
.
HBV Viral Load (Final [**2166-4-8**]):
HBV DNA not detected.
.
CMV IgG ANTIBODY (Final [**2166-4-8**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
352 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2166-4-8**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
.
CMV Viral Load (Final [**2166-4-11**]):
CMV DNA not detected.
.
BAL [**4-10**]:
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2166-4-11**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2166-4-24**]):
YEAST.
ACID FAST SMEAR (Final [**2166-4-11**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2166-5-9**]):
NO VIRUS ISOLATED.
LEGIONELLA CULTURE (Final [**2166-4-17**]): NO LEGIONELLA
ISOLATED.
NOCARDIA CULTURE (Final [**2166-5-2**]): NO NOCARDIA ISOLATED.
.
Cryoglobulin
TRACE POSITIVE
.
Fungitell (tm) Assay for (1,3)-B-D-Glucans
285 pg/mL
Brief Hospital Course:
60 YO M HCV, HIV (recently off ARVs w CD4s in the mid-100s), CKD
on HD, admitted with joint pain, leukocytosis, new
transaminitis, hypotension, and short MICU stay for hypercarbia
which improved without intervention.
.
# Altered mental status. The patient's mental status worsened
during the beginning of his hospitalization and he was found to
have hypercarbic respiratory failure. He was transferred to the
MICU but improved prior to treatment with alternative
ventilation. Once transferred back to the floor, his mental
status quickly returned to [**Location 213**]. Given concurrent anemia,
thrombocytopenia, and worsening renal function, there was
initial concern for TTP/HUS although bili and haptoglobin were
normal. Head CT was without enhancing lesions or hemmorrhage and
LP demonstrated a mild lymphocytic leukocytosis consistent with
known HIV infection but was otherwise within normal limits. Upon
admission, his urine tox was positive for benzodiazepines and
methadone, both of which he denied recently taking. Shortly
after admission, he was started on his home narcotics regimen
per OMR followed by the nadir of his mental status. He was also
noted to have a likely pneumonia on chest XR and CT. A
combination of narcosis and infection was the most likely
etiology of both his hypercarbia and altered mental status. Once
his narcotics were stopped for a short time and then re-titrated
up to his home dosing schedule and he was started on
antibiotics, his mental status was completely normal.
.
# Thrombocytopenia. As above, TTP and HUS were ruled out early
in his course. Alternative diagnoses included ITP, medication
effect, and HIV induced thrombocytopenia. Medications were
thought to be less likely given that the patient had stopped
ARVs several weeks prior to presentation. Hematology was
consulted and performed a bone marrow biospy with results c/w
HIV associated myelopathy with megakaryocytes present in
increased numbers and focally in clusters. His platelets were
trending up in the 60s at his time of discharge. He was asked to
follow up with his PCP for CBC several days after discharge.
.
# Macrocytic Anemia. The patient's Hct remained stable in the
mid-20s with an appropriate reticulocyte index and bone marrow
findings consistent with a normal amount of erythroid
precursors. He was guiac negative. He last had an EGD in [**2164**] w
findings demonstrating CMV esophagitis as well a gastritis
versus portal gastropathy. Although he was noted to be
hypotensive early in his stay, this was likely either related to
hypovolemia or SIRS phenomena in the setting of pneumonia and
resolved with fluids and was not consistent with acute blood
loss anemia. His anemia is most likely multifactorial and
related to HIV disease, HCV, renal failure, poor nutrition and
possibly gastritis or portal gastopathy. He was asked to follow
up with his PCP as above for CBC several days after discharge.
In addition, he should have repeat EGD and c-scope done as an
outpatient.
.
# Pneumonia, Transaminitis. Given the patient's initial
hypotension and leukocytosis w CT findings suggestive of
penumonia, the patient was covered broadly with meropenem,
fluconazole and vancomycin for an 8 day course. He should have
repeat imaging as an outpatient to ensure improvement. His
transaminitis may have been related to a viral URI that then
predisposed him to a bacterial or fungal pneumonia. In addition,
with HCV and worsening immunocompromise, his viral titer may
have transiently risen in the setting of acute illness. While he
was not hypotensive for long periods of time, his hypotension
with reperfusion may have also contributed to his transaminitis.
His AST and ALT were trending toward normal at his time of
discharge. EBV, CMV, PCP were all negative.
.
# HIV. ARVs on hold since [**2-24**] given concern for tenofovir,
bactrim, lisinopril/HCTZ-related ATN. Trial of Pendamidine for
PCP prophylaxis during last hospitalization not well tolerated
by patient and he has not been taking PCP prophylaxis since that
time. PCP DFA from bronch was negative, G6PD was normal, and so
the patient was started on dapsone for ppx during this
hospitalization. He was scheduled to follow up with Dr [**Last Name (STitle) 10103**]
for re-initiation of ARVs as an outpatient.
.
# ATN in setting of chronic renal insufficiency. Possibly
related to tenofovir/bactrim as above although seems somewhat
unlikely given severity requiring HD. He was started on HD
during his last admission. This was continued throughout this
hospitalization and set up for continuance upon discharge. The
patient was continued on calcium acetate and sevelamer. While
the ID service felt a renal biopsy could be helpful, renal
declined biopsy due to low likelihood of gaining any helpful
information. Essentially, given several months of renal failure,
renal felt the biospy would show scarring without any specific
diagnostic gain. The patient was asked to set up an outpatient
nephrology appointment for continued care.
.
# COPD. Albuterol/Atrovent nebs were given.
.
# Chronic Pain. The patient's reported pain regimen was provided
as discussed above. In addition, cryoglobulins were checked in
the setting of known HCV and joint pain and were borderline
positive. This should be reassessed as an outpatient.
.
On [**4-12**], the patient was hemodynamically stable, alert and
oriented and with platelets trending upward. He was therefore
discharged to home with a plan for follow up in place.
Medications on Admission:
Tylenol 325mg po Q6 prn
Ranitidine 150mg po BID
Zolpidem 5 mg po QHS
Combivent Q6
Calcium Acetate 3 caps TID with meals
Oxycontin 40 mg po Q12
Oxycodone 5mg Q4 prn breakthrough pain
Reglan 5-10mg Q6 prn
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*63 Tablet(s)* Refills:*0*
2. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*0*
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*21 Capsule(s)* Refills:*0*
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours) for 7
days.
Disp:*21 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: One (1) Tablet
PO every 6-8 hours for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day for 7 days: 12 hours on, 12
hours off.
Disp:*7 patches* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Thrombocytopenia, NOS
Immunosuppression secondary to HIV infection
Iron Deficiency Anemia
Chronic Kidney Disease on Hemodialysis
Secondary:
Hepatitis C Virus
Discharge Condition:
Hemodynamically stable with normal vitals. Follow up arranged,
including plan for outpatient hemodialysis.
Discharge Instructions:
You were admitted to the hospital because of your malaise, low
blood pressure, and labs showing new findings of liver cell
inflammation and low platelets (thrombocytopenia). You also had
an episode of altered mental status with high blood carbon
dioxide levels for which you had a short stay in the intensive
care unit.
Bone marrow biopsy and bronchoscopy have not revealed a reason
for your symptoms and your lab abnormalities to date. Lumbar
puncture results were within normal limits. The liver
inflammation first noted has resolved. Your platelet count has
been increasing but is not normal. While there are several tests
pending which you should follow up on with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 2148**], your low platelets may likely be the result of a viral
illness, including HIV.
Please follow up with Dr [**Last Name (STitle) 2148**] at the already arranged
appointment. You may likely restart anti-retrovirals at this
appointment.
Please return call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 2148**] or return to the
emergency department if you experience shortness of breath or
difficult breathing, chest pain, abdominal pain, spontaneous
bruising, nose bleeds, blood in your sputum, urine or stool, or
any other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2166-4-15**] 1:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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24,432
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Discharge summary
|
report+report+report
|
Admission Date: [**2131-8-4**] Discharge Date: [**2131-8-6**]
Service: NEUROMEDICINE
CHIEF COMPLAINT: Episodes of left facial twitching.
HISTORY OF PRESENT ILLNESS: This is an 80 year old right
handed man with a history of coronary artery disease,
hypertension, chronic obstructive pulmonary disease, chronic
tumor, who was recently admitted for chest pain in the past
two weeks and discharged with no change in medications.
The patient reports that he has had four episodes of left
facial twitching in the past week. Each of these episodes
has lasted five minutes and they come with chewing. He also
reports that he fells that his dentures have bitten his inner
that the twitching is confined to the lower lip. He has no
decrease in level of consciousness, sensory symptoms, aura,
chest pain, shortness of breath, palpitations, visual changes
or any other sequelae from these events. He has no past
medical history of seizures. He also has noticed no facial
droop or focal motor weakness.
PAST MEDICAL HISTORY:
1. Chronic lymphocytic leukemia diagnosed in [**2104**].
2. Carcinoid tumor.
3. Hypogammaglobulinemia, low IgA and IgM.
4. Hypertension.
5. Coronary artery disease, status post myocardial
infarction in [**2119**].
6. Chronic obstructive pulmonary disease.
7. Chronic bronchiectasis.
8. History of multiple pneumonias complicated by the
hypogammaglobulinemia.
9. Gout.
10. Status post transurethral resection of prostate in [**2112**].
11. Chronic renal insufficiency with creatinine at a baseline
of 4.0.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 mg p.o. once daily.
2. Enteric Coated Aspirin 325 mg p.o. once daily.
3. Procardia 60 mg p.o. once daily.
4. Allopurinol 100 mg p.o. once daily.
5. Albuterol p.r.n.
6. Sublingual Nitroglycerin p.r.n.
7. Calcitrel 0.25 mcg p.o. once daily.
8. Sodium Citrate 10 ml p.o. twice a day.
SOCIAL HISTORY: Retired cab driver. He smokes a pipe twice
a day for forty years. Occasional alcohol only. Widow in
[**2117**], and lives with his daughter.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Significant for recent episode of chest
pain for which he was hospitalized. He reports no unexpected
weight changes, however, visual changes, hearing changes,
fever, chills or night sweats, upper respiratory infection
symptoms or other recent illnesses or injuries. He denies
depression, anxiety, dysuria, hematuria, change in bowel
habits, melena, hematochezia, nausea or vomiting.
PHYSICAL EXAMINATION: On physical examination, his
temperature was 97.0, blood pressure 142/68, pulse 72,
respiratory rate 20, pulse oximetry 92% in room air. In
general, he was a well developed, well nourished male in no
apparent distress, somnolent, normocephalic and atraumatic,
eyes nonicteric, mucous membranes moist, oropharynx clear, no
lymphadenopathy, no carotid bruits. Cardiac examination
revealed normal S1 and S2 with a regular rate, no murmurs,
rubs or gallops. The lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, nondistended
with no hepatosplenomegaly, positive bowel sounds in four
quadrants. He had trace edema in his legs bilaterally. His
pulses were intact and he had no rashes. Neurologic
examination - Mental status - He was oriented to [**Hospital1 346**] and date and stated that he had been
there for over a month which given the recent admissions and
discharges is fairly close to accurate. He was not
cooperative with much of my examination as I had woken him in
the middle of the night but to previous examiners, he was
fluent with normal naming and repetition a digit span of six
digits, able to repeat months of the year backwards. He had
immediate recall three out of three, recall of one out of
three at thirty seconds. I found him to be perseverative and
to give a confused history. Cranial nerve examination
refused. Optic disks not well visualized. The pupils are
equal, round, and reactive to light and dark. Extraocular
movements are intact without nystagmus. Normal facial
sensation with left ptosis. Other facial strength was [**4-15**].
Hearing was intact to finger rub bilaterally. He had normal
oropharyngeal movement and sensation. Tongue midline without
fasciculations. Sternocleidomastoid weak on the right and
strong on the left. Motor examination - tone generally
increased versus an uncooperative examination. His bulk was
decreased throughout. He had a bilateral pronator drift in
the evening it appeared, but it was only a left drift in the
morning. He had no tremors or fasciculations. The patient
had left upper motor neuron weakness pattern in the 4 to 4+
range. His strength was [**4-15**] on the right. His sensation was
decreased to proprioception in the lower extremities
bilaterally, however, intact to all other modalities. Deep
tendon reflexes were symmetric, biceps 2+, triceps 2+,
brachial radialis 2+, patellar 1+, Achilles absent and toes
equivocal bilaterally. His coordination - rapid alternating
movements were slightly slow bilaterally. Finger to nose was
worse on the left than the right and heel tap was also worse
on the left. Gait was wide based with small and steady
steps, would not move without support. He had a positive
Romberg.
LABORATORY DATA: On admission, white blood cell count 18.6,
hematocrit 36.0, platelet count 392,000. Chem7 revealed
sodium 143, potassium 3.8, chloride 108, bicarbonate 20,
blood urea nitrogen 54, creatinine 4.6, glucose 92. Troponin
was negative times three.
He had a head CT with an area of heterogeneous hyperintensity
seen in the right frontoparietal region with mild surrounding
edema and no shift.
HOSPITAL COURSE: The patient was admitted to Neuromedicine
service. He had a gadolinium contrast MR which showed the
same right frontoparietal region with slight enhancement and
a central area of hemorrhage. There was mild edema seen in
the surrounding white matter on FLAIR imaging. There was no
mass shift and no ischemia. The patient was loaded on
Dilantin. The following day the patient was continued on a
dose of Dilantin of 300 mg once daily.
Neurosurgery was consulted. Additionally, CT scans were done
of the chest, pelvis and abdomen which showed a 5.0
millimeter nodule in the left lower lobe but by chart review
has been there since [**2126**]. Additionally, there were multiple
hypointensities in the liver suggesting metastatic disease,
however, these are also old. No contrast was able to be
given due to the patient's chronic renal insufficiency.
The patient's oncologist, Dr. [**Last Name (STitle) 2539**], was contact[**Name (NI) **] and he
determined the course of his workup for primary tumor site. A
lumbar puncture was attempted on Sunday, [**2131-8-5**], however, the
attempt was unsuccessful.
The discharge summary will be continued after his transfer to
Medicine.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17304**]
Dictated By:[**Last Name (NamePattern1) 660**]
MEDQUIST36
D: [**2131-8-6**] 19:49
T: [**2131-8-6**] 20:23
JOB#: [**Job Number 99946**]
Admission Date: [**2131-8-4**] Discharge Date: [**2131-9-5**]
Service: MICU-[**Location (un) 2452**] team
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 8026**] was a pleasant
80-year-old gentleman with a history of coronary artery
disease, hypertension, chronic obstructive pulmonary disease,
chronic lymphocytic leukemia, and hypogammaglobinemia, and
liver and brain metastases with unknown primary, who was
initially admitted with a brain metastatic bleed and
resulting seizure disorder. He was once admitted to the MICU
from [**8-16**] to [**8-17**] for acute respiratory distress which was
thought to be secondary to aspiration pneumonia and he was
started on BIPAP and then weaned to face mask. He was ruled
in, also, for an MI with a peak troponin of greater than 50.
We were unable to treat him due to his metastatic bleed in
his brain, so he was given aspirin and Lopressor. His
aspiration pneumonia was treated with Zosyn, vancomycin, and
Flagyl. He went to the floor on [**8-17**] and was started on
hemodialysis. However, the next day, he developed peripheral
eosinophilia and urine eosinophilia which was thought to be
secondary to his Zosyn and, so, he was changed to
levofloxacin for one dose. He also had his Quinton catheter
pulled out which he was using for his hemodialysis on [**8-19**]
because an AV fistula was formed and there was a big left
groin hematoma with a drop in blood pressure. He also had a
likely aspiration event on [**8-20**] with possible sepsis and the
blood loss in his groin hematoma caused him to become
hypotensive. He was also hypoxic and was found to be 88% on
room air.
He was sent to the MICU and he was started on BIPAP, but
intubated on [**8-20**] for airway protection. He was continued on
levofloxacin, Flagyl, and vancomycin for the presumed line
sepsis and the aspiration pneumonia. A lot of secretions
were being suctioned out. A CT angiogram was also done to
rule out for PE, but that time, bilateral pleural effusions
were found. CT of the abdomen was unremarkable, except for
polycystic kidney disease and liver metastasis. The
patient's sputum grew MRSA and Serratia. He was being
covered with vancomycin, Bactrim, and Ceptaz, but it was
believed that his eosinophilia was secondary to his multiple
drug interactions, and the patient also developed a drug rash
in his axillary area which was also thought to be secondary
to drug reaction. In addition, the patient was still spiking
temperatures and, at that time, it was concluded that it
could be secondary to a drug fever due to the use of
ceftriaxone. Allergy and Immunology were consulted who
recommended that all his antibiotics be stopped and the
patient was started on tobramycin. The patient was also
receiving hemodialysis three times a week.
Despite all these multiple attempts for medical treatment,
the patient did not show any signs of improvement. The
patient's blood pressure was volatile/fluctuating up and down
and the patient was repeatedly spiking temperatures. At that
time, a very detailed family meeting was held between the
attending, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], the resident, Dr. [**First Name8 (NamePattern2) 8516**]
[**Last Name (NamePattern1) **], social worker, and the daughter of Mr. [**Known lastname 8026**],
[**First Name8 (NamePattern2) **] [**Known lastname 8026**], who was actively involved in his care.
During the family meeting, it was decided that the patient
will be made comfort measures only. He will remain trached
and we are going to continue some of his medications at this
time and his tube feed and try to make him as comfortable as
possible. This was decided on [**2131-9-3**].
On [**2131-9-4**], it was decided that we could start slowly weaning
off his medications, except for medications that would keep
him comfortable. All of his medications, including
Lopressor, aspirin, and other medications he was on, were all
discharged and the patient was kept on an Ativan drip,
Fentanyl drip, and his valproic acid to prevent him from
developing any seizures. In addition, the antibiotics were
also stopped because, on the family meeting of [**9-3**], it was
decided that the patient will not undergo any more
hemodialysis and, since tobramycin was cleared by the kidney,
all antibiotics were stopped. The patient's tube feeds were
still continued, but they were decreased from 60 cc per hour
to 10 cc per hour.
On [**2131-9-5**], in the morning, it was decided that we could
slowly start weaning off his trach and moving to pressure
support of 5, PEEP of 5, FIO2 of 21%, in a BIPAP mode and
continue his tube feeds at 10 cc per hour and titrate up the
Fentanyl and the Ativan as needed to make him more
comfortable. In addition, we can add a morphine drip and
titrate that up, as well, as needed for comfort level.
On [**2131-9-5**] at 7:45 p.m., the patient passed away. The
patient did not respond to sternal rub or any pain sensation.
Pupils were fixed and dilated and did not respond to any
light. No breath sounds were heard. No heart sounds were
heard. At that time, the attending, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], was
notified regarding the death of Mr. [**Known lastname 8026**]. In addition,
his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14069**], was also
notified about his expiration. In addition, his daughter,
[**Name (NI) **] [**Name (NI) 8026**], who was actively involved in his medical
care, was also notified regarding her father's death. She
refused any autopsy.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2131-9-5**] 20:55
T: [**2131-9-11**] 09:13
JOB#: [**Job Number 99947**]
Admission Date: [**2131-8-4**] Discharge Date: [**2131-9-5**]
Service: MICU-[**Location (un) 2452**] team
DATE OF DEATH: [**2131-9-5**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 8026**] was a pleasant
80-year-old gentleman with a history of coronary artery
disease, hypertension, chronic obstructive pulmonary disease,
chronic lymphocytic leukemia, and hypogammaglobinemia, and
liver and brain metastases with unknown primary, who was
initially admitted with a brain metastatic bleed and
resulting seizure disorder.
He was once admitted to the MICU from [**8-16**] to [**8-17**] for acute
respiratory distress which was thought to be secondary to
aspiration pneumonia and he was started on BIPAP and then
weaned to face mask. He was ruled in also for an MI with a
peak troponin of greater than 50. We were unable to treat
him due to his metastatic bleed in his brain, so he was given
aspirin and Lopressor. His aspiration pneumonia was treated
with Zosyn, vancomycin, and Flagyl.
He went to the floor on [**8-17**] and was started on hemodialysis.
However, the next day, he developed peripheral eosinophilia
and urine eosinophilia which was thought to be secondary to
his Zosyn and so he was changed to levofloxacin for one dose.
He also had his Quinton catheter pulled out which he was
using for his hemodialysis on [**8-19**] because an AV fistula was
formed and there was a big left groin hematoma with a drop in
blood pressure.
He also had a likely aspiration event on [**8-20**] with possible
sepsis and the blood loss in his groin hematoma caused him to
become hypotensive. He was also hypoxic and was found to be
88% on room air.
He was sent to the MICU and he was started on BIPAP, but
intubated on [**8-20**] for airway protection. He was continued on
levofloxacin, Flagyl, and vancomycin for the presumed line
sepsis and the aspiration pneumonia. A lot of secretions
were being suctioned out. A CT angiogram was also done to
rule out for PE, but that time, bilateral pleural effusions
were found. CT of the abdomen was unremarkable, except for
polycystic kidney disease and liver metastasis.
The patient's sputum grew MRSA and Serratia. He was being
covered with vancomycin, Bactrim, and Ceptaz, but it was
believed that his eosinophilia was secondary to his multiple
drug interactions. The patient also developed a drug rash in
his axillary area which was also thought to be secondary to
drug reaction. In addition, the patient was still spiking
temperatures and, at that time, it was concluded that it
could be secondary to a drug fever due to the use of
ceftriaxone.
Allergy and Immunology were consulted who recommended that
all his antibiotics be stopped and the patient was started on
tobramycin. The patient was also receiving hemodialysis
three times a week.
Despite all these multiple attempts for medical treatment,
the patient did not show any signs of improvement. The
patient's blood pressure was volatile/fluctuating up and down
and the patient was repeatedly spiking temperatures. At that
time, a very detailed family meeting was held between the
attending, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], the resident, Dr. [**First Name8 (NamePattern2) 8516**]
[**Last Name (NamePattern1) **], social worker, and the daughter of Mr. [**Known lastname 8026**],
[**First Name8 (NamePattern2) **] [**Known lastname 8026**], who was actively involved in his care.
During the family meeting, it was decided that the patient
will be made comfort measures only. He will remain trached
and we are going to continue some of his medications at this
time and his tube feed and try to make him as comfortable as
possible. This was decided on [**2131-9-3**].
On [**2131-9-4**], it was decided that we could start slowly weaning
off his medications, except for medications that would keep
him comfortable. All of his medications, including
Lopressor, aspirin, and other medications he was on, were all
discharged and the patient was kept on an Ativan drip,
Fentanyl drip, and his valproic acid to prevent him from
developing any seizures. In addition, the antibiotics were
also stopped because, on the family meeting of [**9-3**], it was
decided that the patient will not undergo any more
hemodialysis and, since tobramycin was cleared by the kidney,
all antibiotics were stopped. The patient's tube feeds were
still continued, but they were decreased from 60 cc per hour
to 10 cc per hour.
On [**2131-9-5**], in the morning, it was decided that we could
slowly start weaning off his trach and moving to pressure
support of 5, PEEP of 5, FIO2 of 21%, in a BIPAP mode and
continue his tube feeds at 10 cc per hour and titrate up the
Fentanyl and the Ativan as needed to make him more
comfortable. In addition, we can add a morphine drip and
titrate that up, as well, as needed for comfort level.
On [**2131-9-5**] at 7:45 p.m., the patient passed away. The
patient did not respond to sternal rub or any pain sensation.
Pupils were fixed and dilated and did not respond to any
light. No breath sounds were heard. No heart sounds were
heard.
At that time, the attending, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], was notified
regarding the death of Mr. [**Known lastname 8026**]. In addition, his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14069**], was also notified about his
expiration.
In addition, his daughter [**Name (NI) **] [**Name (NI) 8026**], who was actively
involved in his medical care, was also notified regarding her
father's death. She refused any autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2131-9-5**] 20:55
T: [**2131-9-11**] 09:13
JOB#: [**Job Number 99947**]
|
[
"496",
"780.39",
"197.7",
"204.10",
"410.91",
"198.3",
"518.81",
"998.12",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.04",
"38.95",
"34.91",
"96.72",
"44.32",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2077, 2095
|
1593, 1898
|
5697, 7271
|
2524, 5679
|
2115, 2501
|
113, 149
|
13205, 18981
|
1032, 1567
|
1915, 2060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,844
| 167,459
|
5725
|
Discharge summary
|
report
|
Admission Date: [**2181-1-23**] Discharge Date: [**2181-1-31**]
Date of Birth: [**2096-7-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Chlorpheniramine / Simvastatin
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Invasive Endotracheal Intubation
History of Present Illness:
84F h/o CAD, bronchiectasis, Asthma, AFIB on coumadin, recently
treated for pneumonia/bronchiectasis flare with levaquin.
.
Per Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] the patient called his office today and was
complaining of difficulty breathing and productive cough. Dr
[**Last Name (STitle) 1007**] noted that the patient was extremely short of breath and
asked her to bypass his office and come directly to the ED.
.
Per Dr[**Name (NI) 19421**] note [**12-29**]: "She describes an upper respiratory
infection one week ago. She developed an increase in her
chronic cough. She restarted her antibiotic (Levaquin) on
[**12-25**]. There was some improvement initially. She
describes continued cough with some sputum. She complains of
malaise and says that she is "on fire" at night."
.
In the ED, initial vitals were 102 120 113/87 28 92% Patient was
initially placed on a non-rebreather which she was not
tolerating. When she pulled off the the non-rebreather she was
noted to be extremely uncomfortable with increased work of
breathing and she received succ and etomadate and was inubated
for respiratory distress. Initial lactate was noted to be 2.3.
Her initial CXR in the ED showed situs inversus, worsening left
sided PNA and a new large R. sided infiltrate worse from prior.
She was given ceftriaxone and azithromycin for abx.
.
On the floor, she is intubated comfortable off of sedation,
satting 100% on 100% FiO2.
Past Medical History:
Kartagener's syndrome (bronchiectasis, situs inversus)
Atrial fibrillation on coumadin
s/p appendectomy.
s/p ovarian cystectomy.
h/o cholelithiasis
Bronchiectasis followed by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **]
History of Atrial Septal Defect
Pulmonary Hypertension
Cardiomegaly
Social History:
Widowed in [**2171-5-28**]. Retired, was a trustee of [**First Name4 (NamePattern1) 1663**]
[**Last Name (NamePattern1) 1688**]. Lives alone, has brother and friends living nearby and
involved. No children. No tobacco. Occasional alcohol with
dinner.
Family History:
Grandmother and mother lived into 80s.
Physical Exam:
On transfer to the MICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2181-1-23**] 05:01PM BLOOD WBC-14.4*# RBC-3.87* Hgb-12.1 Hct-36.0
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.7 Plt Ct-187
[**2181-1-23**] 07:44PM BLOOD PT-40.7* PTT-34.8 INR(PT)-4.3*
[**2181-1-23**] 05:01PM BLOOD Glucose-146* UreaN-18 Creat-0.6 Na-137
K-5.6* Cl-102 HCO3-25 AnGap-16
[**2181-1-23**] 05:01PM BLOOD proBNP-1629*
[**2181-1-23**] 05:01PM BLOOD cTropnT-<0.01
[**2181-1-24**] 03:54AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.7
[**2181-1-23**] 09:42PM BLOOD Type-ART Temp-37.7 Rates-16/ Tidal V-350
PEEP-5 FiO2-100 pO2-346* pCO2-44 pH-7.38 calTCO2-27 Base XS-0
AADO2-341 REQ O2-60 Intubat-INTUBATED Vent-CONTROLLED
[**2181-1-23**] 05:06PM BLOOD Lactate-2.3*
.
[**2181-1-30**] 05:10AM BLOOD WBC-7.4 RBC-3.32* Hgb-10.3* Hct-31.1*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.4 Plt Ct-230
[**2181-1-30**] 05:10AM BLOOD PT-29.6* PTT-32.1 INR(PT)-2.9*
[**2181-1-30**] 05:10AM BLOOD Glucose-107* UreaN-16 Creat-0.5 Na-136
K-4.4 Cl-101 HCO3-30 AnGap-9
[**2181-1-30**] 05:10AM BLOOD ALT-20 AST-30 LD(LDH)-225 AlkPhos-56
TotBili-0.4
.
.
Micro: [**1-23**] urine, blood and sputum cultures:
Blood/Urine Cx: negative
Sputum Cx:
GRAM STAIN (Final [**2181-1-24**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2181-1-28**]):
Commensal Respiratory Flora Absent.
