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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
26,086
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19615
|
Discharge summary
|
report
|
Admission Date: [**2155-4-8**] Discharge Date: [**2155-4-25**]
Date of Birth: [**2095-11-29**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Nausea, vomiting diarrhea and fever
Major Surgical or Invasive Procedure:
1. colonoscopy
2. placement of right IJ
3. placement of PICC
History of Present Illness:
59 year old female 170 days post allogenic BMT for myelodyspasia
presents with sudden nausea and vomiting, found to be
hypotensive in Dr.[**Name (NI) 6168**] clinic to 60/p, AF with RVR to 150s.
Ext warm, pt mentating. Received hydrocort 100mg. In the ED, BP
initally responded to 113/91 after 2L NS. However, pt remained
hypotensive after 6L. Temp was 101.8. MUST protocol was
activated. Started on cefipime & flagyl empirically after
blood/urine cx's taken. Lactate=1.5. Pt started on dopamine and
transitioned to levophed. Pt converted to NSR spontaneously with
stabalization of blood pressure. Pressors changed from dopa to
levophed in ED. Vanco and gent dose given for broader
covergage. Initial CXR was negative, but repeat CXR on [**4-10**]
showed LLL hazy opacity (effusion vs. pna). CT abd/pelvis showed
no acute process; enlarged GB without evidence of cholecystitis.
Blood, urine and stool cx are negative to date. CMV level
pending. In MICU, started on stress dose steroids, prednisone
held, cellcept held. Levophed was weaned off. Pt was ruled out
for MI. Bedside echo without signs of tampanade.
.
Pt is now afebrile. Pt has not had any more diarrhea since
admission, until this morning, when she had 3 episodes of watery
diarrhea. She had had abdominal crampy pain throughout
hospitaliziation, which she feels is getting better. No other
localizing complaints of cough, dysuria.
Past Medical History:
1. Polycythemia [**Doctor First Name **] with subsequent myelofibrosis s/p
non-myelo-ablative alloBMT in [**9-30**]
2. Hx paroxysmal AFib in [**2152**], s/p cardioversion (successful for
only 72 hrs), was on amiodarone for some time, is now only on
digoxin
Social History:
No tobacco, rare glass of wine with dinner, married and lives
with husband on [**Hospital3 **]. 3 children all healthy.
Family History:
4 brothers who were [**6-2**] HLA matches
Physical Exam:
101.6, 125, 77/28- in clinic on [**2155-4-7**] BP = 122/74, CVP = 9,
RR =25, SaO2 = 100%3L NC
P.E. Ill appearing, NAD pleasant
VS: 101.6, 125,
HEENT: dry MMM, JVP,
Neck: supple
Lungs: CTAB
Heart: hyperdynamic, irregular
Abd: Soft, diffuse mild tenderness, lower > upper
Ext: 2+DPP, no demema
Neuro: grossly inctac
Skin: Multiple non-blanching punctate erythematous rash
Pertinent Results:
Admission Labs:
*
CBC: WBC-3.5* RBC-4.14* HGB-13.4 HCT-37.0 MCV-90 PLT 111
*
LFTs: ALT(SGPT)-32 AST(SGOT)-18 LD(LDH)-143 ALK PHOS-187* TOT
BILI-1.3 DIR BILI-0.6 INDIR BIL-0.7
*
CHEM: GLUCOSE-115* UREA N-17 CREAT-0.9 SODIUM-137 POTASSIUM-3.2*
CHLORIDE-101 TOTAL CO2-27 ALBUMIN-3.4 CALCIUM-7.9* MAGNESIUM-1.6
*
LACTATE-1.5
*
U/A: BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
*
Admission abdominal CT:
1. No evidence of colitis, or intraabdominal pathology. The
appendix is visualized within the right lower quadrant and
appears normal.
2. Enlarged gallbladder without evidence of acute cholecystitis.
3. Ossifications within the spleen consistent with prior
granulomatous infection.
*
Admission Chest X ray: Negative
*
Micro:
[**4-8**] Urine Cx: <10,000 organisms
[**4-8**] Blood Cx: Negative
[**4-10**] Stool Cx: Negative
[**4-11**] Stool Cx: Negative
[**4-12**] Stool Cx: Negative
[**4-9**] CMV VL: Not detected
[**4-14**] CMV VL: Not detected
[**4-14**] stool Cx: no C diff
[**4-15**] stool Cx: no C diff
[**4-19**] tissue CMV culture pending
*
CT abdomen/pelvis [**4-16**]:
1. Unremarkable appearance of the bowel. Specifically, no
evidence of infectious or ischemic colitis.
2. Unchanged appearance of gallbladder distention. This can be
an expected finding in a fasting patient. There is no
pericholecystic fluid or gallbladder wall edema. Please
correlate with patient's clinical symptoms.
3. 2-cm aneurysmal dilatation of the splenic artery.
*
Colonoscopy [**2155-4-18**]:
Erythema and granularity in the ascending colon (biopsy).
Ulcers in the terminal ileum (biopsy).
Otherwise normal colonoscopy to terminal ileum.
.
Biopsy results:
A. Terminal ileum biopsy: Fragments of granulation tissue with
acute and chronic inflammation consistent with ulceration and a
fragment of ileal mucosa with reactive and atrophic changes.
B. Right colon biopsies: Colonic mucosa with focal atrophic and
reactive changes.
C. Left colon biopsies: No significant pathology.
D. Rectal biopsies: No significant pathology.
Note: The changes are not specific. Ulceration may be seen in
chronic graft versus host disease but may also be seen in
ischemia, infection, inflammatory bowel disease, etc. Clinical
correlation is needed. An occasional apoptotic cell is seen.
Immunostains for CMV are negative with appropriate positive
control, and no viral inclusions were seen on routine sections.
Special stains for fungi and AFB are negative with appropriate
positive controls.
Brief Hospital Course:
59 yo woman with PCV s/p mini allo-BMT on [**9-30**] , admitted with
sepsis now resolved, w/ persistent diarrhea. See HPI for ICU
course prior to transfer to BMT. A brief problem based course is
outlined below.
1. Hypotension/sepsis - On transfer to BMT her hypotension had
resolved. She had initially presented with hypotensive episode
(60's systolic), which resolved after IV fluids, pressors and
stress dose steroids in the ICU. No clear source was identified,
with initial blood cx, urine cx, and CXR all negative. Initial
lactate was 1.5. A GI source of sepsis was suspected, which
could have been predisposed by gut GVHD, through a cytokine
mediated event. Other potential etiologies were considered
including dehydrational state from emesis/diarrhea vs adrenal
insufficiency, or a combination of factors. In either case, she
subsequently stabilized on broad antibiotics, which were
continued on admission to the transplant service. Stress dose
steroids were stopped, and she was re-started on a GVHD
treatment regimen of cellcept and solumedrol as outlined below.
She remained hemodynamically stable off pressors, and off stress
dose steroids.
2. Diarrhea - Unclear etiology. The differential included CMV
infection, gut GVHD, or other infectious etiology. Factors
supporting a "late" acute GVHD were her recent skin changes of
GVHD and precipitation of diarrhea (>500cc/day) when cellcept
and solumedrol were abruptly held in the ICU. In addition,
symptoms improved following re-initiation of these meds. Other
infectious etiologies were searched for, including CMV, which
was negative by viral load testing. C diff, campylobacter and
shigella stool cultures were also negative. CT scan was
performed which was negative for intra-abdominal pathology. No
evidence for micro-perforation, ischemia, or colitis was seen.
The GI service was consulted, and plan was made for potential
biopsy if diarrhea continued to evaluate for GVHD vs. CMV. Pt's
diarrhea improved but then got worse when she began to advance
her diet. She therefore underwent colonoscopy as her abdominal
pain and diarrhea were persistent and worsening. This showed a
nonspecific acute on chronic inflammatory process, particularly
in the terminal ileum, which could be consistent with acute on
chronic GVHD versus infection versus IBD. Of note, IHC for CMV
was negative. GI was reconsulted; ursodiol was stopped, as this
could induce a bile-acid diarrhea. It was thought that perhaps
the inflammation in the terminal ileum was preventing bile acid
reabsorption in the enterohepatic circulation, causing diarrhea.
Pt began to improve somewhat and increased her ambulation,
which also seemed to result in improvement of abdominal pain.
Her diet was advanced, and her abdominal pain got better. Pt
still had diarrhea on discharge, but stool output was only about
200cc/day.
3. POLYCYTHEMIA [**Doctor First Name **] S/P ALLO-BMT [**9-30**] - >100 days out.
Continued with GVHD medications, including solumedrol and
cell-cept. She was well-engrafted, with WBC >1500, Plt >100K,
and stable hematocrit. Donor/Patient same blood type=O+. Pt's
Solumedrol was ultimately changed to prednisone 20mg po daily,
which can be tapered as tolerated as an outpatient.
4. CAD - Presented wtih lateral changes on EKG with rapid afib.
Pt was ruled out for MI. Remained chest pain free throughout her
admission. Bedside echo in unit was without tamponade signs. Pt
had no further cardiac issues after the resolution of her
sepsis.
5. atrial fibrillation - Presented with Afib with RVR in ED in
setting of fever, hypovolemia. Now in sinus rhythm, with no
further issues.
6. FEN - Pt was begun on TPN as her albumin was in the 2's, and
it was thought that she would likely not be able to manage
adequate nutrition in the setting of continued abdominal pain
and diarrhea. She was discharged on TPN, as well, and she will
continue to advance her diet as tolerated. Of note, she
required calcium and phosphorus repletion to the point that she
may need extra infusions of these, as the Ca x phos product is
greater than what can be given in the TPN solution. Pt had PICC
line placed in R arm in interventional radiology on the day of
discharge.
7. Code - full
Medications on Admission:
Prednisone 25 mg po qd
Cellcept = 500 mg po tid
ursodiol 300 mg
bactrim MWF
protonix
ativan
ambien
acyclovir
folic acid
benadryl
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
8. Budesonide 3 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO tid ().
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. diarrhea
2. graft versus host disease
3. atrial fibrillation with rapid ventricular response in
setting of sepsis
Discharge Condition:
stable, tolerating po, ambulating
Discharge Instructions:
Please keep all of your appointments and take all of your
medications. If your abdominal pain or diarrhea get worse,
please go to the emergency room or call your primary care
doctor.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2155-5-2**] 11:30
|
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23,531
| 193,022
|
8925
|
Discharge summary
|
report
|
Admission Date: [**2183-5-9**] Discharge Date: [**2183-5-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
L-sided chest pain, SOB
Major Surgical or Invasive Procedure:
1. endotracheal intubation
2. thoracentesis
3. chest tube placement
4. flexible bronchoscopy
5. rigid bronchoscopy
History of Present Illness:
Patient is intubated and sedated. This admission note is per
report.
.
92 [**Hospital **] nursing home patient with hx of dementia,
CAD, AF, and hypotension presents to the ED via EMS c/o
non-radiating 8/10 L-sided chest pain and SOB. These started at
his NH, and per reportm patient had an ECG with ischemic changes
and pain was not relieved with 2 SL NTG and 1 dose of tylenol so
EMS was called.
.
Per notes he had been declining with decreased appetite and
weight loss, with c/o abd pain for the past month. No N/V,
normal bowel movements. He had an ?abd U/S and a KUB which were
both negative for intraabdominal pathology but showed a pleural
effusion.
.
In the ED patient was noted to have ST depressions in V4-6 on
ECG. He received 325 mg of ASA and 1 SL NTG en route. He was
given lopressor, morphine 4 mg, a dose of levaquin 750 mg PO,
and started on a nitro gtt. On CXR he was found to have a large
right pleural effusion suspicious for malignancy. An
interpreter was called who said that the patient was very
confused.
.
His family was called to obtain permission for for a therapeutic
thoracentesis and his family reversed his code status. He
desatted into thw 80's despite high flow oxygen and given his
new code status, he was intubated with etomidate and succ, and
then started on a propofol gtt. He then received ativan and his
blood pressure dropped to the 70's. He was started on levophed.
Past Medical History:
Hypotension
dementia
CAD s/p inferior MI
AF
syncope
depression
bilateral hilar LAD
L eye blindness
Social History:
Lives in a nursing home. Speaks Russian only. NOK is
daughter, who lives in the area.
Family History:
NC
Physical Exam:
VS: T: 96.5 BP: 138/91 HR: 62 O2 sat: 99%
Vent settings: AC 500 x 12, FiO2: 50%, PEEP: 5
GEN: elderly man lying in bed, intubated, sedated, NAD
HEENT: MMM
CV: irregular, no murmurs
PULM: CTAB with decreased breath sounds on the R
ABD: soft, protuberant, non-distended, non-tender, + BS
EXT: no edema, + 2 DP pulses
NEURO: intubated, sedated
Skin: small hematoma (1-2 cm) at R neck and L groin (1-2 cm)
Pertinent Results:
[**5-9**] CXR: Large right pleural effusion; this finding raises the
suspicion for an underlying malignancy. CT is recommended.
Brief Hospital Course:
Mr. [**Known lastname 31008**] is a [**Age over 90 **] year-old Russian-speaking male with a history
of dementia, CAD, atrial fibrillation, and hypotension who was
found to have a large right sided pleural effusion during work
up for chest pain and shortness of breath. He was ruled-out for
MI. His code status was DNR/DNI, but was reversed for
therapeutic thoracentesis. During the procedure, his oxygen
saturation dropped into the 80's despite high flow oxygen and
given his new code status, he was intubated and started on a
propofol drip. He then received Ativan and his systolic blood
pressure dropped to the 70's. He was started on Levophed. He was
admitted to the MICU for further management.
.
In the MICU, he remained intubated for hypoxic respiratory
distress and required intermittent Levophed for hypotension. He
was extubated on [**2183-5-15**] without complication and remained
stable on 2L NC. He was also started on vancomycin/Zosyn while
in the MICU given his hypotension. However, a source was never
identified and antibiotics were stopped after 9 days. Since the
initial thoracentesis, he underwent a chest tube placement for
the right-sided pleural effusion. Cytology on pleural fluid was
negative for malignancy, but subsequent rigid bronchial biopsy
was consistent with non-small cell carcinoma. The family decided
to make the patient DNR/DNI given these findings.
.
In collaboration with the Hematology-Oncology, Radiation
Oncology and Pain & Palliative Care teams, the daughter elected
to defer any treatment of his lung cancer at this time. She is
aware that he may become symptomatic from his lung mass and that
the pleural effusion may reaccumulate. The patient's daughter
expressed interest in maximizing the patient's quality of life
and functional status. At the time of discharge, she was
planning to pursue care for symptomatic management as needed.
.
Atrial fibrillation was well-controlled with digoxin and
metoprolol. His INR was elevated on admission and required
reversal with FFP and vitamin K for thoracentesis. Coumadin was
held during this admission given a supratherapeutic INR. The
patient did not undergo staging CT to evaluate for brain or body
metastasis of his newly diagnosed lung cancer. In the interest
of meeting the goals of care, Coumadin was not restarted as
risks and impact on his quality of life potentially outweigh the
benefit. However, Coumadin may be restarted as an outpatient if
his PCP feels that it is indicated.
Medications on Admission:
Digoxin 0.125 mg QD
lasix 40 mg PO QD
SL NTG PRN
Warfarin
Tylenol PRN
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
9. Oxygen therapy
O2 by nasal canula. Titrate to O2 sat of > 93%.
10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
1. non-small cell lung cancer
2. pleural effusion
Discharge Condition:
Stable. Afebrile. Tolerating PO. Activity w/ assistance only.
Discharge Instructions:
You were admitted for shortness of breath and chest pain. You
were found to have fluid around your lung. The fluid is most
likely due to the cancer that was found in your lung. If you
experience worsening shortness of breath, chest pain, fever or
any other concerning symptoms, please call your doctor or go to
the emergency room.
.
Please take all medications as prescribed.
.
Please follow up with all appointments as instructed.
Followup Instructions:
Please follow up with your doctor [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab in 1 week and
as needed. Coumadin was held during this admission, but may be
restarted by his PCP.
.
Primary team should discuss a 'Do Not Hospitalize' order with
the patient's family as soon as possible.
|
[
"692.9",
"519.19",
"414.01",
"458.9",
"511.9",
"162.8",
"427.31",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.27",
"96.72",
"96.04",
"96.6",
"33.24",
"34.91",
"34.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
6097, 6162
|
2692, 5171
|
285, 402
|
6265, 6329
|
2539, 2669
|
6809, 7113
|
2098, 2102
|
5291, 6074
|
6183, 6244
|
5197, 5268
|
6353, 6786
|
2117, 2520
|
222, 247
|
430, 1849
|
1871, 1973
|
1989, 2082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,212
| 157,506
|
1432
|
Discharge summary
|
report
|
Admission Date: [**2164-11-15**] Discharge Date: [**2164-11-18**]
Date of Birth: [**2100-12-9**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
Russian female with a history of pancreatitis in [**2147**], who
presents with twelve hours of fever, chills, nausea, vomiting
and severe epigastric pain in the Emergency Department.
have a temperature of 102. Otherwise, she was hemodynamically
stable. She had severe epigastric pain.
White count was 17.0, increased liver function tests, lipase
1630. Abdominal ultrasound showed dilated common bile duct
with a question of a distal stone.
cholangiopancreatography where she had a sphincterotomy and
removal of multiple 7.0 to 10.0 millimeter stones. Common bile
duct was dilated to 14.0 millimeters. Final cholangiogram was
negative for stones. The patient was admitted to the Intensive
Care Unit for observation for progression of pancreatitis.
PAST MEDICAL HISTORY:
1. Pancreatitis [**2147**].
2. Status post cholecystectomy [**2147**].
3. Breast cyst.
MEDICATIONS ON ADMISSION:
1. Pancreas.
2. Zoloft.
3. Xanax.
The patient did not know the doses of these medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone in [**Location (un) 86**]. No
tobacco and no alcohol use. The patient's daughter is
involved in her mother's care and has been translating for
her mother.
PHYSICAL EXAMINATION: On admission, vital signs revealed
temperature 98.2, heart rate 88, blood pressure 140/68,
respiratory rate 16, oxygen saturation 99% in room air. In
general, she is an elderly female lying in bed in no apparent
distress. Head, eyes, ears, nose and throat is normocephalic
and atraumatic. Extraocular movements are intact. Mucous
membranes are moist. The neck is supple. Cardiovascular
regular rate and rhythm, normal S1 and S2, grade III/VI
systolic ejection murmur heard at the apex. Chest is clear
to auscultation bilaterally. The abdomen is soft, distended
slightly, hypoactive bowel sounds and nontender to deep
palpation. She is guaiac negative. Extremities - no
cyanosis, clubbing or edema. Neurologically, she is alert and
oriented times three. She is grossly intact.
LABORATORY DATA: On admission, white count is 17.0,
hematocrit 40.0, platelets 368,000, differential 81 polys, 3
bands, 9 lymphocytes, 6 monocytes. Sodium 137, potassium
3.4, chloride 100, bicarbonate 23, blood urea nitrogen 13,
creatinine 0.8, platelets 258,000. Calcium is 9.1, ALT 383,
AST 665, alkaline phosphatase 239, amylase 516, lipase 1630,
total bilirubin 2.1. INR was 1.1, partial thromboplastin
time 23.9. Urinalysis was negative. CK #1 54, troponin less
0.3. Blood cultures times four were sent and were pending.
Urine culture was also pending.
Abdominal ultrasound showed common bile duct dilated with
question of distal stone. Electrocardiogram showed sinus
tachycardia at 100, left axis deviation, downward sloping T
waves in V5 and V6.
HOSPITAL COURSE: The patient was initially admitted to the
Endoscopic retrograde cholangiopancreatography Service and
status post performance of her endoscopic retrograde
cholangiopancreatography, she was transferred to the
Intensive Care Unit and later to the regular medical floor.
The patient's vital signs remained stable. Her abdominal
pain improved. She was initially NPO and was advanced to
clear liquids. However, she had some vomiting which was
responsive to Compazine and Droperidol. She was later
changed back to NPO for this and her diet was subsequently
advanced to the point where she was tolerating solids on the
day of discharge. The patient was also started on Protonix,
Ciprofloxacin and Flagyl during this admission for treatment
of potential biliary infection and gastrointestinal
prophylaxis. The patient has been doing well since transfer
to the medical floor. She is being discharged home on
[**2164-11-18**].
MEDICATIONS ON DISCHARGE:
1. Pancreas.
2. Zoloft.
3. Xanax.
She was on these as an outpatient and should continue to take
her outpatient doses.
NEW MEDICATIONS:
1. Ciprofloxacin 500 mg p.o. b.i.d. until [**2164-11-29**].
2. Flagyl 500 mg p.o. t.i.d. until [**2164-11-29**].
3. Protonix 40 mg p.o. q.d.
FOLLOW-UP: The patient will follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8555**], at [**Hospital3 **]. The patient
is being discharged in stable condition.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2164-11-18**] 10:18
T: [**2164-11-18**] 14:04
JOB#: [**Job Number 8556**]
|
[
"577.0",
"574.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
3957, 4697
|
1081, 1215
|
3006, 3931
|
1437, 2988
|
157, 942
|
964, 1055
|
1232, 1414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,423
| 137,573
|
43716
|
Discharge summary
|
report
|
Admission Date: [**2120-12-29**] Discharge Date: [**2120-12-30**]
Service:
CHIEF COMPLAINT: Shortness of breath and hypoxia after a
fall.
HISTORY OF PRESENT ILLNESS: This is an 86-year-old woman who
fell at home around 8 AM stating she "lost her footing, it
was unwitnessed and was found sitting up. She called out to
her daughter on their intercom at home who came to help her.
She was very lucid according to the daughter. There was no
complaints after the fall, loss of consciousness or head
injury. She fell on the left side and possibly hit her flank
and chest on her dresser. After approximately 30 minutes
became increasingly shortness of breath associated with left
pleuritic chest pain and came to the Emergency Room. Sats
were noted to be 75 to 80% with tachypnea, with increased
respiratory rate in the 40's. The patient was intubated and
seen by the Trauma Team. Had a left pleural effusion on
chest x-ray and trauma placed an apical left chest tube.
Also had a fever of 101.1 the previous night with nausea,
diaphoresis and episode of watery diarrhea without blood.
There is no vomiting. The temperature decreased with Tylenol
and she did not note a fever this morning.
On [**12-27**] she noted a headache, nausea as well as feeling
chilled.
In the Emergency Room got a Atomadate 20 intravenous times
one, Succinyl choline one intravenous times one, Propofol for
sedation (blood pressure decreased on the Propofol) also
received Fentanyl 500 mg intravenous times five and 1 mg of
Versed. Got Levaquin 500 mg intravenous times one, 2 liters
of normal saline in the Emergency Room and her vent was set
at assist control, 450x12 with 5 of PEEP and 100% FIO2.
REVIEW OF SYSTEMS: Her great grandchildren had a stomach
virus recently. No chest pain, persistent cough without
sputum that was thought to be either congestive heart failure
or gastroesophageal reflux disease at her PCP. [**Name10 (NameIs) **] lower
extremity edema recently, no dysuria, abdominal pain. Two
pillow orthopnea.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Status post myocardial
infarction in [**2109**].
2. Hypertension
3. Hypercholesterolemia.
4. Triple A (abdominal aortic aneurysm greater than 5 cm
has recently gotten big within the last six months. Gets CT
scans every six months to evaluate.
5. ITP in [**2117**].
6. Question of chronic obstructive pulmonary disease.
7. Left cerebrovascular accident.
8. Cataracts.
9. Congestive heart failure with last echo in [**2120-4-1**]
revealing an EF of 35 to 40% Mild symmetrical left
ventricular hypertrophy, mild LAE, lateral and posterior
hypokinesis, 1 to 2+ MR, +2 Tricuspid regurgitation and
moderate pulmonary hypertension.
10. Anemia/Thalassemia.
11. Degenerative disc disease.
12. Status post API.
13. Osteoporosis.
14. Gastroesophageal reflux disease.
15. Hard of hearing.
16. History of rib fractures.
ALLERGIES: Penicillin and Erythromycin cause hives.
Ciprofloxacin causes a rash. Ampicillin, Amoxicillin and
Cephalexin causes a rash. Azithromycin has been okay.
MEDICATIONS:
1. Zocor 40 mg q day.
2. Toprol XL 100 mg q day.
3. DynaCirc 10 mg q day.
4. Digoxin 0.125 mg q day.
5. Diovan 160/250 once a day.
6. Fosamax 70 mg one times a week every Monday.
7. Lasix 40 mg p.r.n.
8. Aspirin 81 mg q day.
SOCIAL HISTORY: Quit smoking 11 years ago after a 50 pack
year history. Lives with daughter in an upstairs apartment.
Performs full activities of daily living herself. There is
on alcohol or drug use.
PHYSICAL EXAMINATION: Temperature 97.5, heart rate 96, blood
pressure 146/76 then 106/38, then an SPT in the 90's,
respiratory rate 36, O2 sat 100%
General: Elderly woman sedated and intubated. Head, eyes,
ears, nose and throat: Eyes are taped shut. Mucous
membranes are dry. Neck: Supple, flat jugular venous
distention. CV: Distant but regular rate and rhythm.
Respiratory: Clear to auscultation bilaterally with
decreased breath sounds at the left base, left chest tube is
in place. Abdomen: Normal active bowel sounds, soft,
nondistended, pulsatile abdominal mass. Extremities: warm
1+ dorsalis pedis pulses bilaterally. No edema or clubbing.
Rectal: Trace positive per surgery. Normal tone.
DATA: White blood count 5.6, hematocrit 33.3, platelets 130
with a differential of 13 polys, 0 bands and 60 lymphocytes.
135 sodium, potassium 4.4, chloride 95, bicarbonate 18, BUN
63, creatinine 2.2. Glucose 76. Anion gap of 22, a lactate
of 5.2. EDG equals 7.3/40/134/20/-5. A Urinalysis revealed
100 protein, trace ketones, small bili, no leukocytes or
nitrates. 3 to 5 red blood cells, 0 to 2 white blood cells,
0 to 2 epis. No blood,many bacteria.
STUDIES:
1. Electrocardiogram: 95 normal sinus rhythm, normal
intervals, normal axis. UST depressions approximately 1 mm
in V4,V5 and V6. T-wave inversions in V4, V5 and V6, 2, 3, L
(old) and a flat T-wave in F.
2. Chest x-ray: Endotracheal tube in good position with
normal heart size. Left lower lobe opacity revealing either
consolidation or contusion with a small effusion. Left chest
tube in place. Healed right rib fractures and no
pneumothorax.
3. Abdominal CT: Per Surgery this was negative. 5.5 cm
abdominal aortic aneurysm which is old and no change from
[**2121-12-2**]. There is sludge in the gallbladder and
splenomegaly.
4. Chest CT: Large left pleural effusion, consolidation in
the left lower lobe. Small left pneumothorax. Chest tube
was tip at apex, emphysematous changes, calcified aorta and
carotid vessels. Old healed rib fracture on the right.
5. Head CT. Negative for hemorrhage, shift or fractures.
Left frontal lobe with a prior infarct.
6. Pelvis CT was negative.
ASSESSMENT: This is an 86-year-old woman with a one day
history of fever, nausea, status post a fall this morning and
later presented with increased short of breath, O2
desaturations requiring intubation with a left lower lobe
pneumonia and effusion, status post a chest tube, and
metabolic acidosis with an elevated lactate likely secondary
to sepsis.
HOSPITAL COURSE: In the Emergency Room blood pressure had
decreased to the 90's, however, this was attributed to recent
sedation and the patient was stable otherwise. Within hours
of transfer to the floor the patient's blood pressure began
to drop and a Neo-Synephrine drip was started. Pleural fluid
revealed an exudative effusion with a low glucose (2) likely
representing a parapneumonic effusion. It was decided to
double cover with Levaquin and Ceftriaxone (she was
pre-medicated and we were to watch for possible rash or
allergic reaction.
Blood pressures continued to fall ultimately requiring four
pressors (Neo-Synephrine, Dopamine, Dobutamine, and
Vasopressor). Also requiring continues fluid bolus and her
TH had decreased to 7.01 with a metabolic and respiratory
alkalosis with a lactate rising to 5.7. Respiratory rate and
total volumes on the vent were increased in an attempt to
decrease her pACO2. She began to brady done and at one point
her heart rate was in the 30's and then briefly in asystole
which responded to compressions, Epinephrine, Atropine and
bicarbonate.
Her Troponin returned at greater than 50 with negative CKs
and a repeat Electrocardiogram showed more pronounced ST
depression.
Cardiology was called and since there was no pericardial
effusion on CT it was felt that depressed blood pressures
were likely not cardiogenic however, she was obviously having
an acute myocardial infarction in the setting of sepsis.
Heparin was held since a chest tube was recently placed with
a plan to start it if she stabilized. She did receive
aspirin.
Because of the patient's rapid deterioration the family was
called and came in. After discussion it was decided to make
the patient DNR/DNI with a focus on comfort measures.
Aggressive support was discontinued and the family was at the
patient's bedside. She passed away at approximately 5:10 AM
with cessation of heart rate, breathing and fixed dilated
pupils. Since the patient died within 24 hours of admission
Medical Examiner was notified however, the case was waived.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2121-1-12**] 18:03
T: [**2121-1-14**] 09:48
JOB#: [**Job Number 93959**]
|
[
"584.9",
"427.5",
"486",
"276.5",
"861.21",
"518.5",
"428.0",
"E884.4",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6080, 8372
|
3538, 6062
|
1714, 2026
|
102, 149
|
178, 1694
|
2048, 3310
|
3327, 3515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,692
| 175,081
|
4977
|
Discharge summary
|
report
|
Admission Date: [**2208-1-21**] Discharge Date: [**2208-2-5**]
Date of Birth: [**2137-3-18**] Sex: F
Service: SURGERY
Allergies:
Plavix / Sulfur, Elemental / Penicillins / Iodine-Iodine
Containing / Enalapril / Hydralazine And Derivatives / IV Dye,
Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2208-1-21**]: Sigmoidectomy with colostomy (Hartmann's procedure).
History of Present Illness:
70F w/ hx of RCC metastatic to lung, pancreas, bone with
completion of XRT and cycle 20 day 15 of Avastin who presented
to the ED after a fall around midnight with head strike. LOC
uncertain. She lives alone and was down for about 8 hours. She
reports being fine yeserday after her chemotherapy, but has
since the fall felt lightheaded. In the ED, CT revealed
perforated sigmoid diverticulitis and 5cm abscess.
Past Medical History:
PMH: metastatic RCC s/p nephrectomy ([**2198**]), R VATS wedge for
mets ([**2201**]) now on chemo (Avastin - last [**1-20**]), HTN, CAD s/p
PCI/LAD stent ([**2198**]), Hyperkalemia, Hypercholesterolemia, Hx
postop PE [**2182**] (on coumadin s/p IVCF), Hx [**Doctor First Name **] s/p treatment x
18months ([**2201**]), SLE, Antiphospholipid syndrome, Osteoporosis
.
PSH: L radical nephrectomy/adrenalectomy w periaortic
lymphadenectomy ([**2198**]), RLL/RML VATS wedge rsxn x 2 for
metastatic RCC ([**Doctor Last Name **]-[**2201**]), R eye cataract procedure
[**2203**]), L eye cataract ([**2204**]), Excision of right thigh lesion for
atypical squamous proliferation ([**Doctor Last Name 519**]-[**2205**]), L cephalic v
portacath ([**Doctor Last Name 519**]-[**3-/2207**])
Social History:
SOCH: Widow. Lives alone. 3 children/5 grandchildren. Daughters
live nearby and help out with shopping and chores around the
house. Tobacco: 15 pack yr hx - quit [**2166**]; EtOH: Denies
Family History:
FAMH: Two paternal aunts had cancer, and the patient is not sure
what type. One paternal aunt had a colon cancer, a maternal
aunt had stomach cancer. The patient's father had prostate
cancer and her sister may have had a GYN cancer.
Physical Exam:
Physical Exam on admission:
Vitals: HR 102 BP: 101/78 RR 34 SaO2 100%NC
Gen: WD, obese, elderly F; anxious-appearing.
HEENT: anicteric, EOMI
CV: RRR, I/VI murmur along left sternal border
P: CTAB
Abd: soft, Diffusely tender to light palpation, distended
EXT: WWP
NEURO: A&Ox3, non-focal
Pertinent Results:
[**2208-1-21**] 10:25AM BLOOD WBC-2.8*# RBC-4.55# Hgb-11.6* Hct-38.1#
MCV-84 MCH-25.4* MCHC-30.3* RDW-16.6* Plt Ct-362
[**2208-2-1**] 03:39AM BLOOD WBC-5.6 RBC-3.23* Hgb-8.6* Hct-27.5*
MCV-85 MCH-26.7* MCHC-31.5 RDW-20.0* Plt Ct-180
[**2208-2-1**] 03:39AM BLOOD Plt Ct-180
[**2208-1-21**] 04:30PM BLOOD Fibrino-214
[**2208-1-29**] 02:15AM BLOOD ESR-68*
[**2208-2-1**] 03:39AM BLOOD Glucose-166* UreaN-39* Creat-0.9 Na-141
K-4.4 Cl-110* HCO3-22 AnGap-13
[**2208-2-1**] 03:39AM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 20645**]*
[**2208-1-29**] 02:15AM BLOOD ALT-30 AST-27 LD(LDH)-469* AlkPhos-188*
TotBili-1.9* DirBili-1.2* IndBili-0.7
[**2208-2-1**] 08:49AM BLOOD Glucose-138* Lactate-2.3*
Brief Hospital Course:
The patient presented to the [**Hospital1 18**] ED [**2208-1-21**] after being found
by family members s/p fall. On arrival to the ED patient was
manifesting septic physiology with concerning abdominal exam.
CT abd/pelvis was obtained which showed perforated sigmoid
diverticulitis and large pelvic abscess. Central access was
obtained in the ED and resuscitation was initiated with several
liters crystalloid fluid. Patient also found to have INR: 2.5
in setting coumadin use for hx PE. Four units FFP given to
correct coagulopathy. Patient was then taken to the operating
room for exploratory laparotomy with Hartmann's procedure.
Intraoperatively, patient required levo/vaso pressor support and
was transfused 4pRBC and 2FFP. Patient tolerated procedure and
was subsequently transferred to the TSICU for further management
under the ACS service. At time of transfer patient had ETT,
OGT, abdominal JP, colostomy, [**Known lastname **], radial a-line and R IJ CVL.
After a brief uneventful stay in the ICU, she was transferred to
the floor. Given failure to thrive post operatively, her family
elected to make her comfort measures only. She was placed on a
morphone dropp and she passed away at 10:40am [**2209-2-5**].
Medications on Admission:
[**Last Name (un) 1724**]: ALBUTEROL SULFATE 90mcg INH Q4-6H prn, AMLODIPINE 5',
BEVACIZUMAB (last [**1-20**]), DEXAMETHASONE 4'', FLUTICASONE 50/Spray
[**2-15**]', ADVAIR DISKUS 250-50', LORAZEPAM 0.5', METOPROLOL XL 100',
NITROGLYCERIN 0.4', OMEPRAZOLE 20', ONDANSETRON 4 Q8H prn,
OXYCONTIN 20 QAM, 10QPM, PREDNISONE 10', WARFARIN 4 6d/wk, 5
1d/wk, ACETAMINOPHEN 500 Q6H prn, ASA 81', CALCIUM CARBONATE-VIT
D3-MIN 600(1,500)400'', DOCUSATE SODIUM 100'', LOPERAMIDE 2'
prn, SENNOSIDES 8.6'' prn
Discharge Medications:
Patient expired in hospital.
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated diverticulitis
Discharge Condition:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2208-3-23**]
|
[
"998.81",
"562.11",
"V15.3",
"197.0",
"V58.61",
"785.51",
"198.5",
"518.51",
"567.21",
"E878.3",
"997.49",
"V12.51",
"E885.9",
"V45.82",
"401.9",
"V10.52",
"584.9",
"V58.65",
"995.92",
"289.81",
"496",
"V45.73",
"038.9",
"197.8",
"785.52",
"710.0",
"569.5",
"287.5",
"568.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"54.59",
"96.72",
"46.11",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5075, 5084
|
3245, 4475
|
425, 497
|
5153, 5298
|
2523, 3222
|
1960, 2197
|
5022, 5052
|
5105, 5132
|
4501, 4999
|
2212, 2226
|
371, 387
|
525, 938
|
2240, 2504
|
960, 1737
|
1753, 1944
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,978
| 124,735
|
2394
|
Discharge summary
|
report
|
Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
CC:[**CC Contact Info 12393**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is a 84 y/o F with a history of CAD, s/p CABG and
PCI in [**2-20**] on [**Date Range 4532**], HTN, DM II, and dyslipidemia who was
initially was brought to the ED by her granddaughter who noted
the patient having slurred speech earlier this evening. The
patient herself thought she felt "funny" in the face. While in
the ED, the patient was promptly evaluated for possible CVA, and
after returning from CTA of the head and neck, acutely become
dyspneic with RR to the 30's, complained of feeling SOB, and was
noted to be hypoxic to 93% on RA (from 98% on RA). This
occurred while the patient moved from a sitting to a standing
position. She denied any CP, N/V, diarphoresis, jaw pain, arm
pain, lightheadedness or dizziness during the episode. Repeat
CXR showed interval development of worsening bibasilar
interstitial edema pattern concerning for flash pulmonary edema.
Earlier this morning, the patient complained of feeling
generalied fatigue, and an overall decrease in energey level,
which was new since the day prior. Given her symptoms, she
measured her BP at home which was 105/50. Apparently, the
patient frequently develops fatigue and has a history of labile
BP's at home - often low in the AM, and higher in the evening.
Given her low BP, the patient did not take her antihypertensive
medication this morning (atenolol). At that time she denied any
CP, palpitations, SOB, N/V, and drank some herbal tea which made
her feel better. Later that evening, the patient's granddauther
was visiting and thought she noticed her grandmother having
slurred speech with trouble enunciating her words, as well L
sided facial paralysis. The patient said she did not notice any
trouble with her speech, and thought nothing was abnormal,
except for a slight "funny" sensation throughout her face. In
the ED, the pt was noted to possibly have a L sided pronator
drift on exam, and given her symptoms, was evaluated by
neurology for a possible acute CVA. Preliminary report of the
non-contrast head CT shows no acute CVA, and a 50% stenosis of
the right carotid bifurcation.
ROS: No fevers/chills/night sweats, nausea/vomiting, no cough,
sputum production, abdominal pain, change in urine appearance,
dysuria, hematuria, diarrhea, melena, or hematochezia, +
occasional calf cramps, + mild left upper extremity weakness
since CABG in '[**06**]
Past Medical History:
1. CAD: CAD s/p CABG (LIMA to LAD, SVG to OM) s/p PCI ([**2-20**])
2. Peripheral vascular disease: s/p right popliteal angioplasty
3. HTN
4. Hypercholesterolemia
5. Hypothyroidism
6. Collagenous colitis
7. Macular degneration
8. s/p bilateral cataract surgery
9. Glaucoma
Social History:
Social History: Spouse of >50yrs died earlier this year.
Has one daughter that lives in [**Name (NI) 86**], another daughter lives in
[**Location (un) 7349**]. Denies any current or previous history of tobacco use.
Denies EtoH or illicit drug use. She is originally from [**Country 532**].
Family History:
Family history: Non-contributory
Physical Exam:
Physical Exam:
Vitals: T: 97.9 BP: 218/63 P: 70 RR: 20 O2Sat: 98% RA --> 93% RA
Gen: Comfortable appearing elderly woman in NAD
HEENT: PERRL, EOMI, anicteric sclerae, conjunctivae pink
NECK: supple, no LAD, no masses
CV: Regular, nl s1, nl s2, no extra heart sounds. II/VI systolic
murmur. No JVD appreciated. No thrills, or heaves. No audible
carotid bruits
LUNGS: good respiratory effort. bibasilar wet crackles R >> L
ABD: soft, non-tender, non-distended, +BS
EXT: warm, no lower extremity edema.
SKIN: no rashes, no lesions
NEURO: AAO x 3, CN II - XII intact with midline tongue, no
obvious facial droop. 5/5 strength of all extremeties, but 4+/5
of LUE. No finger to nose dysmetria.
Pertinent Results:
[**2109-8-7**] 08:34PM WBC-7.2 RBC-3.94* HGB-12.2 HCT-37.0 MCV-94
MCH-31.1 MCHC-33.1 RDW-13.8
[**2109-8-7**] 08:34PM PT-12.0 PTT-28.1 INR(PT)-1.0
[**2109-8-7**] 08:34PM NEUTS-52.0 LYMPHS-40.2 MONOS-4.5 EOS-2.8
BASOS-0.6
[**2109-8-7**] 08:34PM PT-12.0 PTT-28.1 INR(PT)-1.0
[**2109-8-7**] 08:34PM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-8-7**] 08:34PM GLUCOSE-108* UREA N-27* CREAT-1.0 SODIUM-138
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15
[**2109-8-7**] 08:34PM CALCIUM-9.0 PHOSPHATE-5.1*# MAGNESIUM-2.6
[**2109-8-7**] 08:34PM CK-MB-6
[**2109-8-7**] 08:34PM cTropnT-<0.01
[**2109-8-7**] 08:34PM ALT(SGPT)-19 AST(SGOT)-24 CK(CPK)-142* ALK
PHOS-104 TOT BILI-0.1
[**2109-8-7**] 08:34PM LIPASE-90*
[**2109-8-7**] 09:40PM CK(CPK)-132
[**2109-8-7**] 09:40PM cTropnT-<0.01
[**2109-8-7**] 09:40PM CK-MB-5
[**2109-8-7**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
Brief Hospital Course:
In the ED, the patient's initial vitals were, T 97.9 , HR 70 ,
BP 218/63 . RR 20 , O2: 98% RA. After developing acute SOB, the
patient's RR increased to 36, and her O2 sat dropped to 93% RA.
Given her CXR findings, the patient was given a dose of IV Lasix
and started on a Nitroglycerin gtt following her dyspnea and CP.
The first set of cardiac enzymes were flat. A trial of Bi-pap
was initiated, but was not tolerated well by the patient. The
patient was then placed on a non re-breather mask with
improvement in her symptoms as well as her oxygenation.
On admission to the MICU, the patient is comfortable, she is
no longer complaining of dyspnea or chest pain. Nitro gtt was
d/c'ed in the ER prior to transfer to the MICU given BPs of
111/52. Goal SBP of 140 given possible CVA. The patient
diuresed approx 1 Liter since recieving the IV Lasix. Vitals on
arrival were: T-96, BP 116/79, HR 69, RR 21, O2: 95% RA
Acute pulmonary edema
Etiology likely related to hypertension and labile blood
pressures, especially given systolic BP's in 110's in ED. Given
the timing of acute dyspnea after CTA of head and neck, contrast
reaction a possibility, but unlikely given resolution of
symptoms shortly after control of BP and diuresis w/Lasix. BNP
was elevated to 1700 suggesting that pt. had some acute
decompensated heart failure, likely due to her labile blood
pressure. Her blood pressure stabilized around SBP 120's and pt.
was transferred to the floor where she remained stable.
.
Hypertensive urgency
Likely contributed to development of acute pulmonary edema, and
possibly even neurologic symptoms upon presentation to ED as
well. Given labile blood pressures and history of PVD and CAD,
renal artery stenosis was considered but renal u/s was negative.
Pt briefly on nitro gtt for BP control. Her lisinopril was d/c'd
because of concern for renal artery stenosis and her blood
pressures in the 110s on the floor.
.
Stroke
Slurred speech and facial paralysis noted by family. Pt seen and
evaluated by neurology in ED, s/p CTA of head and neck. Symptoms
seem to have resolved since initial presentation. But Pt. still
has slight L facial droop more than 24 hours later. L sided mild
hand weakness was not appreciated on reexamination on [**8-9**]. CTA
head and neck showed 50% stenosis of R carotid artery, but no
acute defect. Neurology wanted a f/u MRI but Pt. left AMA before
this could occur. Pt. was advised that she could still be at
increased risk and that she could die or have a recurrent stroke
if she left, but stated that her husband had just died at [**Hospital1 18**]
and it was extremely distressing for her to be here.
.
CAD
Currently pt denies any symptoms of chest pain, chest pressure
or discomfort. Given recent acute pulmonary edema, pt ruled out
w/ 3 sets of enzymes not trending up. No change in EKG.
DM II Remained Diet controlled, BG well controlled during
admission.
.
Hypothyroidism: Continued home synthroid dose, TSH 1.3
Glaucoma : continued Xalatan and Trusopt eye drops, pt. had no
eye complaints.
Medications on Admission:
1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 25 mg Tablet Sig: [**1-16**] Tablet PO once a day.
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 25 mg Tablet Sig: [**1-16**] Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Against Medical Advice
Primary
Stroke
Flash pulmonary edema
Congestive heart failure
Secondary
# DM II
# Peripheral vascular disease: s/p right popliteal angioplasty
# Glaucoma
# Macular degneration
# Hypothyroidism
# Hx of AFib after CABG
Discharge Condition:
Stable. Against Medical Advice
Discharge Instructions:
You have been diagnosed with stroke, you need to have a follow
up MRI. You are leaving AGAINST MEDICAL ADVICE. We have
continued your atenolol and stopped your lisinopril, you need to
see you doctor to see if he wants to change your blood pressure
medications.
Please take your medications exactly as prescribed.
Please call your doctor or return to the emergency department
immediately if you have any slurred speech, blurry vision,
numbness or tingling, confusion, chest pain, shortness of breath
or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2148**] [**Telephone/Fax (1) 457**]
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-9-30**] 1:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-9-30**] 2:00
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2109-11-4**] 4:15
Completed by:[**2109-8-9**]
|
[
"428.0",
"401.9",
"244.9",
"300.00",
"V45.81",
"427.31",
"781.94",
"272.0",
"365.9",
"V45.82",
"443.9",
"428.31",
"250.00",
"414.00",
"434.91",
"362.50",
"784.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9378, 9384
|
5125, 8172
|
290, 297
|
9669, 9702
|
4076, 5101
|
10285, 10762
|
3332, 3350
|
8788, 9355
|
9405, 9648
|
8198, 8765
|
9726, 10262
|
3380, 4057
|
221, 252
|
325, 2695
|
2717, 2991
|
3023, 3300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,908
| 172,851
|
43764
|
Discharge summary
|
report
|
Admission Date: [**2186-6-28**] Discharge Date: [**2186-7-4**]
Date of Birth: [**2108-4-22**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Acute blood loss, GI bleed in setting of known GI stromal tumor,
transfer from [**Hospital1 **] after scope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 78yo males w/known non-resectable GI stromal tumor on
Gleevex (dx [**2181**])PMHx significant for prostate cancer w/seed
implant, duodenal ulcer who presented w/weakness, fatigue, SOB
and was found to have HCT of 16. Pt noted symptoms of weakness,
fatigue and SOB on minimal exertion roughly 3-4 days prior to
admission. Denied chest pain or palpiation, no orthopnea, no
diarrhea or constipation, blood in stool or black stool. Did
notice some stool color change several days back after meal high
in iron which he and his wife assumed was related to food they
had eaten. Pt presented to Dr. [**First Name (STitle) 4223**] from Oncology for
regular follow-up and potential change of onco medication and
was found to have HCT of 16. Pt was sent to the [**Hospital1 **] ED
where VS were BP 133/55 71 95% HCT 16, Hgb 5.3 and he was
admitted for GIB. At this time he had maroon color blood stool;
guaiac positive on rectal exam. Of note, CT [**2095-6-10**]* 18 cm
mass, progressed from prior images and pushing on duodenum and
pressing into pancreatic head also w/compression of IVC. Repeat
CT scan yesterday ([**2186-6-27**]) showed minimal necrosis in tumor and
no signs of frank bleeding in abdomen. Pt had EGD on [**2186-6-28**]
prior to transfer to [**Hospital1 18**]; this showed submucosal mass,
invading the wall of the duodenum w/bright blood in duodenum but
no peptic ulcer seen. He was transfused 5 units of pRBC and HCT
improved to 25.3. Last VS prior to transfer 116/64 79 95%
afebrile.
.
On transfer to floor, initial vs were: T 98.6 P 72 BP 124/52 R
13 O2 96% RA. Patient was feeling well, chatting and good
humored. No complaints. No pain no palpitation no abdominal
pain, no chest pain, no fever chills.
.
Review of sytems:
(+) Per HPI, sometimes breaks out in a sweat
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Stromal Retroperitoneal tumor nonresectable on Glevac diagnosed
in [**2181**]
Mild aortic stenosis
CA Prostate w/seed implanting
Asbestosis
PET neg pulmonary nodule
Cholelithiasis
Cirrhosis
Social History:
Live w/wife and is independent for all ADLs. Worked in shipyards
in [**Location (un) 86**] and a boiler maker; has asbestosis. Quit smoking 4-5yr
ago but started at ~18yo 1ppd. Occasional EtOH
Family History:
Father - prostate cancer, died of hemorrhage at 88yo.
Mother - died early age after a fall
Brother - prostate cancer
Physical Exam:
On admission:
Vitals: T 98.6 P 72 BP 124/52 R 13 O2 96% 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,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
best appreciated at sternal border (known AS), no rubs or
gallops
Abdomen: soft, non-tender, moderately protuberant abdomen, mass
appreciated on the R side, bowel sounds present, no rebound
tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
Unchanged- Lungs clear. Cardiac murmur present. Abd mass still
present but no tenderness.
Pertinent Results:
[**2186-6-28**] 09:22PM LACTATE-0.9
[**2186-6-28**] 09:11PM GLUCOSE-87 UREA N-23* CREAT-1.3* SODIUM-139
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2186-6-28**] 09:11PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2186-6-28**] 09:11PM WBC-7.1 RBC-2.98* HGB-9.0* HCT-25.9* MCV-87
MCH-30.2 MCHC-34.8 RDW-18.1*
[**2186-6-28**] 09:11PM PLT COUNT-250
[**2186-6-28**] 03:13PM GLUCOSE-678* UREA N-22* CREAT-1.2 SODIUM-131*
POTASSIUM-6.4* CHLORIDE-102 TOTAL CO2-24 ANION GAP-11
[**2186-6-28**] 03:13PM estGFR-Using this
[**2186-6-28**] 03:13PM ALT(SGPT)-4 AST(SGOT)-19 LD(LDH)-229 ALK
PHOS-53 TOT BILI-0.7
[**2186-6-28**] 03:13PM CALCIUM-7.4* PHOSPHATE-3.3 MAGNESIUM-1.7
[**2186-6-28**] 03:13PM WBC-6.7 RBC-2.77* HGB-7.9* HCT-24.6* MCV-89
MCH-28.4 MCHC-32.0 RDW-18.0*
[**2186-6-28**] 03:13PM PLT COUNT-229
[**2186-6-28**] 03:13PM PT-14.0* PTT-32.9 INR(PT)-1.2*
.
Images:
CT Abd and Pelvis [**2186-6-10**] [**Hospital3 **]
1. Interim enlargement in the 20x18x18 right retroperitoneal
mass. Greater compression of right kidney, right renal pedicle,
ureter, IVC, and greater displacement of the duodenum and
pancreas as described above. Mild right pelvicalyceal dilation.
No definite invasion of the neighboring structures, which
include liver, gallbladder, IVC. No definite IVC thrombosis,
although extrinsic compression is moderate.
2. Lesion shows central nonenhancement suggesting central
necrosis. Again displacing small bowel aneriorly in the right
lower quadrant. Compressing right gonadal vein, possibly cuasing
right varicocele.
3. Aortoiliac ASVD. Uncomplicated gallstone. Calcified pleural
plaques.
4. Small indeterminate sub cm left paraaortic lymph nodes.
5. Sclerotic appearance of the pubic bones, with small extra
osseous soft tissue structure seen adjacent, which are stable
since last year's exam. Possibly representing metastases and
extra osseaous extension, or anterior pelvic wall lymph node
w/out
.
CT ABD and Pelvis [**2186-6-27**] [**Hospital3 **]
1. Large reight retroperitoneal tumor known from prio exams not
significant changed in size. The high density material
surrounding a low density necrotic center consistent with
hypervascularity and/or samll bleed. However, the amount of
high-density material does not account for a significant drop in
HCT.
2. No other acute interval [**Last Name (un) 38815**] from the prior imagaing
studies.
.
GI scope at [**Hospital1 **] [**2186-6-28**]
showed submucosal mass, invading the wall of the duodenum
w/bright blood in duodenum but no peptic ulcer seen
[**2186-7-4**] 06:32AM BLOOD WBC-4.5 RBC-2.97* Hgb-8.8* Hct-26.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-16.9* Plt Ct-249
[**2186-7-3**] 06:50AM BLOOD WBC-5.1 RBC-3.02* Hgb-8.7* Hct-27.0*
MCV-89 MCH-28.7 MCHC-32.1 RDW-17.0* Plt Ct-244
[**2186-7-2**] 06:45AM BLOOD WBC-5.2 RBC-3.00* Hgb-8.8* Hct-26.7*
MCV-89 MCH-29.5 MCHC-33.0 RDW-17.2* Plt Ct-272
[**2186-7-1**] 07:00AM BLOOD WBC-5.4 RBC-2.95* Hgb-8.7* Hct-26.2*
MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-251
[**2186-6-30**] 12:45PM BLOOD Hct-27.8*
Brief Hospital Course:
Pt is a 78yo male w/known non-resectable GI stromal tumor on
Gleevex (dx [**2181**])PMHx significant for prostate cancer w/seed
implant, duodenal ulcer who presented w/weakness, fatigue, SOB
and was found to have HCT of 16 in [**Hospital **] clinic and ED. Found to
have GI bleeding in setting of GIST and transferred from [**Hospital 3856**] after scope for further management given concern for
progression of cancer and continued GI bleeding with tumor
invasion.
.
# GI bleeding in setting of known GIST: Pt was found to have HCT
drop in onc clinic and ED. Found to have GI bleeding and repeat
CT showed progression of known GIST. Pt was scoped at [**Hospital1 **]
which showed invading mass with bleeding. VS on transfer were
stable. Transferred to [**Hospital1 18**] for further managament of GI
stromal tumor and associated GI bleeding. At [**Hospital1 18**], the
patient's Hct remained stabhle. GI, interventional radiology,
and surgery were consulted. Surgery recommended against
prophylactic embolization. The patient was treated with IV
pantoprazole which was later transitioned to PO. Imatinib was
increased to 400 mg [**Hospital1 **]. His diet was restarted and his HCT
remained stable during his 7 days in hospital. He was discharged
to have follow up with his oncologist on Friday of the week of
discharge.
.
# Aortic Stenosis, hypertension: Known moderate aortic stenosis,
audible on auscultation. The patient was continued on
simvastatin, niaspan held in-house as not urgent and
non-formulary. His Amlodipine, hydrochlorothiazide and terazosin
were held in setting of recent GI bleed. His BPs remained stable
throughout hospital course. He will have follow up with his PCP
at which time his BP should be rechecked and medications
titrated accordingly.
.
# Prostate cancer, BPH: Patient has history of prostate cancer
with implanted seeds. Terazosin was held and didn't seem to be
needed so should be restarted as outpt at discretion of PCP.
Medications on Admission:
(pt confirmed as best could but couldn't precisely remember all
the names, list is from [**Hospital3 1280**] records)
Leuprolide (Lupron) 1 inj IM q 3 mo
Imatinib (Gleevec) 400mg daily
Terazosin 2mg PO HS
Hydrochlorothiazide 25mg PO daily
Amlodipine 2.5mg daily
Niaspan ER 1000mg PO daily
Simvastatin 20mg PO qpm
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. imatinib 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): Please take this medication 2 hours
after the rest of your morning pills.
Disp:*30 Tablet(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Lupron Depot (3 Month) 11.25 mg Kit Sig: One (1) injection
Intramuscular every 3 months.
7. Niaspan Extended-Release 1,000 mg Tablet Extended Release 24
hr Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
GIST tumor causing GI bleed
Secondary diagnoses:
Blood loss anemia
Hypertension
BPH
Aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after your hematocrit dropped after you had a
bleed from a tumor in your GI tract at an outside hospital.
While you were here, we closely monitored your blood counts and
they were stable throughout your time here. You were seen by
interventional radiologists, surgeons and oncologists here who
monitored you but did not do any procedures as your bleeding had
stopped by the time you got here. You are being discharged with
follow up this week with your oncologist.
The following changes were made to your medications:
INCREASE imatinib to twice daily
START ferrous sulfate (iron) daily- our pharmacists do not see
an interaction of this with your imatinib but to be safe you can
take this 2 hrs after your morning medications.
START docusate (a stool softener) while you are on iron as iron
can make you constipated. You can stop this medications if you
are having loose stools or diarrhea.
STOP Terazosin for your prostate and high blood pressure as it
was not needed while you were here.
STOP Amlodipine and Hydrochlorothiazide for high blood pressure
as they were not needed while you were here. You can talk to
your primary care doctor about possibly restarting these at your
follow up appointment.
START pantoprazole- it decreases the acid in your stomach and
may help decrease your risk of bleeding again. Talk to your
primary doctor when you follow up about whether you need to keep
taking this medication indefinately.
Followup Instructions:
Please follow up with your primary oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**]
at 1pm on Friday [**7-7**].
Please call your primary care doctor, Dr. [**Last Name (STitle) 94034**] to schedule an
appointment within 2 weeks.
Completed by:[**2186-7-4**]
|
[
"578.9",
"171.5",
"185",
"197.4",
"V15.82",
"285.1",
"496",
"459.2",
"424.0",
"272.0",
"593.3",
"401.9",
"591",
"501"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10119, 10125
|
6935, 8895
|
380, 387
|
10288, 10288
|
3870, 6912
|
11910, 12206
|
2998, 3117
|
9259, 10096
|
10146, 10146
|
8921, 9236
|
10439, 11887
|
3132, 3132
|
10214, 10267
|
3760, 3851
|
232, 342
|
2159, 2558
|
415, 2141
|
10165, 10193
|
3146, 3746
|
10303, 10415
|
2580, 2772
|
2788, 2982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,216
| 188,044
|
9756
|
Discharge summary
|
report
|
Admission Date: [**2134-5-21**] Discharge Date: [**2134-6-4**]
Date of Birth: [**2066-10-28**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: This is a 67-year-old male
status post coronary artery bypass graft times four in [**2134-4-16**], who is also recently status post kidney transplant in
[**2133-12-17**], who presented with purulent drainage from
his midsternal incision. The patient had been admitted on
[**2134-4-2**], for increasing drainage from the sternal wound,
and on [**2134-4-6**], had undergone sternal rewiring. He had
been treated with intravenous and ciprofloxacin and
discharged to complete the course of intravenous antibiotics.
He had remained stable and afebrile postoperatively with a
stable sternum. However, he was seen by his physician on
[**2134-5-17**], who noticed blistering at the inferior aspect
of his wound and started him on Neosporin ointment and
dressing changes t.i.d. The patient noticed increasing
drainage on [**5-18**] which was purulent then changed to
blood-streaked. He had remained afebrile throughout the
entire period. He had also noticed a postoperative cough.
PAST MEDICAL HISTORY:
1. Status post living-related kidney transplant on
[**2134-1-13**].
2. Insulin-dependent diabetes mellitus.
3. Osteoarthritis of the neck.
4. Coronary artery disease, status post coronary artery
bypass graft times four in [**2134-3-16**].
5. Status post non-Q-wave myocardial infarction in [**2134-3-16**].
6. Episodic aortic regurgitation in [**2134-3-16**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Rapamune 6 mg p.o. q.d.,
prednisone 6 mg p.o. q.d., CellCept 1 g p.o. b.i.d.,
Bactrim 1 p.o. q.d., Colace 100 mg p.o. q.d.,
Calcitrel 0.25 mg p.o. q.d., Tums 500 mg p.o. b.i.d.,
Neutra-Phos 1 packet p.o. t.i.d. with meals, vitamin E 1 p.o.
q.d., multivitamin 1 p.o. q.d., Protonix 40 mg p.o. q.d.,
Lasix 60 mg p.o. b.i.d., Aldactone 25 mg p.o. b.i.d.,
Lipitor 25 mg p.o. q.d., Lopressor 100 mg p.o. b.i.d., NPH
insulin 4 units q.p.m. and 8 units q.a.m., aspirin 81 mg p.o.
q.d., Epogen 3000 units p.o. every Monday and Friday.
PHYSICAL EXAMINATION ON ADMISSION: The patient's vital signs
were temperature of 98.1, heart rate 95, blood pressure
147/66, respiratory rate 18, satting 95% on room air. The
patient's appearance revealed a well-appearing male, alert
and oriented times four, in no apparent distress. Neurologic
examination was grossly intact. Cardiovascular revealed a
regular rate and rhythm, sinus. No murmurs. His lungs were
clear to auscultation bilaterally. Abdomen was soft,
nontender, and nondistended, with positive bowel sounds.
Extremities had 2+ pitting edema bilaterally, warm, with 1+
pulses. Saphenous vein graft site was healing well. No
drainage, erythema or induration. His sternum was stable
with wound mostly healed except for purulent to bloody
discharge from the base with a sinus tract superiorly and an
area of erythema of about 2 cm X 2 cm.
LABORATORY ON ADMISSION: White blood cell count 12,
hemoglobin 9.2, hematocrit 31.2, platelets 235. Sodium 136,
potassium 4.3, chloride 96, bicarbonate 23, BUN 32,
creatinine 1.8, glucose 216. AST 19, albumin 3.4.
HOSPITAL COURSE: The patient was admitted with a diagnosis
of recurrent sternal wound infection with possible sternal
osteomyelitis. He was started on intravenous vancomycin and
ceftriaxone. Renal and Infectious Disease consultations were
obtained at that time.
He was taken to the operating room on [**2134-5-24**], where he
underwent sternal debridement. The wound was left open, and
on [**2134-5-27**], the patient underwent partial sternotomy,
debridement of skin subcutaneous tissue and bone, removal of
hardware from sternum, omental flap to sternum, and bilateral
musculocutaneous advancement flap, and closure of his open
sternal wound under general anesthesia. He tolerated the
procedure well and was then sent to the Intensive Care Unit
in stable condition.
His initial cultures grew out coagulase-negative
Staphylococcus as did cultures from his operating room
specimen. The patient had a temperature spike
postoperatively to 101. However, subsequent blood and urine
cultures were negative. He was continued on vancomycin and
ceftriaxone postoperatively.
The patient remained intubated after his initial debridement
and was eventually extubated on [**5-29**]. He tolerated
extubation well. He was transferred to the regular floor on
postoperative day seven and four and had an unremarkable
postoperative recovery. He remained afebrile, tolerating a
regular diet, and ambulating independently.
He continued to be followed by the Renal Transplant Service.
He was restarted on his CellCept.
From an infectious standpoint, the patient continued to be
afebrile. His ceftriaxone was stopped on day 10 due to low
suspicion for sternal osteomyelitis. He was continued on the
intravenous vancomycin which he was to continue on for two
weeks postoperatively. Due to the fact that the patient is a
renal transplant recipient he will be dosed by vancomycin and
levels checked randomly every two to three days. The patient
also had bilateral [**Location (un) 1661**]-[**Location (un) 1662**] drains which had been
draining serosanguineous fluid. He was on levofloxacin which
he was to continue on until the drains are removed.
Postoperatively, the patient also had some swallowing
difficulties and was placed on nectar-thick liquids for two
days; however, he recovered normal function and was able to
take a normal diet.
CONDITION AT DISCHARGE: The patient was stable for
discharge, afebrile, tolerating a regular diet, and
ambulating independently.
DISCHARGE STATUS: Discharged to rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Sternal wound infection, status post sternal debridement.
2. Status post partial sternotomy with omental flap.
3. Status post living-related donor kidney transplant.
4. Coronary artery disease, status post coronary artery
bypass graft.
5. Insulin-dependent diabetes mellitus.
MEDICATIONS ON DISCHARGE:
1. Calcitrel 0.2 mg p.o. q.d.
2. Neutra-Phos 1 packet p.o. q.d.
3. Tums 500 mg p.o. b.i.d.
4. Prednisone 10 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
7. Bactrim-SS 1 p.o. q.d.
8. Heparin 5000 units subcutaneous b.i.d.
9. Lopressor 75 mg p.o. b.i.d.
10. Levofloxacin 250 mg p.o. q.d. times 11 days.
11. Regular insulin sliding-scale.
12. Multivitamin 1 p.o. q.d.
13. Aspirin 81 mg p.o. q.d.
14. Lipitor 10 mg p.o. q.d.
15. Vitamin E 400 units q.d.
16. CellCept [**Pager number **] mg p.o. b.i.d. times four days, then
CellCept 1 g b.i.d.
17. Vancomycin 1 g.
18. NPH 8 units subcutaneous q.a.m., and 4 units
subcutaneous q.p.m.
19. Reglan 10 mg p.o. q.6h.
20. Lasix 20 mg p.o. q.d.
21. Rapamune 8 mg p.o. q.d.
22. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. p.r.n. (for calcium less than 4).
23. Robitussin 10 cc p.o. q.6h. p.r.n. for cough.
24. Percocet 5/325 one to two tablets p.o. q.4h. p.r.n. for
pain.
DISCHARGE INSTRUCTIONS: The patient was to have random
vancomycin levels checked and dosed if less than 20 by 1 g
for a total of two weeks after discharge. Wound care and
[**Location (un) 1661**]-[**Location (un) 1662**] care. The patient was to have Rapamune level
checked on [**2134-6-6**], in the morning before dosed.
DISCHARGE FOLLOWUP: Follow up is the Dr. [**Last Name (STitle) 1537**] in
Cardiothoracic Surgery in one month or p.r.n. Follow up
with Dr. [**Last Name (STitle) 13797**] from Plastic Surgery on [**2134-6-11**].
Followup with Dr. [**Last Name (STitle) **] from Renal Transplant on
[**2134-6-11**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2134-6-4**] 08:50
T: [**2134-6-4**] 09:16
JOB#: [**Job Number 32899**]
|
[
"250.01",
"V45.81",
"998.59",
"V42.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.81",
"78.61",
"77.61",
"86.72"
] |
icd9pcs
|
[
[
[]
]
] |
5789, 6074
|
6101, 7109
|
1626, 2177
|
3253, 5587
|
7134, 7435
|
5602, 5768
|
7456, 8015
|
176, 1156
|
3042, 3234
|
1178, 1599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,078
| 169,838
|
21241
|
Discharge summary
|
report
|
Admission Date: [**2175-6-17**] Discharge Date: [**2175-7-4**]
Date of Birth: [**2128-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Dialysis catheter change
History of Present Illness:
Mr. [**Known lastname **] is a 47yo M w/ a PMH of hep C cirrhosis, schizotypal
personality disorder and polysubstance abuse, presents with
altered mental status and LUE ecchymosis. The patient recently
eloped from the hospital on [**2175-5-24**], with his PICC line in place,
after a month long hospital stay notable for renal failure, HD
initiation, hepatic encephalopathy, scrotal cellulitis, strep
viridans bacteremia, LLE cellulitis, and GIB (esophageal varices
s/p banding). The patient has since presented to the ED on [**5-25**]
and had his PICC line removed by request. Since then, he had
been receiving outpatient HD, but not adhereing to his regular
TThSa schedule. His last full HD was last Friday.
.
Today, he went to HD, was noted to have altered mental status,
worse after HD and called EMS. IN ED, VSS, but responsive only
to pain. He was intubated for airway protection. He also
received Vanc.
Past Medical History:
1. Cirrhosis
- hep C + EtOH abuse
- c/b esophageal varices s/p banding in [**12-26**]
- EGD [**2175-4-28**]: 4 cords of grade II varices, nonbleeding GE jctn
ulcer
- has not been treated for hepatitis C
- has nodular lesions on US -> no MRI to eval for HCC, AFP 4.3
- h/o SBP in [**9-21**], ? SBP during last hospitalization (empiric)
2. h/o major depression
3. h/o alcohol abuse
4. schizotypal personality disorder
Social History:
Lives with wife, smokes occasionally, currently not working;
prior history of heavy alcohol use but currently abstinent.
Prior IV drug use in early 80's (last use in [**4-21**]); attending NA
in [**Location 4288**]
Family History:
Maternal aunt with DM
Physical Exam:
VS 97.8 90/43 hr 55 rr 12 100% on AC 35% vt 872 peep 5
gen intubated sedated gcs 3
heent op clear, mmm, perrl
neck supple, no carotid bruits, elevated jvp to ear
cv nl s1s2
pulm clear laterally
gi +bs abd soft, distended
ext 3+ le edema, dependent edema
skin warm
neuro response to noxious stimuli
Pertinent Results:
[**2175-6-17**] 05:45PM WBC-19.1*# RBC-2.80* HGB-10.4* HCT-31.3*
MCV-112* MCH-37.2* MCHC-33.3 RDW-20.3*
[**2175-6-17**] 05:45PM NEUTS-86.7* LYMPHS-6.1* MONOS-4.6 EOS-2.2
BASOS-0.3
[**2175-6-17**] 05:45PM PLT COUNT-87*
[**2175-6-17**] 05:45PM PT-20.3* PTT-150* INR(PT)-1.9*
[**2175-6-17**] 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-6-17**] 05:45PM GLUCOSE-116* UREA N-35* CREAT-3.7*#
SODIUM-141 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
[**2175-6-17**] 05:45PM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-4.6*#
MAGNESIUM-2.2
[**2175-6-17**] 05:45PM ALT(SGPT)-39 AST(SGOT)-70* CK(CPK)-74 ALK
PHOS-116 AMYLASE-73 TOT BILI-5.7*
[**2175-6-17**] 05:45PM LIPASE-111*
ECHO
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta 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
pericardial effusion.
No vegetation seen (cannot definitively exclude).
CT abd
Evaluation of abdominal and pelvic organs limited secondary to
lack of intravenous contrast.
1. Extensive abdominal and pelvic ascites, anasarca in the
setting of
significant liver disease.
2. No retroperitoneal bleed identified.
3. 2 mm right lower lobe pulmonary nodule.
CT head
Normal CT head
US abd
1. Large ascites. Spot in right lower quadrant marked. Spot
was discussed
with Dr. [**First Name8 (NamePattern2) 2453**] [**Name (STitle) **].
2. Cirrhotic, diffusely nodular/heterogeneous liver.
3. Patent main portal vein with hepatopetal flow.
4. Diffuse gallbladder wall thickening, likely secondary to
liver disease.
Brief Hospital Course:
A/P: 47yo M w/ a PMH of hep C cirrhosis, schizotypal personality
disorder and polysubstance abuse, p/w altered mental status
.
# Resp Failure: Intubated in ED for airway protection given
somnolence. Extubated the following day. No further trouble
breathing, O2 satts maintened.
.
# Altered mental status: Etiology most likely hepatic/uremic
encephalopathy +/- infection. was suspected to have SBP. was
treated empirically with cipro. also found to have coag neg
staph bacteremia which was treated with vanc. had dialysis cath
changed . we wanted to treat with vanc for 2 weeks after the
cath change. continued on lactulose and rifaxamin.
.
#Bacteremia: as mentioned above found to have coag neg staph
bacteremia which was tretaed with IV vanc. pt also had the HD
cath chnaged. we decided to treat with vanc for 2 weeks post
cath change.
.
#Psych issues: as mentioned above the pt had altered mental
status. also pt has past h/o leaving hospital AMA. the pt tried
to do the same this time. a code purple was called. psych was
called to see the pt. they thought that pt did not understand
the seriousness of the underlying medical conditions and the
consequences of refusing the treatment. hence they recommended
that he should not be allowed to leave AMA. pt was also refusing
HD and medications. we had a family meeting with the pt's wife,
SW, psych. then the med attg, SW and pt's wife talked with the
pt and he agreed to comply with the treatment. pt was treated
with haldol IV 1 mg prn for agitation.
.
# ESRD: pt on HD. regular schedule was TThSat. was followed by
renal here. pt also had the HD catheter changed by IR.
.
# ANEMIA: Hct stable. continued on epogen at HD
.
# FEN: Regular, renal diet. No IVF. Check lytes daily, replete
prn.
.
# ACCESS: Tunneled RIJ line.
.
# PPx: Pneumoboots, PPI, bowel regimen (lactulose) prn.
.
# CODE: presumed FULL
.
# DISPO: per hepatology in AM
Medications on Admission:
nadolol 20mg PO QD
rifaximin 400mg PO TID
sevelamer 800mg PO TID
lactulose 30mL PO TID
oxycodone 2.5mg PO Q8 prn
albuterol puffs INH Q6 prn
omeprazole 40mg PO BID
sucralfate 1gm PO QID
miconazole powder TP [**Hospital1 **] prn
pantoprazole 40mg PO QD
cipro 750mg PO qweek
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 tabs* Refills:*2*
6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED).
Disp:*30 doses* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*2*
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) dose
Intravenous HD PROTOCOL (HD Protochol) for 9 days.
Disp:*9 dose* Refills:*0*
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
Disp:*100 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Cirrhosis
ESRD
Bacteremia
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed
.
If you have chest pain, shortness of breath, dizziness,
palpitations, nausea, vomitting, diarrhea, pain in abdomen
please call your prmary care doctor or go to the emergency room
.
Please do not drive till you are seen by your primary care
doctor
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2175-7-20**] 9:15
Please call [**Telephone/Fax (1) 56224**] to schedule an appointment with
neuropsychological testing
Completed by:[**2175-7-8**]
|
[
"572.2",
"567.23",
"608.4",
"305.60",
"286.9",
"070.71",
"790.7",
"041.19",
"789.5",
"301.20",
"311",
"584.9",
"287.5",
"V15.81",
"571.5",
"V45.1",
"518.81",
"585.6",
"782.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"99.04",
"39.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7762, 7806
|
4414, 4705
|
336, 363
|
7876, 7885
|
2348, 4391
|
8224, 8494
|
1991, 2014
|
6630, 7739
|
7827, 7855
|
6333, 6607
|
7909, 8201
|
2029, 2329
|
275, 298
|
391, 1303
|
4720, 6307
|
1325, 1743
|
1759, 1975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,163
| 163,812
|
38391
|
Discharge summary
|
report
|
Admission Date: [**2187-8-26**] Discharge Date: [**2187-8-29**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
abdominal pain, hematemesis
Major Surgical or Invasive Procedure:
Hemodialysis on regular MWF schedule
History of Present Illness:
36 year old man with a history of DM I with ESRD on HD (M,W,F)
and recurrent gastroparesis who presents with hematemisis and
abd pain x 7 hours. He describes the pain as severe, constant,
and epigastric. Pain does not radiate to back. The pain is
associated with nausea and vomiting, consistent with prior
episodes of gastroparesis. The vomit started out clear this
morning, but became dark in color as the day went on. The
patient denies known trigger for symptoms. No recent fevers,
chills, chest pain, shortness of breath, diarrhea, pain with
urination or polyuria. No blurry vision. No heart burn, rising
sensation in his chest, or globus sensation. He has been taking
all of his medications regularly. The patient took his lantus
this morning, but did not use his sliding scale during the day
secondary to nausea. He presented to the ED for multiple
episodes of hematemesis.
.
In the ED, initial VS: 96.0 123 216/126 97% RA. The patient
was given ativan, zofran, and morphine for pain and nausea. CXR
did not show evidence of pneumomediastinum or acute process.
There was concern for multifocal pneumonia, and the patient
received a dose of vancomycin and zosyn. Laboratory testing
revealed a glucose of 314 with an anion gap metabolic acidosis
of 26. He was started on an insulin drip of 5 units/hour. For
his blood pressure, the patient received 5mg IV labetalol. BP
prior to transfer 166/103.
.
On arrival to the MICU, the patient continues to complain of
mild nausea. He otherwise feels well. No chest pain, blurry
vision, diarrhea, melena, hematochezia.
Past Medical History:
- Type I diabetes: since age 19, complicated by gastroparesis,
retinopathy (laser treatment), DKA, chronic kidney disease
- ESRD, on HD MWF, started [**9-4**]; currently on transplant list
- s/p left brachiocephalic AV fistula created on [**2186-7-18**]
s/p angioplasty of the arterial anastomosis, mid cephalic
and cephalic arch, complicated by an extravasation and
mid-fistula hematoma (still usable)
- [**Doctor Last Name 9376**] syndrome
- Hypertension
- Asthma
- HLD
- chronic multifactorial anemia, on Epo, h/o pRBC transfusion x2
in [**2186-7-24**] related to renal failure
Social History:
Lives with his parents. Denies tobacco use, alcohol use, or
illicit drug use
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.8 BP: 165/98 P: 106 R: 18 O2: 95%RA
General: Alert, oriented, no acute distress; appears mildly
uncomfortable
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear,
EOMI, PERRL
Neck: supple, no LAD
CV: Tachycardic S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly tender to palpation in epigastrium; no
rebound or guarding
GU: no foley
Ext: AV fistula in left upper extremity with thrill; warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
.
Discharge Physical Exam:
VITALS:98.2 80 156/100 (sitting) 18 95% RA
GEN: NAD
NEURO: A&Ox3, CNII-XII intact, 5/5 strength in all extremities,
sensation intact grossly
HEENT: sclera anicteric, MMM, PERRL, EOMI, OP clear
CV: RRR, nl S1 and S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, soft, NTND, no HSM.
Ext: AV fistula in left upper extremity with thrill
Pertinent Results:
Admission Labs:
[**2187-8-26**] 06:50PM BLOOD WBC-10.3 RBC-5.14 Hgb-14.5 Hct-45.7
MCV-89 MCH-28.2 MCHC-31.7 RDW-15.0 Plt Ct-187
[**2187-8-26**] 06:50PM BLOOD Neuts-75.8* Lymphs-16.3* Monos-2.5
Eos-3.9 Baso-1.5
[**2187-8-26**] 06:50PM BLOOD Glucose-314* UreaN-70* Creat-10.1* Na-136
K-5.4* Cl-91* HCO3-19* AnGap-31*
[**2187-8-26**] 06:50PM BLOOD ALT-13 AST-31 AlkPhos-131* TotBili-1.1
[**2187-8-26**] 06:50PM BLOOD Calcium-9.4 Phos-6.4* Mg-2.4
.
Interim:
[**2187-8-27**] 05:11AM BLOOD WBC-8.5 RBC-4.00* Hgb-11.3*# Hct-35.4*#
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.0 Plt Ct-162
[**2187-8-27**] 05:11AM BLOOD Glucose-128* UreaN-71* Creat-9.8* Na-137
K-4.3 Cl-99 HCO3-26 AnGap-16
[**2187-8-28**] 03:22AM BLOOD WBC-7.2 RBC-3.93* Hgb-11.3* Hct-35.4*
MCV-90 MCH-28.7 MCHC-31.8 RDW-15.2 Plt Ct-146*
[**2187-8-28**] 03:22AM BLOOD Glucose-207* UreaN-27* Creat-5.9*# Na-141
K-4.9 Cl-103 HCO3-27 AnGap-16
.
Discharge:
[**2187-8-29**] 06:45AM BLOOD WBC-5.9 RBC-3.61* Hgb-10.5* Hct-32.8*
MCV-91 MCH-29.2 MCHC-32.1 RDW-14.8 Plt Ct-147*
[**2187-8-29**] 06:45AM BLOOD Glucose-106* UreaN-42* Creat-8.0*# Na-136
K-4.3 Cl-98 HCO3-30 AnGap-12
CXR
FINDINGS:
Elevation of the right hemidiaphragm is unchanged. A left
axillary vascular stent is again noted. The cardiac,
mediastinal and hilar contours are normal. Lungs are clear. No
pleural effusion or pneumothorax is present. No
pneumomediastinum is identified. Speckled densities within the
right upper quadrant of the abdomen likely reflects ingested
contents within the colon.
IMPRESSION:
No acute cardiopulmonary abnormality. Specifically, no
pneumomediastinum
identified.
Brief Hospital Course:
36 year old man with a history of DM I complicated by severe
gastroparesis and ESRD on HD admitted with acute abdominal pain,
nausea, and hematemesis.
Acute Issues:
# DKA: Patient admitted with glucose near 400 with anion gap
of 26. DKA likely caused by gastroparesis and non-use of
novolog on the day of admission. No evidence of infection on
history or exam. He was started on an insulin drip and his gap
closed quickly. The patient was transitioned to his home
insulin regimen.
#Abdominal pain: Patient admitted with 7 hours of sharp
epigastric, non-radiating pain. As pain is similar to previous
presentations, it was likely caused by known severe
gastroparesis. Pain may have been worsened by DKA. Nausea and
abdominal pain resolved in the ED with ativan, zofran, and
reglan. He was continued on home omeprazole to cover for peptic
ulcer disease or gastritis. LFTs, alk phos, lipase normal.
#Hematemesis. Hematemesis likely due to [**Doctor First Name 329**] [**Doctor Last Name **] tear from
continued vomiting. Hct 45.7 ->35.4 during first day of
hospital stay. Likely combination of Hematemesis and
hemodilution secondary to IVF. H/H stable after that point alone
with resolution of hematemesis. Of note, recent EGD in [**11/2186**]
in the setting of hematemesis was normal. At that time, it was
felt that patient likely had a small [**Doctor First Name 329**] [**Doctor Last Name **] tear that had
resolved.
# Anion gap metabolic acidosis: Likely due to a combination of
diabetic ketoacidosis, starvation ketoacidosis from lack of PO
intake, and uremia. Gap closed with strict control of
hyperglycemia.
# Hypertensive Urgency with orthostasis: While patient says he
routinely goes into hypertensive urgency with exacerbations of
gastroparesis, his hypertensive urgency did not resolve with
resolution of nausea and vomiting. No headache, chest pain,
shortness of breath or vision changes. The patient was
continued on his home clonidine patch. Lisinopril was increased
to 10mg daily and Labetalol 200mg TID was added for better BP
control. Patient had orthostatic hypotension of up 40mmHg
difference from lying down to sitting likely secondary to
autonomic dysfunction. His blood pressure medications were
titrated using pressures while patient is in a sitting position.
He was continued on home dialysis.
Chronic Issues:
# ESRD on HD: Chronic, on HD MWF. The patient is currently on
the dual pancreatic/kidney transplant list. He was continued on
sevelamer and nephrocaps. He was continued on regularly
scheduled hemodialysis.
Transitional Issues:
# Please measure blood pressure with patient in sitting position
in the future. Blood pressure medications have to be readjusted
if hypertensive urgency is truly associated with gastroparesis.
Medications on Admission:
1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
2. Erythromycin 250 mg PO TID
3. Glargine 5 Units Breakfast
Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 5 mg PO DAILY
hold for SBP<90, K>5.5
5. Metoclopramide 10 mg PO TID
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 20 mg PO DAILY
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
Discharge Medications:
1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES
2. Metoclopramide 10 mg PO QIDACHS
3. Nephrocaps 1 CAP PO DAILY
4. Omeprazole 20 mg PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Labetalol 200 mg PO TID
hold for SBP < 130
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*2
7. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
8. Erythromycin 250 mg PO TID
9. Glargine 5 Units Breakfast
Glargine 4 Units Bedtime
Insulin SC Sliding Scale using Aspart Insulin
10. NovoLOG PenFill *NF* (insulin aspart) 100 unit/mL
Subcutaneous TID with meals
Ratio at breakfast: 1u : 15g Ratio at lunch: 1u : 15g Ratio at
dinner: 1u : 15g
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: DKA
Secondary:
HTN, Type I DM, ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 14782**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted for diabetic ketoacidosis likely caused by not taking
your insulin during an episode of your gastroparesis.
Please follow up with your endocrinologist, nephrologist and
primary care physician at the appointments listed below and
continue your dialysis on your regular MWF schedule.
The following changes were made to your medications
- Labetalol 200mg TID was started for your high blood pressure
- increase lisinopril to 10mg daily
Please continue all of your other previously prescribed
medications.
If you develop abdominal pain/N/V in the future, please be sure
to take your glargine regularly and check your blood sugar four
times a day. Please continue to use your sliding scale as well
to prevent further DKA.
Followup Instructions:
Name: Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment: Thursday [**2187-8-30**] 3:30pm
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary endocrinologist after this
visit.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
Appointment: Tuesday [**2187-9-4**] 10:00am
*You had an appointment scheduled for tomorrow morning in your
PCP office but was cancelled and rescheduled for next week. Any
questions or concerns please call the office at
Dialysis Center: [**Location (un) **] [**Location (un) **]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
Phone: [**Telephone/Fax (1) 5972**]
Schedule: Monday, Wednesday, Friday
*Your nephrologist will follow up with you for your
hospitalization at your next dialysis day. If you have any
questions or concerns please call the office.
Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2187-11-19**] at 9:00 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
Completed by:[**2187-8-31**]
|
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icd9cm
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59,736
| 153,856
|
40546
|
Discharge summary
|
report
|
Admission Date: [**2109-6-26**] Discharge Date: [**2109-7-7**]
Service: SURGERY
Allergies:
vancomycin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
R groin infection with exposed synthetic graft
Major Surgical or Invasive Procedure:
[**2109-6-26**] Excision of right fem-[**Doctor Last Name **] bypass graft
[**2109-6-27**] Right groin washout/sartorious flap/wound vac
[**2109-7-3**] right groin washout and closure
History of Present Illness:
88M s/p failed R fem-[**Doctor Last Name **] bypass in [**2101**] and subsequent bilateral
AKA presented with R groin infection with exposed synthetic
graft. Patient had 1 week of chills, nausea, vomiting prior to
coming in. The patient reports that the groin site had been
infected for 3 months but that he had not been able to see the
extent of it himself secondary to stroke deficits.
Past Medical History:
hypertension, neuropathy, [**Female First Name (un) **] ,CHF, recent pneumonia, acute
bronchitis, PAD, NIDDM, urinary incontinence, CVA with right
sided weakness, COPD (home O2 use), OSA
R fem [**Doctor Last Name **] bypass, bilateral AKA, total knee arthroplasty
Social History:
Lives with wife in [**Name (NI) 3146**] receiving 24 hour care, no substance
use
Family History:
Not applicable
Pertinent Results:
[**2109-6-25**] 10:00PM BLOOD WBC-8.3 RBC-4.88 Hgb-13.3* Hct-41.3
MCV-85 MCH-27.2 MCHC-32.1 RDW-16.8* Plt Ct-291
[**2109-7-7**] 12:47AM BLOOD WBC-7.6 RBC-3.33* Hgb-9.2* Hct-28.8*
MCV-87 MCH-27.7 MCHC-32.0 RDW-17.3* Plt Ct-180
[**2109-6-25**] 10:00PM BLOOD Glucose-117* UreaN-32* Creat-1.2 Na-142
K-5.0 Cl-102 HCO3-32 AnGap-13
[**2109-7-7**] 12:47AM BLOOD Glucose-153* UreaN-25* Creat-2.4* Na-128*
K-4.1 Cl-97 HCO3-20* AnGap-15
[**2109-7-4**] 11:06AM BLOOD CK-MB-4 cTropnT-0.24*
[**2109-7-4**] 02:41PM BLOOD proBNP-2971*
[**2109-7-4**] 06:48PM BLOOD CK-MB-4 cTropnT-0.23*
[**2109-7-5**] 02:30AM BLOOD CK-MB-4 cTropnT-0.22*
[**2109-7-5**] 01:54PM BLOOD CK-MB-3 cTropnT-0.19*
[**2109-7-5**] 10:24PM BLOOD CK-MB-3 cTropnT-0.20*
[**2109-7-6**] 04:57AM BLOOD CK-MB-4 cTropnT-0.24*
[**2109-7-6**] 01:21PM BLOOD CK-MB-4 cTropnT-0.23*
Brief Hospital Course:
The patient was found to have a 3 cm opening in his right groin
with exposed graft, significant purulence around the graft, a
medial stump wound with purulent drainage and culture results
consistent with enterococcus. He was placed on linezolid,
cipro,and flagyl. The graft was excised and the wound was
drained. He then went back to the OR to have further
debridement of his right thigh, sartorius flap, VAC dressing
placement. The following week he went to the OR for VAC removal
and groin washout and closure. During his hospital stay he was
seen to be grossly aspirating with symptoms of nausea, emesis,
shortness of breath, and hypoxia after eating. He was made NPO
and bedside swallow evals did not see signs of oropharyngeal
aspiration although a gastrograffin swallow did show
oropharyngeal reflux and a weak LES. A dophoff tube was placed
although discussions with the patient and his family determined
that the patient would be unlikely to want a permanent form of
supplemental feeding. On [**7-5**], he had an episode of chest pain
and a tropnin leak to .2. He had persistent hyponatremia that
was treated with lasix, fluid restriction, and salt tabs. On
[**7-7**] in the morning, he became bradycardic from 80 to 30 and
then his heart stopped and he passed away. He was DNR/DNI and no
interventions were attempted.
Medications on Admission:
cholecalciferol 1000U', vicodin 5/500'', pregabalin 75'', ASA
81', torsemide 20', metoprolol xr 25', omeprazole 20',
amlodipine 10', lisinopril 20', bisacodyl 5', glycolax'', ISS,
docusate sodium 100', timolol maleate 1 gtt, lantus 32u qhs, ?
novolog 56u before each meal(pt does not take this), torsemide
20'', home O2
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
infected bypass graft
fluid overload
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2109-7-7**]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,946
| 100,104
|
54655
|
Discharge summary
|
report
|
Admission Date: [**2201-6-21**] Discharge Date: [**2201-7-3**]
Date of Birth: [**2171-2-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Perforated diverticulitis
Major Surgical or Invasive Procedure:
OSH procedure:
[**2201-6-20**]: Exploratory laparotomy, sigmoid colectomy and
formation of Hartmann's pouch colostomy
[**Hospital1 18**] operations:
[**2201-6-26**]: Exploratory laparotomy with revision of sigmoid
colostomy
[**2201-6-28**]: Abdominal washout, liver biopsy, abdominal closure
History of Present Illness:
HPI: 30 yo male with hx of significant etoh abuse presenting
from OSH with perforated sigmoid colon, s/p sigmoid colectomy,
currently septic on Neo. Intubated the evening prior to
transfer.
The pt initially presented to the OSH with one week of abdominal
pain, nausea and vomiting with associated diarrhea. CT scan in
the ED demonstrated free air. Labs at the time were pertinent
for ARF with Cr. of 2.3. Sodium 125, bicarb 22 with AG of 19 and
T.bili 3.8. Pt was taken to the OR for an ex-lap and found to
have perforated viscous in the sigmoid area. Fibrinous exudate
in the left side was present c/w longstanding process. A
Hartmann pouch and LLQ colostomy was performed. The pt was
started on levaquin, flagyl and zosyn.
Postop the pt had persistent acidosis with a bicarb of 15,
lactate 4.8. He was started on a bicarb gtt. During the course
of the OSH stay the pt has been 9 liters positive. He remains
hypotensive on neo. Of note the pt drinks up to half-a-gallon a
day of whiskey. His last drink was 8 days ago.
Past Medical History:
Alcohol abuse
PSH: Hartmann's procedure
Social History:
History of alcohol abuse
Lives with mother who works at [**Hospital6 5016**], which is
where the patient was admitted previosly
Family History:
Non-contributory
Physical Exam:
On transfer to [**Hospital1 18**]:
100 115 102/55 26 93% CMV 50% 450/13 5
Neuro: Awake responsive to questions/follows commands
Card: tachycardic, no m/r/g/c
Pulm: Intubated clear breath sounds bilaterally
GI:+Bowel sounds. Midline incision c/d/i. dusky sunken appearing
colostomy. Appropriately tender to palpation
Ext: peripheral edema palpable DP, radial pulses
Pertinent Results:
[**6-21**]: OSH CT abd/pelvis CT (OSH) free air and sigmoid
stranding/diverticulitis.
Labs on admission:
[**2201-6-21**] 07:40PM WBC-7.4 RBC-2.62* HGB-9.5* HCT-29.2* MCV-112*
MCH-36.1* MCHC-32.3 RDW-23.0*
[**2201-6-21**] 07:40PM PLT COUNT-171
[**2201-6-21**] 07:40PM PT-16.4* PTT-31.7 INR(PT)-1.5*
[**2201-6-21**] 07:40PM ALT(SGPT)-25 AST(SGOT)-58* ALK PHOS-52 TOT
BILI-3.3* DIR BILI-2.9* INDIR BIL-0.4
[**2201-6-21**] 07:40PM GLUCOSE-141* UREA N-45* CREAT-1.8* SODIUM-138
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-20* ANION GAP-21*
[**2201-6-21**] 07:40PM CALCIUM-6.5* PHOSPHATE-4.7* MAGNESIUM-2.2
[**2201-6-21**] 07:48PM freeCa-0.90*
[**2201-6-21**] 07:48PM GLUCOSE-127* LACTATE-3.7* K+-3.4
[**2201-6-21**] 07:48PM TYPE-ART PO2-70* PCO2-37 PH-7.38 TOTAL CO2-23
BASE XS--
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the trauma ICU on [**2201-6-21**] for further
management following his Hartmann's procedure for perforated
diverticulitis and septic shock. He remained on pressors which
were weaned slightly overnight. He received a blood transfusion
for a hematocrit of 24.1 which increased to 25.9 and was weaned
off pressors. Copious secretions were noted from his ET tube.
Intraoperative cultures from the OSH were obtained. They were
peritoneal cultures and were polymicrobial. He was extubated and
remained hemodynamically stable so was transferred to the floor
on [**2201-6-24**].
At the time of transfer to the floor the pt was NPO with IV
fluids and NG tube to suction. He was on IV zosyn for empiric
coverage and also had a foley catheter in place for urine output
monitoring. On [**6-25**] his NG tube output remained low so it was
removed along with the foley catheter as he was making good
amounts of urine. However, the appearance of his stoma continued
to be dusky and necrotic and his WBC count increased from 9.6 on
[**6-24**] to 15.2 on [**6-26**]. Therefore, he was taken back to the OR for
an ostomy revision on [**2201-6-26**].
Intraoperatively, he received over 3L in crystalloid for
hypotension. His abdomen was left open due to bowel edema and he
was brought to the trauma ICU intubated and sedated. He was
aggressively diuresed overnight and his abdomen was closed on
[**2201-6-28**]. Also of note, the liver was noted to be quite yellowed
in appearance suspicious of acute fatty liver and a biopsy was
sent during the abdominal closure procedure (please see
operative note for details). Postoperatively, his vent was
weaned with continued diuresis. He was extubated on [**2201-6-29**] and
transferred back to the floor hemodynamically stable.
On [**6-30**] he was noted to have gas and a small amout of stool from
his ostomy so his diet was advanced as tolerated. His foley
catheter which had been placed upon return to the operating room
was again removed and he voided without difficulty. His vital
signs were routinely monitored and he remained afebrile and
hemodynamically. His lung sounds were noted to have crackles and
his chest x-ray appreared wet and he was diuresed with lasix as
needed. His white blood cell count began trending downward to
18 from 27. His hematocrit has stabilized at 27. He was
encouraged to mobilize out of bed and ambulate as tolerated
throughout his postoperative course and he remained on SC
heparin for DVT prophylaxis.
Ostomy nursing was consulted and provided appropriate treatment
and supplies for the patient to care for his colostomy.
On HD #13, he was note to have mild erythema around the lower
aspect of his wound and he underwent further removal of staples
from the lower aspect of his wound. Remained of inferior staples
were removed on POD #5 and wound was lightly packed with wet to
dry dressing. The patient has been instructed in caring for his
wound and dressing changes. He partipated in dressing changes
and agreed to continue with them. VNA service will also provide
him with assistance.
His vital signs have been stable and he has been afebrile. He
is preparing for discharge home with follow-up in the acute care
clinic.
Medications on Admission:
None
Discharge Medications:
1. Ostomy supplies
1 piece Coloplast
Sensura ( Dist # [**Numeric Identifier 24338**] [**Doctor First Name **] # [**Numeric Identifier 20839**])
#3 boxes
Refills:6
2. Ostomy Supplies
[**Last Name (un) **] wafer Dist # [**Numeric Identifier 89560**], manf # [**Numeric Identifier 20840**]
#3 boxes
Refills: 6
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 16449**] Homecare and Hospice
Discharge Diagnosis:
Perforated diverticulitis
Sepsis
Acute Kidney Injury
Ischemic sigmoid colostomy
Open abdomen secondary to diverticulitis and sepsis
Acute fatty liver
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from [**Hospital6 5016**] after undergoing
an emergent operation for perforated diverticulitis. You became
septic postoperatively and were transferred here to [**Hospital1 18**] for
further management. You were managed in the ICU and your
condition improved so you were transferred to the surgical
floor. You were then taken back to the operating for because
your stoma was necrotic and had your stoma revised. Because of
bowel swelling you abdomen was left open for a short period of
time. Two days later it was able to be closed in the operating
room. It was also noted that your liver appeared abnormal and a
biopsy of it was taken during your last operation. The results
of the biopsy are still pending at this time.
Your infection has improved and your colostomy is now
functioning well. You have resumed a regular diet and should
continue to do so. You are being discharged home with the
following instructions:
Please follow up in the Acute Care Surgery Clinic at the
appointment scheduled for you below.
Your colostomy: You have received teaching from the ostomy
nurses on how to care for your stoma. Empty the pouch when it
becomes [**2-10**] full as instructed.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Month/Day (4) 5059**] at your next visit.
Don't lift more than [**11-23**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal. Your staples will be removed at your follow up
appointment in clinic.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: TUESDAY [**2201-7-14**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2201-7-8**]
|
[
"E878.3",
"569.82",
"305.01",
"557.0",
"560.1",
"571.0",
"995.92",
"038.9",
"584.9",
"562.11",
"997.49",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.43",
"96.04",
"54.12",
"50.11",
"54.62",
"00.17",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7058, 7130
|
3133, 6374
|
328, 623
|
7324, 7324
|
2320, 2412
|
12841, 13261
|
1900, 1918
|
6430, 7035
|
7151, 7303
|
6400, 6407
|
7475, 12818
|
1933, 2301
|
263, 290
|
651, 1675
|
2427, 3110
|
7339, 7451
|
1697, 1739
|
1755, 1884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,974
| 134,328
|
32193
|
Discharge summary
|
report
|
Admission Date: [**2160-11-25**] Discharge Date: [**2160-11-29**]
Date of Birth: [**2089-12-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath [**2160-11-25**]
VSD Repair/CABG x1 (LIMA to LAD) [**2160-11-26**]
History of Present Illness:
71 year old woman with several months of exertional chest pain.
Woke this morning (about 5 hours prior to presentation) with
chest pressure radiating to the arm, SOB. No diaphoresis, light
headedness, palpitations, syncope. Daughter (nursing student)
listened to her mother's heart and noted that her normal "lub
dub" had changed to a more constant "whirr". Then had her mother
take 4 baby aspirin at home and then brought her to ER. In ED at
OSH tachycardic in the 120's, and prominent murmur on exam. EKG
with Q's in V1-V2, ST elevations in V1-V2-V3 with inverted
T-waves in precordial leads (EKG not available for review).
Treated with 600mg plavix, Heparin bolus without a drip, IV
lopressor, integrilin bolus and drip. Then transferred to [**Hospital1 18**]
for cath.
.
Cardiac Cath demonstrated a proximal LAD stenosis of 90%, LCx,
and RCA without disease. RHC demonstrated an O2 step-up from SVC
to PA of 63 - 86 c/w VSD. Estimated shunt fraction of 3:1.
Intra-aortic balloon pump was placed and patient transferred to
CCU for managment. Plan on admission to CCU is for operative
repair of her VSD, and a LIMA to LAD.
.
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. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
- Dyslipidemia
- Hypertension
- Denies DM
- Cardiac History: No known history of CAD. Had work-up at
[**Hospital 756**] hospital several years ago - does not know results.
Social History:
Social history is significant for the absence of tobacco use.
Patient is a social drinker (no more than occasional [**1-22**]
drinks), no IVDU.
Family History:
Family history notable for a brother with 3 prior CABG's first
in his 50's. Father deceased at 54 years from MI. Mother 89 y/o
w/o significant heart disease.
Physical Exam:
VS: T 99, BP 103/78, HR 92, RR 16 , O2 99%, PAP: 39/21 mean 29,
CVP 12
Gen: WDWN middle aged woman in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant. Fully reclined in bed
with IABP in place.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, unable to assess JVP as fully reclined.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, systolic murmur with prominent diastolic component.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Lungs were clear
anteriorly.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. R-femoral sheath, IABP in
place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
5'2" 61.2 kg
Pertinent Results:
[**2160-11-25**] 12:00PM PT-12.4 PTT-94.8* INR(PT)-1.1
[**2160-11-25**] 12:00PM PLT COUNT-220
[**2160-11-25**] 12:00PM NEUTS-71.2* LYMPHS-22.7 MONOS-3.8 EOS-2.2
BASOS-0.1
[**2160-11-25**] 12:00PM WBC-11.6* RBC-4.17* HGB-13.3 HCT-38.0 MCV-91
MCH-31.8 MCHC-34.9 RDW-13.2
[**2160-11-25**] 12:00PM CK(CPK)-755*
[**2160-11-25**] 12:00PM estGFR-Using this
[**2160-11-25**] 12:00PM GLUCOSE-115* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-19* ANION GAP-18
[**2160-11-25**] 12:55PM HGB-13.0 calcHCT-39 O2 SAT-99
[**2160-11-25**] 12:55PM TYPE-ART O2-100 O2 FLOW-4 PO2-166* PCO2-37
PH-7.42 TOTAL CO2-25 BASE XS-0 AADO2-519 REQ O2-86 INTUBATED-NOT
INTUBA
[**2160-11-25**] 04:52PM PT-11.9 PTT-61.2* INR(PT)-1.0
[**2160-11-28**] 08:17PM BLOOD WBC-16.9* RBC-2.83* Hgb-9.1* Hct-27.6*
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.8 Plt Ct-45*#
[**2160-11-28**] 10:50PM BLOOD Hct-28.2*
[**2160-11-28**] 08:17PM BLOOD PT-28.8* PTT-51.2* INR(PT)-3.0*
[**2160-11-28**] 08:17PM BLOOD Plt Ct-45*#
[**2160-11-28**] 07:45PM BLOOD Glucose-52* UreaN-30* Creat-2.1*# Na-135
K-5.9* Cl-101 HCO3-8* AnGap-32*
[**2160-11-28**] 07:45PM BLOOD ALT-4339* AST-6635* LD(LDH)-5664*
AlkPhos-79 Amylase-338* TotBili-1.9*
[**2160-11-28**] 07:45PM BLOOD Lipase-13
[**2160-11-28**] 07:45PM BLOOD Albumin-2.7*
[**2160-11-28**] 11:43PM BLOOD Glucose-107* Lactate-13.9* K-4.8
[**2160-11-29**] 01:14AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Brief Hospital Course:
Admitted on [**11-25**] and had a cardiac cath ( results above).
Referred for urgent CABG /VSD repair with IABP and Swan in
place. Ruled in for acute MI. echo revealed multiple wall motion
abnormalitites with with akinesis in anteroseptal and apical
areas.Underwent cabg x1/VSD patch closure the following morning
on [**2160-11-26**] with Dr. [**Last Name (STitle) **]. Transferred ot the CVICU in stable
condition on epinephrine and propofol drips. Epinephrine drip
weaned off on POD #1, and extubated early that afternoon.
IABP was removed on POD #2 and that evening, she developed
respiratory distress and becmae unresponsive. She was
reintubated with milrinone and phenylephrine drips started for
hypotension with SBP 100 at time of intubation. Thick brown
secretions were noted with ETT suctioning. Of note, her
creatinine rose to 2.1 from 1.0, and lactate rose throughout the
day with concern for ischemic bowel. Her pH also dropped to 6.99
and urine output continued to decrease. Transplant surgery
consult done for evaluation. INR rose to 3.0 with a lactate of
14. She also developed A fib.TTE that evening showed no
pericardial effusion. TEE that evening showed small aspical VSD,
mild MR, severe TR, trace AI, small pericardial effusion, and
akinetic areas of the septum, anterior wall, apex, and distal
inferior wall. RV was also hypokinetic with a dilated RA.Concern
was high for bowel ischemia and renal consult was done for
evaluation for CVVH.
Support continued with levophed, neosynephrine, vasopressin and
bicarb. Surgery team approached family about exploratory
laparotomy to rule out bowel ischemia as her abdomen became firm
and she remained unresponsive. Her LFTS rose into the thousands.
Her prognosis was very grave and the family stated the pt.would
not want surgery. They requested supportive care at that time.
She developed prolonged hypotension despite maximal support and
became bradycardic. CPR was started and the family was notified
at that time. They agreed with the decision to stop all measures
and the pt. expired at 1:10 AM on [**11-29**]. Family declined
autopsy.
Medications on Admission:
home: norvasc
toprol XL
lisinopril
plavix 600 mg (dose only on [**11-25**])
Discharge Disposition:
Expired
Discharge Diagnosis:
CAD with acute MI/VSD/IABP
s/p CABG x1/VSD repair
HTN
elev. lipids
metabolic acidosis
multi-organ failure
Discharge Condition:
expired
Completed by:[**2160-12-10**]
|
[
"427.5",
"276.2",
"788.5",
"401.9",
"997.5",
"557.9",
"518.5",
"458.29",
"420.90",
"410.11",
"997.1",
"416.8",
"427.31",
"272.4",
"V17.3",
"424.2",
"285.9",
"414.01",
"429.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"99.20",
"34.04",
"38.93",
"37.61",
"88.56",
"88.72",
"35.53",
"89.68",
"39.61",
"99.04",
"96.04",
"89.64",
"36.15",
"37.23",
"96.71",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
7102, 7111
|
4869, 6976
|
315, 397
|
7260, 7299
|
3420, 4846
|
2278, 2437
|
7132, 7239
|
7002, 7079
|
2452, 3401
|
265, 277
|
425, 1905
|
1927, 2101
|
2117, 2262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,184
| 111,781
|
1032
|
Discharge summary
|
report
|
Admission Date: [**2133-10-30**] Discharge Date: [**2133-11-11**]
Service: MEDICINE
Allergies:
Streptokinase / Avandia / Amiodarone / Phenergan / Morphine /
Percocet
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
CC: left lower extremity pain
Major Surgical or Invasive Procedure:
PICC placed on RUE
Swan-ganz catheterization
History of Present Illness:
Mr. [**Known lastname **] is an 87yo male with past medical history significant
for
diabetes, severe PVD, ischemic CMY (EF 25%), stage III CKD, CAD,
hypothyroidism, and chronic atrial fibrillation who presents now
complaining of LLE pain which was fairly abrupt in onset over
last 24 hours, erythema and warmth all concerning for cellulitis
vs. additional vascular compromise. He was seen by nurse
practitioner [**First Name (Titles) **] [**Last Name (Titles) 191**] earlier this afternoon and sent to ED for
additional workup. He denies any numbness or tingling in foot.
Denies fevers or chills. Small superficial left tibal area
lesion but no other open wounds over LE.
.
Of significance, he states that he was seen at [**Hospital3 2358**]
about 2 weeks ago for similar LE erythema and treated with oral
antibiotics that he completed last week. He also had a recent
visit with Dr. [**Last Name (STitle) **] on [**10-12**] and severe right sided SFA
stenosis discussed regarding need for future
angioplasty/stenting but he was noted to have less severe left
sided disease per OMR notes.
.
In the ED, initial vs were: T 97.5F,P 71, BP 127/53, RR 18 and
O2 saturation 99% RA. Patient was given IV vancomycin and IV
Unasyn antiobiotics follwed by Tramadol and Tylenol for pain
with good relief. Two sets of blood cultures sent off. Labs were
notable for a wbc count of 30 with 91% neutrophils. Urinalysis
negative for infection and CXR with no infiltrates just minimal
bilateral effusions. Fully dopplerable pulses in the ED. CT scan
of LLE showed superficial soft tissue edema noted throughout the
left calf, without focal fluid collection to suggest abscess and
without soft tissue air. No concerning bony lesions to imply
oseomyelitis. Also had LE US which was negative for any overt
DVTs.
.
Orthopedic team and vascular surgery both consulted in ED due to
concern for possible compartment syndrome and patient had
Striker intracompartmental pressure monitor measured with
posterior compartment of leg 10 cm H2O while diastolic BP was
52mmHg which ruled against any compartment syndrome.
.
On arrival to the medical floor he appeared to be in no acute
distress. Vital signs were: T 96.9F, HR 69, BP 104/54, O2 sat
99% on 3L NC. States his LLE pain is minimal and denies feeling
chills or feverish.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, URI sx, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Medical History:
- PVD
- Diabetes
- Dyslipidemia
- CAD, s/p two vessel CABG
- Pacemaker/[**Month/Day (4) 3941**], in [**2125**]: Biventricular PCM/[**Year (4 digits) 3941**], s/p ablation
- Diverticulosis
- s/p lower GI bleed
- Ischemic cardiomyopathy, NYHA Class III
- Chronic systolic congestive heart failure with severely
depressed ventricular function, last LVEF 25%
- Chronic a-fib
- s/p MVA [**6-15**] injuring back, chest & hit head
- Chronic renal insufficiency, stage 3
- Cholelithiasis s/p cholecystectomy
- Pancreatic cysts
- Gunshot wounds to left lower extremity with decreased
sensation
- Low back pain
- Cataracts
Social History:
No alcohol drug or tobacco use. Pt lives at home in [**Location (un) 6798**] w/
his wife, daughter is near by and involved in care. Patient is
decorated war hero, WWII veteran from the 1st marine corps, 2nd
battalion, H company (Pacific theater).
States he has a walker at home but does not use it. Daughter
[**Name (NI) **] very involved with his care as well.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 96.9F, HR 69, BP 104/54, O2 sat 99% on 3L NC.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased lung sounds at bases but clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Regular rate and rhythm noted, loud S2 and [**2-14**] apical
holosystolic murmur with radiation to axilla. No rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin/Ext: Warm, well perfused, 1+ DP pulses bilaterally and
difficult to palpate either PT pulse (dopplerable however). Left
tibial area superficial skin ulcer (non bloody, no discharge)
with surrounding bed of erythema that expands several cm, also
erythema over lower shin and ankle area with no clear margins.
No palpable underlying fluctuant areas and 1+ edema over LLE
with minimal warmth compared to RLE.
Pertinent Results:
Admission labs:
[**2133-10-30**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2133-10-30**] 04:50PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2133-10-30**] 04:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2133-10-30**] 05:45PM GLUCOSE-109* UREA N-35* CREAT-1.2 SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2133-10-30**] 05:45PM WBC-30.2*# RBC-4.34* HGB-11.5* HCT-34.9*
MCV-80* MCH-26.4* MCHC-32.8 RDW-17.1*
[**2133-10-30**] 05:45PM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-7 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
Imaging/procdures:
Catheterization
COMMENTS:
1. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 18 mm Hg and mean PCWP of 22 mm Hg.
There was
moderate pulmonary hypertension with PASP of 63 mm Hg. The
cardiac index
was depressed at 2 l/min/m2. The arterial oxygen saturation was
taken
from finger oximetry.
2. Milrinone infusion and repeat hemodynamic measurements to be
completed in the CCU per the CHF team.
FINAL DIAGNOSIS:
1. Left ventricular diastolic dysfunction.
2. Pulmonary hypertension.
3. Depressed cardiac index.
Lower extremity Dopplers [**11-3**]:
IMPRESSION:
Deep venous thrombosis in the left peroneal vein.
Brief Hospital Course:
Mr. [**Known lastname **] is an 87yo male with PMH significant for severe PVD
s/p stenting, CAD, CHF/CMY, atrial fibrillation, diabetes, and
chronic kidney disease who presents with leukocytosis, left LE
pain and erythema most consistent with cellulitis.
.
# LLE DVT/cellulitis and E. coli bacteremia: Presented with LLE
pain, swelling, and erythema. Prior to presentation, had recent
history of LLE cellulitis with outpatient PO antibiotics which
he states he completed about 1.5 weeks ago. He was treated 2
weeks ago with antibiotics at [**Hospital3 2358**] ([**Location (un) 1456**]) for LLE
cellulitis in same distribution of his LLE. Unfortunately, no
culture data or specific antibiotics details were available for
review at time of admission. He presented with a WBC elevation
to 30, with >90% PMNs. Also had local pain, erythema, warmth and
imaging that shows soft tissue edema c/w cellulitis. No
underlying abscesses or early signs of osteomyelitis per
preliminary imaging which is reassuring. Cause may be related to
open stasis wound over left tibia. The patient's Doppler studies
demonstrated a DVT of his left peroneal vein. The patient was
then bridged via heparin to Coumadin to achieve a therapeutic
INR. The patient's blood culture from the Emergency Department
also was positive for E. coli, susceptible to ceftriaxone, which
the patient was started on ([**11-2**]) after two days on cefepime
(started on [**10-31**]). The patient should complete a 14-day course
of antibiotics.
.
# STAGE IV HEART FAILURE: Patient had been medically managed
with ASA, atorvastatin, digoxin, eplerenone,
hydrochlorothiazide, torsemide, and metoprolol. However, he
continued to decline, so there was consideration of benefit from
positive inotrope therapy with home milrinone. Swan-Ganz
catheterization and study with milrinone suggested the patient
would indeed respond to milrinone. Milrinone dose was titrated
to 0.375mcg/kg/min. The patient was kept on ASA, atorvastatin,
eplerenone, and his torsemide was increased to 100mg daily.
Patient is NOT on an ACE-I because it causes severe hypotension.
.
#Severe PVD : He is followed by Dr. [**Last Name (STitle) **] here in vascular
clinic. Recent noninvasive arterial studies showed incalculable
ABIs due to calcified vessels but his pulse volume amplitudes
were dampened at the calf, right ankle, and forefoot per notes.
He has venous stasis ulcers and skin changes over both LEs.
Wound care was consulted and gave the following recommendations:
1. Cleanse LLE shin with normal saline. Pat dry. 2. Apply
Adaptic dressing over site, 4x4 and wrap with Kerlix. 3. Secure
with paper tape. No tape on skin. 4. Apply Aquaphor ointment to
dry intact skin (pharmacy) daily. 5. PT consult for evaluation
of safety and recommendations for
ambulation.
.
#CKD: The patient presented with creatinine in the 1.6-2.0
range, with his baseline typically 1.2-1.4. Likely due to
diabetes and blood pressure issues in the past. The patient's
medications were renally dosed and inpouts/outputs tracked. His
creatinine returned to the 1.2 area.
.
#CAD: As above, severe multi vessel native CAD and history of
several prior PCIs and CABG x2. No current complaints of any
chest pain, chest pressure, palpitations or shortness of breath.
EKG with no new ischemic changes. Continued daily ASA, statin,
beta blocker therapies
.
#Atrial fibrillation: Longstanding history but now has regular
rate on his EKG and telemetry with Biv PCM and HR @70. INR is
subtherapeutic now which may be due to recent adjustments with
antibiotics at outside hospital. The patient had a
subtherapeutic INR and was bridged with heparin while his
coumadin was adjusted. His beta blockade was also adjusted to
150mg metoprolol succinate daily with an eventual goal dose of
200mg daily. His INR on day of discharge was 1.6. He should have
his INR checked daily until he is therapeutic. His Heparin drip
should be maintained for 48 hours once his INR is therapeutic.
.
#Diabetes: The patient had a longstanding history of type II
diabetes and was on insulin at home. The patient was given 30
units glargine in the am and a Humalog sliding scale with qachs
fingersticks relfecting his home dose.
.
#Hypothyroidism: Continued on usual home dose levothyroxine.
.
#GERD: Continued on home dose of Protonix 40mg daily.
.
Also, the patient has an eye appointment at the VA next week
that has to be rescheduled.
Medications on Admission:
HOME MEDICATIONS: confirmed with pharmacy
ASPIRIN - 81MG Tablet - ONE EVERY DAY
ATORVASTATIN - 40 mg Tablet once a day
CARVEDILOL [COREG] - 6.25 mg by mouth twice a day
DIGOXIN - 125 mcg Tablet by mouth daily except
Mon-Wed-Fri take TWO tablets daily
EPLERENONE - 25 mg Tablet - one Tablet(s) by mouth once daily
HYDROCHLOROTHIAZIDE - 25 mg Tablet - one Tablet by mouth 30
minutes before Torsemide not more than 3 times per week
INSULIN GLARGINE [LANTUS] - 30 units in am, can take up to 45
units daily
INSULIN LISPRO [HUMALOG] SSI
LEVOTHYROXINE - 150 mcg Tablet-daily
NITROSTAT - 0.4MG Tablet, SL PRN
PANTOPRAZOLE - 40 mg Tablet daily
POLYETHYLENE GLYCOL 3350 [MIRALAX] - 100 % Powder - 1 tbsp [**Hospital1 **]
PRN
POTASSIUM CHLORIDE - 20 mEq Tab daily
TORSEMIDE - 40 mg twice daily
WARFARIN - 3.75mg on Mon/Thurs, 2.5 mg other five days
ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime
DOCUSATE SODIUM - 100 mg Capsule [**Hospital1 **]
PYRIDOXINE [VITAMIN B-6] -Dosage uncertain
Discharge Medications:
1. 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.
2. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) bag Intravenous Q24H (every 24 hours): last dose
Saturday [**11-14**].
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain .
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO twice a day.
11. Milrinone 0.38 mcg/kg/min IV INFUSION
12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
13. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for pain.
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
17. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal
QID (4 times a day) as needed for irritation.
19. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
22. insulin glargine 100 unit/mL Solution Sig: Thirty Two (32)
units Subcutaneous once a day.
23. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: as per sliding scale units Intravenous continuous:
Please overlap INR > 2.0 with heparin drip for 48 hours, thanks.
24. insulin lispro 100 unit/mL Solution Sig: as per sliding
scale units Subcutaneous four times a day.
25. torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute on chronic Systolic congestive Heart Failure
Deep Vein Thrombosis
Chronic Kidney disease
Diabetes Mellitus
Delerium
Peripheral Vascular Disease
Atrial fibrillation
Internal cardiac Defibrillator
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had a blood clot in your leg and have been started on
intravenous heparin and continued on coumadin to treat the clot.
You have had pain with the clot and have been taking tramadol to
treat the pain. An infection was found in your blood and you
will need intravenous antibiotics until [**11-14**] to treat this. In
addition, we found that you had an acute exacerbation of your
congestive heart failure and started you on a milrinone drip to
help your heart pump better. You will need rehabilitation before
you go home to get stronger.
Medication changes:
1. Stop taking digoxin, carvedilol, HCTZ, potassium, and Ambien
2. Start taking Ceftriaxone IV to treat the bacteria in your
blood
3. Start taking Mirtazipine to help you sleep and increase your
appetite
4. Start taking Metoprolol to slow your heart rate
5. Start taking Tylenol every 8 hours and Tramadol every 4 hours
to treat the pain from the blood clots in your leg.
6. Start taking a multivitamin and iron to help your anemia
7. Increase the lantus to 32 unit daily
8. Increase torsemide to 100 mg daily
9. Increase the warfarin to 4 mg daily
.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up
more than 3 lbs iin 1 day or 6 pounds in 3 days.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2133-11-18**] at 9:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2133-12-23**] at 11:40 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2133-12-29**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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] |
icd9cm
|
[
[
[]
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[
"37.21",
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icd9pcs
|
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[
[]
]
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14312, 14383
|
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|
318, 364
|
14643, 14643
|
5085, 5085
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|
4073, 4091
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|
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|
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|
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249, 280
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5102, 6192
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,036
| 101,411
|
47102
|
Discharge summary
|
report
|
Admission Date: [**2184-7-29**] Discharge Date: [**2184-8-3**]
Date of Birth: [**2129-9-14**] Sex: F
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol /
Erythromycin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
black emesis
Major Surgical or Invasive Procedure:
Upper endoscopy
nasogastric tube placement
History of Present Illness:
54 year old female with stage III endometrial cyst
adenocarcinoma of the ovary s/p multiple chemotherapy regimens
and abdominal colectomy with diverting ileostomy performed on
[**2183-11-21**] p/w black emesis.
.
Patient developed one episode of black emesis last night,
followed by six more episodes since then. She felt dizzy and
lightheaded this morning. She called her PCP in the morning who
sent her to the ED. She had four more episodes of vomiting since
then, each time [**12-25**] cup full of brownish-dark material. She has
also developed [**7-30**] sharp epigastric pain last night, lasting
only for seconds (not radiating). She had recurrent episodes
every 1-2 hours since then although the severity has become less
intense. She has used Ibuprofen recently several times for her
abdominal pain from ovarian cancer as well as fever for which
she was just recently admitted to OMED. She was at [**Hospital1 18**] from
[**7-26**] to [**7-28**] for fever workup (no DC summary yet in OMR). She was
found to have an elevated Tbili but an abdominal U/S was
unrevealing and Tbili was trending down again. It was felt that
her fever was from a UTI and she was discharged on Cipro to be
taken for three more days after discharge after having been on
Cefepime during this admission.
.
On ROS, she has had fever recently as above, mild chills
yesterday AM but no nightsweats. She denies any recent
gastroenteritis but has chronic, intermittent diarrhea. She did
have guaiac positive stools in her ileostomy bag about [**12-23**] year
ago. It was evaluated by Dr. [**First Name (STitle) 2819**] (the surgeon who performed her
abdominal surgery) who cleaned the site and it resolved. She
denies any dyspnea or SOB but CP similar to her epigastric pain
in quality and duration.
.
In the ED, her VS were 99.6, 114, 107/68, 18, 97%RA. An NGT was
placed and black content was returned which cleared with lavage
but recurred soon thereafter. Stool in the ileostomy bag was
guaiac positive. Patient received 18G IV and has a port . Her
Hct was stable around 26 to 27 but down from her baseline of
30-34. INR was slightly elevated with 1.5 and she received
Vitamin K 5mg sc x1. She also received 1L of IV NS, Ativan 1mg
IV x1, Protonix 40mg IV x1 and Zofran 4mg IV x1. She remained HD
stable. A CXR and KUB did not show any acute findings. One of
four units of blood was started in the ED. GI evaluated the
patient in the ED and is planning on performing an EGD once the
patient arrives in the ICU.
Past Medical History:
1)Ovarian cancer (see details below)
2)Asthma
.
Oncologic History: Diagnosed in [**2180-4-20**] with stage III C
endometrial cyst adenocarcinoma of the ovary. Optimally reduced;
received six cycles of carboplatin and Taxol chemotherapy,
completing treatment [**2180-8-23**]. Enrolled on the OvaRex study at
the [**Hospital 4415**]. Right adnexal recurrence was
noted by CT scan in [**2182-9-21**]. She received two cycles of
Taxol/carboplatin, but had a life-threatening platinum reaction
and made it through 6 cycles after converting to Doxil/Taxol.
She then developed severe mucositis and received 5 additional
cycles of single [**Doctor Last Name 360**] Taxol. She developed a large bowel
obstruction during her fifth cycle as a result of progressive
disease and had an abdominal colectomy with diverting ileostomy
performed on [**2183-11-21**]. She subsequently received four cycles
of Halichondrin B as part of the 06-125 protocol, but had
progressive disease and was taken off the protocol on [**2184-4-1**].
