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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
18,543
| 197,640
|
14890
|
Discharge summary
|
report
|
Admission Date: [**2121-9-24**] Discharge Date: [**2121-10-10**]
Date of Birth: [**2056-12-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
BRBPR s/p catheterization procedure
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Right Colectomy
Ileocolostomy
Cardiac cathetrization with stenting of the RPLB and RPDA.
History of Present Illness:
This is a 64 y.o. man with a history of HTN, CAD who underwent
catheterization on [**2121-9-24**] with placement of a total of 5
stents (4 drug eluting in the PLB, PDA and RCA (mid, distal and
proximal) transferred from the CMI service for BRBPR. The
patient was cath'd in the setting of uncontrolled HTN,
progressive DOE x 6 months and a positive stress test. The
patient's cath was without complication and revealed one vessel
disease with in-stent restenosis from a prior cath to the RCA.
Approximately 24 hours post-cath, while on aspirin and plavix
(last heparin pre-cath) the patient had 3 episodes of BRBPR. The
patient has remained hemodynamically stable with BP in the
108-115/50's range with pulse in the 80's. The patient is
without symptoms, denying CP, SOB, dizziness or lightheadedness.
The patient's Hct dropped from 34.2 post-cath to 29.9. NG lavage
was negative for blood.
Colonoscopy showed 2 AVMs near the cecum in the ascending colon,
started bleeding on manipulation - BiCapped/injected,
accidentally perforated cecum. Pt. descended into septic shock,
and was taken to OR for R colectomy and washout.
Past Medical History:
2 infrarenal aortic aneurysms (1.4cm, 2.3cm)
HTN
CAD. s/p cath in [**2116**] due to abnormal stress with totally
occluded mid RCA and 50-70%proximal RCA with successful stenting
x3.
Dyslipidemia
Social History:
Married. Works as a water supply technician. Denies alcohol,
tobacco or drug use.
Family History:
NC
Physical Exam:
VS 97.4 110/60 86 16 97% RA
Gen: NAD. Comfortable.
Integumentary: No rashes or lesions.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: Systolic ejection murmur at 2nd intercostal space with faint
radiation to the carotids.
Pulm: CTA bilaterally.
Abd: Soft, nontender, nondistended. Normoactive bowel sounds.
Ext: No edema.
Neuro: Alert and oriented x3.
Psych: Appropriate mood and affect.
Pertinent Results:
[**2121-10-2**] 06:16AM BLOOD WBC-16.0* RBC-3.30* Hgb-9.9* Hct-29.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.0 Plt Ct-519*
[**2121-10-2**] 06:16AM BLOOD Plt Ct-519*
[**2121-10-2**] 06:16AM BLOOD Glucose-130* UreaN-20 Creat-0.8 Na-146*
K-3.5 Cl-108 HCO3-28 AnGap-14
[**2121-10-2**] 06:16AM BLOOD Calcium-8.3* Phos-4.3# Mg-2.5
Cardiology Report ECHO Study Date of [**2121-9-25**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal, and the cavity is small. Left ventricular systolic
function is
hyperdynamic (EF>75%), without regional wall motion
abnormalities. There is
abnormal flow in the left ventricle, consistent with a
mid-cavitary gradient.
Right ventricular chamber size and free wall motion are normal.
The aortic
root and the ascending aorta are mildly dilated. The aortic
valve leaflets
(?number) are moderately thickened. There may be minimal aortic
valve
stenosis, however present evaluation of aortic valve area is
limited by
high-velocity contamination from the intracavitary gradient.
Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. There is mild pulmonary artery
systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Small left ventricular cavity with hyperdynamic left
ventricular
systolic function. Mid-cavitary gradient. Probable minimal
aortic stenosis.
Mildly dilated thoracic aorta.
A repeat transthoracic study to reassess the mid-cavitary
gradient and
determine severity of aortic stenosis may be performed following
an
intravenous fluid challenge.
.
CT ABDOMEN W/CONTRAST [**2121-9-27**] 8:38 PM
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with 2 infrarenal aotic aneursysms, HTN, CAD,
s/p elective cath, with new LGIB, s/p EGD, cauterized for
polyps/hemmorhoids, today w/ severe abd pain, unable to have BM.
IMPRESSION:
1. There is stranding and cecal wall thickening within the right
lower quadrant, with tiny adjacent foci of air. This is
consistent with focal perforation. There is adjacent fluid
within the mesentery and pelvis also noted.
2. There is calcification of the gallbladder wall and then the
gallbladder lumen, findings are consistent with a single large
calcified stone or porcelain gallbladder.
3. There is aortic calcification noted, however there is no
significant aneurysmal dilatation identified.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 43656**],[**Known firstname **] [**2056-12-19**] 64 Male [**-4/4284**] [**Numeric Identifier 43657**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: RIGHT COLON, DISTAL ILEUM, MESENTERY
Procedure date Tissue received Report Date Diagnosed
by
[**2121-9-28**] [**2121-9-29**] [**2121-10-1**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg
DIAGNOSIS:
I. Ileocolectomy (A-T):
1. Localized area of transmural ischemic necrosis in the cecum,
with acute perforation.
2. Acute peritonitis.
3. Ileal segment, appendix and rest of colon segment, within
normal limits.
II. Ileum, distal (U-V):
Segment of ileum, within normal limits.
III. Mesentery (W-Z):
Adipose tissue with focal fresh hemorrhage.
Clinical: ? perforated ileum.
Cardiology Report ECG Study Date of [**2121-9-30**] 5:40:10 AM
Sinus rhythm
Right bundle branch block
Since previous tracing of [**2121-9-2**], rate decreased
Read by: [**Last Name (LF) 474**],[**First Name3 (LF) 475**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 140 126 [**Telephone/Fax (2) 43658**] 77 28
Brief Hospital Course:
The Surgical service assumed care of the patient and he went to
the OR on [**2121-9-28**]. A
Colonoscopy showed 2 AVMs near the cecum in the ascending colon,
started bleeding on manipulation - BiCapped/injected,
accidentally perforated cecum. Pt. descended into septic shock,
and was taken to OR for R colectomy and washout.
Post-operatively he was admitted to SICU. Intermittently, he was
hypotensive/tachycardic, and responsive to IVF.
Cardiology was consulted and they stated that post op, he had a
brief period on Levophed and neo now off pressors HD sable. [**3-5**]
episodes of SOB lasting ~ 10 mins
EKG unchanged, sinus with RBBB, old inf qs. He had a slight bump
of CK, trop now trending down. He was started back on ASA,
Plavix, Zocor.
Pain: He became slightly confused with IV Morphine. The
narcotics were discontinued and he was comfortable with Tylenol.
ABD/GI: He was NPO, with IV fluids. His abdomen was round and
largely distended. He reported + flatus and +BM. His abdomen
began to soften over the next few days. His diet was slowly
advanced. His incision was intact.
Resp: He was on O2 via nasal cannula and had O2 saturation in
the 90's. As he became more mobile, his O2 requirements
decreased and was discontinued.
PT: PT evaluated this patient and cleared him for home.
[**9-29**] MRSA: neg., VRE: neg. all blood and urine cultures were
negative.
*****
On [**10-5**], he was getting ready for discharge, but then was noted
to have salmon-colored fluid emanating from the lower portion of
his midline incision. Bedside inspection demonstrated no
evidence of evisceration. The decision was made to take the
patient to the operating room for further exploration and to
address a likely dehiscence. The fascia was repaired with
figure-of-eight Prolene sutures and 4 retention sutures.
Post-operatively, he was NPO and antibiotics were continued. He
had a PCA for pain control and was on bedrest for 1 day. He was
then assisted by PT on POD [**9-1**] and encouraged to ambulate
safely. His antibiotics were D/C'd on POD [**9-1**]. The Foley was
removed and he was put back on his PO meds. His diet was
advanced from sips to clears. He was advanced to a regular diet
and was tolerating it fine and reported +flatus and +BM. He also
received Lasix for LE edema and scrotal edema over the next
several days. Pain was well controlled with PO Percocet.
PT recommended that he receive PT at home upon discharge.
He will continue with DSD dressing changes. The incision was
intact and dry. The retension sutures were inplace. His abdomen
was still distended and round and close to his baseline girth.
Medications on Admission:
Zocor 40mg QHS, Toprol XL 100mg QD, Avapro 150mg QD,
Triamterene/HCTZ 37.5/25 QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 3 weeks.
Disp:*60 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*qs Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] associates
Discharge Diagnosis:
CAD
AS
HTN
AVM, hemorroids and polys in colon
duodenitis and erosion in duoneum
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to walk several times per day.
No heavy lifting for 6 weeks.
No baths or showers until you see Dr.[**Last Name (STitle) 519**] at your follow-up
appointment. Keep incision clean and dry. Change daily with Dry
Sterile Dressing.
Please monitor yourself for symptoms of lightedness, bleeding w/
bowel movements, chest pain or shortness of breath and call your
doctor or call 911 (during nite time) as these may indicate a
more serious issue w/ your heart or colon.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] on Monday, [**2121-10-20**].
Call ([**Telephone/Fax (1) 5323**] to schedule an appointment.
Dr. [**Last Name (STitle) 24717**] 1-2 weeks. Call to schedule an appointment
Follow up echocardiograms per Dr. [**Last Name (STitle) 24717**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2121-10-10**]
|
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"557.0",
"455.0",
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"E879.0",
"996.09",
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"413.9",
"272.4",
"593.2",
"441.4",
"211.3",
"E878.6",
"998.32",
"372.30",
"569.85",
"424.1",
"518.0",
"E849.8",
"401.9",
"496",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"45.93",
"00.45",
"00.66",
"00.48",
"99.20",
"45.73",
"99.04",
"45.43",
"36.07",
"45.13",
"83.65",
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] |
icd9pcs
|
[
[
[]
]
] |
9844, 9951
|
6142, 8763
|
353, 468
|
10075, 10082
|
2395, 4040
|
10850, 11302
|
1954, 1958
|
8894, 9821
|
4077, 6119
|
9972, 10054
|
8789, 8871
|
10106, 10827
|
1973, 2376
|
278, 315
|
496, 1620
|
1642, 1839
|
1855, 1938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,251
| 144,671
|
52224
|
Discharge summary
|
report
|
Admission Date: [**2178-4-29**] Discharge Date: [**2178-5-8**]
Date of Birth: [**2119-9-28**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman who presents from home after finding an incidental
right frontal inferior hemorrhage as part of a preoperative
work-up for angiogram for possible coiling of a left internal
carotid artery aneurysm.
PAST MEDICAL HISTORY: 1. Left neck pain status post
radiculopathy and facet blocks. 2. Hypertension. 3.
Gastroesophageal reflux disease. 4. Hypercholesterolemia.
5. Depression. 6. Constipation.
PHYSICAL EXAMINATION: The patient's temperature was 98.7,
heart rate 74, blood pressure 90/palpable. The patient was
awake, alert and oriented x 3, and cooperative. HEENT:
Pupils were equal, round, and reactive to light, extraocular
movements full. Neck: Soft tissue swelling around the
bilateral clavicles related to steroids in the past. Lungs:
clear to auscultation. Cardiac: Regular rate and rhythm
with a systolic murmur [**3-12**]. Abdomen: Soft, nontender,
nondistended, with positive bowel sounds. Extremities: No
cyanosis, clubbing or edema. Positive pedal pulses
bilaterally. Neurologic: Awake, alert, oriented x 3, speech
fluent. Smile symmetric. Tongue midline. Cranial nerves
two through 12 were intact. Sensation was intact. Motor
strength was [**6-8**] in all muscle groups. Gait was normal.
MRI/MRA of the head showed a right inferior frontal
hemorrhage with no obvious aneurysm. MRI without contrast
showed a large high cervical internal carotid artery
pseudoaneurysm. The patient was admitted for q. 4 hour
neurological checks.
HOSPITAL COURSE: Her vital signs remained stable. She was
afebrile. She was taken for angiogram on [**2178-5-1**] which
showed a left internal carotid artery aneurysm. Post
procedure the patient was stable, neurologically intact,
moving all extremities, no groin hematoma, positive pedal
pulses. The patient had a repeat head CT on [**2178-5-3**] which
was stable with no evidence of extension of the hemorrhage.
The patient continued to be neurologically intact. She was
seen by the endocrine service at the patient's request for
problems with temperature fluctuations most likely related to
stopping her hormone replacement therapy. The patient will
be followed up as an outpatient.
She was also seen by the cardiothoracic surgery service for
an incidental finding of a right middle lobe nodule on chest
x-ray. The patient had a CT at an outside hospital which
showed this nodule, and again the patient will be worked up
as an outpatient for further treatment for that nodule.
On [**2178-5-8**] the patient went back for arteriogram and she had
a balloon occlusion and coiling of the left internal carotid
artery aneurysm. The patient postoperatively was in the
intensive care unit, monitored for three days where she
remained neurologically intact with the head of the bed
slowly being elevated. She did remain flat for 48 hours.
She had no periods of dizziness or hypotension with the head
of the bed elevated, and she was then transferred to the
regular floor on [**2178-5-12**]. She was out of bed ambulating,
tolerating a regular diet. On [**5-15**] the patient went back
for arteriogram for evaluation of the balloon occlusion and
coiling. The patient's aneurysm was well coiled and secure.
Her neurologic status remained stable. Her groin was clean,
dry and intact with no hematoma. Her vital signs were
stable. She was out of bed ambulating, tolerating a regular
diet post procedure. She was discharged to home on [**2178-5-16**]
in stable condition for follow up with Dr. [**Last Name (STitle) 1132**] in [**11-17**]
days.
DISCHARGE MEDICATIONS:
1. Celexa 40 mg p.o. q.h.s.
2. OxyContin 20 mg b.i.d.
3. Percocet 1-2 tablets p.o. q. 4 hours p.r.n.
4. Trazodone 100 mg q.h.s.
5. Melatonin 3 grams q.h.s.
6. Corgard 40 mg p.o. b.i.d.
7. Prevacid 30 mg p.o. b.i.d.
8. Topamax 100 mg p.o. q.d.
9. Lopid 600 mg p.o. b.i.d.
10. Ativan 0.5 mg p.o. q. 4 hours p.r.n.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow up with Dr. [**Last Name (STitle) 1132**] in one to two
weeks' time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2178-5-28**] 11:55
T: [**2178-5-28**] 12:18
JOB#: [**Job Number 108034**]
|
[
"300.01",
"272.0",
"442.81",
"530.81",
"627.8",
"729.1",
"431",
"401.9",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3753, 4066
|
1694, 3730
|
4112, 4456
|
629, 1676
|
172, 406
|
429, 606
|
4091, 4100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,411
| 160,912
|
1148
|
Discharge summary
|
report
|
Admission Date: [**2115-6-26**] Discharge Date: [**2115-7-11**]
Date of Birth: [**2053-1-4**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Left ankle pain
Major Surgical or Invasive Procedure:
Left ankle fusion
History of Present Illness:
62 year old male with h/o CAD, HTN, HC, ?AF (on coumadin - per
pt b/o stents), RA, multiple prior myocardial infarctions s/p
multiple stents, and recent in-[**First Name3 (LF) **] thrombosis of OM2 [**First Name3 (LF) **] in
[**2115-4-17**] in the setting of discontinuation of his clopidogrel for
5 days in anticipation of the same elective surgery, now again
admitted for elective left ankle fusion for rheumatoid
associated arthritis, found to have an NSTEMI post-[**Hospital 7375**]
transferred to Medicine for further management.
.
Since the PTCA to his OM2 in-[**Hospital **] thrombosis, the patient says
he is back to his usual baseline. He does get reproducible
angina with exertion (working in the yard), but very
infrequently gets angina at rest (this is also longstanding).
What limits his activity currently is his severe left ankle
pain. Before his ankle began really bothering him, about a year
ago, he was walking three miles on the treadmill everyday with
occasional nitroglycerin use, and no shortness of breath. Now he
simply can't exercise secondary to the pain.
.
He used to smoke remotely, three PPD but quit in the 70s. He
doesn't recall having any pulmonary problems, and denies any
dsypnea.
.
He underwent left ankle fusion on [**6-28**]. His coumadin has been
held since Sunday ([**6-22**]). He was continued on ASA and Plavix for
the procedure, per cardiology and orthopedics, as his prior
in-[**Month/Day (2) **] thrombosis occurred while off Plavix. Post-operatively,
he developed new ST depressions in I and aVL as well as a bump
in his cardiac enzymes. He was started on a heparin drip and
transferred to medicine.
.
Of note, post-OP course was also complicated by nose bleed, now
s/p nose packing. His Hct dropped from admission Hct of 35 to 25
post-OP. EBL during operation was 400cc.
.
On arrival to the medicine floor, his VS were stable. He denied
any CP throughout the hospital stay, only minimal chest pressure
lasting a few seconds shortly prior to admission. Also no SOB or
palpitations. He denies any dizziness and did not note any blood
from below. He did remember blood coming from his oropharynx and
nose post-operatively.
.
Past Medical History:
1) Hypertension
2) Hypercholesterolemia
3) Coronary artery disease, status post multiple MIs with
stents, last PTCA [**4-17**] as above secondary to in-[**Month/Year (2) **] thrombosis
of OM2 while holding Plavix. Otherwise has had stents to
proximal and mid LAD, D1, LCx, OM2, and multiple
atherectomies/PTCAs. On coumadin, clopidogrel, and ASA given
apparent hypercoagulability.
4) Congestive heart failure, EF 30%
5) Rheumatoid arthritis
6) Glucose intolerance
7) ?AF, on coumadin (per patient on coumadin b/o stents; per one
recent cardiology OMR note on coumadin for AF)
.
Detailed cardiac history:
[**4-/2102**]: acute MI treated with TPA.
[**2102-5-23**] cath: 80% pLAD treated with DCA, 30% dLAD, origin D2 with
40% lesion, bifurcating OM1 T.O.
[**2102-11-2**] cath (+ETT): 90% lesion in mLAD at prior DCA site, S/P
[**Month/Day/Year **] X 2 placed to proximal and mid LAD. 80% D2.
[**2104-6-4**] cath d/t rest angina: S/P [**Month/Day/Year **] placement in OM2 with
unsuccessful PTCA of lower pole.
[**2107-6-2**] cath d/t exertional angina: Previously stented OM2
patent
but with occcluded inferior pole, filling via collaterals.
Unable
to cross with wire. 40% pLAD, 70-80% D2.
[**2110-7-11**] S/P successful PTCA and stenting of the proximal OM2
using a 2.5 x 23 mm BX Velocity [**Month/Day/Year **]. Also S/P successful
direct stenting of the proximal circumflex using a 3.5 x 8 mm BX
Velocity Hepacoat [**Month/Day/Year **].
[**8-22**] S/P ptca of D1.
[**11-22**] Admitted to [**Hospital1 18**] with rest angina.+NQWMI. S/P
PTCA/rotational atherectomy of the diagonal and ptca/rotational
atherectomy and beta-brachytherapy of the OM2 instent restenosis
[**3-23**] s/p 2.5x 15mm Biodivysio [**Month/Year (2) **] to the LAD
[**2111-7-29**] R/I for a NSTEMI
[**2111-7-31**] s/p two 2.5 x 23mm Cypher stents to the LAD
[**2111-8-4**] Acute chest pain, MLAD [**Month/Day/Year **] thrombosis, s/p 2.5 x 13
and
2.5 x 8mm Hepacoat stents to the LAD.
[**2111-8-19**] s/p 2.5 x 8mm Cypher [**Month/Day/Year **] to OM2
[**2113-4-4**] s/p 2.5 x 28mm Cypher DES to OM1
[**2114-2-14**] ST elevation MI OM totally occluded at [**Month/Day/Year **] site, s/p
PTCA. Patent LAD stents.
[**2114-3-1**] Cath d/t rest angina, cath did not reveal any flow
limiting CAD.
[**2115-4-16**] Cath due to acute [**Month/Day/Year **] thrombosis of OM2 stents after
an
ankle procedure, treated with thrombectomy and PTCA.
Social History:
He drinks alcohol, mostly on the weekends, and will have "a few"
beers and "a few" margaritas on those times. He used to drink
heavily but stopped in the 80s. He would drink a case of beer
daily and have multiple hard liquor shots. He stopped this at
his wife's encouragement. He currently lives at home with his
wife. [**Name (NI) **] used to smoke 3 PPD, but quit in the 70s. No drug use.
Family History:
Mother with CVA and MIs starting at the age of 60. No premature
CAD.
Physical Exam:
Prior to transfer to medicine (pre-OP):
97.0, 102/60, 67, 18, 97% on RA.
GENERAL: Overweight caucasian male resting comfortably in bed.
HEENT: Moist mucous membranes.
NECK: No JVD.
COR: RR, normal rate, distant heart sounds without obvious
murmur.
LUNGS: Clear bilaterally.
ABDOMEN: Normoactive bowel sounds, soft, non-tender, no bruits.
EXTR: No edema. Marked ulnar deviation of hands bilaterally with
swan neck deformities. Left ankle slightly warm compared to
right, with hypertrophy of joint and limited mobility.
NEURO: Strength is [**5-25**] in the hip and knee flexion/extension,
and upper extremity strength is [**5-25**] at the elbows and wrists.
.
On transfer to medicine (post-OP):
97.7, 108/62, 86, 18, 100% on 3L.
GENERAL: Overweight caucasian male resting comfortably in bed.
Somewhat sedated from narcotics post-operatively.
HEENT: Moist mucous membranes. Clear OP, no lesions, no blood
visualized. No blood in nasal cavities visualized.
NECK: No JVD. Thick neck.
COR: RR, normal rate, distant heart sounds without obvious
murmur.
LUNGS: Mild crackles at both bases. No rhales or rhonchi or
wheezes.
ABDOMEN: Normoactive bowel sounds, soft, non-tender.
EXTR: No edema. Marked ulnar deviation of hands bilaterally with
swan neck deformities. Left ankle and calf in cast.
Pertinent Results:
[**2115-6-26**] 08:30PM WBC-8.5 RBC-3.44* HGB-11.8* HCT-35.5*
MCV-103* MCH-34.2* MCHC-33.1 RDW-17.0* PLT COUNT-233
[**2115-6-26**] 08:30PM GLUCOSE-143* UREA N-29* CREAT-1.5* SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
.
Echo [**1-/2114**]: EF 30%, posterolateral hypokinesis
.
LAST CATHETERIZATION [**2115-4-16**]:
1. Selective coronary angiography of this left dominant system
revealed two vessel disease. There was mild disease in the LMCA.
The LAD revealed widely patent stents. The LCx had a 30% ISR of
the proximal OM2 [**Month/Day/Year **] and total occlusion of the OM2 stents
distally. The RCA was totally occluded proximally.
2. Limited resting hemodynamics revealed an opening aortic
pressure of 111/63mmHg.
3. Left ventriculography was deferred.
4. The [**Month/Day/Year **] thrombosis of the OM2 was treated with thrombectomy
and
balloon angioplasty using a 2.0 mm, 2.5 mm and a 3.0 mm
balloons. The final angiogram showed partially reestablished
flow with no residual
stenosis, no dissection and no embolisation. (see PTCA comments)
5. IVUS intorrogation of the OM2/LCX/LMCA did not show any
significant lesions. It revealed a MLD of 2.1 X 2.3 mm. (see
PTCA comments)
FINAL DIAGNOSIS:
1. Late [**Month/Day/Year **] thrombosis of OM2 stents.
2. Successful PTCA of the OM2.
3. IVUS examination of the OM2/LCX/LMCA showing no critical
lesions.
.
PA CXR [**6-26**]: The heart size is top normal in size. The aorta is
tortuous but stable in contour. The lungs are clear. Pleural
thickening along the right mid costal surface unchanged compared
to the previous study. No pleural effusion or pneumothorax is
identified.
.
Ankle XR (2 views) [**6-28**]: A cast is in place, obscuring fine
detail. Allowing for this, there is an intramedullary rod
extending across the tibiotalar joint and subtalar joint,
secured by two screws in the tibial diaphysis, additional screw
at the tibial metaphysis. An additional lower screw which is
hard to fully evaluate on this
view, and a distalmost screw extending through the calcaneus
from posterior to anterior. Question slight bowing of the
calcaneal spur, which may be accentuated by beam obliquity.
There is an osteotomy through the distal fibula and the distal
fibular fragment is secured to the distal tibia by screw.
Multiple skin staples are present. The tibiotalar and subtalar
joints appear to have been effaced. If clinically indicated,
views centered in the hindfoot could help to better assess the
joint spaces.
.
Baseline EKG pre-OP from [**2115-6-27**]: LAD, TWI I, aVL, ?less than 1mm
ST elevations in aVR and V1, poor RWP, LVH
Post-OP EKG [**2115-6-29**]: same findings as above, in addition very
small ST depressions in I, aVL (versus nonspecific)
.
CT Abdomen/pelvis [**2115-6-29**]: No evidence of retroperitoneal bleed
or other acute intraabdominal pathology.
.
Cardiac cath [**2115-7-1**]:
1. Selective coronary angiography in this left dominant
circulation
demonstrated three vessel coronary artery disease. The LMCA had
an
origin 20% stenosis with 30% stenosis distally. The LAD had a
proximal 60% stenosis and mid 40% instent restenosis. The distal
LAD had only mild plaquing. The D1 was subtotally occluded. The
LCx was without flow limiting disease proximally, but distally
had an eccentric 40-60% stenosis after OM2. OM1 was a small
caliber vessel with moderate diffuse disease. The OM2 was
totally occluded in the proximal [**Month/Day/Year **]. There was some
collateral filling of the lower pole of OM2. There was a 50%
stenosis in L-PL. The RCA was no engaged since it was known to
be non-dominant and severely diffusely diseased.
2. Limited resting hemodynamics from left heart catheterization
demonstrated normal systemic arterial pressure, but severely
elevated left heart filling pressure (27mmHg). There was no
transaortic pressure gradient upon catheter pullback from the
left ventricle to the ascending aorta.
3. Left ventriculography was deferred due to renal
insufficiency.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LAD stents.
3. Totally occluded OM2 stents.
4. Severely elevated left heart filling pressure.
.
CXR [**2115-7-1**]: Moderate cardiomegaly has progressed, and there is
slight increase in pulmonary vascular engorgement but no edema.
Heterogeneous opacification at the right lung base is new and
could represent either atelectasis or aspiration or focal region
of pneumonia or pulmonary hemorrhage.
.
Echo [**2115-7-3**]: The left ventricular cavity size is normal. There
is moderate regional left ventricular systolic dysfunction with
inferolateral akinesis/hypokinesis and mid to distal
anteroseptal and apical akinesis. Estimated left ventricular
ejection fraction ?30% (views suboptimal). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is dilated. Right ventricular systolic function is
borderline normal. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid
regurgitation.] 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. An
eccentric jet of Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is trivial pericardial
effusion.
Compared with the prior study (images reviewed) of [**2115-7-2**]
left ventricular systolic function is probably similar but views
are technically suboptimal for comparison. Mitral regurgitation
and tricuspid regirgitation are now more prominent. Estimated
pulmonary artery systolic pressure is now higher.
.
CT Abd/pelvis [**2115-7-8**]:
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Lung bases
demonstrate bilateral small pleural effusions and adjacent
atelectasis. The liver shows no focal lesion. The gallbladder,
spleen, pancreas, adrenal glands, kidneys are unremarkable. The
intra-abdominal loops of large and small bowel are normal in
caliber. Abdominal aorta maintains a normal contour. Mild
atherosclerotic calcification is seen throughout the aorta and
branched vessels. The celiac, SMA, [**Female First Name (un) 899**] are normally opacified.
Incidental note is made of aberrant origin
of the common hepatic artery from the aorta. No intra-abdominal
free air, free fluid, or lymphadenopathy is appreciated.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid
colon, bladder, prostate, seminal vesicles are unremarkable.
Bilateral rectal sheath hematomas are present, the right
measuring 6.2 x 5.6 cm and the left measuring 5.6 x 5.2 cm.
Hematocrit levels are seen within the rectal sheath hematomas,
suggestive of anticoagulation or hypocoagulable state. Note is
made of a reservoir for penile prosthesis within the right lower
pelvis.
BONE WINDOWS: No suspicious lytic or sclerotic lesion is
identified.
Degenerative changes are seen within the lower lumbar spine,
notably disc space narrowing and endplate sclerosis at L4-L5 and
L5-S1.
Brief Hospital Course:
62 year old male with rheumatoid arthritis, CAD, HTN, HC, AF,
multiple prior myocardial infarctions s/p multiple stents and
extensive history of CAD and multiple MIs, with last PTCA in
[**4-17**] of OM2 in [**Month/Year (2) **] thrombosis secondary to holding Plavix and
coumadin, admitted for ankle fixation, developed NSTEMI post-OP,
was transferred to medicine. Hospital course c/b hypotension
requiring CCU stay from [**7-3**] to [**7-8**], with transient pressor
support. Found to have been septic, likely from LLL HAP, was on
Vanc/Zosyn/Azithro, then transitioned to PO levo given GNR in
sputum. Later hospital course also c/b bilateral rectal sheath
hematomas.
.
1) Hypotension/fever: Patient developed IVF resistant
hypotension to SBP in 70s on [**7-3**] requiring transfer to CCU
where he spiked. He was started on stress dose steroids. CXR
showed a left lower lobe consolidation. Sputum grew GNRs. A
triple lumen cath was placed and he was given IVF resuscitation.
He was started on zosyn and vanco for broad coverage of hosp
acquired pna. Vancomycin and Zosyn were given from [**7-3**] to [**7-9**].
Azithromycin was briefly administered as well ([**2027-7-6**]). Patient
was transitioned to PO levofloxacn on [**7-9**] given GNR in sputum
and clinically stable. Patient was continued on steroid taper
after stress dose steroids. On transfer to medicine floor,
patient was on prednisone 40mg qd which was tapered to his
maintenance dose of 10mg daily. Patient should continue
levofloxacin for a total of 7 days. I&S was pending on GNR in
sputum culture and should be followed up after discharge.
Patient was febrile and hemodynamically stable on discharge. He
should follow up with his PCP after discharge.
.
2) CAD: Multiple cardiac RFs including HTN, HC, RA. H/o multiple
MIs, with last PTCA in [**2115-4-17**] of OM2 late in [**Date Range **] thrombosis
and RCA occlusion secondary to holding Plavix and coumadin. IVUS
of OM2/LCX/LMCA without critical lesions. Now with another
NSTEMI post-OP despite having continued ASA, plavix. EKG showed
new very small ST depressions in I, aVL (versus nonspecific
finding). Normal cardiac enzymes pre-OP on [**2115-6-26**]. CK 124, but
CK-MB of 16 with an index of 12.9 and troponin of 0.11 post-OP
on [**2115-6-29**]. CK went up further, likely because of muscle trauma
during surgery (peaked at [**Numeric Identifier 2249**]). Highest MB index remained at
12.9. Cardiac cath was performed on [**2115-7-1**] which showed three
vessel coronary artery disease, patent LAD stents, but totally
occluded OM2 stents. Also severely elevated left heart filling
pressure were noted. No PCI was performed on the OM2 occlusion
because there were collaterals from LPL and PCI may shower
emboli. Pt remained without CP post-MI until [**10-3**] when he
developed chest burning which he stated was more like his
"heartburn" pain. He took SL nitro with improvement of sx. An
EKG was unchanged but his Troponin was up to 2.0. No change in
mgm given already maximal medical therapy. After transfer to the
CCU he also had intermittent chest pain with slight ST
depressions V2-V6 which were rate-related. He responded to SL
nitro. CEs were flat and it was not thought to be ACS. Patient
was continued on Heparin drip until he developed rectal sheath
hematomas (see below). Patient was continued on ASA, Plavix as
well as his BB, statin, Imdur. His ACEI was held throughout most
of his hospital course b/o ARF (see below). ACEI was restarted
at 5mg daily on day of discharge when his Cr was around his
baseline. Patient should follow up with his cardiologist after
discharge.
.
3) Rhythm: Per recent cardiology OMR note, on coumadin for AF.
Per patient, on coumadin b/o stents. NSR on EKG. Monitored on
tele. Coumadin was held peri-operatively. Patient was continued
on BB, titrated as BP tolerated. Patient was also on heparin
drip after NSTEMI (see above) which was discontinued towards the
end of his hospital stay /o bilateral rectal sheath hematomas
(see below). Coumadin was held as well but restarted upon
discharge at 5mg daily. INR should be checked two days after
discharge, then twice weekly for one month, followed by monthly
INR checks and adjustments of his coumadin dose.
.
4) Pump: EF 30% and posterolateral hypokinesis on last Echo from
1/[**2114**]. Euvolemic on exam. CXR without pulmonary edema. However,
severely elevated left heart filling pressure were noted on
cath. No LV-gram shot given CRI. Echo showed similar LVEF
(approx. 30%) but more prominent MR [**First Name (Titles) **] [**Last Name (Titles) **] as well as PAH.
Patient was diuresed as needed during hospital stay. He was
continued on BB, ASA, Plavix as above. ACEI was held as above
but restarted on day of discharge at 5mg daily.
.
5) Abdominal pain: Patient developed increasing abdominal pain
at the end of his CCU stay. Patient was diffusely tender to
palpation on re-transfer to medicine from CCU. Had formed BM
prior transfer. C. diff has been negative x1. LFTs were normal
Only slightly elevated amylase/lipase. CT abd/pelvis showed b/l
rectal sheath hematomas (5x5cm and 5x6cm). Heparin drip and
coumadin were discontinued. Hct trended slowly down to 26 but
remained stable thereafter. Patient also received blood
transfusion given insufficient level for cardiac issues (see
below). Zofran was given prn nausea. Pain was resolving upon
discharge and patient denied any N/V.
.
6) Hct drop: Hct dropped from admission Hct of 35 to 25 post-OP.
EBL during operation was 400cc. Post-OP course c/b nose bleed,
requiring packing. On Heparin gtt for NSTEMI. Off coumadin
peri-operatively. INR of 1.4 on transfer to medicine. Guaiac
negative on transfer. Possible retropharyngeal bleed vs occult
GI bleed given pt is on heparin gtt, steroids, plavix. CT
abd/pelvis did not show any RP bleed. Received total of 4U pRBC
with 20 IV Lasix in between. PPI was increased to [**Hospital1 **]. Hct up to
30 prior to cath, remained stable thereafter. Hct has still been
stable around 30-32 x24h prior to transfer to CCU but Hct
trended down to 25 in CCU. Received blood transfusions to keep
Hct above 30 given intermittent CP in CCU. Has been CP free for
two days prior to re-transfer to medicine. Hct was 28.7 on
re-transfer but trended down again to 26. Received another
transfusion to keep Hct around 28-30. Hct remained stable
towards discharge. Hct was 36.3 on day of discharge.
.
7) RA: Advanced disease, s/p ankle fusion. Admitted for fusion
of left ankle. On chronic methotrexate, prednisone, and
hydroxychloroquine. Per his rheumatologist, methotrexate to be
held for 3 weeks given the risk of infection. Received hydrocort
peri-OP given long-term steroids use. Also stress dose steroids
in CCU for hypotension, then transitioned to PO Predisone again.
Dose was 40mg daily upon re-transfer to medicine which was
further tapered. Patient was continued on Hydroxychloroquine.
Prednisone was tapered to maintenance dose of 10mg daily on day
of discharge (was on 5mg [**Hospital1 **] prior to admission).
.
8) s/p L ankle fusion: Ankle destruction secondary to RA. Now
s/p fusion. Completed post-OP Ancef x3 doses and post-OP
Hydrocort x3 doses. Tissue cultures from surgical samples with
no growth. Bivalve cast has been placed by ortho. Patient should
follow up with Dr. [**Last Name (STitle) 7376**] in 2 wks post-OP. Patient was
continued on pain meds (Tylenol, gabapentin). Post-OP, patient
was on dilaudid PCA and IV as needed. Weaned dilaudid PCA and
transitioned to Oxycodone PRN. Staples should be taken out on
[**7-18**] per orthopedic recommendations. Patient has an outpatient
with orthopedics on that day for follow up.
.
9) HTN: Was well controlled per last OMR note from his
cardiologist. Continued BB, Imdur. Held ACEI for ARF as below.
Held all BP meds during hypotensive episode (see above).
Continue BB, Imdur and restarted ACEI upon discharge (see
above).
.
10) Acute on CRI: Cr baseline at 1.2-1.4. Post-OP Cr up to 1.9,
thought to be prerenal given Cr came down to 1.5 with IVF and
blood transfusions. Urine lytes checked after rehydration were
not consistent with prerenal state (FENA 1.6%, FEUrea 71%) but
were likely checked too late. Received pre-cath hydration with
HCO3 and mucomyst. Cr came down to 1.1 post cath but jumped to
2.7 the next day when he was transferred to the CCU for
hypotension. Likely multifactorial (prerenal, hypotension,
contrast-induced). Cr peaked at 3.3 and trended down again with
fluid resuscitation. It has been mostly around 1.3-1.8 in the
CCU. Cr was 1.6 on re-transfer to medicine and remained stable
around this baseline thereafter. ACEI was held throughout most
of his hospital stay but restarted upon discharge (see above).
Cr was 1.7 on day of discharge.
.
11) Chronic anemia: Hct baseline at 31-35. Hct drop post-OP (see
above) and after rectal sheath hematomas (see above).
Transfusions given as mentioned above. Continued iron
supplementation with bowel regimen.
.
12) H/o glucose intolerance: Monitored FS qid. RISS.
.
13) Hyperlipidemia: continued statin
.
14) FEN: cardiac diet, NPO for procedures
.
15) PPX: Heparin gtt and coumadin (discontinued after
hematomas), Plavix, bowel regimen, PPI
.
16) Access: PIV, in CCU also CVL (Right SC)
.
17) Code: Full
Medications on Admission:
Aspirin 325 mg daily
Clopidogrel 150 mg daily
Multivitamin
Pantoprazole 40 mg daily
Pravastatin 80 mg daily
Toprol XL 50 mg daily
Hydroxychloroquine 200 mg [**Hospital1 **]
Isosorbide 45 mg daily
Lisinopril 5 mg daily
Prednisone 5 mg [**Hospital1 **]
Iron 325 mg daily
Coumadin on hold
Methotrexate on hold
.
Medications on transfer:
- Hydroxychloroquine Sulfate 200 mg PO BID
- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
- Loperamide 2 mg PO QID:PRN diarrhea
- Acetaminophen 325-650 mg PO Q4-6H:PRN pain/fever
- Metoprolol XL (Toprol XL) 50 mg PO DAILY
- Aspirin 325 mg PO DAILY
- Nitroglycerin SL 0.3 mg SL PRN
- Clopidogrel Bisulfate 150 mg PO DAILY
- Pantoprazole 40 mg IV Q24H
- Cyanocobalamin [**2108**] mcg PO DAILY
- Pravastatin 80 mg PO DAILY
- Erythromycin 0.5% Ophth Oint 0.5 in OD TID Duration: 2 Days
- PredniSONE 5 mg PO BID
- Ferrous Sulfate 325 mg PO DAILY
- Pyridoxine HCl 25 mg PO DAILY
- FoLIC Acid 2.5 mg PO DAILY
- Gabapentin 300 mg PO DAILY
- HYDROmorphone (Dilaudid) 2-4 mg PO Q4-6H:PRN
- HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6
minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s)
- Zolpidem Tartrate 5-10 mg PO HS sleep
- Heparin IV per Weight-Based Dosing Guidelines
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
[**Year (4 digits) **]:*20 Tablet(s)* Refills:*0*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take up to 3 tabs, with 5 minute intervals. Call your PCP.
[**Name Initial (NameIs) **]:*30 Tablet, Sublingual(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
7. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: day 1 = [**7-9**].
[**Month/Year (2) **]:*5 Tablet(s)* Refills:*0*
14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: 1
tab (5 mg) [**7-11**], [**1-22**] tab (2.5 mg ) [**7-12**] & [**1-22**] tab [**7-13**], 5 mg
[**7-14**] then per Dr. [**First Name (STitle) 7366**].
[**First Name (STitle) **]:*30 Tablet(s)* Refills:*2*
15. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
[**First Name (STitle) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
[**First Name (STitle) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
17. Foltx 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day.
18. Outpatient Lab Work
check INR [**2115-7-15**]
Dx 427
please fax results to Dr. [**First Name (STitle) 7366**] [**Telephone/Fax (1) 7377**]
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Left ankle fusion
2. NSTEMI post-OP, s/p cath
3. CAD with multiple MIs, s/p multiple stents
4. Systolic CHF, EF 30%
5. Hospital acquired pneumonia, requiring CCU stay
6. Hypotension secondary to pneumonia, requiring CCU stay
7. Bilateral rectal sheaths bleeds
8. Acute on chronic renal failure
9. Post-OP blood loss anemia requiring several blood
transfusions
.
Secondary Diagnosis:
1. Rheumatoid arthritis
2. Hypertension
3. Hyperlipidemia
4. Atrial fibrillation, on coumadin
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Labs: hct 36.3
Discharge Instructions:
You were admitted for ankle surgery. You developed a heart
attack after the procedure as well as a pneumonia and bleed into
your belly muscles. You have been worked up and treated for all
of these issues.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed. You should take
levofloxacin for five more days. You were also restarted on
coumadin. INRs have to be checked frequently after discharge.
discuss the need for methotrexate with rheumatologist
.
Please keep you follow up appointments as below.
Followup Instructions:
Check INR [**2115-7-15**], Dr. [**First Name (STitle) 7366**] to manage coumadin.
You have an appointment with cardiologist, Dr. [**First Name (STitle) 7366**] [**2115-8-5**] @
11 am. Please follow up with your primary care doctor
([**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 7378**]) in [**1-22**] weeks from now.
Please also follow up with orthopedics as scheduled:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2115-7-18**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2115-7-18**] 9:20
Your staples will be taken out at that time.
|
[
"038.8",
"997.1",
"998.11",
"V15.82",
"482.83",
"428.20",
"427.31",
"410.71",
"250.00",
"272.4",
"412",
"714.0",
"995.91",
"458.9",
"414.01",
"285.1",
"428.0",
"568.81",
"996.72",
"V45.82",
"593.9",
"401.9",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.17",
"81.13",
"81.11",
"99.04",
"21.01",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
27065, 27140
|
13938, 23181
|
284, 304
|
27684, 27750
|
6748, 7956
|
28475, 29183
|
5355, 5425
|
24464, 27042
|
27161, 27161
|
23207, 23516
|
10750, 13915
|
27774, 28452
|
5440, 6729
|
229, 246
|
332, 2502
|
27567, 27663
|
27180, 27546
|
23541, 24441
|
2524, 4931
|
4947, 5339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,353
| 127,626
|
9223
|
Discharge summary
|
report
|
Admission Date: [**2127-12-16**] Discharge Date: [**2128-2-4**]
Date of Birth: [**2057-11-1**] Sex: M
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
AAA open resection-(ABI) [**2127-12-16**]
cardiac catheterzation with PCI of LAD [**2127-12-16**]
Bronchoscopy , Rt. chest tube placement [**2127-12-23**]
bronchcoscopy, thearputic aspiration [**2127-12-25**]
bronchcoscopy with LLL BAL [**2127-12-28**]
trach with PEG [**2127-12-31**]
throcentesis right [**2128-1-9**]
Pussey-Murer Valve trach [**2128-1-10**]
History of Present Illness:
Admitted for elective open AAA repair
Past Medical History:
histroy of hyperlipdemia
history of lumbar disc disease s/p laminectomy of L4-5
histroy of glall bladder disease s/p ccy
histroy of MVA,s/p splenectomy
histroy of current tobacco use
Social History:
married, lives with spouse
retired
[**Name2 (NI) 1139**]: current smoker 1 ppd
ETOH: denies
Family History:
un known
Physical Exam:
general: no acute distress
HEENT: diminished ROM, no carotid bruits, no JVD
Lungs: clear to auscultation
Heart:RRR no mumur,gallop ,rub
ABD: soft, nontender, nondistended + abdominal pulsation
Ext: bilateral femoral pulses dopperable,dopperable DP pulses,
PT pulses?
bilateral iliac bruits
Neuro : alert and oriented x3, nonfocal
Pertinent Results:
[**2128-1-27**] 07:00AM BLOOD WBC-13.7* RBC-3.78* Hgb-11.5* Hct-35.8*
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.5 Plt Ct-501*
[**2128-1-27**] 05:23PM BLOOD WBC-12.5* RBC-3.46* Hgb-10.6* Hct-31.9*
MCV-92 MCH-30.5 MCHC-33.1 RDW-16.3* Plt Ct-463*
[**2128-1-28**] 03:34AM BLOOD WBC-13.6* RBC-3.30* Hgb-10.1* Hct-30.8*
MCV-94 MCH-30.6 MCHC-32.7 RDW-15.7* Plt Ct-454*
[**2128-1-28**] 03:34AM BLOOD Glucose-127* UreaN-11 Creat-0.4* Na-135
K-4.4 Cl-104 HCO3-26 AnGap-9
[**2128-1-27**] 07:00AM BLOOD ALT-90* AST-52* AlkPhos-158* TotBili-1.1
[**2127-12-17**] 04:17AM BLOOD ALT-39 AST-241* LD(LDH)-428*
CK(CPK)-[**2118**]* AlkPhos-33* TotBili-0.5
[**2127-12-16**] 03:52PM BLOOD CK-MB-5 cTropnT-<0.01
[**2127-12-16**] 09:21PM BLOOD CK-MB-123* MB Indx-11.9* cTropnT-1.05*
[**2127-12-18**] 01:51AM BLOOD CK-MB-165* MB Indx-9.8* cTropnT-7.70*
[**2127-12-18**] 01:51AM BLOOD CK-MB-165* MB Indx-9.8* cTropnT-7.70*
[**2127-12-19**] 02:11AM BLOOD CK-MB-28* MB Indx-6.0 cTropnT-6.09*
[**2128-1-5**] 05:07PM BLOOD %HbA1c-5.7
[**2128-1-19**] 06:25AM BLOOD Triglyc-107
[**2127-12-30**] 01:10AM BLOOD Triglyc-128
[**2127-12-31**] 01:10AM BLOOD HBsAb-POSITIVE HAV Ab-POSITIVE
[**2127-12-31**] 01:10AM BLOOD HCV Ab-NEGATIVE
[**2127-12-16**] 01:53PM BLOOD Type-ART pO2-114* pCO2-42 pH-7.37
calTCO2-25 Base XS-0 Intubat-INTUBATED
Brief Hospital Course:
[**12-16**] admitted, AAA open repair( ABI ) , acute myocardial
infract,s/p cardiac cath PCI of LAD.LMT moderate disease,LAD 95%
proximally,Lcx. moderate diffuse disease, rca totallly occluded
, collatralized Left to right. Epi dural d/c' RE intubated for
hypoxia and respiratory acidosis.
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
akinesis of the basal inferolateral segment and mild hypokinesis
of the mid to distal anterior wall, anterior septum and apex.
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. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction consistent with multi-vessel coronary artery
disease.
Based on [**2126**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Compared with the prior study (images reviewed) of [**2127-12-16**],
wall motion abnormalities are better appreciated on the current
study (as above). There is now a wire/catheter in the RA/RV.
[**12-17**] Pulmonary edema, agressively diuresed.
[**12-18**] diuresis continued. nutritional consult for TF
[**Date range (1) 31690**] continued diuresis TPN began.
[**12-21**] temp elevation. CXR with infiltrate antibiotics brodened to
VAnoc,Cipro,Meropeneum.
[**12-22**] dopoff placed. IV lasix gtt discontinued.
[**12-23**] CT chest: RLL,RML consolidation with RML abcess and
moderate pleural effusion
remains on vent support . Bronch with rt. Chest Tube
placement.c/s sputum MRSA, c/s BAL klebsella and beta
strep.Linezolid added to antibiotic regment but d/c 24hrs later.
[**12-24**] Patient in septic shock requiring vassopressor support.
[**12-25**] Thoracic surgery consulted for lung abcess. Recommendations
no ct needle aspiration of abcess ,continue with chest tube
drainage.Bronchoscopy with theareupedic aspiration.ID consulted;
legonella c/s negative.
[**12-26**] persistant leukocytosis. CT of Abd/ chaest. no
intraabdominal source for infection, RLL effusion.
[**12-28**] Bronch with BAL of LLL
[**12-31**] Trach, PEg
[**1-6**] Neruo surgery cx for C spine canal stenosis. cervical
collar.
[**1-9**] TF @ goal. sacral wound care began for stage 2 sacral
decubitus
[**Date range (1) 15945**] awaiting timing of C spine stablization by neuro
surgery. continued elevated WBC and temp.right
thorocentesis>500cc. speech/swallow consulted for ? dysphagia.
continue with Tf no po's. transfused for anemia
[**1-18**] off vent, Trach mask, PMV placed. transfered to VICU
[**1-19**] aphasia and dysphagia very pronounced with increasing
mental confusionn. WBC 20. c/s urine negative no temp.
[**1-20**] Antibiotics discontinued
[**1-22**] planned spine stabllization cancelled secondary to
leukocytosis.
[**1-23**] Neuro consulted for persistant confusion. MRI of head
pending.MRI could not be done because patient needed to be
vnetelated and sedated.WBC monitered
[**2039-1-23**] continued to moniter WBC 12.5 Cervical stablization by
neuro done.
[**1-28**] patient stable.awaiting rehab bed
[**2128-2-2**] repeat swallow study done,patient continues to aspirate
will remain NPO. awaiting rehab bed. treated for UTI with cipro.
[**2128-2-4**] transfered to rehabh. stable.
Medications on Admission:
simvistatin 20mgm daily
atenolol ? daily
asa 81 mg daily
diazapam prn
trazadone prn
vit c daily
vit e daily
pencilliln 500mgm [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day).
8. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
10. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
11. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
13. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: as directed Subcutaneous
four times a day: AC:
glucoses
<120 no insulin
121-140/2u
141-160/4u
161-180/6u
181-200/8u
201-220/10u
221-240/12u
241-260/14u
261-280/16u
281-300/18u
301-320/20u
321-340/22u
341-360/24u
>360 [**Name8 (MD) 138**] Md
u=units.
14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Name8 (MD) **]:
One (1) Inhalation Q6H (every 6 hours) as needed.
15. Ipratropium Bromide 0.02 % Solution [**Name8 (MD) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
16. Lorazepam 2 mg/mL Syringe [**Name8 (MD) **]: One (1) Injection Q6H (every
6 hours) as needed.
17. Hydralazine 20 mg/mL Solution [**Name8 (MD) **]: Ten (10) mg Injection Q6H
(every 6 hours) as needed.
18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Name8 (MD) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed.
19. Docusate Sodium 100 mg Capsule [**Name8 (MD) **]: One (1) Capsule PO BID
(2 times a day).
20. Acetaminophen 325 mg Tablet [**Name8 (MD) **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
21. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Name8 (MD) **]: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
abdominal aortic aneurysem
history of lumbar disc disease s/p laminectomy L4-5
history of gallbladder disease s/p ccy
history of MVA s/p splenectomy
history of hyperlipdemia
history of lung nodules
history of current tobacco use-1ppd
postoperative acute myocardial infract-RCA occlusion
postop pulmonary edema
postoperative klebsella /MRSA PNa of RLL,RML with RML abcess
postoperative septic shock-vasopressors,resolved
postop respirtory failure-Trach
postoperative failure to thrive-PEG placement
postoperative blood loss anemia transfused
postoperative sacral decubitus Stag -2 , treated, stable
postoperative cervical canal stenosis
postoperative dysarthria, aspiration
postoperative encephalopathy
postoop UTI-treated
Discharge Condition:
stable
Discharge Instructions:
call if any questions.
Followup Instructions:
Dr.[**Last Name (STitle) 1391**]. call for appointment [**Telephone/Fax (1) 1393**], post d/c from
rehab
Dr. [**Last Name (STitle) 548**] of neuro surgery in 6 weeks [**Telephone/Fax (1) 1669**]
Dr. [**Last Name (STitle) **]( interventional cardology ) please acll for an
appoointment 6[**Telephone/Fax (1) 31691**]
Completed by:[**2128-2-4**]
|
[
"441.4",
"V09.0",
"998.0",
"998.11",
"785.51",
"997.3",
"707.03",
"428.0",
"997.1",
"414.01",
"285.1",
"518.5",
"345.90",
"482.0",
"599.0",
"721.1",
"410.11",
"482.41",
"428.21",
"513.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.02",
"77.79",
"36.06",
"00.45",
"00.14",
"00.66",
"43.11",
"31.1",
"38.93",
"96.72",
"33.24",
"00.40",
"84.51",
"81.62",
"88.56",
"37.22",
"38.44",
"96.05",
"96.6",
"34.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9061, 9133
|
2723, 6353
|
270, 632
|
9899, 9908
|
1406, 2700
|
9980, 10325
|
1030, 1040
|
6546, 9038
|
9154, 9878
|
6379, 6523
|
9932, 9956
|
1055, 1387
|
227, 232
|
660, 699
|
721, 905
|
921, 1014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,219
| 157,893
|
24707
|
Discharge summary
|
report
|
Admission Date: [**2176-10-4**] Discharge Date: [**2176-10-10**]
Date of Birth: [**2115-8-12**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Elevated LFTs and mild acute cellular
rejection.
HISTORY OF PRESENT ILLNESS: A 61-year-old male status post
cadaveric liver transplant in [**2176-6-18**], status post
transjugular liver biopsy on [**10-3**] which showed mild
acute cellular rejection, pathology results finalized. He was
admitted to the hospital for treatment of rejection.
PAST MEDICAL HISTORY: End-stage liver disease due to
alcoholic cirrhosis, encephalopathy, varices, depression,
gout, diverticulitis, status post colectomy, DVT.
MEDICATIONS AT HOME: Rapamune 0.5 mg daily; CellCept [**Pager number **] mg
b.i.d.; fluconazole 200 mg p.o. b.i.d.; Bactrim single
strength 1 tablet daily; Valcyte 450 mg daily; nicotine patch
14 mg topically daily; Lasix 20 mg p.o. daily; Epogen 20,000
units every Wednesday; Protonix 40 mg daily; Percocet's
p.r.n..
HOSPITAL COURSE: On admission, his temperature was 97.4,
heart rate 78, BP 115/65, with a respiratory rate of 20, of
O2 saturation 97% on room air. He was in no acute distress.
Heart rate was regular. S1-S2 were normal. Lungs were clear.
Midline incision was noted on his abdomen with mild
distention, nontender, positive bowel sounds. He did have
mild lower extremity edema. He was initiated on Solu-Medrol
500 mg IV once a day for 3 days. His blood sugars did
increase, and he required insulin sliding scale for this. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consult was obtained. On admission, his LFTs were AST
29, ALT 32, alkaline phosphatase 210, total bilirubin 0.2
with a Rapamune level of 15.3. LFTs did not decrease
dramatically. He was sent for ultrasound of the liver, which
demonstrated no focal liver lesions or ascites. There was
nonvisualization of the right hepatic artery. A repeat Duplex
of the liver demonstrated normal wave forms of the main
hepatic artery without turbulent flow to suggest stenosis. It
was noted though that the patient had a looped segment of
extrahepatic artery which was noted on an angiogram on the
previous day that demonstrated patent common right and left
hepatic arteries. On the angiogram, it was noted the patient
had a mild stenosis with no significant pressure gradient at
the proper hepatic artery level, that perhaps corresponded to
the surgical anastomosis. AST decreased to 74. ALT decreased
to 117. His alkaline phosphatase trended down to 163 with a
total bilirubin of 0.5. His creatinine decreased to 1.2. His
immunosuppression was changed. He was transitioned off of
Rapamune, and Prograf was started with up titration of doses.
He achieved a Prograf level of 12.6 on hospital day #5 on 1.5
mg p.o. b.i.d. of Prograf. Rapamune was stopped. He also
continued on CellCept [**Pager number **] mg p.o. daily.
DISCHARGE STATUS: The patient was discharged home in stable
condition. He was tolerating a diabetic diet. He was at given
a Glucometer to check his blood sugars at home. Sliding-scale
Humalog insulin was recommended for discharge. The patient
was set up to have visiting nurse services to assist with
glucose monitoring. Of note, the patient was followed closely
by social service while in the hospital for depression, and
the patient's request for individual counseling.
DISCHARGE MEDICATIONS: Included CellCept [**Pager number **] mg p.o. b.i.d.;
Valcyte 400 mg p.o. daily; Bactrim single strength 1 tablet
daily; fluconazole 200 mg p.o. b.i.d.; Protonix 40 mg p.o.
daily; Epogen 20,000 units every Wednesday; Lasix 20 mg p.o.
daily; nicotine 14 mg per 24-hour patch daily; Coumadin 1 mg
p.o. at bedtime; Prograf 1.5 mg p.o. b.i.d..
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2176-10-16**] 15:26:29
T: [**2176-10-16**] 16:58:32
Job#: [**Job Number 62323**]
|
[
"274.9",
"311",
"453.40",
"790.29",
"996.82",
"E878.0",
"276.8",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"88.47",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
3385, 3949
|
1017, 3361
|
701, 999
|
173, 223
|
252, 516
|
539, 679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,297
| 110,968
|
45380
|
Discharge summary
|
report
|
Admission Date: [**2124-2-3**] Discharge Date: [**2124-2-8**]
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
BiPAP on [**2124-2-3**]
History of Present Illness:
89 y/o female with PMH of COPD, CAD, CHF (EF>55%), HTN, DM, pAF,
silent aspirator, recent admission for SOB and new presumed
diagnosis of BOOB (on steroid taper) who is called out from MICU
where she was admitted for hypoxic respiratory distress
requiring BIPAP.
.
Initially presented from [**Hospital 100**] Rehab where she developed acute
SOB. VS at the time were: 168/100, p160s, rr30s, 89% RA. Treated
w/ Lasix 60mg PO + 60mg IV. Transferred to [**Hospital1 18**] ED where VS on
presentation were t 100.6, p130s, 138/76, rr35, 98%NRB. She was
noted to have significant work of breathing. She was placed on
Bipap, which she tolerated well. ABG was 7.36/37/248 on BIPAP
5/5/1.0 after 2 hours. She was given asa, solumedrol 125mg IV
x1, ceftaz 2gm IV and flagyl 500mg IV. Of note, also had an
episode of AFib with AVR with HR in 130s, hemodynamically
stable, HR decreased to 100s after 10mg IV diltiazem.
Transferred to MICU where pt was attempted on trial off bipap.
Maintained off BIPAP and weaned down to 2L NC overnight.
Therefore called out to the floor the following day.
Past Medical History:
1. COPD - [**11-5**] FEV1 1.01 (not on home O2)
2. CAD s/p MI
3. CHF EF> 55%
4. PVD
5. CVA and carotid disease
6. HTN
7. neuropathy
8. hyperlipidemia
9. osteopenia
10. DM
11. vit B12 deficiency
12. gait disorder
13. spinal stenosis -s/p surgery [**2115**]
14. PAFIB
15. ?BOOB (on steroid taper)
16. Recurrent aspiration pneumonia
Social History:
SH: Resides at [**Hospital 100**] Rehab [**Location (un) 550**]. Has 10 children. *Smokes half
ppd*, in
past smoked more (total 40 yrs). Occ EtOH. No other drugs.
Family History:
Noncontributory
Physical Exam:
Exam on Admission:
=================
VS: t98.5, p125, 138/88, rr31, 93% 2L
Gen: NAD, off bipap
HEENT: PERRL, dry MM
CVS: irreg irreg, tachy, [**1-10**] holosystolic murmur at the apex
Lungs: bilateral crackles half way up lung fields
Abd: soft, NT, ND, +BS
Ext: 1+ edema bilaterally
Pertinent Results:
Admission Labs:
==============
WBC-24.9 Hgb-11.5 Hct-35.5 MCV-90 Plt Ct-259
Neuts-90.2* Bands-0 Lymphs-6.3* Monos-2.4 Eos-1.0 Baso-0.1
Glucose-212* UreaN-38* Creat-1.5* Na-135 K-4.9 Cl-102 HCO3-18*
AnGap-20
ALT-237* AST-61* AlkPhos-381* TotBili-1.4
cTropnT-0.03*
CK-MB-NotDone proBNP-4255*
Calcium-9.3 Phos-4.1 Mg-2.1
TSH-2.0
.
Blood gas:
[**2124-2-3**] 05:33AM: Type-ART Temp-38.1 Tidal V-500 FiO2-100
pO2-248* pCO2-37 pH-7.36 calHCO3-22 Base XS--3 AADO2-439 REQ
O2-74 Lactate-2.2*
.
Radiology:
=========
[**2124-2-3**] CXR-
1. Continued right upper lobe consolidation. Worsening left
retrocardiac opacity.
2. Cardiac failure
.
[**2124-2-4**] CXR: There is cardiomegaly unchanged with small bilateral
pleural effusions, unchanged from [**2124-2-3**] with associated
bibasilar atelectasis. The right upper lobe opacity is unchanged
from [**2124-2-3**] allowing for differences in technique.
However, compared to [**2124-1-8**], there has been
improvement in the peripheral right upper lobe opacity.
Brief Hospital Course:
This is an 89 yo female with PMH COPD, CHF, ?BOOP, recurrent
admissions for SOB who presented with acute SOB and hypoxia
requiring BIPAP transiently in the MICU, now weaned off to 2L NC
with stable sats.
.
1. Hypoxic respiratory failure: Improved respiratory status, now
stable on 2L O2 via NC. Most likely etilogy of event was
multifactorial from recurrent pneumonia, CHF (diastolic dysfn),
BOOP exacerbation.
-continue with cefpodoxime to finish total course of 7 days for
possible new PNA
-continue albuterol/atrovent nebs
-continue prednisone 10mg/day until pulmonary appt on [**2124-2-8**] for
further evaluation
-continue with strict I/O's (goal even), daily weights and lasix
prn to meet goal or depending on symptoms (shortness of breath,
etc)
.
2. UTI: on cefpodoxime. Final urine cx from [**2124-2-3**] shows MRSA,
but less than 100,000 colonies, so we are not covering for this
as patient is not bacteremic or febrile. Please recheck urine
analysis and culture in one week and f/u on results. Will see
[**Month/Day/Year **] for follow-up in 2 weeks. Given h/o urinary retention in
past, should keep in foley. If foley removed and patient not
voiding at rehab, bladder scan should be done and foley/straight
cath should be placed if residual>200 cc.
.
3. CHF: BNP elevated. Clinically slightly volume overloaded but
intravascularly depleted. Given renal insufficiency and
respiratory stability will hold off on further diuresis. Already
-1.6 L out for LOS in the hospital.
-maintain even i's/o's
-strict I/O's, daily wts
-lasix prn symptoms and/or to meet goal as above
.
4. Afib: diltiazem and lopressor for rate control. [**Country **] score of
4. Not on coumadin. ASA 325mg for anti-coagulation.
.
5. CAD: cont statin, asa, bb
-holding ACEi in setting of elevated cr
.
6. Elevated Tn: likely tn leak in setting of CHF, renal
insufficiency
.
6. CRI: 1.7. baseline of 1.1-1.5. Hold nephrotoxic agents.
Renally dose meds. Monitor daily lytes.
.
7. DMII: cont glyburide. FS QID. SSI
.
8. Leukocytosis: Likely in setting of steroids. Trend WBC/T
curve. cont abx as above.
.
9. PPX: PPI, tylenol, bowel regimen, Hep SC
.
10. FEN: cardiac/low sodium (passed speech-swallow- no
aspiration) - see dietary instructions as detailed in d/c
paperwork
.
11. Full code
Medications on Admission:
Protonix 40mg qd
Prednisone 10mg qd
Simvastatin 20mg qd
Trazodone 25mg qd
Vit D/cholecalciferol 800mg qd
combivent nebs
asa 325mg qd
calcicum 650mg [**Hospital1 **]
b12 100mcg qd
diltizem CD 240mg qd
Docusate
Folic acid 1mg qd
glyburide 5mg qd
glargine 9U bedtime
humalog SS
lopressor XL 75mg qd
MVI 1 tab qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for HR<60 and SBP<100.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 and HR<60. Tablet(s)
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Insulin Sliding Scale
12 units of Glargine at bedtime with sliding scale
please see attached sheet
20. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary - hypoxic respiratory failure requiring BiPAP, COPD/CHF
exacerbation, A fib with RVR
Secondary - COPD, CHF, ?BOOP, CAD s/p MI, HTN, neuropathy,
hyperlipidemia, NIDDM, PAFIB, recurrent aspiration PNA
Discharge Condition:
Stable, on 2LNC (baseline)
Discharge Instructions:
-continue with medications as prescribed
-physical therapy as tolerated
-if patient having difficulty voiding, please check bladder scan
and if >200, recommend placing foley or straight cath for
drainage
-follow-up with scheduled appts
-please check finger stick glucoses per sliding scale attached
-if patient has shortness of breath, can try nebs and lasix
given h/o COPD, CHF
- please continue with antibiotics for a total of 10 days
- continue oxygen as needed to keep sats > 93%
- continue with RISS while on prednisone, if sugars stable once
off prednisone, then can d/c RISS and continue with just
glyburide
- continue with aspiration precautions as detailed - patient
needs 1:1 assistance with feeding at every meal, needs to be
sitting upright and keep her chin tucked in while swallowing,
alternate small sips with small bites, and diet of
nectar-thickened liquids and ground solids
- encourage chest PT daily, incentive spirometry
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-2-8**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-2-8**] 11:30
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2124-2-23**]
9:00
Completed by:[**2124-2-8**]
|
[
"427.31",
"401.9",
"507.0",
"428.0",
"428.30",
"516.8",
"996.64",
"491.21",
"250.00",
"518.81",
"599.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7703, 7788
|
3297, 5568
|
252, 278
|
8040, 8069
|
2274, 2274
|
9060, 9463
|
1938, 1955
|
5927, 7680
|
7809, 8019
|
5594, 5904
|
8093, 9037
|
1970, 1975
|
193, 214
|
306, 1386
|
2290, 3274
|
1989, 2255
|
1408, 1740
|
1756, 1922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,827
| 123,312
|
23803
|
Discharge summary
|
report
|
Admission Date: [**2137-4-13**] Discharge Date: [**2137-4-26**]
Date of Birth: [**2137-4-13**] Sex: F
Service: NB
HISTORY: [**Known lastname 4248**] [**Known lastname **] is a 30-1/7 week, 1,335 gram female
infant, twin #1, who was admitted to the NICU for management
of prematurity. The infant was born to a 29-year-old, G1, P0
to 2 mother. Prenatal screens: Blood type A+, antibody
negative, Hep B surface antigen negative, RPR nonreactive,
rubella immune, GBS unknown. Cystic fibrosis, as well as [**Doctor Last Name **]-
[**Doctor Last Name 3450**] screening were negative. Pregnancy history was notable
for maternal hypothyroidism (taking Levoxyl) and
monochorionic/monoamniotic twins. Mother was admitted at 27
weeks for monitoring.
Today, there was concern for fetal decelerations in one of
the twins prompting delivery via C-section. Apgar's were 8 at
1 minute and 8 at 5 minutes.
ADMISSION PHYSICAL EXAM: Weight 1,335 grams which is the
50th percentile; length 37 cm which is the 25th percentile;
head circumference 28 cm which is the 50th percentile.
General-preterm infant in respiratory distress with facial
bruising especially over eyes. AFOS, intact palate, nl Red
reflex, subcoastal retractions with poor aeration. CV exam
with regular rate and rhythm, no murmur heard. Abdomen was
soft, nontended with no organomegaly. GU was consistent with
premature infant girl, normal spine, hips and extremities.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Due to respiratory distress, the patient was
intubated shortly after delivery and received 2 doses of
surfactant. On day of life #1 she was weaned to CPAP and
remained on CPAP until day of life #6 when she
transitioned to room air. On day of life #11, due to
desaturation spells, she was placed on nasal cannula where
she currently remains at 25 cc of flow. She has had
between 3 and 4 apneic spells each 24 hours. She is
currently on caffeine.
2. CARDIOVASCULAR: The patient was noted to have a murmur
shortly after delivery, and on day of life #3 an echo
revealed a moderate-sized PDA. Therefore, indomethacin was
started. After the completion of indomethacin on day of
life #4 she no longer had a murmur. She has remained
hemodynamically stable since that point.
3. FEN: The patient was initially n.p.o. on total fluids of
100 cc/kg/D. After the completion of indomethacin, she was
begun on trophic feedings of 10 cc/kg/D, which she slowly
advanced. She is currently on 150 cc/kg/D of breast milk
24 cal/oz.
4. GI: Phototherapy was initiated on day of life #2 for a
bilirubin of 5.8/0.2. Max bilirubin was 6.7/0.3.
Phototherapy was stopped on day of life #10, and rebound
bilirubin was 3.6/0.2.
5. INFECTIOUS DISEASE: Due to preterm labor, CBC and blood
cultures were obtained, and infant was begun on ampicillin
and gentamicin. CBC was benign, and blood cultures were
negative at 48 hours; therefore, antibiotics were
discontinued.
6. NEURO: The patient did have a head ultrasound on day of
life #11 which was normal.
CONDITION ON DISCHARGE: Good.
NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3532**], MD [**First Name8 (NamePattern2) **]
[**Last Name (Titles) **] Pediatrics.
CARE/RECOMMENDATIONS:
1. Feeds at discharge: 150 cc/kg/D of breast milk 24 cal/oz.
Additional calories with human milk fortifier (HMF) 4
cals/oz.
2. Medications: Ferrous Sulfate (25mg/ml) 0.1 ml PO/PG daily;
Vitamin E 5 units po/pg daily.
3. State newborn screen was sent [**4-16**] and [**4-26**], results are
pending.
4. The patient has not yet received any immunizations.
DISCHARGE DIAGNOSIS LIST:
1. Prematurity at 30-1/7 weeks.
2. Twin gestation.
3. Patent ductus arteriosus, status post indomethacin
4. Respiratory distress syndrome, resolved.
5. Hyperbilirubinemia, resolved.
6. Rule out sepsis, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 58729**]
MEDQUIST36
D: [**2137-4-25**] 11:55:04
T: [**2137-4-25**] 12:48:25
Job#: [**Job Number 60757**]
|
[
"V29.0",
"765.15",
"765.25",
"747.0",
"796.3",
"774.2",
"V31.01",
"769"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.04",
"99.83",
"99.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1475, 3097
|
939, 1447
|
3357, 4192
|
3122, 3343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,125
| 127,129
|
34923
|
Discharge summary
|
report
|
Admission Date: [**2180-11-14**] Discharge Date: [**2180-11-24**]
Date of Birth: [**2099-6-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Influenza Virus Vaccine /
Pneumococcal Vaccine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Increased confusion after fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 81 year-old woman with a past medical history
significant for hypertension, hyperlipidemia, type II diabetes
mellitus, multiple foot surgeries and infections, on aspirin and
fondaparinux, who presents as a transfer for intraventricular
hemorrhage. The history is obtained from the patient's daughter
via the telephone as the patient is an unreliable historian.
Of note, she was admitted [**Date range (1) 79915**]/[**2180**] to [**Hospital1 **] with a
complaint of fever and vomiting, found to have an S. aureus
bacteremia and suspected RLE osteomyelitis. The right foot was
surgically debrided on [**8-11**] (cuboid bone removed), and fianl
diagnosis was soft tissue infection and not osteomyelitis. She
was discharged on oxacillin until [**2180-8-21**], and planned "oral
antibiotics for additional 4-6 weeks." A TEE during that
admission "showed no evidence of vegetations". She was treated
with a course of levofloxacin for radiographic pneumonia.
She was recently discharged home ([**2180-11-10**]) after long hospital
course at [**Hospital1 **] when she had a fall that same day while
ambulating with bruise to her sacrum. Confusion started on [**11-12**]
and had another [**2180**] am from her bed to floor, without
apparent injury. After a third fall on [**11-14**] w/o apparent
trauma, she was brought by EMS to MWH, where a head CT showed an
intraventricular hemorrhage. She was transferred to [**Hospital1 18**] for
further management on [**11-14**].
ROS - this is somewhat limited as the patient is a poor
historian. She reported long standing urinary incontinence.
She thinks she lost a considerable amount of weight between her
initial admission in [**Month (only) 205**] and her discharge on Thursday - 40lbs.
The patient denied headache, visual difficulty, hearing changes,
difficulty speaking, language problems, memory difficulty,
difficulty swallowing, dizziness, lightheadedness or vertigo,
paresthesias, sensory loss.
The patient denied appetite changes, chest pain, palpitations,
dyspnes on exertion, shortness of breath, cough, wheeze, nausea,
vomiting, diarrhea, constipation, abd pain, fecal incontinence,
dysuria, nocturia, hot/cold intolerance, polyuria, polydipsia,
easy bruising, depression, anxiety, stress, or psychotic
symptoms.
Past Medical History:
Type II Diabetes Mellitus
MSSA bacteremia in [**8-8**] [**3-4**] to chronic right foot osteo s/p 4
weeks of IV abx at OSH then 10 weeks of dicloxicillin as an
outpt.
Herpes zoster
Bilateral Charcot joints
multiple foot surgeries
Hypothyroidism
Hyperlipidemia
Rheumatioid arthritis
Hypertension
Left buttock decubitus ulcer
Chronic anemia
Peripheral arterial disease with bypass grafts to both legs
Bilateral Total Knee Replacements
Social History:
Lives at home with her husband. Denied tobacco, ETOH, or illicit
drugs.
Family History:
Non-contributory
Physical Exam:
Vitals: T:101.4 P:96 BP:166/48 R:22 SaO2:99% on 2 L.
General: 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
Pulmonary: Lungs CTA bilaterally without wheezes or crackles
Cardiac: RRR, s1/s2 present, no murmur, rubs or gallops
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Has been receiving shots of anticoagulant
in the stomach.
Extremities: No C/C/E bilaterally. Bilateral surgical scars
over knees and ankles. Left knee is tender, but there is no
effusion, erythema or change in temp compared with other parts
of the leg. Left ankle is severely deformed. Right foot has
stitches in the bottom. Neither foot is tender.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to Hospital and [**Location (un) 86**]. Unable
to relate history without difficulty - shortens time periods,
initially said she only fell once. Mildly inattentive, able to
name months of year backward but skipped [**Month (only) 216**]. Language is
fluent with intact repetition and
comprehension. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Able to follow both
midline and appendicular commands. There was no evidence of
apraxia or neglect. Pt. was able to register 3 objects and
recall 0/3 at 5 minutes. The pt. had good knowledge of current
events. There were no paraphasic errors. Normal prosody.
Speech was not dysarthric.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and
brisk. VFF to confrontation. There is no ptosis bilaterally.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. EOMI without nystagmus. Normal saccades. Facial
sensation intact to pinprick. No facial droop, facial
musculature symmetric. Hearing intact to finger-rub bilaterally.
Palate
elevates symmetrically. 5/5 strength in trapezii and SCM
bilaterally. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements noted. No asterixis
noted.
Delt [**Hospital1 **] Tri WE FE FF
C5 C6 C7 C6 C7 C8/T1
L 5 5 5 5 5 5
R 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 4- 5 5 5 NT 5
R 4- 5 5 5 4 5
-Sensory: Stocking deficit to all modalities. Upper extremity
and face were normal. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF bilaterally.
- Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Toes
C5 C7 C6 L4 S1 CST
L1 1 1 - - equi
R1 1 1 - - equi
-Gait: Unable to walk. refused an effort.
Pertinent Results:
ADMISSION LABS:
CARDIAC ENZYMES:
[**2180-11-14**] 06:18PM BLOOD cTropnT-0.02*
[**2180-11-15**] 03:08AM BLOOD CK-MB-4 cTropnT-0.02*
[**2180-11-15**] 02:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2180-11-16**] 06:25AM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-11-20**] 12:14AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2180-11-14**] 06:18PM BLOOD WBC-11.2* RBC-3.02* Hgb-9.7* Hct-26.6*
MCV-88 MCH-32.0 MCHC-36.4* RDW-14.5 Plt Ct-171
[**2180-11-14**] 06:18PM BLOOD PT-13.4 PTT-25.8 INR(PT)-1.2*
[**2180-11-14**] 06:18PM BLOOD Glucose-134* UreaN-33* Creat-1.1 Na-138
K-4.7 Cl-103 HCO3-23 AnGap-17
[**2180-11-15**] 03:08AM BLOOD ALT-20 AST-27 CK(CPK)-418*
[**2180-11-14**] 06:18PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.3* Iron-44
[**2180-11-15**] 03:08AM BLOOD %HbA1c-6.0*
[**2180-11-15**] 03:08AM BLOOD Triglyc-153* HDL-52 CHOL/HD-3.0
LDLcalc-74
DISCHARGE LABS:
[**2180-11-23**] 07:35AM BLOOD WBC-6.8 RBC-2.78* Hgb-8.7* Hct-23.6*
MCV-85 MCH-31.2 MCHC-36.8* RDW-13.5 Plt Ct-267
[**2180-11-23**] 07:35AM BLOOD Plt Ct-267
MICROBIOLOGY:
Time Taken Not Noted Log-In Date/Time: [**2180-11-14**] 11:04 pm
URINE ADD ON @1103 HEM # 2116R.
**FINAL REPORT [**2180-11-18**]**
URINE CULTURE (Final [**2180-11-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 16 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
----------
[**2180-11-19**] 11:23 pm URINE Source: Catheter.
**FINAL REPORT [**2180-11-21**]**
URINE CULTURE (Final [**2180-11-21**]): NO GROWTH.
----------
[**2180-11-22**] 8:34 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2180-11-23**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-11-23**]):
REPORTED BY PHONE TO NORREN [**Doctor Last Name **] @ 4:55A [**2180-11-23**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
-----------
Blood cultures from [**11-14**], [**11-16**], [**11-17**], [**11-19**], 10/20,[**11-22**] no
growth to date
------------
DIAGNOSTIC STUDIES:
CT HEAD [**2180-11-14**]: Hyperdense lesion within the right lateral
ventricle likely represents an intraventricular mass, with
associated hemorrhage, though further evaluation with MRI with
gadolinium is recommended.
PELVIS CT [**2180-11-14**]: IMPRESSION: No acute fracture. Please note,
the examination is limited secondary to osteopenia. If there is
continued clinical concern for fracture, an MRI could be
obtained.
LUMBAR SPINE CT 10/14/08:1. Diffuse osteopenia, which may limit
the sensitivity for detection of nondisplaced fractures.
2. Mild degenerative changes including grade 1 anterolisthesis
at the L4-5
level and loss of intervertebral disc space height at the L5-S1
level.
Significant canal stenosis at the L4-5 level. An MRI of the
lumbar spine
can be performed for further evaluation.
CXR [**2180-11-14**]: PA AND LATERAL VIEWS OF THE CHEST: The heart is
mildly enlarged. The aorta is tortuous and the aortic knob
calcifications are present. Pulmonary vascularity is normal. The
lungs are clear. No large pleural effusions or pneumothorax is
demonstrated. There may be mild scarring within the posterior
costophrenic angles. Degenerative changes are seen within the
thoracic spine.
IMPRESSION: No acute cardiopulmonary abnormality.
Transthoracic Echocardiogram [**2180-11-16**]: he left atrium is mildly
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: no definite vegetations seen
XRAY Bilateral Feet [**2180-11-16**]: Marked arthropathy involving the
bilateral feet as described. Diagnostic considerations include
neurogenic osteoarthropathy (Charcot). The sequela of chronic
infection can have a similar appearance.
BONE SCAN [**2180-11-17**]: IMPRESSION: Positive three-phase bone scan
in the hind and mid feet bilaterally with more focal area of
increased uptake in the left midfoot. The findings likely
reflect Charcot Arthropathy, although an underlying infection
cannot be excluded. Indium 111-WBC study or MRI can be performed
for further evaluation.
HEAD CT WITH AND WITHOUT CONTRAST [**2180-11-17**]: FINDINGS: The
pre-contrast images again demonstrate high density in the right
ventricular atrium, indicative of hemorrhage. The previously
noted small
amount of blood in the left occipital [**Doctor Last Name 534**] is not apparent on
the current
study. There is mild-to-moderate prominence of temporal horns
indicating
early communicating hydrocephalus. This finding is unchanged
from previous
study. Following contrast administration, no abnormal
enhancement is
identified. No other abnormal areas of enhancement are seen.
IMPRESSION: No change in size and appearance of the right-sided
intraventricular hematoma. Persistent mild prominence of
temporal horns
indicating early communicating hydrocephalus. No abnormal
enhancement is seen
surrounding the region of hematoma.
WHITE BLOOD CELL STUDY [**2180-11-20**]:IMPRESSION: Increased tracer
uptake in both feet is a non-specific finding, probably related
to chronic inflammation due to extensive neuropathic changes;
however, a component of bilateral osteomyelitis cannot be
excluded with these findings.
CXR [**2180-11-22**]: FINDINGS: In comparison with the study of [**11-19**],
there is little change. Enlargement of the cardiac silhouette
persists without vascular congestion or pleural effusion.
Specifically no evidence of acute pneumonia.
Brief Hospital Course:
This is an 81 year old female with history of type II diabetes
mellitus, hypertension, charcot feet, who initially presented
with a fall and was found to have and intraventricular
hemorrage.
1)Intraventricular Hemorrhage: Intraventricular hemorrhage felt
by neurosurgery to likely be secondary to trauma. Hemorrhage did
occur in setting of patient taking Arixtra for "clots." Pt was
brought to outside hospital for evaluation after having multiple
falls at home and was found by head CT to have an
intraventricular hemorrhage for which she was transferred to
[**Hospital1 18**] for further management. Head CT did not show evidence of
fracture, nor did L spine films. However, this initial head CT
was concerning for intraventricular mass, with associated
hemorrhage. MRI could not be obtained to clarify this question
of a mass so CT Head with contrast performed and showed
right-sided intraventricular hematoma without any abnormal
enhancement surrounding hematoma. Patient was not felt to
require surgical intervention. Patient remained hemodynamically
stable. Patient not noted to have any motor or sensory deficits
attributable to the hemorrhage.
Mental status has consistently been oriented to person, but not
to place or time. Part of her confusion/disorientation could
certainly be attributed to her intraventricular hemorrhage
versus delirium from her infections. Patient is scheduled to
have a brain MRI on [**2180-12-13**] to assess resolution of hemorrhage.
She is to follow up with Dr. [**First Name (STitle) **] in neurology clinic.
Patient's arixtra was held during this hospitalization and she
was not discharged on this medication. Seroquel was also held
given concern over confusion. Patient can discuss whether or not
to continue these medications with her primary care physician.
2)Fevers: Patient found to spike daily fevers from around [**11-17**]
until [**11-21**]. Patient found to have urinary tract infection
positive for E.Coli on [**11-14**] that was treated with a course of
nitrofurantoin. Fevers continued in spite of UTI being treated.
Infectious disease team was consulted and felt that
intraventricular blood was most likely cause of fever, though
UTI and osteomyelitis were also considered. Patient has had
recent MSSA bacteremias secondary to osteomyelitis of right
foot. An extensive work-up for potential osteomyelitis was
initiated. MRI of right foot, tagged WBC scan and bone scan were
all found to be equivocal. MRI of left foot uninterpretable due
to patient moving. Patient's underlying charcot feet made
differentiating osteomyelitis from her underlying inflammation
very difficult. But given normal white cell count and no
positive blood cultures suspicion for osteomyelitis remained
low. Patient had normal CXR and no clinical signs of pneumonia.
On [**11-22**] patient found to have clostridium dificile and was
symptomatic with diarrhea. It is possible cdiff colitis could
have contributed to the fevers. Patient was started on Flagyl
500mg PO TID for this infection (day 1 of 14 day course [**11-22**])
At time of discharge patient had been afebrile for 48 hours and
continued to have a normal WBC count. She should continue taking
Flagyl for a total of 14 days.
3) Hyponatremia: Patient noted to be hyponatremic to 129. Urine
osmolarity of 501 and urine sodium of 38 consistent with SIADH.
Likely hyponatremia secondary to patient's interventricular
hemorrhage. We fluid restricted patient to 1200 mL/day and
sodium increased to normal range. Would suggest continued fluid
restriction, but increase fluids to 1500ml/day and monitoring
serum sodium until intraventricular hemorrhage resolves.
4)Hypertension: Blood pressures have remained stable. Neurology
recommended keeping systolic pressure <160. Patient was
continued on carvedilol, amlodipine, clonidine and lisinopril.
Lisinopril dose was changed from 40 mg [**Hospital1 **] to 40 mg daily.
5)Anemia: Likely represents anemia of chronic disease, which is
supported by iron studies during this hospitalization.
6)Hyperlipidemia: Patient continued on outpatient regimen of
atorvastatin.
7) Type II Diabetes Mellitus: Blood sugars remained stable.
Outpatient metformin was held. Patient was continued on
outpatient dose of lantus and sliding scale humalog insulin.
Metformin restarted at time of discharge.
8) Diabetic peripheral neuropathy: Stable during this admission.
Patient was continued on his outpatient regimen of gabapentin.
9)Right gluteal ulcer/Left gluteal ecchymosis: Patient seen by
wound care nurse who recommended atmos air mattress,
repositioning every 1-2 hours, waffle boots for charcot feet,
elevating legs, sitting on chairs for now more than 1.5 hours
with pressure relief cushion in place.
10)Hypothyroidism: Patient was continued on outpatient regimen
of synthroid.
11)Rheumatoid arthritis: Patient continued on her outpatient
regimen of prednisone
5 mg daily.
12) Osteopenia: Patient was continued on her outpatient regimen
of vitamin D and calcium.
13) Gastroesophageal reflux disease: Patient was continued on
omeprazole 20 mg daily.
14) Bilateral Charcot Feet: Patient has follow up scheduled with
her podiatrist Dr. [**Last Name (STitle) 1683**]. She should continue to wear her custom
footwear when walking.
Patient was a FULL code during this admission.
Medications on Admission:
Levothyroxine 125 mcg Daily
Omeprazole 20 mg daily
Aspirin 81 mg Daily
Prednisone 5 mg Daily
Colace 100 mg [**Hospital1 **]
Lisinopril 40 mg [**Hospital1 **]
Coreg 25 mg [**Hospital1 **]
Catapres 0.2 mg [**Hospital1 **]
Metformin 1,000 mg [**Hospital1 **]
Neurontin 300 mg TID
Norvasc 10 mg Daily
One Daily Multivitamin
Vitamin C 500 mg SR [**Hospital1 **]
Mirtazapine 7.5 mg Daily
Lipitor 80 mg Daily
Fish Oil 1,000 mg Daily
Seroquel 12.5mg Daily
Zofran 4 mg Every 4-6 hrs PRN
Arixtra (Fondaparinux Sodium)2.5 mg/0.5 mL injection daily
Lidoderm 5 % patch prn.
Lantus 8 units at bedtime
Humalog 4 units before dinner
Tylenol Extra Strength 500 mg Tab Oral [**2-2**] Tablet(s) Every 4-6
hrs PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Traumatic Intraventricular hemorrhage
Delirium
Urinary tract infection
Clostridium dificle colitis
Hyponatremia/SIADH
Decubitus Ulcer
Secondary:
Diabetes mellitus type II
Rheumatoid arthritis - chronic steroids
Anemia of chronic disease
Bilateral Charcot foot
Diabetic neuropathy
Hypertension
Hyperlipidemia
Prior osteomyelitis, right foot
MSSA bacteremia
Hypothyroidism
GERD
Total knee replacement
Discharge Condition:
good
Discharge Instructions:
You were transferred to this hospital to manage bleeding in your
head. The neurosurgeons did not feel you required surgery and
you were initially managed by the neurology team. Head CT at our
hospital confirmed the blood in your brain. This blood did not
result in any neurologic changes on examination. We think that
your bleed was likely due to falling. During your fall you were
on a medication that thins your blood called arixtra- we did not
continue this medication. You will need to get an MRI of your
brain on [**2180-12-13**]. You will also need to follow up with Dr.
[**First Name (STitle) **] in the neurology department.
During your hospitalization you were found to have fevers
multiple days in a row. You were found to have an infection in
your urine that we treated with antibiotics. You also had an
infection in your bowel that caused you to have diarrhea, which
we also treated with antibiotics. At the time you were
discharged you had been without fever for over 48 hours.
You were started on a new medication called Flagyl to treat you
clostridium dificile colitis. You will need to take this for
another 13 days after you are discharged.
We made the following changes to your medications: Your Arixtra
was STOPPED. Please do not restart this medication until you
speak with your primary care physician. [**Name10 (NameIs) **] Lisinopril was
changed from 40 mg twice a day to 40 mg daily.(You can discuss
this dosing frequency with your primary care physician). Your
Seroquel was STOPPED becuase you were having some confusion and
we did not want to further alter your mental status.
You will need to follow up as listed below.
If you experience a recurrence of fevers, or have chills, night
sweats, chest pain , shortness of breath, or increasing weakness
please call your primary care provider or come to the emergency
department for evaluation.
Followup Instructions:
**MRI of Head [**2180-12-13**] at 1:30 in the [**Hospital Ward Name 517**]
**(Podiatry): Dr. [**Last Name (STitle) 1683**] Thursday, [**12-14**] 1:00 Phone
number: [**Telephone/Fax (1) 79916**]
**(Neurology)[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2180-12-19**] 10:00
**(Medicine)Dr. [**Last Name (STitle) **] [**2180-12-21**] 2:15
Completed by:[**2180-11-24**]
|
[
"V43.65",
"357.2",
"401.1",
"851.81",
"E885.9",
"244.9",
"293.0",
"E934.2",
"530.81",
"707.05",
"253.6",
"008.45",
"713.5",
"733.90",
"707.22",
"272.4",
"V58.65",
"041.4",
"714.0",
"599.0",
"285.29",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
19611, 19685
|
13558, 18866
|
372, 378
|
20138, 20145
|
6164, 6164
|
22065, 22496
|
3254, 3272
|
19706, 20117
|
18892, 19588
|
20169, 21352
|
7001, 13535
|
4849, 6145
|
3287, 4116
|
21381, 22042
|
6198, 6985
|
302, 334
|
406, 2693
|
6181, 6181
|
4131, 4832
|
2715, 3149
|
3165, 3238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,461
| 150,051
|
22572
|
Discharge summary
|
report
|
Admission Date: [**2181-4-28**] Discharge Date: [**2181-4-30**]
Date of Birth: [**2105-12-29**] Sex: M
Service: MEDICINE
Allergies:
oxycodone-acetaminophen / hydrocodone-acetaminophen
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 yo M with Crohn's disease on chronic daily Prednisone and
Azathioprine, s/p small bowel resections X 4, perianal fistula,
diverticulitis, GI bleeding, CAD, AFib on Coumadin, esophageal
stricture and recent catheter-associated MSSA bacteremia
currently at Rehab presenting with weakness, fever, and
hypotension.
.
The patient was admitted from [**Date range (3) 58552**] for a contained
bowel perforation, which was medically managed with
Cipro/Flagyl. He developed a septic thrombus at the site of RIJ
CVC placed for TPN. Blood cultures grew MSSA, TTE & TEE were
negative for endocarditis, and the patient was d/c on 6 weeks of
Nafcillin (only completed 4).
Yesterday ([**2181-4-27**]) he spiked a fever to 104 at his rehab
facility
He was started on Vancomycin, Zosyn, and Levaquin.
.
In the ED, initial vs were: 96.6, 116, 75/47, 98% 2L NC. Labs
were notable for Na 130, Cr 1.7 (BL 1.3). White count was 7.7
and lactate 1.6. L PICC line was pulled with tip sent for cx.
Blood and urine cultures also sent. Left IJ was placed and Pt
was given IVF (4L) and started on Levophed (0.1). CXR showed
bibasilar opacities, likely atelectasis. CT C/A/P revealed focal
free air (similar to prior scan). ACS was consulted and
recommended admission to MICU, serial abd exams, trending of lab
markers, and strict NPO given that the Pt's abdominal exam was
unremarkable. He was given 100 mg of IV Hydrocortisone (out of
concern for AI), Micofungin (out of concern for fungal pathogens
[**2-21**] TPN), and Vanco/Levaquin/Zosyn.
.
On admission to the [**Hospital Unit Name 153**], he was sleepy, but arousable and
answering questions appropriately. He denied any localizing
symptoms of infection (no HA, dyspnea, cough, N/V, abd pain,
dysuria, rash) or cardiac disease. His CVP was 4 and he was
given an additional 2L NS bolus with improvement to 12.
.
Review of sytems: as above
(+) Per HPI, + diarrhea (chronic)
(-) HA, seizure, sore throat, chest pain, palpitations, dyspnea,
cough, nausea, vomiting, dysuria, rash, leg swelling
Past Medical History:
-Crohns disease s/p 3 small bowel resections
-Hx of ileocectomy
-Hx of diverticular perforation vs jejunal perforation likely
r/t
Crohns flare s/p ex-lap complicated by MI (in past)
-CAD
-Perianal Fistulas
-Diverticulitis
-Colonic polyp
-Afib rate controlled, on Coumadin
-HTN
-CRI
-Hx of GIB [**2-21**] Coumadin ([**2-/2180**])
-Hx of DVT in RUE [**2175**]
-Hx of PNA
-Chronic hip and back pain d/t bilateral AVN of femoral head
-Gout
-Hx of MRSA and VRE
Social History:
Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital. He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.
Pt currently lives at [**Hospital3 **] since [**Month (only) 404**]. He denies
any current EtOH, tobacco or recreational drug use. Prior hx of
tobacco. He is able to ambulate with a walker.
Family History:
Denies family history of IBD.
Physical Exam:
Vitals: 97.5, 115, 157/100, 17, 99% on RA
General: elderly, well-nourished, sleepy, arousable,
appropriate, oriented, no acute distress
HEENT: sclera anicteric, no conjunctival hemorrhage, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: tachycardic, irregular rhythm, S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: cool, no edema, + [**Male First Name (un) **] hose, distal pulses present and
symmetric, crusted ulceration with surrounding blue macule on R
foot 3rd toe, distal hyperpigmented macule on tip of R hallux
Pertinent Results:
[**2181-4-28**] 06:50PM BLOOD WBC-7.7 RBC-3.09* Hgb-10.0* Hct-28.9*
MCV-93 MCH-32.3*# MCHC-34.6 RDW-16.4* Plt Ct-158#
[**2181-4-29**] 04:07AM BLOOD WBC-9.8 RBC-3.11* Hgb-9.5* Hct-29.9*
MCV-96 MCH-30.5 MCHC-31.7 RDW-16.4* Plt Ct-230
[**2181-4-29**] 09:47AM BLOOD WBC-13.1* RBC-2.99* Hgb-9.2* Hct-28.8*
MCV-96 MCH-30.8 MCHC-32.0 RDW-16.4* Plt Ct-270
[**2181-4-29**] 03:20PM BLOOD WBC-10.2 RBC-3.12* Hgb-9.5* Hct-31.2*
MCV-100* MCH-30.5 MCHC-30.5* RDW-16.3* Plt Ct-225
[**2181-4-28**] 06:50PM BLOOD Neuts-93.8* Lymphs-3.0* Monos-2.9 Eos-0.1
Baso-0.2
.
[**2181-4-28**] 06:50PM BLOOD PT-15.5* PTT-38.4* INR(PT)-1.4*
[**2181-4-29**] 04:07AM BLOOD PT-14.8* PTT-51.9* INR(PT)-1.3*
[**2181-4-29**] 06:30PM BLOOD PT-21.9* PTT-150* INR(PT)-2.1*
.
[**2181-4-28**] 06:50PM BLOOD Glucose-138* UreaN-55* Creat-1.7* Na-130*
K-4.8 Cl-94* HCO3-30 AnGap-11
[**2181-4-29**] 04:07AM BLOOD Glucose-250* UreaN-42* Creat-1.4* Na-131*
K-4.2 Cl-103 HCO3-18* AnGap-14
[**2181-4-29**] 06:30PM BLOOD Glucose-380* UreaN-43* Creat-1.5* Na-131*
K-4.8 Cl-105 HCO3-13* AnGap-18
.
[**2181-4-28**] 06:50PM BLOOD ALT-18 AST-16 LD(LDH)-214 AlkPhos-67
TotBili-0.2
[**2181-4-29**] 06:30PM BLOOD ALT-1122* AST-2277* AlkPhos-94 Amylase-57
TotBili-0.3
[**2181-4-29**] 08:35PM BLOOD ALT-2043* AST-4983* AlkPhos-112
TotBili-0.3
[**2181-4-29**] 06:30PM BLOOD Lipase-77*
[**2181-4-28**] 06:50PM BLOOD cTropnT-0.04*
[**2181-4-29**] 04:07AM BLOOD CK-MB-7 cTropnT-0.12*
[**2181-4-28**] 06:50PM BLOOD Albumin-2.0* Calcium-7.5* Phos-2.7 Mg-2.2
[**2181-4-29**] 04:07AM BLOOD Calcium-6.5* Phos-2.9 Mg-1.9
[**2181-4-29**] 06:30PM BLOOD Calcium-6.7* Phos-4.5# Mg-1.8
.
[**2181-4-29**] 12:25PM BLOOD Type-MIX pH-7.25*
[**2181-4-29**] 03:32PM BLOOD Type-ART pO2-72* pCO2-19* pH-7.25*
calTCO2-9* Base XS--16 Intubat-NOT INTUBA
[**2181-4-29**] 06:40PM BLOOD Type-ART Temp-35.8 O2 Flow-2 pO2-75*
pCO2-23* pH-7.42 calTCO2-15* Base XS--6 Intubat-NOT INTUBA
[**2181-4-30**] 01:00AM BLOOD Type-ART Temp-36.7 pO2-88 pCO2-28*
pH-7.06* calTCO2-8* Base XS--21
[**2181-4-28**] 06:59PM BLOOD Lactate-1.6
[**2181-4-29**] 06:10AM BLOOD Lactate-1.9
[**2181-4-29**] 03:32PM BLOOD Glucose-152* Lactate-6.6* Na-131* K-4.8
Cl-113*
[**2181-4-29**] 08:39PM BLOOD Lactate-6.0*
[**2181-4-29**] 06:40PM BLOOD freeCa-0.98*
.
[**2181-4-28**] 08:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2181-4-28**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2181-4-28**] 08:30PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2181-4-29**] 12:04AM URINE Hours-RANDOM UreaN-863 Creat-51 Na-98
K-39 Cl-34
[**2181-4-29**] 12:04AM URINE Osmolal-561
IMAGING
CT abd/pelvis [**4-29**]
PENDING
CT chest/abd/pelvis [**4-28**]
IMPRESSION:
1. Extensive pneumatosis which was noted on [**2181-1-26**] has
worsened
since that and the most recent prior examination of [**2181-3-7**]. No
portal venous gas seen. Small associated foci of free air are
seen adjacent to the regions of pneumatosis. Etiology is
uncertain but may include both those of ischemic bowel, as well
as benign including connective tissue disorder, infectious
enteritis, and in association with steroid use.
2. No intra-abdominal abscesses or fluid collections are noted.
3. Bibasilar tree-in-[**Male First Name (un) 239**] opacities and trace bilateral pleural
effusions.
Findings may represent infection or aspiration, less likely
atelectasis.
4. Cholelithiasis without evidence of cholecystitis.
5. Avascular necrosis and collapse of bilateral femoral heads.
Findings were initially discussed with Dr. [**First Name4 (NamePattern1) 14552**] [**Last Name (NamePattern1) 17597**] at 11:40
p.m. on [**2181-4-28**] in person. Updated findings were then
discussed with Dr. [**Last Name (STitle) 3450**] at 1:00 a.m. on [**2181-4-29**], and Dr.
[**Last Name (STitle) **] at 3:30pm on [**2181-4-29**].
CHest xray [**4-28**]
IMPRESSION: PICC line appears to be in appropriate position.
Basilar
atelectasis on the left. No acute intrathoracic process
Brief Hospital Course:
75 yo M with Hx of Crohn's complicated by multiple surgeries and
medically-managed perforation in [**1-30**], as well as septic RIJ
thrombus and MSSA bacteremia s/p 4 weeks of Nafcillin presenting
with fever to 104, weakness, and hypotension
.
# Hypotension: Patient presented to ED with BPs in the 70s, for
which a L IJ CVC was placed and he received resuscitation with
IVFs and was started on Levophed. Likely etiology was sepsis,
given high fever. He did not have a leukocytosis, but was on
chronic immunosuppressants. Possible sources included his
indwelling PICC, which was removed and tip sent for culture.
Also, pulmonary, given that his chest CT revealed ground glass
opacities. However, the most likely source was intra-abdominal.