STREPTOCOCCUS PNEUMONIAE. RARE GROWTH.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 1 S
PENICILLIN G---------- 0.25 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
CXR [**2181-1-25**]
FINDINGS: There is dextrocardia consistent with patient's known
Kartagener's syndrome. There is marked cardiomegaly. There is
worsening of the pulmonary vascular and interstitial markings as
well as areas of developing consolidation within the right upper
lobe and left base. Right retrocardiac opacity is also seen and
these findings appear to have increased sincE the previous
study.
.
.
Cardiac Echo [**2181-1-30**]:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.8 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.7 cm <= 5.0 cm
Left Ventricle - Septal [**Known lastname **] Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Stroke Volume: 50 ml/beat
Left Ventricle - Cardiac Output: 4.49 L/min
Left Ventricle - Cardiac Index: 3.23 >= 2.0 L/min/M2
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 1.7 cm
Mitral Valve - E Wave: 1.5 m/sec
Mitral Valve - A Wave: 8.9 m/sec
Mitral Valve - E/A ratio: 0.17
TR Gradient (+ RA = PASP): *75 to 76 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2179-2-26**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Normal LV [**Known lastname **] thickness. Normal LV cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. RV function depressed.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe [3+] TR. Severe PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve
leaflets.
GENERAL COMMENTS: There is situs inversus.
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. Left ventricular [**Known lastname **] thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Right ventricular
chamber size is upper normal with depressed free [**Known lastname **]
contractility. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. There
is eccentric moderate to severe [**Last Name (un) 22837**] regurgitation
(inferolaterally directed). The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. The pulmonic valve leaflets are thickened. There
is situs inversus. There is a secundum type atrial septal defect
(better seen in the prior study).
Compared with the prior study (images reviewed) of [**2179-2-26**],
tricuspid regurgitation is now more prominent. Mitral
regurgitation appears similar. Right ventricular free [**Known lastname **] is
now more hypokinetic and estimated pulmonary artery systolic
pressures are now slightly higher.
Brief Hospital Course:
ACTIVE ISSUES
#Hypoxic respiratory faillure: Pneumonia vs bronchiectasis
exacerbation. Pt was intubated in the ED for worsening
respiratory distress. Given RLL predominance and frequent
antibiotic exposures, pt was initially covered broadly with
vanc, cefepime, flagyl pending sputum culture data. On HD#2, the
patient was oxygenating well on SBT and she was extubated;
antibiotics were tapered to ceftriaxone and azithromycin. CXR on
HD2 revealed clearing of bibasilar infiltrates suggesting an
etiology of pulmonary edema. Pt was given lasix. Patient was c/o
inability to clear secretions. Chest PT was performed. Scheduled
nebs were given due to underlying bronchiectasis and hypertonic
nebs were added to help thin secretions. Patient was
transitioned to floor and her respiratory status continued to
improve. Satuating 92% on RA. Had sporadic oxygen requirements
1-2 L to saturate 93-100%. Completed antibiotic course in house
for 7 day treatment of CAP with ceftriaxone. Sputum cultures
confirmed S. pneumoniae susceptibilities to ceftriaxone and
levafloxacin but resistant to macrolides. Needed to conitnue
with oxygen 1 L. Had cardiac echo on [**2181-1-30**] which showed mild
worsening RV hypokinesis, tricuspid regurgitation, and pulm htn
all secondary to known atrial septal defect.
TO CONSIDER ON AT REHAB/FOLLOW UP
-f/u Chest xray in [**9-7**] weeks.
-reassess need for home oxygen
#AFIB on coumadin: INR was supratherapeutic on admission.
Coumadin was initially Held and INR was trended. Continued to
have suprathereputtic INR. LFTs performed to r/o hepatic cause,
which were normal. Most likely due to poor PO intake and recent
use of macrolides while on coumadin. Had episodes of afib with
RVR, started on metoprolol succinate 100 mg qday.
-cont. BB and reassess for adequate coverage
TO CONSIDER ON AT REHAB/FOLLOW UP
-f/u INR in 5 days after discharge
-start on Dabigatran 150 mg [**Hospital1 **] when INR is less than 2.0
CHRONIC ISSUES
# HLD- continued home atorvastatin 5 mg qod
# HTN- continued losartan with additional metoprolol per above.
# Insomnia: per report, takes ativan qHS per PCP. [**Name10 (NameIs) **] delirious
with lorazepam administration. DC benzodiazepines in house.
Patient states she would continue to take the medication at
home, as she has never had an issue at home with the medication.
Would not continue benzo while at rehab. Can use trazadone 25
to 50 mg qhs for insomnia, although patient states makes her
tired.
# HCP [**Name (NI) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 22838**] [**Telephone/Fax (1) 22839**]. The patient remained full
code this admission.
PENDING LABS AT TIME OF DISCHARGE: NONE
TRANSITIONAL ISSUES: Spoke to patient about code status this
admission. Confirmed full code. Will need discussion regarding
placement after rehab. Has a cousin who is a physician and
married to a nurse, whom offered patient to live with them.
Given advancing age and increased difficulty with ADLs, would be
much safer living with family.
Family expressed concern that patient is still driving, and
occassionally has double vision after cataract surgery. NOT
[**Street Address(1) 22840**] until reassessed. Social [**Street Address(1) 22841**] SAFE program to take onus off family of withdrawing
driving privelages.
Medications on Admission:
ATORVASTATIN 5mg Tablet every other day
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 tsp by mouth
q
3 hours
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays daily
LORAZEPAM - 0.5 mg Tablet - QHS
LOSARTAN - 50 mg Tablet - Daily
WARFARIN - 2 mg Tablet - Daily
ACETAMINOPHEN [TYLENOL] - (OTC) - 650 mg Tablet - q4-6 hours
for pain
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
twice a day: DO NOT START TAKING UNTIL INR IS <2.0.
Disp:*60 Capsule(s)* Refills:*2*
4. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough .
6. trazodone 50 mg Tablet Sig: [**1-28**] to 1 Tablet PO at bedtime as
needed for insomnia: Take at night as needed for sleep ai.d.
7. Outpatient Lab Work
Please Check INR within 5 days of DC (by [**2181-2-6**])
F/u CXR within 8 weeks of discharge
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation. Tablet(s)
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6hrs PRN as needed for shortness of breath or wheezing.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation q4hr prn as needed for
shortness of breath or wheezing.
11. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for sore throat.
12. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for SBP<100, HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
Community Acquired Streptococcus Pneumoniae Pneumonia
.
Secondary:
Kartagener's Disease
Atrial Fibrillation
Bronchiectasis
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 due to worsening shortness of
breath. You were in the intensive care unit for a few days as
you needed your respiratory status to be monitored closely. You
required a machine to breath for you for a short period of time,
as you were having difficulty breathing on your own. You were
found to have a pneumonia, and given antibiotics. You left the
ICU and your breathing symptoms gradually improved. You have
completed your course of antibiotics and should continue to
improve. You will need some physical rehabilitation to continue
to get stronger before going back home.
.
During your hospital stay, you had a bout of rapid heart rate
from your atrial fibrillation. You were started on a new
medication to control your heart rate. You should continue to
take this medication on a daily basis, to avoid having your
heart rate get very elevated.
.
While in the hospital, you were given a medication called
LORAZEPAM to help you sleep . You mentioned you take this
medication at home (also known as ATIVAN), but in the hospital
it made you hallucinate. Please stop taking this medication.
You may take trazadone 25 to 50 mg at night instead as a sleep
aid.
.
Lastly, you have been on coumadin for your atrial fibrillation.
Your blood was too "thin" when you came to the hospital, and
your coumadin was held. Your primary care doctor has wanted to
switch you to a different oral medication for anticoagulation
called DABIGATRAN (also known as Pradaxa). It is important to
take this medication everday as prescribed to avoid developing
blood clots and possibly having a stroke due to your atrial
fibrillation. You will not start taking this medication until
your INR is less than 2.0.
.
CHANGES TO YOUR HOME MEDICATIONS:
Coumadin 5 mg daily---- STOP TAKING
Lorazepam 0.5 mg at night----- STOP TAKING
.
Dabigatran- 150 mg by mouth 2x a day---------- START TAKING once
INR<2
Metoprolol Succinate- 100 mg by mouth dailiy--- START TAKING
Trazadone 25 mg [**1-28**] by mouth at night as needed for sleep--- CAN
USE
.
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
You should schedule a follow up appointment with your primary
care doctor once you have completed your physical rehabilitation
course. Dr.[**Name (NI) 19421**] office can be reached at: [**Telephone/Fax (1) 10492**].
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2181-5-30**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2181-5-30**] at 2:30 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2181-5-30**] at 2:30 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
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"293.0",
"427.31",
"401.9",
"780.52",
"745.5",
"493.90",
"759.3",
"V58.61",
"481",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14351, 14471
|
9067, 11763
|
346, 381
|
14647, 14647
|
3057, 3057
|
17006, 17980
|
2492, 2532
|
12774, 14328
|
14492, 14626
|
12414, 12751
|
14830, 16607
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2547, 3038
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16625, 16983
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11785, 12388
|
287, 308
|
409, 1872
|
3071, 9044
|
14662, 14806
|
1894, 2208
|
2224, 2476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,521
| 127,745
|
54463
|
Discharge summary
|
report
|
Admission Date: [**2133-9-22**] Discharge Date: [**2133-9-30**]
Date of Birth: [**2059-9-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fatigue and dyspnea on exertion
Major Surgical or Invasive Procedure:
EGD with biopsy
History of Present Illness:
74 yo F w/ h/o of subarachnoid hemorrhage, liver hemangioma s/p
resection, DVTs s/p IVC filter placement. The patient is unable
or unwilling to recall events leading up to admission to
hospital. She reports feeling nervous and sick. The patient
noticed that she was constipated with decreased frequency of
stooling and dark stools. The patient reports feeling nauseous
if she did not eat regularly. She had good appetite.
Per MICU Resident, the patient presented with fatigue and
dyspnea on exertion. She first noted feeling fatigued and
unsteady on her feet about 1 PTA. A few times she almost fell
due to feeling so weak and dizzy, although she did not lose
consciousness. She has had a decreased appetite, but no N/V, or
abdominal pain. In retrospect, she says she had noticed that her
stools were dark or black in color. There was no BRBPR. Of note,
she had started taking aspirin 81mg in [**2133-6-16**], but has not
been taking other NSAIDs. She has no past history of GI bleed.
She has also noted increased LE edema over the last few weeks.
This began on the L but is now b/l. She denies orthopnea or PND.
She was seen by her primary care physician today, and she was
found to have hct 14.9 down from a baseline of 30-35 and was
guaiac positive.
.
In the ED, patient had an NG lavage that was positive with
"cherry coke" colored fluid return which cleared. She received
2U of PRBC as well as IV protonix. She remained hemodynamically
stable throughout.
.
Patient admitted to the MICU and in total received 4 units PRBC
(11/7-8). EGD was performed and an ulceral tear was found with a
significant amount of blood. No biopsy was performed because of
the amount of blood, but hemostasis was acheived.
.
The patient was also noted to have new LLE swelling and U/S
showed new DVT. Labs have been notable for elevated alk phos and
bilirubin, with a benign abdominal exam. RUQ ultrasound and
subsequent torso CT noted diffuse metastatic disease to liver
with likely gastric primary.
.
Prior to arrival to the floor, she denied any chest pain,
shortness of breath, or pain. She belly has hurt her on and off
xweeks and is currently feeling okay.
Past Medical History:
1. Sub-arachnoid hemorrhage ([**2113**])
2. Liver hemangioma ([**3-21**]): s/p L lateral sementectomy
3. DVT ([**2121**] and [**2132**])
- Not anticoagulated, presumably due to h/o SAH
- S/p IVC filter placement
4. Diabetes Mellitus Type II
5. Hypercholesterolemia
6. HTN
7. Psoriasis
8. S/p hysterectomy.
Social History:
The patient works in the home and lives with her husband, two
adult daughters and one grandson. One adult son lives
independently. Rare alcohol, no tobacco use.
Family History:
Non-contributory.
Physical Exam:
Gen: Pleasant elderly woman in bed. Slightly anxious. NAD.
VS: Tm 100.0 Tc 98.9 HR 84 BP 126/70 RR 20 Sat 96% 3L NC
Skin: No rashes. No jaundice. 2-3cm ecchymosis on R posterior,
medial calf below the knee. Large abdominal scar.
HEENT: PERRL. Sclerae anicteric. MMM.
Neck: Supple. No masses. No LAD.
CV: RR. Normal S1 and S2. No M/R/G. 2+ radial and dorsalis pedis
pulses bilaterally.
Pulm: Crackles bilaterally [**11-17**] way up with R>L. Decreased
tactile fremitus on L. No wheezes.
Abd: Soft. Non-tender, non-distended. Diminished BS.
Ext: 1+ LE edema bilaterally L>R. Warm in LLE. No swelling or
erythema in LE bilaterally.
Neuro: A&Ox3. CNII-XII intact to direct testing. Full strength
in UE and LE bilaterally. Intact light touch and diminished
joint position sense in LEs.
Pertinent Results:
[**2133-9-22**] 07:32PM HCT-17.6*
[**2133-9-22**] 01:34PM GLUCOSE-104 UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2133-9-22**] 01:34PM ALT(SGPT)-50* AST(SGOT)-42* ALK PHOS-332*
AMYLASE-66 TOT BILI-0.5
[**2133-9-22**] 01:34PM LIPASE-38
[**2133-9-22**] 01:34PM WBC-10.3# RBC-1.88*# HGB-4.2*# HCT-14.4*#
MCV-77*# MCH-22.6*# MCHC-29.5*# RDW-20.1*
[**2133-9-22**] 01:34PM NEUTS-84.4* BANDS-0 LYMPHS-11.5* MONOS-2.1
EOS-1.6 BASOS-0.4
[**2133-9-22**] 01:34PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-1+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2133-9-22**] 01:34PM PLT COUNT-268
[**2133-9-22**] 01:34PM PT-12.1 PTT-22.4 INR(PT)-1.0
Discharge labs
wbc 10.2 hgb 10 hct 29.6 plt 229
138 102 17
-----------< 107
4.0 25 0.8
cea 4860
AFP 4.4
Pathology: Adenocarcinoma
Imaging
LE Doppler: . Right femoral vein deep venous thrombosis
extending to popliteal vein, which is new compared to prior
study of [**2133-9-23**].
2. Persistent DVT of left femoral venous system.
CXR: Elevation of the left hemidiaphragm with atelectasis at the
left base. No signs for focal consolidation or overt pulmonary
edema.
MRI abd: 1. Study limited by patient breath-holding ability.
Exophytic metastasis in segment IVB projects into gallbladder
fossa but does not appear to invade gallbladder wall. Smooth
gallbladder wall edema is likely secondary to liver dysfunction.
No evidence of primary gallbladder neoplasm.
2. Innumerable hepatic metastases.
3. Necrotic-centered lymph nodes along gastrohepatic ligament
with thickened gastric wall near gastroesophageal junction.
Findings are consistent with primary gastric carcinoma with
metastatic lymph nodes and hepatic metastases.
4. Nodular area of high-signal intensity on T2-weighted images
posterior to hepatic flexure. This could be a small amount of
fluid. Although no definite enhancement is identified on
post-gadolinium images, an omental implant cannot be excluded in
this location. Differential diagnosis would include a small
splenule, but the signal intensity properties of this area do
not follow splenic tissue on all pulse sequences.
CT chest: IMPRESSION:
1. Bilateral pleural effusions with volume loss at the bases
bilaterally. Small pericardial effusion.
2. Multiple pulmonary nodules concerning for metastases.
3. Multiple liver masses concerning for metastatic disease.
4. Asymmetric gallbladder wall thickening may represent tumoral
invasion. Lack of enhancement of any portion of the thickened
gallbladder wall, and absence of focal nodularity or evidence of
invasion makes primary gallbladder neoplasm less likely.
5. Abnormal thickening of the lesser curvature of the stomach
with adjacent enhancing soft tissue and necrotic lymphadenopathy
is most concerning for primary gastric neoplasm, most likely a
signet cell-type tumor.
6. Bilateral deep venous thrombosis. IVC filter in place.
RUQ US: 1. Two suspicious masses in the liver, concerning for
primary neoplasm or metastasis. Followup CT or MR would be
useful for further characterization.
2. Eccentrically thickened gallbladder wall concerning for
primary gallbladder neoplasm versus infiltration from adjacent
liver tumor.
3. No evidence of choledocholithiasis, as clinically questioned.
Brief Hospital Course:
# UGI Bleed: Bleeding ulcer seen on initial EGD, hemostasis
achieved. Patient had repeat bx and bx was taken. Patient found
to have adenocarcinoma at GE junction and cardiac region of
stomach. MRI also showed ? mets in liver and CT chest showed ?
nodules in lung c/w metastatic disease. Patient set up with
oncology f/u with Dr. [**Last Name (STitle) **]. Patient was transfused in ICU and
stabilized on transfer to the floor. Treated with [**Hospital1 **] protonix
and held NSAIDS, aspirin, coumadin and heparin.
.
# DVT: Patient found to have b/l DVTs. Patient is probably in a
hypercoagulable state [**12-18**] metastatic gastric cancer. Patient was
not anticoagulated given her GI bleed. She does have an IVC
filter in place.
.
# Hypoxia: Likely due to fluid overload from blood transfusions.
Subacute PE's also possible given DVT's w/o coagulation. Repeat
CXR showed elevation of L hemidiaphragm with atelectasis with
b/l effusions not large enough to tap. No signs of consolidation
or overt pulmonary edema. Pulmonary mets could also be
contributing.
.
# Cough: Patient complains of persistent cough. Likely secondary
to pleural effusion or lung nodules. Repeat CXR on [**2133-9-27**]
showed elevation of L hemidiaphragm with atelectasis at the left
base. No signs of consolidation or overt pulmonary edema.
- PCP informed of patient concern and will f/u as outpatient
.
# UTI: Patient has h/o multiple UTIs and complains of symptoms
of UTI with positive UA. Discharge patient on ciprofloxacin for
7 day course. PCP will [**Name Initial (PRE) **]/u urine cx.
.
# Type II diabetes:
- QAC and QHS finger sticks with Humalog ISS coverage. Patient
had good control of sugars overall.
.
Medications on Admission:
1. Lipitor 20 mg PO daily
2. Aspirin 81mg daily
3. Ditropan XL 10 mg PO daily
4. Diovan 40mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Suspicion for gastric malignancy - bx pending
Gastric Ulcer
Bilateral Deep Vein Thrombosis
UTI
.
Secondary Diagnosis:
HTN
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for bleeding from an ulcer in
your stomach. While you were here you were transfused with red
blood cells and you received supportive care. You had
endoscopies to stop the bleeding from the ulcer in your stomach
and to take biopsies from your stomach.
.
We stopped your blood pressure medication (Diavan) while you
were in the hospital because your blood pressure was low. Please
discuss restarting this medication with your primary care
doctor. Please do not take any NSAIDs (including aspirin,
ibuprofen, advil etc) as they could increase your risk for
re-bleeding.
.
Please attend the appointment with your primary care doctor, Dr
[**Last Name (STitle) 12646**] on [**10-1**] at 10:30 and with your oncologist, Dr
[**Last Name (STitle) **] on [**10-13**] at 1:30.
.
Please report any shortness of breath, abdominal pain, fever
>101, bleeding, or other concerning symptoms to your primary
care physician.
Followup Instructions:
Please attend the following two scheduled appointments:
1. Primary care doctor: Dr. [**Last Name (STitle) 12646**] Phone:[**Telephone/Fax (1) 111468**]
Date/Time:[**2133-10-1**] 10:30AM
2. Oncology: [**Name6 (MD) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2133-10-13**] 1:30PM Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] Area A.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"197.7",
"531.40",
"285.1",
"453.40",
"599.0",
"272.0",
"197.0",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
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|
7212, 8902
|
311, 329
|
9821, 9830
|
3864, 7189
|
10819, 11311
|
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|
9657, 9657
|
8928, 9029
|
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|
3062, 3845
|
240, 273
|
357, 2504
|
9794, 9800
|
9676, 9773
|
2526, 2834
|
2850, 3012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,622
| 129,082
|
40827
|
Discharge summary
|
report
|
Admission Date: [**2155-5-26**] Discharge Date: [**2155-5-31**]
Date of Birth: [**2076-12-31**] Sex: F
Service: MEDICINE
Allergies:
Actifed
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Motor vehicle accident
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo F with PMH of COPD on 2L home O2, CAD with stent on
ASA/[**Hospital 89203**] transferred from [**Hospital **] Hospital after MVA
yestserday with a question of syncopal episode prior to driving
off the road. She was admitted to the trauma service where she
was evaluated by Neurosurgery for ? SAH and L lateral
ventricular bleed per report.
.
Neurosurgery consult though the reported SAH might have been an
overcall and thought it was a trivial SAH. They recommended
starting
Dilantin (x7d), get CTA to assess for aneurysm, perform syncope
workup, q4 Neuro checks, goal SBP <160. She was started on
Dilantin, Aspirin/plavix were held.
.
CT chest was concerning for ground-glass appearance, consistent
with pulmonary contusions and hemorrhage. Patient subsequently
developed a leukocytosis of 23.6, with positive UA and pending
urine culture. Tmax 101.5 at 10 pm on [**2155-5-26**]. Started on
ceftriaxone for PNA without atypical coverage. Received 10 mg IV
lasix this AM for ? volume overload.
.
Syncope workup was started: echo ordered (not done), CE's
negative x2, EKG showing LBBB that appeared in 2/[**2155**].
.
Gyn consult was obtained for ? displaced pessarie and will
likely help reposition.
.
Currently, T 99.9, HR 105, RR24, O2 sat91-94% on 2L NC (on
baseline 2L NC)
Past Medical History:
- CAD s/p stent (prior to [**2152**])
- Hyperlipidemia
- COPD on 2L home O2
Social History:
Lives in split house complex with daughter. At baseline, uses
oxygen for activities. Off oxygen at rest.
Family History:
Noncontributory
Physical Exam:
VS: TC 100.8 Tm 101.5 HR 107 BP 106/46 RR 21 O2sat 94% 4L NC
GA: lying in bed, A&O x3, warm
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: Tachycardic, S1/S2 heard. no murmurs/gallops/rubs.
Pulm: Expiratory wheezes, diffuse crackles
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: petechae under the chin
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar).
Pertinent Results:
1. Labs on admission:
[**2155-5-26**] 06:25PM BLOOD WBC-23.6* RBC-3.56* Hgb-10.8* Hct-31.5*
MCV-88 MCH-30.3 MCHC-34.3 RDW-14.6 Plt Ct-392
[**2155-5-26**] 06:25PM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.2*
[**2155-5-26**] 06:25PM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-133
K-4.0 Cl-96 HCO3-22 AnGap-19
[**2155-5-27**] 12:30AM BLOOD CK(CPK)-162
[**2155-5-26**] 06:25PM BLOOD cTropnT-<0.01
[**2155-5-27**] 12:30AM BLOOD CK-MB-6 cTropnT-<0.01
[**2155-5-27**] 12:30AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.0
[**2155-5-26**] 06:33PM BLOOD Lactate-1.5
.
2. Labs on discharge:
- WBC 14.2 Hct 31.7 Plt 529
- Na 131, K 3.5, Cl 92, HCO3 30 BUN 12 Cr 0.6 Glu 80
- Ca 8.3 Mg 2.1 Phos 2.8
.
3. Imaging/diagnostics:
- CT head ([**2155-5-26**]): Stable focus of intraventricular hemorrhage
in the left lateral ventricle with subtle hyperdensity along the
sulci adjacent to the left temporal lobe suggestive of
subarachnoid hemorrhage, which appears slightly decreased in
conspicuity compared to prior, which could relate to
redistribution. No midline shift or hydrocephalus.
.
- CT chest/abdomen/pelvis ([**2155-5-26**]): Diffuse bilateral pulmonary
alveolar opacities, concerning for hemorrhage/contusion in the
setting of trauma. Aspiration or pneumonia cannot be
excluded,particularly in areas of the right middle and lower
lobes where the consolidation is more confluent and with
air-bronchograms. Mediastinal lymphadenopathy, which is
non-specific and could relate to infection or inflammatory
process, underlying malignancy is also in the differential
diagnosis and should be considered. Follow-up imaging after
acute episode subsides. Hepatic steatosis.
.
- CT spine ([**2155-5-26**]): No evidence for acute fracture or
malalignment of the cervical spine.
.
- Echocardiogram ([**2155-5-28**]): The left atrium is elongated. There
is mild (non-obstructive) focal hypertrophy of the basal septum.
The left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with focal
hypokinesis of the mid to distal septum, inferior wall, lateral
wall, and apex. The remaining segments contract normally (LVEF =
35-40 %). The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w multivessel CAD. Mild pulmonary
hypertension.
.
- CXR ([**2155-5-28**]): Heart size is slightly enlarged unchanged as
well as there is no change in mediastinal silhouette. Multifocal
consolidations are demonstrated, bilateral with no definitive
evidence of interval progression. Overall there is slight
improvement in the right lung aeration. Small amount of pleural
effusion cannot be excluded.
.
- CTA head ([**2155-5-28**]): No evidence of aneurysm larger than 2-mm
in the intracranial anterior or posterior circulation.
Redistribution of intraventricular hemorrhage, with a small
quantity of blood products layering in the occipital [**Doctor Last Name 534**] of the
left lateral ventricle. Resorption or redistribution of
previously seen minimal SAH, with no new
intracranial hemorrhage.
.
- Carotid ultrasound ([**2155-5-29**]): Right ICA with no stenosis. Left
ICA with no stenosis
.
- Echocardiogram ([**2155-5-28**]):
The left atrium is elongated. There is mild (non-obstructive)
focal hypertrophy of the basal septum. The left ventricular
cavity size is normal. There is moderate regional left
ventricular systolic dysfunction with focal hypokinesis of the
mid to distal septum, inferior wall, lateral wall, and apex. The
remaining segments contract normally (LVEF = 35-40 %). The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Regional left ventricular
systolic dysfunction c/w multivessel CAD. Mild pulmonary
hypertension.
Brief Hospital Course:
78 yo F with COPD on home O2, CAD with stents on aspirin/plavix,
presented after MVA with small SAH, initially admitted to Trauma
[**Hospital 2571**] transferred to Medicine Service for syncope workup and
management of pneumonia and UTI.
.
# s/p Motor vehicle accident: Patient was transferred from OSH
after MVA where patient hit a stone wall. She was initially
managed by the Trauma ICU service. CT torso and head confirmed
small SAH and left lateral intraventricular bleed. Neurosurgery
was consulted and recommended seizure prophylaxis with Dilantin
for 10 days. Aspirin and plavix were initially held and then
restarted after clearance from Neurosurgery. No interventions
were performed for the intracranial bleed. Patient had no
neurological symptoms throughout. CTA of the brain did not show
any signs of aneurysms >2 mm and resolution of SAH and
intraventricular bleed.
.
# ? Syncope: There was a question of whether her motor vehicle
accident was a result of syncope. Significant workup was
performed. Patient monitored on telemtry and EKG for signs of
arrythmia which was negative. Echocardiogram showed depressed
LVEF 35-40% and wall motion abnormalities. Outpatient records
from cardiologist showed LVEF >60% on cardiac catheterization as
recent as [**3-14**]. Cardiac enzymes negative x3. It is unclear what
the cause of the acute systolic congestive heart failure is.
Patient instructed to follow-up with repeat echocardiogram after
discharge. CTA of the head was performed which did not show any
aneurysms and also signs of resolution of known SAH and
intraventricular bleed. Carotid ultrasound was negative for
stenosis in either the right or left ICA. Based on EMS report
and patient's clinical presentation, seizures was thought to be
an unlikely cause thus EEG was not performed. Patient was not
orthostatic on multiple exams. Telemetry showed sinus
tachycardia with intermittent PVCs. Tachycardia improved after
restarting diltiazem.
.
# Pneumonia: Shortly after admission, patient developed
increased oxygen requirement (on 2 liters home O2 at baseline
for COPD). Also developed a high leukocytosis (wbc 23.6) and
fever. CT chest showed consolidation in the right middle and
lower lobes. Patient was started on ceftriaxone and azithromycin
for treatment of communitu-acquired pneumonia. Transitioned to
cefpodoxime + azithromycin prior to discharge. Clinically
improved and weaned oxygen to 2L with O2sat>94% at rest.
Leukocytosis continued to trend down and was 14.2 on discharge.
Patient will complete a 10-day course of antibiotics after
discharge.
.
# Urinary tract infection: Urine culture was positive for
10,000-100,000 organisms/ml of Proteus mirabilis, pan-sensitive.
Treated with ceftriaxone/cefpodoxime. Patient remained
asymptomatic throughout.