She then commenced gemcitabine; received three weekly doses
followed by a week off, however progressed after two cycles. She
was admitted to [**Hospital1 18**] from [**Date range (1) 39920**] with pneumonia;
thoracentesis on [**6-8**] revealed suspicious cells c/w metastatic
effusion. She then was referred to the [**Company 2860**] for carboplatin with
desensitization has now received 2 cycles, the last given on
[**7-13**]. She last saw her oncologist for mid-cycle evaluation on
[**2184-7-22**].
Social History:
She has one son who is 30 years old. She has worked as a
freelance writer until recently. She lives in [**Hospital1 **], MA with
her son. She drinks alcohol occasionally and has quit smoking 20
yrs ago (15yr h/o of 1ppd).
Family History:
She had a maternal grandmother with heart disease who at the age
of 83 developed colon cancer. There is no other cancer in her
family. Her mother died of COPD. Her father had a gastric ulcer
and died of renal artery stenosis.
Physical Exam:
VITAL SIGNS: T98.6, HR 100, BP 122/74, RR 18, 97%RA
GENERAL: Chronically ill appearing but in no acute distress.
HEENT: Sclerae anicteric. Oropharynx clear. There are no oral
lesions visible. NG tube in place, not draining any material.
NECK: No LAD, no elevated JVD.
CHEST: Lungs are clear to auscultation and percussion b/l.
HEART: Regular rate and rhythm. No murmurs, gallops, or rubs.
ABDOMEN: Firm, protuberant, TTP over epigastric area, but no
rebound, rigidity or guarding. Her ostomy tube is draining dark,
black stool, there is no surrounding erythema.
EXTREMITIES: Warm feet, good peripheral pulses. No edema,
clubbing or cyanosis.
SKIN: No overt rash noted.
NEURO: Strength 5/5 throughout. A&Ox3.
Pertinent Results:
[**2184-7-28**] 05:04AM WBC-10.8 RBC-2.81* HGB-8.6* HCT-26.3* MCV-94
MCH-30.8 MCHC-32.9 RDW-21.4*
[**2184-7-28**] 05:04AM PLT COUNT-191
[**2184-7-28**] 05:04AM CALCIUM-7.3* PHOSPHATE-1.8* MAGNESIUM-2.0
[**2184-7-28**] 05:04AM ALT(SGPT)-20 AST(SGOT)-37 ALK PHOS-217* TOT
BILI-1.4
[**2184-7-28**] 05:04AM GLUCOSE-93 UREA N-12 CREAT-0.5 SODIUM-140
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-29 ANION GAP-6*
[**2184-7-29**] 02:55PM PT-16.4* PTT-28.0 INR(PT)-1.5*
[**2184-7-29**] 02:55PM NEUTS-84.0* LYMPHS-11.8* MONOS-3.8 EOS-0.2
BASOS-0.2
[**2184-7-29**] 02:55PM CK-MB-NotDone cTropnT-<0.01
.
CXR:
A left PICC terminates with tip projecting over the lower SVC.
An
ill-defined area of opacity projecting over the right mid lung
probably
corresponds to focal atelectasis in the fissure seen on the
previous CT torso of three days prior. There are small
bilateral pleural effusions, right greater than left. The lungs
are otherwise clear. The mediastinal and hilar contours are
unremarkable. The soft tissues and osseous structures appear
within normal limits. IMPRESSION: Small bilateral pleural
effusions, right greater than left. No subdiaphragmatic free
air.
.
Portable Abdomen X-ray:
There are no dilated bowel loops. There are small bilateral
pleural effusions with bibasilar pulmonary atelectasis.
There is no evidence of free air under the diaphragm.
Brief Hospital Course:
54yF with stage III ovarian carcinoma s/p multiple chemotherapy
regimens, presented with UGI bleed, found to have gastric
ulceration and severe esophagitis.
The patient was initially treated in the [**Hospital Unit Name 153**] with 2-3 units of
PRBC transfusions. NG tube was placed, pt made NPO, and she
underwent upper endoscopy which revealed ulcerations from 25cm
to GE junction at 35cm with bleeding of one ulcer at GE junction
with no visible vessel in the esophagus compatible with severe
esophagitis--either reflux vs. chemotherapy vs. [**Female First Name (un) **] and
opening in the wall about 3mm in diameter in the proximal antrum
opposite the ulceration was visualized as well as likely
external stomach compression. She was initially treated with IV
antibiotics and IV PPI [**Hospital1 **]. While there was concern that this
opening represented a gastric peritoneal fistula, after
discussion with the patient and explaining risks of restarting
po diet, her diet was advanced and she tolerated this, though
continued to have already preexisting poor appetite. She had no
further bleeding episodes, and she was treated with pain
control, antiemetics, and was discharged home.
.
# Elevated Tbili: She was found to have an elevated bilirubin
level with LFTs within normal limits. Abdominal U/S on recent
admission showed no evidence of obstruction, and this level did
trend down during the course of her hospitalization.
.
Medications on Admission:
Medications from last admission [**Date range (1) 47643**]:
1. Venlafaxine 37.5 mg Sust. Release 24 hr PO DAILY (Daily).
2. Zolpidem 10 mg PO HS (at bedtime) as needed.
3. Metoclopramide 10 mg Tablet PO QIDACHS
4. Aluminum-Magnesium Hydroxide 15-30 MLs PO QID as needed.
5. Dronabinol 2.5 mg PO BID (2 times a day).
6. Oxycodone 10 mg SR PO Q12H (every 12 hours).
7. Oxycodone 10 mg PO Q6H (every 6 hours) as needed.
8. Lorazepam 0.5 mg PO Q8H (every 8 hours) as needed.
9. Simethicone 80 mg Chewable PO QID (4 times a day) as needed.
10. Loperamide 2 mg PO QID (4 times a day) as needed.
11. Calcium Carbonate 500 mg [**12-23**] Tablet, Chewables PO QID (4
times a day) as needed for heartburn.
12. Cipro 500 mg Tablet PO twice a day for 3 days.
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 1 months.
Disp:*120 Tablet(s)* Refills:*1*
2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
4. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
5. Simethicone 80 mg Tablet, Chewable Sig: [**12-23**] Tablet, Chewables
PO QID (4 times a day) as needed.
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO BID (2
times a day).
Disp:*250 mL* Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea. Tablet(s)
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day:
Take before meals.
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 mL PO four times a day as needed.
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for constipation.
14. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: [**12-23**]
Tablet, Chewables PO four times a day as needed for heartburn.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1.) Esophagitis (chemotherapy-induced versus candidiasis)
2.) Bleeding peptic ulcer
3.) Stage IIIC ovarian cancer
Discharge Condition:
afebrile with normal vital signs, tolerating some po.
Discharge Instructions:
You were hospitalized because of bleeding from an ulcer in your
stomach. You underwent an endoscopy which showed esophagitis
(or ulceration of your esophagus) as well. You were treated
with antibiotics, and medications that help reduce acid
production in the stomach (Pantoprazole) as well as a medication
that helps coat the ulcer (Carafate). It is important that you
continue these medications as instructed.
.
Please continue to take all medications as instructed and
continue to keep all health care appointments.
.
If you experience vomiting of black fluid or blood, have
worsening abdominal pain, are lightheaded, have shortness of
breath or worsening chest pain, or if your condition worsens in
any way, seek immediate medical attention.
Followup Instructions:
You have the following follow-up appointments with Dr.[**Name (NI) 72168**]
office:
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-19**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-19**] 11:00
|
[
"V44.2",
"V10.43",
"197.6",
"530.21",
"531.00",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10863, 10934
|
7073, 8509
|
349, 394
|
11092, 11148
|
5677, 7050
|
11944, 12329
|
4707, 4934
|
9306, 10840
|
10955, 11071
|
8535, 9283
|
11172, 11921
|
4949, 5658
|
297, 311
|
422, 2913
|
2935, 4452
|
4468, 4691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,166
| 123,821
|
22593
|
Discharge summary
|
report
|
Admission Date: [**2100-10-15**] Discharge Date: [**2100-10-19**]
Date of Birth: [**2021-8-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Fatigue, malaise, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo F with h/o DM2 and reactive airway disease p/w with
vomiting (non-bloody/bilious), diarrhea and nausea s abdominal
pain since this morning. Prior to this morning pt had been
feeling very tired since last Sunday. Pt states taht she thought
she might die at home if her daughter [**Name (NI) 9103**]'t taken her to the
hospital because of her increased fatigue/malaise. Pt denies any
focal symptoms prior to today. Pt does have sob and cough, which
have been alright recently. Pt also produces sputum at baseline
which has been better recently. Of note, per pt she was recently
called by her PCP's office and asked to stop using her albuterol
nebs which she uses daily. Also, pt c/o left shoulder pain which
is burning which pt states that she has had on and off for "a
long time", this pain was a [**6-6**] earlier today and is a [**4-6**]
currently. Instead she has been using her albuterol inhaler 5-6x
per day. Pt denies med noncompliance. Pt's daughter is nurses
aid at VA and check's pt's blood sugars occasionally. Over past
week it had been in the mid 100s until today when it was in the
400s. Pt denies fevers, chills, night sweats, HA, changes in
vision, CP, palpitations, abd pain, dysuria, hematuria, bloody
stool, myalgias, joint pain and depressed mood. Pt's daughter
states that pt has longstanding poor appetite.
.
In [**Name (NI) **] pt appeared lethargic though responsive, initially pt
bradycardic and hypotensive and found to be in junctional rhythm
but this resolved after approx 1 hour. Pt got 4L of IVF and
levaquin + ceftriaxone.
Past Medical History:
DM type 2
hypertension
?carpal tunnel syndrome per OMR
hyperlipidemia
memory loss per OMR
reactive airway dis (occasionally requiring short pred course,
seems to have been diagnosed in past few years, though she did
live in [**Country 2045**] prior to that time)
"heavy head and dizzyness" per OMR
Social History:
lives c daughter and her husband. denies smoking, drinking.
Family History:
noncontributory
Physical Exam:
Vitals: T:AF BP:126/63 P:89 R: 30 O2:98% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at angle of jaw at ~70degrees, no LAD
Lungs: wheeze b/l L>R, crackles at R base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding. guiac neg in ED.
back: c/o pain in left scapula, not tender to palpation
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
[**2100-10-15**] 04:00PM BLOOD WBC-9.9# RBC-4.88 Hgb-13.5 Hct-42.9
MCV-88 MCH-27.6 MCHC-31.4 RDW-13.8 Plt Ct-245
[**2100-10-16**] 03:30AM BLOOD WBC-11.1* RBC-4.33 Hgb-12.0 Hct-37.0
MCV-86 MCH-27.6 MCHC-32.3 RDW-14.0 Plt Ct-208
[**2100-10-17**] 07:20AM BLOOD WBC-7.2 RBC-4.26 Hgb-11.7* Hct-36.3
MCV-85 MCH-27.5 MCHC-32.3 RDW-14.2 Plt Ct-224
[**2100-10-19**] 06:00AM BLOOD WBC-6.7 RBC-4.36 Hgb-12.0 Hct-37.2 MCV-85
MCH-27.5 MCHC-32.3 RDW-14.4 Plt Ct-221
.
[**2100-10-15**] 04:00PM BLOOD Glucose-394* UreaN-35* Creat-2.1* Na-136
K-5.9* Cl-98 HCO3-21* AnGap-23*
[**2100-10-16**] 03:30AM BLOOD Glucose-120* UreaN-32* Creat-1.8* Na-138
K-6.8* Cl-106 HCO3-24 AnGap-15
[**2100-10-16**] 09:10AM BLOOD Glucose-112* UreaN-29* Creat-1.7* Na-141
K-4.8 Cl-107 HCO3-25 AnGap-14
[**2100-10-16**] 10:58AM BLOOD Glucose-105 UreaN-28* Creat-1.6* Na-139
K-4.5 Cl-105 HCO3-24 AnGap-15
[**2100-10-18**] 05:45AM BLOOD Glucose-137* UreaN-24* Creat-1.4* Na-140
K-4.6 Cl-104 HCO3-26 AnGap-15
[**2100-10-19**] 06:00AM BLOOD Glucose-138* UreaN-20 Creat-1.2* Na-143
K-4.5 Cl-107 HCO3-25 AnGap-16
[**2100-10-15**] 04:00PM BLOOD ALT-70* AST-111* LD(LDH)-336* CK(CPK)-72
AlkPhos-98 Amylase-39 TotBili-0.6
.
[**2100-10-16**] 03:30AM BLOOD ALT-77* AST-109* LD(LDH)-313*
[**2100-10-16**] 10:58AM BLOOD ALT-73* AST-78* LD(LDH)-228 AlkPhos-67
TotBili-0.6
[**2100-10-17**] 07:20AM BLOOD ALT-82* AST-79* LD(LDH)-284* AlkPhos-64
TotBili-0.6
[**2100-10-19**] 06:00AM BLOOD ALT-55* AST-30 LD(LDH)-178 AlkPhos-80
TotBili-0.8
.
[**2100-10-15**] 04:00PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2100-10-16**] 03:30AM BLOOD CK-MB-5 cTropnT-0.11*
[**2100-10-17**] 07:20AM BLOOD cTropnT-0.08*
.
[**2100-10-16**] 09:10AM BLOOD proBNP-1756*
.
[**2100-10-15**] 04:11PM BLOOD Lactate-5.5*
[**2100-10-15**] 07:02PM BLOOD Lactate-2.1*
[**2100-10-16**] 03:39AM BLOOD Lactate-1.7
.
Echocardiogram: IMPRESSION: Symmetric left ventricular
hypertrophy with global biventricular hypokinesis. Moderate
mitral regurgitation. Increased PCWP. In the absence of a
history of prominent systemic hypertension, an infiltrative
process should be considered (e.g., amyloid, Fabry's, etc.)
.
Chest X-ray ([**2100-10-18**]):IMPRESSION: PA and lateral chest compared
to [**10-16**]: Moderate cardiomegaly and small right pleural
effusion have increased since [**10-15**] and 19. There has not
been enough change in the appearance of the pulmonary
interstitium to say that pulmonary edema is present and there is
no mediastinal vascular engorgement, but the most likely
explanation is volume related to cardiac decompensation.
Brief Hospital Course:
Brief Hospital Course By Problem:
[**Name (NI) **] is a 79 year old female with a PMH significant for DM,
HTN, and RAD who presented with symptoms of fatigue and nausea,
found to have an anion gap metabolic acidosis, hyperkalemia,
bradycardia, hypotension and [**Last Name (un) **], who was initially admitted to
the MICU for management of her multiple medical problems.
.
#) Anion gap metabolic acidosis: at the time of admission,
patient had been complaining of fatigue for 5-7 days prior to
presentation, it was unclear if the fatigue and malaise was due
to a possible infection given left shift on differential. The
initial concern was that her overall fatigue and malaise led to
decreased po intake causing dehydration, which caused poor
perfusion and lactate production. On admission her lactate was
found to be 5.5, she was aggressively volume resuscitated with
4L of NS in the ER and over the next day her lactate decreased
to 2.1 then to 1.7, and her anion gap closed. The lactic
acidosis was also likely exacerbated by continued administration
of metformin prior to her presentation to the hospital. Her
chestx-ray had shown a possible RLL PNA, so she was empirically
treated with levaquin. After closure of her initial anion gap,
symptomatically she felt much better, and was able to tolerate
po intake and maintain hydration without further IV fluid
supplementation.
.
#) Bradycardia: on presentation to the ER patient had an episode
of bradycardia, with a HR in the 40's for about one hour. The
EKG looked like it was junctional, and her potassium was found
to be 5.9, peaked at 6.8, which was thought to be the likely
cause. The initial episode resolved, she was monitored on
telemetry with no further episodes of bradycardia.
.
#) Hypotension: on admission found to have systolic blood
pressures in the 80's to 90's, her blood pressure responded to
aggressive fluid resuscitation, and her outpatient medications
were held. During her hospital stay, her blood pressure
medications continued to be held, and at the time of discharge
no anti-hypertensives had been restarted as her SBP's had been
mostly in the 120's to 130's. On discharge her daughter was
instructed to check her mother's blood pressure daily and if the
SBP was greater than 140, she should restart her enalapril. She
was also scheduled for outpatient follow up with her PCP for
further BP medication titration.
.
#) Hyperkalemia: on admission, found to have K=5.9 which then
increased and peaked at 6.8. Thought to be due to decreased po
intake leading to [**Last Name (un) **] with concurrent ACEi administration.
Potassium normalized the morning of [**10-16**], and remained in the
normal range for the remainder of her hospitalization, as her
renal function improved. Her potassium was 4.5 on discharge.
.
#) SOB/Wheezing: patient initially complained of shortness of
breath, which was thought to be due to her longstanding reactive
airway disease, especially since she had recently been told by
her PCP to decrease her albuterol neb use. Initial chest x-ray
concerning for a possible pneumonia, so she was started on a 7
day course of levaquin, her sputum culture was contaminated,
blood cultures with no growth to date. She also received
albuterol and atrovent nebs every 4 hours as needed with
improvement in her respiratory symptoms. There was also concern
for a possible cardiac source of SOB, as she had a an enlarged
heart with mild pulmonary edema on chest x-ray, so she an
echocardiogram (full report above), that was concerning for an
infiltrative process, and was set up with outpatient follow up.
.
#) Troponin Leak: troponins were checked on [**10-15**], found to be
0.18, cardiology was consulted who felt that since the EKG did
not have any significant changes, it was likely demand ischemia
in setting of hypovolemia. Also, they felt that her current
acute kidney injury was contributing to the elevated troponin.
Troponins trended down over the next 2 days. A fasting lipid
panel was checked, she was started on an 81mg aspirin, her
pravastatin was to be restarted on discharge after her
transminases normalized. An echocardiogram was done to further
assess the function of her heart, and it showed an EF=30-35%,
with concern for an infiltrative process particularly amyloid,
so an SPEP was sent, and she was set up with outpatient
cardiology follow up.
.
#) [**Last Name (un) **]: patient with baseline Cr=1.5, on admission found to have
Cr of 2.1, her creatinine improved quickly with hydration,
making the cause likely prerenal, due to decreased po intake and
dehydration. On discharge patient's creatinine was 1.2, which
was lower than her prior baseline measurements.
.
#) Diabetes Mellitus Type II: initial hyperglycemia to the 400's
on admission, sugars also decreased with IV fluid resuscitation.
Her oral medications were discontinued on admission and she was
started on a humalog sliding scale. With reintroduction of a
diabetic diet, her blood sugars ranged between 140's to 190's.
Her glipizide was restarted the day prior to discharge, but her
metformin was discontiued and not restarted given her recent
lactic acidosis and baseline creatinine in the 1.4 to 1.5 range.
She was discharged on 10mg of glipizide with outpatient follow
up for further blood sugar titration.
.
#) Left Shoulder Pain: chronic based on history, normal amylase
and lipase, used tylenol for pain control.
Medications on Admission:
(per PCP note in [**Name9 (PRE) **] from [**9-5**]):
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) po
four times a day as needed for shortness of breath
ENALAPRIL MALEATE - 20 mg Tablet - 1 Tablet(s) by mouth once a
day for blood pressure
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
puffs(s) po twice a day
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day for
sugar
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day for blood pressure
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day for
diabetes (also called GLUCOPHAGE)
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime for
cholesterol
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1
puffs(s) po twice a day
TIMOLOL MALEATE - 0.5 % Drops - 1 gtt both eyes twice a day
.
Per Pt's Pill Bottles (which daughter brought in)
flovent
proair (uses 4-5x per day)
verapamil 180 daily
pravastatin 40 daily
hctz 25 daily
glipizide 10 daily
enalapril 20 daily
metformin 500 [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every 4-6 hours as needed
for sob/wheeze: One treatment every 4-6 hours as needed for
SOB/Wheeze for the next 2 days and then only as needed after.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
8. Serevent Diskus 50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Lactic Acidosis
2. Acute Kidney Injury
3. Bradycardia
4. Hypotension
5. Pneumonia
Secondary:
-Hypertension
-Diabetes
Discharge Condition:
At the time of discharge patient was ambulating without
difficulty, eating well, no further episodes of bradycardia or
hypotension, electrolytes had normalized and was considered
medically stable for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with about a week of fatigue, and one
day of nausea/vomiting. In the ER, you were found to be
bradycardic and hypotensive (have a slow heart rate and low
blood pressure), we also found that your potassium was high and
your kidney function had gotten a bit worse. They also found
that you had too much lactic acid in your blood, which was
probably from not eating and drinking enough, becoming
dehydrated and taking your metformin. In the ER they gave you
lots of IV fluids to rehydrate you and your lab values improved.
.
You were initially admitted to the ICU for closer monitoring,
during your stay in the ICU they also found that your liver
enzymes were elevated. These also improved with IV fluid
hydration. Also, your lab tests showed signs that your heart
was straining while you were dehydrated. You also had an
echocardiogram (an ultrasound of your heart), which does not
explain your symptoms but was abnormal. We have scheduled you
an appointment with a cardiologist to go over these results for
you. You also have a blood test pending called a serum protein
electrophoresis (SPEP). Dr. [**Last Name (STitle) 8499**] will follow up these
results with you.
.
We changed your diabetes medications while in the hospital, we
STOPPED the metformin, because we think this may have
contributed to the increase in your lactic acid level. We
continued the glipizide 10mg. We also stopped your blood
pressure medicines, since you had low blood pressures during the
start of your hospital stay. If you can check your blood
pressure at home, try to check it daily and if it is
consistently elevated, the top number is over 140, you can
restart the enalapril. Otherwise follow up with Dr. [**Last Name (STitle) 8499**]
regarding further recommendations about your blood pressure
medications.
.
Changes made to your medication regimen:
1. STOPPED Metformin
2. Stopped Verapamil, HCTZ and Enalapril
3. Started Aspirin 81mg daily
4. Can use albuterol nebulizer treatments every 4-6 hours as
needed for shortness of breath for the next 2 days, then only
use as needed
5. Restart your Pravastatin 40mg daily when you get home
.
You should also follow up with Dr. [**Last Name (STitle) 8499**] about getting a
repeat chest x-ray in [**5-3**] weeks to make sure the findings seen
on chest x-ray have resolved.
.
Please call your doctor or return to the hospital if you have
chest pain, trouble breathing, nausea or vomiting, fever/chills,
are unable to eat, drink, take your medications, or any other
concerning symptoms.
.
It was a pleasure caring for you and we wish you the best!
Followup Instructions:
You should follow up with your PCP, [**Name10 (NameIs) **] have scheduled you an
appointment:
Dr. [**First Name8 (NamePattern2) 6**] [**Name (STitle) **]
Specialty: PCP
Date and time: [**2100-10-25**] 11:30am
Location: [**Location (un) 19035**]
Phone number: [**Telephone/Fax (1) 7976**]
During this visit you should discuss your diabetes management,
you should also go over the results of your echocardiogram and
the SPEP blood test that was sent. Also, you may need to have
some of your blood pressure medications restarted during this
visit. Also, you will need a repeat chest x-ray in [**5-3**] weeks to
document resolution of pneumonia.
You also have an appointment with a new Cardiologist to discuss
your Echocardiogram:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: [**2100-10-25**] 2:00pm
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
|
[
"276.2",
"482.9",
"585.2",
"780.93",
"493.20",
"584.9",
"411.89",
"276.7",
"276.51",
"403.90",
"719.41",
"250.02",
"272.4",
"354.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12897, 12903
|
5523, 5529
|
351, 357
|
13075, 13287
|
2948, 5500
|
15962, 16963
|
2358, 2375
|
12011, 12874
|
12924, 13054
|
10966, 11988
|
13311, 15939
|
2390, 2929
|
277, 313
|
5557, 10940
|
385, 1944
|
1966, 2265
|
2281, 2342
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,938
| 193,320
|
23504
|
Discharge summary
|
report
|
Admission Date: [**2149-5-14**] Discharge Date: [**2149-7-23**]
Date of Birth: [**2108-1-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
fevers, enterocutaneous fistula
Major Surgical or Invasive Procedure:
Picc Line removal
Picc Line placement
Enterocutaneous fistula takedown, cholecystectomy
History of Present Illness:
The patient is a 41 year old morbidly obese male, well known to
the surgery service at [**Hospital1 18**], who previously had perforated
diverticulitis and developed an enterocutaneous fistula, and now
returns to [**Hospital1 18**] on [**2149-5-14**] for gram negative rod bacteremia
from a PICC line drawn at his rehab facility. He had previously
been discharged on [**2149-4-30**] after a prolonged hospital stay
(please see discharge summery for details). He does complain of
bilateral lower quadrant abdominal pain that is chronic in
nature, as well as 3 days of nausea and 4 days of malaise and
sweats.
Past Medical History:
- HTN
- hypercholesterolemia
- angina
- diverticulitis s/p sigmoid colectomy in [**9-/2147**]
- appendectomy in [**10/2147**]
- cecectomy in [**1-/2148**]
Social History:
Pt denies EtOH, tobacco, and recreational drug use
Family History:
NC
Physical Exam:
VS- 98.7, 62, 152/82, 16, 98% RA
NAD, AxOx3
CTA b/l
RRR, S1S2
Abd- soft, slightly disetended, dressing in place, no rebound or
guarding, ostomy with leakage
rectal- Guiac negative, normal tone
Pertinent Results:
[**2149-5-14**] 04:00PM BLOOD WBC-8.2 RBC-3.59* Hgb-9.4* Hct-28.6*
MCV-80* MCH-26.3* MCHC-33.0 RDW-17.0* Plt Ct-250
[**2149-5-14**] 04:00PM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-136
K-4.3 Cl-101 HCO3-29 AnGap-10
[**2149-5-14**] 04:00PM BLOOD ALT-32 AST-20 AlkPhos-151* Amylase-30
TotBili-0.6
[**2149-5-14**] 04:00PM BLOOD Albumin-3.0* Calcium-8.2* Phos-3.8 Mg-2.0
Iron-26*
[**2149-7-23**] 05:16AM BLOOD WBC-16.1* RBC-3.31* Hgb-9.2* Hct-27.4*
MCV-83 MCH-27.7 MCHC-33.5 RDW-19.7* Plt Ct-567*
[**2149-7-23**] 05:16AM BLOOD PT-13.4* PTT-22.6 INR(PT)-1.2*
[**2149-7-23**] 05:16AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-134
K-4.7 Cl-98 HCO3-28 AnGap-13
[**2149-7-23**] 05:16AM BLOOD Calcium-9.0 Phos-5.2* Mg-1.6
[**2149-7-21**] 06:20AM BLOOD ALT-57* AST-34 LD(LDH)-340* AlkPhos-325*
TotBili-0.3
[**2149-5-14**] 04:00PM BLOOD calTIBC-247* Ferritn-41 TRF-190*
[**2149-5-15**] 04:57AM BLOOD calTIBC-233* Ferritn-44 TRF-179*
[**2149-5-19**] 05:21AM BLOOD calTIBC-272 Ferritn-27* TRF-209
[**2149-5-26**] 01:55AM BLOOD calTIBC-274 Ferritn-27* TRF-211
[**2149-6-2**] 06:08AM BLOOD calTIBC-255* Ferritn-65 TRF-196*
[**2149-6-9**] 02:55AM BLOOD calTIBC-255* Ferritn-58 TRF-196*
[**2149-6-16**] 05:12AM BLOOD calTIBC-190* Ferritn-231 TRF-146*
[**2149-6-23**] 05:25AM BLOOD calTIBC-220* Ferritn-71 TRF-169*
[**2149-6-30**] 04:58AM BLOOD calTIBC-280 Ferritn-61 TRF-215
[**2149-7-7**] 06:49AM BLOOD calTIBC-270 Ferritn-172 TRF-208
[**2149-7-14**] 05:50AM BLOOD calTIBC-151* Ferritn-526* TRF-116*
[**2149-7-21**] 06:20AM BLOOD calTIBC-237* Ferritn-342 TRF-182*
[**2149-5-14**] 4:00 pm BLOOD CULTURE FROM L PICC LINE # 1.
**FINAL REPORT [**2149-5-17**]**
AEROBIC BOTTLE (Final [**2149-5-17**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) 60187**] [**Last Name (NamePattern1) 60188**] AT 5:31A [**2149-5-15**].
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC BOTTLE (Final [**2149-5-17**]):
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2149-7-20**] 9:06 am PERITONEAL FLUID RECEIVED IN TRANSPORT
SWAB.
Fluid should not be sent in swab transport media. Submit
fluids in a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final [**2149-7-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
FLUID CULTURE (Final [**2149-7-23**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN------------ 4 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2149-5-14**]
1. Large ventral hernia with loops of small bowel without
evidence of strangulation. An enterocutaneous fistula is seen.
Inferiorly, there is a 4.9 x 2.9 cm phlegmon with air-fluid
level and adjacent stranding. This is decreased in size compared
to the prior examination.
2. Ill-defined opacities in both lungs. The right lung opacities
were seen on the prior examination.
3. Gallstone
4. Right kidney exophytic cyst. Left kidney hypodensity cannot
be further characterized on this examination.
5. Tiny soft tissue nodule in left subcutaneous tissues of
uncertain clinical significance.
GALLBLADDER SCAN [**2149-6-13**]
Nonfilling of the gallbladder, consistent with a diagnosis of
acute
cholecystitis. The specificity of the findings on this
examination is decreased by the patient's NPO/TPN status.
Brief Hospital Course:
This patient is well known to the surgery service. He returned
from rehab with gram negative bacteremia. Subsequent blood
cultures were all negative. He was started empirically on
Vancomycin and Zosyn. A CT scan was done which showed a large
ventral hernia with loops of small bowel without evidence of
strangulation. An enterocutaneous fistula was seen. Inferiorly,
there was a 4.9 x 2.9 cm phlegmon with air-fluid level and
adjacent stranding. This was decreased in size compared to the
prior examination. There was no abscess. His nausea was
successfully treated with Anzemet. On HD 2 he had his PICC
changed over a wire (a 45-cm, double lumen PICC line was placed
through the left cephalic vein with the tip in the superior vena
cava). On HD 3, TPN was started at 30 kcal/kg and 1.8 g protein
/kg. He also received daily INR cheack and daily coumadin
dosing because his h/o of DVT. On HD 5, his antibiotics were
changed to Cefazolin only as blood cultures grew back
Klebsiella. On HD 7, the pt was started on Reglan, which helped
his nausea but it persisted. The patient had relief of his
nausea with Zofran and compazine suppository. On HD 10, his
Celexa was increased due to depression. The patient remained
afebrile and normal WBC count and all antibiotics were stopped
on HD 14. On HD 15, psychiatry saw him for depression and
recommended no change in his medications. On HD 18, a new
fistula opened inferiorly and a bag was placed over it. His
fistula drainage aparatus was working well. On HD 23, an OR
date of [**7-10**] was set by Dr. [**Last Name (STitle) 957**]. The plan was to
nutritionally replete the patient before his OR date.
The patient was also seen by orthopedics for his chronic left
shoulder pain. They thought he had some rotator cuff tendonitis
and recommended PT and NSAIDS for pain. X-rays were negative.
On HD 27, Dr. [**Last Name (STitle) 957**] injected his UE with Solu-Medrol and
Lidocaine. The patient began to have progressively worsening
LLQ pain. A CT scan was obtained [**2149-6-13**], which showed possible
cholecystitis and we started him on levoquin and metronidazole.
A HIDA scan was positive for cholecystitis and the patient had a
percutaneous cholecystostomy tube placed. We flushed the
cholecystostomy tube with gentamicin solution daily.
On [**2149-7-7**], the patient had an albumin of 3.0 and a transferrin
of 208. We felt at this time, the nutrition repletion had been
adequate and the patient went to the OR for an exploratory
laparotomy, takedown of his enterocutaneous fistula, a
cholecystectomy. The patient was trasferred to the SICU in
stable condition and treated empircally with cefazolin and
metronidazole. On post-op day 2, the patient was transfused 2
units of packed red blood cells for a Hct of 20.6 and
transferred back to the floor on post-op day 3. The patient's
pain was adequately controlled with a PCA and epidural. The
patient made good progress and was started on a soft diet, TPN
was cycled, and PCA was discontinued on post-op day 5. The
following day, the patient was tolerating a regular diet and PT
was assisting patient with his ambulation. Post-op day 7, the
patient had his epidural and foley catheter discontinued. Three
days later, the patient had drainage through his abdominal wound
dressing. The dressing was taken down and his abdominal wound
opened. We began wet-to-dry dressings with Dakins solution for
this. A wound culture grew back Enterococcus and the patient
was started on Vancomycin. The patient was having adequate PO
intake and his TPN was discontinued on [**7-22**]. The patient was
discharged to home [**7-23**] in stable on a 2 week regimen of
amoxacillin for ampicillin sensitive Enterococcus. VNA will see
the patient for his wound care and drain care. The patient will
also be evaluated for outpatient PT. The patient will follow up
with Dr. [**Last Name (STitle) 957**] in 1 week and his primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1007**] in 1 week as well.
Medications on Admission:
Coumadin 7.5mg qHS
lopressor 50mg [**Hospital1 **]
Celexa 20mg qDay
colace
protonix
atorvastatin
iron
milk of magnesia
loperamide
octreotide
reglan
dilaudid
ativan
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*20 Patch 72HR(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. 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*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Sodium Hypochlorite 0.5 % Liquid Sig: One (1) Appl Miscell.
ASDIR (AS DIRECTED): Apply to wet-to-dry dressing changes daily.
Disp:*1 bottle* Refills:*2*
10. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO three times
a day for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Enterocutaneous fistula, diverticulitis
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor if you experience fever, chills,
lightheadedness, dizziness, chest pain, shortness of breath,
severe abdominal pain, nausea/vomiting, or increased
bleeding/drainage from abdominal wound.
Do not drive while taking pain medication.
No lifting anything over 10 lbs.
Regular diet.
Do not swim or take baths.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in 1 week. Call [**Telephone/Fax (1) 17478**]
for appointment.
Please follow up with Dr. [**Last Name (STitle) 1007**] in 1 week. Call [**Telephone/Fax (1) 10492**]
for appointment.
|
[
"V58.61",
"552.21",
"567.22",
"401.9",
"569.81",
"568.0",
"787.02",
"996.62",
"V12.51",
"518.89",
"703.8",
"726.10",
"309.28",
"574.10",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"46.74",
"99.15",
"86.27",
"88.14",
"54.59",
"99.04",
"51.01",
"51.22",
"53.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11609, 11660
|
6106, 10150
|
346, 436
|
11744, 11753
|
1570, 5159
|
12123, 12366
|
1338, 1342
|
10364, 11586
|
11681, 11723
|
10176, 10341
|
11777, 12100
|
1357, 1551
|
275, 308
|
464, 1075
|
5195, 6083
|
1097, 1253
|
1269, 1322
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,056
| 106,112
|
1691
|
Discharge summary
|
report
|
Admission Date: [**2162-9-24**] Discharge Date: [**2162-9-28**]
Date of Birth: [**2093-3-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Mild exertional dyspnea
Major Surgical or Invasive Procedure:
[**2162-9-24**] s/p AVR (#21mm St.[**Male First Name (un) 923**] epic)/Asc ao replacement
History of Present Illness:
This is a 69 year old female with
known aortic stenosis since [**2158**]. She has experienced a slight
increase in exertional dyspnea. She was recently assessed by an
exercise tolerance test and echocardiogram which revealed more
severe aortic stenosis. At times, the patient is aware of brief
flutters which occur at night without lightheadedness,
dizziness,
presyncope or syncope. She denies effort related chest pain. She
remains very active, and performs routine daily activities
without difficulty. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 116**] for
surgical discussion. She presents today for preadmission testing
for an aortic valve replacement with possible ascending aorta
replacement [**2162-9-20**] with Dr. [**Last Name (STitle) **].
Past Medical History:
Aortic Stenosis
History of Mitral Valve Prolapse
Hypertension
Dyslipidemia
Obesity
Pernicious Anemia
Hypothyroidism
Osteoarthritis
Peripheral Neuropathy
Chronic Back Pain, Degenerative Scoliosis
Lumbosacral radiculitis - prior thoracic block
Past Surgical History:
- Lap Cholecystectomy
- Multiple Lumbar and Thoracic spine fusions(approx nine) One
c/b
likely MRSA
- Left Cataract Surgery, (Right cataract scheduled for [**6-15**])
- Fibroid Removal
- Mohs
Social History:
Last Dental Exam: [**2162-1-10**]
Race: Caucasian
Lives with: Husband
Occupation: Retired, very active golfer
Cigarettes: Never
ETOH: < 1 drink/week [] [**2-16**] drinks/week [] >8 drinks/week [x]
Illicit drug use: Denies
Family History:
non-contributory
Physical Exam:
Physical Exam:
Pulse: 70 Resp: 18 O2 sat: 100% room air
B/P Right: 129/95 Left: 138/87
Height: 65 inches Weight: 197lbs
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [x] grade 3/6 SEM radiating to carotids
Abdomen: Soft, non-distended, non-tender with NABS
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs
Pertinent Results:
Echocargiogram [**2162-9-24**]:
Pre-Bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the ascending aorta, aortic arch, and descending thoracic
aorta.
The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-11**]+) mitral regurgitation is seen.
There is very small pericardial effusion.
Post-Bypass:
The patient is on a phenylephrine infusion s/p aortic vavle and
ascending aortic plication.
There is a well seated #21 bioprosthetic aortic valve. There are
no perivalvular leaks. Peak and mean gradients are 14/7 with a
cardiac output of 3.6.
Left ventricular function is preserved with estimated EF-55%
Mitral regurgitaion appears slightly worse (mild-mod MR).
Tricuspid Reguritaiton remains [**1-11**]+.
There is no echocardiographic evidence or aortic dissection
post-decannulation.
.
[**2162-9-28**] 06:09AM BLOOD WBC-6.8 RBC-2.73* Hgb-8.7* Hct-26.0*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.7 Plt Ct-136*
[**2162-9-27**] 04:48AM BLOOD WBC-7.9 RBC-2.82* Hgb-8.9* Hct-27.4*
MCV-97 MCH-31.7 MCHC-32.7 RDW-15.0 Plt Ct-115*
[**2162-9-28**] 06:09AM BLOOD Glucose-114* UreaN-10 Creat-0.8 Na-134
K-4.1 Cl-98 HCO3-32 AnGap-8
[**2162-9-27**] 04:48AM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-135
K-4.2 Cl-100 HCO3-30 AnGap-9
[**2162-9-28**] 06:09AM BLOOD Mg-1.7
[**2162-9-27**] 04:48AM BLOOD Mg-2.3
Brief Hospital Course:
The patient was brought to the Operating Room on [**2162-9-24**] where
the patient underwent Aortic Valve(#21mm St.[**Male First Name (un) 923**] epic
tissue)/Ascending Aortic replacement . Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. She arrived AP over SB and was hypertensive
required nitro gtt. She was initially hypoxic and required extra
vent support, she eventually extubated without difficulty. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from the Nitro. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. She became hypoglycemic after receiving
Lantus per ICU protocol and remained in the unit one extra day
for monitoring. She was hypotensive and beta blocker was
adjusted. The patient was transferred to the telemetry floor on
POD#2 for further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 40 mg daily, LEVOTHYROXINE 100 mcg daily, ASPIRIN
325 mg daily, CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] 1,000
mcg daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
8. Potassium Chloride (Powder) 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis
History of Mitral Valve Prolapse
Hypertension
Dyslipidemia
Obesity
Pernicious Anemia
Hypothyroidism
Osteoarthritis
Peripheral Neuropathy
Chronic Back Pain, Degenerative Scoliosis
Lumbosacral radiculitis - prior thoracic block
Past surgical history:
Lap Cholecystectomy
Multiple Lumbar and Thoracic spine fusions(approx nine) One c/b
likely MRSA,
Left Cataract Surgery, (Right cataract scheduled for [**6-15**])
Fibroid Removal
Mohs
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Edema +1
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
[**Hospital 409**] Clinic [**Telephone/Fax (1) 170**] Date/Time:[**2162-10-7**] 10:30
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2162-10-27**] 1:00
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9751**] [**Telephone/Fax (1) 9752**], [**2162-10-14**] at 1:00p
Please call to schedule an appointment
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4541**] [**Telephone/Fax (1) 7164**] in [**1-11**] weeks
Completed by:[**2162-9-28**]
|
[
"724.4",
"799.02",
"715.90",
"737.39",
"272.4",
"447.71",
"E932.3",
"278.00",
"244.9",
"428.31",
"V45.4",
"401.9",
"424.1",
"251.1",
"338.29",
"281.0",
"428.0",
"458.29",
"356.9",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.59",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7145, 7194
|
4706, 6155
|
334, 426
|
7688, 7796
|
2697, 4683
|
8420, 8957
|
1965, 1983
|
6343, 7122
|
7215, 7458
|
6181, 6320
|
7820, 8397
|
7481, 7667
|
2014, 2678
|
270, 296
|
454, 1227
|
1249, 1491
|
1724, 1949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,616
| 105,335
|
17916
|
Discharge summary
|
report
|
Admission Date: [**2140-6-30**] Discharge Date: [**2140-7-20**]
Date of Birth: [**2082-4-6**] Sex: F
Service: LIVER TRANSPLANT SURGERY SERVICE
ADMITTING DIAGNOSIS: Fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female status post right donor hepatic lobectomy on [**2139-11-23**], complicated by postop biliary leak requiring a Roux-
en-Y hepaticojejunostomy to the left lateral segment duct on
[**2140-1-29**]. Status post multiple embolization coils
within liver,coiling of small bile ducts from
segment IV leaking into perihepatic space. Transhepatic
catheter was placed for a small contained leak at the
anastomosis. An ERCP performed on [**2140-5-25**] demonstrating
no leakage of the cystic duct remnant and biliary stents
removed.
The patient currently has a JP drain in place and left PTC
tube that is capped. The patient states that for the past 2
days, she has been experiencing temperatures ranging from
100.2-102.5. The patient has decreased appetite x2 days, but
thirsty, occasional left lower quadrant sharp pain, abdominal
pain x a few seconds, but subsides on its own--"feels like a
grinding" sensation. Lower quadrant pain is not positional.
Tylenol relieves sensation. No chills. No nausea or vomiting.
No shortness of breath. No sustained abdominal pain.
PAST MEDICAL HISTORY: Hypertension, history of migraines,
history of MRSA and bile gastritis, history of biliary leak,
status post right lobe hepatic donation [**2139-11-23**],
history of C. diff.
PAST SURGICAL HISTORY: Status post right hepatic lobectomy
and cholecystectomy on [**2139-11-23**], status post Roux-en-
Y hepaticojejunostomy to left lateral segment [**2140-1-29**], status post TAH/BSO, status post PICC line placement
[**2140-5-20**].
ALLERGIES: Ethylene, heparin agents, vancomycin, Zosyn,
meropenem.
MEDICATIONS ON ADMISSION: Vancomycin 250 q.i.d., Levaquin
500 once daily, Imitrex p.r.n., Mirapex 0.025 at bedtime,
atenolol 90 mg q. a.m., Protonix 40 mg b.i.d., clonazepam 1.0
at bedtime, Tylenol p.r.n., Colace 100 mg b.i.d., calcium, a
multivitamin and senna.
SOCIAL HISTORY: Living with sister in [**Name (NI) **]. No alcohol.
No tobacco. No substance abuse.
REVIEW OF SYSTEMS: The patient has had positive loose stools
x1 month, intermittent, 2 times a week, 6 stools a day
intermittently. Patient is on vancomycin 250 q.i.d. finishing
course with C. diff. The patient was supposed to have
elective cholangiogram.
PHYSICAL EXAM: The patient is afebrile at 99.1, heart rate
76, BP 102/71, respirations 20, 97% on room air. HEENT:
Pupils equal, round and reactive to light. EO movements are
full. No icterus. MOUTH: Tongue midline. Moist mucosa. Uvula
symmetric. NECK: Supple. No palpable nodes. No carotid bruits
bilaterally. LUNGS: Clear to A&P bilaterally. CV: Regular
rate and rhythm. Normal S1, S2, without murmurs, rubs.
ABDOMEN: Positive bowel sounds, with a JP drain, dark green
fluid in color. Left PTC capped. Incision site--both sites
are intact. Soft, nontender. No organomegaly. EXTREMITIES: No
C/C/E, +2 AT and dorsalis pedis.
LABS ON ADMISSION: WBC 7.9, hematocrit 31.9, platelets 142,
PT 14.1, PTT 27.0, INR 1.3. On [**6-30**], UA was obtained which
was negative. Sodium 137, 3.6, 100, bicarbonate 29, BUN and
creatinine 15 and 0.7, glucose 137. Patient had an ALT of 54,
AST 83, alkaline phosphatase 1861, total bilirubin 0.7.
HOSPITAL COURSE: Spoke to infectious disease who recommended
starting Zyvox 600 b.i.d. and aztreonam 2 gm x2 prior and
after cholangiogram, which was scheduled on the 15th. CT
abdomen with and without contrast was obtained the evening of
admission, which demonstrated interval mild increase in the
amount of biliary duct dilatation, with new pneumobilia.
Given the patient's recent increase in alkaline phosphatase,
biliary duct ischemia with mild stricture cannot be excluded.
Cholangitis should also be considered given the patient's
history of a fever. 2) Interval improvement in the size of
previously identified biloma and liver infarction. 3)
Interval resolution of the patient's pleural effusion.
On [**2140-7-1**], the patient also had a HIDA scan
demonstrating no definite biliary leak identified, prominence
of the left lateral intrahepatic biliary system, the left
medial biliary ducts less prominent, but no evidence to
suggest exclusion, multiple photopenic foci, corresponding
with areas of known fluid collection seen on the prior cross-
sectional studies.
On hospital day 2, the patient was febrile with rigors. No
nausea, vomiting. The T-tube had not drained due to a kink.
The patient was on linezolid and aztreonam. JP and T-tube
sites were without any redness. On [**2140-7-1**], the patient
had a cholangiogram demonstrating exchange for new 5 French
pigtail catheter, drained the intrahepatic bile duct to
segment III. No dilated ducts in this region.
Nonvisualization of the duct from segment II. Attempt will be
made to access percutaneously the bile duct to segment II via
ultrasonographic guidance in a few days, which was discussed
with Dr. [**Last Name (STitle) **].
Cultures obtained on admission and hospital day 1 for fevers:
Urine culture demonstrated less than 10,000 organisms. Blood
culture demonstrated no growth from [**2140-7-1**]. Also,
stool was collected, demonstrating no C. diff. Fluid was
collected from the JP drain, demonstrating Staph aureus coag-
positive.
The patient continued on linezolid, aztreonam, and also
patient continued on vancomycin for C. diff. The patient
became very emotional, very anxious, and psychiatry did see
patient on [**2140-7-4**]. Psychiatry made some
recommendations with regards to checking labs, as well as
medication suggestions.
On [**2140-7-8**], it was requested by the transplant team to
place a second PTBD tube into the bile duct from segment II,
which was performed on [**2140-7-8**]. There were no
complications. Total contrast used was 50 ml of Optiray.
There was placement of an 8 French PTBD tube into the duct of
segment II, connected to external drainage bag. The tip of
the catheter appears located along the JP drain. Replacement
of a clogged 5 French pigtail PTBD catheter by a new one,
same as before. The catheter is in the duct of segment III
and was capped, performed by Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Doctor Last Name 19595**] and
Dr. [**First Name11 (Name Pattern1) 6339**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 19420**].
On [**7-9**], a CT abdomen and pelvis with contrast were
performed to evaluate placement of percutaneous transhepatic
catheters. Impression: There was a new expansile
retrohepatic, mixed high attenuation collection with mass
effect on the IVC and adjacent liver, consistent with a
hematoma. Small to moderate serosanguineous fluid is seen
throughout the abdomen and pelvis. A nonenhancing hypodense
irregularity of the liver margin and to the aforementioned
collection, the appearance of which tear/laceration of the
liver capsule and/or parenchymal liver injury is possible. 3)
There is irregular attenuation of the proximal intrahepatic
left main duct portal vein. A small focus of high attenuation
seen on series 2, image 18 at the periphery at the
retrohepatic collection could indicate an element of active
extravasation from material entry. These findings were
conveyed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 49634**] from the transplant team.
The patient continued on triple-antibiotics, linezolid,
aztreonam, vancomycin. Infectious disease followed the
patient while the patient was in the hospital making daily
recommendations. On [**2140-7-13**], the patient was
transferred from Far-10 to ICU because of complaints of
abdominal pain and back pain. Also, the patient had
hematocrit drop that evening. A CT abdomen and pelvis were
performed demonstrating features consistent with ongoing
active bleeding into retrohepatic hematoma. These findings
have been communicated to the ordering physician. [**Name10 (NameIs) **] patient
had a hematocrit of 27.2, WBC 11.4, platelets 129. The
patient received 1 unit of packed red blood cells and 2 units
of FFP. The patient was transferred back from ICU to regular
floor, and physical therapy and occupational therapy, as well
as nutrition were consulted.
On hospital day 16, patient afebrile, vital signs stable,
appears comfortable. Diet was advanced. The patient was
transferred to the regular floor on [**2140-7-15**]. The
patient did received Dilaudid p.r.n. for abdominal
pain/discomfort. The patient had calorie counts while being
an inpatient, and it was discussed among the team and to the
patient, that the patient did have poor intake, and that the
patient needed to improve her p.o. intake in order for her to
be discharged. Antibiotics were discontinued, and her labs
had been stable. Today, [**7-20**], her labs are the following:
WBC 10.1, hematocrit 35.3, platelets 208, PT 15.8, 30.5, INR
1.7, sodium 133, 3.6, 95, 30, bicarbonate 30, BUN and
creatinine of 5 and 0.4, and glucose 94. The patient has ALT
of 16, AST 24, alkaline phosphatase of 653 from 719 from the
previous day.
So, the patient will be able to be discharged to home without
physical or occupational services. The patient does have a
pigtail that put out overnight 10 cc, and JP drain 175. The
patient will be leaving on the following medications: Tylenol
500-1,000 mg p.o. q. 6 h. p.r.n., atenolol 125 mg p.o. once
daily, calcium carbonate 500 b.i.d., clonazepam 0.5 mg at
bedtime, Benadryl 25 p.o. q. 6 h. p.r.n., Colace 100 mg
b.i.d., Dilaudid 0.5-1 mg q. 4 h. p.r.n., multivitamin 1 once
daily, nortriptyline 10 mg at bedtime, Protonix 40 mg p.o. q.
12, Paxil 0.25 mg at bedtime, senna 1-2 tabs p.o. b.i.d. or
p.r.n., ursodiol 300 mg b.i.d., Vitamin D 400 units p.o. once
daily.
The patient should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2140-7-27**] at 11:40 a.m. located in the LM [**Hospital Unit Name **], [**Location (un) 20682**], telephone #[**Telephone/Fax (1) 673**]. The patient should also
follow-up with outpatient psychiatry which a date and time
will hopefully be given to her before she is discharged. The
patient should call transplant surgery immediately at [**Telephone/Fax (1) 30335**] if any fevers, chills, nausea, vomiting, abdominal pain,
diarrhea, decreased energy, sustained decreased appetite,
difficulty with urination or bowel movements, also any
increased shortness of breath, chest pain, lower extremity
swelling. Patient will needs labs, unless otherwise, on
Mondays and Thursdays with the following labs: CBC, chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
rapamycin level. These should be faxed immediately to [**Telephone/Fax (1) 24749**].
FINAL DIAGNOSES: History of bile leak and small perihepatic
fluid collection with hematoma in the posterior hepatic
space, who presented with fevers.
ADDENDUM: On [**2140-7-13**], after the CAT scan that was
performed which found hematoma of the posterior hepatic
space, an angiogram was performed demonstrating no evidence
about the source of hepatic artery bleeding. There was a
small pseudoaneurysm at the branch of the midhepatic artery
measuring 5 mm in size, and successful placement of central
venous catheter to the right internal jugular vein with the
tip in the superior vena cava. Currently, the patient will be
going home. The patient may be going home in a couple of days
based on patient's nutrition. She has a very poor intake, and
nutrition is seeing her, but in order for us to discharge her
to home, the patient needs to improve on her p.o. nutrition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2140-7-20**] 11:47:31
T: [**2140-7-20**] 13:09:22
Job#: [**Job Number 49635**]
|
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"041.04",
"296.20",
"576.8"
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icd9cm
|
[
[
[]
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] |
[
"99.04",
"88.47",
"38.93",
"51.98",
"87.54",
"97.05",
"99.07"
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icd9pcs
|
[
[
[]
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1869, 2107
|
3418, 10793
|
1541, 1842
|
2483, 3100
|
10811, 11943
|
2229, 2467
|
224, 1318
|
3115, 3400
|
186, 195
|
1341, 1517
|
2124, 2209
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,559
| 170,231
|
2887
|
Discharge summary
|
report
|
Admission Date: [**2133-4-3**] Discharge Date: [**2133-4-10**]
Date of Birth: [**2064-10-7**] Sex: F
Service: CARDIOTHOR
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old female
who three week prior had laryngitis. She experienced upper
chest and throat burning and exertional dyspnea. She went to
see her primary care physician and during the work-up an
electrocardiogram was done. This showed T wave flattening in
I, aVL, V5, V6, as well as an old myocardial infarction. The
burning with exertion occurred after half a block which
resolved with rest. She denied every having this sensation
at rest. She also had associated lightheadedness, but denies
any nausea, vomiting, orthopnea, paroxysmal nocturnal
dyspnea, or peripheral edema. She is admitted to [**Hospital6 1760**] for cardiac catheterization
and evaluation by the Cardiothoracic Team for coronary artery
bypass grafting.
PAST MEDICAL HISTORY: Significant for hypertension, silent
myocardial infarction, hypercholesterolemia, hypothyroidism
and anemia.
PAST SURGICAL HISTORY: Significant for left knee replacement
in [**2127**] and right knee replacement in [**2132-11-29**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Isordil 10 mg po t.i.d., Lopressor
50 mg po t.i.d., Zestril 2.5 mg po q.d., Lipitor 20 mg po
q.d., allopurinol 150 mg po q.d., aspirin 81 mg po q.d.,
Tagamet 300 mg po q.d., Levoxyl 0.125 mg po q.d., B12 2 mg po
q.d., Vitamin C q.d., Vitamin E q.d., multivitamin q.d.,
ferrous sulfate q.d. and propoxyphene with Tylenol once a
day.
SOCIAL HISTORY: The patient is married. Denies ETOH and
tobacco use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: The patient is a female in no acute
distress. Pulse is 63. Blood pressure 108/64. Respiratory
rate 20 with 02 saturation of 100%. Her heart is regular
rate and rhythm with no murmurs. Chest is clear to
auscultation bilaterally. Abdomen is soft, obese, nontender
with no masses. There is no peripheral edema, clubbing or
cyanosis. Neck is supple with no jugular venous distention
and no bruits.
LABORATORIES ON ADMISSION: White blood cell count of 6.3,
hematocrit of 37, platelets of 342,000. Sodium of 140,
potassium 4.7, chloride 98, bicarbonate of 28, BUN of 16,
creatinine 0.8, INR of 1.0. Chest x-ray is significant for a
large hiatal hernia, no congestive heart failure, pneumonia,
or pleural effusion. Cardiac catheterization shows left
anterior descending with 80% stenosis, left circumflex 70-80%
stenosis, right coronary artery with 2 sequential 95%
stenoses, which was then totally occluded into mid vessel.
The calculated left ventricular ejection fraction was 56%.
There was trace mitral regurgitation seen.
HOSPITAL COURSE: The patient was admitted and underwent a
cardiac catheterization. She tolerated the procedure well
and was on the Cardiac Medical Service and remained stable.
On hospital day number four, the patient was taken to the
Operating Room by the Cardiothoracic Team where she underwent
a coronary artery bypass graft times three. The grafts were
left internal mammary artery to left anterior descending,
saphenous vein graft to right coronary artery PD and
saphenous vein graft to OM. Patient tolerated the procedure
well and was transferred to the Cardiac Intensive Care Unit
on a Neo-Synephrine and propofol drip.
Early postoperative course, patient required low dose
Neo-Synephrine and atrial pacing for blood pressure support.
Patient was extubated without incident. Through
postoperative day number one, the patient continued to
require Neo-Synephrine for blood pressure support, though,
she remained hemodynamically stable. On postoperative day
number one, her hematocrit was found to be 24. She was
transfused with one unit of packed red blood cells. There
was no evidence of active bleeding. Chest tube drainage
remained 300.
On postoperative day number two, she continued on low dose
Neo-Synephrine. Mean arterial pressure remained greater than
60. She is awake, alert and oriented. Respiratory status
continued to improve. Chest tubes were discontinued without
incident and she was transferred to the floor for the
remainder of her recovery.
On the floor, the patient remained hemodynamically stable and
afebrile. Her wires were discontinued on postoperative day
number three without incident. Foley was discontinued and
patient was able to void without incident. She has been
evaluated by Physical Therapy. She is currently at a level 3
activity. After discussing at length, patient desires to go
home as opposed to returning to rehabilitation. She has her
husband and her son for support. She is tolerating a low fat
diet and is stable for discharge.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, now status post coronary artery
bypass graft times three.
2. Hypertension.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Anemia.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg po b.i.d.
2. Lasix 20 mg po b.i.d. times seven days.
3. KCL 20 mEq po b.i.d. times seven days.
4. Colace 100 mg po b.i.d.
5. Tagamet 300 mg po q.d.
6. Enteric coated aspirin 325 mg po q.d.
7. Allopurinol 150 mg po q.d.
8. Levoxyl 0.125 mg po q.d.
9. Dietrol 2 mg po q.d.
10. Percocet 5/325 [**12-31**] po q. 4 hours prn.
11. Lipitor 20 mg po q.d.
12. Vitamin C po q.d.
13. Vitamin E po q.d.
14. Multivitamin po q.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: Patient to follow-up with Dr. [**Last Name (STitle) 70**] in six
weeks. Patient will follow-up with Dr. [**Last Name (STitle) **] in two weeks,
who is the patient's primary care physician.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2133-4-10**] 05:11
T: [**2133-4-10**] 05:11
JOB#: [**Job Number 13970**]
|
[
"244.9",
"276.6",
"285.9",
"458.2",
"413.9",
"424.0",
"414.01",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.53",
"37.22",
"88.56",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1689, 1707
|
4782, 4946
|
4972, 5417
|
1267, 1600
|
2782, 4761
|
1101, 1240
|
1730, 2146
|
156, 169
|
198, 944
|
2161, 2764
|
967, 1077
|
1617, 1672
|
5442, 5958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,673
| 131,970
|
51889
|
Discharge summary
|
report
|
Admission Date: [**2158-6-16**] Discharge Date: [**2158-6-28**]
Date of Birth: [**2095-6-3**] Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypotension, right flank pain
Major Surgical or Invasive Procedure:
Arterial line placement
History of Present Illness:
This is a 63-year-old woman with a history of bilateral PE, RLL
infarct and RLE DVT in [**4-/2158**] on coumadin who presents with
hypotension noted at [**Hospital1 1501**] to 70/40. Patient had RLQ abd pain.
History of light-headedness with syncope on standing, multiple
episodes. Denied chest pain, dyspnea.
.
In the ED, patient triggered for BP of 68/40. Stat HCT was
performed which showed HCT of 21 from previous baseline of 40.
INR was 4.3. CR was elevated to 3.9 from previous baseline of
0.6 on [**6-6**]. Trop was 0.05. LFTs were flat. Patient was
transfused 2U PRBC, 2U FFP and reveresed with 10mg PO vitamin K.
A bedside u/s was performed which showed no evidence of
pericardial effusion and good LV squeeze. EKG showed SR at 62
without evidence of STEMI. CT abd/pelv was performed which
showed evidence of a large right pelvic RP hematoma and second
RP hematoma in the right psoas muscle. Since this was a non-con
CT, active extravasation was unable to be determined. Surgery
was consulted down in the ED and felt patient had no active
surgical issues and recommended admission to MICU with IR made
aware of patient.
.
On arrival to the MICU, patient was alert and oriented to
person, place, year, month, but not date. She reported that she
fell onto her bed about 1 week prior to this admission. Had a
negative right hip x-ray at rehab, but continued to have
increased right sided sharp pain over the next 2 days with
associated nausea and decreased appetite. Denied CP/SOB.
Reported that she was slightly confused on night prior to
arrival.
Past Medical History:
-Pulmonary embolism in [**4-/2158**] on coumadin
-Myasthenia [**Last Name (un) 2902**] dx [**3-/2158**] on mestinon, cyclosporin
---Ptosis
---Diplopia
-Exophoria
-Meibomitis
-S/P Colonoscopy
-Morbid Obesity
-Hypertension
-Hypothyroidism
-Superficial Thrombophlebitis
-Migraine
-COPD
-Positive PPD: age 15, started on INH given immunosuppressants
for MG
-Asthma
-Poliomyelitis
-Chronic Fatiogue Syndrome
-Osteoarthritis
Social History:
Smoking: Former Smoker ([**2146-1-29**]) 1 ppd, 35 pack-years
Alcohol: Rare
Illicits: None
Family History:
Father: CAD/PVD, fatal MI at 52
Maternal Grandmother: Cancer, Thyroid Disorder
2 sisters with PE thought [**3-2**] hypercoagulopathy
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
admission labs
[**2158-6-16**] 02:15AM BLOOD WBC-18.1*# RBC-2.28*# Hgb-6.9*#
Hct-21.7*# MCV-95 MCH-30.5 MCHC-32.0 RDW-13.9 Plt Ct-328
[**2158-6-16**] 02:15AM BLOOD Neuts-85.0* Lymphs-8.1* Monos-6.6 Eos-0.3
Baso-0.1
[**2158-6-16**] 02:15AM BLOOD PT-43.5* PTT-35.5 INR(PT)-4.3*
[**2158-6-16**] 11:44AM BLOOD LMWH-0.27
[**2158-6-16**] 02:15AM BLOOD Glucose-99 UreaN-45* Creat-3.9*# Na-134
K-5.4* Cl-92* HCO3-25 AnGap-22*
[**2158-6-16**] 02:15AM BLOOD ALT-13 AST-62* AlkPhos-53 TotBili-0.5
[**2158-6-16**] 02:15AM BLOOD Lipase-34
[**2158-6-16**] 02:15AM BLOOD cTropnT-0.05*
[**2158-6-16**] 02:15AM BLOOD Albumin-3.3*
[**2158-6-16**] 04:37PM BLOOD Calcium-8.1* Phos-7.3*# Mg-1.8
[**2158-6-16**] 02:15AM BLOOD Cyclspr-162
[**2158-6-16**] 02:45AM BLOOD Lactate-4.2*
[**2158-6-16**] 02:45AM BLOOD Hgb-6.9* calcHCT-21
[**2158-6-17**] 10:06AM BLOOD freeCa-1.03*
.
urine
[**2158-6-17**] 03:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2158-6-17**] 03:30AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
.
Blood and urine cultures negative.
.
CT ABDOMEN AND PELVIS [**2158-6-16**]:
1. A 16 cm right pelvic retroperitoneal hematoma of unclear
site of origin in addition to smaller right psoas hematoma. As
this is a non-contrast study, there is no ability to assess for
continued extravasation.
2. Fatty liver.
3. 15 x 18 mm right inguinal node.
4. Right lower long opacity likely relates to prior pulmonary
infarct.
.
LENIs
No thrombus identified within the veins of the right leg.
Partial chronic
thrombus seen in the left popliteal vein and in the distal
portion of the left superficial femoral vein. No acute DVT is
identified in either leg.
.
ECHO
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). There is an abnormal systolic flow
contour at rest, but no left ventricular outflow obstruction.
Right ventricular chamber size and free wall motion are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic
function. An abnormal LVOT flow contour is seen but an LVOT
gradient is not present. No signifcant valvular abnormality
seen.
.
CXR [**2158-6-18**]
Small region of consolidation or scar-like opacity in the right
lower lobe
laterally is barely visible on the conventional chest
radiograph. Lungs are otherwise clear. Heart size normal. No
pleural abnormality or evidence of central lymph node
enlargement.
CXR [**2158-6-21**]
Left PICC line tip is at the level of superior SVC. Substantial
improvement in the right basilar aeration is demonstrated with
still present bilateral effusions and bibasilar atelectasis. No
pneumothorax is seen.
CTU [**2158-6-24**]
1. Large right intrapelvic hematoma, with leftward inferior
mass effect upon the neighboring uterus and bladder. The size of
this hematoma is unchanged since [**2158-6-16**]. There is no
active contrast extravasation. The location and orientation of
this hematoma suggests a possible right adnexal origin.
2. New mild right hydronephrosis, likely secondary to
mid-ureteral
obstruction from the hematoma.
3. Stable separate small right psoas hematoma.
4. Colonic diverticulosis, with no evidence of diverticulitis.
5. No active extravasation detected.
Brief Hospital Course:
This is a 63-year-old woman with a history of DVT and PE on
coumadin who presents with hypotension and right flank pain from
rehab facility found to have very large right retroperitoneal
bleed while on supratherapeutic warfarin and lovenox. She was
resuscitated with blood products and fluid and anticoagulation
was held until she was stable. She also had [**Last Name (un) **], which resolved
with holding cyclosporine and volume resuscitation as well.
.
# Acute Blood Loss Anemia, SHOCK/BLEED: Patient presented with
RP bleed on CT abd/pelv without contrast. Unable to assess for
active extravasation in the setting of non-con CT. INR 4.3 on
arrival. Received 6 units PRBC and 5 units FFP and was reversed
with 10mg vitamin K and 50mg Protamine. Surgery and IR felt
there was no need for intervention. Her hematocrits were
subsequently stable. Echo showed hyperdynamic LV and normal RV
function. Patient afebrile with stable leukocytosis and no
source of infection to suggest alternative source of
hypotension. Given stable hematocrits and how recently she had
had her pulmonary emboli, she was started on IV heparin with no
bolus. She was also restarted on warfarin. However, patient's
INR was slow to become therapeutic, and she was discharged on
Lovenox 100mg [**Hospital1 **] with bridge to coumadin. Patient should
continue Lovenox for 48 hours after coumadin is therapeutic.
.
# Acute Renal Failure: Patient presented with elevated
creatinine to 3.4 from baseline of 0.8 on [**6-6**]. Likely ATN in
setting of hypovolemia from RP bleed with question component of
cyclosporine toxicity. Nephrology was consulted. There was
initially concern for hyperkalemia, however patient did not
require hemodialysis. Cyclosporine was restarted after
initially being held while renal function recovered. Her renal
function remained stable.
.
# RESPIRTOARY DISTRESS: Patient had worsening respiratory
function with hypoxia and cough through [**6-18**] with increased
oxygen requirement. She required BIPAP for elevated CO2 for one
day with some improvement. Etiology of respiratory distress
unclear but likely related to volume overload. Echo showed no
evidence of RV dysfunction to suggest worsening PEs. Hypercarbia
may be due to retention [**3-2**] muscle weakness from myasthenia,
however NIFs were stable at -50. With diuresis and rest with
bipap, patient was weaned to NC oxygen and had improved
respiratory rate and less work of breathing. Patient continued
to be diuresed on the general medicine floor with 40mg of IV
lasix twice a day. She was weaned down to 1L of oxygen at
discharge. Her lasix was stopped, and her oxygen can be weaned
as tolerated at rehab.
.
# PE: Patient on anticoagulation for recent bilateral PE with
RLL infarction. No clear precipitant, and patient may benefit
from a hypercoagulable work-up. Patient was reversed in ED for
INR of 4.3 and active RP bleed. LENIs showed no acute DVT,
partial chronic thrombus. Once hemodynamically stable, patient
was bridged back to therapeutic warfarin with heparin gtt and
then Lovenox. Patient should have all age appropriate cancer
screenings including a mammogram and a colonoscopy.
# HEMATURIA: Patient had a transient hematuria on [**6-24**]. UA
showed > 188 RBC but repeat UA showed less RBC, and the urine
subsequently become clear. The etiology was not entirely clear,
possibly from prior foley insertion vs kidney stone. A CTU was
performed, which showed mild hydronephrosis on the right side,
likely due to right mid-ureteral obstruction from the main
pelvic hematoma. Urology was consulted and they recommended
sending urine cytology and for outpatient urology follow-up. Her
Hct remained stable. Urine cytology was sent and was still
pending at the time of discharge.
.
# [**First Name9 (NamePattern2) **] [**Last Name (un) **]: Patient with diagnosis of MG in 2/[**2158**].
Primarilyy ocular symptoms. She is on pyridostigmine.
Cyclosporine was held in the setting of acute renal failure, but
restarted [**6-20**] under nephrology guidance.
CHRONIC CARE
# HTN: On atenolol, lisnopril and HCTZ at home, which were all
held in the setting of hypotension. After her blood pressure
improved, we resumed her home atenolol but continued to hold
lisinopril and HCTZ as patient remained normotensive. If she
becomes hypertensive, lisinopril and HCTZ can be added back.
.
# POSITIVE PPD: in setting of immunosuppression for MG,
patient was started on INH and pyridoxine for positive PPD when
she was 15. She was continued on INH and pyridoxine.
.
# TRANSITIONAL ISSUES:
1. Outpatient urology follow up for transient hematuria
2. Follow-up on urine cytology
3. On warfarin, regular INR check
4. Stop Lovenox after INR is therapeutic for 48 hours
5. Needs EGD and screening colonoscopy for guiac positive stools
after acute illness has subsided
6. Needs follow-up with neurology for [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atenolol 25 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Isoniazid 300 mg PO DAILY
4. Pyridoxine 50 mg PO DAILY
5. Pyridostigmine Bromide 60 mg PO Q8H
6. Lisinopril 10 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. CycloSPORINE (Neoral) MODIFIED MD to order daily dose PO
Q12H
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Calcium Carbonate 500 mg PO Frequency is Unknown
Discharge Medications:
1. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
2. Isoniazid 300 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Pyridostigmine Bromide 60 mg PO Q8H
5. Pyridoxine 50 mg PO DAILY
6. Warfarin 7.5 mg PO DAILY16
7. Multivitamins 1 TAB PO DAILY
8. Calcium Carbonate 500 mg PO TID
9. Enoxaparin Sodium 100 mg SC Q12H
10. Pantoprazole 40 mg PO Q24H
11. Atenolol 25 mg PO DAILY
12. traZODONE 25 mg PO HS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary diagnosis: Retroperitoneal bleeding
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 10132**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital because of a bleed in your back, low blood
pressure, and decreased kidney function. This was likely due to
high levels of anticoagulation. You received 6 units of blood,
5 units of plasma, vitamin K and protamine. Your blood count
subsequently stabilized and your kidney function returned to
[**Location 213**]. You also had difficulty breathing because you had some
extra fluid in your lungs. We gave you IV lasix to remove extra
fluid and your breathing became better.
.
You need to be anticoagulated because of your recent DVT and PE.
We started you on a heparin drip and on coumadin. It has been
taking a long time for your INR (coumadin level) to become
therapeutic. As such, we are discharging you on Lovenox
(another blood thinner) until your INR (coumadin level) is
between 2.0-3.0. You should continue taking Lovenox for 48
hours after your INR is therapeutic.
.
You had some blood in your stools, which is likely from
irritation to the lining of your stomach from the stress of
being so sick. However, you did not have dark, tarry stools
(melena). It is important that you follow-up with your [**Location (un) 2274**]
gastroenterologist for an endoscopy and a screening colonoscopy.
.
We stopped your hydrochlorothiazide and your lisinopril because
your blood pressure was normal without these medications. These
can be restarted by your rehab if your blood pressure is high.
.
The following changes were made to your medications:
--START taking Lovenox 100mg twice a day until your INR is
between 2.0-3.0 (and then continue Lovenox for another 48 hours)
--START taking coumadin 7.5mg per day or as directed
--START taking protonix 40mg once a day for gastritis
--STOP taking hydrochlorothiazide for blood pressure
--STOP taking lisinoporil for blood pressure
Followup Instructions:
Please have your rehab facility help you make appointments with
urology (for follow-up of hematuria), gastroenterology (for
EGD/colonoscopy in setting of guaic positive stools but no
melena), and neurology (for [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**]).
.
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2158-8-21**] at 3:40 PM
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: MONDAY [**2158-8-21**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2158-8-21**] at 4:00 PM
|
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icd9cm
|
[
[
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[
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icd9pcs
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1939, 2359
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,786
| 196,708
|
16930
|
Discharge summary
|
report
|
Admission Date: [**2122-9-25**] Discharge Date: [**2122-10-19**]
Date of Birth: [**2082-7-26**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Sulfa (Sulfonamides) / Bactrim / Iodine; Iodine
Containing / Abciximab
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 40 yo woman with AML s/p related allo-SCT in
[**10-14**] with extensive chronic GVHD who is admitted from [**Month/Year (2) **]
for failure to thrive. She was discharged from rehab last
Tuesday (3 days ago) following her last hospital admission and
ever since arriving home she states that she does not have any
desire to eat or drink. She denies sick contacts and fevers. She
spends most of her time in bed. She used to be able to walk
using her walker to transfer from bed to commode, from commode
to wheelchair, etc, but she has not ambulated since the
beginning of her last hospital admission, almost two months ago.
She denies nausea, vomiting, abdominal pain, cough, dysuria,
diarrhea, shortness of breath or chest pain. She denies being
depressed although she endorses most symptoms of depression,
including low energy, depressed mood, anhedonia, hopelessness,
sleep problems, and lack of appetite appetite. Her main concern
is that her husband works at night and cannot help her if she
needs to use the bedpan or the commode. One 15 year old son
helps her, and apparently this is a problem for the patient,
either because the patient is concerned about his back, or
because she does not always get the help she needs, this is
unclear. She has meals served in bed at home. She has a shower
bench, a manual wheelchair, a cane, and a walker but otherwise
no accommodations nor help.
The patient was last admitted one month ago for diarrhea, pain
and leg weakness. This year she also had another admission for
back pain where she was found to have a fracture in T12 with no
cord compression, treated conservatively with TLSO. On that
admission she also had ischemia in the inferioposterior region
of the heart. She last underwent IVIG treatment on [**2122-9-17**]. She
also receives Rituxan. She has a midline in the R arm. She is
following up with an ophtalmologist for treatment of her
cataracts next month.
.
ROS
.
The review of system is mostly positive for pain (mainly back
pain), leg weakness R>L (recent MRI with no cord compression),
and depressive symptoms. She also had a nose bleed while at
Rehab, which was apparently attributed to the nasal oxygen. Also
positive for dyspnea on exertion, orthopnea and difficulties to
see (cataracts).
Past Medical History:
Past Medical History:
#. AML: diagnosed [**4-14**] s/p allo-related SCT [**10-14**] (sister was
donor) Cytoxan/MTX/TBI--recently resumed cytoxan on [**7-24**] for
treatment of extensive sclermadermatoum GVHD
#. CAD s/p STEMI [**11-16**] with 2VD s/p DES in LAD, POBA D1 with BMS
to mid D1. NSTEMI [**2122**] s/p PCI [**4-/2122**] noted below.
#. STEMI [**4-/2122**] s/p CATH:
1. Subacute stent thrombosis of the LCX bare metal stent.
2. Hypotension requiring pressors consistent with hypovolemic
and vasodilatory shock.
3. Possible anaphylactoid reaction to ReoPro.
4. Bleeding from left femoral arteriotomy and venotomy site with
hemostasis achieved after Femstop applied.
5. Blood loss anemia status post 5 units of PRBC.
6. Successful thrombectomy and balloon angioplasty of the LCx.
#. extensive chronic GVHD: skin, gut, left hand digit amps x4,
chronic immune suppression cellcept, entocort, prednisone,
rituxan (last [**2121-8-22**])
#. strep pneumo mastoiditis [**4-18**]
#. Chronic left upper extremity brachiocephalic DVT
#. ankle fracture in left ankle s/p surgical repair [**8-17**]
#. asthma
#. eczema
#. migraine headaches
#. history of oral HSV
#. HTN, however most recent infusion note BP 90/50 and all BPs
need doppler to measure (baseline SBP 90s-low 100s)
#. Diabetes, Hgb A1C ([**9-17**]) 8.9
#. Wheelchair user, but can ambulate with a walker
#. Performance status is 60% [**6-/2122**]
Social History:
- Immigrated from [**Country 6257**] at young age and lived in MA since.
- She currently lives with husband and two sons (12yo, 15yo)
[**Name2 (NI) **]r-in-law on [**Location (un) 1773**].
-TOB: 1pack per 3 days down from 1/2ppd x 20yrs, No ETOH use. No
illicits
Social History:
- Immigrated from [**Country 6257**] at young age and lived in MA since.
- Currently lives with husband and two sons (12yo, 15yo)
mother-in-law on [**Location (un) 1773**].
-TOB: 1pack per 3 days down from 1/2ppd x 20yrs, No ETOH use. No
illicits
.
Family History:
- Mother died of cancer
- No CAD, no sudden death
- No family history of blood clots.
.
Physical Exam:
Physical Exam:
VS: Afebrile, BP 110/65 HR 72
Gen: Flat affect. Poor eye contact. In bed, cushingoid
appearing.
HEENT: Alopecia. Cushingoid facies. Cataracts in both eyes, L>R.
Cannot test extra ocular movements. Dry mucous membranes. poor
dentition.
Neck: Thyroid appears diffusely enlarged. Buffalo hump. No
lymphadenopathy.
CV: RRR. S1 S2. No murmurs rubs or gallops.
Pulm: Diminished breath sounds bilaterally at bases.
Abd: Very distended but not tender. Normal bowel sounds.
Ext: warm, palpable distal pulses, 2+ pedal edema
Neuro: Cannot test II, III, IV and VI. Patient does not follow
finger well. V, VII, VIII, IX, X, [**Doctor First Name 81**] and XII intact. Feet
flexors and extensors are [**3-16**] bilaterally. Hip flexors are [**2-16**].
Other muscle groups were deferred because of malaise and pain.
.
Pertinent Results:
[**2122-9-25**] 06:18PM GLUCOSE-142* UREA N-15 CREAT-0.3* SODIUM-141
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-28 ANION GAP-10
[**2122-9-25**] 06:18PM ALT(SGPT)-23 AST(SGOT)-16 LD(LDH)-316*
CK(CPK)-12* ALK PHOS-68 AMYLASE-24 TOT BILI-0.3
[**2122-9-25**] 06:18PM LIPASE-15
[**2122-9-25**] 06:18PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-3.6
MAGNESIUM-2.3 URIC ACID-2.1* IRON-37
[**2122-9-25**] 06:18PM calTIBC-337 VIT B12-483 FOLATE-GREATER TH
FERRITIN-112 TRF-259
[**2122-9-25**] 06:18PM WBC-6.8 RBC-2.12* HGB-6.9* HCT-21.9* MCV-103*
MCH-32.6* MCHC-31.5 RDW-23.5*
[**2122-9-25**] 06:18PM PLT COUNT-486*
[**2122-9-25**] 06:18PM RET MAN-5.7*
[**2122-9-25**] 03:00PM GLUCOSE-153* UREA N-18 CREAT-0.4 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-31 ANION GAP-10
[**2122-9-25**] 03:00PM estGFR-Using this
[**2122-9-25**] 03:00PM ALT(SGPT)-25 AST(SGOT)-17 LD(LDH)-341* ALK
PHOS-72 TOT BILI-0.3
[**2122-9-25**] 03:00PM ALBUMIN-3.4 PHOSPHATE-3.8 MAGNESIUM-2.4
[**2122-9-25**] 03:00PM WBC-8.8 RBC-2.19*# HGB-7.3*# HCT-22.3*#
MCV-102* MCH-33.3* MCHC-32.7 RDW-23.5*
[**2122-9-25**] 03:00PM NEUTS-90.3* BANDS-0 LYMPHS-7.7* MONOS-1.3*
EOS-0.6 BASOS-0.1
[**2122-9-25**] 03:00PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-OCCASIONAL
SCHISTOCY-1+ BURR-1+
[**2122-9-25**] 03:00PM PLT SMR-VERY HIGH PLT COUNT-523*
[**2122-9-25**] 03:00PM GRAN CT-7970
[**2122-10-18**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-10-18**] 03:04AM 11.7* 2.74* 8.7* 25.9* 95 31.7 33.5 20.5*
479*
Source: Line-right PICC
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2122-10-17**] 04:36AM 88* 0 5* 7 0 0 0 0 0
[**2122-10-13**] MRI THORACIC AND LUMBAR SPINE
Further loss of height of the T5 and T6 compression fractures.
No significant change in the mild-to-moderate compression
fracture of L4 and mild depression of the superior endplate of
L5 as before.
Partially imaged is an enhancing lesion of the right second rib,
which may represent a fracture, but if there is concern for
metastases, this could be better evaluated by either plain films
or CT scan.
[**10-6**] CT SCAN ABDOMEN AND PELVIS
IMPRESSION:
1. No intra-abdominal or retroperitoneal hematoma. Multiple
ventral subcutaneous densities likely represent injection
associated hematomas as described. Many of these were present on
the CT from [**4-13**]. Small left pleural effusion and associated atelectasis. 8 mm
left lower lobe nodular density warrants 6 month followup to
ensure stability or resolution.
3. 5mm left renal lesion too small to characterize and cannot be
classified as a cyst and small tumor is difficult to completely
exclude. Recommend repeat evaluation in 4 months.
[**9-29**] ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to
hypokinesis of the inferior and posterior walls. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2122-8-28**], the findings are similar.
Brief Hospital Course:
The patient is a 40 yo woman with AML s/p rel allo-SCT [**10-14**]
with GVHD,
recent T12 compression fracture, and unstable angina, admitted
from [**Month/Year (2) **] for failure to thrive.
.
# Respiratory failure: The patient was transferred to the ICU on
[**10-17**] due to acute respiratory distress and increasing oxygen
requirement. She was found to have pulmonary edema on chest
X-ray and diuresed but cont. to require very high O2
requirement, eventually becoming BIPIP dependent. She was
treated empirically for hospital acquired pneumonia as well as
PCP. [**Name10 (NameIs) **] continued to have BiPAP dependency. A family meeting
was held and due to her poor prognosis, the patient and her
husband decided that she would become DNR/DNI and then
eventually comfort measures only. All antibiotics were
discontinued and BiPAP and morphine drip were maintained for
comfort. She did eventually remove the BiPAP due to discomfort
and died later that night with her family present.
.
1/ FAILURE TO THRIVE: The patient was somewhat dehydrated upon
admission, but this resolved with IVF. She ate normally since
the moment of admission. There seemed to be a strong component
of major depressive disorder which was impeding proper
rehabilitation and progress. The patient was on 20 mg of Celexa
and was initially reluctant to talk to either SW or Psychiatry,
although later she agreed. Her dose of SSRI was increased and
she underwent daily conversations with medical staff, SW, and
nursing, with great improvement in her mood and outlook. She
participated actively on physical therapy and had a goal to go
to rehab and then home with increased independence, specially
for transfers. At admission, she needed 100% assistance for
transfers, i.e. either her husband or her children had to carry
her from one place to the next. This was in part due to her
advanced GVHD and vertebra fractures, but it was felt that she
had some potential for improvement. see above.
.
2/ GVHD: She was maintained on her current immunosuppresion
medications and prophylaxis, but her prednisone dosage was
decreased from 40 mg daily to 30 mg daily, with the potential
for further taper if her GVHD tolerated it. Her skin seemed to
have responded very well to her outpatient cytoxan. see above
.
3/ PAIN: She was on numerous pain medications, and she did have
severe back pain caused by her vertebral fractures as well as
musculoskeletal chest pain and angina pain. her pain was
exacerbated by her depression and inactivity. She continued her
dilaudid prn as well as her lidocaine patch. Anginal pain
responded to 3 SL NTG. Musculoskeletal pain responded to
morphine IV. She was later started on a fentanyl patch, 100
ug/hour. see above.
.
4/ CARDIAC: the patient initially had daily complaints of
angina-like chest pain. Cardiac enzymes were persistently
negative, and she had no significant EKG changes. Her echo was
similar to one month prior. We found that on occasion her chest
pain was actually not cardiac, as it was easily reproducible on
palpation. Thus, she had symptoms of both vardiac and
non-cardiac chest pain and was treated accordingly. She had
numerous episodes of tachycardia to 120s and cardiology was
consulted. She was kept on telemetry and cardiology was
consulted. Her beta blocker was titrated up. The patient
continued to have episodes of chest pain in the ICU which were
treated with SL nitroglycerin and eventually with morphine drip
as above.
.
5/ VERTEBRAL FRACTURES: the patient had to wear a TLSO on
admission for out of bed activities. An ortho consult was
obtained early on to assess if this was needed, as it was
interfering with rehab. Plain films demonstrated new fractures
and MRI confirmed these findings (see report above). The patient
was fitted for a [**Doctor Last Name **] brace but she preferred her TLSO. She
was eventually started on morphine drip for comfort measures as
above.
Medications on Admission:
- Prednisone 10 mg po qd
- Mycophenolate Mofetil 500 mg po qid
- Acyclovir 400 mg po q 8hrs
- Fluconazole 200 mg po bid
- Folic Acid 1 mg po qd
- Nexium 40 mg po qd
- Clopidogrel 75 mg po BID
- Aspirin 81 mg po qd
- Lovenox 60mg [**Hospital1 **]
- Lasix 20 mg po daily
- Toprol Xl 100 mg po bid
- Lisinopril 5mg daily
- Isosorbide Mononitrate 60mg daily
- Budesonide 3 mg po tid
- Insulin Glargine 35 units qam
- Humalog per sliding scale.
- MagOx 400 mg po bid
- Rituxan monthly for GVHD last dose 6/8, IVIG monthly last dose
[**7-24**], Pamidronate q6months
Discharge Medications:
none
Discharge Disposition:
Expired
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
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|
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[
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icd9pcs
|
[
[
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|
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|
363, 369
|
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|
5612, 9075
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,008
| 106,910
|
46246
|
Discharge summary
|
report
|
Admission Date: [**2157-6-2**] Discharge Date: [**2157-6-7**]
Date of Birth: [**2120-8-28**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Headache, ?seizure.
Major Surgical or Invasive Procedure:
Factor VIII infusions
History of Present Illness:
The pt is a 36 year old male with a history of hemophilia A, HIV
(CD4 count 500 per pt) who presented from OSH on [**2102-6-2**] with a
subdural hemorrhage. The pt. stated that he began to develop a
diffuse, "throbbing" headache on the morning of admission. He
is an attorney and was giving a deposition in a courtroom on the
day of when he suddenly fell to the ground, had what was
described as a generalized seizure lasting several minutes, and
was barely responsive afterwards. The first thing that the pt
recalled after giving the fall and possible seizure is awaking
in the hospital with a "terrible" headache. He was taken to an
OSH where workup included a head CT which showed a subdural
hematoma over the left frontal lobe, interhemispheric fissure,
and around the midbrain. The patient was then transferred to the
[**Hospital1 18**] for further care.
On transfer to [**Hospital1 18**], the pt complained of fatigue and a
headache. The was described as "throbbing" and diffusely
located. He also admitted to photophobia. No neck stiffness,
recent n/v/fevers/recent travel. He is compliant with his
medications. The pt. denied recent neck/back manipulations. He
stated that this sort of episode has never happened before.
There has been no remote head trauma.
The pt. was admitted to the neurologic ICU where he remained for
one day. During this time, he underwent two serial head CTs
which showed stable size of the left frontoparietal subdural
hematoma. He was also loaded with dilantin for seizure
prophylaxis. A hematology/oncology consult was obtained in
light of the pt's diagnosis of hemophilia A. They recommended
q8h factor VIII infusions, which the pt. has received. As the
pt. remained hemodynamically stable, experienced no further
seizures and had a stable size SDH, he was transferred to the
floor on hospital day 2.
At the time of my encounter, the pt. again complained of fatigue
and headache. He stated that there has been no change in the
quality of the headache since onset as described above. He
rated the intensity [**8-13**] despite morphine and demerol. He
otherwise offered no complaints.
Discussion with the pt's parents and brother later on the day of
transfer revealed that the pt. had been complaining of headache
for about 4 days prior to the aforementioned incident on the day
of admission. In addition, the pt's brother stated that he had
spoken to a workmate who was in court with the pt. at the time
of the incident who did not recall any seizure-like activity.
Per this witness, the pt slumped over on a table in a sitting
position and became less responsive during the deposition but
did not have any abnormal movements. Obviously this could not be
confirmed with the pt.
Past Medical History:
1. Hemophilia A/factor VII dependent
2. HIV, cd4 count 500 per pt.
3. Hepatitis C.
Social History:
He does not drink alcohol, smoke tobacco, or use illicit drugs.
He is an attorney and works as an assistant attorney general. He
is single.
Family History:
No family members with hemophilia, seizures.
Physical Exam:
PE: T-98.6F BP-134/60 HR-88 RR-18
Gen: lying in bed, asleep in no apparent distress
Heent: NCAT, oropharynx clear
Neck: supple, no carotid bruits
Chest: clear to auscultation b/l
CV:regular rate, normal s1s2, no m/r/g
Ext: no c/c/e, 2+ dorsalis pedis pulses b/l
Neurologic Exam:
MS: Asleep but easily arousable.
Oriented to person, place and time.
The patient is unable to say moyb. He can do dowb.
Fluent speech, repetition, naming intact. Able to read and
write.
Memory [**2-3**] registration, encodes [**12-7**] with interference. Recall
[**12-7**] at 5 minutes.
No apraxia, neglect, frontal signs. Calculation intact.
CN:
Visual fields intact to confrontation
Pupils normal round 4mm->2mm with light.
EOMI without nystagmus.
Normal facial sensation and musculature.
Hearing intact to finger rub.
Palate rises symmetrically. Tongue midline.
Motor:
Normal tone and bulk. No tremors or fasciculations.
Pronator drift absent.
Strength: 4-/[**3-7**]+ = mild/moderate/great resistance
[**Doctor First Name **] Tri [**Hospital1 **] WrF WrE FiF [**Last Name (un) **] Ilio Quad Ham FoF FoE [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5
Reflexes:
There are [**1-7**] reflexes throughout/
Plantar reflexes flexor bilaterally.
Sensory:
Intact to pinprick, vibration, proprioception and temperature
throughout.
Coordination:
Intact FTN b/l.
Intact [**Doctor First Name **].
Gait:
Romberg sign absent
narrow based, stable, good arm swing. Tandem intact.
Pertinent Results:
Labs on admission:
[**2157-6-2**] 08:35PM BLOOD WBC-14.2*# RBC-4.77 Hgb-13.8* Hct-41.2
MCV-86# MCH-28.8 MCHC-33.4 RDW-14.8 Plt Ct-135*
[**2157-6-2**] 08:35PM BLOOD Neuts-80.2* Lymphs-15.2* Monos-4.4
Eos-0.2 Baso-0.1
[**2157-6-2**] 08:35PM BLOOD PT-12.7 PTT-33.8 INR(PT)-1.1
[**2157-6-3**] 05:36AM BLOOD WBC-11.3* Lymph-18 Abs [**Last Name (un) **]-2034 CD3%-66
Abs CD3-1346 CD4%-21 Abs CD4-428 CD8%-44 Abs CD8-886*
CD4/CD8-0.5*
[**2157-6-2**] 08:35PM BLOOD FacVIII-27*
[**2157-6-2**] 08:35PM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-140
K-3.2* Cl-104 HCO3-26 AnGap-13
[**2157-6-3**] 05:36AM BLOOD ALT-24 AST-19 LD(LDH)-176 CK(CPK)-131
AlkPhos-96 Amylase-140* TotBili-1.3
[**2157-6-2**] 08:35PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2
Imaging:
Head CT ([**2157-6-2**]):
FINDINGS: There is a left frontal and parietal acute subdural
hemorrhage measuring 9 mm adjacent to the left frontal lobe,
where it appears widest on axial images. There is mass effect on
the left cerebral hemisphere and narrowing the left lateral
ventricle, with minimal shift of the normally midline structures
to the right. Subdural blood continues across the left tentorium
and is be present in the left middle cranial fossa, under and
around the temporal lobe. No parenchymal hemorrhage is
identified. The density values of the brain parenchyma are
within normal limits and the [**Doctor Last Name 352**]- white matter differentiation
is preserved.
The surrounding osseous and soft tissue structures are
unremarkable. The visualized paranasal sinuses are normally
aerated.
IMPRESSION: Acute left subdural hemorrhage causing mass effect
on the left cerebral hemisphere with slight shift of the midline
Head CT ([**2157-6-3**]):
CT HEAD FINDINGS: The small left frontal convexity subdural seen
on the prior day's scan is unchanged in size, again exerting
mass effect on the adjacent brain parenchyma. Once again,
subdural blood traverses over the left tentorium, but is again
unchanged compared to the prior study. No new foci of
intracranial hemorrhage are identified. The left ventricle is
mildly effaced, the ventricles are otherwise unremarkable. There
is no obvious blurring of the [**Doctor Last Name 352**]-white interface or focal
effacement to suggest infarction. Bone windows demonstrate no
evidence of fracture. The orbits are unremarkable, and the
sinuses are clear.
IMPRESSION: No significant change in the size or associated mass
effect of the left subdural hematoma compared to the prior day's
study. No new foci of hemorrhage are identified.
Head MRI ([**2157-6-4**]):
FINDINGS: A thin rim of subdural hematoma is identified
extending from the left frontal to the occipital region without
significant mass effect on the adjacent brain. The maximum width
of the subdural is approximately 3 mm. A thin rim of subdural is
also seen along the tentorium on the left side. There is no
midline shift or mass effect. There is no evidence of slow
diffusion to indicate acute infarct. There is no evidence of
focal signal abnormalities within the brain. On susceptibility
weighted images, there is no evidence of acute or chronic blood
products in the brain parenchyma. Following gadolinium, no
evidence of abnormal parenchymal or vascular enhancement seen.
IMPRESSION: Small left-sided subdural from frontal to occipital
region with extension along the tentorium, unchanged from the
previous CT of [**2157-6-3**]. No mass effect or midline shift seen. No
evidence of slow diffusion or intraparenchymal abnormalities. No
evidence of abnormal enhancement.
Brief Hospital Course:
1. Left frontal subdural hematoma: It was felt that the most
likely scenario was that the pt. had low factor VIII levels
secondary to underlying hemophilia A and sustained a spontaneous
SDH. The hematology/oncology service consulted on the pt. and
recommended q8h factor VIII infusions and p.o. steroids (both
were scheduled as tapered doses on discharge as below). The pt
had serial head CTs which demonstrated stable size of the
hematoma. He is to follow-up with a repeat head CT with the
neurosurgical service in 8 weeks to document size. There was
question of whether the pt actually had seizure. Since it was
felt that if the pt were to seize off anti-seizure medication,
in the context of hemophilia, he would be at risk to develop
another intracranial bleed. Therefore, the decision was made to
discharge the pt. on an anti-convulsant. The pt. was originally
loaded with and maintained on phenytoin. He developed a diffuse
papular rash on this medication, however, and the regimen was
changed to keppra prior to discharge. The pt. also had a
signficant headache and blurred vision with a mild degree of
photophobia during the hospital stay. He was initially placed
on intravenous morphine and demerol prn with little effect. He
was therefore placed on a dilaudid PCA. When his requirements
were determined, he was transitioned to p.o. dilaudid prior to
discharge. He was also started on verapamil for headache in the
context of hypertension when this was unsuccesful, Neurontin was
also added. His headache control was tolerable on this regimen,
by time of discharge.
2. Hypertension: The pt. developed difficult-to-control
hypertension during the course of the hospital stay after he was
taken off of labetalol drip. He was placed on captopril with
increasing doses, eventually reaching 50mg tid. Beta-blockers
were held since he was significantly bradycardic on telemetry
(HR in 40s). He was also placed on verapamil as above.
3. HIV: The pt. was maintained on his usual HAART regimen.
The infectious disease service consulted on the pt and felt that
an infectious workup was not warranted given the pts
constellation of symptoms.
Medications on Admission:
1. Factor VIII replacement.
2. Ambien.
3. Zoloft.
4. Prilosec.
5. NSAIDs for arthritis.
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
4. Fosamprenavir Calcium 700 mg Tablet Sig: Two (2) Tablet PO
Q12H (every 12 hours).
5. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Three (3) Cap
PO BID (2 times a day).
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: six Tablet PO once a day for 1
days: Take 60mg daily on [**6-8**], take 40mg daily on [**6-9**], take 20mg
daily on [**6-10**], take 10mg on [**6-11**], take 5mg on [**6-12**]. .
Disp:*14 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain/headache.
Disp:*50 Tablet(s)* Refills:*0*
11. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Take 1 tab po bid for one week, then take 2 tabs
po bid thereafter until instructed otherwise.
Disp:*100 Tablet(s)* Refills:*2*
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left Frontal Subdural Hemorrhage
2. Hemophilia A/factor VIII dependent
3. HIV
4. Hepatitis C
5. Hypertension
Discharge Condition:
Pt. was still complaining of headache (although overall improved
since admission) and some residual photophobia and blurred
vision.
Discharge Instructions:
Continue with medications listed below. Please attend all
follow-up appointments.
Call your doctor or go to the Emergency Room if you have
worsening headache, blurred vision, seizures, dizziness,
worsening nausea/vomiting or any concerning symptoms.
Continue factor VIII replacement as follows:
-one infusion every 8 hours for 3 more days
-then one infusion every 12 hours for 3 days
-than one infusion daily thereafter or until instructed
otherwise by Dr. [**Last Name (STitle) 9625**].
Followup Instructions:
Please call Dr. [**Last Name (STitle) 9625**] ([**Telephone/Fax (1) 9701**]) for follow-up appointment
within the next week.
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Where: [**Hospital6 29**]
RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2157-6-10**] 3:00
Please follow-up with neurosurgery in 8 weeks. Please call Dr. [**Name (NI) 14075**] office at [**Telephone/Fax (1) 1669**] to schedule an
appointment. You will need to have a CT of the head performed
prior to this appointment. Please call radiology [**Telephone/Fax (1) 327**]
to schedule an appointment in 8 weeks.
Please call the [**Hospital 878**] Clinic at [**Telephone/Fax (1) 541**] to schedule an
a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] and Dr. [**First Name8 (NamePattern2) 9485**]
[**Last Name (NamePattern1) **] in [**3-9**] weeks.
|
[
"432.1",
"401.9",
"070.70",
"V08",
"286.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
12571, 12577
|
8580, 10737
|
334, 357
|
12732, 12865
|
5017, 5022
|
13402, 14307
|
3397, 3443
|
10875, 12548
|
12598, 12711
|
10763, 10852
|
12889, 13379
|
3458, 3721
|
275, 296
|
385, 3116
|
5036, 8557
|
3738, 4998
|
3138, 3224
|
3240, 3381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,195
| 193,847
|
46989
|
Discharge summary
|
report
|
Admission Date: [**2131-10-10**] Discharge Date: [**2131-10-12**]
Service: NEUROLOGY
Allergies:
lisinopril / hydrochlorothiazide
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
R gaze palsy and new
garbled speech
Major Surgical or Invasive Procedure:
Intubation at OSH
History of Present Illness:
[**Age over 90 **]-year-old right-handed
man with history of stroke, hypertension, and colon cancer who
presents as a transfer from an OSH with new IPH. Found at his
[**Hospital1 1501**] around 1030AM w/garbled speech, R-sided gaze and was
transferred to an OSH with a reported BP of 210/100s and
reportedly "neurologically intact." He reportedly vomited at
1140 prior to a head CT, and was therefore intubated w/etomidate
and succinylcholine prior to scan. His OSH presentation vitals
were T 97.4, P 45, R 16, BP 163/78, pOx 98%. Where a head CT
demonstrated a R frontal SDH w/2.4cm midline shift. At OSH was
given labetalol 20 mg, etenu, ativan 2 mg, succ, decadron 10 mg,
keppra 500 mg, ativan 2 mg, and was transferred to [**Hospital1 18**] for
further evaluation.
ROS could not be preformed secondary to poor mental status and
intubation
Past Medical History:
-ICH in [**2125**] consistent with amyloid angiopathy, status post a
left frontal craniotomy
-stage IIIB (T3, N1) colon cancer; diagnosed at age 88;
underwent
a laparoscopic right colectomy; pt elected not to undergo
adjuvant chemo
-Hypertension
-Spinal stenosis, status post L3 through L5 laminectomy
=status post right hip replacement.
Social History:
The patient is a widower. He has three
children, a daughter who lives in [**Name (NI) 5256**], a son who
lives
in [**Name (NI) 8780**], and another son [**Name (NI) **] who lives here in [**Name (NI) 86**]. He
is
a former cigar smoker, but quit years ago. He currently is not
drinking alcohol. He is retired, having previously worked in
retail. He currently lives in an [**Hospital3 **] facility.
Family History:
His father had a stroke. No family history of seizures. The
patient's brother and both died of nonspecified
cancers in their late 70s and early 80s.
Physical Exam:
PHYSICAL EXAM:
Vitals: 195/93, R 18, HR 78, pOx 100%, ventalated
General: intubated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple,
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: brady
Abdomen: soft, NT/ND,
Extremities: bipedal edema
Skin: no rashes or lesions noted.
Neurologic:
Mental Status exam:
did no open eyes to noxious. intubated
GCS:6
level of arousal -1
best verbal -1
best motor -4
-Cranial Nerves:
pupils equal are 2mm -> 1 mm. No gaze deviation, no dolls. +
Left corneal, abscent right corneal. no bobbing or robbing. No
nystagmus. +gag, +cough.
-Motor/sensory: increased tone in bilateral lower extremities.
with flicker of withdrawal in all 4 to noxious. no localizing.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes upgoing bilaterally
Dischareg exam:
Deceased
Pertinent Results:
Admission labs:
[**2131-10-10**] 06:15PM BLOOD WBC-13.8* RBC-4.15* Hgb-12.9* Hct-37.3*
MCV-90 MCH-31.1 MCHC-34.6 RDW-12.6 Plt Ct-198
[**2131-10-10**] 06:15PM BLOOD Neuts-92.0* Lymphs-6.7* Monos-1.1*
Eos-0.1 Baso-0.1
[**2131-10-10**] 06:15PM BLOOD PT-12.4 PTT-18.0* INR(PT)-1.0
[**2131-10-10**] 06:15PM BLOOD Glucose-172* UreaN-15 Creat-1.1 Na-140
K-4.5 Cl-103 HCO3-26 AnGap-16
[**2131-10-10**] 06:21PM BLOOD Lactate-2.2*
.
.
Microbiology:
[**2131-10-10**] MRSA SCREEN MRSA SCREEN-PENDING
.
.
Radiology:
CT HEAD W/O CONTRAST Study Date of [**2131-10-10**] 7:21 PM
FINDINGS: There is a large right frontal lobe intraparenchymal
hemorrhage
with minimal interval change from prior exam. There is marked
subfalcine
herniation with leftward shift of midline structures,
approximating 2.6 cm,
previously 2.4 cm. There is significant mass effect on the right
lateral
ventricle with complete effacement of the frontal [**Doctor Last Name 534**]. Again
noted is
transcortical hemorrhagic extension from the right frontal
hematoma with a
combination of right frontal subdural and subarachnoid hematoma.
A small
amount of intraventricular blood is seen layering in the
occipital horns, a
new finding from prior exam. New left parafalcine subarachnoid
hemorrhage is
seen along the cerebral vertex. There is blood in the
interpeduncular
cistern. While there is patency of the suprasellar cistern and
the
perimesencephalic cistern, the degree of subfalcine herniation
is significant.
There is left frontal lobe encephalomalacia as seen on prior CT
from [**2131-9-27**].
Mucosal thickening is noted in the paranasal sinuses. Mastoid
air cells and
middle ear cavities are well aerated. The bony calvarium appears
intact aside
from surgical change in the left frontal lobe.
IMPRESSION: Large right frontal parenchymal hematoma with
transcortical
extension and associated right frontal extra-axial hematoma.
Significant
subfalcine herniation with leftward shift. New areas of
subarachnoid
hemorrhage along the left cerebral vertex, new intraventricular
hemorrhage.
Patent basilar cisterns.
Brief Hospital Course:
[**Age over 90 **]-year-old right-handed man with history of previous ICH felt
secondary to amyloid, hypertension, and colon cancer s.p
colectomy and elected not to have chemotheraoy who presented as
a transfer from an OSH with new IPH and ASDH. Patient was found
with garbled speech and right-sided gaze at his [**Hospital3 **]
- it was unclear whether he fell. EMS were called and patient
was transferred to an OSH where he was noted to have severe
hypertension with BP 210/100s. Patient was intubated prior to
scan. Head CT demonstrated a R frontal SDH with 2.4cm midline
shift and right frontal IPH. Patient was administered IV
labetalol, keppra and dexamethasone and was transferred for
neurosurgical evaluation. Neurosurgery was consulted and
discussion was had with the HCP regarding likely severely
debilitated outcome post surgery. In line with the patient's
wishes, he was made DNR/DNI. His HCP indicated that he should
not undergo any aggressive medical interventions. The plan was
to keep him intubated until the rest of his family could arrive,
and additional decisions regarding his plan of care could be
made at that time. Repeat CT at [**Hospital1 18**] revealed a large right
frontal parenchymal hematoma with transcortical extension and
associated right frontal extra-axial hematoma with significant
subfalcine herniation with increased 2.6cm midline shift and new
areas of subarachnoid hemorrhage along the left cerebral vertex
with intraventricular extension. Patient was transferred to the
ICU. When his family arrived the next morning, they decided to
change his goals of care to comfort care measures only. Pastoral
and palliative care were sought. Prior to elective extubation,
exam revealed extension of LUE to noxious and triple flexion
LLE, localising RUE and flexion RLE with pupils pinpoint 1mm and
reactive, present corneals and gag/cough with plantars extensor
bilaterlly. He was extubated on [**10-11**] and patient died in the
early hours of [**2131-10-12**].
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO three
times a day.
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"V49.86",
"437.9",
"401.9",
"432.1",
"348.4",
"V12.54",
"V43.64",
"430",
"V10.05",
"V66.7",
"277.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7476, 7485
|
5172, 7170
|
287, 306
|
7537, 7547
|
3076, 3076
|
7604, 7615
|
1981, 2133
|
7443, 7453
|
7506, 7516
|
7196, 7420
|
7571, 7581
|
2613, 3057
|
2163, 2596
|
212, 249
|
334, 1185
|
3092, 5149
|
1207, 1546
|
1562, 1965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,124
| 170,883
|
53372
|
Discharge summary
|
report
|
Admission Date: [**2192-4-16**] Discharge Date: [**2192-5-15**]
Service: MEDICINE
Allergies:
Dyazide / Prempro / Nsaids / Percocet / Voltaren
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous catheter placement
History of Present Illness:
This is a 83 YOF with PMHx of DVT, heart failure, and recent hip
fracture s/p ORIF presents from rehab with dyspnea and sats in
the 80s on NRB. She was discharge from [**Hospital1 18**] after ORIF on
[**2192-4-5**]. She states she has had ocasional episodes of dyspnea at
rehab that have resolved on their own. She also states she has
been eating more salt than she usually does at home. She also
complains of increased lower extremity edema over the past
several days. She was acutely dyspnic last night and unable to
sleep secondary to orthopnea. She complained of dyspnea to her
caregivers this am and was found to be hypoxic. She was
transferred from rehab today for respiratory distress.
.
In ED inital vitals T 98.6 BP 106/60 HR 89 RR 20 Sats 93% on
NRB. CXR done with suspicion of CHF. Given 40 mg IV lasix. Put
out 1.4L urine. Was then transiently hypotensive to 91/40. She
was then given 1L NS with SBP back up to 120. Given history of
DVT and recent orthapedic surgery a CTA was performed which
showed no PE.
.
Upon arrival to MICU patient was breathing comfortably on NRB.
Complained only of lower extremity edema. Stated her dyspnea was
improved compared to last night.
Past Medical History:
atrial fibrilation
CAD s/p CABG in [**2180**]
aortic disection
AAA
Chronic renal failure
Hip fracture s/p ORIF on [**2192-3-28**] (hospitalization complicated by
post op hypotension requiring MICU admission and pressors)
DVT [**2190**]
Hypertension
Diabetes
Diastolic heart failure
LVH
Tricuspid regurg (2+)
Glaucoma
pulmonary hypertension
obesity hypoventilation on home O2
PFTs [**2-7**] FEV1 of 1.19 liters/70% predicted a vital capacity of
1.7
liters /70% predicted, a TLC of 3.43/75% predicted with an
FRC of 2.0/72% predicted and DLCO of 70%
Social History:
Home: lives alone at [**Location (un) 109780**]; walks around at home with
walker and has assistance for housework and other activities of
daily living
Denies drugs, EtOH, tobacco
Russian-speaking primarily
Walks with walker and requires home oxygen
Family History:
noncontributory
Physical Exam:
Vitals: T:98.7 BP:113/71 P:98 R:24 SaO2:99% NRB
General: Awake, alert, NAD.
HEENT: NC/AT, , no scleral icterus noted, MMM, no lesions noted
in OP
Neck: supple, JVD to angle of jaw or carotid bruits appreciated
Pulmonary: poor air movement. No rhonchi or crackles.
Cardiac: irregular, nl. S1S2, no M/R/G noted
Abdomen: soft,obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 3+ sacral edema
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty with help of son.
Pertinent Results:
CTA [**4-16**]:
1. No evidence of pulmonary embolus.
2. Status post an ascending aortic graft, with unchanged
appearance of the aortic dissection with major vessels arising
from the true lumen, as well as unchanged appearance of the
large complex aneurysm arising from the false lumen at the
bifurcation.
3. Bilateral pleural effusions with underlying compressive
atelectasis.
4. Stable cardiomegaly, coronary artery disease and aortic
calcifications.
.
ECHO [**4-24**]:
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is 16-20
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated. Right ventricular systolic function is
normal. The aortic root is moderately dilated athe sinus level.
The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. The tricuspid regurgitation jet is eccentric and may be
underestimated. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-3-29**],
estimated
pulmonary artery systolic pressures are higher. No obvious
vegetations
visualized. Mild mitral regurgitation, Eccentric moderate
tricuspid
regurgitation. Right ventricular dilation is now seen (probably
present on prior study). Linear density in descending aorta
seen on the current study as well; this likely represents known
aortic dissection seen on CT scan of [**2192-4-16**].
Brief Hospital Course:
In brief, the patient is an 83 year old female with history of
HTN, DM2, CAD s/p CABG, diastolic CHF, Afib,
obesity-hypoventilation and OSA on home O2, CRI, s/p repaired
aoritic dissection and recent ORIF of L hip here with
respiratory failure, hospital course notable for multiple ICU
transfers for worsening respiratory status as well as MSSA
bacteremia of unclear source. Despite aggressive intervention in
management of her cardio-pulmonary diseases, her conditioned
failed to improve. After extensive discussions with the
patient's family, the patient was ultimately extubated had care
goals directed at comfort and expired. For pertinent details of
the course, see below.
.
1. Respiratory failure and hypoxemia: This was thought to be
multifactorial secondary to a combination of diastolic
congestive heart failure, pulmonary hypertension, and obesity
hypoventilation. There was no evidence of an acute coronary
syndrome. The patient received aggressive heart failure
mangement including attempts at rate control and diuresis.
However these attempts were complicated by acute renal failure
secondary to pre-renal azotemia. After her renal function
resolved, it was still not possible for the patient to
adequately gas-exchange. Given her progressive respiratory
compromise, the patient was initially treated with NIPPV but
eventually required endotracheal intubation and full mechanical
ventilatory support. As above, after extensive discussions with
the family including the [**Hospital 228**] health care proxy, ongoing
medical support and limited functional status were thought not
to be goals compatible with patient's quality of life. The
patient was extubated and received comfort care.
.
2. MSSA bacteremia: There was never a clear souce to the
bacteremia despite extensive imaging including xrays, CTs, TTE,
and tagged WBC scan. As she had a relatively high degree of
bacteremia, she was planned to complete a 6 week course of
nafcillin.
.
3. Decubitus ulcer: There was no clear sign of infection of this
ulcer. She received nutritional support and local wound care.
.
4. Afib: The patient received heart rate control as above. She
was anti-coagulated with goal INR [**2-4**].
.
5. Acute on Chronic renal failure: On presenation, the patient
was at her baseline renal function. However, as above, with the
attempts at the necessary diuresis, she did suffer acute renal
failure from pre-renal azotemia. Following gradual volume
re-expansion toward euvolemia, the patient's renal function
recovered.
.
6. Diabetes Mellitus type 2: Cont glargine and riss, dm diet
.
7. glaucoma: She continued to receive her eye drops as
previously prescribed.
.
8. hypothyroid s/p subtotal thyroidectomy: There were no active
issues and she continued on her thyroid replacement.
.
9. Code: initally FULL then CMO as her conditioned continued to
deteriorate.
.
10. Dispo: The patient expired. The family was contact[**Name (NI) **] and
declined autopsy.
Medications on Admission:
Lisinopril 5 mg DAILY
Spironolactone 25 mg Daily
Atenolol 12.5 mg Daily.
Aspirin 81 mg DAILY
Warfarin 3 mg Tablet HS
Furosemide 60 mg DAILY
.
Atorvastatin 10 mg PO DAILY
.
Timolol Maleate 0.25 % One (1) Drop Ophthalmic [**Hospital1 **]
Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic QAM
(once a day (in the morning)).
Dorzolamide-Timolol 2-0.5 % One (1) Drop QAM
Artificial Tear with Lanolin 0.1-0.1 % PRN
Bimatoprost 0.03 % (1) Ophthalmic qhs ().
Cromolyn 4 % Drop One (1) Drop Ophthalmic DAILY
.
Donepezil 5 mg or placebo DAILY
Alendronate 70 mg PO QSAT
Levothyroxine 50 mcg DAILY
Acetaminophen 325 mg prn
Miconazole Nitrate 2 % Powder
.
Bisacodyl 5 mg prn
Senna 8.6 mg prn
Docusate Sodium 100 mg [**Hospital1 **]
.
Magnesium Hydroxide 400 mg
Calcium Carbonate 1500 mg Daily
Ergocalciferol (Vitamin D2) 800 unit Daily
.
Ipratropium Bromide 0.02 % Solution prn
Albuterol Sulfate 0.083 % prn
.
Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Respiratory Failure
Diastolic congestive heart failure
Obstructive sleep apnea
Chronic Obstructive pulmonary disease
Pulmonary hypertension
Acute renal failure
Bacteremia
.
Secondary:
Atrial Fibrillation
Hypertension
Chronic Kidney Disease
Diabetes mellitus
Aortic Dissection
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
NA
|
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"327.23",
"403.91",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"38.93",
"33.24",
"96.72",
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icd9pcs
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[
[
[]
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|
5007, 7966
|
264, 323
|
9331, 9340
|
3013, 4984
|
9396, 9401
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1557, 2107
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2123, 2375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,322
| 187,907
|
26479
|
Discharge summary
|
report
|
Admission Date: [**2120-11-30**] Discharge Date: [**2120-12-12**]
Date of Birth: [**2061-3-7**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
one week of nausea, vomiting, anorexia, one day of acute dyspnea
Major Surgical or Invasive Procedure:
paracentesis [**2120-11-30**]
History of Present Illness:
Pt is a 59 y/o man with h/o pancreatic CA diagnosed in [**8-16**] at
[**Hospital6 1708**], with metastases to liver, s/p
attempted percutaneous transhepatic drainage, s/p open T tube
placement with interval attempted Whipple procedure [**2120-10-31**] in
[**Country 532**], s/p cisplatin 10 days prior to admission, who presented
to ED on [**2120-11-30**] with 1 week h/o N/V, anorexia, and acute
dyspnea. Pt had returned from [**Country 532**] 3 d PTA. On the morning
of admission, the pt awoke with dyspnea, weakness and
disorientation, was found wandering around his bathroom opening
windows to "get some air." No fever or chills. No
nausea/vomiting today. No chest pain/palpitations. No
abdominal pain, melena, dysuria, hematochezia. On arrival to
ED, the patient's blood pressure was 130s/70s and he was
tachycardic to 130. BP trended down over 4 hours, at nadir, VS:
BP: 89/61 HR 99 RR: 18 satting 95% 2L NC. (91% RA). Had CTA
showing a subsegmental pulmonary embolism in the right lower
lobe. Labs demonstrated a WBC ct of 22, 93% neutrophils, no
bands. Lactate 2.2. Abd CT showed large amount of ascitic
fluid. Paracentesis done revealed 10,325 WBC (94 poly, 1L, 5M),
450 RBC, 3 protein, 182 glucose, 228 LDH, with peritoneal fluid
Gram stain 4+PMH, no microorganisms, fluid cx positive for few
Enterococcus from broth ([**Last Name (un) 36**] to amp, levo, PCN w/ vanco
pending), anaerobic bottle: GNR, beta lactamase pos. Blood cx
with NGTD. In the ED, he got 6L NS, vancomycin IV 1gm,
levofloxacin 500mg, flagyl 500mg, and heparin infusion before
MICU called. In MICU, he was continued on Zosyn, Levoflox, and
Vanco was added, then d/c'd [**12-2**]. He was aggressively fluid
resuscitated. During his stay in the MICU, he continued to
improve, tolerating po, afebrile, WBC ct trending down. IV
heparin drip was continued for his PE, transitioned to lovenox
on transfer to floor.
.
Also of note, CXR and CTA chest showing small left pleural
effusion, with RUL consolidation w/ cavitation.
Past Medical History:
1. Pancreatic CA: diagnosed 3 months ago, with mets in liver,
s/p Whipple 1 month ago, s/p cisplatin 10 days ago
2. s/p Whipple procedure
3. HTN
4. DM2: controlled w/ insulin
Social History:
Lives w/ wife in [**Name (NI) 745**], works as a contractor (currently on
leave of abscence), has a son who is a [**Name (NI) **] resident in
[**Doctor First Name 26692**] and another son who plays the violin
professionally. He has smoked 120 pack-years but quit 5 years
ago, no alcohol or IVDU.
Family History:
No h/o CA or CAD. Two sons are healthy.
Physical Exam:
PE: Temp: 98.0 BP: 98/53 P: 81 RR: 11 Oxygen sat: 100% 3L NC
I/O: 742/610 +132
Gen: Cachectic Russian-speaking only man lying flat in bed,
speaking in full sentences in NAD.
HEENT: anicteric, EOMI, PERRL, OP clear w/ dry MM, no LAD
CV: reg s1/s2, +1/6 systolic murmur loudest at LUSB, no s3/s4/r
Pulm: CTA B, no wheezes or crackles
Abd: distended, tympanitic to percussion, 10cm vertical surgical
incision in midline is well healed, several small scars lateral
to central scar, +BS, soft, tender RUQ, no rebound tenderness,
no [**Doctor Last Name 515**] sign. Small subcutaneous nodules felt luq, and rlq
(?[**2-14**] lovenox injections)
Ext: warm, faint DP B, trace edema bilaterally
Neuro: a/o, moving all extremities, able to follow commands, no
focal deficits.
Pertinent Results:
Admission EKG: sinus tach @ 130 bpm, nl axis, nl intervals, no
ST changes, no prior tracing for comparison
.
CXR([**11-30**]): left sided pleural effusion, rounded opacity in RUL
zone w/ suggestion of cavitation. No pulm edema.
.
CT([**11-30**]): Probable isolated subsegmental pulmonary embolus in
the right lower lobe. Moderate amount of free air and large
amount of ascites in the abdomen. Large pancreatic mass
measuring 4.6 x 4.5 cm, which compresses and nearly occludes the
portal vein and the distal splenic vein. The SMV is patent.
Large left adrenal mass is suspicious for metastatic disease,
but the appeareance is nonspecific. Right upper lobe of the lung
consolidation with cavitation. Small left pleural effusion.
Per Surgical Note/Read: Also with intraabd subphrenic abscess
after recent laparotomy. Did not rec. drainage.
.
CXR ([**12-3**]): New small right pleural effusion and unchanged
right upper lobe opacity, left basilar opacity and left pleural
effusion
.
CXR [**2120-12-9**]: RUL cavitary lesion between 2.5 and 3.0 cm,
unchanged in size, however, new four peribronchial
consolidations suspicious for progressive infection.
.
KUB: [**2120-12-9**]: partial SBO vs. ileus, NGT in stomach
.
[**2120-12-9**]: Liver doppler US: Several areas of focal
heterogeneity, with echotexture c/w metastatic lesions. Several
hypoechoic focal linear lesions seen throughout liver that
likely represent pneumobilia. Lesion seen in falciform
ligament, likely peritoneal mets. Significant ascites.
Irregular slow flow through portal vein.
.
[**2120-12-10**]: Portable CXR showing no significant change. Moderate
bilateral pleural effusions present. NGT in place. Subclavian
line in place, no PTX.
.
[**2120-12-10**]: CT OF THE ABDOMEN WITH IV CONTRAST:
IMPRESSION:
1. A 5.0 x 4.7 cm mass in the pancreatic head, corresponding to
the patient's known pancreatic cancer. There is extension of
this into the adjacent duodenum, and extensive hepatic,
mesenteric, and left adrenal metastases. The main venous and
arterial vasculature appears to be widely patent. The patient is
status post Whipple for this, and changes relating to surgery
can be identified.
2. Extensive ascites. Additionally, there are two small foci of
air adjacent to the liver, which may be from recent intervention
such as paracentesis. No other foci of air or oral contrast
extravasation can be identified. There is no evidence of small
or large bowel obstruction.
3. Focal hypodensities within the kidneys which are too small to
characterize.
4. Bilateral moderate sized pleural effusions with associated
atelectasis.
5. There are wedge-shaped areas of different attenuation within
the liver which may represent focal fatty infiltration or
perfusion abnormalities.
.
[**2120-12-12**]: CXR AP chest compared to [**12-7**] and 29.
Although previous mild edema in the right upper lung has
cleared, atelectasis has worsened and now the right middle,
right lower and left lower lobes are collapsed. There is also at
least a moderate amount of pleural effusion on both sides of the
chest and unchanged. Cardiac silhouette is obscured. There is
probably mediastinal venous engorgement. Tip of the left PIC
catheter projects over the left brachiocephalic vein. No
pneumothorax. Nasogastric tube ends in the stomach. Right upper
lobe nodules are noted.
.
***CULTURES****
[**11-30**] Blood neg X4
[**11-30**] Peritoneal fluid pansens Enterococcus, anaerobic bottle:
Bfragilis
[**12-2**] Neg VRE Rectal swab
[**12-2**] Neg MRSA
[**12-6**] Blood neg X4
[**12-6**] Yeast >100K
[**12-7**] Perionteal fluid no growth
[**12-7**] Urine 10-100K yeast, fungal: yeast not C. albicans, AFB
pending
[**12-7**] Blood Cx neg X4
[**12-9**] Crypto neg in blood
11/30 Peritoneal fluid: no growth, no fungus, no mycobacteria
.