CT A/P revealed intra-abdominal free air, concerning for
perforation. General Surgery was consulted in the ED and
recommended no surgical management, serial exams, and monitoring
of his lactate and WBC. He was admitted to the [**Hospital Unit Name 153**] and started
on broad antimicrobials, including double coverage for GNR and
fungal pathogens. He was also started on stress dosed steroids
for possible adrenal insufficiency. His pressures continued to
fall and he was bolused additional liters of IVFs to maintain
CVP >10 without improvement in urine output, which was minimal.
His lactate rose from normal value and peaked at 6. His liver
enzymes reflected shock liver. A bladder pressure was 13.
General Surgery was made aware, and recommended repeat CT A/P,
which showed unchanged pneumatosis of the small bowel.
Exploratory laparotomy was denied by the family, given the
patient's wishes. After further discussion with the family he
was made DNR/DNI, started on a morphine gtt for pain control,
and expired at 0134 with family at the bedside.
.
# Free Air on Abdominal Imaging: As described above. Likely a
chronic finding related to his multiple abdominal surgeries and
prior perforation. His exam was not initially consistent with
acute new perforation; however, he was on chronic steroids.
GSurgery consulted in ED who felt no surgical treatment was
warranted and provided the recs as stated above. He was kept
strict NPO. The rest of the details are as above under
"hypotension."
.
# Acute Kidney Injury: Likely pre-renal in etiology secondary to
febrile illness and hypotension. Urinalysis with small protein.
FeNa of 2%; however, repeat Cr after fluids showed improvement
to recent baseline (1.4). Slowly uptrending creatinine and
oliguria that evolved throughout the day was attributed to ATN
and hypotension.
.
# Hyponatremia: Given clinical history, likely hypovolemic
hyponatremia. However, urine electrolytes supported SIADH.
Repeat Na mildly improved with IV hydration.
.
# A Fib with RVR: Patient has a hx of chronic A Fib on
anticoagulation. Initial rapid rate to 130s was likely related
to volume depletion. IV Lopressor 5 mg was given once with
subsequent drop in BP, requiring the addition of Neo-Synephrine
for pressure support. Blood pressure was never stable enough for
additional attempt at nodal [**Doctor Last Name 360**] control. Troponins were
elevated at 0.04, likely secondary to demand ischemia. See above
for the progression of illness.
.
# Anticoagulation: The patient has a hx of septic thrombus and A
fib, for which he was anticoagulated (usually on Coumadin,
presented on Lovenox bridge given potential upcoming GI
endoscopy to evaluate esophageal stricture). He was continued on
heparin gtt with goal PTT 60-100. Hct remained stable.
.
# Anemia: Chronic, normocytic. Currently above baseline on
presentation, likely reflecting hemoconcentration. No signs of
active bleeding. Hct was trended. He did not require any blood
transfusions.
.
# Crohn's Disease: He was continued on stress dose steroids and
IV azathioprine dose adjusted to his current creatinine
clearance. Mesalamine was held.
.
# Chronic Pain secondary to B/L AVN: He was continued on his
outpatient fentanyl patch and lidocaine, and started on Dilaudid
for breakthrough pain. Toward the end of his course, he was
changed to a morphine gtt for comfort prior to expiration.
Medications on Admission:
Azathioprine 50 mg Tab Oral 1 Tablet(s) Once Daily
-Prednisone 20 mg Tab Oral 1 Tablet(s) Once Daily (to be tapered
to 10 on [**5-2**])
-Pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet Once
Daily
-Mesalamine Powder Misc 1 Powder(s) Four times daily, 1,00 mg
-Lidocaine- Unknown Strength 1 Patch, Medicated(s) Every 6-8 hr
-Fentanyl 150 mcg/hr Transderm Patch Transdermal 1 Patch 72
hr(s) every 3 days
-Lovenox 80 mg subcut [**Hospital1 **] (Coumadin held for upcoming GI
endoscopy to evaluate esophageal stricture)
-Ultram 50 mg Tab Oral 2 Tablet(s) Every 4-6 hrs, as needed
-Ambien 5 mg Tab Oral 1 Tablet(s) Once Daily, as needed
-Levofloxacin - 1 Solution(s) 500mg iv every 24 hours
-Vancomycin 1,000 mg Intravenous 1 Recon Soln(s) Once Daily
-Zosyn 4.5 gram IV Solution Intravenous 1 Recon Soln(s) every
6-8 hrs
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac Arrest
Septic shock
Discharge Condition:
deceased
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"427.5",
"427.31",
"733.42",
"995.92",
"V58.65",
"585.9",
"V58.61",
"274.9",
"555.9",
"584.9",
"785.52",
"285.9",
"403.90",
"038.9",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13250, 13259
|
8228, 12348
|
332, 338
|
13330, 13340
|
4195, 8205
|
13393, 13536
|
3401, 3432
|
13221, 13227
|
13280, 13309
|
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|
13364, 13370
|
3447, 4176
|
281, 294
|
2226, 2389
|
366, 2208
|
2411, 2869
|
2885, 3385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,486
| 168,769
|
48454
|
Discharge summary
|
report
|
Admission Date: [**2198-1-19**] Discharge Date: [**2198-2-16**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
vertebroplasty [**2198-2-1**]
intubation [**2198-2-1**]
History of Present Illness:
This is a 64 year-old M with ESRD on HD, HTN, obesity, CAD s/p
stenting, HCV, metastatic poorly differentiated cancer (likely
NSCLC) who presents with SOB. He complained of SOB before HD
today, which did not immediately improved post-dialysis, so he
was sent to the ED. No chest pain, jaw pain, dizziness, or
lightheadedness. No fever or chills. Of note, he was recently
admitted [**Date range (1) 58897**] with pulmonary edema in the setting of
hypertension and dietary indiscretion.
On arrival to the ED his SOB had improved. He was given [**Date range (1) **] 325
mg. EKG was reportedly unchanged from baseline, CXR was without
pulmonary edema or infiltrate. Cardiac enzymes were sent with a
troponin slightly above recent values (0.17 from 0.14 last
week). He was admitted to rule-out MI.
Currently reports feeling well, except for neck pain (no pain
meds given since the a.m.).
ROS: No facial pain. No nausea/vomiting/diarrhea. Has been
wearing his cervical collar at all times. He is on antibiotics
for parotiditis and CDiff.
Past Medical History:
#. Onc HX: [**12-11**] pre renal transplant CT scan chest noted
enlarged RML nodule, w/ subcentimeter FDG avid scattered LNs.
Developed neck pain and found to have C2 pathological fracture,
[**11-22**] cytology demonstrated poorly differentiated carcinoma. Per
onc notes, is likely non-small cell lung carcinoma, with RML
mass and metastasis to the cervical and sacral spine. The only
manifestation of his disease currently is cervical neck pain,
s/p pathologic fx and posterior cervical arthrodesis C1-C3 and
palliative XRT.
#. CAD s/p angioplasty D1 [**7-10**] and stents to OM2/3 in [**3-11**]
#. ESRD [**1-6**] FSBS on HD
#. HTN
#. LLE peroneal nerve palsy [**1-6**] GSW to L leg
#. Thalassemia trait
#. h/o Substance abuse (heroin/cocaine); reports none since [**2163**]
#. CHF w/ EF 35% in [**11-11**]
#. MR - 2+ on [**Date Range 113**] in [**11-11**]
#. Pathological C2 Fx s/p C1-3 Fusion
#. Parotiditis - [**12-12**]
#. CDiff - [**12-12**]
#. HCV - grade 1 inflammation and stage 0 fibrosis on bx [**2-9**]
Social History:
lives with girlfriend, has 2 sons, used to work in construction,
+ smoker 1 PPD for many years quit recently, rare ETOH, no
drugs.
Family History:
Brother with CAD, and kidney disease requiring hemodialysis
Physical Exam:
Vitals: T 97.0 BP 121/71 P 79 RR 20 SpO2 98% RA wt 169 lbs
GEN: thin male sleeping, c/o neck pain when awoken.
HEENT: OP with MMM.
Neck: Cervical collar in place.
CV: RRR, nl S1/S2. 2/6 SEM radiating to axillae
CHEST: Good air movement throughout, bibasilar crackles.
ABD: soft, NT/ND. + BS.
EXT: no edema, warm. LUE with fistula + thrill
SKIN: extensive xerosis
NEURO: a+o x 3
Pertinent Results:
CXR [**1-19**]: Two views are compared with recent studies dated [**1-14**]
and [**2198-1-12**]. Allowing for differences in technique, overall
appearance is not much changed. There is persistent right middle
lobe consolidation, likely post-obstructive related to the known
[**Location (un) 21851**] in this location. Infiltration of adjacent
parenchyma is not excluded. No new focal consolidation is seen.
There is mild pulmonary vascular redistribution and blurring,
improved since [**1-12**], with no overt edema or pleural effusion.
.
CT NECK [**11-19**]:
1 Enlarged right parotid gland and right parotid duct. Tiny
1-2 mm stone
within the proximal right parotid duct. No definite obstructing
distal ductal stones although evaluation of the most distal
portion of the right parotid duct is limited by streak artifact
from the patient's dental prosthesis. Possibly the findings
could be explained by recent passage of a stone.
2. Destructive lesion of C2 with associated pathologic fracture
causes
moderate central canal narrowing.
3. Interval posterior cervical fusion from C1 through C3.
4. Several small cervical lymph nodes measure less than 1 cm in
short axis and may be reactive.
5. Multiple small pulmonary nodules of the lung apices measure
up to 9 mm at the right apex are not fully evaluated on this
neck CT.
6. Emphysema.
.
[**2198-1-20**] BILATERAL LENI:
1. Small nonocclusive left common femoral vein thrombus may be
chronic.
2. No right-sided DVT.
.
CT HEAD WITH CONTRAST [**1-21**]:
No hemorrhage or abnormal area of enhancement. If there is high
suspicion of metastatic lesion MRI is more sensitive.
.
CTA OF THE CHEST [**1-21**]: IMPRESSION:
1. No pulmonary embolism.
2. Right middle lobe spiculated mass with increased number and
size of
numerous pulmonary nodules, right hilar and mediastinal
lymphadenopathy, new right middle lobe bronchus encasement and
obstruction as well as osseous metastasis (see below) all
consistent with substantial progression of disease when compared
to the CT of [**2197-12-24**].
3. New acute pathologic compression fracture involving the T4
vertebral body and lytic lesion involving the transverse process
of the T4 vertebral body.
4. Bilateral pleural effusions, right greater than left.
5. Extensive paraseptal and centrilobular emphysematous
disease.
.
[**Date Range **] [**1-23**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= 25-30 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of moderate to severe (3+)
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.
Compared with the prior study (images reviewed) of [**2197-12-4**],
the left ventricle is now more dilated, left ventricular
systolic function is now more depressed and mitral regurgitation
is now more prominent. Regional wall motion abnormalities are
similar.
.
[**2198-1-24**] MRI THORACIC SPINE: IMPRESSION: Signal hyperintensity in
T4 vertebral body and right transverse process, consistent with
known metastasis. No epidural disease is seen, however it cannot
be completely excluded due to the non-diagnostic axial images.
For further details on the cervical spine, please see the prior
examination of [**11-16**].
.
[**2198-2-6**] MRI CERVICAL SPINE: CONCLUSION: Limited study due to the
lack of intravenous contrast and due to artifacts arising from
the fusion hardware. There is angulation and kyphosis with its
apex at C2. This, in addition to tumor breaking through the
posterior margin of the vertebral body produces narrowing of the
spinal canal, but not spinal cord compression. There is
extensive paravertebral tumor spread at the C2 level. There
appears to be a second tumor deposit in the C3-C4 neural
foramen.
.
[**2198-2-12**] CT C-SPINE: IMPRESSION:
1. Complete destruction of C2 vertebral body by tumor
involvement.
2. Fracture of the left lateral mass of C1 just lateral to the
screw.
3. Left lamina of C2 demonstrates screw protrusion anteriorly.
4. Intra-facet joint location of C3 facet screws.
5. Necrotic level II lymph nodes posterior to and causing slight
compression of left IJ vein.
.
[**2198-2-13**] EMG: IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
moderately severe, subacute (between 3 weeks and 3 months) C5
radiculopathy on the left. There is also evidence for an
underlying mild, generalized, sensorimotor polyneuropathy with
axonal features. The findings are less consistent with a
disorder of the brachial plexus on the left.
.
PATHOLOGY:
[**2198-2-1**] T4 VERTEBRAL BODY, biopsy: Predominantly blood with rare
degenerated malignant cells, consistent with poorly
differentiated metastatic carcinoma; see note.
.
Brief Hospital Course:
The patient is a 64 year-old M with ESRD on HD, HTN, CAD s/p
stenting, HCV, recent C. diff infection, and metastatic poorly
differentiated cancer (likely NSCLC) who presented with SOB that
resolved, whose hospital course was complicated by lower
extremity DVT and new T4 compression fracture.
.
HOSPITAL COURSE BY PROBLEM:
.
METASTATIC NON SMALL CELL LUNG CANCER/ VERTEBRAL METASTASES: The
patient has a history of NSCLC diagnosed in [**12-11**] pre-renal
transplant. He developed neck pain and was found to have a
pathologic fracture of C2 with posterior cervical arthrodesis in
[**11-11**]. Cytology demonstrated poorly differentiated carcinoma and
per oncology notes the likely diagnosis is non-small cell lung
cancer. He also has known mets to the sacral spine and upon this
admission noted to have a thoracic (T4) pathologic fracture
which was successfully treated with vertebroplasty on [**2198-2-1**].
Post-operative course was complicated by volume overload
secondary to intra-operative IVF administration that resulted in
brief intubation and ICU transfer. This resolved with volume
removal via HD. The patient continued to complain of neck pain
after the procedure. Further imaging was pursued, which showed
complete destruction of C2, lateral C1 fracture, and anterior
screw protrusion at C2. The patient was evalauted by spinal
surgery, who recommended no further operative measures as the
patient is a poor surgical candidate given poor prognosis,
multiple comorbidities, and morbidity of procedure. They
recommended that a [**Location (un) **] hard collar be worn indefinitely to
stablize the cervical spine. The patient also complained of
progressive LUE weakness since [**11-11**], which was felt to be most
likely secondary to findings of a new paraspinal soft tissue
mass and tumor deposition at C4-5 neural foramen. Radiculopathy
in this distribution was confirmed by EMG testing. The pain
consult service was consulted during admission, and the patient
was continued on oxycontin 20mg tid, oxycodone IR to tid prn,
standing tylenol 1g q6h, and neurontin 300mg qd (renal dosing)
with lidoderm patch and prn fentora for breakthrough.
The patient received navelbine for chemotherapy on [**2-6**] which was
well-tolerated, but given findings of progressive metastatic
disease despite chemo/ XRT it was decided that further
chemotherapy would not be pursued. The patient received 1 dose
of palliative XRT prior to discharge. He will follow-up with
oncology clinic upon discharge for further care.
.
SHORTNESS OF BREATH: The patient initially initially thought to
be volume overload; however, the patient was only mildly volume
overloaded. He was dialyzed without much improvment but then
upon admission his shortness of breath resolved without further
intervention. Given his metastatic lung cancer it was thought
possibly due to the progression of his disease. A CT of his
chest confirmed this progression over the past 4 weeks. In
addition the patient had a small non-occlusive, possibly chronic
DVT and a thought was possible small PEs, this was not evident
on CTA. He was anticoagulated with heparin and bridged to
coumadin for a goal INR [**1-7**]. The patient was continued on
standing albuterol and ipratropium nebulizers while inhouse with
resolution of symptoms.
.
FEVER: On [**2-9**] the patient developed fevers to 101.7 with no
localizing signs or symptoms. CXR was unrevealing and cultures
were negative to date by time of discharge. The patient was
empirically started on with neg. BCX to date (unable to obtain
adequate sputum or urine cultures to date). There was no
evidence of cellulitis or abscess on exam. There was no jaw pain
or exam findings to suggest parotiditis. Possibility of tumor
fevers was considered, but there was no prior history of this.
The patient was started on levofloxacin, vancomycin (with HD),
and briefly flagyl for broad coverage. Levofoxacin and
vancomycin were continued for a 7 day course with no recurrence
of fevers.
.
DVT: As above, the patient was found to have a small
non-occlusive, possibly chronic DVT in the left common femoral
vein. He was anticoagulated with heparin and bridged to coumadin
for a goal INR [**1-7**].
.
CAD: The patient had multiple episodes of chest pain during
admission. He was ruled out for MI several times with negative
cardiac enzymes and no ischemic EKG changes. An [**Month/Day (3) 113**] was
repeated on admission, which did show an EF of 25-30% with 3+ MR
(2 months ago his EF was 35-40% with 2+ MR). Medical management
with aspirin, [**Month/Day (3) 4532**], ACEi, beta blocker and nitrate was
continued.
.
ESRD on HD (FSGS): The patient was maintained his MWF schedule.
Nifedipine was held on HD days given decreased BP.
.
PAROTITIS: stone passage 1 week prior to admission, repeat CT
scan showed a small, 1-2mm stone in stentsons duct without
obstruction. Vanc and Levofloxacin were stopped in discussion
with ENT and the patient was continued on Flagyl for his C diff.
C DIFF COLITIS: patient with a history of C diff colitis, on
flagyl; however, in light of recent antibiotic administration
for parotitis, flagyl was continued for an additional 14 day
course after completion of vanc/ levo.
.
The patient was discharged on [**2198-2-16**] to home in stable
condition, afebrile and VSS, with services. Follow-up in
heme/onc clinic was arranged for [**2198-2-20**].
Medications on Admission:
Calcium Acetate 667 mg PO TID
Nephrocaps
Simvastatin 20 mg Daily
Senna 8.6 mg [**Hospital1 **]
Aspirin 81 mg Daily
Clopidogrel 75 mg Daily
Nifedipine 30 mg Tablet SR Daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Lisinopril 20 mg Daily
Isosorbide Mononitrate 30 mg SR Daily
OxyContin 30 mg Tablet SR Q8 HRS
Oxycodone 5 mg Q6HRS PRN
Omeprazole Magnesium 20 mg Daily
Docusate Sodium 100 mg [**Hospital1 **]
flagyl 500 mg PO BID - for CDiff (needs to take for 2 weeks past
levoflox and vanco courses)
levofloxacin 250 mg PO Q48H - for parotiditis
vanco 1 g QHD protocol - for parotiditis
Discharge Medications:
1. Oxygen
Please provide home oxygen at 2L by nasal cannula, titrated to
comfort
2. Commode
Please provide commode to patient's bedside
3. Wheelchair
Please provide wheelchair as patient has cervival spine
fractures and cannot ambulate
4. Nebulizer & Compressor For Neb Device Sig: One (1)
nebulizer machine and kit Miscellaneous x 1.
Disp:*1 machine/ kit* Refills:*0*
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
8. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed.
Disp:*300 ML(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every 4-6 hours.
Disp:*1 inhaler* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
only on NON-dialysis days.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
14. 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*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily): only on NON-dialysis
days.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
17. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*300 Tablet(s)* Refills:*0*
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
19. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injetion
Injection ASDIR (AS DIRECTED): To be administered during
dialysis .
20. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): On days of dialysis, please hold this med until after
dialysis has taken place. .
Disp:*30 Capsule(s)* Refills:*2*
21. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*2*
22. [**Hospital1 **] 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
23. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: please apply to neck as needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
24. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO q 3 hours as
needed for pain for 5 days.
Disp:*100 Tablet(s)* Refills:*0*
25. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
26. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO every eight (8) hours.
Disp:*76 Tablet Sustained Release 12 hr(s)* Refills:*2*
27. Outpatient Lab Work
please check INR on Monday, [**2198-2-19**] with results faxed to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**] at [**Telephone/Fax (1) 4004**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Metastatic Non small cell lung cancer
Deep Vein thrombosis
Pathologic fracture of T4
Pathologic fracture of C2
Secondary Diagnosis:
ESRD on HD
CHF
CAD
HTN
Pathological C2 fracture s/p C1-3 Fusion
Discharge Condition:
stable, afebrile and VSS, in hard collar
Discharge Instructions:
You were admitted with shortness of breath which was likely due
to having extra fluid. This resolved shortly after dialysis. In
addition, your lung cancer was found to be progressing, which
may have contributed to worsening in your breathing.
.
You were also found to have a new fractured vertebrae which was
treated with a vertebroplasty procedure. You were found to have
worsening of your metastatic disease in your upper neck for
which you should wear your neck / back brace at ALL TIMES as
instructed. Call your doctor or call 911 immediately if there is
weakness or change in sensation in your legs.
.
For your heart failure you should weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet.
.
During your admission several medication changes were made. You
should take all of your medications as prescribed on the updated
list provided. You should attend all of your follow-up
appointments as listed below.
.
If you experience any fevers > 101, chills, shortnes of breath,
cough, chest pain, palpitations, nausea/ vomiting/ diarrhea,
weakness/ numbness/ paralysis, or any other concerning symptoms
please contact your primary care doctor or go to the ER for
further evaluation.
Followup Instructions:
You have the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2198-2-20**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2198-2-20**] 9:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2198-2-20**]
11:00
.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**], within [**12-6**]
weeks of discharge to discuss the events of your
hospitalization. Phone: [**Telephone/Fax (1) 250**].
.
You were started on a new medication, coumadin, to thin your
blood. You will need to have levels checked (=INR). Your
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] these results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**] at
[**Telephone/Fax (1) 4004**] on Monday, [**2198-2-19**]. You will be set up with the
coumadin clinic for monitoring of these levels after this.
|
[
"518.5",
"070.54",
"428.0",
"V45.81",
"403.91",
"414.01",
"585.6",
"282.49",
"453.41",
"198.5",
"733.13",
"162.8",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.49",
"96.71",
"96.04",
"81.65",
"39.95",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
18080, 18137
|
8511, 8806
|
292, 350
|
18397, 18440
|
3091, 8488
|
19717, 20873
|
2617, 2678
|
14527, 18057
|
18158, 18158
|
13915, 14504
|
18464, 19694
|
2693, 3072
|
249, 254
|
8834, 13889
|
378, 1414
|
18310, 18376
|
18177, 18289
|
1436, 2453
|
2469, 2601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,478
| 162,237
|
47130
|
Discharge summary
|
report
|
Admission Date: [**2128-2-9**] Discharge Date: [**2128-2-17**]
Service: MEDICINE
Allergies:
Vioxx / Bactrim / Codeine / Aspirin
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
Angiography.
History of Present Illness:
Pt is 86 yo f with Afib, hx of diverticular bleeding, who p/w
BRBPR upon waking this AM. Episode was very similar to episode
in [**7-12**] which was attributed to diverticular bleeding. She had
some lightheadedness after getting off the toilet this AM but
otherwise has been symptom free, without abd pain, nausea,
vomiting, or changes in bowel habits.
.
In the [**Name (NI) **], pt had 300cc of BRBPR, and SBP dropped to 50's. She
was given 2 U PRBC's, 2L NS, and SBP increased to 120's. NGL was
negative. She was also given Anzemet 12.5 IV. Upon arrival to
the ICU, pt had HR up to 100's (in afib), and SBP dropped to the
80's. She then had about 600cc of BRBPR. Repeat hct was 28.9
(down from 33.8 on presentation). Pt c/o lightheadedness,
nausea, and mild abdominal cramping, but denies CP or SOB. She
was ordered for an additional 2 U PRBC's, and GI and angio
services were notified.
Past Medical History:
1. Afib: not on coumadin
2. chronic diarrhea - Dr [**Last Name (STitle) 3315**]
3. Insulin Dependent DM: HbA1C at 6.9 % on [**2127-6-18**]
4. Hypertension
5. Asthma
6. Gout
7. Recurrent UTIs: most recently with Klebsiella, multiple UTIs
previously with pan-sensitive E.Coli
8. GERD
9. Tremor: essential tremor, followed previously by Dr. [**Last Name (STitle) 17281**]
10. Chronic Renal Failure: baseline of ~1.5
11. Choledocholithiases/cholangitis ([**2126-4-20**]): found to have
pseudomonas bacteremia, treated with ceftazidime and flagyl, and
referred for cholecystectomy but patient refused
Social History:
Social History:
No alcohol, tobacco, or other drugs.
Living: currently living alone. Gets assistance with meals and
cleaning. Currently showers and dresses on her own, but thinks
she may need help with this in the future.
Family History:
Family History:
Maternal history of breast cancer
Uncle with stomach cancer, uncle with liver cancer, brother with
prostate cancer
Physical Exam:
Vitals: T 97.4 BP 123/93 HR 84 RR 17 O2 100% 2L NC
Gen: NAD, pleasant
HEENT: PERRL
Cardio: distant heart sounds, irregularly irregular
Resp: CTAB anteriorly
Abd: obese, soft, nt, +BS
Ext: trace BL LE edema
Neuro: A&Ox3
Pertinent Results:
GI Bleeding Study on [**2128-2-9**]:
IMPRESSION:
Positive examination. Location of bleeding is believed to be
within the
descending and sigmoid colon.
Angiography on [**2128-2-9**]:
IMPRESSION: Mesenteric angiography of the superior and inferior
mesenteric arteries, including superselective injections of
tributaries of the inferior mesenteric artery, showing no
evidence of active contrast extravasation, neovascularity, or
arteriovenous malformation. Findings discussed with Dr. [**Last Name (STitle) 7341**]
on the same evening.
[**2128-2-9**] 07:00AM BLOOD WBC-6.2 RBC-3.87* Hgb-11.1* Hct-33.8*
MCV-88 MCH-28.8 MCHC-33.0 RDW-16.4* Plt Ct-207
[**2128-2-9**] 01:39PM BLOOD WBC-11.1*# RBC-3.24* Hgb-9.7* Hct-28.9*
MCV-89 MCH-29.8 MCHC-33.4 RDW-15.5 Plt Ct-150
[**2128-2-13**] 04:30AM BLOOD WBC-5.0# RBC-2.93* Hgb-8.7* Hct-24.4*#
MCV-84 MCH-29.7 MCHC-35.6* RDW-16.6* Plt Ct-131*
[**2128-2-14**] 04:57AM BLOOD WBC-6.9 RBC-3.59* Hgb-10.8* Hct-29.9*
MCV-83 MCH-30.2 MCHC-36.3* RDW-16.5* Plt Ct-111*
Brief Hospital Course:
86 year-old female with Atrial fibrillation, history of
diverticular bleeding, now with BRBPR. Upon arrival to the ICU,
pt had HR up to 100's (in afib), and SBP dropped to the 80's.
She then had about 600cc of BRBPR. Repeat hct was 28.9 (down
from 33.8 on presentation). Pt c/o lightheadedness, nausea, and
mild abdominal cramping, but denies CP or SOB. She was ordered
for an additional 2 U PRBC's, and GI and angio services were
notified.
.
A tagged red cell scan was positive within 1 minute, but
mesenteric angiogram of SMA and [**Female First Name (un) 899**] was negative. Pt received
total of 7 units RBCs in the MICU and Hct has been stable for 12
hours, and pt was without complaints. She was called out the
floor and Hct stabilized with only 1 unit pRBC's given to keep
Hct>30. More detailed hospital course by problem below:
.
#) BRBPR: Likely due to diverticular bleeding given severe
diverticulosis on endoscopy. Bleeding scan positive in sigmoid,
mesenteric angiography negative. No localization of bleeding.
Colonoscopy performed. It was initially felt that she may need
sigmoid colectomy if she starts to bleed again profusely.
Surgery was consulted for this reason. Patient said she would
be amenable to surgical intervention if necessary. Continued
pantoprazole and held aspirin. Patient will restart ASA in [**6-15**]
as an outpatient with her PCP.
.
#) Atrial fibrillation: Patient in and out of Afib/flutter. BP
stable with rate 60's-90's. Initially held verapamil given
possible rebleed potential however it was restarted after BP and
HR were stablized.
.
#) DM: Patient had been on insulin, but this was recently
changed to glucotrol only. Pt currently with poor control.
Started on NPH 14AM/8PM and uptitrated on HISS.
.
#) Hypertension: Initially held Lasix, verapamil, and lisinopril
given hct drop and hypotension.
.
#) Gout: pt on allopurinol at home, held in light of RF but once
stable, continued allopurinol given sx of gout.
.
#) History of CAD: pt with 1 vessel CAD by '[**15**] cath. Held ASA
but continued statin. Should hold ASA for 7-10 days post
discharge as discussed above.
.
#) Asthma: Stable. continued Zafirlukast.
.
#) OA: continued tylenol for pain. Held oxycodone. Pt to resume
on discharge.
.
Medications on Admission:
Amoxicillin 2g prn procedures
Atorvastatin 10 mg qd
Quinine Sulfate 260 mg qhs prn
Allopurinol 300mg qd
Atrovent prn
Protonix 40 mg [**Hospital1 **]
Tylenol 1g q8h prn
Lisinopril 10 mg qd
Lasix 20mg qd
Glucotrol XL 5mg [**Hospital1 **]
SL NTG prn
Oxycodone 2.5mg [**Hospital1 **] prn
Calcium Carbonate 500 mg tid
Vit D 400 unit [**Hospital1 **]
Verapamil 120 mg SR qd
Aspirin EC 81 mg qd
Zafirlukast 20mg [**Hospital1 **]
.
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO qhs prn.
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
6. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO every
eight (8) hours as needed.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: Please take one under you tongue every
five minutes for continued chest pain/shortness of breath up to
3 times. If the pain persists, go to the ED.
10. Oxycodone 5 mg Tablet Sig: [**12-9**] Tablet PO twice a day as
needed for pain.
11. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
12. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
13. Verapamil 120 mg Cap, 24HR Sust Release Pellets Sig: One (1)
Cap, 24HR Sust Release Pellets PO once a day.
14. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: ASDIR
Subcutaneous twice a day: 14 units in the morning and 8 units at
night.
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Diverticular bleed
Secondary Diagnoses:
Atrial fibrillation
DM
HTN
CAD
Gout
Essential tremor
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized for a severe GI bleed. Your aspirin was
stopped, and other changes were made to your medications (see
med list). You should see your PCP within the next 7-10 days to
decide when you should continue to take your aspirin again if at
all.
.
Return to the ED or call your PCP if you have:
* bright red blood in your stool
* dark or tarry stools
* lightheadedness, chest pain or shortness of breath
* any new or concerning symptoms
Followup Instructions:
The following appointments have been made for you:
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2128-2-23**] 8:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-2-25**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2128-2-26**] 9:20
Completed by:[**2128-2-20**]
|
[
"585.9",
"493.90",
"427.31",
"274.9",
"458.9",
"530.81",
"427.32",
"715.90",
"562.12",
"403.90",
"285.1",
"569.41",
"414.01",
"V58.67",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
7793, 7850
|
3498, 5744
|
248, 274
|
8007, 8016
|
2472, 3475
|
8513, 9025
|
2101, 2217
|
6219, 7770
|
7871, 7871
|
5770, 6196
|
8040, 8490
|
2232, 2453
|
7931, 7986
|
203, 210
|
302, 1193
|
7890, 7910
|
1215, 1828
|
1860, 2069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,615
| 163,684
|
52936
|
Discharge summary
|
report
|
Admission Date: [**2154-9-21**] Discharge Date: [**2154-9-26**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 79-year-old man with a
history of coronary artery disease, peripheral vascular
disease, rectal cancer status post partial colectomy and
chemoradiation, who was recently admitted to [**Hospital6 14430**] on [**8-18**] with left lower extremity pain. He
was treated with intravenous antibiotics but had continued
left lower extremity pain and was treated with a left
below-knee amputation. Postoperative course has been
complicated by confusion contributed to the levofloxacin
which was changed to ceftazidime. He was discharged
postoperatively to [**Hospital6 14480**] Hospital for
acute rehabilitation needs.
Since his discharge from [**Hospital6 **] he has noted
worsening dysphagia as well as odynophagia with both solids
and liquids as well as postprandial vomiting beginning
approximately five to six days prior to admission. He has
also noted an approximately 15-pound weight loss over the
past month as well as increased fatigue and decreased
appetite. On the day prior to admission he was noted to have
guaiac-positive stools which progressed to frank melena. He
had three episodes of melena on the day prior to admission.
At the rehabilitation hospital he was given vitamin K 2.5 mg
p.o. and SPF. Coumadin which he had not taken for several
months was stopped on the day prior to admission and INR was
noted to be 3.6 at the time. Melena progressed on the day of
admission. He denied any palpitations, shortness of breath,
or lightheadedness. The patient has also had a recent
Pseudomonas aeruginosa urinary tract infection and was
started on ciprofloxacin on [**2154-9-20**]. His stool was
also noted to be Clostridium difficile toxin positive on
[**9-19**] and started on Flagyl. He was then sent to [**Hospital1 1444**] Emergency Department for
further evaluation.
In the Emergency Department he was noted to be afebrile,
orthostatic by blood pressure and pulse. An nasogastric
lavage was noted to have a red aspirate which cleared after
600 cc of saline. In the Emergency Department he continued
to have active melena. The patient had also noted some loose
stools that were black in appearance over the past month.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post 4-vessel coronary
artery bypass graft in [**2143**].
2. Left femoral tibial bypass in [**2147-9-26**].
3. Carotid endarterectomy, cerebrovascular accident in [**2141**]
with multiple transient ischemic attacks.
4. Bilateral cataract surgery.
5. Basal cell cancer, removal Moh's times two.
6. Congestive heart failure.
7. Left below-knee amputation in [**2154-7-27**].
8. Atrial fibrillation, on Coumadin.
9. Rectal cancer, status post partial colectomy and
chemoradiation.
10. Esophageal stricture, status post dilation times two.
11. History of [**Doctor Last Name 15532**] esophagus noted on
esophagogastroduodenoscopy in [**2148**].
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Imdur 60 mg p.o. q.d.
3. Spironolactone 25 mg p.o. b.i.d.
4. Thiamine 100 mg p.o. q.d.
5. Folate 1 mg p.o. q.d.
6. Multivitamin tablet 1 tablet p.o. q.d.
7. Lisinopril 40 mg p.o. q.d.
8. Digoxin 0.125 mg p.o. q.d.
9. Lasix 40 mg p.o. q.d.
10. Lopressor 100 mg p.o. b.i.d.
11. Coumadin 5 mg p.o. q.d.
12. Bethanechol 25 mg p.o. b.i.d.
13. Zantac 150 mg p.o. b.i.d.
14. Flagyl 500 mg p.o. t.i.d. (started on [**9-21**]).
15. Ciprofloxacin 500 mg p.o. b.i.d. (started on
[**9-20**]).
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Admits to significant tobacco and ethanol
use.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 96.8,
pulse 64, blood pressure 122/64, oxygen saturation was 98% on
2 liters, respiratory rate 16. Generally, this is an elderly
man in no acute distress. HEENT revealed head was
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light. Extraocular muscles were intact. Throat
was moist. Neck veins were flat. No jugular venous
distention. No thyromegaly. No lymphadenopathy. Heart was
irregularly irregular with a 2/6 systolic ejection murmur in
the left upper sternal border. Lungs had decreased breath
sounds, diffusely mild crackles at the bases. Abdomen was
flat with a well-healed midline scar, nondistended,
nontender. No hepatosplenomegaly. No palpable masses.
Hyperactive bowel sounds. Extremities revealed status post
left below-knee amputation site was clean, dry, and intact.
Right lower extremity were without any edema. Neurologic
examination revealed cranial nerves II through XII were
intact. Reflexes were 2+ and symmetric bilaterally. Moved
all four extremities. Mild intention tremor.
LABORATORY DATA ON PRESENTATION: Sodium 129, potassium 3.1,
chloride 93, bicarbonate 24, BUN 35, creatinine 0.7, glucose
of 134. White blood cell count 31.4, hematocrit 31,
platelets were 335. PT 15.6, PTT 30, INR 1.7. ALT 22,
AST 25, alkaline phosphatase 151, LDH 174, total
bilirubin 1.5, direct bilirubin 0.6, indirect bilirubin 0.9.
GGT 149, calcium 7.5, phosphate 1.7, magnesium 1.2.
Haptoglobin was 206. Helicobacter pylori antibody test was
negative. Urine culture showed Pseudomonas aeruginosa.
RADIOLOGY/IMAGING: CT of the chest, abdomen, and pelvis
revealed proximal esophagus was somewhat dilated. There was
symmetric thickening of the distal esophagus with extension
into the greater and lesser curvatures of the stomach.
Multiple mediastinal lymph nodes were identified, multiple
subcentimeter AP window nodes were also noted. There was
significant right hilar lymphadenopathy. There were small
bilateral pleural effusions with associated compressive
atelectasis. Liver, gallbladder, pancreas, adrenal glands,
kidneys, and spleen were normal in appearance. A large lymph
node was identified in the porta hepatis. There were
multiple subcentimeter lymph nodes about the celiac axis.
Barium swallow revealed a shelf-like mass seen in the distal
esophagus and appeared to extend into the proximal stomach
causing mucosal irregularity. There also appeared to be a
filling defect proximal to this mass.
Esophagogastroduodenoscopy with impression of mucosa was
salmon colored, suggestive of [**Doctor Last Name 15532**] esophagus. A large
fungating mass with evidence of recent bleeding and malignant
in appearance was found at the middle third of the esophagus.
Mass began at approximately 30 cm and appeared to be
protruding from an area of [**Doctor Last Name 15532**] esophagus. The lesions
was not transverse. Cytology samples were obtained using a
brush.
HOSPITAL COURSE: This is a 79-year-old male with a history
of rectal cancer two years ago, status post resection and
chemotherapy and radiation therapy, coronary artery disease,
peripheral vascular disease, status post recent left
below-knee amputation, who presented with dysphagia,
odynophagia, and melena.
1. GASTROINTESTINAL: The patient was felt to be having an
active upper gastrointestinal bleed and was admitted to the
Medical Intensive Care Unit. He was transfused a total of 3
units of packed red blood cells, and his elevated INR was
reversed with 1 mg subcutaneous of vitamin K.
Esophagogastroduodenoscopy was done on hospital day two which
revealed a large fungating mass at the level of the middle
esophagus as above. Brush biopsies were obtained. Given his
recent elevated INR no tissue biopsy was obtained at this
time. Chest and abdominal CT scan revealed multiple areas of
lymphadenopathy in the hilar and mediastinal areas as well as
the celiac area. Barium swallow showed a distal shelf-like
mass as above. He was felt to be hemodynamically stable and
with no further episodes of melena and was transferred to the
medicine floor.
Because the brush biopsy was nondiagnostic, a repeat
esophagogastroduodenoscopy was scheduled with plans for a
tissue biopsy. The patient refused further
esophagogastroduodenoscopy and diagnostic workup and was
wishing no further treatment including blood transfusions,
medications, and intravenous feedings if needed.
2. HEMATOLOGY: Given the recent decrease in hematocrit the
patient was transfused a total of 3 units of packed red blood
cells and given subcutaneous vitamin K and fresh frozen
plasma to reverse his anticoagulation prior to endoscopy.
His hematocrit was stable on discharge, and he did not
require any further transfusions.
3. INFECTIOUS DISEASE: On admission he was continued on
Flagyl for a Clostridium difficile colitis, and ciprofloxacin
for a Pseudomonas positive urinary tract infection. These
medications were discontinued on discharge on his request.
4. FLUIDS/ELECTROLYTES/NUTRITION: After endoscopy, he was
started on a pureed liquid diet which he tolerated without
difficulty. His electrolytes were repleted as necessary.
5. DISCHARGE DISPOSITION: The [**Hospital 228**] medical status was
discussed in detail with him, and the patient wished to have
no further interventions done. Hospice was arranged for him,
and the patient was discharged to home with plans for hospice
care.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Peripheral vascular disease.
3. History of rectal cancer.
4. Upper gastrointestinal bleed with evidence of esophageal
mass.
5. Pseudomonas aeruginosa positive urinary tract infection.
6. Clostridium difficile colitis.
7. Anemia.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2362**]
Dictated By:[**Name8 (MD) 17311**]
MEDQUIST36
D: [**2154-9-25**] 14:39
T: [**2154-9-27**] 08:03
JOB#: [**Job Number 15466**]
(cclist)
|
[
"999.8",
"578.9",
"599.0",
"V10.06",
"V49.75",
"280.0",
"427.31",
"235.5",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8878, 9112
|
9133, 9674
|
3014, 3572
|
6641, 8854
|
111, 2268
|
2291, 2987
|
3589, 6623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 144,257
|
22412
|
Discharge summary
|
report
|
Admission Date: [**2130-3-25**] Discharge Date: [**2130-3-31**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24F with DM1 presented to ED w/ DKA. Had fight with cousin last
night and woke up this morning feeling very anxious with chest
tightness feeling like it was difficult to take a deep breath.
She felt like her sugars were getting higher so came to the ED.
Started vomiting and having diarrhea while in the ED, no blood.
[**8-10**] non-radiating back/abd pain. FSBS typically 170-200s at
home, last A1c was 9%. Found to have AG to 32 with blood glucose
492 and ketones in urine, had not taken insulin this am. Poor
historian. Vomiting constantly in ED. Recently finished 5 day
course of cipro for UTI on monday. Denies being recently
sexually active.
.
Initial VS:
97.6 120s 103/60 20 100% RA
VS at time of transfer:
121 108/40 19 100% RA
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, night sweats, chills, headaches,
dizziness or vertigo, hematemesis, coffee-ground emesis,
dysphagia, odynophagia, constipation, steatorrhea, melena,
hematochezia, cough, hemoptysis, wheezing, chest pain,
palpitations, dyspnea on exertion, increasing lower extremity
swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while
walking, joint pain.
Past Medical History:
-Diabetes Type I: Last A1c 9.7%
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- H. Pylori [**6-/2128**]
- S/P MVA [**5-4**] - lower back pain since then. Per patient
received oxycodone from her primary provider
[**Name Initial (PRE) **] [**Name Initial (PRE) 58252**]
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
shots
- Genital Herpes
-? HTN
- chlamydia
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own appartment near [**University/College 5130**]. She is currently unemployed
and received disability. She has a 6 year old son. [**Name (NI) **] mother
and sisters live nearby. She denies tobacco, alcohol or illicit
drug use.
Family History:
Her grandmother had type I diabetes. No Hx of CAD, HTN
Physical Exam:
On MICU arrival
Vitals: 121 108/40 19 100% RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative,
tearful when discussing situation w/ cousin.
[**Name (NI) 4459**]: no scleral icterus, MM dry, no lesions noted in OP
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: Tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted, no CVA tenderness.
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact.
.
On transfer to floor:
VS: Tm 99.1, Tc 98.8 ??????F, HR 91, BP 126/76, RR 18, O2sat 100% RA
Gen: A/Ox3, comfortable, conversant.
[**Name (NI) 4459**]: No icterus
Heart: Tachycardic, regular rhythm, II/VI systolic murmur
Lungs: Clear bilaterally
Abd: Soft, NT,ND, BS normal
Ext: No edema, 2+ DP and PT pulses.
Pertinent Results:
[**2130-3-25**] 12:05PM BLOOD WBC-10.5# RBC-4.63 Hgb-13.5 Hct-42.6
MCV-92 MCH-29.2 MCHC-31.7 RDW-13.5 Plt Ct-262
[**2130-3-25**] 12:05PM BLOOD Glucose-492* UreaN-28* Creat-1.1 Na-134
K-4.7 Cl-95* HCO3-12* AnGap-32*
[**2130-3-25**] 12:05PM BLOOD Calcium-10.7* Phos-5.0*# Mg-2.1
[**2130-3-25**] 06:01PM BLOOD ALT-150* AST-101* LD(LDH)-175 AlkPhos-80
Amylase-121* TotBili-0.5
[**2130-3-25**] 06:21PM BLOOD Type-[**Last Name (un) **] pH-7.24*
[**2130-3-25**] 02:30PM BLOOD Lactate-3.2*
[**2130-3-25**] 06:21PM BLOOD Lactate-1.5
.
[**2130-3-25**] 03:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.021
[**2130-3-25**] 03:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2130-3-25**] 03:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
[**2130-3-26**] 10:40AM BLOOD Glucose-128* UreaN-11 Creat-0.8 Na-136
K-4.1 Cl-110* HCO3-16* AnGap-14
[**2130-3-26**] 03:13AM BLOOD ALT-88* AST-54* LD(LDH)-191 AlkPhos-54
TotBili-0.4
[**2130-3-26**] 04:43AM BLOOD Type-[**Last Name (un) **] pH-7.38 Comment-GREEN TUBE
[**2130-3-26**] 04:43AM BLOOD Glucose-54* Lactate-0.8 Na-137 K-3.4*
Cl-110 calHCO3-17*
.
[**2130-3-27**] 10:56AM URINE UCG-NEGATIVE
[**2130-3-26**] 04:43AM BLOOD freeCa-1.13
.
[**2130-3-25**] Blood cx NGTD x 2
[**2130-3-25**] Urine cx mixed flora
.
[**2130-3-25**] CXR: No acute cardiopulmonary process. Normal chest
radiograph.
.
[**2130-3-25**] EKG: Sinus tachycardia at 124 bpm. Short P-R interval.
Possible left atrial abnormality. Compared to the previous
tracing of [**2130-3-17**] no diagnostic interim change.
Brief Hospital Course:
24 yo F w/ DMI and Hx of recurrent DKA p/w DKA and now
persistant n/v, not tolerating po. Course as below:
<br>
## DKA/DMI, uncontrolled with complications: Started on insulin
drip with closing of gap on afternoon of [**3-25**]. Transitioned back
to home insulin SC on [**3-26**]. Etiology of DKA unclear with ddx:
acute stress from family situation with increased cortisol vs.
acute gastroenteritis. Of note, pt has had frequent
hospitalizations for this in the last several months. With prior
also [**1-2**] gastroenteritis, one [**1-2**] URI, one [**1-2**] UTI. Appears
infection may be contributing, possible that pt. does not eat
enough or misses her insulin when she is feeling ill or
stressed. Pt noted with low grade temps, persistant sx, with
mild improvement. Pt noted initially making poor efforts to try
- [**3-30**] - pt wanting to go home (main complaint of chronic back
pain) - but instructed needs to adequately keep po intake down
with her insulin regime adjusted as she increases her intake.
- [**Last Name (un) **] consulted on [**3-28**] - appreciated rec - decreased lantus
- down to 25units at time of d/c, cover with humolog [**Name (NI) **] (pt
instructed at d/c to resume prior carb counting coverage as
prior
- UA neg, UCx neg, tried to check stools for c. diff, stool cx
(noted no BM - not clinically relevent by time of d/c
- Diabetes teaching
- Close PCP f/u (arranged for [**4-3**]) AND [**Last Name (un) 387**] (d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**]
service - rec for pt to call clinic - number provided)
- importantly - pt needed SW to assist in coping - stress
factors, pt was recovering very slow - unclear from pt if some
psychosocial aspects related - on [**3-30**] pt not engaging with SW
during encounter - tried again in am - slightly more success -
but pt still limited - I had re-encouraged pt to try along with
d/w pt's father the overall importance and plan.
-****also recommended for pt to seek mental health clinic f/u
with likely underlying depression - PCP to assist though pt also
provided direct numbers by S.W. in-house
<br>
## Nausea with vomiting: Resolved at time of d/c. Most likely
[**1-2**] DKA as was characteristic of prior DKA admissions, possible
gastroparesis component with both DM and narcotic use component
(uses mother's oxycontin at home for back pain) - but with low
grade temps more likely gastroenteritis sx. Beta hCG noted neg.
Pt with very slow but positive improvements - less lethargic
with cut down of anti-emetic regime, improved at time of d/c.
-only zofran prn for nausea in future recommended
-SW consulted as above
-avoid narcotics - counciled pt and father on importance of
avoiding any narcotic pain medication and along with future
improved control of her DM
<br>
## Back pain: [**1-2**] old MVA although not discharged on pain meds
on last admission. Per pt. is worse w/ psychological stress.
Transitioned from dilaudid to percocet prn, then weaned to
tylenol and ibuprofen prn to try to avoid long-term narcotics
dependence given psychosocial nature of stressors AND possible
contribution to GI issues above. Family counciled to NOT give
oxycontin and other medications that are not prescribed to the
patient.
- Tylenol for pain, try to hold off ibuprofen for now given GI
issues above
- Treat anxiety/depression as outpt with close PCP f/u
-SW as above
<br>
## Code status: FULL CODE
.
#Contact: [**Name (NI) 58257**] [**Name (NI) **] (mother) [**Telephone/Fax (1) 58258**]
.
## Dispo: to home today, per pt request - Rx lantus, syringes,
and novolog pens
Medications on Admission:
ASA 81mg daily
Pantoprazole 20mg daily
Insulin [**Telephone/Fax (1) **]
Insulin glargine 31U QHS
Zetia 5mg Daily
Multivitamin
Depo provera
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 25 units
Subcutaneous at bedtime: NOTE THIS IS DIFFERENT THAT PRIOR.
Disp:*qs 25 units* Refills:*2*
6. Insulin Syringe 1 mL 30 x [**4-15**] Syringe Sig: One (1)
Miscellaneous as dir.
Disp:*120 1* Refills:*2*
7. Insulin Aspart 100 unit/mL Insulin Pen Sig: One (1)
Subcutaneous as dir.
Disp:*100 100* Refills:*2*
8. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Zetia 10 mg Tablet Sig: 0.5 Tablet PO once a day: (resume
your prior dose).
10. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Diabetic ketoacidosis
Secondary diagnosis
- Diabetes Type 1 c/b nephropathy
- Anxiety
- Depression
- Back pain s/p MVA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for nausea and found to be in diabetic
ketoacidosis. You were placed on an insulin drip and IV fluids
with resolution of this.
<br>
Your Lantus dose was decreased to 25 units from 31 - please
resume your sliding scale as prior based on carb counting as
you've done before. Please take all medications as prescribed,
especially your insulin. Discuss all changes first with your
PCP.
<br>
If you develop worsening nausea, chest pain, difficulty
breathing, or any other concerning symptoms, please seek
[**Hospital 58259**] medical attention.
<br>
****Very importantly - please just take the medications as
prescribed - you can take tylonol as need for pain (1000mg up to
4x per day (no more than 4grams/day). Do not take any narcotics
from anyone, including the oxycontin you may have recieved prior
from you mother as this will make your longterm and short-term
stomach problems worse and develop a disease called
gastroparesis - will have long-term nausea one of the symptoms
of that disease. Along with this is control of your diabetes.
<br>
Ensure you take adequate oral intake - cont carb counting for
your sliding scale.
Followup Instructions:
Please follow up with your PCP: [**Name10 (NameIs) 58260**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 58261**] on
[**2130-4-3**] (monday) at 7:45pm. (This appointment was made prior to
your discharge.)
<br>
You are instructed to call the [**Hospital **] clinic to arrange your
follow-up as recommended by the [**Last Name (un) **] team in-patient - the
number is [**Telephone/Fax (1) 2378**] - please call to make an appointment
within 1 week ideally.
.
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2130-4-4**] 2:20
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2130-3-31**]
|
[
"724.5",
"338.29",
"583.81",
"276.52",
"V58.67",
"240.9",
"300.4",
"787.91",
"250.43",
"250.13",
"787.01",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9905, 9911
|
5113, 8695
|
275, 281
|
10094, 10103
|
3460, 5090
|
11300, 12070
|
2321, 2377
|
8884, 9882
|
9932, 10073
|
8721, 8861
|
10127, 11277
|
2392, 3441
|
229, 237
|
309, 1494
|
1516, 1982
|
1998, 2305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,244
| 145,055
|
46277
|
Discharge summary
|
report
|
Admission Date: [**2196-6-13**] Discharge Date: [**2196-7-13**]
Date of Birth: [**2135-10-8**] Sex: F
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15499**] is a 60-year-old
female with primary biliary cirrhosis who presented for an
orthotopic liver transplant. She was initially evaluated in
the Transplant Center in [**2196-2-6**] for end-stage liver
disease. She was then seen in [**Hospital 3585**] Clinic in [**2196-4-5**]. She had the usual preoperative workup. At that time
she was not complaining of any abdominal pain. No nausea,
vomiting, chest pain or shortness of breath. She seemed a
little fatigued but otherwise she was doing well. The
patient presented on [**2196-6-13**], for orthotopic liver
transplant which took place on [**2196-6-14**].
PAST MEDICAL HISTORY:
1. End-stage liver disease secondary to primary biliary
cirrhosis.
2. History of mental status changes and encephalopathy.
3. Hypothyroidism.
4. Depression.
5. Osteoarthritis.
6. Thrombocytopenia.
7. Esophageal varices.
8. History of transient ischemic attacks.
ALLERGIES: Penicillin causes hives.
MEDICATIONS ON ADMISSION:
1. Ursodiol.
2. Nexium.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.2, blood
pressure 130/80, heart rate 63, respiratory rate 18, oxygen
saturation 98% on room air. She was an elderly lady in no
acute distress. Oriented to time and place. Head, eyes,
ears, nose and throat: Extraocular movements intact. Pupils
equal, round and reactive to light and accommodation. Moist
mucus membranes. The neck was supple. There was no jugular
venous distention present. There was no scleral icterus.
Lungs were clear to auscultation bilaterally.
Cardiovascularly regular rate and rhythm. Normal S1, S2.
Abdomen was soft and non-tender, non-distended. Bowel sounds
were present. Extremities: There was no clubbing, cyanosis
or edema. Good pulses throughout. Skin: No jaundice.
Neuro: Cranial nerves were intact. Moving all extremities.
LABORATORY ON ADMISSION: White count 4.5, hematocrit 37.3,
hemoglobin 14.6. Platelet count 132,000. PT 14.7, PTT 32.9,
INR 1.4. Sodium 142, potassium 4.1, chloride 112,
bicarbonate 23, BUN 16, creatinine 0.6, glucose 85.
RADIOLOGY: Chest x-ray was negative.
ELECTROCARDIOGRAM: Normal sinus rhythm.
HOSPITAL COURSE: Ms. [**Known lastname 15499**] is a 60-year-old female with
primary biliary cirrhosis and portal hypertension with one
bout of preoperative encephalopathy and no history of bleeds
who underwent an orthotopic liver transplant on [**2196-6-14**]. Intraoperatively the course was remarkable for an
increase in the pulmonary artery pressures, systolic 60-70's,
mean in the 50's, particularly post. New line placed. The
patient was refractory to nitroglycerin, calcium channel
blockers. Otherwise hemodynamically stable. The patient did
have some lateral ST depressions, however, transesophageal
echocardiogram intraoperatively indicated no wall motion
abnormalities and she was brought to the Surgical Intensive
Care Unit intubated. The patient was kept at pulmonary
artery pressures around 35 which was equivalent to patient's
baseline. The patient was running 50's over 20 on nitric
oxide. At that point she was placed on an immunosuppressive
regimen of mycophenolate mofetil and methylprednisolone as
well as the usual prophylactic agents. To control blood
pressure she was placed on metoprolol 5 mg q. 6h. as well as
nitroglycerin and hydralazine p.r.n.
Pulmonary hypertension. There was a question of whether it
was volume related. Mean pulse pressure decreased by 10 on
nitric oxide if it was agreed with diureses. The patient was
making good urine output and she was ruling out for
myocardial infarction. The patient was placed on imipenem.
The patient had a duplex ultrasound of the transplanted liver
on [**2196-6-15**], which indicated normal evaluation of the
hepatic artery, portal vein and extrahepatic vein. There
were two hemangiomas demonstrated with the liver. On the
liver function tests at that point her ALT was 383 down from
400. Her AST was 441 down from 652. Her alk phos was 116
and her T. bilirubin was 2.0 and her D. bilirubin was 1.2.
The patient had an echocardiogram on [**6-15**] which showed
moderate symmetric left ventricular hypertrophy, a normal
left ventricular cavity size and an ejection fraction of 55%.
There was mild 1+ aortic regurgitation, 1+ mitral
regurgitation and moderate 2+ tricuspid regurgitation and
there was moderate pulmonary artery systolic hypertension.
On postoperative day three she was making 3.6 liters of
urine. She was being weaned off of nitric oxide. The
patient was receiving Lasix b.i.d. On postoperative day two
fluid balance was positive ten liters so far. Diuresis was
planned before weaning from vent. Cardiology had been
consulted for increase in pulmonary artery pressures as well
as to rule out any evidence of acute ischemic event. The
patient was seen by the Pulmonary Hypertensive Service. On
postoperative day four, the patient was extubated. The
pulmonary artery pressure was less than 40, and the PA catheter
was removed. The patient was a
little confused but oriented to time, place. At that point
she was placed on enalapril for blood pressure control in
addition to hydralazine and clonidine. By postoperative day
seven, the patient was tolerating clears as well as being at
goal TPN since [**6-19**]. On the 15th [**Hospital **] Clinic was
consulted for blood sugar management secondary to steroids.
The patient was stable and transferred to the floor. By
postoperative day nine, on examination the patient's abdomen
was soft, minimally distended with some peri-incisional
tenderness. The wound was clean, dry and intact. There was
a slight increase in total bilirubin to 1.9 from 0.8. She
had a liver ultrasound which showed adequate flow and no
obstruction. By postoperative day ten, the patient had an
increase in liver function tests which prompted a liver
biopsy which indicated portal neutrophilic infiltrate with
acute cholangitis and mild duct proliferation. There was no
acute cellular rejection seen and there was minimal
lobular cholestasis and focal minimal lobular neutrophilic
infiltrate. Since liver function tests were rising,
cholangitis was suspected so she was started on intravenous
levofloxacin q. day. ERCP showed a biliary
anastomotic stricture, therefore sphincterotomy with stent
placement was performed. The
patient's transaminases were increasing and her hematocrit
had decreased to 20. On [**2196-6-27**], the patient underwent
an ultrasound of the abdomen which showed a large
peritransplant hematoma with likely intraparenchymal
component so the patient underwent a re-exploration of the
abdomen with a liver biopsy and revision of the common bile
duct and anastomosis. The patient postoperatively was
readmitted to the Surgical Intensive Care Unit on the 23rd
intubated. The patient had another duplex ultrasound of the
abdomen the following day which showed no definite
subcapsular hematoma and a normal Doppler evaluation of the
liver. The patient was extubated stable on nitroglycerin.
The patient was transferred to the floor on postoperative day
16 and number three. Her blood pressure, however, continued to
be
elevated with systolic blood pressures in the 170's. She was
continued on Lopressor 50 mg b.i.d., Lasix 20 IV and given
hydralazine. By postoperative day 17 and five, the patient
was tolerating regular diet and her abdominal pain was well
controlled with Percocet. She was being evaluated by
Physical Therapy and Occupational Therapy. On postoperative
day 19 and six, the patient became a little confused and
removed her central line from her neck. Her oxygen
saturation had decreased to 85%. She was immediately placed
on higher oxygen levels. The patient returned to oxygen
saturations greater than 95%. Cardiology was consulted and a
Swan catheter placed to check pulmonary artery pressures once
again. Neurology was consulted for mental status changes.
They felt that her mental status examination was essentially
normal. They felt the mental status changes were most likely
due to exacerbation of sedatives or neuroleptics on top of
metabolic derangement. The patient underwent a CT of the
head without contrast which showed no acute intracranial
hemorrhage or major vascular territorial infarction. On
postoperative day 22 and nine, the patient was transferred to
the Medical Intensive Care Unit secondary to bed required
still a little hypertensive and her captopril dose was
increased. She was tolerating a regular diet, maintaining
good urine output and eventually transferred back to the
floor in stable condition. The patient was restarted on
Synthroid 75 mcg q. day given her past medical history of
hypothyroidism. Nutrition had been consulted and following
the regular hospital admissions, liver function tests were
improved. Pain was well tolerated. She was having regular
bowel movements, ambulating regularly, tolerating solid foods
and it was decided at that point to consider rehabilitation
screening. Her discharge liver function tests were ALT 127, AST
52, alk
phos 463 and T. bilirubin of 1.8. The patient was clinically
improving and, as such, felt to be ready for discharge to a
rehabilitation center on [**2196-7-13**].
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. End-stage liver disease secondary to primary biliary
cirrhosis. .
2. Status post orthotopic liver transplant.
3. Pulmonary Hypertension.
4. Hypothyroidism.
5. Depression.
6. Osteoarthritis.
7. Thrombocytopenia.
8. Esophageal varices.
9. History of transient ischemic attacks.
FOLLOW-UP PLAN: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the Transplant Center, telephone number
[**Telephone/Fax (1) 673**], on [**2196-7-20**], at 10:20 a.m., as well as
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at the [**Hospital Unit Name **] Transplant
Center at [**Telephone/Fax (1) 673**] on [**2196-7-25**], at 10:20 a.m. and
again on [**2196-7-27**], at 10:20 a.m. Additionally, patient
will be instructed to schedule an appointment in seven to ten
days with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 673**].
DISCHARGE MEDICATIONS:
1. Captopril 100 mg p.o. t.i.d.
2. Hydralazine hydrochloride 50 mg p.o. q. 6h.
3. Levothyroxine sodium 75 mcg p.o. q. day.
4. Mycophenolate mofetil 500 mg p.o. b.i.d.
5. Metoprolol 50 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q. day.
7. Fluconazole 400 mg p.o. q. 24h.
8. Bactrim ES one tab p.o. q. day.
9. Clonidine hydrochloride 0.3 mg p.o. t.i.d.
10. Prednisone 20 mg p.o. q. day.
11. Valacyclovir hydrochloride 450 mg p.o. q. day.
12. Neoral 75 mg p.o. b.i.d.
13. Percocet 5/325 mg one to two tablets p.o. q. 6h. p.r.n.
pain.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 98381**]
MEDQUIST36
D: [**2196-7-12**] 21:24
T: [**2196-7-12**] 21:56
JOB#: [**Job Number 98382**]
cc:[**Hospital3 **]
|
[
"416.0",
"998.12",
"424.2",
"572.8",
"997.3",
"998.11",
"571.6",
"997.4",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"89.64",
"50.0",
"50.12",
"54.12",
"51.87",
"50.11",
"38.93",
"50.59",
"00.12",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9453, 10415
|
10438, 11246
|
1192, 1240
|
2368, 9432
|
195, 835
|
2069, 2350
|
857, 1166
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,076
| 193,948
|
33810
|
Discharge summary
|
report
|
Admission Date: [**2151-2-5**] Discharge Date: [**2151-2-27**]
Date of Birth: [**2071-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
intubation/mechanical ventilation
History of Present Illness:
79 yo M w/PMHx sx for atrial fibrillation on coumadin,
Alzheimer's dementia, and congestive heart failure who presents
as a transfer from [**Hospital 1474**] hospital. Patient initially
presented to [**Hospital 1474**] hospital early yesterday morning with
fevers and chest congestion starting the night prior. On the
morning of admission, he was noted to be shaky on his feet, and
had a fever to 101, and his wife called his PCP who advised that
he be brought to the hospital. [**Name (NI) **] wife states that she
was sick with URI symptoms and suspects that she may have
infected him. Patient did receive his flu shot this year. She
states that he did not complain of nausea/vomiting/chest
pain/diarrhea/dysuria.
He was initially admitted to the medicine floor at [**Hospital1 1474**] with
a diagnosis of viral pneumonia based on a positive influenza
DFA. At the time he was noted to be in AF with RVR. Over the
course of the day, however, he became more febrile and
hypotensive, with hypoxia to the 80s-90s and became more
obtunded on exam. He was then sent to the [**Hospital1 1474**] ER where he
was intubated and a central line was placed. He was then
transferred to the [**Hospital1 18**] ED where he was given 2 more liters of
IVF and started on levophed.
Past Medical History:
Alzheimer's dementia--baseline oriented to wife, conversational;
needs assist with bathing, dressing
Congestive heart failure
Atrial fibrillation
NKDA
Social History:
Lives at home with his wife. Is independent in eating. Needs
assistance with dressing and bathing. He is a retired
papercutter. Denies alcohol or smoking. Remote smoking hx in
high school.
Family History:
NC
Physical Exam:
98.2 115/78 93 14 100% on vent
Gen: Intubated.
HEENT: MMM. No oral ulcers.
Hrt: Irregularly irregular. No murmurs or rubs.
Lungs: Rales at the left base anteriorly. No rhonchi or wheezes.
Good air movement throughout.
Abd: Soft, nontender, nondistended. Normoactive BS.
Ext: WWP. No CCE.
Neuro: Unresponsive to sternal rub or loud voice. Pupils
pinpoint. Toes mute bilaterally. Reflexes 1+ patella
bilaterally.
Pertinent Results:
[**2151-2-5**] 02:20AM BLOOD WBC-3.5* RBC-3.70* Hgb-11.9* Hct-35.2*
MCV-95 MCH-32.1* MCHC-33.6 RDW-13.2 Plt Ct-125*
[**2151-2-5**] 02:20AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-139
K-4.2 Cl-109* HCO3-22 AnGap-12
[**2151-2-13**] 04:01AM BLOOD VitB12-1248* Folate-GREATER TH
[**2151-2-13**] 04:01AM BLOOD Ammonia-29
[**2151-2-13**] 04:01AM BLOOD TSH-1.6
Imaging:
CXR [**2-5**]:
Tip of the new left supraclavicular central venous line projects
over the upper SVC. No pneumothorax or mediastinal widening.
Dense consolidation in the left lower lobe accompanied by a
small left pleural effusion is stable. There is new
opacification at the right lung base which could represent
another region of atelectasis or aspiration. ET tube in standard
placement. Right jugular line ends in the upper SVC. No
pneumothorax.
TTE [**2-8**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis/akinesis (LVEF = 20 %). The basal
inferior and septal segments have relatively preserved
contractility. 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 aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe global left ventricular hypokinesis/akinesis.
Mild mitral regurgitaiton. Borderline pulmonary artery systolic
hypertension. No prior echo for comparison.
CT Head [**2-11**]:
There is no evidence of mass, mass effect or large acute
territorial infarct, however, acute/subacute ischemic changes
cannot be completely excluded, MRI is recommended if clinically
warranted.
In the brain parenchyma, there are multiple areas with low
density in the subcortical white matter, likely consistent with
microvascular ischemic changes. Dense arteriosclerotic
calcifications noted in both carotid siphons as well as in the
left vertebral artery as described above.
Mucosal thickening is identified in the maxillary sinuses with
mucous retention cysts, there is also mucosal thickening in the
sphenoidal, ethmoidal and left mastoid air cells as described
above.
CT Abd/Pelvis [**2-12**]:
1. Moderately large left retroperitoneal hematoma expanding the
left psoas and quadratus lumborum.
2. No evidence of bowel obstruction. Sigmoid diverticulosis
without definitive evidence of acute diverticulitis.
3. Cholelithiasis.
4. Left greater than right bibasilar pleural effusions.
5. Copious stool within rectum.
6. Hypoattenuating segment II liver lesion likely represents a
cyst.
CXR [**2-14**]:
Left lower lobe retrocardiac consolidation is persistent.
Small-to-moderate left pleural effusion and probable small right
pleural effusion are unchanged. Cardiomediastinum is within
normal limits. NG tube tip is in the stomach. New faint
ill-defined opacity in the right upper lobe could be due to
aspiration given the clinical history.
Brief Hospital Course:
Mr. [**Known lastname 7518**] is a 79 yo M w/PMHx sx for CHF and dementia
admitted with respiratory failure in the setting of viral
pneumonia secondary to influenza.
#. Respiratory failure. [**1-30**] viral pneumonia.
Patient supported with mechanical ventilation and treated with
tamiflu for influenza. Although he was initially treated with
antibiotics for possible bacterial superinfection, he was
transitioned to nafcillin for bronchial washings positive for
MSSA. He was successfully extubated [**2-10**], and his tamiflu was
stopped after 5 days. During his course in the ICU, he
developed new leukocytosis in the setting of having NG tube
placed. He was started on vancomycin/cipro/zosyn to cover
possible aspiration pneumonia or hospital aquired pneumonia.
Course completed [**2151-2-25**]. He is stable on RA at the time of
transfer.
#. Septic shock. Felt to be due to viral pneumonia with
associated fever, bandemia, tachycardia, hypotension.
Patient was supported with aggressive hydration and levophed
during his initial course in the ICU. His septic physiology
resolved over time.
#. Demand ischemia.
Patient with elevated troponin, with lateral <[**Street Address(2) 4793**]
depressions on EKG. Patient had AF with RVR initially in the
setting of fever and respiratory distress.
Medically treated with ASA, statin, and beta blockade. Evidence
of demand ischemia resolved with improved control of heart rate.
#. Atrial fibrillation.
Beta blockade for rate control. Initially on coumadin, which
was held when his INR became elevated to 7. Once INR dropped,
he was anticoagulated with heparin gtt. His heparin was held on
[**2-12**], when a retroperitoneal bleed was identified on CT Abdomen
and pelvis ordered because of concern for obstruction (there was
no evidence of obstruction on CT). His anticoagulation was
still on hold at the time he was transferred out of the ICU. On
the general medical floor he was started on full dose aspirin.
No plan at this time to restart coumadin, given his
retroperitoneal bleed.
#. Retroperitoneal bleed:
Found on imaging done for concern of possible obstruction. Of
note, patient had had elevated INR to 7.5 early in his course.
He was transfused with RBCs and anticoagulation. Hct responded
appropriately to transfusion and was stable thereafter in Hct
32-34 range.
#. Altered Mental Status - myoclonus and delerium:
Patient was noted to have myoclonal jerking after extubation.
He was initially not speaking, which was a change from his
baseline. Neurology was consulted about the myoclonus, and he
was felt to have a toxic-metabolic process in the setting of his
infection, sepsis, and sedating medications. CNS CT imaging was
negative for acute changes. Over the days following his
extubation, his myoclonal jerking decreased and his alertness
improved to the point of saying a few words. EEG was consistent
with widespread encephalopathy; there was no evidence of
epileptiform activity. TSH, LP normal. Geriatrics team was
consulted and they suggested repeat CT of head to understand
whether pt's delerium would ever improve. CT of head showed no
stroke. He was unable to stay still for MRI. Our hope is that
mental status may improve somewhat, but to what extent is
questionable, given baseline of severe dementia. He has periods
of somnolence alternating with spontaneous one or two word
response. He knows his name but is otherwise not oriented.
# Acute on Chronic Systolic CHF:
Patient noted to have decreased EF to LVEF 20%, global
hypokinesis In setting of influenza, ICU team was concerned
that he might have viral cardiomyopathy. Ischemic event also
possible. Patient's volume status improved with diuresis and he
is currently appearing euvolemic, not on any lasix. He will
need regular weight checks and consideration of diuresis if any
significant increase in weight. Recommend follow-up
echocardiogram in approximately 1-2 months to reassess his LVEF.
# Transaminitis: Likely a muscle source give myocolonus. Mild
elevation wtih slightly increased CK's, CK down to 500's today,
good
UOP.
# Rash: Possibly from Zosyn, resolved shortly after
discontinuing zosyn, but unclear.
#. Code. Wife asked to change code status to DNR/DNI.
.
# Alzheimer's Dementia: Severe dementia, requiring help
dressing and showering before current illness. Namendia and
aricept held for now at suggestion of geriatrics team. Can be
reassessed by his PCP and consider restarting aricept 5 daily as
outpatient.
#Aspiration risk: Swallow eval with aspiration risk. PEG placed
with bumper located at 3.5-4 cm marking. Needs dry sterile
dressing over bumper changed daily, for one week and clean site
with hydrogen peroxide daily for one week. Needs water/soda
flush 10-20cc QID. He will need a repeat swallow evaluation in
the near future as his mental status improves to reasses.
#Nutrition: Please continue tube feeds as per site protocol.
He is currently on Replete with fiber Full strength; Goal rate:
70 ml/hr
Residual Check: q4h Hold feeding for residual >= : 150 ml
Flush w/ 50 ml water q4h
Medications on Admission:
Coumadin
Prilosec
Metoprolol
Captopril
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: give
via PEG.
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed: per PEG.
3. Simvastatin 40 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily): per PEG.
4. Captopril 12.5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO TID (3 times a
day): per PEG.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours): per PEG.
7. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): per PEG.
8. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily):
per PEG.
9. Miconazole Nitrate 2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) treatment Inhalation Q6H (every 6 hours) as needed.
11. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15290**] [**Hospital 2481**] Care Center
Discharge Diagnosis:
pneumonia: influenza, then [**Hospital 78166**] hospital acquired pneumonia
atrial fibrillation
hypersensitivity reaction (rash)
dementia, severe
benign hypertension
Discharge Condition:
stable
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or return to ER with any fevers, dizziness, or
other concerning symptoms.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Telephone/Fax (1) 6699**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2151-2-27**]
|
[
"294.10",
"331.0",
"285.1",
"482.41",
"518.81",
"428.0",
"487.0",
"568.81",
"427.31",
"782.1",
"348.30",
"428.23",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12226, 12306
|
5750, 10838
|
324, 359
|
12516, 12525
|
2509, 5727
|
12678, 12984
|
2051, 2055
|
10927, 12203
|
12327, 12495
|
10864, 10904
|
12549, 12655
|
2070, 2490
|
275, 286
|
387, 1654
|
1676, 1829
|
1845, 2035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,520
| 174,935
|
4237
|
Discharge summary
|
report
|
Admission Date: [**2187-10-30**] Discharge Date: [**2187-11-1**]
Date of Birth: [**2135-1-27**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Augmentin / Lisinopril / Metoprolol
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 y/o woman with severe systemic sarcoid, ESRD on HD (Tu, Th,
Sa), home O2 3.5L for sarcoid and pulmonary hypertension,
presents with shortness of breath. She was in her usual state of
health until 3AM this morning when she awoke from sleep with
painful leg cramp. She sat up in bed and shortly after became
suddenly short of breath. She tried increasing her oxygen to 8L
without relief. Shortness of breath persisted and she presented
to dialysis this morning, where because of respiratory distress
and hypoxia, she was transferred to the ED prior without a
dialysis session completed. She last received dialysis on
Saturday (3 days prior to admission) and today is 55.3kg
(baseline dry weight 51kg). She denies chest pain, palpitations,
cough, or shortness of breath. She had a low grade temperature
of 99F after dialysis on Saturday which resolved spontaneously.
.
In the ED, initial VS were: 98.5 119 126/69 26 100% 10l. CXR
showed right pleural effusion. Labs notable for lactate 4.0, Cr
9.9, BUN 47, K 5.9, Trop 0.15. ABG 7.42/34/54. Nitroglycerin
drip was started @ 1mcq/kg/min and she received Vanco/Zosyn. On
Bipap doing well. Albuterol/ipratropium nebulizers started.
Nephrology was consulted and plans on dialysis upon admission.
Vitals prior to transfer: afebrile, HR 110, BP 121/74, RR 26 and
100% on Bipap FiO2 50%.
.
On arrival to the MICU, she states her SOB has resolved and she
oxygen saturations are 94% on 4L oxygen via nasal canula.
Nitrolgycerin gtt was stopped. Temperature is 101. She endorses
a headache, but no vision changes or neck stiffness. She has
mild nausea, but no vomitting. Denies abdominal pain, diarrhea,
melena/hematochezia. She does not make urine. Her leg cramping
has resolved. She is alert and oriented and able to detail past
medical history and events leading up to admission. She reports
a similary event with SOB happened 1.5 years ago, increased
prednisone and symptoms resolved during hospitalization.
Past Medical History:
- Systemic sarcoidosis (diagnosed in [**2177**]) w/ pancreatic and
liver involvement and pulm HTN (on daily prednisone)
- ESRD [**2-28**] sarcoidosis on hemodialysis T/R/Sa
- Pulmonary Hypertension: Diagnosed via right heart cath;
treated briefly with sildenafil though did not tolerate this
medication
- Heparin-induced thrombocytopenia (HIT)
- Angioectasias of the stomach and colon.
- SVC thrombosis
- Chronic pancreatitis, required common bile duct stenting and
sphincterotomy in [**2179**]
- Hypertension
- Epilepsy, last seizure [**2182**] (bilateral occipital infarct [**2177**])
- Secondary hyperparathyroidism
- Hyperlipidemia (HL)
- Anemia
- h/o small bowel obstruction
- h/o pericardial effusion
- h/o line associated RUE dvt (formerly on coumadin)
- h/o MRSA line infection
- h/o CVA [**2178**] - no residual weakness
Social History:
She lives with her husband and some of her children and
grandchildren. Prior to being medically disabled from
her illness she was a substance abuse counselor.
Denies Tobacco, EtOH and drug use.
Family History:
Father: renal failure at age 70.
Mother: hypertension and breast cancer.
Physical Exam:
General: Alert, oriented, no acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: RRR @100bpm, normal S1 + S2, 3/6 SEM at LLSB
Lungs: decreased breath sounds on right [**1-28**] way up, coarse
crackles at left base, no wheezes or rhonchi
Abdomen: soft, NT/ND, no HSM
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, fistula right upper extremity with thrill
Skin: vitiligo on lower extremities bilaterally
Neuro: 5/5 strength bilaterally, no sensory deficits, CN grossly
intact
Pertinent Results:
[**2187-10-31**] PORTABLE CXR:
In comparison with the study of [**10-30**], there are even lower lung
volumes. Extensive opacification is seen on the right in a
patient with continued enlargement of the cardiac silhouette and
pulmonary edema. Findings are consistent with layering pleural
effusion, though the possibility of developing superimposed
consolidation can certainly not be excluded in the appropriate
clinical setting.
.
[**2187-10-31**] ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The diameters of aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial pericardial effusion.
IMPRESSION: Dilated right ventricle with global hypokinesis.
Moderate to severe tricuspid regurgitation. Severe pulmonary
hypertension. Normal left ventricular regional and global
systolic function.
ADMISSION LABS
[**2187-10-30**] 07:40AM BLOOD WBC-11.1*# RBC-3.17* Hgb-9.3* Hct-31.8*
MCV-100* MCH-29.3 MCHC-29.2* RDW-17.0* Plt Ct-208
[**2187-10-30**] 12:04PM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.2*
[**2187-10-30**] 07:40AM BLOOD Glucose-140* UreaN-47* Creat-9.9*# Na-133
K-9.7* Cl-98 HCO3-17* AnGap-28*
DISCHARGE LABS
[**2187-10-30**] 12:04PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.8*
[**2187-11-1**] 06:45AM BLOOD WBC-4.1 RBC-3.33* Hgb-10.0* Hct-32.0*
MCV-96 MCH-30.0 MCHC-31.2 RDW-16.9* Plt Ct-168
[**2187-11-1**] 06:45AM BLOOD Neuts-61.4 Lymphs-23.9 Monos-7.9 Eos-6.2*
Baso-0.6
[**2187-11-1**] 06:45AM BLOOD Glucose-84 UreaN-41* Creat-8.2*# Na-141
K-4.9 Cl-96 HCO3-31 AnGap-19
[**2187-11-1**] 06:45AM BLOOD Calcium-9.0 Phos-4.8* Mg-3.0*
Brief Hospital Course:
52 yo F with severe systemic sarcoidosis, ESRD on HD, home O2
3.5L for sarcoid and pulmonary hypertension, presents with
shortness of breath.
# ACUTE on CHRONIC RESPIRATORY DISTRESS: Initially admitted with
hypoxia and dyspnea, related to pulmonary edema and pleural
effusions. She also had a 4kg weight gain up from 51kg dry
weight. Unclear what the etiology of the pulmonary edema is,
though it is possible this has been a chronic worsening
condition. She was admitted to the MICU with bipap and a nitro
drip, but nitro was quickly stopped. She underwent hemodialysis
with ultrafiltration and removal of 3+ liters. Her symptoms
resolved significantly and she was called out to the floor. On
the floor, she felt her dyspnea has improved to better than she
had been in weeks. She underwent dialysis again and then was
discharged home.
.
# FEVER: She spiked a fever to 101 in the MICU on admission. No
specific infectious source was identified. She was started on
vanc/ceftaz/azithro for coverage of a possible pneumonia, given
her fluid overloaded xray that could not rule out pna. She
remained afebrile with a normal WBC throughout her admission.
When her fluid had cleared, a repeat CXR showed no consolidation
or pneumonia. IV antibiotics were stopped. She was discharged
home with levaquin to complete a 7 day course. Blood cultures
showed no growth to date but were pending on discharge.
.
# HYPOTENSION: Hypotensive to the 80s while on dialysis. She had
received her anti-hypertensive medication the day prior, so this
was assumed to be in the setting of ultrafiltration with
lingering anti-hypertensives. The blood pressure normalized
without intervention.
.
# HYPOXIA: Overnight in the MICU she desaturated to the mid-80s
while on 4L NC. This was assumed to be due to sleep apnea. She
was started on facemask O2 and her sat improved to 100%.
.
# SYSTEMIC SARCOID: Possibly responsible for worsening of lung
symptoms. Continued prednisone 7.5mg daily. Consulted
pulmonology who recommended continuing steroids.
.
# ESRD on HD: Continued dialysis. Continued sevelamer,
hydroxyzine and nephrocaps. Returned to outpatient Saturday,
Monday, Weds schedule as an outpatient.
.
# SEIZURE DISORDER: Last seizure [**2182**]. Continued lamotrigine
.
# HYPERTENSION: Restarted losartan and nifedipine on discharge.
.
# HIT: History of heparin induced thrombocytopenia. Avoided
heparin products.
Medications on Admission:
EPOETIN ALFA [EPOGEN] - once weekly
FOLIC ACID - 1mg daily
HYDROXYZINE HCL - 25 mg [**Hospital1 **]
LAMOTRIGINE - 150 mg [**Hospital1 **]
LORAZEPAM - 0.5 mg daily PRN cramping
LOSARTAN [COZAAR] - 150 mg [**Hospital1 **]
NIFEDIPINE [NIFEDIAC CC] - 90 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg daily
PREDNISONE - 7.5 mg daily
SEVELAMER HCL [RENAGEL] - 2400 mg TID-QID
URSODIOL - 300 mg TID
DOCUSATE SODIUM [COLACE] - 100 mg daily
Discharge Medications:
1. epoetin alfa Injection
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for cramping.
6. losartan 100 mg Tablet Sig: 1.5 Tablets PO twice a day.
7. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
12. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO once a
day.
13. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO after
dialysis sessions for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY
Systemic Sarcoid
SECONDARY
Pulmonary Hypertension
End stage renal disease on Hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted with worsening shortness of
breath and found to have a fever and fluid in your lungs. We
removed some fluid with dialysis and gave you antibiotics.
Medication changes:
# START levaquin 500mg after dialysis sessions for three doses
to treat an infection
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2187-11-6**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2187-11-21**] at 9:00 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: WEDNESDAY [**2187-11-21**] at 9:30 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.6",
"E879.1",
"345.90",
"403.91",
"416.8",
"276.69",
"V45.11",
"588.81",
"518.84",
"517.8",
"780.60",
"135",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10421, 10479
|
6486, 8879
|
334, 341
|
10621, 10621
|
4082, 6463
|
11152, 12026
|
3406, 3480
|
9356, 10398
|
10500, 10600
|
8905, 9333
|
10771, 11023
|
3495, 4063
|
11043, 11129
|
275, 296
|
369, 2323
|
10636, 10747
|
2345, 3178
|
3194, 3390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,359
| 133,018
|
22093
|
Discharge summary
|
report
|
Admission Date: [**2151-5-17**] Discharge Date: [**2151-5-20**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
L sided weakness - transferred from [**Hospital1 **] [**Location (un) 620**] after IV tPA
Major Surgical or Invasive Procedure:
IV tPA
History of Present Illness:
This [**Age over 90 **] y/o woman with history of AF (not on warfarin), CAD,
CHF, dementia presented to OSH today after acute aphasia and
right hemiparesis.
Per EMS/ER transfer notes, patient was in USOH in [**Hospital 4382**] facility this AM. At 1115h, while sitting in wheelchair
in day room, observed to become "unresponsive" with right
hemiparesis. EMS contact[**Name (NI) **] and patient was brought to [**Hospital1 **]
[**Location (un) 620**]. At [**Location (un) 620**], FSBS 129, SBP 140s, aphasia and right
hemiparesis (NIHSS not documented) reported. WBC 8.1, Plt 227,
Cr 0.9.
Telemedicine consultatants contact[**Name (NI) **] and decision to proceed w/
intravenous tPA was made. Patient's daughter ([**Name (NI) **] [**Name (NI) 7474**])
was contact[**Name (NI) **] by telephone. Per report tPA begun 1210h and
concluded 1330h with a total of 43.4mg infused. Patient was not
noted to have improved prior to transfer to [**Hospital1 18**].
At [**Hospital1 18**], SBP 150s.
Past Medical History:
1. CAD s/p MI, s/p pacer
2. AF (not on warfarin--falls)
3. HTN
4. skin CA
5. L pelvis fx [**10-12**]
6. Dementia
Social History:
Lives at [**Location (un) **] asst living facility. Said to be ambulatory
but dependent for ADLs. Moderate dementia (recognizes family,
has conversations, forgetful, will not remember date or recent
events, restriction of activities over last several months).
Nonsmoker. Nondrinker.
Family History:
NC
Physical Exam:
Temp: 97; BP: 156/82; HR: 70; RR: 21; SaO2: 99%RA
Gen: Alert, mute, cachectic elder woman. Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart irregularly irregular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Neuro:
>>MS??????Alert. Mute. Will follow no commands. Briefly regards
examiner on left side.
>>CN??????Fundi w/ sharp discs. PERRL. Diminished threat blink on
right. No ptosis. Left gaze deviation but able to get to
midline voluntarily. Apparent facial numbness as patient
oblivious of injury when trying to replace her dentures she
caused right perioral abrasion. Right facial weakness. Tongue
protrudes midline.
>>Motor??????Left arm/leg moves spontaneously, purposefully and MRC
[**6-8**]. Right arm 0/5 and flaccid. Right leg 2+/5 prox to [**2-8**]
distally with normal tone.
>>Sensory??????Diminished grimace with noxious stimuli applied to
right hemibody. Visuospatial right hemineglect.
>>DTRs??????L/R: bic 1/0, br 1/0, tri 1/0; pat [**2-4**], Ach 0/0. Right
plantar extensor.
>>Coord/Gait??????No dysmetria apparent with spontaneous movement of
left side.
Pertinent Results:
[**2151-5-17**] 03:00PM BLOOD WBC-9.6 RBC-3.92* Hgb-12.1 Hct-36.1
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.7 Plt Ct-243
[**2151-5-17**] 03:00PM BLOOD Glucose-108* UreaN-15 Creat-0.8 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
[**2151-5-17**] 10:28PM BLOOD ALT-18 AST-29 CK(CPK)-40 AlkPhos-96
TotBili-0.4
[**2151-5-17**] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2151-5-17**] 10:28PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2151-5-18**] 08:35AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2151-5-18**] 07:39AM BLOOD %HbA1c-5.9
[**2151-5-18**] 02:22AM BLOOD Triglyc-216* HDL-38 CHOL/HD-4.5
LDLcalc-90
CT HEAD including perfusion [**5-17**]:
1. Acute left MCA distribution infarct with thrombus noted to
extend from the mid left M1 segment into the MCA bifurcation and
corresponding CT perfusion abnormalities. Some of these regions
do appear to displays slight mismatch suggesting that they may
be ischemic but not yet infarcted. No intracranial hemorrhage
status post TPA administration.
2. Dilated fluid-filled esophagus suggesting underlying
dysmotility or a
distal lesion. If alteration in care will occur and it is
clinically
feasible, dedicated esophogram could be performed on a
non-emergent basis.
3. Likely reactive mediastinal lymphadenopathy. Incidentally
detected left-sided SVC.
CT HEAD [**5-18**]:
Continued evolution of known large left MCA distribution
infarction with
increased edema noted on today's examination. No intracranial
hemorrhage is identified.
Echo: Severe tricuspid regurgitation. Dilated coronary sinus
with probable catheter in the coronary sinus. Mild symmetric
left ventricular hypertrophy with preserved global systolic
function. Dilated right ventricle with preserved function. Mild
aortic stenosis.
Brief Hospital Course:
Patient is a [**Age over 90 **] y/o woman with advanced dementia and CAD s/p
pacer here with acute aphasia and right hemiparesis s/p IV tPA.
History of non-anticoagulated AF and
proximal occlusion suspicious for cardioembolic source of
infarction. Given that patient received IV thrombolysis, not
deemed candidate for further endovascular therapy owing to time
from deficit, partial recanalization after tPA, risk of
hemorrhagic transformation.
She was initially admitted to the ICU and unfortunately, the IV
tPA did not work and she had dense L MCA infarct leaving her
globally aphasic with dense R sided weakness. She had repeated
swallow evaluations including video swallow which showed pureed
diet with nectar thickened liquid is acceptable with some
aspiration risk.
She needs direct supervision with suction as needed per nursing
for feedings.
Although she has Afib, given the advanced dementia with fall
risk and large infarct, no Coumadin was started during this
admission. Coumadin should be re-discussed upon follow-up as
outpatient with Dr. [**First Name (STitle) **] [**Name (STitle) **].
Patient is on aspirin daily. She was also found to be MRSA
positive on nasal swab testing during this admission.
Patient is returning to the nursing home where she resided
before with recommendations to continue with occupational,
physical and speech therapy. She is to follow-up with Dr.
[**First Name (STitle) **] [**Name (STitle) **] as outpatient.
Medications on Admission:
- namenda 10mg PO BID
- senna 1 tab PO QHS
- simvastatin 20mg PO qday
- metoprolol 100mg PO QAM/50mg Po QPM
- milk of magnesia
- prilosec 20mg PO BID
- kcl 20meq PO BID
- tylenol prn
- motrin 400mg PO TID with meals
- vicodin 5-500; 1 tab PO Q4hrs prn pain
- nitroquick prn
- loperamide 2mg PO Q8hrs prn loose stools
- alendronate 70mg tab; 1 PO Qweek with 6-8oz h2o before
breakfast
- colace 200mg PO Qday
- aspirin 325mg Po Qday
- lisinopril 2.5mg Po Qday
- omeprazole 20mg PO Qday
- celebrex 200mg PO Qday
- fuorsemide 20mg Po Qday
- calcium carbonate 600mg PO BID
- bupropion 100mg PO BID
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): [**Month (only) 116**] be titrated up if SBP > 140 or HR > 100.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO
once a day as needed for constipation.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Capsule(s)
14. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
15. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1)
Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
L MCA stroke
Advanced dementia
Atrial fibrillation
Discharge Condition:
Stable - Dense right sided weakness with left gaze preference
plus global aphasia.
Discharge Instructions:
You came in with acute left sided weakness and aphasia and found
to have left MCA occlusion. Because you came in with
significant deficit and you arrived within the window of time
for thrombolytics, you received IV tPA and initially admitted to
the ICU. Unfortunately, the thrombolytics did not work and you
have an extensive, dense L MCA infarct causing you to have dense
weakness of R side plus globally aphasic.
Given your advanced age and dementia plus fall risk and large
infarct, although you have atrial fibrillation, Coumadin was not
started during this admission. It should be re-addressed when
you follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] as an outpatient.
You were evaluated per speech therapist and had video-swallow
test which showed that you are able to swallow pureed solids
with nectar thicked liquid but is at aspiration risk. Upon
discussing with your family, it was decided that despite the
aspiration risk, it would be better to give food by mouth rather
than resort to PEG placement. You need strict supervision with
feeding by nursing staff.
Also, you were found to be MRSA positive with nasal swab during
this admission.
Please take meds as scheduled and follow-up with Dr. [**Last Name (STitle) **] as
scheduled.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2151-7-6**] 3:00 [**Hospital Ward Name 23**] Clinical Center [**Location (un) 858**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2151-5-20**]
|
[
"V45.81",
"V45.01",
"599.0",
"041.4",
"428.0",
"414.00",
"V02.54",
"V10.83",
"427.31",
"434.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8156, 8229
|
4792, 6256
|
352, 360
|
8323, 8407
|
3050, 4769
|
9727, 10072
|
1841, 1845
|
6900, 8133
|
8250, 8302
|
6282, 6877
|
8431, 9704
|
1860, 3031
|
223, 314
|
388, 1384
|
1406, 1521
|
1537, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,472
| 199,590
|
46991
|
Discharge summary
|
report
|
Admission Date: [**2151-9-20**] Discharge Date: [**2151-10-2**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This is an 83 year old female
with a past medical history of hypertension and Parkinson's
disease, status post fall three weeks prior to admission.
The patient had been complaining of low back pain since the
fall and numbness in the saddle distribution. She had been
experiencing bowel and bladder incontinence for eight days
prior to admission. The patient had the Shingles three weeks
prior to admission. The patient states initially that they
thought the pain and numbness were related to that.
Ambulation had diminished from her baseline shuffling gait to
an inability to ambulate at all, secondary to the pain.
Magnetic resonance scan revealed L1 compression fracture with
retropulsed segment compressing the spinal cord.
The patient neurologically, at the time of admission, had a
right tremor in her upper extremity at rest. The patient was
awake, alert; pupils were reactive. The patient responded
appropriately to verbal stimuli. The patient's sensory level
was localized to L1 distribution. The patient had positive
rectal tone. Upper extremities were [**4-10**] throughout, both left
and right. Lower extremities: The patient was 2+ in both
right and left IP's. Plantars were three out of five
bilaterally; dorsiflexion was [**3-10**] and extensor hallucis
longus were [**3-10**]. The patient had increased tone in bilateral
lower extremities. Reflexes were 1+ bilateral knee jerks.
The patient had received some sedation prior to her
examination.
HOSPITAL COURSE: The patient was admitted to the floor for
possible operating room. On [**9-23**], the patient was seen by
cardiology regarding preoperative evaluation. The patient was
considered a low to moderate risk for spine surgery. The
patient was measured for a TSLO brace on [**9-23**] for
postoperative. The patient's neurologic examination improved
since admission secondary to increased alertness. The
patient was able to maintain her lower extremities against
gravity and was [**5-10**] throughout lower extremities.
The patient underwent L1 vertebroplasty; T12 to L2 fusion
with titanium plates and screws on [**2151-9-27**]. Operating room
was unremarkable. Estimated blood loss was 150 cc. The
patient was transferred to the surgical Intensive Care Unit
postoperatively. The patient was cardiovascularly stable
postoperatively. Neurologic examination was unchanged. [**5-10**]
lower extremity strength. Postoperatively, the patient was
extubated on [**9-28**] without difficulty. The patient was
transfused one unit of packed red blood cells on [**9-29**] for a
hematocrit of 27. The patient was started on subcutaneous
heparin
The patient was transferred to the floor on [**9-30**]. Central
line was discontinued on [**2151-10-1**]. The patient is out of bed
with physical therapy. The patient continues to improve.
Lower extremity Dopplers were done on [**10-3**], secondary to left
thigh swelling and warmth. Dopplers were negative. The
patient was discharged to rehabilitation on [**2151-10-4**] with
instructions to follow-up in the office with Dr. [**Last Name (STitle) 1327**] in
one month. The patient was discharged on the following
medications.
DISCHARGE MEDICATIONS:
Metoprolol 125 mg p.o. twice a day.
Hydralazine 50 mg p.o. three times a day.
Diltiazem 30 mg p.o. four times a day.
Percocet one to two tablets p.o. every four to six hours prn.
Atorvistatin 20 mg p.o. q. day.
Mirapax 0.25 mg p.o. four times a day.
Carbidopa/Levodopa 2500 mg 0.5 tablets p.o. four times a day.
Paroxetine 20 mg p.o. q. day.
The patient was neurologically stable at the time of
discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 27454**]
MEDQUIST36
D: [**2151-10-3**] 11:41
T: [**2151-10-4**] 04:12
JOB#: [**Job Number 99650**]
|
[
"414.01",
"424.1",
"272.0",
"806.4",
"E888.9",
"733.00",
"707.0",
"332.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.49",
"77.89",
"38.93",
"84.51",
"81.04"
] |
icd9pcs
|
[
[
[]
]
] |
3335, 4011
|
1640, 3312
|
151, 1622
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,020
| 152,278
|
49673
|
Discharge summary
|
report
|
Admission Date: [**2122-3-12**] Discharge Date: [**2122-3-19**]
Date of Birth: [**2067-8-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 45613**] is a 54yo male with PMH significant for Buerger's
disease, chronic ulcers, and chronic pain syndrome who presented
with 1 day history of fevers, chills, myalgias, and cough. He
was transferred from [**Hospital1 **] [**Location (un) 620**] where he was initially admitted
on [**3-12**]. While there he received Vancomycin since there was
concern that his ulcers were infected. He was then transferred
to [**Hospital1 18**] for further work-up. In the ED he received Levaquin and
Flagyl and was then transferred to the medical floor for
monitoring.
Past Medical History:
1)? Buerger's disease vs. livedoid vasculopathy - Per prior
notes has had extensive work-ups by Dermatology, rheumatolgy,
plastics, etc. Essentially excluded a diagnosis of
cryoglobulinemia, while a presumptive diagnosis of Buerger's or
LV was made. The patient is on Nifedipine to increase
vasodilation and has been counseled to stop smoking many times.
2)Chronic bilateral U+L extremity ulcers - complication of his
vaculitis- ? pyoderma grangulosum
3)Chronic pain [**3-7**] multiple ulcers
4)Sinus tachycardia, presumed reflex sympathetic dystrophy
5)Remote history of testicular cancer in [**2092**] status post
orchiectomy, with recurrence in [**2101**] treated with XRT and LND.
6)Bilateral PEs [**2120-8-3**], on Coumadin
7)Hypersensitivity pneumonitis versus BOOP versus NSIP.
8)Hypothyroidism
9)Hepatitis C - h/o IVDU in [**2084**]
10)GERD - on PPI at home
11)s/p MVA in [**2084**] with traumatic spleen rupture, bilateral
open tibial fractures, and head trauma.
Social History:
1 ppd X 30 yrs. (+) history of IVDU, quit in [**2094**]. No ethanol
use. Lives with his wife in [**Name (NI) 1411**]. Currently unemployed. States
had restarted smoking after last admission and currently smoking
again (states quit 1 day ago). States he has no VNA or home
services, dresses his wounds on his own.
Family History:
Grandfather s/p MI in 70s. Grandmother died in her sleep of
unknown cause in her 70s. No family history of cancer. Cousin
with anti-phospholipid antibody.
Physical Exam:
VS- 99.0 112/68 112 18 95% O2 sat on 2L N/C
GEN- Middle aged male sitting in bed in nad
HEENT- MMM, PERRL, EOMI. Adentulous with upper dentures. No
pharyngeal exudates
LUNGS- some transmitted upper airway sounds but diffusely coarse
breath sounds throughout, with scattered rhonchi, no crackles.
HEART- RRR, no murmurs /rubs/ gallops
ABD- soft, nt, nd + BS
EXT - Black coloration of nail beds bilaterally. Right middle
finger with some duskiness at tip, Right ring finger with
necrotic ulcer at the tip, ttp. R index finger with amputation
at PIP. Bilat LE ulcers on feet (plantar and dorsal surfaces),
shins, some deep ulcers. All appear to have clean bases with
granulation tissue. 2+ radial pulses bilaterally with 1+ DP.
Pertinent Results:
[**2122-3-13**] 09:15AM [**Year/Month/Day 3143**] WBC-4.2# RBC-5.01 Hgb-13.7* Hct-41.7
MCV-83 Plt Ct-440
[**2122-3-14**] 06:15AM [**Year/Month/Day 3143**] WBC-4.9 RBC-5.06 Hgb-13.8* Hct-42.0
MCV-83 Plt Ct-426
[**2122-3-14**] 05:42PM [**Year/Month/Day 3143**] WBC-4.7 RBC-5.12 Hgb-13.7* Hct-42.5
MCV-83 Plt Ct-398
[**2122-3-15**] 04:27AM [**Year/Month/Day 3143**] WBC-4.8 RBC-4.87 Hgb-13.1* Hct-40.1
MCV-82 Plt Ct-414
[**2122-3-16**] 06:15AM [**Year/Month/Day 3143**] WBC-5.0 RBC-5.54 Hgb-14.6 Hct-46.4 MCV-84
Plt Ct-425
[**2122-3-17**] 05:40AM [**Year/Month/Day 3143**] WBC-9.4# RBC-5.04 Hgb-13.9* Hct-41.8
MCV-83 Plt Ct-423
[**2122-3-18**] 06:45AM [**Month/Day/Year 3143**] WBC-12.5* RBC-5.27 Hgb-13.9* Hct-44.4
MCV-84 Plt Ct-488*
[**2122-3-19**] 06:30AM [**Month/Day/Year 3143**] WBC-14.5* RBC-5.91 Hgb-16.0 Hct-47.6
MCV-81* Plt Ct-516*
[**2122-3-19**] 06:30AM [**Month/Day/Year 3143**] Neuts-42* Bands-0 Lymphs-41 Monos-17*
.