.
# COPD: Patient kept on home regimen. Clinically was not
concerned about COPD exacerbation, thus patient was not treated
with steroids.
.
# CAD: Cardiac enzymes on admission were negative. Patient
asymptomatic so acute ACS was thought to be an unlikely cause of
her MVA. Aspirin and plavix were restarted after consultation
with Neurosurgery. Continued on home regimen of Metoprolol and
restarted on diltiazem prior to discharge. Primary care doctor
aware and will discuss the utility of starting an ACE-I after
discharge.
.
Medications on Admission:
- Potassium 20 mEqu per day
- Plavix 75 mg po qd
- Aspirin 325 mg po qd
- Triemterene HCTZ 375/25 qd
- Diltiazem XL 240 mg po qd
- Meotprolol 25 mg po qd
- Lipitor 40 mg po qd
- Advair 250/520 1 puff [**Hospital1 **]
- Spiriva 2 puffs qd
- Carafate gm QID
- Calcium 600 + D qd
- Multivitamin qd
- Omeprazole 20 mg po qd
Discharge Medications:
1. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
5. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: Two (2) puffs Inhalation once a day.
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
12. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day) for 5 days: Please take from
[**2155-5-26**] - [**2155-6-4**].
Disp:*15 Capsule(s)* Refills:*0*
15. azithromycin 500 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 6 days: Please take from [**2155-5-27**] -
[**2155-6-5**].
Disp:*6 Tablet(s)* Refills:*0*
16. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 6 days: Please take from [**2155-5-27**] - [**2155-6-5**].
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Motor vehicle accident
Subarachnoid hemorrhage
Intraventricular bleed
Community-acquired pnemonia
.
SECONDARY DIAGNOSES:
Coronary artery disease
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:
Ms. [**Known lastname **], you were admitted to the [**Hospital1 827**] after your car accident. We found that there was
a small amount of bleeding in your head and gave you medication
to prevent seizures. You developed a pneumonia and we gave you
antibiotics to treat that. You got better. We did an extensive
workup to look for reasons for your car accident. You did not
have small outpouching in the arteries in your brain. The
arteries in your neck were not clogged. You did not have any
abnormal heart rhythm. You did not show signs of a heart attack.
We did find that that your heart was not pumping as well and you
should follow-up with your cardiologist about this. You worked
with physical therapy and they thought you could go home but
would benefit from further physical therapy.
.
You should follow-up with your primary care doctor (see
appointment below) and ask him to check you electrolytes to make
sure they are normal at the same time.
.
Medications:
ADDED:
- Cefpodoxime Proxetil 400 mg by mouth every 12 hours from
[**2155-5-27**] - [**2155-6-5**]
- Azithromycin 500 mg by mouth daily from [**2155-5-27**] - [**2155-6-5**]
- Phenytoin sodium extended 100 mg Capsule from [**2155-5-26**] - [**2155-6-4**]
CHANGED: none
REMOVED: none
Followup Instructions:
You already have an appointment with your primary care doctor
set up for [**2155-6-4**]. Please make sure that you see him.
Name: JOUHOURIAN,ZAVEN E.
Address: [**State **], [**Location (un) **],[**Numeric Identifier 72762**]
Phone: [**Telephone/Fax (1) 79219**]
.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: 2 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 73009**]
Phone: [**Telephone/Fax (1) 58158**]
Appt: [**6-18**] at 8:45am
Please call the office if this appt time doesnt work for you.
.
Please make an appointment and follow-up with your Ob/Gyn doctor
to discuss re-positioning of your pessary.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2155-5-31**]
|
[
"E816.0",
"401.9",
"272.4",
"599.0",
"852.00",
"780.2",
"486",
"V45.82",
"428.0",
"041.6",
"414.01",
"426.3",
"V49.86",
"496",
"276.8",
"428.23",
"853.00",
"V46.2",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12527, 12598
|
7131, 10437
|
292, 298
|
12806, 12806
|
2397, 2405
|
14265, 15103
|
1849, 1866
|
10808, 12504
|
12619, 12619
|
10463, 10785
|
12989, 14242
|
1881, 2378
|
12759, 12785
|
230, 254
|
2955, 7108
|
326, 1612
|
12638, 12738
|
2419, 2936
|
12821, 12965
|
1634, 1711
|
1727, 1833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,140
| 107,714
|
15109
|
Discharge summary
|
report
|
Admission Date: [**2155-11-17**] Discharge Date: [**2155-11-19**]
Date of Birth: [**2126-3-8**] Sex: M
Service: MEDICINE
Allergies:
Haldol / Penicillins / Toradol
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
suicide attempt by drug overdose
Major Surgical or Invasive Procedure:
Intubation [**11-17**], extubation [**11-18**] for airway protection
History of Present Illness:
HPI: 29 yo male, h/o BPD, schizoaffective disorder,
polysubstance abuse, s/p prior suicide attempts (with multiple
hospitalizations for suicidality), presenting s/p ingestion of
multiple substances. Per ED notes, pt took an unknown quantity
of Zyprexa/Klonopin as a suicide attempt; he denied ingestion of
other substances. In the ED,pt was somnolent (hemodynamically
stable, saturating adequately). Received 2 mg of Naloxone in ED
with mild improvement but then became more somnolent requiring
intubation for airway protection. NGT was also placed, and he
received 50 gm of activated charcoal. Serum/urine tox screens
were obtained; urine tox came back positive for benzos,
barbiturates, opiates, and cocaine (negative for methadone and
amphetamines).
Past Medical History:
PMH: (obtained via [**Month/Year (2) **] notes)
1. Bipolar Disorder, Schizoaffective disorder, with multiple
prior suicide attempts/hospitalizations for this (most recently
[**10-4**], methadone, klonopin, chloral hydrate). First admission
for suicidality was at age 13 (ASA overdose)
2. Chronic LBP x 9 yrs, s/p injury to 2 lumbar discs
3. Trigeminal neuralgia
4. Migraines
Social History:
SH: polysubstance abuse, including IV heroin, cocaine,
methadone, speedballs, benzos, smokes 1 ppd, longest sobriety
period 1 yr
?Sexual abuse in childhood, left school in 12th grade and was
working in family business, homeless, homosexual
Family History:
FH: Mother with BPD, schizophrenia, EtOH
Father with BPD
Maternal GM with alcoholism
Physical Exam:
VS: on admission: 97.5 96 101/55 18 97% RA
s/p intubation: 92/41 81 21 100% on AC--
AC: 600/12, PEEP=5, RR=20-21
Gen: intubated, sedated, lying in bed
HEENT: PERRL, OP clear, MMM
Neck: no JVD or LAD
Lungs: CTA ant/lat
CV: RRR, nl s1/s2, no m/r/g
Abd: obese, with pannus, decreased BS, no reb/guard, no
tenderness
Extr: no c/c/e, 2+ PT/DP bilat
Neuro: sedated, not responsive to commands
Skin: erythematous macular rash under pannus, groin region.
Pertinent Results:
[**2155-11-19**] 10:24AM BLOOD WBC-5.3 RBC-4.05* Hgb-11.8* Hct-32.9*
MCV-81* MCH-29.1 MCHC-35.8* RDW-13.3 Plt Ct-131*
[**2155-11-18**] 04:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.3* Hct-32.0*
MCV-83 MCH-29.4 MCHC-35.4* RDW-14.4 Plt Ct-167
[**2155-11-18**] 04:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.3* Hct-32.0*
MCV-83 MCH-29.4 MCHC-35.4* RDW-14.4 Plt Ct-167
[**2155-11-17**] 07:50PM BLOOD WBC-10.8 RBC-4.63 Hgb-13.7* Hct-36.9*
MCV-80* MCH-29.5 MCHC-37.0* RDW-13.1 Plt Ct-207
[**2155-11-19**] 10:24AM BLOOD Plt Ct-131*
[**2155-11-18**] 04:50AM BLOOD Plt Ct-167
[**2155-11-18**] 04:50AM BLOOD PT-13.5* PTT-32.6 INR(PT)-1.2
[**2155-11-17**] 07:50PM BLOOD Plt Ct-207
[**2155-11-17**] 07:50PM BLOOD PT-13.6* PTT-31.3 INR(PT)-1.2
[**2155-11-19**] 10:24AM BLOOD Glucose-116* UreaN-6 Creat-0.7 Na-143
K-3.7 Cl-109* HCO3-24 AnGap-14
[**2155-11-18**] 04:50AM BLOOD Glucose-129* UreaN-12 Creat-0.8 Na-140
K-3.7 Cl-107 HCO3-23 AnGap-14
[**2155-11-17**] 07:50PM BLOOD Glucose-124* UreaN-13 Creat-1.0 Na-136
K-4.5 Cl-98 HCO3-23 AnGap-20
[**2155-11-18**] 04:50AM BLOOD ALT-22 AST-22 AlkPhos-77 TotBili-0.4
[**2155-11-17**] 07:50PM BLOOD ALT-27 AST-31 AlkPhos-93 TotBili-0.6
EKG: NSR=90, nl axis/intervals, ?J-pt elev in I, II, V2-V6;
unchanged from prior, nl QTc
.
CXR: NGT/ETT in place, adequate position, lung fields otherwise
clear
.
CT Head (non-contrast): No acute ICH
Brief Hospital Course:
A/P: 29 yo male, h/o polysubstance abuse,
BPD/schizoaffective/panic disorders, s/p multiple suicide
attempts, presenting s/p overdose with multiple substances.
.
1. Overdose: Multiple substances (cocaine, BZ, barb, narcotics,
zyprexa). s/p activated charcoal and narcan x 1. Neg TCA and QTc
wnl.
- Tox consult: supportive care.
- supportive care for cardiovascular/pulmonary; includes
mechanical ventilation overnight, support of BP, monitoring on
tele
- ?benzo OD; no flumazenil as this can cause withdrawal
seizures, precipitate arrhythmias if concomitant TCA OD
- ?barbits OD--can alkalinize urine, will ck urine/urine pH
- ?cocaine-can become hyperthermic, ?rhabdo, hypertensive; again
supportive measures, alpha/beta blocker
- ?zyprexa--sx can include tachycardia, bp fluctuations, EPS
symptoms
Patient is now 48 hours after admission for overdose and is
stable from a medical standpoint. He is s/p extubation and is
breathing fine on RA without any respiratory compromise. Per
psych recommendations, he has been getting prolexin and ativan
for agitation. Needs inpatient psych admission for further care
and therapy as he is now medically stable.
.
2. Respiratory failure: intubated [**1-22**] somnolence, respiratory
depression, on AC, overbreathing vent
-extubated [**11-18**] without complications, stable respiratory-wise
.
3. Hypotension: Likley secondary to sedation prior to intubation
- now resolved after extubation and off propofol gtt. With
normal BP for over 30 hours.
.
4. Psych: as above, with BPD, schizo, anxiety; will need to
clarify med regimen and consult psych; will likely need Section
12/psych treatment
-psych consult recs prolexin and ativan for agiation as needed
.
5. ?Skin rash: appears c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], can give topical nystatin
powder, keep area dry
.
6. PPX: OOB and walking, eating
.
7. Code: presumed full
.
8. Communication: need to determine (?parents)
.
9. Access: PIVs
.
10. Dispo: ICU care -> now medically stable, to inpatient
psychiatric facility
Medications on Admission:
Meds on Admission: (as per [**Last Name (LF) **], [**First Name3 (LF) **] notes)
methadone 20 mg po qam
klonopin 1 mg po tid
albuterol
zyprexa 20 mg po qhs
effexor XR 75 mg po bid
fioricet
clorhydrate 500 mg po qhs
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO Q2-4H
(every 2 to 4 hours) as needed for severe agitation.
3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
4. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q2-4H
(every 2 to 4 hours) as needed for severe agitation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary - Suicide attempt by drug overdose, bipolar d/o,
schizoaffective d/o, h/o multiple suicide attempts
Secondary - Chronic LBP x 9 yrs, s/p injury to 2 lumbar discs,
trigeminal neuralgia, migraines
Discharge Condition:
Medically stable and cleared for inpatient psychiatric admission
Discharge Instructions:
-please continue with medications and therapy as determined by
Psychiatry facility
-you need to obtain primary medical care here in [**Location (un) 86**] as well
as psychiatric care
Followup Instructions:
As determined by Psychiatric facility
Completed by:[**2155-12-1**]
|
[
"350.1",
"E950.3",
"969.3",
"311",
"V60.0",
"295.70",
"969.4",
"724.2",
"296.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6532, 6547
|
3793, 5837
|
325, 396
|
6795, 6862
|
2417, 3770
|
7094, 7163
|
1849, 1935
|
6102, 6509
|
6568, 6774
|
5863, 5868
|
6886, 7071
|
1950, 1954
|
253, 287
|
424, 1178
|
5882, 6079
|
1200, 1576
|
1592, 1833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,371
| 124,857
|
37949
|
Discharge summary
|
report
|
Admission Date: [**2148-8-26**] Discharge Date: [**2148-8-30**]
Date of Birth: [**2110-10-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Headaches, emesis
Major Surgical or Invasive Procedure:
[**2148-8-26**]: Left third Venriculoscopy
History of Present Illness:
Patient is a 37M who was recently discharged from the
neurosurgery service following a Redo Stereotactic third
ventriculostomy on [**8-15**] by Dr. [**Last Name (STitle) **]. He has a history of
chronic
mucocutaneous candidiasis s/p prolonged hospitalization at
[**Hospital **] [**Hospital 84811**] Medical center for intracranial collection
treatment, and 3rd ventriculostomy. Mr. [**Known lastname 31573**] returned to [**Hospital1 18**]
on [**8-26**] following approximately 24hrs of nausea and vomiting.
Past Medical History:
chronic mucocutaneous candidiasis (complications include mutiple
skin infectious, tooth infections (pt has none of his own teeth)
and eye infectiou leading to R eye blindness
Family History:
NonContributory
Physical Exam:
On admission:
O: BP:102/52 HR:53 RR:14 O2Sats:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT:Normocephalic, intact sutures over left frontal region; no
erythema or exudate
Pupils: Lt [**3-15**](reactive) Rt: NR(blind baseline)
EOMs: intact w/out nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Lt [**3-15**](reactive) Rt: NR(blind baseline)
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-16**] throughout. No pronator drift
Sensation: Intact to light touch
Exam upon discharge:
A&O x 3. EOMs intact.
Right pupil is opacified. Left pupil 5-3mm.
Face symmetric, tongue midline.
No pronator drift.
Strength and sensation full throughout.
Incision: clean, dry, and intact
Pertinent Results:
[**2148-8-26**] 01:12AM GLUCOSE-95 UREA N-9 CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-31 ANION GAP-12
[**2148-8-26**] 01:12AM CALCIUM-9.2 PHOSPHATE-3.6# MAGNESIUM-1.9
[**2148-8-26**] 01:12AM WBC-7.2 RBC-3.75* HGB-11.1* HCT-34.2* MCV-91
MCH-29.5 MCHC-32.4 RDW-13.2
[**2148-8-26**] 01:12AM NEUTS-54.0 LYMPHS-39.5 MONOS-4.4 EOS-1.8
BASOS-0.3
[**2148-8-26**] 01:12AM PLT COUNT-291
[**2148-8-26**] 01:12AM PT-12.7 PTT-23.6 INR(PT)-1.1
OUTSIDE FILMS READ ONLY Head CT [**2148-8-26**]
FINDINGS: No acute hemorrhage is seen. Ventricles are dilated
but unchanged from prior. The configuration of ventricular
dilatation is out of proportion and unchanged from prior CT with
lateral and third ventricular dilatation. There is effacement of
the cerebral sulci and basilar cisterns which is unchanged.
There is altered attenuation material in the right ventricle,
unchanged. A right frontal burr hole is also demonstrated. Low
lying cerebral tonsils with a small posterior fossa are better
evaluated on recent MRI studies. Mastoid air cells are clear.
Scleral bands are seen in the right globe, 2A:2 as well as
possible retinal/choroidal hemorrhage.
IMPRESSION: No significant interval change. Unchanged moderate
dilatation of the third and lateral ventricles with effacement
of the basilar cisterns and cerebral sulci.
MR HEAD W & W/O CONTRAST [**2148-8-26**]
There has been no significant interval increase in ventricular
size which
remains dilated compared to studies going back to [**2148-8-16**].
Enhancing debris in the right temporal and occipital [**Doctor Last Name 534**] is
stable to decreased. Enhancement in the right frontal lobe is
unchanged. There is new enhancement in the left frontal lobe
which likely represents a ventriculostomy tract. An additional
linear enhancing focus in the left frontal lobe also represents
a ventriculostomy tract. Edema in the right parietal occipital
lobe is relatively stable. Left frontal edema has increased
compared to the prior examination along the tract of the
ventriculostomy catheter. Right frontal edema has slightly
decreased.
Intracranial flow voids are maintained.
IMPRESSION:
Slight interval decrease in right ventriculitis and ventricular
debris.
Linear enhancement foci in the left frontal lobe likely along
ventricular
catheter tracts. Stable mild enhancement in the right frontal
lobe.
No new abscess is seen.
Unchanged ventricular dilation.
NON-CONTRAST HEAD CT [**2148-8-29**]: Since the CT of three days prior,
there has been interval near complete resolution of
pneumocephalus, with small bubble of air still noted in the
right frontal [**Doctor Last Name 534**]. Also subcutaneous gas remains within and
overlying the left frontal burr hole. Low density track is again
seen extending from the left frontal burr hole towards the left
frontal [**Doctor Last Name 534**], probably the track of prior ventriculoscopy.
Otherwise, examination of the brain is unchanged, with unchanged
enlargement of the lateral and third ventricles, as well as
opacification of the right occipital [**Doctor Last Name 534**] with isodense
material. White matter hypodensities in the right
parieto-occipital lobes is unchanged. Diffuse cerebral sulcal
effacement, effacement of basilar cisterns, and low lying
cerebellar tonsils are also unchanged. No new shift of normally
midline structures, acute intracranial hemorrhage, new focus of
edema, or evidence of large vascular territory infarction is
seen. Appearance of the soft tissues and orbits are unchanged,
with a right scleral band and high-density material within the
right globe. The visualized paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION: Resolving postoperative pneumocephalus. Otherwise,
no change in hydrocephalus, opacification of right occipital
[**Doctor Last Name 534**] with surrounding edema, and related mass effect.
Brief Hospital Course:
Mr. [**Known lastname 31573**] was admitted to [**Hospital1 18**] ICU on [**2148-8-26**]. He underwent MRI
imaging. Ventricular dilatation was unchanged. He was brought to
the OR by Dr. [**Last Name (STitle) **]. He placed a stereotactic frame and then
the patient had Ct imaging. He returned to the OR for
ventriculoscopy and the 3rd ventricle was found to be patent.
The patient went to the ICU overnight for monitoring. The
patient was transferred to the neurosurgical floor the following
day. On [**2148-8-28**] he underwent an EGD to evaluate for any source
for the nausea and vomiting. The study showed no candidiasis in
the GI tract and no retained food. The patient's nausea resolved
and had no epidsodes after [**2148-8-28**]. He was ambulating well with
PT and was taking in food without difficulty on [**2148-8-29**]. He was
felt to be safe for discharge by PT on [**2148-8-30**].
ID was also consulted for assistance with his antifungal
management. They wanted to continue the voriconazole and will
see the patient in follow-up as an outpatient.
The patient was sent home with his uncle on [**2148-8-30**].
Medications on Admission:
Medications prior to admission:
1. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)).
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q4 ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
5. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q4H (every 4 hours).
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for prn severe pain: No driving while on this
medication.
Disp:*30 Tablet(s)* Refills:*0*
8. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for GI distress.
9. Nystatin 100,000 unit/mL Suspension Sig: One (1) PO Q8H
(every 8 hours).
10. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hydrocephalus
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**6-21**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain with contrast.
You may also follow-up with your surgeon at [**University/College **].
You have an infectious disease appointment with [**Name6 (MD) **] [**Name8 (MD) 84812**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-9-13**] 10:00 am.
Completed by:[**2148-8-30**]
|
[
"331.4",
"324.0",
"348.5",
"348.8",
"112.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
9184, 9190
|
6389, 7516
|
337, 382
|
9247, 9270
|
2482, 6366
|
10748, 11498
|
1136, 1154
|
8020, 9161
|
9211, 9226
|
7542, 7542
|
9294, 10725
|
1169, 1169
|
7574, 7997
|
280, 299
|
410, 921
|
1686, 2250
|
1183, 1434
|
1449, 1670
|
943, 1120
|
2271, 2463
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,984
| 180,053
|
23256
|
Discharge summary
|
report
|
Admission Date: [**2168-12-3**] Discharge Date: [**2168-12-10**]
Service: MEDICINE
Allergies:
Morphine / Codeine / Amoxicillin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Transferred for STEMI
Major Surgical or Invasive Procedure:
Cardiac cath
Intra-aortic balloon pump
History of Present Illness:
87 yo f with HTN as cardiac risk factor tx here from [**Hospital1 **] for
STEMI and urgent cath. Pt was in usual state of health until
11AM DOA when she developed severe right CP radiating to her
left. This was associated with N/V. Took EMS to OSH and was
found to have STE in lateral leads. Heparin, plavix load,
Lipitor, and ASA started. Tx to cath here.
Cath: HD:elevated filling pressures, wedge of 18, CI 2.1
refractory hypotension requiring levo and dopa. EF 30% with
regional wall motion abnormalities. Normal LM, LAD 30% with
possible ulcer, 50% diag 1 with TIMI III flow and ? of spnot
reperfusion. also seen RCA -LAD small fistula to PA or
mediastinum. IABP placed for afterload reduction.
Past Medical History:
HTN, hypothroidsm, s/p right hip fracture
Social History:
Lives alone in [**Hospital3 **]. Never smoked. Drinks occ wine.
She is estranged from her son who she sees for 2 hrs/year during
the holiday. Her HCP is her best friend [**Name (NI) 8214**].
Family History:
Noncontributory
Physical Exam:
Vitals: T= 98.6, HR = 115 , BP = 83/43 on Levo and Dopa, RR = 20
, SaO2 = 97% 5L.
General: appears comfortable, NAD.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: Her chest rose and fell with equal size, shape and
symmetry, her 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 no murmurs 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. Cath site c/d/i without oozing
Integument: no rash
Neuro: CN II-XII
Pertinent Results:
CATH:
1. Selective coronary angiography revealed a codominant system.
The LMCA
was angiographically normal. The LAD had a 30% lesion
proximally,
possibly had an ulcerated area in the mid-vessel. The diagonal
had a 50%
lesion with TIMI 3 flow throughout - possible spontaneous
reperfusion.
The LCX and RCA had mild disease. There was a possible small
fistulae
from teh RCA and LM to PA or mediastinum.
2. Hemodynamics during the case showed elevated filling
pressures (mean
PCWP 18-10) with pulmonary hypertension (PASP 39 mm Hg). There
was
systemic hypotension which required use of dopamine and levophed
for
blood pressure support. An IABP was placed for hemodynamic
support (CI
2.26 on pressors, suggestive of cardiogenic shock). There was no
gradient across the aortic valve on pullback.
3. Left ventriculogram showed an EF of 30% with anterio,
anterolateral,
apical, and inferoapical akinesis/dyskinesis, which corresponds
to a LAD
distribution.
ECHO:
1. The left atrium is elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. There is severe regional left ventricular
systolic
dysfunction. Overall left ventricular systolic function is
severely depressed
(LVEF 20%). Resting regional wall motion abnormalities include
akinesis of the
lower [**2-9**]'s of the left ventricle with relative preservation of
the base. A
resting left ventricular outflow tract gradient was varialby
present which may
be related to the inflation of the intra-aortic balloon pump.
3. Right ventricular chamber size is normal while the apex is
akinetic.
4.The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve
stenosis. Trace aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation
is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension. 7.There is an anterior space which
most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot
be excluded.
Chest CT:
1. No mediastinal mass.
2. Bilateral pleural effusions with scattered septal lines and
areas of ground glass opacity most consistent with mild
pulmonary edema. In the appropriate setting, an infection should
also be considered.
3. 1 year follow up recommedned for small lung nodules in the
absence of underlying malignancy.
Brief Hospital Course:
1. CAD: Pt presented with STEMI s/p cath and became hypotensive
requiring intra-aortic balloon pump and Levophed, dopamine, and
dobutamine. The cath showed 30% proximal LAD, possibly had an
ulcerated area in the mid-vessel, the diagonal had a 50% lesion
with TIMI 3 flow throughout (possible spontaneous reperfusion),
the LCX and RCA had mild disease. There was a possible small
fistulae from teh RCA and LM to PA or mediastinum. Left
ventriculogram showed an EF of 30% with anterio, anterolateral,
apical, and inferoapical akinesis/dyskinesis, which corresponds
to a LAD distribution. Pt was slowly weaned off of pressors,
and intra-aortic pump was successfully removed, and was started
on carvedilol and captopril. She was continued on ASA, Lipitor,
and Plavix. Atenol and lisinopril were started.
2. Pump: The patient had large anterior wall motion
abnormalities on echo in the cath lab. Formal echo done later
showed severe regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
severely depressed
(LVEF 20%). Resting regional wall motion abnormalities include
akinesis of the
lower [**2-9**]'s of the left ventricle with relative preservation of
the base.
Unclear whether this is from this MI or from a previous one. Pt
had bilateral pleural effusion with mild CHF on the chest CT.
Pt required 5L NC, and otherwise would desaturate into 80's.
Standing po lasix 20 mg qd was started. Anticoagulation with
Coumadin and Heparin were started since she is at risk for
cardioembolic event after acute MI. Ideally, she should be on
Coumadin for several months. However, she has a history of fall
in the past, and PT evaluation noted high risk of fall, we
decided to only anticoagulate while she is in-patient in the
hospital and while she is at the acute rehab. Since pt is going
to [**Hospital1 **] Transitional Care where her PCP will be following, we
spoke with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 59754**] Mian about this and said that she
will decide whether the patient is safe to continue Coumadin
once she is discharged from the rehab. Pt noted to have 6 beat
NSVT overnight. Given her low EF, she may benefit from ICD.
However, given her age and her DNR/DNI status, planning of ICD
was thought inappropriate at this time. Further discussion with
the family member/HCP should be made before deciding for ICD.
3. Chest: Possible mediastinal mass was seen during cath.
There was also a question of possible fistula from the RCA and
LM to PA or mediastinum. Chest CT was obtained which showed no
mediastinal mass but did show a 4 mm nodule in the right middle
lobe. There was a suggestion of possible smaller adjacent nodule
in the upper lobe. These small nodules should be followed up
with CT in 1 year.
4. Thrombocytopenia: Pt's platelets started to drop since
admission. HIT antibody was sent which was negative. Once the
intra-aortic balloon pump was removed, her platelet count
recovered suggesting it was secondary to the pump.
5. Anemia: Pt got 1 unit of PRBC with appropriate rise in Hct.
She had a guiac positive stool but her Hct remained stable.
6. Hypothyroid: She was continued on synthroid.
7. Mental status: Pt was initially confused and delirious since
the cath requiring prn antipsychotics and benzodiazepine. She
had a positive UA, so her delirium was attributed to UTI and
sun-downing. She was getting seroquel 25 mg po qhs for several
days with good effect. After treating UTI with levofloxacin,
her metnal status improved. She will complete a 14 day course
of UTI.
8. Code: DNR/DNI after long discussion with HCP [**Name (NI) 8214**].
Medications on Admission:
Actinol
Lisinopril
Synthroid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Check INR frequently and have the dose changed
accordingly until INR [**Last Name (un) 2677**] at 2-3.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
STEMI
HTN
Hypothyroid
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
Pt was instructed to take all of the medications as instructed.
Pt should avoid strenuous activities for 2 weeks. Pt should
engage in cardiac rehab program as directed. Pt needs to seek
medical attention if she develops chest pain, SOB, palpitation,
diaphoresis, nausea/vomiting, dizziness, or any other concerning
symptoms. Pt should take Coumadin and have her INR level
checked and coumadin dose adjusted until level is stable.
Followup Instructions:
Patient needs to follow up with PCP [**Name Initial (PRE) 176**] 1-2 weeks.