**PATHOLOGY**
[**12-11**] peritoneal fluid: blood and inflammatory cells, cytology
negative for malignant cells
Brief Hospital Course:
Impression: 59-yo Russian speaking man w/ pancreatic CA s/p
failed whipple and cisplatin therapy, HTN, DM2 admitted
initially to MICU fpr pulmonary embolism and spontaneous
bacterial peritonitis, s/p IV heparin drip transitioned to
lovenox subcutaneously, with SBP being treated with Zosyn. The
pt also demonstrates portal HTN secondary to a pancreatic mass
compressing the portal vein and splenic vein, with evidence of
peritoneal mets on abdominal ultrasound. He is status post 3
paracenteses this admission (first [**2120-11-30**], 2nd [**2120-12-7**], 3rd
[**2120-12-11**]) with first growing Enterococcus and Bacteroides
fragilis. The 2nd and 3rd show no growth. Despite multiple
consultations with Liver, Infectious Disease, Renal and Surgery
specialists, the patient's prognosis remained poor, and despite
agressive treatment with paracenteses, intravenous antibiotics,
IVF, intravenous heparin, the patient expired on [**2120-12-12**]. He
remained full code until the morning of his death, wherein he
desaturated in the setting of volume overload and bilateral
pleural effusions. Plans were instituted for ICU transfer,
thoracentesis, possible intubation, however, the patient stated
he did not want further agressive measures taken. Multiple
meetings were held with family members throughout his course to
discuss his prognosis and options. On the morning of his death,
he and his wife (his health care proxy), along with his sons,
determined that he did not want further measures taken, and he
wanted to be comfortable. He was made comfortable on a morphine
drip and expired in the afternoon, surrounded by his family.
.
1. Infectious Disease: Thought to have SBP on admission, pt met
criteria for sepsis given tachycardia, elevated WBC count, with
evidence of SBP on fluid studies. S/p 9L IVF for fluid
resuscitation over 24 hours. Pt did not require pressors and he
made gradual improvement in MICU. WBC ct was trending down, pt
remained afebrile X 3 days, tolerating po, and was transferred
from MICU to medical floor. IV Zosyn was continued. Vanco was
d/c'd [**12-2**]. WBC elevated on [**12-7**] to 19.7. Concern for sepsis
[**2-14**] to bacterial peritonitis from recent surgical
procedure/instrumentation vs. questionable abscess on CT abd
according to surgical opinion (again likely [**2-14**] to recent failed
surgical attempt at removal off mass, CT showing free
air/bubbles/septations/loculated ascites) vs. partial
SBO/intermittent SBO causing translocation of enteric organisms
across bowel wall. Other potential sources included the cavitary
lesion seen on CXR therefore there was a questions of a possible
necrotizing PNA with his b/l pleural effusions (at the time felt
to be less likely, most reasonable explanation is old TB
infection but cannot r/out reactivation, especially given the
new [**Name (NI) 65425**] pt was transfered to isolation room, 3 sputum cx
sent, and were much later found to be positive for TB, infection
control notified, as were the health care workers exposed). It
was decided, after consultation with Infectious Disease team, to
not start ambisome (for fungal necrotizing PNA coverage) because
the pt had stable oxygen sats in the setting of no treatment for
? fungal PNA and we felt he was most likely volume overloaded
from repeated fluid boluses on MICU and the medical floor. He
was diuresed for volume overload with IV lasix. The patient
remained on Vanco/Zosyn for broad coverage including coverage of
Enterococcus and Bacteroids growing from pleural fluid. IV
Vancomycin and Zosyn were continued until the patient was made
CMO on [**2120-12-12**].
.
2. Portal vein compression- The patient had evidence on Abd CT
of pancreatic mass nearly occluding portal vein. It was thought
that there was accumulation of ascites secondary to portal
HTN/decline liver [**2-14**] portal vein compression. Liver was
consulted to comment on whether there would be a benefit to
placing a portal vein IR-guided stent through the area of
compression. After consultation with the Liver team, it was
agreed there would be little utility in this procedure. A Liver
Ultrasound completed with dopplers showed slow flow through
portal vein, w/ significant ascites. The liver team felt the pt
would need palliative paracenteses periodically as he
reaccumulates ascites. The pt received a total of three
paracenteses during his admission. He underwent his third and
final therapeutic/diagnostic tap on [**12-11**] with cytology
negative, fluid cx negative, neg for Mycobacteria or fungus as
well.
.
3. Oliguria, resolved: The patient developed oliguria after
transfer to the medical floor from the MICU. His oliguria was
most likely [**2-14**] intravascular volume depletion [**2-14**] prerenal
etiology from poor po intake. Early hepatorenal syndrome vs.
cisplatin nephrotoxicity was also considered, and a Renal
consult was initiated. He was initially started on octreotide
and mitodrine, however, this was tapered off over 3 days, as
hepatorenal syndrome was felt to be less likely after noting the
pt's UOP responded to IVF boluses and IVF hydration. His FENa
was <0.05%, consistent with prerenal etiology. His ins and outs
were strictly monitored during this admission. All nephrotoxic
medications were held and contrast was held in the setting of
his oliguia. His UOP returned to [**Location 213**], and the Renal
consultants signed off.
.
4. Liver Failure. The patient demonstrated low liver function
tests, likely secondary to diseased liver without synthetic
function at this stage, with his PT increasing slowly over time,
Albumin decreasing 1.5->1.2 prior to initiation of albumin. His
platelets, albumin, and glucose was closely followed this
admission. The pt demonstrated liver mets from his primary
pancreatic malignancy. He had multiple hypoattenuating areas
seen on Abd CT, which corresponded to metastatic foci.
Additionally, there are large wedge-shaped areas of difference
in attenuation involving portions of the left and right lobes
which suggest a perfusion difference or areas of fatty
infiltration on Abd CT.
.
5. Hypoxia: Throughout the patient's admission, he required 3L
oxygen by nasal cannula to maintain sats above 95%. His oxygen
requirement was this likely [**2-14**] to his small pulmonary embolism
vs. massive ascites accumulating and pushing up on the diaphragm
limiting respiration. His oxygen saturation was monitored
closely. He desatted two times during this admission, most
likely secondary to volume overload from repeated fluid boluses,
and was given nebs, IV lasix with improvement in respiratory
status. On the morning of his death, the patient desatted to
upper 70s, was given nebs, IV lasix, with CXR showing volume
overload (and prior RUL cavitary lesion), ABG concerning, thus
MICU consult was initiated. Pt refused the MICU consult and
stated he did not want to be intubated, and did not want further
measures taken regarding his medical care. He requested to be
made CMO. He was started on morphine, and his breathing was
made comfortable. He expired later in the afternoon.
Posthumously, the patient's TB sputum cultures came back
positive for Mycobacteria tuberculosis. Indeed, the pt's CXR
demonstrated a concerning RUL cavitary lesion. After transfer to
medical floor, he was put in an isolation room, and TB
precautions were taken. Infection control was notified. His son
brought in prior [**Name (NI) 65426**] from 10 years ago, and these demonstrated
RUL discrete lesions, likely granulomas, no cavitation.
Appropriate health care personnel and Occupational Health were
notified.
.
6. Pulmonary embolism, small subsegmental PE in RLL. He was
initially started on an IV heparin drip with goal PTT 60-80,
then transitioned to lovenox prior to transfer to the medical
floor from the MICU. He remained on lovenox until he was made
CMO/DNR/DNI.
.
7. Pancreatic CA: s/p failed whipple in [**Country 532**] now c/b ?abscess,
bacterial peritonitis. Also with mets on CT to adrenals and
liver. Patient initially seen at [**Hospital1 112**] where dx was made with
liver bx, and elevated tumor markers. Also s/p 10 days of
Cisplatin in [**Country 532**], although records were not available from
[**Country 532**]. The family was informed of the pt's poor prognosis (his
son is a third year medical resident). The pt was told by the
Surgical Service, as well as the primary team that he was a poor
surgical candidate. Hematology/Oncology at [**Hospital1 18**] was called, and
stated that gemcitabine would be a possible option (as an
outpatient), with 30% response rate, impossible to predict
responders. Also, this tx could potentially only incr life span
by a few months. No role for palliative chemo to decr size of
mass compressing the portal vein.
.
8. Type II DM: His glucose levels were well controlled with an
insulin sliding scale, and fingersticks were checked four times
daily.
.
9. Constipation, most likely [**2-14**] pain medications.
He was given a bowel regimen and Milk of magnesia. He responded
well to fleet enemas prn.
.
10. Pain: well controlled. The pt's pain was controlled on
fentanyl and dilaudid, with no pain complaints.
.
Medications on Admission:
1. MS Contin 30mg [**Hospital1 **]
2. Fentanyl patch 100mcg q 72 hours
3. Dilaudid 4mg PO q 4 hours prn
4. Zofran 4mg PO q 8 hours prn
5. reglan 10mg po TID
6. marinol 5mg tid
7. paxil 20mg daily
Discharge Medications:
None, pt expired [**2120-12-12**].
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Pulmonary Embolism
2. Spontaneous Bacterial Peritonitis
3. Metastatic Pancreatic cancer status post failed Whipple
procedure, chemotherapy
4. Oliguria secondary to Prerenal Azotemia
5. Pulmonary Tuberculosis with Right Upper Lobe Cavitary Lesion
6. Portal Hypertension secondary to compression of Portal Vein
by Tumor
7. Hypertension
8. Type II Diabetes Mellitus
9. Anemia of Chronic Disease
10. Constipation
11. Chronic Pain
Discharge Condition:
Expired [**2120-12-12**]..
POST MORTEM the STATE LAB confirmed he was infected with M.
Tuberculosis.
Discharge Instructions:
None, pt expired [**2120-12-12**].
Followup Instructions:
Not applicable
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
Completed by:[**2121-3-4**]
|
[
"560.9",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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icd9pcs
|
[
[
[]
]
] |
17255, 17264
|
7768, 16950
|
398, 429
|
17746, 17849
|
3847, 7745
|
17932, 18068
|
3002, 3044
|
17196, 17232
|
17285, 17725
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16976, 17173
|
17873, 17909
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3059, 3828
|
294, 360
|
457, 2474
|
2496, 2672
|
2688, 2986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,913
| 180,080
|
555
|
Discharge summary
|
report
|
Admission Date: [**2193-8-5**] Discharge Date: [**2193-8-7**]
Date of Birth: [**2118-7-9**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p VF arrest
Major Surgical or Invasive Procedure:
A-line placement
History of Present Illness:
75 yo female with DM presenting with VF arrest. Per patient's
husband, patient was at home with her husband this morning.
Husband was outside walking the dog, and when he walked in heard
his wife call out for him then heard her collapse. He was at
her side immediately, could not feel a pulse. He gave her
glucagon as she has a history of hypoglycemia, with no effect.
He called 911 within 5-10 minutes of finding her down. 911
responded within 2 minutes and defibrillated immediately. She
received three rounds of epinephrine, intubated and started on
dopamine gtt.
.
Initial vital signs in ED were HR 120, BP 75/p. EKG showed afib
with rate [**Street Address(2) 4531**] depressions in V1-V5. Initial labs showed
no leukocytosis, normal hematocrit and were significant for a pH
of 7.17, lactate of 8.8, bicarb of 16 and glucose of 178.
Patient was given a lidocaine bolus and started on a drip. She
was also given levophed for further pressure support in addition
to dopamine drip. She was seen by cardiology and given an
amiodarone bolus and drip for rate control. Post cardiac arrest
hypothermia protocol was initiated.
.
On arrival to the CCU, patient's VS were HR90 in SR with
frequent PVCs, BP 111/55 on levophed (dopamine was discontinued
prior to transfer).
.
According to husband, patient had no recent complaints of chest
pain, shortness of breath, orthopnea or paroxysmal nocturnal
dyspnea. She has known cardiac history. She is a type I
diabetic and has neuropathy and diabetic retinopathy. She is
legally blind.
Past Medical History:
1. CARDIAC RISK FACTORS: Type I diabetes
2. CARDIAC HISTORY:
- None.
3. OTHER PAST MEDICAL HISTORY:
- Type I diabetes
- Glaucoma
- Diabetic neuropathy
- Diabetic retinopathy, legally blind
Social History:
Lives with husband who was an ophthalmologist. Active in
community. No children.
- Tobacco history: Never
- ETOH: Occasional
- Illicit drugs: Denies
Family History:
Non contributory
Physical Exam:
Admission Physical Exam:
VS: T= 94.6 (bladder) BP= 100/64 HR= 78
O2 sat= 98% on CMV- Fi02 100%, R14, PIP 23, PEEP 5, TV 500
GENERAL: Intubated, not responsive.
HEENT: NCAT.
NECK: C-spine collar in place
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: On ventilator. CTA anteriorly, no wheezes, ronchi, rales.
ABDOMEN: Artic sun cooling device in place around abdomen. +BS,
soft, ND.
EXTREMITIES: Cool, good capillary refill. No lower extremity
edema or venous stasis changes.
PULSES:
Right: Femoral 2+ DP 1+ PT 1+
Left: Femoral 2+ DP 1+ PT 1+
Pertinent Results:
Admission labs:
WBC 7.1 Hgb 11.8 Hct 37.0
Lactate 8.8
INR 1.1
pH 7.17
EKG ([**2193-8-5**] @10:26): Atrial fibrillation with rapid ventricular
response, ST depressions in V1-V4 with widening of the QRS
(144ms).
EKG ([**2193-8-5**] @10:55): Atrial fibrillation with rapid ventricular
response, ST depressions in V1-V6 with ST elevations in II, III,
avF.
Head CT ([**2193-8-5**]): 1. No acute intracranial process.
CXR ([**2193-8-5**]): No acute intrathoracic process.
Echo ([**2193-8-5**]): Mild to moderate focal LV systolic dysfunction
consistent with inferior ischemia/infarction. Mild pulmonary
artery systolic hypertension.
EEG ([**2193-8-6**]): Burst suppression with seizure activity
Brief Hospital Course:
75yo female with Type I diabetes s/p ventricular arrest now on
post-arrest hypothermia protocol.
.
#s/p VF arrest: Underlying cause of VF arrest is unclear at
this time. EKG was concerning for potential RCA infarction vs
vasospasm. Patient treated for acute coronary syndrome given
questionable EKG with [**Last Name (LF) 4532**], [**First Name3 (LF) **] and heparin gtt. It is
possible that she had an arrhythmia. Patient has no history of
arrhythmia and electrolytes were all normal on arrival.
Patient's last fingerstick prior to event was 73, so unlikely to
have been related to hypoglycemia. Patient was pulseless for at
least 5-10 minutes prior to defibrillation. On arrival to the
ED, she was cooled with artic hypothermia protocol. She
continued to have lots of ectopy with tachycardia. She initially
required amiodarone gtt but returned to sinus rhythm. EEG showed
burst suppression with seizure activity. Patient was given a
loading dose of valproic acid. Patient was rewarmed after 24
hours of cooling. Following rewarming patient was in status
epilepticus. Neurology was consulted and determined that the
patient had a very poor likelihood of having a neurologic
recovery. [**Name (NI) **] husband [**Name (NI) 382**] decided to make patient [**Name (NI) 3225**].
Pressure support was withdrawn at this time. Patient was
continued on fentanyl for pain, propofol for sedation and ativan
for suppression of seizure activity. Ventilation support was
withdrawn and the electrical activity was no longer seen on the
monitor. Death was confirmed with absence of corneal reflex,
pupillary response, withdrawal to painful stimuli, as well as
absence of breath sounds and cardiac sounds while auscultating
for 60 seconds.
#Hypotension: Patient has required pressure support since she
was found down. She is currently on levophed. This is likely
due to cardiogenic shock in the setting of stunning myocardium.
As above, patient's pressure was supported with levophed. An
arterial line was placed for close hemodynamic monitoring. When
the decision was made for patient to be comfort measures,
levophed was discontinued.
#Type I diabetes: Patient is on lantus 14-15U qAM at home.
Blood sugars were controlled with home lantus dose in addition
to an insulin drop.
Please see death note for further information.
Medications on Admission:
Lantus 14U qAM
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary cardiac arrhythmia, respiratory failure. Death
Discharge Condition:
Death.
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
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"427.31",
"780.01",
"357.2",
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"997.31",
"410.61",
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"250.51",
"276.2",
"518.81",
"250.61",
"369.4",
"345.3",
"V70.7",
"365.9",
"362.01",
"401.9",
"348.1"
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"99.62",
"99.81",
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6127, 6136
|
3699, 6032
|
303, 321
|
6234, 6242
|
2978, 2978
|
6294, 6300
|
2292, 2310
|
6097, 6104
|
6157, 6213
|
6058, 6074
|
6266, 6271
|
2350, 2959
|
1972, 1980
|
250, 265
|
349, 1889
|
2994, 3676
|
2011, 2105
|
1911, 1952
|
2121, 2276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,267
| 135,090
|
17214
|
Discharge summary
|
report
|
Admission Date: [**2193-5-11**] Discharge Date: [**2193-5-19**]
Date of Birth: [**2147-12-11**] Sex: M
Service: MICU
CHIEF COMPLAINT: Upper gastrointestinal bleeding.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old
male with a history of alcoholic cirrhosis and portal
hypertension, alcohol abuse and history of esophageal
varices who is acutely transferred for upper gastrointestinal
bleeding. Over the past three weeks had increasing abdominal
girth, fevers or chills, and fatigue. He has had positive
rectal bleeding over the last week and on the day of
admission had episodes of hematemesis.
He presented to [**Hospital3 **] where he had an
esophagogastroduodenoscopy, which revealed positive
esophageal and gastric varices with a clot in the stomach,
but no active bleeding. He has had increasing confusion over
the past two days prior to admission as well. He has
continued drinking alcohol. He has had increasing lower
extremity swelling over the past week for which he had been
taking Ibuprofen for pain. According to his mother he had
not fallen down at any time. At [**Hospital3 **] he received
fresh frozen platelets, vitamin K, 1 unit of packed red blood
cells and Versed for the esophagogastroduodenoscopy.
PAST MEDICAL HISTORY:
1. Alcoholic induced hepatitis.
2. Cirrhosis.
3. Schizoaffective disorder.
4. Alcohol abuse and history of withdrawal seizure.
5. Acute pancreatitis in [**2193-2-2**].
6. History of gastritis.
7. Gastroesophageal reflux disease.
8. Esophageal varices.
9. Chronic obstructive pulmonary disease.
10. Asthma.
MEDICATIONS AT HOME:
1. Monopril 5 mg po q.d.
2. Advair discus b.i.d.
3. Combivent MDI two puffs inhaled q.i.d.
4. Magnesium oxide 200 mg po q.d.
5. Nicotrol inhaler two to four puffs inhaled q.i.d.
6. Lactulose q.i.d.
7. ................... 30 cc t.i.d.
8. Corgard 20 mg po q.d.
9. Aldactone 25 mg po b.i.d.
10. Atrovent MDI.
11. Protonix 40 mg po q.d.
12. Prednisone 10 mg po b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Smokes one pack per day, extensive alcohol
use about 100 drinks per week according to mother.
FAMILY HISTORY: Mother with hypothyroidism.
PHYSICAL EXAMINATION: Vital signs heart rate 100. Blood
pressure 125/80. Respiratory rate 32. 98% on 2 liters.
General, somnolent, unresponsive to voice. Plus fetor
hepatis. Head: Plus icteric sclera. Neck supple. Lungs
bilateral wheezing diffusely. Cardiovascular tachycardic.
S1 and S2. Abdomen distended, positive splenomegaly.
Extremities 2+ bilateral lower extremity edema. Neurological
lethargic, responds to sternal rub. Skin jaundiced, plus
caput medusa, plus spider angiomatosis.
INITIAL LABORATORIES: White blood cell count of 21.6,
hematocrit 30.0, platelets 122. Chem 7 sodium 127, potassium
4.1, chloride 97, bicarb 13, BUN 43, creatinine 1.6, glucose
107. AST 217, ALT 68, alkaline phosphatase 776, bilirubin
high, amylase 93, PT 14.3, PTT 31.5, INR 1.6.
Electrocardiogram was normal sinus rhythm at 90 beats per
minute, normal axis and normal intervals.
INITIAL ASSESSMENT: The patient is a 45 year-old male with a
history of alcohol abuse and cirrhosis, Child's class C with
episode of upper gastrointestinal bleeding.
HOSPITAL COURSE:
1. Upper gastrointestinal bleeding: The patient was
followed by the Liver Service while in house. He was
initially started on Octreotide, which he remained on the
first five days of hospitalization. The patient received an
esophagogastroduodenoscopy on the morning after admission,
which revealed esophageal and gastric varices with stigmata
of recent bleeding. There was a clot present in the fundus
of the stomach, which was not actively bleeding.
On that same day in the evening the patient underwent an
episode of hematemesis again. The patient received another
emergent esophagogastroduodenoscopy, which revealed some
bleeding from the esophageal varices. These were banded.
The patient did not have any further episodes of
gastrointestinal bleeding while in the hospital. The patient
had two large bore intravenous in place at all time and
required 2 units of packed red blood cells while in the
hospital for gastrointestinal bleeding, but no further blood
products.
2. Liver failure: The patient's transaminases remained
stable while in the hospital at mildly elevated. The patient
had an ultrasound with doppler studies showing reversible
flow in the portal vein, recannulization of the umbilical
vein, small cirrhotic liver with no masses.
The decision to have a TIPS procedure was deferred as the
patient was unstable hemodynamically and had severe
encephalopathy. The patient received Lactulose and Propanolol for
liver failure and portal hypertension. The patient also received
thiamine and folate. The patient had a hepatitis serology panel
sent, which was negative. The patient had liver function tests
checked, which were within normal limits. The patient had a mild
coagulopathy with an INRs at 1.7 to 1.8 range, which were
corrected somewhat by administration of vitamin K. The
patient required no further fresh frozen platelets while in
the hospital.
3. Alcohol withdraw: The patient was monitored closely for
alcohol withdraw / DTs and was maintained on an Ativan drip and a
CIWA scale while in the hospital. The patient had no seizure
activity while in the hospital.
4. Neurological: The patient had an episode of anisocoria
on day four of the hospitalization. The patient received an
urgent head CT, which revealed no acute bleeds. The patient
was evaluated by the neurology service, which suggested that
the patient had a temporary Horner's syndrome due to hematoma
at his right internal jugular central venous catheter site.
The anisocoria self resolved. The patient had no seizure
activity while in the hospital. The degree of hepatic
encephalopathy could not be assessed as the patient was
intubated and sedated for much of his hospital course.
5. Respiratory: The patient was semielectively intubated
for his esophagogastroduodenoscopy procedure. The patient
could not be weaned off the ventilator due to the development
of ARDS. He continued to be hypoxic as lesser pressure support
and PEEP settings were tried. The patient developed fevers and
aspiration pneumonia or pneumonitis from hematemesis and
aspiration of blood was considered, however, serial chest x-rays
revealed no suspicious infiltrates. The patient did require more
PEEP and greater FIO2 throughout his hospital course and had
problems with hypoxemia. The patient was continued on MDI
therapy for his asthma as well as steroids for suspected
asthma.
6. Acidosis: The patient was slightly alkalemic on
admission with a pH of 7.45, however, he became more and more
acidemic throughout the hospital course with eventual pHs of
7.23. The patient was not hypercapneic and he had no anion
gap. It was presumed that he had a hyperkalemic metabolic
acidosis most likely secondary to bicarbonate lost through
diarrhea and lactulose administration. Bicarbonate was
replaced, however, he continued to be acidemic. Lactate
levels were checked and were 1.6 and 1.7 respectively.
7. Infectious disease: The patient had recurrent fevers.
Possible sources were considered. Infectious disease
consultation were called. Possible sources included lungs
aspiration pneumonia, subacute bacterial peritonitis, and
bowel ischemia. The patient was initially on Ceftriaxone,
Azithromycin and Flagyl. However, this was changed to
Vancomycin, Flagyl and Ceftriaxone by the end of the hospital
course. There were no positive blood cultures, no positive
urine cultures and peritoneal fluid cultures had no growth as
well.
8. Subacute bacterial peritonitis: Upon admission to the
hospital the patient had a diagnostic paracentesis. The
results of which revealed a total protein at .2, glucose of
174, LDH of 68 and amylase of 110 and albumin of less then
detectable. The white blood cell count was 2195, red blood
cell count was 945, polys 80, lymphocytes 3, monocytes 0,
macrophages 17. The patient was presumed to have subacute
bacterial peritonitis and was treated with Ceftriaxone.
9. Renal: The patient had an increased BUN and creatinine
upon presentation. BUN continued to increase throughout the
hospital course and creatinine increased from 1.5 to 2.5 on
the last day of hospitalization. Causes for renal failure
was presumed to be hepatorenal syndrome. Nephropathy from a
prior CT scan or hypovolemia. The patient was given multiple
fluid boluses with no correction of his creatinine. He had
diuretics held. Urine sodium was checked and was less then
10.
10. Gastrointestinal: Bowel and intussusception, the
patient had a CT scan of the abdomen, which revealed multiple
bowel intussusceptions. The patient was seen by surgery as
part of an ischemic bowel workup. Given the patient's
extremely grim prognosis he was not deemed to be a surgical
candidate.
11. Pancreatitis: The patient on hospital day five had
rising lipases and amylases. Peak lipase in the 700s and
peak amylase 1200. CT scan of the abdomen revealed a
pseudocyst next to the pancreas, but did not appear infected.
There were no strandings around the pancreas. The patient
was maintained NPO since the diagnosis of pancreatitis.
12. Family discussion: The patient had a progressively
worsening medical outlook throughout his hospital course and
developed multisystem failure including pulmonary, liver,
renal complicated by pancreatitis, subacute bacterial
peritonitis, apparent infection and acidosis, inability to
wean off the ventilator.
Given the patient's extremely grim prognosis the decision was
made by the family to switch to comfort measures only and the
patient was extubated on [**5-18**] and expired on [**5-19**].
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis with liver failure.
2. Respiratory failure / ARDS.
3. Renal failure.
4. Pancreatitis.
5. Subacute bacterial peritonitis.
DISCHARGE CONDITION: Expired.
[**Known firstname **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 6867**]
MEDQUIST36
D: [**2193-5-20**] 06:08
T: [**2193-5-27**] 09:33
JOB#: [**Job Number 48265**]
|
[
"456.20",
"567.2",
"303.90",
"571.2",
"518.81",
"572.2",
"486",
"291.81",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.04",
"96.6",
"96.72",
"54.91",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
10006, 10248
|
2162, 2191
|
9834, 9984
|
3263, 9813
|
1618, 2033
|
2214, 3246
|
152, 186
|
215, 1258
|
1280, 1597
|
2050, 2145
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,034
| 139,541
|
2373
|
Discharge summary
|
report
|
Admission Date: [**2123-1-7**] Discharge Date: [**2123-1-9**]
Service: MEDICINE
Allergies:
Vasotec / Aspirin / Minocycline / Hydralazine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
central line by femoral access
History of Present Illness:
[**Age over 90 **] year-old female with ESRD, chronic AF on coumadin, CAD, HF
admitted with dyspnea and confusion. She was discharged on [**1-5**]
after being admitted for similar issues, which responeded to
volume removal in HD. She would be due for HD today. On [**1-6**],
VNA found her to be hypoxemic with a O2 sat only 76-80 and she
was started on 4L home O2. She had been on O2 in the hospital
but d/c'd off of it. She had been confortable since getting put
on oxygen. She continues to sleep much of the day and not eat
more. This morning, she awoke very confused. She was refusing to
go to HD and wanted to go to the [**Hospital1 **] instead. Her daughter said
she had a similar episode of confusion this past [**Holiday **]
that was attributed to pain meds.
In the ED, she had triage BP 70s and sats 80s, but initial vital
signs were 98.8 102 97/51 26 100/NRB without intervention for
her blood pressure. She was alert and oriented x 2.5. She was
found to have an increased right-sided pleural effusion. She had
LLQ pain and CT abd shoed pneumpbilia. This was atributed to her
stent and thought to be an unlikely source of sepsis. She was
put on BiPAP to tolerate the CT scan. She was given Vanc/Zosyn
for a possible R sided pneumonia and 250 cc NS for the
borderline hypotension. A left femoral line was placed given
poor access. She gets HD via a fistula. Prior to transfer, VS:
98.8 87 93/67 15 100% on NRB. She confirmed being DNR/DNI.
Currently, she does not remember why she came to the hospital.
Her breathing feels better and she complains only of a dry
mouth. She believes that she has been in the hospital for 3
weeks and wants to go home. She complains of an intermittently
sore "butt". She asks for a sip of water and explains that her
doctor tells her that she must chin-tuck to avoid aspiration.
.
Review of systems:
(+) Poor appetite, occasional dry cough, that has been
improving. Occasional constipation, anuric.
(-) Denies chest pain, fever, chills, night sweats. Denies
headache, sinus tenderness, rhinorrhea, or congestion. Denies
nausea, vomiting, diarrhea, or abdominal pain, dysuria. Denies
arthralgias or myalgias.
Past Medical History:
ESRD on HD T, Th, Sat
CAD s/p NSTEMI in [**2114**]
Diastolic CHF
HTN
Brachial Plexus Injury
Anemia of chronic inflammation/CKD
Pulmonary HTN (PASP 29-33)
Papillary thyroid cancer s/p total thyroidectomy in [**2116**]
GERD
h/o SVT
Gout
Colon angiodysplasia with bleeding, [**9-/2114**]
s/p TAH and BSO
s/p appendectomy
s/p bilateral cataract surgery
Social History:
lives with daughter. Widowed. Supportive daughter. [**Name (NI) **] current
tobacco (quit >20yrs ago). No alcohol or drug use. Was a
'stitcher'
Family History:
Non-contributory.
Physical Exam:
Temp 95.5 (ax), HR 80 (64-92), BP 90/50, RR 18, Sat 93 on 3L
General: Alert, oriented x2 (wrong year), says she lives with
her daughter. no acute distress. Cachectic.
HEENT: Sclera anicteric, no rhinorrhea, bald head, Dry mouth
with thick mucous.
Neck: Supple, no appreciable JVD, no lad, hyperdynamic carotids
Lungs: Decreased breath sounds bibasilar; otherwise CTA
bilaterally;
CV: regular irregular; normal S1/S2; no murmurs appreciated
Abdomen: Normoactive bowel sounds; soft, non-tender,
non-distended
Ext: hands are cool, deformed joints with boutonnierre, ulnar
deviation. No edema. Faint radial pulses.
Neuro: CNII-XII intact; moves all extremities, although
movement/strength exam limited by arthritis
Pertinent Results:
ADMISSION
[**2123-1-7**] 07:14AM BLOOD WBC-10.3 RBC-3.83* Hgb-12.8 Hct-39.4
MCV-103* MCH-33.4* MCHC-32.5 RDW-16.6* Plt Ct-259
[**2123-1-7**] 07:14AM BLOOD Neuts-77.7* Lymphs-18.6 Monos-2.4 Eos-0.7
Baso-0.6
[**2123-1-7**] 07:14AM BLOOD PT-28.9* PTT-150* INR(PT)-2.8*
[**2123-1-7**] 07:14AM BLOOD Glucose-137* UreaN-17 Creat-3.8* Na-143
K-5.2* Cl-98 HCO3-28 AnGap-22*
[**2123-1-7**] 07:14AM BLOOD ALT-15 AST-25 LD(LDH)-214 CK(CPK)-42
AlkPhos-17* TotBili-0.1
[**2123-1-7**] 07:14AM BLOOD cTropnT-0.19*
[**2123-1-7**] 04:24PM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2123-1-7**] 07:14AM BLOOD Calcium-9.7 Phos-2.7 Mg-1.8
THYROID
[**2123-1-7**] 07:14AM BLOOD TSH-38*
[**2123-1-8**] 06:50AM BLOOD Free T4-1.0
ABG
ON ROOM AIR
[**2123-1-7**] 07:21AM TYPE-ART PO2-82* PCO2-47* PH-7.43 TOTAL
CO2-32* BASE XS-5
ON NONREBREATHER
[**2123-1-7**] 11:41AM TYPE-ART TEMP-36.1 O2-100 PO2-316* PCO2-42
PH-7.47* TOTAL CO2-31* BASE XS-7 AADO2-377 REQ O2-65
COMMENTS-NON-REBREA
ADMISSION IMAGING
CXR The cardiac silhouette is enlarged and stable
since the prior study. There has been interval improvement of
the
moderate-sized bilateral pleural effusions and atalectasis. The
pulmonary
vasculature is unremarkable and there is no evidence of edema.
There is no
pneumothorax.
CT
IMPRESSION:
1. Moderate-sized bilateral pleural effusions with bibasilar
atelectasis.
2. Sigmoid diverticulosis without diverticulitis.
3. Small amount of pelvic free fluid.
4. T12 compression deformity, which is new from [**2120-11-21**],
but seen on
the prior chest radiographs from [**2122-11-22**].
5. Pneumobilia within the left lobe of the liver, likely related
to recent
sphincterotomy, but clinical correlation is advised.
6. Right renal and hepatic cysts.
7. Trace perihepatic ascites.
8. Diffuse atherosclerotic calcifications.
No intra- or extra-axial hemorrhage,
mass effect, or shift of midline structures is demonstrated.
Diffuse global atrophy is noted, which is age appropriate.
Periventricular white matter hypodensities are stable,
compatible with chronic small vessel ischemicchanges.
Differentiation of [**Doctor Last Name 352**]-white matter is preserved. Visualized
paranasal sinuses and mastoid air cells are well aerated.
Calcification of the cavernous portions of both internal carotid
arteries is again noted.
Brief Hospital Course:
SUMMARY
[**Age over 90 **] year old woman with ESRD on HD, AFib on coumadin, CAD, CHF,
pulmonary HTN, ?aspiation pneumonias, hypothyroidism presenting
with acute agitation and possible hypoxemia. She was recently
admitted for the same issue and returned within 48 hours of
discharge.
Hypoxemia
This patient's peripheral oxymetry readings are unreliable. The
patient saturates well on room air if the oxymetry is taken on
the forehead. The patient's pa02 on room air (on admission) was
in the 80's with an otherwise normal abg. When placed on a
non-rebreather, her PaO2 was 347 and she became alkalotic.
Hypotension
The patient is hypotensive at baseline with home readings that
vary between 70 and 100 in the systolic value. With a pressure
of 80/40, she can interact well and even explain the physiology
of her 'chin-tuck' swallow technique. She was discharged on an
increased dose of midodrine
Pleural effusions
The patient has pleural effusions likely related to diastolic
heart failure, hypothyroidism, afib with rvr and malnutrition.
They were slightly worse on this admission but made no clinical
impact
Afib with RVR
The patient often oscillates in and out of RVR. Her pressures
did not tolerate an increase in metroprolol. Her coumadin doses
were changed on discharge
ESRD on HD
The patient is dependent on HD for renal replacement.
Agitation
The patient will be discharged with an Rx for prn Zydis
Poor apetitie
Patient was discharged on megace
TO BE FOLLOWED
OXYMETRY TO BE TAKEN ON FOREHEAD
BLOOD PRESSURES TO BE COMPARED TO CLINICAL STATUS
Medications on Admission:
Acetaminophen 1000 mg PO TID
Calcium Carbonate 500 PO TID
Cholecalciferol (Vitamin D3) 800 unit PO DAILY
Warfarin 1.5mg PO once a day.
Pravastatin 40 mg PO DAILY
Metoprolol Tartrate 12.5 mg PO BID
Midodrine 5 mg PO TID (
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Levothyroxine 150 mcg PO DAILY
Bisacodyl 10 mg PO DAILY (Daily) as needed for constipation
Epoetin Alfa during HD
Lidocaine 5 %(700 mg/patch) Topical ONCE A DAY
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Midodrine 5 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please draw PT/INR by VNA or at PCP [**Name Initial (PRE) 3726**].
12. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO at bedtime as needed for agitation.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One (1) container
PO three times a day.
14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: take
1mg each day on saturday and sunday.
Disp:*30 Tablet(s)* Refills:*2*
15. Coumadin 1 mg Tablet Sig: 1.5 Tablets PO once a day: take
1.5mg daily on Mon, Tues, Wed, Thurs, and Friday.
16. oxygen
home oxygen. Continuous. 2 liters per minute.
17. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
mL PO QAM (once a day (in the morning)).
Disp:*300 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
Atrial Fibrillation with RVR
Pleural Effusion
Secondary
Hypotension
ESRD on HD
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted for low pressure and low oxygen. You did well
in the hospital and were discharged with home oxygen and a
higher dose of midodrine.
It is crucial that you take your oxygen levels on the forehead,
as your fingers give unreliable readings.
CHANGE
1) Midodrine 7.5 mg TID
2) Coumadin - take 1mg each day on saturday and sunday and 1.5mg
daily on weekdays.
3) Megace- new med for appetite
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1144**] as needed
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2123-1-10**]
|
[
"576.8",
"285.21",
"416.8",
"263.9",
"244.0",
"276.3",
"511.9",
"V10.87",
"V45.11",
"428.30",
"585.6",
"403.91",
"298.9",
"458.9",
"428.0",
"V58.61",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9862, 9919
|
6109, 7679
|
260, 293
|
10054, 10054
|
3787, 6086
|
10654, 10932
|
3020, 3039
|
8157, 9839
|
9940, 10033
|
7705, 8134
|
10226, 10631
|
3054, 3768
|
2160, 2470
|
211, 222
|
321, 2141
|
10068, 10202
|
2492, 2843
|
2859, 3004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,096
| 175,760
|
42938
|
Discharge summary
|
report
|
Admission Date: [**2190-11-13**] Discharge Date: [**2190-11-16**]
Service: MEDICINE
Allergies:
Iodine / Aspirin / Nsaids / E-Mycin / Ciprofloxacin /
Levofloxacin / Phenylephrine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
craniotomy
History of Present Illness:
This is an 89 year old male with a history of dementia,
hypertension, ESRD on hemodialysis and recent admission for
fevers and failure to thrive who presents from dialysis with a
syncopal episode. Per notes he received 2.5 hours of his
dialysis session but during the last 15 minutes he was noted to
slump in his chair and to lose consciousness for 2-3 minutes.
There was no overt seizure activity noted. No tongue biting or
loss of bowel or bladder function. No head trauma. Per EMS on
arrival he was arrousable but not at his baseline. He was
immediately transferred to [**Hospital1 18**]. As per recent discharge
summary his baseline is "confused" and has been deteriorating
rapidly over the past several months with episodes of delerium
and generalized failure to thrive.
.
In the ED, initial vs were: T: 98.3 P: 90 BP: 150/62 R: 14 O2
sat 95% on NRB, FS 98. He had a CXR which was unchanged from
prior films. EKG showed normal sinus rhythm, left axis
deviation, normal intervals, no acute ST segment changes, no
change from prior dated [**2190-10-3**]. He had a head CT which shows a
large new left sided fluid collection with mass effect. Exam in
the emergency room was notable for inability to follow commands
and withdrawal to painful stimuli. He was seen by neurosurgery
who felt that he would be a candidate for burr hole placement if
this were within the patient's goals of care. He is admitted to
the MICU for further management.
.
On the floor he is unable to respond to questions. He screams
out with painful stimuli to extremities. He is able to follow
commands to smile and close his eyes tightly. Otherwise further
history is unable to be obtained.
Past Medical History:
-ESRD on HD
-AV graft thrombosis and stenosis
-Dementia
-Malnutrition/Failure to Thrive
-Asthma
-pulmonary hypertension secondary to VSD
-Anxiety/Depression
-Chronic Bronchitis/COPD
-Traumatic Type II Dens fracture with chronic left jaw, eye,
ear, and neck pain
-Hypertension
-Hypercholesterolemia
-Incontinence of stool
-Benign prostatic hypertrophy
-12-mm left superior parietal meningioma
-Macular degeneration and anterior ischemic optic neuropathy
-Pancytopenia, possible MDS
-Left Renal calculi s/p lithotripsy
.
Social History:
born in [**State 350**]. Married for 55 years. Three children.
Attended college at [**University/College **] and got his doctorate in political
science from [**University/College **]. In [**2168**] he retired as a professor of
political science. He smoked a pipe decades ago. No alcohol
history.
Family History:
per records) sister with [**Name (NI) 5895**] disease who, in her final
years became demented. Brother has [**Name (NI) 5895**] disease.
Physical Exam:
99.8 BP: 139/50 P: 87 R: 17 O2: 94% on RA
General: Alert, unable to respond to questions of orientation,
no acute distress
HEENT: Sclera anicteric, MM dry, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud HSM at apex
radiating to axilla
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, well healed
surgical scars in left abdomen
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, left upper extremity fistula with palpable thrill
Neurologic: PERRL, EOMI, blinks to threat bilaterally, smiles
symmetrically, will not stick out tongue, increased tone in
upper and lower extremities throughout, withdraws upper
extremities to pain, screams in pain to painful stimuli in lower
extremities and withdraws slightly, reflexes 2+ and symmetric in
biceps, triceps, brachioradialis and patellar, toes downgoing,
gait not tested.
Pertinent Results:
WBC 8.4 N66.3 L21.6 M9.9 E1.4 B0.9
Hct 35.8 MCV 102
Plts 223
PT 13.8 PTT 36.2 INR 1.2
142 100 18
--------------------Gluc 106
4.1 35 2.2
ALT 14 AST 19 LDH 187 CK 12 AlkP 150 Tbili 0.4
CE negative x1
Ca 9.3 Phos 2.0 Mg 1.7
Alb 3.3
Dilantin 17.7, 19.2
Serum tox negative
Ua negative for blood, negative for infxn 100 protein, negative
glucose, 10 ketones
BCx negative x2, UCx negative
[**2190-11-13**] EKG
us rhythm. Left anterior fascicular block. Cannot exclude a
prior inferior
myocardial infarction. Compared to the previous tracing of
[**2190-10-3**] precordial
R waves are more prominent.
[**2190-11-13**] CXR
us rhythm. Left anterior fascicular block. Cannot exclude a
prior inferior
myocardial infarction. Compared to the previous tracing of
[**2190-10-3**] precordial
R waves are more prominent.
[**11-13**] CT head
IMPRESSION: Lentiform left frontoparietal fluid collection
measuring 2.6 cm,
new with mass effect. Attenuation values suggest mostly CSF
densoty with some
hemorrhagic elements. This may represent a subdural hygroma
mostly containing
CSF secondary to hypotension.
[**11-14**] EEG
Markedly abnormal portable EEG due to the very frequent and
occasionally rhythmic and persistent sharp waves with following
slowing,
primarily in the left posterior temporal region or left
hemisphere but
occasionally with a generalized distribution, and due to the
slow and
disorganized background. The background abnormalities signifies
an
encephalopathy. The focal sharp waves indicate an area of
cortical
hypersynchrony in the left hemisphere, likely more posteriorly.
They
suggest a focal lesion in that area. The repetitive discharges
suggest
brief electrographic seizures, but there was no definite
clinical
effect. The discharges certainly indicate potential for longer
seizures
at other times.
[**11-15**] CT head
1. Stable large predominantly chronic subdural fluid collection
overlying the
left frontoparietal convexity reaching that vertex; the overall
appearance is
suggestive of a chronic process, either "liquefied" subdural
hematoma or true
hygroma, with fibrovascular strand formation.
2. While the significant degree of mass effect on the subjacent
brain is
unchanged, there is further subfalcine herniation, with 12 mm
rightward shift
of the normally-midline structures; this measured 8 mm on the
admission study.
3. No new cerebral edema or hemorrhage.
[**11-16**] CT head
1. Status post left subdural evacuation with post surgery
changes.
2. Persistent left subdural fluid collection with mass effect,
with mild
decrease in size and attenuation when compared to prior study.
[**11-16**] CXR
Slight improvement of the left lower lobe atelectasis with
stable
small left pleural effusion, otherwise unchanged.
Brief Hospital Course:
89yoM with a history of dementia, hypertension, ESRD on
hemodialysis and recent admission for fevers and failure to
thrive who presents from dialysis with a syncopal episode found
to have a new left sided fluid collection on head CT.
Had focal seizures activity on EEG and per Neuro started on
Dilantin.
Pt was taken to OR for evacuation of fluid collection with
Neurosurgery. MAC was used and pt was not intubated. On day
after procedure, pt noted to be unresponsive, tachypneic and
very stridourous. Bronched, but no obvious abnormality seen.
Discussion with family and pt was made CMO. Pt deceased [**2190-11-16**]
at 2035.
Medications on Admission:
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Mirtazapine 15 mg QHS
Simvastatin 10 mg daily
Captopril 6.25 mg PO TID
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2190-11-30**]
|
[
"294.8",
"432.1",
"416.8",
"272.4",
"493.20",
"403.91",
"300.4",
"745.4",
"285.21",
"780.2",
"799.02",
"263.9",
"780.39",
"585.6",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7748, 7757
|
6917, 7548
|
308, 320
|
7809, 7819
|
4101, 6894
|
7876, 8052
|
2888, 3026
|
7715, 7725
|
7778, 7788
|
7574, 7692
|
7843, 7853
|
3041, 4082
|
260, 270
|
348, 2016
|
2038, 2559
|
2575, 2872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
544
| 186,746
|
18975+57004
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-6-11**] Discharge Date: [**2112-7-4**]
Date of Birth: [**2046-3-4**] Sex: F
Service: MEDICAL ICU
HISTORY OF PRESENT ILLNESS: This patient is a 66 year old
female who presented with light-headedness, dizziness,
hematemesis, to an outside hospital on [**2112-6-6**], and was
found to have a hematocrit of 15.0 and workup was consistent
with an upper gastrointestinal bleed. The patient was
transfused a total of sixteen units of packed red blood cells
and four units of fresh frozen plasma at the outside
hospital. At the outside hospital, the patient underwent
esophagogastroduodenoscopy on [**2112-6-6**], which revealed grade
IV esophagitis, bleeding ulcer 3.0 centimeters proximal to
the gastroesophageal junction and this bleeding ulcer was
cauterized and injected. At the outside hospital, the
patient continued to bleed actively with falling hematocrit
and underwent esophagogastroduodenoscopy two more times. On
[**2112-6-7**], esophagogastroduodenoscopy revealed a spurting
visible vessel in the distal esophagus and 9cc of Epinephrine
were injected. On [**2112-6-8**], esophagogastroduodenoscopy
revealed old blood in the fundus and the distal esophagus was
injected a third time. At the outside hospital, the patient
was intubated for airway protection as she was noted to have
hematemesis with likely aspiration. The patient was
extubated briefly but reintubated after another episode of
hematemesis. The patient was transferred to [**Hospital1 346**] on [**2112-6-11**], for further management
of her upper gastrointestinal bleed and respiratory status.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Malaria.
3. Filariasis.
4. Thyroid surgery.
MEDICATIONS ON TRANSFER:
1. Octreotide.
2. Reglan.
3. Protonix.
4. Levaquin.
5. Clindamycin.
PHYSICAL EXAMINATION: On admission, in general, the patient
is an obese woman, intubated and sedated. Head, eyes, ears,
nose and throat is normocephalic and atraumatic. The pupils
are equal, round, and reactive to light and accommodation.
The oropharynx is with endotracheal tube in place. Heart -
regular rate and rhythm, S1 and S2, no murmurs, rubs or
gallops. Lungs - decreased breath sounds bilateral lower
lobes, coarse upper airway sounds. Abdomen is obese, soft,
nontender, nondistended, normal bowel sounds. Extremities -
2+ pulses throughout, no cyanosis, clubbing or edema.
Neurologically, the patient is sedated, responsive to sternal
rub.
PERTINENT DIAGNOSTIC STUDIES ON ADMISSION: White blood cell
count was 10.0, hematocrit 30.2, platelet count 230,000.
Sodium 142, potassium 3.6, chloride 108, bicarbonate 27,
blood urea nitrogen 13, creatinine 0.5, glucose 114, calcium
7.9, phosphate 3.2, magnesium 1.7. ALT 10, AST 10, alkaline
phosphatase 60, total bilirubin 1.0. Prothrombin time 13.9,
INR 1.3, partial thromboplastin time 24.6.
Chest x-ray showed the endotracheal tube in proper position,
patchy alveolar opacity in the right lung, opacity with air
bronchograms in the left retrocardiac region, differential
diagnosis multifocal aspiration, pneumonia, asymmetric
pulmonary edema.
Electrocardiogram showed normal sinus rhythm at 71 beats per
minute, no ST-T wave changes, normal axis, normal intervals.
HOSPITAL COURSE:
1. Upper gastrointestinal bleed - The patient's hematocrit
remained stable in the low 30.0s and high 20.0s throughout
her hospital stay. The patient did not require a repeat
esophagogastroduodenoscopy and she remained guaiac negative
with no signs or symptoms of active bleed. The patient did
receive one unit of packed red blood cells on [**2112-6-22**], for a
slowly decreasing hematocrit to 27.0 over several days. Her
hematocrit responded appropriately to this one unit of packed
red blood cells and she did not require further transfusions.
The patient was maintained on proton pump inhibitor
throughout her hospital stay. Octreotide was continued until
[**2112-6-15**], when it was stopped with gastroenterology approval.
2. Respiratory distress - The patient was transferred here
intubated and sedated. The patient was difficult to wean
from the ventilator likely due to a combination of bilateral
atelectasis, bilateral pleural effusions, pneumonia,
pulmonary edema. The patient also was found to have a right
pneumothorax on [**2112-6-17**]. No instrumentation had been
performed on that side, and chest x-rays from the previous
days had not shown a pneumothorax. Likely, it was a side
effect of being intubated on the ventilator as well as due to
underlying chronic lung disease. A chest tube was placed on
the right with good results. The patient's bilateral pleural
effusions were decreased with diuresis as well as on the
right side with the placement of the chest tube. Right
pleural fluid was serosanguinous with 400 white blood cells,
50% polys, total protein 2.9, glucose 107, LDH 515, gram
stain negative. The patient was started on Ceftriaxone on
[**2112-6-17**], for her left lower lobe consolidation as well as
spiking fever. On [**2112-6-19**], the patient's pleural fluid and
the blood culture bottle was positive for gram positive
cocci. The patient was afebrile and continued on the
Ceftriaxone. Chest x-ray on [**2112-6-20**], showed that the
pneumothorax had resolved. On [**2112-6-21**], the patient was
extubated and her oxygen saturation remained in the 90s on
nonrebreather face mask. The patient briefly required CPAP
via face mask as she clinically was requiring great effort
for breathing. The patient was started on Albuterol and
Ipratropium nebulizers q4hours, standing dose. On [**2112-6-22**],
the patient was switched from Ceftriaxone after five days to
Ceftazidime and Vancomycin for increased white blood cell
count and fever to 102 degrees with continued left lower lobe
consolidation. These antibiotics were chosen to cover
broadly for pneumonia pathogens including pseudomonas as well
as hospital line infection from her central line. On
[**2112-6-22**], chest x-ray showed increased pulmonary edema, and
the patient was clinically with crackles bilaterally in the
lungs two thirds of the way up. The patient was restarted on
Lasix p.r.n. with a goal of minus one to two liters each day.
The patient responded very well to diuresis and pulmonary
edema decreased significantly. The patient's Lasix dose was
decreased on [**2112-6-28**]. With good diuresis as well as
treatment of the pneumonias and pneumothorax, the patient was
weaned slowly on oxygen from nonrebreather face mask after
extubation to nasal cannula by [**2112-6-28**]. On [**2112-6-27**],
Vancomycin and Ceftazidime were discontinued as the patient
had received six days of these antibiotics as well as five
days of Ceftriaxone and was clinically stable with no signs
or symptoms of infection. The same day the patient's
arterial line and central line were removed.
3. Mental Status Changes - The patient initially transferred
here sedated. After extubation and weaning of sedation, the
patient remained responsive but clearly confused and
disoriented. The patient's TSH and free T4 were within
normal limits. Head CT on [**2112-6-26**], was negative for an
acute process. Psychiatry was consulted and the patient was
started on Haldol 4 mg and then increased to 6 mg q.h.s. The
patient also responded well to Haldol p.r.n. for agitation.
The patient also received Ativan 2 mg once for agitation with
good effect. The patient's mental status changes were
gradually improved on a daily basis and by [**2112-6-29**], she was
conversant and appropriate. The patient was not yet back to
her high baseline mental status, but no further workup was
deemed necessary. The patient's mental status changes were
thought to be due to the fact that she was intubated for
several weeks, on Propofol. Also, in the Intensive Care Unit
setting, the patient was likely very sleep deprived,
contributing to somnolence and agitation intermittently.
4. Cardiovascular - The patient with no known cardiac
history but with pulmonary edema which contributed to
difficulty to wean from ventilator as well as from oxygen
after extubation. Echocardiogram on [**2112-6-22**], revealed a
mildly dilated left atrium, mild symmetric left ventricular
hypertrophy with normal cavity size, normal left ventricular
wall motion, hyperdynamic left ventricular systolic function,
ejection fraction of greater than 75%, right ventricular
chamber size and free wall motion normal. Aortic root was
mildly dilated, ascending aorta moderately dilated. Mitral
and aortic valves were within normal limits. No pericardial
effusion. The patient was diuresed effectively with Lasix.
The patient's heart rate and systolic blood pressure
increased after extubation to a heart rate in the 100 to 130
range, and systolic blood pressure in the 170 to 200 range.
This is of unknown cause although possibly related to the
recent extubation. The patient was started on Nitroglycerin
drip on [**2112-6-21**], which was discontinued on [**2112-6-26**]. The
patient was also started on a Diltiazem drip and then
switched to an Esmolol drip after the Diltiazem did not
affectively control the patient's heart rate. The
Nitroglycerin and Esmolol drips effectively controlled the
patient's heart rate and blood pressure but they remained
labile. Possibly contributing to this were her frequent
nebulizer treatments with Albuterol. Another important
factor contributing to the patient's systolic blood pressure
and heart rate elevation was anxiety and agitation as
mentioned above. The patient was started on Metoprolol three
times a day via her nasogastric tube with good effect and
both the Nitroglycerin and Esmolol drips were tapered to off.
The patient's cardiac vital signs also stabilized as her
agitation decreased and her mental status improved.
Currently, her heart rate and blood pressure are well
controlled on Metoprolol 100 mg three times a day.
5. Liver function - The patient's liver function tests were
within normal limits on admission. On [**2112-6-20**], the patient
was noted to have increased ALT to 106, AST 84, LDH 306,
alkaline phosphatase 158, total bilirubin 0.5, amylase 63,
lipase 106. The patient denied any abdominal pain at this
time or other symptoms. The patient underwent ultrasound of
the abdomen that day which had a normal gallbladder, normal
liver, normal biliary tree and normal kidneys. Also found
mild ascites and bilateral pleural effusions persisting. The
patient's liver function tests normalized within two days and
the etiology of this transient increase in liver function
tests was thought to be possibly drug related.
6. Fluids, electrolytes and nutrition - The patient was
provided nutrition via nasogastric tube and tube feeds were
as per nutrition consultation recommendations. On [**2112-6-30**],
the patient was evaluated by the Speech and Swallow
consultation and found to be grossly aspirating. They
recommended a gastric feeding tube. That day the patient's
daughter was [**Name (NI) 653**] and consented for this procedure on
the patient's behalf. Gastroenterology was [**Name (NI) 653**] and
planned gastric feeding tube placement on [**2112-7-1**], or
[**2112-7-4**]. The patient's potassium and magnesium were
repleted as needed throughout her hospital stay. The patient
was diuresed throughout the second half of her hospital stay
due to pulmonary edema with good effect.
7. Prophylaxis - The patient was started on subcutaneous
Heparin on [**2112-6-17**], after hematocrit continued to be stable
and gastroenterology consultation agreed. The patient was
also maintained on proton pump inhibitor throughout her
hospital stay.
8. Code Status - Full.
9. Communication - The patient was intubated and not
mentally competent to make decisions on her own behalf. The
patient's husband, friend [**Name (NI) 51863**], and daughter [**Name (NI) 51864**] [**Name (NI) 51865**],
were involved in the patient's care and were updated
frequently by the medical team.
10. Access - The patient had a left subclavian central line
which was eventually removed on [**2112-6-27**], as the patient no
longer needed to receive medications via the line.
DISPOSITION: The patient was screened for rehabilitation
facility and approved awaiting a bed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Esophageal ulcer.
2. Pneumonia.
3. Pneumothorax.
4. Respiratory distress.
5. Pulmonary edema.
6. Hypertension.
MEDICATIONS ON DISCHARGE: To be determined by the inpatient
regular [**Hospital1 **] team.
FOLLOW-UP PLANS: The patient to be transferred to
rehabilitation facility with follow-up with primary care
physician.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 6906**]
MEDQUIST36
D: [**2112-7-2**] 16:30
T: [**2112-7-2**] 17:03
JOB#: [**Job Number 51866**]
Name: [**Known lastname 9638**], [**Known firstname 9639**] P Unit No: [**Numeric Identifier 9640**]
Admission Date: [**2112-6-11**] Discharge Date: [**2112-7-6**]
Date of Birth: [**2046-3-4**] Sex: F
Service: [**Hospital1 248**]
ADDENDUM: This is a brief addendum to the Discharge Summary
as follows.
ADDITION TO SUMMARY OF HOSPITAL COURSE BY PROBLEMS:
1. Upper gastrointestinal bleed: The patient's hematocrit
remained stable during her stay on the floor. She did not
require further transfusions.
2. Respiratory: The patient's O2 requirement decreased to
three liters nasal cannula as her mental status improved,
however, the patient was found on chest x-ray to have a new
right lower lobe probable pneumonia. She was not febrile.
The Vancomycin and Ceftazidine were started on [**2112-7-1**],
and will continue for an additional ten days for a total of a
14 day course.
The patient received a PICC line on the right side to
facilitate the delivery of these intravenous medications.
3. Mental status changes: The patient's mental status
improved greatly from [**7-1**] until [**2112-7-4**]. She became
fully conversant, moving all extremities, able now to pass a
swallowing evaluation. Haldol was stopped completely the
night before discharge. Please note precautions and
recommendations regarding swallowing and aspiration risk.
4. Cardiovascular: The patient continued to be mildly
hypertensive on the floor. Treatment with Metoprolol 100 mg
three times a day resulted in blood pressures to the 160s.
The patient's hypertensive regimen should be titrated after
discharge from [**Hospital1 536**].
5. Fluids, Electrolytes and Nutrition: The patient had a
PEG tube placed [**2112-7-1**], because at that time she was
unable to swallow safely. As her mental status improved, her
swallowing ability did as well. The patient will likely be
able to achieve good safe p.o. orally and will likely be able
to have her PEG tube removed at that time.
DISCHARGE DISPOSITION: To extended care facility.
CONDITION AT DISCHARGE: Good.
DISCHARGE INSTRUCTIONS:
1. The patient should contact her primary doctor with any
increased shortness of breath and chest pain, abdominal pain,
or blood in stools or vomit.
2. The patient to receive skin care while at the extended
care facility.
3. The patient is to see primary doctor in follow-up.
4. The patient is to receive an additional ten days of
intravenous Vancomycin and ceftazidine for a total of a 14
day course.
5. The patient is to see her primary doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 9641**] on [**2112-7-19**], at 02:30 p.m.
6. The patient should see a pulmonologist, Dr. [**Last Name (STitle) 9642**],
[**Telephone/Fax (1) 9643**], as referred by primary care physician.
DISCHARGE MEDICATIONS:
1. Albuterol 90 microgram inhaler, one to two puffs q. four
as needed.
2. Multivitamin once a day.
3. Ascorbic acid 500 mg once a day.
4. Miconazole Powder applied twice a day.
5. Hydrocortisone 0.5% cream applied twice a day.
6. Colace 100 mg twice a day.
7. Bisacodyl 10 mg once a day.
8. Metoprolol 100 mg three times a day.
9. Atrovent two puffs inhalation four times a day.
10. Amlodipine 5 mg once a day.
11. Ceftazidime 2 grams intravenously every eight hours for
ten days.
12. Vancomycin one gram intravenously every 12 hours for ten
days.
13. Protonix 40 mg once a day.
DISCHARGE DIAGNOSES:
1. Pneumonia/pneumonitis, aspiration.
2. Anemia.
3. Delirium.
4. Decubitus ulcer.
5. Thyroid mass.
[**First Name8 (NamePattern2) 46**] [**Doctor First Name 258**], M.D. [**MD Number(1) 259**]
Dictated By:[**Last Name (NamePattern1) 2223**]
MEDQUIST36
D: [**2112-7-7**] 15:57
T: [**2112-7-7**] 18:33
JOB#: [**Job Number 9644**]
|
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icd9cm
|
[
[
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[
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14966, 15004
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16419, 16789
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12500, 12566
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3283, 12297
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|
1852, 2517
|
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12584, 14941
|
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|
2532, 3266
|
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29,972
| 155,288
|
45920
|
Discharge summary
|
report
|
Admission Date: [**2176-6-18**] Discharge Date: [**2176-6-20**]
Date of Birth: [**2103-12-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Vioxx / Celebrex / Lasix
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
ICU Monitoring
Non-invasive ventilation
History of Present Illness:
Ms [**Known lastname 54336**] is a 72 year old woman with history of COPD, CHF,
hypertension, obstructive sleep apnea, normally on 2L NC (with
sats near 93%) now presenting with shortness of breath, "not
acting right", and sats down to high 80's at her NH.
.
In the ED, initial vitals were: 98.4 58 112/57 20 93% on 4LNC.
CXR was unremarkable. BNP 681. She was initially to be admitted
to floor; however, became more confused in ED. ABG 7.32/77/82
and she was started on bipap with sats improving to 95-98% on
[**9-18**] 35%. She received solumedrol 125 IV X 1, nebs, ASA 325.
.
Upon arrival to the floor, she is very somnolent, but arousable
and oriented to place, month, and person. Bipap on. She reports
cough with mild sputum production. She cannot tell me when her
SOB or current symptoms started.
Past Medical History:
#. Hypertension
#. Diabetes mellitus - diet-controlled
#. Obstructive sleep apnea on BiPAP 15/? at home
#. ?COPD/Restrictive disease due to obesity
#. Obesity hypoventilation syndrome
#. Hypothyroidism
#. Hypercholesterolemia
#. morbid obesity
#. osteoarthritis
#. gout
#. depression
#. hypothyroidism
#. GERD
Social History:
Currently lives in nursing home. 30-40 ppd smoking history; quit
[**2156**]. No EtOH, IVDU, or illicit drugs. Patient is not sexually
active. Does not excercise regularly.
Family History:
Mother with HTN
Physical Exam:
VS: TL98.1, HR:54, BP:105/58 RR:22, O2Sat: 92% on 2LNC
GEN: Obese pleasant female, very alert, conversant, has
completely finished eating all the food on her breakfast tray.
HEENT: MMM, OP Clear,
NECK: Obese
COR: very distant heart sounds, regular, no mumurs
PULM: No wheezes or rhonchi appreciated, although difficult to
hear
ABD: Soft, NT, obese, +BS
EXT: trace edema
NEURO: Alert, oriented to [**Hospital1 **], knows where she
was before this, understands she was admitted to the hospital
because she was confused but says she does not feel this way
currently
Pertinent Results:
Chest X-ray: IMPRESSION: Ill-defined right middle lobe opacity
which could reflect atelectasis or infection. Recommend
dedicated PA and lateral views for further evaluation.
.
Lab results:
[**2176-6-17**] 08:35PM BLOOD WBC-6.4 RBC-3.91* Hgb-11.1* Hct-36.4
MCV-93 MCH-28.3 MCHC-30.4* RDW-15.7* Plt Ct-179
[**2176-6-18**] 05:31AM BLOOD WBC-5.6 RBC-4.03* Hgb-11.8* Hct-37.4
MCV-93 MCH-29.3 MCHC-31.6 RDW-15.6* Plt Ct-186
[**2176-6-19**] 03:32AM BLOOD WBC-12.5*# RBC-3.82* Hgb-11.3* Hct-35.3*
MCV-92 MCH-29.6 MCHC-32.1 RDW-15.6* Plt Ct-215
[**2176-6-20**] 06:00AM BLOOD WBC-14.7* RBC-4.06* Hgb-11.9* Hct-37.4
MCV-92 MCH-29.3 MCHC-31.8 RDW-15.8* Plt Ct-248
[**2176-6-17**] 08:35PM BLOOD Neuts-63.0 Lymphs-23.4 Monos-8.1 Eos-5.2*
Baso-0.3
[**2176-6-18**] 05:31AM BLOOD PT-14.3* PTT-34.4 INR(PT)-1.2*
[**2176-6-19**] 03:32AM BLOOD PT-15.3* PTT-32.7 INR(PT)-1.3*
[**2176-6-17**] 08:35PM BLOOD Glucose-137* UreaN-25* Creat-1.3* Na-139
K-4.2 Cl-96 HCO3-39* AnGap-8
[**2176-6-18**] 05:31AM BLOOD Glucose-149* UreaN-29* Creat-1.3* Na-139
K-4.9 Cl-96 HCO3-36* AnGap-12
[**2176-6-19**] 03:32AM BLOOD Glucose-130* UreaN-35* Creat-1.2* Na-138
K-4.2 Cl-96 HCO3-34* AnGap-12
[**2176-6-20**] 06:00AM BLOOD Glucose-77 UreaN-37* Creat-1.1 Na-139
K-4.2 Cl-96 HCO3-36* AnGap-11
[**2176-6-17**] 08:35PM BLOOD CK(CPK)-102
[**2176-6-18**] 03:50AM BLOOD CK(CPK)-103
[**2176-6-18**] 05:31AM BLOOD CK(CPK)-90
[**2176-6-17**] 08:35PM BLOOD cTropnT-0.01
[**2176-6-18**] 03:50AM BLOOD cTropnT-<0.01
[**2176-6-18**] 05:31AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-6-18**] 05:31AM BLOOD Calcium-8.8 Phos-4.8*# Mg-1.6
[**2176-6-19**] 03:32AM BLOOD Calcium-8.8 Phos-2.5*# Mg-1.6
[**2176-6-18**] 05:31AM BLOOD TSH-1.6
[**2176-6-18**] 02:31AM BLOOD Type-ART O2 Flow-4 pO2-83* pCO2-77*
pH-7.32* calTCO2-42* Base XS-9 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2176-6-18**] 08:14AM BLOOD Type-ART pO2-69* pCO2-73* pH-7.32*
calTCO2-39* Base XS-7
Brief Hospital Course:
This is a 71 year-old female with a history of obesity, OSA,
COPD, dCHF who was admitted for delirium and hypercarbic
respiratory failure, originally in the MICU, then transferred to
the floor after resolution.
.
# Altered mental status: Likely multifactorial in origin,
secondary to multiple causes of hypercarbic respiratory failure
(OSA, obesity hypoventilation syndrome, COPD exacerbation and
possible PNA), worsened by excessive sedating medications,
probable RML pneumonia, and UTI. The patient's standing
gabapentin, ambien and oxycontin were held. They did not need
to be restarted during her hospitalization. The patient's
hypercarbic respiratory failure was treated with BiPAP, steroids
and antibiotics. By the second day of admission, the patient's
mental status returned to baseline.
.
#. COPD exacerbation/PNA: The patient reports a cough for many
days prior to admission. She reported that it is productive of
yellow sputum. The patient's COPD at baseline was likely
exacerbated from this acute illness. She had improvement of
respiratory symptoms and oxygenation after using BiPAP
overnight, started on steroids, and given levofloxacin for
possible RML infiltrate, even though the PA/Lateral did not show
definite infiltrate. Also, patient did not present with a
leukocytosis, although she did develop one after Solumedrol was
started. Therefore, pneumonia is less likely, but still a
possibility and should be treated as such with a ten day course
of levofloxacin 750mg QOD (last day [**2176-6-28**]). Prednisone was
continued for three days, and should be continued for only one
more day of 20mg tomorrow. The patient was managed with
nebulizer treatments and her home advair with improvement of her
symptoms. These should be continued going to rehab. If the
patient develops worsening symptoms including fevers, increasing
sputum production, then MRSA PNA should be considered, although
very unlikely, given MRSA on [**2174**] sputum culture, and Vancomycin
1gm should be started empirically. The patient should also
continue chest PT, guaifenesin and benzonate for symptomatic
relief.
.
#. Hypertension: The patient's blood pressures were well
controlled during her admission. She was continued on
Amlodipine 10mg daily, Lisinopril 40mg daily, Metoprolol
succinate 300mg changed to tartrate 100mg TID while in house.
She was discharged on these medications.
.
#. CHF: The patient was not in decompensated heart failure on
admission. BNP was 600's on admission and had been as low as 98
in [**4-20**]. Last admission in [**7-22**] for CHF, BNP was 1900, thus
supporting the fact that this was not likely a CHF exacerbation.
Also the patient did not appear volume overloaded. She was
continued on her home regimen of ethacrynic acid, given lasix
allergy. She was discharged with instructions to monitor daily
weights.
.
# OSA: The patient was continued on home BiPAP settings
overnight with improvement of her hypercarbia. She should
continue these BiPAP settings on discharge: Nasal CPAP w/PSV
(BIPAP) Inspiratory pressure: +4 cm/h2o Expiratory pressure:
5-15 cm/h2o
.
# Acute renal failure: The patient had a mild increase in her
creatinine on admission, up to 1.3 on admission. Likely was
prerenal, improved without intervention.
.
# DM: diet controlled, FSBS QID, ISS
.
#. Gout: Continued Allopurinol 100mg [**Hospital1 **]
.
#. Depression: Continued bupropion and paroxetine
.
#. Chronic pain/BL Knee pain: Gabapentin, oxycontin and
oxycodone were held on admission considering altered mental
status. Discussed with the patient the possibility of knee
injections for palliation, however she reported that this was
not helpful in the past. Tylenol XS or Percocet were
recommended.
.
#. Hypothyroidism: Continued levothyroxine. TSH was within
normal limits on admission.
.
#. GERD: Continued pantoprazole
.
# FEN: Continued vitamin C, Low-salt, diabetic diet
.
# Access: Peripheral IV
.
# PPx: Heparin SC
.
# Code: Full code
.
# Comm: with patient.
[**Doctor First Name **]: [**Telephone/Fax (1) 97787**]
Medications on Admission:
Ethacrynic Acid 100 mg daily
Albuterol/atrovent
Allopurinol 100 mg [**Hospital1 **]
Bupropion 100 mg TID
Fluticasone-Salmeterol 250-50 [**Hospital1 **]
Gabapentin 600 mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Lisinopril 40 mg daily
Pantoprazole 40 mg daily
Paroxetine 40 daily
Zolpidem 10 QHS
Senna/colace
Vit C daily
Aspirin 81 daily
Amlodipine 10 mg daily
Oxycodone 5 mg Q4H PRN
Oxycodone 10 or 20 mg Sustained Release [**Hospital1 **]
Miconazole Powder
Toprol 300 mg daily
Discharge Medications:
1. Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily): Hold for Sytolic < 90.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day: Please give standing.
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 10 days: To complete 10-day course on
[**2176-6-28**]. Dosed every other day for GFR.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 90.
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for Systolic<90.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO On [**2176-6-20**]
for 1 doses: Last dose of taper on [**2176-6-20**].
18. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
19. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
20. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
Primary:
Delirium of multifactorial etiology, resolved
Hypercarbic and hypoxic respiratory failure
community-acquired pneumonia
Obstructive Sleep apnea
Secondary Diagnoses:
Chronic obstructive pulmonary disease
Diabetes mellitus type II
Hypothyroidism
Osteoarthritis
Discharge Condition:
Alert, oriented to person, [**Hospital1 **], and
conversant, responding to questions appropriately, neurologic
exam grossly intact, breathing comfortably, O2Sat at baseline
92-93% on 2 litres nasal cannula.
Discharge Instructions:
You were admitted with confusion. This improved with stopping
of your sedating medications, including Oxycontin, Gabapentin,
and Ambien. You also received treatment for your sleep apnea
and a pneumonia. You were started on an antibiotic for the
pneumonia and your symptoms improved. Please complete the
antibiotic and the short course of prednisone as prescribed.
.
New Medications:
Levofloxacin 750mg every other day end date [**2176-6-28**]
Prednisone 20mg once tomorrow [**2176-6-21**]
.
These Medications were discontinued, please do not restart them
on discharge unless instructed to by your physician at [**Hospital 97788**] Nursing Care Center:
Gabapentin
Oxycontin
Oxycodone
Ambien
.
Please contact your physician or return to the emergency room if
you have worsening of confusion, shortness of breath, or any
other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1001**], your physician at [**Hospital 97788**] Nursing Care Center.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2176-6-20**]
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25,278
| 114,130
|
15415
|
Discharge summary
|
report
|
Admission Date: [**2122-9-26**] Discharge Date: [**2122-10-4**]
Date of Birth: [**2122-9-26**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] T, delivered at 40
1/7 weeks gestation, weighing 3,515 grams, was admitted to
the Neonatal Intensive Care Unit from the Newborn Nursery on
day of life number one for evaluation and management of a
fever.
Mother is a 32 year old gravida 1, para 0 now 1 female with
an estimated date of delivery of [**2122-9-25**].
Prenatal screens included a blood type of O positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
B surface antigen negative, and group B streptococcus
negative.
mother presented with spontaneous labor. No maternal fever.
Rupture of membranes 19 hours prior to delivery. No fetal
tachycardia. Delivery by normal spontaneous vaginal delivery
with Apgar scores of nine and nine at one and five minutes
respectively.
The infant was admitted to Newborn Nursery, where he was
reported to be breast feeding well, voiding and stooling
appropriately. At around 41 hours of age, he was noted to
have a fever of 101.4 axillary, with a corresponding rectal
temperature of 101.7. He was admitted to the Neonatal
Intensive Care Unit. On admission, the patient was noted to
have malodorous, mucousy heme positive stools.
PHYSICAL EXAMINATION: On physical examination on admission,
the infant had a birth weight of 3,515 grams (75th to 90th
percentile), length 49.5 cm (50th to 75th percentile) and
head circumference 33 cm (25th to 50th percentile). The
infant was active, pink, with a temperature of 100.2, heart
rate 130, respiratory rate 34, blood pressure 76/47. Breath
sounds clear and equal with comfortable work of breathing.
Heart rate regular with normal S1 and S2, no murmur, equal
pulses. Abdomen soft, nontender, nondistended, no
hepatosplenomegaly. Extremities warm with slightly decreased
perfusion throughout. Spine intact. Hips stable. Testes
descended. Skin with erythema toxicum, Mongolian spot on
right ankle and buttocks, no vesicular lesions. Infant with
appropriate tone and activity.
HOSPITAL COURSE: 1. Respiratory: No respiratory distress
during hospital admission. No apnea witnessed. Had several
episodes of desaturations associated with feeding, the last
one on [**2122-9-30**].
2. Cardiovascular: Has been hemodynamically stable
throughout hospitalization, without murmur. Had a low
resting heart rate which ranged from 80 to the 110s. On
[**2122-9-29**], had three episodes of bradycardia with
heart rate dropping to the 40s while sleeping, no apnea
noted. At time of bradycardia, oximeter was not on, so not noted
if there was desaturation associated with bradycardia. No
color change noted. Subsequently noted to have desaturations
with feedings on [**2122-9-30**]. An electrocardiogram
was normal. The decision was made to monitor in the hospital
for a five day asymptomatic period and he has not had further
episodes. It appears that the episodes were likely due to vagal
events against a background of a physiologic low-resting heart
rate.
3. Fluids, electrolytes and nutrition: On admission, was
given a normal saline bolus for clinical evidence of
dehydration. Has been breast and/or bottle feeding well;
bottle feeds when mother is not visiting; when bottled,
taking two to four ounces every two to four ounces with
weight gain. Discharge weight 3,695 grams.
4. Gastrointestinal: Received phototherapy for indirect
hyperbilirubinemia. Peak bilateral total 18, direct 0.4.
Most recent bilirubin on [**2122-10-2**] was total 9.1,
direct 0.2. Is mildly jaundiced at time of discharge.
5. Hematology: Hematocrit on admission 45%
6. Infectious disease: A sepsis evaluation was done on
admission that included a complete blood count, blood
culture, lumbar puncture, and stool cultures. The complete
blood count showed a white blood cell count of 15,000 with 68
polycytes and no bands, and platelet count 341,000. The
blood culture has remained negative. The cerebrospinal fluid was
negative for bacterial infection and negative
for PCR for HSV. Stool cultures were negative. Received 48
hours of ampicillin and gentamicin while awaiting for blood
culture results. Temperature decreased following admission. Has
had no further fevers. In retrospect, the fever appears to have
been due to dehydration.
7. Neurology: Examination age appropriate.
8. Sensory: Hearing screening was performed with automated
auditory brain stem responses. Infant passed both ears.
9. Psychosocial: The parents have visited frequently and
are comfortable caring for the baby. They are Mandarin
speaking Chinese. The infant's clinical course and discharge
teaching were explained to them through a Mandarin speaking
interpreter.
CONDITION AT DISCHARGE: Stable.
DISPOSITION: Discharged home with family.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 44720**] at [**Hospital3 44721**] [**State 44722**]in [**Location (un) 86**], telephone
number [**Telephone/Fax (1) 8236**], fax #[**Telephone/Fax (1) 26001**].
CARE AND RECOMMENDATIONS:
1. Feeds: Ad.lib. demand breast feeding.
2. Medications: None.
3. State Screen has been sent.
4. Immunizations received: Hepatitis B on [**2122-10-3**].
FOLLOW-UP APPOINTMENTS: Recommended follow-up appointment
with pediatrician; parents will make on Monday or Tuesday.
DISCHARGE DIAGNOSES:
Appropriate for gestational age term male.
Bradycardia secondary to vagal event, resolved.
Rule out sepsis.
Rule out HSV.
Dehydration, resolved.
Indirect hyperbilirubinemia, resolving.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-622
Dictated By:[**Last Name (NamePattern1) 42964**]
MEDQUIST36
D: [**2122-10-3**] 17:11
T: [**2122-10-3**] 19:22
JOB#: [**Job Number 44723**]
|
[
"V30.00",
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"775.5",
"780.2"
] |
icd9cm
|
[
[
[]
]
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[
"99.83",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5461, 5882
|
2179, 4850
|
5160, 5321
|
5346, 5440
|
1387, 2161
|
4865, 5134
|
172, 1364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,384
| 169,052
|
44518
|
Discharge summary
|
report
|
Admission Date: [**2150-1-13**] Discharge Date: [**2150-2-3**]
Date of Birth: [**2073-7-5**] Sex: M
Service: SURGERY
Allergies:
Sulfonamides / Norpace / Quinidine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
Resection and repair of abdominal aortic aneurysm with 18 x 9
bifurcated aortobi-iliac graft.
History of Present Illness:
This 76-year-old gentleman was recently found to have a 6.4 cm
aneurysm which was a juxtarenal aneurysm of the infrarenal
aorta, also involving the right and left common iliac arteries.
The right iliac artery was actually frankly aneurysmal. The left
iliac artery was only ectatic. The patient was not a candidate
for stent graft based on anatomy and was advised to have an open
repair.
Past Medical History:
PMH: HTN, DM, GERD, mild cirrhosis, EF 55%, mild MR
[**Name13 (STitle) **]: varicose veins
Social History:
pos smoker
pos drinker
Family History:
n/c
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2150-2-2**] 05:00AM BLOOD WBC-5.9 RBC-3.55* Hgb-10.7* Hct-30.9*
MCV-87 MCH-30.1 MCHC-34.5 RDW-14.9 Plt Ct-338
[**2150-1-29**] 04:00AM BLOOD PT-14.2* PTT-31.0 INR(PT)-1.3*
[**2150-2-2**] 05:00AM BLOOD Plt Ct-338
[**2150-2-2**] 05:00AM BLOOD Glucose-63* UreaN-18 Creat-0.9 Na-141
K-3.4 Cl-106 HCO3-25 AnGap-13
[**2150-2-2**] 05:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
Cardiology Report ECHO Study Date of [**2150-1-13**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.0 cm (nl <= 4.0 cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.26 (nl >= 0.29)
Aorta - Valve Level: 2.0 cm (nl <= 3.6 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thicknesses and cavity
size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal
inferior - normal; mid inferior -normal; basal inferolateral -
normal; mid inferolateral - normal; basal anterolateral -
normal; mid anterolateral - normal; anterior apex - normal;
septal apex - normal; inferior apex - normal; lateral apex -
normal; apex - normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity
size are normal. Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Brief Hospital Course:
Mr [**Name13 (STitle) 54864**] was admitted on [**2149-1-13**] for an elective Resection and
repair of abdominal aortic aneurysm with 18 x 9 bifurcated
aortobi-iliac graft . Pre-operatively, he was consented,
prepped, and brought down to the operating room for surgery.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication. But EBL intraop 3200
mL--required significant amt. blood products and pressors.
Remains intubated.
He was sent to the SICU immediate post operatively. Pt continued
to recieve pressor and blood products. Once pt was stablaized
with the post operative support. He was extubated without
difficulty.
He was then transferred to the floor for further recovery.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve his
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: aspirin 81qd; celebrex 200qd; cozaar 50qd; isosorbide
dinitrate 20bid; lasix 20qd; lipitor 20qd; metformin 500bid;
lopressor 50bid; zantac 150bid
Discharge Medications:
1. Aspirin 325 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
6. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
9. Isosorbide Dinitrate 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
10. Losartan 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast Dinner
NPH 15 Units NPH 15 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-60 mg/dL [**1-6**] amp D50 D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 3 Units 3 Units 3 Units 3 Units
141-160 mg/dL 5 Units 5 Units 5 Units 5 Units
161-180 mg/dL 7 Units 7 Units 7 Units 7 Units
181-200 mg/dL 9 Units 9 Units 9 Units 9 Units
201-220 mg/dL 11 Units 11 Units 11 Units 11 Units
221-240 mg/dL 13 Units 13 Units 13 Units 13 Units
241-260 mg/dL 15 Units 15 Units 15 Units 15 Units
261-280 mg/dL 17 Units 17 Units 17 Units 17 Units
281-300 mg/dL 19 Units 19 Units 19 Units 19 Units
301-320 mg/dL 21 Units 21 Units 21 Units 21 Units
321-340 mg/dL 23 Units 23 Units 23 Units 23 Units
341-360 mg/dL 25 Units 25 Units 25 Units 25 Units
> 360 mg/dL 27 Units 27 Units 27 Units 27 Units
13. Celecoxib 200 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO daily ().
14. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Abdominal aortic aneurysm
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-12**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-7**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Please call to make an appointment to follow up with Dr.
[**Last Name (STitle) **] within 2 weeks of your discharge: ([**Telephone/Fax (1) 18181**]
Please keep all of your other scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2150-3-10**] 8:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2150-4-7**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2150-4-7**] 1:30
Completed by:[**2150-2-3**]
|
[
"401.9",
"041.4",
"530.81",
"584.9",
"442.2",
"518.5",
"250.00",
"724.5",
"571.2",
"441.4",
"424.0",
"276.0",
"285.1",
"599.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"99.00",
"38.16",
"96.72",
"99.05",
"00.42",
"88.72",
"38.46",
"99.15",
"99.04",
"38.44",
"96.6",
"99.07",
"38.93",
"00.44"
] |
icd9pcs
|
[
[
[]
]
] |
8125, 8183
|
4337, 5396
|
319, 415
|
8253, 8260
|
1504, 4314
|
10999, 11630
|
1003, 1008
|
5619, 8102
|
8204, 8232
|
5422, 5596
|
8284, 10546
|
10572, 10976
|
1023, 1485
|
253, 281
|
443, 832
|
854, 947
|
963, 987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,975
| 119,358
|
19973
|
Discharge summary
|
report
|
Admission Date: [**2176-12-21**] Discharge Date: [**2176-12-25**]
Date of Birth: [**2099-9-16**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: The patient is a 77-year-old male status
post endoscopic retrograde cholangiopancreatography on
[**12-19**] for choledocholithiasis, now presented with bright
red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient was in his usual
state of health but began to experience intermittent middle
abdominal pain. A CT was performed and showed common bile
duct stones, as well as biliary dilatation. On the [**2176-12-19**], the patient underwent uncomplicated endoscopic
retrograde cholangiopancreatography with spincterotomy
producing eight pigmented stones. The patient tolerated the
procedure well and was discharged in stable condition.
However, the patient began to experience diarrhea that was
melenic in character and noted bright red blood times two.
The patient denies any abdominal pain, nausea, vomiting. The
patient was transferred back to the Emergency Department
where an nasogastric lavage was performed and it was
negative.
REVIEW OF SYSTEMS: Notable for no fevers, chills, nausea,
vomiting, jaundice, dark urine, dysuria, urgency, chest pain,
shortness of breath, palpitations, cough, or upper
respiratory infection symptoms. The patient does complain of
dizziness and lightheadedness however.
PAST MEDICAL HISTORY:
1. Choledocholithiasis.
2. Porcelain gallbladder.
3. Spinal stenosis.
4. Near paraplegia secondary to the spinal stenosis.
5. Parkinson's disease.
6. Question coronary artery disease.
7. Autonomic dysfunction.
8. Anxiety disorder.
9. Chronic constipation.
10. Chronic renal insufficiency.
11. Benign prostatic hypertrophy.
ALLERGIES: Patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Zoloft 100.
2. Klonopin 1 b.i.d.
3. Sinemet 25/250 b.i.d.
4. Lasix 20 q.d.
5. Sublingual nitroglycerin prn.
6. Oxycodone prn.
7. Proscar 5 q.d.
8. Prevacid 15 q.d.
9. Prinivil 40 mg q.d.
10. Adalat 30 mg q.d.
11. Zocor 40 mg h.s.
12. Multivitamin capsule.
13. Enteric coated aspirin.
SOCIAL HISTORY: The patient is a resident of the [**Hospital3 1761**]. He has a remote smoking history. He quit
tobacco 40 years ago. He rarely drinks ethanol.
PHYSICAL EXAM ON ADMISSION: Temperature 100. Heart rate 60.
Blood pressure 173/64. Oxygen saturation 97% on room air.
In general, this is a pleasant elderly man in no acute
distress. Head, eyes, ears, nose and throat: There is no
scleral icterus. Conjunctivae are not injected. Pupils
equal, round and reactive to light. Extraocular movements
intact. Neck: No jugular venous distention.
Cardiovascular: Distant heart sounds. Pulmonary: Clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended. Patient is guaiac positive. Extremities: No
edema. Neurological: Awake, alert, oriented times three,
weak diffusely, and unable to stand with assistance.
LABS ON ADMISSION: His sodium is 139, potassium 5.0,
chloride 105, bicarbonate 25, BUN 63, creatinine 1.6, glucose
148, white blood cell count 12.4 with 72 neutrophils, no
bands, hematocrit is 32.5 which is down from 41 previously
and 232 is his platelet count. ALT is 107, AST 80. His T
bilirubin is 0.7. Albumin is 3.3. His lipase is 45.
HOSPITAL COURSE: The patient was initially admitted to the
General Medicine Floor for observation. However, the patient
was noted to have further decline in his hematocrit from the
32 on admission to 26.5 at which point the patient was
transferred to Medical Intensive Care Unit. The patient was
given four units of packed red blood cells and was taken for
emergent endoscopic retrograde cholangiopancreatography/EGD.
Fresh oozing blood was revealed in the duodenal bulb, the
second part of the duodenum. The major papilla was covered
with large clot. Epinephrine injection was performed and
hemostasis was believed to be achieved. However, the
patient's hematocrit was noted to drop subsequently on the
[**12-22**] from 31.5 where he was after receiving an
additional three units of packed red blood cells to 27.3
accompanied by a new episode of bright red blood per rectum.
The patient was, again, taken for emergent endoscopic
retrograde cholangiopancreatography/EGD at which point the
patient was noted to have clotted blood in the stomach body,
as well as an acute crater nonbleeding 5 mm ulcer in the
distal stomach body. Red blood was noted in the anterior
bulb in the second portion of the duodenum and a clot was
unroofed over the major papilla which exposed further
bleeding at the site of the left spincterotomy, at the site
of the major papilla, as well as a visible vessel. The
epinephrine injection was, again, performed and two hemoclips
were placed at the visible vessel. In addition, there was
mild diffuse dilatation of the biliary tree with a single 8
mm round stone causing the partial obstruction at the cystic
duct. A 10 x 15 double pigtail biliary stent was placed. Of
note, biliary pus was suggestive of cholangitis was seen
draining at the major papilla and the patient was begun on
Levaquin.
The patient subsequently seemed to have low grade fevers with
a temperature maximum of 100.6 on the [**12-23**] during
which point he was noted to continue having maroon liquid
stool with a hematocrit that dropped from 30 down to 27. The
patient was again transfused with one unit of blood on the
[**12-24**]. Again, the patient was noted to have a low
grade temperature elevation to a maximum of 100.7 on the
20th. The patient was transferred from the Medical Intensive
Care Unit back to the General Medicine Floor for further
observation. The patient's hematocrit was closely followed
and he was noted to have a stable hematocrit as follows: His
hematocrit was 30.2 post transfusion on the morning of the
20th at 4 a.m. and subsequent hematocrits revealed levels of
30.9, 31.1, 29, 28.9 and then 30.8 on the [**12-25**] at
7:50 a.m. Thus, the patient's hematocrit has been stable for
greater than 24 hours prior to his discharge. It is believed
that the site of post spincterotomy bleeding was identified
and that adequate hemostasis was achieved on the [**12-22**].
Patient has had no further episodes of bright red blood per
rectum since being transferred from the Medical Intensive
Care Unit. He denies any abdominal pain, nausea, vomiting,
fevers, chills, chest pain, shortness of breath, or
palpitations. The patient has not had signs of cholangitis
on physical examination, however, given the drainage noted
operatively on the [**12-22**], the patient was continued
on a ten day course of 500 mg po q.d. of levofloxacin. The
patient has tolerated the antibiotic course well and has had
a decreasing white blood cell count as follows: The
patient's white blood cell count reached a maximum of 13.9 on
the 19th and subsequently has declined to a nadir of 10.7 on
the day of discharge.
The patient has not developed further signs concerning for
worsening cholangitis, and in particular, does not have, over
the 24 hours prior to discharge, fever, right upper quadrant
pain or jaundice. He has a clear mental status and has
remained hemodynamically stable. His ALT was noted to be 9
on the morning of [**12-24**] with an AST of 22, alkaline
phosphatase 60, amylase of 93, total bilirubin of 1.1.,
lipase was 56, LDH 155. The patient's aspirin has been held
out of concern for provoking further gastrointestinal bleed
and the patient has been maintained on 40 mg of intravenous
Protonix b.i.d.
2. Question of coronary artery disease: The patient is
thought to have a history of coronary artery disease,
although, the patient is not aware of any prior exercise
tolerance tests, abnormal electrocardiograms, cardiac
catheterizations, or even any echocardiograms. The patient's
aspirin was held given his gastrointestinal bleed as detailed
above. The patient was maintained on some of his
antihypertensive regimen including nifedipine 30 mg q.d. and
was transitioned to Captopril 75 mg t.i.d. The patient was
also continued on his simvastatin at 40 mg q.d. The patient
did not develop any chest pain or shortness of breath over
the course of this admission.
3. Parkinson's: The patient was maintained on his
outpatient dose of Sinemet which is 25/250 b.i.d.
4. Patient was noted to have hyperglycemia on several
occasions during this admission. In particular, patient was
noted to have elevated glucose and was fasting on the [**12-23**] at a level of 187, as well as slightly elevated a.m.
fasting glucoses on the [**12-25**] at 122 and 121
respectively. The patient is not aware of any history of
diabetes mellitus. The patient was maintained on a regular
insulin sliding scale though had minimal insulin requirements
over the course of this admission.
5. Spinal stenosis pain: The patient was maintained on a
regimen of oxycodone prn.
6. Anxiety: The patient was continued on clonazepam and
Zoloft.
7. Fluid, electrolytes and nutrition: The patient was
intermittently NPO and during those times was given
rehydration with intravenous saline. Patient's diet was
advanced and on the day of discharge, the patient is
tolerating a po diet.
8. Benign prostatic hypertrophy: The patient was continued
on finasteride 5 mg q.d.
DISCHARGE CONDITION: The patient is discharged in stable
condition.
PRIMARY DIAGNOSIS: Primary diagnosis of portal pyemia.
SECONDARY DIAGNOSES:
1. Anemia secondary to blood loss.
2. Melena.
3. Hypertension.
4. Spinal stenosis with neurological deficit.
5. Hyperglycemia.
MEDICATIONS ON DISCHARGE:
1. Sinemet 25/250 mg b.i.d.
2. Clonazepam .5-1 mg po b.i.d.
3. Finasteride 5 mg po q.d.
4. Simvastatin 40 gm po q.h.s.
5. Vitamin G capsules 2 po q.d.
6. Sertraline 100 mg po q.d.
7. Oxycodone 5 mg po q. 6 prn.
8. Pantoprazole 40 mg po q.a.m.
9. Colace 100 mg po b.i.d.
10. Levofloxacin 500 mg po q. 24 hours to complete a ten day
course. Patient will have six days of levofloxacin following
discharge.
11. Acetaminophen 325 mg 1-2 tablets po q. [**3-11**] prn.
12. Prinivil 40 mg po q.d.
13. Lasix 20 mg po q.d.
14. Atenolol 25 mg po q.d.
15. Potassium Chloride 10 mg po q.o.d.
16. Adalat 30 mg po q.d.
FOLLOW-UP: Patient will follow-up with his primary care
physician. [**Name10 (NameIs) **] addition, the patient will follow-up with Dr.
[**Last Name (STitle) **] of the Surgical Division for cholecystectomy.
Patient will also follow-up with Dr. [**Last Name (STitle) 53850**] of the
Gastroenterology Division for repeat endoscopic retrograde
cholangiopancreatography after removal of his bile drainage
stent in approximately eight weeks. Patient also has a
follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] of the Renal
Division on the [**1-2**] at 2:30.
[**Last Name (LF) **], [**First Name3 (LF) 1037**]
Dictated By:[**Last Name (NamePattern1) 11363**]
MEDQUIST36
D: [**2176-12-25**] :
T: [**2176-12-25**] 13:46
JOB#: [**Job Number 53851**]
|
[
"572.1",
"285.1",
"E878.8",
"332.0",
"593.9",
"576.1",
"574.21",
"414.01",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"51.87",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9335, 9383
|
9620, 11075
|
1822, 2119
|
3332, 9313
|
9461, 9594
|
1137, 1391
|
169, 351
|
380, 1117
|
9403, 9440
|
2988, 3314
|
1413, 1796
|
2136, 2298
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,259
| 105,987
|
36861+58111
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-8-27**] Discharge Date: [**2193-9-2**]
Date of Birth: [**2114-9-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening fatigue
Major Surgical or Invasive Procedure:
[**2193-8-27**] Cardiac Catheterization
[**2193-8-28**] Aortic Valve Replacement utilizing a 19mm St. [**Male First Name (un) 923**]
Tissue Valve
History of Present Illness:
This is a 78 year old female with known aortic stenosis who has
been followed closely with serial echocardiograms by
Dr.[**Last Name (STitle) 30538**]. Her most recent echocardiogram showed [**First Name8 (NamePattern2) **] [**Location (un) 109**]
0.6cm2 and a mean gradient of 61 mmHg/peak gradient of 109 mmHg.
The patient now presents for aortic valve replacement.
Past Medical History:
Aortic Stenosis
Hypertension
Hyperlipidemia
Osteoporosis
Macular Degeneration - receive's injections in right eye
H/o Basal cell CA (shoulder and back)
? Old myocardial infarction and RBBB (Patient denies)
s/p Tonsillectomy
s/p Cataracts
s/p D&C's
Social History:
Occupation: Retired sales clerk
Last Dental Exam: [**2193-2-27**], Upper dentures
Lives with: husband
[**Name (NI) **]: Caucasian
Tobacco: Quit 25 yrs ago
ETOH: Approx. 4 glasses wine/wk
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 66 Resp: 18 BP Left: 159/74
Height: 5'3" Weight: 135lbs
General: WD/WN female in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X]- 3/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [] bilateral superficial varicosities
Neuro: Grossly intact [X]
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: Transmitted murmur
Pertinent Results:
[**2193-8-27**] WBC-6.0 RBC-3.43* Hgb-10.5* Hct-29.9* MCV-87 MCH-30.5
MCHC-35.0 RDW-13.7 Plt Ct-215
[**2193-8-27**] PT-12.6 PTT-36.4* INR(PT)-1.1
[**2193-8-27**] Glucose-118* UreaN-17 Creat-0.8 Na-138 K-3.1* Cl-103
HCO3-21* AnGap-17
[**2193-8-27**] ALT-11 AST-18 CK(CPK)-56 AlkPhos-40 Amylase-50
TotBili-0.3
[**2193-8-27**] %HbA1c-5.8
[**2193-8-27**] Cardiac Cath:
1. Selective coronary angiograhpy in this right dominant system
demonstrated no flow limiting lesions. The LMCA, LAD, Cx and RCA
had no
angiographically apparent disease. 2. Limited resting
hemodynamics revealed slightly elevated right and left sided
filling pressures with a RVEDP of 10 mmHg and a mean PCWP of 14
mmHg. There was mild pulmonary artery hypertension with a PASP
of 24 mmHg. The central aortic pressure was 143/56 mmHg.
[**2193-8-27**] Echocardiogram:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild to
moderate ([**11-30**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2193-8-27**] Carotid Ultrasound:
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow. Right ICA stenosis <40%.
Left ICA stenosis <40%.
[**2193-9-2**] 05:40AM BLOOD WBC-10.0 RBC-3.41* Hgb-10.4* Hct-30.9*
MCV-91 MCH-30.6 MCHC-33.7 RDW-13.5 Plt Ct-257#
[**2193-8-28**] 03:25PM BLOOD PT-14.6* PTT-64.7* INR(PT)-1.3*
[**2193-9-2**] 05:40AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-130*
K-3.9 Cl-93* HCO3-31 AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname 4318**] was admitted and underwent cardiac catheterization
which confirmed severe aortic stenosis and showed normal
coronary arteries. Preoperative evaluation was otherwise
uneventful and she was cleared for surgery. On [**8-28**],
Dr. [**Last Name (STitle) **] performed an aortic valve replacement (#19mm St.[**Male First Name (un) 923**]
tissue valve). For further surgical details, please refer to
Dr[**Last Name (STitle) **] operative note. She was intubated, sedated, and
required pressor support, in critical but stable condition when
transferred to the CVICU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. Pressors were weaned off. All lines and drains were
discontinued in a timely fashion.
Beta-blocker/aspirin/statin/diuresis was initiated. She
continued to progress and POD#2 was transferred to the step down
floor for further monitoring. Physical therapy evaluated and
consulted. POD#4 her rhythm went into rapid atrial fibrillation.
She was treated with Amiodarone and beta-blocker and
subsequently converted to normal sinus rhythm. The remainder of
her postoperative course was essentially uneventful. She
continued to do well and was cleared by Dr.[**Last Name (STitle) **] for discharge
to home with VNA on POD#5. All follow up appointments were
advised.
Medications on Admission:
Metoprolol 50mg [**Hospital1 **]
Lipitor 10mg daily
Fosamax 70mg once a week
ASA 81 mg daily
MVI 1 tb daily
Lisinopril/hydrochlorothiazide 20mg/12.5 mg daily
Flaxseed oil 2000mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis, s/p AVR
Hypertension
Dyslipidemia
Discharge Condition:
Stable
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-3**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 39360**] in [**1-1**] weeks, call for appt
Dr. [**Last Name (STitle) 171**] or [**Last Name (STitle) 30538**] in [**1-1**] weeks, call for appt
Completed by:[**2193-9-2**] Name: [**Known lastname 1323**],[**Known firstname **] Unit No: [**Numeric Identifier 13270**]
Admission Date: [**2193-8-27**] Discharge Date: [**2193-9-2**]
Date of Birth: [**2114-9-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Ms. [**Known lastname **] was hyponatremic postop.[**8-31**] her sodium was 130.
Electrolytes were corrected.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2193-11-6**]
|
[
"458.29",
"V10.83",
"401.9",
"733.00",
"427.31",
"276.1",
"424.1",
"E878.1",
"272.4",
"362.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"35.21",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
8330, 8507
|
4079, 5438
|
338, 486
|
6960, 6969
|
2130, 4056
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7512, 8307
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1377, 1415
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6886, 6939
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5464, 5650
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6993, 7489
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1430, 2111
|
281, 300
|
514, 884
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906, 1156
|
1172, 1361
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,517
| 197,625
|
26514
|
Discharge summary
|
report
|
Admission Date: [**2168-4-19**] Discharge Date: [**2168-4-26**]
Date of Birth: [**2119-3-9**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin / Codeine / Tylenol / Sulfa (Sulfonamides) / Percodan /
D.H.E.45
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Has significant pain in her left leg. It is all the way down her
back to the outside of her leg to her lateral calf.
Major Surgical or Invasive Procedure:
L3-L4, L4-L5, L5-S1 lumbar laminectomy, facetectomy and
foraminotomy, bilateral revision.
History of Present Illness:
Mrs. [**Known lastname 65499**] had acute onset and recurrence of her symptoms
postoperatively. She is doing okay at this point. She still
has significant pain, which she rates [**2171-5-27**], in her left leg.
It is all the way down her back to the outside of her leg to her
lateral calf. This is worse with activity. She rates it. No
right leg symptoms, no bowel incontinence, no fevers or chills.
Past Medical History:
Her past medical history is somewhat extensive and includes
Addison's disease, fibromyalgia, chronic back pain with
recurrent radiculopathy, peptic ulcer disease/gastroesophageal
reflux disease. She has also remote history of having a
malignant nodule removed from her foot back in [**2129**]. Her past
history is also significant for L4/5 microdiscectomy.
Social History:
From a social standpoint, she is not a smoker and has never been
a smoker. She does not drink alcohol and she is not getting
routine exercise now since the onset of this hip injury. She is
disabled but she does run a craft store. She lives in [**State 1727**] and
is the youngest of fourteen children.
Family History:
Her family history is significant for skin cancer in many family
members. Her mother and father both have heart disease and
diabetes. Her mother has since passed away.
Physical Exam:
On physical examination today, her gait is within normal limits.
She has good strength in her bilateral lower extremities, in her
quads, extensors, hamstrings, gastrocnemius, and [**Last Name (un) 938**]. The
incision is clean, dry, and intact.
Pertinent Results:
[**2168-4-19**] 02:35PM BLOOD Type-ART pO2-102 pCO2-46* pH-7.41
calTCO2-30 Base XS-3
[**2168-4-21**] 06:49PM BLOOD Type-ART pO2-58* pCO2-53* pH-7.47*
calTCO2-40* Base XS-12
[**2168-4-21**] 09:41PM BLOOD Type-ART pO2-88 pCO2-53* pH-7.44
calTCO2-37* Base XS-9
[**2168-4-22**] 01:53AM BLOOD Type-ART pO2-90 pCO2-55* pH-7.41
calTCO2-36* Base XS-7
[**2168-4-21**] 07:05AM BLOOD TSH-0.24*
[**2168-4-20**] 06:57AM BLOOD Glucose-159* UreaN-8 Creat-0.6 Na-142
K-4.2 Cl-107 HCO3-30 AnGap-9
[**2168-4-21**] 07:05AM BLOOD Glucose-109* UreaN-11 Creat-0.8 Na-143
K-3.9 Cl-106 HCO3-30 AnGap-11
[**2168-4-22**] 02:12AM BLOOD Glucose-131* UreaN-8 Creat-0.7 Na-141
K-3.5 Cl-99 HCO3-31 AnGap-15
[**2168-4-22**] 02:12AM BLOOD PT-12.2 PTT-21.9* INR(PT)-1.0
[**2168-4-20**] 06:57AM BLOOD Hct-34.0*
[**2168-4-21**] 07:05AM BLOOD WBC-10.0 RBC-3.30* Hgb-11.3* Hct-33.1*
MCV-101* MCH-34.1* MCHC-34.0 RDW-13.7 Plt Ct-200
[**2168-4-22**] 02:12AM BLOOD WBC-11.7* RBC-3.90* Hgb-13.3 Hct-37.9
MCV-97 MCH-34.1* MCHC-35.1* RDW-13.2 Plt Ct-256
Brief Hospital Course:
Mrs. [**Known lastname 65499**] is a 49 year old female with a history of left L4-L5
microdiscectomy without complication. She was seen at [**Hospital1 18**]
orthopedic spine clinic for her chief complaint of recurrent
left leg pain that radiates from her back. While at [**Hospital1 18**] she
experienced a period of somnolence
1. Left leg pain- Mrs. [**Known lastname 65499**] underwent L3-Ll4, L4-L5, L5-S1
lumbar laminectomy, facetectomy and foraminotomy, bilateral
revision without fusion on [**2168-4-19**] without complications.
At this time her leg pain has resolved.
2. Altered Mental Status- Likely multifactorial from hypoxia
and hypercarbia. Ddx also includes hypothyroidism as patient
already has another autoimmune condition: Addison's and less
likely from steroids themselves or from infection. Per notes,
she fell on her face, possibly in [**Month (only) 958**], so it is unlikely but
this could have unmasked a subdural hematoma, especialy as she
has a new anemia. Coags last checked in [**Month (only) 958**] and she had a
normal INR. At that time she was transfered to SICU for closer
monitoring. She was taken of her of narcotics, baclofen, and
neurontin and given naloxone to reverse narcotic effect. This
did not change her status. This period of altered mental status
resolved without complication.
Medications on Admission:
Albuterol 2 puffs QID
ambien 10mg qhs
oxygen 2-4L
baclofen 20mg TID
clomirapax 0.1mg 1 per week
fentanyl patch 100mcg q3 days
Alovert 10mg daily
lasix 40mg daily
Hydrocortizone 10mg [**Hospital1 **]
KCl 10mEq [**Hospital1 **]
Lescol 40mg daily
Maxol 10mg PRN
Neurontin 800mg TID
Oxycodone 5mg Q6 hrs
Phenergan 12.5-25mg TID
Zofran 4mg PRN
Ranitidine 300mg qhs
Rastacis 2 Drops per eye [**Hospital1 **]
Multivitamin
Sennocot 2 [**Hospital1 **]
Calcium
glucosamine
Discharge Medications:
1. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: [**12-22**]
Tablet Sustained Release 12 hrs PO Q12H (every 12 hours).
Disp:*56 Tablet Sustained Release 12 hr(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*168 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor - [**Location (un) **]
Discharge Diagnosis:
1. Lumbar stenosis 724.02.
2. Status post multiple lumbar spinal surgeries including L4-
L5 microdiskectomy.
3. Asthma requiring oxygen and nebulizers.
4. Adrenal insufficiency.
5. Chronic pain requiring fentanyl patches as well as other
medications.
Discharge Condition:
Stable to home.
Discharge Instructions:
Please keep your incision clean and dry. You may shower once
you are home,but please do not soak the wound. Please resume
all of your home medication. Your sutures will come out in
approximately 14 days at your post-op follow up. If you see any
drainage or redness at your incision or you have a temperature
greater than 100.5, please call the office at [**Telephone/Fax (1) **].
Please refer to the discharge handout for instructions
concerning activity.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) 1352**] for 2weeks after you
surgery. You can make that appointment by calling [**Telephone/Fax (1) **]
Completed by:[**2168-4-26**]
|
[
"276.3",
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"E937.8",
"255.4",
"E849.7",
"493.90",
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"721.3",
"729.1",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"78.69"
] |
icd9pcs
|
[
[
[]
]
] |
5362, 5438
|
3188, 4521
|
453, 545
|
5746, 5764
|
2154, 3165
|
6272, 6466
|
1700, 1872
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5034, 5339
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5459, 5725
|
4547, 5011
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5788, 6249
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1887, 2135
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297, 415
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573, 979
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1001, 1361
|
1377, 1684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,966
| 186,079
|
12722
|
Discharge summary
|
report
|
Admission Date: [**2109-10-22**] Discharge Date: [**2109-11-22**]
Date of Birth: [**2044-3-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Ventral Hernia
Major Surgical or Invasive Procedure:
1. Takedown colostomy.
2. Repair of peristomal hernia.
3. Cholecystectomy.
4. Coloproctostomy.
5. Ventral hernia with mesh.
6. ERCP with sphincterotomy
History of Present Illness:
65yo M admitted for plasmapheresis in advance of elective
ventral hernia repair. He has had a history of myasthenia [**Last Name (un) 2902**]
(AChR positive) since [**2106**], when he presented with dysarthria.
He was treated initially with mestinon/steroids and then
cellcept, which was discontinued due to its cost. He then
presented in myasthenic crisis in [**2106**] with
dysarthria, dysphagia and respiratory distress and was
intubated,
treated first with plasmapheresis and then IVIG.
His course was then complicated in [**3-15**] when he again went into
myasthenic exacerbation, this time in the context of bowel
perforation and repair. After this exacerbation, imuran was
added
to his regimen.
Since this time, he has had no further exacerbations. However,
he
continues to have symptoms of myasthenia. In [**2109-6-9**], he
presented to clinic reporting difficulty chewing for prolonged
periods of time, as well as mild dysarthria and mild dyspnea on
exertion and ptosis only when tired. Imuran was increased as he
was not felt to be fully in remission.
Since [**Month (only) **], he feels that the difficulty chewing has improved a
bit. He has stable dyspnea on exertion that he feels may be
related to cardiac disease. He continues to deny diplopia or
dysphagia. He has no hoarseness and no weakness of his limbs. He
does get ptosis when fatigued.
He denies side effects of excessive mestinon use.
Past Medical History:
Myasthenia [**Last Name (un) 2902**]
CAD s/p CABG [**2091**]
Hypertension
Dyslipidemia
Atrial flutter/fibrillation
Diabetes Mellitus
Ventral abdominal hernia s/p MVA in [**2092**].
Lower back pain, has l-spine compression fractures
GI bleed
Social History:
Quit tobacco [**2094**]; rarely drinks alcohol; lives with his wife;
Currently on disability, former director of an exercise company
Family History:
Grandmother with pacemaker, no other known heart disease
Physical Exam:
VS Afebrile 211 lbs, 135/71 72 12 96% room air
Counts to 41 in one breath (exam is 45min after last mestinon
dose)
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, obvious ventral
hernia
that is non-tender
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Awake, alert. Fully oriented. Months of the year backwards
were intact. Speech fluent, with normal naming, [**Location (un) 1131**],
comprehension and repetition. Normal prosody. There were no
paraphasic errors. Able to follow both midline and appendicular
commands. No apraxia. Interprets cookie theft picture
appropriately. No dysarthria.
CN
CN I: not tested
CN II: Visual fields were full to confrontation, no extinction.
Pupils 3->2 b/l. Fundi normal
CN III, IV, VI: EOMI no nystagmus or diplopia; no ptosis on
extended upgaze
CN V: intact to LT throughout
CN VII: full facial symmetry and strength
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**5-13**] and symmetric
CN XII: tongue midline and agile
Motor
Normal bulk and tone. No pronator drift
D B T WE FE FF IP Q H DF PF TE
There is no fatigue after exercise of the left deltoid
Sensory intact to light touch, pinprick, joint position sense,
vibration throughout. No extinction to double simultaneous
stimulation.
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2 2 2 2 2 down
R 2 2 2 2 2 down
Coordination Fine finger movements, rapid alternating movements,
finger-to-nose, and heel-to-shin were all normal
Gait slightly wide-based but steady
Pertinent Results:
[**2109-11-6**] 12:45PM BLOOD WBC-8.8 RBC-3.14* Hgb-9.2* Hct-29.3*
MCV-93 MCH-29.2 MCHC-31.3 RDW-20.7* Plt Ct-825*
[**2109-11-6**] 12:45PM BLOOD Neuts-77* Bands-0 Lymphs-10* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2109-11-6**] 12:45PM BLOOD PT-14.5* PTT-31.3 INR(PT)-1.3*
[**2109-11-5**] 05:42PM BLOOD ALT-32 AST-40 LD(LDH)-158 AlkPhos-68
Amylase-81 TotBili-0.5
[**2109-11-5**] 05:42PM BLOOD Lipase-63*
[**2109-11-4**] 05:00AM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.0 Mg-2.1
[**2109-10-24**] 06:18AM BLOOD freeCa-1.15
CT abd/pelvis: 1. Two stones, side by side, measuring up to 7
mm, within the distal CBD at the level of the pancreatic head
without significant intrahepatic biliary dilatation.
Cholelithiasis without evidence of acute cholecystitis. 2.
Single 2-cm intra-abdominal collection in the left upper
quadrant, smaller in size to the CT of [**2108**]. 3. Large ventral
hernia containing multiple loops of small and large bowel
overall unremarkable in appearance. Right-sided diverting
colostomy. 4. New wedge deformity of the T11 vertebral body,
consistent with a compression fracture of indeterminate age.
Multiple other compression fractures of the lower thoracic and
lumbar spine as described.
Abd U/S: Confirmation of two small stones within the distal
common bile
duct. No intrahepatic biliary dilatation seen. Collapsed
gallbladder with
stones and sludge.
Brief Hospital Course:
Admitted [**10-22**] for plasmapheresis (5 doses, QOD, prior to
surgery). He had a pharasis catheter placed in IR with no
complications. Upon admission he was started on a heparin drip
for a-fib. His PTT was maintained between 50-70. Medicine was
consulted on [**10-23**] for assistance with anticoagulation
peri-plasmapheresis (continued on heparin gtt). CT abd/pelvis
on [**10-31**] demonstrated two CBD stones (confirmed on [**11-1**]
ultrasound) and a large ventral hernia containing loops of
small and large bowel. Levo/flagyl started on [**11-3**] (day #1) and
given through [**11-9**]. A pre-op colonoscopy was performed, which
demonstrated a single cecal polyp (shown on pathology to be
adenoma). Transaminases were mildly elevated (AST 58, ALT 43) at
the time of admission. He underwent successful retrieval of his
choledocholithiasis on [**11-4**] via ERCP. His mestinon was tapered
prior to surgery. He underwent colostomy takedown, repair of
ventral hernia with mesh, cholecystectomy, and coloproctostomy
on
[**2109-11-8**] without complications. He was admitted to the SICU post
op for observation, given his history of post op myasthenic
crises requiring re-intubation.
On [**11-14**], some purulent drainage was noted near the site of the
post-op drain; ciprofloxacin and vancomycin were started. The
wound was swabbed and sent for gram stain and culture. Gram
stain showed 1+ PMN's and 1+ GPC's in chains; subsequent
culture, finalized on [**11-17**], showed moderate MRSA and sparse
Enterobacter
(R to ciproflox). Drainage continued since [**11-14**], and a wound vac
was applied on [**11-17**].
[**11-19**] - Wound vac changed with white sponge. Seen by ID with
recs for 2 weeks of Vanco and Meropenem from wound cx's.
[**11-20**] - Doing well, no acute issues, awaiting disposition
[**11-22**] - vac dressing taken down, wet to dry dressing applied
while awaiting placement today
Medications on Admission:
ASA 325 mg daily
Coumadin alternating between 5 and 2.5 mg daily
Lasix 20 mg daily
Amiodarone 200 mg daily
Isosorbide Mononitrate 30 mg daily
Lisinopril 5 mg daily
Simvastatin 40 mg daily
Lidoderm 5% patch 2 patches to back prn
Azathioprine 150 mg qam
Azathioprine 200 mg qpm
Cellcept [**Pager number **] mg [**Hospital1 **]
Fosamax 35 mg qSat
Pantoprazole 40 mg daily
Mestinon 60 mg q3h
Zoloft 50 mg daily
Oxycodone 5 mg 1-2 tabs q4h prn
Oxycontin 40 mg q12h prn
Ativan 0.5 mg q6h prn
Caltrate
Iron 325 mg daily
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-9**]
Puffs Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): give in am.
9. Azathioprine 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily): give in evening.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q48H (every 48
hours): alternate qod with 2.5mg.
18. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Q48H (every 48
hours): alterate qod with 5mg dose.
19. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
20. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every six (6) hours for 2 weeks.
21. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
twice a day for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Ventral hernia with abdominal wall necrosis.
2. Cholecystitis.
3. peristomal hernia.
4. Colonic discontinuity.
5. Loss of eminent domain with the ventral hernia.
6. Choledocholithiasis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Vac dressing should include a white piece of foam, pressure 75,
changed every 3 days.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Insulin Sliding Scale (Humalog)
Breakfast Lunch Dinner Bedtime
Glucose Insulin Insulin Insulin Insulin
0-50 [**1-9**] amp D50
51-150 0 Units 0 Units 0 Units 0 Units
151-200 3 Units 3 Units 3 Units 3 Units
201-250 5 Units 5 Units 5 Units 5 Units
251-300 7 Units 7 Units 7 Units 7 Units
301-350 9 Units 9 Units 9 Units 9 Units
351-400 11 Units 11 Units 11 Units 11 Units
> 400 Notify M.D.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up
appointment in 3 weeks at [**Telephone/Fax (1) 39254**]
Previously scheduled appointments:
Provider: [**Name10 (NameIs) 3523**] [**Name11 (NameIs) 3524**], MD Phone:[**Telephone/Fax (1) 2846**]
Date/Time:[**2109-12-16**] 12:45
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81,229
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1274
|
Discharge summary
|
report
|
Admission Date: [**2196-1-11**] Discharge Date: [**2196-1-14**]
Date of Birth: [**2132-3-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues / Sulfa (Sulfonamide
Antibiotics) / Erythromycin Base / Amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Initiation of milrinone therapy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63 yo male with PMH of adriamycin (Hodgkin's
disease)induced cardiomyotpathy with EF of 15% on metolazone,
torsemide, and aldactone, PAF s/p dual chamber ICD in [**2-11**] after
dofetilide induced torsades, and atrial flutter s/p ablation
[**2190**], who presented to [**Hospital 7927**] Hospital today with a chief
complaint of nausea and epigastric pain. He notes the pain
started friday night and has had poor PO intake since. The pain
is mid-epigastric without radiation. He denies vomitting. He
has been moving his bowels without any blood in the stool or
dark stool. Of note, wife notes that he has had increasing
confusion and anxiety over the past day. At [**Hospital3 **] he was
noted to be hyponatremic to 124, with a baseline in our system
in the low 130s. He was also noted to be in AOCRF with Cr of
1.8, and baseline over past couple of weeks 1.5-1.6. Other labs
significant for K+ of 5.6. He also had altered mental status
and SBPs in the 80s, and in the setting of his hyponatremia and
elevated cr was thought to be in cardiogenic shock. He was
subsequently transferred to [**Hospital1 18**] for milrinone initiation
.
In terms of his heart failure, he has had multiple admissions
over the past several years for acute failure requiring
adjustment of his diuresis regimens. He recently was instructed
to hold his torsemide on [**11-23**] with a plan to restart at a
lower dose of 40mg daily on [**1-10**] (previously 60mg daily). He was
told to continue his metolazone 2.5 mg 3x/week, and
spironalactone 25mg daily. He notes that last week he had an
increase in LE swelling with some SOB, but since restarting his
toresemide yesterday he has had improvment in these symptoms.
His dry weight is 163lb per outpatient records and he is 165 lb
today.
.
Of note, he had a recent admission at the end of [**12/2195**] for leg
erythema thought to be due to erythromelalgia for which he was
started on a full dose aspirin.
.
Vitals on admission were: T: 98 BP: 90/55 HR: 76 (v paced) O2:
99% RA. Pt noted to be A/O x3 but struggling to give a coherent
history and appearing frustrated/anxious
.
On review of systems, he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. He notes headaches
about 1x/week. He also notes a decreased desiire to eat. He
denies changes in bowel habits, difficulty or pain with
urination. He has baseline swelling and dusky color of his
feet. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, syncope or presyncope
Past Medical History:
Cardiac Risk Factors: Diabetes, + Dyslipidemia, + Hypertension
Cardiac History:
- Paroxysmal atrial fibrillation (was on admiodarone which was
stopped - in [**8-9**] [**2-3**] to lung toxicity, then failed dofetilide
therapy)
- Atrial flutter, s/p ablation in [**2190-6-2**]
- S/p Dual-chamber ICD in [**2195-2-2**] after dofetilide induced
torsades
- Dilated cardiomyopathy with EF of 10% secondary to
chemotherapy(Hodgkins) in [**2175**], last ECHO [**8-/2195**], EF 10-15%
.
Other Past History:
# Hx of Hodgkin's disease [**2175**], s/p Chemo and XRT
# Severe GERD
# Chronic constipation
# Chronic Lung Disease with sleep apnea, emphysema and
bronchiectasis with a history of severe hemoptysis in [**2193-6-2**]
# History of Diverticulitis x2; the last one was five years ago.
# Dyslipidemia
# Depression
# Obstructive Sleep Apnea - uses home nasal cannula with 3L O2
at night
Social History:
Patient is a former manager of a warehouse. He has been retired
since age 46. Lives at home with his wife, [**Name (NI) **] [**Name (NI) 5422**]. Does not
drink. He is a former smoker
Family History:
Father with CAD age 70's. No other family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ON ADMISSION:
VS: T: 98 BP: 90/55 HR: 76 (v paced) O2: 99% RA.
GENERAL: NAD. Oriented x3, but difficulty mentating and
struggling to give coherent history. Also appears anxious.
Sitting up but neck contracted and flexed to the right
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not elevated while sitting up
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. Basilar L>R crackles
ABDOMEN: Soft, distended, mid epigastric tenderness to palpation
without rebound or guarding. BS+. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: [**1-3**]+ edema to the shins bilaterally. 2+ dp/pt
pulses. Feet are noted to be bluish/purlple (baseline per
patient) with Chronic venous stasis changes. Also noted to have
bilateral linear heal erosions. He has a gauze wrap on his left
ankle covering a group of varicosities.
SKIN: As above, skin diffusely dry and cracked PULSES:
Right: 2+ DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
ON DISCHARGE:
No major changes in physical exam. Pt began mentating well
shortly after admission but remained significantly agitated
throughout admission
Pertinent Results:
ADMISISON LABS:
[**2196-1-11**] 01:31PM BLOOD WBC-5.7 RBC-5.03 Hgb-12.9* Hct-41.2
MCV-82 MCH-25.6* MCHC-31.2 RDW-21.1* Plt Ct-195
[**2196-1-11**] 01:31PM BLOOD PT-41.2* PTT-38.6* INR(PT)-4.4*
[**2196-1-11**] 01:31PM BLOOD Glucose-74 UreaN-105* Creat-2.1* Na-129*
K-4.4 Cl-89* HCO3-25 AnGap-19
[**2196-1-11**] 01:31PM BLOOD Calcium-9.5 Phos-4.6* Mg-2.2
[**2196-1-12**] 04:26AM BLOOD Digoxin-0.7*
.
DISCHARGE LABS:
[**2196-1-13**] 04:07AM BLOOD WBC-7.0 RBC-4.40* Hgb-11.7* Hct-35.8*
MCV-81* MCH-26.7* MCHC-32.8 RDW-21.3* Plt Ct-168
[**2196-1-13**] 04:07AM BLOOD PT-26.2* PTT-32.2 INR(PT)-2.5*
[**2196-1-13**] 04:07AM BLOOD Glucose-117* UreaN-63* Creat-1.6* Na-131*
K-3.5 Cl-93* HCO3-27 AnGap-15
[**2196-1-13**] 04:07AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3
.
STUDIES:
EKG [**2196-1-12**]: Sinus rhythm with atrial premature beats and
ventricular premature beats. Intraventricular conduction delay
of left bundle-branch block type. Consider inferior myocardial
infarction. Since the previous tracing of [**2195-11-19**] atrial pacing
is now not apparent and there are now premature beats.