[**2122-3-13**] 09:15AM [**Year/Month/Day 3143**] PT-55.1* INR(PT)-6.4*
[**2122-3-19**] 06:30AM [**Month/Day/Year 3143**] PT-22.4* INR(PT)-2.2*
.
[**2122-3-13**] 09:15AM [**Year/Month/Day 3143**] Glucose-86 UreaN-13 Creat-0.7 Na-134
K-4.2 Cl-100 HCO3-26
[**2122-3-19**] 06:30AM [**Month/Day/Year 3143**] Glucose-81 UreaN-13 Creat-0.8 Na-135
K-4.5 Cl-98 HCO3-30
.
[**2122-3-13**] 09:15AM [**Year/Month/Day 3143**] ALT-16 AST-30 LD(LDH)-208 AlkPhos-79
Amylase-25 TotBili-0.3
.
[**2122-3-14**] 06:15AM [**Year/Month/Day 3143**] Calcium-8.0* Phos-3.4 Mg-1.9
[**2122-3-19**] 06:30AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-2.9 Mg-2.1
.
[**2122-3-13**] 09:15AM [**Year/Month/Day 3143**] TSH-0.71
.
[**2122-3-15**] Radiology CHEST (PORTABLE AP):increased opacity in the
left upper
lobe that suggest developing focal consolidation.
[**2122-3-13**] Radiology FOOT (AP & LAT): no evidence of osteomyelitis
[**2122-3-13**] Radiology CHEST (PA & LAT) : no acute cardiopulmonary
process
[**2122-3-12**] Radiology CHEST (PORTABLE AP): no acute pulmonary
process is noted
Brief Hospital Course:
A/P: Mr. [**Known lastname 45613**] is a 54yo male with PMH as listed above who
initially presented with fevers and cough, diagnosed with
influenza with superimposed bacterial pneumonia.
.
1)Hypoxemia: Patient presented with shortness of breath and
hypoxia and was DFA positive for Influenza A and had gram
positive cocci in his expectorated sputum from [**3-13**]. He was
initially started on oseltamivir, levofloxacin, and vancomycin.
On [**3-14**] Pt was transferred to the ICU in respiratory distress,
but was able to wean from NRB face mask to NC O2 on the first
ICU day. Pt was then started on prednisone for suspected COPD
flare contributing to respiratory distress and was transferred
out of the ICU on [**3-15**]. Pt completed a 5 day course of tamiflu
and received 3 days of vancomycin/levofloxacin followed by
levofloxacin for a total of 7 days while in the hospital and was
discharged on a prednisone taper, nebulizers, and a 14 day total
course of levofloxacin.
.
3)Chronic LE ulcers: Patient has multiple ulcers on his upper
and lower extremities secondary to his vasculitis. He received
Vancomycin early in the hospital course since there was concern
infection as the etiology of his fevers. Plastic surgery was
consulted and did not feel that the ulcers were infected and
vancomycin was d/c'd on [**3-15**]. The wounds were examined on a
regular basis and at no time appeared infected following
transfer out of the ICU. Daily dressing changes were preformed.
Prior to discharge Pt was seen by wound care nurse [**First Name (Titles) 151**] [**Last Name (Titles) 99357**]s to clean the ulcers daily and then use adaptive
dressings followed by non-occlusive wraps. Pt declined the offer
to be seen on an outpatient basis by the [**Hospital1 18**] plastic surgery
clinic, choosing instead to continue his outpatient managment as
arranged by Pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8446**].
.
4)Chronic pain: Patient has chronic pain secondary to multiple
ulcers on his lower extremities. He is on a multiple drug
regimen at home and was continued on Oxycontin 80mg [**Hospital1 **] with
Oxycodone 10mg PRN while in the hospital.
.
5)Hx of pulmonary embolism/DVT: Occurred in [**2120**] in the setting
of immobility per OMR. Patient is anti-coagulated as an
outpatient, but was supratherapeutic on admission with INR 6.4.
His coumadin was held and he subsequently became subtherapeutic
with INR of 1.2. Heparin gtt was started as a bridge to
therapeutic coumadin levels were reached. There was no evidence
of DVT on exam and upon discharge Pt's INR was 2.2.
.
6)Hypothyroidism: Pt's TSH was 0.7 upon admission and he was
continued on levothyroxine while in the hospital.
.
7)GERD: Continued on PPI.
Medications on Admission:
Gabapentin 800 mg Capsule PO Q8H
Pantoprazole 40 mg Tablet PO Q24H
Levothyroxine 75 mcg Tablet PO DAILY
Clonazepam 2 mg Tablet PO QHS
Acetaminophen 325 mg as needed.
Oxcarbazepine 300 mg PO DAILY
Oxycontin 80 mg 3x/day
Docusate Sodium 100 mg Capsule PO BID
Nifedipine 30 mg Tablet Sustained Release PO DAILY
Warfarin 7.5 mg M,W,F
Oxycodone 30 mg 1-2 Tablets PO every 4-6 hours PRN
Oxycontin 5mg PRN
Flexeril 10mg Daily
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
[**Year (4 digits) **]:*1 * Refills:*2*
2. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily). Tablet Sustained Release(s)
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone 30 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: Please take 30mg every 4 hours as
needed for breakthrough pain. .
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days: Please take one tablet per day for 7 days
after discharge.
[**Year (4 digits) **]:*7 Tablet(s)* Refills:*0*
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 doses: Please take 2 tablets on [**3-20**], Please take 1 tablet
on [**3-21**], Please take 1 tablet on [**3-22**].
[**Month/Year (2) **]:*4 Tablet(s)* Refills:*0*
11. Oxycodone 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO three times a day as needed
for pain: Please take 1 tablet three times per day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Influenza A
2. Bacterial Pneumonia
Secondary:
1. Buerger's disease
2. Chronic extremity ulcers
3. history of pulmonary embolus
4. Hypothyroidism
5. Hepatitis C
6. Gastroesophageal reflux disease
Discharge Condition:
Stable, afebrile, saturating 95% on RA (93% when ambulating on
crutches).
Discharge Instructions:
You were admitted to the hospital with Influenza A combined with
a concurrent bacterial pneumonia. You were treated with
antibiotics while in the hospital with good resolution of your
respiratory symptoms and upon discharge you were saturating 95%
on room air. Also while in the hospital you were seen by the
plastic surgery service who recommended no interventions at this
time for your chronic extremity ulcers. The wound care nurse
visited you as well and provided recommendations regarding how
to best take care of your ulcers for the immediate future.
.
Please take all medications as instructed, change your wound
dressings as instructed, and keep your follow up appointments as
outlined below.
.
Should you experience increased shortness of breath, chesp pain,
or recurrence/worsening of your cough, fever, chills, night
sweats, nausea, vomiting, abdominal pain, diarrhea, or excessive
pus drainaged from your wounds please do not hesitate to call
your primary doctory or return to the hospital for evaluation.
Followup Instructions:
1. Please follow up with your primary care doctor [**Last Name (Titles) 8446**],
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH on [**3-26**] at 9:30 am.
.
2. Please arrange a follow up appointment with your plastic
surgeon. If this is not possible, you may call the Surgical
[**Hospital **] Clinic at the [**Hospital1 18**] ([**Telephone/Fax (1) 274**]) to arrange an
appointment with the plastic surgery service.
.
Please have your home nurse [**First Name (Titles) **] [**Last Name (Titles) **] for an INR after
discharge and have the results forwarded to your primary care
doctor in order to determine your ongoing coumadin dose.
Completed by:[**2122-3-22**]
|
[
"V12.51",
"V58.61",
"707.14",
"244.9",
"337.20",
"070.54",
"707.12",
"V10.47",
"E934.2",
"530.81",
"790.92",
"443.1",
"491.21",
"338.29",
"487.0",
"482.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9867, 9925
|
5216, 7954
|
291, 297
|
10175, 10251
|
3166, 5193
|
11317, 12038
|
2249, 2405
|
8424, 9844
|
9946, 10154
|
7980, 8401
|
10275, 11294
|
2420, 3147
|
231, 253
|
325, 905
|
927, 1902
|
1918, 2233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,263
| 178,490
|
52377
|
Discharge summary
|
report
|
Admission Date: [**2108-9-4**] Discharge Date: [**2108-9-12**]
Date of Birth: [**2056-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Hypotension, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 51 year-old male with a history of Down's syndrome and
chronic hepatitis B, indwelling Foley catheter due to
quadraparesis s/p fall in [**2108-6-7**], s/p cervical laminectomy,
recent hospital admission for urosepsis (discharged from [**Hospital1 18**]
on [**2108-8-14**]) who presents with fevers, malaise.
According to records from nursing home, pt was noted to be
lethargic and febrile to 104.2 F on the night of admission.
Tylenol 1g and Levoquin 250 mg were given. One hour later at the
nursing home, pt's vitals were: 100.6 F, HR 76 BP 86/48 O2 sat
92% on RA. Pt was sent to [**Hospital1 18**] ED for further management.
.
In the ED, vitals were 101.6 F, HR 88, BP 113/55, RR 18 with O2
sat of 89% on RA (Recovered to 96% on 4 L NC). CXR showed some
opacities suggestive of PNA. Pt received Vancomycin 1g, Zosyn
4.5 mg, and Levaquin 750 mg in the ED for presumed HAP. Also
given were Toradol 15mg x 1, and 2L of fluid as pt was noted to
be hypotensive with SBP in 80s. Pt was admitted to ICU for
hypotension and concern for sepsis.
Past Medical History:
- chronic hep B - on adefovir and lamivudine, no known cirrhosis
- Quadraparesis, s/p posterior cervical laminectomy on [**2108-7-11**]
- trisomy 21
- rosacea
- Right eye blindness - [**3-10**] retinal detachment
- Right cataract
- eczema
- Cholelithiasis
Social History:
Lives at a group home. Sister [**Name (NI) 8513**] is health care proxy.
Family History:
non-contributory per medical record
Physical Exam:
Vitals: T: 98.0 BP: 114/57 HR: 74 RR: 15 O2Sat: 98% on 5L NC
GEN: lying in an awkward position in bed, often yelling
incomprehensible words. Alert, but ineffective communication.
HEENT: EOMI, + hazy opacities over right pupil with purulent
discharge, eyes injected bilaterally, left pupil round and
reactive to light. sclera anicteric, extremely dry MM
NECK: No JVD, no cervical or periclavicular lymphadenopathy,
trachea midline
COR: RRR, [**3-14**] holosystolic murmur, normal S1 S2, radial pulses
+2
PULM: difficult to assess due to pt's inability to cooperate,
however CTAB, no W/R/R
ABD: Soft, ND, +BS, Pt affirms presence of diffuse abdominal
pain. No guarding, rebound.
EXT: No C/C/E. + hyperpigmentation/ thickening of skin in lower
extremities associated with early chronic venous stasis
Back: Stage 2 decubitus ulcer in sacral area.
NEURO: alert, not able to assess orientation.
Pertinent Results:
[**2108-9-4**] 08:10PM WBC-8.2 RBC-3.83* HGB-12.0* HCT-36.4* MCV-95
MCH-31.5 MCHC-33.1 RDW-15.5
[**2108-9-4**] 08:10PM NEUTS-69.1 LYMPHS-25.1 MONOS-4.3 EOS-0.5
BASOS-1.0
[**2108-9-4**] 08:10PM PLT COUNT-306
[**2108-9-4**] 08:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR
[**2108-9-4**] 08:10PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.037*
[**2108-9-4**] 08:10PM URINE RBC-21-50* WBC-[**12-27**]* BACTERIA-MANY
YEAST-NONE EPI-0
[**2108-9-4**] 08:10PM URINE MUCOUS-MANY
[**2108-9-4**] 08:10PM GLUCOSE-105 UREA N-26* CREAT-0.9 SODIUM-140
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2108-9-4**] 08:15PM LACTATE-1.2
[**2108-9-4**] 08:10PM cTropnT-<0.01
[**2108-9-4**] 08:10PM CK-MB-2
[**2108-9-4**] 08:10PM CALCIUM-8.5 PHOSPHATE-5.7*# MAGNESIUM-2.5
Brief Hospital Course:
This is a 51 year-old male with a history of Down's syndrome,
history of chronic hepatitis B, chronic indwelling foley
catheter with recent admission for urosepsis who presents with
hypotension and fevers. The initial suspecion was for urosepsis,
however, the urine culture did not reveal any organisms. He then
developed hypoxemia with CXR concerning for pneumonia, effusion
or atelectasis in right lung lobe, although initial CXR showed
left air space disease. After initial IV ABx, he was placed on
oral levaquin. The patient had stage 2 ulcers that did not look
infected to suggest a source of fever. he was on decubitus ulcer
precautions. His hypotension, for the most part, resolved.
Baseline SBPs in the 100-110. He had no signs of sepsis.
Fludrocort was continued.
He needs to continue course of ABx (levofloxacin) for a [**11-20**]
day course, wean off oxygen, if possibe, and repeat CXR in few
days to role out progressive pleural effusion in the right side.
He may need CT chest if he has progressive effusion, however,
the sister may elect against invasive testing. She expressed
that she may vote against further hospitalizations or more
treatments. he is at risk for recurrent pneumonia/atelectasis
because of his severe kyphosis, poor inspiration effort, and
atelectasis/lung compromise. He needs insentive spirometry
whereever he goes. Again, His sister may decide for comfort
treatments only. She is the DPOA.
# Chronic hepatitis B, stable: continued home meds
# FEN: Regular
# Code: Sister [**Name (NI) 8513**] is HCP. home: [**Telephone/Fax (1) 108244**], cell:
[**Telephone/Fax (1) 108245**] DNR/DNI order accompanied pt from nursing home.
Confirmed with sister. She may go against more invasive
tests/treatments.
Medications on Admission:
Fludrocortisone
multivit with minerals
cyanocobalamin
colace
lamivudine
adefovir
Discharge Medications:
Levaquin
Fludrocortisone
multivit with minerals
cyanocobalamin
colace
lamivudine
adefovir
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Primary: pneumonia
Secondary: cervical stenosis, hepatitis B, Down syndrome,
decubitus ulcer
Discharge Condition:
good
Discharge Instructions:
You were admitted with hypotension and found to have a
pneumonia. You were treated with antibiotics.
If you have recurrent shortness of breath, low blood pressure,
cloudy urine, change in mental status, or any other concerning
symptoms, return to the hospital.
Followup Instructions:
You will be followed by the physicians at your rehab facility.
Please call your primary care physician to set up follow-up 1-2
weeks after you are discharged from rehab.
Follow up with Dr. [**Last Name (STitle) **] (liver doctor) as scheduled:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2108-10-16**] 9:30
|
[
"276.51",
"070.32",
"V15.88",
"756.19",
"366.9",
"574.20",
"344.00",
"695.3",
"692.9",
"458.9",
"486",
"369.8",
"511.9",
"758.0",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5656, 5709
|
3650, 5398
|
333, 339
|
5846, 5852
|
2770, 3627
|
6162, 6551
|
1807, 1845
|
5535, 5633
|
5730, 5825
|
5424, 5512
|
5876, 6139
|
1860, 2751
|
275, 295
|
367, 1418
|
1440, 1698
|
1714, 1791
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,773
| 108,253
|
42858
|
Discharge summary
|
report
|
[** **] Date: [**2109-2-8**] Discharge Date: [**2109-2-19**]
Date of Birth: [**2050-5-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis
History of Present Illness:
58 year old F with Multiple Sclerosis with repeated admissions
this month for AMS who was admitted to [**Location **] [**2-6**] for
confusion after a fall and found to have UTI and bil DVT and is
now transffered to us primarily for continuous EEG monitoring
d/t continued AMS.
.
At baseline pnt is mostly wheelchair bound, but is able to walk
a few steps with a walker and transfer independently, mentates
normally and is able to care for her affairs.
.
She was recently admitted to [**Hospital3 1196**] ON
[**2109-1-24**] for UTI and became delirious at that point. However,
her delirium did improve and she was alert and oriented upon
discharge. transferred to [**Hospital **] Rehab on [**2109-1-23**]. She was
at for less than a day, at which point she was transferred back
to [**Hospital3 1196**] with altered mental status where
she was discharged on [**1-26**] back to rehab. Details of this
[**Month/Year (2) **] are unclear. She then presented [**2-6**] to [**Hospital3 **]
from nursing home due to a fall which she said was [**3-14**] to
neglecting to lock her wheelchair when she was trying to get off
it. She fell backwards and sustained a occipital scalp
hematoma, there was no loss of consciousness, no incontinence,
tongue [**Last Name (un) 20694**] or limb movements. Per nursing home report, the
patient was confused after the fall.
.
At [**Hospital3 **] was reported to have intermitent confusion with
peridos in which she is able to converse and cooperate. Kepra
was started overnight for ? of seizures. Today she became
progressively more lethargic to the point of awakening only to
noxiuous stimuli. Noncontrast head CT showed atrophy but no
acute findings. MRI scan was limited d/t movement and showed
[**Known lastname 1007**] matter findings consistent with multiple sclerosis, but
could not absolutely r/o infarction. EEG show generalized
slowing and some high-amplitude sharp activity which was felt to
be consistent with an encephalopathy, although seizure could not
be ruled out. All centerally acting medications including
baclofen and keppra. She was given IV acyclovir empirically on
day of transfer. LP was performed prior to transfer, initial and
showed: gluc 63, prot 47, gram stain neg, RBC 2140 1st tube 20
4th tube, no xanthrchromia, WBC = 5, 5.
.
.
She also reported increased swelling bilaterally in her lower
extremities over past few months left > right, limiting her
mobility. She denied any chest pain, shortness of breath,
nausea, vomiting, headache, focal numbness or weakness. LENI
demonstarted DVT in the left common femoral and proper femoral
veins + clot was also seen in the right common femoral vein.
She has no family or personal h/o DVT. She denied any CP or SOB.
VQ scan was was interpreted as very low probability for
pulmonary embolism. Echo showed mild-mod TR and minimal PHTN
(28mmHg) w/o RV strain. IV heparin was started + coumadin. Then
reversed for LP and IVC filter was placed.
.
Also UTI was diagnosed per dirty UA, patient received 3 days of
ciprofloxacin which was stopped d/t AMS. Unkown if positive
cultures.
.
Past Medical History:
Osteoporosis
- multiple sclerosis, wheelchair bound with indwelling Foley, -
hyperlipidemia
- frequent urinary tract infections
- myelopathy
- chronic pain syndrome.
Social History:
She lives in a skilled nursing facility. A brother is
healthcare proxy. She has never smoked. She does not drink
alcohol.
Family History:
Mother had multiple sclerosis and father had hypertension and
depression.
Physical Exam:
[**Known lastname **] Exam:
General: awake but not alert, non-verbal, not following
commands, answers in repeated monosylabals, no acute distress,
very thin and wasted.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: bil air entery, no wheezes, rales, ronchi
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: foley in place
Ext: +3 edema bil left > rt, left distal LE is cool with
motelling and cyanosis in toes, DP are however 2+ bilaterally.
Neuro: limited exam: CN's grossly intact, mild spacticity in 4
limbs w/o contracturs, able to move 4 limbs, symetric reflexes
bilaterally, gait deferred
.
Discharge Exam:
VS: T 97-98 BP 120-130/70-90 HR 100-120 RR 20 O2 Sat 97% RA
GEN: Elderly woman in NAD, cachectic.
Neck: Supple
CV: Tachycardic, regular. No m/r/g.
PULM: CTAB, diminished BS at the bases bilaterally. No increased
WOB. No wheezes, rales or rhonchi.
ABD: Firm and slightly distended, NABS. No rigidity, rebound or
guarding.
EXT: 2+ pitting edema to the thighs. DPs 1+, BLEs are WWP.
NEURO: A/O x2.
Pertinent Results:
[**Known lastname **] Labs:
[**2109-2-9**] 12:04AM BLOOD WBC-6.4 RBC-3.30* Hgb-10.3* Hct-30.5*
MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 Plt Ct-375
[**2109-2-9**] 12:04AM BLOOD Neuts-94.5* Bands-0 Lymphs-10.0*
Monos-5.2 Eos-0.3 Baso-0.2
[**2109-2-9**] 08:51PM BLOOD PT-28.6* PTT-36.9* INR(PT)-2.8*
[**2109-2-9**] 02:50PM BLOOD PT-27.0* PTT-77.9* INR(PT)-2.6*
[**2109-2-9**] 07:37AM BLOOD PT-26.8* PTT-105.3* INR(PT)-2.6*
[**2109-2-9**] 12:04AM BLOOD Glucose-109* UreaN-22* Creat-1.1 Na-137
K-4.2 Cl-100 HCO3-25 AnGap-16
[**2109-2-9**] 12:04AM BLOOD ALT-17 AST-19 LD(LDH)-382* AlkPhos-78
TotBili-0.2
[**2109-2-9**] 09:30AM BLOOD T4-7.9 Free T4-1.6
[**2109-2-9**] 12:04AM BLOOD TSH-4.7*
[**2109-2-9**] 09:30AM BLOOD calTIBC-173* VitB12-769 Folate-16.6
Hapto-271* Ferritn-324* TRF-133*
[**2109-2-9**] 09:30AM BLOOD [**Doctor First Name **]-PND
[**2109-2-9**] 12:04AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
[**2109-2-18**] 04:56AM BLOOD WBC-10.4 RBC-2.90* Hgb-9.2* Hct-27.2*
MCV-94 MCH-31.7 MCHC-33.7 RDW-14.7 Plt Ct-377
[**2109-2-17**] 04:49AM BLOOD Glucose-89 UreaN-29* Creat-1.2* Na-133
K-4.8 Cl-101 HCO3-21* AnGap-16
[**2109-2-14**] 05:48AM BLOOD CA125-2614*
.
CT Chest/Abd/Pelvis ([**2109-2-12**]):
1. Large pelvic masses that are mainly composed of soft tissue
but have some cystic components within them. Bilateral
hydronephrosis is detected secondary to external compression of
the ureters by the pelvis masses.
Omental caking and peritoneal seeding are seen along with
malignant ascites. These findings are most probably related to
primary ovarian carcinoma.
.
2. IVC filter is well positioned, filling defects that are
compatible with
DVT are seen in the right common iliac vein. The right external
iliac vein is obliterated. Filling defects are seen in the left
common femoral vein and left superficial femoral vein. The left
iliac veins are not well visualized.
.
Paracentesis ([**2109-2-14**]): Technically successful ultrasound-guided
diagnostic paracentesis Preliminary Reportwith 850 mL of clear
serous fluid removed. No immediate complication. Cytology
consistent with adenocarcinoma.
Brief Hospital Course:
Primary Reason for [**Month/Day/Year **]: 58 year old F with Multiple
Sclerosis with repeated admissions this month for AMS who was
admitted to [**Location **] [**2-6**] for confusion after a fall and
found to have UTI and bilateral DVTs transferred for continuous
EEG monitoring d/t continued AMS found to have widespread
ovarian cancer.
.
Active Problems:
.
# AMS/Delirium: Likely toxic metabolic encephalopathy given
marked improvement with antibiotics and EEG consistent with
generalized encephalopathy and no e/o seizure or epileptiform
activity. She was initially A/O x0, arousable but minimally
verbal, only responsive with echolalia. After initiating
appropriate antibiotic therapy for enterococcus UTI, her mental
status rapidly improved. There was initially concern for
bacterial/viral meningitis/encephalitis and LP was performed at
[**Hospital3 **]. CSF showed Tot Protein 47, Glucose 63, RBC 2140
(Tube 1), RBC 20 (Tube 4), likely representative of a traumatic
tap. HSV PCR and Cryptococcal antigen were negative. Bacterial
cultures were negative and antibiotics were narrowed and
acyclovir was discontinued. MRI was also performed at [**Hospital3 2568**]
and showed periventricular [**Known lastname **] matter changes consistent with
MS. On the floor her mental status rapidly improved, though she
contined to wax and wane with occasional hallucinations and
inappropriate responses to questioning, intersperced with
periods of lucidity consistent with delerium. RPR was negative
and TFTs were normal. At the time of discharge, she was A/Ox3
and able to engange in conversation, though occasionally
confused.
.
# DVT: Pt with b/l DVTs, for which she was started on Heparin
gtt and Warfarin. She also had an IVC filter placed at [**Hospital3 10959**], as she needed to be reversed for urgent LP. CT C/A/P was
performed due to concern for malignancy or IVC clot and showed a
large pelvic mass with widespread peritoneal metastases
consistent with advanced ovarian cancer. Warfarin and Heparin
were stopped and she was placed on therapeutic doses of Loveonx.
She should be continued on Lovenox shots as prescribed for at
least the next 6 months with consideration given to lifelong
anticoagulation given her known hypercoagulable state.
.
# Ovarian Cancer: Large pelvic mass with associated ascites,
omental caking peritoneal seeding and pleural effusion were seen
on CT scan. Ultrasound guided paracentesis was performed and
cells were sent for cytology. Ca-125 was 2614. Ascitic fluid was
exudative, consistent with peritoneal carcinomatosis. Cytology
showed adenocarcinoma and Heme/Onc was consulted. She will
follow up as an outpatient for management of her malignancy.
Final staining for pathology is pending at discharge.
.
# Bleed: Pt's HCT dropped 28->23 s/p paracentesis in the setting
of anticoagulation with Lovenox. For this she was transfused 1U
pRBCs with appropriate response in her HCT from 23->28. Her HCT
remained stable for the remainder of her hospital course.
.
# UTI: She was found to have UTI at [**Hospital3 2568**] and placed on
Cipro, which was stopped after 3d due to worsening mental
status. At [**Hospital1 18**] she was given Ceftriaxone; urine culture grew
enterococcus sensitive to Ampicillin and Ceftriacxone was
stopped and she was given a 7d course of Ampicillin. Ampicillin
was continued due to her recurrent UTIs and hospital admissions
for AMS; she will require lifelong Ampicillin prophylaxis and
should continue q6h straight cath for her neurogenic bladder.
.
# [**Last Name (un) **]: Pt with elevated Cr. Initial concern was for pre-renal
failure given poor PO intake and she was given IVF without
improvement. CT C/A/P was then performed and showed a large
pelvic mass compressing the bilateral ureters and mild bilateral
hydronephrosis. Her Cr and electrolytes were monitored and her
Cr remained stable (1.2-1.3) throughout her course.
.
# Atonic Bladder: At baseline pt straight caths herself for
atonic bladder due to MS. [**First Name (Titles) **] [**Last Name (Titles) **] to [**Hospital1 18**] she had an
indwelling foley. This was d/c'ed upon arrival to the floor and
she was straight cath'ed q6h for the remainder of her hospital
course.
.
# Tachycardia: Likely [**3-14**] hypermetabolic state given widespread
ovarian cancer. She was most tachycardic immediatley prior to
her Metoprolol doses. Given this, her Metoprolol was changed
from 50mg po bid to 37.5mg po tid with imprvement in her
tachycardia.
.
# Malnutrition: Nutrition was consulted and recommended Ensure
supplements with meals. As her mental status improved, her PO
intake also improved. At the time of discharge she was
tolerating POs and eating 3 full meals per day.
.
Chronic Problems:
.
# MS: Current presentation unlikely due to MS flare.
.
Transitional Issues: Pt was d/c'ed with Heme/Onc and GYN/Onc
follow up. Her brother, [**Name (NI) **] is involved in her care and will
be present at her appointments to facilitate discussion of her
options moving forward.
Medications on [**Name (NI) **]:
Tylenol 650 mg p.o. q.6h as needed for pain or fever
Colace 100 mg p.o. b.i.d.
Prozac 20 mg daily
Provigil?
folic acid 1 mg daily
HCTZ/triamterene 37.5/25 mg daily
MiraLax 17 grams daily as needed
Toprol-XL 75 mg daily
milk of magnesia 30 mL p.o. as needed for constipation
Dulcolax 10 mg rectally as needed.
Fosamax 70mg Qweek
ibandronate 150mg Qmonth
Modafinil (provigil) 400mg QD
Baclofen 10mg QID
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast infection.
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. modafinil 100 mg Tablet Sig: Two (2) Tablet PO qday ().
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours).
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for fever or pain.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
14. ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
15. baclofen 10 mg Tablet Sig: One (1) Tablet PO four times a
day.
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Village - [**Location 4288**]
Discharge Diagnosis:
Primary Diagnosis:
Toxic Metabolic Encephalopathy
Secondary Diagnosis:
Ovairan Cancer
Recurrent UTIs
Multiple Sclerosis
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:
Dear Ms [**Known lastname 1007**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for altered mental status,
which we feel was due to your urinary tract infection. For this,
we gave you antibiotics, which you should continue taking
indefinately. Unfortunately, we also found that you have cancer.
We had the Oncologists evaluate you, and we have arranged for
you to see an Oncologist as an outpatient. At this appointment,
you and your brother should discuss how you would like to
proceed in managing your cancer.
Please note the following changes to your medications:
STARTED Ampicillin 500mg by mouth 4 times a day
CHANGED Metoprolol to 37.5mg by mouth three times a day
STOPPED HCTZ/Triamterene 37.5/25mg by mouth daily
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2109-2-21**] at 3:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2109-2-21**] at 3:30 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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247
| 189,521
|
15208
|
Discharge summary
|
report
|
Admission Date: [**2156-8-3**] Discharge Date: [**2156-8-9**]
Date of Birth: [**2097-11-16**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
coronary artery disease, who presents with a 3-week history
of chest pain at bed rest, who presented to an outside
hospital on [**2156-8-4**] after having an episode of severe
chest pain. He was already scheduled for an exercise stress
test by his primary care physician for this date. He had
been chest pain free since his stent five years ago.
However, three weeks ago he had started having jaw pain
(which may be his anginal equivalent) while lying in bed.
The patient was unable to get a cardiac catheterization done
at the outside hospital secondary to insurance noncoverage.
He was given Lovenox, Integrilin, Lopressor, intravenous
nitroglycerin and then transferred to [**Hospital1 190**] for further workup; however, chest pain free.
PAST MEDICAL HISTORY: (This is a 58-year-old male with a
past medical history significant for)
1. Coronary artery disease, status post right coronary
artery stent five years ago.
2. Type 2 diabetes for 20 years.
3. High cholesterol.
4. Hypertension.
5. Depression since [**Month (only) 404**].
MEDICATIONS ON ADMISSION: The patient's medications prior to
admission were Lipitor, Tiazac, aspirin, Toprol-XL,
Glucotrol, Glucophage, and Prozac.
ALLERGIES: The patient has allergies to PENICILLIN and
AMOXICILLIN.
HOSPITAL COURSE: A cardiac catheterization was performed on
[**2156-8-4**] at [**Hospital1 69**] which
revealed severe 3-vessel coronary artery disease with
preserved left ventricular function. The patient underwent a
coronary artery bypass grafting times three on [**2156-8-5**]; with left internal mammary artery to the left anterior
descending artery, saphenous vein graft to the posterior
descending artery, saphenous vein graft to the obtuse
marginal.
The patient was transferred in stable condition to the
Cardiothoracic Surgery Recovery Unit on propofol at 10 mcg/kg
per minute as well as a nitroglycerin drip. The patient was
weaned an extubated at 6 p.m. on the day of surgery. He had
a labile blood pressure which was titrated with
nitroglycerin, Neo-Synephrine, intravenous fluids, and 2
units of packed red blood cells. His blood pressure remained
stable after the volume and transfusion as well as low-dose
Neo-Synephrine, and the patient's anxiety was relieved with
pain medication and verbal support.
On postoperative day one, the patient remained afebrile.
Vital signs were stable, in sinus rhythm. White blood cell
count was 5.3, hematocrit was 26.5, platelet count was 169.
Sodium was 138, potassium was 4.5, blood urea nitrogen
was 13, creatinine was 0.9, and blood glucose was 123 on no
drips with a plan to start his beta blocker later on that day
as well as the Lasix, and to transfer the patient to the
floor. The patient was transferred to the floor on
postoperative day one.
However, on the morning of postoperative day two, the patient
went into a sinus tachycardia with rates above 150s. He was
given 5 mg of intravenous Lopressor times two, and his p.o.
Lopressor was increased to 25 mg p.o. b.i.d. His blood
pressure was stable, and the patient was asymptomatic. Also
on postoperative day two, the patient was complaining of a
headache which he had reportedly had all night. The patient
vital signs were stable. The patient with a low-grade fever
of 99.3; however, he was still tachycardic. The patient was
found to be in atrial fibrillation/atrial flutter which
started at around 6 a.m. that morning. Initially in sinus
tachycardia, but in atrial flutter when slowed. He was given
intravenous amiodarone 150 mg bolus as well as amiodarone
400 mg p.o. t.i.d. The plan was to get a Neurology
consultation for the headache.
Neurology came to consult with the patient for this headache,
and they felt that given the recent history of coronary
artery bypass graft and sudden onset of headache, and its
severity in developing after falling back to bed yesterday,
it was important to rule out a cerebral hemorrhage. They
felt that although the patient had photophobia associated
with this headache, a migraine was unlikely because of the
nature of the headache. The plan was to get a head CT
without contrast, to transfuse 2 units of packed red blood
cells (because of his low hematocrit), and to administer
Fioricet one tablet p.o. q.6h. for 24 hours, then q.4h. as
needed for pain, as well as to volume replete with
intravenous fluids given the increased creatinine which would
exacerbate his headache, to consider transfusion, to keep
hematocrit greater than 30.
On postoperative day three, the patient remained with a
low-grade fever with a temperature maximum of 100.9 and
temperature current of 98.9. Heart rate was 76. In sinus
rhythm. The plan was to continue the Fioricet. The patient
was responding well to this medication, and he continued the
amiodarone. It was decided to hold off on the head CT at
that time.
On postoperative day four, the patient had no complaints
overnight. The patient remained afebrile. Vital signs were
stable with a heart rate of 75 and in sinus rhythm. The plan
was to keep ambulating, and if at level V today the patient
would be able to be discharged home with an expected
discharge date of [**2156-8-9**].
The patient's laboratories included a white blood cell count
of 4.5, a hematocrit of 22.2, platelet count was 169. Sodium
was 139, potassium was 4.5, blood urea nitrogen was 22,
creatinine was 1.2, and blood glucose was 169.
Physical examination on the patient's probable day of
discharge revealed the patient was stable, afebrile, in sinus
rhythm. The patient was awake and alert times three. Moved
all of his extremities. His lungs were clear to auscultation
bilaterally. His heart was regular in rate and rhythm with
no murmurs. His sternum was stable. His incision was with
Steri-Strips, clean and dry. His abdomen was benign. His
extremities were warm and well perfused with a right
saphenous vein graft site clean and dry; no edema.
MEDICATIONS ON DISCHARGE: (His discharge medications were)
1. Aspirin 325 mg p.o. q.d.
2. Metoprolol 25 mg p.o. b.i.d.
3. Amiodarone 400 mg p.o. q.d.
4. Lasix 20 mg p.o. q.d. (times seven days).
5. Potassium chloride 20 mEq p.o. q.d. (times seven days).
6. Metformin 1000 mg p.o. b.i.d.
7. Glyburide 5 mg p.o. b.i.d.
8. Percocet one to two tablets p.o. q.4h. as needed for
pain.
9. Ibuprofen 400 mg to 600 mg p.o. q.4-6h. as needed for
pain.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: In stable condition.
DISCHARGE FOLLOWUP: The patient to follow up with
Dr. [**Last Name (STitle) 70**] in four weeks and with his primary care
physician in three to four weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Type 2 diabetes.
5. Depression.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 182**]
MEDQUIST36
D: [**2156-8-9**] 11:17
T: [**2156-8-14**] 06:17
JOB#: [**Job Number 44275**]
|
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icd9cm
|
[
[
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icd9pcs
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[
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179, 957
|
980, 1258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,615
| 121,097
|
20654
|
Discharge summary
|
report
|
Admission Date: [**2101-4-27**] Discharge Date: [**2101-5-2**]
Date of Birth: [**2037-6-1**] Sex: F
Service: MEDICINE
Allergies:
Thorazine / Stelazine / Benadryl / Compazine
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Reason for MICU: respiratory failure, sepsis
Major Surgical or Invasive Procedure:
respiratory intubation
History of Present Illness:
Patient is a 63 y/o F, NH resident, w/ PMH of schizoaffective
disorder, DM, hypothyroid who presented to ED with fever,
hypoxia and respiratory distress. Further history not available
from patient nor from NH. Per ED/EMS patient tachypneic,
diaphoretic, and hypxoic. Febrile to 102 on presentation.
Patient intubated in ED for hypoxic respiratory failure. CT
chest revealed possible aspiration pneumonia. Work-up revealed
evelated lactate and bandemia, although patient was never
hypotensive. In ED, received Levo, Flagyl, Vanco, 3 liters
normal saline. Has made 400cc UOP. Patient is DNR, but
apparently not DNI per ED.
Past Medical History:
HTN
DM
s/p total thyroidectomy, now hypothyroid
s/p lung bx
arthritis
Schizoaffective
Depression
Social History:
The patient is single and resides in a skilled nursing facility.
She is a former smoker and there is a question of a formal
history of alcohol abuse. The patient completed high school and
previously worked in a bowling alley.
Family History:
[**Last Name (un) 5487**]
Physical Exam:
Temp 102 BP 116/44 HR 120--> 74 RR 45--> 30 100% AC 500x20 FiO2
100% PEEP5
GEN: Sedated, intubated, opened eyes to voice but did not follow
commands
HEENT: anicteric
Neck: Rt subclavian line
CV: RRR no murmurs appreciated
LUNGS: CTA anteriorly
ABD: soft, ND, +BS, ? mild tenderness diffuse
EXT: 2+ LE edema to knee, 2+ DP pulses, warm
Skin: no rash
Neuro: Sedated on propofol, opened eyes to voice
Pertinent Results:
[**2101-4-27**] 01:05AM BLOOD WBC-9.5# RBC-4.99 Hgb-16.6*# Hct-46.0
MCV-92 MCH-33.3* MCHC-36.1* RDW-13.5 Plt Ct-135*
[**2101-5-1**] 03:55AM BLOOD WBC-4.6 RBC-3.59* Hgb-11.7* Hct-33.2*
MCV-93 MCH-32.7* MCHC-35.4* RDW-13.2 Plt Ct-134*
[**2101-4-27**] 01:05AM BLOOD Neuts-71* Bands-15* Lymphs-7* Monos-4
Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2101-5-1**] 03:55AM BLOOD Plt Ct-134*
[**2101-4-28**] 03:20AM BLOOD PT-13.4* PTT-26.0 INR(PT)-1.2*
[**2101-4-27**] 03:09AM BLOOD Glucose-189* UreaN-10 Creat-0.5 Na-148*
K-3.0* Cl-118* HCO3-17* AnGap-16
[**2101-5-1**] 03:55AM BLOOD Glucose-100 UreaN-9 Creat-0.5 Na-143
K-4.1 Cl-108 HCO3-26 AnGap-13
[**2101-4-27**] 03:09AM BLOOD CK(CPK)-101
[**2101-4-27**] 03:09AM BLOOD cTropnT-<0.01
[**2101-4-27**] 09:00AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1
[**2101-4-27**] 09:00AM BLOOD Valproa-78
[**2101-4-27**] 09:00AM BLOOD Cortsol-19.0
[**2101-4-27**] 08:39AM BLOOD Type-ART pO2-342* pCO2-40 pH-7.43
calHCO3-27 Base XS-2
[**2101-4-29**] 12:11PM BLOOD Type-ART pO2-93 pCO2-43 pH-7.41
calHCO3-28 Base XS-1
[**2101-4-27**] 01:13AM BLOOD Lactate-4.6*
[**2101-4-27**] 08:25PM BLOOD Lactate-1.6
.
Chest/Abd CT [**4-27**]: IMPRESSION:
1. Massive distension of the rectum secondary to impaction.
2. Small patchy left lower lobe opacity represents infection
versus aspiration.
3. No evidence for PE.
4. 1.5 cm unchanged left lower lobe calcified nodule.
.
Sputum [**4-27**]:
GRAM STAIN (Final [**2101-4-27**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2101-4-30**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- R
OXACILLIN------------- 0.5 S
Brief Hospital Course:
63 y/o F with DM who p/w hypoxic respiratory failure,
hypotension found to have MSSA pneumonia.
.
1) Respiratory Failure: Patient was admitted for hypoxic
respiratory failure, requiring intubation. CT chest showed a
developing opacity at the left base and sputum cultures showed
growth of staph aureus. She was successfully extubated [**4-30**],
doing well oxygenating on room air. She was initially started
on levofloxacin, flagyl, and vancomycin. Once sensitivities
were available, switched to nafcillin, plan to complete on [**5-5**].
.
2) Hypotension: concerning for sepsis, given presence of
pneumonia, slightly elevated lactate. Responded well to fluid
boluses, resolution of hypotension, lactate normalized. No
evidence of bacteremia on blood cx's. Pt remained afebrile,
without tachycardia.
.
3) Dilated rectum: pt had stoool impaction at admission and
required manual disimpaction. Continue agressive bowel meds with
narcotics for pain.
.
4) DM: Pt with h/o DM. Held hypoglycemics. Well controlled with
RISS.
.
5) Schizoaffective disorder: Continue depakoted, trihexyphenidyl
(? movement d/o), risperdone
.
7) Arthritis: Pt has painful arthritis. The arthritis has been
getting progressively worse. Well controlled with outpatient
doses of oxycontin, prn percocet.
.
8)Hypothyroid: cont levothyroxine
.
9) F/E/N: regular diabetic diet
.
10) Code: Pt is DNR/DNI, confirmed with guardian, documentation
had not indicated DNI status prior to admission.
.
11) PPX: SQ heparin, bowel meds
Medications on Admission:
colchicine 0.6-mg tablets daily
gabapentin 200 mg in the morning
oxycontin 10 mg daily
levothyroxine 200 mcg daily
metformin 850 mg daily
multivitamins
trihexyphenidyl 2 mg daily
vitamin B1 100 mg daily
Colace 100 mg twice daily
Risperdal 2 mg twice daily
fluphenazine 5 mg three times daily
lorazepam 0.5 mg three times daily
Depakote ER 1500 mg at bedtime
gabapentin 300 mg at bedtime
Senokot one tablet at bedtime
insulin sliding scale
fluphenazine 1 mg milligram as needed
Tylenol 650 mg as needed
Percocet one to two tablets every four hours as needed.
.
ALL:
Benadryl, Compazine, Stelazine, and Thorazine
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Risperidone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Fluphenazine HCl 5 mg Tablet Sig: One (1) Tablet PO three
times a day.
6. Trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
9. Gabapentin 100 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
10. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QD ().
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Erythromycin 5 mg/g Ointment Sig: 0.5 mg Ophthalmic TID (3
times a day) for 4 days: to R eye.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours) for 4 days.
16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
17. Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Primary:
Pneumonia, nosocomial
Hypoxemic respiratory failure
Secondary:
Schizoaffective disorder
Diabetes type II
Hypothyroidism
Hypertension
Discharge Condition:
stable
Discharge Instructions:
Please complete antibiotics as scheduled. Follow up with your
regular primary care doctor. Take your medications as
prescribed.
Seek medical care for fever, chills, shortness of breath, or
other concernings symptoms.
Followup Instructions:
follow up with primary care doctor: [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 608**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2101-5-1**]
|
[
"244.0",
"038.9",
"482.41",
"995.92",
"250.00",
"518.81",
"507.0",
"560.39",
"295.70",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7712, 7765
|
4063, 5563
|
348, 372
|
7951, 7960
|
1866, 4040
|
8227, 8462
|
1405, 1432
|
6225, 7689
|
7786, 7930
|
5589, 6202
|
7984, 8204
|
1447, 1847
|
264, 310
|
400, 1022
|
1044, 1143
|
1159, 1389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,233
| 174,974
|
44503
|
Discharge summary
|
report
|
Admission Date: [**2122-8-14**] Discharge Date: [**2122-8-21**]
Date of Birth: [**2046-6-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2122-8-17**]
1. Urgent coronary artery bypass graft x4 with left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to right coronary and obtuse marginal 1 and 2
arteries.
2. Endoscopic harvesting of the long saphenous vein.
[**2122-8-14**] Cardiac Catheterization
History of Present Illness:
76M with recent history of intermittent chest pain on exertion
which recently evolved into chest pain at rest. He p/t an OSH
where EKG showed ST depressions and a LBBB. He was transferred
to [**Hospital1 **] for cath which revealed three vessel CAD. He is referred
for cardiac surgical evaluation.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
DMII
LBBB
CAD (2vd in [**2117**])
BPH
Nephrolithiasis
PAD
Past Surgical History:
[**2117-7-5**]- Right femoral endarterectomy with patch angioplasty
[**2116-10-21**]- left fem-[**Doctor Last Name **] bypass, CFA endarterectomy
[**2105**]- left knee meniscus repair
right ankle surgery
Social History:
Race: caucasian
Last Dental Exam: 2 months ago
Lives with: wife
Occupation: retired electrician
Tobacco: quit 40yrs ago
ETOH: 2beers/day (more when the [**Company **] play)
Family History:
Family History: father, mother brother- all died following MI
(although not premature CAD)
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 100% 2L
B/P Right: Left: 148/77
Height: 5'9" Weight: 72.6kg
General: NAD, WG, WN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] well healed scar left
medial LE, mid leg to groin (s/p fem-[**Doctor Last Name **] bypass)
Edema none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
Admission
[**2122-8-14**] 03:00PM PT-13.7* PTT-31.4 INR(PT)-1.2*
[**2122-8-14**] 03:00PM PLT COUNT-186
[**2122-8-14**] 03:00PM WBC-7.3 RBC-4.37* HGB-13.4* HCT-38.5* MCV-88
MCH-30.7 MCHC-34.8 RDW-12.8
[**2122-8-14**] 03:00PM TRIGLYCER-164* HDL CHOL-37 CHOL/HDL-3.9
LDL(CALC)-74
[**2122-8-14**] 03:00PM %HbA1c-7.5* eAG-169*
[**2122-8-14**] 03:00PM ALBUMIN-3.9 CHOLEST-144
[**2122-8-14**] 03:00PM cTropnT-<0.01
[**2122-8-14**] 03:00PM ALT(SGPT)-18 AST(SGOT)-19 CK(CPK)-49 ALK
PHOS-58 AMYLASE-96 TOT BILI-0.4
[**2122-8-14**] 03:00PM GLUCOSE-129* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
Discharge
[**2122-8-21**] 04:30AM BLOOD WBC-8.3 RBC-3.64* Hgb-11.2* Hct-32.0*
MCV-88 MCH-30.8 MCHC-35.0 RDW-13.1 Plt Ct-204#
[**2122-8-21**] 04:30AM BLOOD Plt Ct-204#
[**2122-8-17**] 11:35AM BLOOD PT-15.1* PTT-39.3* INR(PT)-1.3*
[**2122-8-21**] 04:30AM BLOOD Glucose-143* UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-24 AnGap-15
[**2122-8-21**] 04:30AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
Radiology Report CHEST (PA & LAT) Study Date of [**2122-8-21**] 9:44 AM
Final Report: Compared to [**2122-8-19**], the lung volumes have
improved and there is clearing of atelectasis within the lung
bases. There are persistent small bilateral pleural effusions.
Linear opacity in the right lower lung and slightly
heterogeneous opacity in the left retrocardiac region likely
represent atelectasis/scar. Heart size is within normal limits.
Small dense round opacity at the left lung base was seen
pre-operatively and likely represents a granuloma or vessel on
end overlying the rib.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
A/P: 76yoM with h/o CAD, HTN, DM, PAD s/p L fem-[**Doctor Last Name **] bypass
transferred from [**Hospital1 **]-[**Location (un) 620**] for catheterization after he
presented there on [**8-13**] pm with substernal chest pain.
Cardiac catheterization on [**8-14**] revealed three vessel disease,
mild systolic hypertension, mild LV diastolic dysfunction, and
normal LV systolic function. He was referred to cardiac surgery
for revascularization.
On [**8-17**] he was brought to the opeating room for coronary artery
bypass grafting. Please see operative report for details, in
summary he had:
1. Urgent coronary artery bypass graft x4 -- left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to right coronary and obtuse
marginal 1 and 2 arteries.
2. Endoscopic harvesting of the long saphenous vein. His bypass
time was 67 minutes with a crossclamp time of 58 minutes.
He tolerated the operation well and was transferred
post-operatively to the cardiac surgery ICU in stable condition.
He remained hemodynamically stable in the immediate post-op
period, he woke from anesthesia neurologically intact and was
extubated. On POD1 he continued to be hemodynamically stable and
was transferred to the stepdown floor for further recovery and
physical therapy. All tubes, lines and drains were removed per
cardiac surgery protocol. He was seen by [**Last Name (un) **] diabetes center
for his elevated HgbA1C and was started on Glyburide.
The remainderof his hospital course was uneventful. On POD4 he
was ready for discharge home with visiting nurses. He is to
follow up with Dr [**Last Name (STitle) 7772**] in 3 weeks.
Medications on Admission:
enalapril 10mg [**Hospital1 **]
Lopressor 50mg [**Hospital1 **]
Simvastatin 60 mg daily
asa 325mg daily
Omega 3 fish oil
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. 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 With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Grafting x4
Hypertension, Hyperlipidemia, Diabetes Mellitus 2, Left Bundle
Branch Block, Benign Prostatic Hypertrophy, Nephrolithiasis,
Periperal Arterial Disease, Right femoral endarterectomy with
patch angioplasty([**6-25**]),left fem-[**Doctor Last Name **] bypass([**10-24**]), CFA
endarterectomy([**2105**]), left knee meniscus repair, right ankle
surgery
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Discharge Instructions
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon:[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2122-9-14**]
1:15
Cardiologist: [**Last Name (LF) **], [**First Name3 (LF) 122**] [**Telephone/Fax (1) 5068**] on [**2122-9-21**] @ 2:30
in [**Location (un) 620**]
Primary Care Dr [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15048**], MD Phone:[**Telephone/Fax (1) 9347**]
Date/Time:[**2122-9-11**] 10:30
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2122-8-21**]
|
[
"599.0",
"600.00",
"426.3",
"414.01",
"443.9",
"041.4",
"250.00",
"272.4",
"411.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.53",
"36.13",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7084, 7154
|
4163, 5817
|
332, 636
|
7631, 7843
|
2420, 4140
|
8707, 9501
|
1548, 1625
|
5989, 7061
|
7175, 7589
|
5843, 5966
|
7867, 8684
|
1119, 1325
|
1640, 2401
|
281, 294
|
664, 966
|
1010, 1096
|
1341, 1516
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,373
| 143,349
|
1625
|
Discharge summary
|
report
|
Admission Date: [**2180-12-8**] Discharge Date: [**2180-12-18**]
Date of Birth: [**2107-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cefazolin / Allopurinol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
known severe Aortic stenosis w/ worsening SOB
Major Surgical or Invasive Procedure:
[**2180-12-7**]
1. Aortic valve replacement with a 29-mm [**Company 1543**] Mosaic Ultra
bioprosthesis.
2. Coronary bypass grafting x1: Left internal mammary artery to
left anterior descending coronary artery.
History of Present Illness:
This patient is a 72 year old male who complains of SOB.
PMHX significant for history of renal transplant in [**2165**]
presented with sudden onset of shortness of breath at 5 AM
this morning after getting out of the shower he describes as
a shortness of breath and dyspnea on exertion. He denies any
fevers chills cough chest pain nausea vomiting diarrhea or
increased swelling in his legs.
Past Medical History:
Dyslipidemia
Hypertension
Renal transplant [**2165**]
Chronic venous stasis, swelling R>L
Gout, attacks treated well with colchicine
"oral cold sore" s/p removal
Bilateral Total Knee Replacement
Right Total Hip Replacement
Social History:
Denies tobacco, alcohol, or drug use. Grew up on a farm. Lives
with wife.
Family History:
Two uncles died a sudden death in their 60's. Brother had
polycystic kidney disease. Father died of kidney failure at age
56. Mother died of metastatic cancer. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
Pulse:98 Resp: 18 O2 sat: 3L 98%
B/P Right: 149/87
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Bilateral basilar crackles. No wheezes.
Heart: RRR [x] Murmur III/VI SEM heard best at the left sternal
border.
Abdomen: Soft [x] non-distended [x] non-tender [x] +bowel
sounds [x], obese.
Extremities: Warm [x], well-perfused [x] 2+ RLE edema, 2+ LLE
edema,
+chronic venous stasis changes. Varicosities: None [x]
Right upper extremitity fistula, +thrill.
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 Right: none Left: none
Pertinent Results:
Admission:
[**2180-12-8**] 07:59AM GLUCOSE-131* LACTATE-1.1 NA+-138 K+-4.6
CL--106
[**2180-12-8**] 10:46AM HGB-9.6* calcHCT-29
[**2180-12-8**] 12:37PM FIBRINOGE-285
[**2180-12-8**] 12:37PM PT-15.9* PTT-29.5 INR(PT)-1.4*
[**2180-12-8**] 12:37PM PLT COUNT-240
[**2180-12-8**] 12:37PM WBC-18.1*# RBC-3.28* HGB-10.6* HCT-30.9*
MCV-94 MCH-32.3* MCHC-34.2 RDW-14.4
[**2180-12-8**] 02:06PM UREA N-29* CREAT-1.4* SODIUM-144
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
Discharge:
TEE [**12-8**]:
Conclusions: Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesia of the
apex, apical and mid portions of the inferior and inferoseptal
walls Overall left ventricular systolic function is mildly
depressed (LVEF= 40 %). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is mild valvular mitral stenosis (area 1.5-2.0cm2). Mild to
moderate ([**12-25**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was
notified in person of the results on [**2180-12-8**] at 915am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine
and milrinone. Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. It appears well
seated and the leaflets move well. No aortic insufficiency seen.
The mean gradient across the aortic valve is 11 mm Hg. Mild
mitral regurgitation persists. Aorta is intact post
decannulation.
Radiology Report CHEST (PA & LAT) Study Date of [**2180-12-12**] 8:38 AM
[**Hospital 93**] MEDICAL CONDITION: 72 year old man s/p cabg
Final Report :
Inspiratory effort is improved, although lung volumes are still
low. A right internal jugular line projects over the mid SVC.
Bilateral pleural effusions and associated atelectasis are not
significantly changed since [**2180-12-10**]. Decreased width of the
cardiac and mediastinal silhouettes
may be due to PA technique and are grossly stable. There is no
pneumothorax.
IMPRESSION: No significant change since [**2180-12-10**] with stable
small
bilateral pleural effusions and associated atelectasis.
Brief Hospital Course:
Mr [**Known lastname 9418**] was a same day admit to cardiac surgery for
aortic valve replaceemnt and coronary artery bypass grafting.
Please see the operative report for details, in summary he had:
-Aortic valve replacement with a 29-mm [**Company 1543**] Mosaic Ultra
bioprosthesis.
-Coronary bypass grafting x 1: Left internal mammary artery to
left anterior descending coronary artery. His BYPASS TIME was
109 minutes with a CROSS-CLAMP TIME of 86 minutes. He tolerated
the operation well and was transferred from the operating room
to the cardiac surgery ICU in stable condition on Milrinone,
Phenylephrine and Propofol infusions.
He remained hemodynamically stable and within several hours woke
neurologically intact, was weaned from the ventilator and
extubated. Nephrology was consulted to help manage his renal
disease. He continued to improved was weaned from all vasoactive
infusions and was transferred to the stepdown floor on POD4.
Once on the floor the patient developed atrial fibrillation
which was initially treated with BBlockade, and when that was
not successful, Amiodarone was added. Additionally the patient
was started on coumadin. A single dose of levaquin was given for
sm. amt sternal drainage that resolved in 24 hrs.
Over the next several days the patient worked with nursing and
physical therapy to increase his activity and endurance levels.
On POD#11 he was discharged to home. First INR check day after
discharge with target INR 2.0-2.5 to be followed by ********
Medications on Admission:
1. atorvastatin 10 mg HS
2. azathioprine 50 mg DAILY
3. cyclosporine modified 100 mg every 12 hours.
4. Aldara 5 % Cream 1 application Topical as needed.
5. Centrum Ultra Men's 8 mg (Iron)- 200 mcg-600 mcg 1 Tablet
once a day.
6. prednisone 5 mg DAILY
7. Soriatane 1 tablet once a day.
8. aspirin 325 mg DAILY
9. cholecalciferol (vitamin D3) 400 unit DAILY
10. metoprolol tartrate 25 mg once a day.
11. colchicine 0.6 mg One Tablet once a day as needed for gout.
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg for 7 days then decrease to 200mg ongoing.
Disp:*60 Tablet(s)* Refills:*2*
9. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO
6AM AND 6PM ().
10. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
Dose based on INR for afif
Goal 2-2.5.
Disp:*60 Tablet(s)* Refills:*2*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Check INR daily for coumadin dosing until INR stable.
Check BUN/Creat and cyclopsporin levelon [**2180-12-19**] ans [**2180-12-25**] and
call results to Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 9419**] [**Telephone/Fax (1) 721**] or fax
[**Telephone/Fax (1) 9420**]
Discharge Disposition:
Home With Service
Facility:
All Care VNA
Discharge Diagnosis:
aortic stenosis, coronary artery disease
s/p AVR, CABG
postop A Fib
PMH:
hypertension, hyperlipidemia, DVT [**2164**], basal and squamous cell
carcinoma [**2178**], Gout, Known severe AS w/ [**Location (un) 109**] 1.0-1.2cm,
ESRD s/p transplant ( preop creat 1.5)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance, gait steady
Sternal pain managed with Percocet
Sternal Incision -healing well, no erythema or drainage
Edema: gross lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw [**2180-12-19**]
Results to phone [**Telephone/Fax (1) 721**] / fax [**Telephone/Fax (1) 9420**]
additional labs: MUST BE DRAWN EARLY MORNING FOR CYCLOPSPORIN
LEVEL chem7 and cyclosporin level on [**2180-12-20**] and [**2180-12-25**]
Results to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 9419**] phone [**Telephone/Fax (1) 721**] / fax
[**Telephone/Fax (1) 9420**]
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**1-10**] @2PM
Cardiologist Dr. [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2180-12-19**] 1:00
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2181-1-30**] 1:00
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2180-12-18**]
|
[
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"427.31",
"272.4",
"V43.65",
"285.9",
"E878.8",
"416.0",
"287.5",
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"427.32",
"997.5",
"584.9",
"996.81",
"403.90",
"V58.65",
"585.9",
"V43.64",
"274.9",
"414.01",
"424.1",
"276.52",
"458.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8350, 8393
|
4862, 6360
|
338, 550
|
8701, 8900
|
2369, 4258
|
10152, 10802
|
1328, 1603
|
6873, 8327
|
4295, 4839
|
8414, 8680
|
6386, 6850
|
8924, 10127
|
1618, 2350
|
252, 300
|
578, 972
|
994, 1218
|
1234, 1312
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,450
| 193,156
|
29835
|
Discharge summary
|
report
|
Admission Date: [**2104-7-13**] Discharge Date: [**2104-7-18**]
Date of Birth: [**2025-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Groin pain, nausea & vomitting
Major Surgical or Invasive Procedure:
[**2104-7-13**] Suprapubic catheter changed by Urology.
History of Present Illness:
This is a 79 yo M w/ suprapubic catheter ([**2092**]), hx prostate CA
s/p cryotherapy, and recurrent UTI (last [**2-9**], 3x/year), and
Afib on digoxin, DMII on insulin who p/w groin pain X 2 days.
Pain was bilateral localized to groin, w/o dysuria, hematuria,
fevers, or chills, improved with fluids, advil and aspirin. He
had one episode of nonbloody emesis, but no diarrhea. He denies
melena or hematochezia, but is reported by ED to have
salmony-colored stool. Last episode of groin pain in [**2-9**] was
attributed to UTI and cleared with abx (pt does not recall what
was given). Suprapubic catheter is changed q6wks, and last
changed 3 wks ago (followed by urologist Dr. [**Last Name (STitle) **] in [**Location (un) 583**]).
.
In the [**Name (NI) **], pt's vitals on arrival were stable: HR 56 BP 113/51
RR 16 98% on RA. UA was positive for nitrites and wbc and spgr
1.1015, and he was given 1g Iv Ceftriaxone and 500cc bolus NS
was given, and IVF were started. Urology was consulted and
changed the suprapubic catheter. While in ED, he became
bradycardic to the 30s, coming up spontaneously to the 50s on
arousal (no atropine was administered). At that time,
chemistries revealed a K of 5.6 and Dig 5.7, and 1st degree AV
block on ECG (no priors for comparison). 30 mg po Kayexalate was
given, and 4 vials of digibind were given per toxicology.
Cardiology was consulted re: digoxin toxicity, and recommended
ECHO. He was given 1g IV morphine and zofran and transferred to
[**Hospital Unit Name 153**] for monitoring.
ROS: weight change 8lbs/last several months (unintentional
weight loss 210--140lbs), 1x emesis nonbloody, longstanding
constipation; + long extremity weakness with cramping at ankles,
and increasing gait unsteadiness and burning in legs with
prolonged standing; decreased exercise tolerance over last year
w/o PND, SOB, CP; increasing vision blurriness over last year
but no change in color of vision.
Past Medical History:
A fib, on dig
Chronic Renal Failure
DM II, on insulin
s/p Right sided CEA
h/o Prostate CA, s/p cryotherapy & s/p suprapubic catheter
([**2092**], changed q6wks)
s/p Gallstone pancreatitis ([**2092**])
Intraabdominal hernias ([**2092**])
Social History:
Social History: works (still) in sales from home. lives with
daughter, has help with cleaning. reports that he requires no
help with ADLs (cooking, walking, showering) besides cleaning,
but feels increasingly unsteady on his feet. Drinks reportedly
1-2 beers/night; sometimes 6 pack on weekends - later denies any
EtOH x's 15 years. No smoking hx
Family History:
Family Medical History: mother, colorectal cancer. father died
young.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: T: 96.5, HR: 51, RR: 28, BP: 133/68, O2Sat: 98% ra
GEN: Elder male in bed, in no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: Healed incision on right lateral neck; no JVD, no bruits,
no cervical lymphadenopathy, trachea midline
COR: 3/6 systolic murmur heard widely; soft S2, no bruits
PULM: sparse bibasilar/posterior fine crackles which clear with
DB&C, no wheezes.
ABD: Soft, NT, +BS, no HSM, reducible hernia X2 in left upper
lower quadrant with bowel sounds
EXT: Slight pitting ~ [**1-6**]'s to knee on left & ~[**12-5**] to knee on
right. Bilat LE - Slight hemesidern, DP 1+ bilat, color sl
mottled, sensation & movement intact, slightly cool, cp refill
~4 secs. Positive nail dystrophy bilat w/ dry skin. No
ulcerations.
NEURO: alert, oriented to person, place, and time. Face
symmetrical @ rest & w/ movement, tongue midline. Pupils: 4mm
o.d. & 3mm o.s., round & reactive; EOM - slight nystagmus o.d.
on far lateral. Moves all 4 extremities. SLight tremor on right.
SKIN: No ulcerations.
Pertinent Results:
ADMISSION LABS:
==============
[**2104-7-13**] 09:43PM URINE HOURS-RANDOM UREA N-764 CREAT-75
SODIUM-16
[**2104-7-13**] 09:43PM URINE OSMOLAL-412
[**2104-7-13**] 09:43PM URINE EOS-POSITIVE
[**2104-7-13**] 07:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2104-7-13**] 06:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2104-7-13**] 06:30AM URINE BLOOD-TR NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-LG
[**2104-7-13**] 06:30AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2104-7-13**] URINE C&S - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES)
[**2104-7-13**] 09:42PM GLUCOSE-210* UREA N-78* CREAT-3.1* SODIUM-135
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18
[**2104-7-13**] 09:42PM CK(CPK)-160
[**2104-7-13**] 09:42PM CK-MB-10 MB INDX-6.3* cTropnT-0.08*
[**2104-7-13**] 09:42PM CALCIUM-8.1* PHOSPHATE-6.8* MAGNESIUM-2.3
[**2104-7-13**] 08:45AM GLUCOSE-147* UREA N-79* CREAT-2.8*
SODIUM-132* POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-21* ANION
GAP-22*
[**2104-7-13**] 08:45AM CK(CPK)-208*
[**2104-7-13**] 08:45AM CK-MB-11* MB INDX-5.3 cTropnT-0.08*
[**2104-7-13**] 08:45AM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.3
[**2104-7-13**] 08:45AM VIT B12-1332* FOLATE-18.0
[**2104-7-13**] 08:18AM LACTATE-1.0
[**2104-7-13**] 12:00AM GLUCOSE-150* UREA N-81* CREAT-2.9*
SODIUM-131* POTASSIUM-5.4* CHLORIDE-93* TOTAL CO2-21* ANION
GAP-22*
[**2104-7-13**] 12:00AM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-109 TOT
BILI-1.2
[**2104-7-13**] 12:00AM LIPASE-13
[**2104-7-13**] 12:00AM DIGOXIN-5.7*
[**2104-7-13**] 12:00AM WBC-4.7 RBC-3.93* HGB-13.1* [**Month/Day/Year **]-37.8* MCV-96
MCH-33.4* MCHC-34.7 RDW-12.8
[**2104-7-13**] 12:00AM NEUTS-78.5* LYMPHS-15.0* MONOS-4.6 EOS-1.1
BASOS-0.7
[**2104-7-13**] 12:00AM PLT COUNT-292
[**2104-7-13**]
.
ANEMIA WORKUP:
=============
[**2104-7-16**] Retic 1.1*
[**2104-7-16**] calTIBC 211*/ Ferritin 186/ TRF 162*
[**2104-7-16**] Fe 69
.
IMAGING:
=======
[**2104-7-14**] CARDIAC ECHO (TTE) - The left atrial volume is
markedly increased (>32ml/m2). The left atrium is dilated. The
right atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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 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 mild mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Diastolic dysfunction.
Mild prolapse of the posterior leaflet of the mitral valve (clip
#[**Clip Number (Radiology) **]). Mild mitral regurgitation. Mild pulmonary artery systolic
hypertension.
.
[**2104-7-14**] RENAL ULTRASOUND - FINDINGS: The study is limted due to
bowel gas. The right kidney is hypotrophic measuring
approximately 7.4 cm in diameter and demonstrates mild
hydronephrosis. The left kidney measures 10.4 cm. The renal
parenchymal thickness and echogenicity are normal within the
left kidney without evidence of hydronephrosis. Small left
parapelvic cyst are seen. IMPRESSION: Hypotrophic right kidney
with mild hydronephrosis.
.
[**2104-7-13**] ACUTE ABD SERIES ([**1-6**] VIEWS OF ABD & SGL CHEST VIEW) -
ABDOMINAL SERIES: Heart size is normal. The lungs are clear
without evidence of subdiaphragmatic free air. The bowel gas
pattern is nonobstructive with
nondilated loops of large and small bowel noted. A right total
hip prosthesis is intact and in satisfactory alignment.
IMPRESSION: Nonobstructive bowel gas pattern.
.
DISCHARGE LABS:
==============
[**2104-7-18**] wbc 3.9*/ rbc 2.95*/ Hgb 10.5*/ [**Month/Day/Year **] 30.0*/ MCV 102*/
MCH 35.5*/ MCHC 34.8/ RDW 12.3/ Platelets 177
[**2104-7-18**] glucose 253*/ BUN 47*/ Creatinine 2.2*/ Sodium 139/
Potassium 4.5/ Chloride 108/ HCo3 25/ Anion gap 11
[**2104-7-18**] Calcium 8.5/ Phos 2.9/ Magnesium 2.0
[**2104-7-18**] Digoxin 1.3
[**2104-7-16**] URINE C&S - YEAST. 10,000-100,000 ORGANISMS/ML.
Brief Hospital Course:
# Digoxin toxicity:
On admission, the ECG showed bradycardia with AV block and LBBB.
It is unclear if these were new changes as there was no previous
EKG to compare. Digoxin level was 5.9. He was given digibind
[**2104-7-13**] am and put on telemetry with atropine at the bedside for
symptomatic bradycardia but it was not needed in the ICU. His
K+ was maintained > 4.5 to avoid exacerbating his dig toxicity
and digoxin was held. The digoxin levels steadily decreased.
Given his renal failure he was at risk for delayed recurrent
rebound total/free digoxin peak up to 130 hr after digibind
administration so we continued to monitor digoxin levels through
[**2104-7-18**]. Dig level on day of discharge was 1.3 ([**2104-7-18**]). The
patient has continued with asymmptomatic bradycardia and
occasional PVCs.
# ARF on CRF:
Baseline creatinine is 1.5 ([**1-11**]) and was 3.0 on admission.
Most likely prerenal given hx of weight loss, diuretics use,
FeNa <1%; there may be a component of AIN given FeUN= 39% and
rare Eos in Urine; may be component of post-renal obstruction
given R hydronephrosis seen on renal U/S. His creatinine
improved to 2.2 on doscharge.
# Probable UTI:
Urinalysis on admission concerning for UTI and patient high
risk. Suprapubic cath changed on admission. Urine cultures came
back with mixed flora. Started on ceftriaxone on [**2104-7-13**],
converted to Cefpodoxime PO on [**2104-7-18**].
# Anemia:
[**Date Range **] on admission was 32.3 remained relatively stable. This was
believed to be dilutional. However, he had macrocytosis and ?
history of ETOh use so we put him initially on thiamine and
folate; patient later denied ant alcohol use (adamently & to
multiple providers), in the last 15 years. Needs f/u outpatient
by PCP. [**Name Initial (NameIs) **] 30 on day of fischarge.
# Diastolic CHF with MR:
His troponin and CKMB index were positive but this was thought
to be secondary to acute renal failure. We obtained a TTE which
showed diastolic dysfunction and mild MR. We also held his home
ACEI due to hyperkalemia and we held his home lasix given his
hypovolemia; given the continued renal failure these were NOT
restarted.
# DMII:
Patient was put on sliding scale insulin. He was returned to his
stated [**Hospital1 **] insulin dose. His peripheral neuropathy was treated
with renally dosed gabapentin.
# A fib:
Held patient's digoxin, put him on telemetry and he stayed in
sinus rhythym. He is not on anticoagulation at home. ASA was
added & patient maintained on his home Plavix. THe patient was
NOT placed back on Digoxin.
# Nail Dystrophy:
Probable fungal, needs out-patient podiatry. Follow-up by PCP.
.
# Non-Adherence to prescribed medications:
The patient states that he has adjusted his own doses of
medicines at home.
Medications on Admission:
1. Ramipril 5mg daily
2. Clopidogrel 75mg
3. Digoxin 0.375 mg daily (pt reports taking 125mg/day now)
4. Furosemide 40mg
5. Novalog 70/30 flex pen as directed (6 u qam, 6u qhs)
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for UTI for 4 days: last day should be [**7-22**]
(completes a 10d course IV & PO Abx).
Disp:*8 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day):
hold for loose stools.
Disp:*90 Tablet(s)* Refills:*2*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
=================
Digoxin Toxicity
Acute on Chronic Renal Failure
Urinary Tract Infection in pt with chronic indwelling suprapubic
catheter
Anemia
.
Secondary Diagnosis:
===================
Atrial fibrillation (sinus brady during admission)
Mild symmetric left ventricular hypertrophy, LVEF > 60%
Diastolic dysfunction
Mitral Valve Prolapse with mild (1+) mitral regurgiation
Mild PA systolic hypertension
Chronic Kidney Disease, baseline creatinine reported to be ~1.5
([**1-11**])
Diabetes Type II, controlled on insulin, with complications
s/p R Carotid endarterectomy
h/o Prostate cancer,s/p cryo and suprapubic catheter since [**2092**]
Hypotrophic right kidney with mild hydronephrosis, per Renal
U.S.
s/p gallstone pancreatitis ([**2092**])
intraabdominal hernias ([**2092**])
Constipation
Leg pain, presumed peripheral neuropathy
Discharge Condition:
Stable: Digoxin level 1.3 ([**2104-7-18**]); Physical Therapy screening
indicated that the patient may benefit from Home PT
Discharge Instructions:
Youe were admitted to the hospital after coming to the Emergency
Department on [**2104-7-13**] with bilateral groin pain and vomitting.
It was discovered that your reanl failure had worsened and the
blood level of your Digoxin (a medicine to help regulate your
heart beat) was too high. You were kept in the ICU for
observation and also started on an antibiotic for a urinary
tract infection. It was felt that you did NOT have a heart
attack.
.
Some of your medications have been changed: 1.) DO NOT take any
more Digoxin, Furosemide (Lasix) or Ramipril (Altace) until told
differently by your MD; & 2.) please complete the course of your
antibiotic as has been prescribed. Continue your Clopidogrel
(Plavix) and your Novalog 70/30 flex pen as directed (6 units
every morning and 6 units at bedtime) as you were, before coming
to the hospital. We have also started a baby aspirin once a day
(also to help thin your blood) and medicines (Colace and Senna)
to help you have a bowel movement every day. Another medicine
called Gabapentin (Neurontin) has been started and is helping
with the pain you were having in your legs.
.
Please call your Primary Care Provider [**Name Initial (PRE) **]/or come to the
Emergency Department if you experience any of the following:
chest pain or pressure, very fast or irregular heart beat,
palpitations, fainting, changes in mental status, nausea or
vomitting, trouble breathing, abdominal or groin pain, blood in
your stools or very dark/black stools, blockage of your
suprapubic catheter, fever > 101 and/or shaking chills or any
other health-related concerns.
.
Please make and keep all of your follow-up appointments.
Followup Instructions:
You have an appointment set up to see your Primary Care Provider
([**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 71337**], MD) on Tuesday [**2104-7-22**]. IF YOU CAN NOT
MAKE THIS APPOINTMENT CALL TO RESCHEDULE: [**Telephone/Fax (1) 71338**].
.
Your next suprapubic catheter change is due [**2104-8-24**] (6 weeks
from [**2104-7-13**])
.
It is recommended that you arrange to see a Geritrician as an
out-patient when you return home, for continued consultation in
regards to your care. Two specialists in elder care in the
[**Location (un) 15739**] area are: 1.) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD, [**Telephone/Fax (1) 71339**] (only
available through the [**Hospital **] Healthcare System); or 2.) [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 71340**], MD, [**Telephone/Fax (1) 71341**].
Completed by:[**2104-7-18**]
|
[
"276.52",
"250.00",
"276.2",
"427.89",
"427.31",
"276.7",
"585.9",
"426.10",
"428.0",
"599.0",
"426.3",
"584.9",
"E942.1",
"285.21",
"V58.67",
"276.1",
"428.32",
"V10.46",
"E879.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12543, 12549
|
8724, 11505
|
346, 404
|
13450, 13576
|
4222, 4222
|
15281, 16173
|
3005, 3077
|
11737, 12520
|
12570, 12570
|
11531, 11714
|
13600, 15258
|
8286, 8701
|
3092, 3092
|
276, 308
|
432, 2364
|
12759, 13429
|
4238, 8270
|
12589, 12738
|
2386, 2625
|
2657, 2989
|
3117, 4203
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,333
| 177,817
|
21484
|
Discharge summary
|
report
|
Admission Date: [**2187-4-22**] Discharge Date: [**2187-4-25**]
Date of Birth: [**2117-10-17**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Iron / Latex
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
69 yo F w/PMHx sx for PVD, COPD who presents with shortness of
breath over the course of the last several days. Patient states
that she developed a nonproductive cough last week, and saw her
PCP who diagnosed her with bronchitis and treated her with
ciprofloxacin and guaifenesin with codeine, and then with
albuterol inhalers. She states that the symptoms did not
improve, and she developed SOB at rest, with marked worsening
over the last two days, to the point that she has had to sleep
upright in a chair. She denies any fevers, chills, night sweats.
She states that she develops some chest pain with coughing, but
does not have chest pain at rest. She also notes nausea and
vomiting after fits of coughing. She has never had these
episodes before.
.
Patient was initially seen in the ED where her initial VS were
T97.0 BP 123/60 HR 119 RR 28 O2sat 90% RA. She was felt to have
a pneumonia and CHF, and was given azithromycin, nitro paste,
nebulizers, ceftriaxone, furosemide 40 mg IV, aspirin 325,
zofran, and morphine. Her initial EKG showed sinus tachycardia
with 2 mm STE in V3. She had a CTA which showed bilateral
pleural effusions and GGO c/w pulmonary edema, and she developed
worsening respiratory distress and was placed on BiPap, with
good resolution of her symptoms. Her first set of CE were
positive.
.
Per patient report, she had a recent chemical stress test at her
cardiologist's office 3 weeks ago, which was negative.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. She does note exertional calf
pain, as well as the development of a hematoma at the time of
prior bypass surgery. All of the other review of systems were
negative.
.
*** Cardiac review of systems is notable for chest pain, dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea. She denies
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Hypertension
Hyperlipidemia
Peripheral vascular disease s/p multiple interventions
Retroperitoneal hematoma in setting of PVD fem bypass
Tobacco use
Hx osteomyelitis of left heel
Thyroid resection with resultant hypoparathyroidism
Abdominal aortic aneurysm
Chronic diarrhea
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
She lives alone, and continues to work part time as a cashier.
She has a 40 pack year smoking history, quit sometime this year.
Drinks socially. Denies any illicit drugs. Has a son in the area
who is involved.
Family History:
Has 13 siblings, one with MI < 60 years of age.
Physical Exam:
VS: T97.0, BP 133/69, HR 113, RR 24, O2 100% on BiPap
Gen: well appearing, frail elderly appearing female in mild
respiratory distress on BiPap
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP to tragus.
CV: PMI located in 5th intercostal space, tachycardic. Normal
S1/S2. 2/6 SEM at RUSB. I/IV soft diastolic murmur at RUSB.
Chest: No chest wall deformities, scoliosis or kyphosis.
Increased WOB. Dull at bases. Inspiratory crackles bilaterally
[**12-7**] both lung fields. Expiratory wheezing.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Trace edema at ankles. Cool, hairless.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP
Left: Carotid 1+ without bruit; Femoral 1+ with bruit; 1+ DP
Pertinent Results:
[**2187-4-22**] 02:00PM BLOOD WBC-11.4* RBC-5.07 Hgb-14.6 Hct-43.5
MCV-86 MCH-28.8 MCHC-33.6 RDW-14.0 Plt Ct-374
[**2187-4-23**] 11:07PM BLOOD WBC-15.5* RBC-4.05* Hgb-11.7* Hct-34.0*
MCV-84 MCH-28.8 MCHC-34.3 RDW-14.5 Plt Ct-253
[**2187-4-24**] 07:10AM BLOOD WBC-19.8* RBC-3.97* Hgb-11.8* Hct-33.6*
MCV-85 MCH-29.8 MCHC-35.2* RDW-14.8 Plt Ct-271
[**2187-4-24**] 04:18PM BLOOD WBC-18.0* RBC-3.68* Hgb-10.7* Hct-31.7*
MCV-86 MCH-29.1 MCHC-33.8 RDW-14.9 Plt Ct-235
[**2187-4-24**] 09:30PM BLOOD WBC-20.4* RBC-3.61* Hgb-10.4* Hct-31.4*
MCV-87 MCH-29.0 MCHC-33.2 RDW-14.8 Plt Ct-222
[**2187-4-23**] 12:00AM BLOOD PT-13.5* PTT-66.2* INR(PT)-1.2*
[**2187-4-24**] 09:30PM BLOOD PT-28.3* PTT-78.3* INR(PT)-2.9*
[**2187-4-22**] 02:00PM BLOOD Glucose-120* UreaN-25* Creat-1.1 Na-136
K-5.4* Cl-96 HCO3-22 AnGap-23*
[**2187-4-23**] 11:07PM BLOOD Glucose-111* UreaN-38* Creat-1.6* Na-139
K-4.2 Cl-101 HCO3-21* AnGap-21*
[**2187-4-24**] 07:10AM BLOOD Glucose-153* UreaN-45* Creat-2.0* Na-137
K-4.9 Cl-97 HCO3-26 AnGap-19
[**2187-4-24**] 12:23PM BLOOD Glucose-134* UreaN-51* Creat-2.7* Na-135
K-5.8* Cl-96 HCO3-17* AnGap-28*
[**2187-4-24**] 04:18PM BLOOD Glucose-149* UreaN-55* Creat-3.1* Na-134
K-5.3* Cl-92* HCO3-22 AnGap-25*
[**2187-4-24**] 09:30PM BLOOD Glucose-287* UreaN-56* Creat-3.4* Na-128*
K-5.5* Cl-87* HCO3-18* AnGap-29*
[**2187-4-22**] 02:00PM BLOOD CK(CPK)-498*
[**2187-4-23**] 12:00AM BLOOD CK(CPK)-656*
[**2187-4-23**] 08:38AM BLOOD CK(CPK)-546*
[**2187-4-23**] 11:07PM BLOOD ALT-130* AST-409* CK(CPK)-1299*
AlkPhos-65 TotBili-0.4
[**2187-4-24**] 07:10AM BLOOD CK(CPK)-2391*
[**2187-4-24**] 09:30PM BLOOD ALT-1597* AST-4489* CK(CPK)-2939*
AlkPhos-61 TotBili-0.6
[**2187-4-22**] 02:00PM BLOOD cTropnT-0.91*
[**2187-4-22**] 06:15PM BLOOD cTropnT-1.44*
[**2187-4-23**] 12:00AM BLOOD CK-MB-59* MB Indx-9.0* cTropnT-1.92*
[**2187-4-23**] 08:38AM BLOOD CK-MB-40* MB Indx-7.3* cTropnT-2.74*
[**2187-4-23**] 11:07PM BLOOD CK-MB-73* MB Indx-5.6 cTropnT-7.73*
[**2187-4-24**] 07:10AM BLOOD CK-MB-70* MB Indx-2.9 cTropnT-9.86*
[**2187-4-24**] 09:30PM BLOOD CK-MB-43* MB Indx-1.5 cTropnT-11.87*
[**2187-4-23**] 12:00AM BLOOD Calcium-8.7 Phos-7.2*# Mg-1.6
[**2187-4-24**] 04:18PM BLOOD Calcium-8.5 Phos-9.4* Mg-2.5
[**2187-4-24**] 04:26PM BLOOD Type-ART pO2-126* pCO2-38 pH-7.33*
calTCO2-21 Base XS--5
[**2187-4-24**] 04:54PM BLOOD Type-MIX pH-7.26*
[**2187-4-23**] 03:09PM BLOOD Glucose-342* Lactate-3.2* Na-126* K-4.5
Cl-97*
[**2187-4-23**] 05:54PM BLOOD Lactate-10.9*
[**2187-4-24**] 09:40AM BLOOD Lactate-4.6*
[**2187-4-24**] 04:26PM BLOOD Glucose-131* Lactate-6.7*
.
EKG:
[**2187-4-22**] 16:10: Sinus tachycardia. [**Apartment Address(1) **] mm in V3. [**Apartment Address(1) **] mm V4.
LVH.
.
2D-ECHOCARDIOGRAM performed on [**12-12**] demonstrated: EF 45-50%.
Moderate regional left ventricular dysfunction with moderate
hypokinesis of the basal to mid inferior segments. Moderate to
severe mitral regurgitation. Moderate aortic regurgitation.
Moderate pulmonary artery systolic hypertension.
.
[**2187-4-23**] ECHO:
The left atrium is normal in size. 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. There is moderate regional left ventricular systolic
dysfunction with mid to distal anterior, septal and apical
hypokinesis - LAD territory). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. The aortic valve is not
well seen. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild to moderate ([**12-6**]+) aortic regurgitation is
seen. The aortic regurgitation vena contracta is >0.6cm. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. At least moderate (2+), eccentric mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2186-12-18**],
regional LV systolic dysfunction is new.
.
[**2187-4-23**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated two vessel coronary artery disease. The LMCA was
free from
angiographically-apparent disease. The LAD was severely
calcified
proximally and had 99% stenosis at mid vessel. The LCX was
mildly
diseasd. The RCA was a smaller vessel (2.0 mm) with long 70%
stenosis.
2. Resting hemodynamic assessmet revealed severely elevated
left-sided
filling pressure (mean PCWP 35 mmHg) and moderately elevated
right-sided
filling pressures (RVEDP 13 mmHg). The opening systemic arterial
blood
pressur was normal (104/56 mmHg) and the pulmonary arterial
pressure was
moderately elevated (52/31/41 mmHg). The cardiac output and
cardiac
index were low (2.06 l/min and 1.5 l/min/m2) indicative of
cardiogenic
shock.
3. Left ventriculography was deferred.
4. Unsuccessful attempt at PCI of mid LAD due to inability to
deliver
any devices to lesion.
5. Cardiogenic shock proceeding to PEA from worsening ischemia
necessitating intubation and IABP.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Cardiogenic shock
3. Unsuccessful PCI.
Brief Hospital Course:
Ms. [**Name14 (STitle) 56700**] is a 69 yo F w/hx HTN, hyperlipidemia, PVD, and
tobacco use who presents with SOB [**1-6**] pulmonary edema in the
setting of an NSTEMI.
.
# CAD/Ischemia: Patient with severe PVD, no history of any
cardiac catheterizations. On presentation she had isolated ST
elevation in V3. Cardiac enzymes were positive and she ruled in
for NSTEMI. She was given a Plavix load and started on
Metoprolol, ASA 325mg, Atorvastatin 80mg, Heparin drip and
integrillin. She was taken to the cardiac catheterization lab
on [**2187-4-23**] which showed two vessel disease with a 99% LAD and
70% RCA. PCI was attempted on LAD but unsuccessful. Patient
then suffered from a PEA arrest which resulted in cardiogenic
shock. An Intra-Aortic Balloon pump was placed and the patient
was transferred to the CCU for further care. While in the CCU
she remained on IABP. She was hypotensive and required pressors
for blood pressure support. The patient was DNR/DNI and the
family agreed to not attempt aggressive measures and to not
escalate care. The patient went into Ventricular Tachycardia on
the morning of [**2187-4-25**] and expired from cardiac arrest. The
family was present at the time of death and declined autopsy.
Medications on Admission:
Meprobamate 400 mg QID PRN
Calcium lactate 10 mg - 4 tabs [**Hospital1 **]
Belladona 1 tab qam 2 tabs qpm
Calcitriol 0.25 mcg QD
Levoxyl 100 mg qd
Nifedipine 30 mg qd
Pravastatin 80 mg qd
Cyanocobalamin 1000 mcg qmonth
ASA 81 mg qd
Discharge Disposition:
Expired
Discharge Diagnosis:
ST- elevation MI
Anuric renal failure
Respiratory failure
Suspected aspiration vs. hospital acquired pneumonia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"514",
"997.1",
"507.0",
"427.5",
"518.5",
"584.9",
"410.71",
"414.01",
"785.51",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.61",
"96.6",
"37.23",
"96.04",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
10770, 10779
|
9247, 10488
|
305, 331
|
10934, 10944
|
3937, 9124
|
11000, 11137
|
2977, 3026
|
10800, 10913
|
10514, 10747
|
9141, 9224
|
10968, 10977
|
3041, 3918
|
246, 267
|
359, 2375
|
2397, 2733
|
2749, 2961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,068
| 130,243
|
27929
|
Discharge summary
|
report
|
Admission Date: [**2137-7-14**] Discharge Date: [**2137-7-18**]
Date of Birth: [**2093-6-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
upper endoscopy
Intubation/Mechanical ventilation
History of Present Illness:
Pt is a 44 yo male history of EtOH (stopped 4 years ago) and
varices diagnosed 5 years ago, who presents to [**Hospital3 3583**]
with hematemesis. Per family, pt felt like he had a cold for the
past few days. He was coughing, felt nauseous, and fatigued.
This am when he awoke, he realized his was spitting up blood and
went to the [**Hospital3 3583**] ED. He was hemodynamically stable
upon arrival with Hct 36, plt 95, INR 1.3. Prior to being
admitted, pt had another episode of hematemesis (~1L per report)
associated with syncope and probable aspiration.
.
He was unresponsive and intubated for airway protected (#8 ETT
26 cm). He was transferred to the ICU at 7 pm. An EGD showed
portal hypertension, [**3-9**] very large variceal chains that fill up
most of the lumen. Per report, a culprit lesion could not be
identified. Initial Hct was 36 in the ED and was given 4 units
of pRBC with later Hct of 39. He was given a dose of Zosyn,
started on protonix gtt, octreotide gtt, and given 10 mg vitamin
K.
.
Initial blood gas on ventilation was 7.34/39/62, and vent
changed to
AC 700/12/8/100% (unclear what was before but PEEP was
increased)
He is continuing to suction bright red blood and per report CXR
shows LLL infiltrate.
.
Pt was medflighted to [**Hospital1 18**] for evaluation of varices. Intubated
and sedated on arrival.
Past Medical History:
1. Esophageal varices- hospitalized ? 3 times for variceal
bleeding. Diagnosed at [**Hospital 1562**] Hospital 5 years ago with GIB,
diagnosed with varices. Last ICU stay 3 years ago.
2. History of alcoholism- sober 4 years.
3. Varicose veins
4. Right breast cyst removal-benign
5. Recent intentional weight loss of 85 lbs over past year
Social History:
Former bartender. Now works as resident supervisor at DSS. Quit
smoking 20 years ago. Quit EtOH 4 years ago, "drank vodka
heavily" per family.
Family History:
M: EtOH abuse; MU: EtOH abuse; F: UGIB s/p gastrectomy from
ulcers
Physical Exam:
T: 98.5' BP: 125/65; HR: 60s; AC 500/16/8/60%. O2: 100
Gen: Intubated, sedated
HEENT: Pupils minimally reactive. ETT in place. No conjunctiva
palor. Sclera anicteric.
CV: Bradycardic S1S2. No M/R/G
Lungs: CTA b/l anteriorly
Abd: NABS. soft, ND. +hepatomegaly 2 fingerbreaths below costal
margin
GU: guaiac positive melena
Ext: No edema. DP 2+ . Right femoral triple lumen C/D/I. No
palmar erythema.
Neuro: Intubated, sedated.
Pertinent Results:
Labs at OSH:
Na: 139; K: 4.2; Cl: 112; bicarb: 22; BUN/cr 23/0.7; glucose
127; INR 1.4; Hct: as above. Plt: 118.
[**Age over 90 **]|114|24
-----------<122
4.3|23|0.7
[**2137-7-14**] 11:44PM ALT(SGPT)-22 AST(SGOT)-23 LD(LDH)-171 ALK
PHOS-45 AMYLASE-16 TOT BILI-1.8*
[**2137-7-14**] 11:44PM LIPASE-26
[**2137-7-14**] 11:44PM ALBUMIN-3.3* CALCIUM-7.4* PHOSPHATE-3.4
MAGNESIUM-2.4
[**2137-7-14**] 11:44PM WBC-13.3* RBC-4.40* HGB-14.2 HCT-39.7* MCV-90
MCH-32.2* MCHC-35.7* RDW-15.1
[**2137-7-14**] 11:44PM PLT COUNT-124*
[**2137-7-14**] 11:44PM PT-15.6* PTT-32.1 INR(PT)-1.4*
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Preliminary Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2137-7-16**] 7:52 AM
LIVER OR GALLBLADDER US (SINGL
Reason: Please eval liver for cirrhosis/hepatitis/filling
defects
[**Hospital 93**] MEDICAL CONDITION:
44 year old man with variceal bleed
REASON FOR THIS EXAMINATION:
Please eval liver for cirrhosis/hepatitis/filling defects
INDICATION: 44-year-old man with variceal bleed.
COMPARISON: [**2137-7-15**].
RIGHT UPPER QUADRANT ULTRASOUND: Sludge is seen within the
gallbladder. There is mild gallbladder wall edema. Common bile
duct measures 5 mm. The liver is nodular and heterogeneous in
echotexture consistent with cirrhosis. There are no focal
lesions. The portal vein is patent with appropriate hepatopetal
flow. There is a mild-to-moderate amount of perihepatic free
fluid.
IMPRESSION:
1. Nodular heterogeneous-appearing liver consistent with
cirrhosis.
2. Gallbladder sludge. Mild gallbladder wall edema. This may be
secondary to third spacing from the patient's liver disease.
3. Ascites.
_
_
_
_
_
_
_
_
_
________________________________________________________________
Upper endoscopy - [**2137-7-15**] 4 cords of grade III varices seen in
the middle and lower third of the esophagus which were not
bleeding.
Brief Hospital Course:
44 yo male with h/o EtOH abuse, varices, who presents to OSH
with hematemesis. Found to have large variceal bleeding likely
the source of hematemesis. No active bleeding seen.
.
1. Varices- Likely [**2-7**] EtOH liver disease. Hemodynamically
stable with no active bleed s/p banding x5 of grade [**2-8**] varices.
- Started Nadolol 20mg QD per liver recs.
- Started Spironolactone 100mg QD per liver recs.
- Continue protonix 40 mg IV bid.
- Continue levaquin.
.
2. Liver dx- RUQ ultrasound showed nodular liver consistent with
cirrhosis. This is presumed secondary to prior EtOH abuse. Will
need to rule out other causes.
- hepatitis B/C serologies were negative.
- iron studies pending negative for hemachromatosis
- AFP was checked and normal (1.6).
.
3. Question of Aspiration- On CXR AP here, left hemidiaphragm is
not visualized the whole way. Has been afebrile and WBC is
trending down.
- On levaquin.
- No need for additional abx at this time.
.
4. Respiratory- Successfuly extubated
.
5. EGD to follow in 1 week.
- Advance to soft diet (sodium restrict to <80 mmol/day per
liver recs).
.
6. Access: Right femoral triple lumen placed in OSH. We d/cd it.
Has 3 PIVs (2 large bore). Left A-line placed.
.
7. Contact: Primary contact for family is pt's brother: [**Name (NI) **]
[**Name (NI) 780**] cell:[**Telephone/Fax (1) 68026**]. Backup: Sister: [**Name (NI) 1123**] [**Name (NI) 12303**]
[**Telephone/Fax (1) 68027**]
.
8. Prophylaxis: Hold sq heparin given bleed. Pneumoboots. PPI
[**Hospital1 **]
.
9. Code Status: Full Code
.
10. Dispo: Called out to [**Wardname 13487**].
Medications on Admission:
Medications on transfer:
Protonix 52cc/hr
Octreotide 50 cc/hr
NS 150 cc/ hr
propofol 18 mcg/kg/min
s/p 10 mg vitamin K
.
Medications at home:
Mucinex
CVS cold
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. 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:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding Esophageal Varicies
Discharge Condition:
Hematocrit 32.2. Vital signs stable. Patient able to ambulate.
Tolerating PO and moving bowels and bladder appropriately.
Discharge Instructions:
Please take the discharge medications as recommended below.
Please follow up for endoscopy at [**Hospital1 18**] in two weeks and with a
liver doctor (Hepatologist) in four weeks.
Please note that you have recently bled. If you feel
lightheaded, chest pain, short of breath, throw up blood or if
you see blood in your stool, please come back to the hospital.
Followup Instructions:
Please return in two weeks to see Dr. [**Last Name (STitle) 497**] for EGD. You were
given the contact information from the Gastroenterology fellow.
Completed by:[**2137-7-18**]
|
[
"276.2",
"456.20",
"571.2",
"507.0",
"276.3",
"572.3",
"303.93",
"789.5",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7145, 7151
|
4762, 6352
|
326, 377
|
7224, 7351
|
2810, 3679
|
7760, 7942
|
2280, 2348
|
6562, 7122
|
3716, 3752
|
7172, 7203
|
6378, 6378
|
7375, 7737
|
6520, 6539
|
2363, 2791
|
275, 288
|
3781, 4739
|
405, 1742
|
6403, 6499
|
1764, 2104
|
2120, 2264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,660
| 158,179
|
38332
|
Discharge summary
|
report
|
Admission Date: [**2108-5-15**] Discharge Date: [**2108-5-18**]
Date of Birth: [**2034-7-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Tetracycline / Keflex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall with ICH
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
73yo woman with history significant for Charcot [**Doctor Last Name **] Tooth
Disease was in usual state of health until she sustained a
mechanical fall from her wheelchair this AM ([**5-15**]). Pt struck
her head and right shoulder. Denies LOC. She was brought to
[**Hospital **] Hospital where CT revealed a moderate right sided SDH.
Pt also noted to have a right clavicular fracture. She was
loaded with 1gm of Dilantin and transferred to [**Hospital1 **] where a Neurosurgery consult was requested for
evaluation.
Past Medical History:
Charcot [**Doctor Last Name **] Tooth Disease
HTN
Anxiety
peripheral neuropathy
osteoporosis
GERD
paralyzed phrenic nerve
recent corneal surgery bilaterally
Social History:
lives in [**Hospital3 **] facility, wheelchair bound. Daughter
[**Name (NI) **] is 1st contact [**Telephone/Fax (1) 85406**].
Denies tobacco/etoh or recreational drug use.
Family History:
non-contributory
Physical Exam:
Exam on Admission:
O: T: 98.0 BP: 76/36 HR: 70 R 21 O2Sats 91% NC
Gen: WD/WN, comfortable, NAD.
HEENT: Right frontal laceration with subgaleal collection.
Pupils: left-3.5-2mm right 3-2mm EOMs intact
Neck: hard collar on
Extrem: Warm and well-perfused UE, LE's cool b/l
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, date and president.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Strength: [**Hospital1 **] Tri G IP AT [**Last Name (un) 938**]
right 4 4 3 2+ 0 0
left 4 4 4 2+ 0 0
No pronator drift
Sensation: Intact to light touch, propioception
Reflexes: Pa Ach
Right 0 0
Left 0 0
Toes downgoing bilaterally
EXAM ON DISCHARGE:
As above. Hematoma to R shoulder, R FH
Pertinent Results:
LABS ON ADMISSION:
[**2108-5-15**] 12:40PM BLOOD WBC-14.7* RBC-3.72* Hgb-10.6* Hct-33.5*
MCV-90 MCH-28.4 MCHC-31.5 RDW-14.5 Plt Ct-292
[**2108-5-15**] 12:40PM BLOOD Neuts-91.6* Lymphs-5.6* Monos-2.3 Eos-0.2
Baso-0.4
[**2108-5-15**] 01:30PM BLOOD PT-11.3 PTT-19.5* INR(PT)-0.9
[**2108-5-15**] 12:56PM BLOOD Glucose-96 UreaN-10 Creat-0.3* Na-136
K-3.8 Cl-103 HCO3-23 AnGap-14
LABS ON DISCHARGE:
[**2108-5-18**] 04:45AM BLOOD WBC-6.9 RBC-3.74* Hgb-10.4* Hct-32.2*
MCV-86 MCH-27.8 MCHC-32.3 RDW-14.8 Plt Ct-280
[**2108-5-15**] 01:30PM BLOOD Neuts-91.9* Lymphs-5.5* Monos-2.4 Eos-0.1
Baso-0.1
[**2108-5-18**] 04:45AM BLOOD Glucose-56* UreaN-3* Creat-0.2* Na-134
K-3.2* Cl-96 HCO3-24 AnGap-17
[**2108-5-18**] 04:45AM BLOOD Phenyto-14.6
--------------------
IMAGING:
--------------------
CT HEAD [**5-15**]:
R SDH measuring ~17 mm at its greatest width; no "swirl sign" to
suggest
acute-on-subacute/chronic bleeding; exerts mass effect on R
ventricle with
midline shift of 4 mm R -> L; similar size and amount of midline
shift to OSH CT. No evidence of fracture. R scalp hematoma.
CT C-SPINE [**5-15**]:
no evidence of fracture; grade I anterolisthesis of C5 on C6;
prevertebral
soft tissues are of normal thickness. multilevel degenerative
changes and
facet joint hypertrophy.
CT Head [**5-16**]:
Right-sided subdural hematoma, decreased in size compared to [**5-15**], [**2107**],
with mass effect on adjacent sulci and right ventricle as well
as a 2 mm
leftward midline shift. Stable right scalp hematoma with no
evidence of calvarial fracture. No new foci of hemorrhage.
Brief Hospital Course:
The patient was admitted to the ICU for Q 1 neuro Checks,
dilantin load, and SBP controll < 160. She did well overnight
with no change in her neurological exam, and on the morning of
HD #1 her cervical spine was cleared and the c-collar was
removed. She was seen by orthopedics for her R clavicle
fracture who recommended no hospital interventions, and PRN
outpatient follow up only.
She had a repeat head ct which did not demonstrate any change in
the size of her SDH or MLS. She was transferred to the floor on
[**5-17**].