Completed by:[**2168-12-10**]
|
[
"428.0",
"416.8",
"285.9",
"785.51",
"293.0",
"287.5",
"599.0",
"244.9",
"410.71",
"401.9",
"427.89",
"793.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.04",
"88.53",
"37.23",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
9337, 9410
|
4564, 7766
|
262, 302
|
9476, 9501
|
2158, 4541
|
9982, 10090
|
1323, 1340
|
8300, 9314
|
9431, 9455
|
8247, 8277
|
9525, 9959
|
1355, 2139
|
201, 224
|
330, 1032
|
7781, 8221
|
1054, 1098
|
1114, 1307
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,020
| 181,521
|
10574+56161
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-5-17**] Discharge Date: [**2128-5-27**]
Date of Birth: [**2057-11-17**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 70 year old white female
has a history of type 2 diabetes mellitus, hypertension,
hypercholesterolemia, and smoking and has had one week of
upper abdominal epigastric pain. She woke on the a.m. of
admission acutely dyspneic and called an ambulance and was
transferred to [**Hospital6 3872**]. An
electrocardiogram revealed new Q waves across the precordium
with ST elevations. She was placed on BiPAP for respiratory
distress and received Lasix, Nitroglycerin drip, Integrilin,
Heparin, Aspirin and a beta blocker. She was transferred to
[**Hospital1 69**] for cardiac
catheterization and was transferred to the catheterization
laboratory.
MEDICATIONS ON ADMISSION:
1. Glucotrol XL 1000 mg p.o. once daily.
2. Glucophage 500 mg p.o. twice a day.
3. Lipitor 40 mg p.o. once daily.
4. Avapro.
5. Aspirin.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes
mellitus.
Hypercholesterolemia.
Hypertension.
History of atrial fibrillation fifteen years ago and was
cardioverted.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She smoked two packs a day for many years
and quit three years ago. She does not drink alcohol. She
lives alone.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYMPTOMS: Nonfocal.
PHYSICAL EXAMINATION: On physical examination, she is an
elderly white female in no apparent distress. Heart rate is
92, respiratory rate 14, blood pressure 106/65. Head, eyes,
ears, nose and throat examination is normocephalic and
atraumatic. Extraocular movements are intact. The
oropharynx is benign. The neck was supple with full range of
motion. No lymphadenopathy or thyromegaly. Carotids are two
plus and equal bilaterally without bruits. The lungs are
clear to auscultation and percussion. Cardiovascular
examination is regular rate and rhythm, normal S1 and S2 with
no murmurs, rubs or gallops. The abdomen was soft,
nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities were without cyanosis,
clubbing or edema. Pulses were two plus and equal
bilaterally throughout. Neurologic examination was nonfocal.
HOSPITAL COURSE: She was taken immediately to the cardiac
catheterization laboratory where cardiac catheterization
revealed left ventricle one plus mitral regurgitation and an
ejection fraction of 25 percent with a hyperdynamic base and
an extensive area of anterior and inferoapical dyskinesis.
The left main had an 80 percent stenosis, left anterior
descending coronary artery had a 90 percent stenosis, 70
percent midstenosis, and 99 percent midstenosis. The left
circumflex had a 40 percent midstenosis. Right coronary
artery had an 80 percent midstenosis, 70 percent midstenosis
and she had an intraaortic balloon placed at the time. On
[**2128-5-18**], she underwent a coronary artery bypass graft times
three with left internal mammary artery to the left anterior
descending coronary artery, saphenous vein graft to obtuse
marginal and right coronary artery, cross time was 58
minutes, total bypass time 72 minutes. She was transferred
to the CSRU on Epinephrine, Neo-Synephrine and Propofol. She
had a stable postoperative night and was extubated on
postoperative day number one. She remained on her
Epinephrine and that was weaned off on postoperative day
number one. She then went into atrial fibrillation on
postoperative day number one and was started on Amiodarone
and was given Lopressor. She blocked down and was seen by
electrophysiology who recommended the Amiodarone and wanted
to evaluate her for an ICD. She was changed to oral
Amiodarone on postoperative day number two. She had her
chest tubes discontinued on postoperative day number three.
She required aggressive respiratory therapy. She was
improving and she was anticoagulated with Heparin as she was
going in and out of atrial fibrillation. On [**2128-5-23**], she
went to the Electrophysiology Laboratory where she was
inducible but it could have been because the Amiodarone was
in the proarrhythmic phase or because they did aggressive
induction, but at that point, they decided to wait on ICD and
she will return to the Electrophysiology Laboratory in four
weeks for question of placement of an ICD. She was started
on Coumadin and she was transferred to the floor on
postoperative day number seven. She continued to progress
and was discharged to rehabilitation on postoperative day
number nine in stable condition.
Her laboratories on discharge were white blood cell count
9.5, hematocrit 33.1, platelet count 231,000. Sodium 142,
potassium 4.2, chloride 107, CO2 25, blood urea nitrogen 20,
creatinine 1.3, blood sugar 182 with an INR of 2.3
MEDICATIONS ON DISCHARGE:
1. Potassium 20 mEq p.o. twice a day times ten days.
2. Colace 100 mg p.o. twice a day.
3. Aspirin 81 mg p.o. once daily.
4. Tylenol p.r.n.
5. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
6. Lipitor 40 mg p.o. once daily.
7. Norvasc 5 mg p.o. once daily.
8. Glucophage 500 mg p.o. twice a day.
9. Glipizide 10 mg p.o. once daily.
10. Amiodarone 400 mg p.o. twice a day for one week and
then 400 mg p.o. once daily for a week and then 200 mg
p.o. once daily.
11. Flovent two puffs twice a day.
12. Lasix 20 mg p.o. twice a day for ten days.
13. Coumadin as directed for an INR goal of 2.0 to 2.5.
DISCHARGE DIAGNOSES: Coronary artery disease.
Noninsulin dependent diabetes mellitus.
Hypercholesterolemia.
Hypertension.
Atrial fibrillation.
FOLLOW UP: She will be followed by Dr. [**Last Name (STitle) **] in four weeks,
Dr. [**First Name (STitle) 4640**] in one to two weeks, Dr. [**Last Name (STitle) 34798**] in two to three
weeks and Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2128-5-26**] 17:19:37
T: [**2128-5-26**] 17:54:21
Job#: [**Job Number 34799**]
Name: [**Known lastname 6181**], [**Known firstname **] Unit No: [**Numeric Identifier 6182**]
Admission Date: [**2128-5-17**] Discharge Date: [**2128-5-28**]
Date of Birth: [**2057-11-17**] Sex: F
Service: CSU
ADDENDUM:
Physical examination at the time of discharge revealed vital
signs with temperature 97.8, heart rate 73, sinus rhythm,
blood pressure 149/68, respiratory rate 20, oxygen saturation
93 percent in room air, weight preoperatively 49.9 kilograms
and at discharge 53.5 kilograms. Neurologically, the patient
is awake, alert and oriented times three, moves all
extremities, follows commands. Respiratory - slightly
diminished at the bases and otherwise clear. Cardiac is
regular rate and rhythm, S1 and S2, no murmur. The sternum
is stable and incision with staples, open to air, clean and
dry. The abdomen is soft, nontender, nondistended with
positive bowel sounds. Extremities are warm and well
perfused. Right lower extremity saphenous vein graft harvest
site with steri-strips, open to air, clean and dry.
Laboratory data revealed prothrombin time 18.0, partial
thromboplastin time 30.4, INR 2.2. White blood cell count
7.9, hematocrit 34.6, platelet count 255,000. Sodium 144,
potassium 5.2, chloride 107, CO2 25, blood urea nitrogen 20,
creatinine 1.4, glucose 134.
MEDICATIONS ON DISCHARGE:
1. Glipizide XL 10 mg p.o. once daily.
2. Metformin 500 mg twice a day.
3. Ranitidine 150 mg once daily.
4. Amlodipine 5 mg once daily.
5. Flovent two puffs twice a day.
6. Atorvastatin 40 mg once daily.
7. Aspirin 81 mg once daily.
8. Colace 100 mg twice a day.
9. Amiodarone 400 mg twice a day times one week and then 400
mg once daily times one week and then 200 mg once daily.
10. Regular insulin sliding scale.
11. Lasix 20 mg once daily.
12. Warfarin, titrate dose to a goal INR of 2.0 to 2.5.
Dosing from [**2128-5-25**], 3 mg, [**2128-5-26**], 0 mg, [**2128-5-27**], 1
mg, [**2128-5-28**], 0.5 mg.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation. She is to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts with the
results called to Dr. [**Last Name (STitle) 6183**].
FOLLOW UP: She is also to have follow-up with Dr. [**First Name (STitle) **] in
two to three weeks and follow-up with Dr. [**Last Name (STitle) 6183**] in two to
three weeks, follow-up with Dr. [**Last Name (STitle) **] in four weeks, and
follow-up with Dr. [**Last Name (STitle) 256**] in four weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass graft times three, left internal
mammary artery to left anterior descending coronary artery,
saphenous vein graft to obtuse marginal, saphenous vein graft
to right coronary artery.
Hypertension.
Hypercholesterolemia.
Congestive heart failure.
Atrial fibrillation.
Diabetes mellitus type 2.
PAST SURGICAL HISTORY: Appendectomy.
Removal of pilonidal cyst.
Breast biopsy.
Oophorectomy.
[**First Name11 (Name Pattern1) 255**] [**Last Name (NamePattern1) **], [**MD Number(1) 6184**]
Dictated By:[**Last Name (NamePattern4) 6185**]
MEDQUIST36
D: [**2128-5-28**] 16:39:17
T: [**2128-5-29**] 15:17:29
Job#: [**Job Number 6186**]
|
[
"272.0",
"276.2",
"427.81",
"428.0",
"410.02",
"427.31",
"250.90",
"401.9",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.23",
"36.12",
"88.72",
"38.91",
"99.04",
"37.61",
"99.20",
"89.64",
"39.61",
"88.56",
"89.68",
"36.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1343, 1390
|
8699, 9055
|
7487, 8341
|
842, 981
|
2267, 4794
|
9079, 9424
|
8353, 8645
|
1413, 2249
|
166, 816
|
1004, 1193
|
1210, 1326
|
8670, 8677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,842
| 151,623
|
54787
|
Discharge summary
|
report
|
Admission Date: [**2112-7-25**] Discharge Date: [**2112-7-31**]
Date of Birth: [**2039-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
ultrasound guided biopsy of hepatic mass
History of Present Illness:
73M w/ PMH of CHF (EF 20% per OSH records), Diabetes (on
insulin), and recent diagnosis of pancreatic tail mass was
transfered from OSH for hyponatremia. Pt reports he was in his
usual state of health until ~1mo ago when he had decreased
appetite in the setting of many upsetting life issues, with some
nausea and vomiting. Ovre the past week he reports weight gain
with increasing abdominal girth but denies orthopnea, pnd or
worsening DOE. He reports worsening fatigue with inability to
continue his usual. He reports difficulty urinating but denies
any changes in color or dysuria urinating. He reports overall
not feeling well and went to his PCP where he was found to have
hyponatremia and was called and told to go to the hospital. He
went to lawrenece general where he had labs that were notable
for a Na of 116, WBC of 14.8, Amalyse was 41, and digoxin level
of 0.7. He received benadryl, zofran and NS at 250cc/hr.
In the ED, initial VS were: 20:05 2 100.4 80 94/59 18 98% ra.
His UA was bland, lactate 1.3. CXR showed possible RLL
infiltrate and cardiomegaly per my read. He was given Vanc and
Ceftriaxone and admitted to the MICU for hypotension and
hyponatremia. Her VS on transfer were 99.5 75 98/53 18 97%.
On arrival to the MICU, the patient had no complaints. He
reports no nausea or vomting. He reports having decreased po
intake over the past week, and that he has been tdrinking 15
bottles of water or more per day since he gardens outside in the
heat.
Past Medical History:
DM2
Heart failure (EF 20%)
pAfib
hx alcohol abuse
pancreatic tail mass (not further characterized)
Social History:
LIves with his wife. Originally from [**State 26110**] and then [**State 2690**].
Remote history of alcohol abuse (not since [**2092**])
Family History:
NC
Physical Exam:
Admission exam:
General: Alert and oriented x 3, sitting up on the edge of the
bed comfortably, ill appearing, in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, distant heart sounds 2/6 systolic murmur appreciated at
the LSB.
Lungs: Decreased breath sounds bilaterallys, but no appreciable
crackles.
Abdomen: soft, markedly protuberant. 6inch fluid shift . No
palpable masses. tender to palpation in lower abdomen.
Normoactive bowel sounds. NO palpable masses.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
pitting edema bilaterally, multiple scabbed over areas
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
98.2 102/46 74 18 99%RA
GEN Alert, no acute distress
NECK supple, no JVD, no LAD
PULM Good aeration, bibasilar rales (much improved since
acceptance from ICU)
CV RRR, normal S1/S2, no murmur heard today
ABD soft, mildly distended
EXT WWP, 2+ pedal edema b/l (much improved since accept from
ICU)
Pertinent Results:
Admission labs:
[**2112-7-25**] 08:25PM BLOOD WBC-15.6* RBC-3.50* Hgb-9.7* Hct-29.9*
MCV-85 MCH-27.8 MCHC-32.5 RDW-12.1 Plt Ct-252
[**2112-7-25**] 08:25PM BLOOD Neuts-83.3* Lymphs-5.5* Monos-9.0 Eos-2.0
Baso-0.2
[**2112-7-26**] 03:53AM BLOOD PT-15.8* PTT-28.4 INR(PT)-1.5*
[**2112-7-25**] 08:25PM BLOOD Glucose-84 UreaN-33* Creat-1.2 Na-119*
K-5.0 Cl-85* HCO3-26 AnGap-13
[**2112-7-25**] 08:25PM BLOOD ALT-23 AST-24 AlkPhos-152* TotBili-0.9
[**2112-7-25**] 08:25PM BLOOD Albumin-3.3* Calcium-7.8* Phos-2.7 Mg-2.1
[**2112-7-25**] 08:25PM BLOOD Osmolal-251*
[**2112-7-27**] 04:09AM BLOOD Digoxin-PND
[**2112-7-25**] 08:35PM BLOOD Lactate-1.3
[**2112-7-25**] 10:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2112-7-25**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-7-26**] 12:51AM URINE Hours-RANDOM UreaN-613 Creat-45 Na-LESS
THAN K-29 Cl-LESS THAN
[**2112-7-26**] 12:51AM URINE Osmolal-311
Ascites Studies:
[**2112-7-26**] 01:07PM ASCITES WBC-1150* RBC-[**Numeric Identifier **]* Polys-43*
Lymphs-44* Monos-10* Mesothe-3*
[**2112-7-26**] 01:07PM ASCITES TotPro-3.3 Glucose-119 Creat-0.9
LD(LDH)-90 Amylase-13 TotBili-0.5 Albumin-2.2
Micro:
[**2112-7-26**] 1:07 pm PERITONEAL FLUID
GRAM STAIN (Final [**2112-7-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2112-7-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2112-8-1**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2112-7-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Legoniella antigen Negative
Urine culture negative (x1)
Blood culture negative (x2)
Discharge labs:
[**2112-7-31**] 07:20AM BLOOD WBC-14.9* RBC-3.64* Hgb-10.5* Hct-31.7*
MCV-87 MCH-28.7 MCHC-33.0 RDW-12.2 Plt Ct-275
[**2112-7-31**] 07:20AM BLOOD Plt Ct-275
[**2112-7-31**] 07:20AM BLOOD Glucose-148* UreaN-17 Creat-1.1 Na-129*
K-3.9 Cl-89* HCO3-31 AnGap-13
[**2112-7-31**] 07:20AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 732**] is a 73 yo M w/ PMH of diabetes on inuslin, CHF with
EF of 20% who was found to have new onset hyponatremia in the
setting of worsening ascites and newly diagnosed pancreatic mass
with hepatic spread.
ACTIVE ISSUES:
#Hyponatremia- the patient was transferred to the [**Hospital1 18**] MICU for
management of his hyponatremia to 119 which was symptomatic with
some confusion, but no obtundation or seizures. He was
originally fluid resuscitated given his low blood pressures and
appearance of intravascular depletion, and when his Na did not
respond to this he was switched to diureses after it was found
that he was 10 lbs over his baseline weight. His sodium improved
to 121 at the time of transfer to the floor after being fluid
restricted to 1.5L and given 40 IV lasix. His diuresis was
continued in the MICU until he could be transferred to the floor
(notably, his mental status was at baseline when he was sent to
the floor). His sodium steadily climbed to the mid and high
120s, but on resumption of his home PO furosemide, his sodium
declined from the high to mid 120s. Given the suspicion of poor
absorption from gut edema, the patient was switched to a PO dose
of torsemide (40mg) equivalent to his former PO lasix dose
(80mg). He responded very well to this and his sodium increased
promptly. It was 129 at the time of discharge. Of note, multiple
urine electrolyte studies were used to guide diuresis and the
patient was never terribly sodium avid, even with extensive
diuresis.
#Ascites- The patient had new onset ascites on exam. He denied
abdominal pain. He underwent a diagnostic paracentesis which was
obtained and was a bloody tap. Neither his clinical picture nor
his paracentesis results were consistent with spontaneous
bacterial peritonitis. His ascites did decrease with diuresis,
as did his pedal edema. Given that the patient had no evidence
of acute cardiac decompensation due to intrinsic disease,
medication noncompliance, or dietary indiscretion, it was
thought that this was largely due to the patient's
intra-abdominal neoplasm.
#Pancreatic mass- this was noted on imaging from outside
hospital and he was found to have a pancreatic tail mass.
Multiple hepatic nodules were found as well. The patient
received further workup while at [**Hospital1 18**]. An ultrasound of his
liver was done with subsequent biopsy of an identified mass.
Cytology showed malignant cells consistent with a poorly
differeniated carcinoma. A core biopsy taken from the same
nodule was consistent with adenocarcinoma. Serum CA-19-9 was
1246 and CEA was 8.1.
#Leukocytosis- patient had elevated white blood cell count and
was found to meet SIRS crieria so he was started on broad
spectrum antibiotics which were stopped after transfer to the
ICU, stabilization of vitals, and an unproductive search for
source of infection.
# Anxiety: The patient was very anxious during his hospital
stay. He did speak extensively with our social worker about end
of life issues. He stated on numerous occasions that he was
coming to terms with dying, but that his wife's anxiety was the
primary factor in his anxiety.
#CHF- he has a history of paroxysmal afib with a known LBBB and
EF of 20%. He was not orthopneic or having PND on exam. He was
10 lbs heavier on admission than his dry weight(224) and was
subsequently diuresed. Please see "hyponatremia" above.
INACTIVE ISSUES:
#Anemia- his baseline HCT is 31 and this is where he was on
admission and no further workup was pursued.
#Diabetes- patient is on large doses of lantus at home 42U qhs,
and his blood sugars while in the MICU were low without his home
dose of glargine so he was continued on a sliding scale. His
blood sugars were well controlled while in house.
# Hyperlipidemia: No events in house.
TRANSITIONAL ISSUES:
# Hyponatremia: the patient was discharged with a prescription
for a blood draw to be done on the following day to follow his
sodium. Dr.[**Name (NI) 111981**] fax number was included on the prescription
so that the results could be faxed to her office. The patient
was also sent home with VNA services.
# Pancreatic mass: the work-up as described above will be faxed
to Drs. [**Last Name (STitle) 6352**] and [**Name5 (PTitle) **] along with this discharge summary.
# Anxiety: suggest extensive family counseling re: coping to
increase quality of life for the patient.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Digoxin 0.125 mg PO DAILY
2. Carvedilol 25 mg PO BID
hold for sbp<100 or hr<60
3. Potassium Chloride (Powder) Dose is Unknown PO DAILY
written as 2u once a day
4. Lipitor 20 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
hold for sbp<100 or hr<60
6. Furosemide 80 mg PO DAILY
hold for sbp<100 or hr<60
7. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
8. Sertraline 100 mg PO DAILY
9. ALPRAZolam 0.5 mg PO TID:PRN anxiety
10. Aspirin 81 mg PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12. Vitamin E 400 UNIT PO DAILY
13. Fish Oil (Omega 3) 1200 mg PO DAILY
14. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 200
mg Oral daily
15. DiphenhydrAMINE 25 mg PO Q6H:PRN itchiness
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Carvedilol 25 mg PO BID
hold for sbp<100 or hr<60
3. Digoxin 0.125 mg PO DAILY
4. Lipitor 20 mg PO DAILY
5. Sertraline 100 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. Artificial Tears 1-2 DROP BOTH EYES PRN Eye drops
RX *artificial tear (hypromellose) [Lubricant Eye Drops] 0.3 %
1-2 drops once a day Disp #*1 Bottle Refills:*0
9. Torsemide 40 mg PO DAILY
sbp < 90
RX *torsemide 20 mg 2 tablet(s) by mouth qday Disp #*60 Tablet
Refills:*0
10. Aspirin 81 mg PO DAILY
11. Co Q-10 *NF* (coenzyme Q10;<br>coenzyme Q10-vitamin E) 200
mg Oral daily
12. Fish Oil (Omega 3) 1200 mg PO DAILY
13. Lisinopril 5 mg PO DAILY
hold for sbp<100 or hr<60
14. Outpatient Lab Work
Chem 10 (Na, Cl, K, HCO3, BUN, Cr, Glucose, Mg, P, Ca) panel on
[**2112-8-1**], and have results faxed to PCP [**Name9 (PRE) **] at [**Telephone/Fax (1) 70169**]
15. Glargine 20 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
primary diagnoses:
hyponatremia
lung, liver and pancreas masses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 732**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. As you recall, you were transferred
to the [**Hospital3 **] for a dangerously low sodium level. We found
that you had a great deal of excess fluid in your body, which
likely was contributing to your low sodium level. Your sodium
level improved when we removed some fluid from your body.
We also discovered masses in your liver and your lungs, in
addition to the one known to be in your pancreas.
Unfortunately, this is very suspicious for a malignancy. We
were able to perform a biopsy of one of your liver lesions. The
pathology of this lesion should be very informative.
The following changes to your medication have been made:
STOP furosemide (Lasix)
START torsemide 40mg daily
You should also have your blood drawn on Monday [**2112-8-1**] at your
doctor's office or at a commercial phlebotomist and have the
results faxed to your PCP's office. You will be discharged with
a prescription to have this done.
Followup Instructions:
Name: [**Last Name (un) **],SUETTA M.
Location: [**Hospital 111909**] MEDICAL ASSOCIATES
Address: [**Location (un) 111910**], [**Location (un) **],[**Numeric Identifier 73741**]
Phone: [**Telephone/Fax (1) 70172**]
Please call Dr. [**Last Name (STitle) 111911**] office to be seen within 1 week of your
discharge from the hospital. Let them know it is a post
hospitalization visit. Please discuss the results of your biopsy
with Dr. [**Last Name (STitle) 6352**] at this visit.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 87453**], MD
Specialty: Hematology/Oncology
When: Thursday [**8-18**] at 1:30pm
Location: [**Location (un) **] HEMATOLOGY/ONCOLOGY
Address: [**Last Name (un) 39144**], STE#301, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 80105**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
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"428.0",
"427.31",
"285.22",
"250.00",
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"V58.67",
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icd9cm
|
[
[
[]
]
] |
[
"50.11",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11732, 11815
|
5492, 5723
|
316, 358
|
11923, 11923
|
3318, 3318
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|
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|
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5738, 8883
|
386, 1860
|
8900, 9286
|
3334, 4836
|
11938, 12050
|
1882, 1983
|
1999, 2137
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,501
| 177,317
|
42374
|
Discharge summary
|
report
|
Admission Date: [**2166-12-24**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2086-4-16**] Sex: F
Service: SURGERY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
GENERAL SURGERY: [**2167-1-4**]
1. Inferior vena cava filter
2. Exploratory laparotomy with extensive enterolysis
3. Drainage of retroperitoneal hematoma.
4. Hartmann resection of the sigmoid colon with end-descending
colostomy and Hartmann pouch.
VASCULAR SURGERY: [**2167-1-5**]
Axillary-bifemoral graft
History of Present Illness:
80F s/p multiple endovascular procedures at OSH complicated by
retroperitoneal hematoma, transferred for additional care, now
with persistent abdominal distension. Patient was transferred on
[**2165-12-24**] after prolonged course at OSH requiring multiple
endovascular and open surgical procedures for left common iliac
aneurysm and associated complications of retroperitoneal
hematoma and femoral embolus. During this course, patient had
intermittent episodes of abdominal pain and nausea, but not very
bothersome. Patient reports that prior to her surgeries, she
visited the ER several times for abdominal pain and nausea, with
occasional vomiting of bilious fluid. She has never required NG
decompression for management of these episodes. During her
current admission, CT scan performed to evaluate her hematoma
and surgical sites revealed significant small bowel dilation.
Her abdomen was noted to be distended, however she was not
nauseated or in pain. A concurrent work up for possible
periampullary mass prompted NGT placement for decompression and
subsequent ERCP. However, since placement on [**2165-12-25**], the patient
has had persistently high bilious NG output, averaging
approximately a liter daily. She remains without abdominal pain.
She has not had a bowel movement in at least 5 days and starting
passing a very small amount of flatus today. She has been NPO
and on TPN. She denies recent constipation, change in stool
caliber, melena, and
malaise. She had a normal colonscopy 5 years ago. She feels
weakened and depressed by her prolonged course.
Past Medical History:
Afib, hydronephrosis, diastolic CHF, L common iliac aneurysm,
HTN, hyperlipidemia, GERD, breast cancer s/p mastectomy, chronic
nausea and bloating
Social History:
Minimal alcohol use. Denies smoking tobacco. Main support are
son and daughter who is a pediatric neurologist
Family History:
Mother - pancreatic cancer at 67yrs, Brother - gall bladder
cancer at 62 years
Physical Exam:
Expired
Pertinent Results:
[**2167-1-8**] 01:53PM BLOOD WBC-16.7* RBC-3.93* Hgb-11.9* Hct-33.2*
MCV-84 MCH-30.2 MCHC-35.8* RDW-16.7* Plt Ct-28*
[**2167-1-8**] 01:53PM BLOOD Plt Smr-VERY LOW Plt Ct-28*
[**2167-1-8**] 09:34AM BLOOD PT-23.7* PTT->150* INR(PT)-2.3*
[**2167-1-8**] 01:53PM BLOOD Glucose-69* UreaN-32* Creat-0.9 Na-138
K-4.3 Cl-108 HCO3-19* AnGap-15
[**2167-1-8**] 02:52AM BLOOD ALT-76* AST-202* LD(LDH)-1414*
AlkPhos-141* TotBili-10.2* DirBili-6.5* IndBili-3.7
[**2167-1-6**] 10:42AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2167-1-6**] 10:42AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-TR Ketone-TR Bilirub-SM Urobiln-NEG pH-6.5 Leuks-LG
[**2167-1-6**] 10:42AM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-0 TransE-7
Brief Hospital Course:
Mrs. [**Known lastname 84273**] is an 80-year old female transferred from an OSH
after multiple endovascular procedures for left common iliac
aneurysm and associated complications of retroperitoneal
hematoma complicated by retroperitoneal hematoma and femoral
embolus, transferred for additional care.
Patient had a prolonged ileus and intestinal, colonic and left
ureteral compression by the hematoma, finally requiring an
exploratory laparotomy with Hartmann's procedure.
On POD1 patient had acute ischemia to bilateral lower
extremities and CTA showing occlusion of the aortobifem graft,
needing to go emergently to the OR for ax-bifem
bypass graft to revascularize the lower extremities.
Postoperatively patient did poorly with persistent pressor
requirements, progressive renal failure, liver failure and
possibly a spinal cord infarct not able to move the lower
extremities.
On POD 3 from the last operation patient was not making
substancial improvements and given the multiorgan failure and
poor overall prognosis, the family decided to make her CMO.
Patient was extubated on [**2167-1-8**] in the afternoon and died about
12 hours later on [**2167-1-9**] at 02:25 am. Report of death was
completed.
Patient's family (daughter) were at the bedside and notified.
The admitting office was notified and no need for a Medical
Examiner call was necessary.
The family did not ask for an autopsy.