CXR [**2196-1-13**]:
IMPRESSION: AP chest compared to [**2195-11-18**]:
Lung apices are excluded from the examination. The other pleural
surfaces and the imaged portions of the lungs are normal. A
right PIC line passes as far as the upper SVC, where it is
obscured by a transvenous pacer defibrillator lead going to the
right ventricle and a pacer lead going to the right atrium.
Heart size is normal.
Brief Hospital Course:
63 yo male with chemotherapy induced cardiomyopathy, EF 15%
presenting from OSH with hypotension, altered mental status,
AOCRF, and hyponatremia for initiation of milrinone drip.
.
# Adriamycin induced cardiomyopathy with EF 15% and low-flow
state: He has had multiple admissions over the past few years
for diuresis and on admission was on a home diuresis regimen of
torsemide 40mg [**Hospital1 **], metolazone 2.5 mg 3x/week, and
spironolactone 25 mg daily. At [**Hospital3 **], concern was for
cardiogenic shock given hypotension, AMS, hyponatremia, and
AOCRF, and was transferred to [**Hospital1 18**] for initiation of milrinone
infusion. Upon transfer to [**Hospital1 18**], he continued to be mentating
poorly with BPs ranging 70s-90s concerning for a low flow state,
however this improved throughout admission with milrinone and
supplemental neosynephrine, as well as a lasix ggt. However, pt
was significantly agitated and anxious over the course of
admission and on [**1-13**] self d/c'd his IVs/PICC, vitals checks,
EKGs, and lab draws. We therefore could not continue
milrinone/neo and the decision was made with the family to
pursue home hospice. His PCP was notified of the decsision and
he was set up with a f/u with him. He was subsequently
discharged back on his home diuresis regimen, with the exception
of changing torsemide to 80mg daily from 40mg [**Hospital1 **].
.
# Depression/Anxiety: Pt noted to be significantly anxious over
admission, and described feeling confined by being in the ICU
and hospital and scared by his diagnosis. This was partially
responsive to klonipin and PRN ativan, but eventually required a
psychiatry consult who recommended PRN 5mg IV haldol which
helped his agitation. However, he self d/c'd all IVs and
monitoring as above, and decision was made to pursue home
hospice after which the patient became much more comfortable.
For his depression, he was continued on his home sustained
release wellbutrin at 150mg daily, and sertraline 25mg daily.
.
# Hyponatremia: pt with baseline hyponatremia (low 130s), and
noted to be 124 at OSH. This trended up to 131 at last check.
Likely a hypervolemic hyponatremia given chronic volume overload
and low flow state with improvement on milrinone/neo.
.
# AOCRF: Cr of 1.8 on transfer from [**Hospital3 **], with recent
baselines in our system of 1.5-1.6. Up to 2.1 on admission to
[**Hospital1 18**] and trended down to 1.6 Likely prerenal state in setting
of hypoperfusion with improvement on milrinone/neo
.
# Epigastric pain: Pt noting mid epigastric pain without
radiation that is worse with food starting 2 days PTA. Likely a
worsening of his baseline GERD. Remained asymptomatic over
admission, and we continued home lansoprazole.
.
# Hyperkalemia: K of 5.6 on transfer, down to 4.4 on admission
to [**Hospital1 18**], and eventually trending down to 3.5 likely secondary
to reinitiation of diuresis. We continued his home KCl 40meq
[**Hospital1 **].
.
# PAF s/p dual chamber ICD: Pt remained ventricularly paced.
We held his coumadin given his supratherapeutic INR which
trended down to 2.5 the day prior to discharge. He was
discharged with instructions to continue coumadin at his home
dose and with a prescription for INR check to be done by home
VNA.
.
# Asthma: Continued fluticasone and prn atrovent nebs. Not
active issue in house
Medications on Admission:
-metolazone 2.5 mg m/w/f
-torsemide 60mg [**Hospital1 **] (recently changed to 40mg [**Hospital1 **])
-kcl 40meq [**Hospital1 **]
-tylenol PRN
-bupropion 150mg sustained release daily
-digoxin 62.5 mcg po daily
-flovent 110mcg 1 puff [**Hospital1 **]
-atrovent 1 puff 4x daily PRN SOB
-gabapentin 1200mg po TID (no longer taking)
-lansoprazole 30mg po BID
-toprol-xl 25 mg daily
-nystatin 100,000 u/ml 5cc by mouth 4x daily swish and swallow
prn thrush
-sertraline 25 mg po daily
-simvastatin 10mg po daily
-spironalactone 25mg po daily
-coumadin 4-8mg daily
-aspirin 325mg daily
Discharge Medications:
1. bupropion HCl 150 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO [**Hospital1 4962**] (once a day (in the morning)).
2. fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. metolazone 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
4. torsemide 20 mg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY (Daily).
5. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal [**Hospital1 **]:
Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
6. digoxin 125 mcg Tablet [**Hospital1 **]: half Tablet PO once a day.
7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
One (1) puff Inhalation four times a day as needed for shortness
of breath or wheezing.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. sertraline 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Outpatient Lab Work
INR check. Please fax results to:
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] (fax # [**Telephone/Fax (1) 7922**])
Cardiologist Dr. [**First Name (STitle) 449**] Change (fax #[**Telephone/Fax (1) 4005**])
12. aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
13. spironolactone 25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
14. lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
15. warfarin 2 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
Adriamycin induced cardiomyopathy
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 5422**],
You were admitted to the hospital for management of your
congestive heart failure. We started you on a medication called
milrinone to help with your heart function, as well as
continuing your home diuretics to removed fluid.
Ultimately, the decision was made to stop the milrinone, and we
have discharged you on your home medications, with the only
exception being changing your torsemide to 80mg once daily (from
40 twice daily). You will be seeing by a visiting nurse while
at home.
We have also provided you with a prescription to have your INR
(coumadin level) checked by your visiting nurse.
We have made the following changes to your medications:
CHANGED: Torsemide from 40mg twice daily to 80mg once daily
RESTART: Lyrica for your leg pain
Please continue all other medications as listed below
Also, please note your follow up appointments. If you feel
these appointments will help with your comfort you should go to
these appointments. We have also made an appointment with your
PCP [**Name Initial (PRE) 7928**]
Followup Instructions:
Department: SPINE CENTER
When: TUESDAY [**2196-1-19**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2196-1-28**] at 2:20 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2196-2-1**] at 3:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Primary Care
Name: [**Last Name (LF) 2204**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
Date: [**2-1**] at 2:20pm
|
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"492.8",
"300.00",
"428.22",
"327.23",
"530.81",
"276.1",
"494.0",
"585.9",
"276.7",
"E930.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13077, 13135
|
7197, 10558
|
404, 411
|
13230, 13230
|
5687, 6084
|
14466, 15757
|
4165, 4284
|
11188, 13054
|
13156, 13209
|
10584, 11165
|
13381, 14042
|
6100, 7174
|
4299, 4299
|
5526, 5668
|
14071, 14443
|
333, 366
|
439, 3038
|
4313, 5512
|
13245, 13357
|
3060, 3945
|
3961, 4149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,705
| 128,966
|
5132+5133
|
Discharge summary
|
report+report
|
Admission Date: [**2196-8-17**] Discharge Date: [**2196-8-23**]
Date of Birth: [**2156-9-19**] Sex: M
Service: [**Hospital1 **] INPATIENT MEDICINE
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 21060**] is a 39-year-old
HIV-positive male, status post transplant who was transferred
to the [**Hospital Ward Name 516**] with PCP [**Name Initial (PRE) 1064**]. On the day of
admission, [**2196-8-17**], the patient presented with high
fever and a low-grade headache over the last two days. He denied
shortness of breath, cough, sore throat, photophobia. He was
started on empiric antibiotics including ciprofloxacin for
Legionella coverage, doxycycline for Ehrlichia and Rickettsia
coverage, vancomycin for Streptococcus, pneumococcal, and
Listeria coverage and ceftriaxone for Neisseria and
meningitis coverage. Chest x-ray showed small focal
ill-defined infiltrates at both lung apices.
Head CT showed no hemorrhage or mass affect or edema. Multiple BC
were obtained to r/o routine, AFB, and fungal pathogens; all
initial routine and isolator BC were negative. CXR on
[**2196-8-18**] showed progressive bilateral nodular pulmonary
infiltrates and IV bactrim plus steroids were initiated on [**8-18**]
for empiric treatment of PCP. [**Name10 (NameIs) **] patient underwent BAL on
[**2196-8-19**] to r/o opportunistic infection as cause of his pneumonia;
DFA confirmed PCP.
[**Name10 (NameIs) **] patient remained on Bactrim IV for his PCP and was
also started on Casofungin for fungal infections while awaiting
fungal BAL cultures and stains.
His vancomycin and ceftriaxone were discontinued on [**2196-8-19**].
A lumbar puncture was performed on [**2196-8-19**]; the CSF did
not have any pleocytosis; all CSF cultures returned negative.
During his hospital course on the [**Hospital Ward Name 516**], the patient
continued to spike high fevers. He required multiple
transfusions including 6 units of red blood cells and 4 units
of platelets. He is now presenting to the [**Hospital Ward Name 517**]
complaining of cough, fevers, and a severe frontal headache
that is usually [**5-12**] in severity but increases to [**11-11**] with
coughing.
PAST MEDICAL HISTORY:
1. HIV, diagnosed in [**2185-4-3**]. He was initially
diagnosed when he presented with PCP [**Name Initial (PRE) 1064**]. His most
recent CD4 count from [**2196-8-17**] was 320 which was up from
224 in [**2196-7-3**] and down from 631 in [**2196-6-2**]. His
plasma HIV RNA was less than 50 on [**2196-8-17**]. His CD4
counts throughout his span of HIV infection has fluctuated
but are currently decreased from his preheart transplant
baseline of 375-400. His HIV RNA level has been suppressed to
below 50 c/mL since he commenced RTV as PI therpay in [**2189**] . The
patient is closely followed by the Infectious Disease Clinic .
There has been no overt worsening of his HIV disease progression
since undergoing transplant with no opportunistic
infections documented until now. Previous opportunistic
infections have included:
Disseminated [**Doctor First Name **]
PCP
CMV [**Name9 (PRE) 21061**] disease
pulmonary KS in the early [**2183**] for which he received liposomal
daunorubicin
Recently, his CMV and HHV8 PCR assays obtained in th epost-
transplant setting have been negative. His last EBV viral load
in [**2196-8-2**] had increased to 500 c/100 k lymphocytes.
2. Cardiac transplant in [**2194-3-6**]. The patient
received a cardiac transplant for end-stage dilated
cardiomyopathy which was believed to be due to the liposomal
daunorubicin that he was receiving for treatment of his
pulmonary KS. He has had recurrent episodes of grade
II-III/A rejection on cardiac biopsy since [**2194-5-4**].
These acute rejection episodes have all been managed
successfully with a pulse steroid dose. Repeat
echocardiograms have shown no hemodynamic compromise despite
rejection. Other complications from his cardiac transplant
have included gout and recurrent anal condyloma.
3. Transfusion-dependent anemia since [**2195-8-3**]. The
etiology for his transfusion-dependent anemia is unknown. He
is currently being transfused to maintain a hematocrit of
greater than 25. Workup for his anemia has included bone
marrow biopsy and withdrawal of immunosuppressive
medications. He has also received a colonoscopy which was
negative and this anemia is not responsive to Epogen.
4. History of thrombocytopenia. The thrombocytopenia was
attributed to ITP. He was found to have an antibody to
GP2B3A.
5. Renal dysfunction status post chemotherapy with
creatinine ranging from 2.7 to 3.2 but recently his
creatinine function had been improving.
MEDICATIONS ON TRANSFER FROM THE [**Hospital Ward Name **]:
1. Acetaminophen.
2. Diphenhydramine.
3. Ritonavir 600 mg p.o. b.i.d.
4. Lamivudine 150 mg p.o. b.i.d.
5. CellCept [**Pager number **] mg p.o. q.d.
6. Allopurinol 100 mg p.o. q.d.
7. Acyclovir 200 mg p.o. q.d.
8. Abacavir 300 mg p.o. b.i.d.
9. Loratadine 10 mg p.o. q.d. p.r.n.
10. Colchicine 0.6 mg p.o. q.d.
11. Ciprofloxacin 500 mg p.o. q. 12 hours which had been
started on [**2196-8-17**].
12. Oxazepam 10 mg p.o. q.h.s. p.r.n.
13. Prochlorperazine 5-10 mg p.o. q. six hours p.r.n.
14. Captopril 12.5 mg p.o. t.i.d.
15. Diltiazem extended release 360 mg p.o. q.d.
16. Meperidine 12.5 mg IV q. six hours p.r.n.
17. Neoral 25 mg p.o. q.d.
18. Methylprednisolone 1,000 mg IV q.d.
19. Morphine 2 mg IV q. six hours p.r.n.
20. Bactrim 300 mg IV q. 12 hours which was started on [**2196-8-18**].
21. Pantoprazole 40 mg p.o. q. 24 hours.
22. Casofungin 35 mg IV q.d.
23. Artificial tears.
ALLERGIES: The patient is allergic to penicillin which
causes a rash, and Flagyl.
SOCIAL HISTORY: He denied smoking, alcohol use, or IV drug
use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
101, blood pressure 130/90, heart rate 118, respiratory rate
20, 02 saturation 97% on 50% face mask. General: The
patient was awake, alert male lying in bed. He appears
uncomfortable with his head in between his hands. Lungs: He
had scattered crackles. HEENT: Sclerae anicteric. Extraocular
movements intact. No jugular venous distention.
Cardiovascular: Regular rate and rhythm, no murmurs
appreciated. Chest: Scattered crackles throughout both
lungs, occasional coughing, but no dullness to percussion.
Abdomen: Soft, BSA, nontender, nondistended with good bowel
sounds. +hepatomegaly. Extremities: No lower extremity edema. No
petechiae noted.
LABORATORY/RADIOLOGIC DATA: The laboratories from the day of
transfer include a posttransfusion CBC with a white count of
9.9, hemoglobin 9.9, hematocrit 28.4, platelets 66. Chem-10:
Sodium 135, potassium 4.5, chloride 102, bicarbonate 21, BUN
58, creatinine 2.2, glucose 132, calcium 8.3, phosphate 3.2,
magnesium 1.3. LDH 177.
A chest x-ray from [**2196-8-18**] had shown worsening of his
upper lobe infiltrates.
A chest CT on [**2196-8-18**] showed multiple ill-defined
nodular opacities varying in size predominantly in the upper
lobes associated with bulky mediastinal and hilar
lymphadenopathy.
HOSPITAL COURSE: The patient was transferred from [**Hospital Ward Name 8559**] to [**Hospital Ward Name 517**] on [**2196-8-18**] for a lumbar puncture
under fluoroscopy. He remained on the [**Hospital Ward Name 517**] after his
LP.
1. INFECTIOUS DISEASE: The patient continued to have
high-spiking fevers for two more days but eventually he
defervesced for the remainder of his stay on the [**Hospital1 **] service
until he was transferred to the MICU. He was treated for his PCP
pneumonia with Bactrim IV q. 12 hours. The dose of his
Bactrim IV had to eventually be reduced to 200 mg IV due to
worsening renal function and worsening liver function.
Bactrim was stopped on the day of transfer to the MICU on
[**2196-8-23**] as it was felt to be possibly associated with
worsening hepatic function . Atovaquone 750 mg p.o. b.i.d. was
started instead to treat his PCP [**Name Initial (PRE) 1064**]. The patient was also
treated with ciprofloxacin until his Legionella culture from
his bronchoalveolar lavage returned as negative.
He was also given a stress dose of steroids since he was
chronically taking prednisone at home but it was eventually
tapered down from 1,000 mg to 500 mg IV. The remainder of
his Infectious Disease workup was negative including blood
cultures times four from [**2196-8-18**] which showed no growth
to date, fungal and acid-fast bacilli culture from [**2196-8-18**] showed no growth to date. Blood cultures from
[**2196-8-20**] were still pending at the time of this
dictation. All routine, fungal, AFB, and viral cultures from his
BAL were preliminarily negative; only PCP was confirmed. His
Legionella was negative . Rapid respiratory viral antigen
panel in BAL was also negative. His CD4 count on
admission, [**2196-8-17**], was 320. His serial CMV viral loads
from [**8-16**] and [**2196-8-22**] were negative. CSF cultures from
[**2196-8-19**] remained negative; CSF cryptococal Ag was negative.
CMV PCR and EBV PCR from his CSF were
also still pending.
His Ehrlichia panel from [**2196-8-17**] was pending. His EBV
PCR from [**2196-8-22**] was still pending. HIV viral load
from [**2196-8-17**] was less than 50, Legionella urinary Ag
from [**2196-8-17**] was negative. The monospot test from [**2196-8-17**] was positive. Serum parvovirus B12 IgM negative,
IgG positive, serum cryptococcus antigen was negative, Lyme
serology was negative, and urine culture from [**2196-8-17**]
showed no growth.
2. CARDIAC: The patient is status post cardiac transplant.
He had no CHF throughout the remainder of his
stay on the [**Hospital1 **] service. He was continued on his Neoral
with daily cyclosporin levels drawn. He was also continued
on his CellCept at his usual dose and again the patient was
placed on a stress-dose of steroids which was eventually
tapered from 1,000 to 500 mg IV q.d.
3. TRANSFUSION-DEPENDENT ANEMIA: The patient continued to
require transfusions to maintain his hematocrit at greater
than 25. He was transfused 2 units of red blood cells total
during his stay on the [**Hospital1 **] service on [**Hospital Ward Name 517**].
4. THROMBOCYTOPENIA: The patient continued to be
thrombocytopenic and required a transfusion of 1 aphoresis
unit of platelets for a platelet level of 12.
5. RENAL INSUFFICIENCY: His creatinine continued to rise
throughout the remainder of his stay and on the day of
transfer to the MICU his creatinine had risen up to 4.1 from
2.4 on admission. A Renal consult was obtained and they felt
that his renal failure was probably acute tubular necrosis
due to medications. His medications were all renally dosed.
Kidneys were visualized on ultrasound but ultrasound showed
no hydronephrosis or nephrolithiasis.
6. INCREASED LFTS: A GI consult was obtained. It was unclear
whether a drug insult such as bactrim exposure could have
precipitated the hepatotoxicity or if eth paetint had an
underlying hepatic injury such as cirrhosis.
Tylenol was also discontinued as the patient was taking Tylenol
every four hours for his high-spiking fevers. Liver ultrasound
showed normal echotexture; splenomegaly, mild hepatomegaly, and
enlarged periportal lymph nodes. Doppler study revaled that the
hepatic and portal veins were patent. He was started on
Lactulose.
7. PANCREATITIS: The patient's amylase elevated to 538 and
his lipase also elevated to 116. Again, GI consult commented
on his possible pancreatitis and they felt that it was
possibly due to either renal insufficiency or liver failure
or it could represent a true pancreatitis. The patient was
made n.p.o. and was continued on pain medications.
8. HYPERTENSION: The blood pressures remained stable
throughout his hospital course and was continued on Diltiazem
and Captopril. Captopril was eventually discontinued as it
was felt to be acutely worsening his renal insufficiency.
9. GASTROINTESTINAL PROPHYLAXIS: The patient was continued
on Pantoprazole.
10. RESPIRATORY STATUS: Due to his pulmonary infection, the
patient required increasing amounts of oxygen throughout his
stay on the [**Hospital1 **] Service. He, however, denied any shortness
of breath. A baseline ABG was drawn which revealed a pH of
7.44, PC02 of 28, P02 of 187, and a bicarbonate of 20. This
ABG was drawn when he was saturating greater than 95% on 50%
face mask.
On [**2196-8-22**], the patient was noted to have scleral
icterus and seemed more confused. Liver function tests were
ordered which showed an increased transmainitis and elevated
serum bilirubin levels. His serum creatinine was also
elevated. Repeat hepatitis serologies were negative. The
following day, he continued to become more lethargic. His
creatinine and LFts had continued to increase. It was
felt that the patient required more intensive monitoring than
could be offered on the [**Hospital1 **] service and so he was transferred to
the MICU.
Discharge diagnoses and medications as well as the remainder
of his hospital course will be dictated at a later time.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 21062**]
Dictated By:[**Last Name (STitle) 1030**]
MEDQUIST36
D: [**2196-8-25**] 06:53
T: [**2196-9-4**] 10:29
JOB#: [**Job Number 21063**]
Admission Date: [**2196-8-17**] Discharge Date: [**2196-9-21**]
Date of Birth: [**2156-9-19**] Sex: M
Service: [**Hospital1 **] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 39-year-old male AIDS
on HAART with CD4 count 320 with multiple medical problems in
the past including pulmonary Kaposi's sarcoma status post
daunorubicin which led to cardiac toxicity now status post
heart transplant since [**2194**] and on Sandimmune and CellCept,
which was admitted with fever, malaise, and hypoxia. On
bronchoscopy showed PCP, [**Name10 (NameIs) **] started on Bactrim. He is a
transfer from MICU to the floor.
Chest CT also with pulmonary nodules and pneumomediastinal
hilar LAD concerning for posttransplant lymphoproliferative
disorder. He has a CRI with baseline of 2.7 to 3.2, given
nodules ........... fungal disease was started on
Caspofungin. He is on many many medications, and creatinine
and LFTs started to rise. Creatinine peaked at 4.4.
While in MICU, he had a pancreatitis, hepatitis, PCP
pneumonia, [**Name9 (PRE) 21064**] Staph bacteremia, which were all
resolving and then was transferred to he floor.
When transferred to the floor, he was afebrile and normal
blood pressure, and stable vital signs.
PHYSICAL EXAMINATION: General exam: He was in no acute
distress alert and oriented times three. HEENT: Pupils are
equal and reactive to light. Extraocular movements are
intact, but bilateral scleral icterus and dry membrane
mucosa. Lungs were clear to auscultation bilaterally.
Cardiac examination: Regular, rate, and rhythm, no murmurs,
gallops, or rales. Abdomen: Bowel sounds were present,
nondistended, and nontender. Extremities: No clubbing,
cyanosis, or edema, but he had diffuse jaundice of skin.
Neurologically intact. No sensory or motor deficits noted.
Pertinent positive laboratory findings on transfer to
Medicine [**Hospital1 139**] floor were as follows: He had a resolving
hepatitis, still elevated LFTs, but LFTs trending down since
being transferred out of the MICU. Trending down amylase and
lipase secondary to resolving pancreatitis. A new
hyponatremia, unknown etiology which he had workup. Sodium
had been sitting anywhere from mid 120s to high 120s.
Resolving bacteremia since transfer from MICU.
HOSPITAL COURSE: On [**8-26**], status post liver biopsy from
[**8-25**], and he was awaiting for liver path results. EBV viral
load is up to 2,000, so a rapid taper of high-dosed steroids
going from salmeterol 250 to prednisone 60 for two days to
off to cover PCP. [**Name10 (NameIs) **] CT consistent with improving PCP
pneumonia, but worse [**Doctor First Name **], concerning for PTLD.
Mediastinoscopy planned for Monday after BM biopsy.
Transfused for hematocrit less than 25 and platelets less
than 10. His pancreatitis was improving per amylase, lipase,
but he was still kept NPO for the time-being on [**8-26**].
The next day, [**8-27**], liver biopsies were inconclusive.
Cyclosporin trough levels high, so his dose was decreased to
15, and there was planned for the following cyclosporin
troughs. There was a rusty colored stool and dropping
hematocrit and platelets, so he was transfused and made NPO
after a day of clears and apple juice. Liver team to see him
on [**8-28**].
Access becoming an issue, so request a PICC evaluation and
getting a PICC line placed on [**8-28**]. On [**8-28**], good response
to packed red blood cells and platelet transfusions
overnight. His creatinine has improved, but his liver
laboratories still looked worsened, although they were
stabilizing.
Hepatology thought that it was secondary to drug toxicity,
versus PLTD, versus EBV. ID warned of CMV, Clostridium
difficile, BK virus, primary toxo, which were on the
differential.
On [**8-28**], he was awaiting ID workup laboratories to come
back. Cyclosporin levels okay on the new level, lower dose
of 15, and autodiuresing with great EOP at the time.
On [**8-29**], he grew gram-positive cocci from two bottles and
was put on Vancomycin and he had persistent bleed from IV
site. He was transfused with platelets secondary to the
bleed. Bone marrow biopsy was done. Chest CT scan and
echocardiogram planned for tomorrow.
[**8-30**] improvement of mediastinal LAM on chest CT scan, so
biopsy was cancelled. Increasing Vancomycin to 1.5 grams
q24h, cyclosporin 40 mg total given today. Follow-up level
tomorrow and contact[**Name (NI) **] Dr. [**Last Name (STitle) 977**] for recommended dose. He
had an ultrasound of the abdomen ordered to evaluate for
questionable liver hematoma and a biliary tree evaluation.
Meanwhile he has been NPO after midnight for the ultrasound.
On [**9-1**], his LFTs were improving. CD4 count was down to
70s. Repeat echocardiogram unchanged. His creatinine up to
1.7, white blood cell count up to over 4 from less than two,
breathing better, now on room air. CKs trending down, but
troponin jumps up and down with max of 0.6. He is getting
platelets for level of 8. Will need PICC line for blood
draws and access at the time.
On [**9-2**], improvement in LFTs, liver function, renal
function, CK, and O2 requirement improvements. His PICC line
was placed, then he started developing hyponatremia. His
urine osmolarity was checked for assessing etiology. Since
on the floor, patient hemodynamically stable, but
hyponatremia for past two days consistent with SIADH since
his urine sodium was over 50 and his urine osmolality was
over 200. Last serum sodium was 128 with recheck at
midnight.
On [**9-3**], hyponatremia was improved with fluid restriction
secondary to treatment of SIADH. Underlying cause of the
SIADH unknown. Sedated secondary to Fentanyl and
discontinued his Fentanyl since. Hemodynamically stable and
no pin point pupils, but regular rhythm was breathing at
8-10. All of his sedatives were held secondary to
oversedation due to Fentanyl.
On [**9-4**], per ID recommendations, his G/CSF was stopped
because of his improved white blood cell count and his IV
sodium chloride because of his hyponatremia is probably due
to SIADH. He was also transfused bloods secondary to
decreasing hematocrit.
On [**9-5**], patient has been NPO with one day history of
pneumatosis on CT and Surgery on board. This was secondary
to a one day history of severe abdominal pain which later on
CT was shown to be consistent with typhlitis and pneumatosis,
which were obvious on CT examination. Since then, his
pneumatosis on CT has resolved. He was NPO for the next few
days at which point, he was started on TPN and gradually
while improving his physical examination and his CT
examination findings were improving, he was gradually
switched over to po feeds.
Meanwhile, in the next two days, he developed a rash, which
was thought to be either secondary to meropenem or
Vancomycin. Meanwhile meropenem and Vancomycin were held.
Also Cipro was held thinking the possible interaction that
could lead to the rash. Since discontinuing Cipro,
Vancomycin, and meropenem, his rash had disappeared. His po
Vancomycin was continued for an extra day, thinking that it
had low absorption and decreased chance of leading to a rash.
The po Vancomycin was mainly given due to not being able to
tolerate Flagyl secondary to empiric treatment of Clostridium
difficile.
Meanwhile each day, patient improved. His hyponatremia
improved. His LFTs still elevated today on discharge, but
improving each day. His pancreatitis improving, although
today he was slightly elevated, which needs to be rechecked
as an outpatient with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 977**], and no sign of acute
infection at this point.
His follow-up plans were to followup with his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 977**], who follows up really closely.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: The patient is to be discharged home with
service, and with close followup with Dr. [**Last Name (STitle) 977**], PCP.
DISCHARGE DIAGNOSES:
1. Pneumocystis carinii pneumonia.
2. Hyponatremia.
3. Acute renal failure, not otherwise specified.
4. Thrombocytopenia, not otherwise specified.
5. Anemia, not otherwise specified.
6. Coagulopathy defect, which has resolved since.
7. Abnormal liver function studies.
8. Congestive heart failure.
9. Status post heart transplant in [**2194**].
FOLLOW-UP PLANS: With Dr. [**Last Name (STitle) 977**] at Falbrig Building in
Infectious Disease section, phone number [**Telephone/Fax (1) 457**], date
[**2196-9-26**] at 10:30 am.
DISCHARGE MEDICATIONS: Patient's discharge medications were
discussed in detail by Dr. [**Last Name (STitle) 977**] and by discharging
physician. [**Name10 (NameIs) **] patient's discharge medications were called
in by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 977**], and the patient is to continue his
outpatient medications as directed by Dr. [**Last Name (STitle) 977**].
Discharge medications were as follows:
1. Prednisone 10 mg to do a taper as prescribed by Dr.
[**Last Name (STitle) 977**].
2. Loratadine 10 mg q day.
3. Diltiazem 360 q day.
4. Ursodiol 300 mg tid.
5. Valganciclovir 450 [**Hospital1 **].
6. Pantoprazole 40 q12h.
7. Mycophenolate 500 mg q day.
8. Colchicine 0.6 mg q day.
9. Allopurinol 100 mg q day.
10. Atovaquone 750 mg/5 mL oral suspension q day, 10 mL q
day, which is a total of 1500 mg dose.
11. Cyclosporin to be dosed daily by Dr. [**Last Name (STitle) 977**], the PCP.
Outpatient medications have been called in by Dr. [**Last Name (STitle) 977**]
for specific instructions for patient to follow.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 21062**]
Dictated By:[**Last Name (STitle) 21065**]
MEDQUIST36
D: [**2196-9-21**] 14:56
T: [**2196-9-24**] 07:46
JOB#: [**Job Number 21066**]
|
[
"996.83",
"284.8",
"577.0",
"570",
"584.5",
"136.3",
"286.7",
"790.7",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"50.11",
"41.31",
"03.31",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
21188, 21334
|
21355, 21701
|
21909, 23210
|
15646, 21166
|
14611, 15628
|
21719, 21885
|
13531, 14588
|
5795, 7089
|
2196, 5693
|
5710, 5780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,148
| 171,952
|
37187
|
Discharge summary
|
report
|
Admission Date: [**2147-1-15**] Discharge Date: [**2147-2-3**]
Date of Birth: [**2098-5-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of Life
Major Surgical or Invasive Procedure:
[**2147-1-16**]: Cerebral angiogram with coiling
[**2147-1-22**]: Cerebral angiogram
[**2147-1-23**]: Cerebral angiogram
[**2147-1-31**]: IVCF PLACEMENT
History of Present Illness:
48 year old Portugese speaking female without
significant past medical history who presents to the ED today
with her husband from an outside hospital after experiencing the
worst headache of her life at 1pm this afternoon. The head CT
from the outside hospital was consistent with subarachnoid
hemorrhage and the patient was transferred here for further
evaluation. The patient denies any weakness, numbness, visual
disturbance or hearing deficit.
Past Medical History:
None
Social History:
denies EOTH and tobacco
Family History:
Mother passed from Cerebral Aneurysm
Physical Exam:
On admission:
O: T: BP: 134/69 HR: 94 R: 16 O2Sats: 98%RA
Gen: lethargic comfortable, NAD.
HEENT: Pupils: 4-3mm bilat EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: patient is lethargic, but responds readily to
questions and follows commands consistently. Oriented to person,
place, and date.
Language: Speech fluent with good comprehension and repetition
per husband who acts as an interpreter at the bedside.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-17**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
On discharge
awake alert and with expressive aphasi - able to make needs
known reliably through yes no nodding. Otherwise neurologically
nonfocal
Pertinent Results:
[**2147-1-15**] Head CT:
subarachnoid blood in the left sylvian fissure and throughout
the basilar cisterns. no hydrocephalus. CTA shows a 7 x 5 mm
aneurysm projecting posteriorly in the region of the left ica
bifurcation, likely of left pComm origin. a smaller 3 mm
component projects medially. irregularity may reflect rupture.
no other aneurysms are identified.
[**2147-1-16**] Head CT:
Stable appearance to subarachnoid hemorrhage in the region of
bilateral sylvian fissures, and the basilar cistern. There is no
new hemorrhage.
[**2147-1-17**] Right Femoral Vascular Ultrasound:
No pseudoaneurysm, AV fistula or hematoma in the right groin.
[**2147-1-22**] CT/CTA:
Marked vasospasm related to the SAH, with thrombotic or embolic
etiologies, much less likely.
Brief Hospital Course:
Patient initially presented to [**Hospital3 3583**] on [**2146-1-15**] at
approximately 1pm for complaint of worst headache of her life.
Head CT from [**Hospital1 46**] was consistent with SAH and she was
transferred to [**Hospital1 18**] for further management. Upon arriving at
[**Hospital1 **] she denied any weakness, numbness, visual disturbance or
hearing loss. She received a Head CT in the ER here which
showed a 7mm by 5mm left posterior communicating artery aneurysm
with subarachnoid blood in the left sylvian fissure and the
basilar cistern. She was admitted to neurosurgery and was
planned for cerebral angiography. On [**2147-1-16**] her exam, which was
accomplished through a Portugese interpreter, was positive for
slight lethargy and nuchal rigidity but was otherwise nonfocal.
Her head CT on that day showed stable subarachnoid hemorrhage
and she subsequently underwent angiography with Dr. [**First Name (STitle) **].
During this procedure he coiled the aneurysm with good results
and she was prophylactically place on a heparin gtt overnight.
Her exam was nonfocal after the procedure. On [**2147-1-17**] she was
neurologically intact and had no deficits. On exam of her angio
site on the right groin, a bruit was auscultated. As a result
Dr. [**Last Name (STitle) **] was consulted who recommended ultrasound to assess the
area. Her right femoral, popliteal, dorsalis pedis, and
posterior tibial pulses were all 2+. The ultrasound was
negative.
She continued to do well. She remained nonfocal on exams. On [**1-19**]
she had a fever spike and a urine analysis showed a UTI and
Levaquin was started. On [**1-21**] there was some mental status
(aphasia) changes and her blood pressure dropped required
boluses of normal saline. A CT/CTA was performed which was
suspicious for vasospasm, and she was transferred to the ICU.
Blood pressure was maintained with pressors and IV fluids. On
[**1-23**] she remained expressively aphasic but other wise well. A
repeat angiogram showed the artery to be more open and was given
a one time dosing of Verapamil. She remained aphasic on HHH
therapy. Repeat angio gram was done on [**1-27**] showing improved
vasospasm and verapimil was also administered. Patient's
expressive aphasia fluctates, on [**1-31**], CTA/P was ordered to
access status of vasospam. CTA/P was stable and patient's SBP
parameters were decreased to 120-140.
Patient was transferred to the floor, seen and evaluate by
PT/OT/ST and recommendations were made for acute rehab
placement.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-14**]
Tablets PO Q4H (every 4 hours) as needed for headache.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
decreased stooling.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 6 months.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
left posterior communicating artery aneurysm
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
EXPRESSIVE APHASIC / NEAR COMPLETE
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
You will need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] IN ONE MONTH
WIHT AN MRA OF THE BRAIN AT [**Telephone/Fax (1) **]
Completed by:[**2147-2-3**]
|
[
"434.91",
"784.3",
"518.4",
"997.79",
"430",
"453.41",
"276.6",
"285.9",
"599.0",
"041.10",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"88.41",
"88.51",
"96.6",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
7203, 7348
|
3234, 5754
|
339, 494
|
7437, 7437
|
2442, 2458
|
9528, 9717
|
1058, 1096
|
5809, 7180
|
7369, 7416
|
5780, 5786
|
7617, 8586
|
8612, 9505
|
1111, 1111
|
277, 301
|
522, 973
|
1652, 2423
|
2833, 3211
|
1125, 1306
|
7451, 7593
|
995, 1001
|
1017, 1042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,096
| 162,383
|
36401
|
Discharge summary
|
report
|
Admission Date: [**2103-3-14**] Discharge Date: [**2103-3-29**]
Date of Birth: [**2033-6-18**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids / Allopurinol /
Probenecid / Hydrochlorothiazide / Claritin / Statins: Hmg-Coa
Reductase Inhibitors
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Unresponsiveness, intracranial thalamic hemorrhage
Major Surgical or Invasive Procedure:
[**3-14**] Intubation, mechanical ventilation
4/15 PEG/tracheostomy
History of Present Illness:
69M experienced Right sided weakness, aphasia and headache at
home. Found to have Left thalamic intraparenchymal hemorrhage.
From medicine admission note, [**2103-3-23**]:
In brief, 69 yo M with HTN, CAD s/p PPM, CKD, OSA who presented
on [**2103-3-14**] to an OSH after a sudden fall and found to have a
large intraparenchymal hemorrhage thought to be due to a
hypertensive bleed. He was at an outside hospital and intubated
for airway protection and transferred to the [**Hospital1 18**]. He was in
the neurologic ICU and extubated on [**2103-3-15**] but had difficulty
clearning his secretions and was reintubated. He ultimately
needed a trach and PEG and was taken off the ventilator a couple
of days ago. He was febrile on [**2103-3-21**] to 101 and was found to
have urine with pseudomonas and enterococcus. He was started on
vancomycin and zosyn. A BAL was done and shows 3+ GNR but the
culture then grew oral flora. C diff was negative x 2, BCx have
been negative.
<br>
His course was also complicated also by acute on chronic renal
insufficiency. Nephrology was consulted and thinks this is ATN
and some volume depletion. He may need renal replacement therapy
in the future but is stable now.
Past Medical History:
OSA
Hypertension
Gout
Stage III-IV CKD (baseline creatinine unclear, 3.3 on admission)
Vasovagal syncope
s/p PCM placement
DI s/p removal of pituitary adenoma
CAD
Social History:
Pt was residing at home with his wife.
Family History:
Non-contributory
Physical Exam:
(at time of transfer to medicine)
VS: T 96.9 HR 65 BP 144/55 RR 16 Sats I/Os 2500/1500 (LOS +12L)
Gen: Mildly agitated, but tracking & responding to most commands
HEENT: NCAT. OP clear, MMM. face cachectic appearing
Neck: Supple, fresh trach in place
CV: RRR, occaisional PVC heard
Chest: trach in place, Mildly tachypnea, though CTAB, no rales,
wheezes or rhonchi.
Abd: Obese, Soft, Active BS, G-Tube site mildly tender
Ext: body swollen, especially LEs
Neuro: right sided hemiparesis. with flexed RLE. Squeezes hand
to command. PERRLA, right eye down and inward. Spontaneous
movement on left limbs. toes up on right.
.
ON DAY OF DISCHARGE:
VS: Tm 100.0F, Tc 98.6F, HR 92, Range 62-100, BP 134/74, range
134-168/71-80
Gen: Mildly agitated, but tracking & responding to most commands
HEENT: NCAT. OP clear, MMM. face cachectic appearing
Neck: Supple, fresh trach in place
CV: RRR, occaisional PVC heard
Chest: trach in place, diffuse rhonchi
Abd: Obese, Soft, Active BS, G-Tube site mildly tender
Ext: trace edema
Neuro: Right sided hemiparesis. Follows commands inconsistently.
With flexed RLE. Squeezes hand to command. PERRLA, right eye
down and inward. Spontaneous movement on left limbs. Toes up on
right. Opens eyes to voice. Withdraws to pain in all extremities
except right upper extremity.
Pertinent Results:
[**2103-3-14**] ECG: Atrial paced rhythm. Right bundle-branch block with
left anterior fascicular block. Non-specific ST-T wave changes.
No previous tracing available for comparison.
.
[**2103-3-14**] CXR: 1. ET tube has its tip approximately 59 mm from the
carina. The NG tube has its tip in the distal esophagus and
should be advanced further. 2. Cardiomegaly with atelectasis in
the right mid zone.
.
[**2103-3-14**] CT Head: 1. Large intraparenchymal hemorrhage centered
within the left thalamus with mild surrounding edema and
associated mass effect as described above. There is
intraventricular extension, with no evidence for development of
hydrocephalus. 2. Air-fluid levels in the paranasal sinuses,
likely secondary to intubation. 3. NG tube is coiled within the
posterior nasopharynx.
.
[**2103-3-15**] ECG: Atrial fibrillation with occasional ventricular
paced beats. Left bundle-branch block with left axis deviation.
Non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2103-3-14**] atrial
fibrillation and ventricular pacing appear new. Atrial pacing is
no longer seen.
.
[**2103-3-15**] CT Head: Unchanged large left thalamic intraparenchymal
hemorrhage with surrounding vasogenic edema and mass effect
compressing the mid brain, with significant compression of the
left cerebral peduncle. Intraventricular extension is unchanged.
Unchanged coiled appearance of the nasogastric tube in the
posterior nasopharynx as previously indicated.
However, if there is concern for acute infarction as a cause for
the new
symptoms, MR [**Name13 (STitle) 430**] is more sensitive and ideal to be performed.
.
[**2103-3-15**] Portable CXR: Radiograph centered at the thoracoabdominal
junction was obtained for assessing nasogastric tube, which has
been advanced into the stomach. Within the imaged portion of the
chest, there has been improved aeration at the lung bases with
resolution of atelectatic changes.
.
[**2103-3-16**]: Atrial fibrillation with ventricular premature beats or
[**Last Name (un) **] beats. Intraventricular conduction delay. Diffuse
non-specific ST-T wave
abnormalities. Compared to the previous tracing ventricular
pacing is no
longer noted. Clinical correlation and repeat tracing are
suggested.
.
[**2103-3-17**]: Portable CXR: Lungs are grossly clear. Mild
cardiomegaly is unchanged. Dual-lead left chest wall cardiac
pacemaker wires follow expected course. Nasogastric tube tip is
in the stomach. Interval removal of the endotracheal tube.
.
[**2103-3-20**] CT C-spine: There is no malalignment or loss of
vertebral body height. Degenerative changes are seen from C3
through C6, but no significant stenosis is identified. There is
no definite fracture seen.
There is a possible hypodense nodule in the left thyroid lobe
measuring
approximately 13 mm. This can be assessed with ultrasound when
the patient is stable.
.
[**2103-3-20**] CT head: Relatively stable left thalamic hematoma.
.
[**2103-3-21**] CXR: 1. No evidence of acute pneumonia. Unchanged
cardiomegaly.
2. Tip of NG tube likely in the distal esophagus. Recommend
advancing 10 cm for optimal placement.
.
[**2103-3-22**] Carotid dopplers :No evidence of hematoma along the
right aspect of the neck. No evidence of arteriovenous fistula
or pseudoaneurysm of the right carotid artery.
.
[**2103-3-22**] CXR Portable: In comparison with the study of [**3-21**],
there is a huge amount of subdiaphragmatic air consistent with
the recent PEG placement. Continued moderate cardiomegaly in
patient with dual-channel pacer device in place. Tracheostomy
tube is in good position. Mild suggestion of some air
bronchogram in the retrocardiac region. This could be a
manifestation of an early developing consolidation.
.
[**2103-3-24**] Renal ultrasound: Echogenic kidneys consistent with
medical renal disease. Large simple cyst on the right. No
hydronephrosis or evidence of obstruction. Bladder not well
evaluated.
.
[**2103-3-27**] CXR Portable: In comparison with the study of [**3-22**],
there has been some decrease in the free intraperitoneal gas,
though somewhat less than would be expected. Has the patient
had any interval abdominal surgery or a continued air leak?
There is increased opacification at the left base with
silhouetting of the hemidiaphragm and poor visualization of the
descending aorta. In view of the clinical appearance, the
possibility of pneumonia at the left base must be seriously
considered. The costophrenic angles are poorly seen and small
pleural effusions may be present bilaterally. Tracheostomy tube
remains in place, as does the dual-channel pacemaker.
.
[**2103-3-28**] Right upper extremity ultrasound: Negative for right
upper extremity clot.
.
LABORATORIES: Please see attached.
.
MICROBIOLOGY:
[**2103-3-21**] 10:25 am BLOOD CULTURE A-LINE. (THOUGHT TO BE
CONTAMINANT)
**FINAL REPORT [**2103-3-27**]**
Blood Culture, Routine (Final [**2103-3-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Aerobic Bottle Gram Stain (Final [**2103-3-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO DR [**Last Name (STitle) 82475**] HEARD [**2103-3-24**] @ 10:04 AM.
[**2103-3-21**] 10:56 am URINE Source: Catheter.
ORDER CHANGED P/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**First Name8 (NamePattern2) 2428**] [**Last Name (NamePattern1) **],MD 2106 [**2103-3-21**].
**FINAL REPORT [**2103-3-23**]**
URINE CULTURE (Final [**2103-3-23**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
[**2103-3-21**] 3:18 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2103-3-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2103-3-24**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER AEROGENES. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2103-3-22**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2103-3-21**] 3:18 pm BRONCHOALVEOLAR LAVAGE RIGHT LUNG.
GRAM STAIN (Final [**2103-3-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2103-3-24**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER AEROGENES. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 82476**]
([**2103-3-21**]).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2103-3-22**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2103-3-23**] 12:31 pm URINE Source: Catheter.
**FINAL REPORT [**2103-3-25**]**
URINE CULTURE (Final [**2103-3-25**]):
YEAST. ~7000/ML.
PROBABLE ENTEROCOCCUS. ~1000/ML.
[**2103-3-27**] 4:54 am URINE Source: Catheter.
**FINAL REPORT [**2103-3-28**]**
URINE CULTURE (Final [**2103-3-28**]):
YEAST. >100,000 ORGANISMS/ML..
ALL OTHER CULTURES WERE NEGATIVE
Brief Hospital Course:
Mr. [**Known lastname 20825**] is a 69 year old right handed male with
hypertension, chronic renal insufficiency (baseline creat
3.0-3.3), diabetes, atrial fibrillation s/p pacemaker,
presenting with acute onset of right sided weakness and
decreased responsiveness, found to have left thalamic
hemorrhage.
.
BRIEF HOSPITAL COURSE (NEUROLOGY/SICU):
- [**3-14**] admitted from ED, intubated and sedated. Over night had
pupillary asymmetry that resolved. Head CT showed no acute
change.
- [**3-15**] extubated, unable to obtain MRI to clear c-spine due to
pacemaker, NGT placed and PO antihypertensive meds started
- [**3-16**] remained in ICU for BP control, frequent PVCs / 4-6 beat
runs of ventricular tachycardia, replaced a-line, started tube
feeds
- [**3-17**] requires nicardipine drip intermittently, hypernatremia
worsened, urine osmol sent, increased free water bolus via NGT.
- [**3-18**] hypernatremia evaluated by endocrine, ruled out DI based
on elevated urine osmolality. Increased free water enteral and
IV. No acute events.
- [**3-19**] failed speech and swallow evaluation, metoprolol and
clonidine increased, off nicardipine drip
.- [**3-20**] no acute events
- [**3-21**] C-Spine cleared by CT. Trach and PEG performed at
bedside.
- [**3-22**] goal TFs via PEG, Trach --> secretions, chest PT. BP
labile (120 - 180s), neuro q4hrs
- [**3-23**] transferred to medical service
.
BRIEF HOSPITAL COURSE BY PROBLEM (NEURO/SICU):
.
#) Neurology: CT with left thalamic hemorrhage and surrounding
edema, trace amount of
blood layering in the posterior [**Doctor Last Name 534**] of the left lateral.
etiology of stroke was likely hemorrhagic. He was admitted to
Neuro-ICU; BP was initially controlled on nicardipine drip;
SBP:120-160. repeated CT head showed stable hemorrhage.
cholesterol profile: 151/ LDL 100, trig 123. He was started on
aspirin 1 week after the stroke
.
#) Cardiology: atrial fibrillation; off coumadin (not on
coumadin on presentation); rate controlled. s/p pacer.
.
#) Resp: s/p trach on [**2103-3-21**] because of excessive secretions.
Chronic aspiration.
.
#) GI: s/p PEG on [**2103-3-21**]. On tube feeds with free water
boluses.
ID: Started zosyn and vancomycin renally dosed on [**2103-3-21**] for
fever, empirically as pt spiked fever; now off fever for the
past 24h; aspiration pneumonia, UTI.
.
#) Renal: Patient was hypernatremic initially in ICU; corrected
slowly with D5W; sodium level is normal at the time of transfer
to medicine. He had acute on chronic renal failure on [**2102-3-21**]
(baseline 3.2 and now 4.8) in the setting of infection. IV
Fluids were increased to NS @ 100ml/h. Off lisinopril since
[**2103-3-22**]. FENA: 0.8. Nephrology was consulted.
.
#) Heme: slow and continous drop H/H; multifactorial (slowly
dropping Ht 34 initially; now 25). Guaiac negative. See
assessment below.
.
#) Infectious disease. BAL performed after trach, grew
pan-sensitive Enterobacter. Started on vanco/Zosyn [**3-21**]. Urine
grew Pseudomonas and Enterococcus.
HOSPITAL COURSE BY PROBLEM (from [**3-23**], by medicine service):
ASSESSMENT: Mr. [**Known lastname 20825**] is a 69 year old man with hypertension,
CAD s/p pacemaker, chronic kidney disease (creatinine 3.0), and
obstructive sleep apnea admitted after left thalamic hemorrhage
(stable) secondary to hypertension, with ICU and floor admission
thus far complicated by UTI, ?pneumonia (BAL growing
Enterobacter), acute on chronic renal failure (now resolving),
and hypertension. Called out [**2103-3-23**] from neuro ICU.
<br>
#) Low-Grade Fever: Had Enterobacter pneumonia (from BAL) and
enterococcus and Pseudomonas UTI (treated with Zosyn). Fever
persists, but less frequent and lower grade. Source likely
pneumonia (given increased secretions and findings on chest
x-ray with low-grade fevers) vs. chronic aspiration. Currently
on Zosyn, course to finish on [**2103-4-4**]. White blood cell count
stable. Right upper extremity ultrasound showed no clot. Urine
culture grew yeast, likely colonization. Please monitor fever
curve, WBC count; culture if spikes. Please use condom catheter
instead of indwelling foley to minimize infection risk. Course
(14-days) of Zosyn to complete on [**4-4**].
<br>
#) Anemia. Hematocrit has been slowly trending down since
admission. Received a total of two units of pRBC's ([**3-26**] and
[**3-27**]). Likely multifactorial: acute blood loss (from recent PEG
placement or other UGI source), poor production given acute
illness, chronic renal insufficiency, loss from frequent blood
draws. Guaiac negative, but with gastroccult positive residual
on [**3-27**], now resolved. Continue to guaiac stools, on [**Hospital1 **] PPI,
started epo 20,000 units per week, transfuse to keep hematocrit
over 21%.
<br>
#) Acute on Chronic Renal Failure: Baseline CRI and creatinine
of ~3. BUN/creatinine steadily rose in house with peak uremia of
123/4.8. Likely prerenal etiology +/- ATN, continues to have
excellent urine output. Renal is following. Currently creatinine
trending down (93/3.9) today. Renal ultrasound showed no
evidence of hydronephrosis or obstruction. Unclear if creatinine
today (3.8) represents new baseline or if will continue to
downtrend. Continue sodium bicarbonate for acidosis and monitor
sodium levels (hypernatremic). Monitor lytes closely; renally
dose medications; avoid nephroxin. On epoietin. Will need renal
follow up (has nephrologist at [**Hospital1 **]) in [**5-14**] weeks after
discharge.
<br>
#) Eye discharge. Continue erythromycin ointment x 5 days, last
day is [**3-31**].
<br>
#) Hypernatremia. Resolved. Continue free water boluses with
tube feeds, at 300cc Q3H.
<br>
#) Hemorrhagic stroke: Left thalamic hemorrhage with surrounding
edema likely secondary to hypertension. Appreciate neurology
recommendations. Goal SBP is between 130-160. Continue current
antichypertensive regimen: clonidine, doxazosin, diltiazem (90mg
Q6H), metoprolol; holding lisinopril because of renal failure.
Started amlodipine on [**3-27**] with good results on blood pressure.
Continue aspirin. Monitor blood pressure; can go up on
amlodipine if need additional blood pressure control. Needs
neurology follow up in [**3-12**] weeks after discharge (number of
[**Hospital1 18**] neurology clinic in discharge paperwork).
<br>
#) Atrial fibrillation: no warfarin given bleed. Rate controlled
currently. Continue telemetry, metoprolol, diltiazem (PPM in
place), aspirin.
<br>
#) CAD: continue metoprolol, aspirin. Allergy to statins.
Holding ACEI given renal failure.
<br>
#) Respiratory: trach to humidified oxygen currently. Continue
aspiration precautions, pulmonary toilet. Aspiration
precautions.
<br>
#) F/E/N: Tube feeds. Monitor lytes, continue free water
boluses, at 300mL Q3H.<br>
<br>
#) PPX: heparin SQ for DVT ppx, no bowel reg given diarrhea (but
give as needed). PPI.
<br>
#) CODE: DNR, but OKAY TO INTUBATE (given trach), confirmed with
wife on [**2103-3-27**]. HCP is wife [**Name (NI) **] (form in chart).
<br>
#) Communication. Wife [**Name (NI) **]: [**Telephone/Fax (1) 82477**] (home), [**Telephone/Fax (1) 82478**]
(work)
<br>
#) Dispo. Needs aggressive PT/OT. Confirm Pneumovax status:
[**2101-6-28**] received Pneumovax. Will need renal, neuro, and PCP
follow up upon discharge.
Medications on Admission:
Nephrocaps, Vit D 50,000 weekly, Aspirin 325mg daily, Colcicin
0.6 PRN gout, Methylphenidate 60mg PO TID, Zoloft 25mg daily,
Lisinopril 40mg daily, Atenolol 100mg, Cardura 16mg daily,
Cardizem CD 240mg, Catapress=TTx3 Clonidine transdermal patch
weekly
MVI, Kentoconazonle cream, Androgel daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Month/Day/Year **]: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 6 days.
3. Erythromycin 5 mg/g Ointment [**Month/Day/Year **]: One (1) application (0.5
inch) Ophthalmic QID (4 times a day) for 2 days.
4. Diltiazem HCl 90 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every
6 hours).
5. Amlodipine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO HS (at
bedtime).
6. Clonidine 0.3 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO three times a
day.
7. Hydralazine 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP > 160.
8. Doxazosin 4 mg Tablet [**Month/Day/Year **]: Four (4) Tablet PO HS (at
bedtime).
9. Metoprolol Tartrate 50 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO TID
(3 times a day).
10. Epoetin Alfa 20,000 unit/2 mL Solution [**Month/Day/Year **]: One (1)
injection Injection once a week.
11. Sodium Bicarbonate 650 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID
(2 times a day).
12. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical TID
(3 times a day) as needed.
13. Colace 50 mg/5 mL Liquid [**Month/Day/Year **]: Five (5) mL PO twice a day as
needed for constipation.
14. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
injection Injection TID (3 times a day).
16. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
17. Bisacodyl 10 mg Suppository [**Month/Day/Year **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
19. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) sub q
injection Subcutaneous ASDIR (AS DIRECTED): per sliding scale
(attached).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
- Left thalamic intra-parenchymal hemorrhage
- Hypertension
- Acute on Chronic kidney disease
Secondary:
- Atrial fibrillation s/p Pacemaker placement
- Coronary artery disease
Discharge Condition:
Stable, with low-grade temperatures. Satting 100% on trach mask.
Intermittently follows commands. Blood pressures have been
ranging 120-160 systolic.
Discharge Instructions:
You were admitted after an intracranial hemorrhage in an area of
the brain called the thalamus, which resulted in a stroke. Your
hospital course was complicated by worsening kidney function,
which has partially resolved, a urinary tract infection, and
pneumonia, both of which are being treated with an antibiotic.
You are being discharged to [**Hospital3 **] for further
occupational and physical therapy to rehabilitate from the
stroke.
.
Please take all of your medication as prescribed. Your doctors
at rehab [**Name5 (PTitle) **] arrange follow up with your nephrologist at
[**Hospital1 **], a neurologist (Dr. [**First Name (STitle) **] at [**Hospital1 18**], and your primary
care doctor as needed.
Followup Instructions:
- Follow up with PCP (Dr. [**Last Name (STitle) 12300**] [**Telephone/Fax (1) 23002**]) as appropriate
- Follow up with neurology (Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **], ph [**Telephone/Fax (1) 2574**])
as appropriate, ? 4-6 weeks after discharge from [**Hospital1 18**]
- Follow up with nephrology (patient has a nephrologist at
[**Hospital **] Hospital who has known him for a long time), as
appropriate
|
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icd9cm
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icd9pcs
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[
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2012, 2030
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20202, 22277
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362, 414
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550, 1753
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6268, 11116
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1775, 1940
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1956, 1996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,510
| 152,689
|
53730
|
Discharge summary
|
report
|
Admission Date: [**2190-1-11**] Discharge Date: [**2190-1-15**]
Date of Birth: [**2128-5-7**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 61 year old
female with chronic obstructive pulmonary disease,
interstitial pulmonary fibrosis, diastolic dysfunction,
history of multiple pneumonias, and back pain from vertebral
compression fractures for which she has been on narcotics
recently. On [**2190-1-11**], she was found down by her son and was
unresponsive. Emergency Medical Services was notified and
she was brought to the Emergency Department where she was
found to have pneumonia on x-ray. She was hypoxic to the
80's. She was initially admitted to the Intensive Care Unit.
In the Intensive Care Unit she had leukocytosis,
hyperkalemia, elevated CK's to 918, as well as hypoxia and
hypercapnia. The Intensive Care Unit team felt her
presentation was most consistent with hypoventilation,
secondary to narcotic overuse. She improved over the next
few days with intermittent [**Hospital1 **]-level positive airway pressure
as well as Levofloxacin for pneumonia. She was given
frequent nebulized Albuterol and Atrovent therapies as well
as her twice a day nebulized N-acetylcysteine. She was
continued on narcotic analgesics for back pain. Following
her two day stay in the Intensive Care Unit, she was
transferred to the Medical Floor.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Obstructive sleep apnea with [**Hospital1 **]-level positive airway
pressure at 14/5.
3. Diastolic dysfunction with an ejection fraction of 60% in
[**2188-12-21**].
4. Deep vein thrombosis in the left upper extremity in [**2189-4-21**].
5. Bilateral breast cancer status post bilateral
lumpectomies and chemotherapy followed by Dr. [**First Name (STitle) **] in
Oncology and Dr. [**Last Name (STitle) 11635**] in Surgery.
6. Hypertension.
7. Hyperlipidemia.
8. Steroid induced diabetes mellitus.
9. History of recurrent pneumonia.
10. Organizing pneumonitis.
11. Interstitial pulmonary fibrosis on chronic steroids.
12. Home oxygen 2 liters per nasal cannula at night only.
13. Osteoporosis.
14. Lumbar compression fractures.
15. Question of fibromyalgia/pain syndrome.
ALLERGIES: Tobramycin caused acute renal failure in the
past.
MEDICATIONS AT HOME:
1. Arimidex 1 mg by mouth twice a day.
2. Lipitor 30 mg by mouth once daily.
3. Celebrex.
4. Prednisone 10 mg by mouth once daily.
5. Effexor XR 37.5 mg by mouth twice a day.
6. Bactrim single strength once daily.
7. Protonix 40 mg once daily.
8. Vitamin D 400 international units once daily.
9. Neurontin 600 mg by mouth four times a day.
10. Colace 100 mg by mouth twice a day.
11. Lasix 40 mg by mouth once daily.
12. Regular insulin sliding scale (she stopped taking NPH
insulin about a month ago).
13. Nortriptyline 50 mg qhs.
14. Clonidine 1.5 mg qhs.
15. Percocet 1-2 tablets at about 2:00 p.m. once daily.
16. Combivent inhaler 2 puffs three times a day.
17. Flovent 220 micrograms inhaler 2 puffs three times a day.
18. Fosamax.
19. Nasonex.
20. MS Contin 30 mg twice a day.
21. Mexiletine 150 mg three times a day (for neuropathic
pain).
22. Albuterol and Atrovent nebulizers twice a day.
23. Mucomyst nebulizer twice a day.
SOCIAL HISTORY: She quit tobacco in [**2181**]. She lives alone.
She has a supportive family. She is a retired salon
receptionist. She is separated from her husband for more
than 30 years.
PHYSICAL EXAMINATION IN INTENSIVE CARE UNIT: She was an
elderly female wearing a non-rebreather mask, answering
questions appropriately, but occasionally closing her eyes
during the interaction. She was oriented times three.
Temperature 98.4; blood pressure 112/54; pulse 98;
respirations 22; 86% saturation on room air but 100% on the
non-rebreather. Head, eyes, ears, nose and throat: Mucous
membranes were dry, oropharynx clear, and no jugular venous
pressure elevation. Pulmonary examination: Diffuse
scattered rhonchi and wheezes throughout. Cardiovascular:
Regular rate and rhythm, normal S1 S2, no murmurs, rubs, or
gallops. Abdomen: Soft, non-tender, non-distended, positive
bowel sounds. Extremities: Trace edema.
LABS: Complete blood count: White blood cell count 21.1
with differential 88% neutrophils, 9% lymphocytes, 2%
monocytes; hematocrit 35.6; platelets 398; PT 14; INR 1.3;
PTT 30.1; sodium 138; potassium 5.7; chloride 96; bicarbonate
34; BUN 26; creatinine 1.4; glucose 101; initial CK 918 with
an MB 18 which was an MB index of 2.0; troponin 0.04; finger
stick blood glucose 145; ALT 26; AST 44; alkaline phosphatase
108; amylase 119; albumin 3.3; serum tox screen positive for
tricyclic antidepressants; Arterial blood gases pH 7.32, PC02
67, PO2 375; urinalysis unremarkable; urine culture sterile;
CT angiogram revealed no pulmonary embolism, multifocal
pneumonia, question of congestive heart failure versus
bronchiolitis obliterans with organizing pneumonia; CT of
head was without obvious mass, lesion, or hemorrhage; chest
x-ray showed an infiltrate in the right lower lobe as well as
decreased definition of the vasculature with the suggestion
of pulmonary edema; CT of cervical spine revealed no
fracture; electrocardiogram showed normal sinus rhythm at 97
with left axis deviation, left anterior fascicular block and
no evidence of ischemia.
IMPRESSION: This is a 61 year old female with multiple
pulmonary problems and chronic pain from spinal compression
fractures requiring narcotics who was found down hypoxic and
hypercapnic.
HOSPITAL COURSE BY PROBLEM:
1. Respiratory failure, both hypoxic and hypercapnic. This
was felt to be secondary to hypoventilation of unclear cause.
Possible etiologies might have been overdose of narcotics or
hypoglycemic episode. Syncope was entertained as a
possibility, but there was no evidence of precipitating cause
of this. Unfortunately, the event was unwitnessed.
Echocardiogram showed mild left atrium dilation, normal left
ventricular thickness and cavity size, mild global left
ventricular hypokinesis, normal right ventricular size and
wall motion. Aortic valve was normal. Mild 1+ mitral
regurgitation was seen. Pulmonary artery systolic pressure
could not be determined. The mild global left ventricular
hypokinesis was felt to be consistent with a diffuse process,
i.e. toxic metabolic. There were no structural cardiac
causes of syncope identified. The patient was neither
lightheaded nor pre-syncopal for the duration of her
admission.
2. Pneumonia. Given the patient's elevated white count and
infiltrate on chest x-ray, as well as her hypoxia, the
patient was treated for a presumed pneumonia. Sputum
cultures were not adequate to be interpretable. She was
given a total three week course of Levofloxacin.
3. Obstructive sleep apnea. The patient was continued on
[**Hospital1 **]-level positive airway pressure throughout this admission.
4. Back pain. Patient continued on MS Contin 30 mg by mouth
twice a day as well as Percocet 2 tablets by mouth around
2:00 p.m. once daily. She was given prescriptions for these
upon discharge. She continued on Neurontin, Mexiletine, and
Nortriptyline for her neuropathic pain.
A follow-up x-ray of the lumbar spine was performed to
evaluate the possibility of a new fracture. Although no new
fracture was seen, there was an abnormality at L2 and L3 that
was of uncertain significance. Osteomyelitis could not be
ruled out so it was recommended to obtain a spine magnetic
resonance scan. Unfortunately, this was not possible to
arrange in-house and will have to be performed as an
outpatient. The patient was given the telephone number to
call for an appointment to get the follow-up magnetic
resonance scan.
5. Thrush. The patient developed thrush during this
admission and this was likely due to poor clearing of
secretions during her episode of unresponsiveness. She was
given Nystatin with good resolution of the thrush and she was
given a follow-up course of this for four days.
6. Diabetes mellitus. The patient was continued on regular
insulin sliding scale.
7. Psychiatric. The patient continued on Effexor at her
regular dose.
8. Prophylaxis. She was continued on Protonix and we also
provided heparin subcutaneous for deep vein thrombosis
prophylaxis.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home with services including home
oxygen and [**Hospital1 **]-level positive airway pressure.
DISCHARGE MEDICATIONS:
1. Arimidex 1 mg by mouth twice a day.
2. Lipitor 30 mg by mouth once daily.
3. Celebrex.
4. Prednisone 10 mg by mouth once daily.
5. Effexor XR 37.5 mg by mouth twice a day.
6. Bactrim single strength once daily.
7. Protonix 40 mg once daily.
8. Vitamin D 400 international units once daily.
9. Neurontin 600 mg by mouth four times a day.
10. Colace 100 mg by mouth twice a day.
11. Lasix 40 mg by mouth once daily.
12. Regular insulin sliding scale (she stopped taking NPH
insulin about a month ago).
13. Nortriptyline 50 mg qhs.
14. Clonidine 1.5 mg qhs.
15. Percocet 1-2 tablets at about 2:00 p.m. once daily.
16. Combivent inhaler 2 puffs three times a day.
17. Flovent 220 micrograms inhaler 2 puffs three times a day.
18. Fosamax.
19. Nasonex.
20. MS Contin 30 mg twice a day.
21. Mexiletine 150 mg three times a day (for neuropathic
pain).
22. Albuterol and Atrovent nebulizers twice a day.
23. Mucomyst nebulizer twice a day.
24. Nystatin 5 cc swish and swallow 4 times a day for 4 more
days and as needed thereafter for thrush.
25. Levofloxacin 500 mg by mouth once daily for 14 additional
days.
26. Percocet 2 tablets by mouth once daily, #50, refills 1.
27. MS Contin 30 mg by mouth twice a day, #60, refills 0,
were provided.
FOLLOW-UP: Arranged with Dr. [**Last Name (STitle) 575**] for [**2190-1-22**]
in the Pulmonary Clinic. She will follow-up with Dr.
[**Last Name (STitle) 110297**], her primary care physician, [**Name10 (NameIs) **] [**2190-3-4**].
She had previously scheduled appointments with Dr. [**Last Name (STitle) 19916**] in
Pulmonary Sleep Clinic, as well as Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 11635**] to
follow-up with breast cancer issues. She is expected to keep
these appointments.
DISCHARGE DIAGNOSIS:
1. Change in mental status.
2. Respiratory failure.
3. Pulmonary fibrosis.
4. Pneumonia.
5. Diabetes mellitus.
6. Depression.
7. Osteoporosis.
8. Chronic back pain.
9. Rhabdomyolysis.
10. History of breast cancer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. [**MD Number(1) 13930**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2190-1-15**] 13:51
T: [**2190-1-19**] 19:01
JOB#: [**Job Number 110298**]
|
[
"428.0",
"486",
"276.7",
"518.84",
"780.57",
"428.32",
"515",
"112.0",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8341, 8465
|
8488, 10239
|
10260, 10749
|
2338, 3283
|
5584, 8319
|
165, 1406
|
1428, 2317
|
3300, 5556
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,876
| 176,632
|
42800
|
Discharge summary
|
report
|
Admission Date: [**2102-4-12**] Discharge Date: [**2102-4-18**]
Date of Birth: [**2044-9-13**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
IR embolization
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old male with past medical history of
Crohn's Disease diagnosed 19 years ago, s/p colectomy with
history of GI bleeding, hypertension and alcohol abuse who
presented to [**Hospital 1263**] Hospital on [**2102-4-9**] with bleeding into his
ileostomy bag, recently in ICU for stoma bleed, now being
transferred for stomal re-bleed. Pt was in the MICU from [**4-13**] to
[**4-14**] and transferred 1 unit PRBC's, and was hemodynamically
stable and transferred to the floors on evening [**4-14**]. This
afternoon pt had large rebleed from stomal site, BP's dropped to
70s systolic, pressure was placed, but required balloon
tamponade. Pt was given 2 units PRBC's and transferred to unit.
Pt is mentating well and otherwise feeling ok. Denies abdominal
pain, nausea, vomiting, chest pain, SOB. He does have some
lightheadedness.
Pt initially GI bleeding Saturday [**2102-4-1**]. He describes this
as painless ileostomy bleeding, requiring three bag changes and
then he syncopized. He was admitted to [**Hospital6 33**] that
evening and discharged Monday [**4-3**]. He re-presented to [**Hospital 7912**] Tuesday-Friday, [**2014-4-3**] for ongoing bleeding into
his ileostomy bag. While at [**Hospital3 **] he recieved a CTA,
tagged red blood cell scan, video capsule study and endoscopy;
all tests were negative for bleeding. He also had an ileoscopy
as well which revealed a small ulceration but otherwise negative
for signs of bleeding. The bleeding into his ileostomy bag
occurs 3-4 times/week; it is intermittent, painless and stops on
its own. He describes the blood as bright red mixed with dark
green stool. Aside from the syncopal episode initially and
intermittent fatigue, he has not had any other symptoms (chest
pain, shortness of breath). He denies any recent trauma, nausea,
vomiting, diarrhea, contipation. He has minimal left lower
quadrant tenderness which is intermittent and unrelated to food
intake. He denies any recent medication changes.
On Sunday, [**2102-4-9**], the patient presented to [**Hospital 1263**] Hospital
with persistent bleeding into his ileostomy. His vitals were
normal but he was admitted to ICU for closer monitoring. His
hematocrit remained stable around 32. In the ICU he did recieve
2 units of FFP, 4 units pRBC and 2 units of platelets. His
bleeding resolved on its own. With concerns for Crohn's flare,
he was placed on high dose pulse steroid therapy of
hydrocortisone 100mg Q8H and continued on home Pentasa. CT
enterography revealed cirrhosis with evidence of portal
hypertension and venous collaterals. Ileoscopy revealed active
stomal variceal bleed with limited other endoscopic findings. He
was transferred for TIPS consideration after these findings. His
hydrocortisone was discontinued. Ursodiol was held on transfer
and atenolol was switched to nadolol 20mg daily with
continuation of PPI prophylaxis. He had no bleeding observed
during the hospital stay.
Of note, the patient states his Crohn's Disease had been stable
since colectomy without any need for other medications until
[**2101-9-12**]. At that time, he developed GI bleeding that was
more intermixed with stool and felt due to Crohn's Flare. He was
treated with Pentasa with improvement in his symptoms. He was
recently started on Prednisone 30mg on [**Year (4 digits) 16337**] [**2102-4-7**] upon
discharge from [**Hospital6 33**]. The patient also has
significant alcohol consumption history but denies hepatic
encephalopathy, other GI bleeding (hematemesis), ascites. Also
denies ever becoming jaundiced.
He was admitted on [**3-/2019**] for consideration of TIPS. Abdominal
ultrasound without remarkable findings and TTE (largely normal).
Bled two large bloody movements, apparently achieved control
with a foley in the ostomy. Ordered two units none given but did
receive 1L NS. Urgent TIPS ordered. Upon going for TIPS, he was
found to have a pressure gradient of 5, and was not considered a
candidate for TIPS given that there was no significant benefit.
Following this, he was transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**], where he was
monitored for re-bleeding and maintained on nadalol,
pantoprazole, and ctx.
Past Medical History:
Crohn's Disease - diagnosed 19 years ago, s/p colectomy ~15
years ago
Hypertension
Chronic lower back pain
Alcohol abuse
Social History:
-Tatoos on bilateral arms 7-8 years ago
-Tobacco history: None
-ETOH: 3 drinks/day X years until 10-12 years ago; stopped
secondary to feeling generally "lousy." The patient resumed
alcohol consumption couple years ago, 2 drinks/day. Drink of
choice: Vodka with coke (unclear how much vodka), quit three
weeks ago with onset of GI bleeding
-Illicit drugs: None, denies any history of intranasal cocaine,
marijuana, IVDU
* Also denies herbals, over the counters, anabolic steroids,
excessive green tea
-Home: Lives with wife, three children (aged 22, 23 and 3 years
old)
-Work: Bartender, does not find work to be stressful
Family History:
Father died of liver cancer at 71 years old, had MI when
younger. Mother died of CVA, had diabetes s/p bilateral lower
extremity amputations. Brother with mild diabetes mellitus.
Children are alive and well.
Physical Exam:
Physical Exam on admission:
GENERAL: Well appearing male who appears stated age.
Comfortable, appropriate and in good humor
HEENT: Sclera non-icteric. PERRL, EOMI, dry mucus membranes,
normal oro/nasopharynx.
NECK: Supple with normal JVP
CARDIAC: RRR, normal S1/S2, no murmurs/gallops/rubs. No spider
angiomas noted.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. Dullness to percussion
over dependent areas but tympanic anteriorly. No HSM or
tenderness. Midline vertical subumbilical scar with ileostomy,
balloon in place, no active bleeding
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No
cyanosis/ecchymosis/edema.
Physical Exam on discharge:
99.5, 96-110/56-72, 69-86, 18, 98-99% RA
GENERAL: Comfortable, appropriate and in no distress
HEENT: Sclera non-icteric. PERRL, EOMI, dry mucus membranes,
normal oro/nasopharynx.
CARDIAC: RRR, normal S1/S2, no murmurs/gallops/rubs
LUNGS: CTAB no w/r/
ABDOMEN: Soft, non-tender to palpation. Dullness to percussion
over dependent areas but tympanic anteriorly. No HSM or
tenderness. Midline vertical subumbilical scar with ileostomy
bag in the right lower quadrant, with no blood in the ostomy;
tan/green colored soft stool and pink mucosa.
EXTREMITIES: wwp, 2+ distal pulses
Pertinent Results:
Labs on admission:
[**2102-4-12**] 12:45PM BLOOD WBC-3.9* RBC-4.35* Hgb-12.5* Hct-37.4*
MCV-86 MCH-28.6 MCHC-33.3 RDW-17.2* Plt Ct-68*
[**2102-4-12**] 12:45PM BLOOD PT-13.8* PTT-27.8 INR(PT)-1.3*
[**2102-4-12**] 12:45PM BLOOD Glucose-76 UreaN-13 Creat-0.9 Na-142
K-3.7 Cl-108 HCO3-27 AnGap-11
[**2102-4-12**] 12:45PM BLOOD ALT-242* AST-209* LD(LDH)-154 AlkPhos-79
TotBili-1.5
[**2102-4-12**] 12:45PM BLOOD Albumin-3.3* Calcium-8.7 Phos-4.1 Mg-1.9
[**2102-4-13**] 06:30AM BLOOD calTIBC-321 Ferritn-111 TRF-247
[**2102-4-16**] 01:01AM BLOOD Hapto-27*
[**2102-4-12**] 12:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2102-4-12**] 12:45PM BLOOD Smooth-NEGATIVE
[**2102-4-13**] 06:30AM BLOOD AFP-3.5
[**2102-4-12**] 12:45PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2102-4-12**] 12:45PM BLOOD IgG-1215 IgA-235
[**2102-4-12**] 12:45PM BLOOD HCV Ab-NEGATIVE
Microbiology:
Urine cx [**4-15**]: No growth
Blood cx [**4-14**] and [**4-15**] : NGTD
Imaging:
Echo [**4-13**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. 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. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Normal diastolic function. No pathologic valvular
abnormalities. Mildly elevated pulmonary systolic pressure.
RUQ US [**3-/2019**]:
1. Coarse liver echotexture and lobulated contour, suggestive of
underlying cirrhosis. No focal hepatic lesion is identified.
Hepatic vasculature is patent with hepatopetal flow.
2. Splenomegaly.
3. Small amount of ascites.
4. Cholelithiasis without evidence of acute cholecystitis.
Labs on Discharge:
[**2102-4-18**] 05:45AM BLOOD WBC-3.6* RBC-3.42* Hgb-10.1* Hct-28.6*
MCV-84 MCH-29.7 MCHC-35.5* RDW-15.5 Plt Ct-36*
[**2102-4-18**] 05:45AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-138 K-3.7
Cl-105 HCO3-26 AnGap-11
[**2102-4-18**] 05:45AM BLOOD ALT-41* AST-45* LD(LDH)-162 AlkPhos-63
TotBili-0.9
[**2102-4-18**] 05:45AM BLOOD Albumin-2.8* Calcium-7.6* Phos-2.1*
Mg-1.6
Brief Hospital Course:
57 year old male with past medical history of Crohn's Disease
diagnosed 19 years ago, s/p colectomy with history of GI
bleeding, hypertension and alcohol abuse who presented to [**Hospital 1263**]
Hospital on [**2102-4-9**] with persistent bleeding into his
ileostomy bag.
# Gastrointestinal bleeding: Thought possibly due to stomal
varices which were seen both on CT enteroscopy and ileoscopy. Of
note, these were not frankly bleeding on ileoscopy. No evidence
of gastric/esophageal bleeding given history and physical exam.
Pt had radiographic cirrhosis and associated coagulopathy,
thrombocytopenia, splenomegaly. The patient has not had
complications, however, of encephlopathy or ascites. TIPS was
attempted but his potosystemic gradient was only found to be 6
and therefore TIPS was not deemed to be an option to reduce the
risk of bleeding from his stomal varices. Pt was then
transferred to the ET service where he again had large stomal
bleeding. He became hypotensive and was transferred back to the
MICU. His blood pressure remained stable after 2 units of
PRBC's and balloon tamponade of the stomal bleed. Pt was then
taken to IR where two branches of the superior mesenteric vein
were successfully thrombosed. Pt had no further bleeding after
the procedure and serial Hct's remained stable. Pt was
transferred back to the liver service on [**4-16**] and his hct
remained stable and no further bleeding was experienced x 48
hours. Mr. [**Known lastname **] was discharged with an increased dose of nadolol
40mg daily.
.
# Cirrhosis: Patient is a bartender with recent active drinking.
Thus, cirrhosis most likely due to alcohol consumption although
etiology not confirmed. Cirrhosis also not biopsy proven. He
does not have classic 2:1 AST/ALT. Given history of auto-immune
disease with Crohn's, auto-immune hepatitis is on the
differential athough anti-smooth muscle antibody was negative.
Imaging and laboratory evidence of portal hypertension,
splenomegaly/ thrombocytopenia and impaired synthetic
dysfunction. LFT's mildly increased with normal bilirubin. No
signs of current decompensation including ascites, jaundice,
encephalopathy. He does have possible varices with bleeding
around ileal stoma. Normal AFP.
.
#Crohn's Disease: No current symptoms of clinical exacerbation
aside from bloody stool. The bleeding into the ileostomy,
however, is more brisk than what is usually seen with Crohn's.
Patient did not improve this time with prednisone, and has no
extra-intestinal manifestations (has never had fistulas, rashes,
ulcers etc). Pentasa was continued.
.
# Alcohol abuse: Patient states he has been sober/abstinent for
three weeks. Monitored for signs/symptoms of withdrawal and was
placed on a DMV, thiamine nad folate.
.
# Hypertension: Stable, recent GI bleed, anti-hypertensives were
held in the setting of stomal bleeding.
Medications on Admission:
Pentasa 1000mg QID
Atenolol 50mg daily
Ursodiol 300mg [**Hospital1 **]
Prednisone 30mg daily
Calcium carbonate daily
Fish oil daily
Multivitamin daily
Discharge Medications:
1. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO QID (4 times a day).
2. calcium carbonate 400 mg (1,000 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO once a day.
3. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. ciprofloxacin 250 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:
Stomal Varices
Cirrhosis
Crohn's disease
Hypertension
Chronic Low Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with life threatening bleeding from your stoma site. We
were able to control this bleeding with a non-invasive surgery
known as embolization. We also increased some of your
medications to help ensure that you do not bleed again.
It is of paramount importance that you no longer drink! If
you drink any more, it could kill you.
The following medication changes were made:
STOP Atenolol and ursodiol, these will be replaced by nadolol,
nadolol will prevent bleeding
STOP Prednisone
START nadolol to prevent bleeding
START thiamine and folic acid for nutrition
START Cipro for 7 more days to prevent infection
Followup Instructions:
Please keep your regularly scheduled appointment with your
primary care doctor [**First Name (Titles) 2593**] [**Last Name (Titles) 16337**].
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Specialty: GASTROENTEROLOGY
Location: [**Hospital3 **] MEDICAL CENTER-[**Location (un) **]
Address: [**State **], [**Location (un) **],[**Numeric Identifier 85712**]
Phone: [**Telephone/Fax (1) 17663**]
**We were unable to schedule an appointment with Dr [**Last Name (STitle) 7493**]. It
is recommended you see the Dr [**Last Name (STitle) 176**] 1 week of your discharge.
Please contact the office at the number above to schedule your
appointment**
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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13505, 13511
|
9668, 12529
|
280, 297
|
13631, 13631
|
6983, 6988
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4689, 5313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,226
| 189,226
|
43997
|
Discharge summary
|
report
|
Admission Date: [**2116-3-8**] Discharge Date: [**2116-3-12**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4127**] is a [**Age over 90 **] year old
man with a past medical history significant for atrial
flutter, rotator cuff tendonitis, taking NSAIDs, prostatitis,
and aortic stenosis, who presented to the [**Hospital1 346**] Emergency Department and complained
of dizziness, abdominal discomfort, nausea and multiple loose
dark stools. He had developed lightheadedness, but no loss
of consciousness. He was found on the toilet, pale, and
close to passing out and was transported to the Emergency
[**Hospital1 **].
Two to three weeks prior to this admission, he had developed
a stiff shoulder for which he had been taking
over-the-counter NSAIDs (Naproxen two tablets twice a day per
report). He did report occasional diarrhea during the two
weeks prior to admission and had taken Imodium leading to
constipation.
In the Emergency Department, he was hypotensive to 100/50
with a tachycardia to 110. He received fluids and one unit
of packed red blood cells. NG lavage showed coffee grounds.
He was started on Protonix intravenously and admitted to the
Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Atrial flutter.
3. Prostatitis, on Bactrim starting [**3-4**].
4. Rotator cuff injury.
5. Cholecystectomy [**44**] years prior.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. q. day.
2. Multivitamins one tablet q. day.
3. Naproxen.
4. Bactrim, one double strength q. day since [**3-4**].
5. Metamucil q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Occasional alcohol; no tobacco. Lives at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) **].
PHYSICAL EXAMINATION: On admission, vital signs with blood
pressure 90/60; respiratory rate 24; heart rate 110;
saturation at 93% on four liters nasal cannula. Alert,
oriented, pleasant, talking in full sentences, comfortable.
Anicteric. Pupils equally round and reactive to light.
Extraocular muscles are intact. Oral mucosa dry. No
jaundice. Heart rate irregularly irregular. II/III systolic
murmur with radiation to the carotids noticed. Lungs with
bilateral coarse rhonchi; no crackles, no wheezing. Abdomen
soft, nontender, nondistended. Positive bowel sounds.
Positive epigastric tenderness, no rebound, no guarding.
Rectal was OB positive. Extremities with trace edema. No
calf tenderness. Neurological examination with intact
strength five through five throughout; nonfocal otherwise.
LABORATORY DATA: On admission, white blood cell count of
12.5, hemoglobin 7.2, hematocrit 21.8, platelets 186. Sodium
136, potassium 5.2, chloride 104, bicarbonate 19, BUN 46,
creatinine 1.9, glucose 141, ALT 23, AST 26, CK 53, alkaline
phosphatase 29; amylase 393, total bilirubin 0.3.
Urinalysis, yellow, clear; otherwise negative.
IMAGING: On admission, chest x-ray from [**2116-1-9**], showing
hyperinflated lungs with the question of congestive heart
failure, prominent pulmonary arteries, heart mildly enlarged
with left ventricular prominence consistent with aortic
stenosis. No pleural effusion, no pneumothorax, no focal
consolidation, no pulmonary edema.
EKG on admission: Atrial flutter with a heart rate of
approximately 106, left axis deviation. No Q waves. Right
bundle branch block, early R wave progression; no ST changes.
Chest x-ray from [**2116-3-8**], right prominent hilum, upper
zone redistribution, no effusion.
BRIEF HOSPITAL COURSE: Mr. [**Known lastname 4127**] was initially admitted
to the Medical Intensive Care Unit where he was transfused
with two additional units of packed red blood cells. The
following morning, he received an esophagogastroduodenoscopy
showing ulcers in the pre-pyloric region, the anterior and
posterior bulb, consistent with NSAID-induced ulcers. No
active bleed was seen. While in the Unit, for the subsequent
24 hours he continued to have guaiac positive stools, but no
overt blood. H. pylori and gastrin levels were sent and H.
pylori was positive and he was started on triple therapy of
Clarithromycin, Amoxicillin and Protonix. He will be
continued on this as an outpatient for full therapy.
He was called out of the Medical Intensive Care Unit the
subsequent day to the medical floor with a stable hematocrit
of 30.5. Throughout his stay, his hematocrit remained stable
at this level and he had no repeat episodes of bright red
blood.
The night following his transfer to the floor, he had an
episode of shortness of breath not associated with any chest
pain. He also complained of anxiety at this point. A
routine EKG was checked and while unchanged significantly
from prior EKGs in the Medical Intensive Care Unit, it was
felt that there was an element of ST depressions present in
the precordial and lateral leads. This had developed while
in the Intensive Care Unit and was presumed secondary to rate
related low-level ischemia. Given these findings, cardiac
enzymes were cycled. CKs were negative times three, however,
troponin I returned at 22. It was felt that Mr. [**Known lastname 4127**]
may have suffered an infarction in the setting of profound
anemia, tachycardia and outflow obstruction from his aortic
stenosis. However, given his age and his poor candidacy for
either cardiac catheterization based revascularization or
surgery, the decision was made not to pursue further work-up
of this.
Two days later, the day of discharge, a repeat troponin was
checked and had declined to 8.0. An echocardiogram was
obtained to assess both the degree of aortic stenosis and
assess for any potential wall motion abnormality. This was
significant for mild symmetric left ventricular hypertrophy
with a normal cavity size. Left ventricular systolic
function was assessed as normal. There was mild dilatation
of the ascending aorta. The aortic valve leaflets were
moderately thickened with probable moderate to severe aortic
stenosis. Moderate aortic regurgitation was seen. The
mitral valve leaflets were mildly thickened with moderate to
severe regurgitation. There was mild pulmonary artery
systolic hypertension and no pericardial effusion. Compared
to a prior report of [**2106-1-12**], the aortic stenosis was felt
to be more severe.
Given the probable rate related changes, he was started on a
low dose of beta blocker, Lopressor 12.5 three times a day.
This option had been discussed and initially held while in
the Intensive Care Unit secondary to the fact that he was
felt to be dependent upon his rate for perfusion secondary to
his profound anemia in the setting of blood loss.
Throughout his stay on the medical floor, he had no further
shortness of breath and no further GI bleed or bright red
blood per rectum. He will be followed up by the
Gastroenterology Service and will need an
esophagogastroduodenoscopy in two months at the [**Hospital **] Clinic,
phone number [**Telephone/Fax (1) 1954**].
Again, he will be continued on triple therapy for H. pylori.
He should avoid NSAIDs in the future and if need be take
Tylenol for pain.
Again, given his history of recent prostatitis, a routine
urinalysis was again checked on the floor. It was negative
for indications of infection and he was not continued on his
Bactrim.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to non-steroidal
anti-inflammatories.
2. Aortic stenosis.
3. Atrial flutter.
4. Prostatitis.
DISCHARGE DISPOSITION: To [**Hospital 3058**] rehabilitation.
DISCHARGE MEDICATIONS:
1. Multivitamin, one tablet q. day.
2. Protonix 40 mg p.o. q. day.
3. Atenolol 50 mg p.o. q. day.
4. Amoxicillin 1 gram twice a day for ten days.
5. Clarithromycin 500 mg p.o. twice a day times ten days.
6. Ambien 5 mg p.o. q. h.s. p.r.n. while at [**Hospital 3058**]
rehabilitation.
7. Tylenol 650 mg p.o. q. six hours p.r.n.
DISCHARGE INSTRUCTIONS:
1. The patient should follow-up with his primary care
physician after discharge from [**Hospital 3058**] rehabilitation.
2. Should follow-up with the [**Hospital **] Clinic for a
repeat esophagogastroduodenoscopy and follow-up on his
gastrin level.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2116-3-12**] 11:23
T: [**2116-3-12**] 13:10
JOB#: [**Job Number **]
|
[
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icd9cm
|
[
[
[]
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[
"96.33",
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icd9pcs
|
[
[
[]
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7507, 7547
|
3552, 7321
|
7342, 7482
|
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|
1422, 1623
|
7929, 8439
|
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|
112, 1217
|
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|
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|
1640, 1774
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,290
| 159,495
|
32029
|
Discharge summary
|
report
|
Admission Date: [**2201-10-14**] Discharge Date: [**2201-10-27**]
Date of Birth: [**2143-8-4**] Sex: M
Service: MEDICINE
Allergies:
Aldactone
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transfer from OSH for ongoing management of respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous line placement
foley catheter
arterial line
tracheostomy
bronchoscopy
percutaneous gastric tube placement
History of Present Illness:
MR. [**Known lastname **] is a 58-year-old man with history of congenital heart
disease repairs in [**2160**], [**2185**] and [**2199**], status post replacements
of the pulmonic and mitral valves with mosaic bioprostheses,
closure of VSD and PFO, and surgical repair of the tricuspid
valve, with CHF, DM, chronic afib on coumadin and multiple GIB,
on home O2 transferred from OSH for continued management of
heart failure.
.
Outside hospital course: Patient presented to [**Hospital3 **]hospital on [**10-6**] c/o SOB, dry cough, and chest pressure. He was
found in resp distress, hypoxic, required Bipap initially and
was found to have pH 7.23 PCO2 130 and PO2 134 and was
subsequently intubated on hospital day 2. He was thought to be
in CHF. BNP was 1680. Per report, he was started on lasix gtt
and diuresed 5-7L in first 3 days of admission. He was thought
to be overdiuresed with contraction alkalosis and bicarb peak of
62 and lasix was held. Dopamine and levophed for pressure
support. He was also noted to have clots coming from ET tube
thought to result in transient atectasis of his left upper lung.
Anticoagulation was held. He had a drop in platelets as low as
94 but recovered to 142 prior to baseline. Hct remained stable
~33. LFTs were WNL and cardiac enzymes were flat. INR was 3.8.
.
Echo was perfromed on OSH admission showed markedly elevated
right sided pressures due to increased gradient throught the
pulmonic and mitral valve and the presence of severe TR and
possible VSD. PA pressures were calculated to close to 80mmHg.
Bioprothetic MV looked well seated and no MR. Could not
visualized PV but thought to exhibit increased transvalvular
gradient to a moderately severe degree.
.
Vital signs prior to transfer: T 100.3 103 116/38 91% vent on AC
TV 300 FiOs 40% RR 14 Peep 5.
.
Review of systems could not be obtained [**1-5**] patient intubated
and sedated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-pulmonary valvotomy in [**2160**] and ventricular septal defect
in [**2185**]
-status post replacements of the pulmonic [**2160**]([**Company 1543**] porcine
valve)and mitral valves(porcine valve)
-[**12-11**] Redo sternotomy and mitral valve replacement with a size
33 Mosaic [**Company 1543**] tissue valve, tricuspid valve repair with a
size 36 [**Doctor Last Name **] annuloplasty ring, pulmonary valve replacement
with size 29 [**Company 1543**] Mosaic tissue valve, closure of muscular
ventricular septal defect and patent foramen ovale by [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D.
-afib on coumadin
-CHF
-RBBB
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-DM
-multiple GIB [**2-8**]: EGD and colonoscopy found gastritis, failed
capsule study
-s/p trach, open J-tube in [**1-11**]
-anxiety
-depression
-RLE varicosities
-s/p R hernia repair
-s/p appy
-on home O2
Social History:
disabled
-Tobacco history: never used
-ETOH: occasional ETOH
-Illicit drugs: unknown
Family History:
father had MI at age 55
Physical Exam:
VS: T=97.8 BP=164/64 HR=88 RR=20 O2 sat=100% vent
GENERAL: WDWN [**Male First Name (un) 4746**] 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.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2 murmurs noted. One early systolic
crescendo decrescendo murmur [**3-9**] heard best at LUSB, and one
holosystolic [**2-6**] heard best at LLSB.
LUNGS: Pectus excavatum. Tachypneic, rhonchorous
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.
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:
[**2201-10-20**] 03:45AM BLOOD WBC-5.4 RBC-2.68* Hgb-7.8* Hct-24.9*
MCV-93 MCH-28.9 MCHC-31.1 RDW-14.3 Plt Ct-266
[**2201-10-20**] 03:45AM BLOOD PT-13.4 PTT-31.8 INR(PT)-1.1
[**2201-10-20**] 03:45AM BLOOD Glucose-99 UreaN-33* Creat-1.2 Na-141
K-4.3 Cl-108 HCO3-29 AnGap-8
[**2201-10-18**] 02:24AM BLOOD Ret Aut-0.6*
[**2201-10-14**] 12:36AM BLOOD ALT-12 AST-23 LD(LDH)-199 CK(CPK)-102
AlkPhos-107 Amylase-90 TotBili-0.6
[**2201-10-14**] 12:36AM BLOOD CK-MB-3 cTropnT-0.05*
[**2201-10-20**] 03:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2
[**2201-10-14**] 12:36AM BLOOD calTIBC-229* Hapto-140 Ferritn-355
TRF-176*
[**2201-10-14**] 12:36AM BLOOD D-Dimer-980*
[**2201-10-18**] 02:24AM BLOOD VitB12-912* Folate-GREATER TH Hapto-161
[**2201-10-14**] 05:51AM BLOOD %HbA1c-5.7
[**2201-10-18**] 11:45AM BLOOD Cortsol-29.2*
[**2201-10-14**] 05:51AM BLOOD Triglyc-77
[**2201-10-20**] 03:45AM BLOOD Vanco-25.4*
TTE [**10-14**]:
The left and right atria are markedly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is a 1cm mid-muscular ventricular septal
defect (VSD) with bidirectional flow. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. The aortic root is moderately dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The mitral prosthesis
appears well seated, with normal leaflet motion and
transvalvular gradients. No mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] A tricuspid valve annuloplasty
ring is present with normal gradient. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. A well-seated pulmonic valve
prosthesis is present. The gradient is high normal. No pulmonary
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Muscular ventricular septal defect with
bidirectional flow. Right ventricular cavity enlargement with
free wall hypokinesis. Severe pulmonary artery systolic
hypertension. Moderate to severe tricuspid regurgitation.
Slightly increased pulmonic bioprosthetic gradient. Normal
functioning mitral bioprosthesis.
CLINICAL IMPLICATIONS:
Based on [**2198**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**2201-10-15**]
Bronch:
Edematous & erythamatous macerated posterior tracheal membrane
purulent secretions from BLL. c/w infection
Brief Hospital Course:
58-year-old man with history of congenital heart disease and
repairs in [**2160**], [**2185**] and [**2199**], status post replacements of the
pulmonic and mitral valves with mosaic bioprostheses, closure of
VSD and PFO, and surgical repair of the tricuspid valve, with
CHF, DM, chronic afib on coumadin and multiple GIB, on home O2
transferred from OSH for continued management of heart failure,
respiratory failure.
.
Hypercarbic respiratory failure: Patient uses home O2 for
presumed pulmonary hypertension, it is believed that this low
reserve set him up for acute hypercarbic respiratory failure [**1-5**]
MRSA PNA (via + sputum cultures.) His hypoxia improved with
endotracheal ventilation. Bronchoscopy revealed purulent
discharge consistent with pneumonia and suggested blood was [**1-5**]
trauma from intubation and not true hemoptysis.
He was seen by pulmonary who recommended addl coverage for
gram-neg sources of PNA with cefepime (x 8 days) as well as a 3
week course of vancomycin. He did not tolearte extubation trial
and required repeat tracheostomy as he could not sustain
adequate oxygenation without it. Patient is hypercarbic at
baseline with PCO2 in 60s. He has had trouble being off
pressure support below [**7-8**] with tachypneic and shallow brething.
.
Hypotension: Patient was hypotensive on admission this was [**1-5**]
combined hypovolemic +/- distributive shock. He was
overdiuresed at the OSH who missdiagnosed his PNA as a CHF
exacerbation, and his pressures stabilized without pressors
after several fluid boluses. (5L total)
.
MRSA PNA ?????? Found to have MRSA in sputum cx at OSH, sputum cx and
BAL here grew out MRSA, pulm recomended 3 weeks of vanc and
cefepime for 8 days. The last day of Vanc would be [**11-4**].
PUMP: Mr [**Known lastname **] has a history of pulmonary hypertension and
borderline RV failure presented with hypotension and OSH echo
showed elevated PA consistent with worsened RV failure. Given
history of congenital heart disease etiology of RV failure most
likely [**1-5**] pulmonary hypertension. His pulmonary hypertension is
likely [**1-5**] to worsening VSD or mitral regurgitation.
Alternatively, his worsening RV function can also be due to
worsen tricuspid regurgitation. No ischemic EKG changes to
positive troponins to indicate RV infarct. Bedside echo obtained
upon arrival to [**Hospital1 18**], difficult to interpret, but estimated EF
30-40%. He was thought to be close to euvolemic on discharge.
Because of his severe TR, his baseline euvolemia likely includes
some mild dependent edema.
.
# RHYTHM: Mr [**Known lastname **] was anticoagulated on admissoin with a history
of Chronic Afib present on admission,however he was having
hemoptysis and rate controlled at the time of admission. Once
his Hct stabilized,we restartaed anticoagulation as with goal
INR 2.0 - 3.0 for atrial fibrillation.
.
# thrush ?????? Mr [**Known lastname **] was noted to have thrush on admission, this
did not resolve with nystatin swish and swallow and he was
advanced to fluconazole.
.
# HL: His lipitor was continued
.
# Depression/Anxiety: His abilify was continued
Medications on Admission:
HOME MEDICATIONS:
-omeprazole 40mg [**Hospital1 **]
-Lipitor 20-mg/day
-Coumadin 5mg once a day
-Abilify 5mg/day
-Lasix to 40mg [**Hospital1 **]
-Toprol 25-mg in the morning
-iron and vitamins
.
MEDS UPON TRANSFER:
-lopressor 25mg PO qday
-protonix 40mg IV q12 hours
-Bactroban to nares [**Hospital1 **] x5days
-lasix 40mg IV q12 x3 doses
-combivent inhaler 2 puffs q4hrs
-coumadin 3mg PO x1 dose
-RISS
-asa 325mg PO daily
-abilify 5mg PO qday
-lipitor 20mg PO qday
-ceftriaxone 1g IV x1 dose
-clindamycin 600mg IV q8h (3 doses)
-vanco 1g qday x2 doses
-propofol gtt
-dopamine gtt
-TPN
-levophed gtt
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypercarbic Respiratory Failure
Methacillin-resistant staph aureus pneumonia
ventricular septal defect
Discharge Condition:
hemodynamically stable, requiring mechanical ventilation,
following commands.
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"31.1",
"96.72",
"33.22",
"33.24",
"38.91",
"96.04",
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"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11211, 11282
|
7427, 10561
|
335, 482
|
11429, 11510
|
4496, 7015
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3554, 3579
|
11303, 11408
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10587, 10587
|
961, 2398
|
3594, 4477
|
2502, 3197
|
10605, 11188
|
7038, 7404
|
232, 297
|
510, 944
|
3228, 3436
|
2420, 2482
|
3452, 3538
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,416
| 121,076
|
10718
|
Discharge summary
|
report
|
Admission Date: [**2165-7-24**] Discharge Date: [**2165-7-26**]
Date of Birth: [**2103-8-21**] Sex: M
Service: MICU / MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 63 -year-old
man with known chronic obstructive pulmonary disease and a
history of colon cancer, who presents with hemoptysis. He
was at home when he first had an episode of hemoptysis,
coughed up about a mouthful of blood. The next day he
patient was admitted and placed in the Medical Intensive Care
Unit for further observation and work up. Hemoptysis
spontaneously resolved.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Chronic bronchitis.
Polyp with status post partial colectomy. Per report, he was
medically cleared of the colon cancer. It was noninvasive,
localized to the segment of colon taken. The procedure was
done at the [**Hospital6 1708**].
ADMITTING MEDICATIONS: Included only chronic obstructive
pulmonary disease inhalers, Albuterol and steroid inhaler.
ALLERGIES: No known allergies.
SOCIAL HISTORY: Notable for 50+ pack year smoking history,
quit in [**2164-4-16**]. He lives at home alone, has children.
FAMILY HISTORY: No other family history of cancers.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION: On presentation, all vital signs were
stable. Cardiovascular: regular rate, no murmurs. Pulmonary
revealed very distant breath sounds, prolonged expiratory
phase and faint diffuse wheezing. The head, eyes, ears, nose
and throat examination revealed frank blood in the mouth. It
was estimated that he had coughed up approximately 150 cc of
blood.
HOSPITAL COURSE: Work up in the Intensive Care Unit included
bronchoscopy which revealed evidence of fresh blood clot in the
left upper lobe with no frank lesions. Also CT scan which
revealed no frank mass and no pathologically abnormal
adenopathy. He continued to have a stable course through the
two days in the Intensive Care Unit. No evidence for
oxygen desaturation. Hematocrit remained stable between 39 and
40 with a low white blood cell count in the CBC.
After remaining hemodynamically and clinically stable for 48
hours, he was then transferred to the floor for further
observation and management and discharge. On the floor, he
remained clinically stable. Hematocrit remained stable
between 39 and 40. He had no recurrence of the hemoptysis
and was discharged home on hospital day three.
DISCHARGE MEDICATIONS: Included Robitussin, fluticasone
inhaler two puffs po bid, Levaquin 500 mg po q day for an
extended five day course, and a prednisone taper beginning on
[**7-26**] at 30 mg, 11th and 12th at 20 mg q day, 13th and
14th at 10 mg q day, and then off.
FOLLOW-UP: He was instructed to seek follow-up with his
primary care physician on the outside, will need close
follow-up for the possibility of this being a lung cancer
that is currently non-detectable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 35084**]
MEDQUIST36
D: [**2165-7-26**] 12:57
T: [**2165-8-2**] 09:33
JOB#: [**Job Number 19221**]
|
[
"494.1",
"V10.05",
"786.3",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
1171, 1208
|
2455, 3170
|
1640, 2431
|
1272, 1622
|
1228, 1249
|
172, 572
|
594, 1029
|
1046, 1154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,516
| 188,321
|
30264+57688
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-3-24**] Discharge Date: [**2178-4-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
tachycardia, delerium, lightheadedness, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o F with PMH significant for COPD, PVD, and dementia
admitted to the [**Hospital Unit Name 153**] on [**3-24**] with tachycardia. Of note, a
majority of this note is taken from my gerontology consult note
from [**2178-3-27**]. Patient was sent to the ED from her [**Hospital1 1501**] for
lightheadedness, dizziness, and a HR in the 140s. In the ED, VS
were 98.5 154/49 124 28 96% 2L NC. Her Hct was decreased at 20.6
but stools were guiac negative. The patient was given
ceftriaxone and vanco given concern for infection. She also
received a total of 15 mg of IV diltiazem with minimal effect on
her HR. She was trasfused 2 units of PRBC and received 2376 cc
of NS. She was then started on a diltiazem drip and admitted to
the [**Hospital Unit Name 153**].
.
In the [**Hospital Unit Name 153**] admission note, the patient is noted to be
"pleasantly demented" but more complete mental status testing is
not available. Nursing note notes her to be A&O x1. However, the
sitter log notes that she was very restless and "picking" so it
is likely she was delirious at the time of admission. Nursing
notes that she was aggitated and trying to get out of bed so was
given 1 mg of IV haldol. During her first day in the unit, the
patient alternated between sinus and atrial fib with RVR. ECG
did show evidence of demand in the setting of tachycardia. The
patient was transfused another unit of PRBC. She was treated for
a COPD exacerbation with nebs, IV steroids, and azithromycin. As
it was felt that upper airway issues were also playing a large
role in her wheezing and the steroids were contributing to her
delirium, they have been quickly tapered. She was also started
on treatment for an enterococcal UTI with vanco. There was
concern for a possible PE and the patient had negative LE US and
CTA yesterday. CTA was significant for a spiculated mass is
noted within the right upper lobe which measures 11 x 13 mm.
Another nodule is seen within the left apex that measures 7 mm.
However the assessment of these lesions are some what limited
due to patient movement.
.
On transfer, the patient denied any pain. Unable to focus on
questions. Very inattentive but talking at length about her
family, wanting to leave, and needing to find her grandson an
apartment.
Past Medical History:
1) COPD
2) Previous tobacco abuse
3) OA (on Celebrex)
4) Claudication (on Pletal)
5) Dementia
6) Afib in the distant past (on Dig for years, now in sinus x 15
years)
Social History:
Patient is widowed. She moved to Boson from [**Location (un) **] in [**1-/2178**]
to be near her grandson [**Name (NI) **] [**Name (NI) **]. He is a plastic surgeon
here at [**Hospital1 18**]. She has been living at the [**Hospital1 **]
Alzheimer's Unit since moving to [**Location (un) 86**] but there were plans for
her to move to the [**Hospital2 34116**] [**Hospital3 **] in [**Location (un) 13040**] on
[**2178-3-28**]. The patient has smoked [**11-18**] PPD for 75 years but
appears to have been on a nicotine patch since moving to [**Location (un) 86**].
No ETOH. Ambulates with a front wheeled rolling walker.
Family History:
N/C
Physical Exam:
96.8 158/81 93 ---> 118 20 97% RA
Gen- Frail, cachectic appearing elderly lady laying in bed.
Talking nonstop but responds to reassurance. Appears very
restless.
HEENT- NC AT. Anicteric sclera. Mildly dry mucous membranes with
some yellow crusting on the lips. No visable lesions in the
oropharynx.
Cardiac- Tachycardic. Regular rhythm. No m,r,g appreciated.
Pulm- Scattered wheezes. Much less tight and better air movement
than yesterday.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e. Warm.
Neuro- Patient with eyes open and very talkative which is very
different than yesterday. Poor attention. Oriented only to self.
Does know that her grandson's name is [**Name (NI) **]. Not oriented to
place, city, or date.
Pertinent Results:
[**2178-3-24**] 03:05AM PLT SMR-HIGH PLT COUNT-694*#
[**2178-3-24**] 03:05AM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-3+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
[**2178-3-24**] 03:05AM NEUTS-92.4* BANDS-0 LYMPHS-4.2* MONOS-2.9
EOS-0.1 BASOS-0.3
[**2178-3-24**] 03:05AM WBC-15.3* RBC-2.87* HGB-6.0*# HCT-20.6*#
MCV-72*# MCH-21.1*# MCHC-29.3*# RDW-19.4*
[**2178-3-24**] 03:05AM calTIBC-528* HAPTOGLOB-200 FERRITIN-4.7*
TRF-406*
[**2178-3-24**] 03:05AM IRON-9*
[**2178-3-24**] 03:05AM cTropnT-0.04*
[**2178-3-24**] 03:05AM LD(LDH)-157 TOT BILI-0.4
[**2178-3-24**] 03:05AM estGFR-Using this
[**2178-3-24**] 03:05AM GLUCOSE-135* UREA N-22* CREAT-1.5* SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2178-3-24**] 03:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
TTE: Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is severe
mitral annular calcification with associated mitral inflow
gradient. There is moderate thickening of the mitral valve
chordae. Mild to moderate ([**11-18**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
.
CTA chest: IMPRESSION:
1. No pulmonary embolism.
2. Increased interstitial markings bilaterally. This appearance
suggest heart failure. Moderate bilateral pleural effusions are
also present, which are associated with compressive atelectasis.
3. Spiculated mass is noted within the right upper lobe which
measures 11 x 13 mm. Another nodule is seen within the left apex
that measures 7 mm.
However the assessment of these lesions are some what limited
due to patient movement. Follow up of these masses in 3 month is
recommended.
4. One nodule is seen within the left lobe of the thyroid that
measures 9 x 10 mm. Ultrasound is recommended for further
characterization if clinically indicated.
.
Ultrasound LE bilaterally: IMPRESSION: No evidence of DVT
involving the right or left lower extremities.
.
CXR [**3-30**]: FINDINGS: Compared with [**2178-3-28**], no overt CHF or
edema. The patchy retrocardiac opacity has partially cleared.
Lungs are otherwise clear.
Brief Hospital Course:
Patient initially admitted to the MICU with afib with RVR to the
150s requiring a dilt drip. Received 2U PRBCs (believed
trending down of AOCD; no evidence of acute bleed) that she
responded to. Also treated for COPD flare. EKG showed demand
ischemia when in RVR that resolved with less strain. Also
appeared to have flashed (likely diastolic dysfunction) and
required diuresis. Initially question of pneumonia as well so
given vanc/ceftriaxone; changed to azithro alone and treated 5
days as COPD flare. In ICU respiratory status remained tenuous
so CTA done and heparin started empirically; no PE seen so
heparin stopped. Enterococcal UTI identified so started on
ampicillin as well (sensitive). Geriatrics consulted for
patient's delirium as well.
.
1) Afib with RVR: Improved with improved volume status. No
evidence of acute ischemia. Returned to sinus rhythm.
Maintained on diltiazem. Will change to long acting diltiazem
on discharge. Discussed with grandson who does not want to have
patient anticoagulated at this time. Can readdress in
outpatient setting.
.
2) Delirium: Believed to multifactorial incl. infections, ICU
stay, anemia, COPD exacerbation, diastolic CHF, high dose
steroids. Appreciate [**Female First Name (un) **] consult input. Mental status
continues to improve daily with resolution of above. Discharge
on zyprexa qhs. Avoid haldol/benzos if possible as patient had
occasional paradoxical reaction.
.
3) UTI: Given 7 days ampicillin (enterococcus sensitive) with
completion on [**4-1**].
.
4) COPD exacerbation: Continue steroid taper--3 more days 10mg
daily and then stop. Cont nebs. Off oxygen. S/p 5 days
azithro.
.
5) Diastolic CHF: Appears euvolemic now. No lasix requirement.
TTE wnl.
.
6) Fe def anemia: Responded to 2U PRBCs. Started on daily iron.
Family declines colonoscopy at this time to further work up.
Can readdress in outpatient setting.
.
7) Leukocytosis: Patient with leukocytosis while here ([**10-30**]).
No evidence ongoing infection, afebrile. No diarrhea. Can
repeat UA as outpatient if persists. [**Month (only) 116**] be secondary to
steroids; repeat WBC after finish taper.
Medications on Admission:
Tylenol PRN
Combivent
Colace 100 mg [**Hospital1 **] and 200 mg QHS
Fluticasone 110 mcg 2 puff [**Hospital1 **]
KCl 20 mEq daily
Nicotine patch 14 mg daily
MOM 30 cc PRN
Dulcolax PRN
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Diltia XT 240 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation q6hours () as needed for shortness of breath or
wheezing.
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
1) Afib with RVR
2) Delirium
3) Enterococcal UTI
4) COPD exacerbation
5) Diastolic CHF
6) Fe def anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with delirium, atrial fibrillation with fast
rate, COPD exacerbation, diastolic heart failure, Fe deficiency
anemia. All have been treated and improved. You are being
discharged to a [**Hospital1 1501**] for further rehab. Please call your doctor
or return to the hospital if you develop worsening fever,
diarrhea, shortness of breath, chest pain.
Followup Instructions:
Please arrange a follow up appointment with your primary care
doctor, Dr. [**Last Name (STitle) **] [**Name (STitle) **] (phone [**Telephone/Fax (1) 72051**]), in the next [**12-20**]
weeks.
Name: [**Known lastname **],[**Known firstname 1911**] Unit No: [**Numeric Identifier 12056**]
Admission Date: [**2178-3-24**] Discharge Date: [**2178-4-1**]
Date of Birth: [**2086-12-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 803**]
Addendum:
On CT scan of chest it was noted a spiculated mass in right
upper lobe and nodule left apex; recommend repeat imaging in 3
months to watch stability of these lesions.
.
A nodule was also noted in the left lobe of the thyroid.
Ultrasound is recommended as an outpatient to further evaluate.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12057**] - [**Location (un) **]
[**First Name11 (Name Pattern1) 153**] [**Last Name (NamePattern1) 811**] MD [**MD Number(2) 812**]
Completed by:[**2178-4-1**]
|
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"428.0",
"518.0",
"715.90",
"518.89",
"241.0",
"293.0",
"294.8",
"V15.82",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11837, 12065
|
6911, 9067
|
311, 317
|
10515, 10524
|
4244, 6888
|
10941, 11814
|
3466, 3471
|
9301, 10271
|
10388, 10494
|
9093, 9278
|
10548, 10918
|
3486, 4225
|
222, 273
|
345, 2626
|
2648, 2815
|
2831, 3450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,154
| 144,004
|
2202+2203
|
Discharge summary
|
report+report
|
Admission Date: [**2154-11-20**] Discharge Date: [**2154-11-29**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 85-year-old male
with multiple medical problems, who presents with a one day
history of pleuritic back pain and shortness of breath. It
began the night prior to admission when he took a deep breath
and noticed a pain between his scapulae. It became
progressively worse, to the point where he was unable to take
deep breaths. He had no recent cough, fever, chills, chest
pain, headaches, nausea, vomiting, lightheadedness, weakness
or dysuria. His ambulation was limited by claudication, not
dyspnea on exertion. He denies baseline shortness of breath,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
or lower extremity edema. He had a recent right upper lobe
pneumonia in [**Month (only) 205**], status post a seven day course of
levofloxacin with an additional admission in [**Month (only) 216**], as his
pneumonia did not clear. At that point, he had a
parapneumonic effusion that was tapped and showed to be
exudative. He received a second course of antibiotics,
namely Levaquin and Flagyl, at that time and underwent
bronchoscopy to look for an obstructive lesion. The
bronchoscopy revealed an apical right upper lobe
endobronchial lesion, but the biopsy and bronchoalveolar
lavage were negative for malignant cells. He was followed up
by his pulmonologist as an outpatient in [**Month (only) 359**], and was
doing well. He was asymptomatic at that time. The plan was
to repeat a CT scan in [**Month (only) 1096**] to look for resolution of his
air space disease.
He presented to the Emergency Room, where he was febrile, and
a chest x-ray showed opacification of his right lung,
questionable infiltrate vs. effusion. He was started on
levofloxacin and Flagyl and admitted.
PAST MEDICAL HISTORY:
1. Right upper lobe pneumonia described above, status post
one seven day course of levofloxacin and one 14 day course of
levofloxacin and Flagyl
2. History of congestive heart failure with diastolic
dysfunction. An echocardiogram in [**2152-12-30**] showed an
ejection fraction of 55%.
3. Hypertension complicated by chronic renal insufficiency
with a baseline creatinine of 1.8 to 2.4, complicated by
anemia on Epogen
4. Iron-deficiency anemia status post an
esophagogastroduodenoscopy in [**2154-7-31**] that showed a
gastric arteriovenous malformation status post BiPAP cautery.
A colonoscopy in [**2154-7-31**] was negative. Colonoscopy in
[**2153-6-30**] revealed an adenomatous polyp that was removed.
The colonoscopy in [**2153-6-30**] was done in the setting of a
gastrointestinal bleed.
5. Gastrointestinal bleed x 2, once in [**2153-6-30**], once in
[**2154-7-31**], the first time from an adenomatous colonic
polyp, the second time from a gastric arteriovenous
malformation.
6. Abdominal aortic aneurysm measuring 6.8 cm currently, not
been repaired
7. Left eye blindness secondary to macular degeneration
8. Carotid disease with a 90% right internal carotid artery
stenosis, status post a left carotid endarterectomy
9. Osteoarthritis
10. Peripheral neuropathy, likely secondary to alcohol use
11. History of peptic ulcer disease
12. Nephrolithiasis
13. Cholelithiasis
MEDICATIONS:
1. Lopressor 50 mg twice a day
2. Lasix 20 mg once daily
3. Norvasc 10 mg once daily
4. Aspirin 325 mg once daily
5. Niferex 50 mg twice a day
6. Epogen 3000 units every Wednesday
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives with his wife and daughter. [**Name (NI) **]
smoked three cigars a day for many years, but quit three
months ago. He drinks two beers and two glasses of brandy
every night.
FAMILY HISTORY: Noncontributory.
He has received his flu shot this year.
REVIEW OF SYSTEMS: Positive for claudication for the past
five to six years, that is unchanged.
PHYSICAL EXAMINATION: This is an elderly man, in no acute
distress, who is febrile with a temperature of 101.4,
tachycardic with a heart rate of 106. His blood pressure is
164/71, and his respiratory rate is 28. His oxygen
saturation is 92% on room air, and improves to 94% on 2
liters nasal cannula. Head, eyes, ears, nose and throat
examination is unremarkable. He has no jugular venous
distention or lymphadenopathy. His lungs have decreased
breath sounds at the right base with dullness and no
egophony. His left lung is clear to auscultation. His heart
is regular, with no murmurs. The abdomen is distended, which
he says is a chronic finding. It is nontender, with good
bowel sounds. He has no palpable hepatosplenomegaly,
although he is quite distended. He is guaiac negative. His
extremities are without edema and with 1+ distal pulses. He
has no calf tenderness. He has no lower extremity asymmetry.
His neurological examination is nonfocal, with intact cranial
nerves, normal sensation, and 5/5 strength in all four
extremities.
Chest x-ray reveals an unchanged right upper lobe opacity
from his last chest x-ray, and a new right base opacity,
question effusion vs. infiltrate. His left lung is clear.
There is no widening of the mediastinum.
Electrocardiogram reveals sinus tachycardia at 108. He has a
right bundle branch block and a left anterior fascicular
block. He has a right ventricular strain pattern with S1 Q3
T3 that is old. His electrocardiogram is unchanged from his
baseline electrocardiogram.
LABORATORY DATA: He presented with a white count of 22.9,
hematocrit of 30.2, and a platelet count of 514. He also had
a left shift with a differential that was 93% polys, 3%
lymphs and 3% monos. His coagulations were within normal
limits. His electrolytes were likewise within normal limits
except for a BUN of 34, creatinine of 2.4, and glucose of
160. His liver function tests were normal. His amylase and
lipase were normal as well. His albumin was 4. He ruled out
for a myocardial infarction with negative CKs and troponins.
His blood cultures were negative. A cholesterol panel was
checked, which revealed a cholesterol of 120, with an HDL of
42 and an LDL of 56. His triglycerides were 109.
HOSPITAL COURSE: Mr. [**Known lastname 3075**] was admitted with a recurrent
right pneumonia and increased opacity of his right lung with
question of effusion. An ultrasound-guided tap was
performed, which drained 1.5 liters of fluid. He was changed
to ceftriaxone and Flagyl, given his two previous courses of
levofloxacin. A chest CT was also obtained to evaluate his
effusion, which was shown to be a loculated complicated one.
His pleural fluid revealed an empyema that was growing alpha
streptococcus.
On [**11-23**], he underwent thoracotomy with decortication for
treatment of his empyema. Cytology, cell block,
intraoperative bronchoscopy and biopsies all were negative
for malignancy. Given that he was growing streptococcus, he
was changed to penicillin-G for a two week course. A PICC
line was placed for access.
He was also ruled out for a myocardial infarction. During
his stay, he was continued on his Lopressor, Norvasc and
aspirin. His aspirin was held preoperatively and then
restarted afterwards.
His creatinine increased from his baseline to 3.0 due to
pre-renal azotemia. He responded well to intravenous fluids,
and his creatinine decreased to his baseline by the time of
discharge.
He has iron-deficiency anemia secondary to gastrointestinal
bleed. His hematocrit remained stable during his
hospitalization, but after his surgery, he was quite
fatigued, and so he was transfused two units.
Postoperatively, his chest tubes were removed after they had
minimal drainage with no evidence of air leak.
He suffered from delirium postoperatively, which was likely
multifactorial, related to pain medication, anesthesia,
infection, and distress from surgery. It resolved slowly,
with an improvement in his mental status to baseline. Low
dose Haldol effectively treated his acute symptoms.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: To [**Hospital 3058**] rehabilitation for
strengthening postoperatively. He will need to follow up
with his pulmonologist, Dr. [**Last Name (STitle) 2146**], in two to four weeks.
He may need to follow up with Interventional Pulmonary for a
repeat bronchoscopy in four to six weeks.
DISCHARGE DIAGNOSIS:
1. Alpha streptococcal pneumonia with loculated empyema
status post decortication
2. Hypertension complicated by chronic renal insufficiency
3. Diastolic dysfunction
4. Iron-deficiency anemia from gastrointestinal bleed
5. Abdominal aortic aneurysm
6. Left eye blindness secondary to macular degeneration
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg twice a day
2. Lasix 20 mg once daily
3. Norvasc 10 mg once daily
4. Aspirin 325 mg once daily
5. Niferex 50 mg twice a day
6. Epogen 3000 units every Wednesday
7. Penicillin-G 3 million units intravenously every four
hours until [**2154-12-10**]
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2154-11-28**] 23:55
T: [**2154-11-29**] 00:28
JOB#: [**Job Number 11731**]
1
1
1
R
Admission Date: Discharge Date:
Date of Birth: Sex:
Service:
ADDENDUM TO PREVIOUS DISCHARGE SUMMARY: The remainder of the
[**Hospital 228**] hospital stay was uneventful. His mental status
continued to improve daily. The patient worked with the
Physical Therapy Service and was able to ambulate with
minimal assistance. Per the Physical Therapy Service's
recommendations, it was decided that the patient would
benefit from an acute rehabilitation stay. After an
extensive discussion with the family, several appropriate
options were found. The patient was discharged in stable
condition to rehabilitation facility. Please see the
complete discharge summary for a list of discharge
medications.
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2155-3-6**] 17:25
T: [**2155-3-6**] 17:25
JOB#: [**Job Number 11733**]
|
[
"280.0",
"428.0",
"401.9",
"510.9",
"441.4",
"293.0",
"481",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.23",
"34.91",
"34.51"
] |
icd9pcs
|
[
[
[]
]
] |
3727, 3786
|
8658, 10064
|
8323, 8635
|
6156, 7961
|
3909, 6137
|
3807, 3885
|
134, 1852
|
1874, 3506
|
3524, 3709
|
7987, 8302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 162,085
|
43678
|
Discharge summary
|
report
|
Admission Date: [**2137-9-21**] Discharge Date: [**2137-10-1**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine / Xanax
/ Oxycodone
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
vision changes
Major Surgical or Invasive Procedure:
NGT placement
History of Present Illness:
58 y.o. M with ESRD on HD (last HD [**First Name3 (LF) 2974**] [**2137-9-20**]), s/p kidney
transplant x 2 ([**2121**], [**2129**])with progressive renal disease,
chronic rejection and renal failure (listed for kidney
transplant, but inactive due to underlying liver cirrhosis), HCV
c/b cirrhosis and ascites (requiring serial therpeutic
paracentesis), PVD, CHF (EF 45%, systolic and diastolic
dysfunction), labile HTN with recent admissions ([**2137-4-11**],
[**2137-8-11**]) for hypertensive emergency requiring labetolol gtts,
who presented to ED with visual changes.