She was seen by physical therapy who determined that she met
criteria for an acute rehab facility, since she needed complete
assistance transferring to her wheelchair. She was discharged
on [**5-18**]
Medications on Admission:
trazadone
vit d
ativan
vicodin
senna
tylenol
wellbutrin
calcium
citalopram
detrol
asa 81mg
omeprazole
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
10. Neomycin-Polymyxin-Dexameth 3.5-10,000-0.1 mg-unit/g-%
Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for Pain.
14. Magnesium Citrate Solution Sig: One [**Age over 90 1230**]y (150)
ML PO ONCE (Once) for 1 doses.
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] [**Location (un) **] [**Doctor First Name **]
Discharge Diagnosis:
Right SDH
R clavicle fracture
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this after your follow up appointment
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
You have a Right clavicle fracture. You do not need to be seen
in follow up with the orthopedic surgery clinic, but if you
continue to have problems or pain please call their clinic at
([**Telephone/Fax (1) 1228**] to schedule an appointment
Completed by:[**2108-5-18**]
|
[
"356.9",
"300.00",
"356.1",
"530.81",
"401.9",
"852.21",
"354.8",
"733.00",
"E884.3",
"810.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6760, 6853
|
4329, 5061
|
304, 311
|
6927, 6951
|
2732, 2737
|
8505, 9111
|
1246, 1264
|
5214, 6737
|
6874, 6906
|
5087, 5191
|
6975, 8482
|
1279, 1284
|
247, 266
|
3126, 4306
|
339, 859
|
1832, 2654
|
2673, 2713
|
2751, 3107
|
1585, 1816
|
881, 1040
|
1056, 1230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,530
| 148,476
|
757
|
Discharge summary
|
report
|
Admission Date: [**2166-12-9**] Discharge Date: [**2166-12-12**]
Date of Birth: [**2094-11-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
Hemodialysis.
Intubation.
History of Present Illness:
72 year old man with stage 4 CKD on HD, CAD, HTN, asthma who
presented with multiple falls and was found by EMS to be in a
wide complex brady to 20 bpm with BP of 50 systolic. Per wife
and friend, pt was in USOH until day prior to admission, when he
started to feel shaky & tremulous hands. Gait somewhat unsteady
w/ generalized weakness. Has not had any fevers/chills/sweats,
no diarrhea, no CP/palpitations/SOB.
On morning of admission, pt went shopping w/friend, upon leaving
store pt was very nauseated, +emesis, friend took pt home. At
home, pt became unresponsive, & wife [**Name (NI) 5504**] EMS.
ED Course: Pt found to be bradycardic HR 20s, SBP 50s-received
atropine x1 which precipitated to wide complex tachycardia HR
100s, SBP 200s. Immediately thereafter SBP back down to 50s,
started Levophed. Initial K 8.9, Transcutaneous pacing at 60Amp
attempted was unsuccessful. Continued w/Calcium Chloride,
Atropine x2, Epi x2, Bicarb x1amp, Insulin, D50, kayexalate x1.
Renal to intiate HD when arrives to MICU. EP consulted which
concluded significant Hyperkalemia resulted in bradycardia,
followed by wide complex tachycardia and hypotension.
Past Medical History:
-CAD
-Asthma
-CKD on HD (Polycystic kidney disease), HD-T,Th,Sat at [**Hospital6 5505**]
-HTN
-Prostate CA
Social History:
Pt lives w/wife, retired. [**Name2 (NI) 595**] speaking only.
Family History:
Noncontributory
Physical Exam:
VS 95.7 BP 149/73 HR 107
GEN: Intubated, sedated
HEENT: ETT in place, PERRL
RESP: CTA BL
CV: reg, Nml S1,S2, no M/R/G
ABD:Soft ND/NT, +BS
EXT: No C/C/E, warm, 1+DP pulses b/l
NEURO: Hyporeflexia, sedated, responds to painful stimuli
Pertinent Results:
[**2166-12-9**] 12:30PM GLUCOSE-180* UREA N-90* CREAT-9.8*#
SODIUM-144 POTASSIUM-7.3* CHLORIDE-104 TOTAL CO2-21* ANION
GAP-26*
[**2166-12-9**] 12:30PM CALCIUM-11.9* PHOSPHATE-5.6* MAGNESIUM-1.7
[**2166-12-9**] 12:30PM WBC-16.7*# RBC-3.56* HGB-11.9* HCT-35.9*
MCV-101*# MCH-33.4*# MCHC-33.1 RDW-16.0*
[**2166-12-9**] 12:23PM GLUCOSE-160* NA+-143 K+-8.4* CL--107 TCO2-19*
Brief Hospital Course:
AP: 72 yo w/ ESRD on HD, CAD, HTN, asthma p/w significant
hyperkalemia & associated arrythmias.
.
# Hyperkalemia: Pt arrived in the ED with potassium of 8.4
(arterial). Pt admitted to the MICU, underwent HD with
resolution of hyperkalemia. The cause of the hyperkalemia was
most likely due to inadequate/incomplete HD two days PTA. Pt
reportedly received abbreviated HD session two days PTA--his
regularly scheduled HD day. He reported no increased ingestion
of K, nor any changes in his medications. No clear evidence of
hyperaldo. The pt's K level remained stable after admission.
.
# Dysrythmias: Pt has baseline conduction disease (RBB +/-
fascicular blocks). On admission, he reportedly had bradycardic
(junctional rhythm) to 20's. Became hypotensive to SBP of
50/pulse. He received atropine & epi. Found to be hyperkalemic
(8.4), which was likely the cause of his dysrythmias. In ED,
transcutaneous pacing attempted, but unsuccessful. Went into
wide-complex tachycardia w/ possible sine wave on EKG. Pt
intubated & put on pressors. Received emergent HD. Pt extubated
& weaned off pressors after 1 day. No further dysrythmias
(aside from pt's baseline) after his hyperkalemia was treated.
.
# CAD: not active at present. Continued ASA and statin.
.
# ESRD: History of polycystic kidney disease. On HD on T,TH,Sat
@ [**Hospital3 5506**]. Renal consulted. Pt to resume
outpatient dialysis.
.
# Hypoxia: Patient was hypoxic on admission. Patient was
intubated while in the MICU. Cause of hypoxia unclear: possibly
asthma exacerbation, question of COPD exacerbation (however, the
pt does not have documented COPD, though he does have long
smoking history). No evidence of PNA. Prior to discharge, pt
was tolerating room air, and was discharged on inhalers.
.
# HTN: not an active issue during hospitalization
.
# Anemia: Chronic anemia. Baseline thought to be in low 30's.
Mildly macrocytic. Hct in low 30's during stay. Likely
component of both anemia of chronic kidney disease & anemia of
chronic disease. Iron slightly low, ferritin elevated, TIBC
low. Vitamin B12 & folate normal.
.
# Thrombocytopenia: pt's plts nearly [**1-13**] of that on admission.
HIT antibody negative. Possible component of splenic
sequestration w/ enlarged liver.
.
# Elevated CK: may have been due to falls prior to admission.
.
# Elevated Aminotransferases: trending down. Likely due to
polycystic liver disease.
.
# FEN: Cardiac diet
.
#. PPX: Pneumoboots
.
#. CODE: FULL
Medications on Admission:
-Lotpel
-ASA 81mg
-Phoslo
-Nephrocaps
-Doxazosin
-Calcium +Vitamin D 500/20
-Urosit 10mg
-Nexium 40mg
-Simvastatin 10mg
-Ambien 10mg
-Lasix 80mg
-Singulair 10mg
-Catapres
-Lyrica 75mg
-Bisacodyl
-Megestrol 40mg
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-13**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. PhosLo 667 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
8. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Lyrica 75 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with a change in your heart
functioning related to your electrolytes. The elevated potassium
was treated with several medications and your heart rhythm
abnormality resolved. We stopped one medication that you were
taking- Catapres. Please do not continue taking this medication.
It is essential that you take all of your medications as
prescribed.
Call Dr. [**First Name (STitle) **] or 911 if you experience any chest pains,
palpitations, dizziness, lightheadedness, shortness of breath,
fevers, nausea or vomiting, severe muscle pain or any other
concerning symptoms.
Followup Instructions:
Continue with your regularly scheduled dialysis treatments and
follow up with your kidney doctors. You will need HD tomorrow.
.
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2167-1-29**] 1:00
.
Please call your PCP for [**Name Initial (PRE) **] follow up appt next week.
[**Telephone/Fax (1) 5105**].
.
Please call your cardiologist Dr [**Last Name (STitle) 5507**], ([**Telephone/Fax (1) 5508**] for a
f/u in [**1-13**] weeks. You will need an echocardiogram.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"410.71",
"276.7",
"585.6",
"426.51",
"753.12",
"287.4",
"785.50",
"427.89",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6072, 6078
|
2463, 4947
|
338, 366
|
6135, 6145
|
2061, 2440
|
6799, 7485
|
1774, 1792
|
5209, 6049
|
6099, 6114
|
4973, 5186
|
6169, 6776
|
1807, 2042
|
277, 300
|
394, 1548
|
1570, 1679
|
1695, 1758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,792
| 150,158
|
29242
|
Discharge summary
|
report
|
Admission Date: [**2175-11-12**] Discharge Date: [**2175-12-1**]
Date of Birth: [**2107-3-28**] Sex: M
Service: SURGERY
Allergies:
Codeine / Iodine
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**11-12**] Laparotomy, lysis of adhesions, sigmoid colectomy and
transverse loop colostomy.
[**11-21**] Endotracheal intubation, cardio-pulmonary resuscitation
History of Present Illness:
The patient is a 68 y/o male who presented to an outside
hospital on [**2175-11-12**] for lower abdominal pain. The abdominal
pain started the day prior to presentation and has worsened in
severity. He denies fever, chills, nausea/vomiting, or a change
in bowel habits. He was evaluated at the outside hospital where
a CT scan showed sigmoid diverticulitis, adjacent stranding, and
a small amount of free air. He is referred to [**Hospital1 18**] for
management of his comorbidities.
Past Medical History:
1. CAD - MI, PTCA in [**2170**], deccreased EF
2. CVA - left monocular blindness
3. COPD on home O2
4. Chronic renal insufficiency
5. Renal cell carcinoma s/p nephrectomy
6. sleep apnea
7. diverticulitis
8. iliac stent
Social History:
Patient smokes a pack per day of cigarettes.
Family History:
Non-contributory
Physical Exam:
T 98.0 P 88 BP 132/85 R 26 SaO2 95% 5L nc
Gen - mild discomfort, non-toxic appearing
Lungs - decreased in bases bilaterally
Heart - Regular rate and rhythm, no murmurs rubs or gallops
ABD - very distended, tender to palpation in lower quadrants, no
rebound or guarding
Ext - no lower extremity edema
Pertinent Results:
[**2175-11-12**] 08:42PM BLOOD WBC-23.4* RBC-4.13* Hgb-12.4* Hct-37.3*
MCV-90 MCH-30.2 MCHC-33.4 RDW-15.3 Plt Ct-337
[**2175-11-12**] 08:42PM BLOOD Neuts-90* Bands-4 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2175-11-12**] 08:42PM BLOOD Glucose-224* UreaN-72* Creat-2.4* Na-140
K-4.2 Cl-99 HCO3-28 AnGap-17
[**2175-11-12**] 08:42PM BLOOD ALT-15 AST-11 CK(CPK)-26* AlkPhos-58
Amylase-53 TotBili-0.5
[**2175-11-12**] 08:42PM BLOOD Lipase-30
[**2175-11-12**] 08:42PM BLOOD Albumin-3.2* Calcium-8.3* Phos-5.6*
Mg-2.1
[**2175-11-13**] 8:57 pm SWAB Site: ABDOMEN
**FINAL REPORT [**2175-11-18**]**
GRAM STAIN (Final [**2175-11-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2175-11-17**]):
THIS IS A CORRECTED REPORT [**2175-11-16**].
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. SPARSE GROWTH. 2ND MORPHOLOGY.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
PREVIOUSLY REPORTED AS MOLD ([**2175-11-15**]).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] R.N CC6 [**2175-11-16**] 1PM.
BACILLUS SPECIES; NOT ANTHRACIS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S <=1 S
IMIPENEM-------------- =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 2 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2175-11-18**]): NO ANAEROBES ISOLATED.
[**2175-11-20**] 3:21 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2175-11-21**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2175-11-21**]):
REPORTED BY PHONE TO M. MAL [**2175-11-21**] @8:07 AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
Operative report [**11-12**]:
Perforated sigmoid diverticulitis
with intraabdominal contamination.
PROCEDURE PERFORMED: Laparotomy, lysis of adhesions, sigmoid
colectomy and transverse loop colostomy.
CT scan [**11-21**]:
IMPRESSION:
1. No evidence of pulmonary embolism. Please note that
evaluation of small branches in lower lobes are somewhat limited
due to quantum mottle and atelectasis.
2. Severe centrilobular emphysema with peribronchial opacities,
pulmonary edema, and bilateral small effusion and atelectasis.
Enlarged main pulmonary artery.
3. Probable tracheobronchomalacia.
4. Mediastinal lymphadenopathy, which can be reactive.
5. Multiple small hypodense lesions in the liver, too small to
characterize.
6. Gallstones.
7. 1-cm right renal lesion, of indeterminate appearance on this
one-phase CT. Further characterization by dedicated MRI or CT
scan is recommended on non- urgent basis.
8. Changed appearance of the bowel in this patient with recent
sigmoidectomy.
Head CT scan [**11-21**]:
CONCLUSION:
No evidence of hemorrhage. No mass effect. Opacified ethmoid
sinus.
Chest X-Ray [**2175-11-27**]:
FINDINGS: Since the prior study, the patient has been extubated
and there is a right CVL with the tip in the SVC and no PTX.
There is no focal consolidation; the left CP angle is cutoff
from view. There is continued demonstration of right pleural
thickening, unchanged from the previous study. Pulmonary
vascular markings are within normal limits. Previously seen area
of increased density in left upper lung zone is not seen on the
current film.
IMPRESSION: No radiographic explanation for the patient's
dyspnea
EKG [**2175-11-27**]:
Baseline artifact
Sinus rhythm
Probable left atrial abnormality
Right bundle branch block
Consider prior inferolateral myocardial infarct
Since previous tracing of [**2175-11-22**], no significant change
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 172 136 464/468.71 -1 47 11
Right upper extremity ultrasound [**2175-11-27**]:
MPRESSION: Negative right upper extremity DVT study.
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2175-11-29**] 06:14AM 8.9 3.15* 9.6* 27.6* 88 30.6 34.9 15.4
282
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 36549**]
[**2175-11-29**] 06:14AM 282
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2175-11-30**] 04:45AM 138* 20 1.5* 137 4.1 100 32 9
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2175-11-30**] 04:45AM 8.0* 2.5* 1.9
Brief Hospital Course:
The patient was deemed a poor surgical candidate given his co
morbidities and the initial plan was to admit him to the SICU
for monitoring and to treat his diverticulitis with IV
antibiotics of ampicillin, ciprofloxacin, and Flagyl, and bowel
rest. [**Last Name (un) **]-rectal surgery was consulted to provide
recommendations on management and concurred with the decision to
manage the patient non-operatively. Serial exams were performed
on the patient and he continued not to display any peritoneal
signs. On hospital day #2, conservative management was
continued. However, the patient's abdomen became firmly
distended and became larger throughout the course of the day. A
CT scan was obtained which showed enlarging air and fluid
collection in the central abdomen abutting a region of sigmoid
colon with multiple diverticula. This finding was significantly
larger compared to the CT scan at the outside hospital. In the
context of significantly increasing pneumoperitoneum, the
patient likely had a perforated sigmoid diverticulitis with
associated phlegmon or abscess. Given the new findings, it was
decided to take the patient to the OR for a laparotomy, lysis of
adhesions, sigmoid colectomy and transverse loop colostomy. The
fascia was closed with interrupted sutures and the umbilicus was
loosely
approximated with staples and the abdominal wound was packed.
After the surgery, the patient was transferred back to the SICU
intubated and in stable condition. The patient was able to be
weaned off the vent and was extubated on post-op day 1. Given
the patient's history of COPD, aggressive pulmonary toilet was
initiated to help improved the patient's respiratory status.
The patient received IV hydrocortisone for his COPD and this was
eventually tapered and switched to Prednisone when the patient
was tolerating POs. The patient was doing well post-operatively
and was able to be transferred to the floor on post-op day 3.
However overnight, the patient became agitated and went into
rapid atrial fibrillation and was transferred back into the SICU
where he was started on an amiodarone drip for a his rapid afib.
The patient was able to revert back to sinus rhythm on his own
and amiodarone was switched over to the PO form. The patient's
IV antibiotics were switched to Vancomycin and Zosyn given the
sensitivities on his wound culture. Flagyl was also started for
clostridium difficile colitis. The patient continued to do well
and was transferred back to the floor on post-op day 6. The
patient was tolerating a regular diet and was able to ambulate
in the hallways with Physical Therapy.
On [**2175-11-22**], the patient was set to go to rehab. However,
patient stated that in the morning he felt funny for [**9-14**]
seconds with an "electric" feeling throughout his body and felt
a little lightheaded. He pushed the call button for help and
pitched forward and the nursing aide helped lower him to the
floor and a code was called. Code team promptly arrived and the
patient was ventilated well via a bag-valve mask. The patient
was found to be in PEA and ACLS protocol was initiated. CPR was
started and the patient was given atropine and epinephrine as
well as bicarbonate and calcium. The patient was intubated
without difficulty with good chest rise and bilateral breath
sounds. The patient eventually regained a pulse and maintained
a SBP in the 120s. The patient was transferred to the ICU. The
patient had a CT angiogram which showed no pulmonary embolus. A
head CT scan showed no evidence of hemorrhage or mass effect.
In the ICU, he was noted to have one episode of non-sustained
junctional rhythm, though review of the telemetry strip prior to
code was negative for any arrhythmias. Cardiac enzymes were
cycled which were negative. He was transfused 2 units of packed
RBCs for a Hct of 22.4. The patient was able to be weaned from
the vent and extubated the following day. Cardiology was
consulted and they suggested that a vaso-vagal response could
have been the cause of the patient's code. Prior to the patient
coding, the cap on his central line had fallen off and the
current working diagnosis is that this gave the patient an air
embolus. The patient remained stable and was transferred to the
floor on [**2175-11-24**].
On the floor the patient remained on telemetry for monitoring
and remained normotensive and good rate control with oral
Metoprolol and Amiodarone. The patient was edematous from the
IV fluids he received during his resuscitation and received IV
Lasix. Due to the patient's edema, the fascia from the
abdominal wound pulled apart with bowel exposed. Xeroform was
placed over the exposed bowel and a VAC dressing was placed on
the patient's abdominal wound with continuous suction. He
remained afebrile with no leukocytosis and was to complete his
course of Flagyl on [**12-3**], and low dose Prednisone on [**12-25**]. The
patient was discharged to rehab on [**12-1**], in stable condition
tolerating a regular diet, his colostomy was functioning well,
and with his pain well controlled on oral Dilaudid. He was to
receive continued physical therapy as recommended to increase
his gait and functional mobility.
Medications on Admission:
Plavix
Norvasc
ASA
Tricor
Toprol
Lipitor
Amitriptyline
Prednisone
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: Last dose pm [**12-3**].
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 24 doses: Last dose [**2175-12-25**].
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for HR < 69
Hold for SBP < 120.
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain: Be sure to give 1 hour prior to
VAC dressing changes.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed): To groin area.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
16. Insulin Sliding Scale Sig: Regular Insulin Sliding Scale
QACHS: Insulin SC Sliding Scale Q6H
Regular Insulin
0-60 mg/dL [**11-28**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 3 Units
141-160 mg/dL 5 Units
161-180 mg/dL 7 Units
181-200 mg/dL 9 Units
201-220 mg/dL 11 Units
221-240 mg/dL 13 Units
241-260 mg/dL 15 Units
261-280 mg/dL 17 Units
281-300 mg/dL 19 Units
301-320 mg/dL 21 Units
321-340 mg/dL 23 Units
341-360 mg/dL 25 Units
> 360 mg/dL Notify M.D.
.
17. Glargine Insulin Sig: Ten (10) units at bedtime: Give in
addition to Regular Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Perforated diverticulitis requiring [**Doctor Last Name 3379**] pouch and
transverse colostomy
Abdominal wound with incisional hernia
Atrial fibrillation
Air embolus
Clostridium Difficile
CAD
HTN
Chronic renal failure
CHF
COPD requiring Steroids
Steroid induced DM
Discharge Condition:
Stable
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain not relieved by pain medication
*Fever > 101.5
*Nausea, vomiting, or increased abdominal distention
*Increased or decreased ostomy outputs over 24 hours
*Change in color or appearance of stoma
*Shortness of breath or chest pain
*Changes in appearance of abdominal wound or drainage from VAC
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1120**] in [**11-28**] weeks, call [**Telephone/Fax (1) 160**] for an
appointment
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] upon discharge from the
hospital, call [**Telephone/Fax (1) 56850**] for an appointment
Completed by:[**2175-12-1**]
|
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icd9cm
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238, 254
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1231, 1277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,337
| 106,794
|
47139
|
Discharge summary
|
report
|
Admission Date: [**2166-10-16**] Discharge Date: [**2166-10-31**]
Date of Birth: [**2088-2-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath, weight gain, decreased O2 sats
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78yo F with h/o severe AS (area 1.0-1.2cm2), CAD s/p PCI,
diastolic dysfunction with EF on last TTE >55% admitted with
dyspnea. Patient was recently admitted in [**9-8**] for similar
symptoms and was found to be volume overloaded on exam. She
received lasix and her Imdur was stopped as well and she
improved clinically. At that time she also had some atrial
tachycardia that was treated with a beta blocker and increased
dose of diltiazem. She was discharged to a [**Hospital1 1501**] where she was
progressing with physical therapy. She then developed abdominal
pain and diarrhea and was re-admitted. She had negative CDiff
toxins X 3 and was sent home on an empiric course of
cipro/flagyl and plan for o/p colonoscopy after CT showed
colitis. While admitted she had an episode of hypotension as
well as AV-Junctional rhythm on telemetry. Because of this her
beta blocker was discontinued and her diltiazem dose was
decreased. She was then seen by her cardiologist on [**10-10**] and
was restarted on her metoprolol at 25mg [**Hospital1 **]. She was continued
on her diltiazem at 60mg TID. She was recently discharged from
the [**Hospital1 1501**] and was at home, not on oxygen, with VNA services.
.
On the DOA the VNA came to visit and noted the patient had
gained 4.5 pounds in one day. She was satting 82-84% on RA and
so she was brought to the ED. In the ED her vitals were: T:97.4
HR 74 BP 144/65 RR 20 O2sat 92% on RA and came up to 98% on 2L.
She was given 40mg of IV lasix and diuresed 1Liter. Prior to
transferring to the floor her vitals were: BP 138/61 AR 72 O2
sat 96% on 1.5 L.
Per her son she has been living in the apartment upstairs from
him and has had VNA a few times per week since being discharged
from the rehab facility recently. Her medications are spread
throughout the apartment and of the ones he could find I have
listed them below. He is not sure that she takes them all every
day or as directed.
.
On presentation to the floor the patient notes that she normally
has shortness of breath while walking and can never sleep flat.
However, over the last week she has had increased shortness of
breath when walking and has had to sit in her arm chair to
sleep. She has also woken up at night very short of breath. She
denies chest pain and says that her legs are actually smaller
than they were a few months ago.
Past Medical History:
-CHF: diastolic dysfunction, EF 55%
-CAD, s/p placement of 2 [**Hospital1 **]: In [**2-7**] found to have 90% lesion
of RCA. She was evaluated by cardiothoracic surgery, and she
was felt to not be a candidate for CABG given her co-morbidities
and morbid obesity. On [**2166-9-3**] she was admitted for SOB and
subsequently had placement of 2 drug eluting stents, one for an
ostial lesion for the
right coronary and one for a distal left circumflex lesion.
-Aortic stenosis (moderate-severe): valve area 0.8cm2 on echo,
1.1cm2 on cath
-Diabetes: controlled on oral meds, last HbA1c=6.1% in [**2-7**].
-s/p ventral hernia repair
-History of cholecystitis
-Hypertension
-Obesity
-Hypercholesterolemia: Controlled on atorvastatin, lipids last
checked [**1-/2166**]: Total cholesterol 161, HDL 45, LDL 93.
-Low back pain s/p motor vehicle accident in [**2159**] with
diffuse degenerative joint disease, pain tolerable without pain
meds
-Hypothyroidism
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Was living independently in apartment below son's apartment. Was
at [**Hospital 100**] Rehab since stent placement and is currently living at
home with VNA a few times per week. Walks with a walker, no
problems bathing/dressing. Denies smoking/ETOH use. Worked at
[**Hospital1 **] for 26 years as supervisor coordinator. Son works at [**Hospital1 **] as
materials supervisor, daughter-in-law works as phlebotomist.
Family History:
Father passed away at age 67 from heart attack, mother passed at
82 from heart attack. Has one brother age 65, lives in [**Location **]
[**Country **]. Has two sisters, 83 and 80. No history of cancer in
family.
Physical Exam:
VS - T: 97.9 HR:74 BP: 106/54 RR: 18 O2sat: 98% on 2L Wt
113.4kg (249.5 lbs)
Gen: Obese elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP to earlobe.
CV: Irregular rhythm at normal rate. Blurred S1, S2. [**3-6**] SM RUSB
Chest: Speaking in short sentences, no accessory muscle use.
Decreased lung fields bilaterally. Wet crackles bilaterally [**3-4**]
of the way up. No wheezing appreciated.
Abd: Obese with central scar well-healed. Soft, NTND.
Ext: 2+ pitting edema bilaterally to knees. Erythema bilaterally
from ankles to knees without streaking, discharge, blisters,
lascerations, excoriations. No ulcers on feet.
Pulses: Right: DP 1+ Left: DP 1+
Pertinent Results:
[**2166-10-16**] 04:50PM CK(CPK)-45
[**2166-10-16**] 04:50PM cTropnT-<0.01
[**2166-10-16**] 04:50PM WBC-8.3 RBC-3.80* HGB-10.2* HCT-31.8* MCV-84#
MCH-26.9* MCHC-32.1 RDW-15.1
[**2166-10-16**] 04:50PM NEUTS-80.0* LYMPHS-14.5* MONOS-4.3 EOS-1.1
BASOS-0.1
[**2166-10-16**] 04:50PM PLT COUNT-319
[**2166-10-16**] 04:50PM PT-14.0* PTT-26.8 INR(PT)-1.2*
[**2166-10-16**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**2166-10-16**] CXR (AP): There is stable cardiomegaly. There is
blunting of the costophrenic angles, likely representing small
pleural effusions. There is added density at the right lung base
suggestive of pneumonic consolidation
.
[**2166-10-16**] EKG: Rate 77, Sinus rhythm with atrial premature
depolarizations. Non-diagnostic repolarization abnormalities.
.
[**2166-9-3**] CARDIAC CATH:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel CAD. The LMCA had no angiographically flow limiting
lesions. The LAD had mild diffuse disease. The LCX had an 80%
distal stenosis after the takeoff of the OM2. The RCA was a
dominant vessel with an 80% ostial
stenosis with marked pressure dampening with engagement. 2.
Limited resting hemodynamics revealed severely elevated left and
right sided filling pressures with a mean RA pressure of 23, an
LVEDP and a PCWP of 36. The cardiac index was preserved at 4.3
L/min/cm2. 3. Moderate aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 cm2
and a peak to peak gradient of 60 mmHg. Left ventriculography
was deferred. 4. Successful PTCA and stenting of the ostial RCA
with a 3.0 x 15 mm XIENCE [**Location (un) **]. Final angiography revealed no
residual stenosis in the stent, no dissection and TIMI III flow
5. [**Name (NI) 9927**] PTCA and stenting of the distal LCX with a 2.5 x 18
mm [**Name (NI) **]. Final angiography revealed no residual stenosis in the
stent, no dissection and TIMI III flow (See PTCA comments)
6. Right femoral arteriotomy site was closed with a 6 French
ANgioseal
device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate aortic stenosis.
3. Elevated left and right sided filling pressures.
4. Successful stenting of the ostial RCA.
5. Successful stenting of the distal LCX.
.
[**2166-8-19**] ECHO (TTE) :
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging
are consistent with Grade III/IV (severe) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is moderate to severe aortic valve stenosis (area
0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2166-1-21**], the findings are similar with moderate
to severe aortic stenosis.
Brief Hospital Course:
78 year old F with h/o moderate AS, CAD s/p [**Year (4 digits) **] in [**9-8**] and
diastolic CHF admitted with 4lb weight gain, dyspnea and CHF
exacerbation.
.
1. Diastolic CHF acute and chronic: Combination of acute
exacerbation of diastolic CHF and moderate/severe Aortic
Stenosis. On exam was fluid overloaded and described symptoms
classic of acute CHF exacerbation. She was 4.5 pounds heavier
than her last weight on [**2166-10-10**] at cardiology clinic (245lbs).
Her BNP was over 2X the last measured in our system. Acute CHF
most likely relating to med non-compliance. She was ruled out
for an acute ischemic event with negative cardiac enzymes and
unchanged EKG. Patient aggressively diuresised on Lasix drip.
Goal -3 L reached daily with improvement on physical exam.
Patient discharged on 120 mg Lasix daily. HER DRY WEIGHT IS 103
KG.
.
# Severe Aortic Stenosis: Patient with multiple recent
admissions for heart failure. Once stable and recovered from
acute CHF episode needs C-Surgery consult for possible valve
replacement. Echocardiogram showed valve area of 0.8-1.
.
#. Hypotension: After being re-started on her home
anti-hypertensives including diltiazem, metoprolol, and
lisinopril as well as IV lasix for diuresis she developed
asymptomatic hypotension with BPs ~70s/40s that was unresponsive
to 2 X 500mL NS. There was concern about giving her more fluids
in the setting of her CHF and overloaded volume status, so she
was sent to the CCU for better titration of her medications and
possible initiation of pressors. Dopamine was started however
she developed acute respiratory distress and it was consequently
discontinued. Respiratory distress secondary to acute pulmonary
edema in the setting of hypertension and inotropic effects off
dopamine. Patient's blood pressure was stable with no pressors.
.
#. CAD: s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 10157**] in ostial RCA and distal LCx. She was
ruled out for ACS. Continued on plavix, aspirin, statin. Beta
blocker and ACE-I held in setting of hypotension and
bradycardia. BB restarted temporarily but pt developed a
junctional escape rhythm at rate of 40s, otherwise asymptomatic
and was taken off, while on Amiodarone.
.
#. Rhythm: Patient had episode of A Flutter on [**2166-10-19**] during
acute CHF episode. Patient spontaneously converted. Started
Amiodarone 200 mg [**Hospital1 **] for 2 weeks (Day 1: [**2166-10-21**]).
Anti-coagulation was started, however patient developed
hematuria, guaiac + stool, epitaxsis even on low goal ptt.
Anti-coagulation was stopped due to short duration of A Fib
episode, high fall risk and bleeding. Patient demonstrated
multiple ventricular and atrial ectopy over course of admission.
She was started on daily amiodorone on discharge and outpatient
PFTs were scheduled.
.
#. Hypothyroidism: TSH on this admission was elevated at 6.1. It
is possible she was not taking her home dose of levoxyl, however
a repeat TSH was 7.7 prior to discharge.
These results were communicated to her PCP.
.
#. COPD: Questionable COPD diagnosis with no PFTs and no smoking
history, but is on inhalers at home. Inhalers were discontinued
as it was felt COPD was unlikely with patient's non-smoking
history.
.
#. Glaucoma: Continued home regimen.
#. Iron-Deficiency Anemia: At baseline hematocrit 26-28 during
stay. Colonoscopy [**2163**] with no CA, diverticulosis, and polyp in
T-colon. She is due for a colonoscopy this year and this was set
up on her last admission but she has not been yet. Iron studies
showed iron deficiency anemia. Will have further workup as
outpatient and already has colonoscopy scheduled and will likely
need to be discharged on iron supplements.
#. Diabetes mellitus Type II: Actos discontinued due to history
of heart failure. Glyburide discontinued due to episodes of
hypoglycemia. Patient had several increases in her daily ISS
while hospitalized for tighter glucose control. Started Glargine
QHS dosing as well. Transitioned patient to oral regimen [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommendations (Glipizide [**Hospital1 **]) prior to discharge with
additional 70/30 insulin regimen.
Medications on Admission:
From Discharge Medications from [**9-8**] and Cardiology note
[**2166-10-10**]:
1. Aspirin 81 mg Tablet PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Fluticasone 110 mcg/Actuation Aerosol Sig: One Puff [**Hospital1 **]
5. Lansoprazole 30 mg Tablet Rapid Dissolve PO DAILY
6. Latanoprost 0.005 % Drops Sig: One Drop Ophthalmic HS
7. Levothyroxine 100 mcg 1 Tablet PO DAILY
8. Multivitamin 1 Tablet PO DAILY
9. Calcium Carbonate 500 mg Tablet PO QID as needed.
10. Cyanocobalamin 100 mcg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Diltiazem HCl 60 mg PO TID
13. Metoprolol Tartrate 25 mg PO BID
14. Albuterol Sulfate PRN
15. Glyburide 10 mg b.i.d.
16. Lasix 100mg PO BID
17. Imdur 100mg PO daily
18. Actos 30mg PO QAM 15mg QPM
.
Per Son patient is taking the following at home:
Glyburide 10mg by mouth [**Hospital1 **]
Actos 15mg QAM 30mg QPM
Prevacid 30mg PO daily
Lipitor 40mg PO daily
Levoxyl 100mcg PO daily
Vitamin b12
Ocuphite drops
Xalatan drops
Nitro SL PRN
Albuterol INH 1-2 puffs Q6H PRN
Flovent PRN
Metoprolol 25mg PO BID
Zolpidem 2.5mg PO QHS
Lasix 100mg PO BID
Diltiazem 60mg PO TID
Omeprazole 40mg PO daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
Disp:*30 Tablet(s)* Refills:*11*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: Eight (8) units Subcutaneous twice a day.
Disp:*3 pens* Refills:*2*
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
13. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One
(1) puff Inhalation once a day.
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
16. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
17. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. NitroQuick 0.3 mg Tablet, Sublingual Sig: One (1) tabs
Sublingual every 5 minutes for three [**Last Name (Titles) 4319**] as needed for chest
pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis
Acute on chronic diastolic heart failure
Hypertension
Secondary
Diabetes type 2 non-insulin dependent
Acute Blood loss anemia
Discharge Condition:
The patient was afebrile, hemodynamically stable, with O2 sats
>92% on RA at rest and >88% on RA while ambulating.
The patient's dry weight is 103 kg.
Creat 1.1.
Discharge Instructions:
You were admitted to the hospital with acute worsening of your
baseline shortness of breath. You were found to have heart
failure. We have given you fluid pills to clear the fluid out of
your lungs and legs and you are now feeling better. To prevent
this from happening in the future you need to take your
medications exactly as prescribed every day, including your
lasix once a day. Weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight > 3 lbs. Adhere to 2 gm sodium diet
Your Lisinopril has been discontinued while we are waiting for
your kidney function to return to nomal. This medication needs
to be restarted once you speak with your outpatient physician.
[**Name10 (NameIs) **] should not take your metoprolol while on amiodorone as this
could cause your heart rate to be too low.
Medication Changes:
STOP: Diltiazem and metoprolol,glyburide, and actos.
CHANGE: Lasix to 120mg by mouth daily, start taking insulin
twice daily and amiodarone. You were on 2 medicines for
heartburn, stop taking Lansoprazole but continue omeprazole. You
were started on iron for anemia.
Please call your doctor or come back to the emergency room if
you have light-headedness, dizziness, fainting, worsening
shortness of breath, more than 3 pounds of weight gain,
worsening leg swelling, or any concerning symptoms.
Take your Plavix every day, do not stop taking unless your
cardiologist tells you to.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**],
on [**2166-11-4**] at 1:50pm.
Please follow up with your cardiologist, Dr. [**First Name (STitle) **], and
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 3100**] NP([**Telephone/Fax (1) 62**]), on [**2166-11-13**] at 3:00pm.
.
Please follow up at [**Last Name (un) **] with Dr [**Last Name (STitle) 99905**] on [**11-19**]
at 2:30pm
.
In addition you have a follow up appointment with a nurse
educator to learn how to use the Insulin Pen- this appointment
is for Monday, [**11-3**] at 10 a.m. at the [**Hospital **] Clinic.
Your nurse educator is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
PFT's needed ASAP as outpt. Pt will need LFT's/TFT's q6 months
and yearly CXR.
Completed by:[**2166-11-1**]
|
[
"428.33",
"272.0",
"584.9",
"414.01",
"427.32",
"250.00",
"428.0",
"V45.82",
"244.9",
"401.9",
"424.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15750, 15808
|
8568, 12762
|
345, 352
|
15995, 16160
|
5257, 7360
|
17613, 18518
|
4208, 4423
|
13962, 15727
|
15829, 15974
|
12788, 13939
|
7377, 8545
|
16184, 16986
|
4438, 5238
|
17006, 17590
|
254, 307
|
380, 2722
|
2744, 3755
|
3771, 4192
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,232
| 152,924
|
4795
|
Discharge summary
|
report
|
Admission Date: [**2150-8-12**] Discharge Date: [**2150-8-15**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Isosorbide / quinidine gluconate
Attending:[**Last Name (un) 11974**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Ventricular ablation- [**8-13**]
History of Present Illness:
78F w/ hx CAD s/p CABG, chronic systolic CHF (EF- 25%), VT s/p
pacemaker w/ recent admission for recurrent VTach
([**Date range (1) 20095**]). Patient awoke this morning to palpitations, took
her dofetilide as instructed then called EMS. Pt reports that
yesterday afternoon she felt some lightheadedness after
showering with some mild palpitations, but this resolved with
rest and taking oxazepam. Pt reports intermittent palpitations
throughout today lasting a few seconds. Denies CP, SOB,
dizziness, nausea, diaphoresis today.
Noted enroute to [**Hospital3 **] ED today to have several runs of
VTach, unknown duration, patient does think ICD fired but
unsure. She complains of "spasms" in her chest muscles and her
legs that have continued but states the palpitations have
improved. No episodes of VT at [**Hospital3 **] although noted to have
frequent PVCs, was given 1L NS there. Transferred to [**Hospital1 18**] for
EP eval.
Recent hospital course for VT admission, discharged yesterday
[**8-11**]. Briefly, admitted with multiple episodes of stable VTach
with multiple discharges from ICD. Stabilized on lidocaine gtt
w/ resolution of VTach. Patient requested ICD function turned
off, but after discussion w/ EP her ICD was left on but settings
changed to reduce number of shocks she would receive. Dofetilide
125mcg [**Hospital1 **] was started and lidocaine weaned. No recurrent VT and
discharged home.
On interrogation of ICD: 4am had VTach, then 3 bursts of ATP
that terminated, 430a had more VTach with 6 bursts of ATP that
spontaneously resolved, (not with ATP), no LOC. VTach at 150
bpm.
In the ED, initial vitals were 98.0 62 121/56 16 95%. She denied
SOB or CP. Labs and imaging significant for normal Troponin x1,
normal chemistry including K 4.1 and Mg 1.9, normal CBC and
coags, negative UA. EKG showed PR prolongation, RBBB, and
frequent PVC's.
Patient given oxazepam x1 PO in ED.
Vitals on transfer were 98.2 ??????F (36.8 ??????C), Pulse: 68, RR: 21,
BP: 128/62, Rhythm: Sinus
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p 3 MIs
Cardiomyopathy, EF 25%
NSVT with easily inducible sustained VT on EP study in [**3-/2136**]
-CABG: x2 [**2126**], [**2132**], both done at NEDH
-PACING/ICD: [**Company 1543**] Micro [**Female First Name (un) 19992**] 2 ICD placed on [**2136-3-29**].
Exchanged for [**Company 1543**] ICD, EnTrust D154VRC ?in [**2143**] (last
interrogation per [**Hospital1 18**] webOMR notes [**2145-9-7**]).
Depression s/p ECT
S/p cholecystectomy
S/p hysterectomy
S/p thyroid surgery for a benign mass
S/p cataract surgery
Social History:
Married. Lives at home with her husband and her brother.
[**Name (NI) 1139**] history: remote smoking history from age 20 to 30
ETOH: occasional social drinking
Illicit drugs: none
Family History:
Mother died of MI at age 38, brother at age 37. Other brother MI
at age 60. Father lived to age [**Age over 90 **] and was healthy. No family
history of arrhythmia, cardiomyopathies.
Physical Exam:
Admission PE:
VS: T 98.1, BP 133/63, HR 64, RR 18, 98% RA
GENERAL: A&Ox3, in NAD.
HEENT: Sclera anicteric. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: Normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No LE edema. Extremities well perfused with 2+ DP
and radial pulses
NEURO: grossly nonfocal
Discharge PE
VS: stable
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with flat neck veins
CARDIAC: RR, normal S1, S2. systolic murmur [**3-23**] consistent with
MR.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2150-8-12**] 09:00AM GLUCOSE-97 UREA N-7 CREAT-0.7 SODIUM-142
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2150-8-12**] 09:00AM cTropnT-<0.01
[**2150-8-12**] 09:00AM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2150-8-12**] 09:00AM WBC-6.4 RBC-4.62 HGB-14.0 HCT-41.3 MCV-89
MCH-30.2 MCHC-33.8 RDW-15.7*
[**2150-8-12**] 09:00AM NEUTS-69.6 LYMPHS-23.6 MONOS-3.7 EOS-2.7
BASOS-0.4
[**2150-8-12**] 09:00AM PLT COUNT-258
[**2150-8-12**] 09:00AM PT-11.6 PTT-27.9 INR(PT)-1.1
Discharge Labs
[**2150-8-15**] 07:10AM BLOOD WBC-5.9 RBC-4.40 Hgb-13.4 Hct-39.6 MCV-90
MCH-30.4 MCHC-33.7 RDW-15.9* Plt Ct-205
[**2150-8-15**] 07:10AM BLOOD Glucose-91 UreaN-5* Creat-0.7 Na-141
K-4.2 Cl-104 HCO3-31 AnGap-10
[**2150-8-15**] 07:10AM BLOOD Phos-2.5 Mg-1.9
Brief Hospital Course:
78F with h/o CAD and cardiomyopathy with EF 25% and recurrent VT
recently hospitalized [**Date range (3) 20096**] for VT storm, admitted for
palpitations and found to have runs of VT.
Ventricular Tachycardia:
Patient was admitted to [**Hospital1 1516**] service [**8-12**]. Was placed on sotalol
and dofetilide for her V tach. She was taken for ablation of V
tach on [**8-13**]. Received substrate ablation with large scar across
her inferior wall on lateral and septal edge and put lines
across the scar from lateral to septum. After successful
procedure, patient was transferred to CCU team for
post-procedural monitoring. Sotalol and dofetilide were d/c'ed.
HTN:
Patient's HTN regimen was altered during hospitalization.
Isosorbide dinitrate and hydralazine were d/c'ed and patient was
started on Valsartan 80mg with good response.
Restless Leg Syndrome:
Patient suffers from chronic restless leg syndrome. She was
started on ferrous sulfate 325mg daily and will continue this
med as an outpatient.
Anxiety:
She was also quite nervous and anxious during her
hospitalization. She is known to have baseline anxiety. She
should be considered for SSRI therapy as an outpatient.
CAD:
For her CAD, she was continued on home statin, ezetimibe, ASA,
and metoprolol.
Transitional Issues
-Patient will F/U as an outpatient with Dr. [**Last Name (STitle) **] on Friday [**8-21**] for her successfully ablated VT.
-She is a candidate for SSRI therapy.
-Her BP should be monitored on new BP regimen (stopped
isosorbide and hydralizine, started valsartan)
-Assess response of restless leg syndrome to Ferrous sulfate
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. HydrALAzine 10 mg PO TID
5. Isosorbide Dinitrate 10 mg PO TID
6. Metoprolol Succinate XL 100 mg PO BID
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Oxazepam 30 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Dofetilide 125 mcg PO Q12H VT
Please check ECG 2h after EVERY dose and FAX ECG to [**Telephone/Fax (1) 20093**]
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ezetimibe 10 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO BID
6. Oxazepam 30 mg PO TID
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Valsartan 80 mg PO DAILY
hold for sbp<100
RX *Diovan 80 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 Tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent non-sustained ventricular tachycardia
Discharge Condition:
Clear and coherent
Alert and interactive
Ambulatory- independent
Discharge Instructions:
Dear Ms. [**Known lastname 20097**],
It was a pleasure taking care of you at [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 20098**] [**Hospital1 **].
You were admitted because you were having some palpitations and
found to have some periods of abnormal heart rate called
ventricular tachycardia. This was treated by an ablation
procedure.
Some changes have been made to your blood pressure medications.
Please see below.
Please follow-up at your appointments listed below. Weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2150-8-21**] at 11:40 AM
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: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 10:30 AM
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
Department: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 11:00 AM
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
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
[
"428.0",
"412",
"428.22",
"V70.7",
"427.1",
"425.4",
"300.00",
"V45.01",
"414.00",
"272.4",
"V45.81",
"401.9",
"333.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
8051, 8057
|
5371, 6985
|
322, 356
|
8149, 8216
|
4565, 4565
|
8846, 9771
|
3184, 3370
|
7550, 8028
|
8078, 8128
|
7011, 7527
|
8240, 8823
|
3385, 4546
|
270, 284
|
384, 2393
|
4581, 5348
|
2415, 2967
|
2983, 3168
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,082
| 188,732
|
26816
|
Discharge summary
|
report
|
Admission Date: [**2148-1-22**] Discharge Date: [**2148-2-8**]
Date of Birth: [**2081-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish / Tylenol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain, shorteness of breath
Major Surgical or Invasive Procedure:
[**2148-1-25**] Renal artery angiogram
[**2148-1-26**] Cardiac Catheterization
[**Date range (3) 66012**] Coronary Artery Bypass Graft x 4 (LIMA to LAD,
SVG to PDA, SVG to OM and Diag(y-graft)), Aortic Valve
Replacement w/ 23mm CE pericardial tissue, Mitral Valve
Replacement w/ 27mm CE pericardial tissue
History of Present Illness:
66 year old man with CAD, s/p IMI in [**3-5**] with stent to Cx c/b
cardiogenic [**Date Range **] requiring IABP, repeat cath in [**10-5**] with
Taxus stents to ISR of Cx and stenting of LAD. Last cath [**11-5**]
for recurrent CP-No intervention at that time w/widely patent
stents and non-critical CAD. Pt was readmitted to [**Hospital1 2519**] on [**12-20**] with pulmonary edema, he was diuresed and
ruled out for MI. Has since been diuresed but creatinine has
risen to 2.3 (was 2.0 on admission***creatinine on [**11-5**]: 1.3).
Pt presented to [**Hospital3 **] [**1-21**] morning for increasing SOB,
chest congestion and cough. Pt awoke in USOH but noticed
increasing SOB in particular while ambulating to bathroom, wife
called 911, EMS transported pt to local hosp. Pt also states
that he's had L scapular pain daily while having a BM. During
this admission at OSH he was found to have pulm edema and
diuresed 40IV lasix x1 w/resolving SOB. ETT on [**1-22**]: + ST
depression in the lateral leads with exercise. Imaging: results
w/ischemia. LVEF quoted as 45%. Transferred to [**Hospital1 18**] for cardiac
cath given ETT results and recurrent pulm edema and L scapular
CP, also new ARF.
Past Medical History:
Coronary Artery Disease s/p PCI [**2147**], Myocardial Infarction
[**3-5**], Congestive heart failure, Diabetes Mellitus, Hypertension,
Hyperlipidemia, Chronic Obstructive Pulmonary Disease, Gastric
Ulcers, Peripheral Vascular Disease
Social History:
Lives w/wife and son in [**Name (NI) 21037**]. Retired from Maintenance in
9/[**2147**]. Quit TOB use 30years ago 1.5ppd x20 years. No ETOH use.
Family History:
Father Deceased from MI age 70s, Mother with pacemaker/CAD,
Sister with CAD in 60's, Brother w/IDDM died at age 32 fr/DM
complications
Physical Exam:
VS 72 20 92/39 91%RA 5'7" 163#
Gen: NAD, lying in bed
Skin: W/D, unremarkable
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -varicosities, -edema
Neuro: MAE, A&O x 3, Non-focal
Pertinent Results:
[**2148-1-30**] CXR: There is new near complete opacification of the
left hemithorax with tracheal deviation to the left, tenting of
the left hemidiaphragm suggesting volume loss. A left pleural
effusion has also increased in size since prior exam. The right
lung is clear, and appears hyperinflated. Postoperative changes
consistent with patient's known AVR, MVR and median sternotomy
are again seen.
[**2148-1-26**] Echo: POSTBYPASS: LV systolic function is slighly worse
compared (~40%) to prebypass. RV systolic function remains
preserved. There is a well seated, well functioning
bioprosthesis in the aortic position. There is trace valvular
AI. There is a well seated well functioning bioprosthesis in the
mitral position. There is a mild perivalvular leak laterally.
[**2148-1-26**] Cath: Selective coronary angiography of this left
dominant system revealed left main coronary artery disease, with
a 70% ostial stenosis of the LMCA. The LAD had widely patent
stents and mild luminal irregularities. The LCx also had widely
patent stents and a 50% stenosis at the origin of the PL branch.
The RCA was not ingaged as it was known to be a small,
nondominant vessel and without significant disease. Limited
resting hemodynamics revealed a central aortic pressure of
105/53mmHG. Pressure wire interrogation of LMCA lesion revealed
a resting FFR of 0.76 with catheter damping, signifying a
hemodynamically significant stenosis.
[**2148-1-25**] Renal Angio: Central aortic hypertension. Moderate, non
critical lesion in the LRA.
[**2148-1-24**] MRA Kidneys: Mild-to-moderate (likely less than 50%)
bilateral nonostial, proximal renal artery stenoses. Multiple
bladder diverticula.
[**2148-2-7**] 06:40AM BLOOD WBC-9.2 RBC-3.49* Hgb-10.2* Hct-30.8*
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.6 Plt Ct-270
[**2148-2-8**] 07:00AM BLOOD PT-25.9* PTT-36.8* INR(PT)-2.6*
[**2148-2-7**] 06:40AM BLOOD PT-25.8* INR(PT)-2.6*
[**2148-2-7**] 06:40AM BLOOD Glucose-143* UreaN-18 Creat-1.4* Na-132*
K-4.9 Cl-95* HCO3-33* AnGap-9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with atypical chest pain, congestive
heart failure, supraventricular tachycardia and renal
insufficiency. He underwent renal MRA to evaluate for renal
artery stenosis. The MRA revealed that in both renal arteries,
there was mild-to-moderate nonostial proximal stenosis. The
estimated stenoses was less than 50%. Follow up renal
angiography on [**1-25**] showed no significant disease on the
right with a 40% ostial stenosis in the left. No intervention
was performed and medical management was recommended for his
hypertension. Given episodes of supraventricular tachycardia,
the EP service was consulted. Beta blockade was advanced and an
echocardiogram was obtained. The echocardiogram showed mild
aortic stenosis with 1-2+ aortic insuffiency. There was [**1-2**]+
mitral regurgitation with normal left ventricular function. The
LVEF was estimated between 60-65%. He remained relatively stable
on medical therapy with gradual improvement in renal function.
He eventually underwent coronary angiography which showed a left
dominant system and a hemodynamically significant 70% ostial
lesion in the left main coronary artery disease. The LAD had
widely patent stents and mild luminal irregularities. The LCx
also had widely patent stents and a 50% stenosis at the origin
of the PL branch. The RCA was not ingaged as it was known to be
a
small, nondominant vessel and without significant disease. Given
the hemodynamically significant critical left main lesion, he
was urgently brought to the operating room for surgical
intervention. In the operating room, Dr. [**First Name (STitle) **] performed four
vessel coronary artery bypass grafting along with aortic and
mitral valve replacments. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated. Post
operatively his platelets dropped to 43, a HIT panel was sent
and was negative. He developed a second degree AV block for
which he was seen by EP and remained in the ICU, and his
epicardial pacing wires remained. He also required extensive
pulmonary toilet. He went into atrial fibrillation on POD #6 and
was transferred to the floor. His epicardial wires were dc'd on
POD #8. He was started on couadmin for afib. His INR rose
rapidly to a peak of 9, his coumadin was held and his INR
quickly returned to a therapeutic level. A CXR was done prior to
discharge which showed a new moderatd sized right pneumothorax.
Repeat CXR x 2 showed no change and he was discharged home on
POD #11.
Medications on Admission:
Meds at home: Atenolol 50mg daily, Aspirin 325mg daily, Plavix
75mg daily, Crestor 10mg daily, Lasix 20mg daily, Glipizide 5mg
daily, Isosorbide mononitrate 30mg daily, Lisinopril 20mg daily,
Prilosec 20mg daily
At [**Hospital1 18**]: RISS, Heparin 5000units SQ TID, Lopressor, Crestor
10mg qd, Pantoprazole 40mg qd, Plavix 75mg qd, Aspirin 325mg qd,
Colace 100mg [**Hospital1 **], Senna, Lasix, Diltiazem 60mg [**Hospital1 **], Lisinopril
10mg qd
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:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 2 days: Dr. [**Last Name (STitle) **] will manage Warfarin as an outpatient.
Please have INR checked [**2148-2-10**]. ***VNA should fax results to
[**Telephone/Fax (1) 66013**]***.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Aortic Insufficiency s/p Aortic Valve Replacement
Mitral Regurgitation s/p Mitral Valve Replacement
Congestive heart failure
Supraventricular Tachycardia
Acute Renal Failure
PMH: Myocardial Infarction [**3-5**], Diabetes Mellitus,
Hypertension, Hyperlipidemia, s/p PCI [**2147**], Chronic Obstructive
Pulmonary Disease, Gastric Ulcers, Peripheral Vascular Disease
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Please call your heart surgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], at
[**Telephone/Fax (1) 170**], to schedule a follow-up appoinment. You should be
seen in 4 weeks.
.
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 66014**], to
schedule a follow-up appointment. You should be seen in [**1-2**]
weeks.
.
Please also call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in cardiology at [**Telephone/Fax (1) 4475**]
to schedule a follow-up appointment. You should be seen by him
in [**2-3**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2148-2-9**]
|
[
"398.91",
"440.0",
"403.90",
"443.9",
"V45.82",
"512.1",
"414.01",
"427.31",
"287.5",
"584.9",
"413.9",
"416.8",
"250.00",
"427.1",
"396.3",
"426.13",
"496",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.05",
"88.45",
"36.15",
"89.69",
"99.04",
"36.13",
"39.61",
"37.22",
"35.21",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
9066, 9117
|
4771, 7404
|
318, 626
|
9585, 9591
|
2740, 4748
|
9909, 10661
|
2285, 2421
|
7902, 9043
|
9138, 9564
|
7430, 7879
|
9615, 9886
|
2436, 2721
|
246, 280
|
654, 1849
|
1871, 2107
|
2123, 2269
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,857
| 137,466
|
23858
|
Discharge summary
|
report
|
Admission Date: [**2137-3-31**] Discharge Date: [**2137-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain, transferred from SICU for AFib.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86M w/Afib on warfarin, DM, HTN, TIA, known AAA (x4yrs)
presented to OSH w/2 days of crampy abdominal pain, diarrhea,
and emesis (nonbloody/coffee ground). INR was found to be 13 and
CT @ OSH revealed free interperitoneal blood and the aneurysm
and pt was transferred to Vascular service at [**Hospital1 18**] for possible
urgent surgery. Pt was monitored in [**Hospital1 10115**] x1d, given 2 bags FFP,
1U PRBC, and sent to vascular step-down unti on [**4-1**]. Pt went
into rapid Afib on [**4-2**], controlled with IV CCB & Bblocker.
Currently, pt denies abdom pain, fever/chills, SOB, N/V. Cough
is chronic & unchanged. No B.M. x few days.
Past Medical History:
PMHx:
- COPD (on home O2 at night); recently admitted to OSH for
flare, tx w/steroids & Abx
- paroxysmal Afib on coumadin
- IDDM
- AAA
- CRI; creat 1.8 at previous admission to OSH
- h/o multiple TIAs
- HTN
- hyperlipidemia
- GERD
- BPH
Social History:
50 pack-year distant smoking hx. Denies EtOH. Married. Family
aware and involved in his care.
Physical Exam:
ON TRANSFER FROM [**Month (only) 10115**]:
.
GEN: Lying in bed at an angle, breathing rapidly with apparent
straining of accessory muscles.
.
SKIN: Cyst in middle of sternum. Multiple lentigines throughout
body. No evident cyanosis, rashes, or other lesions. Some
bruising in R antecub fossa.
.
HEENT: PERRL. Cataract in R eye. No palpable lymphadenopathy but
there is pronounced fullness bilt. in submandibular area.
.
CVS: RRR; nl S1, S2; no m/r/g. Elevated JVP appreciated behind
ear; bed at 45 degrees.
.
PULM: Decent inspiratory effort with bilat. expiratory wheezes
throughout fields and inspiratory crackles bibasilar to halfway
up.
.
ABD: Distended, hypertympanic throughout.
.
NEURO: AO to self and to year. Said he was at [**Hospital3 2576**] and
thought month was [**Month (only) 359**]. CN's II-XII all normal. Sensation in
legs and feet intact to light touch. Able to move toes, legs,
thighs. UE's not assessed. Motor strength, reflexes, cerebellar
not yet assessed.
.
EXT: Peripheral edema in UE's, esp. in dorsa of both hands.
Pertinent Results:
AT admission:
[**2137-3-30**] 10:20PM WBC-9.0 RBC-2.57* HGB-7.6* HCT-23.8* MCV-93
MCH-29.6 MCHC-32.0 RDW-15.4
[**2137-3-30**] 10:20PM NEUTS-91* BANDS-3 LYMPHS-6* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2137-3-30**] 10:20PM PT-16.6* PTT-33.9 INR(PT)-1.7
[**2137-3-30**] 10:20PM ALBUMIN-3.4 CALCIUM-9.0 PHOSPHATE-4.0
MAGNESIUM-2.4
[**2137-3-30**] 10:20PM GLUCOSE-65* UREA N-44* CREAT-3.4* SODIUM-143
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-33* ANION GAP-13
[**2137-3-30**] 10:20PM ALT(SGPT)-12 AST(SGOT)-20 CK(CPK)-126 ALK
PHOS-83 AMYLASE-132* TOT BILI-0.6
At time of d/c: patient complained of some abdominal discomfort
a.m. of d/c and the KUB was done which on preliminary read
showed no acute process. A portable cxray showed pleural
effusions (as before).
Brief Hospital Course:
86M with COPD on home O2, IDDM, Afib on coumadin, abdominal
aortic aneurysm, initially admitted to Vascular Surgery service
for hemoperitoneum and consideration of surgery. Pt remained
hemodynamically stable and hemoperitoneum was thought to be most
likely secondary to leaking bowel hematoma (seen on CT scan) and
less likely to be from AAA. Given the high risk for surgical
repair of AAA, pt & family decided against any attempt at repair
of AAA. Pt was transferred to Medicine service for management of
multiple medical problems, including Afib with intermittently
rapid ventricular rate. During hospitalization, pt found to be
in clinical heart failure (echo revealed slightly low EF) and
had marginal blood pressures, precluding aggressive diuresis.
Pt's pulmonary status remained poor but at baseline. Pt's renal
function remained poor but close to baseline. At a family
meeting on [**4-16**], pt was made DNR/I with plan to discharge
patient to facility closer to family's home.
#1 AFIB/CHF
In [**Name (NI) 10115**] pt. entered into AF w/RVR and was successfully
controlled with diltiazem and a beta-blocker. He was transferred
to the medical service where he was maintained on metoprolol and
put on telemetry. We continued to hold his Coumadin due to his
recent INR >12 and internal bleeding from a leaking AAA vs. from
infarcted small bowel vs. from bowel wall hematoma. Discussed
with Dr. [**Last Name (STitle) 1391**] from vascular surgery; while he felt that the
intraperitoneal bleeding was likely secondary to bowel wall
rather than a leaking AAA, the coumadin was held ultimately on
high fall risk.
Atrial fibrillation was intially controlled with IV lopressor,
then po Toprol XL once he was tolerating po meds. Several
episodes of a. fib with rvr throughout hospital course, which
was controlled with prn IV lopressor. He was also started on
digoxin 0.125 qD.
Concerning his CHF, he had a TTE while in house, showing a
hypokinetic LV with EF of 35%. His volume status was tenuous at
times. Diuresis was held with his relative intravascular volume
depletion and hypotension - this resolved with NS fluid boluses.
He remained grossly total body volume overloaded, though.
- He was continued on toprol xl; Ace-I was attempted, but was
precluded by hypotension. Once blood pressure was normalized
patient was started on hydralazine for afterload reduction (at
this time patient was in renal failure).
- Patient was gently diuresed (with low-dose lasix) as needed
for fluid overload, as his blood pressure would tolerate. He
should get low dose lasix periodically to help with diuresis as
renal function will allow.
#2 HEMOPERITONEUM/AAA/ABDOMINAL PAIN
Pt. initially presented to an OSH w/complaints of abdominal
pain/pressure in his LLQ and N/V. There was also a report that
he had fallen at home shortly before presentation. As noted in
HPI, pt. was found to have hemoperitoneum, thickened small
bowel, and INR of 13, prompting transfer to [**Hospital1 18**]. In [**Name (NI) 10115**] pt.
received 2 bags of FFP and 1 unit of pRBC's. After transfer to
medical service for his afib, Coumadin and ASA were held. 1 u of
pRBC's was given due to dropping HCt. HCt then stabilized for
remainder of his course.
Also, pt. had swallow evaluation which he failed and so was made
NPO. However, through discussion w/pt. and his family it was
determined that he had been eating PO and taking meds PO at home
for a long time so NPO order was removed and pt. was switched to
PO meds, which he tolerated along with soft solids.
It became clear that his po intake was totally inadequate; after
discussion/consent from family, a PEG tube was placed, and he
started on tube feeding.
Completed 2 week empiric course of levo/flagyl for small bowel
thickening/hemoperitoneum.
#3 CRI (diabetic vs hypertensive)
As noted in HPI, initial creatinine of 3.4 was judged to be from
hypovolemia and not from pathology a/w pt's AAA. He was hydrated
w/IV fluid and creatinine improved to 1.7, which is thought to
be near his baseline. His creatinine increased to 2.5 on [**4-17**]
and then 2.4 on day of discharge. This was thought to be from
intravascular volume depletion since fena<1 and bun was
increasing as well. However, patient was total body overloaded
with fluids with 2+ pitting edema in LE. Patient was started on
hydral for afterload reduction with good result. The thought is
to get the patient to be euvolemic and then diurese off all his
extravascular fluid.
#4 COPD
This was managed adequately with albuterol,
fluticasone-salmeterol, and ipratropium and pt. maintained O2
sat >94% on low flow O2 throughout his stay.
#5 MRSA
Nasal swab, Urine cultures, and blood cultures grew out MRSA,
which delayed plans for d/c to rehab facility. He was treated
with vancomycin IV, then changed over
to po linezolid for a po alternative for MRSA coverage. Blood
cultures remained no growth throughout. In total, had 8 days of
coverage (vanco/linezolid).
#6 HTN: Pt was actually borderline hypotensive on the
medications to control his atrial fibrillation. BP management as
described above. However, 2 days prior to discharge patient's
blood pressures and urine output improved markedly.
#7 Code: Patient's family, with the medical team and the patient
did decide that the patient would be DNR/DNI. They are coming
to terms with the prospect that their father/grandfather's
health is deteriorating.
Medications on Admission:
- Coumadin 4'
- Tiazac 300'
- Lipitor 10'
- Lasix 20' M/F
- ASA 81'
- Paxil 20'
- Advair 500/50''
- Aricept 5'
- Novolin 20/0
- On 2L home O2
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): or via feeding tube.
5. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO
QHS (once a day (at bedtime)).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
(1) dose PO DAILY (Daily): via feeding tube.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for fever or pain.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
2.5 Tablet Sustained Release 24HRs PO BID (2 times a day).
10. Hydralazine HCl 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8629**] -Greenbriar Terrace
Discharge Diagnosis:
1.hemoperitoneum
2.abdominal aortic aneurysm
3.dementia
4.atrial fibrillation - off coumadin [**2-20**] to fall risk
5.IDDM
6.HTN
7.Hyperlipidemia
8.GERD
9.BPH
10.Chronic renal insufficiency
11.systolic CHF
12.MRSA UTI and + sputum cultures
13.inadequate po nutrition - s/p PEG placement
Discharge Condition:
stable
Discharge Instructions:
contact MD if you develop fever/chills, shortness of breath, or
other concerning symptoms. Please come directly to the ED if
you have chest pain. Call [**Last Name (LF) **],[**First Name3 (LF) 177**] [**Telephone/Fax (1) 60852**] for any
concerning symptoms.
Followup Instructions:
follow-up with primary care physician [**Name Initial (PRE) 176**] 3 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 60852**] Follow-up appointment
should be in 3 weeks
Completed by:[**2137-4-19**]
|
[
"428.0",
"403.90",
"458.9",
"441.4",
"250.00",
"584.9",
"427.31",
"E934.2",
"496",
"286.9",
"V58.67",
"482.41",
"569.9",
"599.0",
"V09.0",
"568.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"38.93",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
10095, 10161
|
3241, 8652
|
308, 314
|
10492, 10500
|
2436, 3218
|
10809, 11050
|
8844, 10072
|
10182, 10471
|
8678, 8821
|
10524, 10786
|
1374, 2417
|
221, 270
|
342, 987
|
1009, 1248
|
1264, 1359
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,884
| 124,869
|
18554
|
Discharge summary
|
report
|
Admission Date: [**2112-10-26**] Discharge Date: [**2112-11-4**]
Service: THORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is an 85-year-old male
with a history of coronary artery disease and mitral
regurgitation requiring a coronary artery bypass graft and
mitral valve replacement in [**2110**] who had a complicated
recovery since the surgery with pneumonia and a history of
intubation and tracheostomy. The patient was complaining of
progressive dyspnea since his recovery from the cardiac
surgery and was evaluated with a CAT scan in [**2111-7-13**] and
was found to have high tracheal stenosis at the level of the
thoracic inlet with the lumen approximately 7 mm in diameter.
However, the patient was hesitant in seeking help and finally
consulted Dr. [**First Name (STitle) **] [**Name (STitle) **] of Interventional Pulmonology and
presents for a flexible bronchoscopy on the day of admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post CABG and MVR in
[**2110**].
2. History of atrial fibrillation and atrial flutter.
3. History of left atrial clot for which the patient has
been taking Coumadin.
4. History of posterior circulation CVA.
5. Obstructive sleep apnea requiring CPAP.
6. History of hip fracture, status post surgical repair.
7. History of fall with recent subdural hemorrhage which is
stable.
8. History of seizure disorder.
9. Benign prostatic hyperplasia.
10. Hyperthyroidism.
11. Irritable bowel syndrome.
ADMISSION MEDICATIONS:
1. Celexa 40 mg q.d.
2. Provigil 200 mg q.a.m.
3. Cozaar 25 mg q.d.
4. Coumadin, alternating doses of 5 mg and 7.5 mg.
5. Lasix 40 mg p.o. q.d.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 10 mEq q. Monday, Wednesday, and Friday.
7. Tegretol 100 mg p.o. b.i.d.
8. Flomax 0.4 mg q.h.s.
9. Guaifenesin 600 mg b.i.d.
10. Celebrex 200 mg q.d.
11. Albuterol/Atrovent nebulizer treatments.
ALLERGIES: The patient is allergic to phenothiazine,
Demerol, and iodine-based IV contrast.
SOCIAL HISTORY: Significant for tobacco smoking. He quit at
the age of 30. Social alcohol consumption.
LABORATORY/RADIOLOGIC DATA: On admission, white count 5.4,
hematocrit 37.8, platelets 166,000. PT/PTT 15.8/29.3, INR
1.7. Chemistries revealed a sodium of 141, potassium 4.3,
chloride 105, C02 26, BUN 24, creatinine 0.9 with a glucose
of 115, calcium 9.3, magnesium 1.9, phosphate 3.3.
Pulmonary function testing done on [**2112-8-5**] with
moderate to restrictive impairment with decreased FVC and
FEV1 and normal FEV1/FVC.
Transthoracic echocardiogram done on [**2112-10-7**]
showed left atrium mildly dilated with an abnormal shadowing
echodensity in the posterior portion consistent with a clot,
moderate to severely reduced global left ventricular systolic
function with an ejection fraction of 20-25% consistent with
his history of MI, coronary artery disease, status post CABG.
Chest CT done on [**2112-10-5**] showed a small subdural hemorrhage
along the right tentorium, cerebellum, without mass affect,
small right frontal and parietal infarcted areas were noted.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile with a temperature of 96.7, heart rate 78, blood
pressure 120/64, respiratory rate 20, saturating at 96% on
room air. General: The patient was alert and oriented times
three, in no apparent distress. The patient stridorous but
speaking. HEENT: Pupils were equally round and reactive to
light and accommodation with extraocular movements intact.
The oropharynx was clear without any lesions. Neck: Supple,
nontender, no bruits noted. Lungs: Clear to auscultation
bilaterally with transmitted upper airway noise.
Cardiovascular: Irregularly/irregular heart rate, no audible
murmurs. Abdomen: Bowel sounds soft, nontender,
nondistended, no hepatosplenomegaly appreciated.
Extremities: No edema with good palpable dorsalis pedis
pulses. Neurologic: Cranial nerves II through XII grossly
intact with intact motor and sensory systems in the
extremities grossly. The rectal examination was Guaiac
negative.
HOSPITAL COURSE: The patient underwent a flexible
bronchoscopy with Interventional Pulmonology and was found to
have severe obstruction at the proximal trachea and was
admitted for further observation and management. Because of
his subtherapeutic anticoagulation, the patient was started
on a heparin drip with a goal to titrate up to PTT of 60-80.
Neurology consult was obtained. A review of the head CT was
done. There were no absolute contraindications to
anticoagulation from their point of view. Cardiology consult
was also called for preoperative evaluation and it was felt
that there was no evidence of ongoing ischemia or severe
decompensation of heart failure at this time. The patient
still has moderate to high risk of perioperative cardiac
event. The patient was started on a beta blocker
preoperatively.
Because of the severe tracheal stenosis and danger of airway
obstruction, the patient was admitted to the MICU for
observation prior to surgery. The patient was evaluated by
the Thoracic Surgery Service and Dr. [**Last Name (STitle) 952**] as consulted by
Interventional Pulmonology and for possible surgical
intervention. At the time, Mr. [**Known lastname 50980**] and his family said
that they did not want a tracheostomy nor did they want a T
tube and stated that he would prefer to die than to have
those procedures. Therefore, the patient was recommended a
tracheal resection and reconstruction or a bronchoscopic
procedure.
After the risks of the surgery was fully explained and all
questions were answered and informed consent was obtained,
the patient was taken to the OR on [**2112-10-31**] for a
possible tracheal resection and reconstruction. However,
this procedure was aborted due to the inability to establish
with any degree of certainty that the anastomosis would be
due without any undue tension. The patient went ahead with
the alternative plan for a bronchoscopic approach and
underwent a rigid bronchoscopy with dilatation and stent of
the proximal tracheal stenosis on [**2112-10-31**] by
Interventional Pulmonology.
Postoperatively, the patient did relatively well. On
postoperative day number one, the patient was complaining of
difficulty swallowing. Given his prior history of CVA and
dysphagia, Speech and Swallow consult was called. The
initial evaluation was that the patient did not demonstrate
any overt signs or symptoms of aspiration. The patient went
ahead with a video swallow study. On video swallow study,
the patient demonstrated aspiration with nectar-thick liquids
and thin liquids and the patient was initially placed on
n.p.o. status.
However, after an extensive discussion with the
Interventional Pulmonology Team and with the patient, it was
clear that this was not an acute process given his history of
CVA and his history of dysphagia and given the fact that the
patient was only a few days out from surgery that these
findings may be transiently related to postoperative
recovery.
With the patient's insistence on starting on a pureed diet
which he had been taking prior to admission and with full
understanding of risks of aspiration and pneumonia as
explained by the staff to the patient, the patient was
cautiously started on a pureed diet. The patient tolerated a
pureed diet without signs or symptoms of aspiration. The
patient was also started on Coumadin per his schedule and
continued on IV heparin and because his INR was not
therapeutic the patient was converted over to Lovenox
anticoagulation therapy at 70 mg subcutaneously q. 12 hours
for full anticoagulant effect while he continued his
anticoagulation with p.o. Coumadin at rehabilitation. At
discharge, the patient's INR was 1.9.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Tracheal stenosis.
2. Coronary artery disease, status post CABG and mitral
valve replacement.
3. Atrial fibrillation.
4. History of left atrial clot.
5. Seizure disorder.
6. Benign prostatic hyperplasia.
7. Obstructive sleep apnea.
8. Dysphagia and aspiration possibly secondary to past
cerebrovascular accident, possibly worsened by postoperative
recovery.
DISCHARGE MEDICATIONS:
1. Albuterol nebulizer treatments, one nebulizer treatment
inhaled every six hours continuously.
2. Atrovent one nebulizer treatment q. six hours.
3. Tegretol 100 mg p.o. b.i.d.
4. Dulcolax 10 mg p.o. q.h.s. p.r.n.
5. Protonix 40 mg p.o. q.d.
6. Lasix 20 mg p.o. every Monday, Wednesday, and Friday.
7. Flomax 0.4 mg p.o. q.h.s.
8. Celexa 20 mg p.o. q.d.
9. Celecoxib 200 mg p.o. q.a.m.
10. Trazodone 25 mg p.o. q.h.s. p.r.n.
11. Guaifenesin 600 mg p.o. b.i.d.
12. Modafinil 200 mg p.o. q.a.m.
13. Tylenol 325-650 mg p.o. q. four to six hours p.r.n.
14. Senna one tablet p.o. b.i.d. p.r.n.
15. Lovastatin 20 mg p.o. b.i.d.
16. Lovenox 70 mg subcutaneously q. 12 until the INR is 2.5.
17. Lopressor 25 mg p.o. b.i.d.
18. Losartan 25 mg p.o. q.d.
19. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q. Monday, Wednesday, and Friday,
check K level once a week.
20. Coumadin 5 mg every Monday, Wednesday, Friday, and
Sunday, 7.5 mg on Tuesday, Thursday, and Saturday.
FOLLOW-UP: The patient is to follow-up with his primary care
physician and have his INR checked three times a week until
it is stabilized to a goal INR of 2.5 and needs to continue
to take his Lovenox until the INR is stabilized to 2.5. The
patient is also to follow-up with Dr. [**Last Name (STitle) **] within two weeks
for future discussions and plans for his tracheal stenosis
and can follow-up with Dr. [**Last Name (STitle) 952**] in his office as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2112-11-4**] 09:16
T: [**2112-11-4**] 09:22
JOB#: [**Job Number 50981**]
cc:[**Telephone/Fax (1) 50982**]
|
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icd9cm
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[
[
[]
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[
"93.90",
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icd9pcs
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[
[
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7895, 8265
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4120, 7790
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944, 1480
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2039, 3131
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7815, 7874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,427
| 166,170
|
36642
|
Discharge summary
|
report
|
Admission Date: [**2144-1-7**] Discharge Date: [**2144-2-5**]
Date of Birth: [**2102-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Respiratory failure and difficult weaning from ventilation after
hernia repair.
Major Surgical or Invasive Procedure:
PICC line placement
Arterial line placement
History of Present Illness:
History of Present Illness, in brief: 41-year-old male with past
medical history of patent foramen ovale s/p closure, PE on
lovenox, diastolic CHF, COPD, pulmonary hypertension, on home O2
at 4L NC (although patient states he was on room air prior to
admission) initially presented to [**Hospital3 10377**]
Hospital with 10/10 periumbilical pain associated with nausea,
vomiting, worse in the right lower quadrant. At that time he was
found to have an incarcerated hernia on imaging and admitted for
open repair of strangulated incisional hernia with mesh
placement, with some strangulated bowel requiring resection (end
to end connection). After the procedure he was transfered to the
ICU, where he was not able to be extubated for 2 days and
apparently developed aspiration pneumonia which was treated with
antibiotics (levofloxacin and metronidazole). He developed
atrial flutter after which he required both face mask and nasal
cannula to maintain oxygen saturations above 90% and required
cardioversion. Patient had difficulty being weaned of venti-face
mask with FiO2 of 50% with 5L NC. Pulmonary was consulted and
thought that the patient had severe pulmonary hypertension and
recommended transfer to tertiary care facility for further
pulmonary care. Surgically, patient has recovered and is
tolerating a regular diet, passing flatus and having normal,
soft bowel movements.
Patient was transferred to [**Hospital1 18**] for severe pulmonary
hypertension with continued elevated O2 requirements. The
patient immediately triggered on the floor with an SaO2 of 88%
on 50% venti-face-mask and a temperature of 101.1. He was given
IV lasix 80mg, nebs, heparin drip continued, vancomycin and
zosyn for HAP/VAP/aspiration PNA, blood and urine cultures
obtained and MICU consulted and subsequent transfer initiated.
In the MICU the patient was maintained on a face mask. He had an
A-line placed and a TTE with bubble study, which showed a septal
occluder device in place without evidence of atrial septal
defect of patent foramen ovale. Mild symmetric left ventricular
hypertrophy with systolic function of EF>75%. Right ventricular
cavity is dilated with borderline depressed free wall motion.
There is severe pulmonary artery systolic hypertension. The
patient was started on a lasix drip and acetazolamide. A PICC
line was placed and a CTA was performed which showed possible
chronic pulmonary emboli and patchy ground glass opacities and
enlarged lymph nodes. The facemask was reduced from 50% to 40%
with stable SaO2s. The lasix drip was stopped with continued
diuresis by the patient. His sotalol was decreased to 40mg [**Hospital1 **],
however, HR increased to 130s and he continued his 80mg [**Hospital1 **]
dosing. The patient was deemed to be stable for general medical
floor treatment and was transferred.
Review of systems:
(+) Per HPI, bilateral lower extremity swelling, flatus, BM, SOB
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
- Congenital birth defects with patent foramen ovale s/p closure
at [**Hospital1 18**] [**7-10**]
- Mild developmental delay
- Hypertension
- Diabetes mellitus type 2
- h/o recurrent PE while on anticoagulation (coumadin and
aspirin - has also been on plavix but developed hemoptysis)
- h/o paradoxial CVA from shunt (s/p repair) in [**2142**]
- Diastolic CHF
- COPD
- Pulmonary hypertension diagnosed [**7-10**] - no vasodilator
challenge, no right heart cath since PFO closure, no
pulmonologist
- Home O2, 4L NC (although patient reports being on RA)
- Aflutter with RVR perioperativly.
Past Surgical History:
- Splenectomy in [**2133**] due to trauma
- Strangulated hernia s/p repair with bowel rescection [**12-10**]
Social History:
Patient lives at home with his parents.
- Tobacco: Denies
- Alcohol: Social, occasional
- Illicits: Denies
Family History:
Non-contributory, denies family history of pulmonary
hypertension.
Physical Exam:
General: Male, alert, oriented, sitting in chair with only nasal
cannula in no apparent distress
HEENT: Sclera anicteric, MMM, oropharynx without lesions, PERRL,
EOMI
Neck: Supple, JVP not elevated, no LAD
Lungs: Crackles bilateral through lower [**2-5**], good air movement,
without wheeze
CV: RR, nl rate, without murmurs, rubs or gallops, S1, split S2
Abdomen: Soft, NT, ND, +BS (some tenderness around surgical
incision site), incision C/D/I, Inferior incision with
serosanguinous drainage with overlying clean, sterile dressing,
no rebound, no guarding
GU: Foley in place
Ext: Warm, well perfused; 2+ DP pulses, trace bilateral lower
extremity pitting edema
Neuro: AOx3, CN II-XII grossly intact, grossly intact, ambulates
without difficulty
Pertinent Results:
[**2144-1-7**] 10:45PM WBC-16.9* RBC-3.65* HGB-10.2* HCT-32.0*
MCV-88 MCH-27.9 MCHC-31.8 RDW-18.1*
[**2144-1-7**] 10:45PM NEUTS-79.0* LYMPHS-14.3* MONOS-5.1 EOS-1.4
BASOS-0.3
[**2144-1-7**] 10:45PM PT-20.4* PTT-39.6* INR(PT)-1.9*
[**2144-1-7**] 10:45PM ALBUMIN-2.6* CALCIUM-8.2* PHOSPHATE-3.0
MAGNESIUM-1.3*
[**2144-1-7**] 10:45PM ALT(SGPT)-163* AST(SGOT)-23 LD(LDH)-214 ALK
PHOS-55 TOT BILI-1.0
[**2144-1-7**] 10:45PM proBNP-3223*
[**2144-1-7**] 10:45PM GLUCOSE-65* UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
[**2144-1-7**] CXR: Lung volumes are low, exaggerating the heart size.
Pulmonary and mediastinal vessels are dilated but there is no
pulmonary edema. Small left pleural effusion may be present.
[**2144-1-8**] TEE: The left atrium is elongated. A septal occluder
device is seen across the interatrial septum. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). The right ventricular cavity is dilated with
borderline depressed free wall motion. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2144-1-12**] CTA chest: 1. Tiny filling defects in the distal
subsegmental branches of the pulmonary arteries bilaterally as
detailed above with an eccentric distribution, the imaging
findings of which are consistent with chronic pulmonary emboli;
however, the chronicity of this finding cannot be definitively
ascertained due to which an acute process is not entirely
excluded. 2. Bilateral patchy ground-glass opacities
predominantly in the upper lobes, left greater than right,
stable since [**2143-11-3**], could represent an
inflammatory/infectious process. 3. Mediastinal adenopathy,
stable since [**2143-11-3**]. Consideration to PET/CT should be
given for further evaluation. 4. Increased size of main
pulmonary artery measuring 3.7 cm consistent with pulmonary
arterial hypertension. 5. Small hiatal hernia. 6. Small amount
of fluid in the left upper quadrant of the abdomen with
nonvisualization of spleen, correlate for history of
splenectomy. 7. Mild fatty infiltration of liver.
[**2144-1-19**] RUQ U/S: Anterior abdominal wall paramedian fluid
collections at the superior aspect of the incisional scar
measuring up to 7.6 cm on the right and 7.4 cm on the left.
Brief Hospital Course:
41M with pulmonary hypertension, history of recurrent PE,
diastolic CHF, and s/p PFO closure, initially admitted to OSH
for strangulated hernia, with persistent hypoxia likely
secondary to pulmonary hypertension.
#. Respiratory distress: The patient has been persistently
hypoxic. Initially he required 5L NC and 50% facemask to
maintain SaO2 of above 92% and was sent to the MICU. The likely
etiology was pneumonia, volume overload and pulmonary
hypertension. The pneumonia was treated with an 8 day course of
vancomycin and zosyn. The patient was placed on a lasix drip
with aggressive diuresis. Finally the patient was treated for
pulmonary hypertension (as below). The patient improved with
diuresis and was transferred to the floor on 3L NC and 35% FM.
The patient did well initially but then developed increased
sputum and an increase oxygen requirement and was transferred to
the MICU. There he was given another 8 day course of vancomycin
and zosyn and was aggressivly diuresed. The patient returned to
the floor on 3L NC during the day and 40% FM overnight. He has
remained on this oxygen level with SaO2 > 92 percent. The
patient continued to have a cough with mimimal sputum
production. He had chest PT, acapella valve and incentive
spirometry. The patient was discharged with home oxygen.
#. Pulmonary Hypertension: The patient has severe pulmonary
hypertension. The likely etiology is from chronic thromboembolic
disease which was worsened from volume overload. The patient was
started on sildenafil, which was uptitrated to 100mg TID. The
patient had daily ambulatory O2 sats. He was continued on
coumadin and aspirin with an INR goal of [**2-5**]. Will need follow
up with a pulmonologist as an outpatient and a pulmonary
hypertension specialist. He may also warrant evaluation for lung
transplantation in the future.
#. Abdominal wound: Due to recent repair of encarcerated hernia
and bowel resection. The abdominal wound is open and draining
serosangiunous fluid at the distal edge of the wound. Surgery
has evaluated the wound and states that it does not appear to be
infected and to continue daily dressings with gauze. The patient
will need to follow as an outpatient with a general surgeon.
#. Leukocytosis: Unclear source. The patient was treated
multiple times for HAP/VAP. Also worrisome for intraabdominal
pathology around wound site. The patient remained afebrile and
clinically did not look infected. CXR showed no evidence of
pneumonia. No evidence of infection on recent cultures.
#. Atrial flutter: The patient had a cardioversion at the
outside hospital. Had one episode in the MICU which resolved
with sotalol and digoxin. He is maintained on these two
medications and should be followed by a cardiologist as an
outpatient.
#. DM type II: The patient was maintained on an insulin sliding
scale.
#. GERD: Continued PPI.
Medications on Admission:
Medications upon discharge at [**Hospital3 10377**]:
- Perceocet [**1-4**] q4 prn pain
- Lovenox 160mg SC qd
- Glipizide 5mg PO daily
- Nexium 40mg PO daily
- Zocor 20mg PO daily
- Metformin 850mg PO bid
- Lasix 80mg PO bid
- Digoxin 0.125mg PO daily
- Sildenafil 20mg PO tid
- Sotalol 80mg PO bid
- Levaquin 500mg PO daily (stop date [**2144-1-9**])
- Albuterol nebulizer prn
- Coumadin 4mg PO daily
- Aspirin 325mg PO daily on hold
- Plavix 75mg daily on hold
.
Medications upon transfer to CC7:
-Enoxaparin Sodium 90 mg SC Q12H
-Aspirin 81 mg PO/NG DAILY
-Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose
-Sotalol 80 mg PO BID
-traZODONE 25 mg PO/NG HS:PRN insomnia
-Furosemide 40 mg IV BID
-Warfarin 3 mg PO/NG DAILY16
-Simvastatin 20 mg PO/NG DAILY
-Vancomycin 1000 mg IV Q 24H
-Morphine Sulfate 2 mg IV Q6H:PRN pain
-Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
-Pantoprazole 40 mg PO Q24H
-Sildenafil 20 mg PO TID
-Digoxin 0.125 mg PO/NG DAILY
-Ipratropium Bromide Neb 1 NEB IH Q4H
-Albuterol 0.083% Neb Soln 1 NEB IH Q4H
-Acetaminophen 500 mg PO/NG Q6H:PRN fever, ha, pain
-Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob wheeze
-Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob
-Piperacillin-Tazobactam 4.5 g IV Q8H
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis:
1. Pulmonary Hypertension
2. Ventilator associated pneumonia
Secondary Diagnosis:
Discharge Condition:
.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital from [**Hospital3 417**] Hospital
after an abdominal surgery. At that time you were found to be
hypoxic and requiring oxygen. You were transferred to [**Hospital1 18**] and
were taken to the intensive care unit for further monitoring.
You were given IV antibiotics for a pneumonia. You were also
diuresed to get rid of extra fluid that built up on your lungs.
With antibiotics and aggressive diuresis your oxygenation
improved. You were continued on oxygen therapy and your previous
medications. You will need to follow up with a pulmonologist as
an outpatient as it appears you have pulmonary hypertension. For
further evaluation and management of your pulmonary hypertension
it is very important for you to go to your appointments.
The following medications were changed:
1. You were started on Viagra 100mg three times per day
2. Your plavix was stopped
3. Your aspirin was changed to 81mg daily
4. Your lasix was decreased to 20mg twice per day
Followup Instructions:
Appointment #1
Dr [**Last Name (STitle) 82906**] - Surgical Follow-up
[**2144-2-20**] at 4:30
[**Apartment Address(1) 82907**], [**Location (un) **]
[**Hospital1 1474**], MA
.
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4318**], NP (works with Dr [**Last Name (STitle) **]
Specialty: Primary Care
Date/ Time: [**2-18**] at 11am
Location: [**Location (un) **] , [**Hospital1 1474**], MA
Phone number: [**Telephone/Fax (1) 10216**]
.
Appointment #3
MD: Dr [**First Name4 (NamePattern1) 714**] [**Last Name (NamePattern1) **] with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Pulmonology
Date/ Time: [**3-11**] at 3:30 for a breathing test and the 4pm
with the doctor.
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**], Medical
Specialites
Phone number: [**Telephone/Fax (1) 612**]
Completed by:[**2144-2-5**]
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78,097
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100+55185
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-11-23**] Discharge Date: [**2195-12-2**]
Date of Birth: [**2127-7-17**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Ativan
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
Incision and drainage with resection of first metatarsal
[**2195-11-25**]
Wound closure [**2195-11-30**]
History of Present Illness:
Mr. [**Known lastname 1137**] is a 68yo M w/hx of DM2 (A1c [**10-23**] 7.1%), afib on
coumadin, chronic diabetic foot ulcers, h/o EtOH abuse, and HTN
who was sent in from his PCPs office with symptomatic
hypoglycemia to 36 that has been ongoing for 3+ days. FSGs have
been 30s-50s, even postprandially. He usually runs in the 130s.
No recent changes to hypoglycemics, and states he has been
adherent to his meds without overdoses. He states that he is
asymptomatic with these sugars, but his wife says he's been
sleepier. Per his wife, his diet has been healthier with less
sugar recently. In his PCP's office, his FSG went up to 70s with
glucose tabs and glucagon. Was also seen by podiatry clinic this
AM with non-healing ulcer that requires surgical debridement.
Then sent to ER.
.
In the ED, VS 97.6 68 142/97 18 96% 2L. Exam revealed guaiac
negative OB brown stool. Labs showed elevated WBC count of 15.6
with 90%PMNs, elevated INR of 9.5, and hypoglycemia with glucose
of 63. Serial glucose monitoring revealed: 12:45 glu 30 -> amp
D50. 1:45 gluc 30 -> amp D50. 14:30 gluc 147. 15:30 FSG 19 --> 2
more amps d50. Also got 1L D51/2NS. Also received octreotide
50mcg. Reveived Vanco, cipro, flagyl per podiatry and was put on
a CIWA for hx of EtOH withdrawal (did not need any down in ED).
Podiatry felt that he will require surgery but deferred given
elevated INR. Most recent vitals: afebrile 63 168/45 20 95% 2L.
.
Currently, he patient denies nausea/vomiting/lightheadedness,
tremulousness, or sweats. He did feel some of these symptoms
down in the ER when his sugar was low. He denies recent fevers
or chills. He does note that he has been on a new medication,
Bactrim, as well as a higher dose of coumadin, since his
admission [**Date range (1) 1138**] for fall, hip pain. No new cough, SOB, chest
pain, palpitations, abdominal pain, nausea, or vomiting. He has
been tolerating his po's very well. He notes asymmetric leg
swelling which is not new for him. He has had more pain in his
foot ulcer and hip (from a fall last week), for which he has
been taking oxycodone.
Past Medical History:
1. Diabetes Mellitus
2. COPD
3. Hypertension
4. Atrial fibrillation
Social History:
Home: lives with wife.
[**Name (NI) 1139**]: [**Name2 (NI) **] tobacco
EtOH: [**4-20**] drinks/day.
Family History:
FH + for Throat cancer and colon cancer.
Physical Exam:
Gen: NAD, elderly male, oriented x3,
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Marked rhinophyma.
Neck: Supple, JVP difficult to assess given habitus.
CV: regular rhythm, normal rate, normal S1, S2. No m/r/g.
Chest: poor air movement with decreased BS at bases, Resp were
unlabored, no accessory muscle use. CTAB, no
rales, wheezes or rhonchi.
Abd: Obese, Soft, NTND. No HSM or tenderness.
Ext: 3+ edema of LLE to knee, foot wrapped in bandages with
bloody drainage from under first MTP. trace edema RLE, asymmetry
c/w prior exams
Neuro: Alert and oriented x 3, 5/5 strength in upper and lower
extremities bilaterally, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS: [**2195-11-23**]
WBC 15.8 / Hct 29.6 / Plt 568
INR 9.3
Na 137 / K 5.2 / Cl 99 / CO2 27 / BUN 19 / Cr 1.1 / BG 63
CK 48 / MB 4 / Trop T .02
AST 22 / LDH 119 / Alk Phos 200 / TB .3 / Alb 3.4 / Dig 2.3
DISCHARGE LABS: [**2195-12-2**]
Na 139 / K 4.2 / Cl 101 / CO2 30 / BUN 9 / Cr .8 / BG 82
Ca 8.9 / Mg 1.8 / Phos 4
WBC 9.9 / Hct 31.8 / Plt 362
INR 2 / PTT 28.9
MICROBIOLOGY:
[**2195-11-23**] Blood Cx negative
[**2195-11-23**] Wound Swab Culture - Presumptive peptostreptococcus
[**2195-11-23**] Urine Cx negative
[**2195-11-25**] Tissue Culture - rare growth - MSSA
[**2195-11-25**] Swab Culture - pan-sensitive Enterococcus
[**2195-11-30**] Tissue Cx - Coag negative Staph
STUDIES:
[**11-23**] Foot Xray:
1) Sensitivity for osteomyelitis somewhat limited by overlying
bandage.
2) Osteopenia, which is worse compared with [**2195-9-23**] and probably
slightly worse compared with [**2195-11-14**], but without definite
discrete bone destruction. Please see comment.
[**2195-11-24**]: TTE: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2195-9-25**], a
left pleural effusion and mild pulmonary artery systolic
hypertension are now identified.
[**2195-11-25**]: Chest xray: In comparison with the earlier study of
this date, there is continued enlargement of the cardiac
silhouette. On the lateral view, there is substantial bilateral
pleural effusion. No evidence of vascular congestion.
[**2195-11-25**] Foot xray: Since the previous study, there has been
debridement at the first MTP joint.
Cortical irregularity at the base of the first proximal phalanx
and of the first metatarsal head is seen. There is gauze
material seen at the surgical site. There are prominent spurs
about the calcaneal tuberosity. There is a lot of soft tissue
swelling. Please refer to the operative note for additional
details.
[**2195-11-30**] Foot XR - There appears to have been resection of the
distal first metatarsal and base of the first proximal phalanx.
There is an overlying skin defect and associated subcutaneous
emphysema. Direct comparison to the [**2195-11-25**] films is limited
due to overlying bandage, but the bone resection is new compared
with [**2195-11-23**]. No other areas of focal osteolysis are identified
at this time.
PATHOLOGY:
[**2195-11-25**]
1. Sesamoid, left foot (A):
- Trabecular bone fragments with marrow fibrosis, acute
osteomyelitis and osteonecrosis.
- Hyaline cartilage with focal acute inflammation.
2. Bone, left first metatarsal head (B-C):
- Trabecular bone with marrow fibrosis, acute osteomyelitis and
osteonecrosis.
- Hyaline cartilage with focal acute inflammation.
3. Bone, base of hallux left foot (D):
- Trabecular bone with focal osteonecrosis, acute inflammation,
marrow fibrosis, and extensive remodelling.
- Hyaline cartilage with focal acute inflammation.
[**2195-11-30**] Left foot, proximal phalanx, excision (A):
- Markedly reactive bone with acute inflammation.
[**2195-11-30**] Left foot, clearing fragment, excision (B):
- Bone with marked reactive changes.
Brief Hospital Course:
68 yo man with type 2 diabetes melitus, atrial fibrilation, and
chronic left foot osteomyelitis with cellulitis was admitted
with hypoglycemia and bradycardia.
1. Hypoglycemia: He was initially admitted to the ICU given
persistent hypoglycemia in the setting of recent bactrim use
with glipizide, which was thought to prolong the effects of the
glipizide. He required D50 boluses and an octreotide drip with
D10 in the ICU to maintain his blood sugar. His blood sugar
improved from 30's to 300's and the octreotide drip and D10 drip
were stopped. After his multiple podiatric procedures were
performed, his oral hypoglycemics were restarted and his blood
sugars remained stable between 80-200.
2. Bradycardia: Noted on admission, thought secondary to
elevated digoxin level and interaction with bactrim. His digoxin
and verapamil were initially held. They were then both restarted
once his many procedures were completed, and his heart rate
remained between 60-80s.
3. Left osteomyelitis and cellulitis: He was treated with
vancomycin, ciprofloxacin and flagyl starting [**2195-11-23**]. He
underwent bone resection with podiatry [**2195-11-25**]. Based on
culutre results, pan-sensitive mssa and enterococcus, so
antibiotics were changed to unasyn on [**2195-11-28**]. He was taken
back to the OR for wound closure on [**2195-11-30**]. He was then
transitioned to augmentin. He was recommended to continue
augmentin at least until he follows up with his primary
podiatrist on [**2195-12-7**] at which time length of treatment course
will be decided. He was evaluated by physical therapy on the day
prior to discharge, and he was cleared to go home with home PT.
He was recommended to remain non-weight bearing on his left
foot.
4. Benign hypertension: The patient has chronic hypertension
with poor blood pressure control. In the intensive care unit,
his systolic blood pressure rose to almost 200, requiring
treatment with hydralazine. The patient's home verapamil was
continued, but his lisinopril was discontinued due to
hyperkalemia. Lasix was used as needed for volume overload and
his lisinopril was restarted with improved blood pressure
control.
5. Volume overload: The patient developed increased work of
breathing and volume overload in the setting of his D10 drip.
The D10 drip was discontinued, and patient was treated with
Lasix, with improvement in his symptoms.
6. Type II Diabetes melitus, uncontrolled with complications:
His oral agents were held in house as above and glycemic control
achieved with sliding scale of insulin. He was restarted on both
his metformin and glipizide 24 hours prior to discharge, and his
blood sugars remained stable between 80-200.
7. Atrial fibrillation: He was rate controlled with verapamil
and digoxin. He is chronically anticoagulated with coumadin, and
was admitted with an inr of 9.3. He had no bleeding. He was
given vitamin k, with gradual improvement in his inr. His
coumadin was held. This was restarted on [**2195-11-30**], and his INR
was 2 on discharge.
8. Chronic diastolic heart failure: He was treated with
intermittent diuresis for volume overload. He was restarted on
ace inhibitor.
9. Anemia: He was noted to have anemia of chronic disease, with
stable hct.
Medications on Admission:
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
Warfarin 3 mg Tablet q TThSat
Warfarin 2 mg Tablet qWMFSun
Omeprazole 20 mg Capsule PO DAILY
Trazodone 100 mg Tablet PO HS as needed for insomnia.
Glipizide 10 mg Tablet PO twice a day.
Verapamil 360 mg Cap,24 hr Sust Release PO once a day.
Lisinopril 40 mg Tablet PO once a day.
Metformin 500 mg Tablet PO twice a day.
Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO q6h
prn
Digoxin 250 mcg Tablet PO once a day.
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID prn
Trimethoprim-Sulfamethoxazole 160-800 mg, 2 tabs PO BID
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. Verapamil 180 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q24H (every 24 hours).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours): Please continue this at least
until your appt with Dr. [**Last Name (STitle) 1140**] on Monday [**12-7**]. .
Disp:*21 Tablet(s)* Refills:*0*
11. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO q Monday
Wednesday Friday Sunday.
12. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO Tuesday
Thursday Saturday.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary:
Hypoglycemia, cellulitis, osteomyelitis, bradycardia.
Secondary:
Type II diabetes mellitus, hypertension, chronic diastolic heart
failure, atrial fibrillation.
Discharge Condition:
Stable vital signs
Discharge Instructions:
You were admitted with low blood sugar and low heart rates
thought due to a medication interaction with an antibiotic and
your usual medications. You were also treated for your infected
left foot with podiatry. You were started on antibiotics. We
recommend that you continue this antibiotic (augmentin) at least
through your next podiatry appointment on [**2195-12-7**] at which time
Dr. [**Last Name (STitle) 1140**] can decide for how long to continue the antibiotics.
We have made the following changes to your medications:
- augmentin: This is an antibiotic to help treat your foot
infection. Please continue this antibiotic until you see Dr.
[**Last Name (STitle) 1140**]. At that time, she can decide for how long to continue the
antibiotics.