Medications on Admission:
MiraLax, Fragmin 10,000 units daily for 10 days, Cardizem CD 240
daily, lisinopril 20 daily, Coumadin 5 daily, furosemide 40
daily, digoxin 125 MWF, atenolol 50 daily, omeprazole 20 daily,
Ascriptin 325 daily while Coumadin and Fragmin on hold
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2167-1-14**]
|
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icd9cm
|
[
[
[]
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[
"38.93",
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icd9pcs
|
[
[
[]
]
] |
5149, 5158
|
3415, 4822
|
311, 618
|
5209, 5218
|
2651, 3392
|
5274, 5312
|
2528, 2608
|
5116, 5126
|
5179, 5188
|
4848, 5093
|
5242, 5251
|
2623, 2632
|
257, 273
|
646, 2215
|
2237, 2385
|
2401, 2512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,982
| 141,119
|
3392+3393
|
Discharge summary
|
report+report
|
Admission Date: [**2176-12-12**] Discharge Date: [**2176-12-29**]
Date of Birth: [**2114-7-9**] Sex: M
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
anuria s/p colovesical fistual takedown
Major Surgical or Invasive Procedure:
s/p takedown of fistula with primary anastamosis and diverting
ileostomy, hemodiaylsis catheter placement and subsequent
removal
History of Present Illness:
62 year old male with PMHx CAD s/p CABG x4 in [**2175**] with normal
EF, low grade bladder CA, diverticulitis c/b colovesical fistula
w/ recurrent UTIs who presents s/p takedown of fistula with
primary anastamosis and diverting ileostomy. Patient had a
cystography which was concerning for colovesical fistula which
was followed by a retrograde fistulogram which confirmed the
diagnosis. He presented today for takedown of the fistula.
Prior to the procedure, ureteral stents were placed to allow for
palpation of the ureters during procedure. Urine output during
the procedure was noted to be ~30cc/hour intra op, which
decreased to the patient being anuric since 1800. He was
resuscitated with 7L of crystalloid and 1 L of albumin and got
lasix 20mg IV x1 with no urinary output. A renal u/s was done
post procedure which showed no evidence of hydronephrosis or
urine in the bladder. The patient was in his usual state of
health prior to the procedure. He denied recent illness,
although he did have one episode of hematuria on Tuesday that
cleared with his next void. He otherwise denied urinary
changes.
Past Medical History:
noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections
Social History:
Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week
Family History:
non-contributory
Physical Exam:
ON ADMISSION:
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry oral mucosa, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
[**2176-12-12**] 10:30PM WBC-6.7 RBC-3.80* HGB-11.2* HCT-32.8* MCV-86
MCH-29.5 MCHC-34.2 RDW-15.2
[**2176-12-12**] 10:30PM PLT COUNT-138*
[**2176-12-12**] 09:44PM GLUCOSE-148* UREA N-24* CREAT-2.4* SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2176-12-12**] 09:44PM CALCIUM-8.0* PHOSPHATE-4.5 MAGNESIUM-1.8
[**2176-12-12**] 05:34PM URINE HOURS-RANDOM CREAT-135 SODIUM-80
POTASSIUM-61
CHLORIDE-85
[**2176-12-12**] 02:10PM GLUCOSE-171* UREA N-22* CREAT-1.4* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2176-12-12**] 02:10PM CALCIUM-8.7 PHOSPHATE-4.1 MAGNESIUM-2.1
[**2176-12-12**] 02:10PM HCT-41.6
[**2176-12-14**] 04:51PM BLOOD Glucose-129* UreaN-59* Creat-8.6*# Na-136
K-4.9 Cl-98 HCO3-24 AnGap-19
[**2176-12-15**] 07:06PM BLOOD UreaN-65* Creat-9.1* Na-134 K-8.1* Cl-96
HCO3-21* AnGap-25*
[**2176-12-18**] 09:20AM BLOOD Glucose-165* UreaN-62* Creat-8.0*# Na-133
K-4.0 Cl-88* HCO3-27 AnGap-22*
IMAGING:
[**2176-12-12**] RENAL ULTRASOUND: No evidence of hydronephrosis.
Findings were discussed with the surgery team including [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the time of exam completion.
[**2176-12-18**] RENAL PERFUSION STUDY WITH NUCLEAR MEDICINE: Prompt and
symmetric renal perfusion, without tracer excretion into the
collecting system, compatible with bilateral acute tubular
necrosis.
Brief Hospital Course:
62 y/o male w/ PMHx sig for CAD, diverticulitis c/b colovesical
fistula with recurrent UTIs who presented for takedown of
fistula. The patient underwent sigmoidectomy with primary
anastamosis with diverting loop ileostomy. Immediately the
patient had been noted to have poor urine output
intra-opertively and in the immediate post-op period was anuric.
Intermittent HD in consultation with renal service resulted in
return of kidney function prior to discharge.
NEURO/PAIN: The patient had initially been receiving pain
medication via an epidural catheter infusion and was
transitioned to a Dilaudid PCA by POD#2. His pain medication was
transitioned to Tylenol and PO narcotics on POD#5. He remained
neurologically intact with excellent pain control.
CARDIOVASCULAR: The patient remained hemodynamically stable in
the post-op period, after his episodic hypotension
intra-operatively. His vitals were continuously monitored in the
ICU immediately post-op until he was deemed stable for floor
transfer on POD#5. Cardiac enzymes on [**12-14**] were sent to rule
out hypoperfusion and global ischemic insult to the kidneys due
to post-op coronary demand ischemia. His troponins were
negative. He remained hemodynamically stable for the remainder
of his hospital course.
RESPIRATORY: He was successfully extubated post-op and was
maintained on continuous oxygen saturation monitoring in the ICU
and on floor transfer given his documented history of
obstructive sleep apnea. He had no desaturation periods and was
offered CPAP at night but continually refused this treatment
even after discussion with the respiratory staff. He had no
evidence of cough, and was encouraged to utilize incentive
spirometry during his stay. Incentive spirometry, early
ambulation were encouraged. DVT/PE prophylaxis including
pneumatic compression stockings and SQH were administered.
FEN/GI: The patient was maintained NPO in the immediate post-op
period with a nasogastric tube in place. The NGT had residuals
that were low by POD#4 and was removed without issue on POD#5.
The patient was then advanced from sips to clears and then to a
renal consistency/diabetic diet on POD#6. IV fluids were avoided
given his renal issues and concern for volume overload. The
patient's ostomy was producing flatus by POD#2 and by POD#3
liquid green stool output was forming. By POD#5 the patient had
a healthy amount of liquid green stool output with variable
flatus. His stoma was healthy and pink. His midline abdominal
incision was monitored closely. On HOD#8 the patient was
tolerating a diabetic consistency diet and IV fluids were
discontinued. Given some persistance of hiccups a KUB had been
completed on HOD#7 which showed no evidence of obstruction, and
thus his diet was continued. A non-contrast abdominal CT scan
was performed on HOD#8 which showed expected post-operative
changes and no acute intraabdominal process. Pt's ostomy output
was controlled with loperamide and psyllium supplements which
were titrated toward a goal of <1200cc per day. He was
discharged with loperamide and psyllium supplements to achieve
adequate ostomy output.
ENDOCRINE: The patient was known to be diabetic on admission.
His blood glucose was closely monitored and a sliding insulin
scale was maintained for adequate glucose control. The patient's
home Metformin was discontinued given his anuria and creatinine
elevation.
RENAL: The post-operative anuria was attributed to
post-operative ATN secondary to hypovolemia during the procedure
likely exacerbated by bowel prep prior to surgery. A short
period of hypotension was documented intra-op. The patient
received nearly 10L of crystalloid for post-op fluid
resuscitation. An ultrasound post-op and CT did not demonstrate
hydronephrosis or obstruction. The CT on [**12-13**] of the
abdomen/pelvis did note a moderate amount of edema and stranding
within the perinephric fa--likely post-surgical. The nephrology
service was consulted given the dramatic presentation of post-op
anuria and renal failure. His creatinine had trended from 1.4
post-op on [**12-12**] to 8.6 on [**12-14**]. Renal recommended Q12 hour
electrolyte monitoring, postassium monitoring, cessation of
fluid volume and on POD#4 hemodiaylsis was initiated given
symptoms of uremia (nausea and volume overload) along with
azotemia. A PICC line was placed for access and a more permanent
HD tunnel catheter was placed on [**12-18**] for outpatient dialysis
considerations. By POD#6 he had only produced 15 mL of
concentrated urine output since post-op. A renal perfusion scan
was completed on [**12-18**] which showed that the patient had
adequate renal perfusion, but inadequate clearance and thus
bilateral acute tubular necrosis was confirmed. The patient was
continued on hemodialysis on T/R/Sat regimen and closely
followed by the renal consultation service. Medications were
dosed appropriately and renal function gradually returned
between POD#7 and #9 with last HD POD#10 and removal of HD
catheter POD#11. Upon discharge, his urine output had maintained
in the 1-2L/day range and he had no longer required
catheterization or hemodialysis.
HEME/ID: The patient remained hemodynamically stable in the
post-op period. His post-op hematocrit remained stable in the
33-44% range over his hospital stay. He showed no evidence of
bleeding. His WBC was 6.7 post-op and he remained without
leukocytosis in the post-op period. He did develop some evidence
of inferior abdominal incision erythema which was closely
monitored on HOD#[**5-27**]. He remained afebrile during his hospital
course. Wound cultures were drawn intra-op given fluid
collections near to the diverticulum given the colovesicular
fistula. The wound cultures grew E. coli and he was treated with
Unasyn IV for a 24-hour period. ID consulation was obtained with
Unasyn discontinued and Vancomycin and Meropenem started, which
was narrowed to Meropenem after speciation/sensitivities. PO
Fluconazole was also started for yeast speciating from two urine
cultures. A 7-day Meropenem course was completed prior to
discharge. Patient is to be discharged on PO Fluconazole for
completion of antibiotic course as outpatient.
PPX: Sequential compression boots and heparin subcutaneously was
maintained to prevent the risk of DVT/PE. The patient was
encouraged to ambulate twice daily, and utilize incentive
spirometry during his stay.
Medications on Admission:
Metformin 500mg PO BID, Metoprolol succinate 25mg PO 2 tablets
[**Hospital1 **], Pravastatin 80mg daily, Ranitidine 150mg PO daily, Aspirin
81mg PO daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
5. loperamide 1 mg/5 mL Liquid Sig: One (1) PO QID (4 times a
day): may adjust dosing for target ostomy output <1200cc/day.
Disp:*500 ml* Refills:*2*
6. trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for Insomnia.
7. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for high ostomy output.
Disp:*30 Packet(s)* Refills:*3*
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Sigmoid Diverticulitis
Colovesicular Fistula
Acute Renal Failure
Wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or in your
ostomy bag.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
* Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Avoid driving or operating heavy machinery while taking pain
medications.
* Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
* Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
* Avoid swimming and baths until your follow-up appointment.
* You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
* You have steri-strips, they will fall off on their own. Please
remove any remaining strips 7-10 days after surgery.
Ostomy Instructions:
* Goal output no greater that 1200 cc within 24-hour period and
no less than 500 cc in a 24-hour period.
* You have been discharged on Immodium and a psyllium wafer and
may adjust the dose as necessary to maintain this target output.
You should not exceed more than 8 mg PO daily of immodium. If
you are experiencing thicker ostomy output and the volume is
low, discontinue the psyllium wafer first, then titrate down the
loperamide.
* Please call the office if you have any questions or concerns.
Followup Instructions:
Please have follow-up labs drawn at your PCP's office on [**2175-12-28**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:
[**2176-12-30**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:
[**2177-1-1**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:
[**2177-1-20**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 721**] Date/Time:
[**2177-1-9**] 1:30
Admission Date: [**2177-1-1**] Discharge Date: [**2177-1-11**]
Date of Birth: [**2114-7-9**] Sex: M
Service: SURGERY
Allergies:
Augmentin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
fevers, UTI
Major Surgical or Invasive Procedure:
IR drainage intrabdominal abscess, [**2177-1-8**]
History of Present Illness:
This is a 62 year-old male with a cardiac history and low-grade
bladder cancer who had a colovesicular fistula after a bout of
diverticulitis and subsequently experienced multiple recurrent
UTIs who was s/p sigmoid colectomy, diverting loop ileostomy and
cystoscopy with ureteral stent placement on [**2176-12-12**]. Of note,
post-operatively, he experienced ATN (since resolved) and was
briefly on multiple antibiotics for positive blood cultures
(please refer to official HPI by Dr. [**First Name (STitle) **].
He returned on this admission with fevers, mild abdominal
discomfort, dysuria and increasing output from his ostomy.
Past Medical History:
noninsulin dependent diabetes mellitus, hyperlipidemia, obesity,
hypertension, sleep apnea on CPAP at home, h/o bladder cancer,
gastroesophageal reflux disease, gout, recurrent urinary tract
infections
Social History:
Lives with: Wife-[**Name (NI) **], Occupation: Salesman, Tobacco: smokes
half pack of cigarettes per day x 40yrs, quit 3 months ago,
ETOH: 3 drinks per week
Family History:
non-contributory
Brief Hospital Course:
Mr. [**Known lastname 15719**] was admitted to the colorectal surgery service under
Dr. [**Last Name (STitle) 1120**] on [**2177-1-1**] with plans for IVF resuscitation,
monitoring fevers as well as ostomy and urine output with blood
and urine cultures. The infectious disease service was
consulted and recommended continuing meropenem for E.Coli UTI
(empirically at first from prior admission cultures but
ultimately [**1-1**] urine culture grew E.Coli meropenem sensitive).
On HD 2 the superior aspect of his midline abdominal wound
appeared to be draining brownish fluid; it was opened partially
at the bedside and continued to drain. He was started on
octreotide for concern of an enterocutaneous fistula. He was
made NPO and started on TPN. He was sent for a pouchogram to
assess his simgoid anastamosis for leak and was negative. The
wound and its output were monitored for the next few days and
with continued drainage he was taken for a CT Abdomen on [**2177-1-7**]
which showed a loculated fluid collection in the abdomen near
his midline abdominal wound and no evidence of an EC fistula.
Octreotide was discontinued and he was taken for insertion of a
drain into the collection by Interventional Radiology on [**2177-1-8**]
with subsequent successful placement of a drain. 200 cc of
purulent fluid was removed immediately; drain output was
monitored for the remainder of his stay and decreased each day
until the drain was removed on day of discharge, [**2177-1-11**].
His diet was subsequently restarted (regular) after drain
placement, which he tolerated without issue and TPN was weaned.
From an ID perspective, his urine culture from [**1-1**], wound swab
from [**2177-1-2**] as well as abcess culture from [**1-8**] grew Ecoli
sensitive to meropenem. Blood cultures were negative. He was
kept on meropenem during his hospitalization and discharged, per
ID recommendations, on a total 2 week course of ertapenem (to be
dc'd on [**2177-1-22**]).
He was discharged on [**2177-1-11**] ambulating, tolerating diet and
with limited pain taking minimal pain medications. The drain
was removed prior to discharge. He was instructed to continue
the ertapenem until [**2177-1-22**] with plans to follow up with Dr.
[**Last Name (STitle) 1120**] on [**2177-1-29**] and for a possible takedown of ileostomy on
[**2177-1-31**].
[**2177-1-9**] drain output decreasing
[**2177-1-8**] IR drainage, octreotide dc'd
[**2177-1-7**] octreotide [**Hospital1 **] to daily; CT abd/pelvis shows fluid
collection
[**2177-1-6**] dressing changes TID, Hct 22.8, 2 units PRBC
transfusion
[**2177-1-6**] [**1-2**] wound cx final: ecoli - [**Last Name (un) 2830**]-sensitive
[**2177-1-5**] NPO, TPN w/o fats; Trigs 294, con't octreotide,
dressing changed [**Hospital1 **]
[**2177-1-2**] EC-fistula? at midline incision, opened, octreotide
started, NPO
[**2177-1-1**] transfered from [**Location (un) 620**] w/ UTI, fever, dehydration/high
ostomy output
[**2177-1-1**] d/c Fluconazole, monitor ostomy output, ID recs,
Regular diet
Discharge Medications:
1. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
daily () as needed for E.coli for 14 days: to be administered by
IV infusion company.
Disp:*14 Recon Soln(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Intrabdominal Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
*Continue packing your midline incision with wet-to-dry
dressings
*You will remain on IV antibiotics until [**2177-1-22**]
Followup Instructions:
[**2177-1-22**] Discontinue antibiotics
[**2177-1-29**] F/U with Dr. [**Last Name (STitle) 1120**]
[**2177-1-31**] Ileostomy takedown
Please call ([**Telephone/Fax (1) 3378**] to schedule follow-up appt with Dr.
[**Last Name (STitle) 1120**] for [**2177-1-29**] and to schedule your surgery for [**2177-1-31**].
Completed by:[**2177-1-12**]
|
[
"584.5",
"041.4",
"596.1",
"569.5",
"274.9",
"276.1",
"414.00",
"530.81",
"599.0",
"272.4",
"997.5",
"250.00",
"327.23",
"401.9",
"V45.81",
"998.59",
"562.11",
"V10.51",
"567.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"59.8",
"46.01",
"38.95",
"54.91",
"39.95",
"35.93",
"57.32",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
20035, 20110
|
16529, 19563
|
15356, 15408
|
20176, 20176
|
2642, 4042
|
22775, 23124
|
16487, 16506
|
19586, 20012
|
20131, 20155
|
10476, 10632
|
20327, 21308
|
21934, 22752
|
2036, 2036
|
21340, 21919
|
15304, 15318
|
15436, 16070
|
2051, 2623
|
20191, 20303
|
16092, 16296
|
16312, 16471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,540
| 110,176
|
14742
|
Discharge summary
|
report
|
Admission Date: [**2157-7-21**] Discharge Date: [**2157-7-24**]
Date of Birth: [**2097-12-30**] Sex: M
Service: General Surgery
HISTORY OF PRESENT ILLNESS: Upper gastrointestinal bleed.
PHYSICAL EXAMINATION: Chest was clear to auscultation
bilaterally. Cardiac regular rhythm rate, no murmurs.
Abdomen: Evidence of prior surgical scars, soft,
nondistended, and mild left sided tenderness, no rebound
signs.
Extremities: No signs of edema.
PERTINENT LABORATORIES: On the date of discharge, patient's
hematocrit was 29.7. Chemistry was sodium 136, potassium
4.1, chloride 100, BUN 12, creatinine 0.6, and glucose 104.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known firstname 1312**] [**Known lastname **] is a
59-year-old male presenting with upper GI bleed from
pre-pyloric ulcer identified with esophagogastroduodenoscopy
and underwent cauterization and injection with Epinephrine
without residual bleed. Patient's hematocrit at the time of
admission was 23, although his vital signs were stable.
Patient was administered 4 units of packed red blood cells
and admitted to the Intensive Care Unit for further
observation. The patient's hematocrit elevated to 31 and
remained stable over the past two days in the Intensive Care
Unit during which time decision was made to transfer the
patient to the floor. Patient was advanced to regular diet
and discharged to home on hospital day #4.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with followup with Dr. [**Last Name (STitle) 468**] in
[**8-10**] days.
DIAGNOSIS: Pre-pyloric ulcer, upper gastrointestinal bleed.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2157-10-12**] 14:23
T: [**2157-10-19**] 07:44
JOB#: [**Job Number 43384**]
|
[
"285.1",
"424.0",
"531.40",
"272.0",
"244.9",
"250.00",
"V11.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.41"
] |
icd9pcs
|
[
[
[]
]
] |
673, 1412
|
228, 644
|
174, 205
|
1437, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,019
| 100,342
|
1879
|
Discharge summary
|
report
|
Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-24**]
Date of Birth: [**2083-2-26**] Sex: M
CHIEF COMPLAINT: Ascites, scrotal swelling, shortness of
breath and lower extremity edema.
HISTORY OF PRESENT ILLNESS: This is a 55 year old male with
infarction times two, status post four vessel coronary artery
bypass graft in [**2135-3-6**], hypercholesterolemia,
hypertension, and congestive heart failure, who reports he
has had increased swelling of his abdomen and legs with
swelling of the scrotum which has progressed over two to
three weeks' time. He also has had associated and frequent
shortness of breath and inability to move.
He was transferred from [**Hospital1 **] [**Hospital1 **] where he was
admitted on the [**3-9**]. There, he was
assumed to have biventricular failure as the cause of his
edema. He received Zaroxolyn and Bumex, but his BUN and
creatinine elevated. An abdominal ultrasound showed
splenomegaly and a renal consult thought patient was
pre-renal and therefore, the patient's diuresis was withheld
except for Spironolactone. ACE inhibitor was held as well.
A cardiac ultrasound was attempted but the study was limited
by obesity and Cardiology there recommended a MUGA Scan which
showed a left ventricular ejection fraction of 60%, good
biventricular function.
A paracentesis was done on [**1-11**], of two liters. The
studies showed 400 white blood cells, 520 red blood cells, no
polys, 41 lymphocytes, 59 monocytes, glucose 126, total
protein 3.9, LDH 110 and Enterococci grew out which was
treated with Ampicillin one gram q. eight hours. For a
hematocrit of 25 he was transfused two units of packed red
blood cells. Repeat paracentesis on [**1-13**] drew off
five liters; this was done only for the patient's comfort and
no studies were sent.
A BUN and creatinine on discharge were 127 and 3.8.
PHYSICAL EXAMINATION: Vital signs were 97.9 F.; 140/72; 56;
20; 97 on room air; 170 kilograms. On examination, the
patient was in no apparent distress. Oropharynx clear.
Mucous membranes were moist. Heart showed regular rate and
rhythm. Normal S1, S2. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, distended with
splenomegaly. Extremities with two plus edema bilaterally.
LABORATORY: Chem 7 as follows: 137, 5.7, 102, 27, 127, 3.8,
153 glucose. Calcium 8.9, iron 53, TIBC 298, hemoglobin A1C
7.3, TSH 17.
Ascites with Enterococci sensitive to Ampicillin and
sensitive to Vancomycin.
HOSPITAL COURSE: This is a 55 year old male with a history
of insulin dependent diabetes mellitus, significant coronary
artery disease, but good ejection fraction on a recent MUGA
scan, obesity, hypertension, and lower extremity edema with
shortness of breath times two to three weeks. He had his
first paracentesis in an outside hospital recently with
unclear etiology of his edema.
A Cardiology consultation was obtained and a repeat
echocardiogram was done to work-up the cause of his edema.
This study was extremely limited and the left ventricular
ejection fraction could not be estimated, but the systolic
function of the left ventricle did not seem to be severely
depressed. The right ventricle was not well seen. Thickened
aortic and mitral leaflets, and a right ventriculogram could be
done if further quantification was to be done.
In addition, the patient had an ultrasound of his right upper
quadrant to determine whether flow was abnormal. This showed
a diffusely increased echogenicity in the liver consistent
with fatty liver. Portal venous flow with hepatopetal
direction and a normal hepatic reflow. The spleen was mildly
enlarged. There were mild ascites but no other abnormality
on this ultrasound.
The patient had paracentesis of five liters of fluid in-house
which was clear and yellow. The fluid showed 310 white blood
cells, total protein of 3.2, albumin of 1.7, glucose 162, LDH
100, amylase 26, gram stain negative and a culture was
pending.
Hepatitis serologies were also sent to determine whether
there was some evidence of liver dysfunction accounted by
Hepatitis. HIV negative, Hepatitis B surface antibody
negative.
The patient was maintained on a cardiac low-salt diet of less
than 2 grams per day and diuretics were initially held
secondary to the question of prerenal azotemia. The Renal
Service was consulted regarding this patient and acute renal
failure was thought to be secondary to ACE inhibitors plus
diuretics plus/minus infection, with the intention to restart
Bumex 2 twice a day once the patient's creatinine reached its
baseline.
A right heart catheterization was performed while the patient
was in-house to find the etiology of his symptoms as well as
transfer to Liver biopsy. The catheterization showed
equalization of pressures consistent with a constrictive
physiology. He was aggressively diuresed with Lasix
overnight while in the Cardiac Care Unit. The patient had
increased right and left heart pressures as well as
cirrhosis. He was continued on a regimen of Lasix 40 twice a
day and Aldactone 100 q. day, aiming for minus 1.5 liters off
per day. It was decided that creatinine could be tolerated
as high as 2.5. There were no further recommendations from
renal at this time, and the patient was cleared for
discharge. Ampicillin was also given in-house while the
patient had an Enterococcus in his prior peritoneal fluid.
DR [**First Name (STitle) **] [**Name (STitle) **] 12.899
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2139-5-20**] 15:12
T: [**2139-5-20**] 16:13
JOB#: [**Job Number 10472**]
1
1
1
R
|
[
"250.01",
"584.9",
"423.2",
"414.01",
"416.9",
"571.5",
"789.5",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"96.71",
"54.91",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
2516, 5625
|
1895, 2498
|
141, 216
|
245, 1872
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Discharge summary
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report
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Admission Date: [**2146-8-10**] Discharge Date: [**2146-8-13**]
Date of Birth: [**2094-1-28**] Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Aspirin / Hydromorphone
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Acute blood loss anemia
Retroperitoneal bleeding
Elective cardiac cath and post-procedure significant
retroperitoneal bleeding presents post embolisation and coiling
of right inferior epigastric artery
Major Surgical or Invasive Procedure:
Cardiac Catherization [**8-10**]
Balloon tamponade of R EIA and coiling of R inferior
epigastric artery.
History of Present Illness:
52 y/o with CAD, s/p RCA stent [**2139**], PVD, s/p celiac and AA
stenting presented for elective cardiac catheterisation to
evaluate progressive anginal symptoms and abnormal ETT. At cath
on [**8-10**] the plan was to open her chronically occluded RCA but
this was unsuccessful. The cath lab team were also unable to
wire the vein for RHC, even under fluoroscopic guidance and the
procedure was stopped. RCA was visualised with 2 layers of prior
stents - they were able to wire across lesion but unable to
deliver the balloon. Pt had a lot of pain and tenderness to
palpation at the venous site.
Cath findings: LMCA - no sig stenosis, LAD - diagonal 50%, LCx
prox 60%, RCA long total occlusion in prior stent with
collaterals L>R.
She received heparin post initial catheterization and went to
floor. At 12:20 ,post-procedure, she complained of severe right
groin/RLQ abdominal pain which also radiated into her legs. She
was given fentanyl 50mcg x2 IV for her pain and when her ACT was
checked, her HCt was noted to have dropped from 40.9 ([**2146-7-28**]
from OSH results) to 22.7. She then proceeded to a stat CT
[**Last Name (un) 103**]/pelvis which showed a sizeable retroperitoneal bleed. She
developed hemodynamic instability in the context of a vagal
event when her sheath was being pulled at 14:00 and dropped to
SBP 50 and HR 40 with associated light-headedness and was given
atropine with good result.
Following this, her vitals normalised with HR 73 and BP 110/64.
She was subsequently taken emergently to the cath lab at 3:30pm
where angiography confirmed a bleeding point at the right
femoral site in the inferior epigastric branch. During the
procedure she received a Dopamine infusion, further fentanyl
25mcg x3 and she remained hemodynamically stable during the
procedure. They performed a balloon tamponade of the right
external iliac artery and eventually coil occluded the right
inferior epigastric artery and hemostasis was achieved. Received
3 units of PRBCs during the procedure. Pt was admitted to the
CCU for further monitoring. Her BP remained stable post her
second cath and she returned to the CCU for monitoring. In total
she received contrast 140+395ml for both caths.
.
On arrival to the CCU at 19:00 vitals were T 97.9, HR 59, RR10,
BP 111/51, sO2 98% RA. She was complaining of tnedreness and
sharp pains in both groins in addition to some lower back pain.
She also noted pain which radiated down both legs. On review at
22:00, these symptoms had considerably eased following tramadol
and morphine and her back/leg pain had resolved with changing
posture. In addition she noted mild constant chest heaviness
which she noted had been present all day but was not troublesome
and was a frequent occurrence.
.
Symptoms provoking cath: patient reported almost constant mild
substernal chestpressure that worsens with activity. Her cehst
pain can last from a few minutes to several hours and is
relieved by Nitroglycerin. She has also noticed a decline in her
exercise tolerance with intermittent wheezing and shortness of
breath with limited activity including walking 5 minutes and leg
fatigue with what sounds like claudication at 500ft in both
calves. She also notes rest pain left worse than right in her
calves which is noticeable when she goes to bed. Of additional
note, she had a short-lived, severe episode of abdominal pain
that lasted approximately one minute before resolving. Patient
reports this to feel similar to what she experienced prior to
her aortic and celiac stenting. Last celiac imaging [**2145**].
ROS:
CVS: CP with Nausea and claudication as above with occasional
palpitations. She denied orthopnea and PND.
RS: SOB and wheezing as above, no cough or sputum.
GIS: [**Last Name (un) **] pain as above,with ntermittent abdominal pain felt to
the left of the umbilicus, occasionally worse with eating. Last
[**Last Name (un) 103**]/celiac study was in [**2144**]. No constipation/dairrhea.
CNS: No weakness/numbness/fits but did note light-headedness as
above
ES: No fevers, sweats, tremors
Urinary: Nil. Pt now catheterised
.
Past Medical History:
Cardiac Risk Factors: Dyslipidemia, Hypertension; No DM
IHD 1-2x/week sharp pain which will radiate to the neck and at
times down the left arm.