.
Patinet reports that he's had nonpainful visual changes for 7
days described as a "shade coming over his eye". Patient also
reports seeing people in the periphery of his right eye. Patient
found to be hypertensive to 221/107 and started on Nipride gtt
with additional 10 iv & 50 PO of Hydral and responded well with
resultant BPs in the 140's. Patinet also seen by Ophtho who
thought that the visual changes were likely due to acute optic
nerve ischemia in setting of hypertension. Head CT was negative
for intracranial process and CXR was negative as well.
.
Patient denies any headache, chest pain, sob, abdominal pain,
nausea, vomiting, diarrhea. Patient reports that he takes his
medications regularly, although can't say that he hasn't missed
any doses of his medications.
.
Renal is also following patient and he's scheduled for HD on
Monday [**2137-9-23**]
.
Of note, patient has been treated for ~1 week of Valtrex for
zoster on the Left thigh.
Past Medical History:
-Seizure disorder
-ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2
failed renal transplants
-labile hypertension
-hypothyroidism
-peripheral [**Month/Day/Year 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-systolic w/ EF 45% and diastolic dysfunction (echo
[**12/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
-Recent admission [**2136-2-29**] for infected L upper arm AV fistula.
-h/o mechanical falls admitted [**1-16**]
-h/o VRE, MRSA
Social History:
Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called
[**Hospital1 **] at
[**Hospital1 1426**], on disability, has two sons. smokes 1ppd x 40 yrs, no
etoh, drugs.
Family History:
Mother with breast CA; father alive with CAD & CHF; sons
healthy.
Physical Exam:
Vitals - T:96.6 BP:152/81 HR:72 RR:15 02 sat:98 RA
GENERAL: laying in bed, NAD, cachectic
SKIN: herpetic vesicles on left flank, warm and well perfused,
no excoriations or lesions, no rashes, well-healed scar in RLQ,
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry MM, good dentition, no LAD, no JVD, no
thyromegaly
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: distended, +BS, positive fluid wave, nontender in all
quadrants, no rebound/guarding, hepatomegaly 5cm below costal
margin
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admit labs:
[**2137-9-21**] 04:30PM WBC-3.7* RBC-3.25* HGB-9.2* HCT-27.2* MCV-84
MCH-28.3 MCHC-33.8 RDW-20.1*
[**2137-9-21**] 04:30PM NEUTS-55.3 BANDS-0 LYMPHS-33.3 MONOS-10.7
EOS-0.2 BASOS-0.5
[**2137-9-21**] 04:30PM GLUCOSE-92 UREA N-41* CREAT-5.1* SODIUM-139
POTASSIUM-5.6* CHLORIDE-97 TOTAL CO2-28 ANION GAP-20
[**2137-9-21**] 04:30PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-203 ALK
PHOS-134* AMYLASE-57 TOT BILI-0.3
[**2137-9-21**] 04:30PM LIPASE-28
[**2137-9-21**] 04:30PM CALCIUM-8.9 PHOSPHATE-7.4* MAGNESIUM-2.5
[**2137-9-21**] 04:35PM LACTATE-1.2
[**2137-9-21**] 05:00PM AMMONIA-37
.
Studies:
.
CT w/o contrast on [**9-21**]: There has been no change in the
appearance of the brain compared with prior study. There is no
evidence of acute intracranial hemorrhage, mass effect, shift of
midline structures, or loss of [**Doctor Last Name 352**]-white differentiation. Areas
of white matter hypodensity are again noted and are unchanged.
The posterior fossa is unchanged, with slight prominence of
extra-axial space. Calcification of the cavernous carotids again
noted. The paranasal sinuses are clear. There is again noted to
be partial opacification of the left mastoid air cells.
.
CXR [**9-21**]: Cardiomegaly, bibasilar atelectasis. No acute
intrathoracic process.
.
MRA NECK W/O CONTRAST, MR HEAD W/O CONTRAST, MRA BRAIN W/O
CONTRAST [**9-24**]:
1. No acute infarcts.
2. Moderate degree of small vessel ischemic changes.
3. MRA of the neck is limited due to patient motion, but no
gross abnormalities are seen.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN, DUPLEX DOPP ABD/PEL [**9-25**]:
1. Moderate perihepatic ascites.
2. Cholelithiasis.
3. Patent hepatic vasculature with normal directional flow and
waveforms.
4. Splenomegaly.
.
EEG [**9-26**]: This telemetry captured no pushbutton activations.
Routine
sampling and spike and seizure detection programs demonstrated
several
episodes of brief generalized polyspike and wave discharges as
well as
several multifocal spike and wave discharges. The discharges
were never
repetitive or sustained. In addition, the background rhythm was
slow
and disorganized, typically achieving a maximum frequency of 7
Hz. The
first finding suggests a potential for ongoing epileptogenesis.
The
second is suggestive of an underlying encephalopathy which could
be due
to deeper midline or subcortical dysfunction.
Brief Hospital Course:
MICU COURSE.
Assessment:
58M with h/o epilepsy, ESRD on HD s/p 2 failed kidney
tranplants, HCV cirrhosis, PVD, CHF, labile hypertension
admitted with hypertensive emergency and nonarteric ischemic
optic neuropathy (R eye). Pt originally presented to the ED c/o
decreased vision in his R eye, and was found to have BPs in the
220s/110s. Upon arrival to the MICU, the patient also had
acutely altered mental status thought to be due to hepatic
encephalopathy. During his MICU stay, the pt was transitioned
to po BP meds with goal SBPs of 140-180s. The patient did have
a seizure thought to be due to missing 1-2 doses of seizure meds
while encephalopathic, but now is back on his po anti-seizure
regimen. Neuro and Hepatology follow the patient. Please see the
problem based plan for details.
.
Plan:
.
# AMS: hypertensive encephalopathy vs. hepatic encephalopathy
vs. uremic encephalophy medication side effects vs. prolonged
post-ictal state. h/o epilepsy on Keppra and Lamictal on
admission. AMS shortly after admission to MICU thought to be
secondary to Perocet given for H. Zoster or olanzapine given for
sleep. Also new dysarthria, slurred speech. Seizure yesterday
appearing partial with sterotypical movements of chin and hand.
MRI/MRA without contrast of neck and head negative. Hepatology
consult assessed pt has grade [**3-16**] encephalophy. U/S liver showed
normal vasculature and normal directional flow. Altered mental
status thought to be due to encephalopathy compounded by
prolonged post-ictal state. Marked improvement with lactulose
and rifaximin. Pt is now alert and oriented. Patient was
continued on lactulose and rifaximin. Started on dilantin per
neuro recs. He will be followed up by Dr.[**First Name (STitle) 437**] from neurology
and Dr.[**Last Name (STitle) 497**] from liver service as out patient.
.
# Rectal bleeding- BRBPR s/p PR lactulose in ICU. Bleeding to
soak 2 chucks. Controlled with tamponade with Foley catheter per
GI recommendation. HCT remains stable. Trace positive stools
in ED. Currently hemodynamically stable with no repeat guaiac
positive stools in unit. Possible due to underlying
hemorrhoids, although may be secondary to bowel hypoperfusion.
Lactate in ED was 1.2, not suggestive of mesenteric ischemia.
Colonoscropy [**8-13**] showing grade 1 hemorrhoids, diverticulosis,
no polyps. Endoscopy [**10-17**] showing grade IV esophagitis with
ulcerations. plyps in the distal bulb. Polyps c/w esophagitis,
duodenitis. Colonoscopy [**2-17**] showing grade 2 hemorrhoids and
no rectal varies, minimal blood loss precipitated by lactulose
enema. His HCT remained stable on discharge.
.
# HTN Emergency - Unclear of patient compliance with medications
with evidence of end organ ishcemia to his right eye. Patient
responded well to Nipride gtt with goal SBP <170 in ED. Pt
briefly on Labetolol gtt in ICU, as he responded to this in the
past and will avoid possible CN toxicity; however, patient's BP
was well controlled with restart of home PO BP meds. Not able
to follow UOP as patient is on HD. Patient was discharged on
lisinopril, metoprolol and clonidine patch.
.
# Herpes Zoster - Patient has had occasional L flank pain
preceeding the vesicles in the distribution of L2-3. Patient
initially written for acyclovir 1g x 5 days (Day 1 [**2137-9-19**]), and
completed the course. Pt. not c/o Zoster pain currently.
Discharged on morphine PRN.
.
# Right eye optic nerve ischemia - Patient seen by Ophtho in ED.
Guarded to poor prognosis in terms of regaining vision and will
follow up in clinic next week (would be [**9-28**]). No intervention
needed at this time. Patient also developed superficial
keratitis and was prescribed erythromycin ointment by ophtho.
Will be f/u with Dr.[**Last Name (STitle) **] as out pt.
.
#. CAD: Patient without evidence of ischemia.
-PUMP: Known EF of 45%. On aggressive outpatient
antihypertensive regimen, thought to be due to renal disease
-RHYTHM: No issues at this point.
-continued on out pt ASA and Plavix
.
# Hyperkalemia -
-corrected with HD
.
# ESRD on HD: To HD on M/W/F via R Hickman catheter. Appreciate
renal recs. Patient has bilateral nonfunctioning AV fistulas in
forearms.
.
# Anemia - [**3-15**] chronic renal disease: Hct baseline 30. Patient
stable as mentioned above.
.
# Hyperparathyroidism: Continued oupatient dose of Cinacalcet
HCl.
.
# PVD s/p bilateral common iliac stents: continued aspirin and
plavix per outpatient regimen.
.
# Epilepsy: h/o primary generalized epilepsy since childhood
with h/o paroxysmal episodes of confusion due to nonconvulsive
seizures. Will continue outpatient meds of keppra and
lamotrigine. Loaded on dilantin s/p seizure, and continued
thereafter. Getting extra dose of dilantin after HD. Will be
followed up by Dr.[**First Name (STitle) 437**] as out pt.
.
FEN/GI: Advanced diet to regular.
PROPHY: SC Heparin
Medications on Admission:
Nephrocaps 1 cap qd
Lamotrigine 250 mg [**Hospital1 **]
Nifedipine 60 mg PO Q8H
Levetiracetam 375 [**Hospital1 **]
Toprol XL 200
Clopidogrel 75 mg qd
Aspirin 81 mg qd
Clonidine 0.1 mg [**Hospital1 **]
Prevacic 30 mg qd
Nortriptyline 10 mg qhs
Cinacalcet 30 mg qd
Lisinopril 20 mg qhs
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
End stage renal disease on hemodialysis
HCV cirrhosis
Congestive heart failure
Seizure disorder
Nonarteric ischemic optic neuropathy
Discharge Condition:
Good. Afebrile and hemodynamically stable
Discharge Instructions:
You have been admitted to [**Hospital1 69**]
with change in mental status and decreased vision in right eye.
Your vision change is due to lack of blood flow to your eye.
Your change in mental status may be due to multiple factors
including increased blood pressure, sever kidney disease, sever
vision disease and/or seizure disorder. Weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Please adhere to 2 gm
sodium diet.
Please take all the medications as written.
Please keep all the follow up appointments.
If you develope chest pain, shortness of breath or any other
concerning symptoms call your primary care doctor or come to the
emergency department.
Followup Instructions:
Please call your primary care doctor within one week of
discharge to make a follow up appointment.
Please continue your hemodialysis 3 times a week as recommended
by your kidney doctors. Your next Hemodialysis will be the
after discharge. Your renal doctors [**Name5 (PTitle) **] let [**Name5 (PTitle) **] know about
the need for dialysis tomorrow.
Neurology: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2137-11-8**]
10:30
Please call [**Telephone/Fax (1) 253**] to make a follow up ophthalmology
appointment with Dr. [**Last Name (STitle) **].
Please call [**Telephone/Fax (1) 673**] to make a follow up appointment with
Dr. [**Last Name (STitle) 497**] in 2 to 4 weeks.
Completed by:[**2137-10-1**]
|
[
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"571.5",
"574.20",
"V09.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
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] |
icd9pcs
|
[
[
[]
]
] |
11040, 11046
|
5823, 10705
|
353, 368
|
11246, 11290
|
3431, 5800
|
12021, 12811
|
2659, 2727
|
11067, 11225
|
10731, 11017
|
11314, 11998
|
2742, 3412
|
299, 315
|
396, 1924
|
1946, 2439
|
2455, 2643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,334
| 191,584
|
39108
|
Discharge summary
|
report
|
Admission Date: [**2181-4-6**] Discharge Date: [**2181-4-8**]
Date of Birth: [**2120-5-3**] Sex: F
Service: MEDICINE
Allergies:
Darvon
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 y/o female with prior alcoholism and possible cirrhosis, DM
II on insulin, who presents from OSH after EGD. The patient had
been feeling well prior to this ambulatory procedure, she was
undergoing EGD at OSH for possible celiac diease work-up,
because of 4 episodes/hospitalizations this past year of
diarrhea and vomiting. During EGD patient has biopsy of GI tract
and apparently had significant bleeding, concern was that a
gastric varix was biopsised. Patient's HCT after the procedure
was 28.5, down from last HCT of 36. Patient was admitted to OSH
ICU for monitoring. Patient was then transferred to [**Hospital1 18**] ICU.
VSS stable on transfer, and throughout [**Hospital1 18**] ICU stay. Never
required transfusion. Called out to general floor on [**4-7**].
.
On transfer, patient denies n/v, BM's, dysuria, CP, AP, SOB. Had
mild lightheadedness on transfer to chair that then resolved,
she often gets lightheaded at home with position change.
Past Medical History:
h/o Alcoholism
DM II
Chronic Pancreatitis
Chronic Back Pain
Hyperlipidemia
Asthma
Depression
h/o Tonsillectomy,
Inguinal hernia repair'[**65**]
h/o LEEP for abnormal PAP smears
h/o Liver bx with chronic hepatitis, inflammation grade [**1-17**],
fibrosis grade II-III.
Social History:
- Tobacco: occasional
- Alcohol: h/o of alcoholism, quit 3 years ago
- Illicits: None
Family History:
Non-contributory
Physical Exam:
Vitals: Afebrile, 90, 101/54, 18, 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
RLQ TTP from hernia
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
RELEVANT LABS:
[**2181-4-6**] 07:58PM PT-13.8* PTT-30.5 INR(PT)-1.2* PLT COUNT-245
[**2181-4-6**] 07:58PM GLUCOSE-162* UREA N-4* CREAT-0.5 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-13
[**2181-4-6**] 07:58PM ALT(SGPT)-13 AST(SGOT)-15 ALK PHOS-43 TOT
BILI-0.2
.
Hematocrits:
[**2181-4-6**] 07:58PM HCT-28.3*
[**2181-4-7**] 02:12AM Hct-24.8*
[**2181-4-7**] 05:59AM Hct-26.6*
[**2181-4-8**] 12:13AM Hct-24.3*
[**2181-4-8**] 05:45AM Hct-24.1* (on discharge)
.
IMAGES/STUDIES:
none
.
MICROBIOLOGY:
- [**2181-4-7**] MRSA screen - PENDING
.
Discharge labs:
[**2181-4-8**] 05:45AM BLOOD WBC-3.6* RBC-2.80* Hgb-7.9* Hct-24.1*
MCV-86 MCH-28.3 MCHC-32.9 RDW-13.8 Plt Ct-247
[**2181-4-8**] 05:45AM BLOOD PT-13.1 PTT-27.5 INR(PT)-1.1
[**2181-4-8**] 05:45AM BLOOD Glucose-179* UreaN-6 Creat-0.6 Na-135
K-4.4 Cl-104 HCO3-26 AnGap-9
[**2181-4-8**] 05:45AM BLOOD ALT-11 AST-11 LD(LDH)-134 AlkPhos-39
TotBili-0.1
[**2181-4-8**] 05:45AM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.6* Mg-2.2
Brief Hospital Course:
60 y/o F with prior alcoholism and alcoholic liver disease (no
known cirrhosis), DM II on insulin, depression, who presents
from OSH after excessive post-biopsy bleeding after EGD, concern
for biopsy of an occult gastric varix.
# UGI Bleed: Patient had bx of gasric mass that was possibly a
gastric varix. After transfer to [**Hospital1 18**], she was hemodynamically
stable on transfer to the MICU. HCT was trended Q6H and remained
stable at between 24-28.. She was kept NPO overnight initially,
and advanced to clears the following morning. She was then
called out to the floor team. She tolerated a regular diet well.
Serial HCTs were stable. She was maintained on ciprofloxacin
500mg [**Hospital1 **] for empiric post-variceal bleeding prophylaxis, even
though there was no good evidence of this. She was discharged on
a total of 5 days of ciprofloxacin, as well as a twice daily
PPI, and instructions to followup with her gastroenterologist.
.
# ? Cirrhosis: Patient has a long history of alcoholism and had
a prior liver bx showing chronic hepatitis, inflammation grade
[**1-17**], fibrosis grade II-III. Patient states that she has no h/o
cirrhosis, and has abstained from alcohol for the past 3 years.
LFTs and liver synthetic markers were within normal limits. She
was instructed on the importance of following up with her
outpatient GI Dr. [**Last Name (STitle) 86659**] in [**Location (un) 5028**], as she will need
further r/o cirrhosis workup inlcluding liver imaging, repeat
endoscopy, hepatitis serologies, iron studies, and consideration
of nadolol or other non-selective beta blocker if in fact
varices are demonstrated.
# DM II: Received home Lantus + HISS while inpatient. Ate a
diabetic diet.
# Chronic Back Pain: Continued on home tramadol.
# Hyperlipidemia: Continued on home simvastatin.
# Asthma: Written for albuterol, ipratropium nebs PRN while
inpatient.
# Depression: Continued home medications (multiple).
Medications on Admission:
fluoxetene 20mg daily
Tramadol 50mg q6hrs prn
Metformin 1000mg [**Hospital1 **]
Albuterol prn
Ranitidine 150mg [**Hospital1 **]
Simvastatin 20mg daily
Calcium + D
Actos (unk dose)
Abilify 15mg daily
Lorazepam 1mg [**Hospital1 **]
Mag Oxide 400mg TID
Glipizide 10mg [**Hospital1 **]
Flovent daily (unk dose)
Fosamax 70mg qweek
Lantus 6u sc daily
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Actos Oral
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Insulin
Please continue your home insulin dosing of Lantus 6 units every
day
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three
(3) Capsule, Sust. Release 24 hr PO DAILY (Daily).
12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO once a day.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
15. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO four
times a day.
16. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
18. Calcium Oral
19. Vitamin D Oral
20. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day.
21. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
post-biopsy upper GI bleeding
.
Secondary:
Chronic Alcoholic Liver Disease
Diabetes type 2, on insulin
Chronic pancreatitis
Chronic Diarrhea
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, sometimes relies on a
cane at home.
Discharge Instructions:
Dear Ms. [**Known lastname 86660**],
It was a pleasure taking care of you. You were transferred to
[**Hospital1 18**] after an endoscopy at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. This
endoscopy was performed to evaluate your chronic diarrhea.
During the endoscopy, a biopsy of the stomach was performed, and
you had excessive bleeding from the biopsy site. You were
transferred to us for monitoring anf further care.
.
Fortunately, there were no signs of any significant or continued
bleeding in the 2 days after your procedure. Your blood counts
were low, but stable. You did not need any blood transfusions.
You did not undergo a repeat endoscopy.
.
Please note the following changes to your medication regimen:
- STOP ranitidine (Zantac)
- START pantoprazole (Protonix) twice daily to prevent any
bleeding from the stomach. This will also reduce stomach acid
and heartburn.
- START ciprofloxacin (Cipro), an antibiotic, 500mg twice per
day, for the next 3 days. This is to prevent any infections
after your episode of bleeding.
.
The remainder of your medications are unchanged.
Followup Instructions:
Gastroenterology:
It is VERY importnant that you see your gastroenterologist, Dr.
[**First Name (STitle) **] [**Name (STitle) 86659**], within the next 1-2 weeks. This is for
arrangement of a repeat upper endoscopy, further imaging, and
possible initiation of medications if needed. His phone number
is ([**Telephone/Fax (1) 86661**].
PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) 75760**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 75761**]. Please make an appointment to be
seen in the next 2 weeks.
Completed by:[**2181-4-9**]
|
[
"724.5",
"577.1",
"493.90",
"571.2",
"250.00",
"E878.8",
"998.11",
"553.8",
"303.93",
"272.4",
"V58.67",
"311",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7215, 7221
|
3232, 5183
|
272, 279
|
7426, 7426
|
2206, 2776
|
8756, 9298
|
1677, 1695
|
5578, 7192
|
7242, 7405
|
5209, 5555
|
7613, 8733
|
2792, 3209
|
1710, 2187
|
224, 234
|
307, 1264
|
7441, 7589
|
1286, 1555
|
1571, 1661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,174
| 130,645
|
17566
|
Discharge summary
|
report
|
Admission Date: [**2136-11-14**] Discharge Date: [**2136-11-22**]
Date of Birth: [**2074-9-4**] Sex: M
Service: MEDICINE
Allergies:
Atenolol
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Altered mental status and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 male with PMH CABG, DM2, HTN, CKD, sciatica, and depression
who presents with acute mental status change. The patient was
unable to give a clear history due to mental status. Called his
Case Manager [**Female First Name (un) 13842**] at [**Street Address(1) 48986**] Inn. She was
unsure of the exact history, but states that he has been "sick"
for the last 2 months. She states that he was complaining of
abdominal pain, fatigue, and malaise. He had complaints of
vomiting all night 6 days PTA and wasn't able to sleep. She said
that he was going to get a "MRI of his abdomen" at the VA for
workup of his vomiting. She did not notice any wounds or lesions
on his skin previosuly. The next time she spoke with the patient
was 3 days PTA and she said he was in good spirits. She saw him
this morning and he was extremely confused and not coherent. She
states he is normally a very intelligent and responsible person.
She was extremely worried and called the ambulance and had him
transferred to the ED.
.
In the ED: 98.7 165/93 99 18 100% RA
His initial FS was 393. Blood cultures were sent. The patient
was found to have a large erythematous hard collection on his
left shoulder and multiple small pustules. A U/S of the back did
not show fluid collection. He was started empirically on
Vancomycin 1gm and Unasyn 3g IV. His K was 5.9 and patient was
given Ca gluconate, 10U insulin & [**12-14**] amp of D50 and kayexalte.
A urine tox was sent and the patient was transferred to the
floor.
.
On the floor: VS 100.5 158/114 114 18 98%RA
The patient was found to be extremely lethargic and minimally
responsive. He was able to answer yes/no questions. He was given
10U insulin. Intial VBG: 7.36/27/40/16, ABG: 7.51/18/101/15. CXR
was performed. The patient was ordered for abdominal/pelvis CT
and head CT. Foley was placed and patient drained 1.7L.
.
ROS: Unable to obtain.
Past Medical History:
Diarrhea since [**9-19**]
HTN
DM Type 2
Hypercholesterolemia
S/p CABG x 5 [**11-18**]
Depression (suicide attempt [**2123**])
S/p Penile implant [**2133**] (MRI compatible)
GERD
Vertigo
Sciatica
Social History:
No tobacco. EtOH described as occasional wine, used to drink
more but not currently, denies h/o alcohol abuse. History of
cocaine and marijuana use, last in [**2132**], denies IVDU. Sexually
active with same male partner for past 5 years.
Family History:
No family history of premature coronary artery disease or sudden
death. Father has history of DM, died at age 89. Mother has
history of skin ca.
Physical Exam:
On Admission:
Vitals: T:100.5, BP:158/114, HR:114, RR:18, 02 sat:98%
Gen: Lethargic and minimally responsive
HEENT: AT/NC, dilated pupils that are sluggish, anicteric, no
conjuctival pallor, dry MM,
NECK: supple, trachea midline, no LAD
LUNG: CTA-B/L
CV: S1&S2, RRR, no R/G/M
ABD: obese/soft/+BS/ distended/ +fluid wave/ +grimace to
palpation in his abdomen/ no rebound/ no guarding
EXT: No C/C/E
SKIN: multiple scabbed lesion on his arms and back/
erythematous, draining, hard collection on Le shoulder, drianing
tract and macerated.
NEURO: minimally awake and not oriented. Unable to test cranial
nerves, dilated pupils that are minimally reactive to light.
Could not test strenght or sensation
Reflexes [**1-16**] brachioradialis, biceps, triceps, patellar,
Achilles
.
On Floor:
Vitals: HR 100, BP 140/90, RR 16, O2 97% RA
Gen: AAO x 3, slow speech with some alternate word choices but
denies any word finding difficulties, abnormal thought
processing.
HEENT: PERRL, EOMI
CVS: Reg rhythm, tachycardic, S1-S2+, no m/r/g
Lungs: CTA b/l
Abd: BS+, soft, NT/ND
Ext: No LE edema b/l
Neuro: AAO x 3 with abnormal affect.
Skin: L shoulder large area of erythema/excoriation/pustular
lesion satellites, edematous and able to express purulent
discharge. Across left arm are scattered lesions, dime-sized
with central ulcerations, surrounding heaped borders of pearly
erythema, pruritic per pt.
Pertinent Results:
ON ADMISSION
[**2136-11-14**] 10:20AM BLOOD WBC-15.4*# RBC-4.65# Hgb-13.0*#
Hct-37.6*# MCV-81* MCH-27.9 MCHC-34.5 RDW-14.5 Plt Ct-438
[**2136-11-14**] 10:20AM BLOOD Neuts-90.5* Lymphs-5.7* Monos-2.5 Eos-1.2
Baso-0.2
[**2136-11-14**] 04:37PM BLOOD PT-15.7* PTT-33.5 INR(PT)-1.4*
[**2136-11-14**] 10:20AM BLOOD Glucose-337* UreaN-82* Creat-4.0*# Na-133
K-5.9* Cl-104 HCO3-16* AnGap-19
[**2136-11-14**] 10:20AM BLOOD ALT-16 AST-19 LD(LDH)-250 AlkPhos-134*
Amylase-64 TotBili-0.1
[**2136-11-14**] 05:40PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
[**2136-11-14**] 06:01PM BLOOD freeCa-1.22
[**2136-11-14**] 10:20AM BLOOD Albumin-2.6*
[**2136-11-14**] 09:06PM BLOOD Cortsol-28.9*
.
ON TRANSFER TO FLOOR
[**2136-11-16**] 04:00AM BLOOD Glucose-145* UreaN-45* Creat-2.3* Na-143
K-3.8 Cl-117* HCO3-14* AnGap-16
.
ON DISCHARGE
[**2136-11-22**] 06:30AM BLOOD WBC-6.4 RBC-3.83* Hgb-10.3* Hct-29.7*
MCV-78* MCH-26.9* MCHC-34.7 RDW-15.1 Plt Ct-328
[**2136-11-22**] 06:30AM BLOOD Glucose-66* UreaN-24* Creat-1.7* Na-139
K-4.2 Cl-114* HCO3-19* AnGap-10
[**2136-11-22**] 06:30AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0
[**2136-11-19**] 07:07AM BLOOD ALT-35 AST-32 AlkPhos-102 TotBili-0.6
.
LIPASE TREND
[**2136-11-14**] 10:20AM BLOOD Lipase-202*
[**2136-11-15**] 05:16AM BLOOD Lipase-251*
[**2136-11-15**] 12:48PM BLOOD Lipase-90*
[**2136-11-16**] 04:00AM BLOOD Lipase-34
.
ANEMIA STUDIES
[**2136-11-18**] 07:30AM BLOOD VitB12-1093* Folate-6.2
[**2136-11-15**] 05:16AM BLOOD IRON 10 calTIBC-160* Ferritn-403*
TRF-123*
.
DRUG SCREENS
[**2136-11-14**] 10:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.9
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2136-11-16**] 04:00AM BLOOD Tricycl-POS
[**2136-11-16**] AMITRIPTYLINE 134
[**2136-11-20**] 06:45AM BLOOD Tricycl-NEG
.
[**2136-11-14**] 09:06PM BLOOD Cortsol-28.9*
[**2136-11-18**] 07:30AM BLOOD TSH-1.2
[**2136-11-16**] 06:43AM BLOOD Lactate-1.0
[**2136-11-17**] 07:15AM BLOOD HIV Ab-NEGATIVE
[**2136-11-21**] 05:00AM BLOOD PSA-7.5*
.
[**2136-11-14**] EKG: Sinus tachycardia. Inferior myocardial infarction,
age undetermined. Poor R wave progression. Consider anterior
myocardial infarction. Non-specific ST-T wave changes. Compared
to the previous tracing of [**2135-11-26**] QRS change in lead V5 is
probably positional.
.
[**2136-11-14**] CHEST US: FINDINGS: Limited views of the area of
interest in the left scapula by ultrasound were obtained. There
is no evidence of fluid collections that would be indicative of
an abscess. IMPRESSION: No fluid collection identified.
.
[**2136-11-14**] CXR: Cardiac size is top normal. The cardiac silhouette
is accentuated by low lung volumes. The lungs are grossly clear
with minimal bibasilar atelectasis. There are no large pleural
effusions or pneumothorax. Sternal wires are in unchanged
position when compared to prior study. The location of the
sternal wires and very mild diastasis of the sternotomy are
better seen in CT from [**2136-11-14**].
.
[**2136-11-14**] CT TORSO:
CT CHEST WITHOUT CONTRAST: The lungs are clear allowing for the
limitations of respiratory artifact. The heart and great vessels
of the mediastinum are remarkable for severe coronary artery
calcification, post-coronary artery bypass. There is no
pericardial effusion. There is trace atelectasis at the left
base. There are no pleural effusions. There is no pathologic
axillary, mediastinal, or hilar adenopathy.
CT ABDOMEN WITHOUT CONTRAST: Allowing for the limitations of a
non-contrast
study and artifact generated from the right arm, the liver,
spleen, stomach, adrenal glands, and small bowel loops are
normal. There are multiple gallstones within an otherwise
normal-appearing gallbladder. The pancreas is nearly entirely
fatty replaced, but there is diffuse non-
specific inflammatory stranding about the pancreas, which could
possibly be
secondary to pancreatitis. There is no evidence for pseudocyst.
Without
contrast, enhancement of the pancreas cannot be determined.
Non-specific
stranding is also present about otherwise normal-appearing
kidneys, but this is a normal finding given the patient's age.
There is no free fluid, free air, or pathologic adenopathy.
CT PELVIS WITH CONTRAST: The rectum, sigmoid, large bowel is
normal. A rectal tube is in situ. A Foley catheter is within a
collapsed bladder. There is no free air, free fluid, or
pathologic adenopathy.
BONE WINDOWS: The patient is status post median sternotomy. No
suspicious
lesions are identified.
IMPRESSION: 1. Non-specific inflammatory stranding about the
pancreas may be secondary to pancreatitis. There is no evidence
for pseudocyst. 2. Cholelithiasis.
.
[**2136-11-14**] CT OF THE HEAD WITHOUT CONTRAST: There is no evidence
of mass, hydrocephalus, shift of normally midline structures,
infarction, or hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation
is preserved. Again noted, ill-defined density in the medulla
which is likely artifactual in nature. The osseous and soft
tissue structures are unremarkable. The visualized paranasal
sinuses are clear.
IMPRESSION: No acute intracranial process.
.
[**2136-11-19**] SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR [**First Name (Titles) **] [**Last Name (Titles) 48987**]S: Six radiographs involving the skull, thorax and
abdomen. No comparison studies. There is no radiopaque foreign
bodies that would preclude MRI. Cavitary fillings are noted as
are median sternotomy wires. There is
vascular calcification of the soft tissues of the neck. Note is
made of some minimally dilated loops of small bowel and mild
osteoarthritic changes of the hips. IMPRESSION: 1) No metallic
foreign bodies that would preclude MRI. 2) Minimally dilated
loops of small bowel.
.
[**2136-11-20**] ORBITS PRE-MRI: No comparison studies. No radiopaque
foreign bodies are seen overlying the orbits. Multiple fillings
are noted. No acute fractures are visualized nor air-fluid
levels within the sinuses.
IMPRESSION: No orbital foreign bodies visualized.
.
[**2136-11-20**] LENIs: FINDINGS: There is normal compression,
augmentation, pulse Doppler waveform, and color Doppler signal
within the left and right common femoral, superficial femoral,
and popliteal veins. Proximal calf veins on the right appear
unremarkable by color Doppler. The left-sided calf vessels are
not well visualized. IMPRESSION: Negative for DVT bilaterally.
.
[**2136-11-20**] MR HEAD W/O CONTRAST: FINDINGS: There are no masses,
lesions, mass effect, or shift of normally midline structures.
The ventricles and sulci are normal in size and configuration.
There are no areas of diffusion abnormalities to indicate acute
stroke. There are small areas of bilateral periventricular white
matter hyperintensities noted on FLAIR sequences and that could
reflect age associated microvascular change. IMPRESSION: No
abnormalities to explain patient's cognitive slowing. No
evidence of acute stroke.
.
[**2136-11-20**] BACK ULTRASOUND: FINDINGS: There is diffuse edema in
the region of the left scapula consistent with site of clinical
concern. There is no drainable fluid collection. IMPRESSION:
Diffuse edema. No drainable fluid collection.
Brief Hospital Course:
62 yo man with history of CAD s/p CABG, DM2, HTN, sciatica,
depression admitted with altered mental status and fever
requiring transfer to floor, likely [**1-14**] to cellulitis.
.
# Altered mental status: Pt initially very lethargic on floor.
He was started on vanco and zosyn empirically for one fever to
100.5 with leukocytosis. Labs also notable for acute on chronic
renal insufficiency, hyperglycemia, and evidence of dehydration.
He was transferred to the MICU for further care. In the MICU,
patient was switched to vancomycin and ampicillin pending LP
results, which were negative. UA and pending blood and urine
cultures were also negative. CT head, CXR, and CT abdomen and
pelvis were unremarkable. HIV, RPR, B12, folate, and TSH nl.
Serum and urine tox were notable only for elevated TCA level,
but quantitative serum amitriptyline was normal, and pt later
denied overdose. He was noted to have an erythematous patch on
his left shoulder with satellite lesions extending down left arm
concerning for cellulitis, for which patient was maintained only
on vanco. Also noted to have urinary retention which may have
contributed to altered mental status. As pt with no further
fevers and initial delirium resolved, patient was transferred
back to the floor on [**2136-11-16**]. Although he was noted to be AAO x
3 on the floor, he displayed a tangential thought process with
some mystical beliefs. He was evaluated by psych who did not see
evidence of active depression recommended continuing to hold
outpatient psych meds (amitriptyline and wellbutrin), which were
discontinued initially in context of elevated TCA. There was a
question of acute personality change, but further neuro workup
with MRI head showed no acute intracranial process. Psych
determined pt without acute safety issues but recommended close
psychiatric follow-up for ongoing problems of [**Name2 (NI) **] disorder and
possible overvalued beliefs.
.
# Urinary retention: Pt with history of BPH and question of
elevated TSA on admission. Foley placed on admission for urinary
retention and noted to have post-obstructive diuresis. Failed
repeat voiding trial despite being restarted on outpatient
terazosin. PSA noted to be 7.5. Foley reinserted and pt
discharged with leg bag, scheduled to follow up with Urology in
2 weeks for further evaluation.
.
# Acute Renal Failure: Baseline unclear, appears to be about
1.7-1.8. Ddx: pre-renal in setting of dehydration (nausea,
vomiting, diarrhea, decreased po intake, post-obstructive
diuresis) vs. post-renal in light of urinary retention. Improved
over hospital course with Cr of 1.7 on discharge. Outpatient
lasix held, to be restarted by PCP as indicated.
.
# Cellulitis: Erythematous and edematous with expressible
purulent drainage with no evidence of drainable fluid collection
on ultrasound, evaluated by Dermatology who agreed with
diagnosis of cellulitis. Initially treated empirically with
Vanco but switched to 1st generation cephalosporin as wound
culture grew out MSSA. Also given tetanus shot as pt reported
development of cellulitis in context of scratching back with
metal pasta spoon. Discharged with VNA for wound care and on
Keflex, to complete a 14-day antibiotic course.
.
# Prurigo nodularis: Pt also noted to have circular lesions with
heaped up borders scattered down left arm. Evaluated by
Dermatology and determined to be prurigo nodularis, self-induced
by scratching. Pt instructed not to touch lesions, attempts made
to keep bandaged although pt non-compliant. He was treated with
Sarna and Bactroban and restarted on outpatient hydroxyzine.
.
# Diabetes: Hb 6.4. Pt started on NPH at lower dose as he had
decreased po intake during hospitalization. Discharged pt on NPH
40 units [**Hospital1 **] with instructions to check regularly and notify PCP
if [**Name9 (PRE) 31567**] running low or high for adjustment of insulin dose. [**Month (only) 116**]
benefit from [**Last Name (un) **] follow-up.
.
# Diarrhea: Pt evaluated for diarrhea which was trace guiaic
positive. No evidence of infectious etiology. Trace guaiac
positive stools attributed to irritation of internal
hemorrhoids, and diarrhea improved spontaneously during
hospitalization and no longer incontinent of bowel. Discharged
with instructions to try immodium if diarrhea worsened.
.
# Anemia: Pt was noted to have microcytic anemia, guaiac on
rectal exam and of stools as trace guaiac positive attributed to
irritation of internal hemorrhoids seen on colonoscopy last
year. Iron studies with low iron level but elevated ferritin. Pt
started on iron supplementation in MICU due to mixed picture. Pt
remained hemodynamically stable with no other signs of active
bleed but Hct slowly trended down to 29.7 on discharge. Would
recommend further outpatient monitoring.
.
# Sinus tachycardia: Pt monitored on telemetry initially for
elevated TCA level. Heart rate initially in 120s to 130s and
sinus. This was thought to persist longer than would be expected
if TCA effect, and quantitative amitryptiline level added to
admission labs later returned normal with negative follow-up TCA
level. Not consistent with alcohol withdrawal. Echo
unremarkable for valvular disease or abnormal contractility. Low
suspicion for PE as oxyenating well with no evidence of right
heart strain and no DVT on LENIs. [**Month (only) 116**] have component of
dehydration from recent nausea/vomiting, diarrhea, as well as
post-obstructive diuresis and received IVF. [**Month (only) 116**] also have had
high adrenergic state in context of urinary retention. Per PCP,
[**Name10 (NameIs) **] noted to have sinus tachycardia on past visits with HR of 109
at last visit. Sinus tachycardia subsequently resolved with HR
80s-90s on discharge, etiology still unclear.
.
# ?EtOH use: Pt with history of heavy EtOH use although denied
current alcohol abuse. However, noted to be perseverative about
drinking ginger beer, "which is non-alcoholic." Concern for
underlying EtOH issue in light of sinus tachycardia although
ethanol negative on admission and no signs of withdrawal. Was
started on folate, thiamine, and MVI, which can discontinued by
PCP if further evaluation not concerning for EtOH abuse.
.
# Non-gap metabolic acidosis: Present throughout hospital course
but improving on discharge, attributed to diarrhea.
.
# ?Pancreatitis: Patient presented with altered mental status,
evidence of dehydration with acute on chronic renal failure,
?report of vomiting, elevated lipase, and CT scan with some
possible stranding on CT scan although reported to be
non-inflammatory. Per MICU report, pt without clinical evidence
of pancreatitis. Lipase normalized on transfer to floor and no
evidence of abdominal pain during rest of hospital course.
.
# CAD: S/p CABG in [**11-18**]. Stable, continued on outpatient
management.
Medications on Admission:
Aspirin 81 mg daily
Amoxicillin 500 mg daily
Furosemide 20 mg daily
Budeprion 150 mg daily
Cozaar 50 mg daily
Amytriptyline 50 mg daily
Simvastatin 10 mg daily
Toprol 200 mg daily
Terazosin 2 mg daily
Hydroxyzine 25 mg daily
Omeprazole 20mg daily
PRN Terbinafine, premethrin, triamcinolone, nitroquick
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: As
directed Units Subcutaneous twice a day: 40 units qAM, 40 units
qHS.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 6 days.
Disp:*18 Capsule(s)* Refills:*0*
14. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
16. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO once a
day as needed for pruritis.
17. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea. Capsule(s)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
- Cellulitis
- Prurigo
- Sinus tachycardia
- Diarrhea
- Anemia
- Acute on chronic renal failure
- Urinary retention
Seconary
- Hypertension
- Hypercholesterolemia
- Diabetes mellitus 2
- CAD s/p CABG [**11-18**]
- BPH
- H/o depression v. adjustment disorder
- GERD
- S/p penile implant [**2133**]
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted with altered mental status. You were found to
have a skin infection (cellulitis) that was treated with
antibiotics. You have another rash called prurigo caused by
scratching. You were also noted to have a fast heart rate, but
there was no abnormality found on various tests, including an
echocardiogram. This resolved on its own. Your diarrhea is also
improving, your anemia is stable, and your kidney function is at
baseline. Please be sure to stay well hydrated. Lastly, you were
noted to have urinary retention. You will be discharged with a
Foley catheter with leg bag and will need to follow up with
Urology for further evaluation.
The following changes were made to your medications:
- Take Keflex for a total of 14 days for cellulitis
- Use Sarna and bactroban for prurigo
- Take Iron for anemia
- Take thiamine, folate, and multivitamins
- Take Immodium (OTC) as needed for diarrhea
- Amitryptiline and wellbutrin discontinued, restart as
instructed by your doctor
- Lasix discontinued, to be restarted by your doctor.
Please take all other medications as prescribed.
Please call MassHealth and notify them of your PCP [**Name Initial (PRE) **]. For
billing purposes, the MassHealth attending name is Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**].
The address is [**Location (un) **]. The phone number is
[**Telephone/Fax (1) 250**].
Please call your doctor or come to the ED if you develop fevers
> 100.4, confusion, worsening skin infection, abdominal pain,
inability to produce urine, chest pain, dizziness, or other
concerning symptoms.
Followup Instructions:
You are scheduled to see your new PCP at [**Hospital1 **], Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on [**2136-11-27**] @ 2:30 pm. You will need follow up with with
him/her regarding your kidney function, anemia, diabetes
control, and cellulitis. Your doctor [**First Name (Titles) **] [**Last Name (Titles) 48988**] to refer you to
see a psychiatrist. He/she may also refer you to a diabetes
specialist. Please call the [**Hospital6 733**] Clinic at
[**Telephone/Fax (1) 250**] with any questions.
You will also need to follow up with Urology for further
evaluation of your urinary retention. You are scheduled to see
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Das on [**2136-12-5**] at 8:30am. Until then, you will
need to keep your Foley catheter in place. Please call the
office at [**Telephone/Fax (1) 921**] if you have any questions.
|
[
"403.10",
"790.93",
"276.51",
"788.20",
"349.82",
"584.9",
"250.02",
"682.3",
"276.2",
"585.9",
"280.9",
"600.01",
"530.81",
"698.3",
"276.3",
"427.89",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
20225, 20283
|
11352, 11543
|
302, 308
|
20632, 20652
|
4270, 11329
|
22292, 23183
|
2700, 2847
|
18510, 20202
|
20304, 20611
|
18184, 18487
|
20676, 22269
|
2862, 2862
|
231, 264
|
336, 2210
|
2876, 4251
|
11558, 18158
|
2232, 2428
|
2444, 2684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,997
| 124,604
|
17266
|
Discharge summary
|
report
|
Admission Date: [**2114-9-19**] Discharge Date: [**2114-9-28**]
Date of Birth: [**2050-9-4**] Sex: M
Service: VASCULAR SURGERY
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 48366**] is a
64-year-old gentleman who approximately two months ago was
admitted to [**Hospital1 18**] after ventricular fibrillation arrest
related to MI. He was quite sick with that admission and
underwent emergency cardiac catheterization with angioplasty
and stent of his coronary artery. Subsequently, he was found
to have a 7 cm abdominal aortic aneurysm as well as bilateral
common iliac artery aneurysms. He presented on [**2114-9-19**] for
elective repair of these defects.
CT scan of the abdomen and pelvis on [**2114-9-7**] revealed a 7 by
7 infrarenal abdominal aortic aneurysm extending beyond the
aortic bifurcation to both common iliac arteries.
Preoperative chest x-ray on [**2114-9-12**] showed no radiographic
evidence of active cardiopulmonary disease. Preoperative EKG
showed sinus rhythm and a prior inferoposterior myocardial
infarction; compared to previous tracing to [**2114-6-22**] there
have been resolution of the inferior ST segment elevation and
lateral ST segment depression and posterior ST segment
depression. Otherwise, no diagnostic interim change.
HOSPITAL COURSE: On [**2114-9-19**], the patient was taken to the
Operating Room for elective repair of a 7 cm abdominal aortic
aneurysm as well as bilateral common iliac artery aneurysms.
The surgeon was Dr. [**Last Name (STitle) 1476**]. The assistant was Dr.
[**Last Name (STitle) 48367**]. The aortic aneurysm was found to be large and
fusiform. The common iliac aneurysms were also large and
fusiform, the larger being on the right side about 5 cm in
diameter. See operative report for detailed account of
aneurysm repair. The estimated blood loss in the OR was 5
units. The patient was resuscitated with 15 liters of
crystalloid, 2 units of bank blood and 2 units of CellSaver
blood. The patient was making urine at the end of the
procedure. No hypotension noted during the case.
The patient was taken to the PACU in good condition. In the
Recovery Room, the patient developed EKG changes with drop in
cardiac output, although remained hemodynamically stable. On
postoperative day number one, the patient was noted to have
fluid egress from the lower portion of his incision. The
incision site was examined. It was found that he had
evidence of omentum insinuating between the staples.
The patient had an abdominal dressing reapplied and was taken
to the OR for repair of wound dehiscence. The patient was
taken to the OR and retention sutures were placed after
repair of the dehiscence. That morning, postoperative day
number one, the patient was ruled in for a myocardial
infarction, although it did not compromise his hemodynamic
status in the Recovery Room or during anesthesia for repair
of the wound dehiscence.
The patient was taken to the ICU where he remained intubated
and sedated. Aggressive volume resuscitation was undertaken
and cardiology consult was obtained. The patient was put on
heparin IV 1,600 units per hour. cardiac enzymes were cycled
and were noted to be trending downwards. However, the EKG
still noted to have some ST changes. Sedation was
accomplished by a propofol drip and Fentanyl. Hands were
restrained for airway safety.
On postoperative day number two from the wound dehiscence
repair, the patient was started to be weaned off the
ventilator. IV heparin was continued and the patient was
transfused 1 unit of blood. Propofol was weaned off on the
morning of [**2114-9-24**]. The patient was tolerating
p.r.n. Fentanyl, Ativan, and Haldol in small doses for
sedation and pain control.
On [**2114-9-24**], the patient was extubated. On [**2114-9-26**], the
patient was transferred to the Vascular Intensive Care Unit.
The patient's stay in the VICU was unremarkable. The patient
was transferred to the floor on [**2114-9-27**].
On the floor, the patient had no issues, was ambulating well
with PT assistance and without assistance, tolerating p.o.
diet well. The pain was well controlled. The central line
was taken out on [**2114-9-27**] as well as Foley. The patient
voided well after discontinuing Foley on [**2114-9-27**]. The
patient was taken off of Telemetry on [**2114-9-27**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Aortoiliac aneurysm.
2. Perioperative myocardial infarction.
3. Wound dehiscence.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Famotidine 20 mg p.o. b.i.d.
4. Zolpidem tartrate 5 mg p.o. q.h.s.
5. Lisinopril 10 mg p.o. q.d.
6. Atorvostatin 10 mg p.o. q.d.
7. Colace 100 mg p.o. b.i.d.
FOLLOW-UP: The patient is to follow-up with cardiology for
possible cardiac catheterization in the future. The patient
is to follow-up with Dr. [**Last Name (STitle) 1476**] in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2114-9-28**] 11:12
T: [**2114-9-28**] 11:37
JOB#: [**Job Number 48368**]
|
[
"410.21",
"442.2",
"441.4",
"998.31",
"E878.2",
"414.01",
"V45.82",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.61",
"38.44",
"38.93",
"39.25",
"39.57"
] |
icd9pcs
|
[
[
[]
]
] |
4549, 5234
|
4437, 4526
|
1309, 4353
|
4378, 4416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,699
| 110,471
|
15937
|
Discharge summary
|
report
|
Admission Date: [**2187-8-22**] Discharge Date: [**2187-8-27**]
Date of Birth: [**2149-6-25**] Sex: M
Service: Medicine and Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old
male who presented with a 3-day history of nausea, vomiting,
coffee-grounds emesis, and dark stools.
Of note, the patient has a history of ethanol abuse and
presented with similar symptoms approximately one month prior
in [**2187-5-21**]. An upper gastrointestinal series at that
time revealed 2+ esophageal varices and 4+ gastric varices.
The patient presented to an outside hospital in Excitor, [**Location (un) 7498**] on [**2187-8-21**]. Upon presentation the patient
was noted to be orthostatic with a hematocrit of 27.4. He
required 4 units of packed red blood cells as well as fresh
frozen plasma. An urgent endoscopy was performed which
showed findings of gastric varices in the stigmata of a
recent hemorrhage. At that time, he was banded five times.
The patient was transferred to [**Hospital1 188**] for evaluation of a transjugular intrahepatic
portosystemic shunt procedure.
Also of note, the patient has a history of ethanol abuse. He
quit approximately two months ago (in [**Month (only) 205**]). He has a
previous 20-year history of ethanol abuse. He started
drinking vodka again (approximately four to five drinks per
day) about two weeks prior to admission. Also of note, prior
to admission the patient had a 4-day history of a toothache
as well as left jaw swelling. He started ibuprofen for this.
He was noted to have fevers to approximately 102 with
associated chills prior to admission.
PAST MEDICAL HISTORY:
1. Ethanol abuse.
2. History of upper gastrointestinal bleed; the first was in
[**2187-5-21**].
3. History of gout.
4. History of psoriasis.
5. History of [**Location (un) 931**] rod placed in [**2166**] for scoliosis.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father has a history of colonic polys,
alcohol abuse, and seizures associated with withdrawal, and
cirrhosis. Mother has a history of ethanol abuse.
SOCIAL HISTORY: The patient is married with no children. He
works as a self-employed computer consultant. He is a
nonsmoker and denies intravenous drug abuse. He has a
history of cocaine abuse in the distant past. He has a
history of alcohol abuse as noted above. He has
approximately a 20-year drinking history and recently quit
two months ago, but restarted within the past two to three
weeks prior to admission drinking about four to five drinks
on routine.
PHYSICAL EXAMINATION ON PRESENTATION: In general, on
admission to [**Hospital1 69**], the
patient was in no acute distress. Temperature was 99.6,
pulse was 64, blood pressure was 154/74, breathing at a rate
of 21, saturating 99% on room air. Head, eyes, ears, nose,
and throat revealed pupils were equally round and reactive to
light. Extraocular muscles were intact. The oropharynx was
notable for extremely poor dentition. Sclerae were
anicteric. The neck was supple with no appreciable jugular
venous distention. The patient had a spider angiomata on the
nose. The lungs were without crackles. The heart was
regular in rate and rhythm. The abdomen was soft and
nontender with slight distention. There was no clubbing,
cyanosis, or edema. On neurologic examination, the patient
was alert and oriented times three. No appreciable asterixis
was seen on examination.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 8.2, hematocrit
was 31.7, platelets were 128. Chemistry-7 revealed sodium
was 138, potassium was 3.7, chloride was 101, bicarbonate
was 23, blood urea nitrogen was 8, creatinine was 0.7, and
blood glucose was 90. AST was 61, ALT was 31, amylase
was 60, lipase was 27, total bilirubin was 1.6, alkaline
phosphatase was 101. PTT was 35.3 and INR was 1.5.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient presented with a history
of upper gastrointestinal bleed in [**2187-5-21**] and repeat
upper gastrointestinal bleed upon this admission in [**2187-8-21**]. At the outside hospital, he had received banding
times five, and an Octreotide drip was started.
The patient received a transjugular intrahepatic
portosystemic shunt procedure on [**2187-8-24**] and
tolerated the procedure well. The ultrasound showed that the
transjugular intrahepatic portosystemic shunt was patent.
The velocity within the transjugular intrahepatic
portosystemic shunt ranged from 80 cm/sec to 140 cm/sec. The
velocity within the portal vein was 32 cm/sec. The left and
right portal veins were patent.
In addition, the patient was started on ciprofloxacin for a
10-day course for spontaneous bacterial peritonitis
prophylaxis. A liver biopsy was also sent during the
transjugular intrahepatic portosystemic shunt procedure; the
results of which was still pending at the time of discharge.
Also, for the esophageal and gastric varices, the Octreotide
drip started at the outside hospital was continued. In
addition, Protonix was continued as well.
After the transjugular intrahepatic portosystemic shunt
procedure, lactulose was started, and the patient was
instructed to titrate the lactulose to approximately three
bowel movements per day to avoid increased encephalopathy
which could be associated with the transjugular intrahepatic
portosystemic shunt procedure.
Hepatitis serologies were also sent which showed hepatitis A
antibody positive, hepatitis B surface antigen negative,
hepatitis B surface antibody positive, and hepatitis C virus
antibody negative.
The patient's hematocrit was stable during the hospital
course, and he did not require further transfusions.
Alpha-fetoprotein levels were sent, and the alpha-fetoprotein
level was 5.4.
2. DENTAL: During this hospitalization, the patient was
seen by the Dental Service given his history of poor
dentition. A Panorex film was performed which showed on
tooth #21 there was very apical pathology and multiple caries
on multiple teeth including #4, #6, #7, #8, #9, #10, #11,
#13, #15, #28, #30, #31, and #32. The assessment at this
time was the #21 tooth showed residual signs of a recent
acute infection. The patient was started on clindamycin
given these findings for the infection.
3. PSYCHIATRY: The patient has a history of ethanol abuse.
During this hospital course, the patient was hemodynamically
stable and did not show any signs or symptoms of ethanol
withdrawal. He was placed on a CIWA scale but did not
require any Valium for a CIWA scale.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with Dentistry. The patient
was given the name of a dentist at the [**Hospital6 1130**] Emergency Clinic. If he were to choose to follow up
there, he could follow up telephone number [**Telephone/Fax (1) 45690**]. In
addition, the patient has arranged to follow up with a
dentist closer to his house two days after discharge for
further evaluation of his teeth.
2. He was also to follow up with [**Hospital 3585**] Clinic as well.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed; status post transjugular
intrahepatic portosystemic shunt procedure.
2. History of ethanol abuse.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Iron 325 mg p.o. q.d.
3. Nadolol 40 mg p.o. q.d.
4. Clindamycin 600 mg p.o. q.8h.
5. Ciprofloxacin 500 mg p.o. b.i.d. (times six days).
6. Lactulose 30 mL to 45 mL p.o. q.6-8h. (to titrate to two
to three bowel movements per day).
DR.[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 12.697
Dictated By:[**Last Name (NamePattern1) 45691**]
MEDQUIST36
D: [**2187-8-27**] 16:43
T: [**2187-8-30**] 14:33
JOB#: [**Job Number 45692**]
|
[
"456.20",
"571.2",
"274.9",
"401.9",
"572.3",
"285.1",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
1952, 2103
|
7199, 7333
|
7359, 7914
|
3934, 6580
|
7094, 7178
|
6600, 7079
|
198, 1650
|
1672, 1935
|
2120, 3916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,692
| 126,075
|
11027
|
Discharge summary
|
report
|
Admission Date: [**2120-9-1**] Discharge Date: [**2120-9-27**]
Date of Birth: [**2058-11-3**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone / Cefepime
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fever, hypotension.
Major Surgical or Invasive Procedure:
Paracentesis [**2120-9-3**], [**2120-9-9**], [**2120-9-15**], [**2120-9-19**]
CVC placed [**2120-9-1**]
PICC placed [**2120-9-4**], replaced [**2120-9-5**]
Bone marrow biopsy [**2120-9-17**]
History of Present Illness:
61yo M with history of NHL s/p autoSCT and subsequent MDS s/p
mini-alloSCT (day 0 = [**2120-3-27**]), 2 recently admissions for
neutropenic fever thought to be due to SBP/pneumonia (discharged
[**8-30**]) who was readmitted [**9-1**] with fever/hypotension initially
to the for levophed gtt and +10 L IVF and DLI stem cells on
[**2120-9-3**]. While in the ICU he had a 27 beat run of monomorphic
VT. He had an ECHO that showed EF 30% c/w NYHA heart failure
class [**Last Name (LF) 1105**], [**First Name3 (LF) **] likely need an ICD in the future. He was
transferred out of the ICU [**2120-9-4**] but had to be transferred
back for hypotension/tachycardia, rising WBC count, fevers. In
the ICU he was started on meropenum, completed vanco x 10d, was
bolused for hypotension, net +6L (approx.) and had a
paracentesis removing 6L. He currently feels very weak and
swollen with edema though his abdomen is less full. He notes
pain of his scrotum, around his foley catheter, and on his back.
He denies fevers, chills, chest pain, shortness of breath,
nausea, vomitting, head ache or leg pain.
Past Medical History:
ONCOLOGY HX:
- [**1-/2115**] Initial dx with non-Hodgkin's lymphoma, presented with L
cervical area adenopathy, bx showed immunoblastic B-cell
non-Hodgkin's lymphoma with an extremely high proliferation
fraction of over 90%. Staging workup showed disease in the left
neck and mediastinum as well as the hilar regions and mesentery.
His bone marrow was negative at that time. No B symptoms, though
LDH was elevated.
- CHOP x 6 cycles, though with continued disease in mediastinum,
supraclavicular, and mesenteric areas.
- RIME x 3 cycles in preparation for auto SCT, with stem cell
collections following the third cycle.
- FDG scan showed persistent avidity in the anterior cervical
lymph node chain as well as the mid abdominal area. Therefore
completed consolidative XRT with an involved field boost to the
anterior cervical nodes and epigastric area and then proceed
with high-dose chemotherapy.
- [**1-17**] Autologous SCT
- 4 weeks posttransplant of Rituxan
- XRT to L abdomen for faint residual uptake in the left
abdomen, after which the avidity resolved and he was in
remission.
- [**9-21**] at routine follow-up PET scan noted a calcified
mesenteric mass on increased FDG avidity. Abd CT showed a
mesenteric mass in the LUQ highly suggestive of tumor.
- [**2119-11-29**] he underwent surgery with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **],
biopsy revealed extensive scar tissue with no evidence for
carcinoid or lymphomatous involvement.
- Also persistent anemia: bone marrow from [**2119-10-13**] revealed
mild dysplastic features with no evidence for lymphoma but with
chromosome abnormalities consistent with MDS. Given the
worsening refractory anemia, the plan was for non-myeloablative
allogeneic stem cell transplant
- [**2120-2-23**] repeat bone marrow showed blasts of up to 9% in the
aspirate smear
- [**2120-3-27**]: underwent non-myeloablative MUD allo SCT with Campath,
fludarabine, and Cytoxan.
- [**6-22**]: Recent bone marrow with unfortunate evidence for
recurrent myelodysplasia
.
PMH:
1. Hodgkin's lymphoma/MDS: as above
2. Hypothyroidism: on replacement therapy
3. OSA: on CPAP.
4. DM2: diagnosed [**2111**], some baseline neuropathy, receives
insulin in TPN
5. Exposure to [**Doctor Last Name **] [**Location (un) **] in the [**Country 3992**] war.
6. Atrial fibrillation: asymptomatic, s/p DCCV in [**2115**], on rate
control
7. CHF: EF 45 %
Social History:
married, very supportive wife, [**Name (NI) **] EtOH, denies tobacco and
illicit drugs
Family History:
noncontributory
Physical Exam:
VS: T: 98.7; HR: 135; BP: 85/58; RR: 20; O2: 98 2L; I/O
2753/3475
Gen: laying in bed speaking, cachectic. in full sentences in NAD
HEENT: Dry MM. Sclera anicteric. EOMI.
Neck: Flat JVD 8 cm
CV: Tachycardic, S1S2. No M/R/G
Lungs: decreased BS at bases 1/4 up, otherwise clear
Abd: +mild distention. soft, nt.
GU: +scrotal edema
Back: could not be examined
Ext: [**3-22**] + pitting edema up legs/thigh. DP 1+. +pitting edema in
arms b/l.
Neuro: A&O x 3.
Pertinent Results:
Admission Data:
139 | 103 | 52 AGap=15
------------- /213
5.2 | 26 |1.8
Comments: Hemolysis Falsely Elevates K
Hemolyzed, Moderately
\ 10.8 /
19.3 D ------- 73
/ 32.2 \
N:42 Band:0 L:12; M:32 E:0 Bas:0 Blasts: 14
bone marrow [**8-29**]: CD34 positive blasts comprise 6% of total
events.
.
[**8-16**] peritoneal fluid - 1+ PMNS, no orgs, fluid/anaerobic/fungal
cx negative; cytology negative
[**8-19**] CMV VL - not detected
[**8-19**] urine cx - <10,000 org
[**8-19**] blood cx - neg
[**8-19**] stool cx - Cdiff neg, no enteric
flora/salm/shig/campylobacter
[**8-20**] blood cx - neg
[**8-21**] peritoneal fluid - gram stain neg x2, fluid/anaerobic cx
neg, no AFB seen on direct smear; cytology negative
[**8-22**] stool cx - neg for Cdiff
[**8-27**] CMV VL - pending
[**8-27**] blood cx - pending
[**8-28**] adenosine deaminase negative
.
Discharge Data:
[**9-1**], [**9-3**] blood cx NGTD, stool from [**9-2**] negative
[**9-2**] cath tip culture neg
[**9-6**] galactomanin neg, beta glucan/ehrlichia pending
[**9-6**] sputum contaminated with upper airway secretions, neg PCP
[**9-6**] mycolitic cultures negative
[**9-7**] stool c.diff neg x3
[**9-8**] sputum contaminated with upper airway secretions
[**9-8**] urine negative
[**9-9**] stool c.diff neg
[**9-9**] Ascites Chemistry-Protein 1.2, Glucose 175, LDH 107,
TotBili: 0.3
Albumin: <1.0, WBC 16, RBC 39, Poly 7, Lymph 2, Mono 0, Macroph:
91; Gram stain neg, culture pending
ECHO [**2120-9-4**]:
A large left pleural effusion is present. The left atrium is
normal in size. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. There is moderate
global left ventricular hypokinesis (ejection fraction 30-40
percent). Tissue velocity imaging demonstrates an e' of
<0.08m/s c/w an elevated left ventricular filling pressure
(>12mmHg). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size is normal. Right ventricular systolic function is
borderline normal. The ascending aorta is moderately dilated.
There are focal calcifications in the aortic arch. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
.
CXR ([**9-11**]): Moderate volume left pleural effusion has been
stable since [**9-4**] and atelectasis at the medial aspect of the
left lower lobe has improved. Right lung grossly clear. Heart
size normal. Tip of the right subclavian line projects over the
lower third of the SVC. No pneumothorax.
.
CT abdomen/pelvis ([**9-15**]): 1) Large 5.4 x 3.8 cm calcified
central mesenteric mass with spoke wheel retraction of the
adjacent mesenteric fat. This mass is not significantly changed
from [**2120-8-5**]. Differential would include carcinoid, sclerosing
mesenteritis, desmoid, and/or treated lymphoma. Correlate with
clinical history.
2) Large amount of abdominal and pelvic ascites, large left and
moderate right pleural effusions (increased from the prior CT),
moderate pericardial effusion, and anasarca.
3) Small nonobstructing renal calculi bilaterally.
4) Lesion involving the lower pole of the left kidney not well
evaluated on this noncontrast study.
5) Minimally prominent loops of small bowel just proximal to the
mesenteric mass; without evidence of obstruction at this time.
No free intraperitoneal air.
.
Peritoneal fluid ([**9-15**]): NEGATIVE FOR MALIGNANT CELLS.
Rare mesothelial cells and inflammatory cells
.
ECG ([**9-15**]): Sinus tachycardia. Occasional ventricular premature
beats. Diffuse low voltage. Compared to the previous tracing of
[**2120-9-11**] occasional ventricular premature beats are new. No other
significant change.
.
CXR ([**9-16**]): No change in comparison to the prior study. Left
pleural effusion and atelectasis of the left lower lobe is
stable.
.
Bone marrow biopsy ([**9-17**]): Acute monocytic leukemia (FAB-M5b)
evolving from myelodysplastic syndrome.
.
Peritoneal fluid ([**9-19**]): NEGATIVE FOR MALIGNANT CELLS.
A few mesothelial cells and inflammatory cells.
.
WBC reached a high of 49,300; on [**9-25**], WBC 14,000 with 15%
blasts, Hct 31.1, Platelets 85,000, ANC 3720
Please see OMR for further details on laboratory studies
Brief Hospital Course:
Mr. [**Known lastname 35695**] is a 61 year old male with a history of Non-Hodgkin's
lymphoma status post auto stem cell transplant and subsequent
myelodysplastic syndrome status post mini-allo stem cell
transplant (day 0 = [**2120-3-27**]), with sclerosing peritonitis
secondary to radiation with recent admissions for neutropenic
fever thought to be due to SBP or pneumonia, who was readmitted
with fever and hypotension. He was moved to the BMT floor
hemodynamically stable with large volume ascites and was made
CMO on [**9-25**] due to persistence of peripherally circulating blasts
as well as massive ascites.
.
# MDS --> leukemia: The patient's hematocrit and platelets
remained stable, but he was transfused for hct <25, plt <10. The
patient was kept on prednisone 2.5 mg, which was his home dose.
A bone marrow biopsy on [**8-29**] demonstrated CD34 positive blasts
comprise 6% of total events. During his admission, we were
awaiting benefit from DLI which he had on [**9-3**] but it was made
clear to the family that no further intervention would
significantly change his hematologic malignancy. A repeat marrow
done [**2120-9-13**]->aspirate results show 64% monocytes and peripheral
smear shows 10% monos->acute monocytic leukemia M5B. After a
long discussion with Dr. [**First Name (STitle) **] at that time, the patient and
family agreed to continue current measures but not to escalate
care greatly with a hope for the DLI to take effect. The patient
did receive hydroxyurea starting on [**9-18**] for escalating white
counts with a decrease in his WBC count from 49.3 to 14.
Allopurinol given as well. As the patient was seemingly
uncomfortable for several days, he was made comfort measures
only on [**9-25**] per Dr. [**First Name (STitle) **] in lengthy discussion with family. At
that time, he was placed on a morphine drip. He passed away on
[**2120-9-27**].
.
# Fever: The patient had been afebrile throughout the majority
of his hospitalization. He did spike a temperature on [**2120-9-17**] to
>99 axillary. Blood cultures at that time were negative. His
urine was positive for leukocytes but no WBCs seen, some yeast
forms. A CXR was negative, and he had no diarrhea. He did have
multiple potential sources of fever including ascites, recurrent
left pleural effusion and indwelling PICC. PICC was removed on
admission, replaced with CVC [**9-1**], then replaced [**9-5**] with PICC.
He did receive meropenum ([**9-6**]), vanco ([**9-1**] - intermittently
dosing due to increased Cr), on acyclovir([**9-1**] - holding due to
increased Cr). Caspofungin was started on [**9-16**]. These were
discontinued on [**2120-9-26**] when the patient was made CMO.
.
# Aanasarca & ascites: The patient did have continuing massive
edema despite paracentesis, also with low albumin. We did
monitor BP closely, but avoided fluid boluses as was possible
due to fluid third-spacing. A cortisol stim test on [**9-22**] did not
demonstrate hypoadrenalism. The patient also received TPN. He
did have a therapeutic paracentesis on [**9-15**] and on [**9-19**] for
symptom relief; 6L removed and patient with much improved pain
and dyspnea.
.
# CHF: By ECHO NYHA class 3.
.
# Scrotal Edema: The patient did have a foley in place. We
elevated his scrotum, and applied bacitracin and lidocaine jelly
to the urethral meatus TID. He did have a PCA prior to a
morphine drip for pain control. He also received pyridium and
detrol as well as urojet to the foley itself.
.
# CKD: His creatinine remained stable at 1.5.
.
# HYPOTHYROIDISM: TSH elevated on last check, ? sick euthyroid.
He was continued on levothyroxine at 50mcg daily.
.
# FEN: TPN was discontinued on [**9-26**].
.
# ACCESS: He did have a right PICC line in place.
.
# CODE: CMO
Medications on Admission:
Levothyroxine 50 mcg qday
Pantoprazole 40 mg qday
Lisinopril 2.5 mg qday
Bisacodyl 10 mg po/pr prn
calcium replacement IV scale
Colace 100 mg [**Hospital1 **]
Potassium phosphate sliding scale
Potassium chloride sliding scale
Prednisone 2.5 mg PO DAILY
levaquin 500 mg IV q24
fluconazole 200mg PO q24
acyclovir 400mg po q12
Discharge Medications:
Patient has expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute myelogenous leukemia, evolving from MDS which was
secondary to treatment for NHL secondary to [**Doctor Last Name **] [**Location (un) **]
exposure
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2120-11-19**]
|
[
"427.1",
"038.9",
"995.92",
"785.52",
"V15.89",
"244.9",
"425.4",
"996.85",
"205.00",
"250.00",
"780.57",
"584.9",
"789.5",
"V10.79",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.09",
"99.15",
"41.31",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
13374, 13383
|
9212, 12954
|
308, 500
|
13580, 13589
|
4672, 9189
|
13641, 13676
|
4166, 4183
|
13329, 13351
|
13404, 13559
|
12980, 13306
|
13613, 13618
|
4198, 4653
|
249, 270
|
528, 1618
|
1640, 4045
|
4061, 4150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,965
| 160,129
|
40578
|
Discharge summary
|
report
|
Admission Date: [**2197-10-2**] Discharge Date: [**2197-10-11**]
Date of Birth: [**2129-6-20**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**2197-10-2**]
1. Lateral lumbar fusion L45
[**2197-10-5**]
Posterior interbody fusion L5, S1.
Interbody biomechanical device L5, S1.
Posterolateral fusion T10-S1.
History of Present Illness:
Sheis a generally healthy 67 uear old female who was diagnosed
with scoliosis in adolescence. She has back pain for which she
underwent physical therapy without significant relief. She has
undergone prolonged multiple course of care at pain management
center including infections and radiofrequency ablation. Pain is
significant at rest however no significant leg pain.
Past Medical History:
HLD, HTN, MVP, Hypothyroidism, fibromyalgia
Social History:
see H7 P
Family History:
NC
Physical Exam:
Alert and cooperative
No spinal tenderness or deformity
No root tension signs (SLR and FST)\
Tone is normal
Power [**6-8**] in BUE and BLE except
Reflexes are normal
Babinski's reflew is negative
[**Doctor Last Name 937**] negative
SILT in BUE and BLE
Pertinent Results:
[**2197-10-8**] 12:12PM BLOOD WBC-9.7 RBC-3.15* Hgb-10.3* Hct-29.3*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.5 Plt Ct-219
[**2197-10-8**] 12:12PM BLOOD Plt Ct-219
[**2197-10-8**] 12:12PM BLOOD Glucose-118* UreaN-14 Creat-0.6 Na-139
K-3.4 Cl-96 HCO3-33* AnGap-13
[**2197-10-8**] 12:12PM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.6# Mg-1.7
[**2197-10-6**] 09:29AM BLOOD Type-ART pO2-140* pCO2-40 pH-7.43
calTCO2-27 Base XS-2
[**2197-10-6**] 09:29AM BLOOD Glucose-175* K-3.9
[**2197-10-5**] 05:03PM BLOOD Hgb-11.4* calcHCT-34
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedures. First
procedure was done on [**10-2**] and second on [**10-5**]. Refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. . Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet. She still requires assistance to get
OOB. Pain is mild to moderate.
Medications on Admission:
Amitryptyline, Calcium, Diclofenac, DIOVAn HCT, Klor-Con,
Levothyroxine, Metoprolol, restasis, Salmon oil, Simvastatin,
Thera tears
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for rash/ irritation.
11. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours) as needed
for pain.
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*0*
12. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] ().
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Degenerate lumbar disease.
2. Progressive scoliosis with instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Requires assistance
Discharge Instructions:
You have undergone the following operation: Lateral lumbar
interbody fusion L45 and Posterior lumbar fusion for
degenerative scoliosis
Immediately after the operation:
- Activity: You should not lift anything greater than 10
lbs for 2 weeks. You will be more comfortable if you do not sit
or stand more than ~45 minutes without getting up and walking
around.
- Rehabilitation/ Physical Therapy:
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 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 while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- 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 with Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] ([**Telephone/Fax (1) 9769**]) 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.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
See instructions
|
[
"276.69",
"401.9",
"729.1",
"278.00",
"424.0",
"338.18",
"477.9",
"244.9",
"250.00",
"V85.34",
"737.30",
"722.52",
"530.81",
"272.4",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.05",
"80.51",
"81.63",
"81.06",
"84.51",
"84.52",
"00.94"
] |
icd9pcs
|
[
[
[]
]
] |
4714, 4786
|
1823, 2801
|
319, 487
|
4902, 4902
|
1286, 1800
|
7691, 7711
|
995, 999
|
2983, 4691
|
4807, 4881
|
2827, 2960
|
5047, 5183
|
1014, 1267
|
7591, 7618
|
7640, 7668
|
6975, 7573
|
5217, 5441
|
270, 281
|
5950, 6964
|
515, 886
|
4917, 5023
|
908, 953
|
969, 979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,814
| 160,644
|
47372
|
Discharge summary
|
report
|
Admission Date: [**2167-11-16**] Discharge Date: [**2167-11-22**]
Date of Birth: [**2111-1-19**] Sex: F
Service: MEDICINE
Allergies:
Depakote
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 year old female with DM, CRI, diastolic HF, 2+AR, 2+MR, from
nursing home, who presents with 1 day tachypnea, hypoxemia with
O2Sat initially 88%, then progressed despite lasix/zaroxyln and
nebulizer treatment. In ED, RR 30, 92% 3liters with nebulizer,
lasix, and prednosine. Later patient noted to have acute HTN
with SBP 200s with acute increased O2 requirement ond
respiratory distress. Patient given nitro drip, and IV lasix
(160mg-->>2.4liters out), hydralazine and morphine for presumed
acute CHF. Patient ABG was 7.30/33/471 on 100% NRB. Patient put
on 3 hour trial CPAP then weaned to weaned to NRB. Patient
currently on nasal cannula. Course further complicated by AMS,
somnolent + transient hypoglycemia. Patient given D50, Narcan,
and negative Head CT. She was transfused 1 unit PRBC and given
HCO3 drip for nonGAP acidosis. Patient transferred to MICU for
management of hypoxia, tachypnea, acute renal failure, altered
mental status, with initial presentation most consistent with
decompensated CHF. In the unit patient was weaned from NRB mask
to nasal cannula. Chest xray suggests more a pneumonitis than
CHF.
Past Medical History:
DM2
Chronic Pancreatitis
GERD
COPD
s/pCCY
Roux en -Y
R hip Fx
CRI
Past ETOH abuse
Social History:
She lives alone. She works in a nursing
home. She has a daughter who lives in [**Name (NI) 108**], also named
[**Name (NI) **]. She smokes cigarettes actively and drinks approximately
one to two drinks per week with a prior history of abuse.
Family History:
Noncontributory.
Physical Exam:
VS: T 98.9 P 110 BP 138/70 O2sat 99% 4L nasal cannula
Gen: NAD, lethargic
Heent: Pupils dialated, poorly reactive. EOMI, Oral pharynx
clear. No teeth.
Lungs: + crackles bilaterally
Cardiac: Tachycardic, regular rhythm S1/S2 no murmur
Abd: soft non-tender, nondistended, positive bowel sounds,
midline scar
Ext: no edema, 2+ DP on left, 1+ DP on right
Pertinent Results:
[**2167-11-16**] 07:40PM GLUCOSE-237* UREA N-56* CREAT-3.2* SODIUM-138
POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-16* ANION GAP-18
[**2167-11-16**] 07:40PM CK(CPK)-41
[**2167-11-16**] 07:40PM cTropnT-0.04*
[**2167-11-16**] 07:40PM CK-MB-NotDone
[**2167-11-16**] 07:40PM TOT PROT-7.1 IRON-12*
[**2167-11-16**] 07:40PM calTIBC-195* VIT B12-617 FOLATE-GREATER TH
FERRITIN-160* TRF-150*
[**2167-11-16**] 07:40PM URINE HOURS-RANDOM
[**2167-11-16**] 07:40PM URINE U-PEP-MULTIPLE P OSMOLAL-314
[**2167-11-16**] 07:40PM URINE UHOLD-HOLD
[**2167-11-16**] 07:23PM URINE HOURS-RANDOM
[**2167-11-16**] 07:23PM URINE HOURS-RANDOM
[**2167-11-16**] 07:23PM URINE UHOLD-HOLD
[**2167-11-16**] 07:23PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-11-16**] 06:35PM TYPE-ART TEMP-36.7 RATES-/25 O2-100 PO2-131*
PCO2-34* PH-7.28* TOTAL CO2-17* BASE XS--9 AADO2-561 REQ O2-91
INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2167-11-16**] 06:00PM GLUCOSE-68* UREA N-57* CREAT-3.3* SODIUM-145
POTASSIUM-5.8* CHLORIDE-116* TOTAL CO2-15* ANION GAP-20
[**2167-11-16**] 06:00PM CK(CPK)-44
[**2167-11-16**] 06:00PM cTropnT-0.04*
[**2167-11-16**] 06:00PM CK-MB-NotDone
[**2167-11-16**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-11-16**] 05:12PM TYPE-ART RATES-/25 PO2-138* PCO2-42 PH-7.22*
TOTAL CO2-18* BASE XS--10 INTUBATED-NOT INTUBA COMMENTS-NRB
[**2167-11-16**] 05:12PM GLUCOSE-26*
[**2167-11-16**] 02:35PM TYPE-ART RATES-40/37 TIDAL VOL-650 PEEP-9
O2-100 PO2-471* PCO2-33* PH-7.30* TOTAL CO2-17* BASE XS--8
AADO2-222 REQ O2-44
[**2167-11-16**] 11:20AM URINE HOURS-RANDOM
[**2167-11-16**] 11:20AM URINE GR HOLD-HOLD
[**2167-11-16**] 11:20AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2167-11-16**] 11:20AM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-LG
[**2167-11-16**] 11:20AM URINE RBC-[**6-25**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2167-11-16**] 10:50AM CREAT-3.3* SODIUM-143 POTASSIUM-5.4* TOTAL
CO2-14*
[**2167-11-16**] 10:50AM GLUCOSE-116* UREA N-55* CREAT-3.3* SODIUM-143
POTASSIUM-5.4* CHLORIDE-116* TOTAL CO2-15* ANION GAP-17
[**2167-11-16**] 10:50AM LD(LDH)-219 DIR BILI-0.0
[**2167-11-16**] 10:50AM ALT(SGPT)-55* AST(SGOT)-34 CK(CPK)-51 ALK
PHOS-328* AMYLASE-19 TOT BILI-0.2
[**2167-11-16**] 10:50AM cTropnT-0.03*
[**2167-11-16**] 10:50AM CK-MB-NotDone
[**2167-11-16**] 10:50AM CALCIUM-8.4 PHOSPHATE-5.0* MAGNESIUM-1.6
[**2167-11-16**] 10:50AM ALBUMIN-3.3* CALCIUM-8.8
[**2167-11-16**] 10:50AM HAPTOGLOB-222*
[**2167-11-16**] 10:50AM OSMOLAL-324*
[**2167-11-16**] 10:50AM ACETONE-NEGATIVE
[**2167-11-16**] 10:50AM WBC-9.7 RBC-2.42*# HGB-7.6*# HCT-24.3*#
MCV-101* MCH-31.5 MCHC-31.3 RDW-18.8*
[**2167-11-16**] 10:50AM NEUTS-73* BANDS-7* LYMPHS-11* MONOS-8 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2167-11-16**] 10:50AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+
[**2167-11-16**] 10:50AM PLT COUNT-228
[**2167-11-16**] 10:50AM PT-12.9 PTT-27.0 INR(PT)-1.0
[**2167-11-17**] 01:47AM BLOOD WBC-9.6 RBC-2.65* Hgb-8.0* Hct-25.9*
MCV-98 MCH-30.3 MCHC-31.0 RDW-20.6* Plt Ct-190
[**2167-11-17**] 01:47AM BLOOD Plt Ct-190
[**2167-11-17**] 04:07PM BLOOD Glucose-335* UreaN-60* Creat-3.1* Na-135
K-4.5 Cl-105 HCO3-15* AnGap-20
[**2167-11-17**] 04:07PM BLOOD Calcium-8.4 Phos-5.9* Mg-1.4*
CXR ([**2167-11-17**]): IMPRESSION: 1) More intense patchy bilateral
interstitial infiltrate with a changing appearance, more
suggestive of patchy pneumonitis than CHF.
2) New left lower lobe atelectasis or consolidation with an
adjacent small- left sided pleural effusion.
CT Chest ([**2167-11-18**]): IMPRESSION:
1. Smooth interstitial thickening with upper lobe predominance
and pleural effusions. Findings are consistent with CHF/fluid
overload. In an immunocompromised patient, diffuse infectious
processes such as PCP may also be considered.
2. Hypodense appearance of the blood consistent with anemia.
3. Air within the biliary system probably relates to prior
biliary procedure. Correlate clinically.
Echo ([**2167-11-18**]): Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). [Intrinsic
left ventricular
systolic function may be more depressed given the severity of
valvular
regurgitation.] Right ventricular chamber size and free wall
motion are
normal. There are simple atheroma in the proximal descending
thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. Mild to moderate ([**1-16**]+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-16**]+)
mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be
quantified. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild-moderate aortic regurgitation. Mild-moderate
mitral
regurgitation. Preserved global and regional biventricular
systolic function.
Compared with the prior report (tape unavailable for review) of
[**4-19**], the
findings are similar.
Brief Hospital Course:
A/P: Patient 56 year old female with DM2, CRI, COPD, diastolic
HF, and 2+AR/2+MR admitted to MICU from nursing home, who
presents with 1 day history of tachypnea, hypoxemia with O2Sat
88%, and concern for respiratory failure.
--Respiratory distress
Most likely multifactorial, but believed to be predominantly CHF
in the setting of diastolic heart failure and flash edema due to
acute HTN (SBP in 200s). In the MICU treated for CHF
exacerbation and given IV lasix with good effect. Afterload
reduction/BP control with Hydralazine, Isosorbide Dinitrate, and
Labetolol. Further review of CXR suggested atypical pnuemonia.
The patient was initially started on started on Levofloxacin and
Zosyn, but antibiotics switched to Azithromycin and Ceftriaxone
(which also covered the UTI in this patient with h/o
levo-resistant UTI). The patient was transferred from the MICU
to the floor on HD2. Chest CT on HD3 suggestive of CHF.
Retrocardiac infiltrate and evidence of emphysema also noted on
chest CT. Echo on HD3 indicated intact systolic function (EF
60%) in the setting of stable mild-mod AR and MR. Diuretics held
due elevated creatinine. She had good urine output w/out
diuretic and since arriving on the floor. COPD exacerbation also
considered. The patient was started on IV steroids in MICU and
wsa then put on a PO prednisone taper. She was also treated with
nebulizers and inhalers. She completed a 5-day course of
Azithromycin and Ceftriaxone. She was weaned off of O2 to room
air by HD5. Repeat CXR on HD5 showed overall improvement of CHF,
but noted a new opacity in the left lingula. On HD6 Azithromycin
and Ceftriaxone stopped and the patient was started on a 7-day
course of Levofloxacin.
--Acute on Chronic Renal Failure
CRI (baseline approx Cr 2.0?), most likely due to diabetic
nephropathy. In addition, the patient thought to have ATN during
[**4-19**] hospitalization. Her creatinine was Cr 3-3.4 during most of
this hospitalization and decreased to 2.7 on HD6. BUN (baseline
40?) increased from 55 to 70 during hospitalization. ARF during
this hospitalization might have been pre-renal in the setting of
aggressive diuretic use. Intrinsic etiologies investigated. The
patient was hyperphosphatemic (secondary to renal disease) and
treated with Tums. In addition, PTH was 277 so she was started
on Calcitriol. Dr. [**Last Name (STitle) 1366**] followed the patient in the hospital
and will follow her as an outpatient (appt scheduled for
[**2167-12-31**].
--Metabolic Acidosis
Pt had elements of AG and non-AG metabolic acidosis. AG
metabolic acidosis most likely due to uremia of ARF. Decreased
renal HC03 production in the setting of CRI +/- type IV RTA the
likely cause of non-AG metabolic acidosis. Patient was taking
HC03 as an outpatient. Her dose was doubled in the hospital.
During the hospitalization her HCO3 increased from 15 to 18.
--Diabetes Mellitus Type 2
This patient had had DM2 for approximately 25 years and had been
insulin-dependent for approx 12 years. During this
hospitalization her blood sugars have been very labile
(10s-400s). Prior records show blood sugars labile in the past.
Recent Hb-A1C 6.4, which is down from previous Hb-A1C of 9.2 in
[**7-19**]. Her outpatient dose was NPH [**12-20**]. [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult
changed her insulin regimen several times during the
hospitalization to better control blood glucose levels. On
discharge her insulin regimen was Lantus 17 units QAM and RISS.
C-peptide level and is pending. Dr. [**Last Name (STitle) 71526**], her PCP, [**Name10 (NameIs) **]
follow her DM as an outpatient.
--Blood Pressure
The patient had a SBP in the 200s on admission, which is thought
to have contributed to her pulmonary edema. During
hospitalization she had BP ranging from 100-160/50-90. Afterload
reduction/BP control with Hydralazine, Isosorbide Dinitrate, and
Labetolol. On HD6, after her creatinine decreased to 2.7,
Lisinopril was re-started (she is on this as an outpatient).
--Anemia
The patient's Hct was 24.3 on admission. She was transfused 1
unit PRBC in the MICU on HD1 and Hct increased to 25.9 on HD2.
On HD3 the Hct was 23.9 so she received 2 units PRBC on HD4 and
Hct increased to 31.1 on HD5. On HD6 her Hct was 33.6. The
patient had low iron level (12) on admission and was given
supplemental iron and vitamin C. Chronic renal disease and
anemia of chronic disease probably contributing etiologies. Pt
has been treated with Epo in the past and will re-institute Epo
(10,000 units per week) as an outpatient.
--UTI
UA on admission suggestive of UTI. The patient has a h/o
levo-resistant UTI. She was treated with Ceftriaxone for 5 days.
She has had no urinary sx.
Medications on Admission:
insulin,
lisinopril
labetolol
lasix
advair
flovent
folate
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day).
2. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**]
Puffs Inhalation Q6H (every 6 hours).
11. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO WITH MEALS ().
13. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Albuterol Sulfate 0.083 % Solution Sig: [**1-16**] Inhalation Q6H
(every 6 hours) as needed.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO
DAILY (Daily).
17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
19. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-16**] Sprays Nasal
TID (3 times a day) as needed.
20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days.
21. Insulin Glargine 100 unit/mL Solution Sig: Seventeen (17)
units Subcutaneous qam.
22. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
23. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)).
24. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO
QAM (once a day (in the morning)).
25. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
Congestive Heart Failure
Pnuemonia
UTI
Chronic Renal Failure
Discharge Condition:
Stable - Patient respiratory status stable. Patient with
chronic renal failure needs to follow up with renal doctor for
further managment, currently stable.
Discharge Instructions:
Please continue to take medications as prescribed
Please make sure you follow up with Dr. [**Last Name (STitle) 1366**] (kidney doctor);
appointment scheduled below.
Please make sure you follow up with your primary care doctor
next week; Dr [**Last Name (STitle) **] @ [**Telephone/Fax (1) 608**]
On chest xray it was found that you have a small pnuemonia.
Please continue to finish course of antibiotics as prescribes
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2167-12-31**] 4:30
(renal doctor)
Schedule appointment to see your primary care doctor next week
|
[
"491.21",
"428.0",
"530.81",
"584.9",
"428.33",
"V58.67",
"583.81",
"486",
"305.1",
"577.1",
"403.91",
"250.40",
"599.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14496, 14532
|
7496, 12195
|
291, 297
|
14636, 14795
|
2248, 7473
|
15265, 15550
|
1841, 1860
|
12303, 14473
|
14553, 14615
|
12221, 12280
|
14819, 15242
|
1875, 2229
|
232, 253
|
325, 1459
|
1481, 1565
|
1581, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,035
| 188,041
|
12377
|
Discharge summary
|
report
|
Admission Date: [**2169-3-29**] Discharge Date: [**2169-4-4**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
Russian speaking male who presented with shortness of breath
and chest pain combined with nausea and vomiting. The
patient was taken to the catheterization laboratory which
showed three-vessel disease. The patient's ejection fraction
was 45%. The patient had chest pain during the procedure and
then an intra-aortic balloon pump was inserted.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chronic bronchitis.
3. Multiple amputations of left hand.
MEDICATIONS:
1. Nitroglycerin sublingual.
2. Atenolol 50 mg p.o. three times a day.
3. Ambien.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Heart rate 60; blood pressure 140/90.
HEENT is normal. Neck with no carotid bruits. Chest:
Regular rate and rhythm. No murmurs, rubs or gallops. Lungs
are clear. Abdomen soft, nontender, nondistended.
Intra-aortic balloon pump was in place in the right groin.
HOSPITAL COURSE: The patient was admitted on [**2169-3-29**], and
underwent a coronary artery bypass graft times three with
left internal mammary artery to the left anterior descending,
saphenous vein graft to right coronary artery and saphenous
vein graft to obtuse marginal 1. The patient did well
postoperatively and was transferred to the CICU
postoperatively.
The patient was extubated and the patient's Dobutamine was
weaned to off. Postoperative day one, the patient went into
atrial fibrillation and was started on amiodarone. The
patient's Swan-Ganz catheter and chest tubes were removed on
postoperative day number two and the patient was transferred
to the Floor. On postoperative day number three, the
patient's wires were removed. The patient's Foley catheter
was removed also on postoperative day number three.
The patient's Lopressor was decreased to 12.5 mg p.o. twice a
day due to a heart rate of 60 and a low blood pressure of
92/47. The patient continued to do well and was ambulating
with Physical Therapy on postoperative day number four. As
the family felt that he could use some rehabilitation, the
patient was placed for a screen for rehabilitation. Physical
Therapy thought that this could be done as well.
Also, on postoperative day number four, it was noted that the
patient had some sternal wound drainage from the inferior
portion of his wound. The patient was started on Kefzol one
gram intravenous q. eight hours for this. The patient's
creatinine also was noted to be rising on postoperative day
number four. The patient's Lasix was changed to once a day.
On postoperative day number five, the patient's creatinine
had come down to 1.3 from 1.6. The patient continued to do
well and discharged to rehabilitation facility with plan for
[**2169-4-4**].
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. twice a day.
2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day times seven days.
3. Colace 100 mg p.o. twice a day.
4. Lasix 20 mg p.o. q. day times seven days.
5. Zantac 150 mg p.o. twice a day.
6. Aspirin 325 mg p.o. q. day.
7. Kefzol one gram intravenous q. day.
8. Alphagan 0.2% eye drops, one drop o.u. twice a day.
9. Lumigan 0.03% eye drops, one drop o.u. q. h.s.
10. Cosopt eye drops, one drop o.u. twice a day.
11. Amiodarone 400 mg p.o. three times a day times four days,
then Amiodarone 400 mg p.o. twice a day times seven days,
then Amiodarone 400 mg p.o. q. day times seven days, then
off.
12. Percocet 5/325, one to two tablets p.o. q. four to six
hours p.r.n.
DISCHARGE STATUS: Good.
DISPOSITION: Discharge is to rehabilitation facility.
DISCHARGE INSTRUCTIONS:
1. Follow-up will be in six weeks with Dr. [**Last Name (STitle) 70**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times three with
left internal mammary artery to the left anterior descending,
saphenous vein graft to obtuse marginal 1 and saphenous vein
graft to right coronary artery.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2169-4-3**] 11:41
T: [**2169-4-3**] 11:56
JOB#: [**Job Number 38544**]
|
[
"410.71",
"416.0",
"424.0",
"414.01",
"429.9",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.23",
"88.53",
"37.61",
"88.56",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3818, 4336
|
2854, 3699
|
1048, 2831
|
3723, 3797
|
764, 1030
|
112, 488
|
510, 741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,670
| 181,893
|
1300
|
Discharge summary
|
report
|
Admission Date: [**2152-11-25**] Discharge Date: [**2152-11-30**]
Date of Birth: [**2093-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
pericardial effusion
Major Surgical or Invasive Procedure:
Left side Thoracentesis
History of Present Illness:
59 yo M with CAD was diagnosed with acute pericarditis on
[**2152-11-18**] at an outside hospital. He presented with 'global' ST
elevations, pleuritic chest pain, ESR 55, CRP 155. TTE at that
time showed no effusion. He was discharged home on ibuprofen
800mg tid initially with good effect. He was also given Abx for
abnormalities on a Chest CXR/CT, although he had no clinical
signs of PNA and radiology reports described the posterior left
base opacity as likely atelectasis.
Two days after completing the 5 day course of ibuprofen 800mg
tid which he was prescribed, he developed diffuse left sided
chest pain different from his initial pleuritic pain (and not as
intense). He recalls what his stable angina felt like 10 years
ago prior to having stents placed in the proximal LAD and mid
RCA; states this is different from his angina.
Repeat ECHO done at [**Hospital1 **] showed a moderate effusion (report
not available) which had evolved within 5 days--reportedly not
concerning for tamponade. No pulsus on exam with BP
95-105/50-60. Pt was transferred to [**Hospital1 18**] for further mgt. On
arrival, neck veins wnl, BP at baseline, no pulsus, prelim ECHO
without diastolic collapse of RV.
Of note, co-synotropin testing at [**Hospital1 **] showed that pt is
adrenally insufficient s/p distant unilateral adrenalectomy
after which he never followed up with an endocrinologist.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent chills or rigors,
although felt briefly febrile on the night prior to admission.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2136**]: Palmaz-[**Doctor Last Name 8030**] sents to mid-RCA and proximal LAD for stable
angina
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Dyslipidemia
-Unilateral Adrenalectomy for [**Location (un) 3484**] Syndrome; he was told
that contralateral gland was hypoplastic, but her never followed
with endocrine regarding this. Labs at OSH notable for
inadequate co-synotropin stim.
Social History:
-Tobacco history: distant limited cigar smoking
-ETOH: no ETOH abuse
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Father and mother with CAD in 60s-70s
Physical Exam:
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : left base)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
x3, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2152-11-25**] 07:10PM PT-15.2* PTT-34.0 INR(PT)-1.3*
[**2152-11-25**] 07:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2152-11-25**] 07:10PM NEUTS-73* BANDS-0 LYMPHS-17* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2152-11-25**] 07:10PM WBC-10.4 RBC-4.03* HGB-12.3* HCT-36.3* MCV-90
MCH-30.5 MCHC-33.8 RDW-12.8
[**2152-11-25**] 07:10PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.4
[**2152-11-25**] 07:10PM CK-MB-NotDone cTropnT-0.01
[**2152-11-25**] 07:10PM ALT(SGPT)-44* AST(SGOT)-35 LD(LDH)-183
CK(CPK)-87 ALK PHOS-76 TOT BILI-0.6
[**2152-11-25**] 07:10PM GLUCOSE-104 UREA N-16 CREAT-1.2 SODIUM-133
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
Microbiology:
pleural fluid [**11-28**]:
THIS IS A CORRECTED REPORT [**2152-11-29**] 12:50PM.
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN (SMEAR REMADE).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
PREVIOUSLY REPORTED AS [**2152-11-28**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 8031**] [**Last Name (NamePattern1) 8032**] [**2152-11-28**] 7:45PM.
CORRECTIONS REPORTED BY PHONE TO DR. [**Last Name (STitle) 8033**] [**2152-11-29**]
12:50PM.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
urine cx: [**2152-11-26**]: negative
blood cx: [**2152-11-26**]: no growth to date
TELEMETRY: no events
.
ETT: Reportedly negative within last few years
.
2D-ECHOCARDIOGRAM: [**2152-11-25**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is a moderate sized
circumferential pericardial effusion without echocardiographic
evidence of tamponade physiology.
IMPRESSION: Moderate circumferential pericardial effusion
without echocardiographic evidence of tamponade physiology. If
clinically indicated, serial evaluation is suggested
.
2D-ECHOCARDIOGRAM: [**2152-11-27**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). There is a small circumferential
pericardial effusion (0.5cm around the apex, <0.5cm
inferolateral to the left ventricle and anterior to the right
ventricle. There are no echocardiographic signs of tamponade.
.
CXR: PA, LATERAL: [**2152-11-27**]
there is evidence of substantial effusion posteriorly on the
lateral view. To evaluate the amount of free pleural fluid, a
lateral decubitus view would be recommended.
Brief Hospital Course:
59 yo M w/ CAD developed pericarditis one week ago, then
developed moderate sized effusion w/o tamponade over the course
of one week.
1. Pericardial Effusion/Pericarditis: The patient had a rapid
accumulation of moderate sized effusion over the span of one
week. Etiology unknown, negative evaluation most consistent with
viral infection. Preliminary ECHO without tamponade physiology.
Pulsus remained [**7-10**]. He remained hemodynamically stable during
this admission. A repeat echocardiogram 2 days later showed
decrease in size of the pericardial effusion. He was treated
empirically with standing NSAIDs, once his renal function had
improved. At time of discharge, patient had no further
recurrence of chest discomfort, dyspnea, lightheadedness or
other symptoms consistent with pericarditis/ pericardial
effusion. Patient will follow up with outpatient cardiologist
in 3 weeks for repeat echo.
2. Pleural effusion: Although the pericardial effusion improved,
the patient was noted to have a significant left sided pleural
effusion. He underwent thoracentesis on [**11-28**], with fluid
studies revealing an exudative effusion. The gram stain was
initially reported as having 2+ GNRs and 3+ PMNs. The patient's
ceftriaxone was restarted after having been temporarily
discontinued. Several hours later, though, the microbiology lab
reported an error in their reporting, stating that nothing had
grown on culture and that there were actually no micro-organisms
seen. Ceftriaxone was discontinued, as the patient was afebrile
at this time, with no localizing signs of infection. Of note,
his breathing felt significantly easier after the thoracentesis.
3. Fevers: The patient had fevers to 101.6 during this
hospitalization. He did not have an elevated white blood cell
count. Fevers were most likely secondary to inflammation from
the pericarditis. The patient was initially treated empirically
with vancomycin and ceftriaxone to cover a purulent
pericarditis, which was later changed to ceftriaxone for the
erroneously-reported positive gram stain on the pleural fluid
(see above). Patient discharge without requirement for further
antibiotic use.
4. Possible adrenal Insufficiency: The patient was started on
replacement doses of hydrocortisone given his history of
adrenalectomy and [**Last Name (un) 104**]-stimulation test at the OSH. Endocrine
recommended that the patient take hydrocortisone 20mg qam and
10mg qpm, and follow up in the endocrine clinic.
5. Subclinical hypothyroidism: In addition, his TSH was elevated
at 10, but his free T4 was normal. He will need thyroid
function tests rechecked in [**3-6**] weeks.
Code status: The patient was confirmed full code for the
duration of the hospitalization
Medications on Admission:
Simvastatin 10'
Niacin (unsure about dose) 500'?
ASA 81'
Fish oil
Folic Acid
Vitamins
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrocortisone 10 mg Tablet Sig: Two (2) Tablet PO once a
day: Take in the morning.
Disp:*120 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
5. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO take
between 4pm and 5pm at night.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO twice a
day.
8. Niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pericarditis
Pericardial Effusion
Pleural Effusion
Anemia
Adrenal Insufficiency
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had pericarditis and a fluid collection around your heart.
This improved without needing to be drained. You also had some
fluid collections in your lungs that was tapped and cultured.
Initially it seemed the fluid was infected and you were on
antibiotics. Eventually the fluid was found not to be infected
and the antibiotics were discontinued. Your fluid collection
around your heart is improving. You will need another
echocardiogram by Dr. [**First Name (STitle) 1075**] when you see him in [**Month (only) 404**].
.
Medication changes:
1. Start Hydrocortisone 10 mg Tablets: take two in the morning
and one at night to treat your adrenal insufficiency
2. Stop taking Ibuprofen
Followup Instructions:
Primary Care:
[**Last Name (LF) 8034**],[**First Name3 (LF) 8035**] A. Phone: [**Telephone/Fax (1) 8036**] Date/time: Wed [**12-7**]
at 11:00 am.
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD Phone: [**Telephone/Fax (1) 6256**] Date/time: Friday [**12-16**]
at 11:00am.
.
Endocrine:
Shun How [**Location (un) **] Phone: Date/Time: [**2152-12-8**]
|
[
"244.9",
"420.91",
"285.9",
"272.4",
"255.41",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10643, 10649
|
7105, 9842
|
338, 364
|
10779, 10779
|
3829, 5304
|
11633, 12025
|
3038, 3163
|
9978, 10620
|
10670, 10758
|
9868, 9955
|
10924, 11448
|
3178, 3810
|
2472, 2639
|
11468, 11610
|
278, 300
|
392, 2364
|
5383, 7082
|
10793, 10900
|
2670, 2914
|
2386, 2452
|
2930, 3022
|
5336, 5347
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,726
| 190,310
|
28948
|
Discharge summary
|
report
|
Admission Date: [**2141-8-26**] Discharge Date: [**2141-9-5**]
Date of Birth: [**2097-5-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory Laporatomy
Liver Wedge Biopsy
J tube placement
Resection of Gastrojejunostomy Anastomosis
New Gastrojejunostomy Formation
History of Present Illness:
This is a 44 year old male who was transfered from [**Location (un) 5503**]
in an emergent condition. He had a 12 hour history of abdominal
pain precipitated by urinating
at 2:30 on the night prior to this operation. He went to his
local emergency room and was found to have free air and evidence
of a perforated viscus, with oral contrast extravasation on his
CAT scan. His prior medical history was
consistent with a Roux-en-Y gastrojejunostomy for morbid
obesity, performed laparoscopically 5 years ago in [**State 3908**].
Since then, he has lost 200 pounds and has decreased many of its
comorbidities. He has had a history of hard drinking in the past
and had been drinking until a few weeks ago.
He was recently admitted to the hospital following his recent
unemployment. He was found to have evidence of the liver
decompensation, as well as renal insufficiency. He was treated
for these and released from the hospital for a few
days prior to the current presentation of rigid abdominal pain
last night.
He was found to have florid peritonitis upon meeting him here at
the [**Hospital1 18**]. He was pretty well resuscitated from a volume status
and his mental status was completely intact. He required an
emergency operation to repair a perforated viscus.
Past Medical History:
Hypothyroid
Depression
Past Surgical Hx:
Gastric Bypass 5 years ago lost approximately 200lbs
Cholecystectomy
Shoulder Surgery x 4
Left Knee hematoma evacuation after motorcylce accident
Social History:
Smoking: 80 pack yr hx
ETOH: [**3-17**] alcoholic drinks/day for 20 yrs.
Poor nutrition
Family History:
Mother died from stroke at young age and history of alcohol
abuse
Father had urethral cancer and history of alcohol abuse.
Physical Exam:
VS: 99.8, HR 150, SBP 80-90, 99% 2L
Gen: Writhing in pain
Head: EOMI, PERRL
Chest: CTAB
CV: Tachy RR
GI: + tenderness diffusely, + rebound, + peritoneal signs, +
distension, + dullness inferiorly to percussion
Skin: +2 edema LE
Pertinent Results:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 69811**],[**Known firstname **] P. [**2097-5-1**] 44 Male [**-7/2767**]
[**Numeric Identifier 69812**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/et
SPECIMEN SUBMITTED: LIVER BX & GASTRO-JEJUNAL PERFORATION SITE.
Procedure date Tissue received Report Date Diagnosed
by
[**2141-8-26**] [**2141-8-28**] [**2141-9-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/cma??????
DIAGNOSIS
I. Liver, wedge biopsy (A):
1. Marked steatosis, predominantly large droplet type,
involving virtually 100% of hepatocytes.
2. Moderate, predominantly mononuclear cell, inflammation in
portal tracts and fibrous septa, with bile duct proliferation.
3. Intracytoplasmic hyaline seen, without lobular neutrophils.
4. Trichrome stain demonstrates nodule formation consistent
with cirrhosis.
5. Iron stain shows increased iron in Kupffer cells and
hepatocytes. The findings are consistent with toxic metabolic
liver injury, with progression to cirrhosis.
II. Resection of gastroenteric anastomosis (B-K):
1. Transmural perforation of the small bowel with acute
inflammatory exudate, granulation tissue, and early fibrosis.
2. The remaining small bowel is unremarkable. No features of
enteritis are identified.
3. Resection margins (small bowel and proximal stomach): No
diagnostic abnormalities recognized.
CHEST (PORTABLE AP) [**2141-8-27**] 7:43 AM
CHEST (PORTABLE AP)
Reason: position of ett after repositioning?
[**Hospital 93**] MEDICAL CONDITION:
44 year old man s/p exploratory laparotomy s/p intra-operative
right IJ CVL placement and removal and subsequent
intra-operative left IJ central line placement
REASON FOR THIS EXAMINATION:
position of ett after repositioning?
HISTORY: Check ET tube placement.
CHEST, SINGLE AP PORTABLE SUPINE VIEW.
An ET tube is present -- the tip lies above the level of the
clavicles, 9.5 cm above the carina, somewhat high. A left IJ
central line is present, tip overlying distal portion of the
left innominate vessel. An NG tube is present, tip beneath
diaphragm extending off film.
There is upper zone redistribution and diffuse vascular
blurring, consistent with CHF, similar to, but slightly worse
than, on [**2141-8-26**]. There is increased hazy opacity at the left
base with new partial obscuration of the left hemidiaphragm. No
gross effusion is identified on either side.
Old healed right-sided rib fractures noted. At the periphery of
these films, under penetrated and therefore faintly seen, or
right upper quadrant clips, skin staples, and some form of
catheter drain over the upper abdomen from an inferior approach.
IMPRESSION :
1. Mild CHF, slightly worse compared with one day earlier. New
patchy opacity left base -- question atelectasis or early
infiltrate.
2. ET tube remains above the level of the clavicles and
attempted repositioning should be considered. Left IJ line as
described.
UGI SGL W/ SBFT [**2141-9-1**] 10:30 AM
UGI SGL W/ SBFT
Reason: Want to make sure that his new Gastrojejunostomy
anastomosis
[**Hospital 93**] MEDICAL CONDITION:
44 year old man POD# 7 s/p resection and formation of perforated
gastrojejunostomy after a gastric bypass in [**2136**]
REASON FOR THIS EXAMINATION:
Please use Gastrograffin. Want to make sure that his new
Gastrojejunostomy anastomosis site is patent and that it is not
obstructed.
INDICATION: 44-year-old gentleman postop day 7 status post
revision of a gastric bypass done in [**2136**] with reformation of
gastrojejunostomy. Patient referred to evaluate
gastrojejunostomy anastomosis.
TECHNIQUE: Upper GI study. Study done using Conray. This is a
very limited study due to patient sedated on Dilaudid PCA and
Ativan prior to arrival.
FINDINGS: Conray was administered to the patient while in a
semi-upright position. Contrast passes freely through the
esophagus into the stomach. There is evidence of free reflux
with slow clearance. The stomach fills with contrast and empties
into the small bowel without difficulty. Contrast flows
antegrade and retrograde into the Roux limb of the gastric
bypass. There is no evidence of extravasation of contrast.
Gastrojejunostomy anastomosis site is patent without evidence of
leak. In the obtained images there are dilated loops of small
bowel which may represent an ileus.
IMPRESSION:
1. Gastrojejunostomy anastomosis is intact without evidence of
leak. There is no evidence of obstruction.
2. Dilated loops of small bowel concerning for ileus.
3. Limited exam due to patient sedation from narcotics and
benzodiazepine.
Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2141-8-26**] to Dr. [**Last Name (STitle) **] for
perforated viscus. The CT from Outside hospital showed free air
with contrast extravasation, and ascites. The ascites is most
likely due to cirrhosis of the liver. He was resuscitated with 4
liters and was emergently taken to the OR for an exploratory
laparotomy. He then went to the SICU post-operatively sedated
and intubated. He continued to receive fluids post-op for low
urine output. He had a PCA for pain control. He was switched to
Percocet when he was taking PO's.
GI/Abd:
He was markedly distended with a dressing in place. He had a
J-tube to gravity. His NGT was patent and draining small amounts
of bilious drainage. He was started on J tube feedings POD 2 and
slowly advanced to his goal rate. The NGT was self D/C'd POD 4.
He was tolerating a clear diet and was advanced to a regular
diet on POD 8. The [**Doctor Last Name 406**] drain, which was putting out about
1700cc daily was D/C'd POD 8, so that the fluids would be
reabsorbed.
He had +4 pitting edema to the lower extremities and had massive
scrotal swelling. His Albumin was 1.4. Most of the fluid was
third space and would gradually improve when his nutrition and
Albumin improved. Lasix was ordered for diuresis, with moderate
effect.
An UGI was performed on [**2141-9-1**] and showed the anastomosis is
intact without evidence of a leak.
His abdominal incision with staples was clean, dry, and intact.
The edges were well approximated and there was no redness. The
staples will remain in place until his follow-up appointment.
His [**Doctor Last Name 406**] tube and drain were D/C'd POD 8 and a U-stitch was
placed.
CV:
IV fluids were ordered for tachycardia and hypotension with a
good response.
Resp:
He was weaned off the vent POD 2 and doing well. He was
instructed to continue deep breathing and incentive spirometry.
ID:
He was started on Fluconazole, Zosyn, Flagyl, and Vanco. He
continued with the antibiotics until discharge.
Physical Therapy: The patient was deconditioned and had trouble
ambulating due to the large amount of edema. Physical Therapy
worked with him several times and deemed him safe to go home
with home PT.
He was started back on his home medications and discharged in
good condition.
Medications on Admission:
levoryl 0.025, oxycontin 40", K dur, aldactone 100", miralax 17
gm, wellbutrin 150', valium 10q8
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
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. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 3 weeks.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
southcaost home care services
Discharge Diagnosis:
Perforated Gastrojejunostomy
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Continue to walk several times every day.
You may shower and wash incision with soap and water. Pat dry.
No tub baths or swimming
No heavy lifting >10 lbs for 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 1231**]
for an appointment.
Please follow-up with your PCP for continued pain management.
Completed by:[**2141-9-5**]
|
[
"534.50",
"V45.3",
"571.5",
"568.89",
"997.4",
"244.9",
"567.9",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"44.39",
"45.33",
"50.12"
] |
icd9pcs
|
[
[
[]
]
] |
10623, 10683
|
7272, 9285
|
326, 462
|
10756, 10763
|
2475, 4174
|
11141, 11351
|
2088, 2212
|
9713, 10600
|
5777, 5897
|
10704, 10735
|
9592, 9690
|
10787, 11118
|
2227, 2456
|
9303, 9566
|
272, 288
|
5926, 7249
|
490, 1756
|
1778, 1967
|
1983, 2072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,083
| 150,325
|
50085
|
Discharge summary
|
report
|
Admission Date: [**2119-6-28**] Discharge Date: [**2119-7-6**]
Date of Birth: [**2051-4-24**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Retroperitoneal mass
Major Surgical or Invasive Procedure:
[**2119-6-28**] ex lap, biopsy of mass
History of Present Illness:
[**Known firstname **] is a very pleasant 68-year-old female who has had
approximately two months of right back and flank pain that
occasionally radiates to the shoulder. The pain has also been
associated with early satiety, no nausea, no vomiting. She has
had no change in bowel or bladder habits, no shortness of
breath, but just a generalized discomfort on the right side.
She has lost approximately [**10-28**] pounds over this period of
time. No jaundice, no fevers, no chills. She has had no
flushing, no diarrhea. CT of the abdomen on [**2119-6-13**] showed a
retroperitoneal mass measuring 15.8 cm, intimately associated
with the right lobe of the liver and abutting the right kidney.
Past Medical History:
HTN, h/o Gastric ulcer, migraines
Social History:
She is an ongoing tobacco smoker, probably one pack per day. No
alcohol, no drugs.
Family History:
noncontributory.
Physical Exam:
VS: 98.5, 103, 120/62, 14
General: Patient intubated and weaned off vent post op overnight
Card: RRR
Lungs: Intubated, lungs CTA bilaterally, sat 100%
Abd: Non-distended, non-tender, minimal serosanguinous drainage
on dressing
Extr: No C/C/E
Pertinent Results:
On Adission: [**2119-6-28**]
WBC-10.2 RBC-3.63*# Hgb-10.5*# Hct-30.7*# MCV-85 MCH-28.8
MCHC-34.1 RDW-13.8 Plt Ct-314
PT-13.6* PTT-29.9 INR(PT)-1.2*
Glucose-122* UreaN-8 Creat-0.7 Na-141 K-4.2 Cl-108 HCO3-26
AnGap-11
Calcium-8.8 Phos-4.2 Mg-1.7
[**2119-6-28**] 03:15PM Cortsol-29.3*
[**2119-6-29**] 05:55AM Cortsol-33.0*
[**2119-6-29**] 05:56AM Cortsol-22.0*
[**2119-6-29**] 05:56AM CEA-2.3 CA125-22
[**2119-6-29**] 01:18AM BLOOD Type-ART Temp-37.7 Tidal V-500 PEEP-5
FiO2-50 pO2-181* pCO2-39 pH-7.31* calTCO2-21 Base XS--6
[**2119-7-1**] 08:30AM BLOOD WBC-10.1 RBC-3.77* Hgb-10.6* Hct-32.7*
MCV-87 MCH-28.1 MCHC-32.5 RDW-14.0 Plt Ct-312
[**2119-7-5**] 04:45AM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-132*
K-4.3 Cl-94* HCO3-30 AnGap-12
[**2119-6-28**] Pathology specimen:(Cava Tumor)
DIAGNOSIS:
1. Tumor #2, cava (A):
Small cell carcinoma consistent with a lung primary, see note.
2. Cava tumor (B):
Small cell carcinoma consistent with a lung primary, see note.
The tumor cells are positive for TTF1, CD5/6, p63 AE1/3, CK CAM
5.2, cytokeratin cocktail and CK7. The tumor cells are negative
for LCA, CK20, Chromogranin, synaptophysin, WT-1, HepR1, CEA
unabsorbed and CD10. These findings, particularly the positive
for TTF1 and CD56 support the lung origin or a small cell
carcinoma.
Brief Hospital Course:
On [**2119-6-28**], she was taken to the OR with plan to explore the
lesions and then proceed with the resection. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Ex lap was performed noting extent of tumor. It
was deemed unresectable. Biopsy was taken of the liver/caval
tumor. Please refer to operative note for further details. She
was sent to the SICU postop for management. She was extubated
without incident. Urine output was on the low side and IV fluid
boluses were given with improved urine output. [**Last Name (un) **] stim test
revealed cortisol level of 29.3. Repeat cortisol levels was 33
and 22. She had some nausea with emesis and was given IV Zofran
with relief.
Postop, vital signs remained stable. Pain was managed initially
with IV morphine pca. This was switched to dilaudid with
improved pain control. However, she continued to experience
incision and back pain. Chronic pain service was consulted and
recommend continuation of scheduled tylenol with prn dilaudid.
Neurontin and tizanidine were added. Recommendations for
Tizanidine were 2-4mg po q 8 hours and Neurontin 300mg at HS
with increase to tid as needed. This regimen worked fairly well
to decrease her pain.
Diet was slowly advanced. She did experience some nausea and
fullness. Zofran was given initermittently. Dulcolax pr was
administered without results. Fleets enema was given with BM.
Milk of Magnesia was given on day of discharge. On day of
discharge, she was tolerating small amounts of regular food plus
supplements.
Incision remained intact, without redness or drainage. Staples
were removed and incision steri stipped on day of discharge.
She did experience cough with O2 desaturations to 85%. CXR
demonstrated bilateral
lower lung opacifications consistent with pleural effusions and
compressive
basilar atelectasis. Breath sounds were diminished on the left
base greater than the right base. . O2 nasal cannula was placed
on the patient with increased O2 sats to 92-93% on 2 liters.
During ambulation, she required a venturi mask plus nasal
cannula.
Atrius heme/onc was consulted. Recommendations were to obtain
CEA and CA [**27**]-9. Results were 2.3 and 22. Pathology report of
caval tumor demonstrated small cell carcinoma consistent with
lung primary. Recommendations for f/u treatment were with
discussed with patient and husband once recovered from surgery.
A f/u visit was set for [**7-12**].
PT assess her and recommended pulmonary rehab. On [**7-7**], she was
transferred to [**Hospital **] Rehab in [**Location (un) 53637**].
Medications on Admission:
Vicodin 1-2 tabs q6h prn pain;nifedipine 30',pantoprazole 40',
tiotropium 18mcg INH '
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Zofran 4 mg Tablet Sig: One (1) Tablet PO prn every 8 hours
as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Retroperitoneal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assist with rolling
walker (required venturi mask plus O2 8liters nasal cannula
during ambulation.
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever (temperature 101 or greater), chills, nausea,vomiting,
jaundice, increased abdominal pain/distension, incision
redness/bleeding/drainage
You may shower, but no tub baths or swimming for 6 weeks
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2119-7-13**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: TUESDAY [**2119-9-19**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2119-9-19**] 1:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2119-9-19**] 11:45
Department: Hemato-Oncology
PROVIDER:[**Name10 (NameIs) **], [**Name11 (NameIs) **]
When: WEDNESDAY [**Month (only) **] ,29, [**2119**] at 10:00AM at [**University/College **] Vangaurd
at [**Location (un) **]
Completed by:[**2119-7-6**]
|
[
"V12.71",
"197.6",
"401.9",
"198.89",
"496",
"346.90",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"54.23"
] |
icd9pcs
|
[
[
[]
]
] |
6603, 6703
|
2846, 5423
|
286, 327
|
6768, 6768
|
1524, 2823
|
7342, 8337
|
1228, 1247
|
5560, 6580
|
6724, 6747
|
5449, 5537
|
7014, 7319
|
1262, 1505
|
226, 248
|
355, 1053
|
6783, 6990
|
1075, 1110
|
1126, 1212
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,356
| 122,532
|
26995
|
Discharge summary
|
report
|
Admission Date: [**2113-11-20**] Discharge Date: [**2113-11-25**]
Date of Birth: [**2063-3-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Elevated LFTs
Major Surgical or Invasive Procedure:
cholangiogram x2
ERCP
picc line placement
liver biopsy
History of Present Illness:
Mr. [**Known lastname 34850**] is a 55 year old gentleman with hx
HIV/HCV coinfection, last CD4 134, VL UD on [**2113-11-2**], s/p recent
OLT in [**6-1**] on MMF and tacrolimus and right inguinal hernia
repair with mesh in [**10-1**] who was admitted [**11-20**] for
cholangiogram to evaluate for etiology of elevated LFTs in the
setting of increasing intrahepatic ductal dilatation on recent
CT
scan.
Past Medical History:
HIV
HCV cirrhosis
HCC s/p RFA [**3-31**] (4.5x3.4 cm
hepatoma, which was biopsy-proven hepatocellular
carcinoma (HCC).)
OLT [**6-1**] c/b portal vein thrombectomy and roux en y [**2113-6-25**]
Recurrent HCV
DM II
Appendectomy at age 18
multiple R inquinal hernia repairs x4
PTC [**2113-11-23**]
liver biopsy-[**2113-11-23**]-no rejection
Social History:
He lives alone in [**Hospital1 3494**], MA. He has no children.high
school graduate. For the last 25 years he has worked primarily
as a disk jockey in the [**Location (un) 86**]
area. He also has worked part time as a security
officer in the past. He is currently on medical
disability and reports that he last worked about 1 year ago. He
has no military history.
h/o iv cocaine use in 80s, heavy etoh use and occas marijuana
use in the past
Has several friends that are very supportive and committed to
help post transplant
Family History:
not addressed
Physical Exam:
102 111 112/66 30 96%RA
NAD
Cor RRR
Lungs CTA Bilat
Abd soft, slightly distended nontender
Pertinent Results:
[**2113-11-20**] 08:29PM WBC-2.8* RBC-3.50* HGB-10.5* HCT-30.7* MCV-88
MCH-30.0 MCHC-34.2 RDW-16.6*
[**2113-11-21**] 05:03AM BLOOD ALT-131* AST-108* AlkPhos-216* Amylase-35
TotBili-1.1
[**2113-11-24**] 05:20AM BLOOD ALT-98* AST-65* AlkPhos-173* Amylase-26
TotBili-1.5
[**2113-11-24**] 05:20AM BLOOD Vanco-16.5
[**2113-11-23**] 05:05AM BLOOD FK506-9.0
[**2113-11-23**] 5:39 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**Doctor Last Name 2191**] RUE @ 4:42A [**2113-11-24**].
ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
VANCOMYCIN------------ R
[**2113-11-25**] 04:17AM BLOOD WBC-3.5* RBC-3.39* Hgb-10.1*# Hct-28.8*
MCV-85 MCH-29.8 MCHC-35.1* RDW-17.4* Plt Ct-82*#
[**2113-11-24**] 09:20AM BLOOD Neuts-77.3* Lymphs-15.0* Monos-5.3
Eos-2.4 Baso-0.1
[**2113-11-20**] 08:29PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2113-11-25**] 04:17AM BLOOD Plt Ct-82*#
[**2113-11-25**] 04:17AM BLOOD PT-16.6* PTT-41.1* INR(PT)-1.5*
[**2113-11-25**] 04:17AM BLOOD ALT-104* AST-94* AlkPhos-185* Amylase-28
TotBili-1.0
[**2113-11-25**] 04:17AM BLOOD Lipase-21
[**2113-11-25**] 04:17AM BLOOD Albumin-3.4 Calcium-8.3* Phos-1.9* Mg-2.0
[**2113-11-24**] 05:20AM BLOOD Vanco-16.5
[**2113-11-23**] 05:05AM BLOOD FK506-9.0
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 66353**],[**Known firstname 7167**] M [**2063-3-16**] 50 Male [**-6/4654**]
[**Numeric Identifier 66354**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**], [**Last Name (un) 48203**],[**Doctor First Name **]/mtd
SPECIMEN SUBMITTED: LIVER BIOPSY (1 JAR) - RUSH CASE.
Procedure date Tissue received Report Date Diagnosed
by
[**2113-11-22**] [**2113-11-22**] [**2113-11-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/cma??????
Previous biopsies: [**-6/3694**] LIVER CORE BIOPSY (SAME DAY
RUSH), (1).
[**-6/3568**] TRANSJUGULAR LIVER BX.
[**-6/3267**] LIVER BX (1).
[**-6/2594**] LEFT LOBE LIVER, RIGHT LOBE LIVER.
(and more)
************This report contains an addendum***********
DIAGNOSIS:
Liver, allograft, needle core biopsy:
1. Features consistent with recurrent viral hepatitis C (Grade
[**12-27**]).
2. No diagnostic findings of acute cellular rejection
identified.
3. Focal, mild bile duct damage with a rare associated
neutrophil (see note).
4. A single poorly-formed lobular granuloma is identified;
special stains for fungi and acid fast bacilli will be performed
and reported separately in an addendum.