Please return to the emergency department or call your physician
if you experience fevers, chills, palpitations, bleeding, foot
pain, light-headedness, dizziness, or passing out.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1141**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], DPM Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2195-12-7**] 9:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2195-12-7**] 12:30
Name: [**Known lastname 99**],[**Known firstname 33**] J Unit No: [**Numeric Identifier 100**]
Admission Date: [**2195-11-23**] Discharge Date: [**2195-12-2**]
Date of Birth: [**2127-7-17**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Ativan / Bactrim Ds
Attending:[**Last Name (NamePattern1) 101**]
Addendum:
Patient's fluid overload as described in problem #5 was an acute
exacerbation of his known chronic diastolic heart failure as
described in problem #8.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) 102**]
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 103**]
Completed by:[**2195-12-20**]
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41,976
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35278
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Discharge summary
|
report
|
Admission Date: [**2201-11-16**] Discharge Date: [**2201-11-19**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Decreased responsiveness
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
Femoral central line
History of Present Illness:
65M with PMHx of CVA (nonverbal and does not move his arms or
legs at baseline), Afib on coumadin, multiple pneumonias (s/p
trach/PEG [**3-/2200**]), multiple UTI/urosepsis with Proteus sensitive
to Cefepime/ceftriaxone/meropenem, ESBL Klebsiella sensitive to
cipro/meropenem/zosyn, C diff s/p colectomy, type 2 diabetes
mellitus, peripheral vascular disease. Patient presents from
[**Hospital1 1501**] found today with sats 80s and not responding to commands,
not nodding. Baseline non-verbal, but will nod to questions.
In ED, BPs dipped to high 80s, low 90s. Patient with a trach,
seems to have a cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] need to be changed out. UA
positive. Given cefepime and vanco. Trop may be demand. Given 2L
NS.
On transfer, VS: 85 95/52 16 100% trach mask.
On arrival to the ICU, HR 73, BP 87/53, RR 11, 93% trach mask.
Patient unresponsive, not moving extremities.
Review of systems: unable to obtain, patient unresponsive
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) -
Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**]
(outside facility, [**12/2198**] here)
Social History:
Prior resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], now at [**Hospital 16662**] Nursing Home.
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
Admission exam:
Vitals: HR 73, BP 87/53, RR 11, 93% trach mask
General: Unresponsive, no respiratory distress. No facial
expression, not moving extremities
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchi from anterior lung fields. No crackles.
CV: RRR, 2/6 systolic ejection murmur. No rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: Foley draining purulent urine
Ext: cold, not well perfused, slow cap refill. b/l hands and
feet contracted. no cyanosis or edema
Discharge exam:
Vitals: HR 84 BP 128/72 97% trach mask
Gen: Nodding to questions
GU: foley draining clear urine
Ext: warm and well perfused
Exam otherwise unchanged
Pertinent Results:
[**2201-11-16**] 07:45PM BLOOD WBC-21.5*# RBC-6.16 Hgb-13.5* Hct-43.8
MCV-71* MCH-21.9* MCHC-30.8* RDW-16.8* Plt Ct-213
[**2201-11-16**] 07:45PM BLOOD Neuts-86.9* Lymphs-7.5* Monos-4.4 Eos-1.0
Baso-0.1
[**2201-11-16**] 07:45PM BLOOD PT-22.3* PTT-30.1 INR(PT)-2.1*
[**2201-11-16**] 07:45PM BLOOD Glucose-171* UreaN-47* Creat-2.0*# Na-137
K-6.4* Cl-97 HCO3-27 AnGap-19
[**2201-11-16**] 07:45PM BLOOD ALT-33 AST-62* AlkPhos-88 TotBili-0.8
[**2201-11-16**] 07:45PM BLOOD Lipase-32
[**2201-11-16**] 07:45PM BLOOD cTropnT-0.13*
[**2201-11-16**] 07:50PM BLOOD Glucose-160* Lactate-3.5* Na-142 K-5.3*
Cl-98 calHCO3-29
MICROBIOLOGY:
Blood culture x2 ([**2201-11-16**])- pending, NGTD
Urine culture ([**2201-11-16**])- preliminary, pending final
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Sputum culture ([**2201-11-16**])-
GRAM STAIN (Final [**2201-11-16**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2201-11-19**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Stool culture ([**2201-11-17**])- negative for c.difficule toxin
IMAGING:
CT head [**2201-11-16**]:
FINDINGS: No hemorrhage, evidence of acute major vasculaR
territorial
infarction, edema, or shift of normally midline structures is
present.
Ventricles and sulci remain mildly prominent. Large arachnoid
cyst in the
left middle cranial fossa is stable. ICA, vertebral and basilar
calcifications are stable. Periventricular hypodensities are
consistent with small vessel ischemic changes. Retained
secretions are seen in the
oropharynx. The visualized mastoid air cells and paranasal
sinuses are well aerated. Minimal thickening is seen in the
anterior left ethmoid air cells.
IMPRESSION: No acute intracranial process.
CXR [**2201-11-16**]:
FINDINGS: Portable AP upright chest radiograph is obtained. Hazy
opacities
are new in the mid and lower lungs, which is concerning for
pneumonia. No
large effusion or pneumothorax is seen. Cardiomediastinal
silhouette appears grossly stable.
IMPRESSION: New hazy opacities involving the mid and lower lungs
could
reflect pneumonia.
CXR [**2201-11-18**]: PICC tip projecting over mid SVC
Brief Hospital Course:
65M with PMHx of CVA, h/o multiple pneumonias (s/p trach/PEG
[**3-/2200**]) with Pneudomonas, multiple UTI/urosepsis with Proteus
and ESBL Klebsiella, presents from [**Hospital1 1501**] with sats 80s and
decreased responsiveness.
# Hypotension: Patient initially hypotensive with SBP 80s and
MAP 50s. Hypotension due to septic shock as lactate elevated to
3.5 on presentation. Given grossly dirty UA, UTI was thought to
be most likely source. However, with hypoxia, pneumonia and
pulmonary source were also considered. Patient has an extensive
history of UTI and pneumonia with ESBL Kleibsiella, and
Pseudomonas sensitive to cipro and gentamicin. Hypovolemic
hypotension possible, but patient only minimally responsive to
fluid boluses. No obvious source of bleeding. Hct well-above
baseline, likely hemoconcentrated. In the [**Hospital Unit Name 153**], femoral CVL
placed, and patient responded to some fluid boluses. He briefly
required levophed. He was off of pressure support and not
requiring fluid boluses for greater than 24 hours on the day of
discharge. Blood cultures showed no growth to date and urine
cultures grew proteus and gram negative rods in sputum. Patient
was broadly covered with meropenem, cipro and vancomycin. Cipro
was discontinued and patient was discharged on vancomycin and
meropenem with planned 8 day course (day 3 on day of discharge).
A PICC line was placed on [**2201-11-18**] for antibiotic
administration.
# Hypoxia: O2 sat in 80s at nursing home. Improved to mid 90s
on trach mask. Patient was treated with antibiotics as above
and improved.
# [**Last Name (un) **]- Patient with history of [**Last Name (un) **] with septic episodes. Given
elevation BUN/Cr ratio, likely pre-renal etiology in the setting
hypotension and hypoperfusion. Cr trended down to baseline
(1.0) with fluid resuscitation.
# Goals of care: Discussed at length with family. Decided to
make patient DNR but ok to ventilate via trach if needed.
# Atrial Fibrillation - EKG was consistent with Sinus rhythm.
Coumadin initially held and INR was 3.8 on the day of discharge
so was held.
# Sacral decubitus ulcer: Granulation tissue with no exudate.
Two Stage 2 ulcers.
# Hypothyroidism: stable. T4 in [**9-/2201**] 10.0 (wnl). Continued on
home Levothyroxine.
# Type 2 Diabetes: Stable. FS Glucose, HISS.
# Peripheral Neuropathy: Continued home Gabapentin and Fentanyl
Patch
# Depression: Switched duoloxetine to Paxil for NG tube.
Continued mirtazapine.
# GERD: Continued lansoprazole.
.
TRANSITIONAL ISSUES:
- held warfarin at the time of discharge as INR 3.8
- meropenem and vancomycin x 8 days (final day = [**2201-11-24**])
- code status: CHANGED to DNR, ok to ventilate via trach if
necessary
- pending labs/studies: blood cultures x 2, final urine culture
- follow-up: vancomycin trough on [**11-20**] prior to AM dose needs to
be drawn
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) nebs q6H
2. ipratropium bromide 0.02 % nebs q6H
3. baclofen 15mg PO QID
4. duloxetine 30 mg Capsule, Delayed Release(E.C.) PO BID
5. fentanyl 100 mcg/hr Patch q72hr
6. gabapentin 300 mg q8H
7. levothyroxine 25 mcg PO DAILY
8. mirtazapine 15 mg PO qHS
9. acetaminophen 650 mg/20.3 mL Solution PO Q6H prn pain
10. ascorbic acid 500 mg PO DAILY
11. miconazole nitrate 2 % Powder Appl Topical [**Hospital1 **] prn skin
irritation
12. senna 8.6 mg PO BID prn constipation.
13. lansoprazole 30 mg Tablet,Rapid Dissolve DR [**Last Name (STitle) **] DAILY
14. bisacodyl 10 mg Tablet PO DAILY prn constipation.
15. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution PO daily
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) nebs q2H prn SOB
17. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension
15-30ml PO QID prn stomach upset.
18. meropenem 500 mg Recon Soln IV Q6H for 11 days (last day
[**10-13**])
19. docusate sodium 50 mg/5 mL Liquid 10ml PO qHS
20. enoxaparin 80 mg/0.8 mL Subcutaneous [**Hospital1 **] until INR is
therapeuic
21. [**Hospital1 8472**] 100 unit/mL Solution 34 units qHS
22. Insulin Sliding Scale
23. warfarin 4 mg PO daily
24. acetylcysteine 20% (200 mg/mL) 1 QID
25. ipratropium bromide 0.02 % nebs q2h prn SOB
26. Milk of Magnesia 400 mg/5 mL 30 ml PO daily prn constipation
27. Glucerna Liquid [**Hospital1 **]: One (1) app PO once a day: 1.2 via
feeding pump at 75 mL/hr. Up at 2pm down at 10am.
28. multivitamin PO daily
29. Novolin R 100 unit/mL Solution [**Hospital1 **]: per sliding scale
Injection QAC.
Discharge Medications:
1. levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. therapeutic multivitamin Liquid [**Hospital1 **]: Five (5) milliliters
PO DAILY (Daily): Gtube at 9AM.
3. Novolin R 100 unit/mL Solution [**Hospital1 **]: per sliding scale
Injection four times a day: 6:30, aA:00, 16:00, 21:0O daily.
Sliding Scale: 0-200 = 0 units, 201-250 = 2 units, 251-300 4
units, 301-350 = 6 units, 351-400 = 8 units, 401 - 450 = 10
units, 451-500 = 12 units, >500 units = [**Name8 (MD) **] MD/NP.
4. mirtazapine 15 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO HS (at
bedtime): 9 PM.
5. acetaminophen 325 mg Tablet [**Name8 (MD) **]: Two (2) Tablet PO four times
a day as needed for pain: or temperature > 100.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name8 (MD) **]: One (1) Inhalation q2hrs as needed for
shortness of breath or wheezing.
7. bisacodyl 10 mg Suppository [**Name8 (MD) **]: One (1) Rectal once a day
as needed for constipation.
8. glucagon (human recombinant) 1 mg Recon Soln [**Name8 (MD) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: PRn glycometer check < 70 special insrtuctions: if BS
< 70 and resident unresponsive give glucagon 1 mg sub-q, recheck
FS in 10 minutes, notify MD/NP.
9. Milk of Magnesia 400 mg/5 mL Suspension [**Name8 (MD) **]: Thirty (30)
milli-liters PO once a day as needed for constipation.
10. Mylanta 200-200-20 mg/5 mL Suspension [**Name8 (MD) **]: Thirty (30) PO
four times a day as needed for heartburn.
11. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Name8 (MD) **]:
0.25 milliliters PO every twelve (12) hours as needed for pain.
12. senna 8.6 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. miconazole nitrate 2 % Powder [**Name8 (MD) **]: One (1) Topical twice a
day as needed for groin.
14. nystatin 100,000 unit/g Powder [**Name8 (MD) **]: One (1) Topical twice a
day as needed for hand (right).
15. zinc oxide Ointment [**Name8 (MD) **]: One (1) Topical twice a day as
needed for buttocks.
16. baclofen 10 mg Tablet [**Name8 (MD) **]: 1.5 Tablets PO QID (4 times a
day): g tube.
17. docusate sodium 50 mg/5 mL Liquid [**Name8 (MD) **]: Ten (10) PO once a
day as needed for constipation.
18. Cymbalta 30 mg Capsule, Delayed Release(E.C.) [**Name8 (MD) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
19. fentanyl 75 mcg/hr Patch 72 hr [**Name8 (MD) **]: One (1) Transdermal
once a day: change q72 hours.
20. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution [**Name8 (MD) **]: Five
(5) mL PO once a day.
21. gabapentin 250 mg/5 mL Solution [**Name8 (MD) **]: One (1) PO every eight
(8) hours.
22. Glucerna Liquid [**Name8 (MD) **]: One (1) PO qshift.
23. lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Name8 (MD) **]: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
24. insulin glargine 100 unit/mL Solution [**Name8 (MD) **]: Thirty Four (34)
Subcutaneous at bedtime.
25. meropenem 500 mg Recon Soln [**Name8 (MD) **]: One (1) Intravenous every
eight (8) hours for 5 days: ending [**2201-11-24**].
26. vancomycin 1,000 mg Recon Soln [**Year (4 digits) **]: One (1) Intravenous
every twelve (12) hours for 5 days: ending [**2201-11-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Urosepsis v pneumonia
Discharge Condition:
Mental status: nonverbal, nods to questioning
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Patient was admitted with hypotension concerning for septic
shock. He was treated with meropenem and vancomycin and a PICC
line was placed for ongoing IV antibiotics. Antibiotics should
be continued through [**2201-11-24**]. Patient will need vancomycin
trough level checked tomorrow morning prior to 4th dose
([**2201-11-20**]).
Warfarin was held as INR supratherapeutic at 3.8.
MEDICATION CHANGES:
START vancomycin 1000mg IV q12h ending [**2201-11-24**]
START meropenem 500mg IV q8h ending [**2201-11-24**]
HOLD warfarin until INR therapeutic
Followup Instructions:
Department: [**Year (4 digits) 706**] CARE UNIT
When: WEDNESDAY [**2202-1-27**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) 706**]
When: WEDNESDAY [**2202-1-27**] at 10:00 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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"V58.61",
"V44.0",
"272.4",
"584.9",
"038.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13555, 13654
|
5746, 8270
|
13720, 13720
|
3235, 5723
|
14442, 14959
|
2363, 2431
|
10251, 13532
|
13675, 13699
|
8652, 10228
|
13868, 14253
|
2446, 3050
|
3066, 3216
|
8291, 8626
|
1336, 1376
|
14273, 14419
|
267, 372
|
400, 1316
|
13735, 13844
|
1398, 2017
|
2033, 2347
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,510
| 144,403
|
2938
|
Discharge summary
|
report
|
Admission Date: [**2144-2-16**] Discharge Date: [**2144-2-25**]
Date of Birth: [**2109-5-30**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Dilaudid / Compazine
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
TIPs
History of Present Illness:
34 yo male with Factor IX deficiency, HIV/AIDS, and HCV
co-infection acquired from transfusion of contaminated blood
products, presented as a transfer from [**Hospital3 **] Hospital after
presenting on [**2-15**] with hematemesis and BRBPR x 1 day. On
arrival to OSH intial VS: 98.3 94 85/45 16 97% RA and Hct
17 (baseline 37). Pt was bolused with 50 mcg of octreotide and
given 5000 U of Factor IX. Hct post transfusion with 5U pRBC was
39. He was also treated with IVF and IV PPI.
Past Medical History:
1. Factor 9 deficiency. Diagnosed at 3 months. Ankle
hemarthroses but no prior severe bleeding. On weekly monoclonal
Factor 9 (3000U). Baseline Factor 9 < 1%
2. HIV - dx'ed [**2127**]. CD4 [**2-8**] 49, nadir CD4 2. VL < 50. H/o MAC
and thrush.
3. HCV with cirrhosis. C/b ascites, edema, varices,
encephalopathy, SBP.
4. H/o ankle hemarthroses.
5. Cutaneous molluscum contagiosum
6. H/o paraappendiceal abscesses
7. Peripheral neuropathy
8. Low testosterone
Social History:
No EtOH (quit 4 yrs ago)
Married with 3 children
No tob
On disability
Family History:
Mother - RA. 6 of 7 of the mother's brothers have hemophilia.
Physical Exam:
97.5 115/64 104 21 97%3L
Awake, alertMMM
PERRL
s1s2 tachycardic, rrr
CTA
soft, NT +BS
1+ UE edema, no edema LE's
Pertinent Results:
[**2-19**] Post Tips Doppler
LIVER ULTRASOUND WITH COLOR DOPPLER: The liver parenchyma
demonstrates no diffuse abnormalities. There is no intra or
extrahepatic ductal dilatation. Noted is a moderate amount of
intra-abdominal ascites. There is redemonstration of sludge
layering within and otherwise normal-appearing gallbladder.
Color Doppler images of the liver and TIPS stent were obtained.
The hepatic veins and intrahepatic arteries are patent, with
flow in the appropriate direction. The intrahepatic arteries
show normal-appearing waveforms, with brisk upstrokes. The main
portal vein is patent, with flow in the appropriate direction
and velocity measured at 65 cm per second. The stent is widely
patent, with wall-to-wall flow demonstrated. Within the proximal
stent, a precise velocity could not be calculated secondary to
technical difficulties. Within the mid stent, the maximum
velocity is 173 cm per second. Within the distal stent, the
maximum velocity is 161 cm per second. Flow within the left
portal vein and anterior right portal vein is appropriately
reversed.
IMPRESSION:
1. Patent TIPS stent, with wall-to-wall flow. Velocities as
discussed above.
2. Gallbladder sludge.
3. Abdominal ascites.
Brief Hospital Course:
EGD showed Grade I non-bleeding esophageal varices, gastric
varices, and portal hypertensive gastropathy. In the gastric
fundus there was a questionable gastric varix with small ulcer.
No active bleeding was noted. He was transferred to the [**Hospital1 18**] on
[**2-16**] for evaluation by liver team for TIPS. On presentation to
[**Hospital1 18**] pt c/o nausea with dry heaves and epistaxis increased from
baseline. Reports last episode of BRBPR was earlier this
afternoon. Denied confusion, f/c, abdominal pain. 10 lb weight
loss over past month.
.
On admission to the [**Hospital1 18**] MICU, the pt was continued on PPI
q12h, octreotide drip, and with q6h hct checks. His BB was held
in the context of UGIB. Ceftriaxone was continued in the setting
of bacteremia prophylaxis. RUQ US on [**2-17**] showed cirrhotic liver
with ascites and splenomegaly, without evidence of hepatic or
portal venous thrombosis. EGD done at the [**Hospital1 18**] on [**2-17**] showed:
1) Snake skin appearance of the mucosa with no bleeding was
noted in the antrum and stomach body, compatible with portal
gastropathy. 2) Five non-bleeding polyps of benign appearance
(hyperplastic) found in the stomach in the pyloric region. 3)
Non bleeding conglomurate of varices was seen in the fundus, the
biggest of which was 1.5 cm, with a small non bleeding fibrin
covered ulcer of 0.3 cm. TIPS for decompression of varices was
recommended. The pt was pladed on standing lactulose with goal
of 3 stools per day.
.
Prior to the TIPS procedure on [**2-18**], the patient was given
fandostatin (Factor 9) 25U /kg q12 hours, then 25U/kg. The TIPS
procedure was completed by IR without difficulty but due to a
combination of the sedative medication used during the procedure
and onset of acute hepatic encephalopathy secondary to liver
shunting after the procedure, the patient had mental status
changes and was unable to protect his airway. He had copious
blood tinged secretions and an O2 sat of 93% on 6L FM. HR 120's
BP 120/70. He also had facial swelling from 4.5L rec'd in OR. He
was intubated at 7pm on [**2-18**]. CXR showed B interstitial and
alveolar opacities and effusions, c/w LVF.
.
RUQ US done [**2-19**] showed widely patent stent, main portal vein
patent, main portal vein patent, mid-stent velocity 173cm/s, GB
sludge. Octreotide and CTX were continued. Pt was extubated on
[**2-20**]. He continued to remain stable and was transferred from
the unit on [**2-21**]. His octreotide and ceftriaxone was stopped.
.
On the floor, his Hct remained stable without transfusions. He
was continued on his HAART and lactulose which he tolerated
well. His mental status remained blunted but stable. Abd US
taken the day prior to discharge revealed a patent tips.
.
He was continued on 1000 units [**Hospital1 **] of Factor IX when he was in
the hospital and was sent home on 2500 units [**Hospital1 **] of factor IX.
He will continue this for one week and follow up with his
hematologist.
.
Full code
Medications on Admission:
HOME MEDS:
Lactulose
Dapsone
Vitamin E
Viread
Epivir
Zithromax
Fosamax
Sustiva
Neupogen
Ethambutol
Phenergan
Spironolactone
Nadolone
.
ALL: Sulfa, aspirin
Discharge Medications:
1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
2. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
3. Enfuvirtide 90 mg Kit Sig: One (1) injection Subcutaneous [**Hospital1 **]
(2 times a day).
4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO Q AFTERNOON ().
5. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO Q AFTERNOON
().
6. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Testosterone 2.5 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours).
12. Ethambutol HCl 400 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [**4-8**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Mononine 1,000 (+/-) unit Recon Soln Sig: 2500 (2500) units
Intravenous twice a day for 7 days.
Disp:*[**Numeric Identifier 14123**] units* Refills:*0*
17. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection
twice a day for 7 days: use flushes with each injection of
mononine.
Disp:*14 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Liver Failure
HIV
HEP C
Factor IX deficiency
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications and make all appointments as listed
in the discharge paperwork.
You will need to give your self 2500 units of factor IX twice a
day for 1 week. Then you should call your hematologist for
further dosing. PLease follow each dose with a sterile saline
flush.
Please seek medical attention if you experience any of the
following: Fevers, chills, abdominal pain, blood in you stool,
vomitting, chest pain, shortness of breath, or severely clouded
thought.
Followup Instructions:
Please follow up with your primary care doctor, Dr [**Last Name (STitle) **]
([**Telephone/Fax (1) 14124**]) in [**2-6**] days of discharge. It is very important
that you get your electrolytes (esp potassium and magnesium)
checked since we changed your diuretics. Again this needs to be
done within 2-3 days!!! Remind him that we increased your
aldactone from 50mg to 100mg a day. Also we decreased your
lasix from 80mg to 40 mg a day.
Please call Dr. [**Last Name (STitle) 497**] [**Telephone/Fax (1) 673**] to schedual an appointment in
[**2-7**] weeks. Also please follow up with your hematologist to find
the dosing of your Factor IX after 1 week.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2144-2-27**]
8:30
Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2144-2-27**] 10:00
Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2144-2-27**] 2:30
|
[
"572.3",
"537.89",
"578.9",
"042",
"789.5",
"571.5",
"070.44",
"286.1",
"456.8",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"99.06",
"96.71",
"96.6",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7786, 7792
|
2861, 5848
|
295, 302
|
7881, 7889
|
1618, 2838
|
8421, 9545
|
1403, 1466
|
6053, 7763
|
7813, 7860
|
5874, 6030
|
7913, 8398
|
1481, 1599
|
252, 257
|
330, 819
|
841, 1300
|
1316, 1387
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,483
| 136,829
|
33763
|
Discharge summary
|
report
|
Admission Date: [**2124-5-18**] Discharge Date: [**2124-6-19**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
[**2124-5-20**] celiac, SMA, common/proper hepatic angiogram, PTC
cholangiogram & exchange
[**2124-5-24**] celiac & SMA angiogram
[**2124-6-2**] PTC exchange
[**2124-6-2**] GJ tube exchange
[**2124-6-9**] percutaneous tracheostomy
History of Present Illness:
This is a 76M with h/o gallstone pancreatitis c/b necrotizing
pancreatitis and prolonged ICU course ([**Date range (3) 78092**]), during
which he had an open tracheostomy ([**2124-2-4**]), open G/J tube
placement ([**2124-2-11**]), and percutaneous cholecystostomy tube
placement ([**2124-2-17**]). His cholecystostomy tube fell out on
[**2124-3-29**], leaving him with an uncontrolled cholecystocutaneous
fistula. He underwent subtotal cholecystectomy ([**2124-4-2**]),
internal-external biliary drain placement ([**2124-4-7**]), upsizing of
drain ([**2124-4-13**]), and replacement of PTBD with stent/pigtail
([**2124-4-27**]). He was discharged to rehab on [**2124-5-1**].
He was was readmitted on [**2124-5-13**], treated for pneumonia, and
discharged on [**2124-5-17**].
He returned on [**2124-5-18**] for guiaic positivity. In the ED, melena
was discovered.
Past Medical History:
PMH: gallstone pancreatitis, necrotizing pancreatitis, CAD s/p
MI (15 years ago), HTN, hyperlipidemia, obesity, OA, BPH,
duodenal ulcer, DM, atrial fibrillation, recent pneumonia
PSH: open trach ([**2124-2-4**]), open G/J tube placement ([**2124-2-11**],
percutaneous cholecystostomy tube ([**2124-2-17**]), open subtotal
cholecystectomy ([**2124-4-2**]), internal-external biliary drain
placement ([**2124-4-7**]), drain upsizing ([**2124-4-13**]), replacement of
PTBD with biliary stent/pigtail ([**2124-4-27**]), b/l TKR (most
recently R [**2124-1-5**])
Social History:
Being admitted from rehab. Previously lived with 2nd wife. [**Name (NI) **]
a daughter and 4 sons. Quit smoking 15 yrs ago. No history of
alcohol or IVDU. Retired contractor.
Family History:
Parents - HTN
Mother - CVA
Physical Exam:
On admission:
96.8 80 118/68 18 94%2L
MS/Neuro: A/O
HEENT: PERRLA, EOMI
CVS: RRR, no MRG
Pulm: CTA b/l, no RRW
Abd: soft, NT, ND, +BS, incision c/d, R sided WTD gauze packing,
PTC drain on R with no erythema, GJ tube capped
Ext: 1+ edema, pulses present b/l
On discharge:
98.2 69 125/74 18 99% CPAP & PS 0.4/360x26/5/5
Gen: NAD, trached
CVS: RRR
Pulm: CTA b/l, no resp distress
Abd: soft, distended, NT, incision c/d/i
Ext: no c/c/e
Pertinent Results:
On admission:
[**2124-5-17**] 06:45AM BLOOD WBC-9.9 RBC-2.80* Hgb-8.3* Hct-25.5*
MCV-91 MCH-29.4 MCHC-32.4 RDW-15.7* Plt Ct-229
[**2124-5-17**] 06:45AM BLOOD Glucose-74 UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-103 HCO3-29 AnGap-9
[**2124-5-17**] 06:45AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.9
[**2124-5-19**] 06:25AM BLOOD ALT-14 AST-15 AlkPhos-90 Amylase-31
TotBili-0.8
[**2124-5-19**] 06:25AM BLOOD Lipase-13
[**2124-5-19**] EGD:
GJ tube and internal biliary drain noted. Erosion in the second
part of the duodenum. Otherwise normal EGD to third part of the
duodenum. There was no source of bleeding noted on this exam to
the 3rd portion of the duodenum. The procedure was done by the
attending and GI Fellow.
[**2124-5-20**] EGD
GJ tube entering stomach body with adherent clot attached near
the bumper but NO source of bleeding noted. Biliary drain
entering duodenum through ampulla. No fresh or old blood in the
duodenum. Non-bleeding erosion in the second part of the
duodenum. Otherwise normal EGD to third part of the duodenum.
Additional notes: After extensive exploration, no source of
bleeding could be identified in the esophagus, stomach or
duodenum to the 3rd portion. A dieulafoy could have bled and
stopped or the patient could have hemosuccus which also stopped
spontaneously. Recommend angiography. If no source identified,
would proceed to colonoscopy as planned on Monday. The procedure
was done by the attending and GI Fellow.
Cultures:
[**2124-5-22**] 11:30 am SWAB Source: Rectal swab.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2124-5-25**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
[**2124-5-24**] 8:00 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2124-5-24**]):
[**10-7**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2124-5-26**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2124-6-1**] 4:09 pm URINE Source: Catheter.
URINE CULTURE (Final [**2124-6-2**]):
YEAST. >100,000 ORGANISMS/ML..
[**2124-6-6**] 7:07 am URINE Site: CLEAN CATCH
URINE CULTURE (Final [**2124-6-9**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
[**2124-6-6**] 7:08 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2124-6-6**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2124-6-8**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2124-6-7**] 2:26 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2124-6-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2124-6-10**]):
~1000/ML OROPHARYNGEAL FLORA.
ESCHERICHIA COLI. ~[**2115**]/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2124-6-16**] 5:00 pm SWAB Source: drainage around G-J tube.
GRAM STAIN (Final [**2124-6-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ENTEROCOCCUS SP.. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2124-6-18**]):
DUE TO LABORATORY ERROR, UNABLE TO PROCESS.
TEST CANCELLED, PATIENT CREDITED.
Radiology:
[**2124-5-20**] 4:37 PM Angiography & PTC exchange: 1. Normal SMA and
celiac trunk mesenteric angiograms with conventional anatomy and
no evidence of active bleeding, pseudoaneurysm or vascular
biliary fistulous connection. Limited dedicated angiogram of the
common/proper hepatic arteries as described above was also
unremarkable. 2. Replacement of right PTBD (double J) catheter
with distal pigtail coiled in jejunum and proximal pigtail
coiled within the biliary confluence. No hemobilia noted during
examination. The catheter is capped for internal drainage. Of
note, the insertion site does appear slightly indurated and
tender to touch, consistent with a mild local infection.
[**2124-5-23**] 4:17 PM UE US: No evidence of bilateral upper extremity
deep vein thrombosis.
[**2124-5-24**] 8:31 AM Angiography: Selective arteriograms were
performed in the celiac and superior mesenteric arteries without
signs of active bleeding. There are signs of occlusion of the
GDA since the original arteriogram a few days ago. Because no
obvious intervention was feasible, the procedure was terminated.
[**2124-6-2**] 11:07 AM Echo: The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%) The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small sized pericardial
effusion. The effusion appears loculated subtending the right
atrial free wall. There is brief right atrial diastolic
invagination but cardiac tamponade is not present.
Compared with the findings of the prior study (images reviewed)
of [**2124-1-21**], the findings are similar, but the
technically suboptimal nature of both studies precludes
definitive comparison.
[**2124-6-1**] Urine cytology: NEGATIVE FOR MALIGNANT CELLS
[**2124-6-1**] 1:09 PM CT chest: 1. No evidence of ARDS. Multifocal
peribronchial infiltrates are seen in the aerated portion of the
right lung, likely infectious versus aspiration. 2. Endotracheal
tube tip is in the right main bronchus resulting in almost
complete collapse of the left lung. This needs to be retracted
by at least 3 cm. 3. Worsening bilateral moderate-to-severe
pleural effusion with adjacent atelectasis. 4. A new hypodense
area in the liver worrisome for infection given the known
pancreatitis. A dedicated study such as ultrasound or dedicated
CT scan
examination of the abdomen is recommended. 5. In the presence of
extensive intrabdominal infection the possibility of bilateral
empyema could not be excluded, although the effusion appears
simple with no loculations or hyperdense material. This report
was discussed with Dr [**First Name (STitle) **].
[**2124-6-2**] 1:24 PM CT head: No acute abnormality. Sinus
opacification.
[**2124-6-2**] 1:47 PM PTC exchange: 1. Malpositioned and obstructed
indwelling right percutaneous trans-hepatic biliary drain, which
was successfully removed and replaced with a new 10 French 22 cm
double-pigtail internal-external biliary drain. 2. Unchanged
appearance to mild-to-moderate distal CBD stricture and known
variant biliary anatomy and remnant cystic duct/gallbladder. No
definite leak noted on today's exam.
[**2124-6-2**] 1:48 PM G/J tube exchange: Obstructed native/indwelling
GJ tube with crack in the jejunal tubing exiting into the
stomach lumen. Successful replacement with new 18 French MIC GJ
tube through the indwelling tract. The new GJ tube is
appropriately positioned and ready to use.
[**2124-6-6**] 9:28 AM CT torso: 1. Multifocal pulmonary opacities
particularly in the right middle lobe and left upper lobe may
represent multifocal pneumonia or aspiration. Moderate bilateral
pleural effusions remain; pigtail catheters in place. Bilateral
lower lobes remain collapsed. 2. Multiple rim-enhancing fluid
collections in the abdomen are little changed. Fluid collections
along the right paracolic gutter and also anterior to the
pancreatic head again contain foci of gas. Infectious process
cannot be excluded. Increased ascites compared to [**2124-5-13**]. 3.
Peripheral and wedge-shaped hypodensities along right hepatic
lobe and spleen, new compared to CT torso from [**2124-5-13**],
consistent with infarct.
4. Percutaneous gastrostomy and percutaneous transhepatic
catheter, again
both terminate in proximal jejunum. 5. Foley catheter with
balloon and tip terminating in prostate, with fluid distended
bladder. 6. Non-occlusive thrombus in right jugular vein
partially visualized.
[**2124-6-7**] 12:51 PM R subclavian & IJ US: Non-occlusive thrombus
in the right internal jugular vein.
On discharge:
[**2124-6-19**] 01:52AM BLOOD WBC-13.1* RBC-2.68* Hgb-8.2* Hct-24.2*
MCV-91 MCH-30.5 MCHC-33.7 RDW-15.7* Plt Ct-436
[**2124-6-19**] 01:52AM BLOOD Glucose-120* UreaN-14 Creat-0.4* Na-138
K-4.6 Cl-106 HCO3-26 AnGap-11
[**2124-6-19**] 01:52AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.9
Brief Hospital Course:
GI was consulted. EGD on [**5-19**] demonstrated a non-bleeding
erosion in D2. On [**5-20**], he developed hypotension, hematochezia,
and was transferred to the SICU. Repeat EGD demonstrated a clot
adherent to the GJ tube, but no active bleeding. Angiogram was
recommended, and was also negative. His PTC was exchanged at
that time. On [**5-24**], pt developed hematemesis, hematochezia,
hypotension, and desaturation. He was transferred to the SICU,
intubated, and started on pressors. Repeat angiogram
demonstrated a thrombosed GDA, but no source of bleed.
Vancomycin and Zosyn were started for presumptive aspiration
pneumonia. He was in ARDS and was oliguric. On [**5-25**], diltiazem
gtt was started for a-fib. Vanc was changed to linezolid on
[**5-26**]. On [**5-28**], antibiotics were changed to cefepime only, and
TPN was started. Diuresis was begun. He was gradually weaned
off pressors. Tube feeds were started on [**5-30**]. TPN and
antibiotics were d/c'd on [**6-1**]. CXR on [**6-1**] demonstrated
complete L lung white-out. CT chest demonstrated R
peribronchial infiltrates and b/l pleural effusions. Fluc was
started for yeast in urine. On [**6-2**], his GJ tube was changed as
the J tube was clogged. The PTC was also exchanged as the
pigtail was cracked. Lasix gtt was started. A CT head was
performed as the CT chest had demonstrated infarcts in the
liver; there were no infarcts in the brain. On [**6-3**], a L
pigtail was placed in the chest. On [**6-5**], a pigtail was placed
in the R chest. On [**6-6**], he was febrile to 102.2. CT torso
demonstrated multifocal pulmonary opacities. He was started on
vanc/Zosyn/Flagyl for presumptive pneumonia and C.diff
prophylaxis. CT incidentally demonstrated a RIJ thrombus.
Bronchoscopy was performed on [**6-7**]. All sputum and BAL cultures
eventually grew E.coli. ID was consulted and recommending
d/c'ing fluc. A RIJ U/S demonstrated a non-occlusive thrombus.
Vascular was consulted; anticoagulation was unnecessary. On
[**6-8**], the R chest pigtail was d/c'd. On [**6-9**], ID recommended
d/c'ing vanc and Flagyl. Patient underwent percutaneous
tracheostomy at the bedside by the Red Surgery team. On [**6-11**],
the L chest tube was d/c'd. Zosyn was d/c'd on [**6-12**], completing
a 7 day course. He had persistent high stool output. C.diff
was negative several times. On [**6-14**], pancreatic enzymes were
started. G tube was capped on [**6-16**]. For the remainder of the
hospital stay, patient was diuresed to near baseline weight and
his vent was weaned. Lasix gtt was changed to PO on [**6-19**]. On
discharge, he was tolerating trach collar intermittently. He
was afebrile with stable vital signs, tolerating tube feeds, and
getting out of bed to chair with PT. He is being discharged to
vent rehab.
Medications on Admission:
Medications on discharge [**2124-5-17**]:
1. Albuterol 90 mcg/Actuation Aerosol [**Month/Day/Year **]: One (1) Puff
Inhalation Q6H (every 6 hours).
2. Amiodarone 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder [**Month/Day/Year **]: One (1) Appl Topical PRN
(as needed).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Paroxetine HCl 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day).
9. Levofloxacin 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H (every
24 hours).
10. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Viokase 16 935 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO four times a
day.
13. Terazosin 10 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO at bedtime.
14. Finasteride 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO at bedtime.
15. Ursodiol 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO twice a day.
16. Insulin Regular Human 100 unit/mL Solution [**Month/Day/Year **]: Sliding
Scale Injection ASDIR (AS DIRECTED).
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day/Year **]: [**12-15**]
Drops Ophthalmic PRN (as needed).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
3. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2
times a day).
5. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
6. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs
Inhalation QID (4 times a day).
8. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
[**Telephone/Fax (3) **]: One (1) Powder in Packet PO TID (3 times a day).
10. Acetaminophen 160 mg/5 mL Solution [**Telephone/Fax (3) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed.
11. Metoprolol Tartrate 25 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID
(2 times a day).
12. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Age over 90 **]: Two (2) Cap PO TID (3 times a day).
13. Lorazepam 0.5 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
14. Simvastatin 10 mg Tablet [**Age over 90 **]: Two (2) Tablet PO DAILY
(Daily).
15. Furosemide 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times
a day).
16. Potassium Chloride 20 mEq Packet [**Age over 90 **]: Three (3) Packet PO
BID (2 times a day): check K daily while on Lasix and change KCl
dose as needed.
17. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
18. HydrALAzine 10-20 mg IV Q3H:PRN SBP>160
19. HYDROmorphone (Dilaudid) 0.125-0.5 mg IV Q4H:PRN
20. Protonix 40 mg Recon Soln [**Age over 90 **]: Forty (40) mg Intravenous
once a day.
21. Insulin Sliding Scale
Insulin SC Sliding Scale Q6H
Glucose Regular Insulin Dose
0-60 mg/dL [**12-15**] amp D50
61-120 mg/dL 0 Units
121-150 mg/dL 2 Units
151-180 mg/dL 4 Units
181-200 mg/dL 6 Units
201-220 mg/dL 8 Units
221-240 mg/dL 10 Units
241-260 mg/dL 12 Units
> 260 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
primary:
GI bleed, ARDS, pneumonia, ventilator dependence
.
secondary:
gallstone pancreatitis, necrotizing pancreatitis, CAD s/p MI (15
years ago), HTN, hyperlipidemia, obesity, OA, BPH, duodenal
ulcer, DM, atrial fibrillation, recent pneumonia; s/p open trach
([**2124-2-4**]), open G/J tube placement ([**2124-2-11**], percutaneous
cholecystostomy tube ([**2124-2-17**]), open subtotal cholecystectomy
([**2124-4-2**]), internal-external biliary drain placement ([**2124-4-7**]),
drain upsizing ([**2124-4-13**]), replacement of PTBD with biliary
stent/pigtail ([**2124-4-27**]), b/l TKR (most recently R [**2124-1-5**])
Discharge Condition:
Afebrile, vital signs stable, tolerating trach mask
intermittently, tolerating tube feeds at goal, out of bed to
chair daily.
Discharge Instructions:
Please call or return to ED with fevers >101.5, chills,
vomiting, hematemesis, melena or hematochezia, obstipation,
severe abdominal pain unresponsive to medication, incisional
erythema or purulent drainage,
.
Clamp G tube. All tube feeds via J tube. NPO. Physical therapy
as tolerated. Biliary drain capped.
Followup Instructions:
Please call Dr.[**Name (NI) 9886**] office at ([**Telephone/Fax (1) 14347**] to schedule a
follow up appointment within 2-3 weeks.
Completed by:[**2124-6-19**]
|
[
"250.00",
"427.31",
"999.9",
"584.5",
"482.82",
"578.1",
"444.89",
"401.9",
"V55.4",
"518.82",
"453.8",
"577.0",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"33.24",
"97.02",
"96.72",
"31.1",
"87.51",
"38.93",
"96.6",
"88.47",
"99.15",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
20990, 21070
|
13986, 16812
|
320, 552
|
21737, 21865
|
2751, 2751
|
22222, 22384
|
2246, 2274
|
18438, 20967
|
21091, 21716
|
16838, 18415
|
21889, 22199
|
2289, 2289
|
13687, 13963
|
274, 282
|
8431, 11797
|
580, 1451
|
11806, 13673
|
2765, 8396
|
1473, 2032
|
2048, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
980
| 145,579
|
25442
|
Discharge summary
|
report
|
Admission Date: [**2115-7-9**] Discharge Date: [**2115-7-15**]
Date of Birth: [**2044-5-3**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Bilateral arm pain
Major Surgical or Invasive Procedure:
ORIF of bilateral humerus fracture
History of Present Illness:
71 year old female
patient who was involved in a motor vehicle accident. She
sustained bilateral upper extremity injuries requiring
surgical management, given that they are bilateral. She
presents today for operative fixation, primarily of the right
distal humerus fracture, sequentially followed by the left
humerus fracture. She understands the indications and risks,
which were clearly discussed with her and her family. She
understands that her right elbow will have significant
difficulties in terms of range of motion and stiffness, and
that she will require significant therapy to regain
functional range of motion of her right elbow.
Past Medical History:
PMH: CAD s/p MI, COPD, HTN, ^chol, T2DM, PVD, anemia, PUD,
osteoporosis, depression, LBP/OA
PSH: L CEA [**2111**], bilat iliac angioplasties [**2110**] (neg angio
[**2112**]), R THR, BTL, hemorrhoidectomy
Social History:
Lives with husband
Occasional ETOH
Family History:
NC
Physical Exam:
Gen-Alert/Oriented
VS-98.9, 120/82, 96, 20, 95%RA
CV-RRR
Lungs-CTA bilat
Abd-soft NT/ND
Ext:
RUE-Hindge elbow brace in place, Incision with small amt of
sero/sang d/c, without evidence of infection. +m/r/u nerve
intact. +radial pulse.
LUE-incision clean/dry/intact. +m/r/u n. intact, +radial pulse.
Pertinent Results:
[**2115-7-9**] 08:20PM GLUCOSE-131* UREA N-40* CREAT-1.3*
SODIUM-146* POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-26 ANION
GAP-13
[**2115-7-9**] 08:20PM WBC-10.2 RBC-3.50*# HGB-11.3*# HCT-32.7*#
MCV-93 MCH-32.4* MCHC-34.6 RDW-14.7
Brief Hospital Course:
71 yo woman s/p [**Hospital 8751**] transferred to [**Hospital1 18**] from OSH. Patient was
evaluated in emergency department. Patient was found to have
bilateral humerus fractures. Patient was admitted to trauma
service and taken to trauma ICU for serial HCT, patient remained
stable in unit. Plan was for surgical fixation of bilateral
humerus. Patient was taken to surgery on [**2115-7-11**] for ORIF of
bilateral humerus fracture. Surgery went without complications,
please see op-note [**2115-7-11**]. Patient was taken to post-operative
holding area after surgery. Patient remained afebrile/vital
signs stable. Patient was then transferred to orthopedic floor.
While on floor patient remained stable. Pain was well
controlled, HCT on [**2115-7-13**] did drop to 23, patient was
transfused 2 units and HCT bumped appropriately. Occupational
therapy was initiated for PROM of upper extremity bilaterally.
Patient continued to progress throughout hospital course. ON day
of discharge pain was well controlled, incision was
clean/dry/intact, HCT was stable at 33, pain was well
controlled. Patient was discharged in stable condition.
Medications on Admission:
[**Last Name (LF) 4532**], [**First Name3 (LF) **], lisinopril/HCTZ 20/12.5', toprol XL 50', lipitor
20', lasix 20', tramadol 50", ativan 0.5 prn, atrovent, calcium
600", mylanta prn, actonel, MVI, nasacort, prilosec 20', feso4,
vit
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily) as needed.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
bilateral humerus fracture
Post-op anemia
Discharge Condition:
stable
Discharge Instructions:
Please cont with non-weight bearing upper extremity bilaterally.
Hindged elbow brace to right arm. Please keep incision clean.
Please do not scrub or wash incision with soap. If incision gets
wet please pat dry. Oral pain medication as needed. Please
call/return if any fevers, or increased discharge from incision.
Followup Instructions:
Follow-up with Dr.[**Last Name (STitle) 1005**] 2weeks after discharge, please call
this week for appt. [**Telephone/Fax (1) 4845**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2115-7-15**]
|
[
"E812.1",
"496",
"733.00",
"812.21",
"285.1",
"401.9",
"443.9",
"412",
"272.0",
"812.44"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.31",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4411, 4499
|
1935, 3073
|
337, 374
|
4584, 4592
|
1682, 1912
|
4957, 5252
|
1344, 1348
|
3356, 4388
|
4520, 4563
|
3099, 3333
|
4616, 4934
|
1363, 1663
|
279, 299
|
402, 1046
|
1068, 1275
|
1291, 1328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,737
| 150,959
|
51807
|
Discharge summary
|
report
|
Admission Date: [**2171-5-15**] Discharge Date: [**2171-5-18**]
Date of Birth: [**2104-10-2**] Sex: M
Service: MEDICINE
Allergies:
fish / Spiriva with HandiHaler / Lithium
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 91849**] is a 66 year old male with history of COPD, recurrent
pneumonias in setting of Churg-[**Doctor Last Name 3532**], multiple sclerosis, and
recurrent aspiration. He was admitted on [**5-15**] to the MICU for
hypoxemia and hypotension.
.
Per previous notes, he has a history of recurrent aspiration
pneumonias of unclear etiology - he has a G tube in place
through which he gets tube feeds nightly. He does not take any
PO feeds currently. His history is significant for esophageal
dysmotility of unclear etiology; furthermore, he carries a
diagnosis of Churg [**Doctor Last Name 3532**] vasculitis and multiple sclerosis. He
also has COPD and is on 2 L of oxygen at home that he uses
inconsistently. In the past, he also had a pulmonary embolus for
which an IVC filter was placed.
.
His prior history of his recurrent pneumonia is as follows,
taken from hospital records: in early spring of [**2169**], the
patient was well enough to have a vacation in the [**Country 13622**]
Republic, swimming, etc. Over the past 16 months, however the
patient has had multiple bouts of pneumonia that number 15-20.
He first presented in the spring of [**2169**] with cough, shortness
of breath, yellow thick sputum, chest tightness, weakness and
wheezing. He was treated with antibiotics and prednisone with a
presumptive diagnosis of pneumonia and improved, only to have a
relapse of symptoms within days to week or so. This happened
several times in the spring of [**2169**] and by mid spring of last
year, he was noted to have high levels of peripheral eosinophils
as well as eos in his sputum (BAL [**7-/2169**]), and the patient was
treated for worms given his exposure abroad. In the summer of
[**2170**], given gastroesophageal reflux disease and significant
esophageal dysmotility, potentially leading to his recurrent
pneumonias, a decision was made to place a G-tube, through which
he now gets his tube feeds and medications. Several motility and
EGD studies have not revealed a clear cause for his dysmotility.
Recently he was hospitalized for an aspiration event and was
treated with levofloxacin
.
Currently he lives at [**Hospital3 2558**], where he has been in
rehabilitation over the past 1 year. On the day of admission, he
developed a fever to 101; the night prior he said he felt short
of breath after his evening tube feed. He says his aspiration
events occur at night, after he lays down, following his G tube
feedings.
.
In the ED, his systolic blood pressure fell to 89; he had 2 L of
fluid given with improvement in his pressure to 100 systolic. He
was placed initially on a nonrebreather which was quickly weaned
to a venti-mask, his saturations in the low 90s. Chest x-ray was
obtained showing bilateral lower lobe infiltrates that remain
unchanged from prior chest x-ray and likely are secondary to his
underlying eosinophilic process.
.
In the MICU, the patient was stabilized with fluids, supportive
oxygen supplementation, and vancomycin + zosyn for coverage of
HCAP. His outpatient pulmonologist was consulted and the
suspician was for aspiration pneumonia related to tube feeds as
a precipitation for this acute presentation. The plan was for
48 hours of IV antibiotics, with conversion to PO if tolerated
for an additional 5 day course. The patient has a history of
chronic lower back pain on morphine, however this was held out
of concern for respiratory failure. Nutrition was consulted for
help to minimize aspiration events.
.
On the floor, patient is without complaint. His back pain has
returned, and he would like morphine. He feels his breathing has
improved since admission. he is still coughing, productive of
some sputum. Denies f/c/s, shortness of breath. He also notes
some chronic b/l lower leg pain.
Past Medical History:
Suspected Churg [**Doctor Last Name 3532**]
Recurrent aspiration pneumonia
h/o PE s/p IVC filter
MS (diagnosed in [**2158**], presenting with optic neuritis and lower
extremity weakness)
chronic back pain
s/p spinal fusion
depression
bipolar disorder
hypothyroidism
henia repair
multiple spinal compression fractures (thought to be secondary
to prednisone use)
COPD with 2L NC at home
OSA with CPAP at home
Social History:
75 pack year h/o smoking; quit several years ago. H/o heavy
alcohol use, also quit several years ago.
Family History:
Not discussed this admission
Physical Exam:
Discharge physical exam:
Pertinent Results:
Admission:
[**2171-5-15**] 09:08AM BLOOD WBC-7.5 RBC-3.53* Hgb-11.1* Hct-33.7*
MCV-95 MCH-31.5 MCHC-33.0 RDW-15.7* Plt Ct-212
[**2171-5-15**] 09:08AM BLOOD Neuts-92.6* Lymphs-4.1* Monos-2.6 Eos-0.5
Baso-0.3
[**2171-5-15**] 09:08AM BLOOD PT-12.8* PTT-28.7 INR(PT)-1.2*
[**2171-5-15**] 09:08AM BLOOD Glucose-139* UreaN-13 Creat-0.5 Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
[**2171-5-15**] 09:08AM BLOOD ALT-13 AST-20 AlkPhos-55 Amylase-24
TotBili-0.6
[**2171-5-16**] 04:39AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
[**2171-5-15**] 09:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2171-5-15**] 09:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.5 Leuks-NEG
.
Micro:
[**2171-5-16**] 12:56 pm SPUTUM Source: Expectorated.
DUE TO LABORATORY ERROR, SPECIMEN PLANTED [**2171-5-17**].
FASTIDIOUS ORGANISMS [**Month (only) **] NOT GROW.
GRAM STAIN (Final [**2171-5-16**]):
[**11-7**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
.
[**5-15**] MRSA screen negative
.
[**5-15**] BCx: pending at discharge (no growth at time of d/c)
.
[**5-16**] CXR:
There is significant bibasal infiltrate, much of which is linear
suggesting an atelectatic component. While that in the left
lower lung zone has improved somewhat compared to prior study,
that on the right is unchanged, though not worsened. Poor
inspiratory effort and low lung volumes. Allowing for
projection, the heart size is normal. The remainder of the lung
parenchyma is grossly clear.
CONCLUSION:
Low lung volumes, with bibasal infiltrates. There is probably a
large
atelectatic component as an additional finding of note. Minor
interval
improvement over prior study.
.
Discharge labs:
Brief Hospital Course:
SUMMARY: Mr [**Known lastname 91849**] is a 66 year old male with history of COPD,
recurrent pneumonias in setting of Churg-[**Doctor Last Name 3532**], multiple
sclerosis, and recurrent aspiration, admitted to MICU [**5-15**] and
treated for aspiration pneumonia.
.
# Cough/Fever: Given his history, the most likely etiology was
aspiration pneumonia vs pneumonitis, as time course and
presentation fits with this. He was initially treated with IV
antibiotics, and subsequently transitioned to a course of PO
augmentin, on which he improved. He was also given nebulizer
treatments.
.
# Chronic lung disease: Patient has suspected Churg-[**Doctor Last Name 3532**], for
which he is on a prednisone taper, and azathioprine. He was
continued on his original Prednisone taper set forth prior to
this admission by his outpatient Pulmonologist. He also
continued on Bactrim for PCP [**Name Initial (PRE) 1102**]. He also has OSA, and
CPAP was continued.
.
# Weight loss, eosinophila: [**Month (only) 116**] be explained by Churg-[**Doctor Last Name 3532**],
however there is a concern for potential underlying malignancy.
The patient will follow-up with his outpatient pulmonologist,
who will consider referral to hematology oncology. This was
discussed with the pulmonologist and patient.
.
# Bipolar disease - continued quetiapine and citalopram
.
# Hyperlipidemia - continued pravastatin
.
# Back pain, leg pain - continued gabapentin, morphine, fentanyl
.
# Hypothyroidism - continued levothyroxine
.
# Multiple sclerosis - continued immunosuppression as above
.
TRANSITIONAL ISSUES:
-consider heme/onc referral for weight loss, persistent
peripheral eosinophilia
-consdier tube feeding during the waking hours (or as much
during day hours as possible) to prevent aspiration (which
typically occurs at night)
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Doctor Last Name **]: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
2. ipratropium bromide 0.02 % Solution [**Doctor Last Name **]: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
3. pravastatin 40 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day.
4. citalopram 20 mg Tablet [**Doctor Last Name **]: 1.5 Tablets PO DAILY (Daily).
5. trazodone 50 mg Tablet [**Doctor Last Name **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. metoclopramide 10 mg Tablet [**Doctor Last Name **]: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. fentanyl 50 mcg/hr Patch 72 hr [**Doctor Last Name **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Doctor Last Name **]:
Twenty (20) ML PO EVERY OTHER DAY (Every Other Day).
9. azathioprine 50 mg Tablet [**Doctor Last Name **]: Three (3) Tablet PO DAILY
(Daily).
10. levothyroxine 25 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Doctor Last Name **]: One (1) Tablet, Chewable PO TID (3 times a day).
12. cholecalciferol (vitamin D3) 400 unit Tablet [**Doctor Last Name **]: One (1)
Tablet PO DAILY (Daily).
13. bisacodyl 10 mg Suppository [**Doctor Last Name **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Last Name (STitle) **]:
1.25 PO Q4H (every 4 hours) as needed for pain.
16. quetiapine 25 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO HS (at
bedtime).
17. gabapentin 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times
a day.
18. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
19. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice
a day as needed for constipation.
22. prednisone 10 mg Tablet [**Last Name (STitle) **]: TAPER PER BELOW Tablet PO once
a day: Take 6 tablets for 3 more days. Then 5 tablets for 3
days. Then 4 tablets for 3 days. Then 3 tablets for 3 days. Then
2 tablets for 3 days. Then 1 tablet for 5 days. Then [**1-14**] tablet
until you see Dr. [**Last Name (STitle) 575**] in [**Month (only) 116**] or discuss this with him
sooner.
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month (only) **]: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
2. ipratropium bromide 0.02 % Solution [**Month (only) **]: One (1) inhalation
Inhalation Q6H (every 6 hours).
3. pravastatin 40 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day.
4. citalopram 20 mg Tablet [**Month (only) **]: 1.5 Tablets PO DAILY (Daily).
5. trazodone 50 mg Tablet [**Month (only) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. metoclopramide 10 mg Tablet [**Month (only) **]: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. fentanyl 50 mcg/hr Patch 72 hr [**Month (only) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Month (only) **]:
Twenty (20) ML PO EVERY OTHER DAY (Every Other Day).
9. azathioprine 50 mg Tablet [**Month (only) **]: Three (3) Tablet PO DAILY
(Daily).
10. levothyroxine 25 mcg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Month (only) **]: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours).
12. cholecalciferol (vitamin D3) 400 unit Tablet [**Month (only) **]: One (1)
Tablet PO DAILY (Daily).
13. bisacodyl 10 mg Suppository [**Month (only) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. morphine 20 mg/5 mL Solution [**Last Name (STitle) **]: 1.25 PO PO every four (4)
hours as needed for pain.
16. quetiapine 25 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO QHS (once a
day (at bedtime)).
17. gabapentin 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times
a day.
18. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
20. prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 3 days: Then take [**1-14**] tab until you see your outpatient
pulmonologist.
21. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
injection Injection TID (3 times a day).
22. amoxicillin-pot clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Month/Day (2) **]: One (1) Tablet PO Q12H (every 12 hours) for
4 days.
Disp:*8 Tablet* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for fever, and this was most likely related to
a pneumonia or inflammation in your lung from aspiration. We
treated you with IV antibiotics, and transition to oral
antibiotics to kill any possible infection.
.
You should also attempt to keep your tube feeds running during
the day, rather than at night, to prevent future aspiration.
.
Please note the following medication changes:
-Please START Augmentin for 4 more days
Followup Instructions:
Please see Dr. [**Last Name (STitle) 91639**] at 1pm on Wednesday [**2171-5-22**] at 1pm. He will
arrange your heme-onc appointment so it can all stay within the
[**Hospital3 **] system and we talked to him about this. His office
phone number is [**Telephone/Fax (1) 78691**].
.
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2171-6-4**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2171-6-4**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2171-6-4**] at 9:30 AM
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
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"729.5",
"530.81",
"507.0",
"327.23",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13707, 13777
|
6585, 8152
|
307, 314
|
13842, 13842
|
4770, 6544
|
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|
4679, 4709
|
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|
8173, 8399
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14425, 14466
|
262, 269
|
342, 4113
|
13857, 14001
|
4135, 4543
|
4559, 4663
|
4751, 4751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,678
| 165,503
|
37882+58176
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-11-10**] Discharge Date: [**2169-12-1**]
Date of Birth: [**2114-5-9**] Sex: M
Service: SURGERY
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
hypotension, abdominal pain
Major Surgical or Invasive Procedure:
Pancreatic pseudocyst, jejunostomy, cholecystectomy and
placement of feeding J-tube - [**2169-11-20**].
History of Present Illness:
Patient is a 55 year old male well known to [**Hospital1 18**] who was
recently d/c on [**2169-10-25**] after 1 month stay in hospital for
gallstone pancreatitis complicated by respiratory and renal
failure which ultimately improved with supportive care. He was
discharged to rehab and was recently sent home 3 days ago.
Today, he awoke with a headache and complained of increasing
abdominal pain. He was
seen by a visiting nurse who noted that the patient appeared
sweaty and diaphoretic. A blood pressure taken demonstrated a
SBP in the 60's. He was sent to [**Hospital3 **] Hospital, where BP was
70s/40s. The patient received 5L IVF resuscitation and was
started on Levophed and given Zosyn 4.5g x1. He was transferred
to [**Hospital1 18**] for further care.
Past Medical History:
PMHx: gallstone pancreatitis, renal insufficiency recently
weaned
off hemodialysis, HTN, asthma/COPD, Type II DM, Obstructive
Sleep Apnea, eczema
.
PSHx: [**Hospital1 **], h/o spinal surgery
Social History:
Lives alone. Drinks a few beers a week. Quit smoking in [**2145**].
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: T 97.2 HR 84SR BP 104/68 RR 18 SpO2 95-96%
General: awake and alert
CV: RRR
Lungs: CTA bilaterally
Abdomen: soft, obese/protuberant, diffusely tender but greatest
in LLQ and RUQ, no rebound or guarding
Ext: warm, 2+ peripheral edema, 2+ DP pulses bilaterally
.
At Discharge:
VS: 98.4 PO, 74, 114/58, 18, 96% RA
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD: Midline incision with staples with mild surrounding
erythema, otherwise c/d/i. No drainage or exudate. (R) and (L)
prior JP sites (now discontinued) intact and healing. (L)
abdominal J-tube clamped; insertion site intact. BSx4. Mild
distension. Appopriately tender to palpation along incision,
otherwise soft/NT.
EXTREM: No c/c/e
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On Admission:
[**2169-11-10**] 07:30PM GLUCOSE-152* UREA N-25* CREAT-1.4*#
SODIUM-137 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-10
[**2169-11-10**] 07:30PM ALT(SGPT)-29 AST(SGOT)-27 CK(CPK)-16* ALK
PHOS-87 TOT BILI-0.8
[**2169-11-10**] 07:30PM LIPASE-5
[**2169-11-10**] 07:30PM cTropnT-0.05*
[**2169-11-10**] 07:30PM ALBUMIN-2.6* CALCIUM-7.6* PHOSPHATE-4.8*
MAGNESIUM-1.5*
[**2169-11-10**] 07:30PM WBC-8.4 RBC-3.44* HGB-9.8* HCT-30.3* MCV-88
MCH-28.6 MCHC-32.5 RDW-14.0
[**2169-11-10**] 07:30PM NEUTS-83.8* LYMPHS-10.0* MONOS-3.5 EOS-2.3
BASOS-0.3
[**2169-11-10**] 07:30PM PLT COUNT-240
[**2169-11-10**] 07:30PM PT-20.7* PTT-45.2* INR(PT)-1.9*
[**2169-11-10**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-11-10**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2169-11-10**] 07:30PM URINE RBC-0-2 WBC-[**2-16**] BACTERIA-OCC YEAST-NONE
EPI-<1
[**2169-11-10**] 07:30PM URINE HYALINE-0-2
.
IMAGING:
[**2169-11-10**] AP Chest:
No acute findings. Persistent bibasilar opacities, likely
atelectasis vs. small effusions.
.
[**2169-11-10**] ABD/PELVIC CT W/O CONTRAST:
1. Findings progressed from prior study, compatible with
pancreatic necrosis with phlegmonous collection in the
pancreatic bed containing trapped gas. The possibility of
superinfection cannot be excluded.
2. Small volume ascites, unchanged.
3. Cholelithiasis.
4. CBD stent in appropriate position.
5. Small bilateral pleural effusions, stable.
.
[**2169-11-11**] AP Chest:
Right internal jugular line is now in central position.
Subsegmental atelectasis. Evidence for accumulation of small
bilateral pleural effusions and possible development of mild
vascular congestion as well.
.
[**2169-11-12**] BILAT LOWER EXT VEINS:
1. Focal occlusive thrombus in the right cephalic vein around
the peripheral IV catheter. No proximal extension.
2. No DVT in the deep veins.
.
[**2169-11-14**] CT ABD W&W/O CONTRAST; PELVIC CT W/CONTRAST:
1. Necrotizing pancreatitis with large collection of air and
necrosed tissue in the pancreatic bed involving whole pancreas
measuring 8.7 x 17 x 13 cm, which is stable as compared to the
previous examination.
2. Stent in the CBD in appropriate placement.
3. Gallbladder stones and small amount of air.
4. Splenomegaly.
5. Moderate amount of peritoneal fluid which has increased in
size as compared to the previous examination.
6. Bilateral moderate-sized pleural effusions which have also
increased in size compared to the previous examination.
.
[**2169-11-17**] CXR:
Small bilateral pleural effusions are stable. Bibasilar
atelectases have increased on the left side. Cardiomediastinal
contours unchanged. Cardiac silhouette is partially obscured by
the pleural parenchymal abnormalities. The upper lungs are
grossly clear.
.
[**2169-11-25**] CXR:
One portable view. Comparison with the previous study of
[**2169-11-21**]. There is streaky density of the lung bases consistent
with subsegmental atelectasis. The costophrenic sulci are
blunted. The left hemidiaphragm is indistinct. Mediastinal
structures are unchanged. A nasogastric tube and left subclavian
catheter have been removed. A PICC line has been inserted on the
left and terminates in the superior vena cava. There is no other
significant change.
.
MICROBIOLOGY:
[**2169-11-20**] 9:20 am TISSUE PANCREATIC NECROSIS.
**FINAL REPORT [**2169-11-24**]**
GRAM STAIN (Final [**2169-11-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2169-11-24**]):
REPORTED BY PHONE TO DR.[**Last Name (STitle) 41449**] ON [**2169-11-21**] AT 12:00.
IDENTIFICATION AND SENSITIVITY TESTING ON ALL ORGANISMS
REQUESTED BY
DR.[**Last Name (STitle) 41449**].
KLEBSIELLA OXYTOCA. MODERATE GROWTH.
ENTEROBACTER CLOACAE. SPARSE GROWTH.
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.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| ENTEROBACTER CLOACAE
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 2 I 0.5 S
GENTAMICIN------------ <=1 S <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- 8 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2169-11-24**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was transferred from [**Hospital3 **] Hospital and admitted
to the [**Hospital Unit Name 153**] via the ED on [**2169-11-10**] for further evaluation and
treatment of hypotesion. In the [**Hospital1 18**] ED, his initial vital
signs were T 97.2 HR 84 BP 104/68 RR 18 O2 95-96%. He was
continued on norepinephrine. A CT abd was performed which showed
findings compatible with pancreatic necrosis with phlegmonous
collection in the pancreatic bed containing trapped gas as well
as cholelithiasis.
.
[**Hospital Unit Name 13533**] [**2169-11-10**] - [**2169-11-12**]:
1. Respiratory failure: The patient was intubated this morning
due to tachypnea and hypoxia in the setting of receiving many
liters of IVF while oliguric. CXR to confirm ETT placement.
Weaned his FiO2 as tolerated. Increasing PEEP seemed to decrease
his oxygen sat so will aim to keep his PEEPs in the mid-range.
Serial ABGs were checked to assess ventilation. Propofol and
fentanyl prn for sedation. He was readily extubated prior to
transfer to the floor.
.
2. Gallstone pancreatitis: The patient presented with
pancreatitis and was found to have a CBD stone. He was medically
treated for pancreatitis with bowel rest and IVF, however he has
clinically continued to worsen and his amylase has continued to
rise raising concern that the stone is still causing blockage
and damage to the pancreas. [**Month/Day/Year **] fellow consulted regarding [**Month/Day/Year **]
to evaluate for persistent pancreatic blockage. Surgery
consulted. NPO with IVF. Trend LFT's and pancreatic enzymes.
.
3. Hypotension: Patient became hypotensive during transport and
after arrival to the [**Hospital Unit Name 153**]. Likely due to a combination of his
sedation, hypocalcemia, and high PEEP. Also could be secondary
to sepsis given a possible biliary source for infection.
Repleted hypocalcemia with calcium gluconate. Will trend and
replete prn. Levophed prn to maintain MAPs>65. Will follow CVP
and continue with aggressive IVF (LR) fluid repletion given 3rd
spacing physiology with pancreatitis. Will try to keep PEEP < 15
if possible. Sending blood cultures, UA, and UCx. Zosyn, renally
dosed due to concern for possible cholangitis.
.
4. Acute renal failure: The patient per OSH records had normal
renal function at baseline. Over the past few days his Cr has
increased to 4.2 and his urine output has dropped off. In the
setting of pancreatitis with significant third-spacing and
hypotension he likely has oliguric ATN. Also in the differential
is postrenal and other intrarenal causes such as AIN. Will
consult renal as he may need CVVH in the near future if he
remains oliguric and his K continues to rise. Will check urine
lytes. Trend Creatinine. Renal US to rule out postrenal cause.
Renally dose medications and avoid nephrotoxins.
.
5. Hyperglycemia: The patient does not have known history of
diabetes, however was found to have sugars in the 500's at the
OSH so he likely had underlying type II diabetes. He was weaned
off the insulin gtt prior to transfer. Unfortunately there is no
documentation sent with the amount of insulin he received over
the last 24 hours. Will check q6h fingersticks and cover with
SSI. Will add up his 24 hour requirements and start a
long-acting [**Doctor Last Name 360**].
.
6. Anemia: The patient's Hct is 39.8. No clinical evidence of
bleeding. Likely secondary to his acute illness. Active type and
screen. Continue to trend. Guaiac stool.
.
7. Thrombocytopenia: His platlets are 136 which is stable from
his values at the OSH. Were 202 on admission. Continue to trend.
.
[**Hospital Ward Name **] 9 COURSE [**2169-11-12**] - [**2169-11-20**]:
The patient was transferred to the General Surgery Service on
[**2169-11-12**]. He remained NPO except medications for bowel rest, on
IV fluids, with a foley catheter in place, and was given
Dilaudid IV PRN for pain control with good effect. He was placed
on contact precautions as the standard MRSA screen performed in
the [**Hospital Unit Name 153**] was positive. Also, the team was contact[**Name (NI) **] on [**2169-10-17**]
that a urine culture performed at the outside hospital grew VRE.
The Patient was hemodynamically stable.
.
Given expected prolonged NPO status, a PICC line was placed, and
TPN started on [**2169-11-14**]. The foley catheter was discontinued on
[**11-13**]; the patient subsequently voided without problem. [**2169-11-14**]
abdominal/pelvic CT revealed necrotizing pancreatitis with large
collection of air and necrosed tissue in the pancreatic bed
involving whole pancreas measuring 8.7 x 17 x 13 cm, which is
stable as compared to the [**2169-11-10**] examination. Moderate amount
of peritoneal fluid which has increased in size as compared to
the previous examination. Pre-operative screening and labwork
was completed. On [**2169-11-20**], the patient was brought to the
Operating Room.
.
POST-OPERATIVE COURSE [**2169-11-20**] - [**2169-12-1**]:
On [**2169-11-20**], the patient underwent ancreatic pseudocyst
jejunostomy,necrosectomy, cholecystectomy and placement of
feeding J-tube, which went well without complication (reader
referred to the Operative Note for details). In the OR, 2400mL
of ascites was found, EBL 300mL, received 4L IVF, and received 2
units PRBCs. After a brief, uneventful stay in the PACU, the
patient was admitted to the TICU NPO with an NG tube, intubated
on mechanical ventilation, on IV fluids, with a foley catheter
and two JP drains in place, a J-tube to gravity drainage, and
Fentanyl IV for pain control. The patient was hemodynamically
stable. Decreased urine output immediately postoperatively
responded well to albumin. On POD#1, the patient extubated
easily. TPN continued with insulin increased in TPN. Dilaudid
PCA started. Patient OOB to chair. Intra-abdominal collection
culture growing 2 types of GNR + likely enterococcus; patient
started on IV Vancomycin. The patient was transferred to the
inpatient floor on [**2169-11-22**].
.
Neuro: Post-operatively, he was placed on a Fentanyl IV drip in
the TICU, then a Dilaudid PCA on the floor with good pain
control. When tolerating oral intake, the patient was
transitioned to oral pain medications with continued good
effect. He remained neurologically intact during admission.
.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
Pulmonary: [**Date range (1) 84717**] patient experienced shortness of breath and
rales on examination. CXR revealed findings consistent with
bibasilar atelectases. 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: Post-operatively, patient had two JP drains and a J-Tube.
Left JP discontinued due to low output on [**2169-11-29**]. J-tube was
initially to gravity drainage, the tubefeeds were started. Once
tube feeds discontinued, the J-tube was clamped. Right JP, which
had been putting out over 1 liter daily, was discontinued on
[**2169-11-30**]. The patient denied abdominal pain, bloating, and did
not experience abdominal distension. By discharge, patient was
tolerating his diet, passing flatus, and having formed bowel
movements.
.
GU/FEN: Post-operatively, the patient was NPO on IV fluid and
continued on TPN. Patient was weaned off TPN on [**2169-11-22**], and the
patient started on trophic tube feeds via the J-tube. The J-Tube
feeds were progressively advanced to goal with good
tolerability, but the patient experienced severe diarrhea. On
[**2169-11-25**], the patient was started on sips of clears. Diet was
progressively advanced to a diabetic, heart healthy regular by
[**11-28**], which was well tolerated. Given patient's excellent oral
intake and probable tubefeed-related diarrhea, tubefeeds were
discontinued on [**2169-11-26**]. Foley catheter was discontinued on
[**2169-11-25**]; the patient subsequently voided without problem.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
.
ID: Cultures of tissue from the pancreatic cyst taken during the
[**2169-11-20**] surgery were sent and grew Klebs oxytoca, Enterobacter
and Enterococcus. He was initially started onto Meropenem 500 mg
IV Q6H and Vancomycin 1000 mg IV Q 12H. Transitioned to
Meropenem monotherapy on [**11-23**] with plans to transition to
Ertapenem for four week course after discharge. The patient
received and tolerated his initial dose of Ertapenem prior to
discharge. Serial cdiff screens when patient experiencing
diarrhea were negative; diarrhea related to tubefeeds. The
patient's white blood count and fever curves were closely
watched for signs of infection. Wound: Mid-abdominal incision
with staples with mild surrounding erythema; continued on
antibiotic therapy. Staples will be removed at follow-up
appointment. Precautions: Routine MRSA screening was positve on
[**2169-11-11**]. Outside Hospital urine reported positive for VRE on
[**2169-11-13**] (also resistant to Levofloxacin, Nitrofuratoin, and
Cipro). Patient placed on contact precautions. Repeat Urine Cx
[**2169-11-14**] revealed no growth.
.
Endocrine: The patient's blood sugar was monitored throughout
his stay; sliding scale insulin was administered accordingly and
Lantus insulin added to the regimen. Insulin in TPN was adjusted
as well. The patient was discharged on Lantus 10units SQ QHS as
well as a Humalog Insulin Sliding Scale.
.
Hematology: The patient's complete blood count was examined
routinely; the patient received 2 units of PRBCs in the OR, but
did not require further transfusions.
.
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 diabetic,
heart healthy regular diet, ambulating, voiding without
assistance, and pain was well controlled. (L) abdominal J-tube
was clamped. PICC line was patent and intact. He was discharged
to an extended care facility for further management. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Renagel (now discontinued)
4. Nephrocaps (now discontinued)
5. Neurontin
6. Naprosyn 250-500mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
6. 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.
7. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
8. Insulin Lispro 100 unit/mL Solution Sig: 2-22 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
10. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 4 weeks.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-20**]
hours as needed for fever or pain.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Care Center [**Location (un) **]
Discharge Diagnosis:
1. Necrotizing pancreatitis and gallstones.
2. Renal insufficiency
3. Type II DM
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
*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.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-23**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water or saline. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
J-Tube Care:
*Clamped.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the insertion site gently with warm, soapy water or
saline. Place a drain sponge. Change daily and PRN.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the J-Tube attached securely to your body to
prevent pulling or dislocation.
*Flush J-Tube with 30mL water TID.
Followup Instructions:
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2169-12-1**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2169-12-1**] 1:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2169-12-27**] 10:00
.
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) **] (Surgery) in 10 days.
.
Please call ([**Telephone/Fax (1) 66955**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-17**] weeks.
Completed by:[**2169-12-1**] Name: [**Known lastname 13457**],[**Known firstname **] Unit No: [**Numeric Identifier 13458**]
Admission Date: [**2169-11-10**] Discharge Date: [**2169-12-1**]
Date of Birth: [**2114-5-9**] Sex: M
Service: SURGERY
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 3149**]
Addendum:
The patient was scheduled for ERCP for stent removal on [**12-1**],
the date of discharge. The procedure was cancelled, and the
patient will be contact[**Name (NI) **] by the ERCP team to reschedule the
procedure in approximately 2 weeks. The Team was notified.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Care Center [**Location (un) 13459**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**]
Completed by:[**2169-12-1**]
|
[
"599.0",
"577.2",
"574.91",
"275.41",
"785.52",
"567.29",
"041.12",
"278.00",
"285.9",
"995.92",
"038.9",
"511.9",
"577.0",
"250.00",
"493.20",
"518.0",
"287.5",
"584.5",
"401.9",
"V09.80",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"46.39",
"99.15",
"51.22",
"96.6",
"52.4"
] |
icd9pcs
|
[
[
[]
]
] |
24172, 24417
|
7921, 18300
|
300, 406
|
20012, 20012
|
2381, 2381
|
22838, 24149
|
1518, 1536
|
18593, 19778
|
19908, 19991
|
18326, 18570
|
20277, 21761
|
21777, 22815
|
1551, 1551
|
1848, 2362
|
233, 262
|
434, 1199
|
2396, 7898
|
20146, 20253
|
1221, 1414
|
1430, 1502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,182
| 118,084
|
40493
|
Discharge summary
|
report
|
Admission Date: [**2102-7-30**] Discharge Date: [**2102-8-9**]
Date of Birth: [**2055-7-16**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
[**2102-7-30**]: Diagnostic Cerebral Angiogram
[**2102-7-31**]: Right frontal craniotomy for aneurysm clipping
[**2102-7-31**]: Diangostic cerebral angiogram
History of Present Illness:
Mr. [**Known lastname 13060**] is a 47 yo Right handed man who presents with
SAH.
He states being in his usual state of good health until this
afternoon. He was lifting weights (using dumbells). He went to
rest for a while, then noticed the abrupt onset of severe
headache. He relates this as being bifrontal and associated with
neck and shoulder pain. Describes HA as [**8-30**] in intensity. He
had
some nausea and dizziness with this. Importantly, he denies the
presence of any diplopia, dysarthria, dysphagia, unilateral
weakness, numbness, vertigo.
He waited to see if the pain would pass, but it did not so he
called EMS and was taken to [**Hospital6 **]. There, he
was noted to remain fully alert and awake and non-focal. A head
CT showed diffuse SAH so he was transferred to [**Hospital1 18**]. Currently,
after getting morphine in the ED his pain is 0/10.
Past Medical History:
Thyroid cancer s/p resection
Social History:
Married, works as a firefighter. Denies any TOB. Social EtOH. No
illicit drugs such as cocaine.
Family History:
No history of aneurysm.
Physical Exam:
On Admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: I [**Doctor Last Name **]: GCS E: 5 V: 5 Motor: 5
O: T: afebrile BP: 129/68
Gen: WD/WN, comfortable, NAD.
HEENT: No evidence of trauma
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Orientation: Oriented to person, place, and date.
Recall: [**3-23**] objects at 5 minutes. Language: Speech fluent with
good comprehension and repetition. Naming intact. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation. Discs
sharp.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-25**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE:
Awake, Alert. Oriented x3. MAE with full motor strength. No
pronator. Incision C/D/I. Speech clear, follows commands.
Pertinent Results:
CTA Head [**2102-7-29**]:
IMPRESSION:
Saccular aneurysm in the junction between the A1 and anterior
communicating artery on the right, measuring approximately 2.9
mm in anterior-posterior direction, no other aneurysms are
identified. The anterior, middle and posterior cerebral arteries
are patent with mild diffuse narrowing, suggesting possible
early vasospasm.
Chest Xray [**2102-7-29**]:
There is probable mild cardiomegaly. The aorta is minimally
unfolded. No
CHF, frank consolidation, or effusion.
There are faint, slightly patchy opacities at the left base.
These are
nonspecific, but in this setting may represent a small amount of
aspiration. An early pneumonic infiltrate is considered less
likely.
Chest Xray [**2102-7-31**]:
Normal heart, lungs, hila, mediastinum and pleural surfaces.
Vascular clips denote prior left neck surgery. No evidence of
pneumonia.
TCD [**2102-8-4**]:
Normal velocities. No vasospasm.
LENIS [**2102-8-7**]:
IMPRESSION: No evidence of right or left lower extremity DVT.
CTA Head [**2102-8-8**]:
IMPRESSION:
1. Resolution of subarachnoid hemorrhage.
2. No evidence of residual filling of the surgically treated
anterior
communicating artery aneurysm. No evidence of vasospasm.
Brief Hospital Course:
47M admitted for a SAH and small ACOMM aneurysm noted at A1
junction. He went to cerebral angiogram but the aneurysm was
small and wide necked thus it was not amendable to coiling and a
surgical clipping was recommended. He was started on Nimodipine
and monitored closely in the ICU. He was pre-op on [**7-30**]. Consent
was obtained. He went to the OR on [**7-31**] with Dr [**Known firstname **] for a R
frontal craniotomy for clipping of the aneurysm. There was no
complications intraoperatively and post-operatively he went for
angiogram for confirmation of clip placement.
On [**8-1**], his exam remained stable. His Aline was removed as it
was not working well and given his stable exam it was not
replaced. On [**8-2**], his foley was removed and his activity was
advanced. His SBP remained liberalized without issue. He
remained in the ICU for vasospasm watch. On [**8-4**], he had a TCD
which showed normal velocities and no vasospasm.
He was transferred to the Step Down Unit on [**2102-8-6**]. Screening
LENIS were done which were negative. He remained stable and had
repeat CTA on [**8-8**] to help prepare for discharge. The CTA was
stable with no vasospasm. He was discharged home on [**8-9**] with
Nimodipine for a full 21 day course.
Medications on Admission:
Levoxyl 175 mcg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 11 days: you need to complete the full course of this
medication .
Disp:*132 Capsule(s)* Refills:*0*
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
ACOMM Aneurysm (A1)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Please follow-up with Dr [**Known firstname **] in 4 weeks with A CT scan of the
brain. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Please follow-up with Dr [**First Name (STitle) **] from Neurology in 4 weeks.
Our office will coordinate this appointment and Dr[**Name (NI) 66745**]
office will call you to schedule.
FROM A NEUROSURGICAL STANDPOINT, WE RECOMMEND THAT YOU DO NOT
RETURN TO YOUR DUTIES AS A FIRE FIGHTER UNTIL YOU ARE CLEARED TO
DO SO - THIS WILL BE RE-ASSESSED IN TWO MONTHS TIME.
Completed by:[**2102-8-9**]
|
[
"285.1",
"V10.87",
"430",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
6803, 6809
|
4503, 5756
|
309, 469
|
6897, 6897
|
3256, 4480
|
7928, 8480
|
1549, 1575
|
5828, 6780
|
6830, 6876
|
5782, 5805
|
7048, 7905
|
1619, 1925
|
3117, 3237
|
266, 271
|
497, 1366
|
2218, 3103
|
1604, 1604
|
6912, 7024
|
1388, 1419
|
1435, 1533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,773
| 172,324
|
13060
|
Discharge summary
|
report
|
Admission Date: [**2179-8-13**] Discharge Date: [**2179-8-21**]
Date of Birth: [**2113-5-20**] Sex: F
Service: MED
Allergies:
Bactrim
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
transferred from the OSH following tonic/clonic seizure after
found to have subdural hematoma
Major Surgical or Invasive Procedure:
mechanical ventilation, bronchoscopy
History of Present Illness:
66 yr old female with complicated PMH including h/o follicular
lymphoma s/p BMT in [**2168**], DM, MRSA septicemia (per records),
chronic thrombocytopenia (baseline plt count around 30) with
frequent recurrent pneumonias in the last ? BOOP but never had a
biopsy, who was innitially admitted to the OSH for presumed PNA
with symptoms of right sided pleuritic chest pain of several
days duration. WBC 20.9 on admission, afebrile. CXR with right >
left pleural effusion. The patient was r/o for PE with chest
CTA. The patient was also hyponatremic with Na of 127. The
patient was treated with Doxycycline and Rocephin (then changed
to Ivanz). Then on HD #7 developed tonic-clonic seizure. Head CT
was subsequently done and revealed left chronic subdural
hematoma with 5 mm left to right shift. The patient was loaded
with dilantin and then transferred to the BIBMC for further
management of her subdural hematoma. Labs from OSH on the day of
transfer Na 128, Ca 5.3 (alb 2.2), Mg 1.2.
Upon arrival to [**Hospital1 18**], she was admitted to the neurosurgery
service. The patient declined to undergo evacuation of her
subdural hematoma. She had had no further seiuzure activity. She
developed respiratory distress RR in 30-40's with new increased
oxygen requirements (requiring 50-70% VM). The patient is now
being transferred to the medicine service.
ROS is negative for f/c, cough, hemoptysis, abd pain, change in
bowel, bladder habits. The patient's husband related [**Name2 (NI) 39939**] in
patient's gait from normal to shuffling, small steps for about 2
months prior to admission. She also fell back in [**Month (only) 205**] in
bathroom hitting her head. She has not had any falls since that
time.
Past Medical History:
1. Follicular lymphoma diagnosed [**2164**], s/p BMT [**2168**], has been in
remission since
Dr. [**Last Name (STitle) **] (oncologist)
2. Frequent pneumonias ? BOOP but never had biopsy
Was started on Prednisone 20 mg po qd but it was d/c'd after
2 weeks b/o hyperglycemia
3. DM (diagnosed in [**Month (only) 205**] of this year)
4. Facial skin cancer
5. MRSA septicemia [**2175**]
6. s/p stomach surgery for lymphoma
7. s/p chole
8. s/p hysterectomy for uterine fibriods
9. s/p hemorrhoidectomy
10. s/p stapidectomy
Social History:
Lives with husband. [**Name (NI) **] 4 children. Tobacco: none EtOH: none
IVDU: none
Family History:
Non-contibutory
Physical Exam:
T 96.6 BP 112/60 HR 32 O2 sat 98% on 70% VM
General: frail elderly woman, cachectic, with face mask on, able
to speak in full sentences, appears uncomfortable but in no
distress
HEENT: NC, AT, EOM intact, sclera non-icteric, PERRL, VM on
Neck: No LAD, no thyromegaly, JVD at 14 cm
Pulm: pulmonary crackles bilaterally, decreased BS at bases
(R>L)
CV: regular, nl S1S2, no m/g/r
Abd: +BS, soft, NT, ND, no HSM
Extr: 2+ pitting edema to knees bilaterally, chronic stasis
changes
Neuro: CN II - XII intact
Pertinent Results:
[**2179-8-16**] 02:46PM BLOOD WBC-16.7* RBC-2.86* Hgb-10.7* Hct-31.6*
MCV-110* MCH-37.4* MCHC-33.9 RDW-17.3* Plt Ct-58*
[**2179-8-16**] 02:46PM BLOOD Plt Ct-58*
[**2179-8-16**] 04:06AM BLOOD PT-13.7* PTT-25.9 INR(PT)-1.2
[**2179-8-13**] 05:00AM BLOOD Fibrino-906*
[**2179-8-13**] 05:00AM BLOOD FDP-40-80
[**2179-8-16**] 02:46PM BLOOD Glucose-145* UreaN-15 Creat-0.4 Na-132*
K-4.0 Cl-93* HCO3-28 AnGap-15
[**2179-8-13**] 05:00AM BLOOD ALT-103* AST-144* CK(CPK)-51 AlkPhos-835*
Amylase-14 TotBili-0.9
[**2179-8-15**] 03:30AM BLOOD Phenyto-11.6
[**2179-8-14**] 04:25AM BLOOD Type-ART pO2-95 pCO2-41 pH-7.47*
calHCO3-31* Base XS-5
[**2179-8-13**] 05:54AM BLOOD Lactate-2.6*
[**2179-8-14**] 04:25AM BLOOD freeCa-0.96*
CXR: Improved bilateral infiltrates and improved right effusion.
Head CT: Moderate to left chronic left subdural hematoma with
mild mass effect on the left cerebral hemisphere, with no
appreciable shift of the midline structures. The maximum width
of SDH is 16mm. No acute intracranial hemorrhage seen.
Brief Hospital Course:
66 yr old female with complicated PMH including follicular
lymphoma s/p BMT, BOOP?/recurrent pneumonias, chronic
thrombocytopenia admitted with PNA and found to have subdural
hematoma.
1. Pulmonary opacities/ pleural effusions - PNA vs. BOOP (no
biopsy or bronchospcopy in the past), effusion differential was
broad with h/o malignancy, pneumonia (. Completed 10 days of
Doxycycline and 4 days of Ceftriaxone. The patient was started
on Zosyn for broad coverage although remained Blood cultures
NGTD. Unable to get any information from Dr [**Last Name (STitle) **] primary
pulmonologist, although husband provided old CT results from
outside hospital. Pt intubated electively after much discussion
and informed consent, in order to investigate by bronchoscopy
for a reversible cause of her SOB with the understanding that if
nothing was discovered that she would be comfort measures only
and extubated. While preparing for elective intubation, pt
became progressively more short of breath and became distressed.
Pt urgently intubated. Bronchoscopy did not demonstrate a
pneumonia nor mass.
2. Thrombocytopenia - History of TCP since bone marrow
transplant for lymphoma treatment many years ago per primary
physcian.
3. Seizure - no further seizures during hospitalization here at
[**Hospital1 18**]. Prior seizure likely secondary to SDH (although appears
chronic) or electrolyte imbalances. Pt kept on dilantin until
made CMO.
4. Subdural Hematoma: pt transferred her for further managment
of SDH discovered at OSH after seizure, however after discussion
with neurosurgery pt decided to decline any intervention.
5. Code: after discussion with Ms [**Known lastname 39940**] family (husband and
children), she was made comfort measures only and was placed on
a morphine drip and scopolamine patch. After several hours of
comfortable but progressive cardiopulmonary failure, the patient
passed away on [**2179-8-21**].
Medications on Admission:
Synthroid 0.125 mg po qd
Premarin 0.625 mg po qam
Toprol XL 50 mg po qam
MVI
Doxy 100 mg po q8(started [**8-7**])
Ivanz 1 gm qam
Salagen 5 mg po tid
CaCO3 1000 mg po qd
Vit D
Kcl 40 mEq po qd
Insulin
Epogen
Actonel
Discharge Medications:
n/a
Discharge Disposition:
Home
Discharge Diagnosis:
cardiopulmonary failure, CMO
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"780.39",
"996.85",
"287.5",
"432.1",
"486",
"518.81",
"250.00",
"202.00",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"99.04",
"38.91",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6630, 6636
|
4403, 6336
|
356, 394
|
6708, 6717
|
3359, 4140
|
6773, 6783
|
2797, 2814
|
6602, 6607
|
6657, 6687
|
6362, 6579
|
6741, 6750
|
2829, 3340
|
223, 318
|
422, 2127
|
4149, 4380
|
2149, 2679
|
2695, 2781
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,150
| 141,512
|
42133
|
Discharge summary
|
report
|
Admission Date: [**2179-12-14**] Discharge Date: [**2179-12-29**]
Date of Birth: [**2094-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Fosamax
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2179-12-14**]
Aortic valve replacement(19-mm [**Doctor Last Name **] Magna Ease) Model number
3300TFX. Serial number [**Serial Number 91388**] & Patch aortoplasty with a bovine
pericardium.
Insertion of tunnelled dialysis catheter
[**2179-12-14**]
Aortic valve replacement(19-mm [**Doctor Last Name **] Magna Ease) Model number
3300TFX. Serial number [**Serial Number 91388**] & Patch aortoplasty with a
bovine pericardium.
Insertion of tunnelled dialysis catheter
[**2179-12-14**]
Aortic valve replacement(19-mm [**Doctor Last Name **] Magna Ease) Model number
3300TFX. Serial number [**Serial Number 91388**] & Patch aortoplasty with a
bovine pericardium.
Insertion of tunnelled dialysis catheter
[**2179-12-14**]
Aortic valve replacement(19-mm [**Doctor Last Name **] Magna Ease) Model number
3300TFX. Serial number [**Serial Number 91388**] & Patch aortoplasty with a
bovine pericardium.
Insertion of tunnelled dialysis catheter
History of Present Illness:
This 85 year old female has known aortic stenosis. She has
undergone serial echocardiograms with worsening aortic stenosis,
the last demonstrating severe stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.6cm2.
She states she is mostly asymptomatic but develops mild dyspnea
on exertion. In addition, has experienced some lightheadedness.
.
Past Medical History:
Aortic Stenosis
Hypercholesterolemia
Hypertension
gastroesophageal reflux
s/p Appendectomy
s/p TAH/BSO
Social History:
Race: Caucasian
Last Dental Exam: [**9-21**]
Lives: alone
Contact:[**Name (NI) 2092**] (son) Phone #[**Telephone/Fax (1) 91389**]
Occupation: Retired postal worker
Cigarettes: Smoked no [X] yes []
Other Tobacco use: denies
ETOH: < 1 drink/week [X]
Illicit drug use: denies
Family History:
No premature coronary artery disease
Physical Exam:
Pulse:80 Resp:14 O2 sat: 97%/RA
B/P Right:151/56 Left:142/63
Height: 60" Weight: 137 lbs
General: Well-developed female in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] JVD [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] soft systolic ejection Murmur grade [**2-15**] with
radiation to the L carotid area
Abdomen: Soft [X] non-distended [X] non-tender [X] + BS [X]
Extremities: Warm [X], well-perfused [X] min Edema, no
varicosities
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 soft (likely radiating cardiac murmur)
Pertinent Results:
[**2179-12-27**] 09:00AM BLOOD WBC-13.4* RBC-3.34* Hgb-9.9* Hct-30.5*
MCV-91 MCH-29.7 MCHC-32.6 RDW-15.0 Plt Ct-299
[**2179-12-26**] 06:00AM BLOOD WBC-15.0* RBC-3.45* Hgb-10.4* Hct-31.6*
MCV-92 MCH-30.1 MCHC-32.8 RDW-15.0 Plt Ct-294
[**2179-12-19**] 02:54AM BLOOD WBC-13.3* RBC-3.89* Hgb-11.4* Hct-34.6*
MCV-89 MCH-29.4 MCHC-33.0 RDW-15.2 Plt Ct-75*
[**2179-12-20**] 01:41AM BLOOD WBC-11.1* RBC-3.83* Hgb-11.3* Hct-34.4*
MCV-90 MCH-29.4 MCHC-32.7 RDW-15.4 Plt Ct-96*
[**2179-12-27**] 09:00AM BLOOD Glucose-111* UreaN-104* Creat-2.5* Na-145
K-3.4 Cl-105 HCO3-27 AnGap-16
[**2179-12-26**] 06:00AM BLOOD Glucose-111* UreaN-107* Creat-3.1* Na-138
K-3.3 Cl-98 HCO3-26 AnGap-17
[**2179-12-25**] 05:55AM BLOOD Glucose-125* UreaN-103* Creat-3.6* Na-141
K-3.6 Cl-99 HCO3-26 AnGap-20
[**2179-12-24**] 02:34AM BLOOD Glucose-113* UreaN-87* Creat-3.8* Na-141
K-3.8 Cl-98 HCO3-27 AnGap-20
[**2179-12-20**] 01:41AM BLOOD Glucose-144* UreaN-120* Creat-5.9* Na-140
K-4.3 Cl-101 HCO3-22 AnGap-21*
[**2179-12-19**] 02:54AM BLOOD Glucose-120* UreaN-90* Creat-5.2* Na-138
K-4.2 Cl-101 HCO3-22 AnGap-19
[**2179-12-18**] 02:59PM BLOOD Glucose-124* UreaN-74* Creat-4.8* Na-138
K-4.2 Cl-102 HCO3-21* AnGap-19
[**2179-12-18**] 05:07AM BLOOD UreaN-60* Creat-4.6* Na-139 K-4.1 Cl-103
HCO3-23 AnGap-17
[**2179-12-15**] 01:20PM BLOOD Glucose-126* UreaN-20 Creat-1.5* Na-141
K-3.8 Cl-110* HCO3-22 AnGap-13
[**2179-12-24**] 02:34AM BLOOD T4-5.6 T3-59*
[**2179-12-29**] 04:30AM BLOOD WBC-13.7* RBC-3.38* Hgb-10.1* Hct-30.7*
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.6* Plt Ct-323
[**2179-12-29**] 04:30AM BLOOD Glucose-155* UreaN-69* Creat-1.8* Na-146*
K-4.4 Cl-109* HCO3-25 AnGap-16
Brief Hospital Course:
This 85 year old white female with known aortic stenosis was a
same day admission to the Operating Room for aortic valve
replacement by Dr. [**Last Name (STitle) 914**] on [**2179-12-14**]. Please see the operative
report for details. She underwent aortic valve replacement with
a 19-mm [**Doctor Last Name **] Magna Ease aortic valve bioprosthesis and patch
aortoplasty with a bovine pericardial patch. Her bypass time was
84 minutes with a crossclamp time of 69 minutes.
Post-operatively she was transferred to the cardiac surgery ICU
on Neosynephrine and Propofol infusions.
Her cardiac function was suboptimal and she was subsequently
started on Milrinone to support her cardiac function.
Additionally she was somewhat hypoxic and she was kept sedated
through POD 1. On POD 2 her sedation was stopped, her Milrinone
was weaned off and diuretics were started. She failed to respond
to Lasix infusion. Her platelet count fell and a Heparin
antibody test was negative. She remianed profoundly oliguric
and her creatinine rose to 6. The Lasix infusion at 20mg/hour
was continued and CVVH was instituted. Her urine output improved
and diuretics were continued with CVVH. She remained
hemodynamically stable. She took several days to awaken, but
when her BUN was below 100 she awoke and was intact. She was
subsequently extubated and after a couple of days was able to
swallow food and her medications. She required hemodialysis and
as the renal function deteriorated again despite good urine
output. A tunnelled dialysis line was placed by Interventional
Radiology. She improved and her creatinne fell, she remained
alert and intact.
Her renal numbers improved daily with good urine output off any
diuretics. On [**12-29**] her BUN and creatinine were 69 and 1.8
repectively. The dialysis catheter was removed easily and the
site was clean.
Physical Therapy worked with her and a rehabilitation screen was
performed for discharge as she remained very weak. CTs and
wires were removed in the ICU in a timely fashion without
problem. Tube feedings were administered for a few days when
she was sedated and intubated.
On [**12-29**], POD 15, her BUN and creatinine had fallen to 69 and
1.8. The dialysis catheter was removed sterilely with local
anesthesia. She was discharged to [**Hospital1 **] for further
recovery and rehabilitation. The renal numbers will be repeated
there.
Medications on Admission:
AMLODIPINE 5 mg daily
NEXIUM 40 mg daily
LOSARTAN 50 mg daily
SIMVASTATIN 20 mg daily
ASPIRIN (Not Taking as Prescribed: ran out 3 days ago) 81 mg
daily
CALCIUM CARBONATE-VITAMIN D3- 500 mg calcium (1,250mg)-200 unit
Tablet) daily
CHOLECALCIFEROL (VITAMIN D3)400 unit daily
FLAXSEED OIL 1,000 mg daily
CENTRUM SILVER MVI 1 tablet daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection three times a day: discontinue when fully ambulatory.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Aortic stenosis
s/p aortic valve replacement(19-mm [**Doctor Last Name **] Magna Ease)
postoperative renal failure
Hypercholesterolemia
Hypertension
gastroesophageal reflux
s/p Appendectomy
s/p TAH/BSO
s/p Tunnelled dialysis catheter implant
Discharge Condition:
Alert and oriented x3, nonfocal
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema:trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**]([**Telephone/Fax (1) 170**]) on [**2180-1-24**] at 1:45pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] on [**2180-1-19**] at 10;30am
Please call to schedule appointments with your
Primary Care Dr.[**First Name11 (Name Pattern1) 569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1968**] ([**Telephone/Fax (1) 91390**]) in [**3-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2179-12-29**]
|
[
"518.4",
"414.01",
"V58.61",
"285.1",
"458.29",
"584.5",
"401.9",
"276.69",
"287.49",
"530.81",
"518.51",
"V17.49",
"453.81",
"997.5",
"424.1",
"V64.1",
"799.02",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"96.72",
"96.6",
"38.95",
"35.21",
"96.04",
"39.95",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8375, 8511
|
4576, 6973
|
291, 1245
|
8797, 8931
|
2910, 4553
|
9855, 10542
|
2077, 2116
|
7360, 8352
|
8532, 8776
|
6999, 7337
|
8955, 9832
|
2131, 2891
|
236, 253
|
1273, 1640
|
1662, 1767
|
1783, 2061
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,200
| 199,998
|
33528
|
Discharge summary
|
report
|
Admission Date: [**2119-2-18**] Discharge Date: [**2119-2-24**]
Date of Birth: [**2049-12-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Midazolam Hcl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2119-2-20**] Off Pump Coronary Artery Bypass Grafting utilzing the
left internal mammary artery to left anterior descending with
vein grafts to obtuse marginal and posterior descending artery.
History of Present Illness:
This is a 69 year old male in known coronary artery disease,
with prior PCI/stenting. Over the last several months, he had
noticed worsening chest pain and dyspnea on exertion. He denied
symptoms at rest. Exercise tolerance test was strongly positive
for ischemia. Outside cardiac catheterization at [**Hospital3 **]
revealed severe three vessel disease including in-stent
restenosis. He was subsequently transferred to the [**Hospital1 18**] for
cardiac surgical intervention.