1. coronary artery disease s/p BMSx2 to RCA in [**1-/2139**] for
angina, 3 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32522**] stents to RCA for in-stent restenosis of
prior stent in [**9-/2139**]
2. Peripheral vascular disease status post aortic stenting for
claudication in [**2144-1-14**], stenting of the celiac artery with
a genesis 6 x 18 stent dilated to 7 mm for mesenteric ischemia
in
[**2144-2-14**] under Dr [**Last Name (STitle) **]
3. Hypertension.
4. Hyperlipidemia.
5. Colonoscopy [**8-/2145**] - Five sessile polyps of benign appearance
and ranging in size from 4mm to 6mm were found in the sigmoid
colon. Single-piece polypectomies were performed using a cold
forceps in the sigmoid colon. The polyps were completely
removed. Evidence of adenomatous polyp on pathology.
6. COPD (emphysema)- no inhalers
7. Resection of breast cysts
8. Anxiety no depression
9. s/p cholecystectomy, [**2139**]
Social History:
Patient is married with one child age 16.
Currently on medical disability but medically retired substitute
teacher.
Mobility: Independently mobile.
Smoking: occasional 1-2cigs/week last regularly c 1year ago when
smoked 40/day. Started at age [**12-26**].
Alcohol: occasional glass of wine when socializing - rughly [**1-15**]
drinks/week.
Family History:
Strong FH of CVS disease at a VERY EARLY AGE
Mother - breast ca
Father - Several [**Name2 (NI) **] first age 28, TIAs, 1x stroke, T2DM
All paternal uncles died of cardiac disease all had [**Name2 (NI) **] in their
30s and none lived past 65.
Sister -[**Name (NI) 77552**] first age 50. Stents. Sister has two children in
their 30s who are well
Brother - well
1 daughter age 16 - well
Physical Exam:
Ht: 5 feet 2 inches
Wt: 110 pounds
VS: T=97.5 BP=126/57 HR=58 RR=16 O2 sat=99% RA
GENERAL: C/O groin pain especially on movement. A+Ox3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRLA, EOMI. Conjunctiva not
pale, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 2 cm.
CARDIAC: Undisplaced apex beat. No R-R delay. HS I+II + 0 no
added sounds no m/r/g. Quiet HS. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Anterior exam was clear
to auscultation bilaterally.
ABDOMEN: Soft, not distended. Tender + in both groins L>R with
no significant superficial hematoma. Minimal groin bruising.
enous sheath in situ L groin. No bruits. Generalised lower
abdominal tenderness no guarding worse on the right/suprapubic.
Dullness to percussion in right flank. BS noraml.
EXTREMITIES: Warm, well perfused. No femoral bruits. Tenderness
in palpating posterior calves bilaterally L>R no clinical
evidence of DVT - pt says chronic.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Rad 2+ Femoral unable to assess given
tenderness DP 2+
Left: Carotid 2+ Rad 2+ Femoral unable to assess given
tenderness DP 2+
NEURO: A+Ox3. No focal deficit. CN 2-12 normal. No fundoscopy.
PERRLA. UL and LL examination normal as could be examined
secondary to pain. No decreased sensation or reflex
abnormalities noted.
Pertinent Results:
Admission Labs
.
[**2146-8-10**] 04:35PM BLOOD Hct-26.3*
[**2146-8-10**] 03:50PM BLOOD Hct-21.1*#
[**2146-8-10**] 02:00PM BLOOD Hct-28.6*#
[**2146-8-10**] 01:26PM BLOOD WBC-3.4* RBC-2.77* Hgb-7.4*# Hct-22.7*#
MCV-82# MCH-26.7*# MCHC-32.6 RDW-18.2* Plt Ct-256
[**2146-8-10**] 01:26PM BLOOD Neuts-49.3* Lymphs-39.7 Monos-5.3
Eos-5.5* Baso-0.3
[**2146-8-10**] 01:26PM BLOOD Glucose-75 UreaN-8 Creat-0.4 Na-145
K-2.5* Cl-116* HCO3-24 AnGap-8
[**2146-8-11**] 08:04AM BLOOD WBC-6.0 RBC-3.63* Hgb-10.2* Hct-29.6*
MCV-81* MCH-28.1 MCHC-34.5 RDW-18.3* Plt Ct-216
[**2146-8-11**] 06:16AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.3* Hct-29.9*
MCV-83 MCH-28.5 MCHC-34.4 RDW-18.4* Plt Ct-210
[**2146-8-10**] 01:26PM BLOOD Neuts-49.3* Lymphs-39.7 Monos-5.3
Eos-5.5* Baso-0.3
[**2146-8-11**] 08:04AM BLOOD Plt Ct-216
[**2146-8-11**] 08:04AM BLOOD Glucose-100 UreaN-6 Creat-0.7 Na-144
K-4.1 Cl-113* HCO3-24 AnGap-11
[**2146-8-11**] 04:30AM BLOOD ALT-7 AST-16 CK(CPK)-124 AlkPhos-63
TotBili-0.5
[**2146-8-11**] 08:04AM BLOOD Calcium-8.2* Mg-2.3
[**2146-8-11**] 08:28AM BLOOD Type-[**Last Name (un) **] pH-7.39
[**2146-8-11**] 08:28AM BLOOD Lactate-2.1*
[**2146-8-11**] 04:42AM BLOOD Lactate-0.9
[**2146-8-11**] 08:28AM BLOOD freeCa-1.13
[**2146-8-11**] 04:42AM BLOOD freeCa-1.28
.
[**8-11**] CT Scan of abdomen and Pelvis
CT PELVIS W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip #
[**Clip Number (Radiology) 77553**]
Reason: retroperitoneal bleed ?
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with groin/abdominal pain post cath
REASON FOR THIS EXAMINATION:
retroperitoneal bleed ?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: [**Last Name (un) **] WED [**2146-8-10**] 5:25 PM
High-density material in the retroperitoneal region extending
inferiorly along
the right iliopsoas and terminating at the right inguinal
region, is
concerning for retroperitoneal hematoma with pelvic extension.
Minimal
stranding around the region of the right inguinal region may
represent site of
venous access. Findings were discussed with Dr. [**Last Name (STitle) **] at 3 p.m.
on [**2146-8-10**].
Final Report
INDICATION: 52-year-old woman with groin and abdominal pain
post-cath;
evaluate for retroperitoneal bleed.
COMPARISON: CT abdomen and pelvis [**2144-3-20**].
TECHNIQUE: Contiguous axial images were obtained through the
abdomen and
pelvis without the administration of IV contrast. Multiplanar
reformats
(axial, coronal, sagittal) were generated and reviewed.
CT OF THE ABDOMEN: Visualized lung bases show bibasilar
dependent atelectasis with minimal areas of air trapping at the
lung bases bilaterally. Visualized heart and pericardium are
unremarkable. The liver, spleen, pancreas, bilateral adrenal
glands, and both kidneys appear unremarkable. The patient is
status post cholecystectomy. There is no free air within the
abdomen. High-density material anterior to the right psoas
muscle(2, 48) measures 55 x 34 mm and continues inferiorly along
the right iliacus up to the right inguinal region. Increased
stranding about the right inguinal region may represent site of
venous access.
A stent is noted within the celiac axis. A stent graft is noted
within the infrarenal aspect of the abdominal aorta.
CT OF THE PELVIS: The bladder appears filled with contrast,
likely secondary to cath procedure and is displaced to the left
by pelvic extension of retroperitoneal hematoma. There is trace
pelvic fluid. The rectum and descending colon appear
unremarkable. There is evidence of diverticulosis within the
descending colon, but no evidence of diverticulitis.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesions
suspicious for
malignancy are identified.
IMPRESSION:
1. High-density material in the retroperitoneal region extending
inferiorly
along the right iliopsoas and terminating at the right inguinal
region, is
concerning for retroperitoneal hematoma with pelvic extension.
Minimal
stranding around the region of the right inguinal region may
represent site of
venous access.
2. Visualized lung bases show bibasilar dependent atelectasis
with minimal
areas of air trapping at the lung bases bilaterally.
3. Diverticulosis within the descending colon but no
diverticulitis.
Findings were discussed with Dr. [**Last Name (STitle) **] at 3 p.m. on [**2146-8-10**].
The study and the report were reviewed by the staff radiologist.
Renal U/S [**2146-8-12**]
FINDINGS: The right kidney measures 10.2 cm. The left kidney
measures 9.3
cm. There is no evidence of stones or hydronephrosis in either
kidney. There
is a small 8 x 8 x 10 mm caliceal cyst in the mid pole of the
right kidney.
There is a small 8 x 7 x 7 mm caliceal cyst in the lateral left
kidney. The
bladder is compressed with a Foley present and cannot be
assessed.
IMPRESSION:
1. No evidence of hydronephrosis, stones, or focal lesions.
2. Small bilateral caliceal cysts.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2146-8-12**] 4:29 PM
Brief Hospital Course:
52F y/o with CAD, s/p RCA stent [**2139**] and repeat stenting for
in-stent stenosis, PVD, s/p celiac and AA stenting presented for
elective cardiac catheterisation to evaluate progressive anginal
symptoms and abnormal ETT. Cath was complicated by
retroperitoneal bleed from R femoral site in the context of
hemodynamic instability and substantial HCt drop. Emergently
taken to cath lab for balloon tamponade of R EIA and coiling of
R inferior epigastric artery. She went to CCU for observation,
there was no further bleeding, pain was managed and she was
discharged home.
.
# Retroperitoneal bleed: A procedural complication of failed
cath. Following her procedure, she complained of severe R groin
pain and her BP was not complomised until a vagal episode when
her bp dropped to SBP 50. At this point her HCt was checked and
it was noted that this had dropped from 40.9 to 22.7. A CT
demonstrated significant retroperitoneal bleed. She returned to
the cath lab where they located the bleeding point and the R
inferior epigastric artery was successfully coiled and
hemostasis was achieved. Post-procedure, she had wide bore IV
access and was closely monitored in CCU. She remained
hemodynamically stable for the rest of her hospital stay. Her
Hct and lactate and ionized calcium remained stable. She was
transfused 3 untis of blood during her coiling but required no
further blood products. Her Hct increased appropriately
following her transfusions. We monitored bladder pressures
because of concern regarding hydronephrosis secondary to
compression from her bleed and they remained stable with
monitoring stopped after 12 hours. Although she complained of
groin pain which radiated into her anterior legs to the knees,
there was no evidence of neurovascular compromise post-procedure
and her foot pulses were palpable. This leg and back pain later
eased. A renal ultrasound showed no evidence of hydronephrosis,
stones, or focal lesions and non-significant small bilateral
caliceal cysts. Her groin and back/leg pain was controlled
initially with tramadol and morphine and latterly with low dose
oxycodone and acetaminophen. She had an allergic reaction to
dilaudid with a rash which was treated with IV benadryl.
.
# CORONARIES: Angiography revealed LMCA - no sig stenosis, LAD -
diagonal 50%, LCx prox 60%, RCA long total occlusion in prior
stent with collaterals L>R. Unfortunately, during the cath they
were able to wire across the occluded RCA but they were unable
to balloon during the procedure. As above, this was complicated
by a retroperitoneal bleed following laceration of the right
inferior epigastric artery which was coiled. The initial
intention had been to repeat the cardiac cath the following day
with RCA PCI with laser however understandably this plan was
abandoned following her RP bleed. This may be undertaken if
necessary at a later date. Her aspirin and clopidogrel have been
continued. Due to her "allergy" to statins (severe muscle
cramps) we continued Ezetimibe and Niacin for lipid control
although it was considered whether it may be of value to
re-trial a statin with concomitant CoQ10. Of note her lipid
profile was markedly abnormal. Cardiac enzymes were not elevated
post-procedure.
.
# RHYTHM: SR bradycardia. Observed on telemetry during the
catherization repair procedure which improved later with
atropine dose and repair of the R inferior epigastric artery. We
observed her on telemetry for any further episodes and she did
not require any further atropine.
#Hyperlipidemia. Grossly abnormal lipid profile - LDL 187 HDL 51
TGCs 314 Chol 301. She had previously tried a statin but
suffered severe muscle cramps. The thought was that re-trial may
be of value possibley with CoQ10 coverage. Continued niacin and
ezetimibe. She additionally has a very notable FH of
cardiovascular disease at a very young age and is concerning for
a genetic hypercholesterolemia. Her father had his frst MI at
age 28 and following this had further [**Year (4 digits) **], TIAs and 1x stroke.
All paternal uncles died of cardiac disease and all had [**Year (4 digits) **] in
their 30s with none living past 65. Her sister has had two [**Year (4 digits) **],
the first at age 50 and has cardiac stents. Her sister has two
children in their 30s who are well. Pt has a brother who is
well. The patient's daughter is age 16 and well. She has been
referred to the lipid clinic and should be evaluated for genetic
causes of early onset cardiovascular disease. A re-trail of
statin should be pursued.
.
# PVD. s/p stenting of AA and celiac. Continued short distance
claudication but has palpable foot pulses and very rare symptoms
suggestive of ? mild msesnteric ischemia. A previous celiac
doppler showed minimally reduced flow. Further outpatient lower
limb arterial imaging with duplex ultrasound can be considered.
.
# HTN. Held anti-hypertensives on the CCU floor given low SBP.
These should be restarted as tolerated by her PCP.
Medications on Admission:
Active Medication list as of [**2146-8-9**]:
ATENOLOL - 25 mg tid
CITALOPRAM - 30 mg qd
CLOPIDOGREL [PLAVIX] - 75 mg qd
EZETIMIBE [ZETIA] - 10 mg qd
FOLIC ACID - 1 mg qd
FUROSEMIDE - 40 mg qd
NIACIN [NIASPAN] - 1000 mg qd
NIFEDIPINE [NIFEDIAC CC] - 30mg qd
NITROGLYCERIN - 0.4 mg PRN
ACETAMINOPHEN - 650 mg qd
ASPIRIN - 325 mg qd
Discharge Medications:
1. Outpatient Lab Work
Please check CBC and Chem 7 on Monday [**8-15**] and call results
to Dr. [**First Name8 (NamePattern2) 73257**] [**Name (STitle) **] at [**Telephone/Fax (1) 8506**]
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Niacin 500 mg Tablet Sustained Release Sig: Two (2) Capsule,
Sustained Release PO HS (at bedtime).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times
a day: Stop taking once pain is gone. .
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Retroperitonial Bleeding
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a cardiac catheterization and we were unable to fix the
blockages in the right coronary artery. You had some bleeding
from the right groin artery after the procedure with blood
leaking in to your abdominal space. The leak was treated using a
coil to repair the vessel. You required 3 units of blood, but
once your artery was repaired, you required no further
transfusion and your blood level remained stable. This caused a
lot of pain and you required strong pain medicine to treat the
pain. One of these medicines, Dilaudid or Hydromorphoone,
elicited an allergic reaction that we treated with Benedryl and
Ranitidine. You should not take this medicine again. There are
no plans at this time to try to fix your right coronary artery,
however you should follow up closely with your cardiologist for
further managment. A referral was made to the [**Hospital **] Clinic here
at [**Hospital1 18**] to try to find a cholesterol medicine that is OK for
you to take. You should never smoke cigarettes again as even a
few cigarettes can damage your arteries and increase your risk
for a heart attack.
Medication changes:
1. START: Acetaminophen 1 gram every six hours for pain. You
should not take more than 4 grams in 24 hours.
2. START: Oxycodone 5 mg every 4-6 hours for pain. This
medication can make you very constipated. You should take the
medications prescribed below for constipation while taking this
medication.
3. START: Colace 100 mg twice a day while taking oxycodone.
4. START: Senna 1 tablet twice a day as needed for constipation.
5. START: Miralax 1 packet daily as needed for constipation.
6. HOLD: Nifedipine until you see your primary care doctor.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2146-10-5**] at 8:30 AM
With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], 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
Department: NUTRITION
When: WEDNESDAY [**2146-10-5**] at 9:30 AM
With: LIPID NUTRITIONIST [**Telephone/Fax (1) 2207**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
We are working on an appointment for you to see your primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19772**]. The office will contact you at home
with an appointment. If you do not hear from them shortly,
please call [**Telephone/Fax (1) 8506**]. You should see your PCP this week.
.
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Doctor Last Name 19408**] MD
Appointment: TUESDAY, [**8-23**], 2:45PM
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9311**]
Phone: [**Telephone/Fax (1) 8506**]
*Please call Dr. [**Last Name (STitle) **] office to confirm your appointment.
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2146-10-5**] at 8:30 AM
With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], 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
Department: NUTRITION
When: WEDNESDAY [**2146-10-5**] at 9:30 AM
With: LIPID NUTRITIONIST [**Telephone/Fax (1) 2207**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2146-10-5**] at 8:30 AM
With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], 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
Department: NUTRITION
When: WEDNESDAY [**2146-10-5**] at 9:30 AM
With: LIPID NUTRITIONIST [**Telephone/Fax (1) 2207**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
We are working on an appointment for you to see your primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19772**]. The office will contact you at home
with an appointment. If you do not hear from them shortly,
please call [**Telephone/Fax (1) 8506**]. You should see your PCP this week.
.
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Doctor Last Name 19408**] MD
Appointment: TUESDAY, [**8-23**], 2:45PM
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9311**]
Phone: [**Telephone/Fax (1) 8506**]
*Please call Dr. [**Last Name (STitle) **] office to confirm your appointment.
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2146-10-5**] at 8:30 AM
With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], 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
Department: NUTRITION
When: WEDNESDAY [**2146-10-5**] at 9:30 AM
With: LIPID NUTRITIONIST [**Telephone/Fax (1) 2207**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"411.1",
"414.2",
"414.01",
"693.0",
"275.2",
"276.2",
"998.2",
"V45.82",
"E879.0",
"285.1",
"443.9",
"496",
"272.4",
"E935.2",
"998.11",
"401.9",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"37.22",
"99.04",
"88.53",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
19671, 19677
|
13274, 18228
|
525, 633
|
19798, 19798
|
8092, 9516
|
21710, 25476
|
6208, 6593
|
18619, 19648
|
9556, 9610
|
19698, 19777
|
18254, 18596
|
19949, 21052
|
6608, 8073
|
21072, 21687
|
284, 487
|
9642, 13251
|
662, 4747
|
19813, 19925
|
4769, 5834
|
5850, 6192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,334
| 155,535
|
3396
|
Discharge summary
|
report
|
Admission Date: [**2113-8-22**] Discharge Date: [**2113-8-28**]
Date of Birth: [**2057-10-7**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This is a 55-year-old man with
history of inferior wall myocardial infarction in [**2108**] with
stent to the mid right coronary artery and percutaneous
transluminal coronary angioplasty of the PL at that time.
The patient has been without symptoms until approximately two
to three days prior to admission where he was noted to have
intermittent chest pain with radiation to the right shoulder.
This initially happened twice with exertion, but then woke
him once on Saturday and Sunday night. Patient did not use
nitroglycerin.
PAST MEDICAL HISTORY: Significant for coronary artery
disease and angina in [**2106**], peripheral vascular disease,
status post bilateral femoral bypass in [**2108**].
CARDIAC RISK FACTORS: Hypertension, family history and
borderline high cholesterol.
ALLERGIES: Patient has no known drug allergies.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] exercise stress test was done on the [**7-22**] which was significant for 3/10 chest pain after
four minutes with [**Street Address(2) 1766**] depression in leads V4 and V5.
Electrocardiogram returned to baseline after ten minutes.
Patient underwent coronary artery bypass grafting times
three. Left internal mammary artery to the left anterior
descending, right internal mammary artery to the right
coronary artery and radial artery to the OM. Patient was
transferred to the unit on propofol, phenylephrine at 1.5 and
nitroglycerin at .5 being apaced at a rate of 90 beats per
minute. Patient underwent the surgery on the 28th. On the
29th, the patient was extubated. Vital signs were stable.
Patient remained afebrile, saturating at 96-98%. Cardiac
output: An index of 8.5 and 4.1 with an SVR of 664. Chest
tube drainage 250/shift.
PHYSICAL EXAMINATION: The patient was neurologically intact.
Lungs were clear to auscultation with slightly decreased
breath sounds at the bases. Heart was regular. Abdomen was
soft. Extremities were warm.
LABORATORIES: Hematocrit of 24 which is down from 27.
Sodium 137, potassium 4.7, BUN 12, creatinine .6 with a
glucose of 134, ionized calcium 1.15.
HOSPITAL COURSE: The plan was to decrease the Neo-Synephrine
and start the Lasix, Lopressor and aspirin. Plans were also
to discontinue the chest tubes and transfer to the floor. On
postoperative day two, patient remained stable, afebrile,
vital signs stable, saturating at 95% on four liters. On
physical examination, the patient was conversational. Chest
with bronchial breath sounds at the bases bilaterally. Heart
was regular rate and rhythm. Sternum was stable and dry.
Abdomen was soft. Extremities were warm with no lower
extremity edema. Left forearm was swollen from the radial
artery harvesting. Plan was to discontinue the Foley,
continue Lopressor, continue aspirin and to continue to
diurese.
Postoperative day three, the patient was discharged. On
physical examination, the patient remained afebrile, vital
signs stable. Chest: Right lower lobe rales, no wheezing.
Heart: Regular rate and rhythm. Incisions were clean, dry
and intact with no drainage and no pus. Patient was
discharged home on the following medications:
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg po q.d.
2. Imdur 30 mg po q.d.
3. Lasix 20 mg po q. 12 hours for five days.
4. Percocet 1-2 tablets po q. 3-6 hours prn.
5. Potassium chloride 20 mEq po b.i.d.
6. Lipitor 10 mg po q.d.
7. Atenolol 25 mg po q.d.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Coronary artery disease.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 15735**]
MEDQUIST36
D: [**2113-11-20**] 08:19
T: [**2113-11-20**] 08:19
JOB#: [**Job Number 15736**]
|
[
"401.9",
"443.9",
"996.74",
"414.01",
"413.9",
"V17.3",
"V15.82",
"412",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.63",
"36.11",
"39.61",
"89.68",
"88.53",
"88.56",
"36.16",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3349, 3595
|
3641, 3961
|
2291, 3326
|
1935, 2273
|
3610, 3619
|
168, 698
|
721, 1912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,177
| 161,207
|
29128
|
Discharge summary
|
report
|
Admission Date: [**2101-1-26**] Discharge Date: [**2101-2-1**]
Date of Birth: [**2043-8-17**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Darvon / Lorazepam
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
lethargy, elevated glucose
Major Surgical or Invasive Procedure:
none, NGT placement
History of Present Illness:
HPI: Ms. [**Known lastname 47331**] is a 57 yo female with a recent diagnosis of
metastatic renal cell cancer who presents after being found to
be lethargic in clinic today with a critically high glucose. She
was brought to the ER where she was c/o abdominal pain and was
quite somnolent. She was given 2L of IVFs and 6 units of regular
insulin and started on an insulin gtt. Blood cultures were done
and she was treated with 2 gm cefepime, 500 mg flagyl and
levaquin. An abdominal CT was done and showed massive
intraperitoneal and retroperitoneal free air. Findings
concerning for ischemic bowel, perforation and multiple
abscesses. Surgery was consulted and initially considered
surgical intervention. After d/w the family it was decided due
to her underlying disease, she was not a surgical candidate. She
was sent to the MICU for further treatment.
.
Of note pt was just recently admitted to [**Hospital 33316**] Hospital in
[**State 2748**] for SBO and was found to have SBO with mass
obstructing the proximal jejunum, invasion of the L paraspinal
muscle and L1-L2 neural foramen invasion. She had a GJ tube
placed and has been getting TPN since that time. She has had
increased fatigue, weight loss and lethargy over the past two
weeks
Past Medical History:
PMHX(per onc note):
1. TAH/BSO [**2095**] due to bleeding fibroids.
2. s/p tubal ligation
3. s/p appy
4. RCC diagnoes in [**8-5**]. S/p L renal aretery embolization
followed by nephrectomy on [**9-10**]. She later developed renal
failure and recurrent disease in L renal fossa with extension
into the pancreatic region and left psoaas muscle in [**12-6**]. New
malignant left pleural effusion was found in [**12-6**], as well as
SBO described above.
Baseline creatinine since diagnosis has been 3.5.
Social History:
SHX: Married lives in [**Location 16221**], CT. No tob history per record.
Occ
ETOH. Patient worked as a factory assembler and did have
exposure
to chemicals/toxins (details unknown).
Family History:
FHX: Both parents died of CAD and brother died at 66 from CAD.
Sister died of cancer (unknown type),other sister with CAD and
CABG. 2 children in their 30's in good health.
Physical Exam:
VS: T 96.9 BP 117/58 HR 105 O2 sat 96% RR 26
Gen: pale appearing female, mumbling, in some pain
HEENT: dry MM
Neck: supple
Cardio: tachy with reg rhythm, 2/6 systolic murmur loudest LUSB
Pulm: CTA b/l ant
Abd: rigid, distended, NT, +BS
Ext: 2+ DP pulses
Neuro: answering some ?s, responding to some commands
Pertinent Results:
[**2101-1-26**] 06:10PM BLOOD WBC-35.5* RBC-2.81* Hgb-7.7* Hct-24.6*
MCV-87 MCH-27.2 MCHC-31.1 RDW-19.1* Plt Ct-259
[**2101-1-26**] 06:10PM BLOOD Neuts-96* Bands-1 Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2101-1-26**] 06:10PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-1+ Polychr-NORMAL
[**2101-1-26**] 06:10PM BLOOD Plt Smr-NORMAL Plt Ct-259
[**2101-1-26**] 06:10PM BLOOD Glucose-627* UreaN-114* Creat-2.9* Na-142
K-4.5 Cl-101 HCO3-23 AnGap-23*
[**2101-1-26**] 06:10PM BLOOD CK(CPK)-8*
[**2101-1-26**] 06:10PM BLOOD ALT-17 AST-12 LD(LDH)-951* AlkPhos-166*
Amylase-28 TotBili-0.9
[**2101-1-26**] 06:10PM BLOOD Lipase-32
[**2101-1-26**] 06:10PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2101-1-26**] 08:58PM BLOOD Lactate-4.4*
[**2101-1-26**] 06:17PM BLOOD Glucose-556* Lactate-3.6*
.
CT abd:
1. Massive free intraperitoneal air with large intraperitoneal
and retroperitoneal fluid collections and portal air concerning
for ischemic bowel and likely perforation involving the splenic
flexure. Retroperitoneal fluid tracks up through a likely defect
of the diaphragm into the left pleural space.
.
CT head:IMPRESSION: No evidence of hemorrhage or mass effect.
.
CXR: IMPRESSION: Extensive opacification of the left hemithorax
with multiple small regions of lucency within it. This finding
could represent infection, but another consideration is a
diaphragmatic hernia. Chest CT would be helpful, or comparison
to prior studies.
Brief Hospital Course:
57 yo female with a recent diagnosis of metastatic renal cell
cancer who presents with ischemic bowel and bowel perforation
and is not a surgical candidate.
.
*Ischemic bowel/bowel perf: Patient was seen in the ER and
found to be hyperglycemic and somnolent. She was started on an
insulin gtt and treated with IV antibiotics. She had an
abdominal CT that showed free air in the abdomen suggesting
bowel perforation and ischemic bowel, as well as possible
multiple abscesses. Surgery was consulted and after a
discussion with the family it was decided that the patient was
not a candidate for surgery. The patient was transferred to the
MICU for further care. She was continued on IVFs and
antibiotics. After discussion with the family it was decided
that the patient's comfort was the most important factor for the
family with regard to to furthur care of the patient. She was
continued on antibiotics but her care was not escalated. She was
treated symptomatically with pain meds and anti-emetics on the
regular medical floor.
.
*Communication: Husband, daughter, family at bedside
.
*Code: DNR/DNI; comfort measures-will cont with current
medications and not escalate care further. On morphine gtt for
comfort.
.
*Dispo: Expired
Medications on Admission:
beta-blocker
Zoloft
Aranesp
Fentanyl
dilaudid
Discharge Medications:
None
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 16221**] Home Care
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"189.0",
"557.0",
"567.22",
"198.89",
"197.8",
"038.9",
"995.92",
"569.83",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5722, 5788
|
4359, 5597
|
315, 336
|
5839, 5848
|
2872, 4004
|
5901, 5908
|
2351, 2526
|
5693, 5699
|
5809, 5818
|
5623, 5670
|
5872, 5878
|
2541, 2853
|
249, 277
|
364, 1609
|
4012, 4336
|
1631, 2133
|
2149, 2335
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,626
| 192,117
|
47234
|
Discharge summary
|
report
|
Admission Date: [**2113-7-2**] Discharge Date: [**2113-7-29**]
Date of Birth: [**2063-2-20**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
[**2113-7-2**]: I+D, IM nail R tibia w/ VAC placement
[**2113-7-4**]: I+D RLE w/ VAC placement
[**2113-7-7**]: right fibula plated, STSG
[**2113-7-13**]: closed reduction right knee uner anesthesia
[**2113-7-20**]: ACL/LCL/posterior corner repair
History of Present Illness:
50 yo male helmeted driver s/p motorcycle crash; reportedly
crashed into a parked vehicle
Past Medical History:
s/p spinal fusion
Social History:
NC
Family History:
NC
Physical Exam:
Gen: 50 YO male, thin WN, NAD alert.