5. Trichrome stain demonstrates increased portal fibrosis
(Stage 1).
6. Iron stain is negative for iron deposition.
Note: The bile duct findings are suggestive of a mild component
of biliary obstruction/ischemia. Compared to the prior biopsy
(S07-[**Numeric Identifier 66355**]), the current biopsy demonstrates a relative increase
in lobular apoptotic hepatocytes and similar degrees of portal
inflammation, with an overall reduction in the amount of bile
duct damage. Dr. [**Last Name (STitle) **]. [**Doctor Last Name 497**] was notified of the findings by Dr.
[**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2113-11-23**].
Clinical: Specimen submitted liver core biopsy. Liver
transplant [**2113-6-7**], hepatitis/HIV, elevated liver function test.
Gross: The specimen is received in one formalin container,
labeled with the patient's name, "[**Known firstname **] [**Known lastname 34850**]", the medical
record number and consists of two tan-yellow tissue cores
measuring 1.1 cm each, which are entirely submitted in cassette
A
Brief Hospital Course:
He was admitted post cholangiogram. This revealed no dilated
bile ducts and patent choledochojejunal anastomosis site with
only mild smooth narrowing. Able to enter, but could not
successfully catheterie the nondilated intrahepatic ducts.A
chest portable AP with upright position was ordered to rule out
pneumothorax. Post procedure, he spiked a temp to 102. Blood and
urine was sent for culture. Vanco and zosyn were started. Blood
cultures became positive GPC on [**11-23**]. UA/cx was negative. ID
was consulted.
On [**11-22**] repeat cholangiogram was performed. Decompressed
intrahepatic duct with severe stricture at the
hepaticojejunostomy was noted. Performed serial cholangioplasty
with a cutting balloon and conventional balloons at the
stricture with substantial improvement but presnce of a residual
moderate stricture. Successful placement of right
internal/external drainage tube and Percutaneous trashepatic
liver biopsy and tract embolization with Gelfoam slurry was
done.
The liver biopsy was negative for rejection. Features were
consistent with recurrent viral hepatitis C (Grade [**12-27**]). Focal,
mild bile duct damage with a rare associated neutrophil (see
note). A single poorly-formed lobular granuloma was identified;
special stains for fungi and acid fast bacilli will be performed
and reported separately in an addendum. Trichrome stain
demonstrates increased portal fibrosis (Stage 1). Iron stain is
negative for iron deposition.
Note: The bile duct findings are suggestive of a mild component
of biliary obstruction/ischemia. Compared to the prior biopsy
(S07-[**Numeric Identifier 66355**]), the current biopsy demonstrates a relative increase
in lobular apoptotic hepatocytes and similar degrees of portal
inflammation, with an overall reduction in the amount of bile
duct damage.
Coumadin and lovenox were resumed. A picc line was placed on
[**11-24**] for iv antibiotics.
The blood cultures grew VRE and the patient will need IV
daptomycin 450mg q 24hrs, PO ciprofloxacin 500mg q 12hrs.
Plan: The patient may return in 6 weeks for re-dilatation at the
hepaticojejunostomy, for instance with a 7 mm cutting balloon
and 8 mm and 9 mm conventional balloon catheters and 10 F
drainage catheter palcement. Eventually, an external drain may
be placed and capped in order to challenge internal drainage as
indicated.
The patient left the hospital on [**2113-11-26**] against medical advice
without informing any of the staff. The transplant coordinator
on call and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] were contact[**Name (NI) **] to inform them of
the patient's actions. It was stressed that he should be
contact[**Name (NI) **] at home to urge him to return to the hospital due to
the fact he still had a PICC line in place and vancomycin
resistant enterococcus positive blood cultures.
Medications on Admission:
Tenofovir 300', Lopinavir (Kaletra) 2tab", Prilosec 20',
Abacavir 300", MMF 1000", Bactrim SS', NPH 36u AM, Reg Insulin
ss, Azithromycin 1200 qSat, Prograf 0.5 qSat, Warfarin 4 mg',
lovenox 70"
Discharge Medications:
The patient left against medical advice without any medications
Discharge Disposition:
Home with Service
Discharge Diagnosis:
elevated lfts
biliary stenosis
+ blood cultures-enterococcus
VRE
Discharge Condition:
The patient left against medical advice.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] if you
experience fever, chills, nausea, vomiting, inability to take
any of your medications, jaundice, abdominal pain, or weakness.
Labs weekly
IV antibiotics as ordered
The patient left against medical advice.
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2113-11-30**] 2:20
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-12-28**]
10:20
|
[
"996.82",
"790.7",
"997.4",
"576.2",
"070.70",
"042",
"998.59",
"E878.0",
"041.04",
"V10.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"38.93",
"46.85",
"87.51",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
9250, 9269
|
6054, 8918
|
329, 386
|
9378, 9420
|
1890, 2287
|
9746, 10047
|
1744, 1759
|
9162, 9227
|
9290, 9357
|
8944, 9139
|
9444, 9723
|
1774, 1871
|
276, 291
|
2317, 6031
|
415, 818
|
840, 1180
|
1196, 1728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,965
| 134,304
|
49498+59183
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-10-15**] Discharge Date:
Date of Birth: [**2072-3-23**] Sex: F
Service: OMED
PRIMARY DIAGNOSIS: Metastatic breast cancer.
HISTORY OF THE PRESENT ILLNESS: This is a 49-year-old female
with metastatic breast cancer to the liver, chest wall, neck,
pericardium, invading the brachial plexus and brain mets who
was recently discharged on [**2121-10-9**]. She presents
with change in mental status following whole brain radiation
therapy. After discharge, the patient had whole brain
radiation therapy at [**Hospital1 **] and received three out of ten
treatments starting on [**2121-10-10**] and since that time
has had increasing sedation, lethargy, sleeps all the time
and was unable to go for her last whole brain radiation
therapy. The patient did not take her medications at home
because of being somnolent constantly. She is currently
complaining of nausea without emesis.
After discussions with husband, she was noncompliant on her
Decadron.
REVIEW OF SYSTEMS: Notable for incontinence of urine,
wearing a diaper, pain well controlled on Fentanyl patch.
Denied fevers, chills, chest pain, shortness of breath, or
dyspnea on exertion.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer, initially T2, N0, M0 with
lymphatic invasion, multiple mets, see HPI.
2. Total abdominal hysterectomy/bilateral
salpingo-oophorectomy in [**2118**].
3. Cesarean section times three.
4. Depression. See psychiatry and social work evaluations.
FAMILY HISTORY: No breast, ovarian, or colon cancer.
ALLERGIES: Taxol/Taxotere.
ADMISSION MEDICATIONS:
1. Fentanyl patch 75 micrograms q. 72 hours.
2. Neurontin 600 mg b.i.d., 900 mg q.h.s.
3. Protonix 40 mg q.d.
4. Acetaminophen 650 mg q. four to six hours as needed for
pain.
5. Venlafaxine 150 mg q.d.
6. Dexamethasone 4 mg q.i.d.
7. Dilaudid 40 mg q. four to six hours as needed for pain.
8. Bactrim double-strength Monday, Wednesday, and Friday PCP
[**Name Initial (PRE) 1102**].
SOCIAL HISTORY: The patient lives with husband and has three
children, 16 to nine-years-old. Sister, [**Name (NI) **], intermittently
involved along with her mother. [**Name (NI) **] tobacco, alcohol
occasional before recent hospitalizations.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile,
80, 120/86, 18, 98% on room air. General: Alert and
oriented times three, lying in bed, limited because not
following commands, moist mucous membranes. PERRLA. No
pinpoint pupils. Specific eye examination difficult because
patient noncompliant, moving around. Heart: Regular rate
with normal S1, S2, no murmur. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, mildly tender, diffuse,
nondistended, absent bowel sounds. Neurologic: Difficult to
assess because not compliant. Upgoing/upgoing toes.
LABORATORY/RADIOLOGIC DATA: White blood cell count 11.8,
hematocrit 39.9, no left shift, platelets 348,000. Sodium
133. The rest of the electrolytes were normal. Anion gap of
7. LFTs unremarkable. Calcium 9.3.
HOSPITAL COURSE: 1. CHANGE IN MENTAL STATUS: Similar to
the previous admission. The patient was restarted on the
Decadron that she was noncompliant with. The patient became
more somnolent overnight so an MRI was ordered the next day.
The patient did not show the marked improvement that she
initially did when started on Decadron the previous
admission. The MRI showed increasing size of the right
frontal and right parietal metastases which are cystic in
nature and that the brain was herniating.
Neurosurgery was consulted. The patient was started on
Mannitol and Dilantin for seizure prophylaxis and transferred
to the ICU for bedside bur hole drainage of these mets
because she was becoming bradycardiac and hypertensive. The
patient was intubated and remained intubated for two days
following the procedure and then was extubated without
difficulty. Each day subsequently, her mental status
appeared to improve slightly to the point where she is alert
but not oriented to place.
She became more competent to discuss her medical care at that
point. The Dilantin was changed to Keppra because she
continued to receive whole brain radiation treatment during
these episodes and the goal is to complete a course, three
from the outside hospital and seven while she is here in the
hospital. There has been association between Dilantin and
whole brain radiation leading to [**Doctor Last Name **]-[**Location (un) **] syndrome so
she was switched to Keppra.
2. BREAST CANCER: The patient, as she became more alert,
expressed her wishes that she would not like to proceed any
further with chemotherapy treatment and that she felt that
she could not handle any more treatments. The Palliative
Care Team was consulted along with Dr. [**Last Name (STitle) **] and it was
felt best that if she finishes the whole brain radiation
treatment that she then goes to a rehabilitation center to
try to build up her strength. She will not have any further
chemotherapy.
3. HYPONATREMIA: The patient was fluid restricted to 750 cc
and her sodium remained 132. It is most likely secondary to
an SIADH component of her increased intracranial pressure.
4. PAIN: Well controlled with the Fentanyl patch 75
micrograms and Dilaudid was used for breakthrough pain as
needed.
5. CODE STATUS: The patient was initially full code. After
further discussions with her family and the patient, it was
felt that she would become DNR/DNI. The Palliative Care Team
was extremely helpful in facilitating this process along with
Dr. [**Last Name (STitle) **].
DISCHARGE MEDICATIONS: Deferred.
DISCHARGE STATUS: To rehabilitation center.
CONDITION ON DISCHARGE: Deferred.
FOLLOW-UP: Deferred.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], M.D. [**MD Number(1) 15577**]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2121-10-26**] 10:56
T: [**2121-10-26**] 11:04
JOB#: [**Job Number 103567**]
Name: [**Known lastname 13638**]([**Known lastname 16780**]), [**Known firstname 356**] Unit No: [**Numeric Identifier 16781**]
Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-30**]
Date of Birth: [**2072-3-23**] Sex: F
Service:
ADDENDUM: This is an Addendum that will detail an account of
the [**Hospital 1325**] hospital course from [**10-27**] to [**10-30**].
The patient remained at the [**Hospital1 1943**] for the purposes of pain control while placement was
found for this patient.
Initially, she was maintained on a Fentanyl patch at 75 mcg,
and this was then increased to 100 mcg. By the day of
discharge, the patient was on Fentanyl patch 125 mcg.
Breakthrough pain was initially managed by Dilaudid and then
later changed to morphine sulfate. The patient was requiring
anywhere from 2 mg to 4 mg as needed. The patient's
requirement for breakthrough pain was more than three times
per day. The Fentanyl patch should be titrated up
accordingly.
The patient was also maintained on Decadron. Initially, she
was on a Decadron taper; however, the patient's mental status
began to decline. Therefore, the patient was then increased
to 8 mg intravenously q.8h. of Decadron. The patient was to
be maintained on this dose of Decadron without taper from
this point on. The patient will also need to be continued on
Keppra for the purpose of seizure prophylaxis. Additionally,
she was maintained on Protonix and an insulin sliding-scale
with very good glycemic control.
Throughout her hospitalization, the patient had problems
taking by mouth medications. Therefore, necessary
medications were maintained in intravenous form.
The patient tolerated a regular diet. Her electrolytes were
followed closely and repleted as needed. The patient was
also maintained on a bowel regimen. The patient's hematocrit
slowly trended down toward 24.7 on the day prior to
discharge, and she was transfused one unit of packed red
blood cells. Additionally, she experienced mild
thrombocytopenia with a platelet count of 144; which, by the
day of discharge, had increased to 156. It was felt this
could be secondary to Bactrim which she had been on for
Pneumocystis carinii pneumonia prophylaxis. Therefore, the
Bactrim was discontinued.
MEDICATIONS ON DISCHARGE: (The patient's medications on
discharge included)
1. Fentanyl patch 125 mcg transdermally q.72h.
2. Morphine sulfate 2 mg to 10 mg intravenously q.4h. as
needed.
3. Dexamethasone 8 mg intravenously q.8h.
4. Sliding-scale.
5. Zofran 4 mg intravenously q.6h. as needed.
6. Pantoprazole 40 mg by mouth once per day.
7. Keppra 500 mg by mouth twice per day.
8. Docusate 100 mg by mouth twice per day.
9. Bisacodyl 10 mg by mouth/per rectum once per day as
needed.
10. Nystatin swish-and-swallow.
CONDITION AT DISCHARGE: The patient's Condition on discharge
was fair. The patient was stable on room air and able to
ambulate. Mostly disoriented but communicative.
DISCHARGE STATUS: The patient was to be discharged to
[**Hospital3 14**] today.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2463**], M.D. [**MD Number(1) 2464**]
Dictated By:[**MD Number(1) 16782**]
MEDQUIST36
D: [**2121-10-31**] 07:43
T: [**2121-10-31**] 09:04
JOB#: [**Job Number 16783**]
|
[
"196.0",
"431",
"348.4",
"253.6",
"198.3",
"174.8",
"198.89",
"V15.81",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.24",
"01.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1505, 1572
|
5609, 5666
|
8309, 8831
|
3047, 3061
|
1595, 1986
|
8846, 9343
|
1016, 1190
|
141, 996
|
2269, 3029
|
3077, 5585
|
1212, 1488
|
2003, 2254
|
5691, 8282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,599
| 178,362
|
50093
|
Discharge summary
|
report
|
Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-6**]
Date of Birth: [**2114-7-7**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female admitted to [**Hospital1 18**] ICU via [**Location (un) **] from [**Hospital 8**]
Hospital on [**2174-6-6**] at 17:42. The patient was recently
discharged from [**Hospital 8**] Hospital on [**2174-8-1**] after
undergoing an exploratory laparotomy, lysis of adhesion, and
small bowel resection on [**2174-7-27**] for a small bowel
obstruction and ischemic/necrotic small bowel. The patient
was readmitted to the [**Hospital 8**] Hospital 1 day prior to
admission complaining of fatigue, nausea, and vomiting x2
days; and a presyncopal episode. The patient denied
abdominal pain at that time and was found to be tachycardiac
to 128, systolic blood pressure in the 80s with a saturation
of 89 percent. The patient's white count at this time was
27.4 and ABG was 7.45/26/80/19; and of note, had a positive
UA. The patient, in addition, had extensive history of UTIs
and pyelonephritis.
HOSPITAL COURSE: The patient was admitted for antibiotics,
fluid resuscitation with some improvement. Early on the day
of admission, the patient acutely decompensated with
tachypnea, heart rate in the 120s, systolic blood pressure
less than 60. The patient was intubated, resuscitated with
IV fluids, and pressors were initiated. The patient was
transferred to [**Hospital1 18**] Surgery Service for definitive
treatment. On arrival, the patient was bradycardiac with
heart rate in the 40s with systolic blood pressure less than
50 during transfer requiring epinephrine and atropine. The
patient arrived to [**Hospital1 18**] intubated with IV fluids running and
Pitressin at 0.04, Neo-Synephrine at 8 and Levophed at 1.
PAST MEDICAL HISTORY: The patient's past medical history
includes gastroesophageal reflux disease, history of UTIs,
hypertension, and seizure disorder.
PAST SURGICAL HISTORY: Past surgical history includes
cholecystectomy, TAH/BSO, arthroscopies, and exploratory
laparotomy, lysis of adhesions, and small bowel resection as
mentioned above.
MEDICATIONS: At home,
1. Dilantin.
2. Protonix.
3. Topamax.
4. Verapamil.
ALLERGIES: NKDA.
PHYSICAL EXAMINATION: On exam, the patient was intubated,
unresponsive, cool, and cyanotic. The patient's temperature
was 98.4, heart rate 128, blood pressure 110/78, and
saturating at 90 percent, intubated. Physical exam was
remarkable for coarse breath sounds bilaterally and distended
soft abdomen with a clean, dry, and intact incision.
Extremities were cool and cyanotic.
LABORATORY DATA: On admission, white count 4, hematocrit
27.4, platelets 342, PTT 44, PT 16.5, INR 1.8, and fibrinogen
329. Electrolytes were 138, 3.6, 112, 15, 40, 1.6, and 129.
LFTs were within normal limits. Albumin was 1.6.
RADIOGRAPHIC STUDIES: A CAT scan of the abdomen and pelvis
showed ascites and thickened small bowel, question of free
air and pneumatosis. CT of the chest, abdomen, and pelvis
showed no pulmonary emboli or evidence of mesenteric vessel
compromise.
After lengthy discussion with the patient's family who were
present, which included 2 brothers and a sister, Dr.
[**Last Name (STitle) **], and Dr. [**Last Name (STitle) 51267**], the family made a decision to
withdraw all care and to stop all medications and to extubate
the patient. The patient was pronounced dead at 21:50 of
[**2174-8-6**] with a diagnosis of overwhelming sepsis. The
medical examiner was called at this time, Dr. [**Last Name (STitle) 104583**] [**Name (STitle) 7324**],
who waived the case. The family requested an autopsy and the
department pathologists were contact[**Name (NI) **] regarding this issue.
DISCHARGE DISPOSITION: Expired at the time mentioned above.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern1) 4881**]
MEDQUIST36
D: [**2174-8-6**] 22:54:46
T: [**2174-8-7**] 03:05:30
Job#: [**Job Number 104584**]
|
[
"038.9",
"789.5",
"530.81",
"780.39",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"88.01",
"87.41"
] |
icd9pcs
|
[
[
[]
]
] |
3795, 4104
|
1122, 1832
|
2010, 2273
|
2296, 3771
|
180, 1104
|
1855, 1986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,279
| 184,516
|
4487
|
Discharge summary
|
report
|
Admission Date: [**2200-2-23**] Discharge Date: [**2200-2-26**]
Date of Birth: [**2120-12-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 F with a history of asthma vs. COPD (no definite diagnosis)
and restrictive pattern on PFTs who presents with acute
worsening of dyspnea x 2 days. She has been on O2 at home since
an admission approximately one year ago, with occasional "good"
days off but generally using oxygen every night and most of
every day. She also has a home nebulizer which she is prescribed
to use up to three times a day, but for the past few weeks has
been using at least 3-4 times per day. About one month ago she
had a URI characterized by copius mucous production, cough and
rhinorrhea. The cough has persisted, but is +/- productive at
this time.
.
Upon arrival to the ED vitals were: 97.1 68 154/83 40 100% 15L.
She was placed on BiPap temporarily. She received solumedrol
125, combivent, azithromycin, CTX. ABG immediately after
starting Bipap was 7.26/74/286/35. On transfer to the MICU,
vitals were 64, 167/90, 26, 100% on neb, NC at 4L.
.
On arrival to the floor, she is with her daughters. She reports
feeling some improvement with BiPap in the ED.
Past Medical History:
# SEIZURE DISORDER
# HYPERTENSION
# OBESITY
# HYPERCHOLESTEROLEMIA
# DIVERTICULOSIS
# TOTAL KNEE REPLACEMENT
# AORTIC SCLEROSIS
# VITAMIN D INSUFFICIENCY
# HYPOTHYROIDISM
# RESTRICITVE LUNG PHYSIOLOGY, THOUGHT TO BE MOST LIKELY DUE TO
MORBID OBESITY
Social History:
she lives with family. She is a retired former health aide. She
is a long-time never smoker. She has no asbestos exposure that
she knows of. She emigrated here from [**Country 3594**] from the [**Location (un) 19194**]approximately 40 years ago and does return occasionally.
Family History:
Significant for asthma with her younger daughter and
granddaughter both with asthma which appears to be severe. She
is not allergic to any medications that she knows of.
Physical Exam:
On Admission
GEN: Awake in bed on 2L NC, somewhat tachypneic with speaking
and pauses between sentences, otherwise amiable, appears well
HEENT: NC in place, arcus senilius bilaterally, pupils small but
reactive, upper dentures in place (forgot lower dentures at
home)
NECK: Supple, JVP difficult to asses but no clear JVD
PULM: Poor air movement bilaterally with diffuse end-expiratory
wheezing
CARD: RRR, no M/R/G
ABD: Soft, NT/ND, +NABS
EXT: Edema of the ankles R > L (baseline per patient), palpable
DP pulses
PSYCH: Appropriate mood and affect
.
On discharge
T: 98.4 Bp:118/70 Hr: 66 RR:22 O2 sat 95% on 2L
General: NAD
Cardiac: RRR, no m/g/r
Pulm: moderate air movement, small amount of wheezing and
crackles at bases.
Abdomen: soft, NT
Ext: small amount of pedal edema and edema of forearms. No
erythema, no tenderness.
Pertinent Results:
[**2200-2-23**] 04:44PM BLOOD WBC-9.5# RBC-4.55 Hgb-12.5 Hct-37.4
MCV-82 MCH-27.5 MCHC-33.5 RDW-14.9 Plt Ct-405
[**2200-2-24**] 10:11AM BLOOD WBC-8.2 RBC-4.43 Hgb-12.0 Hct-36.3 MCV-82
MCH-27.2 MCHC-33.2 RDW-15.1 Plt Ct-393
[**2200-2-25**] 05:35AM BLOOD WBC-8.4 RBC-4.07* Hgb-10.8* Hct-33.6*
MCV-83 MCH-26.4* MCHC-32.0 RDW-15.1 Plt Ct-371
[**2200-2-26**] 05:50AM BLOOD WBC-8.1 RBC-4.38 Hgb-11.8* Hct-36.5
MCV-83 MCH-26.9* MCHC-32.4 RDW-14.8 Plt Ct-436
[**2200-2-23**] 04:44PM BLOOD Neuts-75.8* Lymphs-16.4* Monos-2.9
Eos-4.6* Baso-0.4
[**2200-2-23**] 04:56PM BLOOD PT-13.2 PTT-23.0 INR(PT)-1.1
[**2200-2-23**] 04:44PM BLOOD Glucose-134* UreaN-26* Creat-1.3* Na-141
K-6.3* Cl-104 HCO3-28 AnGap-15
[**2200-2-24**] 02:30AM BLOOD Glucose-119* UreaN-26* Creat-1.5* Na-142
K-6.6* Cl-103 HCO3-33* AnGap-13
[**2200-2-24**] 10:11AM BLOOD Glucose-134* UreaN-32* Creat-1.7* Na-142
K-5.7* Cl-101 HCO3-32 AnGap-15
[**2200-2-25**] 05:35AM BLOOD Glucose-84 UreaN-43* Creat-1.7* Na-142
K-5.0 Cl-103 HCO3-31 AnGap-13
[**2200-2-26**] 05:50AM BLOOD Glucose-98 UreaN-41* Creat-1.6* Na-143
K-5.4* Cl-101 HCO3-33* AnGap-14
[**2200-2-24**] 02:30AM BLOOD Calcium-8.6 Phos-4.8* Mg-1.9
[**2200-2-24**] 10:11AM BLOOD Calcium-8.8 Phos-5.1* Mg-1.9
[**2200-2-25**] 05:35AM BLOOD Calcium-7.6* Phos-4.4 Mg-1.9
[**2200-2-26**] 05:50AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.3
[**2200-2-24**] 02:30AM BLOOD TSH-1.6
[**2200-2-25**] 05:35AM BLOOD Phenyto-10.5
[**2200-2-23**] 04:44PM BLOOD Type-ART pO2-286* pCO2-74* pH-7.26*
calTCO2-35* Base XS-3
[**2200-2-23**] 06:05PM BLOOD pO2-33* pCO2-68* pH-7.16* calTCO2-26 Base
XS--6
[**2200-2-24**] 01:16AM BLOOD Type-ART Temp-37.3 O2 Flow-2 pO2-91
pCO2-78* pH-7.25* calTCO2-36* Base XS-3 Intubat-NOT INTUBA
[**2200-2-24**] 03:25AM BLOOD Type-ART Temp-37.3 Rates-/22 PEEP-5
FiO2-30 pO2-74* pCO2-66* pH-7.32* calTCO2-36* Base XS-4
Intubat-NOT INTUBA
[**2200-2-23**] 04:44PM BLOOD Lactate-0.6
[**2200-2-23**] 05:37PM BLOOD K-6.0*
[**2200-2-23**] 06:05PM BLOOD K-3.7
[**2200-2-24**] 01:16AM BLOOD Lactate-0.6 K-6.6*
[**2200-2-24**] 01:24AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
[**2200-2-23**] 4:56 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
.
[**2200-2-24**] 1:24 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2200-2-25**]**
MRSA SCREEN (Final [**2200-2-25**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
[**2200-2-24**] 1:24 am URINE Site: CATHETER
URINE CX ADDED ON [**2200-2-24**] AT 1510.
**FINAL REPORT [**2200-2-25**]**
ANAEROBIC CULTURE (Final [**2200-2-24**]):
TEST CANCELLED, PATIENT CREDITED.
Test performed only on suprapubic and kidney aspirates
received in a
syringe.
URINE CULTURE (Final [**2200-2-25**]): NO GROWTH.
ECHO: [**2200-2-25**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2199-1-28**], the RV systolic function may have
slightly improved. Otherwise, no big change.
.
CHEST RADIOGRAPH PERFORMED ON [**2200-2-23**]
COMPARISON: [**2199-11-15**] as well as a CTA chest from [**2199-1-29**].
CLINICAL HISTORY: 79-year-old woman with acute dyspnea, question
acute
process in the chest.
FINDINGS: Portable AP upright chest radiograph is obtained. Low
lung volumes and patient rotation to the left, somewhat limit
the evaluation. Allowing for this, there is no focal
consolidation, effusion, or pneumothorax. Mild left basilar
plate-like atelectasis is noted. Cardiomediastinal silhouette
appears grossly stable. Bony structures appear intact.
IMPRESSION: Mild left basilar atelectasis. Otherwise,
unremarkable study.
Brief Hospital Course:
Ms. [**Known lastname 805**] is a 79 F with a history of "asthma or COPD" and
restrictive defect on PFTs who presents with 2 days of worsening
dyspnea. She was admitted to the MICU and called out the
following day. The rest of her course is described below by
system.
.
#. RESPIRATORY DISTRESS: Patient's underlying pulmonary
physiology is somewhat unclear. [**Name2 (NI) 227**] her restrictive defect on
PFTs, she is likely to have a component of obesity-related
restrictive lung disease (possibly also related to chronic
hypoventillation/OSA). CXR is notable for a small opacity at
left base which is new from prior and may represent infection
(vs. atelectasis). It seems likely that infection (URI vs.
bacterial pneumonia) superimposed on poor baseline function is
responsible for her current dyspnea. As she did well on Bipap in
ED, she was maintained on Bipap overnight in the MICU and did
well. She was called out the following day. She was treated with
60mg prednisone, Ipratropium nebs Q6H and albuterol nebs Q4H
PRN, Singulair, Advair and did well. PT evaluated her and felt
she was safe for discharge. On [**2-26**], all her medications were
switched back to her home regimens except for prednisone which
will be a slow taper, (40mg QD x 2 days->20mg QD x2 days-> home
dose of 10mg QD) and finishing the course of azithromycin.
.
#. HYPERKALEMIA: Noted in ED. This seams to be a chronic issue,
likely related to lasix use. Her potassium was monitored closely
while she was admitted and remained high-normal and no
intervention was required.
.
#. HYPOTHYROIDISM: A TSH was WNL. Ms. [**Last Name (Titles) **] home dose of
levothyroxine was continued.
.
#. HYPERTENSION: Hypertensive in unit to SBP 160s. Continued
home antihypertensives with holding parameters
.
#. HYPERCHOLESTEROLEMIA: Statin was continued.
.
#. ANKLE SWELLING: Furosemide continued while in house. ECHO
repeated, which did not show decreased RV function.
.
#. STRESS INCONTINENCE: Urinalysis and urine culture were
performed which were negative
Medications on Admission:
- Singulair 10 mg PO daily
- Advair 500-50 IH [**Hospital1 **]
- Spiriva 18 mcg IH daily
- Cholecalciferol 50,000 u twice weekly
- Atenolol 50 mg PO daily
- Albuterol neb TID PRN
- Furosemide 40 mg PO daily
- Hydralazine 50 mg PO TID
- Simvastatin 40 mg PO daily
- Prednisone 10 mg PO daily
- Levothyroxine 50 mcg PO daily
- Phenytoin 200 mg PO BID
- Cough syrup with codeine PRN since Friday
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation three times a day as
needed for wheezing.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. phenytoin sodium extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days: PLease take on [**2200-2-27**].
Disp:*1 Tablet(s)* Refills:*0*
12. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One
(1) Capsule PO twice a week.
13. Cough Syrup Oral
14. prednisone 10 mg Tablet Sig: as per instructions below
Tablet PO once a day: Please take 40mg (4 tabs) on [**2-27**] and [**2-28**],
then 20mg (2 tabs) on [**3-1**] and [**3-2**], then go back to 10mg (1 tab)
daily.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
At Home VNA
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 805**],
It was a pleasure taking care of you during your recent
admission for a COPD exacerbation. YOu were treated with
nebulizers, steroids, and azithromycin, at first in the ICU,
then on the regular floor and you did well. We think you are
stable enough to go home.
.
We made the following changes in your medication.
-We increased your prednisone to 60mg. We would like you to
taper this back down to 10mg. YOu will need to take 40mg on
[**2200-2-27**] and [**2200-2-28**], then take 20mg on [**2200-3-1**] and [**2200-3-2**].
After that you can take your home dose of 10mg.
- We would like you to take 5 days of azithromycin. The last day
you need to take it is tomorrow ([**2200-2-27**]). You have a follow
up appointment with your primary care doctor tomorrow morning.
Followup Instructions:
Department: INTERNAL MEDICINE STE 2F
When: THURSDAY [**2200-2-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 11595**] [**Last Name (NamePattern4) 19195**], MD [**Telephone/Fax (1) 19196**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2200-5-20**] at 7:40 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: TUESDAY [**2200-5-20**] at 8:00 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
|
[
"268.9",
"278.01",
"244.9",
"V43.65",
"491.21",
"401.9",
"272.0",
"276.7",
"788.30",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11330, 11372
|
7453, 9481
|
313, 319
|
11434, 11434
|
3008, 5192
|
12446, 13421
|
1974, 2146
|
9925, 11307
|
11393, 11413
|
9507, 9902
|
11617, 12423
|
2161, 2989
|
5226, 7430
|
266, 275
|
347, 1391
|
11449, 11593
|
1413, 1665
|
1681, 1958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,587
| 111,918
|
43995
|
Discharge summary
|
report
|
Admission Date: [**2165-9-30**] Discharge Date: [**2165-10-15**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2165-10-4**] - s/p Coronary Artery Bypass Graft x4 (Left internal
mammary artery -> Left anterior descending, Saphaneous Vein
graft -> Obtuse marginal, Saphaneous Vein graft -> Diagonal,
Saphaneous Vein graft -> Posterior descending Artery)and Left
atrial appendage ligation
[**2165-10-1**] - Cardiac Catheterization
History of Present Illness:
82 y/o female who presented to an outside hospital with chest
pain. She was transferred to the [**Hospital1 18**] and underwent cardiac
catheterization.
Past Medical History:
Hypertension
hypercholesterolemia
Atrial Fibrillation
Skin cancer
carpal tunnel syndrome
hypothyroid
Social History:
Retired. Former 1ppd smoker for 20 years. Quit 30 years ago.
Lives alone. Rarely uses alcohol.
Family History:
Mother with heart disease
Physical Exam:
Admission
HR 70 RR 18 B/P 144/85 151/75 64" weight 149 pounds
GEN: NAD
HEENT: Unremarkable
NECK: Supple, FROM, No JVD, No carotid bruits
HEART: RRR, no m/r/g
LUNGS: Clear
ABD: Benign
EXT: Warm, well perfused , no edema, 2+ Pulses
NEURO: Grossly intact
Pertinent Results:
[**2165-10-1**] 08:30AM BLOOD WBC-10.4 RBC-4.50 Hgb-13.9 Hct-40.3
MCV-90 MCH-30.8 MCHC-34.4 RDW-12.8 Plt Ct-271
[**2165-9-30**] 01:15PM BLOOD INR(PT)-1.6*
[**2165-10-1**] 06:10AM BLOOD PT-15.5* PTT-70.2* INR(PT)-1.4*
[**2165-10-1**] 08:30AM BLOOD Plt Ct-271
[**2165-10-1**] 06:10AM BLOOD Glucose-102 UreaN-12 Creat-0.7 Na-142
K-4.0 Cl-107 HCO3-28 AnGap-11
[**2165-10-1**] 12:00PM BLOOD ALT-25 AST-26 AlkPhos-81 Amylase-51
TotBili-0.7
[**2165-10-1**] 12:00PM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2165-10-1**] 12:00PM BLOOD Triglyc-99 HDL-49 CHOL/HD-3.6 LDLcalc-109
[**2165-10-8**] 06:00AM BLOOD TSH-4.0
[**2165-10-8**] 06:00AM BLOOD T4-6.7 T3-65*
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The rhythm appears to be atrial fibrillation. Results
were
Conclusions:
PRE-CPB The left atrium is markedly dilated. Moderate to severe
spontaneous
echo contrast is seen in the body of the left atrium. No
mass/thrombus is seen
in the left atrium or left atrial appendage. Moderate to severe
spontaneous
echo contrast is present in the left atrial appendage. The left
atrial
appendage emptying velocity is depressed (<0.2m/s). The right
atrium is
elongated. No spontaneous echo contrast is seen in the body of
the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or
color Doppler. Left ventricular cavity size is normal. There is
mild symmetric
left ventricular hypertrophy. Regional left ventricular wall
motion is normal.
Overall left ventricular systolic function is mildly depressed.
There is mild
global right ventricular free wall hypokinesis. There are simple
atheroma in
the ascending aorta. There are complex (>4mm) atheroma in the
descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are
mildly thickened. Significant pulmonic regurgitation is seen.
There is a
trivial/physiologic pericardial effusion.
POST-CPB Normal right ventricular systolic function. Left
ventricle initially
with some mild septal hypokinesis which improved after 15
minutes. Overall EF
about 50-55%. No other changes from pre-CPB.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2165-10-4**] 13:17.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Ms. [**Known lastname 8026**] was admitted to the [**Hospital1 18**] on [**2165-9-30**] for further
management of her chest pain. She underwent a cardiac
catheterization which revealed 95% mid LAD lesion, 80% LCX
stenosis,and a 99% diffuse RCA lesion. An echo showed an EF of
60-70%. Given the nature and severity of her disease, the
cardiac surgery service was consulted for surgical
revascularization. She was worked-up in the usual preoperative
manner including a carotid duplex ultrasound which showed
minimal internal carotid artery disease bilaterally.
Ciprofloxacin was started for a urinary tract infection. Heparin
was continued for anticoagulation. On [**2165-10-4**], Ms. [**Known lastname 8026**] was
taken to the operating room where she underwent coronary artery
bypass grafting to four vessels and a left atrial appendage
ligation. Postoperatively she was transferred to the cardiac
surgical intensive care unit for monitoring. She developed some
atrial fibrillation overnight that was self limited. On
postoperative day one, Ms. [**Known lastname 8026**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. She was transfused for postoperative anemia.
Coumadin was resumed for her atrial fibrillation. On
postoperative day three, she was transferred to the step down
unit for further recovery. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperativ strength and mobility. The
geriatrics service was consulted for assistance with her memory
loss. Multiple medications as well as a social work evaluation
were recommended and implemented. It is recommended that she
follow up with the neurobehaviorist after discharge (Dr. [**First Name (STitle) 6817**].
Ms. [**Known lastname 8026**] continued to make steady progress and was discharged
to rehab on [**2165-10-15**] in stable condition. She will follow-up
with Dr. [**Last Name (STitle) 914**], her cardiologist and her primary care
physician as an outpatient.
Medications on Admission:
Coumadin 2.5mg daily
Univasc 15mg QD
Diltiazem 240mg QD
Synthroid 88mcg QD
Zocor 20mg QD
MVI
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO twice a
day.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: then check INR on Wednesday, [**10-17**] and dose for INR
2.0-2.5.
12. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO four
times a day for 5 days: for EVH site erythema.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
s/p Coronary Artery Bypass Graft x4 (Left internal mammary
artery -> Left anterior descending, Saphaneous Vein graft ->
Obtuse marginal, Saphaneous Vein graft -> Diagonal, Saphaneous
Vein graft -> Posterior descending Artery)and Left atrial
appendage ligation
Primary medical history:
Hypertension
hypercholesterolemia
Atrial Fibrillation
Skin cancer
carpal tunnel syndrome
hypothyroid
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 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:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 4966**] after discharge from rehab ([**Telephone/Fax (1) 40969**])
please call for appointment
Dr [**Last Name (STitle) **] after discharge from rehab ([**Telephone/Fax (1) 285**]) please
call for appointment
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**] (neuro behaviorist) [**Telephone/Fax (1) 1690**]
Completed by:[**2165-10-15**]
|
[
"782.2",
"285.9",
"V10.83",
"599.0",
"486",
"427.31",
"V15.82",
"693.0",
"272.4",
"294.8",
"293.0",
"410.71",
"244.9",
"V17.3",
"733.00",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.60",
"39.61",
"37.99",
"88.56",
"99.04",
"37.22",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7205, 7276
|
3897, 5927
|
236, 558
|
7707, 7713
|
1312, 3840
|
8178, 8712
|
993, 1020
|
6070, 7182
|
7297, 7686
|
5953, 6047
|
7737, 8155
|
1035, 1293
|
186, 198
|
586, 740
|
3874, 3874
|
762, 865
|
881, 977
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
124
| 172,461
|
2574
|
Discharge summary
|
report
|
Admission Date: [**2160-6-24**] Discharge Date: [**2160-7-15**]
Date of Birth: [**2090-11-19**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 69-year-old man was
transferred from [**Hospital6 5016**] on the [**10-24**] to
[**Hospital1 69**]. He has a history of
coronary artery disease, hypertension, hyperlipidemia,
prostate and lung cancer with severe carotid stenosis and
transient ischemic attacks who is referred now with the
abrupt onset of speech difficulty and right-sided weakness.
The patient had been hospitalized briefly in [**Month (only) 116**] with speech
difficulty and right-sided weakness. His studies back in [**Month (only) 116**]
showed severe bilateral carotid stenosis and there was
thought to be a critical stenosis on the right, a marked
stenosis on the left. CT scan was normal and the patient had
been on aspirin and was then started on Plavix. He was
referred to [**Hospital3 **] and he was scheduled for a carotid
endarterectomy a week prior to his admission. On the day of
admission aspirin and Plavix had been stopped in anticipation
of this upcoming surgery, however, while at home patient fell
asleep, complained to his wife of not feeling well and found
him a few hours later slumped over in the bed and felt that
his speech was slurred and not very comprehensible. He
complained of double vision at the time. Paramedics reported
that he was moving his extremities, however, developed
right-sided weakness when he arrived at [**Hospital6 5016**].
MEDICATIONS PRIOR TO ADMISSION: Lipitor, Cardia,
hydrochlorothiazide, bronchodilators.
PAST MEDICAL HISTORY: Coronary artery bypass graft in [**2152**].
SOCIAL HISTORY: He had been a smoker for the majority of his
life though only smoking a few cigarettes a day. He quit in
[**2160-5-15**].
PHYSICAL EXAMINATION: He was awake and fairly alert with
fluent speech. No dysarthria. He repeats well and there is
no anomia. He follows commands. Cranial nerves: Pupils
were small and reactive to light. Fundi were not seen. He
had a fairly pronounced vertical gaze palsy. There was
suggestion of slight lateral rectus weakness. Visual fields
were full to confrontation testing. There was mild right
central facial weakness. The other cranial nerves were
intact. Motor examination showed no drift and normal
strength to confrontation. Fine finger movements were intact
but finger-to-nose testing was ataxic, especially on the
right. The patient's findings were remarkable for a vertical
gaze palsy, maybe a right VI nerve palsy which relates to his
complaint of double vision.
The patient was transferred to [**Hospital1 188**] where he was admitted to the hospital, was started on
anticoagulation and carotid duplex was performed. He was
admitted to the Vascular Service there and a stroke consult
was done.
LABORATORY ON ADMISSION: White count 13.7, hematocrit 34.6,
platelet count 209,000, PT 12.8, PTT 36.4, INR 1.1. Sodium
137, potassium 4.0, BUN 24, creatinine 1.4.
HOSPITAL COURSE: The stroke team recommended stopping
heparin on his admission day and just continuing on aspirin
and Plavix with their considering recent strokes. The MRI
showed acute stroke in the paramedian thalamus and left of
the midbrain. He also had small areas of stroke in the
cerebellum. They recommended a four vessel angiogram and a
carotid endarterectomy on the right carotid and once again
the patient was now on the 11th started on heparin. The
patient was monitored on the floor where he did continue with
double vision and he was prepped for the carotid artery
endarterectomy. His repeat carotid ultrasound was completed
which shows a narrowing of 80-99% bilaterally of the tardive
RPPCA suggest proximal disease. On the 12th the patient
continued with double vision. His blood pressure was in the
140's to 180's and no other distress. The patient was made
known to the Neurosurgery Service where he was to have an
angiogram done. On the [**5-26**] he had an angiogram
which showed greater than 85% left vertebral artery stenosis,
an occluded right vertebral artery. He had greater than 85%
of the right common carotid bifurcation stenosis, 75%
innominate origin stenosis. It was noted that patient had a
left groin hematoma after the angiogram where he was
monitored closely post-angiogram. He was also on telemetry
during this time. He did end up having an ultrasound of the
groin to rule out pseudo-aneurysm. The Stroke Team, the
Neurology Team and the Vascular Team decided that the patient
should have a right carotid endarterectomy and then have a
stenting of his left vertebral artery. On the 13th he did
have the ultrasound of his left groin which showed no
pseudo-aneurysm. The patient was kept on heparin during this
time. On the [**5-31**] the patient had a right carotid
endarterectomy done. He tolerated the procedure well. On
postoperative day one he was awake, alert and oriented.
Incision was clean, dry and intact. He was reevaluated by
the Stroke Service the same day. His blood pressure was
140/46, heart rate 74, respirations 14, temperature 97.8. At
that point he was transferred back to Neurology Service. The
patient did receive one unit of red blood cells on the 18th.
It was noted on the 19th that he had slight swelling of the
surgical scar, otherwise the patient was okay. On the 19th
it was noted that that scar had serous fluid. No pus or
edema. The site was monitored by the Vascular Service. The
patient's pain was under control with Percocet. A follow-up
ultrasound on the 20th showed a patent right carotid, small
right neck hematoma, no evidence of pseudo-aneurysm. His
left groin hematoma was small, however, improving. The
patient remained awake, alert and oriented. His neurological
status was unchanged. During the postoperative period the
patient was on aspirin and Plavix. His staples were removed
from the surgical neck site on the 21st. The site was dry
and intact. He continued to be followed by Neurology and
Neurosurgery. Labs on the 23rd showed white count of 7.5,
hematocrit of 39.2, 297,000 for platelets. On the 25th
patient did have a left vertebroangioplasty and stent.
Estimated blood loss was minimal. The patient did well with
the procedure. He woke up awake, alert and oriented. He had
no drift. Grasp was [**5-19**] bilaterally. Lower extremities were
full. He remained on heparin post stenting at 800 units an
hour and continued on aspirin and Plavix. The patient was
monitored in the Trauma Intensive Care Unit postoperatively.
He was kept on a Nipride drip to keep his blood pressure less
than 140. A Rheumatology consult was asked for on the 26th
because of right-sided knee swelling. There was no erythema,
however, there was increase in warmth. Patient was thought
to have heterotopic ossification. It was thought not to be
an infectious process. Patient was already on aspirin. They
recommended topical aspirin cream. The patient was monitored
in the Intensive Care Unit. On the 27th he continued to need
Nipride to keep his blood pressure less than 140. He
remained neurologically intact. Case Management was
following him at this time. He was moved out of the Unit on
the 28th. His groin incision was noted to be intact with no
infectious process noted. No further hematoma. He remained
neurologically intact. His blood pressure was well
controlled on oral antihypertensives. Physical Therapy and
Occupational Therapy were involved in the patient's care and
they recommended home physical therapy and also for Nursing
to follow up with the patient to check blood pressure.
Rheumatology's final recommendations were prednisone taper,
NSAIDS and some local therapy to his right knee. Patient was
treated for methicillin-resistant Staphylococcus aureus
urinary tract infection diagnosed on the [**6-10**]. He
was started on intravenous vancomycin. Infectious Disease
recommended that he start on dicloxacillin for one week after
discharge.
DISCHARGE MEDICATIONS: Include:
1. Atorvastatin 20 mg one tablet q. day.
2. __________ 110 mcg two puffs b.i.d.
3. Albuterol 90 one to two puffs every q. 4-6h.
4. Oxycodone one to two tablets q. 4-6h.
5. Aspirin 325 one tablet q. day.
6. Plavix 75 mg one tablet q. day.
7. Cardizem 240 mg SA one tablet q. day.
8. Salmeterol 50 mcg one Diskus inhalation q. 12h.
9. Lopressor 50 mg twice a day.
10. Hydrochlorothiazide 1.5 tabs q. day.
11. Doxycycline 100 mg q. 12h.
12. Rheumatology recommended a prednisone taper which was
given to the patient.
13. Motrin 600 mg p.o. t.i.d. was given for the patient's
inflammatory process of his right knee.
DISCHARGE INSTRUCTIONS: Patient is to follow up with Dr.
[**Last Name (STitle) **] in five weeks. Follow up with Dr. [**Last Name (STitle) 1132**] in one
month. He will have home visits from VNA nurses to check his
blood pressure and a home safety evaluation with Physical
Therapy.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 13027**]
MEDQUIST36
D: [**2160-7-15**] 15:08
T: [**2160-7-15**] 15:13
JOB#: [**Job Number 13028**]
|
[
"272.0",
"433.31",
"998.12",
"433.20",
"436",
"V45.81",
"493.90",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"39.50",
"88.41",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
8013, 8644
|
3023, 7989
|
8669, 9214
|
1546, 1602
|
1834, 1964
|
161, 1513
|
1981, 2850
|
2865, 3005
|
1625, 1670
|
1687, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,499
| 199,736
|
38661
|
Discharge summary
|
report
|
Admission Date: [**2126-2-20**] Discharge Date: [**2126-2-26**]
Date of Birth: [**2043-10-16**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Augmentin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
headache, neck pain, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The pt is a 82 year-old RH woman w/ Afib (on coumadin),
HTN/CHF/HL/COPD who apparently had developed sudden onset R
sided
HA with pain behind the right eye with radiation to the neck and
difficulties with vision. Apparently had called EMS herself and
was taken to [**Hospital **] hospital where on initial evaluation was
noted to have BP of 175/89, exam notable for being alert,
oriented, following commands and moving extremities
symmetrically
and to have a visual field cut. She underwent a CT head w/
showed a R P/O 5.8x2.9 cm hemorrhage w/ surrounding edema. INR
was 2.0. She was given 10mg SC of Vitamin K, 2U FFP, 1g of
fosphenytoin and zofran. She had subsequently developed
hypotension reportedly to 60s systolic and required Dopamine
temporarily. She was not febrile. Given ICH, she was
transferred to [**Hospital1 18**] and was intubated prior to [**Last Name (un) 62483**] and
sedated w/ versed.
On arrival to [**Hospital1 18**], VS were [**Age over 90 **]F 155/97 90 14 on CMV/AC. She
was
awake, sleepy but arousable and following commands (see exam
below). She received versed 2mg prior to repeat CT and was
restarted on gtt. Pt. also received 30U PCC.
Neuro ROS: unable to obtain.
General ROS: unable to obtain.
Past Medical History:
[ + ] HL
[ - ] DM
[ + ] Afib
[ - ] prior CVA/TIA
[ + ] HTN
- CHF
- COPD
Social History:
Lives alone in [**Hospital3 **]. She drives, takes painting
lessons and is independent in her ADLs. She does not use a cane
or a walker to ambulate. Son [**Doctor First Name **] is the closest family
member. Tobacco - 30+ pk year hx, quite decades ago
EtOH - denied
Drug use - denied
Family History:
did not obtain as patient intubated.
Physical Exam:
Vitals: T: 98F P:90 R: 14 BP:155/97 SaO2:98% on CMV/AC, 100%
FiO2
General: Awake, intubated, follows commands, requires cont.
verbal. and physical stimulation to remain awake and with the
examiner.
HEENT: NC/AT, anicteric, dMM, OG/ETT in place.
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTA bilaterally
Cardiac: [**Last Name (un) **]/[**Last Name (un) 3526**], nl. S1S2, no M
Abdomen: soft, NT/ND.
Extremities: warm, dry, no edema
Pulses: 2+ radial.
Neurologic:
GCS 13.
-Mental Status:
Awake, intubated, follows commands, requires cont. verbal. and
physical stimulation to remain awake and with the examiner.
Nods to hospital, [**Location (un) 86**] appropriated, shakes head to being at
movies or at home.
Inattentive as drifts off after a few seconds of not being
provided with commands.
Language: unable to assess.
Appears to attend to R side more than left. Head turned to the
right but follows past midline.
Closes, opens eyes, sticks tongue out, shows teeth, shows left
and right thumbs, lifts both [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 85903**], points to
ceiling,
examiner only when on the right. Reaches across to left side to
clap, though misses left hand, that is pronated. Will lift up R
arm to request to lift L arm, however on tactile pointing to
left, will lift left arm.
-Cranial Nerves:
II: Right 1.5->1mm, brisk, 2.5 ->1.5mm, brisk.
VF: intact to threat on R, but not left. Can not assess
formally.
III, IV, VI: No eye deviation, EOMI though would close eyes
before completely moved to each extreme.
V: intact to LT (nods for touch)
VII: No facial droop, facial musculature symmetric, though
intubated.
VIII: did not test.
IX, X: positive cough on demand.
[**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
XII: Tongue protrudes towards midline, but ETT in the way.
-Motor: Decr. bulk b/l, nl tone throughout.
L pronator drift.
No tremor, noted.
When asked to lift
Delt Bic Tri WrE FFl FE
L 5- 5 4+ 4 5- 4
R 5 5 5 5 5 5
IP Quad Ham TA Gastr
L 4- 5- 4- 3 5-
R 5 5 5 5 5
-Sensory:
Ext. to DSS on L.
Light touch - intact (says yes)
Pinprick - not tested
Cold sensation - not tested
Vibratory sense - not tested
Proprioception - not tested
Withdraws L less briskly than RLE to noxious stimulus.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 2 3 0 tr
R 3 2 3 2 2
Plantar response:
RIGHT - flexor
LEFT - extensor
-Coordination: FNF intact w/ R index in R visual field, misses
w/
L index in L visual field by ~3cm. Unable to find finger in L
visual field. HKS intact b/l.
-Gait: deferred.
Pertinent Results:
[**2126-2-20**] 02:55AM BLOOD WBC-13.2* RBC-5.33 Hgb-12.4 Hct-39.8
MCV-75* MCH-23.2* MCHC-31.1 RDW-14.4 Plt Ct-293
[**2126-2-20**] 02:55AM BLOOD PT-19.4* PTT-25.8 INR(PT)-1.8*
[**2126-2-20**] 09:15AM BLOOD PT-14.5* PTT-24.7 INR(PT)-1.3*
[**2126-2-20**] 09:15AM BLOOD Glucose-152* UreaN-14 Creat-0.7 Na-140
K-4.7 Cl-100 HCO3-29 AnGap-16
[**2126-2-20**] 02:55AM BLOOD ALT-184* AST-216* CK(CPK)-107 AlkPhos-103
[**2126-2-21**] 07:40AM BLOOD ALT-322* AST-201* AlkPhos-105 TotBili-1.2
[**2126-2-20**] 02:55AM BLOOD cTropnT-0.04*
[**2126-2-20**] 09:15AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2126-2-20**] 04:47PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2126-2-22**] 02:21AM BLOOD Osmolal-297
TTE [**2126-2-20**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears depressed (ejection
fraction 30 percent) secondary to extensive severe anterior and
apical hypokinesis/akinesis, and hypokinesis of the septum and
inferior free wall. There is no ventricular septal defect. The
right ventricular cavity is dilated with focal hypokinesis of
the apical free wall. 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 left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT head [**2126-2-20**]
IMPRESSION: Large right occipitoparietal lobar hemorrhage with
surrounding
edema and mass effect on the lateral ventricle, unchanged over
the short-
interval. No shift of midline structures, or transtentorial or
uncal
herniation.
NOTE ADDED IN ATTENDING REVIEW: Also demonstrated is a very
small amount of
subarachnoid hemorrhage, localized in the immediately-overlying
parietovertex
sulci. In the context of the acute lobar hemorrhage (as well as
the patient's
advanced age), this finding - which raises the possibility of
associated pial
vessel involvement - is strongly suggestive of underlying
amyloid angiopathy.
Liver ultrasound [**2126-2-20**]
Echogenic liver consistent with fatty infiltration. Note, other
more severe
forms of liver disease such as cirrhosis or fibrosis cannot be
excluded on
this study.
CT head [**2126-2-20**]
IMPRESSION:
1. No significant change in right occipital hemorrhage with
persistent 2 mm
shift towards the left. Small amount of subarachnoid hemorrhage
is also
stable. No new hemorrhage is identified.
2. Small calcified meningioma, stable in the left frontoparietal
region.
MRI/A
No iv contrast, giving suboptimal evaluation for mass. There is
a saccular 4 mm aneurism at the bifurcation of L MCA, with
vessels arrising.
Brief Hospital Course:
Ms. [**Known lastname 65763**] is an 82 year-old woman w/ Afib (on coumadin),
HTN/CHF/HL/COPD who apparently had developed sudden onset R
sided HA, n/v, including behind the right eye, neck discomfort.
She called EMS herself and was taken to [**Hospital **] hospital where
she was noted to be hypertensive, found to have a RIGHT P/O
5.8x2.9 cm hemorrhage w/ surrounding edema. She received Vit. K
and FFP for INR 2.0, fosPHT 1g, and was transferred to [**Hospital1 18**],
but not before being intubated for transport. At [**Hospital1 18**] she was
awake, inattentive but following axial and appendicular
commands. Remainder of exam is notable for anisocoria of R < L
by ~ 1mm, but reactive, impaired
L VF (unable to assess visual fields formally), crossess midline
to reach to the L arm to clap, R/L confusion, L pronator drift,
LLE UMN weakness ~ 4 to 4-, upgoing L toe, ext. to DSS on L. CT
head showing R P/O 5.3x3cm lobar hemorrhage, corresponding to an
ICH score = 2 (age, volume), with predicted 1 month mortality of
26%. Etiology of ICH is most likely amyloid given location and
age, though an underlying mass can not be ruled out in this pt.
w/ long smoking hx. AVM also on DDX. Despite HTN at OSH ED,
unlikely to be HTNsive hemorrhage give location and character.
She was admitted to the neurology ICU for further management.
.
Hospital course by problem;
.
Neuro; The patient was monitored in the neurology ICU with q1h
neurochecks. HOB was elevated at 30 degrees, SBP was maintained
120-160 and MAP < 110. Antiplatelet and anticoagulants were
held and she was started on mannitol 0.5 g/kg q 6 h x1 day, then
q12h x1 day. Her serum osmolarity and sodium were essentially
unchanged and mannitol was discontinued. A non-contrast MRI
brain was performed and post-contrast imaging showed a small
calcified meningioma, and an unchanged parieto-occiptial
infarct. MRI showed no signs of amyloid. She was also found to
have a 4mm aneurysm at the bifurcation of the left MCA. This
was discussed with Neurosurgery, and it was recommended that she
undergo repeat screening of this in 1 year. She will also get a
repeat MRI/MRA prior to her Neurology follow-up appointment in 6
weeks. Exam on discharge was notable for a left field cut, with
upper quadrant sparing and a left pronator drift.
.
CV; The patient had a troponin peak of 0.12, which trended down
to 0.04. Her EKG showed T wave inversions in the inferior and
lateral leads. Echocardiogram showed a depressed EF as well as
anterior and inferior hypokinesis. Her baseline EF is not
known. It was thought her troponin leak may have been due to
demand ischemia. She was continued on her home digoxin, lasix,
and beta blocker. Her coumadin is being held and she restarted
aspirin on [**2-23**].
.
Abd/GI; The patient has a mild transaminitis of unclear
etiology. A liver ultrasound showed fatty infiltration. Her
statin was discontinued [**2-22**] afterwhich LFTs improved.
.
Medications on Admission:
- Coumadin 4mg daily
- Digoxin 0.25mg daily
- Spiriva 1 cap am
- symbicort 80/4.5 [**Hospital1 **]
- singulair 10mg daily
- Lipitor 20mg daily
- Furosemide 30mg daily am
- Metoprolol 50mg [**Hospital1 **]
- Diovan 160mg AM
- Vit D 1000U daily
- MVI
- Caltrate + D [**Hospital1 **]
- magnesium PO (unknown dose)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) dose Inhalation twice a day.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for c.
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5682**] Nursing Home
Discharge Diagnosis:
Primary: Intraparenchymal hemorrhage
Secondary:
HTN
COPD
CHF
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Left sided field cut. Left pronator drift.
Discharge Instructions:
You were admitted following acute onset of headache and
confusion. You were found to have a large intraparenchymal
hemorrhage. Your Coumadin was stopped and you were started on
aspirin.
Medication changes:
-Stop Coumadin and start full dose aspirin
-Increase metoprolol to 75mg tid
If you notice any of the concerning symptoms listed below,
please call your doctor or return to the emergency department
for further evaluation.
Followup Instructions:
Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2126-3-27**] 4:30
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Tuesday, [**3-5**] at 11:15am. Phone:
[**Telephone/Fax (1) 13553**]
|
[
"428.0",
"437.3",
"348.5",
"277.39",
"401.9",
"437.9",
"427.31",
"431",
"496",
"428.22",
"272.4",
"225.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12345, 12404
|
7799, 10754
|
320, 326
|
12528, 12528
|
4828, 7776
|
13206, 13583
|
2016, 2055
|
11116, 12322
|
12425, 12507
|
10780, 11093
|
12751, 12940
|
3423, 4809
|
2070, 2565
|
12960, 13183
|
251, 282
|
354, 1598
|
12543, 12727
|
1620, 1695
|
1711, 2000
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,403
| 109,390
|
17291
|
Discharge summary
|
report
|
Admission Date: [**2130-9-3**] Discharge Date: [**2130-9-11**]
Date of Birth: [**2051-12-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo F w/ hx of depression, with worsening sx. not eating, not
walking. in bed most of day xweeks. She reports that this bout
of depression began 3-4 years ago. Could not specify a specific
trigger. "Its hard not to be depressed." + deconditioning.
Passive SI, no active HI. In the ED her VS on presentation were:
98.4, 84, 198/83, 98% on RA. Her blood pressure then rose to
224/63 in the ED. She received lopressor 5 mg IV x2, 10 mg IV x
1, 1 mg ativan, 10 mg hydralazine IV and 400 mg IV cipro. FS =
141 on presentation. She was also given 1L NS
Past Medical History:
Chronic depression- Long hx of depression, with her first
hospitalization when she was around 25 yo. The patient has had
[**1-1**] hospitalizations after that (unsure exactly how many). She
denied any suicide attempts in the past. She currently has a
psychiatrist Dr. [**Last Name (STitle) 48416**] ([**Telephone/Fax (1) 48417**]. No therapist.The
patient has had ECT treatments for her depression in the past
that had been successfull
DM
HTN
Likely CAD
Vitamin B12 def-dx this admission
Anemia
Social History:
Pt born and raised in [**State 350**]. She describes childhood as
good. She attended school until the 10th grade and worked as a
[**Last Name (un) 19441**] after that. She never married and has no children. She
is currently living in a house with her sister (who is also
demented per Dr. [**Last Name (STitle) 48416**] and her nephew. She collects SSI.
ADLS: Independent of ADLS when not depressed.
Family History:
Father with depression.
Physical Exam:
on discharge
Vitals: 98.5 132/60 84 18 99%RA
Access: PIV
Gen: nad, thin female lying in bed
HEENT: mm dry, missing teeth
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Chest: ecchymosis over right anterior chest and breast, mild
tenderness over swelling of soft tissue
Abd; soft, nontender, +BS
Ext; no edema
psych: flat affect
Pertinent Results:
chem panel unremarkable
Hgb 12--->10s
CK 1083-->400s
LFTs stable, albumin 3.3
Trop 2.71-2.91, finally drop to 2.26 [**9-8**], stop checking
TSH 0.76
Vit B12 146 (low), folate nl, ferritin 294
UA [**9-3**]: 21-50 wbc, mod LE, few bacteria
urine cx: contamination and >100K corneybacterium
blood cx [**9-3**] ntd X2
Imaging/results:
Xray L spine: osteopenia, no fracture
Echo normal EF >55%, mod TR and mod pulm HTN, otw normla
LE dopplers: no DVT b/l LE
CT head [**9-3**]: no acute intracranial process
CT chest [**9-8**]: Large right pectoral hematoma running along the
right breast into the anterior right axillary region, with a
large amount of subcutaneous soft tissue swelling. Mixed high
density is consistent with acute hemorrhage. No other hematoma
or fracture is seen.
A subpleural nodule in the left lower lobe measures 4 x 2 mm.
3-mm and 2-mm left upper lobe nodules are also noted.
Brief Hospital Course:
Pt was admitted from home on [**9-3**] per her nephew for essentially
failure to thrive and placement. Per the nephew, [**Name (NI) **], who is
her HCP, she has progressively been more depressed and less
attentive to her personal care. She has not been participating
in any activities, even ADLs. Around the time of admission, she
was so weak, he couldnt event get her off the toilet. He is also
caring for his ailing mother and it is very hard for him.
Upon admission, her CKs were mildly elevated to 1000s, thought
to be rhabdo [**12-31**] inmobility. She was hydrated and CKs
downtrended. However, her troponin was also checked on admission
given her BP was 242/60s and came back at 2.71. Repeat troponins
over the next 36hours oscillated between 2.71-2.93 as did CKMB.
Her EKG was unremarkable and she did not have any cardiac
complaints and was hemodyamically stable. Her Echo did not show
any WMA and EF was normal (only showed mod TR/pulm HTN) and LE
dopplers negative/good O2 sats. The etiology of her trop leak is
not very clear at this point, esp since it remains elevated when
her BP has improved (normal creat). Cardiology has also been
following and don't have a good explanation, ?tail end of
cardiac event a few weeks ago? vs hypertensive heart disease vs
less likely myocarditis. Given her RF for likely CAD, she was
started her on [**Last Name (LF) 4532**], [**First Name3 (LF) **] 325 and kept on the ACE/BB/statin.
Since there is no acute event and she is poor candidate for
cath/stent placement given ?compliance with [**First Name3 (LF) 4532**] if she needs
it, and pt not interested in pursuing cath, plan is to medically
manage and f/u with STRESS ECHO in on month (PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
was notified of this plan).
On [**9-8**], her hematocrit was noted to have dropped 10 points
throughout the day, and she had swelling and ecchymosis of the
right anterior chest. A CT scan showed a large right pectoralis
major hematoma. A code blue was called that evening because the
patient was noted to be unreponsive, not answering questions but
did respond to painful stimuli. SBP was int he 80s and
increased to 108 with a 500cc NS bolus. By the time of transfer
to the ICU, her mental status had already improved dramatically.
She received 2U PRBC that had been ordered earlier, and since
then her hematocrit has been stable at 27-29. Surgery was
consulted but felt that given the nature of the hematoma surgery
could potentially make it worse and recommended compression
dressings and limiting movement of the right arm. Etiology was
unclear but could have been minor trauma such as boosting in bed
or steadying her under the arm while ambulating in the setting
of recently-started anticoagulation with [**Month/Year (2) **] and [**Month/Year (2) **]. [**Month/Year (2) **] and
[**Month/Year (2) **] were stopped, cardiology was notified and agreed.
Her other issues include her c/o some prox LE
weakness/discomfort with ambulation. L spine films negative, no
objective weakness, ESR 14, CK down to 500s, TSH wnl. She was
participating in PT and her history was inconsistent, so this
was not w/u further at this time. She is also B12 def and she
was started on high dose oral supp (2000mcg qd) as well as other
vitamins per psych. Lung nodules were noted in the left lower
and upper lobes; as there was no CT available for comparison and
there is no history of smoking or malignancy, 1-year followup CT
is recommended
Medications on Admission:
Risperdal 1 mg qhs
Atorvastatin 10 mg qd
Calcium + D 1250/200
[**Month/Year (2) **] 81 mg
Lisinopril 5 mg qd
Vitamin D 400 IU qd
Glipizide 10 mg qd
Metformin 500 mg qd
Toprol 200 mg qd
Effexor 150 mg qd
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2561**] - [**Hospital1 8**]
Discharge Diagnosis:
Severe Depression
Elevated Troponin of unclear etiology (recent cardiac event vs
hypertensive heart disease and HTN urgency)
Rhabdomyolysis-mild
Vitamin B12 deficiency
Anemia
right pectoralis major hematoma
Discharge Condition:
Improved
Discharge Instructions:
You were admitted because you were having hard time taking care
of yourself and your nephew, [**Name (NI) **], was concerned for your
health.
You have severe depression that is not well controlled and you
will go to a facility to manage this.
While here you were found to have Vit B12 def and you were
started on Vitamin B12 supplemenation as well as other vitamins.
Also, your heart enzymes were elevated, the reasons for which
was not clear to us. Cardiology saw you while here and
recommended you get an outpatient Stress Echo.
You also had a bleed into the tissues of your right chest wall
after being placed on anticoagulation. Your [**Name (NI) **] and [**Name (NI) **] was
stopped and compression dressings applied per recommendation by
surgery, and after transfusion of 2 units of blood you remained
stable.
You will be followed by the doctors at your facility; if you
have lightheadedness, episodes of loss of consciousness,
evidence of active bleeding, fevers, chills, or any other
concerning symptoms, you may need to be transferred to another
facility for further medical care.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 month to set up
Stress echo. Call his office at [**Telephone/Fax (1) 1579**] to make an
appointment.
Please follow up with psychiatry as instructed by your
physicians after discharge from [**Hospital3 **].
|
[
"E934.8",
"E935.3",
"266.2",
"599.0",
"410.91",
"728.88",
"728.89",
"402.00",
"250.00",
"414.01",
"285.1",
"296.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8132, 8199
|
3192, 6677
|
333, 339
|
8450, 8461
|
2268, 3169
|
9600, 9907
|
1873, 1898
|
6930, 8109
|
8220, 8429
|
6703, 6907
|
8485, 9577
|
1913, 2249
|
276, 295
|
367, 920
|
942, 1439
|
1455, 1857
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,555
| 162,904
|
51489
|
Discharge summary
|
report
|
Admission Date: [**2169-9-12**] Discharge Date: [**2169-11-6**]
Date of Birth: [**2103-2-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Lethargy, left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 68 yo R handed man with no known PMH (patient does not see
physicians) who was found slumped in a busy elevator at around
3:20pm. EMS found him to be hypertensive (197/144), FS 114 with
urinary and bowel incontinence. He was found to have left
facial,
arm and leg weakness. He was also dysarthic and with right gaze
preferance. His comprehension was normal and his was fluent. On
arrival here NIHSS was 12 and his head CT showed right thalamic
and capsular hemorrhage, most likely hypertensive.
ROS: Patient complained of lower back pain. His mood was very
dysphoric and he refused to answer most of the questions.
The patient denied visual difficulty, hearing changes,
difficulty
vertigo, paresthesias, sensory loss.
The patient denied fever, wt loss, appetite changes, cp,
palpitations, DOE, sob, cough, wheeze, nausea, vomiting,
diarrhea, constipation, abd pain, fecal incont, dysuria,
nocturia, urinary incontinence, muscle or joint pain, hot/cold
intolerance, polyuria, polydipsia, easy bruising, depression,
anxiety, stress, or psychotic sx.
Past Medical History:
- unknown. Patient denies any medical problem. [**Name (NI) **] does not see
doctors for years.
- there have been multiple admissions for psychiatric causes,
and he is thought to likely have schizophrenia vs cluster A
personality disorder.
Social History:
patient lives by himself, he refused to name any relatives we
could contact. [**Name (NI) **] refused to speak about his work. He denied
alcohol use, but has smoked for 30 years
Family History:
States "I have no family" when asked
Physical Exam:
T-97.6 BP-197/114 HR-88 RR-14 98O2Sat
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, supple, no carotid or
vertebral
bruit
Back: Mild tenderness on mid-lower back
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, very dysphoric, only partly
cooperative to exam. Oriented to person, place, and date.
Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal
comprehension and repetition; naming intact. Mild dysarthria was
present. He refused to [**Location (un) 1131**] or to write. No right left
confusion. Left side Neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Extraocular movements intact bilaterally, however,
patient had right gaze preference. No nystagmus. Sensation
intact
V1-V3. Left facial weakness. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 3 3 4 3 3 3 4 4 3 5 3 4 3 4
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS. Of note,
patient
was not cooperative with exam
Reflexes: B T Br Pa Pl
Right 2 1 2 1 0
Left 3 2 2 2 0
Toe was upgoing on left
Coordination: finger-nose-finger normal on the right only
Gait: not tested.
Pertinent Results:
Admission Labs:
[**2169-9-12**] 03:55PM BLOOD WBC-6.5 RBC-5.08 Hgb-14.5 Hct-43.0 MCV-85
MCH-28.5 MCHC-33.6 RDW-15.8* Plt Ct-157
[**2169-9-12**] 03:55PM BLOOD PT-11.4 PTT-26.9 INR(PT)-0.9
[**2169-9-13**] 03:00AM BLOOD UreaN-14 Creat-0.8 Na-135 K-3.6 Cl-102
HCO3-23 AnGap-14
[**2169-9-14**] 01:43AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2169-9-12**] 03:55PM BLOOD Triglyc-246* HDL-40 CHOL/HD-3.9
LDLcalc-68
Imaging:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2169-9-12**]
4:13 PM
FINDINGS:
There is a 22 x 21 mm hyperdense collection at the right
thalamus, consistent
with thalamic hemorrhage. This lesion surrounding edema
encroaches the
posterior limb of the internal capsule. There is no significant
mass effect.
There is no shift of midline structures. There is mild symmetric
prominence
of the ventricles, which is consistent with age. The sulci are
of normal
configuration.
There are no fractures. The included views of the mastoid air
cells and the
paranasal sinuses are clear.
IMPRESSION: Right thalamic hemorrhage measuring 22 x 21 mm with
a small rim
of edema, and encroachment of the neighboring posterior limb of
the internal
capsule.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2169-9-12**]
4:21 PM
FINDINGS: There is a linear lucency of the posterior left lamina
of C1 which
may represent a nondisplaced fracture. The margins are
well-defined, but no
adjacent hematoma is seen. Vertebral body heights are preserved.
There is no
prevertebral soft tissue swelling identified. Multilevel
degenerative changes
are identified including large anterior osteophyte formation and
disc space
narrowing. Mild asymmetrical widening of the anterior disc space
at C3-4 is
also noted, with a minimally displaced anterior osteophyte
fragment.
The visualized lung apices are clear.
IMPRESSION: Possible posterior C1 left lamina non-displaced
fracture and
asymmetric widening of C3-C4 anterior disc space. Given
equivocal findings,
acute injury cannot be excluded. MRI is recommended for further
evaluation.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2169-9-12**]
4:31 PM
CT CHEST: The heart and great vessels are unremarkable. There is
no
pericardial or pleural effusion. There is no evidence of acute
aortic injury.
The airways are patent to subsegmental level. There is no
pleural effusion.
Mild paraseptal emphysematous changes are noted. There is
bibasilar
atelectasis. There is no axillary, hilar or mediastinal
lymphadenopathy. There
is a hiatal hernia and mild cardiomegaly.
CT OF THE ABDOMEN: The spleen, liver, adrenal glands, kidneys
are
unremarkable. The gallbladder contains small amount gallstones.
There is no
intrahepatic biliary dilatation. The pancreas is normal in
appearance. Small
bowel loops are normal in caliber and without focal wall
thickening. There is
no mesenteric or retroperitoneal lymphadenopathy. There is no
free air or
free fluid.
CT OF THE PELVIS: The rectum and sigmoid colon are unremarkable
except to
note scattered diverticula. There is no evidence of acute
diverticulitis.
There is mild bladder wall thickening which is likely due to
underdistension,
although correlation with UA is recommended. The prostate gland
is
unremarkable except to note mild enlargement measuring 5.3 cm.
There is no
pelvic or inguinal lymphadenopathy. There is no free fluid or
free air.
Incidental note is made of a lipoma within the left latissimus
dorsi measuring
approximately 5.1 x 2.9 cm (2, 60).
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
There is no evidence of acute fracture. Multilevel degenerative
changes are
noted.
IMPRESSION:
1. No evidence of acute traumatic injury.
2. Mild cardiomegaly.
3. Hiatal hernia.
4. Cholelithiasis.
5. Diverticulosis without evidence of acute diverticulitis.
6. Mild bladder wall thickening likely due to underdistension.
Clinical
correlation is recommended.
CT head [**9-13**]:
IMPRESSION:
1. 25 x 19-mm right thalamic hemorrhage, with no
intraventricular extension
and no significant mass effect. This is strongly suggestive of
underlying
hypertensive etiology.
2. No other foci of hemorrhage and no acute territorial
infarction.
COMMENT: There are currently no other studies available on the
PACS;
comparison with the prompting OSH study (once uploaded on to
PACS) might help characterize the time course of this process.
CXR [**10-4**]
IMPRESSION:
1. Small left pleural effusion and linear atelectasis in the
left lower
lobe, though relatively nonspecific, may represent pulmonary
embolism in the appropriate clinical setting. Recommended
clinical correlation.
There was no clinical correlation for pulmonary embolism (no
dyspnea, no tachycardia, no hypoxemia).
Scrotal US [**10-6**]
IMPRESSION: Markedly enlarged right testicle measuring 8 x 6.2.x
5.5 cm
showing no evidence of internal vascularity, overall concerning
for a torsed testicle.
Scortal US [**10-9**]
The right testicle is again enlarged and hypoechoic with minimal
vascularity. The concern for right testicular torsion remains.
This is a suboptimal examination, as the patient declined
further imaging of the testes.
CXR [**2169-10-30**]:
Atelectasis at the base of the left lung is more pronounced
today. Previous small left pleural effusion is probably still
present. Milder atelectasis at the right lung base is stable.
The upper lungs are clear and the heart is normal size.
CT abd/pelvis/scrotum ([**2169-10-30**]):
IMPRESSION:
1. No lymphadenopathy to suggest malignancy.
2. Enlarged right testicle with no etiology identified on this
examination; however, CT has no role in the assessment of acute
testicular pathology. As per prior tests testicular torsion
remains a possibility and cannot be excluded by CT.
Brief Hospital Course:
Mr. [**Known lastname **] is a 66 yo man w/unknown PMH who was found down in a
busy elevator, found to have left sided weakness and a right
thalamic hemorrhage.
1. Thalamic hemorrhage/HTN. Based on the location and his
significantly elevated blood pressure, this was suspected to be
a hypertensive hemorrhage. He was initially started on a
nicardipine drip for blood pressure control, then titrated off
of that to PO lisinopril. He eventually required treatment with
lisinopril, metoprolol and Norvasc for BP control of SBP < 140
mmHg. His blood pressure has been well controlled on these
agents.
His examination was remarkable for severe L hemiparesis with
flaccid LUE and [**2-2**] in [**Last Name (un) 938**] and EDB with spasticity in LLE but
not LUE. He had grimace to noxious on the LLE without
withdrawal, while no response to noxious in LUE. The patient
has refused most rehab attempts.
His SBP goal is < 140 mmHg. Given prolonged HTN, he was started
on 81mg of ASA for primary cardiac prevention.
2. C-spine. As the patient had fallen, he underwent a trauma
series, which raised the question of a possible non-displaced C1
fracture. A C-collar was placed, but he ripped it off, and
refused to wear it while undergoing further screening. He
refused to undergo an MRI. The CT imaging was reviewed further
with radiology and fracture was felt to be more consistent with
a chronic one than acute one. Given that patient began to
develop stage I skin ulceration his spine was clinically cleared
and he was allowed to be turned in bed to prevent further
ulceration and sepsis.
3. Psych. The patient had a history of schizophrenia, confirmed
on further discussion with his former case manager, requiring
multiple hospitalizations in the past, but has been off
medication for several years. He requested to sign out AMA, but
was evaluated by psychiatry, who determined he did not have
insight of his current medical condition and risks associated
with no receiving care to do so. He developed paranoid ideation
refused his medications, PT/OT and his food. He was treated
with Haldol IV with some effect, however became somnolent after
titration of the dose to 3mg [**Hospital1 **]. Due to his inability to
participate in care and extreme potential of harm (chronic
malnutrition, risk of skin ulceration, another hypertensive
hemorrhage) legal guardianship was pursued. Guardianship was
eventually established (the Guardian is [**Name (NI) 553**] [**Name (NI) 656**] office [**Telephone/Fax (1) 106758**], cell [**Telephone/Fax (1) 106759**]). His care and workup has been
discussed with the guardian and it has been determined that he
would not have wanted aggressive procedures or a feeding tube.
He was treated with Zydis and low dose Haldol. He has done was
on Haldol 0.5mg twice a day and olanzapine 10mg as needed.
4. Nutritional status. Poor due to refusal to eat hospital food
and paranoid ideation. Albumin on admission was 3.3 and
decreased to 2.6 on [**10-9**]. The patient initially during the
hospital course had difficulty with swallowing but eventually
was cleared to swallow. This was reversed while the patient was
undergoing a urinary tract infection. However he was recently
cleared again for puree and nectar thick liquids. There was
concern that the patient was not taking enough to meet his
nutritional requirements. The issue of a feeding tube was
discussed with the guardian. She talked to many of his distant
family and friends and the decision was made that the patient
would not have wanted a feeding tube. He was very independent
and would not want his life prolonged by artifical means. He is
currently able to take as much food as he desired by mouth.
5. Testicular mass. Noted once patient permitted GU examination.
Was concerning for old torsion vs. malignancy. US confirmed no
blood flow to testicle, suggesting likely torsion, however
malignancy could not be ruled out. Patient refused MRI imaging.
AFP, hcg and LDH were within normal limits. Urology was
consulted who agreed with above, there was no surgical
intervention indicated as testicle was felt to be nonviable.
Urology did want further imaging. Eventually the patient was
able to undergo a CT abdomen and pelvis with a view of the
scrotum. There was no evidence of mass or lymphadenopathy. Per
GU the patient could have the testicle removed or pursue a
course of watchful waiting. The guardian agreed to this plan.
The patient can be periodically reassessed. The patient would
likely refuse any further intervention.
6. UTI - patient was found to have a UTI and was treated with a
7 day course of ceftriaxone with good resolution.
Medications on Admission:
none
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for SBP <100 and HR < 50.
12. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
PO DAILY (Daily).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**]
Discharge Diagnosis:
Primary: right thalamic hemorrhage, hypertensive; torsion of
right testicle; malnutrition
Secondary: Hypertension, Schizophrenia.
Discharge Condition:
Mental Status: Confused - sometimes, oriented to person, nothing
else
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
CN: Left facial droop
Motor: no withdrawal of left UE to noxious stimuli. Minimal
withdrawal of left LE. Moves right arm and leg spontaneously
Sensory: Grimaces to pain at all 4 ext
Gait: not ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 18**] after a fall and weakness. You were
found to have an intracranial bleed. For this you were treated
in the ICU with fluids, blood pressure control. You bleeding
was felt to be due to poorly controlled hypertension. This was
treated as well.
Of note, you were found to be acutely psychotic and required
treatment for this. You were started on haldol and Zydis as
needed. You improved with this treatment.
You were also found to have an enlarged testicle. This was felt
to be due to torsion. Your imaging was not concerning for
lymphoma and it was decided with your guardian to defer any
surgical procedure and just watch the testicle for any
worsening.
Because of your psychosis and non-cooperation with care, you
became malnourished. Becaus of all of the above, you required
an appointment of a guardian. This was done and this guardian
has determined that you would not have wanted aggressive care
and would not have wanted a feeding tube.
You also had a UTI for which you were treated.
You were started on multiple medications. You were discharged
to a long term living facility.
Please follow up with all of your appointments.
Should you develop any concerning symptoms to you, please call
your doctor or go to the emergency room.
Followup Instructions:
Please follow up with:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2169-11-27**] 2:00
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name **]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"707.8",
"584.9",
"301.9",
"263.9",
"608.20",
"599.0",
"431",
"V60.0",
"574.20",
"342.00",
"553.3",
"401.9",
"351.8",
"295.64",
"562.10",
"784.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15467, 15553
|
9480, 14155
|
346, 352
|
15727, 15727
|
3713, 3713
|
17453, 17889
|
1915, 1953
|
14210, 15444
|
15574, 15706
|
14181, 14187
|
16139, 17430
|
1968, 2300
|
277, 308
|
380, 1439
|
2716, 3694
|
3730, 9457
|
15742, 16115
|
2324, 2324
|
1461, 1703
|
1719, 1899
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,458
| 177,701
|
29833
|
Discharge summary
|
report
|
Admission Date: [**2150-11-30**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2095-6-8**] Sex: M
Service: MEDICINE
Allergies:
Dicloxacillin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
-Cardiac catheterization with stenting of Left circumflex.
History of Present Illness:
Pt is 55 yo M with CAD (s/p several MI's, s/p 3V CABG in [**2132**]),
DM2, who presented to [**Hospital3 59514**] Hospital last PM with chest
tightness, diaphoresis, and nausea. At around 11:30 pm on [**11-29**],
pt experienced chest tightness, diaphoresis, nausea, and
bilateral elbow pain after returning home from a holiday party.
Had not had recent CP, SOB, DOE prior to this episode; was able
to climb 5 flights of stairs in parking lot without CP in recent
days. Pt went to OSH ED and EKG showed up to 2-mm STD in V1-3, Q
and TWI in III. Enzymes were flat at OSH, but were drawn about
2-3h after onset of CP. He receieved ASA, heparin, and
integrilin. Chest pain went from [**5-16**] to [**12-16**] with 3 SL NTG. He
then received morphine and NTG gtt 30mcg in ambulance on the way
to [**Hospital1 18**], and then he fell asleep.
.
In the [**Hospital1 18**] ED, his vitals were stable and he had [**12-16**] chest
pain. He was given plavix 300mg, atorvastatin 80mg, Metoprolol
5mg IV, Atenolol 50mg, Morphine 4mg IV, and was continued on
integriling gtt, heparin gtt, and nitro gtt. ECG improved when
compared OSH.
.
Pt currently c/o continued chest discomfort, which he desribes
as a [**1-16**] "pressure." He denies SOB, N/V.
Past Medical History:
- CAD: s/p several MI's (s/p cardiac arrest after auto accident
in [**2126**] and was "brought back by CPR"), s/p 3V CABG in [**2126**]. Last seen at [**Hospital 2940**] in [**2132**] and records are paper only,
in warehouse and unavailable over holiday. PCP/Cardiologist-
[**First Name8 (NamePattern2) 29069**] [**Doctor Last Name 29070**] ([**Hospital1 3597**], NH) [**Telephone/Fax (1) 37284**] has done stress and
cath within the last several years. Reportedly pt had patent
LIMA-LAD, thrombosed SVG-OM graft, unknown 3rd graft (cath
approx [**2-7**] yrs ago for NSTEMI, no stents placed). Stress 1.5-2
years ago with reported inferior hypokinesis, but complete
results unavailable.
- DM2: on metformin at home
- Recurrent cellulitis of R leg
- hyperlipidemia
Social History:
Married. Lives at home with wife. Smoked 3ppd x 25 yrs (quit in
[**2123**]'s). Drinks 1 glass wine per day. No IVDU. Works as a
corporate manager for [**Company 71334**].
Family History:
Father died of heart disease at age 72. Sister with CAD (s/p
CABG) and hyperlipidemia.
Physical Exam:
On admission:
Vitals: T 98.6 BP 136/84 HR 72 RR 18 O2 96% 3L NC
Gen: NAD, comfortable, pleasant
HEENT: PERRL. OP clear.
Neck: Supple. No JVD.
Cardio: RRR, nl S1S2, no m/r/g
Resp: crackles at L base
Abd: soft, nt, nd, +BS. No rebound/guarding
Ext: 1+ BL LE edema, healed scars BL from vein harvesting. No
signs of infection. 2+ DP/PT pulses BL. 2+ fem pulses, no fem
bruits.
Neuro: A&Ox3.
Pertinent Results:
REPORTS:
.
Cardiac Cath [**11-30**]:
Initial angiiogram demonstrateda 50% stenosis of the
proximal LCx and a subsequent 90% stenosis. The SVG to the diag
was full
of thrombus and had very poor flow and considered too high risk
to
intervene. It was planned to treat the native LCx lesion with
PTCA and
stenting. Integrelin was the anticoagulant used during the
procedure. A
7FXB 3.5 guide catheter provided optimal support. The lesion was
crossed
with an Asahi prowater wire into the distal vessel.
The lesion was pre-dilated with a 2.25 x 15 Quantum Maverick
balloon at
10 ATM, a 2.5 x 20 Taxus DES was deployed across the lesion at
14 ATM
and post dilated with a 2.75 Quantum Maverick at 20 ATM distally
and
proximally. Final angiography demonstrated no residual stenosis
and no
angiographic evidence of dissection, thrombus or perforation
with TIMI
III flow in the distal vessel. The patient left the lab in
stable
condition and pain free.
.
[**12-2**] TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with basal
inferior akinesis and mid to distal inferolateral hypokinesis
and apical hypokinesis (apex not fully
visualized). Overall left ventricular systolic function is
mildly depressed. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) 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 borderline pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2150-11-30**], there is no definite change.
.
[**12-2**] CXR:
PA and lateral chest compared to [**2150-12-1**]: Patient has
had median sternotomy and coronary bypass grafting.
Cardiomediastinal silhouette is normal and unchanged. Lungs are
clear and there is no pleural effusion.
.
LABS:
.
[**2150-12-3**]: Na 139, K 4.2, Cl 103, HCO3 27, BUN 19, Cr 1.3, Glu
126
[**2150-12-3**]: Ca 8.9, Mg 2.1, PO4 2.6
[**2150-12-3**]: WBC 8.0, Hct 41.4, Plt 226
[**2150-12-2**] 06:11AM BLOOD WBC-9.0 RBC-4.59* Hgb-15.2 Hct-42.3
MCV-92 MCH-33.1* MCHC-35.9* RDW-13.4 Plt Ct-216
[**2150-12-1**] 04:50AM BLOOD WBC-11.1* RBC-4.84 Hgb-15.8 Hct-44.9
MCV-93 MCH-32.6* MCHC-35.1* RDW-13.1 Plt Ct-184
[**2150-11-30**] 11:30PM BLOOD Hct-44.1
[**2150-11-30**] 06:13PM BLOOD WBC-11.2* RBC-4.74 Hgb-15.7 Hct-43.3
MCV-91 MCH-33.2* MCHC-36.4* RDW-13.4 Plt Ct-208
[**2150-11-30**] 06:45AM BLOOD WBC-12.2* RBC-4.72 Hgb-15.5 Hct-43.4
MCV-92 MCH-32.9* MCHC-35.8* RDW-13.6 Plt Ct-238
[**2150-11-30**] 06:45AM BLOOD Neuts-78.7* Lymphs-16.6* Monos-4.4
Eos-0.1 Baso-0.2
[**2150-12-2**] 06:11AM BLOOD Plt Ct-216
[**2150-12-1**] 04:50AM BLOOD Plt Ct-184
[**2150-12-1**] 04:50AM BLOOD PT-11.1 PTT-23.9 INR(PT)-0.9
[**2150-11-30**] 06:15PM BLOOD PTT-38.1*
[**2150-11-30**] 06:13PM BLOOD Plt Ct-208
[**2150-11-30**] 12:40PM BLOOD PTT-54.2*
[**2150-11-30**] 06:45AM BLOOD Plt Ct-238
[**2150-11-30**] 06:45AM BLOOD PT-12.7 PTT-75.4* INR(PT)-1.1
[**2150-12-2**] 06:11AM BLOOD Glucose-140* UreaN-15 Creat-1.2 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
[**2150-12-1**] 04:50AM BLOOD Glucose-185* UreaN-14 Creat-1.1 Na-136
K-3.9 Cl-99 HCO3-26 AnGap-15
[**2150-11-30**] 11:30PM BLOOD Glucose-142* K-4.3
[**2150-11-30**] 06:20PM BLOOD Glucose-158* K-3.9
[**2150-11-30**] 06:45AM BLOOD Glucose-179* UreaN-13 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-23 AnGap-15
[**2150-12-1**] 04:50AM BLOOD CK(CPK)-1094*
[**2150-11-30**] 11:30PM BLOOD CK(CPK)-1398*
[**2150-11-30**] 06:20PM BLOOD CK(CPK)-1567*
[**2150-11-30**] 10:39AM BLOOD CK(CPK)-1325*
[**2150-11-30**] 06:45AM BLOOD CK(CPK)-324*
[**2150-12-1**] 04:50AM BLOOD CK-MB-78* MB Indx-7.1* cTropnT-1.68*
[**2150-11-30**] 11:30PM BLOOD CK-MB-135* MB Indx-9.7*
[**2150-11-30**] 06:20PM BLOOD CK-MB-186* MB Indx-11.9* cTropnT-2.27*
[**2150-11-30**] 10:39AM BLOOD CK-MB-178* MB Indx-13.4* cTropnT-1.70*
[**2150-11-30**] 06:45AM BLOOD cTropnT-0.34*
[**2150-11-30**] 06:45AM BLOOD CK-MB-36* MB Indx-11.1*
[**2150-12-2**] 06:11AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.2
[**2150-12-1**] 04:50AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.1
[**2150-11-30**] 06:20PM BLOOD Cholest-143
[**2150-11-30**] 06:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
[**2150-11-30**] 06:20PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2150-11-30**] 06:20PM BLOOD Triglyc-149 HDL-37 CHOL/HD-3.9 LDLcalc-76
.
MICRO:
.
URINE CULTURE (Final [**2150-12-2**]): NO GROWTH.
.
[**2150-12-1**] 4:50 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
Assessment/Plan: 55 year old man with CAD status post 3 vessel
CABG in [**2132**] who presented on [**11-29**] with NSTEMI. In past
several years, per cardiologist patent LIMA-LAD, with thrombosed
SVG-OM graft. Cardiac stress test one year ago revealed
inferior hypokinesis.
Repeat cardiac catheterization on [**11-30**] revealed 3 vessel
disease. Taxus DES placed in mid L circumflex.
.
1) CP/NSTEMI:
Patient with known CAD, status post multiple MI's and status
post 3-vessel CABG in [**2150**]. PCP/cardiologist
has done stress and caths within the last several years
(reported patent LIMA-LAD). Patient ruled in for NSTEMI and was
taken to cardiac catheterization on [**11-30**]. Found to have 90%
LCx, which was stented. Pt also with SVG to diagonal with
occlusion. The chronicity was unclear, and this lesion was not
stented. Elevated LVEDP status post procedure.
- Continue ASA 325, plavix 75 qd. Received plavix load.
- Integrillin was continued for 18hrs and then off after
procedure.
- Increased metoprolol to 125mg [**Hospital1 **] on night of [**12-2**]. As
outpatient, can consider uptitrating for HR<70.
- Started lisinopril 5mg qd.
- Increased atorvastatin to 80mg qd
- CK peaked at 1567 ,but has trended down.
- Repeat echo on [**12-2**] revealed an EF of 50%. Normal PCPW.
Basal inferior akinesis and apical hypokinesis. Mild MR.
- Patient will need Echo and/or cardiac MRI in 6 weeks for
prognosis. Patient's cardiologist to schedule.
- Sent TSH level on [**12-3**], so results will need to be assessed
by PCP [**Name Initial (PRE) **]/or cardiologist.
.
2) Fever:
-Patient with fever to 101.5 after procedure. Blood cx's
pending. UA negative. UCx negative. CXR shows opacity which
represents atalectasis vs. aspiration.
- Repeat PA and lateral CXR on [**12-2**] was improved and no
evidence of PNA. Patient has remained afebrile in past several
days.
.
3) DM2:
On metformin at home, but holding in hospital.
- Will continue q6hr FS with RISS
- A1c 6.3 %.
- Will restart metformin as outpatient.
.
4) Hyperlipidemia:
- Given NSTEMI, increased lipitor to 80mg qd.
- Cholesterol panel: chol 143, TG:149, HDL 37, LDL 76.
.
5) FEN:
Placed on cardiac diet.
.
6) Prophylaxis:
Placed on heparin SC, PPI, bowel regimen.
.
7) Dispo:
Pending discharge for [**2150-12-3**].
.
8) Code:
Full Code
Medications on Admission:
MEDS (at home):
Atenolol 50mg qd
Lipitor 20mg qd
Metformin 1000mg qam, 500mg qpm
Niacin 2000mg qd
Fish oil
.
MEDS (on transfer):
heparin gtt
nitro gtt
integrilin gtt
ASA
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO qAM.
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO qPM: Take one
tablet at night.
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Five (5) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*300 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
CAD/NSTEMI
Secondary diagnoses:
DM2
Hyperlipidemia
Discharge Condition:
Vitals stable. Afebrile. Ambulating. Taking good PO.
Discharge Instructions:
-Please seek medical attention immediately if you experience
chest pain, shortness of breath, nausea, vomiting, palpitations,
excessive sweating, or any other concerning symptoms.
-Please take all medications as prescribed. You should take
Aspirin and Plavix every day. Your cholesterol medication,
atorvastatin, was increased to 80mg every day. You will no
longer take atenolol, but have changed to metoprolol 125 [**Hospital1 **].
-You should schedule a cardiac MRI or echocardiogram in
approximately 6 weeks. Please have your cardiologist schedule
this test for you. Your cardiac ECHO and catheterization
results have been included.
Followup Instructions:
-Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week.
-Please follow up with your cardiologist in [**12-8**] weeks. You
should schedule a cardiac MRI or echocardiogram in approximately
6 weeks. Please have your cardiologist schedule this test for
you.
|
[
"272.4",
"414.02",
"414.01",
"780.6",
"250.00",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"00.66",
"37.22",
"00.45",
"88.56",
"99.20",
"36.07",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
11446, 11452
|
7948, 10266
|
287, 348
|
11567, 11622
|
3116, 7865
|
12313, 12588
|
2604, 2692
|
10487, 11423
|
11473, 11473
|
10292, 10464
|
11646, 12290
|
2707, 2707
|
11525, 11546
|
236, 249
|
7895, 7895
|
7925, 7925
|
376, 1612
|
11492, 11504
|
2721, 3097
|
1634, 2400
|
2416, 2588
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,706
| 178,898
|
52153+59405
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-6-30**] Discharge Date: [**2108-4-9**]
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
Spanish speaking male with a history of hypertension, iron
deficiency anemia, obstructive/restrictive lung disease and
primary biliary cirrhosis who was in his usual state of
health until four days prior to admission when he developed
progressively worsening edema in his lower extremities and
dyspnea on exertion that has progressed to shortness of
breath at rest. The patient denies any recurrent or current
chest pain and pleuritic chest pain. He had a stress test in
[**2134-5-10**], consistent with average exercise tolerance and
his last echocardiogram was in [**2134-2-9**], which showed an
ejection fraction over 55 percent. The patient reports that
he is now unable to climb more than one to two stairs without
becoming short of breath and that he sleeps on a large pillow
at night although he denies that his dyspnea is positional.
In addition, the patient reports milder symptoms of shortness
of breath since being seen in the Emergency Department at
[**Hospital1 69**] in [**2136-2-9**], when he
was diagnosed with a pneumonia/upper respiratory infection.
The patient reports that he has not experienced lower
extremity swelling in the past. In addition to these
symptoms, the patient reports an unintentional weight loss of
20 pounds in the last year and five pounds in the last month
in addition to generalized fatigue.
The patient denies recent fevers, chills, night sweats,
cough, nausea, vomiting. diarrhea and proximal/distal muscle
weakness. He was treated in the Emergency Department with 20
mg of intravenous Lasix and had approximately one liter of
clear urine output. A bedside ultrasound was consistent with
pericardial effusion. A bedside echocardiogram was performed
and consistent with moderate pericardial effusion, left
atrial compression, right ventricular flap but no
compression, normal flow and ejection fraction with no
abnormalities in the left ventricular wall thickness or
motion.
PAST MEDICAL HISTORY: Primary biliary cirrhosis diagnosed by
serologic markers/liver biopsy in [**2132**].
Anemia, baseline hematocrit around 30.0 with MCV around 80,
diagnosed as iron deficiency anemia with a ferritin of 6.3 in
[**2136-5-10**].
Obstructive/restrictive lung disease diagnosed by recent
pulmonary function tests.
Benign prostatic hypertrophy.
Hypertension.
Gastroesophageal reflux disease.
Echocardiogram in [**2134-2-9**], revealed a left ventricular
ejection fraction over 55 percent, patent foramen ovale,
normal left ventricular wall thickness and motion.
Last stress test in [**2134-5-10**], revealed average functional
exercise tolerance without anginal symptoms.
MEDICATIONS ON ADMISSION:
1. Terazosin 1 mg once daily.
2. Flovent 220 mcg.
3. Ursodiol 250 mg once daily.
4. Nadolol 40 mg once daily.
5. Norvasc 5 mg once daily.
6. Protonix 40 mg once daily.
7. Iron supplementation.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is retired. He lives with his
wife and grandson in [**Name (NI) 8**]. He has a 60 pack year
smoking history. He has not drank alcohol in six years and
was a previous social drinker only. The patient denies
history of drug use.
PHYSICAL EXAMINATION: Temperature is 95, blood pressure
137/66, heart rate 52, respiratory rate 16, oxygen saturation
94 percent on two liters. In general, he is awake, alert and
oriented times three in no acute distress. Head, eyes, ears,
nose and throat examination - The pupils are equal, round and
reactive to light and accommodation. Extraocular movements
are intact. The patient has moist mucous membranes. His
oropharynx is clear. There is no rhinorrhea or frontal or
maxillary sinus tenderness. The neck is supple with no
lymphadenopathy, no masses or thyromegaly, jugular venous
pressure is estimated at ten centimeters. Lungs - The
patient has bibasilar inspiratory crackles without wheezing.
There are mild rales diffusely, no dullness to percussion, no
egophony, good respiratory effort. Cardiovascular is regular
rate and rhythm, II/VI holosystolic murmur at the inferior
sternal border, no gallops or rubs. No carotid bruits.
Pulsus paradoxus is around 12 mmHg. The abdomen is soft,
nontender, mildly distended, normoactive bowel sounds, no
rebound or guarding. There is evidence of hepatomegaly.
Extremities are warm and well perfused. Capillary refill is
less than two seconds. The patient has two plus pitting
edema in the lower extremities bilaterally extending up to
his knees. Neurologically, cranial nerves II through XII are
intact. Strength is [**6-13**] at elbows and hips bilaterally.
Sensation is intact in all fields.
LABORATORY DATA: White blood cell count was 6.2, hematocrit
32.3, platelet count 147,000. Sodium 140, potassium 4.4,
chloride 100, bicarbonate 33, blood urea nitrogen 11,
creatinine 0.9, glucose 99. ALT 13, AST 35, alkaline
phosphatase 141, total bilirubin 0.6, CK 107, CK MB 2.0,
troponin less than 0.01.
HOSPITAL COURSE: Shortness of breath - The patient was
admitted with progressive shortness of breath and bilateral
lower extremity edema and found to have an elevated jugular
venous pressure on examination. A bedside ultrasound in the
Emergency Department was consistent with pericardial effusion
and a bedside echocardiogram revealed left atrial compression
and a moderate pericardial effusion. The patient was
admitted to the general medical service and his pulsus
paradoxus was monitored. A cardiology consultation was
obtained on admission and performed a pericardiocentesis on
[**2136-7-2**]. Pericardial access was obtained on the first
attempt of the xiphoid with yellowish serosanguinous fluid.
An echocardiogram after 300cc of fluid removed showed a
smaller pericardial effusion and ultimately 600cc of bloody
serosanguinous fluid that appeared yellow in the tubing was
eventually removed with improvement in pericardial and right
atrial pressures. The patient was followed by the Coronary
Care Unit team for several days. Given continuous output
from the pericardial drain, cardiac surgery team was
contact[**Name (NI) **] and performed a pericardial window on [**2136-7-6**].
Studies on the pericardial fluid were negative for infection
and cytology. The patient had a normal TSH. The patient
notably has a positive [**Doctor First Name **] with a titre of 1:40. Looking
through the previous records, the patient had a previous
titre from [**2132-5-10**], of 1:640. The significance of this is
unclear especially given that other workup has been negative.
The etiology of the patient's pericardial effusion at this
point is considered idiopathic. The patient will be
evaluated by a repeat echocardiogram and cardiac surgery is
scheduled to remove the chest tube they placed during
pericardial window placement.
Primary biliary cirrhosis - The patient is noted to have a
history of primary biliary cirrhosis and was asymptomatic
with stable liver function tests and coagulation studies
throughout his hospitalization. He was continued on Nadolol
and Ursodiol throughout this admission. The patient also has
a history of grade I varices and esophagitis/gastritis and
was continued on proton pump inhibitor .
Anemia - The patient was admitted with a history of iron
deficiency anemia. He had a stable hematocrit throughout his
hospitalization and was continued on iron replacement with
Vitamin C for improved absorption of iron.
Hypertension - The patient was noted to be hemodynamically
stable and normotensive throughout his admission. He was
continued on Norvasc 5 mg p.o. once daily.
Pulmonary - The patient was admitted with a history of
obstructive/restrictive lung disease by recent pulmonary
function tests. The etiology of his shortness of breath as
discussed previously was considered likely secondary to his
pericardial effusion. After pericardiocentesis and
pericardial window placement, the patient's shortness of
breath improved throughout the remainder of his
hospitalization. He was continued on Albuterol and
Fluticasone inhalers p.r.n. for shortness of breath.
Benign prostatic hypertrophy - The patient was asymptomatic
throughout his hospitalization and he continued on his
outpatient dose of Terazosin.
The remainder of the [**Hospital 228**] hospital course, his discharge
medications, diagnoses and follow-up will be dictated at the
time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 99859**]
Dictated By:[**Last Name (NamePattern1) 12325**]
MEDQUIST36
D: [**2136-7-9**] 11:09:33
T: [**2136-7-9**] 12:03:15
Job#: [**Job Number **]
Name: [**Known lastname 17634**], [**Known firstname 17635**] Unit No: [**Numeric Identifier 17636**]
Admission Date: [**2136-6-30**] Discharge Date: [**2136-7-13**]
Date of Birth: [**2055-9-29**] Sex: M
Service: MED
ADDENDUM:
HOSPITAL COURSE: The patient had chest tube in place after
pericardial window and drainage gradually decreased and chest
tube was eventually pulled on [**2136-7-11**]. The patient had a
follow-up echocardiogram done after his pericardial window
which showed trivial pericardial effusion times two. The
patient's oxygen saturation in room air were 96 percent prior
to discharge. The patient's symptoms gradually improved and
he was able to tolerate ambulation with minimal dyspnea. The
remainder of the [**Hospital 1325**] hospital course was without
significant events.
CONDITION ON DISCHARGE: Stable tolerating room air with
chest tube removed and minimal pericardial effusion and small
bilateral pleural effusions.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Idiopathic pericardial effusion.
Primary biliary cirrhosis.
Anemia.
Obstructive restrictive lung disease.
Hypertension.
Gastroesophageal reflux disease.
Bilateral pleural effusions.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg twice a day.
2. Norvasc 5 mg once daily.
3. Iron 325 mg once daily.
4. Ascorbic Acid 500 mg twice a day.
5. Flovent 110 twice a day, two puffs.
6. Albuterol q6hours as needed.
7. Nadolol 40 mg once daily.
8. Ursodiol 300 mg twice a day.
9. Protonix 40 mg once daily.
10. Aspirin 325 mg once daily.
11. Senna.
12. Lactulose as needed.
13. Multivitamin.
14. Terazosin 1 mg q.h.s.
15. Lasix 20 mg p.o. once daily.
FOLLOW UP: He is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
next one to two weeks and call [**Telephone/Fax (1) 9754**] to schedule an
appointment. He is also to follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5503**] of gastroenterology on [**2136-7-23**], at 1:00 p.m.
INVASIVE SURGICAL PROCEDURES: Pericardiocentesis.
Pericardial window.
Chest tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 15926**]
Dictated By:[**Last Name (NamePattern1) 17637**]
MEDQUIST36
D: [**2136-7-13**] 14:20:29
T: [**2136-7-15**] 14:14:27
Job#: [**Job Number 17638**]
|
[
"428.0",
"496",
"423.9",
"599.0",
"280.9",
"428.32",
"530.81",
"571.6",
"402.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
9775, 9964
|
9990, 10450
|
2795, 3028
|
9017, 9575
|
10462, 11166
|
3312, 5063
|
117, 2074
|
2097, 2769
|
3045, 3289
|
9600, 9753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,099
| 199,480
|
26574
|
Discharge summary
|
report
|
Admission Date: [**2129-5-4**] Discharge Date: [**2129-5-10**]
Date of Birth: [**2093-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Band
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 317.7 lbs as
of [**2129-3-21**] (his initial screen weight on [**2129-3-11**] was 315.5 lbs),
height of 68 inches and BMI of 48.3. His previous weight loss
efforts have included couple of months of the [**Doctor Last Name 1729**] diet in
[**2120**]
losing 20 lbs and Slim-Fast that he just started taking. He has
not taken prescription weight loss medications or used
over-the-counter ephedra-containing appetite suppressants/herbal
supplements. He weighed 200 lbs at age 21 his lowest adult
weight
with his highest weight being his current weight of 317.7 lbs.
He
has been struggling with weight since his early 20's and cites
as
factors contributing to his excess weight large portions,
convenience eating, inconsistent meal schedules, too many fats
and carbohydrates, stress, genetics and lack of exercise
secondary to damage knees and multiple surgical reconstructions.
He denied history of eating disorders or depression but has some
issues with anxiety.
Past Medical History:
b/l knee OA, crush injury, mandible fx, orbital fx, GERD
Social History:
He has no known drug allergies or food intolerances. He denied
tobacco, recreational drugs or alcohol usage, drinks 8 ounce
soda 3 times a week, no caffeinated beverage. He is on
Workmen's
Compensation secondary to injury (used to work as foreman in
produce company). He is divorced and lives with mother age 60,
his 2 children ages 7 and 10, his girlfriend age 33 and his
girlfriend's son age 12.
Family History:
Family history is noted for both parents living father
age 62 with cancer; mother age 60 with obesity; sister living
age
39 with obesity; brother living age 40 with thyroid disease.
There is h/o prostate, liver and lung CA.
Physical Exam:
His blood pressure was 130/82, pulse 98 and O2 saturation 95%
room air. On physical examination [**Known firstname **] was casually dressed
and in no distress. His skin was warm, dry, no rashes. Sclerae
were anicteric, conjunctiva clear, pupils were equal round and
reactive to light, fundi were normal, mucous membranes were
moist, tongue pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was supple
without adenopathy, thyromegaly or carotid bruits. Chest was
symmetric and the lungs were clear to auscultation bilaterally
with good air movement. Cardiac was regular rate and rhythm,
normal S1 and S2, no murmurs, rubs or gallops. The abdomen was
obese but soft and non-tender, non-distended with normal bowel
sounds and no masses or hernias, no incision scars. There was no
spinal tenderness or flank pain. There was no edema, venous
stasis or clubbing of the lower extremities. There was no joint
swelling or inflammation of the joints, there were well-healed
vertical incision scars of both knees. There were no focal
neurological deficits and gait was noted for limp.
Pertinent Results:
[**2129-5-5**] 02:07AM BLOOD WBC-10.6 RBC-4.60 Hgb-13.7* Hct-39.1*
MCV-85 MCH-29.9 MCHC-35.2* RDW-13.8 Plt Ct-214
[**2129-5-8**] 01:58AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.5* Hct-34.3*
MCV-88 MCH-29.5 MCHC-33.6 RDW-13.5 Plt Ct-200#
[**2129-5-5**] 02:07AM BLOOD Plt Ct-214
[**2129-5-8**] 01:58AM BLOOD Plt Ct-200#
[**2129-5-5**] 02:07AM BLOOD Glucose-113* UreaN-18 Creat-1.1 Na-136
K-5.9* Cl-102 HCO3-24 AnGap-16
[**2129-5-8**] 01:58AM BLOOD Glucose-102 UreaN-11 Creat-0.7 Na-142
K-3.9 Cl-108 HCO3-26 AnGap-12
[**2129-5-8**] 01:58AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.9
CT Scan [**2129-5-5**]
Extremely limited study for evaluation of PE given suboptimal
contrast timing
despite two attempts. Atelectasis/consolidation in the lower
lobes
bilaterally. Fatty liver. The gastrojejunal anastomosis appears
grossly
unremarkable without frank leak of oral contrast. The
jejuno-jejunal
anastomosis is incompletely imaged.
Chest X-ray [**2129-5-6**]
New patchy opacities have developed in both perihilar
regions, accompanied by persistent patchy retrocardiac
opacities. This may be due to atelectasis and/or aspiration.
Small left pleural effusion is
unchanged.
Chest X-ray 05/17/009
The low lung volumes are noted with worsening of bibasal
atelectasis, new
finding since the prior study. There is unchanged position of
the
intra-abdominal drainage. The upper lungs are clear. No
pneumothorax is
seen.
Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass.
Postoperatively patient developed increased oxygen needs with
tachycardia refractory to fluid, pain control and
benzodiazepines. CTA was obtained to rule out pulmonary
embolism.
He developed fever on postoperative day one and patient was
taken back to the operating room for exploratory laparoscopy. No
leak or bleeding was identified. He was transferred to the
intensive care unit after his second surgery. Chest x-rays
showed Left lower lobe consolidation with increasing bibasilar
atelectasis. On postoperative day 4 he was extubated. He
recieved extensive pulmonary toilet on postoperative day 5.
On day 6 he was much improved with oxygen saturation 98% on 2
liters. He was progressed to stage 2 and tolerated this well. He
was transferred to the regular floor.
On day 7 he progressed to a stage 3 diet and tolerated that
well. His oxygen saturations were fine on room air.
We will send him home today with follow up with Dr. [**Last Name (STitle) **]
next week.
Medications on Admission:
vit D3 1000U', MVI'
Discharge Medications:
1. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day:
Please open capsule and place in drink. You must take this for 6
months.
Disp:*60 Capsule(s)* Refills:*5*
2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please
take for one month.
Disp:*600 ml* Refills:*0*
3. Roxicet 5-325 mg/5 mL Solution Sig: [**5-1**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day.
Disp:*500 ml* Refills:*0*
5. medication
Please resume multivits
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. 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.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-6**] 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.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2129-5-19**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2129-5-19**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2129-6-10**] 9:00
Completed by:[**2129-5-10**]
|
[
"719.46",
"278.01",
"V85.4",
"997.1",
"780.62",
"799.02",
"785.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.13",
"44.38",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6429, 6435
|
4772, 5806
|
360, 400
|
6506, 6515
|
3357, 4749
|
8693, 9212
|
1973, 2198
|
5876, 6406
|
6456, 6456
|
5832, 5853
|
6563, 7129
|
2213, 3338
|
274, 322
|
8336, 8670
|
428, 1457
|
6475, 6485
|
7154, 8324
|
1480, 1538
|
1554, 1957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,718
| 171,172
|
26416
|
Discharge summary
|
report
|
Admission Date: [**2174-1-24**] Discharge Date: [**2174-1-30**]
Date of Birth: [**2104-8-15**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Percocet / Ampicillin / Ancef
Attending:[**First Name3 (LF) 53626**]
Chief Complaint:
transfer from OSH for worsening cellulitis
Major Surgical or Invasive Procedure:
operative debridement of left LE
central venous line placement
History of Present Illness:
HPI: Ms. [**Known lastname 65329**] is a 69 year old female admitted to a hospital
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] where she lives on [**1-22**] with cellulitis of
her foot/leg one day after her toddler nephew's toy motorcycle
ran over her second left toe and broke her skin. She was
initially febrile at home (low grade) with malaise, nausea and
pain. She was started at OSH on IV Ancef and placed on a CIWA
scale with Ativan. She developed diarrhea which was treated with
Imodium. No abdominal rash was noted on admission but she
developed one prior to discharge (although the patient claims
that this rash may have started concerrently with her LE
cellulitis). She developed a wheeze and was treated with nebs
and started on Zithromax 500mg PO x 1 and planned for 250mg PO
on day #[**2-27**] (day of transfer would have been day 2). CXR at OSH
was read as: "probable bilateral pleural effusions associated
with atalectasis/consolidations of the left base and increased
right apical density." LLE LENI was performed and negative for
clot. Her WBCs were elevated >16 with a left shift. Her
creatinine went from 1.0 to 1.5 but this was in the setting of
having received a dose of lasix. She developed marked groin pain
with ? LAD of the groin on the left side (note that her LLE LENI
included normal imaging of the groin vasculature). She was also
hyponatremic at OSH with a sodium of 130.
Past Medical History:
Osteoporosis
Alcohol abuse
Breast Cancer: s/p radical mastectomy [**2139**]; mastectomy [**2145**]
Colon Cancer
HTN
s/p Appendectomy
s/p Tonsillectomy
Social History:
Retired manager of a gift business. Reports drinking about [**2-28**]
glasses of wine per day and roughly 30 glasses of wine per week.
Denies all CAGE screening questions. Denies other current drug
use. Roughly 50 pack/year smoking hx, stopped in [**2160**]. Not
currently sexually active and was previously monogamous.
Family History:
Maternal side with heart disease; sister with breast CA.
Physical Exam:
Vitals: T 98.5
BP 110/60
HR 108
R 28
Sat 95% RA
.
Gen: NAD, WN, WD
HEENT: Clear OP, MMM
Neck: Supple, No LAD, No JVD
Lungs: Diffuse wheeze, decr. BS at bases bilat. No crackles
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, Markedly distended. No fluid wave but ? ascites.
NL BS.
Ext: No edema. 2+ DP pulses BL.
Skin:
-Diffuse abdominal rash: erythematous, blanching, macular with
one 5x7 cm area of increased warmth, non-tender.
-LE rash: erythematous, warm, well circumscribed rash within
previously drawn borders at ankle but extending beyond borders
proximally and including upper thigh and groin.
Neuro: A&Ox3. Slight delay in response but reponds
appropriately. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**1-24**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred. Slight tremor of
hands and legs that, per pt, is "hereditary".
Pertinent Results:
[**2174-1-24**] 07:19PM GLUCOSE-147* UREA N-20 CREAT-1.0 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2174-1-24**] 07:19PM ALT(SGPT)-30 AST(SGOT)-50* ALK PHOS-68 TOT
BILI-0.7
[**2174-1-24**] 07:19PM LIPASE-101*
[**2174-1-24**] 07:19PM ALBUMIN-3.1* CALCIUM-7.3* PHOSPHATE-1.9*
MAGNESIUM-1.4*
[**2174-1-24**] 07:19PM WBC-13.5* RBC-4.04* HGB-13.4 HCT-40.3
MCV-99.7* MCH-33.2* MCHC-33.3 RDW-13.9
[**2174-1-24**] 07:19PM NEUTS-52 BANDS-33* LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2174-1-24**] 07:19PM PLT SMR-LOW PLT COUNT-144*
[**2174-1-24**] 07:19PM PT-13.3 PTT-29.7 INR(PT)-1.2
[**2174-1-24**] 06:27PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**1-24**]: CXR showed no infiltrates or pulmonary edema
[**1-25**]: Abd. U/S showed fatty infiltration of the liver but no
evidence of ascites
[**1-26**]: Tibia/fibula films showed soft tissue changes and
subcutaneous edema/disruption of dermis but no bony changes
[**1-26**]: Lower extremity vein doppler showed no evidence of DVT.
Brief Hospital Course:
Ms. [**Known lastname 65329**] was transferred to [**Hospital1 18**] on [**1-24**] with worsening rash
in setting of low-grade fevers on Ancef, occasional SOB/wheeze
and nonproductive dry cough. Due to concern for EtOH
withdrawal, thiamine and folate were given and the patient was
placed on a CIWA scale q 4 hrs. An infectious disease consult
was called and levofloxacin and clindamycin were initiated for
cellulitis treatment on [**1-24**]. On the floor, the patient
developed hypotension and tachycardia and dopamine was started.
The patient was then transferred to the MICU. Due to
progressing infection of the LLE, vancomycin was initiated on
[**1-25**]. Out of high clinical suspicion for necrotizing fasciitis,
operative debridement of the LLE was done on [**1-25**]; no
intra-operative evidence for necrotizing fasciitis was found.
She was admitted to the Trauma ICU still intubated. Because of
continuing leg rash, swelling, and redness a lower extremity
vein doppler was done on [**1-26**] that showed no evidence of DVT.
The patient was extubated on [**1-26**], remained stable, and was
transferred to the medicine service on [**1-28**]. Urine and blood
cultures showed no growth. Her abdominal rash and hypotension
had resolved. She remained afebrile with stable vital signs,
and and cultures with LLE fluid and deep tissue samples showed
no growth. She was discharged on an 8-day course of levoflox
and clinda, to complete a 14 day total course.
.
The patient developed abdominal distention during her stay; in
this setting, her history of heavy EtOH intake was worrisome for
ascites. An abdominal ultrasound on [**1-25**] showed fatty
infiltration of the liver but no evidence of ascites. Her
macrocytosis was thought to be secondary to EtOH intake, and
folate and B12 levels were normal. A social work consult was
called on [**1-26**]. The patient denied having an alcohol problem,
yet her son felt that this problem was worsening. She given
prescriptions for thiamine and folate.
.
The patient's cough continued but a CXR showed no evidence of
consolidation, and the patient had good air movement in all
fields. She developed soft stools/diarrhea on [**1-29**], and a stool
sample analyzed on [**1-30**] was negative for C. diff toxin. It was
also noted that her fasting blood glucose levels were slightly
elevated during her stay (120s). She continued to improve and
was discharged on [**1-30**] with home VNA services to care for the
wound and for home physical therapy. She also went home on a
nasal steroid that seemed to help her post-nasal drip cough.
She also received instructions to consult a general surgeon for
follow-up care of her wound, and to consult her primary care
provider regarding her cough, high alcohol intake, and high
blood glucose levels.
Medications on Admission:
Aspirin 81mg PO daily
Fosamax 70mg PO weekly
Atenolol 50mg daily
Multivitamin daily
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 spray* Refills:*0*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO four
times a day for 8 days.
Disp:*64 Capsule(s)* Refills:*0*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] community vns
Discharge Diagnosis:
lower left extremity cellulitis
..
chronic cough
alcohol abuse
anemia
Discharge Condition:
stable
Discharge Instructions:
Please return with any fever, chills, shortness of breath, chest
pain, or persistent diarrhea. Also return with any worsening
swelling, redness, weakness, numbness, tingling or pain in your
left leg.
.
Please take all medications as directed. You have received
prescriptions for levofloxacin and clindamycin, and you should
take the entire suggested course of these antibiotics.
.
The dressing on your wound should be changed once a day with the
assistance of a visiting nurse. Also please make sure that you
follow the suggested physical therapy regimen for your leg.
Followup Instructions:
Please schedule an appointment with a general surgeon in your
area within the next 1-2 weeks to ensure that the wound is
healing properly.
.
Please also schedule an appointment with your primary care
provider within the next week. You should also discuss your
chronic cough with her and receive continued monitoring of your
health care. You might need lung function tests to evaluate your
chronic cough and the low oxygen in your blood. You should also
talk to her about your alcohol consumption.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 53627**]
|
[
"790.29",
"787.91",
"303.90",
"461.9",
"782.1",
"458.9",
"E917.9",
"733.00",
"401.9",
"V10.00",
"917.1",
"786.2",
"V10.3",
"276.52",
"291.81",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"96.71",
"00.17",
"38.93",
"83.21"
] |
icd9pcs
|
[
[
[]
]
] |
8395, 8502
|
4521, 7322
|
345, 409
|
8616, 8624
|
3395, 4498
|
9245, 9868
|
2400, 2458
|
7457, 8372
|
8523, 8595
|
7348, 7434
|
8648, 9222
|
2473, 3376
|
263, 307
|
437, 1867
|
1889, 2042
|
2058, 2384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,307
| 154,767
|
35572
|
Discharge summary
|
report
|
Admission Date: [**2197-2-28**] Discharge Date: [**2197-3-13**]
Date of Birth: [**2140-7-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
HPI: 56 yo F complaint of sudden onset of severe headache w/o
LOC, nausea or vomiting or motor defecits.
Major Surgical or Invasive Procedure:
Craniotomy for Aneurysm clipping
History of Present Illness:
HPI: 56 yo female who presented with complaint of sudden onset
of severe headache,Pt did not experience any LOC. Pt denied any
visual
changes or any other sensory or motor changes. Pt called her
PCP
and presented to OSH where she was diagnosed with SAH and
transferred to [**Hospital1 18**].
Past Medical History:
Hep C "cured"
Gastric banding
TAH/SBO
Lumpectomy
Septoplasty
HTN
Bipolar
Endometriosis s/p resection
Borderline DM
Gout
Social History:
Pt lives alone, is self-employed. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80972**] III
is health-care proxy.
Family History:
No history of aneurysmal or kidney disease.
Physical Exam:
Exam on admition:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 mm B/L EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR with diastolic murmur
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Exam on discharge:
Gen: WD/WN, comfortable, NAD. Afebrile. VSS.
HEENT: Pupils: 3->2 mm B/L EOM's full. No nystagmus
Neck: Supple. No Upstroke or bruits present
Lungs: CTA bilaterally.
Cardiac: RRR, +murmur, -rub. No Substernal chest discomfort
Abd: Soft, NT, BS+. Tolerating all p.o. food and fluids without
associated
nausea or vomiting.
Extrem: Warm and well-perfused. No dependent peripheral edema
Mental status: Awake and alert, cooperative with exam, normal
affect. Orientated x3. Stream of thoughts is fluid. Speech is
clear with
normal volume. Good comprehension. No dysarthria or dysphagia.
Pertinent Results:
CT result on presentaion:
HEAD CT: Faint hyperdensity is noted in the bifrontal sulci,
bilateral Sylvian fissure and right pontine cistern concerning
for acute subarachnoid hemorrhage. In addition, there is a small
amount of hyperdense blood layering in the occipital [**Doctor Last Name 534**] of the
right lateral ventricles. No mass, mass effect, or major
vascular territorial infarction is identified. The ventricles
and sulci are normal in size and configuration. No soft tissue
or osseous
abnormality is detected.