Past Medical History:
Coronary Artery Disease
Prior PCI/Stenting to Right Coronary Artery
Peripheral Vascular Disease
Hypertension
Hyperlipidemia
Surgeries: Elbow, Tonsillectomy, Knee
Social History:
Married, 5 children. Stop smoking in [**2096**].
Family History:
Denied premature coronary artery disease
Physical Exam:
Vitals: 98.2, 122/70, 54, 18, 98%RA
General: WDWN male in NAD
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, soft systolic
murmur noted
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2119-2-18**] 06:58PM BLOOD WBC-9.6 RBC-3.89* Hgb-12.8* Hct-37.0*
MCV-95 MCH-33.0* MCHC-34.7 RDW-13.7 Plt Ct-241
[**2119-2-24**] 05:00AM BLOOD WBC-7.8 RBC-2.57* Hgb-8.4* Hct-24.4*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.6 Plt Ct-194
[**2119-2-18**] 06:58PM BLOOD PT-11.7 PTT-29.0 INR(PT)-1.0
[**2119-2-20**] 03:05PM BLOOD PT-13.2 PTT-38.8* INR(PT)-1.1
[**2119-2-18**] 06:58PM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-141
K-4.3 Cl-103 HCO3-27 AnGap-15
[**2119-2-24**] 05:00AM BLOOD Glucose-112* UreaN-25* Creat-1.1 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
[**2119-2-18**] 06:58PM BLOOD Glucose-109* UreaN-16 Creat-0.9 Na-141
K-4.3 Cl-103 HCO3-27 AnGap-15
[**2119-2-24**] 05:00AM BLOOD Glucose-112* UreaN-25* Creat-1.1 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-16
[**2119-2-18**] Chest CT Scan:
1. Aortic and coronary artery mural calcification, consistent
with atherosclerotic disease. No evidence of thoracic aortic
aneurysm.
2. 2-mm non-calcified left lower lobe pulmonary nodule. If there
are no risk factors for lung cancer, no further followup is
required. If there are risk factors for lung cancer, followup CT
in one year is recommended.
3. Dense coronary artery calcifications.
[**2119-2-20**] Intraop TEE:
1. The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No mass/thrombus is seen in the left atrium or left
atrial appendage. No thrombus is seen in the left atrial
appendage.
2. 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.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are complex (>4mm) atheroma in the aortic root. There
are complex (>4mm) atheroma in the ascending aorta. There are
complex (mobile) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta.
6. The aortic valve leaflets are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened.
8. Trivial mitral regurgitation is seen.
Brief Hospital Course:
Mr. [**Known lastname 77739**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Part of his workup
included a chest CT scan which was remarkable for a heavily
calcified aorta. Workup was otherwise unremarkable and he was
cleared for surgery. On [**2-20**], Dr. [**Last Name (STitle) **] performed off
pump coronary artery bypass grafting surgery. For surgical
details, please see separate dictated operative note. Following
the operation, he was brought to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. Low dose beta blockade was
resumed. He maintained stable hemodynamics and transferred to
the SDU on postoperative day one. Experienced some urinary
retention which required Foley re-insertion, and his
preoperative Cardura was resumed. Chest tubes and epicardial
pacing wires were removed per protocol. He went on to experience
atrial fibrillation and was started on Amiodarone and eventually
Coumadin. He otherwise made a good recovery and worked with
physical therapy for strength and mobility. On post-op day four
he was discharged home with the appropriate medications and
follow-up appointments. Dr. [**Last Name (STitle) 66588**] will follow his Coumadin
and INR.
Medications on Admission:
Aspirin 325 qd, Cardura 1 qhs, HCTZ 25 [**Hospital1 **], Zestril 40 qd,
Norvasc 10 qd, Zocor 40 qd, Metoprolol 100 qd, Valium 10 qhs,
Plavix 75 qd - stopped [**2-16**], Darvocet prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Outpatient Lab Work
Please draw an INR on Monday and fax results to [**Doctor First Name **] in the
office of Dr. [**Last Name (STitle) 67247**] at ([**Telephone/Fax (1) 77740**].
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*1*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400mg [**Hospital1 **] x 7 days. Then 200mg [**Hospital1 **] x 7 days. Then
200mg daily until stopped by cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
per cardiologist for a goal INR of [**12-24**].5.
Disp:*30 Tablet(s)* Refills:*1*
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take
per cardiologist for a goal INR of [**12-24**].5.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease - s/p Off Pump Coronary Artery Bypass
Graft
Postoperative Atrial Fibrillation
Heavily Calcified Aorta
Pulmonary Nodule
PMH: Prior PCI/Stenting to Right Coronary Artery, Peripheral
Vascular Disease, Hypertension, Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-25**] weeks, call for appt
Dr. [**Last Name (STitle) 66588**] in [**12-25**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-25**] weeks, call for appt
Please fax INR results to [**Doctor First Name **] at the office of Dr. [**Last Name (STitle) 67247**]
([**Telephone/Fax (1) 77740**]. Spoke to [**Doctor First Name **] to confirm plan on [**2119-2-23**]
Completed by:[**2119-2-24**]
|
[
"429.3",
"V45.89",
"443.9",
"411.1",
"997.5",
"427.31",
"E878.2",
"997.1",
"788.20",
"V45.82",
"401.9",
"414.01",
"518.89",
"272.4",
"272.0",
"440.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
7510, 7593
|
4035, 5324
|
292, 489
|
7887, 7893
|
1720, 4012
|
8228, 8665
|
1263, 1305
|
5556, 7487
|
7614, 7866
|
5350, 5533
|
7917, 8205
|
1320, 1701
|
242, 254
|
517, 996
|
1018, 1181
|
1197, 1247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,778
| 184,135
|
40694+58393
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-6-14**] Discharge Date: [**2182-6-23**]
Date of Birth: [**2113-10-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
OxyContin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2182-6-18**] urgent CABG x5 ( LIMA to LAD, SVG to OM1, SVG to
OM2-seq. to OM3,SVG to RCA)
History of Present Illness:
68 year old male with hypertension,
diabetes, hyperlipidemia, obesity and COPD. Work up for history
of syncope included positive stress test at [**Hospital6 88998**].Cath revealed 3VD and he was transferred in for CABG.
Past Medical History:
Hypertension, hyperlipidemia, diabetes, MI [**2164**], renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].
Social History:
Last Dental Exam: 2 years ago
Lives with: Widowed. Has girlfriend. Lives alone in [**Location (un) **]
Occupation: Gun store owner
Tobacco: smoked 3ppd of cigars for 30 years, quit [**2173**]
ETOH: none
Family History:
mother died at 91 with multiple CVAs, MI, and
Cancer. father died of MI at 71. Brothers alive at age 70 and 64
- older brother has cancer
Physical Exam:
Pulse: 63 Resp: 18 O2 sat: 98% RA
B/P Right: 137/60 Left:
Height: 5'[**81**]" Weight: 132.3 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]obese
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ cath site clean Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: + bruit Left: + bruit
Pertinent Results:
[**2182-6-23**] INR 1.1 (dose 2.5 mg coumadin)
[**2182-6-22**] WBC-12.4* RBC-3.20* Hgb-9.6* Hct-28.5 Plt Ct-310#
[**2182-6-14**] WBC-6.7 RBC-3.87* Hgb-11.3* Hct-33.9 Plt Ct-221
[**2182-6-22**] UreaN-25* Creat-1.2 Na-135 K-3.6 Cl-94*
[**2182-6-14**] Glucose-114* UreaN-22* Creat-1.0 Na-140 K-3.9 Cl-104
HCO3-25
[**2182-6-14**] ALT-38 AST-63* LD(LDH)-134 AlkPhos-60 TotBili-0.3
[**2182-6-14**] HbA1c-6.5* eAG-140*
CXR:
[**2182-6-20**]:
AP single view of the chest has been obtained with patient in
upright position. Comparison is made with the next preceding
supine
postoperative chest examination of [**2182-6-18**]. The patient is
now
extubated. Previously described sternotomy wires in place,
unchanged.
Previously described right internal jugular approach central
venous line
remains in place. The patient is now extubated and the
left-sided chest tube has been removed. Lungs remain ventilated
and no evidence of pneumothorax is seen on this portable chest
examination obtained in upright position.
Date of [**2182-6-17**]
SPIROMETRY Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 3.77 4.57 82
FEV1 2.37 3.09 77
MMF 1.26 2.79 45
FEV1/FVC 63 68 93
LUNG VOLUMES 11:09 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 5.61 7.15 78
FRC 2.61 4.07 64
RV 2.01 2.58 78
VC 3.60 4.57 79
IC 3.00 3.08 97
ERV 0.60 1.49 40
RV/TLC 36 36 99
He Mix Time 3.00
DLCO
Actual Pred %Pred
DSB 21.24 25.64 83
VA(sb) 5.20 7.15 73
HB 11.30
DSB(HB) 23.80 25.64 93
DL/VA 4.58 3.59 128
Echocardiogram: [**2182-6-15**]
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 12 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.70
Mitral Valve - E Wave deceleration time: *301 ms 140-250 ms
TR Gradient (+ RA = PASP): *26 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Normal mitral valve supporting structures. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). The inferior wall appears hypokinetic. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2182-6-15**]: Chest CT
1. Moderate calcifications of the aortic arch. No calcification
of the
ascending aorta.
2. 1.7 cm right adrenal gland nodule, incompletely characterized
on this CT and MR is recommended for further work-up
3. Pathologically enlarged celiac axis lymph node which can be
further
assessed with MRI.
4. Cholelithiasis without cholecystitis.
Brief Hospital Course:
Transferred in [**6-14**] and preop w/u completed. Underwent surgery
with Dr. [**Last Name (STitle) **] on [**6-18**] and was transferred to the CVICU in stable
condition on titrated nitroglycerin and propofol drips.
Extubated later that day and transferred to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed per protocol. Gently diuresed toward his preop
weight.
Respiratory: aggressive pulmonary toilet, nebs, ambulation his
oxygen requirement improved to 96% 3L via nasal cannula. He
continued CPAP overnight, saturations 98%
Home inhalers were continued.
Cardiac; Intermittent atrial fibrillation low 100's amiodarone
bolus, drip and PO was started. His beta-blocker was increased.
His Diltiazem was restarted. He continued to rate control
atrial fibrillation. Hemodynamically stable BP 120-140's.
Statins were restarted ( at lower than home dose d/t
amiodarone). Coumadin was started for Afib on [**2182-6-22**]. he has
rec'd 2 doses of 2.5 mg couamdin and his INR was 1.1- NO need
lovenox bridge)
GI: PPI & bowel regime. Nutrition tolerated a regular diet
Renal: Renal function normal baseline CRE 1.0-1.2. He was gently
diuresed. Electrolytes repleted. Foley removed with good urine
output. His gout medication continued.
Endocrine: Insulin while in CVICU, transitioned to SQ insulin
(regaulr insulin sliding scale and lantus) and once tolerating
PO his metformin was restarted to maintain blood sugars < 150.
He will require transitin back to januvia (home medication) and
off lantus.
Pain: well controlled with PO Dilaudid and acetaminophen
Disposition: he was seen by physical therapy, ambulates with a
rolling walker and would benefit from rehab. He was discharged
on [**2182-6-23**] to [**Location (un) 13040**] Health Rehab
Medications on Admission:
diltiazem 180 mg daily, Isorbide mononitrate 30 mg daily, toprol
XL 12.5 daily, Dipyridamole 25mg [**Hospital1 **], lasiz 40mg daily,
omeprazole 40 mg daily, Januvia 100mg daily, Metformin 500mg
[**Hospital1 **],
simvastatin 80mg daily, ultram prn, spiriva 18mcgs daily, ASA
325
daily, genfibrozil 300mg [**Hospital1 **], allopurinol 300mg daily, xanax .25
hs.
Discharge Medications:
1. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. dipyridamole 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily for 7 days then 200mg ongoing until d/c'd by
cardiologist.
15. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
16. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): home dose is 80mg-please increase to 80mg when off
amiodarone.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: home
dose is 40mg daily- decrease when at pre-op weight 132kg and
edema resolved.
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Indication afib
coumadin dose based on INR goal 2.0-2.5 .
19. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day:
Transition off lantus and back to Januvia.
20. lantus
lantus 65 units daily with breakfast.
transition off lantus to Januvia (home medication)
21. regular insulin
regular insulin per finger stick. See sliding scale
22. Outpatient Lab Work
Daily INR until INR stable at goal of 2.0-2.5 then twice weekly
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 13040**] Nursing & Rehabilitation Center
Discharge Diagnosis:
Coronary artery disease s/p CABG x5
Post-operative afib
Hypertension, hyperlipidemia, diabetes, MI [**2164**], renal cancer
[**2172**], Obesity, obstructive sleep apnea with CPAP, left upper
lung
resection at [**Hospital1 2025**] [**2173**] s/p radiation in [**2173**], right foot plantar
fasciitis, CVA with right facial numbness, gastroparesis,
anxiety, gout, hard of hearing
Past Surgical History:
hiatal hernia repair x2, removal of gastric polyp, left upper
lung resection at [**Hospital1 2025**] [**2173**], right nephrectomy for renal cancer
[**2172**].
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Labs: PT/INR for Coumadin ?????? indication post-op afib
Goal INR 2.0-2.5
First draw [**2182-6-24**]
Coumdin follow up to be arranged with PCP upon discharge from
rehab. Thank you
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **] at [**Hospital1 **], [**Telephone/Fax (1) 6256**])
Thursday, [**2182-7-18**] 9am
Cardiologist:Dr. [**First Name (STitle) **], [**2182-7-23**], 1:15pm
Primary Care Dr.[**Last Name (STitle) **] [**7-18**] at 2:00pm
Labs: PT/INR for Coumadin ?????? indication post-op afib
Goal INR 2.0-2.5
First draw [**2182-6-24**]
Coumdin follow up to be arranged with PCP upon discharge from
rehab. Thank you
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Follow up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], regarding adrenal nodule noted on
CT scan- MRI recommended for follow up.
Completed by:[**2182-6-23**] Name: [**Known lastname **],[**Known firstname 126**] P Unit No: [**Numeric Identifier 14120**]
Admission Date: [**2182-6-14**] Discharge Date: [**2182-6-23**]
Date of Birth: [**2113-10-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
OxyContin
Attending:[**First Name3 (LF) 135**]
Addendum:
Amiodarone discontinued prior to discharge to avoid untoward
effects of 3 nodal agents. Afib is rate controlled.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14121**] Nursing & Rehabilitation Center
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2182-6-23**]
|
[
"782.0",
"278.00",
"V10.11",
"427.31",
"411.1",
"V15.3",
"V10.52",
"438.89",
"414.01",
"V85.38",
"401.9",
"536.3",
"272.4",
"250.00",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"84.94",
"36.14",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
14622, 14863
|
6874, 8673
|
284, 379
|
12032, 12253
|
2241, 5806
|
13275, 14599
|
1396, 1536
|
9085, 11319
|
11447, 11826
|
8699, 9062
|
12277, 13252
|
11849, 12011
|
5845, 6851
|
1551, 2222
|
237, 246
|
407, 629
|
651, 974
|
1175, 1380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,023
| 169,061
|
1506
|
Discharge summary
|
report
|
Admission Date: [**2142-2-20**] Discharge Date: [**2142-2-27**]
Date of Birth: [**2085-11-25**] Sex: F
Service: [**Doctor Last Name 1181**] ME
ADMITTING DIAGNOSIS: Cellulitis.
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
female who originally presented to her primary care physician
on [**2-16**] with a cellulitis which failed to relieve with
Keflex, who was admitted on [**2142-2-20**], for treatment
by Cardiothoracic Surgery with Vancomycin and debridement.
She was sent to the CSRU with course complicated by nausea,
vomiting and abdominal pain. An ultrasound was normal. The
patient had a Gastrointestinal consultation at that time
which showed likely medication related versus viral. Course
also noted for hypertension, hyperglycemia. She was then
transferred to the Medical Intensive Care Unit for blood
glucose control.
She was placed on insulin drip and received [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consultation. Her course there was also significant for
mental status change secondary to medication effects. She
was then transferred to the Medicine Service for continued
control of her nausea, hypertension, blood glucose and to
finish a ten day course of Levofloxacin for saphenous vein
graft harvest site cellulitis.
She is currently complainign of pain in the saphenous vein
graft debridement site.
PAST MEDICAL HISTORY:
1. Status post coronary artery bypass graft [**2142-2-1**] with
left internal mammary artery to left anterior descending,
saphenous vein graft to obtuse marginal and saphenous vein
graft to right coronary artery.
2. Cerebrovascular accident.
3. Diabetes mellitus.
4. Hypertension.
5. Coronary artery disease.
6. Chronic low back pain.
7. Back surgery.
8. Status post appendectomy.
SOCIAL HISTORY: She has occasional alcohol. Former
tobacco.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Aspirin 325.
2. Lisinopril 30.
3. Lopressor 50 twice a day.
4. Protonix.
5. Plavix.
6. Amaryl 4.
7. Lasix 80.
8. MS-Contin 20 three times a day.
MEDICATIONS ON TRANSFER FROM THE MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Morphine SR 100.
2. Reglan.
3. Senna.
4. Lopressor 50 twice a day.
5. Hydril.
6. Lisinopril.
7. Tylenol.
8. Insulin.
9. Dulcolax.
10. Ativan.
11. Protonix.
12. Zofran.
13. Vancomycin one q. 12.
14. Heparin subcutaneously.
15. Plavix 75.
16. Colace.
17. Aspirin 325 mg.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: This is an ischemia patient who is
status post coronary artery bypass graft for three vessel
disease. She was ruled out during this admission. For
nausea, she was continued on her aspirin, beta blocker,
Plavix. She is not on a statin for unclear reasons.
2. PUMP: The patient is on outpatient Lasix dose. There is
no echocardiogram in computer. Her Lasix was held for
several days. Her intakes and outputs were monitored and
were stable. She was never in florid failure at this time.
Her rhythm was stable throughout.
3. CELLULITIS: The patient was continued on her Vancomycin
to receive a full four week course. She received a PICC line
placement by Interventional Radiology and continued on her
dressing changes twice a day.
4. PAIN: The patient with low back pain and pain at her
debridement site, on high dose MS-Contin at home and was
continued.
5. HYPERTENSION: The patient with difficult blood culture
control during this admission. It was controlled using
intravenous Hydralazine. She was continued on her beta
blocker and ACE.
She had an abdominal examination significant for bruits
suspicious for renal artery stenosis. She is to be worked up
as an outpatient.
6. GASTROINTESTINAL: The patient with nausea and vomiting
and unclear source. She was seen by Gastroenterology as an
inpatient with a normal ultrasound. Likely medication effect
versus viral gastroenteritis, resolved with supportive
management.
7. HYPERGLYCEMIA: The patient was continued on her insulin
dosing in the Medical Intensive Care Unit for desired tight
control given her cellulitis.
8. GENITOURINARY: The patient with some urinary retention,
which resolved on its own without intervention.
DISCHARGE MEDICATIONS:
1. Vancomycin one gram q. 12 for four weeks.
2. Aspirin 325 mg p.o. q. day.
3. Colace.
4. Plavix 75.
5. Heparin subcutaneously.
6. Protonix 40 mg p.o. twice a day.
7. Tylenol.
8. Lisinopril 30 mg p.o. q. day.
9. Senna.
10. MSO4 SR 100 twice a day.
11. Metoprolol 75 mg p.o. twice a day.
12. Oxycodone 10 q. six p.r.n.
DISCHARGE DIAGNOSES:
1. Cellulitis.
2. Hyperglycemia.
3. Hypertension.
4. Nausea and vomiting.
5. Coronary artery disease.
6. Diabetes mellitus.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 8838**]
D: [**2142-7-10**] 11:08
T: [**2142-7-14**] 17:45
JOB#: [**Job Number 8839**]
|
[
"998.59",
"794.31",
"724.2",
"682.6",
"250.00",
"008.8",
"V45.81",
"787.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"86.28",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4584, 4945
|
4235, 4563
|
2483, 4212
|
225, 1382
|
182, 195
|
1404, 1794
|
1812, 2456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,471
| 115,958
|
15522
|
Discharge summary
|
report
|
Admission Date: [**2164-10-5**] Discharge Date: [**2164-10-15**]
Date of Birth: [**2164-10-5**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] twin number one
was born at 34 5/7 weeks gestation to a 32 year-old gravida
one para 0 now 2 woman. Her prenatal screens are blood type
O positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis surface antigen negative and group B
pregnancy was uncomplicated until premature rupture of
membranes of this twin one day prior to delivery. The onset
of preterm labor ensued. The mother received a complete
course of antibiotics prior to delivery. The infant was
delivered by spontaneous vaginal delivery. Apgars were 8 at
one minute and 8 at five minutes. The birth weight was 1900
grams, birth length was 43.5 cm and the birth head
ADMISSION PHYSICAL EXAMINATION: Revealed a comfortable
active preterm infant. Anterior fontanel is soft and flat.
Some periorbital puffiness. Palette intact. Lungs clear and
equal. Heart was regular rate and rhythm. No murmur.
Femoral brachial pulses +2 and equal. Abdomen soft. No
hepatosplenomegaly. Normal phallus. Testes high on the
left, but palpable. The right is descended. Patent anus.
No sacral anomalies. Stable hips. Well perfused.
Generalized decreased tone.
HOSPITAL COURSE:
Respiratory status: The infant has
remained in room air throughout the Neonatal Intensive Care
Unit stay. He has had no apnea or bradycardia. His
respirations are comfortable. Lungs are clear and equal.
Cardiovascular status: The infant required one fluid bolus at
the time of admission to maintain blood pressure and has
remained normotensive since that time. On examination he has
a normal S1 and S2 heart sounds. No murmur. He is pink and
well perfuse.
Fluids, electrolytes and nutrition: His weight at the time
of discharge is 2070 grams. Enteral feeds are begun on day
of life number one and advanced without difficulty to full
volume feeding on day of life number two. At the time of
transfer he is eating premature Enfamil 26 or breast milk 26
calories per ounce made with MCT oil and human milk
fortifier. Total fluids are 150 cc per kilogram per day. He
was requiring most of his feedings by gavage.
Gastrointestinal status: He was treated with phototherapy
for hyperbilirubinemia of prematurity on day of life number
two until day of life number six. His peak bilirubin
occurred on day of life number two and was total 11.2, direct
0.3. His rebound bili on day of life number seven was total
9.5, direct 0.3.
Hematological status: His hematocrit on admission was 49.7.
The infant has received no blood product transfusions during
this Neonatal Intensive Care Unit stay.
Infectious disease status: The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
risk factors. The antibiotics were discontinued after 48
hours when the infant was clinically well and the blood
cultures were negative.
Sensory status: Hearing screening was performed
with automated auditory brain stem responses and the infant
passed in both ears.
Psycho/social: The parents have been involved in the
infant's care throughout his Neonatal Intensive Care Unit
stay.
DISCHARGE CONDITION: The infant is being discharged in good
condition to [**Hospital3 **] Special Care Nursery for
continuing care. Primary pediatric care will be provided by
Dr. [**Last Name (STitle) **] of [**Hospital **] Pediatrics in [**Location (un) **]
[**State 350**].
CARE AND RECOMMENDATIONS: Feedings at discharge are 26
calories per ounce primi Enfamil or breast milk made with 4
calories per ounce of human milk fortifier and 2 calories per
ounce of MCT oil. Total fluids 150 cc per kilogram per day.
Medications, Fer-In-[**Male First Name (un) **] 0.2 cc po q day. The infant has not
yet had a car seat test. A state newborn screen was sent on
[**2164-10-8**]. The infant has not yet received any immunizations.
Immunizations recommended, Synagis RSV prophylaxis to be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria, born at less then 32
weeks, born between 32 and 35 weeks with plans for day care
during the RSV season, with a smoker in the household, or
with preschool siblings or with chronic lung disease.
Influenza immunizations should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and the
other care givers should be considered for immunizations
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity 34 and 5/7 weeks.
2. Twin number one.
3. Sepsis ruled out.
4. Status post hyperbilirubinemia.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2164-10-15**] 06:11
T: [**2164-10-15**] 07:11
JOB#: [**Job Number 40935**]
|
[
"V29.0",
"779.3",
"796.3",
"774.6",
"V31.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.83",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3287, 3544
|
4680, 5068
|
1359, 3265
|
3571, 4659
|
889, 1342
|
173, 866
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,589
| 113,195
|
317
|
Discharge summary
|
report
|
Admission Date: [**2186-8-7**] Discharge Date: [**2186-8-26**]
Date of Birth: [**2120-1-2**] Sex: M
Service: SURGERY
Allergies:
Pneumovax 23
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
c diff colitis
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 66-year-old male who is known to have C.
difficile colitis and was admitted to the Gold surgery service
in
3/[**2186**]. He was referred to [**Hospital1 18**] for weakness, rigidity,
lethargy, decreased level of interaction, and anorexia. About a
week ago, he began having diarrhea. He has been on metronidazole
500mg po BID for several weeks.
In the ED, his initial vital signs were 97.3 129 146/93 18 99RA.
His heart rate stabilized to 80-90s after 2 liters of IVF. At
around 23:30, he became acutely hypotensive to SBP of 80s-90s,
maintaining his heart rate in the 90s. ICU bed was arranged for
close monitoring.
Past Medical History:
- Paroxysmal Atrial Fibrillation
- History of C diff colitis
- Bipolar Affective Disorder
- History of resolved hepatitis B
- History of rheumatic heart disease
- History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**]
- History of pernicious anemia
- Gastroesophageal reflux disease
Social History:
He lives with his wife. Questionable history of alcohol abuse
(did abuse alcohol >20 years ago). He has not smoked for one
month but previously has a 40 pack year history. Previously on
2L O2 at home but not prior to this hospitalization.
Family History:
His father had lung cancer and his mother had congestive heart
failure.
Physical Exam:
PHYSICAL EXAM on admission:
97.3 129->90 146/93->80/50 18 99RA
Gen: thin male, NAD, no icterus, expressive aphasia, but A&0 x 3
HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits
Lungs: CTA bilat.
[**Last Name (un) **]: +BS, soft, distended with tympany, NT, no masses, no
hernias
Ext: cold hands and feet, no edema, palpable pulses
PE: at discharge
Gen: grey, pale, mask faces, tremmer (pin wheel), expressive
aphasia, but AOx3
HEENT: PERRL, EMOI
COr: RRR
Lungs: CTA
Abd: +BS, still distended but improved, not "soft"
skin: calor and rubo s/p cellulitis from back spreading around
to front bilaterally, improved with antibiotics.
decubitus ulcer stage 3 maybe 4.
ext: cold, no edema
Pertinent Results:
[**2186-8-7**] 02:41PM WBC-14.6*# RBC-4.20*# HGB-13.6*# HCT-41.2#
MCV-98 MCH-32.4* MCHC-33.0 RDW-15.9*
[**2186-8-7**] 02:41PM NEUTS-66 BANDS-10* LYMPHS-14* MONOS-7 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-1*
[**2186-8-7**] 02:41PM LIPASE-21
[**2186-8-7**] 02:41PM ALT(SGPT)-9 AST(SGOT)-30 ALK PHOS-201* TOT
BILI-1.3
[**2186-8-7**] 02:41PM GLUCOSE-138* UREA N-22* CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
[**2186-8-7**] Abdominal CT:IMPRESSION: Wall thickening in the
descending and sigmoid colon, including
the rectum with mesenteric stranding consistent with colitis.
Interval
increase in large amount of free intra- abdominal and mesenteric
fluid.
[**2186-8-10**] Renal Ultrasound :
CONCLUSION: No evidence of renal abnormalities. Large volume of
ascites
noted.
[**2186-8-17**] Abdominal CT: IMPRESSION:
1. Increased size of bilateral simple pleural effusions with
increased
bibasilar dependent atelectatic changes.
2. Large volume abdominal pelvic ascites which appears grossly
stable.
3. Evaluation of bowel loops is limited by lack of IV and oral
contrast.
Given this limitation, there is no evidence for obstruction or
bowel
perforation.
4. Shrunken liver with nodular contour. Status post
cholecystectomy.
5. 4mm left pulmonary nodule. Per Fleichner society guidelines,
recommend
[**7-28**] month follow up chest CT if patient has risk factors for
pulmonary
malignancy.
[**2186-8-23**] Abdominal CT:
IMPRESSION:
1. Unchanged bilateral pleural effusions with associated
atelectasis.
2. Nodular, cirrhotic liver with no focal lesions on this
single-phase study.
There is again moderate ascites, with large gastric varices.
3. Normal appearance of intra-abdominal loops of small and large
bowel. No
evidence for colitis or enteritis.
4. Diffuse superficial soft tissue induration, consistent with
cellulitis.
There is no air in the soft tissues to suggest a more aggressive
process such
as necrotizing fasciitis, although this cannot be excluded by
imaging.
Brief Hospital Course:
Mr. [**Known lastname 2933**] was admitted to the intensive care unit and
underwent vigorous fluid resuscitation and maintained on IV
Flagyl and PO Vancomycin. He was seen by the infectious disease
service for further input in the treatment of his prolonged C
Diff colitis and they recommended continued treatment with
Flagyl and Vancomycin plus stopping any narcotics as he was at a
high risk of developing toxic megacolon.
His initial blood and urine cultures were negative and stool for
C Diff was positive.
His blood pressure improved with fluids and he did not require
any pressor support.
Vancomycin retention enemas were added for persistent diarrhea
and he underwent serial abdominal CT's to assess any colonic
changes. His abdominal exam over 3-4 days showed mild lower
abdominal tenderness and mild distention therefore continued
conservative non operative treatment with antibiotics was
planned.
Due to his prolonged period of poor nutrition/NPO,
hyperalimentation was started on [**2186-8-10**] and eventually he had a
PICC line placed in the left antecubital on [**2186-8-21**] for TPN and
antibiotics.
Of note, Mr. [**Known lastname 2948**] platelet count gradually decreased since
his admission from 130K to a low of 49K. His HIT was negative
and SRA is still pending. The hematology service was consulted
and felt that it was multifactorial including secondary to
cirrhosis, sepsis and anemia of chronic disease. Heparin was
not contraindicated and over the course of his hospitalization
his platelet count gradually increased to the 90K range.
Transfer to the [**Known lastname **] floor occured on [**2186-8-12**] and Lasix was
started to try to help with fluid mobilization. His PE showed
[**4-19**]+ peripheral edema as well as scrotal edema and some ascites.
He was treated with Lasix on a prn basis and his BUN/Cr
remained stable (22/0.5).
A superficial abdominal cellulitis was noted on [**2186-8-21**] beginning
on both flank areas and extending to the lower abdomen with no
connection to his sacral decubitus. He was started on broad
coverage antibiotics including Vancomycin and Zosyn without
improvement. He was subsequently changed to Daptomycin,
Ciprofloxicin and Flagyl with some improvement. Due to the
addition of broad spectrum antibiotics his oral Vancomycin was
increased to QID. He had no evidence of diarrhea and no change
in his abdominal exam. Recommendations from the infectious
disease service recommends cipro/flagyl/ dapto until [**8-31**] (10
days total).
Pt c diff colitis has responded well to PO vanco. Pt will
continue on 125 [**Hospital1 **] until [**8-31**] when [**Doctor Last Name 2949**] 125 TIDx7d, 125
BIDx7d, 125 qdx7d, 125 qodx7d, 125 q3dx14d.
The Neurology service was consulted during this admission for
evaluation of his bilateral hand tremors which seemed a bit
worse. Although Parkinson's disease could not be ruled out his
current situation precluded a definite assessment and they
recommended an out patient follow up with Dr.[**First Name (STitle) 951**]. His
Depakote continues at his home dose with a level of 53.
A speech and swallow evaluation was also done to assess the
ongoing question od possible aspiration. His baseline diet was
ground solids however over the last week he was tolerating
nectar thick liquids and pureed with no evidense of aspirating.
He remains on TPN while his diet is being slowly advanced.
Continue on nector thickness liquids and TPN until cleared to
advance, with one to one supervision.
Mr [**Name13 (STitle) 2950**] also impaired skin integrity on his R buttocks first
seen [**2186-8-22**]
[**Month/Day/Year 409**] Assessment by [**Month/Day/Year **] nurse [**2186-8-22**]: Sacral/coccygeal
unstageable pressure ulcer that is a DTI. Ulcer has evidence of
healing with necrotic area measuring 2 cm x 1 cm but affected
area measures 5 x 2 with ulcer on (R) buttock of 1 cm and more
linear ulcers on (L).Drainage is sero sang moderate amount. ALSO
there are superficial erosions on soft tissue of buttocks that
are caused by moisture and fungal rash.The area causes pain. ID
recommended Cipro/flagyl / Dapso treatment and standard [**Month/Day/Year **]
care.
Medications on Admission:
Zantac 150 mg po qd
Seroquel 25 mg po qhs
Heparin 5000u sc bid
Flagyl 500 mg po bid
Nystatin i po qid
Depakote 1000 mg po qhs
Albuterol neb inh q6h prn
MVI qd
digoxin 0.125mg po qd
flecainide 50mg po q12h
ASA 325mg po qd
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze/cough.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze/cough.
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
10. Vancomycin 125 mg Capsule Sig: One (1) liquid PO QID (4
times a day) for 2 months: Pt should be on 125 QID until [**8-31**],
then taper to 125 qdx7d, 125 qodx7d, 125 q3dx14d.
Disp:*240 liquid* Refills:*0*
11. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours).
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): Continue till [**8-31**].
13. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours): Continue till [**8-31**].
14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): Continue until [**8-31**].
15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
c diff colitis.
Please continue on antibiotics:
continute PO vanco 125 four times a day until [**8-31**] when [**Doctor Last Name 2949**]
125 three times a day x7days, 125 twice a day x7days, 125 per
day x7days, 125 every other day x7days, 125 every third day
x14days.
Cellulitis
ciprofloxacin / flagyl/ dapto until [**8-31**]
Nutrician, 1 to 1 feeding to prevent aspiration on nectar
thickened liquids. Please continue TPN until safe to advance
diet
Continue on nector thickness liquids and TPN until cleared to
advance
Discharge Condition:
improving
Discharge Instructions:
c diff colitis.
Please continue on antibiotics:
continute PO vanco 125 four times a day until [**8-31**] when [**Doctor Last Name 2949**]
125 three times a day x7days, 125 twice a day x7days, 125 per
day x7days, 125 every other day x7days, 125 every third day
x14days.
Cellulitis
ciprofloxacin / flagyl/ dapto until [**8-31**]
Nutrician, 1 to 1 feeding to prevent aspiration on nectar
thickened liquids. Please continue TPN until safe to advance
diet
Ulcer: Continue pressure relief measures per pressure
ulcer guidelines. Patient is on a 1st Step mattress
Continue with current [**Month/Year (2) **] care as per previous note.
Commercial [**Month/Year (2) **] cleanser cleanse all open wounds. Pat the
tissue dry. Apply moisture barrier antifungal ointment Apply a
piece of Aquacel AG to ulcer
Apply 1 pack of 4 x 4 gauze. Secure with 1 piece of pink hytape
across the center.
Do not cover the superficial areas on lower buttocks with gauze.
Treat with Miconazole powder and Criticaid clear anti fungal 3 x
a day.
Suspend heels off the bed with pillows under his calf.If these
do
not stay in place then order Waffle boots from distribution.
Notify MD [**First Name (Titles) **] [**Last Name (Titles) **] care nurse [**First Name (Titles) **] [**Last Name (Titles) **] or skin deteriorates.
You have had c diff colitis.
Please continue on antibiotics, cipro/flagyl/ dapto until [**8-31**]
continute PO vanco 125 [**Hospital1 **] until [**8-31**] when [**Doctor Last Name 2949**] 125 TIDx7d,
125 BIDx7d, 125 qdx7d, 125 qodx7d, 125 q3dx14d.
Continue on nector thickness liquids and TPN until cleared to
advance
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB)
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2186-9-20**] 3:45
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-9-26**] 1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-2-7**] 2:40
|
[
"707.23",
"518.0",
"682.2",
"284.1",
"110.3",
"070.30",
"707.25",
"571.5",
"707.09",
"285.29",
"008.45",
"427.31",
"608.86",
"296.80",
"789.59",
"276.6",
"456.8",
"112.0",
"398.90",
"707.03",
"530.81",
"511.9",
"V02.54",
"438.11",
"038.9",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10802, 10881
|
4482, 8662
|
11448, 11460
|
2445, 4459
|
14148, 14666
|
1581, 1654
|
8934, 10779
|
10902, 11427
|
8688, 8911
|
11484, 14123
|
1669, 1683
|
231, 310
|
338, 979
|
1702, 2426
|
1001, 1305
|
1321, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,558
| 149,137
|
12181
|
Discharge summary
|
report
|
Admission Date: [**2105-5-13**] Discharge Date: [**2105-5-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
syncope and melanotic stools
Major Surgical or Invasive Procedure:
EGD
Bronchoscopy
History of Present Illness:
82 year old man with hx. of CAD and PCI to LAD, ? of
Parkinsonism, anemia, notes 2 falls, one 2 weeks ago and one one
week pta without prodrome or LOC. He did suffer head impact with
both falls. He cannot remember why he fell.
He has additionally noted melenotic stools over the past 2
months. He denies F/C/N/V/NS. His weight has been stable. Over
the past two days, he has had increasing Rt. hip pain, and
increasing difficulty walking. He states that his legs have felt
weak. He has been taking naprosyn 2 tablets per day for the past
2 days, and today noted abdominal pain in the "pit" of his
abdomen - points to suprapubic, infraumbilical region.
He was brought to the ED, and there found to be AF, with VSS,
but noted to have guaiac positive stool and hct of 17.
s/p PRBC transfusion, EGD with injection and cauterization,
briefly in MICU. Transferred to floor the same day.
Past Medical History:
Chronic Anemia, HCT 28-31
Chronic Hyponatremia
s/p colectomy for volvulus
CAD, s/p LAD stent, old LBBB
BPH
Vertigo
Parkinsons Disease, atypical presentation, medication
unresponsive
Hypercholesterolemia
Tuberculosis 50 yrs prior
Social History:
The patient lives at home with his wife. [**Name (NI) **] is a retired
federal employee (worked in Army and Air Force Service). The
patient quit tobacco 53 years ago. He reports approximately two
alcoholic drinks per week. The patient walks two miles a day
with no shortness of breath.
Family History:
Non-Contributory
Physical Exam:
On transfer,
T 97.9 HR 80 BP 121/48 RR 26 O2Sat 94%RA
GEN: pleasant, reclining in bed, NAD
HEENT: PERRL, MM dry
CV: distant, no MRG appreciated
Lungs: +air movement anteriorly
Abd: soft, NTND, +BS
Ext: w/wp, no edema
Neuro: alert, non focal
Pertinent Results:
Chemistries
[**2105-5-13**] 06:15PM GLUCOSE-111* UREA N-63* CREAT-1.0 SODIUM-135
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14
[**2105-5-13**] 06:15PM ALBUMIN-3.5
.
CBC
[**2105-5-13**] 06:15PM WBC-10.6# RBC-1.94*# HGB-5.4*# HCT-17.2*#
MCV-88 MCH-27.7 MCHC-31.4 RDW-17.2*
[**2105-5-13**] 06:15PM NEUTS-93.7* BANDS-0 LYMPHS-4.1* MONOS-2.2
EOS-0.1 BASOS-0.1
[**2105-5-13**] 06:15PM PLT COUNT-297#
.
LFTs
[**2105-5-13**] 06:15PM ALT(SGPT)-18 AST(SGOT)-25 CK(CPK)-45 ALK
PHOS-54 TOT BILI-0.3
.
Cardiac Enzymes
[**2105-5-13**] 06:15PM CK(CPK)-45
[**2105-5-13**] 06:15PM CK-MB-3 cTropnT-<0.01
.
Fe Studies
IRON-12*
[**2105-5-13**] 06:15PM calTIBC-312 VIT B12-GREATER TH FOLATE-GREATER
TH FERRITIN-13* TRF-240
[**2105-5-13**] 06:15PM TSH-0.76
[**2105-5-13**] 06:15PM SED RATE-33*
.
U/A
[**2105-5-13**] 06:37PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2105-5-13**] 06:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2105-5-13**] 06:37PM URINE RBC-0-2 WBC-[**3-28**] BACTERIA-OCC YEAST-NONE
EPI-0-2
.
Coags
[**2105-5-13**] 08:22PM PT-13.6 PTT-24.0 INR(PT)-1.2
.
Head CT
IMPRESSION:
1) No acute hemorrhage or mass effect.
2) No CT evidence of an acute major territorial infarction.
.
EGD
Impression: Erosions in the cardia.
Ulcer in the stomach body (lesser curvature) (injection, thermal
therapy).
Gastric deformity.
Erythema in the duodenum.
Ulcers in the bulb and sweep.
Erythema in the stomach compatible with gastritis.
Nodule in the cardia.
.
CXR
IMPRESSION:
1) Persistence of right upper lobe consolidation, present since
at least [**2105-3-18**]. Its persistence is concerning for
bronchioloalveolar carcinoma, although other entities such as an
atypical infection or recurrent aspiration are also possible.
2) New opacities at both lung bases, which may represent
atelectasis versus aspiration.
3) Stable appearance of bulla on left.
4) Extensive gas within the colon and small bowel.
.
Bronchoscopy cytology: POSITIVE FOR MALIGNANT CELLS, consistent
with non-small cell carcinoma; favor adenocarcinoma.
.
Bone Scan: 1. Possible compression fracture of L3, though
metastatic disease cannot be excluded. 2. Foci of uptake in
multiple ribs, as described. Metastases cannot be excluded.
Brief Hospital Course:
82 y/o man with a history of CAD s/p PTCI [**11-25**] complicated by
GIB while anticoagulated, with subsequent colonoscopy that was
not diagnostic [**2-25**] poor prep, a history of ?parkinson's disease
(atypical presentation, medication non-responder) presents with
multiple recent falls including one day of difficulty walking
presents with complaints of 'weakness' found to have Hct of 17,
guaiac pos stools.
.
Upper GI Bleed
The patient presented with a HCT of 17 down from 33 in [**Month (only) 956**].
He was given 4 units of PRBCs, started on PPI IV bid, and was
admitted to the MICU for close monitoring; GI was consulted and
the following morning he underwent an EGD. This showed a normal
esophagus, a difficult to visualize stomach raising the question
of hernia, gastritis, a nodule and erosions in the cardia, and
an ulcer in the lesser curvature of the stomach with stigmata of
recent bleed which was injected and cauterized. There were also
non-bleeding ulcers in the duodenum. The patient tolerated the
procedure well, had a stable post procedure hematocrit, and was
called out of the unit to the floor. He had a CXR that did not
demonstrate a hiatal hernia. An h pylori antibody test was sent
and was negative. The GI team scheduled him for a repeat EGD and
colonoscopy on [**2105-6-24**]. The patient's HCT remained stable during
the latter part of his hospitalization, and diet was advanced as
tolerated.
.
RUL Opacity on CXR
This radiologic finding had been unchanged since [**2105-2-24**];
the patient underwent a chest CT for further evaluation which
showed an increased RUL opacity but additionally new lucencies
in the thoracic spine which were read as lytic lesions. The
major differential for this was TB versus malignancy. The
patient does have a history of TB >50 years ago. The patient
was placed on airborne precautions, and had induced sputums x3
sent for AFB. The smears returned negative, and cultures were
pending on discharge. Additionally he had sputum cytology sent
which was negative for malignant cells. He undewent a thoracic
and lumbar spine MR which confirmed multiple involved vertebrae
without any cord compression. Pulmonary was consulted and
offered bronch for further diagnosis. However, the patient
initially refused this intervention. A family meeting was held
on [**2105-5-22**] to discuss the possible diagnoses and the goals of
care; at this time the patient and family decided to proceed
with bronchoscopy. The patient underwent bronch on [**5-25**] and
biopsy revealed non-small cell lung cancer. He will follow-up
with thoracic oncology.
.
Falls
The patient has a history of recent falls in the context of gait
disturbances and a possible diagnosis of parkinson's disease for
which he has been followed by the neurology service. It appears
that he did not respond to Sinamet or Mirapex ([**2-25**] GI
difficulties). His recent history of falls is likely
multifactorial, including parkinsonism complicated by severe
anemia and resulting orthostatsis, as well as spinal involvement
of infection vs. tumor. A head CT was negative for bleed.
Given his complaint of right hip pain on admission, he had plain
films of the right hip that did not show fracture or
dislocation. Physical therapy and occupational therapy worked
with the patient while in house. A bone scan was done out of
concern for mets and showed increased uptake in both the spine
and ribs. Pt was given vicodin for his hip pain.
.
Anemia
In addition to the patient's acute GIB, he has a chronic
normocytic anemia with a baseline HCT between 28-31. He has
been on B12 repletion, but Fe studies sent on admission were
consistent with severe iron deficiency anemia, with appropriate
B12 and folate levels. He received transfusions as above, and
can be started on oral iron repletion on discharge (this was
tried in house but stopped [**2-25**] GI side effects).
.
CAD s/p stenting
The patient had a mid-LAD stent placed in [**2102**] and a repeat cath
in [**2103**] without instent restenosis. He does have an old LBBB on
EKG. The patient had been on aspirin 81mg on admission. He was
not restarted on his aspirin on discharge given the GI bleed,
and after his EGD/colonoscopy in [**Month (only) **], can discuss with the GI
doctors [**Name5 (PTitle) **] his [**Name5 (PTitle) 3390**] whether to start plavix instead for secondary
CAD prevention as it has been associated with less GI bleeding
risk than ASA. He should also get his lipid panel checked if it
has not been recently (no records at [**Hospital1 18**]) and consider
initiating a statin.
.
Hypertension
The patient has an EF of 60% per a [**2103**] cath that also showed a
patent stent. He was restarted on his ACEI once he was stable
out of the MICU.
.
BPH
The patient was restarted on finasteride once stable.
.
FEN
The patient was evaluated by speech and swallow who felt that he
was not an aspiration risk.
.
Proph
Once out of the MICU, the patient was initially prophylaxed for
DVT with pneumoboots. However, given the concern for metastatic
malignancy and the resultant hypercoagulable state, heparin SQ
was added.
.
Medications on Admission:
Vitamin B12 250mcg daily
Trandolapril 1mg daily
Finasteride 5 QHS
Trazadone 12.5mg qhs prn
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
Courtyard - [**Location (un) 1468**]
Discharge Diagnosis:
Primary Diagnosis
Upper GI bleed s/p EGD
Non-small cell lung cancer with metastases to spine
.
Secondary Diagnoses
? Parkinson's Disease
History of bowel obstruction
BPH
CAD s/p LAD stenting
Discharge Condition:
Stable, HCT stable, tolerating an oral diet
Discharge Instructions:
Please take your pantoprazole twice a day as prescribed. Call
your doctor or return to the emergency room if you notice
fevers, chills, abdominal pain, nausea or vomiting, diarrhea,
blood in your stool, black stools, lightheadedness, dizzyness,
or any other symptoms concerning to you. Please see Dr. [**First Name (STitle) **]
within 1-2 weeks of discharge. Her number is [**Telephone/Fax (1) 18145**].
Talk to her about starting iron supplementation. You are
scheduled for a repeat EGD and colonoscopy on [**2105-6-24**], please
complete your pre colonoscopy preparation as prescribed (this
information will be mailed to you).
Followup Instructions:
Please see Dr. [**First Name (STitle) **] on [**6-2**] at 12:30pm as scheduled.
Location: [**Street Address(2) **], [**Hospital Unit Name **]. Her number is [**Telephone/Fax (1) 18145**].
.
Please keep the following appointment (repeat EGD):
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Where: GI ROOMS
Date/Time:[**2105-6-24**] 12:30. Arrive at 11:30AM.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] PROCEDURES ENDOSCOPY SUITES Where: [**First Name8 (NamePattern2) **]
[**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2105-6-24**] 12:30
.
Please call cardiology ([**Telephone/Fax (1) 62**]), and make an appointment
to see a cardiologist in [**Month (only) **] regarding your coronary artery
stent.
.
Please call [**Telephone/Fax (1) 15512**] to make an appointment with Dr.
[**Last Name (STitle) 3274**], a thoracic oncologist in the next 1-2 weeks.
|
[
"332.0",
"162.3",
"285.1",
"V45.82",
"600.00",
"531.40",
"414.01",
"198.5",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"33.24",
"33.27",
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10600, 10663
|
4433, 9562
|
292, 311
|
10898, 10943
|
2098, 4410
|
11624, 12660
|
1800, 1818
|
9705, 10577
|
10684, 10877
|
9588, 9680
|
10967, 11601
|
1833, 2079
|
224, 254
|
339, 1225
|
1247, 1477
|
1493, 1784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,410
| 116,747
|
8009
|
Discharge summary
|
report
|
Admission Date: [**2127-3-24**] Discharge Date: [**2127-3-31**]
Date of Birth: [**2063-7-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
positive stress test
Major Surgical or Invasive Procedure:
CABG X 3, PFO closure, MV repair (26 mm ring) on [**2127-3-24**]
History of Present Illness:
63 y/o w/known CAD, monitored by regular stress tests, most
recently positive, referred for cardiac catheterization. This
revealed 3vCAD, & MR. She was referred for suregery.
Past Medical History:
CAD s/p LAD stenting
hyperlipidemia
DM
Hodgkin's disease
hypothyroidism
GERD
Barrett's esophagus
s/p hemmorhoidectomy
Social History:
divorced, lives alone
works as a software trainer
no ETOH or tobacco
Family History:
non-contributory
Physical Exam:
unremarkable pre-operatively
Pertinent Results:
[**2127-3-31**] 06:40AM BLOOD WBC-12.9* RBC-2.79* Hgb-8.2* Hct-25.0*
MCV-90 MCH-29.6 MCHC-32.9 RDW-16.8* Plt Ct-463*
[**2127-3-31**] 06:40AM BLOOD Plt Ct-463*
[**2127-3-30**] 05:55AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1
[**2127-3-30**] 05:55AM BLOOD Glucose-141* UreaN-18 Creat-0.9 Na-140
K-4.9 Cl-104 HCO3-30 AnGap-11
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Right ventricular
function.
Height: (in) 64
Weight (lb): 210
BSA (m2): 2.00 m2
BP (mm Hg): 110/46
HR (bpm): 80
Status: Inpatient
Date/Time: [**2127-3-28**] at 10:00
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: Definity
Tape Number: 2007W000-0:00
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.38 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - Peak Velocity: 1.4 m/sec
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - Pressure Half Time: 115 ms
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A Ratio: 1.17
Mitral Valve - E Wave Deceleration Time: 407 msec
TR Gradient (+ RA = PASP): 23 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2127-3-13**].
LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function. No
resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter.
AORTIC VALVE: ?# aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Mild mitral
annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - bandages, defibrillator pads or electrodes.
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional
left ventricular wall motion is normal. Right ventricular
chamber size and
free wall motion are normal. The number of aortic valve leaflets
cannot be
determined. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation
is seen. A mitral valve annuloplasty ring is present. There is
turbulent
transmitral flow, but no frank mitral stenosis. Trivial mitral
regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is
no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
Normally-functioning mitral annuloplasty band. Mild aortic
regurgitation.
Compared with the prior study (images reviewed) of [**2127-3-13**],
mitral
annuloplasty band is now present. The other findings are
similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2127-3-28**] 14:38.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Brief Hospital Course:
Admitted to the pre-op holding area on [**2127-3-24**], taken to the OR,
underwent CABG X 3, PFO closure, MV repair. In the initial
post-op period she required pressors and inotropes, she had a
metabolic acidosis for which she received NaHCO3. She was
weaned from mechanical vantilation, and extubated on POD # 1.
On POD # 2, she was placed on IV ceftriaxone for positive gm
stain of her sputum and elev. WBC. Her pressors and inotropes
were weaned off over the next few days. Ms. [**Known lastname 28673**] did have
some junctional rhythm while in the CSRU, and her beta blockers
were initially held for this. She returned to [**Location 213**] sinus
rhythm, her beta blocker was started, and well tolerated. She
was transrferred to the telemetry floor on post-op day # 4. She
has remained hemodynamically stable, and has progressed well
with physical therapy. She is ready to be discharged home on
post-op day # 7.
Medications on Admission:
metformin
omeprazole
levoxyl
toprol XL
lipitor
insulin
folic acid
ASA
niaspan
Discharge Medications:
1. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: as pre-op
Units Subcutaneous twice a day: 22 U Q am, and 28 U Q pm as
pre-op.
Disp:*1 vial* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caritas Home Care
Discharge Diagnosis:
MR
PFO
CAD
DM
hyperlipidemia
GERD
Barrett's esophagus
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**1-4**] weeks
with Dr. [**Last Name (STitle) 7047**] in [**1-4**] weeks
with Dr. [**Last Name (STitle) **] in [**3-6**] weeks
Completed by:[**2127-3-31**]
|
[
"201.90",
"272.4",
"458.29",
"745.5",
"530.81",
"250.00",
"428.0",
"413.9",
"530.85",
"276.2",
"424.0",
"427.31",
"244.9",
"780.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12",
"35.71",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7479, 7527
|
4710, 5637
|
294, 361
|
7625, 7632
|
893, 1211
|
7804, 8001
|
811, 829
|
5766, 7456
|
7548, 7604
|
5663, 5743
|
7656, 7781
|
1237, 4574
|
844, 874
|
234, 256
|
389, 567
|
4606, 4687
|
589, 709
|
725, 795
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,883
| 110,084
|
47300
|
Discharge summary
|
report
|
Admission Date: [**2124-3-6**] Discharge Date: [**2124-3-6**]
Date of Birth: [**2043-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Mental status change; hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 80 year-old woman with a history of CAD and
neurogenic bladder requiring suprapubic catheter who presents
with change in mental status and hypotension. In speaking with
nurse [**First Name (Titles) **] [**Last Name (Titles) **], patient was in her usual state of health
yesterdy though constipated requiring a suppository (reportedly
with good effect). On the morning of admission, noted by staff
to be altered, "throwing her arms all over" and saying "help,
help, help" with some complaints of back/abdominal pain. The
[**Name8 (MD) 11582**] MD was notified and the patient was sent to the ED for
evaluation. EMS vitals included RR of 28 with SBP>110.
.
In the ED, initial T 98.1, BP 153/129, HR 100, RR 24, unable to
get O2 sat. BP trended down to as low as 85/43 with HR in the
90s. T as high as 100.6. RR increased to 30s with O2 sat in
90s on NRB. Was given ~5 liters. Also given vanco 1g IV, zosyn
4.5mg IV and was started on levofed.
.
Of note, suprabupic catheter was last changed on [**2124-2-7**]. Was
supposed to be changed on [**2-28**] but didn't go because of weather.
Past Medical History:
1. Coronary artery disease
- s/p inferior MI in [**2117-10-29**] with PCI with BMS to RCA
- s/p PCI ([**10-4**]) for instent restosis
2. Multiple Sclerosis
- wheelchair bound
- neurogenic bladder with suprapubic catheter - changed qmonth
3. Diastolic dysfunction
4. Peripheral vascular disease with history of RLE ulcers
5. Osteoporosis
6. Depression
7. History of left tib/fib fracture s/p external fixation
([**6-1**])
8. History of right hip fracture, status post open reduction and
internal fixation ([**5-/2113**])
9. History of multiple falls
10. History of sacral decub ulcer, complicated by osteomyelitis
in [**2121-4-28**]
Social History:
Previously smoked 2ppd tobacco x several years; quit >15 years
ago. History of alcohol abuse, but no alcohol for > 50 years.
Currently lives at [**Hospital1 599**] of [**Location (un) 55**].
Family History:
Non contributory
Physical Exam:
VITALS: T 95.6, BP 91/25, HR 97, O2 98% on NRB
GEN: Lying on left side, in mild distress complaining of back
pain. Bear-hugger on.
HEENT: Pupils 4mm->3mm and sluggish.
CV: Borderline tachycardic; no obvious murmur.
PULM: Diffiult to hear breath sounds though no obvious crackles.
ABD: Distended and tympanic; mildly TTP
EXT: Warm in UE and cool in LE. No edema.
BACK: No spinal tenderness or CVA; sacrum skin intact.
NEURO: Alert but not oriented (won't answer when asked her
name). Moving upper extremeties but no lower.
Pertinent Results:
[**2124-3-6**] 11:00AM WBC-40.2*# RBC-3.77* HGB-10.7* HCT-35.2*
MCV-94 MCH-28.4 MCHC-30.4* RDW-15.6*
[**2124-3-6**] 11:00AM NEUTS-71* BANDS-8* LYMPHS-7* MONOS-12* EOS-0
BASOS-1 ATYPS-0 METAS-1* MYELOS-0
[**2124-3-6**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-3-6**] 11:00AM cTropnT-0.04*
[**2124-3-6**] 11:00AM LIPASE-25
[**2124-3-6**] 11:00AM ALT(SGPT)-12 AST(SGOT)-31 CK(CPK)-40 ALK
PHOS-77 AMYLASE-276* TOT BILI-1.3
[**2124-3-6**] 11:00AM GLUCOSE-144* UREA N-60* CREAT-1.7*#
SODIUM-138 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-13* ANION
GAP-25*
[**2124-3-6**] 11:06AM LACTATE-8.0*
[**2124-3-6**] 04:32PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-9.0* LEUK-MOD
[**2124-3-6**] 04:32PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**3-2**]
[**2124-3-6**] 08:12PM LACTATE-8.9*
[**2124-3-6**] 08:12PM TYPE-CENTRAL VE TEMP-38.9 PO2-49* PCO2-39
PH-6.98* TOTAL CO2-10* BASE XS--24 INTUBATED-NOT INTUBA
COMMENTS-100.1 AXIL
[**2124-3-6**] 11:00PM LACTATE-10.6*
[**2124-3-6**] 11:00PM TYPE-CENTRAL VE PO2-37* PCO2-66* PH-6.87*
TOTAL CO2-13* BASE XS--25
Brief Hospital Course:
Medical ICU Course:
The patient was admitted with septic shock, likely due to
urosepsis or perforated abdominal viscus. She received
early-goal directed therapy with 6L IVF and was placed on
pressors for a few hours. Abdominal CT showed significant fecal
overload, and manual disimpaction was attempted. Initially her
lactate responded well to IVF, however she became increasingly
acidotic with hypotension and bradycardia. Per her advanced
directive, she was not intubated, and she expired.
Medications on Admission:
1. FUROSEMIDE - 20 mg three times weekly
2. LISINOPRIL - 5 mg daily
3. NITROGLYCERIN - 0.3 mg SL PRN
4. SIMVASTATIN - 80 mg daily
5. BACLOFEN - 15 MG QID
6. MIRTAZAPINE - 30 mg QHS
7. QUETIAPINE - 50 mg QHS
8. RISEDRONATE - 35 mg weekly
9. TRAMADOL - 25 mg Q6H PRN
10. ZOLPIDEM - 5 mg QHS
11. OMEPRAZOLE - 20 mg [**Hospital1 **]
12. ACETAMINOPHEN - PRN
13. ASCORBIC ACID
14. CALCIUM CARBONATE-VITAMIN D3 - 600 mg (1,500 mg)-200 unit
[**Hospital1 **]
15. DOCUSATE - 100 mg [**Hospital1 **]
16. MILK OF MAGNESIA PRN
17. JUVEN - 1 Packet daily
18. SENNOSIDES - 8.6 mg QHS
19. FLEET ENEMA - weekly
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock secondary to probable perforated viscus complicated
by severe constipation
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
Noen
Completed by:[**2124-3-15**]
|
[
"276.2",
"412",
"599.0",
"443.9",
"584.9",
"311",
"518.82",
"340",
"995.92",
"V15.88",
"285.9",
"276.50",
"038.9",
"596.54",
"V44.6",
"V13.02",
"560.39",
"V45.82",
"414.01",
"733.00",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5325, 5334
|
4158, 4651
|
347, 353
|
5465, 5474
|
2960, 4135
|
5527, 5562
|
2385, 2403
|
5296, 5302
|
5355, 5444
|
4677, 5273
|
5498, 5504
|
2418, 2941
|
274, 309
|
381, 1505
|
1527, 2160
|
2176, 2369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,582
| 104,701
|
5625
|
Discharge summary
|
report
|
Admission Date: [**2193-4-13**] Discharge Date: [**2193-4-25**]
Date of Birth: [**2125-5-9**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 22559**] is a
67-year-old female with a history of severe mitral
regurgitation, who recently underwent mitral valve
replacement two weeks prior to admission, complicated only by
a brief episode of postoperative bradycardia. The patient
for a visit on the day of admission due to worsening
shortness of breath, cough, and paroxysmal nocturnal dyspnea
with orthopnea since she went home. She was sent to the
Emergency department from [**Hospital **] Clinic via ambulance.
On further questioning through the translator, the patient
reported that she was feeling ill on her day of discharge,
discharge she had developed worsening cough, producing white
phlegm and occasional blood-tinged sputum, but never yellow
or green. She reported that she had not been able to sleep,
and she has not been able to lie flat, and she has been
sitting in a chair at night. She denied any fever, chills,
or any chest pain. She denied any nausea or vomiting, but
she had one episode of frequent loose stools. She denied any
melena or hematochezia. She denied any palpitations.
In the emergency department, the patient was found to have
bibasilar crackles and an elevated jugular vein at
10 cm to 12 cm. A portable chest x-ray result was reported
to show congestive heart failure and right sided pleural
effusion. The patient was given 40 mg IV Lasix with good
output. The patient was given Levofloxacin for questionable
UTI by urine dipstick. Blood cultures were not obtained.
The patient was transferred to [**Hospital Ward Name 121**] 3.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. Mitral regurgitation, mitral valve prolapse status post
mitral valve replacement in [**2193-3-8**].
3. Hypertension.
4. Congestive heart failure.
5. History of dental abscess.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o.q.d.
2. Colace 100 mg one tablet b.i.d.
3. Potassium chloride 20 mEq p.o.b.i.d.
4. Lasix 20 mg p.o.one tablet b.i.d.
5. Percocet 5/325 one to two tablets q.4h. to 6h.p.r.n.
6. Lipitor 20 mg p.o. one tablet q.h.s.
7. Amiodarone 200 mg p.o.q.d.
8. Mavik 4 mg p.o.q.d.
9. Coumadin 1 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smoked in the past, no alcohol
history. She lives with her sister.
PHYSICAL EXAMINATION: Examination revealed the following:
Heart rate 96 and irregular, blood pressure 124/70,
respiratory rate 22, oxygen saturation 99% on three liters
nasal cannula. GENERAL: The patient is an alert, awake
female looking slightly tremulous and short of breath upon
speaking. Head, eyes, ears, nose, throat: Examination
demonstrated mucous membranes mildly dry, no icterus.
Conjunctiva, pallor found. CARDIOVASCULAR: S1 metalic, soft
1/6 systolic murmur, irregular rhythm.
PULMONARY: Right decreased air entry in the lower chest,
crackles and rubs in mid chest left basilar crackles, no
wheezing, postoperative wound well approximated, no apparent
drainage, no pain over the chest wound. ABDOMEN:
Nondistended, nontender, positive bowel sounds, no mass,
right flank changes with local skin breakdown extending into
the right hip, back, and buttock regions. Possible resolving
hematoma. RECTAL: Rectal examination revealed no
obstipation, guaiac-negative stool. EXTREMITIES: No lower
extremity edema. No calf tenderness. NEUROLOGICAL: The
patient is alert, awake, oriented times three; appears to
answer appropriately to questions, moving all four
extremities, asymmetric.
LABORATORY DATA: Labs upon admission revealed the following:
White count 18.2, hematocrit 27.8, platelet count 781,000, PT
21.6, PTT 39.5, INR 3.2. Sodium 128, potassium 5.3, chloride
92, bicarbonate 25, BUN 17, creatinine 0.8, glucose 165, CK
222, troponin less than 0.3. Urinalysis showed 3 to 5 white
cells plus nitrites. Catheterization results on [**2193-2-26**] revealed the coronary arteries normal,
moderate-to-several mitral regurgitation plus severe mitral
annular calcification and normal ventricular function with a
EF of 64%.
HOSPITAL COURSE:
CARDIOVASCULAR: The patient was maintained on telemetry and
[**Hospital Unit Name **] service. By ECHO, she was subsequently found to have an
approximately 500 cc pericardial effusion, which was drained
percutaneously without any complications. Coumadin was held
prior to procedure and ordered to decrease the INR to less
than two. Also, after the patient's pericardiocentesis she was
cardioverted secondary to her atrial fibrillation; it was
successful. The patient was maintained in normal sinus
rhythm throughout the course of her stay.
RESPIRATORY: The patient also was found to have a right phrenic
nerve paresis, likely temporary as the nerve was not
transected, apparently irritated during the mitral valve
replacement procedure. She was found to have a left-sided
pleural effusion, which was successfully drained by the
pulmonary fellow. Fluid was sent off for analysis and no
infection or malignancy was found.
The patient's symptoms improved. She has a baseline
shortness of breath when she lies down, however, she had no
worsening of shortness of breath, cough, or chest pain
throughout the course of stay.
HEMATOLOGY: The patient was restarted on her Coumadin with a
Coumadin load secondary to her atrial fibrillation history,
as well as prosthetic valve. It was considered crucial that
her INR is at least 2.5 before she is discharged. She was to
follow-up with the [**Hospital 197**] Clinic.
DISCHARGE DIAGNOSES:
1. Mitral valve replacement.
2. Pericardial effusion, status post pericardiocentesis.
3. Left pleural effusion status post right thoracocentesis.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o.q.d. until [**2193-4-29**] and
then 200 mg p.o.q.d.
2. Lipitor 20 mg p.o.q.h.s.
3. Mavik 4 mg p.o.q.d.
4. Coumadin 5 mg p.o.q.h.s.
5. Iron sulfate 325 mg p.o.q.d.
6. Lasix 40 mg p.o.q.d.
7. Captopril 6.25 p.o.t.i.d.
8. Calcium carbonate 500 mg p.o.t.i.d.
DISCHARGE INSTRUCTIONS: The patient is to followup with her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**5-1**] at 2:30. She
is to followup with Dr. [**Last Name (STitle) 1911**], her cardiologist on
[**5-2**], 4:15 and Dr. [**Last Name (STitle) 1537**], her CT surgeon [**4-30**] at
10 a.m. She was also to call the [**Hospital 197**] Clinic at
[**Telephone/Fax (1) 2173**] for follow up care.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
[**MD Number(1) **]
Dictated By:[**First Name3 (LF) 22560**]
MEDQUIST36
D: [**2193-4-25**] 15:16
T: [**2193-4-25**] 15:40
JOB#: [**Job Number **]
|
[
"427.31",
"511.9",
"428.0",
"285.9",
"V43.3",
"401.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"99.61",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
5675, 5825
|
5848, 6138
|
1988, 2365
|
4232, 5654
|
6163, 6809
|
2486, 4214
|
1742, 1962
|
2382, 2463
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,131
| 129,195
|
39548
|
Discharge summary
|
report
|
Admission Date: [**2109-8-13**] Discharge Date: [**2109-8-17**]
Date of Birth: [**2038-3-11**] Sex: M
Service: NEUROLOGY
Allergies:
Fentanyl / Sporanox
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
L-sided weakness, falling, dysarthria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname **] is a 71 yo M with h/o metastatic inoperable NSCLC
s/p chemo and radiation who presented to the [**Hospital1 18**] ED after
developing L-sided weakness and falling when attempting to rise
from a chair around 10:30pm on [**2109-8-12**]. His wife states that he
had developed difficulty speaking, a left-sided forehead sparing
facial droop prior to falling. Mr [**Known lastname **] was diagnosed with
NSCLC approximately 1 year ago and two metastatic brain lesions
were found in [**Month (only) 216**] (one R thalamic lesion and one R temporal
lesion). Upon falling, Mr [**Known lastname **] was taken to [**Hospital6 50929**], where he was found to have bleeding of the R thalamic
metastatic brain lesion with significant intraventricular
extension.
Mr [**Known lastname **] notes that he has experienced intermittent vertigo for
the past several months, often experienced when standing, but
denies lightheadedness. He also notes veering to the left when
he walks for the past several months. The pt states that he has
fallen several times over the past 1-2 years -- so many times
that he has lost count. He also states that he has hit his head
on multiple occasions when he has fallen. Prior to these falls,
the pt had a h/o head trauma with multiple concussions (w/o
loss
of consciousness) as a boxer from ages 11 to 29. The pt also
has
a 90 pack year smoking history.
The pt denies any diplopia, blurring of vision, or other changes
in his vision. He endorses mild retro-orbital HA, but denies
fevers, chills, nausea, vomiting , and diarrhea. He denies any
pain, numbness, or tingling, but acknowledges weakness of his L
side.
Past Medical History:
-NSCLC s/p chemo and radiation (see HPI)
-DM
-Glaucoma
-s/p b/l cataract surgery
-Lupus
-Peripheral artery disease
Social History:
The pt lives with his wife in [**Name (NI) **]. He worked for most of his
life
as a bricklayer, and retired approximately 10 years ago. He
spent much of his childhood boxing, from the ages of 11 to 29.
He states that he drank heavily for approximately 20-25 years,
about a quart of whiskey a day. Pt smoked about 1.5 PPD for 59
years. He quit one year ago when he was diagnosed with NSCLC.
Family History:
No known family history of malignancy.
Physical Exam:
Vitals 98.0 BP 113/61 HR 86 RR 20 SpO2 98% on NC
Physical Exam:
Gen: Man with several tattoos lying in bed only partially
draped
appearing his stated age of 71
HEENT: No scleral icterus. No conjunctival injection. MMM.
Poor dentition.
Neck: Supple, no LAD in cervical chains.
Lungs: Crackles in bases bilaterally, decreased breath sounds
throughout. Increased respiratory effort.
CV: RRR, no m/r/g
Abdomen: soft, NT, ND, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
edema in LE. RUE with fluid infiltrate in forearm.
Skin: No rashes or ulcers.
Neurologic examination:
Mental status: Awake, alert, cooperative, affect appropriate
ORIENTATION: Oriented to person and place, was able to state
that
it was toward the end of [**2109-7-24**]
ATTENTION: + DOW forward and backward, not able to perform MOYB
SPEECH/LANGUAGE: Speech fluent but dysarthric with intact
comprehension, repetition, naming. Can follow simple commands.
Poor lingual pronunciation, labial and gutteral pronunciation
intact. No paraphasic errors.
MEMORY: Registered [**1-23**] after drilling, recalled [**12-26**] words at 5
minutes
CALCULATION: $1.75 = 7 quarters, $2.25 = 9 quarters
PRAXIS/NEGLECT: No evidence of apraxia with RUE (LUE immobile).
Able to simulate hammering a nail with right hand. Pt is
unaware
of his inability to move his L side. When asked to simulate
hammering a nail with his left hand, believes he is hammering
the
nail, when he is actually not moving his LUE.
Cranial Nerves:
I - not tested;
II, III - Pupils equal, round, not reactive to light (s/p
cataract surgery b/l). Visual fields full to confrontation
bilaterally
III, IV, VI - EOMI, no nystagmus bilaterally, normal saccades
V - Sensation intact V1-V3
VII - Forehead sparing facial droop on L side. Smile
asymmetric.
Pt unable to close L eye tightly.
VIII - Hearing intact to finger rub bilaterally, L > R
IX, X - Voice normal, palate elevates symmetrically
[**Doctor First Name 81**] - Sternocleidomastoid, trapezius grossly intact.
XII - Tongue protrudes midline, movements intact
Motor:
Normal bulk, tone throughout. Mild pronator drift on right, no
asterixis. Postural tremor seen on right. Spontaneous movement
of all extremities.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
5
5
Sensation: Intact to light touch and proprioception except for L
arm. L arm shows diminished sensitivity to light touch and
extinction to DSS. L arm also shows diminished sensitivity to
pinprick.
Reflexes: Br [**Hospital1 **] Tri [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
L 2 2 2 3 1
R 2 2 2 2 2
No clonus. Downgoing toe on right, but upgoing on left.
Coordination: Mild dysmetria on FNF. Mirror test normal. RAMs
slow.
Gait: Not tested
Pertinent Results:
[**2109-8-13**] 04:40PM GLUCOSE-168* UREA N-23* CREAT-0.6 SODIUM-142
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
[**2109-8-13**] 04:40PM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2109-8-13**] 04:40PM WBC-9.8 RBC-3.89* HGB-13.3* HCT-37.2* MCV-96
MCH-34.1* MCHC-35.6* RDW-15.6*
[**2109-8-13**] 04:40PM PLT COUNT-168
[**2109-8-13**] 04:40PM PT-12.4 PTT-19.5* INR(PT)-1.0
[**2109-8-13**] 03:10AM URINE GR HOLD-HOLD
[**2109-8-13**] 03:10AM WBC-10.4 RBC-3.87* HGB-13.0* HCT-35.9* MCV-93
MCH-33.7* MCHC-36.4* RDW-15.8*
[**2109-8-13**] 03:10AM NEUTS-93.2* LYMPHS-5.2* MONOS-1.2* EOS-0.2
BASOS-0.1
[**2109-8-13**] 03:10AM PLT COUNT-158
[**2109-8-13**] 03:10AM PT-11.9 PTT-19.1* INR(PT)-1.0
[**2109-8-13**] 03:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2109-8-13**] 03:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-500 KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
HEAD CT [**8-13**]
1. Stable right intraparenchymal hemorrhage. Stable
intraventricular
extension of hemorrhage.
2. Stable vasogenic edema within the right temporoparietal lobe.
HEAD CT [**8-14**]
1. Unchanged right hemispheric parenchymal hemorrhages at the
site of known masses, with stable degree of intraventricular
extension of the hemorrhage.
3. Stable asymmetric dilatation of the temporal [**Doctor Last Name 534**] of the
right lateral
ventricle at the level of the ventricular atrium.
Brief Hospital Course:
Mr [**Known lastname **] is a 71 yo M with h/o metastatic inoperable NSCLC
s/p chemo and radiation who presented to the [**Hospital1 18**] ED after
developing L-sided weakness and falling when attempting to rise
from a chair around 10:30pm on [**2109-8-12**].
He was found to have intraparenchymal hemorrhage into a right
thalamic metastases.
Another CT scan on [**8-14**] was performed to view if there was any
change in his hemorrhage which showed unchanged right
hemispheric parenchymal hemorrhages at the site of known masses,
with stable degree of intraventricular extension of the
hemorrhage. There was stable asymmetric dilatation of the
temporal [**Doctor Last Name 534**] of the right lateral ventricle at the level of the
ventricular atrium.
He was seen by speech and swallow as there were concerns about
his ability to swallow. There evaluation showed aspiration with
thin liquids and prolonged mastication with mild-moderate
residue with regular solid. They recommended him for PO diet of
nectar-thick liquids and soft solids and that medications should
be take whole with nectar-thick liquids or puree.
Patient was seen by palliative care who discussed with the
patient and his family
the two options for radiotherapy which include whole brain
radiation therapy, which is standard of care,especially for lung
cancer with brain metastases. The logistics
and side effects and expected outcomes of the treatment were
discussed in detail with the patient. The advantage of the
whole brain therapy to treat both visible and undetectable
disease was outlined to the patient. The patient and his wife
ultimately will likely decide against this, and pursue only
palliative directed therapies.
Medications on Admission:
Decadron 4 [**Hospital1 **] and Keppra 500 [**Hospital1 **]
started 2 days ago for Cyberknife prep, xanax prn, ibuprofen,
metformin, plavix, xalatan, nitroquick, humolog, prednisone
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(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. 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*
4. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours).
Disp:*180 Tablet(s)* Refills:*2*
5. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Insulin sliding scale 150-180
give 2 units, 180-220 give 4 units, 220-250 give 6 units,
250-300 give 8 units, 300-350 10 units.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) **]
Discharge Diagnosis:
Right sided thalamic hemorrhagic stroke
Non small cell lung cancer with two metastasis to the brain
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:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for acute onset of left sided
weakness, left sided facial droop, and difficulty speaking. You
were found to have a R sided brain bleed.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-9-9**]
10:35
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2109-9-9**]
11:30
|
[
"162.9",
"496",
"250.00",
"365.9",
"431",
"V15.3",
"401.9",
"710.0",
"198.3",
"V15.82",
"342.92",
"443.9",
"348.5",
"V87.41"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9920, 9994
|
7102, 8807
|
319, 326
|
10138, 10138
|
5647, 7079
|
10541, 10804
|
2591, 2632
|
9039, 9897
|
10015, 10117
|
8833, 9016
|
10314, 10518
|
2716, 3228
|
242, 281
|
354, 2023
|
4157, 5628
|
10153, 10290
|
3252, 3252
|
2045, 2162
|
2178, 2575
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,222
| 118,843
|
46070
|
Discharge summary
|
report
|
Admission Date: [**2133-7-5**] Discharge Date: [**2133-7-16**]
Date of Birth: [**2050-7-3**] Sex: M
Service: MEDICINE
Allergies:
Horse/Equine Product Derivatives / Calcium Channel Blocking
Agents-Benzothiazepines / Metoprolol
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
AV Nodal ablation with pacemaker placement--[**7-13**]. [**2132**]
History of Present Illness:
The patient is an 83 yo M with ESRD on HD (MWF), h/o a fib and
PAT, baseline AV conduction delay, CAD, moderate MR, moderate AS
who p/w dyspnea. He developed acute shortness of breath after
lunch today and called the EMS. He denied any syncope, chest
pain, palpitations, nausea/vomiting, diaphoresis. He reports
worsening orthopnea and couple of episodes of PND in the past 2
nights. He has poor functional status due to excessive fatigue
more than SOB. His pedal edema is the same, and he denies any
weight gain. He urinates 500 cc per day. He has not missed any
dialysis days. He had half a hotdog and puts salt on his food
but no more than usual. He takes all his medications as
prescribed. He had a cough with clear sputum, no hemoptysis, in
last day. No fever, chills, sick contacts.
On arrival to the ED, VS were: T 97.4, P 117, BP 210/130, R40,
75% on RA. Pt was not able to speak in full sentences. He was
started on BiPap with improvement and transitioned to NRB with
O2 sats of 95-97. He was also started on nitro gtt with improved
BP to 120/80s. He also received 20 mg IV Lasix with ?response
(unable to pass catheter [**12-20**] BPH). EKG showed atrial
fibrillation, noted to be regular at rate of 120s with but no p
waves. No ischemic changes on EKG. His shortness of breath has
improved but he is unable to eat without desaturating.
.
On review of symptoms, he denies any deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery. He has back
pain but no other myalgias or joint pains. He has some nausea on
days off HD in the past week. No vomiting, abdominal pain, black
stools or red stools. All of the other review of systems were
negative.
Past Medical History:
- Chronic renal failure on HD x 4 years (thought to be due to
obstructive uropathy, kidney stones, BPH)
- Hx moderate (2+) MR, moderate AS, mild AI
- Hx mild LV dysfunction
- Hx atrial fibrillation and paroxysmal atrial tachycardia
- Baseline AV conduction delay
- Hypertension
- Coronary artery disease with old posterior MI on EKG and pMIBI
in [**6-/2130**] with EF44%, global hypokinesis, no reversible defects.
- Hx Left 4-9th rib fx, Left hemothorax
- R kidney stone s/p Lithotripsy
([**6-23**], complicated by Klebsiella UTI)
- s/p stroke (cerebellar), found on MRI, sxs of gait instability
- hx gait d/o, hand paresthesias, polyneuropathy, C3/C4 spinal
cord compression [**12-20**] cerival spondylosis, L median nerve injury
- Anemia
- Benign prostatic hypertrophy
- [**Month/Day (2) 98041**] headaches
- Hx of positive PPD, never treated
- Hx squamous cell and basal cell ca
- HSV keratouveitis
- ventral hernia
- s/p open cholecystectomy [**2130-4-21**]
- s/p small bowel resection (80-90%) for mesenteric ischemia
- s/p umbilical hernia repair
- s/p cystocele repair
- s/p laminectomy - c/b osteomyelitis
- s/p TURP [**9-24**]
Social History:
Patient lives with his wife in [**Name (NI) 8**]. He is a former chief
of psychiatry at the [**State 43840**]. Social history
is significant for the remote tobacco use, 3ppd x 40 years, quit
20 years ago. He drinks 1 [**Female First Name (un) **] every 2 weeks.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 100.2, BP 127/74, HR 111, RR 30, O2 98% on NRB, wt 78.5 kg
Gen: Older male in mild respiratory distress. Alert and oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Regular rhythm, tachycardic, systolic murmur best at LLSB. No
S4, no S3.
Chest: Resp were mildly labored, no accessory muscle use.
Bilateral crackles [**11-20**] way up, decreased breath sounds at L
lower lung base. No wheezes.
Abd: Well-healed scars. Normoactive bowel sounds. NTND, No HSM
or tenderness. No abdominial bruits.
Ext: 1+ pitting edema bilaterally. L 3rd toe blue but with
intact sensation. Palpable thrill over left arm AV fistula.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Petechial rash on lower extremities. Ecchymoses on upper
extremities.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2133-7-5**] 04:40PM
WBC-11.7*# RBC-3.87* HGB-13.7* HCT-42.2
MCV-109* MCH-35.3* MCHC-32.4 RDW-20.9*
NEUTS-89.1* BANDS-0 LYMPHS-6.5* MONOS-3.8 EOS-0.3 BASOS-0.2
HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+
MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+ BURR-1+
GLUCOSE-213* UREA N-66* CREAT-4.7*# SODIUM-140 POTASSIUM-5.8*
CHLORIDE-99 TOTAL CO2-22 ANION GAP-25*
.
[**2133-7-6**] 02:38AM BLOOD Triglyc-57 HDL-69 CHOL/HD-2.1 LDLcalc-66
[**2133-7-12**] 06:20AM BLOOD VitB12-816 Folate-16.6
.
Discharge Labs:
[**2133-7-16**] 07:20AM BLOOD WBC-8.9 RBC-3.43* Hgb-12.1* Hct-37.4*
MCV-109* MCH-35.4* MCHC-32.4 RDW-20.0* Plt Ct-245
Glucose-102 UreaN-28* Creat-3.7* Na-142 K-4.9 Cl-102 HCO3-31
AnGap-14
Calcium-9.0 Phos-2.7 Mg-1.7
.
ECG Study Date of [**2133-7-5**] 2:45:08 PM
Sinus tachycardia. Prolonged P-R interval. Left axis deviation.
Probable
left anterior fascicular block. Possible inferior myocardial
infarction,
age undetermined. Compared to the previous tracing of [**2133-6-9**] P
waves are
now visible, right bundle-branch block has resolved and the rate
has increased somewhat. Otherwise, no significant difference.
.
Portable TTE (Focused views) Done [**2133-7-6**] at 3:43:34 PM
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Overall left ventricular systolic function is
severely depressed (LVEF= 25-30 %). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The inferolateral segments are
akinetic. The number of aortic valve leaflets cannot be
determined. The aortic valve is not well seen. There is moderate
aortic valve stenosis (area 1.0-1.2cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension.
.
Compared with the prior study (images reviewed) of [**2133-6-5**],
overall LV systolic function is probably slightly worse. The
degrees of aortic stenosis and mitral regurgitation are similar.
.
ECG Study Date of [**2133-7-14**] 2:33:46 PM
Atrial sensed and ventricular paced rhythm with left
bundle-branch block
pattern. Compared to the previous tracing of [**2133-7-13**] there is
now one hundred percent atrial sensing and ventricular pacing.
Brief Hospital Course:
Patient is an 83 yo M with ESRD on HD (MWF), h/o a fib and PAT,
baseline AV conduction delay, CAD, moderate MR, moderate AS who
presented with acute shortness of breath on [**7-5**] and found to be
in CHF.
.
# Pump/Acute Congestive heart failure: The patient appeared to
have acute on chronic congestive heart failure with EF of 35% on
last ECHO from [**5-26**]. Repeat ECHO this admission demonstrated a
EF of 25-30%. He was clinically volume-overloaded on exam and
CXR on presentation was consistent with flash pulmonary edema.
It was felt that these symptoms were from his elevated blood
pressure and prolonged tachycardia. The patient's dyspnea
improved on an non-rebreather mask. Given his volume overloaded
status, the patient underwent urgent hemodialysis with marked
improvement on exam as well as his oxygen requirements. The
patient was able to demonstrate good oxygen saturation at rest,
but during evaluations with physical therapy, the patient
consistantly desaturated to the low 80's with ambulation. PT
recommended that the patient go to rehab, but the patient
disagreed and wished to return home. He was discharged home
with a plan for home VNA/PT/OT services as well as home oxygen.
.
# Rhythm/Atrial Tachycardia: The patient and was known to have a
history of atrial fibrillation with RVR as well as paroxysmal
atrial tachycardia, and he presented with a HR of 117. The
patient was previously scheduled for pacemaker placement with AV
nodal ablation prior to his admission. Given the patient's CHF
symptoms, however, it was felt that the patient would benefit
from undergoing the procedure earlier than planned. The
patient's home Coumadin regimen was held to prepare for the
procedure and the patient underwent the ablation and pacer
implantation without complications on [**7-13**]. Post procedure
x-ray demonstrated correct lead placement. The patient was
noted to be entirely atrial paced per ECG. Amiodarone was
discontinued. Following the procedure, the patient was
restarted on his home doses of Coumadin. His last documented INR
prior to discharge was 1.6. The patient was scheduled for
follow-up with his primary cardiologist as well as the device
clinic. He was also instructed to have his INR followed by the
[**Hospital3 **].
.
# Valves: The patient had a history of Moderate (2+) MR,
moderate AS, mild AI. A repeat ECHO this admission showed
little change in valvular disease. No interventions were made
during this hospitalization.
.
# HTN: The patient was noted to be hypertensive 210/130 on
presentation to the ED. According to the patient, he was not
taking anti-hypertensives at home due to significant drug side
effects. He was initially started on a Nitro drip for blood
pressure control, but this was discontinued following dialysis,
which resolved his volume status issues and returned the patient
to a normotensive state 130's/50's.
.
# ESRD on HD: The patient initially underwent several rounds of
dialysis within the first 3 days of admission after which he
resumed his normal 3 day per week hemodialysis schedule. The
patient was maintained on his home doses of phoslo, sevelemar,
and nephrocaps.
.
# Low grade fever: The patient presented with a cough and low
grade fever of 100.2. He otherwise denied any recent symptoms
of infection. He was noted to have a mild leukocytosis with
neutrophil predominate. Chest xray was without obvious
infiltrate. Urine analysis/culture were notable only for urine
cultures positive for >3 species of bacteria, consistent with
contamination. Blood culture were also negative. Other than his
initial presentation, the patient was afebrile throughout his
hospitalization.
Medications on Admission:
Pantoprazole 40 mg Tablet PO Q24H
Aspirin 81 mg PO DAILY
Calcium Acetate 667 mg Two (2) Capsule PO TID W/MEALS
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Sevelamer HCl 400 mg PO DAILY
Lotemax 0.5 % Drops One (1) Ophthalmic QID
Trifluridine 1 % Drops One (1) Drop Ophthalmic Q4H
Amiodarone 100 mg PO once a day
Acyclovir 200 mg One (1) Capsule PO Q12H
Warfarin 2/4 mg PO once a day.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
5. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Lotemax 0.5 % Drops, Suspension Sig: One (1) drop Ophthalmic
twice a day.
7. Trifluridine 1 % Drops Sig: One (1) Drop Ophthalmic twice a
day.
8. Acyclovir 200 mg Capsule Sig: [**11-19**] Capsule PO DAILY (Daily).
9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO F,SA,[**Doctor First Name **].
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MTWTh.
13. Oxygen
Home oxygen 2-4L via NP to keep O2 sat> 90% with ambulation.
O2 sat in hospital 82% with ambulation on room air.
14. Oxygen
Oximeter to monitor O2 saturations at home.
15. Tylenol Ex Str Arthritis Pain 500 mg Tablet Sig: Two (2)
Tablet PO four times a day as needed for pain.
16. Outpatient Lab Work
Please check your INR on Friday [**7-17**] and call results to
Dr. [**Last Name (STitle) 1911**], office: [**Telephone/Fax (1) 98045**], secretary [**Doctor First Name **]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary:
Acute on Chronic systolic Heart Failure
Hypertension
Atrial Fibrillation/Atrial tachycardia
Secondary:
End Stage Renal disease on hemodialysis
Fever
Discharge Condition:
Patient is in good condition. His vital signs are stable.
Discharge Instructions:
You were admitted to the hospital because you were very short of
breath. You had a very fast heart rate (atrial tachycardia),
which we believe is the cause of your acute congestive heart
failure. You experienced hypertension during this hospital
stay, which required a nitroglycerin drip and aggressive
dialysis to remove fluid. On [**7-13**], you underwent a procedure
where we ablated your AV node. We then put in a pacemaker to
make your heart continue to beat at a normal rate.
.
While you were here, we made the following changes to your
medications:
1. We discontinued your amiodarone 200 mg daily
2. We started you on tylenol, extra strength, for pain at the
pacer site.
Please take all medications as prescribed. Please check your INR
tomorrow, [**7-17**] and call results to Dr. [**Last Name (STitle) 1911**],
office: [**Telephone/Fax (1) 98045**], secretary [**Doctor First Name **]
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider immediately
if you experience increased shortness of breath, chest pain,
nausea, excessive fatigue, chills, fevers, swelling of your legs
or feet, or difficulty lying flat.
.
Please adhere to a low-sodium (2 gm/day), low protein, low-fluid
(1200 cc) diet, of which information was given to you on
discharge. Please weight yourself daily in the morning before
breakfast and call Dr. [**Last Name (STitle) **] if you have a weight gain of more
than 3 pounds in 1 day or 6 pounds in 3 days.
.
No lifting more than 5 pounds for six weeks. Avoid extreme
movements of your right arm such as reaching for objects or
tucking your shirt in. Please refer to the booklet we gave you
on discharge regarding post pacemaker care. No showers for one
week.
Followup Instructions:
Primary Care:
Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2133-7-23**] 3:30
Cardiology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 1911**], MD Phone: [**Telephone/Fax (1) 62**] Date/Time:
[**9-17**] at 4:30pm. Office will call you with an earlier
appt.
Neurology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**]
Date/Time:[**2133-9-29**] 10:30
.
Device Clinic: [**2133-7-21**] at 9:30 am. [**Hospital Ward Name 23**] Center,
[**Location (un) 436**].
Completed by:[**2133-7-26**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,598
| 124,360
|
4833
|
Discharge summary
|
report
|
Admission Date: [**2114-6-22**] Discharge Date: [**2114-7-5**]
Date of Birth: [**2049-1-8**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman
with known coronary disease was in his usual state of health,
was in synagogue when he was noted to lose consciousness. At
that time he was found to have no pulse. CPR was initiated
with return of pulse of approximately 30 seconds later.
Patient was transferred to [**Hospital1 188**] for workup.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Celiac sprue.
4. Benign essential tremor.
5. Cataracts.
6. Osteoporosis.
PREOPERATIVE MEDICATIONS:
1. Atenolol 25 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Benicar 25 mg p.o. q.d.
4. Hydrochlorothiazide 12.5 mg p.o. q.d.
5. Primidone 75 mg p.o. q.h.s.
6. Calcium 1000 mg p.o. q.d.
ALLERGIES: The patient is allergic to gluten and allergic to
seafood, which gives him hives.
SOCIAL HISTORY: The patient is married and lives at home
with his wife. There is a remote tobacco history, quit three
years ago and admits to occasional EtOH.
HOSPITAL COURSE: Upon admission to [**Hospital1 **],
patient was neurologically stable and hemodynamically stable.
Patient was taken for a stress test, which was markedly
positive for ST segment changes, and decrease in blood
pressure. Patient had also been found to have an elevated
creatinine on admission with previously documented normal
renal function. The acute renal failure was felt to be
possibly due to the arrest. Over the first several days of
his hospital course, patient's creatinine gradually improved.
On hospital day number five, patient was taken to cardiac
catheterization laboratory, where he was found to have an
ejection fraction of approximately 50 percent, left
ventricular end diastolic pressure of 12, 60-70 percent left
main coronary disease, 70 percent LAD lesions, 60 percent
ostial left circumflex lesion, 50 percent proximal RCA
lesion, and 70 percent mid vessel RCA lesion.
Patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery
bypass grafting, and patient was taken to the operating room
on [**6-28**] with Dr. [**Last Name (STitle) 70**] for CABG x3 LIMA to LAD,
saphenous vein graft to OM, and saphenous vein graft to PDA.
Please see operative note for operative details. Total
cardiopulmonary bypass time was 69 minutes. Cross-clamp time
was 45 minutes. Patient was transported to the Intensive
Care Unit in stable condition.
Immediately postoperatively, the patient had multiple
episodes of hypotension, required significant amount of fluid
resuscitation. A transesophageal echocardiogram was done in
the Intensive Care Unit at the bedside, which showed normal
biventricular systolic function with an ejection fraction of
60 percent and no wall motion abnormality, no change from
intraoperatively. Patient had on chest x-ray a left lower
lobe opacity with some significant respiratory acidosis
despite being intubated. The patient underwent a
bronchoscopy, which showed minimal secretions.
Patient eventually stabilized and had good hemodynamics. Was
weaned and extubated from mechanical ventilation early in the
morning of postoperative day number one. They vasopressors
were weaned to off on postoperative day number one. Patient
continued to have good cardiac output and remained
hemodynamically stable. Patient was started on low-dose
diuretics. With the addition of the diuretics, the patient
again required low-dose Neo-Synephrine, which was used to
maintain adequate systolic blood pressure. Patient continued
to have good cardiac output.
Patient continued to have a left lower lobe opacity on chest
x-ray. A Thoracic Surgery consult was obtained, and per
their request a CT scan of the chest was performed, which
showed multiple prevascular lymph nodes coalescing. No
hematoma, no evidence of consolidation. It was felt that
patient did not require any intervention for this at the
time.
On postoperative day number three, the Neo-Synephrine was
weaned to off. By postoperative day number four, the
patient's chest tubes and epicardial wires were removed
without incident, and patient was transferred from the
Intensive Care Unit to the regular part of the hospital. The
patient began working with Physical Therapy and by
postoperative day number six, the patient was able to
ambulate with Physical Therapy approximately 500 feet and
climb one flight of stairs.
On postoperative day number five, the patient was noted to
have a rise in creatinine. Postoperatively, the patient's
creatinine had been stable at 1.0. creatinine had risen to
1.4. The patient had been started on Motrin for pain relief,
which was discontinued. By postoperative day number seven,
the patient's creatinine began to decrease to 1.3, and
patient was cleared for discharge to home.
DISCHARGE CONDITION: Temperature 99.4, pulse 83 in sinus
rhythm, blood pressure 111/51, respiratory rate 16, on room
air oxygen saturation 95 percent. Laboratory data: White
blood cell count 8.5, hematocrit 29.2, platelet count 285.
Sodium 141, potassium 4.5, chloride 100, bicarb 34, BUN 24,
creatinine 1.3.
Patient's weight on [**7-5**] is 79 kg. Preoperatively, the
patient weighed 76 kg. Neurologically: The patient is
awake, alert, and oriented times three. Examination is
nonfocal. Heart: Regular, rate, and rhythm without rub or
murmur. Respiratory: Breath sounds are decreased at the
left base, clear on the right. GI: Positive bowel sounds,
soft, nontender, and nondistended. Sternal incision: Steri-
Strips are intact. There is no erythema and no drainage.
Sternum is stable. Right lower extremity vein harvest site:
There is minimal erythema at the knee and at the mid calf
without warmth. There is no drainage. Bilateral lower
extremities have [**2-16**] plus pitting edema of the right leg,
more edema than the left. Lower extremities are warm and
well perfused.
Chest x-ray on [**7-4**] shows the continued left lower lobe
opacity. No significant effusion. No pneumothorax.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Zantac 150 mg p.o. b.i.d.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. prn.
5. Lasix 20 mg p.o. b.i.d. x7 days.
6. Potassium chloride 20 mEq p.o. b.i.d. x7 days.
7. Primidone 75 mg p.o. q.h.s.
8. Atenolol 25 mg p.o. q.d.
9. Lipitor 20 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Hypertension.
4. Celiac sprue.
5. Postoperative elevated creatinine due to nonsteroidal anti-
inflammatories versus intravenous dye.
6. Postoperative left lower lobe opacity on chest x-ray due
to multiple prevascular lymph nodes on CT scan.
7. Benign essential tremor.
The patient is to be discharged to home in stable condition.
He should follow up with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 14116**] in [**2-16**] weeks, his cardiologist, Dr. [**Last Name (STitle) **] in [**2-16**]
weeks, and Dr. [**Last Name (STitle) 70**] in [**6-21**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], MD 2358
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2114-7-5**] 11:13:25
T: [**2114-7-5**] 12:12:12
Job#: [**Job Number 20216**]
|
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icd9cm
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icd9pcs
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|
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|
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|
666, 947
|
163, 495
|
517, 640
|
964, 1109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,891
| 152,677
|
24615+24616+57408
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2121-12-10**] Discharge Date:
Date of Birth: [**2075-12-28**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with cryptogenic cirrhosis and history of recent
hepatitis C encephalopathy, ascites, SBP, hepatorenal
syndrome and grade I esophageal varices. Last admission to
[**Hospital6 256**] was on [**2121-10-22**],
with worsening ascites. He denies any recent fevers or
chills. The patient does complain of a cough but no
expectorant. He denies abdominal tenderness. The patient is
complaining of bloating. The patient has been admitted on
[**2121-12-10**], for potential liver transplant.
PAST MEDICAL HISTORY: Cryptogenic cirrhosis. End-stage liver
disease. Right inguinal hernia, at this point cannot be
repaired secondary to liver disease. Cryptococcal PNA on
[**2120-12-12**]. Right thoracotomy and right upper lobe
lobectomy secondary to cavitary lesions found to be
Cryptococcus, negative LP for Cryptococcus. Also grade I
varices on [**2120-11-16**]. Gastropathy in [**2121-4-16**].
Diverticulitis in [**2121-4-16**]. Internal hemorrhoids.
Spontaneous bacterial peritonitis, [**2121-5-6**]. Hepatorenal
syndrome.
MEDICATIONS ON ADMISSION: Lactulose 30 ml p.o. t.i.d.,
please titrate to [**1-17**] bowels/day, Ergocalciferol 50,000 units
1 capsule q.week, fluconazole 200 mg q.24, Prevacid 30 mg
daily, ciprofloxacin 750 1 tablet once a week, rifaximin 400
mg t.i.d.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Lives with mother. [**Name (NI) 4084**] married. No
children. Denied tobacco. Denied alcohol. Denied IV drug use.
No travel outside the United States.
FAMILY HISTORY: Denies any history of CAD, hypertension.
There is a history of diabetes mellitus and thyroid in
father, deceased secondary to lung cancer with brain
metastasis.
REVIEW OF SYMPTOMS: The patient is a poor historian; he
answers "yes/no" answers. Review of systems unremarkable
except for occasional bloody stool. Positive jaundice.
PHYSICAL EXAMINATION: General: The patient is a lethargic,
ill-appearing male. Vital signs: Temperature 97.8, heart rate
81, blood pressure 105/51, weight 90.5, respirations 20.
Skin: Jaundice. HEENT: Normocephalic. Pupils equal, round and
reactive to light. EOMs full. Tongue midline, no exudates.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2
without murmurs, rubs, or gallops. Lungs: Clear to
auscultation and percussion bilaterally. Abdomen: Positive
bowel sounds. Large, round, soft, nontender. Positive
hepatomegaly. Musculoskeletal: Extremities 2+ AT, dorsalis
pedis bilaterally warm. Extremities x 4. Neurologic: The
patient is confused with rambling speech, one-word answers,
moving all extremities well. Cranial nerves II-XII seem to be
intact.
HOSPITAL COURSE: The patient went to the OR on [**2121-12-10**], with a preoperative diagnosis of end-stage liver
disease secondary to cryptogenic cirrhosis. The patient had a
piggyback orthotopic liver transplant with a Roux-and-Y
biliary reconstruction performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Two drains were placed; 1 drain was placed beneath the
biliary anastomosis, and the other drain was placed under the
suprahepatic cava. All bleeding points were ligated, and the
abdomen was closed in a single layer with a running double
looped #1 PDS. Staples were used for the skin. The patient
tolerated the procedure well. Please see the operative note
for details.
Labs were stable. On [**2121-12-10**], after surgery, WBC was
2.4, hematocrit 25.5, platelets 59. LFTs showed an ALT of 47,
AST 1057, alkaline phosphatase 61, total bilirubin 5.4,
direct bilirubin 3.6. BUN and creatinine were 47 and 1.8.