HEENT: NCAT, PERRLA, EOMI b/l, no septal deviation, hearing
good.
Neck: Supple, trachea intact, No goiter, no nodules,no masses.
no lymphadenopathy.
Lungs: CTAB
Heart: RRR, no M/R/G
Abd: soft NTND, +BS. no masses, No HSM.
Ext: RUE: soft tissue injury and ulnar arterial bleed. Grade
IIIB open Tib/Fib fx. Obvious knee dislocation. Grossly NVI.
Weak Palpable DP pulse (+) doppler.
LUE: No injuries.
Neuro: Alert and Oriented x 3. DTR 2+ LUE and LLE. No LOC.
Pertinent Results:
[**2113-7-2**] 11:06PM TYPE-ART PO2-124* PCO2-35 PH-7.35 TOTAL
CO2-20* BASE XS--5 INTUBATED-INTUBATED
[**2113-7-2**] 11:06PM GLUCOSE-157* LACTATE-3.0* K+-3.9
[**2113-7-2**] 11:06PM HGB-10.5* calcHCT-32
[**2113-7-2**] 11:06PM freeCa-0.92*
[**2113-7-2**] 10:00PM TYPE-ART PO2-146* PCO2-38 PH-7.34* TOTAL
CO2-21 BASE XS--4 INTUBATED-INTUBATED
[**2113-7-2**] 10:00PM GLUCOSE-112* LACTATE-3.0* NA+-138 K+-3.9
CL--109
[**2113-7-2**] 10:00PM HGB-12.9* calcHCT-39
[**2113-7-2**] 10:00PM freeCa-0.98*
[**2113-7-2**] 09:50PM PLT COUNT-210
[**2113-7-2**] 09:50PM PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2113-7-2**] 09:50PM FIBRINOGE-102*
[**2113-7-2**] 06:40PM URINE HOURS-RANDOM
[**2113-7-2**] 06:40PM URINE UHOLD-HOLD
[**2113-7-2**] 06:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2113-7-2**] 06:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-7-2**] 06:40PM URINE RBC-[**4-9**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2113-7-2**] 06:37PM GLUCOSE-117* LACTATE-3.5* NA+-140 K+-3.5
CL--103 TCO2-25
[**2113-7-2**] 06:30PM GLUCOSE-119* UREA N-15 CREAT-1.0 SODIUM-136
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2113-7-2**] 06:30PM AMYLASE-27
[**2113-7-2**] 06:30PM ASA-NEG ETHANOL-59* ACETMNPHN-13.0
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-7-2**] 06:30PM WBC-9.6 RBC-4.09* HGB-13.1* HCT-36.5* MCV-89
MCH-32.0 MCHC-35.8* RDW-13.3
[**2113-7-2**] 06:30PM PT-13.1 PTT-23.1 INR(PT)-1.1
[**2113-7-2**] 06:30PM PLT COUNT-369
[**2113-7-2**] 06:30PM FIBRINOGE-148*
Brief Hospital Course:
50 YO male s/p motorcylce hit parked car [**2113-7-2**]. NO LOC. RUE
and RLE injuries. Right arm soft tissue injury and ulnar artery
bleed. Right annkle Grade III open Tib/Fib fx with obious knee
dislocation. Admitted to trauma and ortho service. Closed
reduction and splinting rt. open tib/fib and rt knee
dislocation. On [**2113-7-4**] went to OR I & D w. IMN rt tibia and vac
placement. On [**2113-7-7**] ORIF rt fibula , STSG by plastics. On [**7-20**]
went back to OR for ACL/LCL and posterolateral corner repair rt
knee. Pt did well with PT and placed in cylinder bilvalved cast
at 30 degrees with WBAT status. pt on lovex a/ appropriate
antibiotics. On DC is takin PO / cleared by PT / pos BM / pos
urination.
Ortho procedures
Closed reduction and splinting Right open tib/fib and R knee
dislocation.
I&D, IMN R Tibia and VAC placement.
[**7-4**]: I+D, VAC placement
[**7-7**]: fibula plated, STSG by plastics
[**7-12**]: + knee dislocation on films- needs MRI
[**7-13**]: closed reduced in OR and placed in knee immobilizer
[**7-20**]: repair of ACL/LCL + posterolateral corner ([**Location (un) **])
Plastic procedures
[**7-7**]: fibula plated, skin graft performed, ulnar nerve repaired
[**7-12**]: vac dressing removed, xray- R knee dislocation
[**7-13**]: OR for closed reduction/brace
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
6. Hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q 3-4H as
needed for pain.
7. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): On for pain control per recommendation of Pain service.
8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
10. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous
Q8H (every 8 hours).
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
6. Hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q 3-4H as
needed for pain.
7. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): On for pain control per recommendation of Pain service.
8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
10. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous
Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p Motorcycle crash
Right knee dislocation
Right tibia open fracture
Degloving injury right arm
Discharge Condition:
Stable
Discharge Instructions:
You may bear weight on your RUE while in the splint. You may
also WBAT on your RLE while wearing the bivalve cast. Continue
with the daily dressing changes as directed. If you notice any
increased redness, swelling, drainage, temperature >101.4, or
room. Take all medications as prescribed. You may continue any
normal home medications. Please follow up as below. Call with
any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: WBAT in splint
Right upper extremity: WBAT in bivalve (at 30 degrees)
Right knee immobilizer
Treatments Frequency:
Site: RUE
Type: Surgical
Change dressing: qd
Comment: xeroform, dry gauze, kerlix
Site: Right lower leg
Type: Surgical
Change dressing: qd
Comment: xeroform, dry gauze, kerlix over skin graft
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] at the [**Hospital 5498**] clinic in 2 weeks.
Call [**Telephone/Fax (1) 1228**] to make an appointment.
Follow up with Plastic Surgery Clinic in 2 weeks, call
[**Telephone/Fax (1) 5343**] for an appointment.
Completed by:[**2113-7-29**]
|
[
"955.2",
"285.1",
"958.4",
"305.1",
"305.60",
"873.42",
"903.3",
"V45.4",
"E812.2",
"836.0",
"305.00",
"881.10",
"836.51",
"823.32",
"958.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.46",
"79.66",
"86.74",
"38.83",
"80.6",
"79.76",
"79.36",
"38.93",
"83.45",
"83.65",
"99.04",
"78.17",
"86.69",
"83.09",
"99.07",
"86.22",
"04.3",
"81.45",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
6092, 6189
|
2942, 4248
|
339, 588
|
6330, 6339
|
1318, 2919
|
7184, 7470
|
784, 788
|
5183, 6069
|
6210, 6309
|
4274, 5160
|
6363, 6760
|
803, 1299
|
6778, 6933
|
6956, 7161
|
279, 301
|
616, 707
|
729, 748
|
764, 768
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,424
| 148,744
|
16474
|
Discharge summary
|
report
|
Admission Date: [**2161-12-17**] Discharge Date: [**2162-1-19**]
Date of Birth: [**2119-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
transfer from OSH with prosthetic aortic valve endocarditis
Major Surgical or Invasive Procedure:
transesophageal echocardiogram
History of Present Illness:
42 y.o. male s/p mechanical [**First Name3 (LF) 1291**] (St. [**Male First Name (un) 1525**]) in [**2157**] with re-do
in [**2158**], HIV, HBV, HCV with MSSA AV endocarditis transferred
from [**Hospital3 **] for consideration of a third AV
Replacement. He has been extremely non-compliant with
medications (stopped his coumadin and HAART regimen for the
entire month of [**Month (only) 1096**]). He initially presented to [**Hospital **]
Hospital on [**2162-11-17**] with fevers and chills after being found
unresponsive in his bathroom. Per report, he was found to have
an NSTEMI with TN-I of 2.67. Blood cultures demonstrated MSSA
and TEE had a question of thrombus vs. vegetation on his aortic
valve. He was also noted to be hypotensive with large left
perinephric hematoma. He developed ARF thought to be due to
external compression from the hematoma and was transfused 6
units of PRBC and his anticoagulation was held. He was then
transferred to the [**Hospital3 **] CCU. Course at [**Hospital 2586**] notable for: Hypotension, Endocarditis (on
Vanco/Gent/oxacillin/gati at different times, MRI with multiple
brain emboli), Anticoagulation for [**Hospital 1291**] held due to RP bleed and
septic emboli to brain, large perinephric hematoma with RP
component, as well as splenic hematomas on CT, NSTEMI (TN- I
peak 18.0, no cath), SIADH, ARF, HIV(non-compliant with HAART).
.
He was admitted here for evaluation of third aortic valve
replacement by Dr. [**Last Name (STitle) 1290**]
.
ROS:
NEGATIVE: fevers, chills, CP, SOB, edema, DOE, PND, N/V/C/D,
rashes, wt loss, weakness, numbness, headache, visual changes.
.
Past Medical History:
PMH:
1) HIV+, diagnosed in [**2157**] at time of [**Year (4 digits) 1291**]. Followed by Dr.
[**Last Name (STitle) 46825**] at [**Hospital3 5097**]. CD 4 nadir of 57 on [**2161-3-3**]. Uncompliant
with HAART.
2) HCV, diagnosed in [**2157**].
3) MSSA Endocarditis of the AV due to IVDU in [**2157**] (see PSH
below)
4) SIADH with seizures
5) Left perinephric hematoma
6) Retroperitoneal hematoma
7) Septic emboli to the brain, Right RCA territory (see MRI
below).
8) NSTEMI (see above)
.
PSH
1) Aortic Valve Replacment with mechanical St. Jude Valve on
[**2158-11-2**] with re-do in [**2158**] because of a perivalvular abscess
with insufficiency. Surgeries performed at [**Hospital3 **] by
Dr. [**Last Name (STitle) 46826**].
2) Hepatic artery aneurysms s/p ligation and resection on
[**2159-1-23**], discovered in the course of a workup for ABD pain.
3)s/p CCY
4) s/p 5 umbilical hernia repairs, known to Dr. [**Last Name (STitle) **]
Social History:
Hairdresser. History of IV cocaine use in the distant past and
more recent cocaine inhalation. Occasional alchohol use. Never
smoked tobacco
Family History:
NC
Physical Exam:
Temp:98.0 BP:98/58 HR:80 RR:18 O2:100 RA
Gen: Well appearing. NAD. A/O x 3.
HEENT: Fundi not visualized. PEARLA. EOMI. OP:dry mm, poor
dentition. No obvious lesions.
CV: Midline median sternotomy scar. RR. III/VI SEM with
mechanical S2. No thrill. Right carotid bruit. Non-displaced
PMI.
Pulm: CTA b/l
ABD: Diffusely TTP. Soft. No peritoneal signs. Mild splenomegaly
to 3 f.p below the costal margin. No appreciable hepatomegaly.
Ext: No edema or track marks. Oslers nodes on middle and ring
finger pulp on right hand. No splinter hemorrhages or [**Last Name (un) 1003**]
lesions. 1+DP/PT/Radial b/l. Erythemata at site of tape on rigth
AC.
Neuro: Motor [**3-26**] at upper and lower flex/ex. [**Last Name (un) **]: GI to LT b/l.
CNII-XII GI. Gait:Antalgic due to back pain. FTN grossly intact.
No visual field cut appreciated
Pertinent Results:
Labs on Admission
[**2161-12-17**] 09:11PM WBC-6.7 RBC-3.01* HGB-9.5* HCT-27.0* MCV-90
MCH-31.4 MCHC-35.1* RDW-16.8*
[**2161-12-17**] 09:11PM PT-19.7* PTT-38.2* INR(PT)-1.9*
[**2161-12-17**] 09:11PM SED RATE-65*
[**2161-12-17**] 09:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-12-17**] 09:11PM ALBUMIN-2.9* CALCIUM-8.1* PHOSPHATE-3.6
MAGNESIUM-1.7 IRON-76
[**2161-12-17**] 09:11PM ALT(SGPT)-74* AST(SGOT)-140* LD(LDH)-815*
CK(CPK)-100 ALK PHOS-93 AMYLASE-66 TOT BILI-0.5
[**2161-12-17**] 09:11PM CK-MB-4 cTropnT-3.18*
[**2161-12-17**] 09:11PM GLUCOSE-79 UREA N-19 CREAT-2.3* SODIUM-126*
POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-19* ANION GAP-19
.
Labs on Discharge
[**2162-1-12**] 05:19AM BLOOD Hct-28.9*
[**2161-12-29**] 04:22AM BLOOD Neuts-68.8 Lymphs-27.0 Monos-2.6 Eos-0.8
Baso-0.9
[**2162-1-11**] 05:49AM BLOOD Plt Ct-292
[**2162-1-12**] 05:19AM BLOOD Glucose-84 UreaN-13 Creat-1.3* Na-134
K-3.2* Cl-101 HCO3-23 AnGap-13
.
Studies:
Head CT [**2161-12-17**] - Hypodensity in the right frontal lobe
compatible with the history of infarction, high density within
the right frontal
lesion may reflect hemorrhage within the infarction, vs a small
region of preserved cortex.
.
Head MRI [**2161-12-20**] - Multiple cerebral and cerebellar areas of
signal abnormality are noted. There are some foci with diffusion
signal abnormality, and these may indicate areas of infarction.
There is a previously identified dominant right frontal lobe
mass lesion with signal characteristics that are compatible with
the presence of an abscess. Additionally, multiple foci of
susceptibility artifact are identified within the brain. The
constellation of findings is
consistent with embolic events, in this patient with known valve
replacement and endocarditis.
.
TEE [**2161-12-21**] - EF 40%, septal, apical HK, prosthetic valve well
seated with 1.7 cm vegetation, lucency around valve consistent
with abscess.
TTE [**2161-12-21**] - Large mobile prosthetic aortic valve vegetation
with mild-moderate aortic regurgitation and possible large
abscess formation in the anterior aortic root. Regional left
ventricular dysfunction with moderately depressed LV function
and prominent trabeculations; cannot exclude LV apical thrombus.
Possible large abscess extending from the aortic root into the
septum.
.
MRI Abdomen [**2161-12-24**] - 1. Large fluid collection anterior to
ascending aorta, likely a periaortic hematoma. Further
assessment with chest CTA is recommended. 2. Multiple splenic
infarcts.
3. Moderately large subcapsular left renal hematoma. Both
kidneys enhance homogeneously allowing for limitations of the
study.
.
CTA [**2161-12-26**] - . Large aortic root pseudoaneurysm, which appears
to have two compartments. There is a jet of contrast material
extending into one portion of the pseudoaneurysm sac. This
likely represents aortic regurgitation or dehiscence of the
aortic valve root. 2. Numerous splenic infarcts. 3. Minor
basilar atelectasis.
.
CXR [**2161-12-27**] - There is continued cardiomegaly without evidence of
congestive heart failure. Minimal patchy atelectasis is seen in
the left lung base. The tip of the right-sided PICC line is
identified in the superior vena cava. The patient has prior [**Month/Day/Year 1291**]
and median sternotomy. No pneumothorax is identified. No change
from [**2161-12-23**].
.
TTE [**2161-12-28**]:
The right atrium is moderately dilated. The inferior vena cava
is dilated (>2.5 cm). There is mild symmetric left ventricular
hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic
dysfunction. Resting regional wall motion abnormalities include
akinesis of the LV septum. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal. A
bileaflet aortic valve prosthesis is present. The aortic
prosthesis leaflets appear to move normally.
.
***There is a large vegetation on the aortic valve - anterior
leaflet- (1.5 x 1.8 cm) prolapsing into the LVOT. There is a
large space extending from the basal LV septum to the ascending
aorta that is occupied by a large, mobile echodense mass (1.5 cm
wide by 4.5 cm long). An aortic annular abscess is suggested
(associated thrombus?). At least moderate (2+) aortic
regurgitation is seen. [Due to acoustic shadowing, the severity
of aortic regurgitation may be significantly UNDERestimated.]
The mitral valve leaflets are mildly thickened. The aortic valve
vegetation abuts the anterior mitral leaflet in diastole. A
separate mass or vegetation on the mitral valve cannot be
excluded. Mild (1+) mitral regurgitation is seen (may be
underestimated). The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2161-12-18**],
the aortic valve vegetation is more prominent and the anterior
mass is larger. In addition, the degree of aortic regurgitation
appears increased. If clinically indicated, a TEE is suggested.
[**Last Name (NamePattern4) 4125**]ospital Course:
Assessment: 42yo M HIV/HBV/HCV+ and polysubstance abuse with St.
[**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] x 2 and multiple episodes of endocarditis, now with
endocarditis w/ septic emboli to brain/kidney/spleen/coronaries
and 4 days s/p [**Hospital 39700**] transferred from OSH for consideration of
a third aortic valve replacement by Dr. [**Last Name (Prefixes) **].
.
Plan:
.
1) Endocardtitis: The patient has a history of endocarditis
dating back to [**2157**]. On presentation to [**Hospital3 **] in later
[**10/2161**] was spiking temps to 101, 101.6, 102.8. He was initally
treated with IV vanco/gent/rifampin. He was briefly switched to
oxacillin on [**11-19**]. Then switched to rifampin/oxacillin (varying
doses from q4 to q6) on [**2161-11-22**]. Initial cultures w/ MSSA
resistant to PCN and Intermediate resistance to gentamycin.
However repeat cultures were resistant to rifampin as well. A
TEE at [**Hospital3 **] demonstrated a small vegetation on the
Aortic valve. ID was consulted and recommended holding gent on
[**2161-11-22**] given sensitivities (unavailable at present) . On
[**2161-11-20**], An MRI of the brain demonstrated multiple emboli
(likely septic) most prominently in the right MCA distribution.
An MRI of the spine, after the patient complained of back pain,
demonstrated hypointense T1 signal without evidence of osteo or
abscess. ESR was 41 on [**2161-11-22**]. On [**2161-11-25**] the gentamicin was
added back and ciproflox 750 po bid was started. On [**2161-11-27**] he
was switched to ox/gent/gatiflox. On [**2161-11-28**] vancomycin was added
because of Coag negative staph from line sensitive only to vanc
and gent. Patient continued to spike temps. On [**2161-12-5**] gent and
vanco were discontinued. Ox/gatiflox were continued and bactrim
was changed to SS daily, then d/c;d on [**12-7**] due to worsening
renal function. Gatiflox d/c'd on [**12-8**]. He continued to spike
temps with temp of 103.0 on [**2161-12-14**]. He was scheduled for repeat
TEE on [**2161-12-16**], but refused.
.
The patient was transferred to [**Hospital1 18**] for evaluation for 3rd
valve placement. The patient was initially placed on IV
oxacillin 2gIV q6. Blood cultures were also drawn. The
patient's abx regimen later consisted of gent and oxacillin.
Gent was later discontinued because the patient was not
bacteremic. The patient was kept on oxacillin. For the
remainder of his course the patient remained afebrile. At the
time of discharge, ID recommended oxacillin indefinitely.
However, patient pulled out his PICC line and thus it was
recommended for indefinite dicloxacillin therapy.
.
The family was updated frequently during this admission on the
pt's status and management of his multiple medical conditions.
The patient was DNR/DNI. Despite aggressive therapy and
measures, his prognosis continued to remain extremely poor. In
the days prior to his death, the pt remained sleepy,
encephalopathic. Upon discussion with the health care proxy,
family and the patient, it was decided to discontinue his HAART
therapy, and prophylaxis meds were stopped. He was going to
continue with morphine, haldol, symptomatic meds for nausea, etc
with the primary goal being to make the pt as comfortable as
possible, however, on the day of discharge, the patient expired
after respiratory failure. His sister was at his side. He was
pain-free, comfortable on oral morphine solution.
.
1) Hypotension: A right IJ was placed and he was transiently on
levophed (<1 day). Thought to be due to hypovolemia from large
intra-ABD hematoma (see below) +/- sepsis from endocarditis. The
IJ line was removed on [**2161-11-27**] and a PICC line was placed. He was
given multiple blood transfusions. SBP was subsequently above
100 thoughout his course. PICC line (1 lumen clotted on
[**2161-12-14**]).
.
Trigger called on [**2161-12-27**] for HR of 150s and rigors. On [**2161-12-27**]
antibiotic coverage was broadened to include Zosyn and Vanco. He
developed hypotension that did not respont to IV fluids. He was
started on peripheral Dopamine for blood pressure control. He
was then transferred to the unit for further care. The patient's
pressures were not maintained on dopamine. He was started on
Levophed. His pressures improved and he was weaned off.
.
The patient was triggered once on the floor after coming out of
the MICU. His BP was 78/42. The patient was asymptomatic. An
EKG was done and was normal. Stat labs were checked and they
were also normal. He received a 250cc bolus over 1/2 hour and
his pressures improved.
.
2) Aortic Valve: He was placed on lovenox (in place of heparin),
but this was soon stopped due to worsening renal function. A CT
surgery was consulted and determined that there was no
indication for a 3rd valve replacement. Discussion with [**Hospital1 336**]
resulted in the conclusion "we have a 2 valve limit."
Anticoagulation has been held given perinephric hematoma, RP
bleed and septic emboli to the brain.
.
3) Hemorrhage/hematomas: A CT ABD demonstrated a large
perinephric hematoma with Retroperitoneal component, as well as
splenic hematomas. Aspirin and lovenox d/c'd on [**2161-11-22**]. He has
received multiple units of PRBC (at least 9).
.
4) NSTEMI: On [**2161-12-14**] he had SSCP with nausea and dry heaves.
ECG with STD I/L and V5/V6. He was given ASA 81 mg and
beta-blockers, and his TN-I peaked at 18.0 and then trended
down. Lipitor 80 added on [**2161-12-15**]. His MI was thought to be due
to ?septic emboli to coronaries. No cath given multiple medical
issues and resolution of pain. Due to the patient's frequent
triggers for hypotension he was not started on a beta blocker.
He was maintained on an aspirin, which was discontinued when the
pt, along with his family and health care proxy, decided to
discontinue this medication.
.
5) SIADH: Diagnosed based on urine lytes/osm. Uosm of 516 with
serum Na of 123. Thought to be due to pain or septic emboli to
the brain. Na nadir of 123. Treated with fluid restriction and
sodium tablets.
.
Repeat Urine lytes were sent once the patient was transferred
out of the MICU. The values were consistent with hypovolemic
hyponatremia. The patient's fluid restriction was discontinued.
.
6) ARF: His Cr gradually rose. With increased PO intaked and IVF
the patient's creatinine improved. The etiology of his ARF was
septic emboli and intravascular depletion.
.
7) HIV. Pt had been non-compliant as an outpatient with HAART.
Found to have extremely elevated viral loads (see data below).
Started on bactrim on [**2161-11-23**] for PCP [**Name Initial (PRE) 1102**]. HAART
(Combivir, Kaletra and Tenofavir) was started on [**2161-12-2**] in
order to "make him a better surgical candidate." On [**2161-12-15**]
atovaquone 750 weekly, azithro 1200 weekly and daily fluconazole
added prophylactically. HAART therapy as well as prophylaxis
was discontinued upon discussion with the pt, his health care
proxy, and family.
.
9)Brain abscess: Seen on MRI at OSH, now with some surrounding
edema. CD4 66 so may not necessarily be just [**12-24**] MSSA, ddx
should also include fungal, Toxo, ?lymphoma. Neurosurgery was
consulted and they attributed this to a septic emboli. The
patient was not deemed a surgiical candidate. He was started on
Keppra for seizure ppx. This was discontinued per HCP as per
discussion mentioned above.
.
10) Anemia: Hct continues to be stable after transfusions
earlier in admission. unit. Likely to due hemolysis from
shearing forces from valve, as well as multiple hematomas.
However could be ACD from HIV.
.
11) Scrotal Edema: The [**Hospital 228**] hospital course was recently
complicated by scrotal edema over the course of two days. An
U/S noted edema. The patient receieved 20 IV lasix and there
was gradual improvement of his edema.
Medications on Admission:
1) Lopressor 37.5 po tid
2) Oxacillin 2g q4 hours
3) Atrovent MDI
4) ASA 81 daily
5) Atovaquone 750 weekly
6) Azithromycin 1250 weekly
7) Fluconazole 100 daily
8) Lopressor 37.5 tid
9) Kaletra 3 tabs daily
10) Combivir 1 tab [**Hospital1 **]
11) Liptor 80 daily
12) Folate 1 g daily
13) Protonix 40 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
7. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg oral
solution PO every 4-6 hours as needed for pain: hold for
sedation.
Disp:*qs 1 bottle* Refills:*3*
8. Haldol Decanoate 50 mg/mL Solution Sig: 2-4mg intramuscular
injection Intramuscular every 4-6 hours as needed for
agitation.
Disp:*qs 1 bottle* Refills:*2*
9. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
qday:prn as needed for constipation: until BM.
Disp:*30 suppository* Refills:*3*
10. Ativan 2 mg/mL Solution Sig: Two (2) mg injection Injection
every 6-8 hours as needed for agitation.
Disp:*qs 1 bottle* Refills:*2*
11. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO every
six (6) hours: If the patient cannot swallow [**Last Name (LF) **], [**First Name3 (LF) **] not force
him to take antibiotic. .
Disp:*120 Capsule(s)* Refills:*5*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary Diagnosis
1. MSSA Endocarditis
2. Dissecting Aortic Mycotic Aneurysm
.
Secondary Diagnosis
3. HIV
4. Hepatitis B
5. Hepatitis C
6. Left perinephric hematoma
7. Retroperitoneal hematoma
8. Septic Emboli to the Brain, Right RCA territory
9. Non-ST elevation myocardial infarction
Discharge Condition:
expired
Discharge Instructions:
Not Applicable, pt expired [**2162-1-19**]
Followup Instructions:
Not applicable, pt expired [**2162-1-19**]
Completed by:[**2162-1-19**]
|
[
"410.71",
"276.52",
"253.6",
"724.2",
"584.9",
"304.70",
"286.7",
"441.2",
"V15.81",
"070.71",
"042",
"434.11",
"444.89",
"593.81",
"038.11",
"996.62",
"996.61",
"518.81",
"567.29",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"00.17",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
18875, 18948
|
373, 405
|
19286, 19295
|
4057, 9173
|
19386, 19460
|
3190, 3194
|
17409, 18852
|
18969, 19265
|
17079, 17386
|
19319, 19363
|
3209, 4038
|
9224, 17053
|
274, 335
|
433, 2056
|
2078, 3016
|
3032, 3174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,426
| 154,252
|
19329
|
Discharge summary
|
report
|
Admission Date: [**2116-3-22**] Discharge Date: [**2116-3-28**]
Date of Birth: [**2050-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2116-3-24**] - Coronary artery bypass grafting to three vessels.
(left internal mammary artery to left anterior descending artery
and saphenous vein grafts to obtuse marginal and posterior left
ventricular branch).
[**2116-3-19**] - Cardiac Catheterization
History of Present Illness:
66 M with h/o CAD (LMCA, LAD, RCA), chronic diastolic CHF, HTN,
hyperlipidemia, and GERD a/w retrosternal burning which lasted
~1.5 hrs and resolved with a "GI cocktail" in the ED.
Nitroglycerin did not affect the pain. He also describes a
gurgling sensation in his upper chest. He attributes similar
prior episodes to GERD. He clearly states that this pain is
dissimilar to the sharp left-sided chest pain that he
experienced prior to his most recent admission. He denies fever,
chills, dizziness, lightheadedness, chest pain, palpitations,
cough, shortness of breath, abdominal pain, N/V/D, edema or calf
pain.
During his hospitalization [**Date range (1) 52620**] for chest pain, cardiac cath
revealed a 70% LMCA lesion, 60% LAD lesion, and 80-90% RCA
lesions. He was discharged with the plan to return for CABG on
[**3-24**].
In the ED, initial V/S T 98.1 BP 112/80 HR 88 RR 16 O2sat
100%RA. EKG showed SR with an old RBBB and inferior Q's and new
downsloping ST segments inferiorly and in the precordial leads.