CTA: There is a bilobed vascular anomaly near the anterior
communicating
artery at the junction of the right A1 and A2 segments. The
largest lobe of the anomaly measures 5 mm and the longest
dimension of the entire lesion is 9 mm. These findings are
concerning for an aneurysm of the anterior communicating artery.
The remainder of the intracranial carotid and vertebral arteries
and their major branches are patent without evidence of
flow-limiting stenoses, mural irregularity or other vascular
abnormality.
IMPRESSION: Bilobed anterior communicating aneurysm with
associateddiffuse
subarachnoid hemorrhage in an atypical distribution. No evidence
of
additional vascular abnormality.
CT Perfusion:
1. Evolving infarction in the inferior right frontal lobe.
2. Infarction or contusion is again seen in the anterior right
temporal lobe.
3. Persistent small amount of intraventricular hemorrhage, with
stable
ventricular size. No new hemorrhage.
4. Limited evaluation of the A1 segments of the anterior
cerebral arteries, and of the M1 segment of the right middle
cerebral artery. Mild vasospasm in the proximal right middle
cerebral artery cannot be excluded.
Brief Hospital Course:
Ms. [**Known lastname 80973**] was admitted to the neurosurgery service after a
diagnosis of aneurysmal SAH for work up and treatment. Cerebral
Angiogram revealed a bilobed ACOM aneurysm that was not
treatable via indovascular coiling.Pt. was consented and taken
to the OR for an open clipping.
Post operatively pt. was transferred to the ICU with a
ventricular drain. The ventricular drain was raised to 10 on
post operative day 2 and well tolerated. Pt. was cultured post
operatively on day 3 for fever spikes, no active infection was
revealed. A CT perfusion revealed a evolving infarct in the
right inferior frontal lobe and Mild vasospasm, pt. was treated
with fluids/hydration. Patient's exam remained stable and her
Ventricular drain was removed and after evaluation by speech
therapy her diet was advanced.
She was subsequently transferred to the floor where she remained
stable throughout her stay. Psychiatry was called to evaluated
the patient's pre-existing Bipolar diagnosis and to make
recommendations regarding her medications which she had stopped
taking pre-operatively. At this point her medication regimen has
been stablized. The patient should discuss further changes with
her Primary care doctor or before abruptly stopping any
medications that she is currently on. It is important for Ms.
[**Known lastname 80973**] to continue the full 21 day regimen of Nimodipine.
Medications on Admission:
Unknown
Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours): Last Dosing to be on [**2197-3-22**].
Disp:*60 Capsule(s)* Refills:*1*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-20**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*2*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*60 Suppository(s)* Refills:*2*
8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*1*
10. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*1*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
SAH
Acom aneurysm
Hep C
Gastric banding
TAH/BSO
Septoplasty
HTN
Bipolar
Endometriosis
Borderline DM
Gout
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain with without contrast.
Completed by:[**2197-3-13**]
|
[
"070.54",
"293.0",
"274.9",
"430",
"V45.86",
"434.91",
"296.80",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51",
"96.6",
"88.41",
"38.93",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
6737, 6756
|
3933, 5330
|
415, 450
|
6905, 6914
|
2223, 2250
|
8488, 8754
|
1089, 1134
|
5388, 6714
|
6777, 6884
|
5356, 5365
|
6938, 8465
|
1149, 1362
|
271, 377
|
478, 774
|
1616, 2004
|
2259, 3910
|
2019, 2204
|
796, 918
|
934, 1073
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,792
| 196,336
|
14081
|
Discharge summary
|
report
|
Admission Date: [**2152-9-21**] Discharge Date: [**2152-9-23**]
Date of Birth: [**2103-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Adhesive Tape
Attending:[**Known firstname 922**]
Chief Complaint:
Failed LV lead placement
Major Surgical or Invasive Procedure:
[**2152-9-21**] - Thoracoscopic LV Lead Placement
History of Present Illness:
This 49 year old male has an extensive history of coronary
artery disease, dating back to [**2139**] when he had his first stent
placed. Since then, he has had multiple stents placed to the
LAD, LCX and RCA. He has LV dysfunction with an echo done in
[**2152-7-14**] demonstrating an EF of 30%-35%. He has symptoms of
shortness of breath with minimal activity such as walking [**Age over 90 **]
yards. He denies
any PND or orthopnea. He has chest pain with activity such as
doing heavy lifting but denies any chest pain at rest. He denies
any recent lightheadedness or palpitations. He was recently
evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
biventricular ICD placement and was found to meet criteria. He
underwent implantation of a [**Company 1543**] BiV ICD, Concerto C154DWK
on [**2152-9-11**] and was discharged the following day. He returned to
the device clinic on [**2152-9-13**] when he developed stimulation of
his diaphram causing continuous hiccups. His LV lead was
deactivated and the patient returned for revision of his LV lead
however attempts were unsuccessful to place the lead. He is now
admitted for a thoracosopic LV lead placement.
Past Medical History:
Coronary artery disease status post multiple stent placements
in the LAD, left circumflex, and right coronary artery beginning
in [**2139**] with subsequent interventions in [**2148**], [**2150**], and most
recently drug-eluting stents placed in the distal right in
12/[**2150**].
Long-standing left bundle-branch block.
Class III congestive heart failure symptoms
Depressed LV function with the recent echo showing an ejection
fraction of 30%.
Hypertension
Hyperlipidemia
Diabetes
Cardiomyopathy, s/p BiV ICD placementon [**2152-9-11**]
LBBB
Substance abuse in the [**2113**]/[**2123**] with marijuana, acid, ETOH;
denies using drugs presently
Social History:
Married with 3 children. He is currently not working. His wife
will bring him to the procedure and can be reached at [**Telephone/Fax (1) 41991**]. Drinks alcohol on occasion.
Family History:
father had a stent placed at age 73. mother has a LBBB.
Physical Exam:
Vital Signs: His blood pressure is
110/70, heart rate 70, and sats 96. Neck: JVP 6 cm. Carotids
without discernible bruits. No neck masses or thyroid masses.
Lungs: Clear. Heart: Regular rate and rhythm, good S1 and S2,
with an S3 gallop. Abdomen: Soft, nontender. Extremities:
Pulses are 1+ distally.
Pertinent Results:
[**2152-9-22**] 02:14AM BLOOD WBC-12.8* RBC-3.75* Hgb-11.6* Hct-32.6*
MCV-87 MCH-31.0 MCHC-35.7* RDW-14.7 Plt Ct-281
[**2152-9-21**] 09:10AM BLOOD WBC-5.4 RBC-3.81* Hgb-11.7* Hct-33.3*
MCV-88 MCH-30.8 MCHC-35.1* RDW-14.6 Plt Ct-255
[**2152-9-21**] 01:25PM BLOOD PT-13.8* PTT-20.3* INR(PT)-1.2*
[**2152-9-21**] 09:10AM BLOOD PT-13.7* PTT-22.0 INR(PT)-1.2*
[**2152-9-23**] 07:20AM BLOOD UreaN-16 Creat-0.9 K-4.2
[**2152-9-21**] 01:25PM BLOOD UreaN-18 Creat-0.8 Na-138 Cl-104 HCO3-24
[**Known lastname 41992**],[**Known firstname 177**] E. [**Age over 90 41993**] M 49 [**2103-2-23**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-9-22**] 9:25
AM
[**Last Name (LF) **],[**Known firstname 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2152-9-22**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 41994**]
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
49 year old man s/p Left thoracoscopy/pacer lead placement
REASON FOR THIS EXAMINATION:
PTX
Provisional Findings Impression: LCpc FRI [**2152-9-22**] 6:50 PM
No pneumothorax.
Final Report
CHEST, PORTABLE AP
REASON FOR EXAM: 49-year-old man status post left
thoracoscopy/pacer lead
placement. Rule out pneumothorax.
Since earlier today, the left chest tube was removed. There is
no
pneumothorax. There is otherwise no overall change since this
morning.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: SAT [**2152-9-23**] 8:34 AM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2152-9-21**] for surgical
placement of his LV lead. He was taken directly to the operating
room where he underwent a thoracoscopic LV lead placement.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring.He was later
extubated without issue. He reported feeling typical anginal
symptoms that evening. He was treated per CP protocol: NTG
SL/O2/MSO4. 12 Lead EKG done.No evidence of ischemia. Cardiac
enzymes cycled negative. Cardiology consulted. No further
episodes occurred. POD#1 the left CT was discontinued.
Mr.[**Known lastname **] was doing well and was transferred to the floor for
further monitoring and recovery. POD#2 He was cleared for
discharge to home. He was advised to follow up with Dr.[**Last Name (STitle) 914**]
in 2 weeks time and to have a CXR done prior to his appointment.
Medications on Admission:
Metformin 500 mg PO BID
Lisinopril 20 mg PO DAILY
Aspirin 325 mg
Metoprolol Succinate 50 mg Tablet
Discharge Medications:
1. Metformin 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Packet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Outpatient Lab Work
CXR: PA/LAT->s/p left thorascopic LV lead placement 2 weeks
after discharge
Discharge Disposition:
Home with Service
Discharge Diagnosis:
[**2152-9-21**] - Thoracoscopic LV Lead Placement
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks.[**Telephone/Fax (1) **]*Please
have CXR done prior to appointment.
Scheduled Appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2152-11-3**] 9:40
Completed by:[**2152-9-23**]
|
[
"426.3",
"250.00",
"V45.82",
"401.9",
"996.04",
"428.0",
"272.4",
"E879.8",
"423.0",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"37.74"
] |
icd9pcs
|
[
[
[]
]
] |
6584, 6603
|
4468, 5394
|
303, 355
|
6697, 6706
|
2857, 3744
|
7371, 7703
|
2462, 2519
|
5543, 6561
|
3784, 3843
|
6624, 6676
|
5420, 5520
|
6730, 7348
|
2534, 2838
|
239, 265
|
3875, 4445
|
383, 1582
|
1604, 2252
|
2268, 2446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,410
| 115,288
|
22196
|
Discharge summary
|
report
|
Admission Date: Discharge Date: [**2150-4-2**]
Date of Birth: [**2089-9-10**] Sex: M
Service: CSU
ADMISSION DIAGNOSES:
1. Hypotension.
2. Status post AVR/MVR/MAZE.
3. Atrial fibrillation.
4. History of rheumatic heart disease.
DISCHARGE DIAGNOSES:
1. Pericardial effusion, status post pericardial window.
2. Rheumatic heart disease, status post aortic valve
replacement (21 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]) mitral valve replacement (29
[**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]).
3. Status post MAZE procedure.
4. Atrial fibrillation.
5. Pleural effusion.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 60 year-old
gentleman with a history of rheumatic heart disease, who
underwent an AVR, MVR, MAZE procedure on [**2150-3-12**]
without significant complication in his postoperative course.
He was discharged to home in good condition. He presented to
his primary care physician on [**2150-3-23**] with some fatigue
and light headedness. He was found to be hypotensive at the
time and in rapid atrial fibrillation. He was, therefore,
admitted to the Emergency Department for management of this.
He was cardioverted in the Emergency Department. It was felt
that his rapid atrial fibrillation was the cause of his
hypotension. He was subsequently admitted to the medical
service for further management. On his initial examination,
his temperature was 98.3; pulse was in the 1-teens to 130's.
His blood pressure was 88/53 and he was saturating 96 percent
on room air. He followed commands. He had a significant
amount of jugulovenous distention and his heart sounds were
distant. His breath sounds were decreased in the lower lobes.
His abdomen was otherwise soft and his extremities had no
edema. His initial white blood cell count was 20.1 with a
hematocrit of 28. His INR was markedly elevated at 6.0 and
his BUN and creatinine were 34 and 1.6.
The patient's initial chest x-ray showed low lung volumes,
ill-defined bibasilar opacities, which were thought to
represent consolidation and presence of cardiomegaly.
HOSPITAL COURSE: The patient was admitted as noted to the
medical service for further work-up. Given his clinical
scenario, it was felt prudent to obtain an echocardiogram to
rule out tamponade or pericardial effusion, responsible for
his hypotension and his acute renal insufficiency. He did
undergo this echocardiogram which revealed presence of
significant pericardial effusion, although there was no
evidence of pericardial tamponade. The effusions seemed
loculated and it was felt that interventional attempts at
drainage would be unsuccessful. Therefore, he was
transferred to the cardiac surgery service and taken to the
operating room on [**2150-3-24**] at which time he had a
pericardial window created and evacuation of his pericardial
effusion. Notably preoperatively, the patient had markedly
elevated transaminases with an ALT of 1139 and an AST of 1415
with a normal total bilirubin and normal alkaline
phosphatase, amylase and lipase. A right upper quadrant
ultrasound was obtained on our service and didn't show any
evidence of biliary tract obstructions. It was felt that
this may have been secondary to cardiogenic etiology and
congestion. The liver function tests subsequently normalized
without any intervention after his pericardial window.
Postoperatively, the patient did quite well. We initially
held his Coumadin until his INR drifted back down towards
2.5. He had multiple episodes of atrial fibrillation
postoperatively which required starting Amiodarone. By the
time he was ready for discharge, though, his rate was
controlled with a blood pressure in the 100/60's and rate of
80 to 90 and atrial fibrillation. To note, the patient
developed an increase in oxygen requirement towards the
latter part of his hospitalization and chest x-ray showed
accumulation of a large right pleural effusion. A pig-tail
drain was placed in this effusion and approximately 2.2
liters of old blood and serous fluid were drained. The
pigtail catheter remained in place for two days and was
subsequently removed without reaccumulation of the fluid. By
hospital day number 11, as the patient had been afebrile and
otherwise hemodynamically normal with rate controlled atrial
fibrillation and lungs clear to auscultation on examination,
it was felt that he could be discharged to home in stable
condition. By the time of his discharge, his liver function
tests had normalized and his white blood cell count had
normalized to 8.8. To note, his hematocrit was 36.4 and his
INR was 3.0. His renal function had normalized to its
baseline with BUN and creatinine of 22 and 0.9. His
transaminase, as noted, had normalized and his chest x-ray
showed the presence of no significant effusion and he only
had small apical pneumothoraces which had been stable.
To note, he was treated empirically with Vancomycin and
levofloxacin throughout his hospitalization for the question
of infection of his pericardial effusion, given that his
white blood cell count was elevated. This was discontinued
prior to his discharge as none of his culture data showed any
growth. He was discharged to home on [**2150-4-2**] on the
following medications:
1. Colace 100 mg p.o. twice a day when taking narcotics.
2. One multi-vitamin a day.
3. Percocet prn.
4. Aspirin 81 mg daily.
5. Protonix 40 mg p.o. once daily.
6. Amiodarone 400 mg p.o. once daily for seven days and then
200 mg once per day.
7. Lasix 40 m once per day for 10 days and then 20 mg once a
day.
8. Coumadin as directed for a goal INR of 3 to 3.5.
9. Lopressor 12.5 mg p.o. twice a day.
10. Potassium chloride 20 meq p.o. once daily when
taking Lasix.
FOLLOW UP: He was to follow up in Dr.[**Name (NI) 57924**] clinic on the
following day for INR check. She manages Coumadin and INR
levels.
She is to follow up with Dr. [**Last Name (STitle) 7047**] and Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2150-4-2**] 17:17:19
T: [**2150-4-2**] 18:02:03
Job#: [**Job Number 57925**]
|
[
"511.9",
"V43.3",
"423.9",
"584.9",
"427.31",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"37.12",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
282, 2146
|
2164, 5783
|
5795, 6282
|
151, 261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,882
| 157,780
|
8866
|
Discharge summary
|
report
|
Admission Date: [**2146-5-1**] Discharge Date: [**2146-5-9**]
Date of Birth: [**2083-2-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Presented to ED with 6 days of worsening abdominal pain. He had
fevers, chills, dark urine, decreased appetite, nausea, and
abdominal distention but denied emesis.
Major Surgical or Invasive Procedure:
none
IV antibiotics
History of Present Illness:
HPI: 63M with h/o an appendiceal abscess in [**2140**] treated with an
IR drain placement.
Given his history of COPD and PVD, appendectomy was deferred
indefinitely.
He presented to the ED with6 days of worsening abdominal pain.
He has
had fevers, chills, dark urine, decreased appetite, nausea, and
abdominal distention. He denies any emesis or history of
surgery.
Past Medical History:
Insulin-dependent Diabetes Mellitus
COPD
Peripheral vascular disease
Hypercholesterolemia
Obstructive Sleep Apnea
S/P CVA [**2-23**] - very mild dysarthria/mild left facial weakness
[**2115**]'s right fem-[**Doctor Last Name **] bypass graft x 2
Hepatomagaly
Social History:
The patient is happily married. He is a former smoker. He admits
to drinking [**1-26**] drinks a day.
Family History:
non contributory
Physical Exam:
PE: 99.3 87 126/83 16 98 3L
General: A&Ox4, mod distress
Lungs: RRR, Wheezing
Abdomen: obese, distended, RLQ ttp
Rectal: no blood
Extremities: no edema, warm
Pertinent Results:
[**2146-5-1**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2146-5-1**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2146-5-1**] 10:50AM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE
EPI-0-2
[**2146-5-1**] 10:50AM URINE HYALINE-0-2
[**2146-5-1**] 10:30AM estGFR-Using this
[**2146-5-1**] 10:30AM WBC-20.0*# RBC-4.20* HGB-13.1* HCT-37.9*
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.5
[**2146-5-1**] 10:30AM NEUTS-92* BANDS-1 LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2146-5-1**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2146-5-1**] 10:30AM PLT SMR-NORMAL PLT COUNT-332
[**2146-5-1**] 10:30AM PT-34.3* PTT-28.1 INR(PT)-3.5*
CT ABDOMEN W/CONTRAST [**2146-5-1**]: Findings consistent with
perforated acute appendicitis, including early abscess formation
and a trace quantity of distant free air. There is no large
drainable fluid collection.
Small umbilical hernia/diastasis with bowel identified at the
hernia neck.
CT ABDOMEN W/CONTRAST [**2146-5-5**]: Slight interval organization of
perforated appendicitis. No drainable fluid collection at this
time.
ECG [**2146-5-1**]: Sinus rhythm. Poor R wave progression is probably
a normal variant. Low QRS voltage in the limb leads. Compared to
the previous tracing of [**2144-6-8**] there is no significant
diagnostic change.
CHEST (PORTABLE AP) Study Date of [**2146-5-1**]: Right costophrenic
angle not fully included on the image. Mild central pulmonary
vascular congestion.
CHEST PORT. LINE PLACEMENT [**2146-5-4**] 2:32 PM: PICC line has been
placed from a left upper extremity approach. The distal tip is
at the superior cavoatrial junction in appropriate position.
Lung volumes are diminished with minimal bibasilar atelectasis,
left slightly worse than right.
Blood, urine, and MRSA were all negative.
Brief Hospital Course:
Mr. [**Known lastname 634**] was admitted from the emergency room to Dr. [**Name (NI) 30888**] Surgical Service for perforated appendicitis. He was
placed in the ICU due to respiratory distress. He was placed on
antibiotics and inhalers, but his coumadin was held.
Pain and nausea were well controlled. He worked with physical
therapy and recommended pacing, breathing and gait training in a
rehab center.
On HD 4, he was transferred from the ICU to the floor. He was
given 3 boluses of fluid for low urine output. Chest PT as well
as PT for ambulation was begun. A PICC line was placed.
On HD 5, the patient had his foley removed and a condom catheter
was placed and the patient voided appropriately.
On HD 6, the patient had flatus and was given a clear liquid
diet, which he tolerated rather well.
On HD 8, the patient was doing well, eating well and passing
flatus. He is ready to leave the hospital for physical
rehabilitation.
Medications on Admission:
albuterol 2 puffs""
alendronate 1
asa 81
atenolol 50
budesonide 0.5" neb
citalopram 20
coumadin 12.5
lasix 60
folic acid 800
humalog prn lunch/dinner
humulin 45 am/15pm
lipitor 20
lisinopril 20
pantoprazole 40
prednisone 7.5
proventil 2 puff""
O2 3L
salsalate 750"
spiriva
mvi
vit b1
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Salsalate 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze/sob.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze/sob.
12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily). Tablet(s)
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 22 days:
please administer through PICC line.
16. Humulin R Injection
17. Humalog Subcutaneous
18. Heparin Lock Flush 10 unit/mL Solution Sig: Two (2) mL
Intravenous once a day: Please flush with 10 mL of sterile
normal saline, then heparin as above, then 10 mL of NS every day
and prn per line.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: do NOT exceed 3 grams of
tylenol in anny given 24 hour period.
20. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
21. Multiple Vitamin Oral
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
perforated appendicitis
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 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.
You are being discharged on antibiotics. You must finish the
entire course of antibiotics.
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 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 [**10-7**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2146-5-13**] 8:10
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2146-5-13**] 8:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2146-5-13**] 8:30
Please call [**Telephone/Fax (1) 2835**] to make an appointment with Dr.
[**Last Name (STitle) 468**]
Completed by:[**2146-5-9**]
|
[
"496",
"305.1",
"518.0",
"250.01",
"327.23",
"272.0",
"443.9",
"540.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6803, 6903
|
3502, 4447
|
474, 496
|
6971, 6971
|
1521, 3479
|
8704, 9281
|
1309, 1327
|
4781, 6780
|
6924, 6950
|
4473, 4758
|
7147, 8681
|
1342, 1502
|
271, 436
|
524, 891
|
6986, 7123
|
913, 1173
|
1189, 1293
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,050
| 163,020
|
24337
|
Discharge summary
|
report
|
Admission Date: [**2193-9-3**] Discharge Date: [**2193-9-9**]
Date of Birth: [**2130-6-7**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Asymptomatic / incidental 5.2-cm infrarenal abdominal
Major Surgical or Invasive Procedure:
AAA repair
History of Present Illness:
This 63-year-old gentleman was found to have a 5.2-cm infrarenal
abdominal aortic aneurysm with some mild ectasia of the iliac
arteries. He did not want a stent graft.
Past Medical History:
AAA, HTN, GERD, BPH, elevated cholesterol, Obesity, Hip
discomfort, s/p melanoma excision
Social History:
Quit tobacco 7 years ago. Admitted to smoking 2 packs per day
for "many years". He denies excessive ETOH. He is married with
two grown children.
Family History:
Father suffered MI at age 65 with subsequent CABG. Mother also
suffered from MI in her 60's.
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2193-9-7**]
WBC-7.2 RBC-3.56* Hgb-11.2* Hct-31.3* MCV-88 MCH-31.3 MCHC-35.7*
RDW-14.5 Plt Ct-135*
[**2193-9-7**]
PT-13.3 PTT-29.9 INR(PT)-1.2
[**2193-9-7**]
Glucose-93 UreaN-13 Creat-0.6 Na-131* K-3.4 Cl-97 HCO3-25
AnGap-12
[**2193-9-3**]
freeCa-1.17
[**2193-9-5**] 9:29 AM
CHEST PORT. LINE PLACEMENT
FINDINGS: The patient has been extubated, and Swan-Ganz catheter
has been replaced with a right internal jugular central venous
line with tip in good position in the distal SVC. No
pneumothorax is seen. Cardiomediastinal borders are unchanged.
Right basilar atelectasis improved. No change to left basilar
atelectasis. Left costophrenic angle is excluded from view. No
pleural effusions. NG tube tip is in the stomach.
IMPRESSION: Satisfactory position of right central venous line.
No pneumothorax.
Cardiology Report ECG
Normal sinus rhythm with borderline A-V conduction delay.
Compared to the
previous tracing of [**2193-8-27**] the occasional ventricular premature
beats are no longer present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 206 98 [**Telephone/Fax (2) 61658**] 3 2
Brief Hospital Course:
Pt admitted [**2193-9-3**]
Pt underwent a AAA reapir. There were no complications. The pt
tolerated the procedure [**Doctor Last Name **]. He was extubated in the OR.
Transfered to thh PACU in stable condition.
Once recovered from anesthesia. Pt transfered to the VICU in
stable condition.
[**2193-9-4**]
Pt diuresed
NGT remained
[**2193-9-5**]
Lopresor increased for BP control / Pain control
Swan DC'D
Diuresed
[**2193-9-6**] - [**2193-9-7**]
OOB / NPO (NGT remaines ) / diuresed / lytes replenished / I&O
monitered
PT consult obtained.
[**2193-9-8**]
Pos BS
NGT removed / diet advanced / foley DC'd / central line DC'd /
pt made floor status
[**2193-9-9**]
Pt cleared for DC
Taking PO / amb / urinating / pos BM.
Medications on Admission:
Metoprolol Tartrate 50 mg
Aspirin 81 mg
Atorvastatin 40 mg
Clopidogrel 75 mg
Oxybutynin Chloride 5 mg
Buspirone 10 mg Tablet
Tamsulosin 0.4 mg Capsule
Pantoprazole 40 mg Tablet
Oxycodone-Acetaminophen 5-325 mg
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal aortic aneurysm
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed. Please call your
doctor if you experience abdominal pain, lightheadedness,
fever>101.5, or any other concerns. Please do not lift anything
heavier than a gallon of milk for 6 weeks.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in 1 week. Please call [**Telephone/Fax (1) 3121**]
for an appointment.
Completed by:[**2193-11-18**]
|
[
"414.01",
"272.4",
"V45.81",
"441.4",
"560.1",
"600.00",
"997.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
4685, 4691
|
2547, 3283
|
322, 335
|
4761, 4768
|
1418, 2524
|
5041, 5186
|
828, 922
|
3544, 4662
|
4712, 4740
|
3309, 3521
|
4792, 5018
|
937, 1399
|
229, 284
|
363, 533
|
555, 646
|
662, 812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,917
| 117,548
|
36566
|
Discharge summary
|
report
|
Admission Date: [**2182-8-17**] Discharge Date: [**2182-8-22**]
Date of Birth: [**2120-5-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Upper Endoscopy with epinephrine injections
History of Present Illness:
62 yo F w/ PMH of progressive GBM p/w massive upper GI bleed, on
dex for GBM, taking motrin daily. HCT 22 at OSH. Taking 1.5mg
daily dex and daily ibuprofen. Tx from [**Hospital3 **]. Found on
toilet w/ BRB in toilet by husband, Hit back of head on sink. BP
55/palp in the field. [**Hospital3 **] CT head/neck negative. Got one
unit uncrossed blood at [**Hospital3 **] and was getting second on way
up from ED. has 2 18gs and one 20g PIV. BPs 105-115 in ED. Pulse
around 90. A/Ox2 (baseline). PPI bolus 80mg and drip started in
ED. GI and surgery were consulted.
Past Medical History:
Past Oncologic History:
# Right parietal glioblastoma multiforme, s/p
(1) a gross total surgical resection of a right parietal
glioblastoma by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2181-3-26**],
(2) s/p involved-field cranial irradiation to 6,000 cGy from
[**2181-4-16**] to [**2181-5-28**],
(3) s/p 1 cycle of adjuvant temozolomide, and
(4) started XL-184 on [**2181-10-2**] and has had 7 cycles so far.
Other Past Medical History:
(1) Insomnia
(2) Low back pain
(3) HSV oral ulcerations
(4) Cognitive impairment related to GBM
Social History:
She is married and she lives with husband. She smokes [**Date range (1) 61126**]
PPD. She reports drinking 2 small glasses wine per week, but
her brother reports that she drinks daily. Her husband
primarily caregiver. [**Name (NI) **] brother expressed concern that patient
may be neglected.
Family History:
Non-contributory; denies familial history of brain [**Name (NI) **] or
cancer.
Physical Exam:
On admission to ICU:
Vitals: T: 96.5 BP: 113/74 P: 95 R: 18 O2: 98% 2L
General: Alert, oriented x2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Chapped lips and
scaling of skin on L side of face
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2182-8-17**] 07:47PM TYPE-[**Last Name (un) **] TEMP-35.9 PH-7.31*
[**2182-8-17**] 07:47PM freeCa-1.05*
[**2182-8-17**] 07:20PM GLUCOSE-172* UREA N-31* CREAT-0.3* SODIUM-136
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-21* ANION GAP-9
[**2182-8-17**] 07:20PM CALCIUM-6.7* PHOSPHATE-2.6* MAGNESIUM-1.3*
[**2182-8-17**] 07:20PM WBC-8.0 RBC-3.90*# HGB-12.2# HCT-35.1* MCV-90
MCH-31.3 MCHC-34.9 RDW-17.2*
[**2182-8-17**] 07:20PM PLT COUNT-221
[**2182-8-17**] 07:20PM PT-15.6* PTT-23.6 INR(PT)-1.4*
[**2182-8-17**] 03:06PM TYPE-[**Last Name (un) **] TEMP-36.3 PH-7.26* COMMENTS-GREEN
TOP
[**2182-8-17**] 03:06PM LACTATE-2.0
[**2182-8-17**] 03:06PM freeCa-1.07*
[**2182-8-17**] 02:39PM HCT-30.6*
[**2182-8-17**] 02:39PM PLT COUNT-257
[**2182-8-17**] 02:39PM PT-15.1* PTT-26.1 INR(PT)-1.3*
[**2182-8-17**] 10:10AM LACTATE-2.6*
[**2182-8-17**] 10:00AM GLUCOSE-95 UREA N-35* CREAT-0.4 SODIUM-136
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2182-8-17**] 10:00AM estGFR-Using this
[**2182-8-17**] 10:00AM ALT(SGPT)-46* AST(SGOT)-30 ALK PHOS-63 TOT
BILI-0.3
[**2182-8-17**] 10:00AM LIPASE-27
[**2182-8-17**] 10:00AM ALBUMIN-2.6*
[**2182-8-17**] 10:00AM WBC-10.0 RBC-2.88* HGB-9.1*# HCT-27.6* MCV-96
MCH-31.6 MCHC-33.0 RDW-17.6*
[**2182-8-17**] 10:00AM NEUTS-80.4* LYMPHS-17.4* MONOS-1.7* EOS-0.2
BASOS-0.3
[**2182-8-17**] 10:00AM PLT COUNT-370
[**2182-8-17**] 10:00AM PT-15.5* PTT-25.8 INR(PT)-1.4*
Brief Hospital Course:
Upper GI [**Last Name (un) **]: Patient was given Blood(1 at OSH, 1 at ED, 2 on
the floor). She underwent upper endoscopy, found large ulcer in
Anterior duodenal bulb, that did not bleed on Upper endoscopy,
but pt continued to bleed post procedure. Patient was subjected
to another endoscopy found more bleeding ulcers, epi injected
into multiple sites. Found a diverticulum that was bleeding near
the ampulla, epi injected as well.
After the procedure overnight patient continued to have melena,
and had a large hematoma on the scalp.Hematomal bleeding was
well controlled and patient did not rebleed from that site,
which was likely a result of her fall while on the toilet with
the massive bleed via GI tract. Overnight after the procedures
she has been tachycardic (high 120s) and hypotensive (low 90's).
After discussion with the family it was felt that patient would
be better served with no more transfusions and no angio
intervention to control the bleeding if it recurs. DNR/DNI
status was confirmed with the Healthcare proxy.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"305.1",
"920",
"305.01",
"V49.86",
"531.40",
"191.3",
"528.9",
"E884.6",
"345.90",
"285.1",
"294.9",
"562.02",
"458.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5110, 5119
|
4050, 5087
|
308, 353
|
5170, 5179
|
2583, 4027
|
5235, 5245
|
1868, 1948
|
5140, 5149
|
5203, 5212
|
1963, 2564
|
264, 270
|
381, 945
|
1441, 1538
|
1554, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,224
| 131,175
|
31156
|
Discharge summary
|
report
|
Admission Date: [**2188-5-31**] Discharge Date: [**2188-6-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
86M h/o colon CA, atrial fibrillation on anticoagulation, HTN,
hyperchol, anemia presents as CODE STROKE. Pt originally
presented to OSH on [**5-26**] with exertional dyspnea and unstable
angina. Found to also be in mild CHF. Called at 4:30pm at
bedside within minutes. Went to diagnostic catherization on
[**2188-5-29**] showing severe R-coronary and L-anterior descending
artery disease, diffusely diseased circumflex. S/p angioplasty
and 2 DES to RCA and 1 DES to LAD with residual moderate
cardiomyopathy with LVEF 35-45%. Baby aspirin dc'd per OSH
notes [**12-28**] concomitant Coumadin and Plavix Rx. Trop peak ~9.
Notes from [**2188-5-30**] at 12:30pm report pt adamant about going home.
Oriented to self and day. Able to attend. Last seen well @
10am today Onset of symptoms @ 1pm today
OSH staff was noted patient having difficulty seeing, not
talking and right hemiparesis. As patient outside of 3 hour
window for IV TPA, patient was transferred to [**Hospital1 18**] for possible
IA TPA or clot retrieval.
NIHSS
1a. alert 0
1b. LOC questions 2
1c. LOC commands 2
2. Gaze 1
3. Visual 2
4. Facial palsy 1
5. Motor L arm 0
5. Motor R arm 4
6. Motor L leg 0
6. Motor R leg 4
7. Limb ataxia X
8. Sensory 2
9. Best language 3
10. Dysarthria 2
11. Extinction X
NIHSS Total 23
OSH head CT noncontrast: Left dense MCA sign and loss of
[**Doctor Last Name 352**]-white matter differentiation in left basal ganglia and
frontal lobe. No bleed.
Past Medical History:
- h/o R sided colon CA (adenocarcinoma) 7cm through to mesentery
0/14 lymph nodes involved, no mets R s/p R hemicolectomy ([**6-28**])
- HTN
- restless leg syndrome
- anxiety
- pulsation left ear with left carotid bruit refused eval
[**2184-9-15**] with carotids, sxs resolved [**2185-8-29**]
- hyperchol
- BPH
- Atrial fibrillation (EF 50% 08/04 mild global hypokinesis)
- Anemia
- Post-herpetic neuraglia
- R hemicolectomy as above
- s/p b/l cataract surgery
Social History:
Married and care for wife with [**Name (NI) 11964**], 2 children, retired
school maintenance worker. Quit tobacco [**2166**], no ETOH.
[**Telephone/Fax (1) 73535**]
Family History:
Sister w/DM
Physical Exam:
T- AF BP- 148/88 HR- 120 afib RR- 18 98 O2Sat RA 149 lbs
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple
CV: irreg irreg, Nl S1 and S2
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert. Mute and not following
commands.
Will sustain extremities antigravity if lifted by examiner.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Decreased blink to threat from right with left gaze
deviation. Crosses midline with oculocephalic maneuvers. Mild
right nasolabial flattening. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact.
Motor:
Normal bulk bilaterally. Decreased tone on the right. No
observed
myoclonus or tremor. Right no spontaneous or purposeful movement
on the right. Left side spontaneous and purposeful.
Sensation: Decreased sensation to noxious stim on the right
side.
Reflexes: +2 slightly increased on the right throughout.
Right toe upgoing and left toe downgoing.
Coordination: unable
Gait: unable
Romberg: unable
Pertinent Results:
[**2188-5-31**] 04:45PM PT-20.8* PTT-30.8 INR(PT)-2.0*
[**2188-5-31**] 04:45PM PLT COUNT-353
[**2188-5-31**] 04:45PM WBC-8.1 RBC-4.02* HGB-13.4* HCT-40.0 MCV-99*
MCH-33.3* MCHC-33.5 RDW-14.1
[**2188-5-31**] 04:45PM DIGOXIN-0.8*
[**2188-5-31**] 04:45PM TSH-4.5*
[**2188-5-31**] 04:45PM CK-MB-3 cTropnT-0.49*
[**2188-5-31**] 04:45PM LIPASE-33
[**2188-5-31**] 04:45PM ALT(SGPT)-31 AST(SGOT)-44* CK(CPK)-65 ALK
PHOS-143* AMYLASE-35 TOT BILI-0.7
[**2188-5-31**] 04:45PM estGFR-Using this
[**2188-5-31**] 04:45PM UREA N-19 CREAT-0.8
[**2188-5-31**] 04:54PM GLUCOSE-105 NA+-140 K+-4.7 CL--110 TCO2-24
[**2188-5-31**] 04:54PM COMMENTS-GREEN TOP
[**2188-5-31**] 08:00PM URINE RBC-0-2 WBC-[**1-28**] BACTERIA-MANY YEAST-NONE
EPI-<1
[**2188-5-31**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0 LEUK-TR
[**2188-5-31**] 08:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2188-6-1**] 01:30AM BLOOD Triglyc-97 HDL-38 CHOL/HD-3.7 LDLcalc-85
[**2188-5-31**] 04:45PM BLOOD TSH-4.5*
[**2188-5-31**] 04:45PM BLOOD Digoxin-0.8*
.
Non-contrast head CT 7/7/7
FINDINGS: There is no evidence of hemorrhage, mass lesion, shift
of normally midline structures, hydrocephalus, or infarction.
Mild confluent periventricular hypoattenuation consistent with
chronic microvascular ischemic changes. There is coarse
calcification within the visualized portion of the left
vertebral artery and basilar artery as well as cavernous carotid
arteries. The orbits are grossly unremarkable. Within the left
sphenoid sinus, there is a soft tissue density most consistent
with an inclusion cyst. There is also opacification within the
right frontal sinus which may also represent an inclusion cyst.
IMPRESSION:
No evidence of hemorrhage or infarction.
.
Chest X-ray 7/7/7
IMPRESSION:
Small bilateral pleural effusions. Increased airspace opacities
involving the bilateral lungs represents pulmonary edema.
Radiopaque tubing projecting over the soft tissues of the
lateral right neck is of uncertain clinical significance.
Clinical correlation is requested.
Carotid Dopplers:
70-79% right ICA stenosis. Likely distal left ICA significant
stenosis.
Echo:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 5-10 mmHg. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>50%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion
ECG:
[**6-7**]
Atrial fibrillation with rapid ventricular response. ST segment
depressions in the anterior leads suggestive of anterior
ischemia. There are also T wave inversions in the inferior
leads. Compared to the prior tracing of [**2188-6-1**] the T wave
inversions in the anterior leads are slightly less prominent
Brief Hospital Course:
Mr. [**Known lastname **] is an 86-year-old man with a history of atrial
fibrillation who was status post recent NSTEMI. He was admitted
for acute onset right sided weakness. His exam was initially
notable for complete right sided hemiplegia, with aphasia and
eyes looking to left side. MRI showed acute infarction in the L
MCA distribution, likely embolic. Unfortunately, the patient
arrived at [**Hospital1 18**] 6.5 hours after he was last seen normal, making
IA tPA not possible. IV tPA had not been possible at [**Location (un) 12017**]
since he was already outside the 3 hour window. He was admitted
to the Neuro ICU for close monitoring. He was given IVF to
maintain his pressure with goal SBP 120-160. Echo was performed
that showed EF of 50% and no thrombus or ASD. Carotid U/S showed
a 70-79% stenosis in the R ICA, but no intervention was desired.
A1c was < 7, LDL was 85. His exam slowly improved. He was
maintained euglycemic and normothermic.
His Atrial fibrillation was rate-controlled with digoxin and
metoprolol. The metoprolol dosage was increased to 37.5 mg TID
(from 25mg [**Hospital1 **]). His warfarin was held given concern for
hemorrhagic conversion of his large stroke. This should be
restarted around [**6-14**], if his family accepts the risks of
bleeding. His recent NSTEMI had been stented and he was
continued on Plavix. Aspirin was also held given concern for
possible bleeding.
During his hospital course, he was never intubated, but did
require significant suctioning initially. After 3 days in the
ICU, he was stable on room air. He was found to have an
enterococcal UTI and was switched from levo to ampicillin after
sensitivities were available. Once stable, he was evaluated by
Speech & Swallow, who felt he should remain NPO. The family
requested a PEG which was placed.
In the early morning of [**6-7**] he was noted to be hypoxic with O2
sats at 88 and borderline hypotensive, SPB 90-100. A stat CXR,
ECG and cardiac enzymes were drawn and he was placed on a face
mask. His O2 sats improved to the 93%. The ECG showed ST
depression in V1-V4 concerning for an NSTEMI which was confirmed
with postive cardiac enzymes. His CXR showed pulmonary edema.
Given his BP, lasix was held and he was maintainted on the
face-mask and given Aspirin 325. 4 Hours after the initial event
he became increasingly hypoxic and hypotensive. His family was
contact[**Name (NI) **] to discuss the goals of care. He had been DNR/DNI up
to this point. They requested he be made CMO. He was treated
with morphine as needed and died the following day.
Medications on Admission:
Plavix 75mg QD
Lopressor 50mg [**Hospital1 **]
Coumadin 5mg QHS
Diltiazem 120mg QD
Lipitor 20mg QHS
Lisinopril 10mg QD
Elavil 12.5mg QHS
Seroquel 25mg QHS
Lopressor 5mg Q4hrs:PRN tachycardia
Following meds were dc'd [**5-30**]:
Lanoxin 0.25mg QD
ASA 81mg QD
Elavil 25mg [**Hospital1 **]
Morphine sulfate 4mg Q1H:PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection three times a day: subcutaneous.
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
3. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 250 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2
times a day).
7. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) dose
Injection ASDIR (AS DIRECTED): per sliding scale. .
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID
(2 times a day).
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke. Left MCA stroke.
Discharge Condition:
Expiried
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"285.9",
"041.04",
"433.10",
"410.71",
"V10.05",
"333.94",
"511.9",
"300.00",
"486",
"799.02",
"433.30",
"434.11",
"427.31",
"331.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
10846, 10855
|
6938, 9509
|
273, 281
|
10924, 10934
|
3650, 6915
|
10985, 11083
|
2456, 2470
|
9876, 10823
|
10876, 10903
|
9535, 9853
|
10958, 10962
|
2485, 2720
|
222, 235
|
309, 1771
|
2887, 3631
|
2759, 2871
|
2744, 2744
|
1793, 2256
|
2272, 2440
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,922
| 169,296
|
7225
|
Discharge summary
|
report
|
Admission Date: [**2110-11-20**] Discharge Date: [**2110-12-4**]
Date of Birth: [**2033-11-8**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 77 year old, white
female with known coronary artery disease. She developed
chest pain on vacation. She had cardiac catheterization that
showed significant coronary artery disease. She was referred
to Dr. [**Last Name (STitle) 1537**] for operative treatment.
PAST MEDICAL HISTORY: Coronary artery disease. Insulin
dependent diabetes mellitus. Hypothyroidism.
Hypercholesterolemia. History of congestive heart failure.
Hypertension. Status post appendectomy. Status post
tonsillectomy. Status post right eye laser surgery.
PREOPERATIVE MEDICATIONS:
Diovan 80 mg p.o. twice a day.
Lasix 20 mg p.o. q. day.
Lipitor 40 mg p.o. q. day.
Insulin NPH 16 units q. a.m. and NPH 7 units q. p.m. with
regular insulin 7 units at dinner.
Synthroid 88 mcg p.o. q. day.
Fluoxetine 10 mg p.o. q. day.
Epogen q. weekly.
Zestril 20 mg p.o. q. day.
Nitroglycerin patch.
Multi-vitamins and iron supplements.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2110-11-20**] with Dr. [**Last Name (STitle) 1537**] for a coronary artery
bypass graft times one. The patient initially had a LMA to
left anterior descending with a revision and saphenous vein
graft to left anterior descending. Please see operative note
for further details. The patient was transported to the
Intensive Care Unit in stable condition on epinephrine,
Neo-Synephrine and Propofol infusion.
On postoperative day number one, the patient was weaned off
the epinephrine infusion with good cardiac indices. The
patient awoke and followed commands with a stable neurologic
examination. The patient was weaned off the ventilator and
when the patient was ready to extubate, the team determined
that the patient did not have an adequate cuff leak around
the endotracheal tube. It was decided that the patient would
get four doses of Decadron prior to extubation.
On postoperative day number two, the patient continued to
have no cuff leak. The patient's creatinine, baseline of
1.5, had risen to 1.9 with continued good hemodynamics. The
patient was started on Lasix for diuresis. The patient
remained on minimal ventilatory support.
On postoperative day number three, the patient had an episode
of rapid atrial fibrillation and was treated with Amiodarone
and Lopressor. The patient subsequently converted to sinus
rhythm. The patient continued to have inadequate cuff leak
for extubation in spite of good oxygenation and ventilation.
The patient's creatinine began to trend down, down to 1.6 on
postoperative day number five.
By the evening of postoperative day number four, it was
decided that the patient was appropriate for extubation.
After extubation, the patient initially had some stridor
which was treated with racemic epinephrine with good
resolution. It was also noted on the evening of
postoperative day number four that the patient had a diffuse
maculopapular rash on her back, which was thought to be
contact dermatitis. By postoperative day number five, the
rash was noted to be worsening. A dermatology consult was
obtained which felt that the rash was due to a combination of
contact dermatitis with an element of miliaria and
recommended flying Clobetasol ointment to her back as well as
Benadryl prn.
On postoperative day number five, the patient was started on
routine beta blockers which were increased. On postoperative
day number six, the patient was transferred from the
Intensive Care Unit to the regular medical floor. The patient
began ambulating with physical therapy.
On postoperative day number six, the patient was noted to
have symptoms of dysuria, urinary frequency and urinary
urgency. A urine culture was sent which was subsequently
positive for Enterobacter. The patient was started on
Levofloxacin. The patient continued to have oxygen
requirement. On postoperative day number eight, it was
decided to discontinue the Amiodarone as the patient had
remained in sinus rhythm and the patient had the rash. The
patient's rash continued to improve. The patient continued
to ambulate with physical therapy.
On postoperative day number 12, the patient was preliminarily
scheduled to be discharged to home, after having completed
physical therapy; however, the patient's white blood cell
count was elevated to 16. The patient was pan cultured. On
chest x-ray, it was noted that the patient had a left sided
pleural effusion. On postoperative day number 13, the
patient underwent an ultrasound guided thoracentesis.
Cytologic analysis of the pleural fluid showed significant
numbers of red blood cells. Microscopic evaluation showed 1+
polymorphic leukocytes, no micro-organisms. Initial fluid
culture shows no growth to date. The patient subsequently no
longer had an oxygen requirement and was able to ambulate on
room air without any shortness of breath. The patient's room
air oxygenation remained stable. The patient's white blood
cell count decreased to 13 and on postoperative day number
14, the patient was cleared for discharge to home.
CONDITION AT DISCHARGE: T max of 96.9; pulse 72 and sinus
rhythm; blood pressure 140/76; respiratory rate 18; room air
oxygen saturation 94%. The patient's weight on [**12-4**]
is 70.8 kg. The patient was 70.4 kg preoperatively.
LABORATORY DATA: White blood cell count of 13.3; hematocrit
of 30.7; platelet count 556. Sodium of 144; potassium of
4.0; chloride of 106; bicarbonate of 30; BUN 14; creatinine
1.4. Of note, the differential of the patient's white blood
cell count showed 11% neutrophils which was thought to be due
to the resolving contact dermatitis.
On physical examination, the patient was awake, alert and
oriented times three. Heart was regular rate and rhythm
without rub or murmur. Breath sounds were clear bilaterally.
Abdomen was soft, nontender, nondistended, positive bowel
sounds. The patient was tolerating a regular diet.
Steri-Strips were intact on the incision. Sternum is stable.
There is no erythema or drainage. Right lower extremity vein
harvest site, Steri-Strips are intact and there is no
erythema or drainage. The patient's back has a resolving
rash with several areas of peeling skin and healing blisters.
There is minimal erythema. The patient denies any
significant pruritus.
The patient's chest x-ray on [**12-4**] showed significantly
decreased effusion, no pneumothorax.
DISCHARGE DIAGNOSES:
Coronary artery disease.
Status post coronary artery bypass graft.
Status post left thoracentesis.
Contact dermatitis on back with associated eosinophilia.
Insulin dependent diabetes mellitus.
Postoperative urinary tract infection.
DISCHARGE MEDICATIONS:
Enteric coated aspirin 325 mg p.o. q. day.
Percocet 5/325 one to two p.o. every four to six hours prn.
Fluoxetine 10 mg p.o. q. day.
Lipitor 40 mg p.o. q. day.
Synthroid 88 mcg p.o. q. day.
Valsartan 80 mg p.o. q. day.
Zantac 150 mg p.o. twice a day.
Pletal 100 mg p.o. twice a day.
Bacitracin ointment to blisters on back three times a day
prn.
Clobetasol ointment to back, twice a day times two weeks
only.
Lopressor 75 mg p.o. twice a day.
Levofloxacin 500 mg p.o. q. day times seven days.
Lasix 20 mg p.o. q. day times ten days.
Insulin NPH and regular, per patient's regular home dosage.
Colace 100 mg p.o. twice a day.
The patient is to be discharged to home in stable condition.
The patient is to follow-up with her cardiologist, Dr. [**Last Name (STitle) **]
on [**12-17**] between 9 and 10 a.m. The patient is to
follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one
to two weeks and the patient is to follow-up with Dr. [**Last Name (STitle) 1537**] in
one month.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**First Name3 (LF) 26767**]
MEDQUIST36
D: [**2110-12-4**] 01:48
T: [**2110-12-4**] 15:03
JOB#: [**Job Number 26768**]
|
[
"599.0",
"427.31",
"996.03",
"998.11",
"414.01",
"427.41",
"511.8",
"424.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"36.15",
"36.11",
"39.61",
"96.71",
"89.68",
"99.62",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
6541, 6774
|
6797, 8103
|
1127, 5198
|
732, 1109
|
5213, 6520
|
161, 435
|
458, 706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,196
| 156,619
|
4536
|
Discharge summary
|
report
|
Admission Date: [**2139-4-11**] Discharge Date: [**2139-4-24**]
Date of Birth: [**2073-7-28**] Sex: M
Service: MEDICINE
Allergies:
Dilantin / Penicillins / Aspirin / Lasix / Diltiazem / Alteplase
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
pericardiocentesis, drain placed and then removed
thoracentesis
CT-guided biopsy of mediastinal mass
History of Present Illness:
65M with slowly progressive increased shortness of breath for
the last 2 months. He describes that is has been worse in the
last week and acutely worsened yesterday. He previously had been
going to the gym and able to ride a stationary bike for 30
minutes and lately has only been able to ride for 5 minutes. He
denies any cough, fever or weight loss. He saw his PCP who is [**Name Initial (PRE) **]
cardiologist last week and was started on lasix and scheduled
for an echo next week. He has chronic LLE edema, and notes new
RLE edema in the last day. His dyspnea worsened earlier today
and he presented to [**Hospital3 2783**], a chest xray showed
cardiomegaly and an echo was done which showed pericardial
effusion. He was transferred to [**Hospital1 18**] ED for further evaluation.
On presentation to [**Hospital1 18**], he complains of shortness of breath,
denies chest pain, back pain, abdominal pain, N/V.
.
His VS in ED were 96.7, 135, 188/118, 30, 100%NRB. Bedside ECHO
by cardiology fellow showed large pericardian effusion (mostly
posterior, 3.5cm). CT Chest r/o PE, dissection. Showed large
anterior mediastinal mass, pericardial effusion. INR was 3.3.
Patient was given 4units FFP, 10mg IV Vit K and transferred to
CCU for pericardiocentesis vs window. He was in ED on an esmolol
drip for a question of afib/dissection in setting of HTN, but
ECG showed sinus tachycardia and APCs/VPCs.
.
A CTA confirmed the presence of a large pericardial effusion as
well as an anterior mediastinal mass. An echo showed right
ventricular collapse and less than 20% LVEF. Cardiac
catheterization was performed for pericardiocentesis; 1020 ccs
of straw-colored fluid was drawn out, with an immediate relief
of symptoms. Follow-up echo confirmed successful drainage. Mr
[**Name13 (STitle) 4143**] was admitted to the CCU for further care.
.
.
Past Medical History:
- CAD s/p ant MI [**40**] year ago, given TPA with resultant
hemorrhagic stroke, still has residual L sided weakness
(LLE>LUE), bilateral DVT during the same admission, IVC filter
placed, on coumadin.
- HTN
- Hypercholesterolemia
- Seizure disorder
- Asthma
PSH: surgery to repair multiple forearm fractures s/p accident
where he fell from a tree
Social History:
Cigarettes: Never
Occupation: worked as a lawyer
Marital Status: Married
Lives:With family
ETOH: No
Exposure: No Asbestos, Radiation
Family History:
No family history of cancer
Mother: heart disease, Father: heart disease
Physical Exam:
PE: VS 95.9, 133, 143/106, 30, 99%NRB 15L
Gen: mild resp distress, mask on
HEENT: MMM, anicteric, JVD to neck, no [**Doctor First Name **]
CV: tachy, irreg, no murmurs
Chest: crackles B/L 1/3 up
Abd: S/NT/ND
Ext: R>L 3+ edema
Neuro: AOx3
.
ECG: sinus tachy, APCs
.
CTA (prelim report):
1. Large heterogeneous and cystic anterior mediastinal mass with
calcifications and associated large pericardial effusion.
Differential considerations include invasive thymoma, teratoma
and less likely to represent lymphoma given calcifications.
2. No evidence of pulmonary embolism or aortic dissection.
3. Small right pleural effusion.
Pertinent Results:
LABORATORIES ON ADMISSION:
[**2139-4-11**] WBC-7.8 (NEUTS-81 BANDS-0 LYMPHS-9 MONOS-7 EOS-1
BASOS-2 ATYPS-0 METAS-0 MYELOS-0) HGB-15.9 HCT-46.5 PLT
COUNT-202
PERIPHERAL SMEAR: HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+
TEARDROP-1+
[**2139-4-11**] 01:20AM PT-32.1 PTT-33.0 INR(PT)-3.3
[**2139-4-11**] 02:22AM SODIUM-135 POTASSIUM-9.0 CHLORIDE-105 TOTAL
CO2-23 UREA N-21 CREAT-1.0 GLUCOSE-132
.
Pericardial fluid:
[**2139-4-11**] 12:46PM OTHER BODY FLUID WBC-[**Numeric Identifier 19337**] RBC-6325 POLYS-0
LYMPHS-97 MONOS-3
[**2139-4-11**] 12:46PM OTHER BODY FLUID CD23-D CD45-D HLA-DR[**Last Name (STitle) **]
[**Name (STitle) 7736**]7-D KAPPA-D CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D
CD16/56-D CD5-D
[**2139-4-11**] 12:46PM OTHER BODY FLUID CD3-D CD4-D CD8-D
[**2139-4-11**] 12:46PM OTHER BODY FLUID IPT-D
PERICARDIAL FLUID Procedure Date of [**2139-4-11**] - No malignant
cells.
.
LABORATORIES UPON DISCHARGE:
[**2139-4-24**] 07:40AM WBC-21.2 RBC-5.21 Hgb-16.2 Hct-49.9 MCV-96
MCH-31.0 MCHC-32.4 RDW-13.9 Plt Ct-326
[**2139-4-24**] Na-143 K-4.9 Cl-103 HCO3-31 UreaN-23 Creat-1.1
Glucose-128
[**2139-4-24**] 07:40AM BLOOD PT-15.8 PTT-27.0 INR(PT)-1.4
.
TTE (Focused views) Done [**2139-4-11**] at 7:20:07 AM
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis in the basal
anterior/anteroseptal walls and hypokinesis of the mid-distal
anterior/anteroseptal walls (LVEF = 20%) Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened. Severe aortic stenosis is not
suggested but mild aortic stenosis cannot be excluded. Mild [1+]
aortic regurgitation is seen. The mitral valve appears
structurally normal with mild [1+] mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is a large, circumferentially, partially echo filled
pericardial effusion extending 3cm inferolateral and lateral to
the left ventricle and anterior to the right atrium, 1.5cm
around the left ventricular apex and 1.0cm anterior to the right
ventricle. There is right ventricular diastolic invagination and
eccentuated respiratory variation in the transmitral Doppler c/w
tamponade physiology.
IMPRESSION: Large circumferential (likely hemorrhagic)
pericardial effusion with right ventricular collapse c/w
tamponade physiology. Underlying severe regional left
ventricular systolic dysfunction c/w CAD.
.
[**2139-4-11**] CTA CHEST W&W/O C&RECONS, NON-CORONARY
CT CHEST WITHOUT AND WITH IV CONTRAST: There is a large
heterogeneous
anterior mediastinal mass containing central coarse
calcifications and areas of cystic change. This mass abuts the
aortic arch, right brachiocephalic, left common carotid, left
subclavian artery and also abuts the main pulmonary artery.
There is no vascular invasion or compression. There is a
markedly large pericardial effusion. There is no evidence of
invasion into the lung parenchyma. There is scalloping of the
undersurface of the sternum adjacent to this mass suggesting
osseous infiltration. There is a small right pleural effusion
with associated mild atelectasis. No pulmonary nodules are
identified. There is additional soft tissue mass extending from
the right paratracheal region out to the right hilum, likely
representing a conglomerate of lymphadenopathy. Limited views of
the upper abdomen are unremarkable, aside from reflux of
contrast into the hepatic veins, indicative of right heart
failure.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
Moderate spurring is seen along the anterior portions of the
vertebral bodies of the thoracic spine.
IMPRESSION:
1. Large heterogeneous and cystic anterior mediastinal mass with
calcifications and associated large pericardial effusion.
Differential
considerations include lymphoma, invasive thymoma, teratoma and
less likely thyroid malignancy. This information was conveyed to
Dr. [**Last Name (STitle) **] at the time of study interpretation on [**2139-4-11**]
2. No evidence of pulmonary embolism or aortic dissection.
3. Small right pleural effusion.
4. CT evidence of right heart failure.
.
CT LUNG/MEDIASTINAL BX Study Date of [**2139-4-14**] 2:32 PM
PATHOLOGY
[**2139-4-23**] I) Subpectoral nodule (A-B): Adenocarcinoma involving
fibroadipose tissue.
II) Anterior mediastinal mass (C-D): Adenocarcinoma involving
fibroadipose tissue and bone.
ADDENDUM #1: Fresh tissue sent for karyotype to Women's Hospital
Cytogenetics Laboratory, [**Last Name (NamePattern1) 14305**], [**Location (un) 86**] [**Numeric Identifier 6425**].
Test result (see below) do not clarify the diagnosis since the
pattern does not show characteristics features of either colon
or germ cell tumor. KARYOTYPE: 46, XY. META PHASES COUNTED:
15 ANALYZED: 15 SCORED: 10 BANDING: GTG
INTERPRETATION: No cytogenetic aberrations were identified in
metaphases analyzed from this specimen. This normal result does
not exclude a neoplastic proliferation.
COMMENTS: Mosaicism and small chromosomes anomalies may not be
detected using the standard methods employed. Chromosome
analysis was performed at a level of 400 bands or greater.
ADDENDUM #2: Stains for markers of embryonal carcinoma (PLAP
and CD30) were negative.
.
TTE (Focused views) Done [**2139-4-16**]
There is no pericardial effusion.
Brief Hospital Course:
# Mediastinal mass discovered with pericardial effusion:
Mediastinal mass was biopsied via a CT-guided biopsy.
Additionally, cytology was sent on pleural fluid, drawn by
thoracentesis. Thoracic surgery service followed from early in
the admission to contemplate surgical options, but given that
the mass appeared to wrap around the great vessels, surgery
deferred to oncology and radiation oncology for the initial
treatment planning with the hopes that they would be able to
devise a treatment plan to shrink the mass before resection.
Preliminary biopsy results had results consistent with colon
cancer. This was puzzling, given the clinical history, and given
that a follow-up CT scan of abdomen and pelvis showed no liver
metastases or abdominal lymphadenopathy. Cytgenetics did not
clarify the diagnosis since the pattern does not show
characteristics features of either colon or germ cell tumor.
Nonetheless, a follow-up colonoscopy was recommended. In terms
of the pericardial effusion, treaters have assumed that this was
the direct result of the mass. Repeat ECHO prior to discharge
showed resolution of the pericardial effusion. The patient was
instructed to followup with oncologist, Dr. [**Last Name (STitle) 3274**], as an
outpatient.
.
# Tachycardia. Tachycardia eased somewhat with pericardial
drainage but nonetheless, ongoing atrial fibrillation with
recurring RVR required significant doses of metoprolol to keep
in the high 90s/low 100s. Additionally, it appeared that for a
time Mr [**Name13 (STitle) 4143**] was effectively dehydrated because of the
extensive extravasation associated with his full-torso rash; IV
hydration did help to reduce heart rate during this time. Atrial
fibrillation was not helpful, but during this period of
dehydration was likely not the major factor. Boluses of fluid
were given cautiously given his 25% EF.
.
# Rash: Mr [**Name13 (STitle) 4143**] developed a significant morbilliform rash
which was consistent in appearance and clinical course with a
drug rash, likely in response to lasix. Lasix was added to his
drug allergies. Dermatology was consulted and as the rash
expanded, recommended a five day course of prednisone 60 mg
daily, which was given. There was no mucosal involvement and the
rash did begin to fade in its initial areas of appearance (back)
by [**4-19**], at which point there was clearly the beginning of
resolution of the original sites even as the newer areas of
involvement (lower parts of upper and lower extremities) became
more erythematous and confluent. A skin biopsy was also
consistent with drug rash. Symptomatic treatment including
antihistamines and topical creams were also given. At discharge,
the rash was nearly resolved.
.
# History of PE: Originally the team held coumadin during the
initial time in which the pericardial drain remained in place.
The team restarted anticoagulation with a heparin drip to bridge
back to coumadin. At discharge his coumadin dose was 2.5 mg
daily and he was discharge on a lovenox bridge.
.
# CAD: s/p ant MI 10y ago. Restarted aspirin (after being held
by past clinicians because of past stroke), as we judged the
benefit of aspirin for CAD to outweigh the risk. We continued
beta-blocker and statin.
.
# Seizure: Neurontin was continued.
.
# Asthma: Nebs prn
.
# Hypercholesterolemia: Statin was continued.
.
# BPH: foley in earlier part of admission; flomax
.
# FEN: cardiac diet, replete lytes prn
# PPx: initially pneumoboots, then heparin to coumadin bridge
# Code: FULL
# Dispo: CCU
# Contact: wife
.
Medications on Admission:
Coumadin 2.5'
lasix (first dose 5/16)
neurontin[**Telephone/Fax (1) 19338**]
diovan40'
atenolol25''
flomax
lipitor 20'
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8AM AND
4PM ().
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Injection
Subcutaneous Q12H (every 12 hours).
Disp:*20 Injection* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice
a day.
Disp:*120 Tablet(s)* Refills:*2*
10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Hydrocortisone Valerate 0.2 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply until rash has improved,
please discontinue after 2 weeks.
Disp:*1 tube* Refills:*2*
12. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every
6 hours) as needed for itching.
Disp:*90 Tablet(s)* Refills:*2*
13. Pramoxine 1 % Lotion Sig: One (1) Appl Topical TID (3 times
a day) as needed.
Disp:*1 tube* Refills:*0*
14. Prednisone 10 mg Tablet Sig: As Directed Tablet PO once a
day: take 2 tablets [**4-25**] and 1 tablet [**4-26**], then stop.
Disp:*3 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
INR - please have your INR checked next week before your
appointment with Dr. [**Last Name (STitle) 19339**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion
Malignant mediastinal mass
Atrial Fibrillation
Drug Rash
Discharge Condition:
Amublating, tolerating POs
Discharge Instructions:
You had fluid build-up in your lungs and around your heart,
which was drained. This was likely related to the mass that has
been found in the middle of your chest. One biopsy performed
showed evidence for adenocarcinoma, which was an unexpected
finding. A colonoscopy was performed, as were further biopsies,
the results of which are pending. The specimens were also sent
to the [**Hospital6 **]/[**Hospital3 328**] pathology department for
a second opinion.
Please attend your follow up appointments and take all
medications as prescribed. You will be discharged with Lovenox,
an injectible blood thinner, to be taken with your coumadin
until your INR, or Coumadin levels are within the therapeutic
range.
As you are aware, you had a significant drug reaction, the most
likely suspect is Lasix, or Furosemide. This has been added to
the list of medications to which you are allergic.
It is important that you stay hydrated. Please keep up with your
nutrition. If you develop a rapid heart rate, weakness,
dizziness, or shortness of breath, please contact your doctors
[**Name5 (PTitle) **] away [**Name5 (PTitle) **] return to the emergency department.
.
The oncology department (Dr.[**Name (NI) 3279**] office) will call you
with an appointment for either on Thursday, [**4-30**] or Tuesday
[**5-5**]. They are aware that you need follow up. If you do not
hear from them early next week, please call to schedule an
appointment is [**0-0-**].
.
You have an appointment with Dr. [**Last Name (STitle) 5466**] for [**Last Name (LF) 2974**], [**5-1**] at
12:45 PM. Please follow up with Dr. [**Last Name (STitle) 5466**] for continued
management of your medical conditions and management of your INR
(Coumadin levels).
Followup Instructions:
The oncology department (Dr.[**Name (NI) 3279**] office) will call you
with an appointment for either on Thursday, [**4-30**] or Tuesday
[**5-5**]. They are aware that you need follow up. If you do not
hear from them early next week, please call to schedule an
appointment is [**0-0-**].
.
You have an appointment with Dr. [**Last Name (STitle) 5466**] for [**Last Name (LF) 2974**], [**5-1**] at
12:45 PM. Please follow up with Dr. [**Last Name (STitle) 5466**] for continued
management of your medical conditions and management of your INR
(Coumadin levels).
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2139-5-19**] 9:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
|
[
[
[]
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[
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"45.23",
"37.0",
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icd9pcs
|
[
[
[]
]
] |
14498, 14504
|
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|
345, 448
|
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|
3586, 3599
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2338, 2686
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2702, 2836
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,268
| 142,718
|
6051
|
Discharge summary
|
report
|
Admission Date: [**2115-10-19**] Discharge Date: [**2115-10-29**]
Date of Birth: [**2036-2-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
colonoscopy
upper endoscopy
History of Present Illness:
79 y/o F with hx of DM, HTN, HL and recent RCC s/p nephrectomy
in mid [**Month (only) 359**] presents approx a week after discharge from her
post surgical care with decreased appetite, lethargy and altered
mental status with seizure in bed witnessed by husband.
Emergently brought to [**Hospital 23767**] hospital, stabalized and
transferred to [**Hospital1 18**].
.
At [**Hospital1 18**] she was admitted to the surgery ICU and seen by
neurology and diagnosed with PRESS syndrome. Seizures treated
with dilantin. During her hospitalization, she also had
worsening renal failure (which began after her nephrectomy),
NSTEMI diagnosed by troponin leak and new hypokinesis, and hct
drop with melanotic stools. Pt had been started on aspirin, not
plavix, by cardiology as a result of her NSTEMI.
.
Upon transfer, the patient is feeling well. Has no complaints.
Has never experienced chest pain in the recent past, does not
endore shortness of breath. Had some SOB post surgery, but
otherwise, no SOB, cough, DOE, PND. Did have some edema with 10
lb weight gain post surgery as well, but has improved. No
dizziness or headache. No abdominal pain, nausea, vomitting. Is
up in chair without problems, not ambulating on her own yet.
Past Medical History:
DM
HTN
Hyperlipidemia
RCC s/p nephrectomy
Social History:
married with 4 children, nonsmoker, no etoh/illicts
Family History:
non contributory
Physical Exam:
PE on discharge:
Vitals - Tc 97.4, Tm 99.5, BP 152/60, P 74, R 18, 93% on RA
Gen - pleasant elderly woman in bed, eating dinner, NAD
HEENT - ATNC, PERRLA, EOMI, supple neck, no JVD, no bruits
CV - RRR, no m,r,g
Lungs - decreased breath sounds at the bases, otherwise CTA B
Abd - soft, nontender, nondistended, hypoactive but present
bowel sounds; L flank incision with steristrips, CDI and healing
well
Ext - warm feet with palpable pulses, no edema; palpable radial
pulses, normal capillary refill
Neuro - A+Ox3, CN intact, moving all 4 extremities, strength 5/5
throughout, no focal deficits
Pertinent Results:
EEG:
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
was
generally slow and of lower voltage. Often, the background
included
alpha frequencies with a generalized distribution but a possible
frontal
maximum.
ABNORMALITY #2: There were additional bursts of generalized
slowing and
some bursts of relative attenuation of the background in all
areas for
up to 1.5 seconds or so.
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 widespread
suppression and slowing of the background and due to bursts of
generalized slowing and bursts of suppressed background
activity. These
findings indicate a widespread encephalopathy affecting both
cortical
and subcortical structures. The very regular portions of the
background
raise the possibility of medication effect. Such
encephalopathies are
often due to metabolic disturbances, infection, medication, or
hypoxia,
but the etiology cannot be determined from the tracing.
Nevertheless,
there were no areas of prominent focal slowing (although
encephalopathies may obscure focal findings), and there were no
epileptiform features.
[**10-19**] MRI:
FINDINGS:
BRAIN MRI:
Diffusion images demonstrate no evidence of acute infarct. There
is no
evidence of mass effect, midline shift or hydrocephalus.
Mild-to-moderate
brain atrophy is seen.
There are several hyperintensities seen in the periventricular
white matter including some patchy hyperintensities in the
subcortical white matter of both frontal and parietal lobes as
well as in the left posterior temporal and occipital lobe.
Following gadolinium, no abnormal enhancement is seen. In
addition, subtle signal abnormalities are seen in the region of
facial colliculi bilaterally in the pons as well as subtle
increased signal is seen in the pons.
IMPRESSION:
1. The patchy FLAIR hyperintensities seen in the subcortical
white matter of both frontal and parietal lobes as well as in
the left posterior temporal lobe are not typical for small
vessel ischemic changes. This finding could represent reversible
encephalopathy syndrome.
2. The other periventricular hyperintensities visualized as well
as
hyperintensities seen in the brainstem could be due to small
vessel disease.
3. Moderate brain atrophy.
4. No enhancing brain lesions or acute infarcts.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal in the superior
sagittal sinus and transverse sinuses. No evidence of sinus
thrombosis is seen.
[**10-26**] MRI:
1. Interval complete resolution of the patchy FLAIR-hyperintense
foci in
bilateral frontal and parietal and left posterior temporal and
occipital
subcortical white matter, consistent with clinical impression of
PRES, with no evident sequelae.
2. Moderate atrophy and chronic microvascular infarction,
largely in
bifrontal subcortical white matter, unchanged.
3. No pathologic enhancement.
4. Fluid/opacification of right mastoid air cells.
Echo:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severer hypokinesis of the basal 2/3rds of the anterior septum
and anterior walls. The remaining segments contract normally
(LVEF = 40%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction most
c/w CAD (mid-LAD distribution). Aortic valve sclerosis. No
definited structural cardiac source of embolism identified.
Renal US:
IMPRESSION:
1. No hydronephrosis, stones or solid masses seen in the right
kidney.
2. Tardus parvus waveform of the main right renal artery could
suggest a
renal artery stenosis but in the absence of the left kidney
ultrasound is
unable to further characterize.
Pertinent Labs:
Brief Hospital Course:
79 y/o F with hx of recent nephrectomy for RCC presents with
altered mental status and new onset seizures. Likely secondary
to PRES syndrome. While an inpatient, has worsening ARF, found
to have NSTEMI and significant Hct drop with melanotic stools.
S/p endoscopy and colonoscopy showing severe gastritis. Doing
well with stable Hct. Gout is bothering her.
.
# GI bleed - secondary to gastritis. Pt had both a colonoscopy
and endoscopy while here in the workup of the bleed. She is to
cont [**Hospital1 **] protonix PO, hct stabalized with no melanotic or bloody
stools by the time of discharge. Discussion with both
cardiologists and gastroeneterologist thought it was fine to
start asa for treatment of NSTEMI discussed below.
.
# NSTEMI - patient with troponin leak, TWI V1-V3, and new
hypokinesis. On baby aspirin and high dose statin. Titrated up
beta blocker yesterday, HR in 70s and SBPs in 130s-140s, could
likely increase again this evening after monitoring her on new
dose of 400 mg tid of labetolol. Cards following. Plavix not
needed at this time. She should follow up with cards regarding
when stress testing and/or cath or other workup is needed.
.
# Pump - patient with decreased EF in setting of NSTEMI. EF 40%.
Pt without signs of fluid overload. Follow up echo with cards to
see permanent pump dysfunction after NSTEMI.
.
# HTN - HTN was initial problem causing the seizure with PRES
syndrome. She was titrated up on BB over the course of the
[**Last Name (LF) 23768**], [**First Name3 (LF) **] be discharged on labetolol. Renal was
following and there was a question of whether renal artery
stenosis was possible, epecially after her recent nephrectomy.
It was thought that no stenosis was present and an ACEI could be
added. Her BP was well controlled by the time of discharge with
goal SBPs under 140s.
.
# Gout - had flare in big toes. rheum and podiatry do not
inject big toe joints; given low dose dilaudid (was receiving
post nephrectomy) and see if pain improves at all. No NSAIDs or
colchicine due to decreased renal function. No steroids due to
gastritis.
.
# Seizure - initial presenting symptoms. Neuro following along,
was on neuro service initially. The seizure was secondary to
PRES syndrome, on dilantin and titrated according to level;
patient only needs to be antisiezure for 10-14 days post
seizure. Will continue tight BP control. Repeat MRI done and
show resolution of PRES changes.
.
# ARF - had ARF. Treated with fluids due to likely prerenal
state. Renal followinged. Expected her to find new baseline,
although likely has some more recovery. Electrolytes stable.
.
# RCC - staples removed, scar well healed. Tumor was clear cell
renal cell carcinoma, s/p left radical nephrectomy and
adrenalectomy, left para aortic lymph node dissection on
[**2115-10-8**] for 6.1 x 5.9 x 5.0 cm mass in the lower pole of the
left kidney and bilateral small adrenal nodules found on MRI
abdomen [**2115-8-23**].
.
# DM - on sliding scale.
.
# Respiratory - stable, no problems.
.
# Communication - husband [**Name (NI) **] [**Telephone/Fax (1) 23769**], [**Name2 (NI) **] daughter
[**Telephone/Fax (1) 23770**].
.
# Code - full
Medications on Admission:
-Atorvastatin 20 mg qhs
-Timolol 0.5% drops, 1 drop as directed
-Dorzolamide-timolol 2-0.5% drops 1 drop tid
-Bimatoprost 0.03% drops q drop qPM
-Atenolol 50 mg daily
-Tylenol 1000 mg PO q6 hr
-Dilauded 2 mg, 1-2 tablets PO q4 hr prn pain
-Gemfibrozil 600 mg [**Hospital1 **]
-Lisinopril 30 mg daily
-Metformin 500 mg [**Hospital1 **]
-Calcium-Chjolecalciferol 500 mg-400 U, 2 tablets daily
-MVI
-HCTZ 25 mg daily (d/ced prior to admission)
-Colace 100 mg PO bid (d/ced prior to admission)
Discharge Medications:
1. 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*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
Disp:*240 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic qHS ():
one drop in each eye nightly.
8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day): one drop left eye three times
daily.
9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day): one drop right eye two times daily.
10. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed: for constipation, make sure to take
if you are taking the pain pill dilaudid.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. PRES syndrome
2. Seizure
3. Acute renal failure
4. GI bleed
5. Gastritis
6. NSTEMI
7. Gout
Discharge Condition:
patient stable, SBPs in 130s, afebrile, ambulating without
difficulties.
Discharge Instructions:
You were admitted to the hospital with a seizure. The seizure
was related to a syndrome called PRES. It was due to very
elevated blood pressure. While you were here, you also had a
small heart attack. When we started the blood thinners for your
heart, you developed a bleed in your stomach that required you
to have several transfusions.
The gastroenterologists did a colonoscopy and endoscopy showing
severe gastritis. That is why you need to continue the medicine
called protonix. You can take aspirin. You must be careful to
monitor your stools and watch for black tarry stools or bloody
stools. Your doctor will monitor you blood counts when they see
you in the office.
You will need to follow up with several different doctors. You
should see a cardiologist and have a stress test in the future.
You should also follow up with the nephrologists about your
kidney function. And finally you should follow up with a
neurologist about your seizures. You can stop taking dilantin
at home.
Please return to the hospital for any seizures, headaches,
dizziness, chest pain, shortness of breath, abdominal pain,
black stools, bloody stools, or any other concerns. Feel free
to call your doctor with any questions.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] tomorrow [**2115-10-30**]
at 11:30 am. His phone number is [**Telephone/Fax (1) 9347**].
Please follow up with cardiology. Your doctor will be Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. The appointment is on [**2115-11-18**] at 1pm in [**Hospital Ward Name 23**]
Building on the seveth floor. The number is ([**Telephone/Fax (1) 2037**].
Please follow up with neurology. Your doctor will be Dr. [**First Name (STitle) **].
Your appointment is on [**12-2**] at 2:30 pm. They are located
in the [**Hospital Ward Name 23**] building level 5. His phone number is ([**Telephone/Fax (1) 8951**].
Please follow up with nephrology. You have an appointment with
Dr. [**Last Name (STitle) 23771**] on [**11-21**] at 9 am. They are located on [**Hospital Ward Name 23**]
level 7. Their number is ([**Telephone/Fax (1) 773**].
Please follow up with your urology surgeons. Please call them
and ask when they would like to see you again. Their number is
([**Telephone/Fax (1) 772**].
Completed by:[**2116-2-14**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,602
| 107,955
|
9708
|
Discharge summary
|
report
|
Admission Date: [**2110-12-12**] Discharge Date: [**2110-12-20**]
Date of Birth: [**2094-8-6**] Sex: F
Service: MED ICU/[**Doctor Last Name 1181**] MED
PATIENT'S ANTICIPATED DATE OF TRANSFER IS [**2110-12-20**].
HISTORY OF PRESENT ILLNESS: This is a 16 year old female
with a history of cystic fibrosis status post bilateral lung
transplants in [**2108-9-11**], who was admitted on [**2110-12-12**], following a rigid bronchoscopy with dilation and
Mitomycin application to reduce swelling and scar tissue in
the left main stem bronchus. Shortly after application of
Mitomycin, the patient developed a stridor and was treated
with Albuterol and racemic epinephrine treatment before
transfer to the Post Anesthesia Care Unit for observation.
While in the Post Anesthesia Care Unit, the patient acutely
desaturated with a pulse oximetry of 60%, was given a
nebulizer treatment, non-rebreather mask and failed to
improve with hypoxia in a range of pAO2 of 44. The patient
was on CPAP with a pressure support of 8 and PEEP of about 10
and FIO2 of 100, and her oxygen saturations improved to the
90s. The patient was transferred to the Medical Intensive
Care Unit for observation.
Initially, this was thought to be an allergic reaction to
Mitomycin and was treated with intravenous steroids, Benadryl
and Pepcid. For the next 36 hours in the Medical Intensive
Care Unit, the patient could not be weaned off oxygen and
would acutely desaturation if the FIO2 dropped below 90%.
With the concern of her possible PE causing shunt, the
patient was intubated on the third day of hospital stay for a
CT scan. The patient acutely desaturated with oxygen of 60s
while on the vent prior to having the CT scan. Multiple
blood gases drawn showed pO2 in the 31 to 35 range. The
decision was made for an emergent bronchoscopy at the bedside
where a mucous plug was discovered in the left main stem
bronchus. Once removed, the patient's oxygen saturations
rapidly improved.
The patient was extubated the following day with oxygen
saturations in the 95 to 96% on room air. She was observed
overnight and transferred to the Medical Floor. The patient
was scheduled for a stent on Friday, [**2110-12-19**].
PAST MEDICAL HISTORY:
1. Cystic fibrosis status post bilateral lung transplant in
[**2108-9-11**].
2. Asthma.
3. Gastroesophageal reflux disease.
4. Pancreatic insufficiency.
5. Seizures thought secondary to cyclosporin.
ALLERGIES: Multiple, multiple allergies including Imipenem,
Zosyn, Piperacillin, penicillin, Estrianam, Vancomycin,
.............and tobramycin.
SOCIAL HISTORY: The patient lives in [**Hospital3 **]. Sister also
with cystic fibrosis.
MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Prograf 7 mg p.o. twice a day.
2. Cellcept [**Pager number **] mg p.o. twice a day.
3. Prednisone 5 mg p.o. q. day.
4. Zantac 150 mg p.o. twice a day.
5. Bactrim Double strength Monday, Wednesday and Friday.
6. Neurontin 300 mg p.o. twice a day.
7. Procardia 30 mg p.o. q. day.
8. Ultrase 7 to 8 with meals, 3 to 4 with snacks.
9. Insulin NPH 32 units q. a.m.
10. Humalog 2 units q. a.m.
PHYSICAL EXAMINATION: Temperature 101.6 F.; blood pressure
between 100 and 140 over 50 to 90; pulse between 70 and 145;
the patient's respirations between 20 and 30. She was 96% on
room air. In general, pleasant young female in no acute
distress. HEENT: Moist mucous membranes. No oropharynx
lesions. Heart: Regular rate and rhythm, S1, S2, no
murmurs, rubs or gallops. Lungs clear to auscultation
bilaterally, no wheezes, rhonchi or crackles. Abdomen soft,
nontender, nondistended. Bowel sounds are positive.
Extremities are warm, two plus dorsalis pedis pulses. No
edema. Neurological: Answers questions appropriately.
LABORATORY: On [**2110-12-19**], white blood cell count of
5.4, hematocrit of 26.7, platelets of 150, neutrophils of
64.7, lymphocytes 30.4, monocytes 3.4, eosinophils 1.0,
basophils 0.5. Chemistry sodium 139, potassium 4.2, chloride
99, bicarbonate 27, BUN 18, creatinine 0.6, glucose 113,
calcium 8.9, phosphorus 3.6, magnesium 1.4.
The patient had a CT scan of the chest which ruled out
pulmonary embolism and showed diffuse air space and disease
in the right lung and left lower lobe consistent with
infection. It showed parenchymal opacification around the
left lower lobe consistent with bleeding. There were
multiple enlarged lymph nodes in the mediastinum and hilum,
consistent with post-infectious lymphadenopathy or with
secondary post-transplantation lymphoma. A small right
pleural effusion.
ASSESSMENT: This is a 16 year old white female with a
history of cystic fibrosis status post bilateral lung
transplant now status post stent placement in the left
mainstem bronchus with a right middle lobe and left lower
lobe pneumonia, awaiting transfer back to the [**Hospital3 18242**].
HOSPITAL COURSE:
1. PULMONARY: The patient is now status post stent
placement with oxygen saturations in the mid-90s on two
liters. Currently, the patient is continued on her
immunosuppressants including mycophenolate mofetil and
tacrolimus and she is on a Prednisone taper. She should be
receiving 30 mg for the next two days, and 20 mg for the two
days after that, 10 mg for the two days after that and then
back down to 5 mg every day as her baseline dose. It should
be noted that prior to the stent placement, the patient's
oxygen saturations continued to decline. It was unclear
whether or not the patient was not appropriately hypoxic
vasoconstricting versus if she had a pulmonary embolism. A
CT angiogram showed no evidence of a pulmonary embolism.
The patient was instructed to lay on her right side to help
with the ventilation perfusion match. Post-stent placement
the patient now is saturating well.
2. INFECTIOUS DISEASE: The patient continued to spike
temperatures up to 101.6 F., after transfer from the Medical
Intensive Care Unit to the floor. Pan cultures show the
patient has a likely source of pulmonary given the findings
on chest x-ray and follow-up CT scan. At the time of
dictation, sputum Gram stain and culture were pending. The
patient was started on Clindamycin for questionable
aspiration. At the time of this dictation, the patient was
to be started on tobramycin, Ciprofloxacin and Vancomycin as
well although these are pending to be started upon her
transfer to [**Hospital1 **].
3. GASTROINTESTINAL: The patient with a history of
pancreatic insufficiency. The patient takes her own Ultrase,
pancreatic enzymes prior to meals and snacks.
4. ENDOCRINE: The patient with insulin dependent diabetes
mellitus. Blood sugars have been completely out of control
given that the patient's p.o. intake has also been very
erratic. The patient usually takes 32 units of NPH in the
morning with 2 units of Humalog. These will need to be
adjusted according to the patient's p.o. intake. She is also
covered with a Humalog insulin sliding scale. We are just
covering with q.a.d. fingersticks and adjusting as necessary.
5. OPHTHALMOLOGY: The patient was seen by Ophthalmology
regarding blurry vision. No pathology was seen on
examination. It was determined that she likely has a
refractory error and they recommended follow-up as an
outpatient.
6. CARDIOVASCULAR: The patient had an echocardiogram while
she was at the [**Hospital1 69**].
Findings were consistent with right ventricular strain.
Question whether this is acute versus chronic. A CT scan
showed no evidence of pulmonary embolism. The patient also
with status post new lung status post transplant, so it would
be less likely that it is a permanent pulmonary process as
usually right ventricular strain would improve with improved
lungs. We would recommend a follow-up echocardiogram once
her acute issues have been treated.
7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient has been
very hypophosphatemic and hypomagnesemic treated with p.o.
Neutra-Phos and magnesium oxide. Once the patient gets a
PICC line placed, we would recommend intravenous replacement.
8. NEUROLOGICAL: The patient has history of seizures,
questionable secondary to cyclosporin. Would continue
patient on Gabapentin.
DISCHARGE DIAGNOSES:
1. Cystic fibrosis status post bilateral lung transplant in
[**2108-9-11**].
2. Asthma.
3. Gastroesophageal reflux disease.
4. Pancreatic insufficiency.
5. Seizures thought secondary to cyclosporin.
CONDITION ON DISCHARGE: Fair.
DISPOSITION: The patient will be discharged to [**Hospital3 18242**].
DISCHARGE MEDICATIONS: As per her Page One and to be
determined by her physicians at [**Hospital3 1810**]. Her
baseline medications include:
1. Mycophenolate mofetil 500 mg p.o. twice a day.
2. Ranitidine 150 mg p.o. twice a day.
3. Bactrim double strength one tablet p.o. q. Monday,
Wednesday and Friday.
4. Gabapentin 300 mg p.o. three times a day.
5. Tacrolimus 6 mg p.o. twice a day; note this level was
changed from her usual 7 mg dose given that her trough levels
were above standard.
6. Prednisone taper.
7. Procardia 30 mg p.o. q. day.
8. NPH 32 units q. a.m.
9. Humalog 2 units q. a.m.
10. Humalog insulin sliding scale.
11. Ultrase 7 to 8 with meals, 3 to 4 with snacks.
Antibiotic regimen again to be discussed with the [**Hospital1 **]
attendings.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 6369**]
MEDQUIST36
D: [**2110-12-19**] 18:52
T: [**2110-12-19**] 20:26
JOB#: [**Job Number **]
|
[
"507.0",
"250.01",
"E878.0",
"493.90",
"996.84",
"530.81",
"277.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"96.71",
"96.04",
"33.91",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
8215, 8420
|
8551, 9560
|
4890, 8194
|
3157, 4873
|
264, 2222
|
2244, 2597
|
2615, 3133
|
8446, 8526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,306
| 163,276
|
24417
|
Discharge summary
|
report
|
Admission Date: [**2148-6-14**] Discharge Date: [**2148-7-1**]
Date of Birth: [**2124-3-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
bruising, fever
Major Surgical or Invasive Procedure:
plasmapheresis
History of Present Illness:
24 yo F without significant past medical history transferred
from [**Hospital6 **] for management of likey TTP. She
complains of 1 week of easy bruising, 2 days of worsening
fatigue and 1 day of fever and confusion. She had URI 1 month
prior to admission and was treated with azithromycin. She also
noted dark stook, dark urine and nose bleeds and heavy menses.
At [**Hospital3 17162**]. She was found to have Hct 23.3, platelet of 9 and
total bilirubin of 7.4 with direct of 0.9 and retic 4.5. Head CT
was negative and she was guaiac negative. In the ED her initial
vitals were T100 P113 BP 122/69 R16 97%. Peripheral smear was
consistent with microangiopathic hemolytic anemia.
Patient denies any drug use, no identifiable risk for HIV, last
menstrual was 3 days prior to admission.
Past Medical History:
asthma
eczema
s/p appendectomy
Social History:
smokes 1ppd, occasional etoh, no drugs
Family History:
noncontributory
Physical Exam:
T=100.2
P=108
BP=124/56
RR=18
O2sat=100% RA
Gen-NAD, lethargic, pleasant
HEENT-anicteric, slightly jaundiced skin, oral mucosa moist,
neck supple
CV-rrr, no r/m/g
resp-CTAB
[**Last Name (un) 103**]-soft, NT/ND
ext-no edema, multiple bruises on arms and legs in no organized
distribution
Pertinent Results:
CBC
[**2148-6-14**] 12:30AM BLOOD WBC-9.7 RBC-2.83* Hgb-7.5* Hct-21.3*
MCV-75* MCH-26.5* MCHC-35.2* RDW-19.9* Plt Ct-13*
[**2148-6-14**] 12:30AM BLOOD Neuts-60.4 Bands-0 Lymphs-33.6 Monos-3.8
Eos-1.7 Baso-0.4
[**2148-6-14**] 06:13AM BLOOD Plt Ct-7*
Chemistries
[**2148-6-14**] 12:30AM BLOOD Glucose-101 UreaN-22* Creat-1.0 Na-142
K-3.4 Cl-109* HCO3-22 AnGap-14
[**2148-6-14**] 06:13AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
LFTs
[**2148-6-14**] 12:30AM BLOOD ALT-37 AST-55* LD(LDH)-1410* AlkPhos-67
Amylase-43 TotBili-7.1*
Other
[**2148-6-14**] 12:30AM BLOOD Hapto-<20*
[**2148-6-14**] 06:13AM BLOOD HCG-<5
Fe studies
[**2148-6-24**] 05:25AM BLOOD Iron-74
[**2148-6-14**] 06:13AM BLOOD Ret Aut-6.4*
[**2148-6-24**] 05:25AM BLOOD calTIBC-254* Ferritn-304* TRF-195*
Immunology
[**2148-6-15**] 03:25AM BLOOD IgA-187
[**2148-6-26**] 05:30AM BLOOD dsDNA-NEG
[**2148-6-26**] 05:30AM BLOOD Smooth-NEG
[**2148-6-26**] 05:30AM BLOOD SM/RNP ANTIBODIES (WITHOUT [**Doctor First Name **])-PND
[**2148-6-14**] 06:14AM BLOOD ADAMTS13 ACTIVITY LOW (<4%) AND INHIBITOR
HIGH (4.4)
[**2148-6-14**] 09:39AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:160
[**2148-6-14**] 06:14AM BLOOD HIV Ab-NEGATIVE
ANTICARDIOLIPIN Ab
ANTI-CARDIOLIPIN IgG : 14.2 0 - 15
GPL
ANTI-CARDIOLIPIN IgM : 35.4 0 - 12.5
MPL
U/A
[**2148-6-18**] 04:16PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-8.0 Leuks-NEG
[**2148-6-18**] 04:16PM URINE RBC-0-2 WBC-[**3-30**] Bacteri-OCC Yeast-NONE
Epi-0-2
Urine Lytes
[**2148-6-18**] 04:16PM URINE Hours-RANDOM Creat-144 TotProt-42
Prot/Cr-0.3* Albumin-14.5 Alb/Cre-100.7*
Brief Hospital Course:
Thrombocytopenia
The patient initially presented with bruising, fatigue and fever
to an OSH with anemia and thrombocytopenia. She was transferred
to [**Hospital1 18**] for management of what was thought to be TTP given the
constellation of thrombocytopenia, microangiopathic hemolytic
anemia, fever, normal PT/PTT, negative D-dimer. She had a
weakly positive Coombs test, a positive [**Doctor First Name **] (1:160) and positive
anticardiolipin IgM, suggesting possible autoimmunity. To
further evaluate this, an anti-DS DNA antibody and a anti-Sm
antibody were sent. The anti DS-DNA Ab was negative, the anti
Sm antibody was pending on discharge.
On admission the patient had a platelet count of 7, and was
started on daily plasmapheresis and prednisone 80 mg QD.
Hematology and transfusions consults were obtained. She had a
marked allergic reaction to pheresis (hives, itching, wheezing)
that required premedicating her with hydrocortisone and
benadryl, and standing famotidine. Notwithstanding her allergic
reaction, she responded well to plasmapheresis, and her platelet
count rose to 224K after daily therapy. At this point pheresis
was changed to QOD, but the patient's platelet count fell on
this regimen to a nadir of 99, and she was restarted on daily
pheresis. Daily pheresis resulted in platelets rebounding to
238, and at this point pheresis was held and her platelet count
was followed. They remained in the 200s until discharge. An
ADAMTS13 assay was performed and showed high inhibitor units and
low activity levels.
Initially the patient had a groin line for pheresis, but this
was removed and a right subclavian catheter was placed. This
was removed prior to discharge.
On discharge, the patient had hematology follow up in place
close to her home in [**Location (un) 5503**] for further management.
Anemia
The patient had a microangiopathic anemia as noted above:
normocytic, hemolytic (haptoglobin <20, LDH=1410, Tbili=7.1),
and with an appropriate bone marrow response (retic count=6.4).
The laboratory values were not consistent with Fe deficiency
anemia Fe=74, calTIBC=254, Ferritn=304 TRF=195. Her hemolysis
labs normalized after initiation of therapy. The patient was
stable with a HCT in the mid-20s while admitted.
Elevated WBC Count
The patient's WBC count rose to the low-20,000 range once she
started the steroid therapy. There was no evidence of
infection.
Confusion
The patient was thought to be confused at the outside hospital,
but did not demonstrate any evidence of confusion during her
admission at [**Hospital1 18**] and had a non-focal neurologic exam.
Smoking Cessation
The patient was smoking one pack per day on admission. She was
interested in quitting and was initiated on a nicotine patch
while admitted, which was tapered. On discharge she was given a
prescription for a nicotine patch and will follow up with her
PCP.
Steroid prohpylaxis
The patient was started on Ca, vitamin D, and fosamax, to
continue while she is on steroids. She was also discharged with
famotidine for GI prophylaxis. She was on an insulin sliding
scale while in the hospital, and her FS remained in the mid-100s
while on steroids, so she was not discharged on any agents, but
will get her glucose checked weekly along with her platelets
while on steroids.
Medications on Admission:
none
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
3. Prednisone 20 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily) for
1 weeks: Then 3 tablets daily for one week. Then 2.5 tablets
daily for one week. Then 2 tablets daily for one week. Then 1.5
tablets daily for one week. Then 1 tablet daily for one week.
Then 0.5 tablets daily for one week.
Disp:*98 Tablet(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
7. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once
a day.
Disp:*30 patches* Refills:*0*
8. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
while on steroids.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Thrombocytopenia
2. Antiphospholipid antibody positivity
3. Asthma
Discharge Condition:
Good, with stable platelet count >150
Discharge Instructions:
You are discharged to home and should continue all medications
as prescribed. Please contact your physician or present to the
ER if you experience fevers, chills, night sweats, bleeding,
bruising or other concerns. Get your platelet count and glucose
checked weekly at your hematologist's office. Please continue
to take famotidine, fosamax, calcium and vitamin D while you are
on prednisone.
Followup Instructions:
Please schedule a follow-up appointment with a primary care
physician [**Name Initial (PRE) 176**] 1 week after discharge; call the [**Hospital1 18**]
physician referral line to find someone.
Please keep your appointment with Dr. [**First Name8 (NamePattern2) 3613**] [**Last Name (NamePattern1) 61812**]
[**Telephone/Fax (1) 61813**] in [**Location (un) 5503**] for hematology care within 1 week of
discharge.
|
[
"E932.0",
"692.9",
"493.90",
"283.0",
"305.1",
"251.8",
"708.0",
"V58.65",
"999.8",
"446.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7779, 7785
|
3277, 6581
|
284, 300
|
7899, 7938
|
1581, 3254
|
8382, 8797
|
1241, 1258
|
6636, 7756
|
7806, 7878
|
6607, 6613
|
7962, 8359
|
1273, 1562
|
229, 246
|
328, 1115
|
1137, 1169
|
1185, 1225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,727
| 162,371
|
49902+59213
|
Discharge summary
|
report+addendum
|
Admission Date: [**2127-1-2**] Discharge Date: [**2127-1-8**]
Date of Birth: [**2059-7-15**] Sex: M
Service:
CHIEF COMPLAINT: The patient was a direct admit to the
Operating Room where he underwent coronary artery bypass
grafting.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old man
with severe coronary artery disease who had been seen
previously at [**Hospital6 256**] for
cardiac catheterization on [**2126-12-13**]. Please see
catheterization report for full details.
In summary the catheterization showed that he had 40% left
main, left anterior descending that was totally occluded,
filled with left-to-left collaterals. He had a circumflex
with 50% lesion and a right coronary artery with a 70%
lesion. Ejection fraction via echocardiogram was 30%.
He was discharged to home after his catheterization. He
returned to [**Hospital6 256**] later in
[**Month (only) 404**] at which time he had a Port-A-Cath placed so that he
could have hemodialysis prior to his coronary artery bypass
grafting.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, status post multiple myocardial infarctions,
insulin-dependent diabetes mellitus, end-stage renal disease,
status post Port-A-Cath placement, hypercholesterolemia,
hypertension, recurrent pancreatitis, osteoarthritis, gout.
MEDICATIONS PRIOR TO ADMISSION: Aspirin 81 mg q.d.,
Lopressor 12.5 mg q.d., Lipitor 10 mg q.d., Elavil 50 mg
q.d., Lovenox 60 b.i.d., Glucosamine, Allopurinol 100 b.i.d.,
Ultram 50 q.d., sublingual Nitroglycerin.
ALLERGIES: DRICORT, DIOVAN.
SOCIAL HISTORY: Positive tobacco use; he quit 16 years ago.
PHYSICAL EXAMINATION: Vital signs: Prior to admission
temperature was 96.9??????, heart rate 78, respirations 18, oxygen
saturation 98% on room air, blood pressure 150/76. HEENT:
pupils equal, round and reactive to light. Extraocular
movements intact. Moist mucous membranes. Neck: Supple.
No lymphadenopathy. No jugular venous distention. Chest:
Clear to auscultation bilaterally. Heart: Regular, rate and
rhythm. Distant heart sounds. S1 and S2. Abdomen: Soft
and nontender. Positive bowel sounds. Extremities: No
clubbing or cyanosis. Trace edema.
LABORATORY DATA: Chest x-ray prior to admission showed lungs
clear without focal opacities or pleural effusions. No
evidence of pneumothorax.
HOSPITAL COURSE: As stated previously the patient was a
direct admission to the Operating Room on [**1-2**]. At
that time, he underwent coronary artery bypass grafting times
three with a LIMA to the left anterior descending and
saphenous vein graft to OM, and saphenous vein graft to the
distal right coronary artery. He tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit.
At the time of transfer he had a left radial and a right
femoral arterial line, a left IJ oximetric Swan-Ganz
catheter, two ventricular and two atrial pacing wires, and
two mediastinal and left pleural chest tube.
At the time of transfer his mean arterial pressure was 83.
He was atrial paced at a rate of 90. His CVP was 8. He had
Propofol at 10 mcg/kg/min and Levophed at 0.2 mcg/kg/min, and
Milrinone at 0.2 mcg/kg/min.
The patient did well in his immediate postoperative period.
His Levophed was weaned to off, and his Milrinone was weaned
to off during the recovery period from his surgery. He
remained intubated until postoperative day #1 because of a
mild acidosis. On postoperative day #1, the patient was seen
by the Renal Service after which he was hemodialyzed. The
patient was also weaned from the ventilator and ultimately
extubated. His chest tubes were also removed on
postoperative day #1.
He remained in the Cardiothoracic Intensive Care Unit
throughout the course of postoperative day #1 to monitor his
hemodynamic and respiratory status. On postoperative day #2,
the patient was transferred from the Intensive Care Unit to
................. for continuing postoperative care and
cardiothoracic rehabilitation.
Over the next several days, the patient was followed closely
by the Renal and Cardiothoracic Services. This activity was
gradually increased with the assistance of Physical Therapy
and the nursing staff. On postoperative day #5, it was felt
that the patient was stable and ready to be discharged to
home. This was discussed with the patient, and he requested
that he be discharged to home on postoperative day #6, so
arrangements were made for the patient to be discharged home
on postoperative day #6.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
98??????, heart rate 88 sinus rhythm, blood pressure 116/70,
respirations 18, oxygen saturation 92% on room air. Weight
preoperatively is 79.5 kg, discharge 86.8 kg.
DISCHARGE LABORATORY DATA: White count 17, hematocrit 26,
platelet count 180; sodium 138, potassium 4.1, chloride 100,
CO2 22, BUN 89, creatinine 5.9, glucose 138, magnesium 2.4,
phosphorus 7.9. General: The patient was alert and oriented
times three. He was conversant. He moves all extremities.
Respiratory: Clear to auscultation bilaterally. Heart:
Regular, rate and rhythm. S1 and S2. No murmur. Sternum is
stable. Incision with Steri-Strips, open to air, clean and
dry. Abdomen: Soft, nontender, nondistended. Normoactive
bowel sounds. Extremities: Warm with no clubbing, cyanosis,
or edema. Right saphenous vein graft site with Steri-Strips
open to air, clean and dry, no erythema.
DISCHARGE MEDICATIONS: Lopressor 50 mg b.i.d., PhosLo 2 tab
t.i.d., Epogen 4000 U subcue 2 times per week, Lasix 20 mg
q.d., Enteric Coated Aspirin 325 q.d., regular Insulin
sliding scale q.a.c. and q.h.s., Percocet 5/325 [**12-25**] tab q.4
hours p.r.n., Ibuprofen 600 mg q.6 hours p.r.n.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three with LIMA to left anterior
descending, saphenous vein graft to OM, saphenous vein graft
to right coronary artery.
2. Diabetes mellitus, type 1.
3. End-stage renal disease.
4. Hypercholesterolemia.
5. Hypertension.
6. Osteoarthritis.
7. Gout.
8. Recurrent pancreatitis.
9. Status post appendectomy.
10. Status post left renal stone removal.
11. Status post left varicose vein stripping.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with his
primary care physician [**Last Name (NamePattern4) **] [**2-24**] weeks. He is to have follow-up
with Dr. [**Last Name (STitle) 70**] in six weeks. He is to have follow-up
with the Renal Service per their recommendations.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2127-1-7**] 13:23
T: [**2127-1-7**] 15:50
JOB#: [**Job Number 42594**]
Name: [**Known lastname **], [**Known firstname 389**] Unit No: [**Numeric Identifier 16907**]
Admission Date: [**2127-1-2**] Discharge Date:
Date of Birth: [**2059-7-15**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM: The patient was stable for
discharge on [**2127-1-2**]. However it was noticed that his white
blood cell count was increasing. White blood cell count
increased on a daily basis until it was 26 which was on
[**2127-1-13**]. The patient was completely asymptomatic during
this time period with no complaint of pain and he was
afebrile. Multiple blood cultures obtained from both his
peripheral IV and dialysis catheter were all negative for
growth. Multiple chest x-rays revealed no consolidation.
It was decided at that point to get a General Surgery consult
due to the fact the patient had a history of pancreatitis.
The patient was made NPO and he began to improve in terms of
his white blood cell count.
On [**2127-1-15**] the patient was brought up for dialysis and
during dialysis he had an episode of hypotension and
bradycardia. He was noted to be in second degree heart
block. The patient was seen by Electrophysiology service
after he was transferred to the Intensive Care Unit.
It was decided that the patient would have a pacemaker
placed. This was done by the Electrophysiology service on
[**2127-1-15**].
Upon discharge the patient was completely stable and was
tolerating a regular diet well.
DISCHARGE LABORATORY DATA: White blood cell count 13.5,
hematocrit 31, platelet count 211,000. Sodium 136, potassium
4, chloride 100, bicarbonate 23, BUN 42, creatinine 4.2,
amylase 105, lipase 119, AST 9, ALT 23, alkaline phosphatase
116, bilirubin 0.3.
PHYSICAL EXAMINATION: Afebrile, vital signs are stable. COR
- regular rate and rhythm. Lungs are clear to auscultation.
Abdomen is soft, nontender, nondistended.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Name8 (MD) 1561**]
MEDQUIST36
D: [**2127-1-20**] 12:58
T: [**2127-1-22**] 11:54
JOB#: [**Job Number 16908**]
|
[
"577.1",
"411.1",
"414.01",
"401.9",
"403.91",
"250.40",
"577.0",
"997.1",
"426.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"36.12",
"39.95",
"39.61",
"36.15",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
5495, 5763
|
5784, 6263
|
2368, 4548
|
6288, 8571
|
1360, 1572
|
8594, 9026
|
147, 253
|
282, 1038
|
1061, 1327
|
1589, 1634
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,710
| 195,139
|
25091
|
Discharge summary
|
report
|
Admission Date: [**2169-7-29**] Discharge Date: [**2169-8-10**]
Date of Birth: [**2094-5-16**] Sex: M
Service: NEUROLOGY
Allergies:
Percocet
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Intraparenchymal bleed
HPI: 75 year old male with history of recently diagnosed LEFT
leg
DVT, has been on Lovenox and warfarin for about one week. INR
[**2169-7-27**] was 2.8. Pt. presents with acute-onset of severe LEFT
sided headache over left eye and intermittent changes in mental
status, specifically confusion and increased sleepiness.
ROS: No F/c/s/n/v/d. No diplopia, blurry vision, slurred speech,
weakness, ataxia, vertigo, dizziness.
PMH:
" HTN
" BPH
" Hip replacement 8 years ago
" Bilateral hearing aids
" nephrolithiasis
MED:
" Lovenox
" warfarin
lisinopril
ALL: NKDA
SH: Tobacco, ETOH, drugs
FH: no history of ICHs, aneurysms or vascular anomalies.
VS: T afebrile HR79 BP 143/53 RR16 Sat 100 % on
respirator
PE:Genl Supine, intubated
HEENT AT/NC, MMM no lesions
Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits
Chest CTA B
CVS RRR w/o MGR
ABD soft, NTND, + BS
EXT no C/C/E, distal pulses full, no rashes or petechiae
Neuro
MS: Intubated. On midazolam. Responsive to sternal rub with
grimace or cough.
CN: I--not tested; II,III-Pupils bilaterally pinpoint;
III,IV,VI- no OCRs ; V-Right corneal reflex intact, LEFT not
elicited; VII--face symmetric without obvious asymmetry; IX,X--
gag intact.
Motor/Sensory: Patient able to withdraw to painful stimuli in
all
extremities. Minimal spontaneous movement of upper extremities,
RIGHT>LEFT
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 3 | tr | eq |
R | 3 | 3 | 3 | 3 | tr | eq |
LAB:
Na 140, K 4.2, Cl102, Co2 27, BUN/Cr 13/1.1, Glu 122
PT/INR/PTT: 18.1/2.2/34.5
IMG:
Head CT:
left temporal lobe intraparenchymal hemorrhage with
intraventricular extension
- effacment of left ambient cistern by left uncus, no other
significant mass
effect
IMP: 75 year old male with HTN, on warfarin for LEFT DVT with 2
days of severe headache and changes in mental status found to
have a large LEFT temporal lobe intraparenchymal hemorrhage
with
ventricular involvement and mild effacement of the basal
cistern.
Neurological exam compromised by sedation however, differences
in
corneal reflexes between left and right and relative RIGHT
hyperreflexia are of concern. Etiology of bleed unclear, may be
secondary to aneurysm or severe HTN in the setting of high INR.
REC:
" MRI/MRA
" Maintain SBP <140
" As much FFP as required to normalize INR
" Repeat CT scan in about 8-10 hours
" Follow-up with Neurosurgery
" Monitor INR every 3-4 hours.
Major Surgical or Invasive Procedure:
Intubation
IVC filter placement
History of Present Illness:
75 year old male with history of recently diagnosed LEFT leg
DVT, has been on Lovenox and warfarin for about one week. INR
[**2169-7-27**] was 2.8. Pt. presents with acute-onset of severe LEFT
sided headache over left eye and intermittent changes in mental
status, specifically confusion and increased sleepiness.
ROS: No F/c/s/n/v/d. No diplopia, blurry vision, slurred speech,
weakness, ataxia, vertigo, dizziness.
Past Medical History:
HTN
BPH
Hip replacement 8 years ago
Bilateral hearing aids
nephrolithiasis
Social History:
Tobacco, ETOH, drugs
Family History:
no history of ICHs, aneurysms or vascular anomalies.
Physical Exam:
T afebrile HR79 BP 143/53 RR16 Sat 100 % on respirator
.
PE:Genl Supine, intubated
HEENT AT/NC, MMM no lesions
Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits
Chest CTA B
CVS RRR w/o MGR
ABD soft, NTND, + BS
EXT no C/C/E, distal pulses full, no rashes or petechiae
.
Neuro
MS: Intubated. On midazolam. Responsive to sternal rub with
grimace or cough.
CN: I--not tested; II,III-Pupils bilaterally pinpoint;
III,IV,VI- no OCRs ; V-Right corneal reflex intact, LEFT not
elicited; VII--face symmetric without obvious asymmetry; IX,X--
gag intact.
Motor/Sensory: Patient able to withdraw to painful stimuli in
all
extremities. Minimal spontaneous movement of upper extremities,
Left > Right
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 3 | tr | eq |
R | 3 | 3 | 3 | 3 | tr | eq |
At discharge:
The patient had fluent speech but some difficulty with
comprehension. He was not oriented to hospital, date, or time.
He was able to move all 4 extremities but L > R.
Pertinent Results:
[**2169-7-30**] 12:00AM PT-15.7* PTT-31.7 INR(PT)-1.6
[**2169-7-29**] 08:49PM PT-16.0* PTT-31.9 INR(PT)-1.7
[**2169-7-29**] 03:43PM LACTATE-2.3*
[**2169-7-29**] 02:52PM GLUCOSE-122* UREA N-13 CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2169-7-29**] 02:52PM ACETONE-NEGATIVE
[**2169-7-29**] 02:52PM WBC-5.3 RBC-3.98* HGB-11.9* HCT-33.9* MCV-85
MCH-29.9 MCHC-35.1* RDW-13.8
[**2169-7-29**] 02:52PM NEUTS-73.4* LYMPHS-21.3 MONOS-4.1 EOS-1.0
BASOS-0.2
[**2169-7-29**] 02:52PM PLT COUNT-154
[**2169-7-29**] 02:52PM PT-18.1* PTT-34.5 INR(PT)-2.2
.
MRI/MRA brain - Left temporal hematoma with extension to the
ventricular system without evidence of hydrocephalus. It should
be noted that on the current examination gadolinium-enhanced
images were not obtained. Gadolinium-enhanced images are
recommended to exclude underlying mass. No abnormal flow voids
are seen to indicate an associated aneurysm or arteriovenous
malformation. No acute infarct is seen. Chronic right parietal
infarct is noted.
.
MRA head - normal flow signal within the arteries of anterior
and posterior circulation.
.
CT head [**7-29**] - Left temporal lobe intraparenchymal hemorrhage
with extension into the left lateral ventricle. There is mild
surrounding mass effect with the left uncus abutting the
midbrain on the left.
.
CXR - 1. Lines and tubes in satisfactory position. 2. Bibasilar
atelectasis. 3. Left lower lobe atelectasis versus
consolidation.
.
ECG - Sinus rhythm. Right bundle-branch block with ST-T wave
changes. Ventricular premature beats. Compared to the previous
tracing no significant change.
.
CT head [**8-2**] - Stable appearance of left temporal
intraparenchymal hemorrhage, with slight interval decrease in
the intraventricular component. Trace bitemporal subarachnoid
hemorrhage. No change in surrounding edema or mass effect. No
hydrocephalus.
Brief Hospital Course:
In the emergency room, the patient was given 2 units of FFP and
Vitamin K in order to decreased his INR. The patient was
evaluated by neurosurgery for possible surgical drainage of his
hemorrhage. They felt no intervention was warranted. The
patient was admitted to the neuro ICU intubated on cardiac
telemetry. He was placed on dilantin for seizure prophylaxis.
He was extubated after 1 day in the ICU. Due to the patient's
history of DVT along with his present intracranial hemorrhage,
the decision was made to place an IVC filter. The patient
tolerated this procedure well without complications. The
patient was transferred from ICU to a stepdown unit on the
neurology floor. His blood pressure was controlled for a SBP <
140. The patient was on clonidine, lisinopril, and metoprolol.
His BP eventually normalized and he was maintained only on
metoprolol and lisinopril. The patient had an interval CT scan
on [**7-/2142**] that showed a decreased size of his hemorrhage.
His course was complicated by an aspiration pneumonia for which
he was treated with levofloxacin and flagyl for a 10 day course.
There was some difficulty maintaining therapeutic levels of
dilantin thus the patient was switched to trileptal. His
seizure prophylaxis is only meant to continue for 30 days since
the hemorrhage. It can be stopped on [**8-28**]. The patient was
initially nourished with tube feeds via an NG tube. He was
eventually evaluated by speech therapy and was cleared to take
pureed thin liquids. His strength markedly improved on his
right side throughout the course of his hospitalization. The
etiology of his bleed was unclear at the time of d/c. DDz
included an AVM, aneurysm, hemorrhage secondary to a mass, and
amyloid angiopathy. The patient was scheduled for a f/u MRI
study on [**9-14**] to better assess the etiology of his bleed. He
was given an appointment with Dr. [**Last Name (STitle) **] in stroke clinic on
[**9-19**].
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
9. Insulin Regular Human 100 unit/mL Solution Sig: per insulin
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
ICH
HTN
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or call the emergency room if you
experience headache, increasing confusion, new weakness,
numbness, tingling, visual changes, worsened swallowing, chest
pain, shortness of breath, heart palpitations.
Please stop taking your trileptal on [**2169-8-28**]
Please call the [**Hospital1 **] radiology department [**Telephone/Fax (1) 22726**] to
arrange a time to have your MRI scan on [**2169-9-14**]
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2169-9-19**] 5:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"507.0",
"401.9",
"453.42",
"432.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.7",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9270, 9367
|
6477, 8434
|
2810, 2844
|
9419, 9428
|
4561, 6454
|
9902, 10188
|
3447, 3502
|
8457, 9247
|
9388, 9398
|
9452, 9879
|
3517, 4358
|
4372, 4542
|
230, 1910
|
2872, 3293
|
1919, 2772
|
3315, 3392
|
3408, 3431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,289
| 160,945
|
2423
|
Discharge summary
|
report
|
Admission Date: [**2110-5-4**] Discharge Date: [**2110-5-23**]
Service: MEDICINE
Allergies:
Benadryl
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
Intubation
Pressors (medications to support blood pressure)
Thoracentesis ([**5-23**])
History of Present Illness:
84 yo M h/o systolic CHF (EF 20-25% in [**3-20**]), HTN, afib on
warfarin, CKD (baseline Cr 2.1), DM2, and L MCA CVA who
presented with anemia from nursing home. He was recently d/c'ed
from [**Hospital1 18**] after an admission [**Date range (1) 12479**] for generalized
weakness attributed to CHF exacerbation. Today, on routine lab
check his Hct was 22 from baseline of low 30s, and Cr 3.7 from
baseline 2.1. There was reportedly no evidence of acute bleeding
at his NH. Pt was alert and oriented to self and place, however
VS were notable for a HR of 130s and sat of 84% on RA. He was
brought to the ED.
.
On arrival, patient was reportedly somnolent. His SBP was in the
70s and his sats were 80's on room air. Exam revealed guaiac
positive stool with melena. Hct was 21 with INR 4.0 He then
vomitted and was intubated for airway protection. An NG tube was
placed with lavage reportedly negative, but NG tube later
drained out 50cc of frank red blood. He had a torso CT that was
unremarkable. Head CT initially raised some concern for SAH but
upon reviewing, neurosurg considered the findings old infarct
without hemorrhage. ECG showed slow afib with no ischemic
changes. Trop was 0.17 with flat CK. Cr 3.9 from baseline 2.1.
He received one dose of vanc and zosyn, 2L of fluid with
improvement in BP and therefore got a femoral line placed with
initiation of norepinephrine. He received 3 u pRBCs, 4 FFP,
vitamin K 10 mg IV x 1, and activated facotr IX. After blood and
FFP transfusions, Hct improved to 30 and INR decreased to 2.2.
GI saw the patient in the ED, recommended EGD in a.m. with
serial Hcts and suppportive care.
.
Of note, patient was recently admitted to [**Hospital1 18**] from [**2110-4-15**] to
[**2110-4-25**] for CHF exacerbation. He was discharged to rehab with
furosemide 120 mg [**Hospital1 **]. Furosemide has been held for 2 days prior
to this admission with plan to restart on day of admission.
.
Complete review of systems is unable to be obtained due to
patient's sedation and intubaiton.
.
Past Medical History:
Chronic Systolic CHF - Echo [**3-20**] with EF 25%
Hypertension
Dyslipidemia
Afib on coumadin
CKD IV, baseline 2.1-2.5, sees Dr. [**Last Name (STitle) 4883**]
Anemia - likely mixed, CKD and Iron Deficiency, baseline 35-39
DM, on insulin, hgb A1c 9.2 [**3-20**]
Gastritis
- hematemesis [**2109-7-12**]. EGD with antral erosions, small AVM in
duodenum
- colonoscopy [**12/2108**] with single sessile 2 mm polyp of benign
appearance in the proximal transverse colon (not removed [**1-13**]
bleeding risk)
Prior Tobacco use
Osteoarthritis
Prostate Cancer s/p prostatectomy
Urinary incontinence
Social History:
Widowed and lived with his daughter [**Name (NI) 12469**], who is his health
care proxy, until his recent CVA afterwhich he was staying at a
rehab. Wife passed away in the summer of [**2108**]. Former [**Year (4 digits) 1818**],
smoked 1-2 packs daily for ~40 years. Previously drank one shot
of whiskey daily. No known history of illicit drug use.
Family History:
Unable to obtain.
Physical Exam:
Upon admission to the ICU:
Vitals: T: 95.3 BP: 102/64 P: 65 R: 14 O2: 97% on A/C
50/14/5/60%
weight 188
General: intubated and sedated
[**Year (4 digits) 4459**]: Sclera anicteric, pupils sluggish but reactive equally
Neck: JVP elevated to 10cm. No bruits. Bandage on L neck from
failed CVL attempt.
Lungs: slightly decreased BS at bases but overall clear to
auscultation
CV: irregularly irregular with 2/6 systolic murmur non-radiating
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Groin: R femoral CVL site with mild oozing, dressing intact
Ext: slightly cool, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Pertinent Results:
[**2110-5-4**] 10:18PM LACTATE-1.2
[**2110-5-4**] 10:16PM GLUCOSE-153* UREA N-119* CREAT-3.5*
SODIUM-136 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
[**2110-5-4**] 10:16PM CK(CPK)-86
[**2110-5-4**] 10:16PM cTropnT-0.13*
[**2110-5-4**] 10:16PM CALCIUM-7.9* PHOSPHATE-5.5* MAGNESIUM-3.1*
[**2110-5-4**] 10:16PM WBC-11.3*# RBC-3.45*# HGB-10.1*# HCT-30.6*#
MCV-89 MCH-29.3 MCHC-33.0 RDW-19.3*
[**2110-5-4**] 10:16PM NEUTS-77* BANDS-0 LYMPHS-5* MONOS-14* EOS-2
BASOS-1 ATYPS-0 METAS-1* MYELOS-0
[**2110-5-4**] 10:16PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ BURR-1+
ACANTHOCY-NORMAL
[**2110-5-4**] 10:16PM PLT SMR-NORMAL PLT COUNT-214 PLTCLM-1+
[**2110-5-4**] 10:16PM PT-23.0* PTT-38.4* INR(PT)-2.2*
[**2110-5-4**] 08:24PM TYPE-ART TEMP-36.2 RATES-/14 TIDAL VOL-600
PEEP-5 O2-100 PO2-478* PCO2-36 PH-7.43 TOTAL CO2-25 BASE XS-0
AADO2-202 REQ O2-42 -ASSIST/CON INTUBATED-INTUBATED
[**2110-5-4**] 08:24PM O2 SAT-98
[**2110-5-4**] 04:53PM LACTATE-1.4 K+-4.5
[**2110-5-4**] 04:53PM HGB-7.3* calcHCT-22
[**2110-5-4**] 04:35PM GLUCOSE-84 UREA N-129* CREAT-3.9*# SODIUM-137
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-27 ANION GAP-19
[**2110-5-4**] 04:35PM CK(CPK)-62
[**2110-5-4**] 04:35PM cTropnT-0.17*
[**2110-5-4**] 04:35PM CALCIUM-8.3* PHOSPHATE-5.4* MAGNESIUM-3.5*
[**2110-5-4**] 04:35PM WBC-5.1 RBC-2.36*# HGB-6.8*# HCT-21.2*#
MCV-90 MCH-28.8 MCHC-32.1 RDW-19.8*
[**2110-5-4**] 04:35PM NEUTS-71.7* LYMPHS-16.1* MONOS-8.6 EOS-3.0
BASOS-0.5
[**2110-5-4**] 04:35PM PLT COUNT-176
[**2110-5-4**] 04:35PM PT-37.6* PTT-44.5* INR(PT)-4.0*
.
CT Head [**5-4**]: 1. Evolution of the right parietal infarct with
development of cortical serpiginous hemorrhage (laminar
necrosis). 2. Near-complete opacification of the nasopharynx.
Recommend clinical correlation.
.
CT Torso [**5-4**]: 1. Bowel wall thickening, most pronounced along
the right hemi-colon, compatible with colitis. The differential
diagnoses include infectious, inflammatory, and ischemic
etiologies. 2. Interval increase in a moderate right and small
left pleural effusion with right lower lobe consolidation
(likely aspiration). 3. Anasarca.
.
Right hip XR [**5-13**]:
Two frontal radiographs of the right hip are obtained in
relatively similar positioning. No fractures are identified,
although this assessment is suboptimal due to positioning and
patient's size. Multiple metallic clips overlie the partially
visualized pelvis suggesting lymph node dissection. Focal
calcifications adjacent to the medial cortex of the proximal
femoral shaft are of unknown etiology but doubtful clinical
significance. IMPRESSION: No fracture.
.
CT Head [**5-14**]: FINDINGS: Exam is somewhat limited due to motion
artifact. Within this limitation, there is no evidence of new
acute hemorrhage or shift of normally midline structures. The
ventricles and sulci are prominent consistent with age-related
atrophy. Again identified is an area of hypodensity in the right
parietal lobe (2B, 31) consistent with evolving infarct. There
is a thin rim of cortical hyperdensity surrounding this area
likely representing hemorrhage in the setting of laminar
necrosis, unchanged. Progression of expected encephalomalacia is
also identified. Again identified is a likely left frontal
arachnoid cyst, unchanged in size and configuration. Diffuse
periventricular white matter hypodensities compatible with
chronic small vessel ischemic changes are unchanged. There has
been interval resolution of opacification of the nasopharynx.
The visualized paranasal sinuses are clear.
IMPRESSION:
1. No new areas of hemorrhage.
2. Evolving right parietal infarct with areas of laminar
necrosis and
serpiginous areas of hemorrhage, unchanged.
3. Resolution of opacification of the nasopharynx.
.
Right lower extremity U/S [**5-19**]: Normal right lower extremity
ultrasound examination. No evidence of DVT.
.