Glucose was 135.
The patient was kept in the ICU over night. The patient was
intubated and received morphine for pain control. The patient
was off pressors. On the following day, the patient did get
an ultrasound of his liver demonstrating that there was
abnormal arterial flow in the main, right and left hepatic
arteries with a high-resistance wave form that suggests
diffuse parenchymal edema such as preservation injury.
Hepatic veins and portal veins were with flow in the
appropriate direction. No thrombus was identified. There was
a 2.3 x 5 cm likely postoperative hematoma adjacent to the
left lobe of the liver. These findings were discussed with
Dr. [**Last Name (STitle) 816**] at the time.
Drain #1 put out 160, drain #2 70. Infectious disease was
consulted postoperative for a history of cryptococcal PNA.
They had suggested that once the patient completes
fluconazole per the liver transplant protocol, that the
fluconazole can be decreased to 200 mg p.o. daily. The
patient does need to remain on fluconazole 200 mg once a day
indefinitely.
On [**2121-12-12**], the patient had another ultrasound of
the liver demonstrating 1) persistent abnormal high-
resistance Doppler arterial wave forms, unchanged compared to
[**2121-12-11**], that may be related to diffuse edema in the
transplanted liver, 2) there is an unchanged small
perihepatic, likely postsurgical hematoma.
Prior to the transplant, the patient did have blood cultures
obtained on [**2121-12-10**], which demonstrated that there
was no growth, and also a swab was obtained on [**2121-12-10**], which demonstrated that the patient had enterococcus
sensitive to linezolid.
Inpatient clinical nutrition consult was obtained, and the
dietician made recommendations.
The patient was extubated and doing well. Platelets were
increasing slowly. On [**2121-12-12**], the patient had been
bolused times 3 with 500 cc of normal saline. CVP was 0-2.
Urine output was 10-15 cc/hr. The patient had a hematoma in
groin. The ultrasound demonstrated a hematoma in the medial
right groin on [**2121-12-12**], and showed no evidence of
pseudoaneurysm.
On [**2121-12-13**], the patient was still in the ICU. Urine
output was slightly improved to 45 cc/hr, platelets to 84.
Hematocrit was stable at 71. The patient was tolerating clear
liquids. The patient received morphine p.r.n. for pain. JPs
were drainage serosanguineous fluid in large amounts.
On [**2121-12-14**], the patient had a right internal jugular
catheter changed demonstrating that there was a persistent
right-sided effusion but no pneumothorax.
On [**2121-12-14**], ALT was 261, AST 77, alkaline
phosphatase 90. Creatinine was up slightly from 2.4 to 2.8.
on [**2121-12-14**], the patient was transferred to the floor
with no over night events. The patient received tacrolimus 1
and 1, prednisone 35. The patient was receiving MMF 1 g
b.i.d. He had good input/output. The patient had a T-tube
with a lateral drain and medial drain.
Cholangiogram was performed on [**2121-12-15**], as a regular
postoperative exam demonstrating that there was biliary
drainage, the catheter was at the tip of the jejunum, patent
hepaticojejunostomy and anastomosis with reflux of contrast
material from the jejunum into the hepatic duct. There was no
significant dilatation of visualized intrahepatic ducts, but
dilated common duct was seen. Again these findings were
discussed with Dr. [**First Name (STitle) **].
PT/OT were consulted for assessment of rehab. The patient's
diet was advanced. The patient continued to be afebrile with
vital signs stable. He had good input/output.
On [**2121-12-18**], the medial JP drain was removed with a
figure-of-eight stitch placed. The patient tolerated the
procedure well. Podiatry met with the patient on [**2121-12-21**], for a left ingrown nail. The patient's medial aspect of
the nail was excised with partial wedge resection and covered
with triple antibiotic ointment.
On [**2121-12-22**], the patient had an ultrasound of the
liver secondary to increased ascites which showed that there
was a patent extrahepatic main hepatic artery with improved
wave forms, but the enterohepatic arteries could not be
found. There was no evidence of portal hepatic venous
problems. There was a small right pleural effusion without
evidence of gross ascites.
On [**2121-12-25**], the patient had intravenous fluids half
normal saline to replete JP output 0.5 cc/cc. The patient,
over 24 hours from JP output, was 1640. On [**2121-12-26**],
labs that morning included a WBC of 6.3, hematocrit 24.0,
platelets 158, sodium 134, 5.5, 112, 17, BUN and creatinine
54 and 1.7, glucose 104, ALT 20, AST 8, alkaline phosphatase
66, total bilirubin 0.4.
The patient continued to eat well with supplements of Nepro
drinks 3 times a day. The patient was out of bed working with
physical therapy. He was urinating on his own. He continued
0.5 cc/cc. He was placed on normal saline for JP output.
[**Last Name (un) **] continued to see the patient and felt that the patient
should be encouraged to drink water in place of coke and be
sure that he is eating a reasonable amount of food.
Currently the patient has no JP drains. His T-tube is capped.
He is tolerating a diet well. He should remain a low
carbohydrate diet with supplement and also should be on a low-
potassium diet. The patient will be leaving today to go to
rehab in [**Doctor Last Name **].
DISCHARGE MEDICATIONS: Heparin 5000 units subcu q.8 hours,
prednisone 20 mg daily, Protonix 40 mg q.24, Bactrim SS 1
tablet daily, the patient is going to be an insulin NPH 28
units at breakfast and then Humalog sliding scale with
fingersticks checked q.i.d. The patient is also going to be
discharged on MMF 1000 b.i.d., oxycodone 5-10 mg q.6 hours
p.r.n., Valcyte 450 q.o.d., fluconazole 400 q.24, tacrolimus
1 mg b.i.d.
The patient will need outpatient lab work every Monday and
Thursday and have the results faxed to the transplant center.
The patient or the facility needs to call transplant surgery
immediately at [**Telephone/Fax (1) 673**] for any fevers, chills, nausea,
vomiting, inability to take medications, any increased
drainage from the incision site or around the T-tube,
jaundice, redness, bleeding, pus at the incision or with any
questions or concerns.
The patient should have labs every Monday and Thursday which
include CBC, CHEM10, AST, ALT, alkaline phosphatase, total
bilirubin, albumin and Prograf trough level which the results
should be faxed to [**Hospital6 256**]
Transplant Office at [**Telephone/Fax (1) 697**].
FOLLOW UP: With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2122-1-1**], at 10:20
a.m., [**2122-1-8**] at 9 a.m., [**2122-1-15**], at 10 a.m.
Please call [**Telephone/Fax (1) 673**] for any questions about the
appointments.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Liver transplant on
[**2121-12-10**].
LABORATORY DATA: On [**2121-12-29**], WBC was 4.5,
hematocrit 28.6, platelets 120; sodium 135, 5.7, 112, 18, BUN
and creatinine 50 and 2.0; ALT 11, AST 10, alkaline
phosphatase 55, total bilirubin 0.4.
The patient is 1 and 1 of Tacrolimus with level today of
10.9.
FINAL DIAGNOSIS: End-stage liver disease secondary to
cryptogenic cirrhosis.
CONDITION ON DISCHARGE: The patient is stable for discharge
today.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2121-12-29**] 12:36:10
T: [**2121-12-29**] 13:39:01
Job#: [**Job Number 62139**]
Admission Date: [**2121-12-10**] Discharge Date:
Date of Birth: [**2075-12-28**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with cryptogenic cirrhosis and history of recent
hepatitis C encephalopathy, ascites, SBP, hepatorenal
syndrome and grade I esophageal varices. Last admission to
[**Hospital6 256**] was on [**2121-10-22**],
with worsening ascites. He denies any recent fevers or
chills. The patient does complain of a cough but no
expectorant. He denies abdominal tenderness. The patient is
complaining of bloating. The patient has been admitted on
[**2121-12-10**], for potential liver transplant.
PAST MEDICAL HISTORY: Cryptogenic cirrhosis. End-stage liver
disease. Right inguinal hernia, at this point cannot be
repaired secondary to liver disease. Cryptococcal PNA on
[**2120-12-12**]. Right thoracotomy and right upper lobe
lobectomy secondary to cavitary lesions found to be
Cryptococcus, negative LP for Cryptococcus. Also grade I
varices on [**2120-11-16**]. Gastropathy in [**2121-4-16**].
Diverticulitis in [**2121-4-16**]. Internal hemorrhoids.
Spontaneous bacterial peritonitis, [**2121-5-6**]. Hepatorenal
syndrome.
MEDICATIONS ON ADMISSION: Lactulose 30 ml p.o. t.i.d.,
please titrate to [**1-17**] bowels/day, Ergocalciferol 50,000 units
1 capsule q.week, fluconazole 200 mg q.24, Prevacid 30 mg
daily, ciprofloxacin 750 1 tablet once a week, rifaximin 400
mg t.i.d.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Lives with mother. [**Name (NI) 4084**] married. No
children. Denied tobacco. Denied alcohol. Denied IV drug use.
No travel outside the United States.
FAMILY HISTORY: Denies any history of CAD, hypertension.
There is a history of diabetes mellitus and thyroid in
father, deceased secondary to lung cancer with brain
metastasis.
REVIEW OF SYMPTOMS: The patient is a poor historian; he
answers "yes/no" answers. Review of systems unremarkable
except for occasional bloody stool. Positive jaundice.
PHYSICAL EXAMINATION: General: The patient is a lethargic,
ill-appearing male. Vital signs: Temperature 97.8, heart rate
81, blood pressure 105/51, weight 90.5, respirations 20.
Skin: Jaundice. HEENT: Normocephalic. Pupils equal, round and
reactive to light. EOMs full. Tongue midline, no exudates.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2
without murmurs, rubs, or gallops. Lungs: Clear to
auscultation and percussion bilaterally. Abdomen: Positive
bowel sounds. Large, round, soft, nontender. Positive
hepatomegaly. Musculoskeletal: Extremities 2+ AT, dorsalis
pedis bilaterally warm. Extremities x 4. Neurologic: The
patient is confused with rambling speech, one-word answers,
moving all extremities well. Cranial nerves II-XII seem to be
intact.
HOSPITAL COURSE: The patient went to the OR on [**2121-12-10**], with a preoperative diagnosis of end-stage liver
disease secondary to cryptogenic cirrhosis. The patient had a
piggyback orthotopic liver transplant with a Roux-and-Y
biliary reconstruction performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Two drains were placed; 1 drain was placed beneath the
biliary anastomosis, and the other drain was placed under the
suprahepatic cava. All bleeding points were ligated, and the
abdomen was closed in a single layer with a running double
looped #1 PDS. Staples were used for the skin. The patient
tolerated the procedure well. Please see the operative note
for details.
Labs were stable. On [**2121-12-10**], after surgery, WBC was
2.4, hematocrit 25.5, platelets 59. LFTs showed an ALT of 47,
AST 1057, alkaline phosphatase 61, total bilirubin 5.4,
direct bilirubin 3.6. BUN and creatinine were 47 and 1.8.
Glucose was 135.
The patient was kept in the ICU over night. The patient was
intubated and received morphine for pain control. The patient
was off pressors. On the following day, the patient did get
an ultrasound of his liver demonstrating that there was
abnormal arterial flow in the main, right and left hepatic
arteries with a high-resistance wave form that suggests
diffuse parenchymal edema such as preservation injury.
Hepatic veins and portal veins were with flow in the
appropriate direction. No thrombus was identified. There was
a 2.3 x 5 cm likely postoperative hematoma adjacent to the
left lobe of the liver. These findings were discussed with
Dr. [**Last Name (STitle) 816**] at the time.
Drain #1 put out 160, drain #2 70. Infectious disease was
consulted postoperative for a history of cryptococcal PNA.
They had suggested that once the patient completes
fluconazole per the liver transplant protocol, that the
fluconazole can be decreased to 200 mg p.o. daily. The
patient does need to remain on fluconazole 200 mg once a day
indefinitely.
On [**2121-12-12**], the patient had another ultrasound of
the liver demonstrating 1) persistent abnormal high-
resistance Doppler arterial wave forms, unchanged compared to
[**2121-12-11**], that may be related to diffuse edema in the
transplanted liver, 2) there is an unchanged small
perihepatic, likely postsurgical hematoma.
Prior to the transplant, the patient did have blood cultures
obtained on [**2121-12-10**], which demonstrated that there
was no growth, and also a swab was obtained on [**2121-12-10**], which demonstrated that the patient had enterococcus
sensitive to linezolid.
Inpatient clinical nutrition consult was obtained, and the
dietician made recommendations.
The patient was extubated and doing well. Platelets were
increasing slowly. On [**2121-12-12**], the patient had been
bolused times 3 with 500 cc of normal saline. CVP was 0-2.
Urine output was 10-15 cc/hr. The patient had a hematoma in
groin. The ultrasound demonstrated a hematoma in the medial
right groin on [**2121-12-12**], and showed no evidence of
pseudoaneurysm.
On [**2121-12-13**], the patient was still in the ICU. Urine
output was slightly improved to 45 cc/hr, platelets to 84.
Hematocrit was stable at 71. The patient was tolerating clear
liquids. The patient received morphine p.r.n. for pain. JPs
were drainage serosanguineous fluid in large amounts.
On [**2121-12-14**], the patient had a right internal jugular
catheter changed demonstrating that there was a persistent
right-sided effusion but no pneumothorax.
On [**2121-12-14**], ALT was 261, AST 77, alkaline
phosphatase 90. Creatinine was up slightly from 2.4 to 2.8.
on [**2121-12-14**], the patient was transferred to the floor
with no over night events. The patient received tacrolimus 1
and 1, prednisone 35. The patient was receiving MMF 1 g
b.i.d. He had good input/output. The patient had a T-tube
with a lateral drain and medial drain.
Cholangiogram was performed on [**2121-12-15**], as a regular
postoperative exam demonstrating that there was biliary
drainage, the catheter was at the tip of the jejunum, patent
hepaticojejunostomy and anastomosis with reflux of contrast
material from the jejunum into the hepatic duct. There was no
significant dilatation of visualized intrahepatic ducts, but
dilated common duct was seen. Again these findings were
discussed with Dr. [**First Name (STitle) **].
PT/OT were consulted for assessment of rehab. The patient's
diet was advanced. The patient continued to be afebrile with
vital signs stable. He had good input/output.
On [**2121-12-18**], the medial JP drain was removed with a
figure-of-eight stitch placed. The patient tolerated the
procedure well. Podiatry met with the patient on [**2121-12-21**], for a left ingrown nail. The patient's medial aspect of
the nail was excised with partial wedge resection and covered
with triple antibiotic ointment.
On [**2121-12-22**], the patient had an ultrasound of the
liver secondary to increased ascites which showed that there
was a patent extrahepatic main hepatic artery with improved
wave forms, but the enterohepatic arteries could not be
found. There was no evidence of portal hepatic venous
problems. There was a small right pleural effusion without
evidence of gross ascites.
On [**2121-12-25**], the patient had intravenous fluids half
normal saline to replete JP output 0.5 cc/cc. The patient,
over 24 hours from JP output, was 1640. On [**2121-12-26**],
labs that morning included a WBC of 6.3, hematocrit 24.0,
platelets 158, sodium 134, 5.5, 112, 17, BUN and creatinine
54 and 1.7, glucose 104, ALT 20, AST 8, alkaline phosphatase
66, total bilirubin 0.4.
The patient continued to eat well with supplements of Nepro
drinks 3 times a day. The patient was out of bed working with
physical therapy. He was urinating on his own. He continued
0.5 cc/cc. He was placed on normal saline for JP output.
[**Last Name (un) **] continued to see the patient and felt that the patient
should be encouraged to drink water in place of coke and be
sure that he is eating a reasonable amount of food.
Currently the patient has no JP drains. His T-tube is capped.
He is tolerating a diet well. He should remain a low
carbohydrate diet with supplement and also should be on a low-
potassium diet. The patient will be leaving today to go to
rehab in [**Doctor Last Name **].
DISCHARGE MEDICATIONS: Heparin 5000 units subcu q.8 hours,
prednisone 20 mg daily, Protonix 40 mg q.24, Bactrim SS 1
tablet daily, the patient is going to be an insulin NPH 28
units at breakfast and then Humalog sliding scale with
fingersticks checked q.i.d. The patient is also going to be
discharged on MMF 1000 b.i.d., oxycodone 5-10 mg q.6 hours
p.r.n., Valcyte 450 q.o.d., fluconazole 400 q.24, tacrolimus
1 mg b.i.d.
The patient will need outpatient lab work every Monday and
Thursday and have the results faxed to the transplant center.
The patient or the facility needs to call transplant surgery
immediately at [**Telephone/Fax (1) 673**] for any fevers, chills, nausea,
vomiting, inability to take medications, any increased
drainage from the incision site or around the T-tube,
jaundice, redness, bleeding, pus at the incision or with any
questions or concerns.
The patient should have labs every Monday and Thursday which
include CBC, CHEM10, AST, ALT, alkaline phosphatase, total
bilirubin, albumin and Prograf trough level which the results
should be faxed to [**Hospital6 256**]
Transplant Office at [**Telephone/Fax (1) 697**].
FOLLOW UP: With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2122-1-1**], at 10:20
a.m., [**2122-1-8**] at 9 a.m., [**2122-1-15**], at 10 a.m.
Please call [**Telephone/Fax (1) 673**] for any questions about the
appointments.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Liver transplant on
[**2121-12-10**].
LABORATORY DATA: On [**2121-12-29**], WBC was 4.5,
hematocrit 28.6, platelets 120; sodium 135, 5.7, 112, 18, BUN
and creatinine 50 and 2.0; ALT 11, AST 10, alkaline
phosphatase 55, total bilirubin 0.4.
The patient is 1 and 1 of Tacrolimus with level today of
10.9.
FINAL DIAGNOSIS: End-stage liver disease secondary to
cryptogenic cirrhosis.
CONDITION ON DISCHARGE: The patient is stable for discharge
today.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2121-12-29**] 12:36:10
T: [**2121-12-29**] 13:39:01
Job#: [**Job Number 62139**]
Name: [**Known lastname **], [**Known firstname **] V. Unit No: [**Numeric Identifier 11193**]
Admission Date: [**2121-12-10**] Discharge Date:[**2121-12-29**]
Date of Birth: [**2075-12-28**] Sex: M
Service: [**Last Name (un) **]
ADDENDUM
When the patient came in for this liver transplant on [**2121-12-10**], the patient was slightly confused, answering yes
and no questions. Prior to the liver transplant, the patient
have a CT of the head at 8:14 a.m. demonstrating that there
was no intracranial hemorrhage. Cerebella was atrophic, and
there was a mildly enlarge pituitary gland; however, there
was no evidence of intracranial hemorrhage.
The patient then had the transplant on [**2121-12-10**],
after the CT was reviewed and radiologist thought that there
was no intracranial hemorrhage.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 7503**]
Dictated By:[**Last Name (NamePattern1) 3068**]
MEDQUIST36
D: [**2121-12-29**] 12:39:47
T: [**2121-12-29**] 13:41:52
Job#: [**Job Number 11194**]
|
[
"571.5",
"998.12",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"87.54",
"50.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13079, 13411
|
20632, 21756
|
12640, 12893
|
14198, 20608
|
22382, 22443
|
21768, 22364
|
13434, 14180
|
11563, 12080
|
12103, 12613
|
12910, 13062
|
22468, 23893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,145
| 192,778
|
28104
|
Discharge summary
|
report
|
Admission Date: [**2186-6-2**] Discharge Date: [**2186-6-8**]
Date of Birth: [**2108-9-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 F with h/o Alzheimer's dementia, HTN, Hypothyroid,
osteoporosis presents from NH with 24 hrs of increasing
shortness of breath and weakness. Patient was unable to provide
any history which was obtained from ED physician and review of
chart. Upon arrival to the ED patient's O2 sat was 74% with
excellent response to NRB. Pt given 60 mg IV lasix and put out
1L of urine in [**1-21**] hrs. CXR c/w pulm edema with b/l effusions.
CPAP was attempted but unsuccessful. EKG showed STE in V2-6 and
I, II. Cardiac enzymes with mild troponin elevation and flat CK.
Cardiology was consulted in the ED and after discussion with
patients health care proxy decision was made to manage
medically. No cath, intubation, resucitation. In the ED given
Plavix, heparin, sl nigto, lasix. Patient also started on
Azithro/Ceftriaxone for ?aspiration PNA.
Past Medical History:
Dementia - ?[**Last Name (un) 309**] Body
HTN
hypothyroidism
?NPH with gait benefit post-LP (at [**Hospital1 2025**])
Ulcerative proctitis
Nephrocalcinosis
L urethrostomy
osteoporosis
Recurrent falls
Social History:
Lives at [**Hospital3 **] facility. 3 daughters, oldest is
resident in [**State 2690**] and health care proxy. Divorced from first
husband. Remarried 20 years ago and second husband died 15y ago.
Has close male friend. Previously employed as Head of [**Name (NI) **]
Department
HCP is [**Name (NI) 26196**]: reachable at [**Telephone/Fax (1) 68336**]
Family History:
Mother [**Name (NI) 68337**] of uterine cancer; Father died of CVA, also
increased EtOH use
Physical Exam:
Per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Temp 98.6, BP 198/86 HR 74 RR 28 98% NRB
tachypneic but no accessory muscle use
JVD increased to jaw at 10-15 cm
crackles at bases
nl S1S2 RRR no MGR
no LE edema
abd BS+ ntnd soft
Pertinent Results:
EKG: NSR at 70, normal axis and intervals, mild ST elevations I,
II; V3-V6; pos LVH
.
141 106 46
--------------< 174
6.2 26 2.1
.
12.5
15.9 >-----< 299
36.6
N:90.9 L:5.3 M:3.6 E:0 Bas:0.1
.
PT: 11.5 PTT: 22.8 INR: 1.0
Admission CXR [**6-2**]: Perihilar and basilar pulmonary edema
accompanied by bilateral pleural effusions
.
Echo [**6-5**]: The left atrium is dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. There is at least moderate to severe
pulmonary artery systolic hypertension.
.
trends:
WBC 15 - 11 - 12 - 8
Hct 36 - 29
Creatinine 2.1 - 3 - 2.2
K 4.9 - 5.8 - 5.0
CK [**Medical Record Number 68338**]
Trop 0.12 - 0.15
TSH 2.7
.
Micro:
Urine and blood cx NGTD
Brief Hospital Course:
Pt is a 77 F with h/o dementia (Alzheimer's vs. [**Last Name (un) 309**] body) from
NH presented with pulmonary edema. Hospital course by problem
.
#) CAD: The patient had a concerning ECG as well as a troponin
leak. We were concerned she had an NSTEMI. Heparin, aspirin,
plavix, and metoprolol were administered. We discussed options
of therapy with the patient's HCP who recommended no cardiac
catheterization. Instead we optimized medical management of her
CAD. She did not have any episodes of chest pain or acute
distress after her respiratory issues resolved. On discharge,
she was on aspirin, plavix, and Toprol XL for CAD treatment.
.
#) Rhythm: The patient developed atrial fibrillation with RVR.
It was difficult to rate control so we uptitrated metoprolol.
We also briefly treated with diltiazem gtt. This was weaned and
she returned to NSR. To maintain NSR upon discharge, amiodarone
was initiated. We discharged her on a tapering regimen. We
also discharged her with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to have
results obtained and faxed to Dr. [**Last Name (STitle) **] for med monitoring. She
should continue on this medication unless told otherwise. In
terms of anticoagulation, we discussed anticoagulation with the
patient's HCP. [**Name (NI) 227**] her other medical issues, it was
determined that she is not a good anticoagulation candidate.
.
#) Pump: Pump function as per echo. On presentation, she was
hypertensive and tachycardic (with atrial fibrillation). We
believe this led to diastolic dysfunction causing her acute
pulmonary edema. With diuresis, blood pressure control, rate
and rhythm control her function improved. She received
intermittent dosages of lasix 20IV if she had increased O2
requirement.
.
#) Acute on CRI: Patient has baseline Cr of 2.0. After
diuresis, it increased to 3.0 but improved to 2.2 prior to
discharge. We renally dosed meds.
.
#) HTN: She was quite hypertensive on admission and throughout
parts of her hospitalization. We stopped the atenolol given her
Acute on CRI. We started metoprolol and uptitrated. She also
was on a nitro gtt initially (also for CHF). Once this was
weaned to off, we initiated therapy with amlodipine as well as
HCTZ. Her BP meds may need further adjustment as an outpatient.
We held her lisinopril on admit given her ARF. We continued to
hold it given her borderline hyperkalemia. She will be
discharged with Toprol XL 50mg po Qday, HZCT 25mg po qday, and
Amlodipine 10mg poi Qday.
.
#) Hypothyroidism: TSH normal. rx with synthroid
.
#) Dementia: rx with home meds
.
#) FEN: regular with supplements
.
#) Dispo status: patient is minimally verbal. She has
difficulty with simple commands. She was on RA or up to only 2L
prior to discharge. She was pleasant and comfortable.
.
#) Code: DNR/DNI. Discussed with daughter/HCP. She also
requests no escalation of care. IE: no pressors or central
venous lines.
Comm: [**Name (NI) 26196**] daughter [**Telephone/Fax (1) 68336**]
Medications on Admission:
ALLERGIES: NKDA
.
CURRENT MEDICATIONS:
Synthroid 75 mg daily
Lisinopril 40 mg daily
Actonel 70 q week
Atenolol 37.5 mg daily
Aricept 10 mg daily
Namenda 10 mg [**Hospital1 **]
Sulfasalazine 500 [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
please take this dosage after 1 week of [**Hospital1 **].
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Actonel 75 mg Tablet Sig: One (1) Tablet PO once a week.
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
14. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
16. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
- CAD, likely NSTEMI
- CHF exacerbation with diastolic failure
- atrial fibrillation with rapid ventricular response
- Alzheimer's dementia
- hypertension
Secondary:
- hypothyroidism
- osteoporosis
Discharge Condition:
fair
Discharge Instructions:
You were admitted with increasing shortness of breath and
weakness. You were treated with high dose oxygen and diuresis.
You had evidence of a heart attack. After discussion with your
family, we opted to treat your heart failure and heart attack
with medications. You also had a fast heart rate called atrial
fibrillation. We changed some of your medications to assist
with control of the heart rate. We also recommend that you use
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of heart monitor to assess for any medication side
effects.
.
Please take your medications as instructed. Please followup
with your PCP within the next 1-2 weeks. Please have the heart
monitor results faxed to Dr. [**Last Name (STitle) **] as instructed while in the
hospital.
.
Please contact your PCP if you experience shortness of breath,
chest pain, palpitations, abdominal pain, worsening weakness.
Followup Instructions:
Please followup with your PCP within the next 1-2 weeks.
Please have the results of your heart monitor faxed to Dr. [**Name (NI) 65218**] office as instructed during your hospital stay.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"428.31",
"397.0",
"244.9",
"424.0",
"331.0",
"733.00",
"403.90",
"427.31",
"585.9",
"428.0",
"410.71",
"294.10",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8369, 8442
|
3526, 6566
|
346, 353
|
8693, 8700
|
2211, 3503
|
9654, 9972
|
1828, 1921
|
6828, 8346
|
8463, 8672
|
6592, 6610
|
8724, 9631
|
1936, 2192
|
274, 308
|
6631, 6805
|
381, 1218
|
1240, 1441
|
1457, 1812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,195
| 135,215
|
5257
|
Discharge summary
|
report
|
Admission Date: [**2101-3-24**] Discharge Date: [**2101-4-6**]
Date of Birth: [**2019-12-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache, nausea, vomiting
Major Surgical or Invasive Procedure:
Cerebral Angiogram [**3-24**] Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
History of Present Illness:
81 yo Mandarin-speaking female p/w HA, neck pain and dizziness.
Patient reports symptoms initially began on the date of
admission at 8PM when having a bowel movement. She noted sudden
onset of headache, dizzyness, neck pain, and vomiting. She was
able to ambulate only with assistance. Upon admission she
reported a bifrontal headache as well as neck pain mildly
improved since time of
onset.
Past Medical History:
hypertension, osteopenia
Social History:
Supportive family. No ETOH/tobacco/illicit drugs
Family History:
non-contributory
Physical Exam:
EXAM on ADMISSION:
PHYSICAL EXAM:
O: T 96.4 P 88 BP182/84 RR 18 98% RA FS 155
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ERRL b/l, 4 -> 2 b/l EOMs b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speaks manderin
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-30**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
DISCHARGE EXAM:
Spontanious Eye opening, NAD, Not following commands.
Pertinent Results:
Admission labs:
[**2101-3-23**] 10:00PM WBC-5.1 RBC-3.48* HGB-11.2* HCT-35.0*
MCV-101* MCH-32.1* MCHC-31.9 RDW-19.2*
[**2101-3-23**] 10:00PM GLUCOSE-146* UREA N-17 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
[**2101-3-24**] 02:30AM PT-12.8 PTT-24.6 INR(PT)-1.1
[**2101-3-24**] 03:23AM WBC-5.2 RBC-3.15* HGB-10.4* HCT-31.7*
MCV-101* MCH-33.0* MCHC-32.7 RDW-20.1*
IMAGING:
CTA Head [**3-23**]
1. 3-mm bilobed aneurysm projecting anteromedially at the
junction of the
ACOM and left A2 segment with diffuse subarachnoid and
intraventricular
hemorrhage. Though ventricles are prominent, they appear
appropriate in size for the patient's age of 81 years without
definite evidence of hydrocephalus.
2. No acute territorial infarction.
CT Head [**3-24**]:
Diffuse subarachnoid hemorrhage, stable in appearance and extent
since the previous study. Small amount of layering hemorrhage
within the
occipital horns, unchanged. No evidence of hydrocephalus.
CTA/CTP [**3-25**]:
1. CT head demonstrates interval coiling with coil artifact in
the region of anterior communicating artery. No hydrocephalus.
Subarachnoid hemorrhage. Loss of [**Doctor Last Name 352**]-white matter
differentiation in the left anterior cerebral artery
distribution.
2. CT perfusion of the head demonstrates increased mean transit
time and
decreased blood volume in the left anterior cerebral artery
territory
indicative of acute infarct.
3. CT angiography of the head demonstrates occlusion of the A2
segment of the left anterior cerebral artery. No evidence of
vasospasm or other vascular occlusions are seen. Status post
embolization of the anterior communicating artery aneurysm.
CXR [**2101-3-29**]
In comparison with the study of [**3-28**], the monitoring and support
devices remain in place. There is persistent enlargement of the
cardiac
silhouette with bilateral effusions and basilar atelectasis.
More focal area of opacification at the left base could
represent a region of developing pneumonia.
CTA [**2101-3-29**]
1. Redemonstration of the subacute infarction involving the
vascular territory of the left anterior cerebral artery, the
area of
infarction appears more conspicuous with no evidence of
hemorrhagic
transformation or significant shifting of the normally midline
structures.
There is minimal mass effect in the left frontal ventricular
[**Doctor Last Name 534**].
2. Interval decrease in the amount of subarachnoid hemorrhage.
No new areas of ischemia are identified.
3. The CTA demonstrates lack of filling of the left anterior
cerebral artery at the level of the A2 segment. Streak artifact
related with coils obscures anatomical detail in this area.
There is no evidence of diffuse or focal vasospasm.
CTA [**2101-3-31**]
1. Redemonstration of subacute infarction of the left anterior
cerebral
artery vascular territory. No evidence of hemorrhagic
transformation.
Unchanged mild mass effect on the left frontal [**Doctor Last Name 534**].
2. Similar amount and distribution of subarachnoid hemorrhage.
No new areas of intracranial hemorrhage.
3. No evidence of vasospasm. Unchanged lack of filling of the
left anterior cerebral artery at the level of the A2 segment.
Streak artifact from the coils again obscures the anatomical
detail in this area.
CXR [**2101-4-2**]
The lungs are hyperinflated. The heart is enlarged. There are
small-to-
moderate left greater than right pleural effusions, with
underlying collapse and/or consolidation. Minimal upper zone
redistribution, but no overt CHF.
An NG tube is present, tip extending beneath diaphragm off film.
A left
subclavian central line is present, tip over proximal SVC.
Compared with [**2101-4-1**], I doubt significant interval change
Brief Hospital Course:
The patient was admitted under the neurosurgery service to the
ICU for Q1 neuro checks. Her blood pressure was kept from
120-140, and she was placed on nimodipene for vasospasm
prophylaxis. On [**3-24**] she went to the angio suite for coiling of
the ACOMM aneurysm; however, the patient suffered a left sided
infarct during the procedure due to a dislodged coil.
She returned to the ICU and had a worsening exam; she was
completely plegic on the RU and RL extremities, and moved
spontaneously on the left. Her blood pressure was kept below
140. She developed labored breathing throught the day on [**3-25**]
and into [**3-26**], but remained on nasal cannula only
A discussion was had with the family regarding the patient's
code status. They wised to make the patient DNR/DNI, as the
patient had previously stated wishes of not being intubated or
having any extreme interventions or procedures.
On [**4-1**] patient opens eyes spontaneously and moves LUE
spontaneously. There is a question if patient is able to track
the examiner. She briskly withdraws LLE and no movement on R
side. Her CTA showed no evidence of vasospasm and patient was
transferred to step down. A PT eval was also requested.
On [**4-2**] a u/a was obtained but results were questionable,
therefore we awaited a culture before starting antibiotics. A
CXR was also obtained which revealed worsensing of
opacities/effusions. central venous line was removed. Pts exam
remained stable.
On [**4-3**] the urine culture was positive. A repeat U/A was obtained
for confirmation. Pt's exam stable.
On [**4-4**] The second u/a returned as positive therefore the
patient was started on Bactrim per the sensitivies of the
original culture. Her foley catheter was also changed. Speech
and swallow consultation was obtained for PEG planning. This was
discussed with the family but they were resistant to the idea of
placing one. The patient upon exam was opening eyes to minimal
stimuli, attending examiner, Left UE localizing and hemiplegic
on the right.
On [**4-5**] A family meeting was held with the patients HCP,
daughter in law, and interpreter. It was discussed at the
length, the patients prognosis and the risks and benefits of PEG
placement. The patient's HCP and family were very adiment about
not placing a PEG tube or other feeding device. At this time
they wished to stop feeding and start Hospice Planning. The
palliative care team was consulted for assistance in
hospice/discharge planning. The patient was made CMO, the NGTube
was removed and all unneccessary interventions/medications were
discontinued.
On [**4-6**] the patient was transfered to a hospice facility.
Medications on Admission:
unknown BP medicine, Xeloda,
ativan PRN, calcium
Discharge Medications:
1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dryness.
2. Morphine Concentrate 20 mg/mL Solution Sig: [**11-27**] 5 mg PO Q1H
(every hour) as needed for sob or pain .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
SAH
ACOMM aneurysm
urinary tract infection
pleural effusions
cerebral infarct
right hemiplegia
aphasia
pneumonia
Discharge Condition:
[**Hospital 21492**] hospice
Discharge Instructions:
comfort measures only
Followup Instructions:
NONE
Completed by:[**2101-4-6**]
|
[
"342.90",
"486",
"599.0",
"E878.2",
"434.91",
"401.9",
"997.02",
"794.4",
"781.8",
"511.9",
"996.74",
"V10.05",
"041.12",
"V66.7",
"790.29",
"784.3",
"285.8",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.75",
"38.93",
"96.6",
"38.91",
"88.41",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
9112, 9195
|
6120, 8777
|
343, 437
|
9352, 9382
|
2367, 2367
|
9452, 9486
|
992, 1010
|
8877, 9089
|
9216, 9331
|
8803, 8854
|
9406, 9429
|
1060, 1297
|
2292, 2348
|
277, 305
|
465, 861
|
1460, 2276
|
2384, 6097
|
1045, 1045
|
1312, 1444
|
883, 909
|
925, 976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,612
| 181,786
|
6282
|
Discharge summary
|
report
|
Admission Date: [**2146-4-29**] Discharge Date: [**2146-5-8**]
Date of Birth: [**2067-9-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2146-5-3**] - Redosternotomy, Coronary artery bypass grafting to two
vessels (Left internal mammary artery->Left anterior descending
artery, saphenous vein graft->obtuse mraginal artery)
History of Present Illness:
78M hx CAD s/p CABG (RIMA to RCA) [**2129**], DM2, in [**2145-11-23**]
developed chest pain and cath showed LAD disease not amenable to
intervention. Also showed disease in the distal RIMA prior to
touchdown and DES was paced. He was discharged on
ASA/plavix/atenolol/statin. According to the patient he was
doing well until over the past few days he has had epigastric
buring that occurs with rest. Denies other associated symptoms.
His cath today revealed signifcant Left main disease.
Past Medical History:
- Coronarary artery disease
- Diabetes
- Hypertension
- hx of vocal chord tumor
Social History:
Married and lives with his wife in [**Name (NI) 2624**], insurance [**Doctor Last Name 360**] and
still works part time.
-Tobacco history: quit 45 years prior, approx [**7-31**] pack-year
history.
-ETOH: None
Family History:
Mother - died of "old age" in 90s
Father - died of "massive MI" in his 60s
Physical Exam:
Admission exam:
VS: T 98.0 BP 120/54 HR 66 RR 15 SpO2 96/RA Weight: 229 Kg
103.8 kg
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**6-30**] cm H2O
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB in anterior lung fields (pt on bedrest after cath),
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND, obese.
EXTREMITIES: No c/c/e. TR band in place on right wrist,
sensation intact in fingers and cap refill <2 sec. Right groin
access site has some oozing of blood, no tenderness or hematoma.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Discharge:
VS: T: 98.0 HR: 50-60's SR BP: 100-120's/60's Sats: 93% 3L
Weight: 107.7 kg
General: 78 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on left 1/4 up otherwise clear
GI: benign
Extr: warm bilateral with 1+ edema
Incision: sternal clean dry intact no erythema or sternal click.
Left lower extremity vasoview site clean dry intact no erythema
Neuro: awake, alert oriented.
Pertinent Results:
Admission labs:
[**2146-4-29**] WBC-4.4 RBC-3.73* Hgb-10.7* Hct-33.0* MCV-89 MCH-28.7
MCHC-32.4 RDW-14.0 Plt Ct-189
[**2146-4-29**] PT-12.2 PTT-91.4* INR(PT)-1.1
[**2146-4-29**] Glucose-81 UreaN-12 Creat-0.1* Na-143 K-4.2 Cl-110*
HCO3-23
[**2146-4-29**] Albumin-3.4*
[**2146-4-29**] %HbA1c-6.4* eAG-137*
[**2146-4-29**] ALT-20 AST-7 AlkPhos-81 TotBili-0.3
Discharge labs:
[**2146-5-8**] WBC-9.8 RBC-3.08* Hgb-9.3* Hct-29.1* MCV-95 MCH-30.1
MCHC-31.8 RDW-15.1 Plt Ct-289
[**2146-5-8**] Glucose-189* UreaN-29* Creat-1.1 Na-141 K-4.0 Cl-102
HCO3-31
[**2146-5-6**] Mg-2.3
Imaging:
-CXR ([**2146-4-30**]): No acute cardiopulmonary radiographic
abnormality.
-CXR ([**2146-5-6**]): There is no evident pneumothorax. There are low
lung volumes with increasing bibasilar atelectasis, larger on
the left side. If any, there is a small left pleural effusion.
Right IJ catheter tip is in the lower SVC. There are no other
interval changes.
-TEE ([**2146-5-3**]):
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. Trace to mild
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-24**]+) mitral regurgitation
is seen. There is no pericardial effusion. Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]
were notified in person at the time of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function. Valvular functiojn is
unchanged. The thoracic aorta is intact after decannulation.
-Carotid US ([**5-2**]/ Right ICA 60-69% stenosis. Left ICA 40-59%
stenosis.
-Cardiac CAth [**2146-4-29**]:
1. Selective coronary angiography showed LMCA disease. The LMCA
had a
90% distal stenosis. THe LAD had mild luminal irregularities.
The LCX
had mild luminal irregularities. The RCA is known occluded.
2. Limited hemodynamics showed mild hypertension with central
pressure
of 142/61/75 mmHg.
3. Arterial conduit angiography showed via nonselective imaging
the RIMA
was widely patent with patent distal stent. The RIMA was unable
to be
engaged selective via the right radial approach (using many
differnt
catheters) or via the femoral approach using an [**Female First Name (un) 899**] guide.
Brief Hospital Course:
Mr. [**Known lastname 24393**] was admitted to the [**Hospital1 18**] on [**2146-4-29**] for further
management of his chest pain. He underwent a cardiac
catheterization and was found to have a 90% stenosed left main
coronary artery. Given the severity of his disease, the cardiac
surgery service was consulted for surgical management. Plavix
was continued given his drug eluting stent from [**2145-11-23**].
He was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which showed right internal carotid
artery of 60-69% stenosed and a left internal carotid artery
40-59% stenosed. He complained of thigh claudication, mostly in
his right thigh, which is reporoducible with walking 100-200
yards and relieved by rest. His non-invasive vascuilar studies
were normal however. On [**2146-5-2**], Mr. [**Known lastname 24393**] was taken to the
operating room where he underwent a redo sterontomy with
coronary artery bypass grafting to two vessels. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one, he
awoke neurologically intact and was extubated. He was gently
diuresed towards his preoperative weight. He developed
post-operative atrial fibrillation and converted to sinus rhythm
with amiodarone. Beta-blockers were continued. Aggressive
pulmonary toilet continued. His oxygenation improved but still
required supplemental oxygen via nasal cannula. His glyburide
was restarted with blood sugars 69-170's. Insulin sliding scale
continued. He was seen by physical therapy service for
assistance with his postoperative strength and mobility. He was
discharged to the [**Hospital 19771**] Rehab [**Telephone/Fax (1) 24394**] on POD5. He will
follow-up as an outpatient.
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for cardiac stents.
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever, pain.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: then 200 mg daily starting [**5-15**].
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Hellenic - [**Location (un) 2624**]
Discharge Diagnosis:
- Coronarary artery disease
- Diabetes
- Hypertension
- hx of vocal chord tumor
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 170**] Date/Time:[**2146-6-8**] 2:45 in
the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: [**Doctor Last Name **] [**2146-5-16**] at 2:00p ([**Apartment Address(1) 24395**], [**Location (un) **],MA)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 24396**] in [**4-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2146-5-8**]
|
[
"V58.61",
"285.1",
"433.10",
"401.9",
"V45.81",
"518.0",
"250.00",
"276.69",
"411.1",
"997.1",
"V45.82",
"E878.2",
"440.21",
"272.4",
"998.11",
"433.00",
"414.01",
"458.29",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.11",
"36.15",
"39.61",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
9137, 9199
|
5587, 7372
|
326, 518
|
9323, 9537
|
2779, 2779
|
10426, 11157
|
1384, 1460
|
7963, 9114
|
9220, 9302
|
7398, 7940
|
9561, 10403
|
3152, 5564
|
1475, 2760
|
270, 288
|
546, 1039
|
2795, 3136
|
1061, 1142
|
1158, 1368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,165
| 157,670
|
1270
|
Discharge summary
|
report
|
Admission Date: [**2172-3-2**] Discharge Date: [**2172-3-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
OUTPATIENT CARDIOLOGIST: Dr [**Last Name (STitle) **]
Chief Complaint: Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Placement and removal of intra-aortic balloon pump
Swan-Ganz catheter
History of Present Illness:
This is a 83 Y/o M with h/o CAD s/p CABG [**2157**] (LIMA to LAD, SVG
to OM, SVG to D1, SVG to PDA) who presented with chest pain.
.
Patient reports that his chest pain started at 5pm on the day
prior to admission while eating at a birthday party. It was a
sharp, constant, radiated to the left arm chest pain. It was
also associated with SOB and vomiting x1 this am. He took 2 NTG
with no improvement. On admission refer chest pain [**7-31**]. He felt
that it was the same pain he had with prior MI.
.
Of note he was seen on [**2172-1-21**] at [**Hospital3 **] for chest pain
but per OMR note there were no interventions done. He was seen
by cardiology on [**2-3**] were his lisinopril was re-started.
.
In the ED T 94.4, Hr 83, Bp 134/75 RR 26 Sat 95% on RA. He was
given Lopressor 5 mg x2, Nitroglycerin and heparin were started.
EKG showed normal sinus, normal axes, HR 82, 1st degree av
delay, St depression v2-v5, t waive inversion on I-[**Last Name (LF) **], [**First Name3 (LF) **]
elevation on AVR. CK: 406 MB: 49 MBI: 12.1 Troponin 0.77.
.
In the Cath lab: RA: 20 (Mean), RV 52/11 (20), PA 55/27 (42),
PCW 34, AO 103/57 (68)CI 1.29 --> 1.93 IABP
Findings: MR, Right dominant, LMCA: severe diffuse disease with
moderate calcification; LAD- occluded proximally, distal flow
from patent [**Female First Name (un) 899**]; LCX 90% lesion proximal, RCA Dominant vessel
and occluded proximally; SVG- RCA patent with diffuse disease in
the PDA/PLB; SVG- OM occluded; LIMA-LAD patent. Distal LCX
lesion was left untreated. Balloon Angioplasty-- LCx and Left
main.
Dobutamine was started, IABP and Lasix was given.
.
ALLERGIES: *NKDA
Past Medical History:
CAD, MI [**2154**] and [**4-26**] s/p CABG ([**2157**]) LIMA to LAD, SVG to OM,
SVG to D1, SVG to PDA)
Diabetes Type 2
gout
arthritis
CABG
RT leg bypass - NOS
CHF
hypertension
hypercholesterolemia
chronic renal insufficiency
peripheral vascular disease
Psoriasis
Social History:
The patient currently lives at home with services for assistance
with ADLs. He was an accountant in [**Country 532**]. He denied smoking,
alcohol or illicit drugs. He does not recall any family history
of premature coronary artery disease of sudden death.
Family History:
No history of premature CAD
Physical Exam:
VS: T 96.7 Bp 134/58 HR 89 RR 26 95% on 5 L
General: the patient was well developed, well nourished and well
groomed. The patient was oriented to person, place and time.
HEENT: no xanthalesma. conjuctiva pink. dry oral mucose. Neck
supple.
there was no thyromegaly. JVD - lying flat ~ 7cm
Chest: No chest wall deformities, scolisosis or kyphosis.
Lungs: + crackles bilaterally anteriorly.
Cardiac: Palpation of the heart revealed the PMI to be located
in the 5th intercostal space, mid clavicular line. Regular rate
and rhythm,
distant. Balloon pump audible.
Abdominal: The abdominal aorta was not enlarged by palpation.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended.
Extremities: No pallor, no cyanosis. There were no abdominal,
femoral or carotid bruits. Leg immobilizer bilaterally
Skin: = psoriatic plaques over extensor surface forearms
Right and Left groin + lines.
Guaiac + per ED note
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal unable to asses DP 1+
PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal unable to assess DP
1+ PT 1+
Pertinent Results:
[**2172-3-2**] 09:10AM BLOOD WBC-10.4 RBC-3.67* Hgb-10.6* Hct-33.4*
MCV-91 MCH-29.0 MCHC-31.9 RDW-14.5 Plt Ct-219
[**2172-3-5**] 06:45AM BLOOD WBC-11.2* RBC-3.72* Hgb-10.7* Hct-32.1*
MCV-86 MCH-28.8 MCHC-33.4 RDW-14.5 Plt Ct-134*
[**2172-3-2**] 09:10AM BLOOD Neuts-89.2* Bands-0 Lymphs-7.6* Monos-2.8
Eos-0.2 Baso-0.2
[**2172-3-3**] 09:39AM BLOOD PT-12.8 PTT-91.2* INR(PT)-1.1
[**2172-3-2**] 09:10AM BLOOD Glucose-575* UreaN-47* Creat-2.5* Na-136
K-6.8* Cl-95* HCO3-21* AnGap-27*
[**2172-3-5**] 06:45AM BLOOD Glucose-181* UreaN-31* Creat-1.6* Na-143
K-4.4 Cl-106 HCO3-30 AnGap-11
[**2172-3-2**] 09:10AM BLOOD ALT-98* AST-129* CK(CPK)-406*
AlkPhos-130* Amylase-99 TotBili-0.3
[**2172-3-2**] 04:20PM BLOOD ALT-83* AST-197* AlkPhos-97 TotBili-0.3
[**2172-3-2**] 07:15PM BLOOD CK(CPK)-1376*
[**2172-3-3**] 03:15AM BLOOD ALT-70* AST-162* CK(CPK)-976* AlkPhos-83
TotBili-0.3
[**2172-3-2**] 09:10AM BLOOD CK-MB-49* MB Indx-12.1*
[**2172-3-2**] 09:10AM BLOOD cTropnT-0.77*
[**2172-3-2**] 07:15PM BLOOD CK-MB-176* MB Indx-12.8* cTropnT-10.65*
[**2172-3-3**] 03:15AM BLOOD CK-MB-84* MB Indx-8.6* cTropnT-7.58*
[**2172-3-2**] 04:20PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.7*
[**2172-3-5**] 06:45AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.5
[**2172-3-3**] 03:15AM BLOOD Triglyc-64 HDL-51 CHOL/HD-3.6 LDLcalc-122
.
[**3-4**] CXR
IMPRESSION: Improved pulmonary edema.
.
[**3-2**] C Cath
FINAL DIAGNOSIS:
1. Acute posterior myocardial infarction.
2. Three vessel coronary artery disease.
3. Widely patent LIMA-LAD and SVG-RCA, occluded SVG-OM.
4. Severely elevated right and left sided filling pressures.
5. IABP placement due to low cardiac output.
6. Successful PTCA of the left main and ostial Cx.
.
[**3-3**] ECHO
IMPRESSION: Regional left ventricular systolic function
consistent with CAD. Mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2171-7-18**],
there is new regional dysfunction in the anterolateral wall.
Estimated pulmonary artery pressures are slightly higher. Mitral
regurgitation is not well seen on the current study.
Brief Hospital Course:
This is a 83 y/o M with h/o HTN, dyslipidemia, CAD s/p CABG [**2157**]
who presents with chest pain and positive enzymes. Hospital
Course complication by:
.
CARDIAC
# CAD/ chest pain: patient with h/o of CAD. + st changes on EKG,
positive cardiac enzymes --> NSTMI s/p cardiac cath with balloon
angioplasty to LM + LCX. No stents placed. hemodynamics
compatible with poor CI + elevated wedge. CK peaked at 1376.
- received heparin/Integrilin (18h)
- Continued aspirin/ Plavix
- Weaned off Dobutamine and then IABP
- re-started ACEI/B-blocker once BP tolerated
- no additional chest pain during his hospital course
.
Pump: EF 30% Patient with elevated pressures in the cath lab. He
was in pulmonary edema on admission but was euvolemic on
discharge.
- he was re-started on his outpt diuretic on discharge
.
Rhythm: NSR
.
# HTN: Blood pressure medicines initially held but lisinopril
and metoprolol were re-started by discharge
.
# Hyperlipidemia: continued high dose statin.
.
# Acute on Chronic renal insufficiency: Most likely pre-renal in
the setting of low cardiac index. Cr 2.5 on admission but back
to baseline of 1.6 on discharge. On lisinopril.
.
# Hyperkalemia: Hyperkalemic on admission likely [**1-24**] acute renal
failure.
No EKG changes suggested of hyperkalemia. Received calcium
gluconate. Resolved by discharge.
.
# DM/Hyperglycemia: Elevated on admission. Apparently he was
using his insulin as prescribed. Anion gap acidosis on admission
which may also represent his worsening renal failure with
accumulation of organic anions. Was not in DKA. Insulin gtt
was started but d/c'd once taking pos. Was re-started on home
insulin doses on discharge.
.
# Elevated LFT's: currently on statins as outpatient. Prior
records on OMR showed normal LFT's. No history of alcohol abuse.
- ? [**1-24**] statin use, may need to decrease dose as outpatient
.
# FEN:
- Cardiac/renal diet
.
# ??Depression: will continue Celexa as per outpatient regimen.
.
# communication: HCP [**Name (NI) **] (Son) [**Telephone/Fax (1) 7908**]
.
# Code: DNR/DNI confirmed with the patient
Medications on Admission:
Aspirin 81 mg once daily,
Celexa 10 mg once daily,
clobetasol 0.05. p.r.n.
Colace 100 mg p.o. b.i.d
Humulin NPH 14 units in morning and 6 units at night
Lipitor 80 mg q.h.s.,
Neurontin 600 mg b.i.d.
Nitro-Dur 0.8 one patch once daily
Norvasc 5 mg once daily,
Plavix 75 mg once daily,
Renexa 500 mg once daily
Senna two tablets b.i.d.
Toprol-XL 50 mg once daily,
torsemide 20 mg once daily.
Lisinopril 5 mg /day
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Renexa Sig: Five Hundred (500) mg once a day.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed uniuts Subcutaneous twice a day: Inject 14 units each
morning and 6 units each evening.
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
1. Acute Coronary syndrome, posterior MI
2. Cardiogenic shock, s/p intra-aortic balloon pump
Discharge Condition:
Stable, maintaining BP and chest pain free.
Discharge Instructions:
You were admitted with chest pain, found to have a heart attack,
and underwent angioplasty to open up the arteries. In addition,
your heart does not pump as well as it should.
* Please take all medications as prescribed
* Follow up with your Cardiologist, Dr. [**Last Name (STitle) **] as previously
scheduled.
* Follow up with your primary care physician [**Name Initial (PRE) 176**] 1 month.
* Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
* Adhere to 2 gm sodium diet
Followup Instructions:
Your cardiologist: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD
Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2172-3-23**] 10:40
.
Your primary care physician:
[**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7909**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2172-4-15**] 9:30
|
[
"414.01",
"696.1",
"428.20",
"585.9",
"410.61",
"794.8",
"428.0",
"440.21",
"285.9",
"250.00",
"274.0",
"414.02",
"724.02",
"V58.67",
"412",
"403.90",
"272.0",
"785.51",
"311",
"584.9",
"366.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"88.56",
"37.21",
"88.57",
"37.61",
"99.20",
"00.66",
"99.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
9397, 9472
|
5932, 8015
|
343, 439
|
9609, 9655
|
3848, 5207
|
10203, 10584
|
2686, 2717
|
8477, 9374
|
9493, 9588
|
8041, 8454
|
5224, 5909
|
9679, 10180
|
2732, 3829
|
293, 305
|
467, 2110
|
2132, 2396
|
2412, 2670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,164
| 170,249
|
36023
|
Discharge summary
|
report
|
Admission Date: [**2160-12-29**] Discharge Date: [**2161-1-23**]
Date of Birth: [**2111-8-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status, renal failure
Major Surgical or Invasive Procedure:
intubated
Percutaneous Tracheostomy
History of Present Illness:
Mr. [**Known lastname 38681**] is a 49 y/o man with morbid obesity, hypertension,
type 2 diabetes brought to an OSH By EMS earlier today with
respiratory distress and acute renal failure. The patient was
more somnolent for the past few days per his wife. At baseline,
he ambulates several feet around his house. He has not left the
house in the last 4-5 years (since he fell and injured his knee
per wife's report). He has not actually left the bed for the
past several days. Notably, he recently has been taking percocet
every day for chronic back pain; in the past, he has taken this
only intermittently. His rash, located all over his trunk and
for which he has been treated with miconazole powder/cream in
the past, has gotten worse in the past week per the patient's
wife. [**Name (NI) **] has had increased serosanguinous seepage from the open
areas of the wound. His wife reports that he has been very
thirsty lately and drinking a lot of water; his PO intake of
food has been poor per her report. He has had decreased urine
output for several days. He has not had any new medications per
his wife, other than taking percocet for increased back pain.
.
The patient's wife reports that her father in law arrived at
their house earlier today and the patient was complaining of
dyspnea. The patient's father then called 911. On arrival of
EMS, the patient was noted to be lethargic and was intubated in
the field. He was bradycardic and received atropine X 1 with
some improvement in HR. He was then transported to [**Hospital **]
[**Hospital 1459**] Hospital. There, he was found to have acute renal
failure (cr 6.3, K > 8). He was treated with calcium,
insulin/d50, and bicarb fluids. He had a right hemodialysis
temporary catheter placed; during line placement, his ET tube
fell out and had to be replaced. This was done without immediate
complication. NG tube contents were noted to be guaiac positive.
D dimer was also elevated at 7.8 (normal <0.5).
.
On arrival to the outside ED, HR remained in the 48-50 range.
His BP was low in the 70s systolic. ET tube was confirmed below
the clavicles. EKG showed junctional rhythm per their report in
the 40s. Cardiology was contact[**Name (NI) **] who recommended using dopamine
to maintain the patient's blood pressure and heart rate. He was
evaluated by the renal team who arranged HD line placement and
coordinated dialysis session prior to transfer. NG tube was
placed which was grossly bloody; he did received 40 mg IV
protonix. He was treated with zosyn 3.375 g IV X 1 and
vancomycin 1 g IV for possible infectious etiologies of sepsis.
He ws dialyzed for several hours at [**Location (un) **] [**Location (un) 1459**] prior to
transfer (no fluid removed) but repeat K prior to transfer was
still ~ 8.
.
On arrival to the [**Hospital1 18**] ICU, the patient is intubated. He is on
the ventilator, pressure control ventilation. Initial blood
pressures were 130s systolic, on dopamine. He was seen
immediately by Renal consultants for initiation of HD. Arterial
line was placed after cuff pressures read 50s systolic; this was
confirmed on arterial line once placed. At that point, his
sedation (propofol) was discontinued and he was given a bolus of
NS as well as placed on dopamine and levophed drips. BPs
increased quickly to the 130s systolic.
Past Medical History:
morbid obesity
* hypertension
* type 2 DM
* hypothyroidism
* h/o anemia (on iron therapy)
* h/o palpitations (avoids caffeine)
* GERD
* h/o constipation
Social History:
Lives with wife, mother, and 5 children. He has not left the
house in [**4-19**] years. He does not smoke and his wife denies
illicit drugs. He rarely drinks alcohol.
Family History:
No family h/o CAD, CHF, or renal failure.
Physical Exam:
T: 95.7 (oral) BP: 134/92 --> down to 52/35 off of dopamine and
with propofol hanging HR: 81 RR: 24 O2 99% on A/C 450X25, peep
10, FiO2 60, wt ~ 290 kg
Gen: morbidly obese gentleman, lying in bed, intubated
HEENT: no scleral icterus, pupils small but reactive
NECK: right IJ dialysis line in place, no lymphadenopathy
CV: difficult to hear
LUNGS: coarse breath sounds bilaterally
ABD: obese, hypoactive bowel sounds
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: skin breakdown on bilateral flanks (left > right) with
serosanguinous oozing, on multiple levels of panus and confluent
areas
NEURO: pupils small but reactive BL. moving both arms.
Pertinent Results:
Echo [**2160-12-30**]: Due to extreme nature of body habitus, no useful
transthoracic echocardiographic images are obtainable
.
Repeat Echo [**2160-12-31**]: No mass or thrombus is seen in the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is no pericardial effusion.
Impression: Normal left and right ventricular systolic function.
No masses or vegetations are seen on the aortic or the mitral
valve. There is no pericardial effusion.
.
Foot X-ray [**2161-1-1**]: No findings to confirm the presence of
osteomyelitis.
.
Venous Dupplex [**2161-1-2**]: IMPRESSION: Extremely limited study
without gross evidence of occlusive DVT in the left superficial
femoral vein or popliteal vein.
.
CXR's
[**2160-12-30**]: FINDINGS: No previous images. The size of the patient
makes it difficult to properly evaluate the study. There is some
enlargement of the cardiac silhouette. No gross evidence of
acute pneumonia or vascular congestion on this extremely limited
study.
.
[**2160-12-30**]: FINDINGS: In comparison with the earlier study of
this date, there has been placement of a left IJ catheter. It is
extremely difficult to evaluate the tip beyond the mid portion
of the SVC. An oblique view would be necessary to try to
demonstrate the tip more precisely.
Persistent enlargement of the cardiac silhouette with probable
left basilar atelectasis without evidence of definite pneumonia
or vascular congestion.
.
[**2161-1-4**]: IMPRESSION: Evaluation limited due to motion. Low
lung volumes. Bibasilar opacities may represent atelectasis vs.
pneumonia.
.
[**2161-1-13**]: IMPRESSION: Tracheostomy tube is seen ending in the
expected position of the trachea at the level of the clavicle.
The tracheostomy tube appears tilted with the end abutting the
expected location of the right wall of the trachea.
.
[**2161-1-15**]: Technical quality is limited by the patient's size and
respiratory motion. Severe cardiomegaly is unchanged. Right
hemidiaphragm remains markedly elevated. Pulmonary vascular
congestion is present. There may be a small region of
consolidation in the right upper lobe. Lungs are otherwise clear
of focal abnormalities. Tracheostomy tube in place. Nasogastric
tube can be traced to the upper stomach and passes out of view.
Pleural effusion is small, on the right. No pneumothorax. Right
subclavian line can be traced as far as the cavoatrial junction.
.
[**2161-1-20**]: AP SUPINE CHEST RADIOGRAPH: The tracheostomy tube is
improved in alignment, terminating 4 cm from the carina. A
nasogastric tube extends out of the field-of-view well below the
diaphragm. A right PICC terminates at the cavoatrial junction.
The lung volumes again are low. The hearts is enlarged but
stable. There are bilateral opacities with predominance in the
left lower lobe which are unchanged. Along with infection, this
could represent congestion.
.
Labs:
Hct trend: On admission was 30.7, decreased to range of 26 down
to 21 for the rest of his hospital stay, 21.7 on discharge, but
refused transfusions.
.
WBC trend: 16.2 on admission, decreased to 7.4 prior to
discharge.
.
Crn trend: On admission 5.3, down to 1.0 prior to discharge.
.
Microbiology:
[**2161-1-10**] 6:47 pm CATHETER TIP-IV Source: Left I J.
**FINAL REPORT [**2161-1-14**]**
WOUND CULTURE (Final [**2161-1-14**]):
ACINETOBACTER BAUMANNII COMPLEX. >15 colonies.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
TOBRAMYCIN REQUESTED BY DR.[**First Name (STitle) **]. SENSITIVE TO
TOBRAMYCIN.
TOBRAMYCIN sensitivity testing performed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- 4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R <=0.5 S
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 2 S
.
[**2161-1-14**] 10:36 pm URINE Source: Catheter.
**FINAL REPORT [**2161-1-17**]**
URINE CULTURE (Final [**2161-1-17**]):
ACINETOBACTER BAUMANNII COMPLEX. >100,000
ORGANISMS/ML..
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 8 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2161-1-14**] 10:36 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2161-1-19**]**
GRAM STAIN (Final [**2161-1-15**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2161-1-19**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
ADDITIONAL SENSITIVITES REQUESTED BY DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
(PAGE [**Numeric Identifier 36772**])
ON [**2160-1-18**] - PLEASE REFER TO ACC# [**Serial Number 81765**] FROM
[**2161-1-15**].
ENTEROBACTER CLOACAE. MODERATE GROWTH.
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.
ADDITIONAL SENSIS REQUESTED BY [**Last Name (NamePattern4) 81766**], MD (I.D.)
BNU [**Numeric Identifier 36772**] ON
[**2160-1-18**] - PLEASE REFER TO ACC# [**Serial Number 81765**] FROM [**2161-1-15**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ENTEROBACTER CLOACAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- =>64 R <=1 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- 8 I
MEROPENEM------------- <=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 I 32 I
TOBRAMYCIN------------ <=1 S 4 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
[**2161-1-15**] 1:43 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2161-1-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2161-1-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Location (un) **] @ 0407 ON [**2161-1-16**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
.
[**2161-1-15**] 5:17 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2161-1-19**]**
Blood Culture, Routine (Final [**2161-1-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND MORPHOLOGY.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 3RD MORPHOLOGY.
ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON
REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 4TH MORPHOLOGY.
ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON
REQUEST..
Aerobic Bottle Gram Stain (Final [**2161-1-16**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO PAT BOYKSS [**2161-1-16**] 11:45AM.
Anaerobic Bottle Gram Stain (Final [**2161-1-17**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
A/P: This is a 49 y/o man with PMH of morbid obesity, type 2 DM,
and hypertension admitted with shock, respiratory failure, and
acute renal failure.
.
# Shock: Initial presentation of hypotension thought be most
likely from septic shock. Potential sources of infection
included urine and most likely skin (multiple open areas with
surrounding erythema and pus-like drainage). Other source
considered was pulmonary but unclear if could visualize on
imaging. He was initially on levophed and dopamine which was
titrated down to levophed, then eventually was able to be
discontinued with maintenance of goal blood pressures off
pressors. He was broadly treated with antibiotics, including
vancomycin and zosyn, for presumed infection although initial
source was never determined given difficulty of imaging.
Imaging also not indicative of infection although only films
obtained were chest X rays and foot X rays. Plastics was
consulted and did not recommend changing management for
decubitus ulcers and did not believe these were the source of
his fevers. Antibiotics were slowly peeled away, starting on
[**2161-1-13**], as no culture data was positive. After antibiotics
removed, the patient became febrile again. Repeat cultures on
[**2162-1-14**] and [**2161-1-15**] showed acinetobacter in the urine and
sputum. CXR showed questionable evidence of pneumonia, however
difficult to asertain given body habitus. The patient was
empirically treated for acinetobacter hospital acquired
pneumonia with meropenem, tobramycin and vancomycin, which was
narrowed to tobramycin, unasyn and vancomycin after
sensitivities returned. A course was set for a vancomycin to be
discontinued on [**2161-1-24**] and tobramycin and unasyn to be
discontinued on [**2161-1-31**] based on trough dosing, which daily
troughs for tobramycin, to be started tonight [**2161-1-23**] at 8pm.
One blood culture drawn from the PICC line grew coag neg staph,
which was presumed to be contaminent given no other blood
cultures grew back positive. The patient should continue
vancomycin, unasyn, tobramycin and metronidazole at rehab
facility.
.
# Respiratory failure: Unclear precipitant. Patient has baseline
respiratory difficulty and is not compliant with sleep apnea
prescriptions (no cpap). He had been more dyspneic for several
days per her report and more somnolent, likely a sign of
hypercarbia. Could be that hypercarbia due to increased
narcotics (percocet) precipitated respiratory failure. Given
history of hypertension and acute renal failure with decrease
urine output, could also represent flash pulmonary edema (very
difficult to tell on CXR). PE was considered, however not
likely. The patient required a tracheostomy considering
prolonged time on the ventilator, and will likely required
ventilatory support for some time. Currently on PSV, should
continue at current settings of PS10 and PEEP8, with increase in
PEEP to 10 for transfers and bathing.
.
# Acute on chronic renal failure: Unclear chronicity as wife
reports he was told lately that kidneys were not functioning
normally. However, missed recent home lab draw as no one at home
to open the door per wife. ? relationship to elevated CK (only
5000 at OSH and ~ 9000 here); likely not precipitant but related
to tissue hypoperfusion when hypotensive. He had CVVH x 1day
for hyperkalemia during hospital course then no longer required
dialysis. Renal followed and creatinine improved and remained
stable during hospital stay.
.
# C. Diff Colitis: The patient tested positive for C. diff on
[**2161-1-15**]. He was started on oral flagyl on. The plan is for him
to continue on flagyl until he is 5 days post his unasyn and
tobramycin dosing, which will be discontinued on [**2161-2-5**].
.
# Metabolic acidosis: Resolved. Likely was secondary to renal
failure and lactic acidosis on pH improving since arrival at
OSH. Did receive bicarb fluids at OSH. Likely secondary to renal
failure and component of lactic acidosis. Lactate trended down.
.
# Guaiac + NG output, likely Gastritis with H/o GERD: Noted at
OSH. Hct ~ 30 since arrival at OSH. Continued PPI. Likely
gastritis related to acute decompensation. Per wife, pt is
[**Name (NI) 81767**] witness and would not want blood products, confirmed
with patient. This was reversed for the OR when he went for
tracheostomy. Therefore, just trended the patient's hematocrits
during stay. They stayed stable, however low. He was started
on epo and treated with [**Hospital1 **] PPI for possible gastritis.
.
# Multiple areas of skin breakdown: Likely fungal in nature with
? superinfection of open areas. Covered with broad spectrum
antibiotics for septic shock, then for ventilator AP and UTI.
Wound care daily. Wound care was consulted. Should continue
miconazole powder to affected areas.
.
# Anemia: Hct 30 on arrival to [**Hospital1 18**]. Unclear baseline and
patient is Jehovah's witness so NO BLOOD PRODUCTS. Likely
secondary to anemia of chronic disease and gastritis. Treated
with epo, will likely need to repeat as an outpatient. Hct as
above came down initially with likely gastritis, however stayed
stable, however low at 21.7 prior to discharge. Patient
continues to refuse transfusions. Please restart iron
supplementation at rehab.
.
# Type 2 DM: Was on actos and glucophage as an outpatient.
Transfered to sliding scale insulin, controlled well. Will
continue sliding scale insulin in the acute illness setting.
Should discuss with outpatient physician the possibility of
restarting oral medications after discharge from rehab.
.
# Hypertension: Held all antihypertensives given hypotension on
admission, and attempt to diurese fluids as very positive for
length of stay. On Lasix only, was on lasix drip for increased
diuresis, however will put on oral lasix 40mg [**Hospital1 **] in rehab
facility. Should have daily Chem 7 to monitor electrolytes and
renal function. Please discontinue lasix if patient's
creatinine increases significantly.
.
# Elevated CK: Likely related to tissue hypoperfusion when
hypotensive. MB index quite low making cardiac ischemia less
likely. Also, EKG without clear evidence of ischemia. CK
trended down with IVF.
.
# Elevated D dimer: ? relevance of this in context of current
situation. Certainly massive PE could have cause respiratory
failure but also could have elevated d dimer due to acute renal
failure, SIRS, and/or tissue hypoperfusion. Given guaiac
positive NG output and knowledge that patient would not want
transfusions, did not start anticoagulation. There are other
explanations for d dimer and lack of good test to make this
diagnosis (CT not possible, VQ not possible, LENIs not good for
diagnosis). Oxygenation improved during hospital stay.
.
# H/o Hypothyroidism: TSH 3.6 on admission. Did not start
levothyroxine, but presumably was taking at home. Will contact
regarding restarting levothyroxine as checking TSH today now
that acute illness has passed.
.
# PPx: heparin 7500 units sc tid, ppi [**Hospital1 **], bowel regimen
.
# CODE: full code, confirmed with wife, HCP is father, with
alternate as wife
.
# COMM: with patient and family. Wife [**Name (NI) **] [**Name (NI) 38681**] is
[**Telephone/Fax (1) 81768**].
.
Please contact the medical residents in the MICU at
([**Telephone/Fax (1) 81769**] with any questions regarding management
Medications on Admission:
* levothyroxine 75 mcg daily
* actos
* glucophage
* lisinopril (dose unknown)
* asa 325 mg daily
* mvi daily
* ferrous sulfate 325 mg daily
* atenolol (dose unknown)
* ranitidine
* wellbutrin
* nystatin powder
Discharge Medications:
1. Tobramycin Sulfate 40 mg/mL Solution [**Telephone/Fax (1) **]: 1000mg Injection
Q48H (every 48 hours) for 10 days: Please dose according to
troughs, please contact Dr. [**Last Name (STitle) **] with trough information.
2. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 750mg Recon Solns
Intravenous Q 24H (Every 24 Hours) for 5 days: End date [**2161-1-27**],
please dose according to levels to be drawn daily and sent to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
3. Ampicillin-Sulbactam 3 gram Recon Soln [**Last Name (NamePattern1) **]: 3gm Recon Solns
Injection Q4 () for 10 days: End date [**2161-2-1**].
4. Metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day) for 15 days: End date [**2161-2-6**].
5. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day/Year **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
7. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical DAILY
(Daily).
8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO TID (3
times a day).
9. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
10. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One
(1) Tablet PO once a day.
14. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Last Name (STitle) **]: One
(1) PO BID (2 times a day).
15. Haloperidol 1 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO HS (at bedtime).
16. Haloperidol 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
17. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Subcutaneous four times a day: Per Insulin Sliding Scale.
18. Lasix IV
Please continue IV drip for goal of UOP >100cc/hr. If this is
not possible, would recommend 20mg IV of lasix at 8am and 4pm to
continue diuresis with goal of >100cc/hr, until Crn becomes
significantly elevated.
19. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Five (25)
units Subcutaneous at bedtime.
20. Outpatient Lab Work
Please check CBC, Chem 7, mag, phos, ca, LFT's, tobramycin and
vancomycin troughs daily. Please fax this information to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 6313**]. Also, please page Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 24484**] with tobramycin and vancomycin troughs
and any critical lab results.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnsoses:
Sepsis of unclear etiology
[**Hospital 81770**] Hospital Acquired Pneumonia
UTI
C. Diff
Morbid obesity
Hypercarbic respiratory failure
Acute on chronic renal failure
.
Secondary diagnoses:
type 2 DM
hypothyroidism
h/o anemia (on iron therapy)
h/o palpitations (avoids caffeine)
GERD
h/o constipation
Discharge Condition:
fair. Pt is hemodynamically stable not requiring pressors. His
respiratory status is stable on PSV through a tracheostomy.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of fevers and
respiratory distress. You were thought to have an infection in
your blood stream. You were treated with antibiotics and your
condition improved. Antibiotics were stopped, then you
developed fevers again. You were found to have a pneumonia, UTI
and infectious diarrhea called C. diff, at that time. You were
restarted on antibiotics. You will continue on the current
regimen of antibiotics including vancomycin, unasyn, tobramycin
and metronidazole. You will continue on the vancomycin until
[**2161-1-24**], the unasyn and tobramycin until [**2161-1-31**] and
metronidazole until [**2161-2-5**]. You were continued on ventilatory
support for respiratory distress, thought to be secondary to
obesity and obstructive sleep apnea. A tracheotomy was
performed to assist with prolonged mechanical ventilation. You
will require ventilatory support for some time following at the
rehab facility.
.
These medications were started:
Vancomycin
Unasyn
Metronidazole
Tobramycin
Insulin lispro sliding scale
Iron supplementation
Lasix
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the ID department as
directed. Please call ([**Telephone/Fax (1) 14199**] to schedule an
appointment.
.
Please follow up with your primary care physician following
discharge from the rehab facility
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2161-1-27**]
|
[
"518.81",
"327.23",
"276.2",
"112.3",
"584.9",
"707.03",
"535.51",
"276.7",
"997.31",
"707.22",
"038.9",
"285.29",
"041.85",
"785.52",
"244.9",
"995.92",
"707.09",
"V85.4",
"278.01",
"599.0",
"008.45",
"250.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.1",
"38.93",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
25841, 25941
|
15238, 22586
|
360, 397
|
26305, 26432
|
4823, 15215
|
27581, 28042
|
4107, 4150
|
22847, 25818
|
25962, 26150
|
22612, 22824
|
26456, 27558
|
4165, 4804
|
26171, 26284
|
284, 322
|
425, 3730
|
3752, 3907
|
3923, 4091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,725
| 118,849
|
17529
|
Discharge summary
|
report
|
Admission Date: [**2102-7-1**] Discharge Date: [**2102-7-5**]
Date of Birth: [**2021-3-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
This is a 81 YOM with known CAD who presents with dyspnea. He
saw his primary care yesterday with out significant event. He
takes his own pulse frequently and states it has been in the 80s
and regular. Today he felt suddenly short of breath with
exertion. He also felt dizzy. He laid down and his symptoms
resolved. He had no chest pain or palpitations. Recently had
hospital stay for spine surgery complicated by urinary
retention. During that hospital stay he was found to have an
atrial tachycardia. He was DCCV to sinus brady. He then
developed symptomatic bradycardia. His beta blocker and
amiodarone were transiently held. He is now off amio. His beta
blocker dose was recently doubled.
.
In the ED he was found to be in a wide complex ventricular
rhythm with rate of 35 bpm. He was given 2.5L of NS and 3 baby
aspirin.
Past Medical History:
1. Coronary disease s/p CABG x4 in [**2090**]
- NSTEMI [**12-19**]
2. Hypertension
3. Hypercholesterolemia
4. Diabetes mellitus
5. Chronic kidney disease
6. Back surgery 1 week ago for spinal stenosis
7. Atrial fibrillation on coumadin
Social History:
He lives at home with his wife. [**Name (NI) **] has three children. He is a
retired auto body man. No EtOH or ivdu. He quit smoking about
45 years ago.
Family History:
He has two brothers with CAD, one who died of SCD.
Physical Exam:
Blood pressure was 85/46 mm Hg while seated. Pulse was 36
beats/min and regular, respiratory rate was 12 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVD. There were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. Bilateral crackles at the bases.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed profound
bradycardia with a normal S1 and the S2 was normal. There were
no rubs, murmurs, clicks or gallops.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. There were no abdominal, femoral or
carotid bruits. Inspection and/or palpation of skin and
subcutaneous tissue showed no stasis dermatitis, ulcers, scars,
or xanthomas.
.
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:
EKG demonstrated bradycardia rate 35 bpm. nl axis. long qrs. No
ST changes or TWI. No atrial activity seen.
.
TELEMETRY demonstrated: bradycardia
.
2D-ECHOCARDIOGRAM performed on [**2102-5-19**] demonstrated:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
CXR: Portable chest radiograph was compared to [**2102-5-24**].
No
significant pulmonary edema. The cardiac and mediastinal
contours are both remarkable for stable cardiomegaly and
tortuous thoracic aorta. Patient is status post median
sternotomy with coronary bypass grafting. The lungs are clear.
.
Admission LABORATORY DATA:
136 98 50
-- |--|-- < 271 AGap=18
4.5 25 2.1
CK: 59 MB: Notdone Trop-T: 0.07
Ca: 9.0 Mg: 3.0 P: 5.0
PT: 13.3 PTT: 25.5 INR: 1.2
12.4>---<428
31.7
Brief Hospital Course:
This is a 81 YOM with CAD s/p CABG x4 in [**2090**], Afib on coumadin,
DM, HTN, HL, CKD (Cr 1.4-1.6), s/p recent spine surgery p/w DOE,
dizziness, found to be bradycardic in 30s with junctional escape
rhythm and acute on chronic renal failure, a temporary pacemaker
was placed as a bridge to a permanent pacemaker. He tolerated
the procedure well. His BP medications for adjusted and he was
discharged home.
.
1)Bradycardia - The patient had a hx in the distant past of
bradycardia in setting
of dig toxicity. However, he was currently not taking digoxin.
His Bradycardia was likely due to conduction disease and a
recent increased dose of beta blocker. His beta blocker was held
and a temporary pacing wire was placed (AAI). HE also had recent
atrial tachycardia, thus the decisison was made to place a PPM
for tachy/brady syndrome. His coumadin was held and he was
maintained on a heparin GTT. He tolerated the procedure well.
After placement of the PPM, he had episode of tachycardia (c/w
atrial tach), we re-started BB and and added CCB for optimal BP
and HR control.
.
2)Acute on chronic renal failure - the patient has a Cr baseline
around 1.4-1.6. He presented with a crt. of 2.5. Initially his
ARF was thought likely due to increased diuresis. However, on
exam he seemed volume overloaded and receiving Lasix prn. His
creatinine gradually trended back to baseline during his stay.
3)Afib - On coumadin prior to admission. Coumadin was held and
a heparin drip was started until all procedures were done. He
was discharged on his home coumadin dose.
.
4)Hyperlipidemia - cont statin
5)DM - Continue glipizide. RISS.
Full code
Medications on Admission:
Aspirin 81 mg DAILY
Tamsulosin 0.4 mg HS
Docusate Sodium 100 mg PO BID
Finasteride 5 mg DAILY
Metoprolol Tartrate 50 mg PO BID
Coumadin 2.5 mg
Lasix 80 mg PO bid.
Multi-Vitamin
Glipizide 5 mg PO once a day.
Simvastatin 20 mg PO once a day.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 1 days.
Disp:*3 Capsule(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Cardizem SR 60 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2*
12. Outpatient Lab Work
INR check on [**2102-7-7**]
Please send results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48918**], MD ph# [**Telephone/Fax (1) 39260**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Tachybrady syndrome s/p pacemaker
Acute renal failure
Secondary:
HTN
CAD
Atrial fibrillation on coumadin
CRI
Hypercholesterolemia
Diabetes
Discharge Condition:
Afebrile. Stable. Ambulating without difficulty.
Discharge Instructions:
You were admitted to the hospital for bradycardia. You had a
permanent pacemaker placed for this problem. We have adjusted
some of your medications. Your metoprolol dose has been
increased to 100mg three times a day. You were started on
Cardizem SR 60mg twice a day for you elevated heart rate. We
have also started you on a new medication called amiodarone for
your arrythmia.
.
Please continue to take your other medications as directed.
.
Please call your doctor if you experience high fevers, chills,
shortness of breath, chest pain or other concerning symptoms.
Followup Instructions:
You will need to follow up in the device clinic. You already
have an appointment shceduled for Date/Time:[**2102-7-12**] 3:00.
Phone:[**Telephone/Fax (1) 59**]
.
You should see your PCP [**Last Name (NamePattern4) **] 2 days to have your INR checked.
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2102-9-15**] 3:00
Completed by:[**2102-7-5**]
|
[
"412",
"427.31",
"584.9",
"250.00",
"427.81",
"V58.61",
"428.0",
"403.91",
"272.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"38.93",
"99.61",
"37.78",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
7931, 8002
|
4765, 6404
|
319, 341
|
8194, 8247
|
3073, 4742
|
8864, 9291
|
1645, 1698
|
6695, 7908
|
8023, 8173
|
6430, 6672
|
8271, 8841
|
1713, 3054
|
272, 281
|
369, 1198
|
1220, 1457
|
1473, 1629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,511
| 192,668
|
16208
|
Discharge summary
|
report
|
Admission Date: [**2101-1-18**] Discharge Date: [**2101-1-22**]
Date of Birth: [**2052-8-7**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 48-year-old
gentleman who presented in [**2100-10-1**] with right arm
numbness. On a subsequent workup, a left MCA stroke was
diagnosed. In the ensuing workup he was found to have no
carotid artery disease; however, a transesophageal
echocardiograph revealed left atrial myxoma. He was referred
for evaluation with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. CVA in [**2100-10-1**], as described above. He denied
any residual symptoms.
2. Hypertension.
3. Status post tonsillectomy in [**2067**].
4. Denied any history of diabetes or coronary artery
disease.
MEDICATIONS ON ADMISSION: Aspirin, discontinued one week
prior to admission.
ALLERGIES: Peanuts cause throat swelling. The patient has
no known drug allergies.
FAMILY HISTORY: The mother died of cancer, unspecified, at
age 83. The patient's father passed away at age 82 of
Alzheimer's disease.
SOCIAL HISTORY: Mr. [**Known lastname 28212**] works as a receiver. He is
single. He had a 40 pack year tobacco history which he quit
in [**2100-10-1**]. He stopped drinking alcohol in [**2082**].
REVIEW OF SYMPTOMS: Neurologic review of symptoms is
negative. He does, however, describe some difficulty with
his penmanship. Otherwise, he has no complaints or signs or
symptoms of neurologic deficit.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 75,
blood pressure symmetric in both arms, 130s/80s. General:
This is a well appearing, well-nourished, well-dressed
gentleman consistent with his stated age. Skin: Without
rashes or jaundice. HEENT: The extraocular muscles were
intact. He has no icterus. No oropharynx lesions. No
cervical adenopathy. Neck: Supple without carotid bruits.
Chest: Clear to auscultation bilaterally. Heart: Regular
without murmur. Abdomen: Soft, nontender, nondistended
without organomegaly. Extremities: Warm without edema. He
has no evidence of lower extremity varicosities.
Neurological: A careful neurological examination was
performed in which cranial nerves II through XII were intact.
The only exception to this is a slight deviation of the
tongue to the right. Pulses: He has 2+ femoral pulses
bilaterally without bruits. He has 1+ DP, 1+ PT, and 2+
radial pulses.
HO[**Last Name (STitle) **] COURSE: Mr. [**Known lastname 28212**] was admitted to the [**Hospital6 1760**] on [**2101-1-17**]. On the date of
admission, he underwent a left atrial myxoma removal, with a
patch repair of the resulting atrial septal defect. The
procedure was performed by Dr. [**Last Name (Prefixes) **] and assisted by
Dr. [**Last Name (STitle) 21815**] and Dr. [**Last Name (STitle) 7625**].
The procedure was performed with a bypass time of 114 minutes
and a cross-clamp time of 76 minutes. The procedure was
performed without complication. Please see the previously
dictated operative not for more details.
At the termination of the procedure, Mr. [**Known lastname 28212**] was
transported intubated to the Cardiac Surgery Recovery Unit.
Mr. [**Known lastname 28212**] did well in his postoperative course and was
extubated on the day of the operation. He required only
minimal perioperative pressor support and was able to be
discharged to the Patient Care floor on postoperative day
number one.
One issue that did arise was that Mr. [**Known lastname 46249**] oxygenation
was somewhat decreased and did not respond very well to
oxygen therapy. A chest x-ray revealed a left lower lobe
infiltrate. This occurred in the setting of an elevated
white count. The diagnosis of pneumonia was made and he was
begun on a seven day course of levofloxacin.
Mr. [**Known lastname 28212**] [**Last Name (Titles) 27836**] well with physical therapy. He was
able to clear level V ambulation without difficulty. By
postoperative day number three, his oxygenation was still
somewhat a issue and a repeat chest x-ray was obtained. At
this point, a large effusion had gathered on the left side.
A flexible Cook catheter was introduced in the left pleural
space and left to suction overnight. His left pleural cavity
drained 1,500 cc of serosanguinous fluid consistent with a
pleural effusion.
A follow-up x-ray on the following morning revealed the
drained effusion and a well-inflated lung. The catheter was
removed without incident.
PHYSICAL EXAMINATION ON DISCHARGE: This a well-appearing
gentleman who is very comfortable. Vital signs: Temperature
99.4, pulse 75, blood pressure 113/62, breathing 20 breaths
per minute, and saturating 92% on room air. General: He was
alert and oriented times three. Lungs: Clear to
auscultation bilaterally with slightly diminished sounds at
the left base. Heart: Regular. His incision was well
healed without any evidence of erythema or exudate. Abdomen:
Soft, nontender, nondistended. Extremities: The lower
extremities are without any evidence of edema.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Status post removal of left atrium
myxoma.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 411**] in four weeks.
The patient should follow-up with his cardiologist, Dr.
[**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**], at the [**Hospital1 **] Heart Center. He should
follow-up within the next week.
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg p.o. q.d. to complete the seven day
course.
2. Lopressor 12.5 mg p.o. b.i.d.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2101-1-22**] 12:20
T: [**2101-1-22**] 12:45
JOB#: [**Job Number 27031**]
|
[
"E878.8",
"997.3",
"511.9",
"285.9",
"486",
"212.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.91",
"35.51",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
989, 1109
|
5543, 5906
|
5140, 5520
|
834, 972
|
4546, 5084
|
1554, 4531
|
598, 807
|
1126, 1539
|
5109, 5118
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,527
| 115,562
|
36736
|
Discharge summary
|
report
|
Admission Date: [**2144-6-28**] Discharge Date: [**2144-7-2**]
Date of Birth: [**2060-9-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Cardiac tamponade
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
Ms. [**Known lastname 83057**] is an 83 yo female with IDDM, HTN, dyslipidemia and
h/o lung cancer s/p XRT and RLL resection who was taken to an
OSH by her family for increased SOB and found to be hypotensive
with a large pericardial effusion and RUL opacity on CT. She was
transferred to [**Hospital1 18**] for further workup and management of the
pericardial effusion.
.
Per family, she has had progressive SOB over the past month. At
baseline, she is a "couch potato" and does not leave the house
or exert herself much, but on the morning of admission stayed in
bed due to fatigue and told her family that she wanted to be
taken to the hospital. She has had a cough for several weeks,
which has sounded wet but not been productive of sputum or
blood. She has been clammy but the family denies F/C, N/V. She
has had decreased appetite but no weight loss.
.
On further review of systems, the family denies any prior
history of MI, syncope, stroke or TIA. Her husband does note
black stools recently, but in the setting of iron pills. She is
incontinent of urine at baseline. She is also occasionally
lightheaded at home.
.
At the OSH, she had negative LENIs and no PE on CTA. She was
started on ceftriaxone and azithromycin for ? RUL PNA.
.
In our ED, initial vitals were T 97.3, HR 103, BP 111/67, POs
100%. She was given 1.5L fluid, ondansetron, albuterol and
ipratroprium nebulizers. Bedside U/S showed a large effusion
with RV collapse and tamponade physiology. Pulsus paradoxus was
30-40. She was taken to the cath lab for pericardiocentesis.
.
In the cath lab, she was initially hypotensive. An arterial
groin line and venous groin line were place along with swan-ganz
catheter. Initial PCWP was 30mmHg. Pericardicentesis showed
initial pericardial pressure 30mmHg. 600cc of bloody fluid were
drained and the pericardial pressure decreased to zero. PCWP
post-procedure declined to 20mmHg. She was intubated due to
increased agitation and progression of her acidosis which was
thought to represent lactic acidosis. She received 2g zosyn in
the cath lab.
.
On arrival to the unit, she was sedated and intubated, with
stable blood pressures of SBP 130s.
Past Medical History:
CARDIAC RISK FACTORS: IDDM, Hypertension, Dyslipidemia
No past cardiac history
OTHER PAST MEDICAL HISTORY:
-h/o lung cancer (patient declined treatment upon diagnosis)
-Depression (no current meds)
-Parkinson's Disease with dementia
-hypothyroidism
-Anxiety
-s/p shoulder fracture [**2138**]
-s/p arm fracture [**2139**]
.
Social History:
Worked in a light bulb soldering and packaging factory for many
years.
-Tobacco history: Heavy smoker, quit [**2134**].
-ETOH: Family denies.
Family History:
No family history of lung cancer
Physical Exam:
VS: T= 97.1 BP= 139/76 HR= 94 RR= O2 sat= 100% on 40% FiO2
GENERAL: Sedated, Intubated.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink.
NECK: Exam limited by large neck. JVD could not be appreciated.
CARDIAC: Exam limited by continuous rhonchi and soft heart
sounds but RRR appreciated. No thrill was appreciated.
LUNGS: Resp appear unlabored on vent, no visible accessory
muscle use. Diffuse, loud rhonchi and wheezes throughout. No
crackles appreciated on left lat decubitus exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abd bruits. +BS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+
Left: Carotid 2+ Femoral 2+ DP 1+
Pertinent Results:
[**2144-6-28**] 06:05PM
8.4
10.8>----< 509
26.8
NEUTS-89.6* LYMPHS-6.1* MONOS-3.8 EOS-0.4 BASOS-0.2
PT-16.8* PTT-28.8 INR(PT)-1.5*
141 / 108 / 66
--------------
5.2 / 18 / 1.4
ANION GAP-20
CALCIUM-9.6 MAGNESIUM-2.9*
LACTATE-2.0
URINE RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0
BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15
BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD
ABG: PO2-247* PCO2-38 PH-7.34* TOTAL CO2-21 BASE XS--4
TSH-1.5
%HbA1c-7.7*
Brief Hospital Course:
1. Cardiac tamponade-
On arrival, the patient was noted to have a large pericardial
effusion on bedside echo. She underwent pericardiocentesis in
the cath lab, with 600 cc bloody fluid drained, resulting in
normalization of systemic and pulmonary wedge pressures. Fluid
was sent for chemical and cytological analysis, and showed no
malignant cells. However, etiology of pericardial effusion is
most likely malignant, as patient has lung cancer diagnosed over
1 year ago for which she preferred no treatment. She remained
hemodynamically stable throughout course. Home BP meds (ACE)
were held for borderline blood pressures. A repeat echo on [**6-30**]
showed no evidence of pericardial fluid reaccumulation, with
normal RV chamber size and wall motion. LVEF was >75%.
2. RUL PNA-
CXR at admission showed right upper lobe pneumonia, likely
post-obstructive due to right upper lobe mass, and small right
pleural effusion. WBC was 12.5 at admission. The patient was
started on Levo/Flagyl for a 10 day course which will be
completed on [**7-7**]. Blood cultures were pending, sputum cultures
showed rare yeast and urine Legionella antigen was negative.
Patient remained afebrile throughout course and WBC trended down
to normal range. She was initially intubated
post-pericardiocentesis for agitation and increasing anion gap
metabolic acidosis, thought to be lactic acidosis. She was
successfully extubated, but continued to require high flow
oxygen and nebs prn. Family and patient were consulted regarding
possible pulmonary intervention (bronchoscopy +/- stenting) but
they declined in favor of non-invasive care moving towards
palliative care.
3. R pleural effusion-
Etiology may be malignant or infectious. Unlikely to be cardiac
etiology since echo showed normal EF and effusion was
right-sided only. Therefore, diuretics would likely not be
helpful, and were held in light of tenuous blood pressure.
4. UTI-
Urinalysis on admission showed 21-50 WBCs and moderate bacteria.
Patient was already on Levofloxacin for [**Last Name (LF) **], [**First Name3 (LF) **] no additional
antibiotics were started. Urine culture was negative.
5. Respiratory distress-
Patient was extubated successfully but required high Fi02 face
mask and nebs prn. Likely due to underlying COPD and lung
pathology, as well as post-obstructive PNA. Will continue to
oxygenate as needed and complete course of Levo/Flagyl as above.
6. Acid/base disturbance-
ABG post cath showed pH 7.26, down from 7.34 in ED with a
lactate of 1.3 and normal PCO2. Given hypotension in the setting
of cardiac tamponade, this likely reflected lactic acidosis
along with respiratory alkalosis in the setting of respiratory
distress. Acid-base status improved as vent settings were
adjusted accordingly. Her most recent ABG was from [**6-29**]- pH 7.34
CO2 41 O2 87.
7. CAD/HL-
No prior history of CAD and no CP during this episode. Cardiac
enzymes negative for ACS. Off simvastatin given comfort focus
of care.
8. Presumed ARF-
Baseline Cre unknown but was 1.4 at admission. A component of
prerenal ARF was likely given hypotension in setting of
tamponade. Creatinine trended down to 0.8 by discharge.
9.DM-2: Home basal lantus dose was continued with SSI coverage.
10. Speech/swallow- Patient is approved for thin liquids and
crushed or whole medications as tolerated.
Medications on Admission:
Lisinopril 20 mg PO daily
Carbidopa/Levodopa 25/100 mg PO qid
Vitamin B12 SR 1,000 mcg PO daily
Hydroxyzine 25 mg/mL IM syringe qhs
Lantus 45U SC daily at supper
Regular Insulin 20U SC daily at noon
Simvastatin 40mg daily
Synthroid 88mcg daily qam
Ferrous sulfate PO daily
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze, cough, SOB.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days.
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 6 days.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Solution Sig: SLIDING SCALE
Subcutaneous QACHS: see attached SLIDING SCALE.
17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Tablet, Rapid Dissolve(s)
18. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for nausea.
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5682**] Rehab & Nursing Center
Discharge Diagnosis:
Primary diagnosis: Pericardial tamponade
.
Secondary diagnoses:
- Primary lung cancer
- Pneumonia
- Pleural effusion
- Anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing. You were found to have a build-up of
fluid around your heart, so this fluid was drained. You also
had pneumonia which was treated with antibiotics, and fluid in
your lungs. All of these problems were most likely caused by
the cancer in your lungs.
.
You were started on two antibiotics, Levofloxacin and Flagyl.
You should keep taking these antibiotics for 6 more days. You
were also started on some medications to make you more
comfortable, including percocet for pain, Zofran and Phenergan
to help with nausea, trazodone to help you sleep and ipratropium
and albuterol to help with your breathing. You can keep taking
these medications as needed to make you more comfortable. We
stopped your lisinopril because your blood pressure has been
low, and stopped your simvastatin because it is no longer
necessary. We lowered your dose of Lantus insulin to 40 Units
because you are not eating as much. You should keep taking
carbidopa/levodopa, synthroid, Iron and Vitamin B12 because they
will help you feel better.
.
You are being discharged to a nursing facility.
Followup Instructions:
Please follow-up your primary care physician in about two weeks.
You can contact his office Dr. [**Last Name (STitle) 75078**] [**0-0-**]
Completed by:[**2144-7-2**]
|
[
"458.29",
"423.3",
"162.5",
"250.00",
"244.9",
"272.4",
"300.4",
"401.9",
"486",
"V15.82",
"599.0",
"V64.2",
"331.82",
"511.9",
"518.82",
"584.9",
"496",
"276.4",
"V58.67",
"294.10",
"V66.7",
"420.90",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.21",
"37.0",
"38.91",
"89.64",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9904, 9973
|
4345, 7681
|
331, 352
|
10143, 10152
|
3850, 4322
|
11352, 11521
|
3062, 3096
|
8004, 9881
|
9994, 9994
|
7707, 7981
|
10176, 11329
|
3111, 3831
|
10058, 10122
|
274, 293
|
380, 2540
|
10013, 10037
|
2670, 2887
|
2903, 3046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,212
| 165,765
|
13445
|
Discharge summary
|
report
|
Admission Date: [**2160-3-24**] Discharge Date: [**2160-4-3**]
Date of Birth: [**2087-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR/ replacement asc. and hemi-arch aorta ( 25 mm [**Company 1543**]
Mosaic porcine valve/ 26mm Gelweave graft) [**2160-3-25**]
History of Present Illness:
73 yo male with known AS and A fib with increasing DOE. Treated
for URI with zithromax in late [**Month (only) **]/[**Month (only) 958**]. Now referred for
surgical repair.
Past Medical History:
AS
ascending aortic aneurysm
CHF
Afib
recent URI
prostate CA with prostatectomy
colon polypectomy
chronic bronchitis
hydocelectomy at age 13
basal cell skin Ca
Social History:
lives with wife
retired insurance business
[**Company **]. tobacco use for 4 years
2 glasses wine/night
Family History:
no premature CAD
Physical Exam:
68" 71.2 kg 98% RA sat.
NAD, no rashes or lesions
PERRL/EOMI, anicteric
neck with no LA/TM , radiated murmur to carotids
CTAB anteriorly
irregularly irregular, S1 S2 with 4/6 blowing murmur
soft, NT, ND, + BS no HSM
warm, well-perfused, no edema or varicosities
neuro non-focal exam
Pertinent Results:
[**2160-3-28**] 01:26AM BLOOD WBC-11.1* RBC-2.75* Hgb-9.1* Hct-25.0*
MCV-91 MCH-33.1* MCHC-36.4* RDW-15.3 Plt Ct-87*
[**2160-3-28**] 01:26AM BLOOD PT-12.7 PTT-27.0 INR(PT)-1.1
[**2160-3-28**] 01:26AM BLOOD Plt Ct-87*
[**2160-3-28**] 01:26AM BLOOD Glucose-135* UreaN-17 Creat-0.9 Na-136
K-4.0 Cl-103 HCO3-24 AnGap-13
[**2160-3-28**] 01:26AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.6
Cardiology Report ECHO Study Date of [**2160-3-25**]
Findings:
LEFT ATRIUM: Normal LA size. Mild spontaneous echo contrast in
the body of the
LA. Moderate to severe spontaneous echo contrast in the LAA.
Depressed LAA
emptying velocity (<0.2m/s) Cannot exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Mildly
depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall
hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic
root. Moderately dilated ascending aorta. Focal calcifications
in ascending
aorta. Normal aortic arch diameter. Focal calcifications in
aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve
leaflets. Severe AS (AoVA <0.8cm2). Trace AR. Eccentric AR jet.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. No MS. Mild to moderate ([**11-27**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The rhythm appears to be atrial fibrillation. Results
were
Conclusions for
post-bypass data The post-bypass study was performed while the
patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions:
PRE-BYPASS:
1. The left atrium is normal in size. Mild spontaneous echo
contrast is seen
in the body of the left atrium.
2. Moderate to severe spontaneous echo contrast is present in
the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s).
A left atrial appendage thrombus cannot be excluded. No atrial
septal defect
is seen by 2D or color Doppler.
3. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function
is mildly depressed.
4. The right ventricular cavity is mildly dilated. There is mild
global right
ventricular free wall hypokinesis.
5. There are simple atheroma in the aortic root. The ascending
aorta is
moderately dilated. There are focal calcifications in the aortic
arch. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the
descending thoracic aorta.
6. The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2).
Trace aortic regurgitation is seen. The aortic regurgitation jet
is eccentric.
7. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-27**]+)
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive
infusions including epinephrine and phenylephrine.