CK 195 MB 4 trop<0.01 Cr 1.3. He was given morphine 2 mg IV x 2
and maalox/benadryl/lidocaine.
Past Medical History:
CAD - 70% LMCA lesion, 60% LAD lesion, 2 80-90% RCA lesions on
cath [**2116-3-19**]
Chronic diastolic CHF
HTN
Hyperlipidemia
GERD
Hepatitis C
s/p bilateral rotator cuff tears [**2113**]
s/p L shoulder surgery [**10/2114**] c/b empyema, PTX
s/p right shoulder surgery in [**2095**]
s/p right knee surgery x 2
Social History:
He is married with one grown child. He is currently on
disability. He drinks socially and does not smoke.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. His father had CABG x 4 in his 60??????s.
Physical Exam:
On admission:
V/S: T 97.6 BP 144/69 HR 66 O2sat 97% RA
GEN: Well-appearing gentleman in NAD
HEENT: OP clear with MMM
NECK: neck veins flat
CV: reg rate nl S1S2 no m/r/g
PULM: CTAB no w/r/r
ABD: soft NTND NABS
EXT: warm dry +PP no edema
Pertinent Results:
[**2116-3-22**] 02:40PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2116-3-22**] 02:40PM WBC-11.1* RBC-4.51* HGB-14.2 HCT-40.2 MCV-89
MCH-31.5 MCHC-35.4* RDW-13.9
[**2116-3-22**] 02:40PM ALT(SGPT)-28 AST(SGOT)-71* CK(CPK)-195* ALK
PHOS-70 TOT BILI-0.6
[**2116-3-22**] 02:40PM GLUCOSE-126* UREA N-31* CREAT-1.3* SODIUM-133
POTASSIUM-6.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
ECHO [**2116-3-24**]
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving phenylephrine. Regional and global left ventricular
systolic function are normal. No aortic dissection. No new
valvular abnormalities noted
Brief Hospital Course:
Mr. [**Known lastname 29239**] is a 66 M with history of severe coronary artery
disease who was admitted to the cardiology service on [**2116-3-22**]
with an episode of retrosternal burning. He was monitored on the
cardiology [**Hospital1 **] for 36 hrs without event, had no further
episodes of chest pain, ruled out by cardiac enzymes for
myocardial infarction. The cardiac surgical service was
consulted for surgical management and he was worked up in the
usual preoperative manner. On [**2116-3-24**], he was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. He later woke neurologically intact and was
extubated. His pressors were weaned. On postoperative day one,
he was transferred to the step down unit for further recovery.
He was gently diuresed toward his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. His chest tubes and
epicardial wires were removed. His beta blockade was increased
as tolerated. He was cleared for discharge to home with VNA
services on [**2116-3-28**].
Medications on Admission:
Amlodipine 7.5 mg daily
HCTZ 25 mg daily
Lisinopril 40 mg daily
Metoprolol 50 mg [**Hospital1 **]
Simvastatin 20 mg daily
Omeprazole 20 mg daily
Tylenol prn
Vit C 1000 mg daily
ASA 325 mg daily
MVI daily
Vit E 400 units daily
Omega 3-6-9 capsule 1200 mg daily
Maalox with simethicone prn
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: when you finish taking this medication, resume
HCTZ.
Disp:*14 Tablet(s)* Refills:*0*
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: Begin on [**2116-4-5**].
11. Naprosyn 500 mg Tablet Sig: One (1) Tablet PO bid prn: you
may resume this medication on [**2116-4-5**] as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p Coronary artery bypass grafting to three vessels.
Hypertension
Hyperlipidemia
Former tobacco use
Discharge Condition:
Good
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. Gently pat the wound
dry. 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 from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with [**Doctor Last Name 73**] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 11616**] in [**1-15**] weeks.
Please call all providers for appointments.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-3-28**]
|
[
"272.4",
"401.9",
"584.9",
"428.32",
"428.0",
"070.70",
"414.01",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15",
"36.12",
"39.61",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
6783, 6841
|
3841, 5066
|
330, 592
|
6990, 6997
|
2605, 3818
|
7795, 8194
|
2204, 2333
|
5405, 6760
|
6862, 6969
|
5092, 5382
|
7021, 7772
|
2348, 2348
|
280, 292
|
620, 1733
|
2362, 2586
|
1755, 2065
|
2081, 2188
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,778
| 152,906
|
19144
|
Discharge summary
|
report
|
Admission Date: [**2109-7-10**] Discharge Date: [**2109-7-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
weakness, falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 yo male with h/o DM2, HTN, chronic LBP s/p steroid injections
and facet block on [**2109-6-19**] who presents with worsening LBP,
frequent falls, and weakness. History was obtained from the
patient, his wife, and their family friend. [**Name (NI) 3003**] to the facet
block, the patient was apparently walking around and doing his
ADLs, though had significant LBP. After his facet block, he has
had progressive weakness in his BLE, and according to his wife,
worsening hunching of the back. Over the last few days, it has
progressed to where the patient is unable to ambulate with his
walker, and even falling off the couch requiring his family
members to lift him up. Also, his wife states over the last [**2-3**]
days, he's also had worsening BUE. They have also noticed that
he has started to have increase drooling from the right side of
his mouth. The patient fell last night, and now has some right
eye swelling, though his wife states that he did not hit his
head. According to them, he has not had any loss of
consciousness, or seizure like activity. He was evaluated by his
PCP last week for syncope, and had a bilateral carotid US and CT
head performed yesterday. His wife brought him to the [**Name (NI) **] today
because of his worsening back pain. The patient denies fevers,
chills, nausea, vomiting, chest pains, shortness of breath,
diarrhea, or abdominal pain. He has been constipated recently,
and has not had a BM in a few days. He denies melena, BRBPR, or
weight changes. Of note, the patient started mirapex and
gabapentin within the last 2 weeks for his RLS.
In the ED, vitals were 100.2 91/36 16 100% NRB. During his ED
stay, he dropped his BP to 84/36, and was given IV fluids. He
was eventually weaned down to 2LNC and was still 100%. He was
given a total of 3L NS, 3 amps HCO3 (for CKD and CT with
contrast), Vancomycin 1 gm, Levofloxacin 750 mg x 1, and
ceftriaxone 1 gm x 1. He had a CTA chest/abdomen/pelvis which
showed no evidence of aortic dissection or PE. His BP improved
107/50 prior to transfer. He was transferred to the MICU for
hypotension and weakness.
Past Medical History:
1) DM2
2) Depression
3) Chronic Anxiety
4) Chronic Low Back Pain s/p ruptured intervertebral disk at the
age of 52
5) Dyspepsia on PPI
6) Osteoarthritis
7) BPH s/p TURP
8) HTN
9) Gout
10) OSA
11) Abnormal stress test, medically managed
12) restless leg syndrome
Social History:
Retired Longshoreman. Lives with his wife. [**Name (NI) **] had Caregroup
VNA in the past. Quit smoking 50 years ago. No ETOH.
Family History:
Non-contributory
Physical Exam:
VS: 97.3 62 108/46 12 100% RA
GEN: elderly male, appears to be in NAD
CV: distant HS, RRR. could not appreciate murmurs
LUNGS: diminshed BS, but otherwise clear without rales/rhonci/or
wheezes
ABDOMEN: soft, NT, normal BS
EXT: trace pedal edema. chronic venous stasis changes
NEURO: A/O x 3; slightly tangential in thought process, but
overall appropriately answers questions. Could not assess gait.
PERRL, EOMi. CN II-XII grossly intact.
Motor: RUE 3+ LUE 4+ (distal and proximal) LLE 2+ RLE 2+
(proximal) and 4+ distally
Sensory: intact to fine touch
no clonus, negative babinski. 2+ reflex biceps, patellar, and
achilles
Pertinent Results:
[**2109-7-10**] 04:25PM BLOOD WBC-8.3 RBC-4.14* Hgb-12.2* Hct-35.8*
MCV-87 MCH-29.5 MCHC-34.1 RDW-14.5 Plt Ct-305
[**2109-7-13**] 07:10AM BLOOD WBC-4.4 RBC-3.87* Hgb-11.5* Hct-34.3*
MCV-89 MCH-29.8 MCHC-33.6 RDW-14.3 Plt Ct-233
[**2109-7-17**] 05:50AM BLOOD WBC-4.5 RBC-3.96* Hgb-11.8* Hct-35.3*
MCV-89 MCH-29.9 MCHC-33.6 RDW-14.6 Plt Ct-276
[**2109-7-10**] 04:25PM BLOOD Glucose-83 UreaN-65* Creat-2.2* Na-138
K-5.0 Cl-100 HCO3-26 AnGap-17
[**2109-7-13**] 07:10AM BLOOD Glucose-122* UreaN-11 Creat-1.0 Na-144
K-4.4 Cl-110* HCO3-27 AnGap-11
[**2109-7-17**] 05:50AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-142
K-4.0 Cl-106 HCO3-27 AnGap-13
[**2109-7-10**] 04:25PM BLOOD ALT-122* AST-324* LD(LDH)-514*
CK(CPK)-7090* AlkPhos-97 TotBili-0.4
[**2109-7-11**] 05:24AM BLOOD ALT-92* AST-206* LD(LDH)-369* AlkPhos-76
[**2109-7-13**] 07:10AM BLOOD ALT-64* AST-94* CK(CPK)-729* AlkPhos-90
TotBili-0.2
[**2109-7-15**] 06:15AM BLOOD ALT-102* AST-106* CK(CPK)-225*
AlkPhos-107 TotBili-0.2
[**2109-7-17**] 05:50AM BLOOD ALT-131* AST-96* CK(CPK)-85 AlkPhos-123*
TotBili-0.2
[**2109-7-11**] 09:02AM BLOOD calTIBC-211* Ferritn-163 TRF-162*
[**2109-7-11**] 01:20AM BLOOD T4-4.1*
[**2109-7-14**] 07:35AM BLOOD Free T4-1.1
.
MRI/MRA -
FINDINGS: BRAIN MRI:
There is no evidence of acute infarct seen. There is
mild-to-moderate brain atrophy identified. No midline shift or
hydrocephalus seen. A few prominent perivascular spaces are seen
in the basal ganglia region bilaterally.
IMPRESSION: No evidence of acute infarct.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal in the arteries of
anterior and posterior circulation. There are bilateral fetal
posterior cerebral arteries noted an incidental finding with
consequent small basilar artery.
IMPRESSION: Normal MRA of the head.
.
CT abd -
CHEST: Unenhanced CT of the chest demonstrates atherosclerotic
calcification
along the thoracic aorta and coronary arteries. Several small
calcified
mediastinal and right hilar lymph nodes are seen. Post-contrast
imaging
demonstrates nodular enlargement of the right lobe of the
thyroid gland. The
aorta is tortuous but normal in caliber and there is no evidence
of
dissection. There is no pleural or pericardial effusion. No
pathological
enlargement of lymph nodes is seen in the axillary, mediastinal,
or hilar
stations. The central pulmonary arterial branches appear patent.
The airway
is patent centrally.
No concerning nodule, mass, or airspace consolidation is seen
within the lungs
bilaterally. Dependent atelectasis is noted in the lungs
posteriorly. There
is also compressive atelectasis in the left lower lobe adjacent
to the
tortuous aorta. A 4-mm nodule in the right lower lobe on image
61 of series 3
is stable from prior study from [**2108-4-9**]. No additional nodules
are seen within
the lungs.
ABDOMEN: The liver and spleen appear unremarkable, though
contrast phase is
suboptimal for detection of small lesions. The gallbladder
appears
unremarkable and is well distended. There is no biliary ductal
dilatation.
The portal vein appears patent. The pancreas, adrenal glands
have a normal
configuration. Kidneys are unremarkable. There is no
lymphadenopathy.
The abdominal aorta is tortuous but normal in caliber. There is
no aortic
dissection. There is mild atherosclerotic aortic calcification.
There is
tortuosity of the iliac vessels.
PELVIS: Small bowel demonstrates no evidence of ileus or
obstruction. There
is a normal appearance of the appendix. Large bowel contains a
moderate-to-
large amount of fecal residue. There is no definite evidence of
bowel wall
thickening, though lack of enteric contrast limits the
sensitivity of the
study. There is also no evidence to of mesenteric ischemia. The
urinary
bladder is well distended and appears essentially unremarkable.
Large amount
of stool is seen within the rectal vault. Clinically correlate
for impaction.
OSSEOUS STRUCTURES: Degenerative changes are noted without
suspicious lytic
or sclerotic lesion. A sclerotic focus in the left iliac bone is
likely a
bone island, unchanged from [**2108**] CT.
IMPRESSION:
1. No evidence of aortic dissection or other acute process.
.
CT of head -
IMPRESSION: No evidence of acute hemorrhage.
Lytic changes are noted in the skull of uncertain etiology. A
bone scan may be
performed to exclude neoplatic process as clinically warranted.
.
Echo - The left atrium is elongated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Transmitral Doppler
and tissue velocity imaging are consistent with Grade I (mild)
LV diastolic dysfunction. Right ventricular chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Normal global and regional biventricular systolic
function. Left atrial enlargement with mild diastolic LV
dysfunction. Mild aortic regurgitation. Moderate pulmonary
hypertension.
Brief Hospital Course:
A/P 88 yo male HTN, DM2, chronic LBP s/p fascicular block L3-L5
admitted for worsening low back pain, weakness, and hypotension.
Pt was stabalized in ICU for hypotension. Then transferred to
the floor where LFTs and CKs normalized. PT was consulted and
worked on strength, but determined he needed rehab. Likely d/t
combination of deconditioning, underlying parkinson's and poor
po intake before admission. He also needed medicine adjustment
to minimize risk of hypotension. See below for summaries of
each problem...
.
#. Hypotension: Patient is hypertensive and on medications for
hypertension as an outpatient. usually, his BP tends to run
100s-120. Unclear why his BP was very low on admission, but
causes include medication, cardiac, infection. Most likely
etiology is medication- recently started on pramipexole (for
RLS), and gabapentin. Pramipexole can cause postural
hypotension, and possibly combined with his antihypertensives,
and medications like Detrol, this could have combined to his
hypotension. Improved with fluids. Infection can also be a
cause, though afebrile and no WBC count. Received abx in the ED,
but no other antibiotics were given. UA clean, urine/blood
cultures sent. CXR without e/o PNA. Cardiac etiology is also
possible given previous abnormal stress; though without chest
pain, and low MB/MBI and no ECG changes, unlikely to have been
new cardiac event. Trop may be explained by worsening CKD, and
CK could be [**2-2**] fall. Pt remained normotensive on the floor
after the MICU stay. We restarted his RLS medicines during his
stay, but no anti-hypertensives. He can be monitored in rehab
and as an outpatient and they can be restarted as deemed
neccessary.
.
#. Weakness: unclear etiology, but almost seems as if diffuse,
symmetric process, and especially more proximal than distal.
Causes could include myopathy (inflammatory disorders such as
polymyositis, dermatomyositis), hypothyroidism, electrolyte
disturbances, viral infection, rhabdo. Also, neuromuscular
causes such as MG, LES. Parkinson's also possible given resting
tremor, difficult gait, drooling. MRI ruled out stroke.
Neurology consult thought underlying Parkinson's was likely
contributing to gait disturbance and weakness. It is a minor
component and deconditioning from back pain is likely the
biggest cause. He will need extensive work with physical
therapy to rebuild his strength.
.
#. Syncope: unclear whether patient experienced syncopal event.
possible especially if having frequent falls, and could just be
from hypotension, possibly postural hypotension that is
medication induced. Carotid US pending as outpatient and echo
did not reveal cardiac cause of syncope. Likely related to
hypotension.
.
#. CKD3: creatinine normalized during his hospitalization. Can
continue to monitor as outpatient. No treatment at time of
discharge.
.
#. CAD: old defect on previous stress test. Held
antihypertensive meds as well as statin d/t elevated liver
enzymes. Would consider restarting as an outpatient.
.
#. Low Back Pain: chronic low back pain, and not improved with
recent facet block. CT with evidence of DJD changes, unlikely
MRI would be more helpful though given recent worsening
weakness, MRI may help show new lesions if any. Unclear whether
patient would tolerate an MRI though. Pain consulted, and using
lidocaine patch with gabapentin. Is a chronic issue. Oxycodone
does not make him feel good, so narcotics are avoided as much as
possible.
.
#. Transaminitis - starting to decrease over time. [**Month (only) 116**] be due
to hypoperfusion of liver, recommend repeat LFTs at outpatient
visit next week to watch. No obvious cause of transaminitis.
.
# Elevated CK - treated with IV fluids, likely due to fall.
Normal levels at time of discharge.
.
# RLS - Pt had a lot of difficulty with RLS during stay,
restarted his outpatient meds per Dr. [**Last Name (STitle) **], who was really
helpful with her recommendations. Will continue to monitor
blood pressures and titrate meds slowly for RLS. It will be a
chronic problem. [**Name (NI) **] tried and not effective. Ambien
sedated him very much. Would recommend continuing with
medications on which he was discharged and following up with
sleep medicines for any changes.
.
#. CODE: Full Code
.
#. Contact: Wife [**Name (NI) 4248**] [**Telephone/Fax (1) 52242**]
Medications on Admission:
ALENDRONATE 70 mg po weekly
ALLOPURINOL 300 mg every other day
FUROSEMIDE 40 mg daily
GABAPENTIN 100 mg TID
IODOQUINOL-HC [VYTONE] - 1 %-1 % Cream - apply to irritated skin
on buttocks after domeboro soaks twice a day
LISINOPRIL 2.5 mg daily
LOPERAMIDE 2 mg [**Hospital1 **] PRN
LORAZEPAM 1 mg QID PRN
MECLIZINE 12.5 mg TID PRN
METOPROLOL SUCCINATE 50 mg daily
MIRTAZAPINE 30 mg QHS
MUPIROCIN CALCIUM [BACTROBAN] - 2 % Cream - apply oozing spot
[**Hospital1 **]-
OMEPRAZOLE 20 mg
PRAMIPEXOLE 0.125 mg QHS
SILVER SULFADIAZINE - (Prescribed by Other Provider) - 1 % Cream
- apply to affected area twice a day as needed
SIMVASTATIN 40 mg daily
TOLTERODINE 4 mg Sust. Release [**Hospital1 **]
VARDENAFIL 20 mg Tablet daily PRN
ASPIRIN 325 mg daily
CALCIUM 600 + D(3) 3 Tablet(s) by mouth as directed
DOCUSATE 50 mg twice a day
LANCETS [LANCETS,THIN] - Misc - as directed [**Hospital1 **] and prn
MENTHOL [ICY HOT] - (OTC) - 5 % Adhesive Patch, Medicated -
apply patch as instructed, as needed
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
3. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
12. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain, restless legs.
Disp:*15 Tablet(s)* Refills:*0*
14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qhs ().
16. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Hypotension secondary to medicine effects plus poor PO intake
2. Parkinson's disease
3. Restless leg syndrome
.
Secondary Diagnosis:
1. Hypertension
2. Chronic Back Pain
3. Diabetes
4. Anxiety
5. Gout
6. Osteoarthritis
Discharge Condition:
vital signs stable, afebrile, able to ambulate with walker and
assistance. patient has mild R facial droop with drooling and
slight intention tremor.
Discharge Instructions:
You were admitted to the hospital with weakness and falls at
home. In the ambulance, you were also found to have low blood
pressure. Your blood pressure responded and normalized when you
were given IV fluids. You were watched in the Intensive Care
Unit while your blood pressures returned to [**Location 213**]. It was
likely caused by some of your new medicines for Restless leg
syndrome, as well as not drinking enough fluid the few days
before admission.
.
Your weakness is likely multifactorial. A big factor in it is
your back pain. It does not let you get enough strengthening
exercise and you have become somewhat deconditioned. Neurology
also saw you and thinks that there is a small componenent of
Parkinson's disease as part of your diagnosis. That is why you
have some drooling from the right side of your mouth. You did
have an MRI that showed you had not had a stoke.
.
You also had some elevated muscle and liver enzymes. These
likely were high from the fall and spending time on the floor
where your muscles got injured. We watched them during your
hospital stay and they are all starting to go back towards
normal. You will follow up with your primary care doctor to
make sure they are all the way back to normal.
.
You also had restless leg syndrome during this stay. We
adjusted your medicines some. Please see medicine
reconciliation form for the doses you should be taking.
.
Please return to the hospital for any worsening weakness,
lightheadedness, falling, low blood pressures, chest pain,
shortness of breath or any other concerns. Call 911 if it's an
emergency.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2109-7-25**] 12:40
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2109-7-25**] 4:00
.
Provider: [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2109-8-1**] 2:50
.
Completed by:[**2109-7-17**]
|
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"E936.4",
"724.2",
"300.4",
"458.29",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16082, 16147
|
8821, 13177
|
278, 285
|
16432, 16585
|
3540, 5040
|
18235, 18711
|
2862, 2880
|
14219, 16059
|
16168, 16168
|
13203, 14196
|
16609, 18212
|
2895, 3521
|
223, 240
|
313, 2411
|
16324, 16411
|
5057, 8798
|
16187, 16303
|
2433, 2697
|
2713, 2846
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,463
| 128,430
|
12342
|
Discharge summary
|
report
|
Admission Date: [**2173-11-5**] Discharge Date: [**2173-12-2**]
Date of Birth: [**2110-5-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
63-year-
old female with a history of the hepatitis C virus related
cirrhosis and hepatocellular carcinoma who was evaluated and
found to be a suitable candidate for liver transplantation.
Major Surgical or Invasive Procedure:
[**11-5**]:Orthotopic deceased donor liver
transplant (piggyback, portal vein conduit from the recipient
portal vein to the donor portal vein), common bile duct to
common bile duct anastomosis, donor common hepatic artery to
recipient common hepatic artery end-to-end anastomosis
[**11-7**]:Exploratory laparotomy, evacuation of intra-
abdominal hematoma, portal vein exploration, intraoperative
ultrasound, Tru-Cut biopsy of the liver
[**11-9**] 1. Orthotopic deceased donor liver transplant (piggyback/
ABO incompatible).
2. Superior mesenteric vein to portal vein iliac vein
conduit, donor common hepatic artery to donor #1
branch patch, Roux-en-Y hepaticojejunostomy
[**11-13**] 1. Exploratory laparoscopy.
2. Right and left lobe liver biopsy.
3. Abdominal washout.
4. Thrombectomy.
5. Attempted revision of accessory left hepatic artery
thrombosis.
[**11-16**] 1. Re-opening of recent laparotomy.
2. Exploration of liver.
3. Intraoperative ultrasound.
4. Liver biopsy.
5. Debridement of necrotic muscle and fascia
[**11-26**] 1. Open tracheostomy.
2. Re-exploration of liver transplant with washout liver
biopsy and Vicryl mesh closure of abdominal wall
[**12-2**] 1. Exploratory laparotomy.
2. Portal vein thrombectomy.
3. Hepatic artery thrombectomy.
4. Lysis of adhesions.
5. Peripancreatic and pancreatic debridement, evacuation of
hematoma and temporary abdominal closure.
6. Left liver lobe biopsy
History of Present Illness:
63-year-old female
who presented to the transplant service with end-stage liver
disease and a hepatoma. She was taken to the operating room
where she underwent a difficult liver transplantation that
was complicated by primary nonfunction. She was then taken
back to the operating room and underwent AB/O incompatible
liver transplantation and underwent temporary abdominal
closure. She was taken back to the operating room for a Vicryl
mesh closure of the abdomen and liverbiopsy that demonstrated
some mild central lobular necrosis.
She underwent followup Doppler ultrasound that demonstrated
patent vessels to the liver and, because she required a
portal vein jump graft to the SMV to re-establish portal
vein inflow, we placed her on heparin after she completed her
abdominal closure. Approximately 24 hours into her
heparinization, she developed an upper GI bleed. She
underwent endoscopy that demonstrated some blood and old
blood in the stomach but no active bleeding or ulcer. There
was what appeared to be a small duodenal diverticulum but no
obvious source of upper GI hemorrhage. Based upon our concern
that the diverticulum may, in fact, have been a small ulcer,
she underwent a CT scan of the abdomen which demonstrated a
contrast extravasation and periduodenal air.
Past Medical History:
HCC HEP B CVA HYPOTHYROIDISM
Social History:
ETOH ABUSE:Pt WAS sober from alcohol for three
smoker up to 3 years ago. Denies any IV drug or any other
illicit drug use.
Physical Exam:
On physical examination,PRE TRANSPLANT she appeared tired. Skin
warm and
well perfused. Pupils equal, round, and reactive to light
directly and consensually. Extraocular motions intact.
There is no jaundice. She had a plate in her mouth. Oropharynx
is otherwise benign. No carotid bruits. The trachea
is midline. There is no thyromegaly. The lungs clear
bilaterally. Heart rate is regular without rub, murmur, or
gallop. The abdomen is soft, nontender, and nondistended.
The liver is palpable 1 cm below the costal margin. I was not
able to feel the spleen. She has palpable pedal and groin
pulses. Extremities are normal strength and sensation.
Neurologic is intact.
Pertinent Results:
Ct Scan 1/5/6
1) Extraluminal hyperdense material in the right upper quadrant
posteriorly
(superior peripancreatic and inferolateral peripancreatic) area
most likely
due to extraluminal oral contrast from proximal small bowel or
duodenum.
2) Small (less than 4.5 cm transverse x 2 cm AP) collection
anterior to the
peripancreatic neck/body region.
3) Small splenic infarct, hypoperfusion or small infarct in the
lower pole
cortex of the right kidney.
4) Moderate bibasilar pleural effusions.
Brief Hospital Course:
63-year-old female
who presented to the transplant service with end-stage liver
disease and a hepatoma. She was taken to the operating room
where she underwent a difficult liver transplantation that
was complicated by primary non function. She was then taken
back to the operating room and underwent AB/O incompatible
liver transplantation and underwent temporary abdominal
closure. She was taken back to the operating room this past
Friday for a Vicryl mesh closure of the abdomen and liver
biopsy that demonstrated some mild central lobular necrosis.
She underwent follow up Doppler ultrasound that demonstrated
patent vessels to the liver and, because she required a
portal vein jump graft to the SMV to re-establish portal
vein inflow, we placed her on heparin after she completed her
abdominal closure. Approximately 24 hours into her
heparinization, she developed an upper GI bleed. She
underwent endoscopy that demonstrated some blood and old
blood in the stomach but no active bleeding or ulcer. There
was what appeared to be a small duodenal diverticulum but no
obvious source of upper GI hemorrhage. Based upon our concern
that the diverticulum may, in fact, have been a small ulcer,
she underwent a CT scan of the abdomen which demonstrated a
contrast extravasation and peri duodenal air. She was taken to
the operating room emergently for exploration.
Exploration showed intestinal contents free in the peritoneal
cavity. Hepatic artery ap reared clotted and she also had a
splenic infarct.At this time, without what
appeared to be a significant insult that we did not believe
was survivable, namely an identified hollow visceral
perforation, portal vein and hepatic artery thrombosis in the
setting of a 2nd liver transplant and infected necrotic
pancreas, pancreatic necrosis, we did not believe that this
was a salvageable situation.Pt was made CMO after discussion
with health proxy abdomen was closed and pt was transferred to
ICU where She expired short after.
Medications on Admission:
fluoxetine, furosemide, lactulose, Synthroid,
Zyprexa, Protonix, Seroquel, spironolactone, [**Last Name (un) **], and Flagyl.
Discharge Medications:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Hepatitis C virus related cirrhosis
and hepatocellular carcinoma. S/P OTL x2 after abo
incompatibility
1. Perforated viscus.
2. Infected pancreatic necrosis.
3. Portal vein thrombus.
4. Hepatic artery thrombosis.
5. Necrotic liver
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2173-12-2**]
|
[
"567.22",
"998.12",
"452",
"996.74",
"578.9",
"998.2",
"570",
"572.3",
"348.31",
"410.71",
"070.54",
"584.5",
"155.2",
"569.83",
"996.82",
"577.0",
"512.1",
"444.89",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.22",
"39.32",
"54.12",
"50.11",
"34.04",
"83.39",
"00.14",
"50.12",
"39.1",
"00.93",
"83.32",
"99.25",
"45.13",
"50.59",
"38.07",
"89.64",
"99.15",
"39.95",
"38.86",
"96.6",
"87.51",
"38.06",
"31.1",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
6829, 6908
|
4641, 6622
|
503, 1913
|
7182, 7191
|
4120, 4618
|
7244, 7406
|
6800, 6806
|
6929, 7161
|
6648, 6777
|
7215, 7221
|
3430, 4101
|
274, 465
|
1941, 3222
|
3244, 3274
|
3290, 3415
|
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