Video Swallow [**5-20**]: A swallowing videofluoroscopy study was done
in conjunction with the Speech Pathology service. Multiple
consistencies of oral barium were administered and passed freely
beyond the oropharynx without evidence of obstruction. A small
amount of penetration and aspiration was noted with thin
liquids.
.
Right ankle XR [**5-20**]:
Three views of the right ankle and three views of the right foot
demonstrate a large amount of lower extremity edema with soft
tissue swelling about the ankle and foot of unclear etiology.
Distal tibia, fibula, talar dome and mortise appear normal.
Incidental note is made of spurring arising from the talus
medially. Incidental note is made of an os naviculare. Aside
from the soft tissue swelling in the foot, no osseous
abnormality identified within the foot. No acute fracture or
malalignment.
.
CXR [**5-19**]: Left PICC has been partially withdrawn, now positioned
with tip in the left subclavian vein just posterior to the head
of the left clavicle. There is no pneumothorax. Enlarged cardiac
silhouette is not significantly changed. Moderate-to-large
right pleural effusion has increased, now layering predominantly
laterally along the right chest wall. Associated right basilar
atelectasis has also increased.
IMPRESSION:
1. Left PICC withdrawn, tip now in the left subclavian vein.
2. Increased right pleural effusion and atelectasis.
.
CXR [**5-23**]: Dictated report. No pneumothorax. Small amount of
atelectasis at right lung base. No further pleural effusion.
Brief Hospital Course:
84 yo M with severe systolic heart failure and atrial
fibrillation on coumadin transferred from OSH with respiratory
failure and hypovolemic shock s/p stabilization with course c/b
delirium, aspiration pneumonia, deconditioning and dehydration.
.
# Respiratory. Initial respiratory failure likely related to
acute on chronic systolic CHF complicated by aspiration
pneumonitis with development of aspiration pneumonia. Patient
required intubation early in his hospital course and had several
episodes of apnea, which were felt to be due to sedation
(fentanyl, midazolam). These episodes stopped after these
medications were held. He was aggressively diuresed and
extubated on [**5-9**]. Several days thereafter, the patient was
noted to be tachpneic with leukocytosis which improved with
treatment of hospital acquired pneumonia. His course is
scheduled to end on [**5-24**]. In addition, he was noted to have an
increasing pleural effusion for which he had thoracentesis for
1.3L noted to be serous and transudative in nature likely
related to CHF.
.
# Shock/UGIB. This was attributed to hypovolemic shock given
large hematocrit drop from baseline and melanotic stools.
Patient has known upper GI AVMs and EGD during this admission
showed gastritis with dried blood in the stomach. No active site
of bleeding was located. C-scope was not done as patient had
outpatient c-scope 1 month ago showing only polyps. Pt. was
resuscitated w/ 4U PRBCs, FFP, [**Hospital1 **] IV PPI. His HCT stabilized
on [**5-6**] and remained stable for the remainder of his
hospitalization. His coumadin and aspirin were held and stopped
indefinately given the severe, life-threatening nature of his
bleed. PPI was switched to PO and should be continued until the
patient is stable enough to be evaluated by an outpatient
gastroenterologist.
.
# s/p Right parietal CVA. No new stroke on CT head on admission,
however evolution of encephalomalacia was noted, development of
cortical serpiginous hemorrhage (laminar necrosis) in area of
old RMCA in setting of supratherapeutic INR. Neurology and
Neurosurgery were consulted. It was felt that the bleed was not
signficant enough to warrant surgical intervention. Patient's
neurological exam was remarkable for impaired sensorium,
inattention, inability to follow simple commands, dysarthria,
impaired strength in LUE, LLE w/ slight L NLF flattening and
upgoign L toe (all of the motor findings were felt to be old).
His serial Neurological exams were w/o focal features upon
transfer to the floor. An MRI was suggested for ? RLE weakness
(also edematous), however this was deferred given no change in
management (Pt. not candidate for lysis, anticoagulation at this
time). Pt. was not deemed a candidate for anticoagulation given
lifethreatening GIB, despite a very high risk for a recurrent
CVA (CHADS = 6, ~ 20% risk of CVA within a year).
.
# Delirium. Felt to be multifactorial related to hospitalization
and pneumonia. Improved significantly at time of discharge to
alert and oriented to person, place, and year. Encourage
frequent reorientation and monitoring for further mental status
insults.
.
# ARF/CKD. Stage III (baseline [**1-14**]), Cr peaked at 4.1 during
admission and was 2.5 at time of discharge. [**Last Name (un) **] was thought to
be related to pre-renal physiology. Lytes and renal function
should be checked 2 times weekly at LTAC.
.
# A. Fib, rate controlled. Patient was off coumadin in the
setting of acute GI bleed. CHADS2 score 6 -> ~ 20% risk of
recurrence of a CVA within one year. Given recent life
threatening bleed, will not restart AC at this time. Patient
was continued on Carvedilol..
.
# Stage 3, Chronic systolic CHF. [**2110-4-2**] ECHO w/ global LV and
RV hypokinesis, EF 25%. Patient's fluid balance was tenuous and
he required lasix dose titration as well as holding lasix for
several days in the setting of orthostasis. He should be
restarted on lasix 80mg PO BID on the day after discharge. He
will need to follow up in [**Hospital 1902**] clinic with Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] once
his clinical status is improved. He was kept on his coreg and
Low dose ACEI was added to his regimen
.
# RLE edema, pitting to hip. No DVT on R LE ultrasound. No pain
evident w/ flex/ext/abd/add/rotation and plain films of hip and
ankle were unrevealing. Etiology of this was unclear and may
well have a dependent component. It is also possible that this
is HF, but the degree of discrepancy is too great. DDx also
includes intramuscular bleed, but no echymoses on exam and HCT
is stable. Recommend further monitoring.
.
# Diabetes. HgA1C 9.7. Longstanding, poorly controlled diabetes.
Given variable PO intake, standing insulin was stopped and a low
dose, prn sliding scale was used. He will likely need addition
of a long-acting insulin such as lantus/glargine once his PO
intake becomes more reliable.
.
# HTN. Longstanding hypertension treated with carvedilol.
Lisinopril 2.5mg was added for its cardioprotective effects as
above.
Medications on Admission:
lasix 120mg po bid (held since [**4-28**], decreased to 80 \mg daily
on [**5-4**])
colchicine 0.6mg daily
aspirin 325mg daily
atorvastatin 10mg daily
carvedilol 12.5mg [**Hospital1 **]
valsartan 80mg daily
pantoprazole 40 daily
colace
senna
miralax
bisacodyl 10mg prn
HISS
insulin levemir 50 units sq qHS
coumadin dosed prn (usually 5mg)
FeSO4
calcitriol 0.25mg daily
tylenol prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold if loose
stools.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for Wheezing.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-13**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for right leg discomfort.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
15. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
16. Insulin Lispro 100 unit/mL Solution Sig: [**12-16**] units
Subcutaneous ASDIR (AS DIRECTED) as needed for hyperglycemia.
17. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
18. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) capful
PO once a day.
19. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day.
20. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 days.
22. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY:
-GI Bleeding in setting of Supratherapeutic INR
-Hemorrhagic Shock
-Acute on Chronic Kidney Disease (Stage 3)
-Aspiration Pneumonia
-Pleural Effusion
-Hypernatremia
-Delirium
.
SECONDARY:
-Chronic Systolic Heart Failure (EF 20-25%)
-Atrial Fibrillation
-Right Parietal CVA
Discharge Condition:
Good
Discharge Instructions:
You were admitted with anemia secondary to bleeding as well as
renal failure. You were found to have a supratherapeutic INR on
Coumadin; your elevated INR likely contributed to your bleeding.
You experienced shock and respiratory compromise and required
intubation and intesive care in the Coronary Care Unit. You were
evaluated by neurosurgery and neurology given the finding likely
old bleeding in your head. You will require follow-up as listed
below. You had some confusion that was likely associated with
hypernatremia (high sodium) as well as a pneumonia. Your sodium
was corrected and your pneumonia is being treated with
antibiotics. Your confusion improved at time of discharge.
.
You were found to have fluid surrounding your right lung. You
had a procedure called a thoracentesis to help determine why
this fluid accumulated and to help remove some of the fluid so
that you can breathe better. 1.3 liters of fluid was removed.
.
Please take all of your medications as prescribed. A medication
list has been attached. Compliance with the recommended
medications is critical to optimization of your health.
.
Please follow-up with your providers as below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Return to the ED or call your PCP if
you experience chest pain, shortness of breath, new confusion or
changes in mental status, dizziness, weakness, loss of function
of a limb or difficulty initiating movements, bleeding, nausea,
vomiting, fever, chills, sweating or any other symptom that
intuitively concerns you.
.
It was a pleasure caring for you. We wish you the best.
Followup Instructions:
You will see a physician at the facility where you are going.
You should follow up with Dr [**Last Name (STitle) 8499**] (phone number
[**Telephone/Fax (1) 7976**]) after you leave the facility.
.
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2110-6-9**] 3:30
|
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"584.9",
"785.59",
"790.92",
"348.30",
"V58.61",
"250.00",
"285.21",
"276.0",
"V12.54",
"E934.2",
"272.4",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91",
"96.71",
"96.04",
"45.13",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17294, 17365
|
9577, 14623
|
222, 311
|
17691, 17697
|
4105, 9554
|
19387, 19741
|
3361, 3380
|
15054, 17271
|
17386, 17670
|
14649, 15031
|
17721, 19364
|
3395, 4086
|
176, 184
|
339, 2364
|
2386, 2977
|
2993, 3345
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,047
| 179,157
|
29814
|
Discharge summary
|
report
|
Admission Date: [**2111-2-10**] Discharge Date: [**2111-4-15**]
Date of Birth: [**2046-3-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 64 [**Doctor First Name **] Scientist female w/ h/o untreated
diabetes who presents from her living facility with change in
mental status. She has been living at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist
facility receiving supportive care for the past 2 months. She
was ambulatory as recently as a few days ago, able to ambulate
to a bedside commode, and she was noted to have urinary
frequency. Over the past couple of days, her family noticed a
change in mental status, as she became less verbal and less
lucid. By this morning she was clearly delirious and agitated
and was brought to [**Hospital1 18**] ED.
.
In the ED, her blood glucose level was found to be 1135. She was
started on an insulin gtt and given aggressive IVF hydration.
Her rectal temp on arrival was 99.8 and her abdomen was noted to
be distended and firm. The patient was initially treated broadly
with Vancomycin and Flagyl. A Foley catheter was placed and 2L
of urine was drained. UA was positive and CT abdomen showed
mod/severe bilateral hydronephrosis with pyelonephritis. The
patient was given CTX. The patient was given a total of Haldol
5mg IV and Ativan 1mg IV for agitation. A CXR and 2 head CTs
limited by motion were unremarkable.
.
On arrival to the [**Hospital Unit Name 153**], FS was critically high (>400). A 5U
bolus of insulin was given and the rate of the gtt was increased
to 10U/hr.
Past Medical History:
Diabetes
Poor vision (?diabetic retinopathy vs. cataracts)
Social History:
Has 2 children (son and daughter), has been a practicing
[**Doctor First Name **] Scientist for at least 30 years
Family History:
mother, sister w/ DM
Physical Exam:
VS: 97.2 (axillary), 113, 117/66, 19, 99% 2L NC
Gen: drowsy, intermittently agitated, not responsive to commands
HEENT: left pupil opaque, right pupil round and reactive to
light, anicteric
Neck: supple, no carotid bruits
Lungs: limited by inability to follow commands, but CTAB
CV: tachy, RR, nl S1S2, no m/r/g
Abd: hypoactive bowel sounds, S/NT/ND, midline surgical scar
from lower abdomen to pubic symphysis
Rectal: guaiac neg per ED
Ext: no c/c/e, DP/PT pulses 2+ b/l
Neuro: drowsy, not oriented, unable to conduct full neuro exam
due to mental status
Pertinent Results:
Imaging:
CXR: No acute cardiopulmonary disease. No evidence of
infiltrate or
aspiration.
.
Head CT #1: Technically limited study secondary to patient
motion artifact. No gross abnormality identified. The foramen
magnum was not evaluated on this exam.
.
Head CT #2: Limited study with no evidence of acute intracranial
hemorrhage.
.
CT Abd/pelvis [**2111-2-10**]:
1. Moderate/severe bilateral hydronephrosis with right sided
pyelonephritis and evidence of early liquefaction. Follow-up CT
is recommended following treatment to exclude an underlying
lesion.
2. Dilated ureters extend into the pelvis to a
circumferentially thick-walled, enhancing bladder - the
appearance is concerning for infection.
3. Distended bladder despite foley catheter. Clinical
correlation is requested.
4. Mild stranding in right inguinal region may be related to
renal infection/inflammation. While the appendix is not clearly
visualized, there is no abnormal enhancement in and around the
cecum to suggest appendicitis.
.
CT ABD/PELVIS/CHEST [**2111-2-17**]:
1. Interval development of right perinephric abscess inferior
to the lower
pole of right kidney.
2. Interval resolution of left hydronephrosis and hydroureter.
Partial
resolution of the right hydronephrosis and hydroureter.
Complete drainage of
the enlarged bladder.
3. Prebronchial opacity in the right upper lobe most likely
represents
inflammatory change, please correlate clinically and evaluate
for resolution.
.
[**2110-2-20**] CT-GUIDED DRAINAGE: Successful percutaneous CT
fluoroscopy-guided aspiration of the
perinephric abscess.
.
[**2111-4-7**] CT ABD/PELVIS:
1. No evidence of bowel obstruction or bowel wall thickening to
explain the patient's persistent diarrhea.
2. Interval resolution of right perinephric abscess/infection
inferior to the lower pole of the right kidney.
3. Decreased size of hypodense wedge-shaped areas of low
attenuation within the lower pole of the right kidney, likely
reflecting resolving
pyelonephritis.
4. Mild to moderate bilateral hydronephrosis and hydroureter.
No obstructing stone or mass identified. There is marked
distention of the bladder. Findings may represent ureteral
reflux secondary to bladder outlet obstrution or atony.
Clinical correlation is recommended.
.
EKG: sinus tachy at 109, nl axis, nl intervals, no ST-T changes
.
[**2111-2-10**] URINE INSTRUMENTATION: NEGATIVE FOR MALIGNANT CELLS.
Urothelial cells, squamous cells, histiocytes, neutrophils, and
red blood cells.
.
[**2111-2-16**] RENAL U/S: Persistent hydronephrosis, moderate on the
right and borderline mild on the left. Heterogeneous
echogenicity with several echogenic areas in the right kidney
likely pyelonephritis.
.
[**2111-3-9**] MR [**Name13 (STitle) 6452**]: No evidence of focal disc protrusion. Facet
disease at 4-5 and [**5-26**]. Diffusely abnormal marrow signal
attributable to fibrosis. No definite evidence of disc
infection or epidural abscess.
.
[**2111-4-6**] ABD (SUPINE AND ERECT): No evidence of free air or
obstruction.
.
[**2111-2-10**] 10:30AM PT-11.7 PTT-26.3 INR(PT)-1.0
[**2111-2-10**] 10:30AM WBC-13.5* RBC-4.43 HGB-12.4 HCT-38.4 MCV-87
MCH-28.1 MCHC-32.4 RDW-13.9
.
[**2111-2-10**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-2-10**] 10:30AM cTropnT-<0.01
[**2111-2-10**] 10:30AM GLUCOSE-1135* UREA N-59* CREAT-1.5*
SODIUM-131* POTASSIUM-6.0* CHLORIDE-89* TOTAL CO2-21* ANION
GAP-27*
[**2111-2-10**] 11:29AM GLUCOSE-748* K+-3.9
.
URINE CULTURE (Final [**2111-4-4**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
URINE CULTURE (Preliminary):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
FURTHER IDENTIFICATION TO FOLLOW.
Brief Hospital Course:
64F w/ untreated diabetes presents with altered mental status,
found to be in DKA.
.
## DKA: Glucose was found to be 1135 on admission. She was
started on insulin gtt in the ED and received IV hydration with
NS originally. She did have ketones in her urine and her bicarb
was 21. Her anion gap had closed upon transfer to ICU and her
glucose had corrected to 400s. Her insulin drip was continued
and her blood glucose continued to correct. With improved
control of her glucose, insulin gtt was stopped and she was
started on basal insulin and sliding scale with good control of
her BS. This occurred in the setting of a UTI/pyelonephritis
and longstanding uncontrolled diabetes. [**Last Name (un) **] followed
throughout hospital course. Eventually patient transferred to
NPH [**Hospital1 **] with outstanding control of blood sugars.
.
## Transaminitis: Suspect secondary to antibiotics.
Hepatititis A,B,C serologies negative. CK normal. CT showed a
normal liver. Bilirubin remained normal and patient had no ruq
pain. LFTs have since returned to the normal range.
.
## Diarrhea: Suspect viral gastroenteritis. C diff negative x
3, including toxin B negative. Symptom free x 5 days.
.
## Altered mental status: At baseline, son reports very
functional w/o delirium nor dementia. Certainly multifactorial
in the setting of gross hyperglycemia and metabolic insult,
hypernatremia, and infection. Her mental status began to clear
with correction of the above. With continued treatment of her
pyelonephritis, her mental status returned to baseline. Folate,
B12, TSH, and RPR unrevealing.
Psychiatry was consulted later in the hospital course, who was
concerned about an underlying dementia (see legal issues,
below).
.
#Legal Issues: as noted above, the patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Scientist. She was living in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist group home,
and during the hospital course she expressed some remorse that
her son had allowed her to come to the ED. She expressed doubts
about modern medicine and remained adamant that prayer and
healing would cure her diabetes. However, while in the hospital
she did not refuse medical treatments and was quite agreeable to
the medical team's recommendations for acute treatment.
Psychiatry was consulted to help to determine whether the
patient truly understood the basis of her disease and had the
capacity to make her own decisions. Further history obtained
from psychiatry was that the patient had several pscyh
hospitalizations in the past, and that her [**Doctor First Name **] Scientist
beliefs were not mainstream. Hence, legal gaurdianship was
pursued and is currently pending. Her son was not intereseted
in pursuing this role as he felt his mother still harbored
resentment to his views of [**Doctor First Name **] Scientists. Please note,
patient is not felt to be competent to refuse insulin treatment.
.
## UTI/pyelonephritis: In the ED, her UA was positive, but
urine culture revealed microflora. When foley was placed, 2L of
urine returned. CT abdomen/pelvis revealed bilateral
hydronephrosis and right pyelonephritis. She was started on
vancomycin and ceftriaxone. In the [**Hospital Unit Name 153**], vanco was discontinued
and antibiotics were changed to ciprofloxacin. However, while
on cipro she again began to spike fevers so her antibiotics were
changed to zosyn. She continued to have fevers and thus repeat
CT was done which showed a small perinephric fluid collection.
Given persistent fevers, this collection was drained to identify
the underlying organism to rule out resistance. CT done for
this procedure showed a resolving fluid collection. 2 cc of
bloody fluid was obtained but culture was negative. Patient
defervesced (following addition of azithro as well for ? RUL
infiltrate). ID consulted to aid with possible po regimen. She
completed a total of 3 weeks of antibiotics (eventually changed
to PO Augmentin/Cipro. She is now back on cipro for a recurrent
UTI (CITROBACTER FREUNDII COMPLEX and a 2nd gram negative rod).
Sensitivities of the 2nd gram negative rod are still pending at
the time of this dictation.
.
## Urinary retention: Given untreated diabetes, may reflect
neurogenic bladder w/ bilateral hydronephrosis resulting. A
foley was placed and maintained while mental status remained
depressed. Urology was consulted in house and do not recommend
stenting at this time, given hydronephrosis improving. She
subsequently failed multiple voiding trials. For a period of
time she received intermittent straight cath but is requiring
this at least 1-2 times per day to decompress her bladder.
Given current UTI, foley placed to aid in clearance of UTI and
to minimize risk of ascending infection. She will need
outpatient urology follow-up for urodynamic testing.
.
## ARF: Likely from dehydration and UTI/pyelo/obstruction. Her
creatinine normalized rapidly with IV hydration, relief of
obstruction, and antibiotic initiation.
.
## Anemia: Unknown baseline. She was without evidence of active
bleeding and hct drop was likely from aggressive fluid
resuscitation. Hct remained stable following initial
resuscitation. Anemia stuides c/w Anemia of Chronic Disease.
.
##Toe Drop: the patient developed Left Toe drop while in house.
Neuro consulted, who felt that likely etiology was peripheral
neuropathy. MRI L spine negative. Improved sponatenously
during hosptialization.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
2. insulin 70/30
9 units SQ qam, 10 units SQ qpm
3. regular insulin sliding scale
1 injection sq qid
Please follow insulin sliding scale provided
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
primary:
pyelonephritis complicated by perinephric abscess
diabetic ketoacidosis
secondary:
urinary tract infection
viral gastroenteritis
urinary retention - foley in place
anemia of chronic disease
Discharge Condition:
good: afebrile, tolerating po, no diarrhea x 5 days
Discharge Instructions:
Please monitor for temperature > 101, lethargy, or other
concerning symptoms.
Followup Instructions:
1. Please follow-up with the [**Last Name (un) **] diabetes doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**],
[**2111-4-21**] at 9:00 AM (This will be a 2 hour appointment).
Phone: [**Telephone/Fax (1) 2384**]
2. Please follow-up with your new primary care doctor, Dr.
[**First Name (STitle) **] [**Name (STitle) **] on Wednesday, [**2111-4-29**] at 1:30 PM.
Phone: [**Telephone/Fax (1) 250**]
3. Please follow-up with the urologist, Dr. [**Last Name (STitle) **], on Monday,
[**2111-4-20**] at 2:00 PM.
Phone: ([**Telephone/Fax (1) 772**]
|
[
"590.10",
"355.3",
"285.29",
"596.54",
"788.20",
"590.2",
"V58.67",
"357.2",
"276.51",
"790.4",
"008.8",
"276.0",
"250.62",
"584.9",
"369.4",
"V62.5",
"591",
"293.0",
"250.12",
"301.20",
"112.1",
"041.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13006, 13084
|
7191, 8403
|
337, 343
|
13328, 13382
|
2642, 6418
|
13508, 14068
|
2027, 2050
|
12746, 12983
|
13105, 13307
|
12717, 12723
|
13406, 13485
|
2065, 2623
|
276, 299
|
6453, 7168
|
371, 1798
|
8419, 12691
|
1820, 1880
|
1896, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,615
| 176,516
|
33485
|
Discharge summary
|
report
|
Admission Date: [**2179-2-5**] Discharge Date: [**2179-2-9**]
Date of Birth: [**2144-3-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2179-2-5**] - Mitral Valve Repair (28mm CG Annuloplasty Ring)
History of Present Illness:
34 year old woman with Marfan's syndrome and known severe mitral
valve prolapse
with regurgitation, who was planned for a MV repair in [**Month (only) 547**] of
[**2176**] with Dr. [**Last Name (STitle) **] but was lost to follow-up. She remains
symptomatic and is now prepared to undergo mitral valve
repair/replacement surgery.
Past Medical History:
Marfans Syndrome
MVP with severe mitral regurgitation
Gastric reflux disease
History of gestational diabetes mellitus
Hypertension with pregnancy
Obesity
c-section x 2
laser eye surgery
cataract surgery
foot surgery (shorten bone length)
Social History:
Lives with: husband and 2 children
Occupation: homemaker
Tobacco: never
ETOH: denies
Rec drug use: none
Family History:
Mother with coronary artery disease in her 20s and Marfan's
Physical Exam:
Vitals: BP: 125/82 HR: 71 RR: 14 O2 sat: 97%-RA
Height: 5'9" Weight: 260lbs
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6SEM
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2179-2-9**] 05:20AM BLOOD WBC-12.3* RBC-3.63* Hgb-10.0* Hct-31.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-13.6 Plt Ct-226
[**2179-2-5**] 01:46PM BLOOD WBC-25.5*# RBC-3.83* Hgb-10.6* Hct-32.6*
MCV-85 MCH-27.6 MCHC-32.4 RDW-13.5 Plt Ct-163
[**2179-2-9**] 05:20AM BLOOD Plt Ct-226
[**2179-2-5**] 12:52PM BLOOD PT-23.0* PTT-44.5* INR(PT)-2.2*
[**2179-2-5**] 12:52PM BLOOD Plt Ct-116*
[**2179-2-5**] 12:52PM BLOOD Fibrino-97.0*
[**2179-2-9**] 05:20AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-141
K-4.0 Cl-101 HCO3-34* AnGap-10
[**2179-2-5**] 01:46PM BLOOD UreaN-10 Creat-0.6 Cl-114* HCO3-23
[**2179-2-9**] 05:20AM BLOOD ALT-15 AST-21 LD(LDH)-290* AlkPhos-108*
Amylase-41 TotBili-0.4
[**2179-2-9**] 05:20AM BLOOD Lipase-28
[**2179-2-9**] 05:20AM BLOOD Albumin-3.1* Mg-2.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **]-[**Doctor Last Name **], [**Known firstname 77648**] [**Hospital1 18**] [**Numeric Identifier 77649**]
(Complete) Done [**2179-2-5**] at 11:47:53 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2144-3-11**]
Age (years): 34 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Mitral valve disease. Mitral valve prolapse. Murmur.
Shortness of breath.
ICD-9 Codes: 786.05, 424.0
Test Information
Date/Time: [**2179-2-5**] at 11:47 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW33-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 60% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good
(>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Normal ascending aorta diameter. Normal aortic
arch diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Elongated
mitral valve leaflets. Moderate/severe MVP. Normal mitral valve
supporting structures. No MS. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are elongated. There is moderate/severe mitral
valve prolapse with severe prolapse of P2.. Moderate to severe
(3+) mitral regurgitation is seen. The mitral annulus is dilated
and measures 3.7 cm in the 4-chamber and 3.9 cm in the
commisural view.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. Sinus tachycardia.
Well-seated annuloplasty ring in the mitral position with no MR.
Mild MS with a gradient of 9 with a cardiac output of 6 L/min.
Preserved biventricular systolic function. Aortic contour is
normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2179-2-5**] 13:
Brief Hospital Course:
Admitted same day surgery and underwent mitral valve repair.
Please see operative note for details. Postoperatively she was
taken to the intensive care unit for monitoring. Over the next
several hours, she awoke neurologically intact and was
extubated. On postoperative day one she was transferred to the
step down unit for further recovery. She was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. She continued to progress and was ready for discharge
home with services on post operative day four.
Medications on Admission:
None
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
MVP with severe mitral regurgitation s/p MV repair
Marfans Syndrome
Gastric esophageal reflux disease
History of gestational diabetes mellitus
Hypertension with pregnancy
Obesity
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Dr [**Last Name (STitle) **] at [**Hospital1 **] heart center Thrusday [**2-25**] at 9am
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 27772**] in [**12-19**] weeks [**Telephone/Fax (1) 12295**]
Cardiologist Dr. [**Last Name (STitle) 5874**] in [**12-19**] weeks [**Telephone/Fax (1) 5879**]
Completed by:[**2179-2-9**]
|
[
"V45.89",
"759.82",
"V45.69",
"530.81",
"746.89",
"278.00",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12",
"35.33",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9063, 9122
|
7356, 7961
|
339, 406
|
9345, 9441
|
1878, 5515
|
10065, 10417
|
1165, 1227
|
8016, 9040
|
9143, 9324
|
7987, 7993
|
9465, 10042
|
5564, 7333
|
1242, 1859
|
280, 301
|
434, 767
|
789, 1028
|
1044, 1149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,305
| 182,143
|
5510
|
Discharge summary
|
report
|
Admission Date: [**2134-10-26**] Discharge Date: [**2134-11-7**]
Date of Birth: [**2093-5-31**] Sex: M
Service:
CHIEF COMPLAINT: Bilateral hip and calf claudication.
HISTORY OF PRESENT ILLNESS: This is a 41 year old diabetic
with multiple risk factors and known coronary artery disease
referred for peripheral vascular angiography due to severe
bilateral leg claudication. He complains that his calf and
thighs "ache 24 hours a day" over the past six months. He
has had progression in his symptoms. He describes bilateral
severe cramping behind both knees extending down to the feet.
This occurred after walking only 20 feet. The patient does
not admit to rest pain. The patient underwent PVRs which
demonstrated distal superficial femoral artery, proximal
popliteal disease with bilateral tibial disease. The patient
is admitted for elective diagnostic angiography.
PAST MEDICAL HISTORY: Hypertension , hypercholesterolemia,
diabetes, hypothyroidism, left shoulder bursitis and
peripheral vascular disease.
PAST SURGICAL HISTORY: Coronary artery bypass graft in [**2124**],
laser surgery on both eyes.
ALLERGIES: Vancomycin. Negative to shellfish and dye.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg daily
2. Lipitor 80 mg daily
3. Tricor 67 mg daily
4. Toprol XL 250 mg daily
5. Plavix 75 mg daily
6. Levoxyl .15 mg daily
7. Zestril 40 mg daily
8. Norvasc 20 mg daily
9. Prevacid 30 mg daily
10. Imdur 60 mg q.d.
11. Lente insulin 17 units q AM and 8 units at supper
12. Regular insulin sliding scale before meals
13. Mirapex .125 mg at h.s.
SOCIAL HISTORY: He is divorced, former smoker, 1.5 packs per
day times 28 years.
LABORATORY DATA: Complete blood count revealed white count
8.2, hematocrit 38.7, platelets 227. BUN 49, creatinine 2.1,
potassium 5.0, INR normal. Electrocardiogram showed a sinus
rhythm with a normal axis with inferolateral ischemic
appearing ST segment depressions.
PHYSICAL EXAMINATION: The patient is a 41 year old male in
no acute distress. His vital signs are stable. His head,
eyes, ears, nose and throat examination is unremarkable
except for a right carotid bruit probably secondary to murmur
radiation. There is no jugulovenous distension. Heart is
regular rate and rhythm with a systolic murmur. Lungs were
clear to auscultation. Abdomen is soft, nontender,
nondistended. There are no bruits. Bowel sounds are
present. Pulse examination as follows: Femoral on the right
1+ with a bruit, left femoral 1+ with a bruit, dorsalis pedis
and posterior tibial are dopplerable.
HOSPITAL COURSE: The patient was admitted to the hospital
after undergoing an arteriogram which demonstrated mild
infrarenal abdominal aortic disease. The renals were
bilaterally single with right stenosis of 60% and left
stenosis of 40%. Right lower extremity showed mild ostial
disease in the right common iliac of 40 to 50%. The right
superficial femoral artery had moderate segmental lesions of
50%. The popliteal was patent. Anterior tibial had mild
diffuse disease to the foot. The TPT with moderate diffuse
disease. The posterior tibial was occluded and reconstituted
from peroneal collaterals. The left lower extremity showed
iliac artery was patent but the left common femoral was
normal. The proximal left superficial femoral artery was 70%
stenosed the popliteal was patent, anterior tibial was
proximally occluded, the posterior tibial and peroneal were
patent to the foot. The proximal vessels had moderate severe
diffuse disease. After these findings Dr. [**Last Name (STitle) 1476**] was
consulted. The patient was cleared by his cardiologist and
did serial CKs and electrocardiograms postoperatively.
Endocrinology was consulted perioperatively for diabetic
management. The patient underwent on [**10-28**], a left
femoral distal popliteal tibia with in situ saphenous vein
and venovenostomy. He tolerated the procedure well and was
transferred to the Post Anesthesia Care Unit with a
dopplerable posterior tibial and faint dopplerable dorsalis
pedis. He was transferred to the Surgical Intensive Care
Unit for continued monitored care. He required an additional
unit of packed red blood cells, infusion for his hematocrit
of 26.5. He will receive 6 units of packed red blood cells
intraoperatively. The patient required Neo for pressor
support. Serial CKs, MBs and troponins were drawn. His
initial troponin level was less than .3, the second level was
9.3 with a peak CK of 261 and MB of 6. The patient's diet
was advanced as tolerated and he was transferred to the
Vascular Intensive Care Unit for continued monitoring and
care. His creatinine bumped to 3.8 with oliguria. He was
transfused for a hematocrit of 30. Neo was weaned for
maintaining blood pressure greater than 160. Cardiology was
requested to evaluate the patient with recommendations during
the perioperative management. Recommendations were to
reinstitute his nitrates, Norvasc and beta blockers. Most of
this increased creatinine was probably secondary to his
diload. The patient was finally transferred to the floor on
postoperative day #2. On postoperative day #3 the patient
continued to show improvement showing a temperature maximum
of 101.5. Hematocrit was 27.1. BUN was 27 and creatinine
2.4, down from a peak of 4.0. The cardiac medications were
continued and Lopressor was increased and he required
diuresis. The patient was pancultured of blood and urine.
He was continued on Levofloxacin and Flagyl. The patient
went into pulmonary edema and was re-intubated and
transferred back to the Surgical Intensive Care Unit on
[**11-1**]. Tube feeds were begun on postoperative day #4
and the rate was advanced as the patient tolerated. He
required two units of packed cells on postoperative day #5
for hematocrit of 24. Cardiology continued to follow the
patient during this period of time. Cultures on urine were
negative and sputum were negative. Chest x-ray showed some
lateral infiltrates. The patient's platelets continued to
remain low even post transfusion, platelets intraoperatively
and HIT was sent which was negative, so impression was that
it was related to a drug reaction. Blood cultures remained
negative. Central venous pressure tip catheter remained
negative but sputum did grow out gram positive cocci. The
patient was continued on his Levofloxacin. Tricor was
discontinued as considered a possible reason for the
thrombocytopenia. Post transfusion hematocrit remained
stable at 30.3. BUN and creatinine continued to show a
downward trend of 22 and 1.7. Oxygen was finally weaned off
on [**10-26**], which was postoperative day #7 and the patient
was extubated. The patient again was transferred to the
Vascular Intensive Care Unit. The tube feels were
discontinued on [**11-5**] and he began p.o. intakes. His
insulin regime was adjusted as necessary. The patient
continued to see improvement and he was discharged from the
Vascular Intensive Care Unit on postoperative day #9 in
stable condition. Wounds were clean, dry and intact. He had
dopplerable distal pulses. The patient was discharged on one
five day course of Levofloxacin. He should follow up with
Dr. [**Last Name (STitle) **] regarding anticoagulation. He should follow up
with Dr. [**Last Name (STitle) 1476**] in two weeks.
DISCHARGE MEDICATIONS:
1. Lente Insulin 20 units q. AM and 16 units at h.s. with
sliding scales at breakfast, lunch, dinner and h.s. as
follows, glucose less than 70 no insulin, 71-100 1 unit,
101-150 2 units, 151-200 4 units, 201-250 6 units, 251-300 8
units, 301-350 10 units, greater than 351 call. Dinner
sliding scale is the same as breakfast. Lunch sliding scale,
glucose less than 150 no insulin, 151-200 2 units, 201-250 3
units, 251-300 4 units, 301-350 5 units, greater than 351 6
units, h.s. insulin glucose less than 200, no insulin,
201-250 2 units, 251-300 4 units, 301-350 6 units, 351 or
greater 8 units.
2. Metoprolol 50 mg b.i.d.
3. Imdur 60 mg q. day
4. Levaquin 500 mg q. day times five days
5. Aspirin 81 mg q. day
6. Levoxyl 0.5 mg q.d.
7. Lisinopril 40 mg q.d.
DISCHARGE DIAGNOSIS:
1. Ischemic left foot secondary to artery occlusion, status
post femoral distal posterior tibial bypass with in situ
saphenous vein and venovenotomy
2. Hypertension, controlled
3. Congestive heart failure
4. Compensated blood loss anemia, corrected
5. Pneumonia, treated
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: 11/17/[**2033**] 21:08
T: [**2134-11-7**] 21:07
JOB#: [**Job Number 22247**]
|
[
"440.21",
"997.2",
"285.1",
"428.0",
"997.3",
"486",
"444.22",
"250.01",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.71",
"39.50",
"39.29",
"88.48",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
7350, 8121
|
8142, 8701
|
1220, 1591
|
2589, 7327
|
1064, 1194
|
1969, 2571
|
150, 188
|
217, 897
|
920, 1040
|
1608, 1946
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,029
| 165,125
|
1807
|
Discharge summary
|
report
|
Admission Date: [**2156-3-14**] Discharge Date: [**2156-3-17**]
Date of Birth: [**2108-12-31**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
Melena x 1 day, fevers and chills x 1 month
Major Surgical or Invasive Procedure:
Tracheal intubation with mechanical ventilation
Endoscopy with lidocaine injection and electrocautery
Blood product transfusions
History of Present Illness:
47M with gastric bypass in [**2151**] (s/p 150# wt loss) and recent
complaints of fever and cough x one month presented to OSH with
cough, fever and found to have melena. Pt states he started
developing RUQ and RLQ pain 2 days ago. He had a normal bowel
movement this am but his next bowel movement was thick and tarry
with visible blood associated with some diaphoresis. Pt then
went to OSH ED where hct was noted to be 39. Pt also had a fever
and was given Unasyn. Pt remained HD stable but given the
melena, he was transferred to [**Hospital1 18**]. On arrival to [**Hospital1 **], hct was
31 with an SBP in the 90s. He received one liter of fluids and
SBP improved to 140s. NG placed with 20cc of bright red blood
and coffee grounds immediately on return. Lavage unsuccessful.
Due to a fever to 102.8, pt was given one dose of Vancomycin. GI
and surgery were called. In [**Name (NI) **], pt received 4L of NS, 4U of
PRBCs and 40mg of IV protonix.
.
Per family, pt is very noncompliant with diet and takes no
medications. He recently saw his PCP complaining of 21 day hx of
nonproductive cough, nasal congestion, sinus pressure, ear
fullness, coryza, sore throat, and malaise. Pt reports that he
has measured his temp at home at 102. He also notes worsening
dyspnea on exertion. A CXR was normal and he was started on a
Z-pack.
.
On arrival to MICU, pt was HD stable but having continuous red
stool output. He was emergently scoped by GI but visibility was
poor [**3-18**] the large amount of bleeding. A pumping vessel was seen
and injected with 10cc of epi but the scope was too small for
adequate suctioning. The scope was then terminated after the pt
vomited a large amount of blood. His BP at the time was noted to
be hovering in the 80s-90s so an EGD with a larger scope was
deferred. Pt received 9 more units of PRBCs, 2U of FFP along
with 1.5 more liters of NS. An a-line was placed and BP found to
be normal with SBP in the 150s. A femoral line cordis and right
IJ cordis were both attemped and failed due to inability to find
the vessel. Due to pt's stable BP and need for further scope,
the line was deferred. The decision was then made to intubate
for airway protection given the pt's emesis and high risk for
aspiration. He was intubated by anesthesia without difficulty.
The scope was then reattempted. This time, a large clot was seen
at the gastro-enteric junction. The fold was injected with epi
several times and then cauterized. The bleeding appeared to
stop.
.
Mr. [**Known lastname 10125**] is currently asymptomatic, alert and oriented. He has
been extubated and is sipping ice water. He denies abd pain,
nausea and current cough/SOB. He has a rectal tube in for liquid
melena, as well as a Foley. ROS notable for occassional night
sweats (old per review of OMR), cough, SOB and fever x 1 month.
Past Medical History:
* morbid obesity s/p gastric bypass in [**2151**]
* depression
* s/p splenectomy
* s/p cholecystectomy
Social History:
Lives at home with wife and 2 children, occasional etoh, no
tobacco, chef at hotel
Family History:
Noncontributory
Physical Exam:
Exam (on arrival to MICU): temp 98.9, BP 132/60, HR 104, R 12,
O2 100% on 2L
Gen: coughing, gagging, appears anxious
HEENT: pale, EOMI, MMM
Neck: obese, no JVD
CV: RRR, no g/m/r
Chest: clear anteriorly
Abd: obese, +BS, soft, mildly tenderness in RUQ, no rebound
Ext: warm, no edema, 2+ DP
Pertinent Results:
Admission labs:
CBC: WBC-13.4* RBC-3.55*# Hgb-11.1*# Hct-31.0*# MCV-87# MCH-31.2
MCHC-35.7*# RDW-14.2 Plt Ct-239
Diff: Neuts-44* Bands-0 Lymphs-39 Monos-3 Eos-0 Baso-0 Atyps-14*
Metas-0 Myelos-0
Coags: PT-14.0* PTT-25.6 INR(PT)-1.2*
Fibrino-125*
Chem 10: Glucose-123* UreaN-20 Creat-0.8 Na-140 K-4.9 Cl-108
HCO3-22
Calcium-7.6* Phos-3.1 Mg-1.7
LFTs: ALT-277* AST-294* AlkPhos-113 Amylase-26 TotBili-0.3
Lactate-1.7
ABG: Type-ART pO2-283* pCO2-40 pH-7.37 calHCO3-24 Base XS--1
Discharge labs:
CBC: WBC-12.1* RBC-4.10* Hgb-12.6* Hct-35.5* MCV-87 MCH-30.7
MCHC-35.4* RDW-15.6* Plt Ct-178
Coags: PT-12.6 PTT-26.7 INR(PT)-1.1
Fibrino-159
Chem10: Glucose-96 UreaN-7 Creat-0.7 Na-137 K-3.5 Cl-104 HCO3-25
Calcium-7.6* Phos-3.2 Mg-1.6
LFTs: ALT-275* AST-282* AlkPhos-101 TotBili-0.4 Albumin-2.7*
Hepatitis labs:
HAV Ab-POSITIVE HBsAg-NEGATIVE HBsAb-POSITIVE HCV Ab-NEGATIVE
CXR: Lungs are low in volume but clear. The heart is normal
size. There is no pleural effusion or evidence of central
adenopathy. There are large degenerative osteophytes in the mid
and lower thoracic spine.
LLE u/s: 1. There is no evidence of DVT.
2. Thrombophlebitis of superficial medial vein in the calf at
the site of pain.
Liver u/s: 1. The patient is S/P cholecystectomy and a
splenectomy.
2. IVC, hepatic and portal veins patent with normal directional
flow.
3. No focal lesions are seen in the liver.
4. Coarse echogenicity of the liver
EGD:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
Conscious sedation anesthesia. The patient was placed in the
left lateral decubitus position and an endoscope was introduced
through the mouth and advanced under direct visualization until
the second part of the duodenum was reached. Careful
visualization of the upper GI tract was performed. The procedure
was not difficult. The patient tolerated the procedure well.
There were no complications.
Findings: Esophagus: Normal esophagus.
Stomach: Contents: Red blood was seen in the stomach pouch.
There was a large clot at the gastro-enteric anastomosis.
Attempts were made to dislodge clot, revealing a large area of
active bleeding just behind the fold at the gastroenteric
anastomosis. A vissible vessel was not seen. These findings are
consistent with an ulcer at the gasto-enteric anastomosis. 17
cc.Epinephrine 1/[**Numeric Identifier 961**] were injected in two separate sessions,
hemostasis with success. [**Hospital1 **]-CAP Electrocautery was applied to
clotted area for hemostasis successfully.
Duodenum: Contents: Red blood was seen in the duodenum (see
above).
Impression: Active bleeding in the stomach pouch at the
gastro-enteric anastomosis. Blood in the duodenum
Recommendations: IV access; Please page GI immediately if
re-bleeds. Serial hematocrits. Transfusion support. Protonix
drip
Brief Hospital Course:
Assessment: 47yo man with past medical history significant for
morbid obesity status post gastric bypass in [**2151**] who presented
with melena found to be secondary to bleeding gastric ulcer.
Hospital course is reviewed below by problem:
1. Upper GI bleed - The source appeared to be an ulcer at the
gastroenteric junction. He was treated with transfusions as
needed, FFP, and IVF, as well as IV protonix and sucralfate. His
hematocrit stabilized. He was discharged home on sucralfate and
a PPI.
2. Transaminitis: The differential diagnosis includes NASH,
hepatitis, med-related, alcohol, less likely right heart
failure. Alk phos and bili were normal making a biliary source
less likely. At the time of discharge, most hepatitis panel labs
were pending. A RUQ ultrasound was unremarkable. His hepatitis A
virus recently returned positive, which may mean he had been
exposed previously vs having active virus. This will be followed
up as an outpatient. On discharge, his LFTs were improving.
3. Fever: Cough, rhinorrhea, sore throat all indicate an upper
respiratory viral infection. However, fever to 102-103 is more
concerning, though a bacterial process lasting 3 weeks is very
unlikely. CXR and urinalysis were normal. The patient was
initially treated with antibiotics, but these were stopped when
no source was identified. Concern for a malignancy, such as
lymphoma, which could cause both fevers and ulcers. He will
follow up with a CT scan in the future once the ulcer has better
healed.
4. Leg pain: He had left lower extremity pain, was found to have
no DVT but thrombophlebitis of the calf that improved with warm
packs.
5. Code status: full
Medications on Admission:
Azithromycin x 4 days
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper gastrointestinal bleed
2. Fevers of unknown origin
3. Transaminitis
4. Superficial thrombophlebitis
Discharge Condition:
Stable; his hematocrit is rising and is currently 35, and his
liver function tests are improving. He continues to have fevers
on the day of discharge but is hemodynamically stable.
Discharge Instructions:
Please take all medications as prescribed. We have started you
on new medications - omeprazole and sucralfate. These
medications act to heal the ulcer in your stomach. It is
critical that you take them as directed, and do not stop them
until directed by your doctors.
Follow up with the appointments listed below.
Call your doctor or go to the emergency room if you have any
bright red blood per rectum, worsening black stools, abdominal
pain, lightheadedness, dizziness, fatigue, chest pain,
palpitations, difficulty breathing, or any other concerning
symptoms.
You can use heat packs (as directed on the packs) for your left
leg pain. If you experience any worsening of the pain, redness
or swelling of the leg or the site of the vein, pus near the
vein, or spreading hardness of the vein up into your thigh, call
your doctor. You should discuss having another ultrasound of
your leg in the next week or two to ensure that it has not grown
in size.
Followup Instructions:
Please attend the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-3-19**] 11:40
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] (GI) Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2156-4-7**] 3:30 - [**Location (un) 436**], [**Hospital Ward Name 23**] building, medical
specialties.
Call [**Telephone/Fax (1) 10126**] to make an appointment for a repeat EGD (upper
endoscopy) in 6 weeks.
|
[
"V45.79",
"285.1",
"790.6",
"790.4",
"V45.3",
"518.81",
"465.9",
"534.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"43.41",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8869, 8875
|
6874, 8536
|
313, 444
|
9028, 9211
|
3878, 3878
|
10213, 10801
|
3537, 3554
|
8608, 8846
|
8896, 9007
|
8562, 8585
|
9235, 10190
|
4371, 6851
|
3569, 3859
|
230, 275
|
472, 3294
|
3894, 4355
|
3316, 3421
|
3437, 3521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,693
| 134,587
|
7853
|
Discharge summary
|
report
|
Admission Date: [**2201-5-13**] Discharge Date: [**2201-5-25**]
Service: MEDICINE
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Source: History obtained through interpretor and patient's
daughter.
HPI: 87 yo Cantonese speaking F, NH resident with PMHx of AFib
with LV mural thrombus on coumadin admitted with BRBPR. Pt was
at baseline when was found to have BRB in diaper in the
afternoon on the day of admission. The bleeding was first noted
at 16:30 and the patient soaked 4 diapers in the course of 1.5
hours.
In triage in the ED 99.0 79 122/71 16 98% RA. Throughout ED
time, patient was HD stable, HR 104-110 in a. fib, BP
119-140/49-88. Seen to have clots passing from rectum. Tried NG
lavage in ED but not successful due to patient non-cooperation.
Hct was stable at baseline of 32, INR 3.7. Patient received 5mg
SC vitamin K and 1 unit FFP as well as pantoprazole 40mg IV.
Past Medical History:
1. Chronic renal insuffeciency- Past creatinine range from 1.6
to 2.2.
2. CHF- Last echo was 08/[**2193**]. At that time, LVEF of 55 to 60%.
Moderate aortic regurg. Moderate pulmonary arterial systolic
hypertension.
3. Depression
4. Dementia
5. HTN
6. S/P CVA in [**12/2197**] with resultant left sided weakness
7. LV thrombus anticoagulated with coumadin
8. S/P left hip fracture in [**5-/2198**] following a fall
9. Atrial fib- Anticoagulated on coumadin.
Social History:
lives at [**Location **], Cantonese speaking, family involved
Family History:
NC
Physical Exam:
97.9 100 129/67 20 98% RA
Gen: Alert. Following commands.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: Irregularly irregular. No M/R/G.
Pulm: CTAB. No wheezes, rales, or rhonchi.
Abd: Soft, NT, ND. Positive bowel sounds.
Rectal: No active bleeding. Fresh blood. Large clot on the bed.
No lesions.
Ext: No lower extremity edema.
Pertinent Results:
[**2201-5-20**] 06:40AM BLOOD TSH-0.65
[**2201-5-20**] 06:40AM BLOOD VitB12-[**2107**]* Folate-9.9
[**2201-5-13**] 07:00PM BLOOD ALT-20 AST-18 AlkPhos-115 TotBili-0.6
[**2201-5-13**] 07:00PM BLOOD Glucose-107* UreaN-39* Creat-1.6* Na-138
K-5.0 Cl-104 HCO3-25 AnGap-14
[**2201-5-25**] 06:10AM BLOOD UreaN-11 Creat-1.2*
[**2201-5-13**] 07:00PM BLOOD PT-34.0* PTT-40.0* INR(PT)-3.7*
[**2201-5-18**] 09:00PM BLOOD PT-16.2* PTT-150* INR(PT)-1.5*
[**2201-5-25**] 06:10AM BLOOD PT-32.6* PTT-46.9* INR(PT)-3.5*
[**2201-5-13**] 07:00PM BLOOD WBC-14.7* RBC-3.55* Hgb-11.1* Hct-32.6*
MCV-92 MCH-31.2 MCHC-33.9 RDW-14.1 Plt Ct-328
[**2201-5-14**] 12:18AM BLOOD WBC-12.4* RBC-3.01* Hgb-9.2* Hct-28.5*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.7 Plt Ct-307
[**2201-5-17**] 09:30PM BLOOD Hct-27.5*
[**2201-5-25**] 06:10AM BLOOD WBC-5.9 RBC-3.08* Hgb-9.5* Hct-29.5*
MCV-96 MCH-30.8 MCHC-32.1 RDW-16.6* Plt Ct-348
[**2201-5-22**] 11:48PM URINE RBC-14* WBC->1000* Bacteri-MOD Yeast-NONE
Epi-<1
[**2201-5-22**] 11:48PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
.
Urine Cx:
**FINAL REPORT [**2201-5-23**]**
URINE CULTURE (Final [**2201-5-22**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
OXACILLIN Sensitivity testing performed by Sensititre.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
2ND MORPHOLOGY.
OXACILLIN Sensitivity testing performed by Sensititre.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
NITROFURANTOIN-------- 256 R 128 R
OXACILLIN------------- 1 R 1 R
PENICILLIN------------ 0.25 R 0.25 R
VANCOMYCIN------------ <=1 S <=1 S
.
EF >60%
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is no aortic valve stenosis. Mild to moderate
([**12-23**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
Colonoscopy
Multiple diverticula with mixed openings were seen in the
ascending colon, transverse colon, descending colon and sigmoid
colon. Diverticulosis appeared to be of moderate severity. There
were two small, ulcerated diverticula in the sigmoid colon and
one large diverticulum with a large clot over it. The clot could
not be flushed off, but was able to be partially dislodged.
There was active bleeding from the diverticulum after the clot
was removed. 4 injections of [**12-23**] cc. of isotonic saline solution
injections were applied for hemostasis with some success and
decreased bleeding. Two endoclips were applied to the large,
bleeding diverticulum for hemostasis with success. This
diverticulum was located at 32 cm and the other two diverticula
with ulceration were located at 35 cm.
.
Impression: External hemorrhoids
Blood in the sigmoid colon, descending colon, splenic flexure
and rectum
Diverticulosis of the ascending colon, transverse colon,
descending colon and sigmoid colon (injection, ligation)
Stool in the whole colon
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
# BRBPR: Hematochezia due to bleeding diverticuli, s/p injection
and ligation during colonoscopy on [**2201-5-15**]. Did not require
blood transfusion. Challenged with heparin gtt in house and
hematocrit remained stable. Thus, coumadin restarted. Patient
completed 10 days cipro/flagyl for presumed underlying
diverticulitis.
.
# Coagulase negative staph UTI: Dirty urinalysis. Urine culture
grew oxacillin-resistant coagulase negative staph. PICC placed
to complete 7 day course of vancomycin (given CrCl, will only
need doses on [**5-26**] and [**5-28**]). Blood cultures remain no growth to
date.
.
# Atrial fibrillation: On coumadin and beta blocker. Would
restart coumadin once INR 2-2.5 (was rising on antibiotics).
.
# CRI: At baseline creatinine. NO issues.
.
# Dementia: Stable. NO issues.
.
# HTN: Controlled w/ BB alone (Toprol XL 25). Have not yet
restarted nitrate/norvasc. Can be restarted prn at long-term
care facility.
Medications on Admission:
Senna 8.6mg QHS
Mirtazapine 30mg QHS
Trazodone 50mg QHS
Metoprolol 50mg QAM, 25mg QPM
Warfarin 1 vs. 1.5mg QHS
Norvasc 10mg QD
Omeprazole 20mg QD
Isosorbide Mononitrate 30mg QD
Docusate liquid 150mg/15ml given 10ml [**Hospital1 **]
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Gram
Intravenous Q48H (every 48 hours) for 4 days: Please 1 gm of
Vancomycin on Tuesday [**5-26**] and Thursday [**5-28**] then stop.
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Resume previous dose; restart when INR <2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center
Discharge Diagnosis:
Diverticular Bleed s/p Clipping
Diverticulitis
Coagulase Negative Staph UTI
Secondary Diagnoses
Atrial Fibrillation
Chronic Kidney Disease
Dementia
Depression
HTN
h/o LV thrombus
h/o CVA
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) 1266**] should you develop any fevers,
chills, sweats, blood in your stools, black stools, nausea,
vomiting, or any other complaints.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1266**] within 1-2 weeks.
|
[
"403.91",
"585.9",
"438.89",
"427.31",
"599.0",
"428.0",
"455.3",
"562.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
8667, 8727
|
6608, 7547
|
248, 262
|
8959, 8968
|
2006, 6585
|
9191, 9268
|
1624, 1628
|
7830, 8644
|
8748, 8938
|
7573, 7807
|
8992, 9168
|
1643, 1987
|
181, 210
|
290, 1046
|
1068, 1528
|
1544, 1608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,140
| 179,002
|
16465
|
Discharge summary
|
report
|
Admission Date: [**2157-12-2**] Discharge Date: [**2158-1-18**]
Date of Birth: [**2101-9-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Altered mental status, fatigue
Major Surgical or Invasive Procedure:
[**2157-12-12**] liver [**Month/Day/Year **]
[**2157-12-14**] roux en y hepaticojejunostomy
[**2157-12-18**] ex lap
colonoscopy
History of Present Illness:
56yo man with hepatitis C/ETOH-induced liver cirrhosis with
history of decompensation with recurrent ascites and recurrent
encephalopathy s/p TIPS in [**8-/2156**], who is transferred from [**Location (un) 21541**] Hospital after presenting there with weakness. Per report,
pt called EMS with weakness x 4days with fever and chills. He
reports poor po intake/anorexia during this time. He denies any
dietary indescretion, but he reports increasing abd girth and
leg swelling. He did report a few missed doses of lactulose
prior to weakness.
.
He was found by EMS in pool of stool, BS of 42, given an amp of
D50 and brought to [**Hospital3 **] hospital. He was found to be
confused, but reorientable, incontinent of urine, 3+edema. On
labs he had k of 6.2 and was given kaexalate, insulin/dextrose,
calcium gluconate and repeat of 4.9 on transfer. He had abd CT
and u/s of his abdomen which showed ascites, TIPS occlusion. A
paracentesis was done. He had bld cxs that grew out GNRs. Pt
received 8 vials of albumin for hepatorenal ppx, 1 dose of
ceftriaxone and 1 dose of cefotaxime. He was transferred to
[**Hospital1 18**].
.
Initial ROS was (+)increasing protuberance of abd with abd pain,
He reports that he has gained weight (ideal wt of 149-152),
currently 70kgs. +SOB with increasing abd distension. + maroon
stools.
(-) denies significant confusion, n/v/d/dysuria/cp or any other
symptoms.
Past Medical History:
- Cirrhosis, s/p TIPS placement [**8-15**]
- HepC, dx [**2129**]: Nonresponder to interferon and ribavirin after
six months of therapy in [**2149**]. From [**Month (only) 116**] to [**2151-12-10**], the
patient was treated with pegylated interferon and ribavirin for
a period of six months. For unclear reasons, this treatment was
discontinued. The patient was subsequently enrolled in the
colchicine arm of the COPILOT trial in the past. [**10-15**] viral load
is 441,000 IU/mL.
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression.
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- s/p Umbilical hernia repair
.
Social History:
Lives on [**Hospital3 **] in a garage apartment which he rents from a
family with whom he has a good relationship. Also has
supportive ex-wife and daughter. [**Name (NI) **] works in a recording studio
and plays the guitar in a band. He has a history of alcohol
abuse (last drink [**2136-10-9**], drank heavily for 12 years). Also
h/o IV drug use many years ago. Pt smoked occasionally for 30
years, quit a year ago. Denies any recent ETOH ingestion.
Family History:
non-contributory
Physical Exam:
On arrival to the MICU
VS 100.6, 126, 185/90, 27 and 100% on NRB, then 3L NC
GENERAL - chronically ill appearing man in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, slightly icteric sclera, MMM, OP
clear
NECK - supple, no thyromegaly, no JVD
LUNGS - breath sounds in upper lobes, decreased breathsounds at
bases, no r/r/w, no accessory muscle use
HEART - slightly tachy, RR, with systolic murmur, nl S1-S2
ABDOMEN - tense, tender to palpation, shifting dullness,
+splenomegaly, no rebound/guarding, +umbilical hernia - easily
compressed
EXTREMITIES - WWP, 1+ edema on left, 3+ edema on right 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox2, CNs II-XII grossly
Pertinent Results:
On Admission: [**2157-12-2**]
WBC-12.9* RBC-2.93* Hgb-10.7* Hct-31.8* MCV-109* MCH-36.5*
MCHC-33.6 RDW-16.1* Plt Ct-21*#
PT-31.8* PTT-56.1* INR(PT)-3.3*
Glucose-112* UreaN-63* Creat-2.1*# Na-132* K-4.2 Cl-99 HCO3-26
AnGap-11
ALT-36 AST-76* LD(LDH)-488* AlkPhos-143* TotBili-5.6*
DirBili-3.3* IndBili-2.3 Albumin-3.0* Calcium-10.7* Phos-3.2
Mg-2.4
At Discharge: [**2158-1-17**]
WBC-10.3 RBC-2.92* Hgb-9.6* Hct-28.4* MCV-97 MCH-32.8* MCHC-33.8
RDW-19.2* Plt Ct-220
Glucose-145* UreaN-52* Creat-1.3* Na-134 K-4.8 Cl-101 HCO3-25
AnGap-13
ALT-157* AST-90* AlkPhos-215* TotBili-0.2
Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-1.6
tacroFK-9.3
[**2158-1-2**] TSH-15* T4-3.0* T3-53*
Brief Hospital Course:
Upon arrival at [**Hospital1 18**], patient was admitted to the [**Doctor Last Name 3271**]-[**First Name4 (NamePattern1) 679**]
[**Last Name (NamePattern1) 4869**]. He was treated with Ceftrixone and albumin for
presumed SBP and hepatorenal syndrome. Diuretics were held.
Lactulose, rifaxamin, and ursodiol were continued. Abdominal
ultrasound confirmed no flow through portal vein and likely TIPS
occlusion. OSH cultures revealed GNR, speciation revealed
Serratia. Ceftriaxone was continued.
.
On [**12-3**] a diagnostic paracentesis was performed. Post
procedure, he became rigorous with brief hypoxia to 80% on 2L.
He was then placed on NRB and transfered to the MICU given
concern for impending sepsis, need for high volume resuscitation
and poor respiratory status.
.
Upon arrival the MICU, patient was rigorous, VS 100.6, 126,
185/90, 27 and 100% on NRB, then 3L NC. He denied any pain or
recent fever but did report increase in diarrhea. He quickly was
weaned from the oxygen. He remained hemodynamically stable with
no evidence of sepsis, although he did have recurrent episode of
rigors. Blood cultures were negative.
.
Given known occluded TIPS, elevated bilirubin, and severe
ascites, there was consideration of TIPS revision. This was
decided against out of concern for worsening liver failure.
Therapeutic tap was not performed initially because of infected
peritoneum and later out of concern for worsening renal failure
(see below). The patient was noted to be on the top of the
liver [**Month/Year (2) **] list. An NG tube was placed under direct
visualization in order to optimize nutrition.
.
Urinary tract infection: Urine grew enterococcus sensitive to
vanco which was started. Vancomycin was held for 4 days for a
high level. Creatinine was elevated to 2.1 from 1.0 from three
weeks prior. Diuretics were held. Creatinine trended down to
1.4. However, it then rose again. Albumin was given for two
days for likely hepatorenal syndrome.
.
Abdominal pain and elevated WBC: On hospital day 7, a day after
beginning tube feeds, the patient complained of abdominal pain
with upward WBC trend. KUB did not show evidence of
obstruction. The tube feeds were stopped, and stool studies
sent for c diff. Repeat diagnositic paracentesis demonstrated
190 leukocytes, 78% PMN.
.
Osteoporosis/hypercalcemia: Patient had known vertebral
compression fractures and low bone mineral density. The etiology
of osteoporosis was thought to be a combination of poor
nutrition, alcoholism, and hypogonadism (see below). Spine films
to rule out new fracture showed evidence of pelvic fracture.
Follow-up dedicated pelvic films confirmed fractures involving
bilateral superior and inferior pubic rami and bilateral sacral
ala fractures. The orthopedics consult service saw the patient
and recommended weight bearing as tolerated and brace to be worn
when oob.
The patient was initially given calcitriol and calcium
supplementation for treatment of osteoporosis. These were
stopped in consultation with the endocrinology consulting
service given borderline elevated calcium and replete 1,25
hydoxy vitamin D levels. His hypercalcemia was thought to be
due to prolonged immobilization, and PTH levels were
appropriately low.
.
Hypogonadism: As part of the work-up of his osteoporosis,
testosterone, FSH, and LH were checked and found to be low. He
was given a testosterone patch for supplementation. Further
work-up with pitutitary MRI was deferred to the outpatient
setting.
Hypothyroidism: The patient was found to be hypothyroid, and
levothyroxine supplementation was begun. The dose was raised
early in [**Month (only) **]. Repeat Thyroid studies should be done
mid-Decemeber
On [**12-12**], a liver donor was available and the patient accepted
the donation. He underwent cadaveric liver [**Month/Day (4) **]. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative report for complete
details. He received standard induction immunosuppression
consisting of solumedrol and cellcept. He received multiple
blood products and was transferred to the SICU intubated
immediately postop where he continued to recieve blood products
for hemostasis. LFTs trended down, but he experienced a large
volume of bilious drainage via the JP drains. Therefore, on
[**12-14**], he returned to the OR and underwent roux en y
hepaticojejunostomy for cystic duct leak and necrotic recipient
bile duct. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Postop, he returned to the
SICU intubated.
On [**12-18**], he had melena and NG aspirate that was blood tinged. A
colonoscopy was performed noting blood in the entire colon from
introduction of the scope in the rectum througout the colon to
the cecum. there was blood in the terminal ileum. No discrete
bleeding source could be localized in the colon. He received
PRBC,plt and FFP. He was taken to the OR by Dr. [**Last Name (STitle) 816**] for
exploratory laparotomy for GI bleeding. There was no obvious
blood in the stomach and duodenum, the jejunojejunal
anastomosis as well as hepaticojejunostomy were without
bleeding. A small incision was made in the Roux limb and
irrigated. The anastomosis was fine.
There was no obvious blood. Hct stabilized. A PPI drip was
given.TPN was given then discontinued when a post pyloric
feeding tube was placed. Tube feedings were advanced to goal.
Zosyn was stopped on [**12-23**]. He continued to be hypertensive and
tachycardic receiving beta blockers. Free water was given for
hypernatremia to 155. This trended down to 148 11/13 am. He
became disoriented and a bit paranoid with diffuse tremor. He
received zyprexa briefly for this. Protonix drip changed to [**Hospital1 **].
A cholangiogram was done on [**12-21**] which showed the Roux tube
migrated out of the
biliary tree and out of the Roux limb, terminating within the
peritoneal
cavity.
The patient did not have any more episodes of hematemesis or
hematochezia, Hct remained stable at 35, and so his flexseal was
placed back again and his NGT removed. His dobhoff tube feeds
continued. His sodium rose again to 150 and his free water
replacements began. He continued having loose stool.
[**Date range (1) 46801**] Cellcept was decreased to 500 [**Hospital1 **] from 1000 [**Hospital1 **], and
his stool became less loose. Flexaseal was removed. Multiple
stool samples were sent for c.diff and culture which were all
negative. Banana flakes were added to the feedings. Serum sodium
responded to free water replacements and was down to 136. Water
boluses were stopped. He remained hemodynamically stable, and so
was transferred to the [**Hospital Ward Name 121**] 10 (Med-[**Doctor First Name **] Unit) on [**12-28**]. Tube
feedings were changed from 1/2 strength Nutren Renal to full
strength. Diet was slowly advanced. A speech and swallow eval
cleared him for solid food. He did not have dysphagia, but
lacked lower dentures. Kcal counts were insufficient
(143-545/day).The feeding tube was self removed on [**1-1**] and
attempts were made on [**1-2**] and [**1-3**] in fluoro to place this
post pyloric. This was unsuccessful.
The JP drainage decreased significantly allowing for removal of
the JPs. The foley was removed and he was initially incontinent
requiring a condom catheter.
On [**12-28**], Orthopedics was consulted for the patient's
compression fractures; kyphoplasty was not recommended upon
review of the CT. Though he got a brace for walking, he remained
with back pain. He ambulated a few steps with PT with moderate
to max assist with TLSI brace used.
[**Last Name (un) **] was consulted for hyperglycemia. Low dose NPH insulin was
used with sliding scale. NPH was then stopped and just sliding
scale utilized for glucoses in the 100-170 range.
Immunosuppression was adjusted per protocol with solumedrol
weaned down to prednisone taper which is due to be tapered to
off within the next ten days. cellcept continued at 500mg [**Hospital1 **]
and prograf which was adjusted based on daily trough levels with
goal level of 10. LFTs were normal and stable. Creatinine
fluctuated some likely from prograf. TSH was noted to be 13 on
[**12-8**]. Levoxyl was started. On [**1-2**], TSH was 15 with T4 of 3.0
and T3 of 53. Levoxyl was increased to 75mcg once daily.
He was started on a 14 day course of H Pylori therapy for
positive antibody and notation of gastritis and esophagitis when
Dobhoff had to be replaced.
He received oxycodone for abdominal and back pain. Social work
followed for support.
He continues with tube feeds at goal with the bridled Dobhoff
tube. Diet remains thin liquids which he is tolerating. He is
ambulating with 2 person assist and brace whenever he is upright
or ambulating. He has intermittent stooling which have all been
C diff negative.
Medications on Admission:
1. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
2. Furosemide 40 mg Tablet Sig: (3) Tablet PO DAILY (Daily).
3. Vicodin/Oxycodone 5 mg PRN pain.
4. Pantoprazole 40 mg Tablet, Delayed Release Daily
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID,
titrate to 3 bowel movements per day, do not exceed > 5 BM.
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Rifaxamin 200mg TID
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP < 110 or HR < 60.
9. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (MO).
13. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 8 days: H pylori prophylaxis.
Through [**1-26**].
16. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours): H pylori prophylaxis.
Through [**1-26**].
17. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
18. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
20. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: [**1-18**] - [**1-22**] then decrease to 5 mg daily on [**1-23**].
22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
starting [**1-23**].
23. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
24. Tacrolimus
Please provide 0.25 mg PO BID in suspension form
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HCV cirrhosis
s/p liver [**Hospital1 **] [**2157-12-12**]
bile leak
GI bleeding: resolved
malnutrition
serratia bacteremia
UTI< Enterococcus
vertebral compression fractures
Discharge Condition:
stable, fair
Discharge Instructions:
Please call the [**Month/Day/Year 1326**] Office [**Telephone/Fax (1) 673**] if fever > 101,
chills, nausea, vomiting, inability to take any of your
medications, abdominal pain, worsening diarrhea, abdominal
distension, continued weight loss or any concerns
Labs every Monday and Thursday
[**Telephone/Fax (1) 1326**] office to adjust all medications
Continue tube feeds as ordered
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-1-26**] 10:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] [**First Name3 (LF) **] SOCIAL WORK Date/Time:[**2158-1-26**] 11:00
Completed by:[**2158-1-18**]
|
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icd9cm
|
[
[
[]
]
] |
[
"45.23",
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[
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[]
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16355, 16434
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275, 307
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503, 1901
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1923, 2596
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2612, 3066
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,703
| 120,793
|
22627
|
Discharge summary
|
report
|
Admission Date: [**2196-1-14**] Discharge Date: [**2196-2-11**]
Date of Birth: [**2120-6-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right hemiplegia and aphasia.
Major Surgical or Invasive Procedure:
-Endotracheal intubation and mechanical ventilation
-Bronchoscopy
-Tracheostomy
-PEG placement
History of Present Illness:
Patient is a 75 year old right handed man with a history of diet
controlled
cholesterol, previous stroke, who presented to [**Hospital **] Hospital
with right hemiplegia and aphasia.
His wife reports that patient was well at 10pm when he went to
take a shower. She then went to get ready for bed, and found
patient lying in shower. Patient was not moving right side, was
using left arm to try and get up. He did seem to recognize wife,
but did not seem to understand speech or commands when spoken
to.
EMS transported patient to [**Hospital **] Hospital within 3 hours.
While there, he had episode of vomiting, and was intubated due
to concerns for aspiration. CT scan there showed no hemorrhage.
Wife and daughter report that patient was following commands
after intubation. ED physician at [**Name9 (PRE) **] Hospital gave NIHSS 22
while neurologist scored his NIHSS as 29. Policy at [**Hospital **]
Hospital is no IV tPA for NIHSS>20. Therefore, patient was
transferred to [**Hospital1 18**] for consideration for IA tPA.
Patient arrived at [**Hospital1 18**] at 4hrs, 20min. He was initially
hypertensive to 185 systolic, but subsequently SBP fell to 100s
and patient was started briefly on neosynephrine. On arrival,
NIHSS 21. Emergent CTA was performed, which confirmed no
hemorrhage and showed patent large vessels. Since there was no
evidence for clot, IA tPA was not given. Instead, pt was
enrolled in DEFUSE trial with consent of wife and daughter. MRI
was performed. Paitent then given IV tPA approixmately 5 hours
and 55 minutes after onset.
On review of systems, has had no recent fevers, chills,
illnesses, chest pain, palpitations, shortness of breath, or
headaches per his wife.
Past Medical History:
1. Stroke, 2 [**11-22**] yrs ago. Presented with expressive aphasia per
family, no residual deficit. Workup at [**Hospital 1774**] Hospital with small
vessel disease per family. Was on coumadin for 6 weeks, and has
[**Doctor First Name **] on Aggrenox since. Sees Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58659**] in Neurology at
[**Hospital1 1774**].
2. Hypercholesterolemia: currently diet-controlled
3. S/p appendectomy
4. Hard of hearing bilaterally
Social History:
Lives with wife. [**Name (NI) **] tobacco, excessive alcohol, or drug use. At
baseline is fully functional and independent in all activities
of daily living. Exercises frequently and walks 1 [**11-22**] miles per
day.
Family History:
No family history of stroke, seizures.
Physical Exam:
Physical Exam on Admission:
Vitals: BP 180s, then 100s, then 150s on neosynephrine drip, HR
50s, oxygen in high 90s on ventilator.
General: Well-developed, well-nourished man, appears stated age,
intubated, starting to arouse.
HEENT: Normocephalic, atraumatic. Sclera anicteric.
Neck: In hard collar.
Lungs: Clear to auscultation anterolaterally.
Cardio: Bradycardic but regular, normal S1 and S2 heart sounds
auscultated, no murmur.
Abdomen: Soft, nontender, nondistended with normoactive bowel
sounds.
Extremities: Warm, well-perfused, with no clubbing, cyanosis,
edema.
Neurologic Examination:
Mental Status: Intubated, coming off sedative meds. Arouses
easily to voice, keeps eyes open. Follows simple commands,
though hard of hearing so need to shout in ear.
Cranial Nerves: Pupils equally round and reactive to light.
Leftward eye deviation. Right facial droop.
Motor: Decreased tone on right, fasiculations absent in upper
and lower extremities. No tremor. Moves left side spontaneously,
purposefully, and with full strength. No spontaneous movement on
right sided. Has extensor posturing to stimulation on right.
Sensation: Brisk and purposeful withdrawal to pain on left.
Moves left side in response to noxious stimuli presented on the
right.
Reflexes: Toes up bilaterally.
Unable to assess coordination and gait.
Pertinent Results:
[**2196-2-11**]: CSF ANALYSIS
WBC RBC Polys Lymphs Monos
[**2196-2-11**] 12:10PM 0 15* 01 502 50
TUBE #4
[**2196-2-11**] 12:10PM 0 75* 671 0 33
TUBE #1
Chemistry
CHEMISTRY TotProt Glucose
[**2196-2-11**] 12:10PM 22 100
TUBE #2
Miscellaneous (viral culture, gram stain and culture)
CSF HOLD
[**2196-2-11**] 12:10PM PND
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2196-2-11**] 04:06PM 15.3* 2.73* 8.1* 25.3* 93 29.5 31.9 15.2
275
[**2196-2-11**] 01:57AM 16.1* 2.78* 8.2* 25.8* 93 29.3 31.7 14.9
282
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2196-2-10**] 04:24AM 76.0* 12.3* 3.7 7.7* 0.4
RED CELL MORPHOLOGY Hypochr Poiklo
[**2196-2-10**] 04:24AM 2+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2196-2-11**] 04:06PM 275
[**2196-2-11**] 11:39AM 30.0
[**2196-2-11**] 01:57AM 282
[**2196-2-11**] 01:57AM 13.1 57.3* 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2196-2-11**] 04:06PM 150* 4.6
[**2196-2-11**] 01:57AM 130* 35* 0.7 150* 3.8 117* 29 8
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2196-2-10**] 04:24AM 48* 31 296* 82 244* 0.2
OTHER ENZYMES & BILIRUBINS Lipase
[**2196-2-10**] 04:24AM 292*
[**2196-1-15**] 03:16AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.8* Hct-31.8*
MCV-92 MCH-31.3 MCHC-34.0 RDW-12.5 Plt Ct-147*
[**2196-1-15**] 03:16AM BLOOD Plt Ct-147*
[**2196-1-15**] 03:16AM BLOOD PT-13.4 PTT-28.9 INR(PT)-1.1
[**2196-1-15**] 03:16AM BLOOD Glucose-102 UreaN-8 Creat-0.6 Na-144
K-2.4* Cl-118* HCO3-19* AnGap-9
[**2196-1-15**] 04:46AM BLOOD ALT-13 AST-24 CK(CPK)-490* AlkPhos-53
TotBili-0.6
[**2196-1-15**] 12:13PM BLOOD CK(CPK)-681*
[**2196-1-15**] 08:04PM BLOOD CK(CPK)-693*
[**2196-1-15**] 04:46AM BLOOD CK-MB-4 cTropnT-<0.01
[**2196-1-15**] 12:13PM BLOOD CK-MB-4
[**2196-1-15**] 08:04PM BLOOD CK-MB-5
[**2196-1-15**] 03:16AM BLOOD Calcium-5.6* Phos-1.7* Mg-1.1*
[**2196-1-15**] 04:46AM BLOOD %HbA1c-5.4
[**2196-1-15**] 04:46AM BLOOD Triglyc-102 HDL-43 CHOL/HD-3.4 LDLcalc-83
-----
EKG [**2196-1-14**]: Sinus rhythm with frquent atrial ectopy. P-R
interval 0.16. No previous tracing available for comparison.
-----
Transthoracic Echo [**2196-1-14**]: The left atrium is normal in size.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is normal (LVEF 60%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic root
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
-----
Transesophageal Echo [**2196-1-29**]: The left atrium is mildly dilated.
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with preserved global systolic function. There are
simple atheroma in the ascending aorta, the aortic arch and the
descending thoracic aorta. The aortic valve leaflets(3) are
minimally thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**11-22**]+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
There is no pericardial effusion.
IMPRESSION- No atrial hrombus tidentified. Mild-moderate mitral
regurgitation.
-----
MRI/MRA head [**2196-1-14**]:
An area of restricted diffusion is seen involving the cortex of
the left medial frontal and parietal lobes, consistent with an
acute anterior cerebral artery territory infarction. A second
smaller area of restricted diffusion is seen in the left
occipital region. No abnormal susceptibility signal is
identified. Patchy areas of T2 hyperintensities are seen in the
periventricular and subcortical white matter consistent with
chronic microvascular ischemic changes. Midline structures are
normal in position. Midbrain and cerebellum are within normal
limits.
IMPRESSION:
Acute left anterior cerebral artery territory infarction. Small
acute infarct also seen in the left occipital lobe. Areas of
encephalomalacia most likely representing chronic infarction.
CIRCLE OF [**Location (un) **] MRA: This is a technically limited examination,
distal aspect of the vessels were not included. Proximal
anterior cerebral arteries, middle cerebral arteries, and
posterior cerebral arteries are normal in appearance. No
aneurysms nor hemodynamically significant areas of stenosis are
identified. Distal vertebral arteries and basilar arteries are
also normal in appearance. Carotid arteries were not included in
this examination.
IMPRESSION:
Normal circle of [**Location (un) 431**] MRA
-----
MRI/MRA head [**2196-1-14**]: Again, there is visualization of
restricted diffusion along the left anterior cerebral artery and
left posterior cerebral artery territories. New areas of
magnetic susceptibility are seen along the posterior frontal and
parietal lobes, on the medial aspect adjacent to the cortex
consistent with petechial hemorrhages. Slightly larger subacute
infarct alomg the left Calcarine region on the left. Stable left
occipital lobe subacute infarct. Midline structures are normal
in position. Ventricles and subarachnoid spaces are stable.
Findings consistent with chronic infarcts.
IMPRESSION:
New petechial hemorrhages are seen involving the left ACA
territory infarction. Slightly larger subacute infarct along
calcarine resion on the left. Stable left occipital lobe
infarction.
CIRCLE OF [**Location (un) **] MRA: Anterior cerebral arteries, middle
cerebral arteries, as well as posterior cerebral arteries are
normal. No hemodynamically significant stenoses are visualized.
No aneurysms are noted. Distal vertebral arteries as well as
basal artery are also normal.
IMPRESSION:
Unremarkable circle of [**Location (un) 431**] MRA.
-----
CTA head [**2196-1-14**]: Three-dimensional reformatted images of the CT
angiogram have become available. Review of these images does not
indicate a left middle cerebral arterial occlusion. The
trifurcation of the left middle cerebral artery has a middle
branch with a sharp bend and the artery continues
anteroinferiorly from the bend. The right middle cerebral,
anterior and posterior cerebral main arterial trunks are patent.
Vascular occulsions which would correspond with the recent
territorial infarctions are not identified at the level of
resolution of this study.
INDICATION: A 76-year-old woman with left MCA stroke.
CT ANGIOGRAM: Anterior cerebral arteries, middle cerebral
arteries, and posterior cerebral arteries are normal in
appearance. No aneurysms nor areas of stenosis are identified.
The right internal carotid artery, at the skull base, has a
somewhat irregular contour, there appears to be a double lumen
on the axial scans at this level. On sagittal images, there is
demonstration of dilatation of right internal carotid artery at
the same region. The left internal carotid artery is normal.
Remaining visualized vasculature is normal.
IMPRESSION:
Acute left anterior cerebral artery territorial infarction.
Areas of encephalomalacia in the right parietal and left
occipital regions, indicating chronic infarcts. Right internal
carotid artery dissection is suspected, which is at the skull
base and of indeterminate age. No acute territorial infarcts are
seen in the right cerebral hemisphere.
-----
Carotid ultrasound [**2196-1-15**]: Duplex evaluation was performed of
both carotid and vertebral arteries. Minimal plaque was
identified. On the right, peak systolic velocities are 79, 88,
and 177 in the ICA, CCA, and ECA respectively. The ICA to CCA
ratio is 0.9. This is consistent with less than 40% stenosis. On
the left, peak systolic velocities are 98, 99, and 106 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This
is consistent with less than 40% stenosis. There is antegrade
flow in both vertebral arteries.
IMPRESSION:
Minimal plaque with bilateral less than 40% carotid stenosis.
-----
Noncontrast head CT [**2196-1-18**]: There is low attenuation in the
left frontal lobe medially in the region of the left anterior
cerebral artery territory consistent with the acute infarct seen
on the recent MR. There is an additional area of low attenuation
in the left occipital region, also seen as an area of acute
infarction on the recent MR. Within the left frontal cortex
infarct, there are islands of relative [**Name (NI) 33214**],
consistent with the areas of susceptibility on the MR [**First Name (Titles) 767**] [**1-15**] at 10:30 a.m. These areas are most consistent
with areas of hemorrhage, but are not changed in appearance,
allowing for modality differences. There are no new areas of
hemorrhage. There are also stable areas of low attenuation in
the distribution of the left posterior cerebral artery territory
as seen on the most recent MR. There is no change in the
appearance of the ventricles and no new shift of normally
midline structures. There is revisualization of low attenuation
within the periventricular white matter of both cerebral
hemispheres, consistent with chronic microvascular infarcts. The
osseous structures and paranasal sinuses are unremarkable.
IMPRESSION:
There appears to be no change in the extent of infarcts
involving the left anterior and posterior cerebral artery
territories, as well as areas of hemorrhage within the left
frontal cortex.
-----
CT/CTA Chest [**2196-1-31**]: CT OF THE CHEST WITH AND WITHOUT IV
CONTRAST: There are no filling defects within the pulmonary
arteries to indicate a pulmonary embolism. The endotracheal tube
is in satisfactory position above the carina. There is an NG
tube in place. There is a left-sided central venous catheter
terminating in the SVC. There are no pathologically enlarged
axillary lymph nodes. There are multiple mediastinal lymph
nodes, including multiple small subcentimeter pretracheal lymph
nodes measuring up to 7 mm as well as right paratracheal lymph
nodes, measuring approximately 1 cm. There are multiple smaller
prevascular lymph nodes. There is a 1 cm left paratracheal lymph
node. There is a 1.3 cm precarinal lymph node, which contain
some calcification. There are multiple other calcified
precarinal lymph nodes. There is a calcified right hilar lymph
node, calcified subcarinal lymph nodes. There are left hilar
lymph nodes, measuring approximately 1 cm. There are diffuse
ground- glass opacities within both lungs. There are also
emphysematous changes and honeycombing within the lungs. The
airways are patent to the level of the segmental bronchi. There
are some calcifications in the region of the liver and spleen,
which could represent granulomatous disease. There are no
pleural or pericardial effusions. There are calcified pleural
plaques bilaterally. There are some coronary artery
calcifications. Calcified pleural plaques.
REFORMATTED IMAGES: These show diffuse airspace opacities within
the lungs.
IMPRESSION:
1) No pulmonary embolism.
2) Diffuse airspace opacities within the lungs. This could
represent atypical pneumonia, ARDS, and/or pulmonary edema.
Follow-up to resolution is recommended.
3) Mediastinal and hilar lymphadenopathy. This was discussed
with Dr. [**Last Name (STitle) **].
4) Calcified pleural plaques consistent with previous asbestosis
exposure.
-----
Bronchoalveolar lavage [**2196-2-2**]: NEGATIVE FOR MALIGNANT CELLS.
Numerous pulmonary macrophages and some inflammatory cells.
-----
EEG [**2196-2-8**]
ABNORMALITY #1: The background rhythm is slow in the 6 to 7 Hz
theta
frequency range and disorganized. There are bursts of
generalized delta
frequency slowing in the 2 to 4 Hz frequency range.
BACKGROUND: As above.
HYPERVENTILATION: Was not performed due to the patients clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because this
was a
portable study.
SLEEP: Normal transition of sleep architecture were not seen.
CARDIAC MONITOR: A tachycardiac arhythmia with a rate of 154 bpm
was
recorded.
IMPRESSION: This is an abnormal portable EEG due to the presence
of the
slow and disorganized background rhythm with generalized bursts
of delta
frequency slowing. These findings suggest both subcortical and
cortical
dysfunction in this areas. No lateralization or epileptiform
abnormalities were seen. A tachycardia was noted.
MRI brain [**2196-2-9**]
Diffusion-weighted images reveal no new areas of signal
abnormality to indicate interval infarction.
There are foci of susceptility artifact in the left anterior
cerebral arterial territory infarction, indicating blood
products, as were observed on the [**2196-1-14**] study. There
is also a small focus of susceptibility artifact in the left
occipital lobe, which may be a microhemorrhage.
There are no signal abnormalities in the brain stem or
cerebellum. Multiple foci of increased T2 signal observed in the
white matter of the cerebral hemispheres are stable in
appearance.
The size and shape of the ventricles are unchanged. Areas of
encephalomalacia and volume loss, such as the right occipital
lobe, are again observed.
There is fluid within the mastoid air cells and middle ear
cavities bilaterally, probably more on the right than the left.
The paranasal sinuses appear clear.
MR angiography is unchanged since the previous study. There is
flow in the major branches of this circulation.
IMPRESSION:
Stable appearance of the brain and late subacute infarction,
compared to
[**2196-1-14**] MR.
[**Name13 (STitle) **] in the major branches of the circle of [**Location (un) 431**] on MRA.
CXR [**2196-2-10**]:
AP portable view of the chest dated [**2196-2-10**] is compared
with the same examination from [**2196-2-8**]. The tracheostomy
tube is in good position. The left subclavian central venous
catheter tip is within the SVC. There has been no significant
change in the bilateral pulmonary parenchymal opacities
indicating diffuse interstitial lung disease. Again noted is
subsegmental atelectasis within the right middle lobe.
Cardiomegaly is unchanged. Multiple calcified plaques are
notedon the pleura, specifically in the region of the right
hemidiaphragm, and the medial pleural edges bilaterally.
IMPRESSION: No short interval. Diffuse interstitial lung disease
& calcified pleural plaques is suggestive of asbestosis.
Brief Hospital Course:
The patient is a 75 year old right handed male with history of
high cholesterol and previous stroke who presented to [**Hospital1 18**] on
[**2196-1-14**] as a transfer from [**Hospital **] Hospital with right
hemiplegia and likely global aphasia most consistent with MCA
infarct. He was felt not to be an IV tPA candidate at [**Hospital **]
Hospital and so he was transferred to [**Hospital1 18**] for consideration of
other interventions. Initial MRI imaging with demonstrated left
ACA and PCA acute infarcts. Clinically, his deficits were more
consistent with a left MCA lesion. Together, this pattern was
suggestive of an ICA clot that then embolized to multiple
branches. Most likely etiology of this ICA clot was felt to be
embolic.
The [**Hospital 228**] hospital course by system is as follows:
1. Neurology: After discussion of the patient's clinical and
imaging findings and consent from his wife, the patient was
enrolled in the DEFUSE trial. He received IV tPA at 5 hours, 59
minutes post symptom onset. Post tPA MRI showed visualization of
restricted diffusion along the left anterior cerebral artery and
left posterior cerebral artery territories. New areas of
magnetic susceptibility are seen along the posterior frontal and
parietal lobes, on the medial aspect adjacent to the cortex
consistent with petechial hemorrhages. He was admitted to the
NeuroICU for monitoring, blood pressure control. Given the
discrepancy between the patient's clinical findings suggestive
of MCA stroke and his left ACA/PCA infarcts on imaging, blood
pressure parameters of 120-180 systolic were maintained with
neosynephrine in order to enhance cerebral perfusion.
Investigation into the etiology of patient's infarcts then
ensued. CTA of the head and neck demonstrated that the right
internal carotid artery, at the skull base, has a somewhat
irregular contour, there appears to be a double lumen on the
axial scans at this level. On sagittal images, there is
demonstration of dilatation of right internal carotid artery at
the same region. The left internal carotid artery is normal.
Remaining visualized vasculature is normal. However, the imaging
findings on the CTA were ipsalateral to the patient's deficits
and felt to be non-etiologic. Carotid ultrasounds demonstrated
no clinically significant stenosis. While on telemetry
monitoring, the patient demonstrated a heart rhythm consistent
with atrial fibrillation with intermixed atrial flutter. It is
likely that his atrial fibrillation predisposed him to the
current stroke due to a cardioembolic event. Therefore,
anticoagulation was initiated with coumadin. For secondary
stroke prevention, Lipitor was started. Blood glucose was
monitored and tight glycemic control maintained per-stroke.
Unfortunately, the patient's neurologic exam remained largely
unchanged post IV tPA and throughout his hospital course. He was
intermittently awake, alert, attentive; this was mediated by
concomitant sedation and superimposed medical issues. He was
able to move left side spontaneously. His right arm was
hemiplegic and right leg had a triple flexion response to
noxious stimuli. Once medically stable, he will need a repeat
CTA of the head and neck to evaluate his right ICA.
After which complications arose from which Pt never fully
recovered to his pre-respiratory failure baseline. Namely, he
could only alert briefly to voice, briefly track. There were no
spontaneous movements of the extremeties and minimal withdrawl
of only the LUE to noxious stimulus. He did grimace to noxious
stim on the L side but not the right. Repeat MRI was performed
([**2-9**]) and did not show any new infarct or structural lesion to
explain the encephalopathy. Additionally, a repeat EEG was
performed ([**2196-2-8**]) and showed diffuse slowing but no PLEDs. The
current thought is that the prolonged period of
hypoxia/hypercarbia prior to the tracheostomy resulted in some
hypoxic brain injury that is not apparent on neuroimaging.
Alternatively, toxic/metabolic causes for his deterioration
neurologic status were being investigated at time of transfer to
[**Hospital1 2025**].
2. Pulmonary: The patient arrived to [**Hospital1 18**] intubated. He was
extubated on [**2196-1-14**]. However, in spite of aggressive pulmonary
toilet, he became increasingly tachypneic. Out of concern for
possible aspiration pneumonia, he received 2 days of empiric
therapy with Zosyn. Zosyn was discontinued after serial chest
Xrays failed to disclose a pulmonary infiltrate. He was
reintubated on [**2196-1-16**]. He proved to be slow to wean from the
ventilator. Sputum on [**2196-1-22**] demonstrated methicillin-sensitive
staph aureus. Antibiotic coverage with Oxacillin was initiated.
He was extubated again around [**2196-1-24**]. However, he required
continuous positive pressure ventilation to maintain
satisfactory respiratory parameters. He had recurrent
respiratory failure and was reintubated on [**2196-1-27**]. He
continued on Oxacillin until [**2196-1-28**]. At that time, repeat
sputum cultures demonstrated methicillin-resistant staph aureus;
gram stain also showed gram negative rods. As such, antibiotic
coverage was switched to Zosyn and Vancomycin, with first dose
of these agents [**2196-1-28**]. Out of concern for pulmonary embolus,
he underwent CTA Chest on [**2196-1-31**]. While there was no pulmonary
embolus, there was demonstration of extensive bilateral
interstitial and alveolar opacities consistent with ARDS. He was
subsequently paralyzed, sedated, and switched to a volume
targeted ventilatory mode with high PEEP. He was seen in
consultation by the Pulmonary Service. He underwent bronchoscopy
and BAL on [**2196-2-2**]. This was consistent with ARDS but no
evidence of bronchoalveolar hemorrhage. Per pulmonary
recommendations, he was continued on Vancomycin and Zosyn and
should continue on these agents until [**2196-2-16**]. Over course of
[**3-13**] his respiratory parameters and PEEP requirement
improved. He underwent tracheostomy on [**2196-2-4**] requiring some
sedation and paralysis to maintain compliance with mechanical
ventilation. These were discontinued on [**2196-2-6**] after which Pt
did not fully recover fully to his pre-op baseline. At time of
transfer he was on Assist Control with Fi02=40%, PEEP=5,
rate=34.
3. Cardiology: The patient ruled out for myocardial infarction
with three sets of negative cardiac enzymes. On telemetry
monitoring, he demonstrated atrial fibrillation with
intermittent flutter. He underwent transthoracic and
transesophageal echocardiograms; these revealed no evidence of
intraluminal clot, patent foramen ovale or atrial septal defect.
Initially, he was rate controlled with Metoprolol. However, he
became more difficult to rate control around [**Date range (3) 58660**].
There was concern that his rapid rate was contributing to his
pulmonary difficulties via pulmonary edema. As such, he was
cardioverted on [**2196-1-30**]. He reverted to normal sinus rhythm. Per
cardiology recommendations, he was started on Amiodarone.
Unfortunately, he reverted to atrial fibrillation on [**2196-2-3**].
Again, rate control was achieved with Metoprolol.
Anticoagulation with heparin and/or coumadin was continued
throughout his hospital course. Lipitor was started for
cholesterol.
4. Infectitious Disease: Patient had initial temperature spike
on [**2196-1-14**]. He was pancultured. Zosyn was started empirically
out of concern for aspiration pneumonia. This was discontinued
after 2 days. Sputum later grew methicillin-sensitive staph
aureus on [**2196-1-22**]. Treatment with oxacillin was continued until
sputum from [**2196-1-27**] showed methicillin-resistance staph aureus
as well as gram stain with gram negative rods. As such,
antibiotics were switched to Zosyn and Vancomycin on [**2196-1-28**].
Per pulmonary recommendations, he will continue on these agents
until [**2196-2-16**]. At no times did urine nor blood cultures
demonstrate bacterial infections. On [**2196-2-8**] he had additional
fevers and was again pan-cultured (sputum, urine, blood) all of
which are negative to date. Pt had C. Diff toxin sent on
[**2196-2-6**] which was negative. On [**2196-2-11**] LP was performed with
CSF results not suggestive of any infectious or inflammatory
process.
5. Gastrointestinal: Patient had [**Last Name (un) **]- or orogastric tubes
placed for medication administration and feedings. PEG was
placed on [**2196-2-4**]. He is on full tube feeds with free water
boluses qid.
6. FEN: Increasingly prerenal (hypernatremic, elevated BUN/Cr)
prior to [**2196-2-8**] therefore started gradual fluid replacement via
free H20 boluses throught the GT. Slight improvements over this
past week. Daily CXR should be followed to evaluate for
pulmonary edema. Lasix for pulmonary edema discontinued on
[**2196-2-9**].
7. Endocrine: Tight glycemic control was achieved via a regular
insulin sliding scale. Hemoglobin A1c was 5.4.
8. Heme: Hct=25.8 on discharge, which has been stable over
several days. Slight decrese from last week likely due to
hemodilution from fluid resuscitation.
9. PPx: PPI, RISS, hep SC
10. Code: FULL.
Medications on Admission:
1. Aggrenox 1 capsule po bid
2. Multivitamin
Discharge Disposition:
Extended Care
Discharge Diagnosis:
embolic stroke
Discharge Condition:
guarded
Discharge Instructions:
[**Hospital3 2576**] [**Hospital3 **]- Neurologic ICU, [**Doctor Last Name 406**] 12.
Accepting Attd: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 58661**]
Followup Instructions:
per [**Hospital1 2025**] Neurology Service
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2196-2-11**]
|
[
"518.5",
"272.0",
"427.31",
"276.0",
"507.0",
"482.41",
"434.11",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"31.1",
"99.10",
"99.04",
"38.91",
"96.04",
"96.71",
"88.72",
"96.6",
"96.72",
"33.24",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
28476, 28491
|
19234, 28381
|
346, 442
|
28550, 28559
|
4330, 19211
|
28780, 28946
|
2925, 2965
|
28512, 28529
|
28407, 28453
|
28583, 28757
|
2980, 2994
|
276, 308
|
470, 2170
|
3762, 4311
|
3008, 3554
|
3593, 3746
|
3578, 3578
|
2192, 2673
|
2689, 2909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,883
| 116,351
|
49329+59150
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-6-3**] Discharge Date: [**2107-6-9**]
Service: MEDICINE
Allergies:
Univasc
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
vomiting, hemoptysis
Major Surgical or Invasive Procedure:
fluoro-guided PICC placement
History of Present Illness:
[**Age over 90 **] yo G6P2 woman, with recent history of endometrial cancer
diagnosed on exploratory laparotomy with bilateral
salpingo-oophorectomy on [**5-13**] and discharged to [**Hospital3 2558**] on
[**5-23**], presents with vomiting undigested food, hematemesis vs
hemoptysis, and confusion. The patient had been doing well at
rehab until yesterday per notes and her report. She tells me
that she vomited yesterday; per records sent with her, it
appears as though the patient vomited undigested food and then
had episodes of "spitting up blood-tinged sputum." She had one
episode of coughing up bright red blood. Per report, her initial
blood pressure was in the 60s systolic. The patient's mental
status had been improving since her discharge, but today she was
noted to be more confused and less oriented.
.
In the ER, the patient had abdominal imaging which showed ileus
without obstruction. She was evaluated by both the General
Surgery and the Gyn-Onc teams. She had an NG lavage with small
amounts of pink fluid which cleared; she was guaiac positive on
rectal exam per ER exam but remained hemodynamically stable
throughout her ED course. She was transfused with 2 U PRBCs as
well as 2 U FFP for INR 3.4. Repeat Hgb at 0100 was 32.6 from
25.8. She also received 1 L NS. Head CT was without bleed or
mass effect. She was also evaluated by the GI team.
.
In the ED, she was also found to have a right middle lobe
pneumonia in conjunction with WBC count of 13.8 (92%
neutrophils). She was treated with one dose of levofloxacin.
Blood cultures were sent and are pending.
.
At the present time, the patient denies abdominal pain. She
cannot remember exactly why she was brought to the hospital; she
does remember that she vomited "yesterday" and that she has been
feeling poorly since that time though she cannot elaborate. She
denies cough, chest pain, coughing up blood, and shortness of
breath. She cannot tell me whether or not she has been having
bowel movements or whether her abdomen is distended.
Past Medical History:
PMHx:
* Endometrial carcinoma with torsion - s/p exploratory
lapartomy, bilateral salpino-oophorectomy, and bowel
disimpaction on [**5-13**] complicated by postoperative delirium
* Partial SBO (admission [**5-7**]) thought due to mechanical
obstruction from ovarian mass (now s/p removal)
* Catheter-associated DVT (R IJ)
* Coronary artery disease, status post MI in [**2070**].
* Hypertension.
* Breast cancer [**2061**], status post right radical mastectomy.
* Iron deficiency anemia, baseline HCT 36-39
* Diverticulosis.
* Carpal tunnel syndrome.
* Osteoarthritis.
* Chronic Renal Insufficiency (baseline 1.5-1.7 --> GFR
30cc/min)
.
PSH:
1. Appendectomy
2. Right radical mastectomy
3. Cone biopsy
4. [**2107-5-13**] ex lap/BSO/bowel disimpaction for endometrial Ca
Social History:
She is widowed and previously lived alone. Prior to recent
admission was able to take care of self overall: was ambulating,
toileting, dress. No history of alcohol use. She has smoked two
packs per week for over sixty years. >120 pkyr hx. Has several
children, all except one lives in state. Recently was discharged
to [**Hospital3 2558**] on [**5-23**].
Family History:
Mother lived to age [**Age over 90 **]. Otherwise unknown.
Physical Exam:
PE: T 99.6 BP 146/78 HR 98 RR 14 O2Sat 100% RA
Gen: Patient awake and cooperative
Heent: OP clear, MMM
Neck: no palpable lymphadenopathy
Cardiac: RRR S1/S2 grade III/VI SEM heard throughout precordium
Lungs: slight crackles in right midlung/base, otherwise clear to
auscultation
Abd: surgical scar at midline below umbilicus well-healed,
distended abdomen but soft and nontender to palpation.
Normoactive bowel sounds.
Ext: Right UE larger in size than left UE. Anasarcatous.
Neuro: Awake, pleasant. Oriented to self, year, location
(building). Not oriented to month, name of hospital.
Pertinent Results:
[**2107-6-2**] CT ABD/PELVIS: 1. Findings consistent with ileus. No
evidence of small bowel obstruction.
2. Ascites, small pleural effusions, and anasarca. These
findings are likely related to the patient's recent operation,
and volume-related hemodilution could contribute to the
apparently "decreased hematocrit."
.
[**2107-6-2**] CT HEAD: No acute intracranial hemorrhage or mass
effect.
.
[**2107-6-2**] CXR: Right middle lobe pneumonia. Small bilateral
pleural effusions.
.
[**2107-6-2**] KUB: Prominent loops of small bowel may be related to
ileus, early or partial small bowel obstruction cannot be
excluded.
.
[**2107-6-2**] ECG: Sinus rhythm. Borderline low limb lead voltage.
Leftward axis. Lead V2 is technically difficult. Since the
previous tracing of [**2107-5-13**] the Q-T interval is shorter.
.
[**2107-6-3**] CXR: 1. Re-identification of patchy right middle lobe
pneumonia.
2. Increased left lower lobe atelectasis.
3. Resolving small bilateral pleural effusions with probable
mild interstitial remaining edema.
.
[**2107-6-4**] CT CHEST: 1. Left upper lobe cavitary lesion concerning
for primary lung cancer or metastatic disease. An infectious
process is less likely.
2. Redemonstration of right middle and upper lobe pneumonia.
3. Moderate right and small left pleural effusions.
.
[**2107-6-7**] CXR: There is now a small right pleural effusion. The
patient's CHF has essentially cleared. There is some patchy
linear atelectasis at the right base.
.
blood cx [**2107-6-2**]: no growth
.
[**2107-6-5**] 5:00 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2107-6-6**]):
[**12-1**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2107-6-8**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
ACID FAST SMEAR (Final [**2107-6-6**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
[**2107-6-6**] 3:40 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2107-6-7**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
[**2107-6-7**] 3:40 pm SPUTUM Site: INDUCED induction
verified.
ACID FAST SMEAR (Final [**2107-6-8**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
.
[**2107-6-2**] 08:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2107-6-2**] 08:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2107-6-2**] 01:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2107-6-2**] 01:35PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2107-6-2**] 01:35PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-[**7-17**]
.
[**2107-6-2**] 12:45PM BLOOD WBC-13.8*# RBC-2.84* Hgb-8.4* Hct-25.8*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.6* Plt Ct-293
[**2107-6-2**] 12:45PM BLOOD Neuts-91.5* Bands-0 Lymphs-4.8* Monos-3.2
Eos-0.3 Baso-0.2
[**2107-6-2**] 12:45PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2107-6-2**] 12:45PM BLOOD Plt Smr-NORMAL Plt Ct-293
[**2107-6-2**] 12:45PM BLOOD PT-31.9* PTT-33.5 INR(PT)-3.4*
[**2107-6-2**] 03:45PM BLOOD Glucose-116* UreaN-25* Creat-1.4* Na-136
K-4.8 Cl-103 HCO3-27 AnGap-11
[**2107-6-2**] 12:45PM BLOOD Glucose-106* UreaN-25* Creat-1.5* Na-132*
K-7.4* Cl-100 HCO3-26 AnGap-13
[**2107-6-2**] 12:45PM BLOOD Calcium-8.1* Phos-3.9 Mg-2.4
[**2107-6-2**] 04:10PM BLOOD K-4.8
[**2107-6-2**] 12:55PM BLOOD Lactate-2.2* K-6.3*
[**2107-6-2**] 12:55PM BLOOD Hgb-8.9* calcHCT-27
.
[**2107-6-3**] 07:45PM BLOOD Hct-31.7*
[**2107-6-3**] 11:41AM BLOOD Hct-32.0*
[**2107-6-3**] 02:46AM BLOOD WBC-15.8* RBC-3.67*# Hgb-10.9*#
Hct-33.5*# MCV-91 MCH-29.7 MCHC-32.5 RDW-14.9 Plt Ct-237
[**2107-6-3**] 02:46AM BLOOD Plt Ct-237
[**2107-6-3**] 02:46AM BLOOD PT-26.2* PTT-33.7 INR(PT)-2.7*
[**2107-6-3**] 01:00AM BLOOD PT-26.6* PTT-32.2 INR(PT)-2.7*
[**2107-6-3**] 02:46AM BLOOD Glucose-82 UreaN-22* Creat-1.3* Na-136
K-4.5 Cl-100 HCO3-27 AnGap-14
[**2107-6-3**] 01:00AM BLOOD Glucose-88 UreaN-21* Creat-1.3* Na-135
K-5.3* Cl-102 HCO3-25 AnGap-13
[**2107-6-3**] 02:46AM BLOOD Lipase-14
[**2107-6-3**] 02:46AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.2 Mg-2.1
Iron-80
[**2107-6-3**] 02:46AM BLOOD calTIBC-285 Ferritn-113 TRF-219
[**2107-6-3**] 02:46AM BLOOD TSH-3.2
[**2107-6-3**] 02:46AM BLOOD Free T4-1.3
[**2107-6-3**] 12:57AM BLOOD Lactate-1.5
[**2107-6-3**] 12:57AM BLOOD Hgb-10.6* calcHCT-32
.
[**2107-6-8**] 06:55AM BLOOD WBC-6.8 RBC-3.36* Hgb-9.8* Hct-31.0*
MCV-92 MCH-29.1 MCHC-31.6 RDW-14.5 Plt Ct-267
[**2107-6-8**] 06:55AM BLOOD Plt Ct-267
[**2107-6-8**] 06:55AM BLOOD PT-14.4* INR(PT)-1.3*
[**2107-6-8**] 06:55AM BLOOD Glucose-85 UreaN-11 Creat-1.3* Na-138
K-3.7 Cl-102 HCO3-31 AnGap-9
[**2107-6-8**] 06:55AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
.
Brief Hospital Course:
# Right middle and upper lobe pneumonia: Suspect nosocomial,
given recent hospital admission. Micro unrevealing. Blood
cultures were negative. Remained stable on room air and will
complete a 10 day course of zosyn/vancomycin for treatment.
Given pneumovax and influenza vaccine prior to discharge. Nebs
prn.
.
# Hemoptysis: INR therapeutic. [**Month (only) 116**] be secondary to pneumonia
or left upper lobe lesion which is likely malignant. Ruled out
for TB with AFB negative x 3 induced sputums. Hematocrit and
oxygen stable. Daughter states she and her mother wish to defer
biopsy. They are aware this is a probable malignancy but do not
wish further treatment.
.
# Ileus: Concern for obstruction last admission. S/p
intraabdominal surgery [**2107-5-13**]. CT this admission showed ileus
but no obstruction. NGT placed for decompression and has since
been discontinued. Patient's diet was advanced. She is
currently tolerating a regular diet without nausea, vomiting,
bloating, or abdominal pain.
.
# Anemia: HCT 25 on admission (down from baseline 29-30).
Suspect contribution from chronic kidney disease + acute
infection. Guaic positive on admission but hematocrit
stabilized with 2 units PRBC and has remained 29-30 x days.
Thus, consider outpatient C-scope and EGD for further work-up,
if patient wishes (discussed with daughter). Of note, iron
studies at this time, do not reflect iron deficiency. TSH,
vitamin B12 also normal. Folate added on on the day of
discharge and will be pending.
.
# History of right IJ clot: Restarted on anticoagulation in
house (lovenox to bridge given subtherapeutic on coumadin).
Please check Factor Xa level tonight (4 hours after dose of
lovenox) and adjust as needed. Lovenox can be d/c once coumadin
level therapeutic (INR 1.2 on day of discharge).
.
# Atrial fibrillation: Rate stable on beta blocker. On
anticoagulation.
.
# Hypertension: Blood pressure high in house, but patient was
not receiving her minitran. Nifedipine and metoprolol doses
have been increased since admission. Minitran restarted at
discharge.
.
# Delirium: Resolved with treatment of pneumonia. Zyprexa prn.
.
# Chronic kidney disease: Creatinine at baseline (1.4 on day of
discharge). Recommend outpatient follow-up with renal to
consider epo given chronic anemia.
.
# FEN: low sodium
.
# PPX: sacral decub care, PPI
.
# Full code
.
# Dispo: discharged to [**Hospital3 2558**]
Medications on Admission:
Meds at recent discharge/per [**Hospital3 2558**] records
Docusate Sodium 100 mg PO BID
Aspirin 81 mg daily
Prilosec 40 mg PO daily
Valsartan 40 mg PO daily
Nifedipine 60 mg PO daily
Minitran 0.1 mg/hr Patch (on during day, off at night)
Coumadin 3 mg PO daily
Nitroglycerin 0.1 mg/hr Patch (on during day, off at night)
Olanzapine 5 mg PO QHS (discontinued [**5-19**])
Olanzapine 2.5 mg PO TID prn agitation
Acetaminophen 650 mg PO Q8H pain
Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
3. Minitran 0.1 mg/hr Patch 24 hr Sig: One (1) patch Transdermal
once a day: APPLY TO CHEST EACH DAY, OFF AT BEDTIME.
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a
day.
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: DOSE DAILY, BASED ON DAILY INR.
6. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) MG
Subcutaneous Q24H (every 24 hours): PLEASE CHECK FACTOR Xa
TONIGHT, AS REQUESTED.
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation, delerium.
8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every eight (8)
hours as needed for pain.
9. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 3 days.
Disp:*2 gram* Refills:*0*
15. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
primary:
ileus
nosocomial pneumonia
hemoptysis with underlying left upper lobe lesion - suspect
malignancy (ruled out for TB with AFB negative x 3; family
deferred biopsy for definitive diagnosis)
secondary:
history of right IJ thrombus
atrial fibrillation
chronic kidney disease
chronic anemia
Discharge Condition:
good: stable on room air, hematocrit stable, taking good po
Discharge Instructions:
Please monitor for temperature > 100.5, worsening hypoxia,
vomiting, abdominal pain, or other concerning symptoms.
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2107-6-16**] 11:00. [**Telephone/Fax (1) 250**]
Name: [**Known lastname 14466**],[**Known firstname 5139**] L. Unit No: [**Numeric Identifier 16671**]
Admission Date: [**2107-6-3**] Discharge Date: [**2107-6-9**]
Date of Birth: [**2015-6-29**] Sex: F
Service: MEDICINE
Allergies:
Univasc
Attending:[**First Name3 (LF) 4787**]
Addendum:
Folate 6.3, which is low normal. Consider checking MMA and
homocysteine outpatient for further work-up.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4788**] MD [**MD Number(2) 4789**]
Completed by:[**2107-6-9**]
|
[
"560.1",
"427.31",
"403.90",
"V10.3",
"280.9",
"585.9",
"486",
"162.8",
"414.01",
"786.3",
"182.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14938, 15166
|
9126, 11556
|
234, 265
|
14056, 14118
|
4171, 4504
|
14281, 14915
|
3488, 3548
|
12082, 13623
|
13737, 14035
|
11582, 12059
|
14142, 14258
|
3563, 4152
|
6503, 9103
|
174, 196
|
293, 2309
|
4513, 6081
|
2331, 3100
|
3116, 3472
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
158
| 169,433
|
44843
|
Discharge summary
|
report
|
Admission Date: [**2170-2-3**] Discharge Date: [**2170-2-6**]
Date of Birth: [**2102-2-26**] Sex: M
Service: MED-BLUMGA
For content of this Discharge Summary, please refer to the
Discharge Summary dictated by myself, with Discharge Date of
[**2170-2-3**], for content.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-419
Dictated By:[**Last Name (NamePattern1) 14783**]
MEDQUIST36
D: [**2170-4-19**] 13:56
T: [**2170-4-19**] 14:03
JOB#: [**Job Number 19220**]
|
[
"401.9",
"V45.81",
"493.20",
"532.40",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,258
| 103,498
|
19889
|
Discharge summary
|
report
|
Admission Date: [**2197-11-18**] Discharge Date: [**2197-11-20**]
Date of Birth: [**2141-4-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male
with no previous medical history, who was out shoveling snow
on the day of admission. Five to 10 minutes into shoveling,
the patient experienced very heavy chest pressure associated
with shortness of breath, diaphoresis, and general weakness.
The patient has never experienced anything like this before.
The patient exercises regularly and has noticed that his
exercise tolerance has not changed recently. He jogs
approximately three miles every day and bikes regularly. The
patient immediately called 911 and was taken to the Emergency
Department, where he was found to have ST segment elevations
in leads II, III, and aVF as well as a Q wave in leads II,
III, and aVF.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: The patient has a 30 pack year smoking
history, but quit three years ago. He drinks half a bottle
of wine everyday. He is employed and moved from Europe three
years ago with his wife due to her job. He is not currently
employed, but does fly planes.
FAMILY HISTORY: The patient's maternal grandfather had a
heart attack at age 60. Otherwise, his mother and father are
both alive with no coronary artery disease.
PHYSICAL EXAMINATION: Physical exam is notable for a heart
rate of 64 and a blood pressure of 99/60. His lungs are
clear. His heart is regular, rate, and rhythm with no
murmur. The remainder of his physical exam is unremarkable.
LABORATORIES ON ADMISSION: Notable for a CK of 64 and a
troponin of less than 0.01. The remainder of his
laboratories are all within normal limits.
EKG: Shows sinus bradycardia at a rate of 58. There are 2
mm ST segment elevations in leads II, III, and aVF. There
are also Q waves in leads II, III, and aVF. There is left
atrial enlargement and borderline left ventricular
hypertrophy.
HOSPITAL COURSE: The patient was admitted with a ST segment
elevation MI in the inferior leads. He was taken immediately
to cardiac catheterization, where he was found to have
complete occlusion of his right coronary artery. The artery
was stented. There was no evidence of stenosis in any of the
other arteries.
Following procedure, the patient became briefly hypotensive
and was started on a dopamine drip. He was admitted to the
CCU for close monitoring. The patient was quickly weaned off
dopamine with systolic blood pressures in the 90s to low
100s. The patient had several episodes of nonsustained VT,
which he spontaneously broke out of in the day following
cardiac catheterization. These episodes of NSVT most likely
represent reperfusion injury. Throughout the remainder of
the hospitalization, the patient experienced no further
episodes of chest pain, diaphoresis, shortness of breath,
nausea, or vomiting.
Post cardiac catheterization EKG showed resolution of ST
elevations. The patient was started on aspirin, Plavix, and
Lipitor. He was started on a low dose of a beta blocker
which he tolerated well. It was decided not to start ACE
inhibitor prior to discharge due to a borderline blood
pressure with a systolic blood pressure of 100. The patient
was advised to never take up smoking again, and was asked to
reduce his alcohol intake to a maximum of two drinks per day.
Patient was also advised not to fly planes at least until he
sees a cardiologist.
An echocardiogram was performed prior to discharge, which
showed a mildly depressed left ventricular ejection fraction
of 45-50% with marked inferior hypokinesis. There was also
1+ mitral regurgitation and a mildly dilated left atrium.
CONDITION ON DISCHARGE: Stable, chest pain free with no
shortness of breath, and ambulating well without assistance.
DISCHARGE STATUS: The patient is discharged to home without
any home services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post ST segment elevation
myocardial infarction with stenting of the right coronary
artery.
2. Hypotension.
3. Hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. x3 months.
3. Lipitor 10 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
FOLLOW-UP PLANS:
1. The patient is asked to followup with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53713**] on Friday, [**11-24**]. A phone
call was made to Dr. [**Last Name (STitle) 53713**] and a message was left
explaining the reason for hospitalization, and the
recommendation that the patient be started on an ACE
inhibitor if his blood pressure can tolerate it.
2. Patient is scheduled to followup with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in
Cardiology on [**2197-12-15**] at 3 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.12.222
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2197-11-20**] 13:45
T: [**2197-11-22**] 07:31
JOB#: [**Job Number 53714**]
|
[
"410.41",
"272.0",
"414.01",
"458.29",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"99.20",
"36.01",
"36.06",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
1253, 1401
|
3973, 4135
|
4158, 4279
|
2047, 3752
|
1424, 1648
|
4296, 5092
|
958, 965
|
163, 868
|
1663, 2029
|
891, 936
|
982, 1236
|
3777, 3952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,755
| 148,217
|
55115
|
Discharge summary
|
report
|
Admission Date: [**2105-8-10**] Discharge Date: [**2105-8-14**]
Date of Birth: [**2026-6-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79M s/p transduodenal resection ampullary mass (pathology
benign) w/reimplantation of pancreatic and biliary ducts on
[**2105-7-28**] presents at clinic outpatient visit with fatigue and
tarry well-formed stools (2 days' duration) and a hematocrit of
20.3. He also reports decreased appetite (one week's duration),
and shortness of breath (morning of admission). Denies fevers,
chills, weight change, and urinary changes. Reports that
glucose was 290 the morning prior to admission, which is rare
for him (it is usually 95-105). Labs were drawn after the visit:
Hematocrit was 20.3, down from 28.5 on [**8-3**]. WBC was 12.7, up
from 6.4 on [**8-3**]. The patient was admitted for further
evaluation.
Past Medical History:
PMH: CAD, MI s/p CABG 4v in [**2084**] and Stent x 2 in 08,
Hyperlipidemia
HTN, DMII, last HgA1c 6, CKD (Cr 1.7-2.1)
PSH: CABG 4v in [**2084**], stents x2 n [**2100**], Open cholecystectomy [**42**]
yrs ago, hemmoroidectomy tonsilectomy.
Social History:
The patient does not drink or use tobacco.
Family History:
There is no family history of pancreatic cancer.
Physical Exam:
Upon Discharge:
Vitals: 98.3, 81, 137/44, 18, 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses. Surgical incision
healed well.
Ext: LE warm and well perfused
Pertinent Results:
[**2105-8-13**] 01:09PM BLOOD Hct-30.2*
[**2105-8-14**] 05:00AM BLOOD WBC-10.2 RBC-3.45* Hgb-10.0* Hct-30.6*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.3* Plt Ct-308
[**2105-8-14**] 05:00AM BLOOD Glucose-102* UreaN-17 Creat-1.0 Na-133
K-3.8 Cl-102 HCO3-25 AnGap-10
[**2105-8-13**] 02:08AM BLOOD Amylase-240*
[**2105-8-14**] 05:00AM BLOOD Calcium-7.5* Phos-2.4* Mg-2.0
[**2105-8-12**] 06:05AM BLOOD Type-ART pH-7.47*
[**2105-8-10**] CT ABD:
IMPRESSION:
1. Intraperitoneal lesion adjacent to the third portion of the
duodenum
represents an intraperitoneal hematoma in the setting of recent
surgical
procedure and hematocrit drop. No clear relationship with any
major abdominal vessel is seen.
2. Stranding around the pancreatic head raises suspicion for
focal
pancreatitis. Correlation with amylase and lipase is
recommended.
3. Unchanged common bile duct dilatation. Intrahepatic biliary
duct
dilatation and pneumobilia are the result of recent
sphincterotomy.
4. Mildly atrophic kidneys are consistent with chronic kidney
disease.
[**2105-8-11**] EGD:
Impression:
No evidence of blood in the stomach
Traces of fresh blood seen in the duodenum.
The biliary anastomosis was visualized and was patent.
The duodenotomy site was visualized as well.
No evidence of ulcer or bleeding at the biliary anastomosis or
at the duodenotomy site.
Brief Hospital Course:
The patient s/p transduodenal ampullary mass resection [**7-28**] was
readmitted to the HPB Surgical Service from clinic with HCT 20.3
and complains of melena at home. Abdominal CT scan revealed
intraperitoneal hematoma and focal pancreatitis. The patient was
transferred on the floor NPO with IVF, he was transfused with
one unit of pRBC, patient's [**Month/Year (2) **] and Aspirin was held. Post
transfusion HCT was 21.6 and patient received 2 more units of
pRBC. The patient's HCT was 21.0 after second transfusion and
patient was transferred in ICU for closer observation. On HD #
2, patient underwent EGD, which demonstrated no evidence of
ulcer or bleeding at the biliary anastomosis or at the
duodenotomy site. He received 5 units of pRBC and one unit of
FFP. Patient's HCT increased to 31.6 and remained stable prior
discharge. He was transferred back to the floor on HD # 4 in
stable condition. The patient continued to have melena stool on
HD 1 and 2, the melena subsided prior discharge. The patient was
hemodynamically stable during admission.
Neuro: The patient remained stable from neurological stand point
during admission. Post op pain was controlled with PO Tylenol.
CV: The patient's [**Month/Year (2) **] and Aspirin were held on admission.
Aspirin 81 mg was restarted on HD # 3 and patient's Cardiology
was contact[**Name (NI) **] about [**Name (NI) **]. Aspirin 325 mg QD was restarted
prior discharge, patient's [**Name (NI) **] was held for 2 weeks per his
Cardiologist. The patient was instructed to restart his [**Name (NI) **]
on [**2105-8-25**]. The patient was restarted The patient remained
stable from a cardiovascular standpoint; vital signs were
routinely monitored with telemetry.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced to clears on HD # 3 and to regular on
HD # 4, which was well tolerated. Patient's intake and output
were closely monitored, and IV fluid was adjusted when
necessary. Electrolytes were routinely followed, and repleted
when necessary.
ID: No issues.
Endocrine: No issues.
Hematology: As above.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
amlodipine 20 mg QD, atenolol 50 [**Hospital1 **], atorvastatin 20 mg QD,
clopidogrel 75 QD, doxazosin 1 mg QD, lasix 40 mg QD, isosorbide
dinitrate 60 mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325 mg QD, saxagliptin 2.5 mg QD
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Amlodipine 10 mg PO DAILY
9. Isosorbide Dinitrate ER 60 mg PO DAILY
Do not crush
10. Losartan Potassium 100 mg PO DAILY
11. Doxazosin 1 mg PO HS
12. Furosemide 40 mg PO DAILY
13. saxagliptin *NF* 2.5 mg Oral QD
14. Clopidogrel 75 mg PO DAILY
Please restart [**First Name3 (LF) **] on [**2105-8-25**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
1. Melena
2. Upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] with symptoms
of upper GI bleed. You now safe to return home to complete your
recovery with the following instructions:
You can restart taking [**Hospital1 **] on [**2105-8-25**], please do not take
[**Date Range **] until [**2105-8-25**].
Please resume other regular home medications.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-9**] 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.
.
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.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2105-9-14**] at 9:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with Dr. [**First Name (STitle) **] on [**1-2**] weeks after discharge.
.
Please follow up with your Cardiologis Dr. [**Last Name (STitle) 112449**] as scheduled.
Completed by:[**2105-8-14**]
|
[
"272.4",
"412",
"414.00",
"E878.8",
"998.12",
"285.1",
"278.00",
"V45.81",
"578.1",
"585.9",
"250.00",
"458.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6860, 6918
|
3172, 5989
|
309, 316
|
6990, 6990
|
1821, 3149
|
8910, 9406
|
1390, 1440
|
6279, 6837
|
6939, 6969
|
6015, 6256
|
7141, 8887
|
1455, 1455
|
263, 271
|
1471, 1802
|
344, 1049
|
7005, 7117
|
1071, 1313
|
1329, 1374
|
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