1. A well-seated bioprosthetic valve is seen in the aortic
position with
normal leaflet motion and gradients (mean gradient = 7 mmHg). No
aortic
regurgitation is seen.
2. LV function is slightly improved, RV function is unchanged.
3. A ascending aorta graft is seen.
4. Other finding are unchanged
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2160-3-27**] 10:41.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 40774**])
Brief Hospital Course:
Admitted [**3-24**] off coumadin and underwent AVR /replacement of
ascending and hemi-arch aorta with Dr. [**Last Name (STitle) 1290**] on [**3-25**].
Transferred to the CSRU in stable condition on titrated
epinephrine and propofol drips. Extubated on POD #2 after
bronchoscopy was done for thickened secretions. The
bronchoscopy noted tracheal malacia. Beta blockade, aspirin and
a statin were resumed. On postoperative day three, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. He developed
atrial fibrillation which was treated with diltiazem and an
increase in his beta blockade. As he had chronic atrial
fibrillation, heparin in transition to coumadin was started for
longterm anticoagulation. The opthalmology service was consulted
for an injected left eye. He was placed on tobradex for five
days for conjuctivitis. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. By post-operative day ten he was ready for discharge
to home in good condition with coumadin follow-up.
Medications on Admission:
coumadin 10 mg daily ( stopped prior to admission)
lasix 20 mg daily
toprol XL 75 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
8. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 5
days: please take 10mg of coumadin daily until instructed
differently by Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
10. Outpatient Lab Work
Please check INR on Friday [**4-4**] and call results to the office
of Dr. [**Last Name (STitle) **] at ([**2160**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p AVR/ asc. and hemi-arch aortic replacement
AS
A fib
CHF
chronic bronchitis
prostate Ca s/p prostatectomy)
colon polyp ( removed during prior colonoscopy)
hydrocelectomy at age 13
skin Ca
tracheal malacia
Discharge Condition:
good
Discharge Instructions:
may shopwer over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) **] [**Name (STitle) 766**] [**4-7**] ([**2160**].
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2160-4-3**]
|
[
"V10.46",
"428.0",
"427.31",
"441.2",
"519.19",
"372.30",
"998.2",
"V10.83",
"V12.72",
"746.4",
"491.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"33.23",
"89.60",
"99.04",
"39.32",
"38.45",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7994, 8052
|
5290, 6395
|
324, 454
|
8304, 8311
|
1315, 5194
|
8572, 8761
|
977, 995
|
6537, 7971
|
8073, 8283
|
6421, 6514
|
8335, 8549
|
1010, 1296
|
281, 286
|
482, 656
|
5229, 5267
|
678, 840
|
856, 961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,045
| 113,067
|
22015
|
Discharge summary
|
report
|
Admission Date: [**2164-9-20**] Discharge Date: [**2164-10-9**]
Date of Birth: [**2089-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
recurrent V-tach
Major Surgical or Invasive Procedure:
VT ablation including cold tip
cardiac catherization
Pericardial window with placement of intrapericardial catheter
Intubation
History of Present Illness:
75 yo man with h/o 2V CAD (occluded RCA and LCx), CHF (EF 20%)
and an ICD placed in [**2157**] for inducible VT, HTn, high
cholesterol, COPD who presented with recurrent V-tach. Pt was
admitted to [**Hospital 1514**] Hospital on [**2164-9-10**] for an episiode of ICD
firing and subsequently transfered to CMC on [**2164-9-12**] where his
ICD was upgraded to a biventricular device and PT underwent a VT
ablation. Unfortunately VT ablation was unsuccesful.
Furthermore Pt's LV required revision on [**2164-9-17**] secondary to
central line placement. Pt continued to have runs of slow
V-tach and multiple ICD firings after unsuccessful ATP. Pt
experienced all of this even while on lidocaine, amiodarone and
quinidine. Pt transfered to [**Hospital1 18**] CCU after failed VT ablation
for closer monitoring. Upon presentation Pt with some shortness
of breath contributable to mild CHF, otherwise hemodynamically
stable.
Past Medical History:
CAD (occluded RCA and LCx)
CHF (EF 20%)
s/p ICD
AS
HTn
Hypercholesterolemia
GERD
COPD
Anxiety
Macular degeneration
Social History:
Former tobacco smoker (quit [**2150**]) and rare alcohol. Lives with
his wife. Retired technical writer and editor.
Family History:
NC
Physical Exam:
VS: Afebrile, paced at 80, BP 122/55, rr 14 98% RA
PE:
Awake, alert, NAD
Anicteric, blind, MMM, OP wnl
supple, JVP 8-10 cm
RRR, nl S1/S2, [**1-6**] SM heard best at apex
CTAB
abd soft, NT, ND, NABS, no HSM
ext without edema, 2+ DPs bilat, thrombophlebitis right hand,
femoral arteriol/venous sheath in place without hematoma
A&O
Pertinent Results:
[**2164-9-20**] 07:00PM BLOOD WBC-11.9* RBC-3.15* Hgb-10.8* Hct-31.2*
MCV-99* MCH-34.3* MCHC-34.6 RDW-13.5 Plt Ct-174
[**2164-9-23**] 05:50AM BLOOD WBC-11.9* RBC-3.18* Hgb-10.8* Hct-32.0*
MCV-101* MCH-34.0* MCHC-33.8 RDW-14.0 Plt Ct-169
[**2164-9-27**] 05:58AM BLOOD WBC-11.6* RBC-3.02* Hgb-10.6* Hct-30.0*
MCV-99* MCH-35.2* MCHC-35.4* RDW-13.8 Plt Ct-191
[**2164-10-1**] 05:03PM BLOOD WBC-9.1 RBC-3.17* Hgb-10.7* Hct-32.0*
MCV-101* MCH-33.8* MCHC-33.5 RDW-13.8 Plt Ct-258
[**2164-10-4**] 05:56AM BLOOD WBC-9.0 RBC-2.95* Hgb-9.6* Hct-29.1*
MCV-99* MCH-32.5* MCHC-33.0 RDW-14.5 Plt Ct-245
[**2164-10-7**] 06:55AM BLOOD WBC-9.5 RBC-3.03* Hgb-10.0* Hct-30.0*
MCV-99* MCH-33.1* MCHC-33.5 RDW-14.8 Plt Ct-237
[**2164-9-20**] 07:00PM BLOOD PT-15.5* PTT-108.8* INR(PT)-1.5
[**2164-9-20**] 07:00PM BLOOD Plt Ct-174
[**2164-9-28**] 04:36AM BLOOD PT-14.1* PTT-31.1 INR(PT)-1.3
[**2164-9-30**] 01:02AM BLOOD Plt Ct-242
[**2164-10-2**] 04:53AM BLOOD Plt Ct-252
[**2164-10-7**] 06:55AM BLOOD Plt Ct-237
[**2164-9-20**] 07:00PM BLOOD Glucose-133* UreaN-26* Creat-1.1 Na-143
K-3.5 Cl-105 HCO3-28 AnGap-14
[**2164-9-22**] 05:22AM BLOOD Glucose-101 UreaN-26* Creat-1.2 Na-144
K-4.3 Cl-106 HCO3-29 AnGap-13
[**2164-9-24**] 06:01AM BLOOD Glucose-114* UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2164-9-28**] 04:36AM BLOOD Glucose-122* UreaN-29* Creat-1.0 Na-142
K-3.9 Cl-106 HCO3-30* AnGap-10
[**2164-10-7**] 06:55AM BLOOD Glucose-123* UreaN-25* Creat-1.1 Na-138
K-4.0 Cl-104 HCO3-25 AnGap-13
[**2164-9-20**] 07:00PM BLOOD CK(CPK)-218*
[**2164-9-21**] 04:44AM BLOOD ALT-84* AST-113* LD(LDH)-309*
CK(CPK)-203* AlkPhos-97 TotBili-0.5
[**2164-9-20**] 07:00PM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-2.65*
[**2164-9-21**] 04:44AM BLOOD CK-MB-20* MB Indx-9.9* cTropnT-3.66*
[**2164-10-1**] 05:03PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2164-9-23**] 05:50AM BLOOD ALT-104* AST-88* LD(LDH)-339* AlkPhos-109
TotBili-0.6
[**2164-9-25**] 05:30AM BLOOD ALT-104* AST-112* LD(LDH)-288*
AlkPhos-100 TotBili-0.5
[**2164-9-25**] 02:43PM BLOOD ALT-126* AST-129* LD(LDH)-334*
AlkPhos-105 TotBili-0.7
[**2164-9-30**] 01:02AM BLOOD ALT-147* AST-98* AlkPhos-124* TotBili-0.7
[**2164-9-30**] 08:45AM BLOOD ALT-145* AST-95* AlkPhos-123* TotBili-0.8
[**2164-9-28**] 11:19PM BLOOD Mg-2.0
[**2164-9-29**] 06:17AM BLOOD Calcium-8.2* Mg-1.9
[**2164-10-6**] 06:40AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
[**2164-10-7**] 06:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.9
[**2164-9-23**] 05:50AM BLOOD VitB12-438 Folate-10.3
[**2164-9-25**] 02:43PM BLOOD TSH-1.7
[**2164-9-25**] 02:43PM BLOOD Free T4-1.8*
[**2164-10-4**] 09:03AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-460
PEEP-5 O2-40 pO2-127* pCO2-42 pH-7.41 calHCO3-28 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU
[**2164-10-1**] 05:01PM BLOOD Lactate-4.2*
[**9-22**] SUPINE AP PORTABLE CHEST: The tip of the right internal
jugular line ends just below the level of the right clavicular
head. A 3-lead pacemaker is present. The heart is enlarged, and
the aorta is tortuous. There is increased pulmonary vascularity
with indistinctness of the vascular margins and peribronchial
cuffing, compatible with congestive heart failure. No pleural
effusion is detected. The lateral portions of the right lung,
including the right lateral costophrenic angle, are excluded
from examination.
IMPRESSION: Congestive heart failure.
[**9-24**] Echo Conclusions:
1. The left atrium is dilated.
2. The left ventricular cavity is dilated. Overall left
ventricular systolic
function is severely depressed.
3. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation
is seen.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5. There is no pericardial effusion. There are no
echocardiographic signs of
tamponade.
Cath:
1. Selective coronary angiography demonstrated a right dominant
circulation with two vessel coronary artery disease. LMCA had
no
angiographically apparent CAD. LAD had mild diffuse
irregularites. LCX
was totally occluded after small OM1. Large OM2 filled via left
to left
collaterals. RCA was known to be occluded and therefore not
selectly
engaged. Distal RCA filled via left to right collateralls.
2. Limited resting hemodynamics showed normal blood pressure.
FINAL DIAGNOSIS:
1. Severe two vessel coronary artery disease.
Brief Hospital Course:
75 yo male w/ 2VD (occluded RCA, LCx), severely depressed EF,
s/p ICD placement for VT in 98' admitted to an OSH for frequent
ICD firing for VT and transferred after failed VT ablation.
1) V-Tach: Pt with a complicated history with an ICD placed in
[**2157**] for inducible V-tach who originally presented to OSH for
ICD firing; course there significant for upgrading his ICD to a
[**Hospital1 **]-ventricular device, an unsuccessful VT ablation and courses
of lidoncaine, amiodarone and quinidine. Pt transferred to
[**Hospital1 18**] for further EP evaluation. Initial study significant for
probable scar in posterobaslal region of LV, initiation of VT
after spontaneous VPDs and after failed attempt of pace
termination the VT degenerated into VF requiring DCCV, lastly an
ablation was undertook through the posterobasal scar. Pt with
continued runs of V-tach after ablation. Pt maintained on
lidocaine drip for antiarrthymic therapy. Pt continued to
suffer from persistent runs of VT (many of the slow variety) of
different morphology with ATP mostly ineffective; a few of which
resulting in ICD firing. Mexelitine increased and lidocaine
weaned to off and plan for epicardial ablation. Unfortunately,
Pt with increased slow VT and a episode of sustained monomorphic
VT with ICD firing requiring lidocaine gtt to be restarted and
mexilitine held. Pt underwent epicardial ablation without
difficulty, yet once again was unsuccessful as Pt continued to
suffer from episodes of ventricular ectopy most likely secondary
to an intramural VT. Pacer parameters were changed to DDI 90
with AV delay of 250 with hopes that the increased rate would
suppress VT. Lidocaine was continued and mexilitine held. Yet
again Pt with continued episodes of VTach. Hospital course then
complicated by acute agitation and confusion secondary to
lidocaine gtt (see details below). Lidocaine thus weaned to off
and mexilitine and amiodarone restarted. Pt again to EP lab for
NIPS, interrogation and attempted overpacing. As before Pt with
recurrent episodes Vtach after reprogramming. Given
unsuccesfull history after multiple ablations and pacer
re-programming decision made to proceed to cold tip ablation and
cardiac catherization to r/o ischemia as nidus for VT.
Procedure without complication and tolerated well by Pt who
returned to DDI 90 with BiV pacing. [**Name (NI) 57398**] Pt without
further episodes of VTach or ICD firing. Pt transferred from
CCU to floor and maintained on amiodarone 400mg daily and
mexiletine 150mg q6hr. Pt to be discharged home on both of
these medications at stated doses. Pt should follow up with Dr
[**Last Name (STitle) 23246**] closely upon discharge.
2) CAD: Pt with known 2V CAD (RCA and LCx)and negative MIBI
([**5-4**]) who is medically managed. On presentation, Pt with
positive cardiac enzymes without ECG changes most likely
representating damage from recurrent VT and ICD firing however
NSTEMI still a possibility. Pt clinically stable during
hospital stay without obvious evidence of acute ishcemia. Pt
maintained on ASA, Lipitor and Coreg, with Lisinopril being
started. Given Pt's refractory VT after several ablations and
medical management, it was felt appropriate to undergo a cardiac
catherization to rule out reversible ischemia as a contributing
factor to his ventricular ectopy. Results of which showed
severe 2V CAD without evidence of reversible lesions. Pt to be
managed with BB, ASA, statin, aldactone, ACEi. AS Pt stabilizes
as an outpatient, up titration of the beta-blocker and ACEi
might be necessary.
3) CHF: Pt with ischemic cardiomyopathy and EF ~20% who on
presentation was volume overloaded with evidence of slight CHF
requiring additional lasix for diuresis. Pt improved clinically
and was maintained on BB, ACEi, Aldactone, Lasix. Volume status
was assesed daily and at times requiring lasix and other days
euvolemic. During hospital course, Pt pacer was changed so that
LV pacing was stopped. This along with volume overload the
night before Pt experienced episode of flash pulmonary edema.
Pt given Lasix 80 IV times two with good diuresis however Pt
with continued difficulty breathing. Given his increased work
and signs of tiring, respiratory therapy summoned to bedside and
Pt began on non-invasive continous positive pressure
ventilation. Pt did quite well and after several hours was
slowly weaned from requiring pressure support to face mask and
to nasal canula by the morning. Echo obtained during course
showed worsening LV function and MR. For the remaining hospital
stay Pt stable without signs of CHF exacerbation. Discharge home
on LAsix 40 PO qd, lisinopril 2.5, aldactone 50.
4) MS change: While on Lidocaine gtt, Pt became increasingly
confused and agitated to the point where psychiatry was called
and Pt place in restraints for his own safety. Pt was given
Haldol with good result. Lidocaine gtt discontinued and Pt
slowly improved over the next few days. Pt given Haldol on a PRN
basis only with avoidance of ativan. By discharge Pt at or near
baseline, being alert and oriented with agitation.
5) Resp: Pt intubated for cold tip ablation and cardiac
catherization. Pt weaned the following morning and extubated
without difficulty.
6) Dysphagia: At the end of admission, Pt complaining of
dysphagia to solids. Pt underwent a speech and swallow
evaluation; through which Pt gave a prolonged history of early
satiety, weight loss and the feeling of food getting stuck.
Neurologically Pt was intact without lesion. Pt is in need of
GI workup for dysphagia which should be partaken soon after
discharged from rehab. Pt was instructed to make an appointment
with a gastroenterologist in his area per his PCP's
recommendation.
Medications on Admission:
Amiodarone 400 qAM and 200 qPM
Lanoxin 0.125 mg daily
Lasix 40 mg PO daily
Potassium 20 mEq daily
Hytrin 5 mg qHS
Mg 400mg daily
Coreg 25 mg [**Hospital1 **]
Lipitor 20mg qd
Nitro patche 0.4 mg qPM
Celexa 20 mg daily
Actonel 5 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD ().
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
().
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Mexiletine HCl 150 mg Capsule Sig: One (1) Capsule PO Q6HR
().
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
ventrial tachycardia
s/p ablation
CHF
CAD
ventrial tachycardia
s/p ablation
CHF
CAD
Discharge Condition:
good
Discharge Instructions:
please take all medications as prescribed.
please call PCP or return to ED if suffering from severe chest
pain, firing of ICD, syncope, shortness of breath, persistent
nausea or vomitting, inability to tolerate food or liquid,
significant weight loss or gain.
Followup Instructions:
please call and make a follow up appointment with cardiologist
Dr [**First Name4 (NamePattern1) 8797**] [**Last Name (NamePattern1) 23246**] [**Numeric Identifier 57618**]) one to two weeks after
discharge from rehab.
please call and make a follow up appointment with your PCP Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] one to two weeks after discharge.
you will need to follow up with a gastroenterologist of your
PCP's choosing in the next few weeks to evaluate your recent
weight loss, early satiety and dysphagia.
|
[
"787.2",
"414.01",
"369.4",
"458.29",
"281.9",
"496",
"427.1",
"412",
"416.8",
"V53.31",
"292.81",
"398.91",
"396.2",
"451.89",
"414.8",
"401.9",
"272.4",
"V53.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"88.56",
"37.12",
"93.90",
"37.26",
"37.22",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
13496, 13603
|
6405, 12154
|
331, 460
|
13732, 13738
|
2074, 6317
|
14047, 14604
|
1703, 1707
|
12440, 13473
|
13624, 13711
|
12180, 12417
|
6334, 6382
|
13762, 14024
|
1722, 2055
|
275, 293
|
488, 1414
|
1436, 1553
|
1569, 1687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,500
| 132,875
|
32297
|
Discharge summary
|
report
|
Admission Date: [**2163-11-9**] Discharge Date: [**2163-11-17**]
Date of Birth: [**2110-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung cancer.
Major Surgical or Invasive Procedure:
Bronchoscopy
Right Video-Assisted Thorascopy, right thoracotomy, right middle
lobe lobectomy, pleural flap, atrial repair
History of Present Illness:
The patient is a 53-year-old woman who has an endobronchial
right lower lobe tumor and hemoptysis. She has pulmonary
function tests which revealed
an FEV-1 which is 62% or predicted and a DLCO which is 65%
predicted. The rest of her staging workup assess for negative,
including mediastinoscopy.
Past Medical History:
Pulmonary nodules
Depression/anxiety
Hypertension
Spinal stenosis/chronic back pain
Social History:
Smoked 2 packs per day since age of 14, stopped 1.5 years ago,
for a total of 76 pack year history. No ETOH. No illicits.
Worked transporting lab specimens. On disability [**1-21**] shoulder
problems, depression. Originally from [**Country 1684**], moved to US 21
years ago.
Family History:
no FH of malignancy. Mother alive and well. Father died, was
heavy drinker.
Physical Exam:
General: 53 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Cardiac: regular, rate, rhythm, normal S1,S2, no murmur/gallop
or rub
Resp: decreased breath sounds on right with faint crackles [**12-23**]
up, left clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Ext: warm no edema
Incision: clean dry intact, no erythema
Neuro: non-focal
Pertinent Results:
[**2163-11-8**] WBC-5.9 RBC-4.62 Hgb-13.1 Hct-40.5 Plt Ct-505*
[**2163-11-15**] WBC-8.1 RBC-4.28 Hgb-12.4 Hct-36.6 Plt Ct-424
[**2163-11-8**] Glucose-93 UreaN-10 Creat-0.7 Na-142 K-4.5 Cl-102
HCO3-29
[**2163-11-16**] Glucose-113* UreaN-12 Creat-0.6 Na-141 K-3.9 Cl-96
HCO3-35*
Brief Hospital Course:
Mrs. [**Known lastname 75489**] was admitted on [**2163-11-9**] and underwent successful
flexible bronchoscopy, right thoracoscopy, right thoracotomy and
right middle lobe and right lower lobe
[**Hospital1 **]-lobectomy with mediastinal lymph node dissection, pleural
flap buttress and atrial repair. She was transferred to the
surgical intensive care unit with hypotension and responded well
to volume and pressors. She was started on beta-blockers and
her pain was control with an epidural and PCA managed by the
acute pain service. The anterior and posterior [**Doctor Last Name **] drains
remained on suction. On postoperative day #2 she was weaned off
the pressors remained hemodynamically stable. Her diet was
advanced as tolerated. On POD #3 she transferred to the floor.
Overnight she developed respiratory distress and was transferred
to the intensive care unit. A right upper lobe infiltrate and
right lower lobe collapse was seen on chest-x-ray. She was
started on IV antibiotics. Interventional pulmonary was
consulted and she underwent bronchoscopy and they removed thick
secretions in the right middle and left lower lobe. Her
respiratory status improved. On POD #5 she had a repeat
bronchoscopy which revealed a clean stump and minimal
secretions. She was transferred back to the floor and continued
to do well.
Her Epidural was removed and her pain was well controlled with a
PCA. On POD #6 the posterior [**Doctor Last Name **] was removed and the anterior
remained on suction. Her PCA was converted to PO pain
medication with good control. On POD #6 the anterior [**Doctor Last Name **] was
removed and no pneumothorax was seen on chest film. She was
tolerating her regular diet, her pain was well controlled and
she was discharged to home. She will follow-up with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Klonopin 1mg tid
Lisinopril 10mg once daily
Wellbutrin XL 150mg once daily
Zoloft 100mg once daily
Vicodin 1 tab qam & 3 tabs qhs
Tyenol as needed
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Klonopin 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Wellbutrin XL 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO qd: Dr.
[**Last Name (STitle) **] will stop this medication at your follow up
appointment.
Disp:*30 Tablet(s)* Refills:*1*
8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. Nystatin 100,000 unit/mL Suspension Sig: 5-10 mls PO four
times a day.
Disp:*1 bottle* Refills:*1*
10. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary nodules
Hypertension
Anxiety/Depression
Back pain/spinal stenosis
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased sputum production, cough or shortness of breath
-Chest pain
-Incision develops drainage or increased warmth or redness
Chest-tube site: remove dressing on Saturday and cover site with
a bandaid until healed
Should site begin to drain cover with a clean dressing changing
as needed to keep site clean and dry
You may shower on Saturday.
No driving while taking narcotics.
Take stool softners with narcotics.
Continue to walk frequently.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on on [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**]
Clinical Center [**Location (un) **] on [**12-1**] 2:30 with Dr. [**Last Name (STitle) **]
and 3pm with Dr. [**Last Name (STitle) **].
Report to the [**Hospital Ward Name **] clinical center [**Location (un) **] radiology 45
minutes before your appointment for a Chest X-Ray.
Follow-up with Dr. [**Last Name (STitle) 12593**] your PCP [**Telephone/Fax (1) 12597**]
Completed by:[**2163-11-22**]
|
[
"934.1",
"196.1",
"401.9",
"724.00",
"E915",
"244.1",
"162.8",
"458.29",
"786.3",
"V64.42",
"998.2",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.49",
"38.85",
"96.05",
"33.23",
"34.93",
"40.3",
"03.90",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
5120, 5126
|
2058, 3939
|
353, 477
|
5246, 5253
|
1757, 2035
|
5850, 6362
|
1219, 1296
|
4136, 5097
|
5147, 5225
|
3965, 4113
|
5277, 5827
|
1311, 1738
|
283, 315
|
505, 803
|
825, 910
|
926, 1203
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,706
| 108,890
|
29354
|
Discharge summary
|
report
|
Admission Date: [**2116-1-23**] Discharge Date: [**2116-2-7**]
Date of Birth: [**2047-11-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**1-24**]: Stereotactic 3rd ventriculostomy
[**1-31**]: Suboccipital craniotomy for mass resection
History of Present Illness:
68M with known posterior fossa mass was admitted s/p fall with
an increased of cerebellar density on CT. Pt denied any LOC,
headache, visual changes, new difficulties with speech or any
other motor or sensory loss. Pt did report a gradual increas in
difficulty walking forcing him to use a cane to walk. Pt
reports falling 2X. Pt has a laceration on the bridge of his
nose.
Past Medical History:
Stage III esophageal cancer
R eye prosthesis
HTN
DOE
BPH chronic foley
Diabetes
h/o trach/PEG in [**11/2113**]
h/o anemia in [**12/2113**]
s/p cholecystectomy
cognitive impairment s/p MVC
Social History:
Pt lives alone. Pt denies alcohol use. Pt has 80 pack-year
smoking history, quit 9-10 years ago.
Family History:
Remarkable for mother with diabetes and a brother with diabetes
and prostate cancer.
Physical Exam:
On Admission:
O: T: 97.6 BP: 137/68 HR: 66 R 16 O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Nasal bridge laceration
Pupils: 3mm R, 2.5 mm L, ->2 mm EOMs
Neck: C-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Mild confusion.
Orientation: Oriented to person, place, and date.
Language: Dysarthria. Answers inappropriate. Speech garbled at
times.
Cranial Nerves:
I: Not tested
II: Left pupils equally round and reactive to light, to
mm, left visual fields are full to confrontation. R eye loss of
vision, no accomodation
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice, not finger rub
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-14**] throughout. No pronator drift.
Spastic, unable to relax lower extremities for exam.
Sensation: Intact to light touch, temperature, and pinprick
bilaterally. Unable to relax LE for appropriate proprioception
exam
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ hypreflexive, triple flexes to babinski exam
Left 2+ 2+ 2+ hypreflexive, triple flexes to babinski exam
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger right, abnormal
finger-to-nose on left, normal rapid alternating movements and
heel to shin.
On Discharge:
XXXXXXXXXXXXXXX
Pertinent Results:
Labs on admission:
[**2116-1-23**] 07:50AM BLOOD WBC-4.8 RBC-4.37* Hgb-13.5* Hct-39.8*
MCV-91 MCH-30.8 MCHC-33.8 RDW-14.8 Plt Ct-159
[**2116-1-23**] 07:50AM BLOOD Neuts-81.8* Lymphs-12.1* Monos-4.5
Eos-1.2 Baso-0.4
[**2116-1-23**] 07:50AM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2*
[**2116-1-23**] 07:50AM BLOOD Glucose-105 UreaN-23* Creat-0.9 Na-143
K-4.2 Cl-103 HCO3-33* AnGap-11
[**2116-1-23**] 07:50AM BLOOD ALT-32 AST-18 LD(LDH)-160 AlkPhos-70
Amylase-21 TotBili-0.6
[**2116-1-23**] 07:50AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.1 Mg-1.8
Iron-61
[**2116-1-23**] 07:50AM BLOOD calTIBC-270 Ferritn-117 TRF-208
[**2116-1-30**] 05:59AM BLOOD %HbA1c-6.3*
Misc. Significant Lab studies:
[**2116-2-2**] 03:08AM BLOOD WBC-12.5* RBC-3.48* Hgb-11.2* Hct-31.8*
MCV-92 MCH-32.1* MCHC-35.1* RDW-15.2 Plt Ct-168
[**2116-2-3**] 12:29AM BLOOD WBC-20.2*# RBC-3.88* Hgb-12.9* Hct-35.4*
MCV-92 MCH-33.2* MCHC-36.3* RDW-14.9 Plt Ct-188
[**2116-2-4**] 05:14AM BLOOD WBC-43.6*# RBC-4.79 Hgb-15.4 Hct-44.7#
MCV-93 MCH-32.1* MCHC-34.4 RDW-14.9 Plt Ct-252
[**2116-2-4**] 11:30AM BLOOD WBC-32.4* RBC-4.61 Hgb-14.7 Hct-42.3
MCV-92 MCH-31.9 MCHC-34.9 RDW-15.1 Plt Ct-262
[**2116-1-23**] 07:50AM BLOOD Neuts-81.8* Lymphs-12.1* Monos-4.5
Eos-1.2 Baso-0.4
[**2116-2-4**] 11:30AM BLOOD Neuts-93.9* Lymphs-3.0* Monos-2.9 Eos-0
Baso-0.1
[**2116-2-3**] 12:29AM BLOOD PT-17.6* PTT-36.7* INR(PT)-1.6*
[**2116-2-3**] 12:29AM BLOOD Plt Ct-188
[**2116-2-4**] 03:20PM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2116-2-5**] 09:44AM BLOOD PT-27.2* PTT-44.2* INR(PT)-2.7*
[**2116-2-5**] 09:44AM BLOOD Glucose-75 UreaN-71* Creat-2.2*# Na-146*
K-5.7* Cl-112* HCO3-13* AnGap-27*
[**2116-2-4**] 05:14AM BLOOD Glucose-96 UreaN-45* Creat-1.0 Na-136
K-5.1 Cl-108 HCO3-16* AnGap-17
[**2116-1-23**] 07:50AM BLOOD ALT-32 AST-18 LD(LDH)-160 AlkPhos-70
Amylase-21 TotBili-0.6
[**2116-2-4**] 05:14AM BLOOD ALT-144* AST-171* LD(LDH)-536* AlkPhos-94
Amylase-43 TotBili-0.9
[**2116-2-5**] 01:20AM BLOOD CK(CPK)-559*
[**2116-2-5**] 09:44AM BLOOD ALT-183* AST-203* AlkPhos-160*
TotBili-1.2
[**2116-2-5**] 09:44AM BLOOD Albumin-2.7* Calcium-8.0* Phos-5.9*#
Mg-2.2
[**2116-2-4**] 05:14AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.8 Mg-1.9
[**2116-1-23**] 07:50AM BLOOD calTIBC-270 Ferritn-117 TRF-208
Labs on Discharge:
XXXXXXXXXXXXXXXXXXXXX
EKG [**1-24**]:
Sinus rhythm. Probable old septal myocardial infarction. Low QRS
limb lead
voltage. Otherwies, normal tracing. Compared to the previous
tracing of [**2115-12-25**] no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 152 86 [**Telephone/Fax (2) 70523**]
Imaging:
Head CT [**1-23**]:
IMPRESSION:
Interval increase in size of patient's known left cerebellar
hemorrhagic mass with surrounding vasogenic edema. Mass effect
and partial effacement of the fourth ventricle and left
posterior aspect of the perimesencephalic cistern with no
evidence of hydrocephalus. An MRI is recommended for further
evaluation.
Bilateral nasal ala and nasal septum fractures with adjacent
soft tissue
edema.
CT C-Spine [**1-23**]:
IMPRESSION:
1. Multilevel degenerative disc disease with no evidence of
acute fracture.
2. Soft tissue density adherent to the right tracheal wall which
may
represent mucus versus polyp. Further imaging on a non-emergent
basis may be obtained as deemed clinically necessary.
MRI Head [**1-24**]:
IMPRESSION:
1. Left cerebellar mass with hemorrhagic foci and surrounding
edema causing
effacement of the fourth ventricle and quadrigeminal cistern.
Differential
diagnosis includes lymphoma and metastatic disease.
2. Chronic right frontal lobe changes consistent with prior
history of trauma and contusion.
CTA Head [**1-25**]:
IMPRESSION:
1. Status post gastric pull-through for esophageal carcinoma,
with no
definite metastatic disease.
3. Stable 15-mm right hepatic lesion with suggestion of
peripheral
enhancement, and which may represent a hemangioma. This lesion
is stable from [**2114-12-13**].
3. New rib fractures involving the left sixth and right tensor
ribs, without definite underlying lytic lesion or associated
soft tissue mass. Correlation should be made to the patient's
trauma history. If there is no history of trauma, bone scan may
be beneficial to exclude osseous metastases.
4. T10 compression fracture, of indeterminate age but new since
[**2115-7-12**].
5. Sclerosis and cystic changes in the bilateral femoral heads,
which can be seen with avascular necrosis, particularly in
patients on steroid therapy.
6. Prostatic enlargement.
MRI Head [**2-3**](post-op):
IMPRESSION: Status post left occipital craniotomy. Resection of
the
previously demonstrated infiltrative mass lesion on the left
cerebellar
hemisphere. Residual pattern of enhancement in the surgical bed
with a
nodular area of enhancement as described above, measuring
approximately 19 x 9 mm in size possibly related with volume
averaging, persistent edema in the posterior fossa involving the
left cerebellar hemisphere. Unchanged
microvascular ischemic disease in the periventricular white
matter. Small
amount of intraventricular hemorrhage. Blood products identified
in the
surgical bed. Followup MRI is recommended to demonstrate any
further change or stability in the pattern of enhancement in the
surgical area.
Head CT [**2-3**]:
IMPRESSION:
1. Status post occipital craniotomy with surgical changes in the
craniotomy
bed and edema in the left cerebellar hemisphere, similar in
extent to MR done on [**2116-2-1**]. Similar degree of mass
effect on the fourth ventricle.
2. Trace intraventricular hemorrhage layering in the posterior
horns of the
lateral ventricles. No new intracranial hemorrhage.
3. Slightly increased size of the lateral ventricles.
Bilateral Knee images [**2-4**]:
IMPRESSION: No acute fracture detected on either side. Stable
medial tibial
plateau fracture on left, with marked medial compartment
narrowing on the
left.
RUQ Ultrasound [**2-5**]:
IMPRESSION: Limited study but with normal portal and hepatic
veins. Status
post cholecystectomy. No evidence of biliary dilatation.
Brief Hospital Course:
Pt was admitted on [**1-23**] s/p fall. He underwent MRI which
revealed progression of the previously seen lesion. As pt was
unable to urinate in the ED s/p mannitol, the urology was
[**Month/Year (2) 4221**] for foley placement. On [**1-24**], pt underwent a third
ventriculostomy without complications. Staging for esophageal
carcinoma was performed. No sites of metastasis were
identified. On [**1-25**], the pt was transferred to the stepdown
unit. On [**1-27**], [**Last Name (un) **] was [**Last Name (un) 4221**] for increased blood
glucose. CTA/V of the head was performed which demonstrated no
evidence of venous sinus thrombosis. On [**1-31**], he went to the OR
for suboccipital craniotomy for mass resection. Post operatively
he was transferred to the ICU for continued monitoring. On
[**2-1**], post-operative MRI was performed and he was subsequently
extubated. MRI revealed a gross total resection of the lesion.
He was moving all extremities purposefully, spontaneous eye
opening, with some bouts of agitation. On [**2-2**], his coagulation
studies were found to be slightly elevated. Hematology was
[**Month/Year (2) 4221**], and this was thought to be due to Vitamin K
deficiency, and he subsequently received 10mg of Vitamin K. On
[**2-3**], he was transferred to the neurosurgery floor. Repeat
speach and swallow study was perfomed, but due to agitation, and
complaince, they were not able to complete their examination.
On [**2-4**], he was much more awake, and following simple commands
consistently. However routine CBC evaluation revealed a white
blood count of 40, which had doubled in 24hrs. This was
repeated to ensure no error, and the repeat revelaed a WBC of
34. He was also found to have transamintis. Medicine and the ID
services were [**Month/Year (2) 4221**] to help determine the causation of the
elevated WBC and transaminitis. They recommended, multiple
laboratory studies, and ultrasound of the right upper quadrent
to evaluate hepatic blood flow. All work up were negative
including a stool specimen for C. diff.
On the evening of [**2-4**] and into the early morning of [**2-5**], Mr.
[**Known lastname 70518**] became much more tachycardic(EKG showing sinus tach), and
had low blood pressures(SBP 80-90). His peripheral IV
infiltrated and he had no access. The IV team tried repeatedly
to place a new line but were unsuccessful. Finally, his
Port-a-Cath was accessed and he was able to receive fluids
through that line. His heart rate temporarily decreased from 140
to 120s but that only lasted a short time. Medicine team was
again called, and it was collaboratively decided that his
present condition would be best monitored and treated further in
the ICU. At approximately 6am on [**2-5**] the patient was
transferred to the SICU.
The patient became progressively lethargic required intubation.
He subsequently suffered multi-organ failure including hepatic
failure, renal failure, and profound coaguloathy. He remained
hypotensive requiring aggressive fluid resuscitation. While his
blood pressure had subsequently stabilized, he subsequently
suffered ARDS with progressive worsening of his ventilation
status. Because of volume overload, he was started on CVVH for
ARF.
Given the progressive worsening of the patient's status despite
aggressive measures and the poor prognosis associated with
esophageal metastasis, the family decided to make the patient
CMO. The patient expired shortly thereafter.
Medications on Admission:
Amantidine
Citalopram 10 mg
Finasteride 5 mg
Lactulose 30 ml PRN
Lansoprazole 30 mg q day
Metformin 500 mg
Metoprolol XL 25 mg
Flomax 0.4 mg
Trazadone 50 mg QHS:PRN
Colace 100 mg [**Hospital1 **]
MVI
B12
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
Completed by:[**2116-2-7**]
|
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"790.4",
"V15.3",
"600.01",
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"293.0",
"331.4",
"038.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"01.59",
"96.04",
"93.59",
"02.12",
"02.2",
"54.98",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12776, 12785
|
9010, 12482
|
324, 426
|
12845, 12863
|
2971, 2976
|
12927, 12973
|
1176, 1262
|
12736, 12753
|
12806, 12824
|
12508, 12713
|
12887, 12904
|
1277, 1277
|
2934, 2952
|
280, 286
|
5221, 8987
|
454, 833
|
1779, 2920
|
2990, 5202
|
1569, 1763
|
855, 1044
|
1060, 1160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,932
| 185,061
|
38992
|
Discharge summary
|
report
|
Admission Date: [**2119-4-4**] Discharge Date: [**2119-4-7**]
Date of Birth: [**2048-4-10**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / Procainamide / Sotalol / Amiodarone
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Femoral central venous line placement.
Femoral arterial line placement.
History of Present Illness:
Mr. [**Known lastname 86497**] is a 70-year-old man with dyslipidemia,
hypertension, diabetes, overweight, coronary artery disease,
atrial fibrillation, COPD, presenting after cardiorespiratory
arrest at home.
.
Mr [**Known lastname 86497**] felt unwell yesterday, short of breath and out of
sorts. This resolved somewhat, but today he again became even
more short of breath before collapsing at home. His daughter was
at home with him and began chest compressions after calling 911.
AED pads were placed on him en route and it his rhythm was
shocked, purportedly while in VF, although we cannot confirm. He
then became asystolic, given epinephrine, atropine,
defibrillated again twice, given amiodarone and intubated in the
field. Went to [**Hospital3 **], by which time he was in sinus
rhythm with normal blood pressure. Significant labs from that
admission include D-dimer in 2400s. Cooling commenced and he was
transferred to [**Hospital1 18**] for further management.
.
Upon arrival in the ED his HR was noted to be in the 80s, blood
pressure in 140s/80s. Oxygen saturation was 98%. He was having
irregular myoclonic jerks in the ED. Cooling was continued and
he was sent to the cath. lab. In the cath. lab. his right
dominant system revealed some diffuse, non-flow-limiting
disease, that did not warrant intervention (see summary of cath
findings below).
.
He was transferred to the CCU, already intubated and sedated.
Vital signs on arrival were 94.8 F, 117 BPM, 142/85 mmHg, RR 21
and 100% O2 saturation (ventilated on CMV, 22 x 500, PEEP 5,
FiO2 100%).
.
Review of systems was not possible.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: Today.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
a) Coronary artery disease, per Mrs. [**Known lastname 86497**], possible past MI
without intervention.
b) Dyslipidemia
c) Diabetes
d) Obesity
e) Hypertension
f) Atrial fibrillation, for about one year, unclear if
persistent
g) Depression
h) Osteoarthritis, knee
i) Abdominal aortic aneurysm, purportedly 3.3 cm
j) COPD
k) BPH
l) Cholelithiasis
m) Disc displacement, L2-3
.
Surgery
a) Shoulder, unclear type
b) Tonsilectomy
Social History:
-Tobacco history: 120 pack/years, quit [**2105**].
-ETOH: Rare - 1 in 6 mo.
Retired, spends time at home watching TV etc. Activities limited
by osteoarthritis of knee.
Family History:
Unknown
Physical Exam:
VS: 94.8 F, 117 BPM, 142/85 mmHg, RR 21 and 100% O2 saturation
(ventilated on CMV, 22 x 500, PEEP 5, FiO2 100%).
GENERAL: Overweight man with myoclonus every 10 to 20 seconds
involving limbs, primarily. GCS 3. Looks stated age.
HEENT: NCAT. Sclera anicteric. Pupils fixed in mid-position.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple, JVP not evaluated - patient flat.
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: Intubated with mechanical ventilation, occasional
overbreaths of vent initially. Bilateral air entry. No loud
adventitious sounds anteriorly, laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
NEUROLOGIC: Myoclonus every 10 to 20 seconds involving limbs,
primarily. GCS 3. Comatose. No purposive movements. Myoclonus
only. No withdrawal to very firm nail-bed pressure. No brainstem
or spinal reflexes (no doll's eyes, blink to threat, spontaneous
eye movement, even during fundoscopy, no blink to glabella tap,
no pout, jaw jerk, biceps, brachioradialis, knee, ankle or
plantar reflexes bilaterally. Tone flacid. Bulk normal.
Myoclonus present in all limbs, but strength could not be
assessed.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Trophic
changes evident at feet/ankles.
Pertinent Results:
[**2119-4-4**]
Cardiac Cath
COMMENTS:
1. Coronary angiography in this right-dominant system
demonstrated
two-vessel disease. The LMCA was short and had no
angiographically
apparent stenosis. The LAD had minimal disease. The LCx had
serial
stenoses, with the distal lesion appearing ulcerated but without
significant stenosis. The ramus intermedius had mild disease.
The
RCA was chronically occluded proximally and filled via
left-to-right
collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure.
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
.
[**2119-4-4**]
CTA Chest
IMPRESSION:
1. No pulmonary embolus.
2. Moderate cardiomegaly including left/right heart.
3. Moderate interstitial fluid edema.
4. Extensive bilateral lower lobe atelectasis/near lobar
collapse.
.
[**2119-4-4**]
Head CT
IMPRESSION: No acute intracranial hemorrhage. Extensive
periventricular white matter hypodensities which may represent
sequelae of chronic small vessel ischemic disease; however,
given patient's history, infarct cannot be excluded.
NOTE ADDED IN ATTENDING REVIEW: As above, there is no
intracranial hemorrhage. Allowing for the evidence of severe
sequelae of chronic microvascular infarction, there is no
finding to suggest acute vascular territorial infarction. There
is disproportionate 3rd and lateral ventriculomegaly, which may
represent central atrophy.
.
[**2119-4-7**]
EEG
IMPRESSION: This is an abnormal video EEG study due to severe
suppression of the background. This findings is consistent with
a severe
anoxic-ischemic encephalopathy. Note is made of rhythmic muscle
artifact
extending from the bitemporal to bifrontal regions as detailed
above but
without apparent eleptiform activity. There was no evidence of
electrographic seizures in this recording. Compared to prior 24
hours,
this study is unchanged.
Brief Hospital Course:
After completing the cooling protocol in the CCU, attempts were
made to wean the patient's sedation. When this was done,
persistent myoclonic jerking was noted without any improvement
in mental status, requiring re-sedation and, at times, even
paralysis to maintain synchrony with the ventilator. Neurology
followed the patient throughout his hospital course and, based
on the findings of early myoclonus and a markedly abnormal EEG,
felt that his chance for a meaningful neurologic recovery was
minimal. In light of this, the patient's family changed his
goals of care to be comfort only. He was extubated and expired
shortly thereafter.
.
Of note, the patient did develop a fever one day prior to death
and a CXR was suspicion for VAP. Empiric broad spectrum
antibiotics were started, but stopped when the patient became
CMO.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
anoxic brain injury s/p cardiac arrest
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7141, 7150
|
6225, 7054
|
314, 412
|
7232, 7235
|
4342, 4877
|
7285, 7289
|
2886, 2895
|
7112, 7118
|
7171, 7211
|
7080, 7089
|
4894, 6202
|
7259, 7262
|
2910, 4323
|
2151, 2228
|
267, 276
|
440, 2041
|
2259, 2684
|
2063, 2131
|
2700, 2870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,546
| 168,671
|
47359
|
Discharge summary
|
report
|
Admission Date: [**2133-10-21**] Discharge Date: [**2133-10-22**]
Date of Birth: [**2073-8-7**] Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccine / Penicillins / aspirin
Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
elective admission for aspirin desensitization/cardiac
catheterization
Major Surgical or Invasive Procedure:
[**2133-10-22**]: Cardiac catheterization
History of Present Illness:
60 y.o. woman with hx of SLE, CVA, EF 45%, ?hx of MI [**2131**],
moderate mitral regurgitation, ESRD on HD MWF, presents from
home for aspirin desensitization and cardiac catheterization in
preperation for renal transplant.
.
She notes that she has had multiple episodes of exposure to asa
with throat swelling and hives, the last of which was in [**2082**].
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope. She does report that since [**2131**] during a
hospitalization at [**Hospital1 112**] at which point she had sepsis, was
crtically ill and was told that she had had a previous MI, she
has had 2 pill orthopnea. She also states that since that time
her exercise tolerance decreased. She can climb the 15 stairs in
her home without difficulty but becomes short of breath if she
were to go up and down 2 flights. She states that she thinks
this is from her deconditioning rather than any cardiac issues.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes (though states diet
controlled and from SLE/prednisone), -Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS: patient unaware of prior
catheterization
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
SLE
HTN
ESRD (lupus nephritis) on HD mon-wed-Friday
CHF (in the setting of renal failure), EF 45% [**6-/2133**]
Anemia
Chest Pain ?????? Adenosine Stress negative [**11-10**]
Hyperparathyroidism
Osteopenia
Mitral Regurgitation, moderate [**6-/2133**]
Aortic Insufienency
Long QT Syndrome ?????? now resolved by last EKG
Colon Polyps
Diverticulosis
Morbid Obesity
CVA- on chronic Coumadin last dose [**2133-10-18**] (occurred in setting
of septic shock [**11-11**])
Mild RLD on office spirometry
OSA on CPAP
Social History:
Worked for insurance industry for 36 years. Now disabled.
- Tobacco history: Negative
- ETOH: Negative
- Illicit drugs: Negative
Family History:
- No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death.
- Mother: SLE
- Father: MI
8 siblings, 6 of which have SLE. 2 brothers with [**Name2 (NI) **].
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 68, 116/48, 17, 98%/RA
GENERAL: NAD. Obese. 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. Unable to assess JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-8**] holosystolic MR murmur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No edema. Bruit and thrill over right forearm AVF.
SKIN: No rashes. Scar from HD line right chest wall.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.9, Tc 98.8, HR 70(64-70), BP 141/77 {116/48 -
141/77}, R 18 (13-23)SpO2: 99%
GENERAL: NAD. Obese. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. MMM.
NECK: Supple. Unable to assess JVP 2/2 habitus
CARDIAC: RR, normal S1, S2. [**3-8**] holosystolic MR murmur. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No edema. Bruit and thrill over right forearm AVF.
SKIN: No rashes. Scar from HD line right chest wall.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
NEURO: facial muscles equal and intact bilaterally, patient
reports slight increased sensation to light touch on right vs.
left
Pertinent Results:
Admission Labs:
[**2133-10-21**] 08:45PM BLOOD WBC-6.7 RBC-3.51* Hgb-11.3* Hct-33.0*
MCV-94 MCH-32.3* MCHC-34.3 RDW-14.5 Plt Ct-258
[**2133-10-21**] 08:45PM BLOOD PT-14.2* PTT-26.5 INR(PT)-1.2*
[**2133-10-21**] 08:45PM BLOOD Glucose-106* UreaN-14 Creat-5.2*# Na-143
K-3.7 Cl-97 HCO3-37* AnGap-13
[**2133-10-21**] 08:45PM BLOOD Calcium-9.2 Phos-2.5* Mg-1.8 Cholest-169
.
Disharge Labs:
[**2133-10-22**] 12:37PM BLOOD WBC-4.9 RBC-3.39* Hgb-10.7* Hct-32.9*
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.4 Plt Ct-260
[**2133-10-22**] 12:37PM BLOOD Neuts-55.2 Lymphs-34.6 Monos-5.9 Eos-3.5
Baso-0.9
[**2133-10-22**] 12:37PM BLOOD PT-13.9* INR(PT)-1.2*
[**2133-10-22**] 12:37PM BLOOD Glucose-85 UreaN-20 Creat-6.7*# Na-139
K-3.4 Cl-95* HCO3-34* AnGap-13
[**2133-10-22**] 12:37PM BLOOD Calcium-8.2* Phos-2.9 Mg-2.3
[**2133-10-21**] 08:45PM BLOOD Triglyc-127 HDL-63 CHOL/HD-2.7 LDLcalc-81
.
IMAGING
- ECG: rate 70, mild 1st degree AVB. NL axis. Qtc mildly
prolonged 458. Compared to [**5-/2133**], Q waves in II and avF have
resolved though there are diffuse TWI similar to prior.
.
[**2133-10-22**] Cardiac Catheterization:
COMMENTS:
1. Selective coronary angiography of this mixed dominant system
demonstrated mild non-obstructive coronary artery disease. The
LMCA was
without angiographically apparent flow-limiting disease. The LAD
had a
40% proximal stenosis. The LCx was large and had no
angiographically
apparent flow-limiting disease. The RCA had mild luminal
irregularity
without angiographically flow-limiting disease.
2. Resting hemodynamics revealed normal right-sided pressures
with RVEDP
of 8 mmHg. The left-sided filling pressures were mildly elevated
with an
LVEDP of 15 mmHg. There was moderate pulmonary arterial
hypertension
with PASP of 42 mmHg. The cardiac index was preserved at 3.7
L/min/m2.
There was moderate systemic arterial hypertension with central
aortic
pressure of 153/70 mmHg with mean of 101 mmHg.
4. Left ventriculography revealed 1+ mitral regurgitation. The
LVEF was
60%.
FINAL DIAGNOSIS:
1. Mild non-obstructive coronary artery disease.
2. Mild mitral regurgitation.
3. Mild pulmonary hypertension.
4. Well compensated left and right heart hemodynamics.
Brief Hospital Course:
60 y.o. woman with hx of SLE, CVA, EF 45%, ?hx of MI [**2131**],
moderate mitral regurgitation, ESRD on HD MWF, presents from
home for aspirin desensitization and cardiac catheterization in
preparation for renal transplant.
.
.
ACTIVE ISSUES:
# Aspirin allergy: Patient with hx of anaphylaxis to aspirin
most recently in [**2082**]. Needs aspirin prior to catheterization,
in case she will have a stent placed. Montelukast caused stomach
upset and sweating at midnight, so the aspirin trial was delayed
until the morning of [**2133-10-22**], and with zafirlukast instead.
However, pt began to experience tingling around mouth and on
cheeks, which spread to fronts of legs and knee caps after 4th
dose of ASA (3 mg). ASA stopped, and she was given Benadryl 50
mg IV, with eventual resolution of symptoms. Therefore, pt did
not successfully desensitize to aspirin.
.
# CAD: Pt had wall motion abnormality on TTE from 6/[**2133**].
Unclear if had previous cardiac catheterization. Cardiac
catheterization on [**2133-10-22**] showed mild non-obstructive coronary
artery disease, mild mitral regurgitation, mild pulmonary
hypertension, and well compensated left and right heart
hemodynamics. Left ventriculography revealed 1+ mitral
regurgitation.
.
.
CHRONIC ISSUES:
# CHF: Last known EF 45% in [**2133-6-3**]. Right and left heart
catheterization showed EF 60% by LV-gram. She was noted to have
1+ MR.
.
# HTN: Documented history of this problem, for which the patient
was continued on her home amlodipine and metoprolol. Her
metoprolol was held prior to the aspirin desensitization and
prior to re-starting, pts BP was 141-150/63-71 but HR was 61-62,
and so her metoprolol was not continued in house. She will
resume taking it as an outpatient.
.
# HLD: Documented history of this problem, for which the patient
was continued on her home simvastatin.
.
# Hx of CVA: Not known if embolic or thrombotic. CHADS2 score 3.
Her home coumadin was held for catheterization, but was
continued upon discharge.
.
# SLE: Currently well-controlled on home asathioprine,
prednisone, oxycodone and tylenol.
.
# ESRD on HD: She was continued on her home nephrocaps, tums,
calcium carbonate, vitamin D, but her home bicarbonate was held
during admisssion given bicarbonate elevation.
.
.
TRANSITIONAL ISSUES: no changes were made to medications. She
was not started on aspirin.
Medications on Admission:
(confirmed with patient)
AMLODIPINE 5mg daily
AZATHIOPRINE 50mg daily
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] daily
Oxycodone 5mg Q3-4H prn pain (usually takes twice a day)
Sodium bicarbonate 40 grams daily
Metoprolol 25mg [**Hospital1 **]
Omeprazole 80mg daily (!!)
Pantoprazole 40mg daily
Prednisone 5mg daily
Simvastatin 40 mg daily
Coumadin (stopped Sunday)
Tums 500mg Qam
Sensipar 30mg daily
Phoslo TID with meals
Nitrostat 0.4mg prn (not needing)
Calcium carbonate 600mg [**Hospital1 **]
Tylenol prn
Ambien 5mg QHS prn insomnia
Vitamin D [**2122**] mg daily
Zinc 50mg daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QAM (once a day (in the
morning)).
6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. sodium bicarbonate Oral
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Monday, Wednesday, Friday.
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Sun,
Tues, Thurs, Sat.
15. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: Two (2)
Capsule PO once a day.
17. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
18. zinc 50 mg Tablet Sig: One (1) Tablet PO once a day.
19. Outpatient Lab Work
Please check INR on Monday [**2133-10-25**] with results to the
[**Hospital3 **] at [**Location (un) 2274**] [**University/College **]
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiac catheterization
End stage renal disease
Mild Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname **],
You had a cardiac catheterization performed which showed a 40%
blockage of the left anterior descending artery and normal heart
pressures. In preparation for the catheterization, we attempted
to desensitize you to aspirin. You had a positive reaction to
the aspirin so we will not send you home on aspirin. You still
have an allergy to aspirin. We have restarted your warfarin at
your previous doses and you should have your INR checked on
Monday [**10-26**] with results to the [**Hospital3 **] in
[**University/College **].
Please resume your home medicines as you were taking them
before, there were no changes made.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 86132**]
Fax: [**Telephone/Fax (1) 6808**]
Thursday [**2133-10-29**] at noon
.
Department: TRANSPLANT SOCIAL WORK
When: THURSDAY [**2133-11-5**] at 11:00 AM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2133-11-5**] 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: TRANSPLANT CENTER
When: THURSDAY [**2133-11-5**] at 3:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"396.3",
"250.00",
"V45.11",
"585.6",
"V12.54",
"272.4",
"414.01",
"562.10",
"V58.65",
"583.81",
"V49.83",
"403.91",
"327.23",
"V12.72",
"710.0",
"278.00",
"V13.81",
"733.90",
"V58.61",
"V85.41",
"V14.8",
"V72.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
11061, 11067
|
6421, 6649
|
381, 424
|
11188, 11188
|
4225, 4225
|
12015, 13156
|
2428, 2604
|
9419, 11038
|
11088, 11167
|
8811, 9396
|
6231, 6398
|
11339, 11992
|
2644, 3394
|
1621, 1724
|
8714, 8785
|
271, 343
|
6664, 7669
|
452, 1458
|
4241, 6214
|
11203, 11315
|
1755, 2263
|
7685, 8693
|
1480, 1601
|
2279, 2412
|
3419, 4206
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,442
| 159,721
|
52598
|
Discharge summary
|
report
|
Admission Date: [**2138-8-15**] Discharge Date: [**2138-8-25**]
Date of Birth: [**2060-10-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20640**]
Chief Complaint:
Fatigue, DOE, Fever
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
77 yo female receiving adjuvant chemotherapy for stage II breast
cancer who presents with generalized weakness/fatigue and DOE x
1 week and is found to be febrile to 103 in the ED. She reports
feeling "wiped out" since her chemotherapy on [**8-4**] with
progressive generalized fatigue. She then noted SOB with
extertion for the past week. She has felt chilled at home but
could not get a reliable [**Location (un) 1131**] on her home thermometer. She
denies cough, abdominal pain, nausea, vomiting. She has also
had 2-3 days of diarrhea; improved now after one day of
immodium. Also very poor appetite. Initially presented to
clinic where she was found to be hypoxic to 91% at rest and 88%
with exertion. She was afebrile at that time and was referred to
the ED for evaluation. In the ED was found to be febrile to 103
but HD stable. She was hydrated and given Levaquin for ? PNA.
Currently she feels much improved.
Past Medical History:
#. Left breast invasive ductal CA (dx [**2138**]), 1.4 cm/ grade III,
considered a 2nd primary involving the left breast, in a
different location, s/p excision, last chemo [**8-4**] (Cytoxan and
Taxotere adjuvant therapy)
#. Left breast infiltrating ductal CA (dx [**2117**]), 2.5 cm/ stage
II, T2 N1, ER negative with 1 of 4 lymph nodes, with
micrometastases, s/p wide-excision, XRT & chemotherapy.
#. Mild-to-moderate atherosclerotic calcifications in the aorta
and coronary arteries, per CTA/Chest ([**2138-8-15**])
#. HTN
#. High cholesterol
#. OCD
#. Hypothyroidism, s/p removal of thyroid due to benign disease.
.
PSHx:
[**2138-4-24**] - s/p Wide excision of left breast carcinoma
[**2138-4-10**] - s/p ultrasound-guided bx, left breast, monstrated
(on )
[**2126-11-19**] - s/p Collagen injection, for Type III stress urinary
incontinence
[**2126-9-30**] - s/p Cystometrogram, urodynamics, uroflow for Stress
urinary incontinence, type III with stable urethra
[**2126-6-3**] - s/p Pubovaginal sling, with [**Doctor Last Name 4726**]-Tex graft,
cystoscopy, and suprapubic tube placement
[**2126-1-7**] - s/p Flexible cystoscopy
[**2125-8-13**] - s/p Urodynamic evaluation: Uroflow, Postvoid
residual, cystometrogram, Voiding cystourethrogram.
[**2118**] - s/p bilat Carpal Tunnel release
[**2117**] - s/p Wide-excision of Left axillary tail invasive breast
cancer with concurrent left axillary nodal sampling.
At age 49 yo - s/p TAH with ovary removal, [**3-8**] fibroid, was on
Premarin and progesterone prior to the last CA
Social History:
Relationships: Born in [**Country 74323**], grew up in [**Location (un) **]/[**Country 18084**],
came to the US for PhD. She lived with her husband in [**Name (NI) 745**], no
children. Has travelled extensively. Supports: friends, husband.
[**Name2 (NI) **] wine w/ dinner, former smoker (quit 20+ yrs ago), denies
IVDA
.
Functional Baseline: She is a clinical psychologist and is still
working one day a week, office is on [**Location (un) 1773**] of home.
Hobbies: travel, [**Location (un) 1131**], movies. Assistive devices: glasses
only. No VNA.
Family History:
Maternal grandparent died of TB (before pt born), mother died of
TB (44 yo) & sister (2 yo) of TB/menningitis, pt (thinks) she
has h/o positive PPD. Father has lung cancer and died at 69 yo
(was a heavy smoker). No family history of breast cancer.
Physical Exam:
ON ADMISSION:
=============
VITAL SIGNS:
Temperature 98.1
Blood pressure 130/62
Heart rate 76
Resp rate 20
97%2L
WT 147.5 LB
.
GENERAL: Pleasant female in no acute distress; appears
comfortable.
HEENT: Sclerae anicteric. Pupils equal, round, reactive to
light. Oropharynx is clear without lesions or thrush.
NECK: Supple, without lymphadenopathy or thyroid nodules.
LUNGS: Clear to auscultation and percussion bilaterally. No
rhonchi, rales or wheezes.
HEART: Normal S1, S2. Regular rate and rhythm. No murmurs,
rubs, or gallops.
ABDOMEN: Soft, nontender, nondistended, normal bowel sounds.
EXTREMITIES: No cyanosis, clubbing, edema. No nail changes.
SKIN: No rash.
Pertinent Results:
18.9 > 27.8 < 328
N:89.2 L:6.6 M:3.4 E:0.5 Bas:0.2
.
Trop-T: <0.01
.
CK: 76 MB: Notdone
ALT: 30 AP: 90 Tbili: 0.2
AST: 55 (hemolyzed)
.
TSH:Pnd
.
PT: 13.5 PTT: 26.8 INR: 1.2
.
136 / 100 / 12
----------------
4.5 / 26 / 0.9
.
UA: negative
.
CXR: no infiltrate
.
CTA (prelim): no PE
.
BCs pending
IMAGING:
========
[**2138-8-17**] CHEST (PA & LAT) - FINDINGS: Comparison is made to
previous study from [**2138-8-15**]. Cardiac silhouette and
mediastinum are within normal limits. There is coarsening of the
bronchovascular markings without overt pulmonary edema. There is
atelectasis in the left upper lobe. The right apex is within
normal limits. No pleural effusions or signs for overt pulmonary
edema is present.
.
[**2138-8-15**] CTA CHEST W&W/O C&RECONS, NON-CORONARY - CTA CHEST: No
evidence of filling defect to the subsegmental level to suggest
pulmonary embolism. The thoracic aorta is normal in caliber
throughout. There are mild-to-moderate atherosclerotic
calcifications in the aorta and coronary arteries. Heart size is
normal. There is no central or axillary lymphadenopathy. There
is no pleural or pericardial effusion. A calcified 9 mm
perihilar nodule ((3:43) and a 4 mm lower lung nodule (3:82) was
noted. Right lower lobe scaring is noted. There no effusion or
consolidation. A 3.6 x 2.1 cm fluid collection is noted in the
left breast. Bone windows demonstrate moderate degenerative
changes. IMPRESSION: 1. No evidence of pulmonary embolism; 2.
Recommend 12 month followup for 4 mm lower lobe nodule; 3.
postsurgical changes in the left breast.
.
[**2138-8-15**] CHEST (PA & LAT) - FINDINGS: Cardiomediastinal and
hilar contours are unremarkable. The aorta is calcified and
tortuous. Again identified is bibasilar scarring, unchanged.
There is no consolidation or pleural effusions identified. The
osseous
structures are grossly unremarkable. IMPRESSION: No acute
cardiopulmonary process.
.
[**2138-4-21**] CHEST (PRE-OP PA & LAT) - CHEST, PA AND LATERAL: The
heart size is at upper limits of normal. The aorta is calcified
and tortuous. Pulmonary vasculature is unremarkable. Linear left
upper lung and right lower lung opacities are consistent with
atelectasis or scarring. The lungs are otherwise clear. There
are no pleural effusions. Mild degenerative changes of the
thoracic spine are observed. IMPRESSION: No acute
cardiopulmonary process.
Brief Hospital Course:
77 yo F w/ hx left breast grade III invasive breast CA s/p L
breast excision and recent adjuvant chemo (cytoxan and taxotere
on [**8-4**]), untreated LTBI in setting of known TB exposure
presented with one week of generalized weakness and fatigue on
[**8-15**]. Pt had chemo on [**8-4**] and reported generalized weakness
and decreased po intake. On [**7-14**], she was seen at [**Hospital 478**]
clinic and cbc showed wbc of 29.2 no differential available
(prior wbc on [**8-4**] was 6). Of note, had Neulasta on [**8-5**]. On
[**8-15**], pt was again seen in clinic where she was noted to be
hypoxic with sat 91% at rest and 88% with exersion. She also
complained of subjective fever, ?dry cough, emesis X3 and a
couple days of nonbloody watery stools. She also reported a 5lb
wt loss over past 6 weeks, but denied any night sweats, chills,
shortness of breath or hemoptysis.In ER she was febrile to 103
and received levaquin for possible pneumonia, however a CXR
showed no infiltrate. A CTA was performed which showed no PE,
but there R LL scaring and a calcified 9 mm perihilar nodule and
4 mm lower lung nodule. She was placed in isolation given hx
untreated LTBI and findings on CTA concerning for tuberculosis.
Infectious disease was consulted who recommended stopping
levaquin because of possible effect on AFB smears, ruling out
for TB and starting bactrim for possible PCP [**Name Initial (PRE) 1064**]. She
underwent bronchoscopy with BAL for specimen collection, then
shortly after the bronchoscopy, she became hypoxic to 70-80's
and was sent to the ICU for respiratory distress. A repeat
chest X-ray showed flash pulmonary edema and she was diuresed
with IV lasix. She was also started on ceftriaxone,
azithromycin, bactrim and steroids. She responded well to IV
lasix and was eventuaky transferred back to the floor when
hypoxia improved. She was ruled out for PCP, [**Name10 (NameIs) **] and
tuberculosis, therefore she was continued on levofloxacin alone
for presumed community aquired pneumonia complicated by flash
pulmonary edema after bronchoscopy.
Medications on Admission:
1. Lipitor 10 mg PO QD
2. [**Doctor First Name **] 60 mg PO QD
3. Fluoxetine 20 mg PO QD
4. Vicodin 5 mg-500 mg [**2-5**] Tablet every 4-6 hours prn, uses for
bone pain after Neulasta
5. Levothyroxine 125 mcg PO QD (125 mcg is listed in OMR,
patient states she has been taking 100 mcg)
6. Lisinopril 20 mg PO QD
7. Zofran 8 mg every 8 hours as needed for nausea
8. Compazine 10 mg q4-6 hours as needed for nausea
9. Ranitidine 150 mg PO QD
10. Aspirin 81 mg PO QD
11. Calcium 500 mg PO QD
12. Multivitamin one tablet PO QD
13. Vitamin D 1000 mg PO QD OTC
14. Dexamethasone 4 mg Tablet, 2 Tablet(s) PO BID for 3 days
beginning the day before chemotherapy
15. Lorazepam [Ativan] 0.5 mg Tablet, 1 Tablet(s) by mouth every
4-6 hours as needed for nausea. [**Month (only) 116**] use 2 tablets in the evening
for sleep (per OMR, but DOES NOT TAKE)
16. Pegfilgrastim [Neulasta] 6 mg/0.6 mL Syringe once, 24hours
after chemotherapy, SQ
17. Triamterene-Hydrochlorothiazide 37.5 mg-25 mg Tablet 1
Tablet(s) by mouth MWF - (NONE FOR LAST 2 WEEKS [**3-8**] to "urinate
too much")
18. Xanax 0.5 mg PO PRN sleep (DOES take at home PRN)
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO ONCE (Once) for 1 doses.
8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
12. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**5-11**]
hours as needed for nausea.
15. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. Outpatient Lab Work
BMP, Ca, Mg, PO4. Please fax results to Dr. [**Last Name (STitle) **] at
[**0-0-**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute pulmonary edema
Secondary:
Breast cancer
Hypertension
Discharge Condition:
Good. Hemodynamically stable and afebrile. Satting 95% on room
air.
Discharge Instructions:
You were admitted for fever and difficulty breathing. An
interventional procedure called a bronchoscopy was performed to
get samples to determine if you had an infection in your lungs.
After this procedure, you developed flash pulmonary edema which
is when fluid rapidly accumulates in the lungs, and were
admitted to the ICU for difficulty breathing. You were given
medicine to remove some of the fluid from your lungs, steroids
and antibiotics.
None of the medicines that were started during the
hospitalization need to be continued after discharge.
You need to get your labs redrawn on Friday, [**8-29**] and faxed
to Dr. [**Last Name (STitle) **] at [**0-0-**]. You should follow-up with Dr.
[**Last Name (STitle) **] as listed below.
Please go immediately to the emergency room if you should
experience fevers, difficulty breathing, chest pain, shortness
of breath or any other symptoms that are concerning to you.
Followup Instructions:
Dr. [**Last Name (STitle) **]; Monday, [**9-1**] at 9am.
Completed by:[**2139-1-26**]
|
[
"518.3",
"428.0",
"174.8",
"276.7",
"799.02",
"518.81",
"244.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
11409, 11415
|
6803, 8875
|
337, 352
|
11529, 11599
|
4408, 6780
|
12570, 12658
|
3446, 3696
|
10048, 11386
|
11436, 11508
|
8901, 10025
|
11623, 12547
|
3711, 3711
|
278, 299
|
380, 1306
|
3725, 4389
|
1328, 2862
|
2878, 3430
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,238
| 110,221
|
15181
|
Discharge summary
|
report
|
Admission Date: [**2128-7-15**] Discharge Date: [**2128-7-17**]
Date of Birth: [**2071-10-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male
with a history of hypertension and diabetes mellitus type 2,
hypercholesterolemia, who presented to his primary care
physician with complaints of chronic nonproductive cough
times the past seven months, coinciding with initiation of
ACE inhibitor therapy. He also complained of dizziness,
fatigue, and occasional diaphoresis, not related to exertion.
He reports that he can walk up two flights of stairs and ride
a bike without any shortness of breath, dyspnea on exertion,
chest pain, chest pressure. Additionally, he denies edema,
paroxysmal nocturnal dyspnea, orthopnea, syncope, presyncope.
He was recently on antibiotics for cough with some relief.
He had a recent admission in [**2128-4-8**] for a laminectomy.
Patient's primary care physician ordered an exercise
tolerance test/Myoview to rule out cardiac cause of his
cough. He exercised 18 minutes per standard [**Doctor First Name **] protocol.
He had a blunted heart rate response and got 0.5 mg of
atropine at 16.5 minutes. He had no complaints of chest
pain. He achieved 74% maximal heart rate. Myoview imaging
revealed anterior ischemia. Therefore, the patient was sent
for cardiac catheterization on [**2128-7-15**].
Catheterization revealed severe diffuse LAD disease with
proximal tandem 70% stenosis, subtotally occluded mid vessel,
very small apical LAD. Left ventricular ejection fraction
was preserved at 65%. He underwent successful PTCA, stenting
of the LAD with two overlapping Cypher stents. Additionally,
the left main coronary artery was noted to be nonobstructed.
Left circumflex was nonobstructed. OM-1 was large vessel
with an eccentric mid 40% stenosis. RCA showed a 50% mid
stenosis.
Initially, the patient tolerated coronary catheterization
well. He was transferred to the holding area. He then
developed episode of hypotension to BP of 70s after femoral
sheath removal. He received IV fluid therapy, Integrilin was
discontinued, and dopamine drip was started. He was taken to
CT scan to rule out retroperitoneal hematoma. CT scan
revealed a psoas hematoma.
PAST MEDICAL HISTORY:
1. Diabetes mellitus x5 years.
2. Hypertension.
3. Hypercholesterolemia.
4. Gout.
5. Glaucoma.
6. History of struck by lightening in [**2092**].
PAST SURGICAL HISTORY:
1. Status post laminectomy 05/[**2127**].
2. Status post hernia repair.
3. Status post multiple knee and shoulder surgeries.
ALLERGIES: Patient reports allergies to Morphine resulting
in rash, and amoxicillin resulting in diarrhea.
MEDICATIONS PRIOR TO ADMISSION:
1. Aspirin 325 mg po q day.
2. Atenolol 50 mg po q day.
3. Triamterene/hydrochlorothiazide 75/50 mg po q day.
4. Glucophage 1,000 mg po bid.
5. Lisinopril 40 mg po q day.
6. Pravachol 60 mg po q day.
7. Betoptic one drop each eye [**Hospital1 **].
FAMILY HISTORY: Patient reports that his mother died at age
58 from complications of congestive heart failure and
diabetes. Father deceased from stroke.
SOCIAL HISTORY: Patient is married. He is semiretired from
sales. He denies any alcohol use. Denies illicit drug use.
Reports one pack per day smoking history for many years
having quit in [**2111**].
PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 99.0,
blood pressure 113/43, pulse 70, respiratory rate 20, and
oxygen saturation 98% on 4 liters O2 nasal cannula. General
appearance: Well-developed, well-nourished male lying flat,
denying pain, plethoric face, in no acute distress. HEENT:
Normocephalic, atraumatic. Sclerae are anicteric. Mucous
membranes moist. No jugular venous distention or increased
jugular venous pressure noted. Carotids with normal upstroke
and amplitude. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular, rate, and rhythm. S1 heart sound
obscured by 3/6 systolic murmur heard best at right upper
sternal border. Murmur did not radiate to carotids. No
carotid, abdominal, femoral bruits. Abdomen: Obese, soft,
nontender, and nondistended, positive bowel sounds, no
hepatosplenomegaly. Extremities: Cool, pale, no edema
noted. Groin: Ecchymotic lesion 1 x 3" noted in right
groin. No masses. No oozing from catheterization site.
Slightly nontender, no bruit auscultated.
PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES:
Laboratories on admission showed complete blood count with
white blood cells 15.0, hematocrit of 36.8, platelet count of
239. Serum chemistries showed sodium of 139, potassium 4.5,
chloride 103, bicarbonate 26, BUN 23, creatinine 1.6, glucose
97. Additional electrolytes showed phosphorus 2.2, magnesium
1.5, CK 47.
Exercise tolerance test/Myoview ([**2128-7-14**]): Showed blunted
heart rate response, so patient was given 0.5 mg of atropine
to increase heart rate. Myoview images revealed anterior
wall ischemia.
ELECTROCARDIOGRAM: Shows sinus rhythm, first degree A-V
prolongation. [**Street Address(2) 4793**] elevations in leads V2 through V5, no
left ventricular hypertrophy noted. Left atrial abnormality.
Incomplete right bundle branch block.
CATHETERIZATION ([**2128-7-15**]): Showed ejection fraction
approximately 65% with normal left ventricular function. No
mitral regurgitation. Left main coronary artery without
significant disease. Left LAD with proximal tandem 70%
stenosis, subtotally occluded mid vessel, the left circumflex
with nonobstruction. OM-1 with eccentric mid 40% lesion.
RCA with 50% mid lesion. LAD lesion was stented x2 with
Cypher stents.
CT SCAN OF THE ABDOMEN/PELVIS WITHOUT CONTRAST ([**2128-7-15**]):
Showed moderate to large right pelvic hematoma, originating
in the region of the right psoas muscle.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Coronary artery disease: Patient with three vessel
disease on cardiac catheterization and status post PCI with
two Cypher stents placed in his left anterior descending
artery. Plan was to continue aspirin, Plavix, statin, and
beta blocker/ACE inhibitor, if the patient's blood pressure
tolerated. Namely, the patient should be on aspirin and
Plavix for nine months post-stent. As he had complications,
hematoma development, Integrilin was discontinued.
He was managed and monitored for symptoms of chest pain or
dyspnea, and this was of concern for possible stent
thrombosis. He remained chest pain free throughout the
remainder of his hospital course, and cardiac enzymes were
ruled out for myocardial infarction.
Ventriculogram performed during coronary catheterization
showed an ejection fraction of 65%. Therefore, the patient's
cardiac decompensation was likely secondary to diastolic
dysfunction secondary to a longstanding history of
hypertension. Initially, plan was made to continue ACE
inhibitor and beta blocker therapy if the patient's blood
pressure tolerated. However, he arrived to the floor in need
of pressor support on a dopamine drip. He was weaned off the
dopamine slowly as the blood pressure tolerated, and atenolol
50 mg po q day, and Valsartan 240 mg po q day were added to
his medication regimen. Please note, that the patient had
been on an ACE inhibitor prior to admission, however, it was
felt that the side-effects from the ACE inhibitor therapy
could be contributing to his complaint of cough, and
therefore an angiotensin receptor blocker was substituted in
place of the ACE inhibitor.
2. Right psoas muscle hematoma: Vascular Surgery was
consulted. They recommended serial hematocrit values,
hemodynamic monitoring, and serial peripheral pulse checks.
The patient was transfused 2 units of packed red blood cells
for a drop in his hematocrit from 37 to 27. He tolerated
this well. Additionally, Heparin and Integrilin were
discontinued as this is felt to be contributed to bleeding
complications. At time of discharge, the patient's
hematocrit value had been stable for greater than 24 hours.
Value at discharge was 36.3.
3. Diabetes mellitus: Patient's outpatient metformin dose
was held after receiving an intravenous contrast load during
cardiac catheterization, out of concern for possible acute
tubular necrosis, exacerbation of renal insufficiency, and
possible development of lactic acidosis. He was monitored
with serial fingerstick blood glucose testing and covered on
regular insulin-sliding scale. He was started on a diabetic
diet.
Postcatheterization, he was given Mucomyst 600 mg po bid due
to his history of renal insufficiency.
4. Renal insufficiency: On admission, the patient's
creatinine was elevated. It was not clear if this was his
baseline or the results of intervention. It was felt that it
was multifactorial given his history of hypertension and
diabetes. Postcatheterization, he was hydrated aggressively
with IV fluid therapy. Initially, his ACE inhibitor was held
for renal production. After two days of fluid therapy, the
patient's creatinine value returned to stable level of 0.9,
and this was the level at the time of discharge.
5. GI: As the patient's chronic cough could be secondary to
gastroesophageal reflux disease, he was started on Protonix
40 mg po q day.
6. Activity level: Prior to discharge, the patient was
cleared by Physical Therapy staff, is not needed Physical
Therapy services after discharge. At time of discharge, he
was ambulating independently.
CONDITION ON DISCHARGE: Good. Right groin hematoma stable
with hematocrit stable at 36.3 at time of discharge. Cleared
by Physical Therapy for discharge to home.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post catheterization,
status post stent placement.
2. Right groin hematoma.
3. Heart failure, diastolic dysfunction.
4. Diabetes mellitus type 2.
5. Hypertension.
6. Hypercholesterolemia.
7. Gout.
8. Glaucoma.
DISCHARGE MEDICATIONS:
1. Pravastatin 20 mg three tablets po q day.
2. Betaxolol 0.25% solution one drop each eye [**Hospital1 **].
3. Aspirin 325 mg one po q day.
4. Metformin 500 mg two po bid.
5. Clopidogrel 75 mg po q day for nine months.
6. Atenolol 50 mg one po q day.
7. Valsartan 80 mg one po q day.
8. Outpatient occupational therapy, patient with history of
coronary artery disease, status post cardiac catheterization
and stent placement. He is given a prescription to institute
a program of outpatient cardiac rehabilitation therapy.
FOLLOW-UP PLANS: Patient was told that he must make
follow-up appointments with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] and with his cardiologist, Dr. [**Last Name (STitle) **]. He can call
[**Telephone/Fax (1) 3183**] to make an appointment with each of those
providers. He was instructed to make an appointment within
the next 1-2 weeks.
Additionally, he was told to notify his primary care
physician or visit an Emergency Room immediately if he
experienced any chest pain, shortness of breath, dizziness,
or lightheadedness, palpitations, back pain, pain in his
catheterization site, or fainting. He is instructed that we
had changed some of his medications. He was told to
discontinue his triamterene/hydrochlorothiazide and his
lisinopril. He was instructed that he was started on the new
medications of valsartan 80 mg po q day and Plavix 75 mg po q
day. Finally, he was told not to operate any heavy
machinery, including a motor vehicle for the next one week.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2128-7-17**] 17:56
T: [**2128-7-21**] 09:42
JOB#: [**Job Number 44223**]
cc:[**Last Name (NamePattern4) 44224**]
|
[
"272.0",
"428.0",
"428.32",
"998.12",
"E878.8",
"250.00",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.53",
"36.01",
"99.20",
"36.07",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
2978, 3117
|
9621, 9866
|
9889, 10414
|
2445, 2680
|
5808, 9378
|
2712, 2961
|
10432, 11751
|
162, 2254
|
3352, 5780
|
2276, 2422
|
3134, 3337
|
9403, 9600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,464
| 113,594
|
47338
|
Discharge summary
|
report
|
Admission Date: [**2173-4-14**] Discharge Date: [**2173-4-18**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
Hypoxia & GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 y/o M with PMHx of Dementia, CAD s/p PCI, COPD and recent
ARDS s/p appendectomy who was at [**Hospital **] rehab prior to recent
admission for GI bleed. Pt was discharged on [**4-7**] and was found
this morning to have black guaic positive stools and increased
work of breathing.
.
In the ED, initial vs were: T 100.3 P 100 BP 102/48 R 30 O2 sat
of 100% on NRB. Pt triggered on arrival with diaphoresis and
tachypnea. He was noted to black guaic + stool and concentrated
urine. He was weaned from NRB and had a Tmax of 102 in the ED.
CXR showed worsening in bilateral infiltrates and he was given
Zosyn, Levofloxacin, Protonix and 1L IVF for possible PNA. PIV
was placed and blood was typed/crossed for GI bleed.
.
On arrival to the ICU, pt was oriented to person only and c/o
feeling tired and thirsty. Pt has mild shortness of breath but
denies cough, congestion or significant increased work of
breathing. He denies abd pain, nausea, vomiting, diarrhea,
bloody stools, changes in vision or sore throat but does report
decreased appetite.
Past Medical History:
Severe Dementia
Depression
CAD s/p MI in [**2162**] c/b VF with stenting of the L circ, PCI to R
PDA with DES in [**2169**]
COPD
Recent ARDS s/p appendectomy
Type II DM
Hypertension
Spinal Stenosis
Hyperlipidemia
CDiff
Zoster on rectal area
.
Surgical History
s/p CCY
s/p hernia repair
s/p appendectomy
Social History:
Former smoker approx 30 pack year history, retired post-officer.
Pt was living with wife but has been at rehab since complicated
admission in [**2173-2-8**]
Family History:
His father died of a myocardial infarction at 84. His mother
died of a myocardial infarction at 74. His three brothers, who
died one of a motor vehicle accident and one of leukemia.
Physical Exam:
T 97 HR 95 BP 98/41 RR 29 Sats 95% on 6LNC
General: NAD, comfortable, breathing comfortably with NC O2
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: no pre-cervical lymphadenopathy
Lungs: Bilateral inspiratory rales, no rhonchi, no congestive
cough
CV: Irreg, mildly tachy, intermittent S4. PMI non-displaced
Abdomen: soft, NT/ND, NABS, no rebound or guarding
Ext: cool hands, warm feet, good distal pulses
Pertinent Results:
[**2173-4-15**] 01:55AM BLOOD WBC-11.2* RBC-3.29* Hgb-10.4* Hct-31.2*
MCV-95 MCH-31.8 MCHC-33.4 RDW-17.2* Plt Ct-340
[**2173-4-14**] 07:15PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.8* Hct-33.0*
MCV-95 MCH-30.9 MCHC-32.7 RDW-17.5* Plt Ct-372
[**2173-4-15**] 01:55AM BLOOD PT-16.1* PTT-28.8 INR(PT)-1.4*
[**2173-4-14**] 07:15PM BLOOD PT-14.8* PTT-28.8 INR(PT)-1.3*
[**2173-4-14**] 07:15PM BLOOD Glucose-166* UreaN-6 Creat-0.6 Na-133
K-3.7 Cl-93* HCO3-31 AnGap-13
[**2173-4-15**] 01:55AM BLOOD Glucose-168* UreaN-6 Creat-0.6 Na-135
K-3.3 Cl-97 HCO3-32 AnGap-9
[**2173-4-15**] 01:55AM BLOOD CK(CPK)-31*
[**2173-4-15**] 01:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-4-14**] 07:15PM BLOOD Albumin-2.6*
[**2173-4-15**] 01:55AM BLOOD Calcium-7.5* Phos-1.3* Mg-1.7
[**2173-4-14**] 10:50PM BLOOD Type-ART Temp-37.2 pO2-66* pCO2-45
pH-7.48* calTCO2-34* Base XS-8
[**2173-4-14**] 07:16PM BLOOD Lactate-2.4*
.
CXR [**2173-4-14**]: FINDINGS: AP upright portable chest radiograph is
obtained. As compared with the prior radiograph, there has been
no significant change. Motion artifact somewhat limits
evaluation. Bilateral extensive parenchymal opacities are again
noted, consistent with the provided history of ARDS. There has
been no significant interval change. Small bilateral pleural
effusions cannot be excluded. Heart size is difficult to assess.
No large pneumothorax is present. Bony structures appear intact.
Brief Hospital Course:
# Hypoxic Resp Distress: Pt with poor substrate given recent
ARDS who p/w fever, increased O2 requirement and worsening in
bilateral infiltrates concerning for PNA. Appeared clinically
euvolemic to dry and large A-a gradient on ABG. There was no
evidence of COPD exacerbation or acute CO2 retention.
Oxygenation remained poor despite broad spectrum antibiotics,
patient was unable to be weaned off O2, he remained on 6 L plus
facemask. After discussion with HCP and patient on [**4-15**],
decision was made to transition patient to CMO. IV antibiotics
were continued at the family's request because they wanted to
have some more time to spend with him. Patient passed away on
[**2173-4-18**].
.
# GI bleed: Pt presented with guaiac positive black stools, but
had stable hematocrit at his baseline. He likely has a slow
upper GI bleed. After patient was made CMO, morphine was used
to treat abdominal pain.
Medications on Admission:
Sitagliptin 50mg daily
Vancomycin 250mg po BID
Ipratropium neb q6hrs
Senna prn
Clotrimazole TP
Lasix 20mg IV
Insulin SS
Lactobacillus [**Hospital1 **]
Levalbuterol neb q6hrs
Omeprazole 40mg [**Hospital1 **]
Sertraline 50mg daily
Simvastatin 40mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"799.02",
"401.9",
"V66.7",
"V45.82",
"250.00",
"518.81",
"276.2",
"496",
"995.92",
"294.8",
"578.1",
"599.0",
"486",
"038.9",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5170, 5179
|
3922, 4835
|
248, 254
|
5230, 5239
|
2494, 3899
|
5295, 5305
|
1845, 2028
|
5138, 5147
|
5200, 5209
|
4861, 5115
|
5263, 5272
|
2043, 2475
|
190, 210
|
282, 1328
|
1350, 1655
|
1671, 1829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,934
| 105,353
|
54541
|
Discharge summary
|
report
|
Admission Date: [**2196-12-7**] Discharge Date: [**2196-12-14**]
Service: MEDICINE
Allergies:
Scopolamine
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Right Foot Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 85yo F with a PMH significant for CAD, HTN,
hyperlipidemia s/p MI and CVA with residual right-sided weakness
who presents with right heel pain. Patient states that the pain
began 2 nights ago and awoke her from her sleep. She states that
she has had pain in that foot before but nothing like this. She
states that the pain bothered her at rest but was worse with
weight bearing. She states that it is a sharp pain. She denies
any trauma to the foot. She states that the foot is not sore to
the touch. She is not able to wiggle her toes at baseline [**1-29**]
CVA, however, she reports that he sensory funtion is intact. She
states that she has swelling on and off in her LE at baseline.
.
Pt initially presented to her PCP who referred her to the ED for
concern over her what seemed to be cold foot. In the ED, initial
vitals were T: 99.2 BP: 116/68 P: 95 RR: 16 O2: 100% RA. The
patient was evaluated by vascular surgery who did not feel that
this was a vascular issue. US of the RLE was negative for DVT
and x-rays of the foot were unrevealing. An EKG was performed
that showed flattened T waves in V4-6, cardiac enzymes were sent
and the patient was found to have a troponin leak and elevated
CK, .54 and 231 respectively. Patient denied any chest pain or
shortness of breath. While in the ED the patient was hypotensive
to 78/32 and was responsive to a 500cc bolus of NS. Patient
given ASA and started on heparin gtt. Transferred to [**Hospital Unit Name 153**] for
ROMI.
.
On arrival in [**Hospital Unit Name 153**], vitals T: 100.1 BP: 98/57 HR: 101 RR: 18
O2sat: 100% 2L. Patient complains solely of right heel pain.
.
ROS: + runny nose, occasional palpitations, swelling in legs,
occasional numbness and tingling in hands and toes
Past Medical History:
-CAD s/p inferior MI [**2186**], NSTEMI [**11-29**]; known 3VD ([**11-29**] cath)
-CVA with residual left hemiparesis '[**86**]
-HTN
-Hyperlipidemia
-Chronic gastritis
-Vasovagal episodes
-Questionable R CEA '[**86**]
-CHF:diastolic and systolic dysfunction (TTE in [**2195-11-27**]:
LVEF 20-25%, 1+AR/2+MR/2+TR, impaired diastolic)
Social History:
Lives with daughter [**Name (NI) 41890**] [**Location (un) 6409**]. Has 17 children.
Currently attends [**Last Name (un) 35689**] Adult Day Care Center.
Tobacco: denies
Alcohol: denies:
Illicit drug use: denies
Family History:
Denies any h/o CVA, MI. Does not know cause of parents' deaths.
Physical Exam:
VS: Temp: 100.1 BP: 98/57 HR: 101 RR: 18 O2sat: 100% 2L
GEN: pleasant, comfortable, NAD
HEENT: NC, AT, EOMI, anicteric, MMM, OP without lesions
NECK: no supraclavicular or cervical lymphadenopathy, JVD to
level of ears
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: soft, NT, ND, no masses or hepatosplenomegaly
EXT: mild, non-pitting edema bilat R>L, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], dopplerable
pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 4/5 strength on right, [**4-30**] left.
No sensory deficits to light touch appreciated.
Pertinent Results:
[**2196-12-7**] 02:00PM BLOOD WBC-6.1 RBC-3.45* Hgb-10.2* Hct-31.3*
MCV-91 MCH-29.6 MCHC-32.7 RDW-14.6 Plt Ct-277
Neuts-70.4* Lymphs-20.6 Monos-6.5 Eos-1.7 Baso-0.8 Plt Ct-277
Glucose-93 UreaN-26* Creat-0.9 Na-141 K-3.2* Cl-101 HCO3-31
AnGap-12 Calcium-8.1* Phos-3.4 Mg-1.8
[**2196-12-7**] 02:00PM BLOOD CK(CPK)-231* CK-MB-7 cTropnT-0.33*
[**2196-12-7**] 07:50PM BLOOD CK(CPK)-218* cTropnT-0.51* CK-MB-6
[**2196-12-8**] 01:57AM BLOOD CK(CPK)-187* CK-MB-4 cTropnT-0.53*
proBNP-3235*
[**2196-12-8**] 05:20AM BLOOD CK(CPK)-179* CK-MB-4 cTropnT-0.56*
[**2196-12-8**] 11:52AM BLOOD CK(CPK)-180* CK-MB-3 cTropnT-0.58*
[**2196-12-8**] 09:52PM BLOOD CK(CPK)-158* CK-MB-3 cTropnT-0.63*
[**2196-12-7**] 02:05PM BLOOD Lactate-1.5
[**2196-12-8**] 10:25PM BLOOD O2 Sat-87
[**12-7**] CXR IMPRESSION: No radiographic evidence of pneumonia or
CHF. Persistent small bilateral pleural effusions. No change
from [**2196-1-11**].
UNILAT LOWER EXT VEINS RIGHT [**2196-12-7**] 2:38 PM
IMPRESSION: No deep vein thrombosis in the right lower
extremity.
ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the basal and mid-inferolateral segments, and
near-akinesis of the mid-septum and distal LV segments/apex.
There is mild hypokinesis of the remaining segments (LVEF =
20-25%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. The tricuspid regurgitation jet is eccentric and may be
underestimated. There is moderate pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate-to-severe tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2195-12-2**],
left ventricle is now dilated. The other findings are similar.
Brief Hospital Course:
A/P: This is an 85yo F with a PMH significant for CAD, HTN,
hyperlipidemia s/p MI and CVA with residual right-sided weakness
who presented with right heel pain.
1. ROMI/Ischemia/CAD: The patient had a PMH with CAD s/p
inferior MI [**2186**], NSTEMI [**11-29**]; She has known three vessel
disease, with her last study in [**2192**]. She has declined
intervention or CABG ever since. It was felt that Trop and mild
CK elevation could be due to failure rather than ACS however she
also had new pseudonormalization of T waves in leads V4-V5 which
were concerning for ischemia and flipped R waves and loss of R
wave progression on repeat ekg. Given that the patient refused
further intervention she was medically managed with asa, statin,
beta-blocker and ACE-I. She remained asymptomatic and denied CP
or SOB throughout the hospitalization once transferred to the
floor.
.
2.CHF acute on chronic systolic failure--the patient had a
repeat echo performed during this admission (see results above).
Her lasix was transiently held upon leaving the [**Hospital Unit Name 153**] due to
hypotension. The patient had evidence of fluid overload upon
stopping the diuretics which were slowly added back at a lower
dose due to the patient's lower BP. This will need to be
titrated back up in the outpatient setting. The discharge dose
is lasix 40mg po bid. She did not require any K repletion on
this regimen so this will need to be re-evaluated as an
outpatient as well.
3. HTN: The patient was hypotensive to 80s on admission. All of
her BP meds were initially held and then titrated back during
her stay. The patient did not tolerate a high dose of
beta-blocker and was discharged on Toprol XL 25mg po daily. She
was discharged on the rest of her incoming meds besides lasix at
the previous dose and frequency.
Medications on Admission:
Lasix 80 mg qam, 40 mg qom
KCl liquid one tablespoon daily
Toprol-XL 100 mg daily
Lisinopril 10 mg daily
Imdur 30 mg daily
Lipitor 80 mg daily
Plavix 75 mg daily
Aspirin 325 mg daily
Pantoprazole 40 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 35689**] Day Care
Discharge Diagnosis:
Hypotension
Non ST elevation Myocardial infarction
History of Coronary artery disease, native
Acute on chronic systolic heart failure
Plantar fasciitis
New diagnosis of peripheral vascular disease
History of Gastroesophageal reflux disease
History of Hyperlipidemia
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Take the medicines as prescribed.
Keep your appointments
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3511**] Date/Time:[**2197-1-3**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2197-2-27**]
9:30
You will be discharged with home PT and OT.
|
[
"428.0",
"272.4",
"410.71",
"401.9",
"438.20",
"443.9",
"414.01",
"530.81",
"458.9",
"428.23",
"728.71"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8720, 8786
|
5838, 7654
|
236, 242
|
9096, 9106
|
3342, 5815
|
9313, 9702
|
2624, 2690
|
7913, 8697
|
8807, 9075
|
7680, 7890
|
9130, 9290
|
2705, 3323
|
181, 198
|
270, 2022
|
2044, 2379
|
2395, 2608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,817
| 120,284
|
3447
|
Discharge summary
|
report
|
Admission Date: [**2137-2-18**] Discharge Date: [**2137-2-22**]
Service: NEUROLOGIC MEDICINE
ADDENDUM: The following history and physical is as noted on
arrival by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
HISTORY OF THE PRESENT ILLNESS: This is an 84-year-old woman
with atrial fibrillation on Warfarin who was found down at
her home on the day of presentation. On arrival, she was
unresponsive and no family was available at the bedside and,
therefore, the history is limited but we know that she has
left eye deviation and a left-sided weakness initially. Per
the EMS and ED records, she is thought to have been sitting
in a chair at home and was noted to be less responsive at
about 8:30 p.m. on the night of arrival. About an hour
later, EMS was called and they found her to be minimally
responsive with withdrawal on the right side to pain and no
response on the left. Her eyes were deviated to the left.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Ischemic stroke 20 years ago with transient left-sided
weakness.
3. Cataract surgery.
4. Hypertension.
ADMISSION MEDICATIONS:
1. Warfarin.
2. Losartan.
3. HCTZ.
4. Potassium chloride.
5. Magnesium supplements.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: She lives with her husband. She does not
drink or smoke. She lives in [**Location 620**] with her husband,
[**Name (NI) **]. Their number is [**Telephone/Fax (1) 15904**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 220/100, pulse 80, respirations 18, 75-90% 02
saturation on arrival. General: The initial examination was
made after sedation with Fentanyl, Ativan, and paralytics;
Dr. [**Last Name (STitle) **] saw her briefly prior to intubation. She was
unresponsive to verbal stimuli and would not follow commands.
Corneals were present bilaterally. She would withdrawal to
pain in all four extremities and was moving all extremities
spontaneously. Her eyes were deviated to the left. The toes
were upgoing on the left and equivocal on the right. The
deep tendon reflexes were diminished but symmetric.
Subsequently, she was intubated by the ED staff for airway
protection.
Further examination revealed an intubated elderly woman with
a supple neck. Lungs: Clear. Heart: Regular. Neurologic:
Her pupils were pinpoint and nonreactive. She had no dolls.
The face seemed symmetric bilaterally. Bulk was normal but
tone was decreased throughout. However, she was paralyzed.
Muscle strength could not be tested. Reflexes were
diminished throughout. Toes were upgoing on the left and
equivocal on the right. Gait and coordination could not be
assessed.
STUDIES: INR 2.3, PT 18.6, PTT 30.2. White count 13.2,
hematocrit 38.1, platelets 224,000. The U/A showed small
blood and protein of 100. ABGs 7.58, 22, 417, and 21.
Sodium 128, K 4.4, chloride 98, bicarbonate 23, BUN 33,
creatinine 1.7, glucose 144, CK 158.
Head CT did not reveal an acute bleed.
HOSPITAL COURSE: Mrs. [**Known lastname 15905**] was admitted to the Neuro
Intensive Care Unit for further management. Her clinical
presentation is most consistent with a significant cerebral
infarction. Her further workup revealed a significant
myocardial infarction with a troponin greater than 50 and CK
MB greater than 20. Her neurologic status continued to be
poor. Her imaging studies done revealed multivessel ischemic
infarction including MCA and PCA territories bilaterally in
the setting of an acute MI in a patient with atrial
fibrillation.
Her clinical prognosis is extremely poor and neurologically
she appears to be devastated after multivessel infarction,
although we continued to control her blood pressure and
provide Warfarin.
Given the overall clinical picture, a family discussion
resulted in a decision to focus on Mrs.[**Known lastname 15906**] comfort.
Her medications were discontinued and she was given
analgesics as needed for her comfort. Subsequently, she died
on [**2137-2-22**] in no pain.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 4267**] 13-282
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2137-5-27**] 06:53
T: [**2137-5-27**] 20:33
JOB#: [**Job Number 15907**]
|
[
"428.0",
"V58.61",
"780.01",
"342.90",
"427.31",
"518.81",
"410.91",
"434.11",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"93.90",
"96.71",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3018, 4249
|
1140, 1284
|
1513, 3000
|
982, 1117
|
1301, 1498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,906
| 156,866
|
50854
|
Discharge summary
|
report
|
Admission Date: [**2120-3-1**] Discharge Date: [**2120-3-10**]
Date of Birth: [**2052-8-26**] Sex: M
Service: [**Hospital1 **]/MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 64 year old male with
multiple medical problems including coronary artery disease,
status post coronary artery bypass graft in [**2115**], complicated
by right coronary artery rupture and infarct, who recently in
[**2119-12-27**], sustained a PEA arrest thought to be secondary
to hyperkalemia, end stage renal disease, severe
biventricular congestive heart failure secondary to dilated
cardiomyopathy with an echocardiogram [**9-26**], showing an
ejection fraction between 20 and 30% and 3+ mitral
regurgitation and 3+ tricuspid regurgitation, ascites
secondary to right heart failure requiring ultrasound guided
paracentesis in the past, Heparin induced thrombocytopenia
leading to bilateral lower extremity thrombi and bilateral
lower extremity below the knee amputation, gout,
hypothyroidism, history of Methicillin resistant
Staphylococcus aureus infection, hemodialysis Monday,
Wednesday and Friday, who presented from dialysis with a
fever to 103 degrees, rigors and hypotension to 60/palpable.
He was admitted to the Medical Intensive Care Unit on
[**2120-3-1**], and treated with intravenous Vancomycin dosed for
levels less than 15. On [**2120-3-1**], he was positive for
Methicillin resistant Staphylococcus aureus, six out of six
bottles contained Methicillin resistant Staphylococcus
aureus. His hypotension was treated with a Dopamine drip
which was weaned off on [**2120-3-3**]. The source of the
infection most likely was left internal jugular permacath
that was removed on [**2120-3-2**]. Rifampin was added on
[**2120-3-3**], which caused the questionable development of a rash
and was discontinued on the same day. Right femoral triple
lumen catheter was placed on [**2120-3-1**], for access and
dialysis was accomplished through that on [**2120-3-5**]. He was
called out from the Medical Intensive Care Unit to the floor
on [**2120-3-4**].
PHYSICAL EXAMINATION: His physical examination showed a
temperature of 94.6 to 97.6, pulse 61 to 64, blood pressure
103 to 145 over 55 to 91, respiratory rate 17 to 20, oxygen
saturation 94 to 99%. In general, this is an elderly male
with bilateral below the knee amputations resting in bed,
snoring. He is easily awakened and appears in no apparent
distress. Head, eyes, ears, nose and throat examination -
The pupils are equal, round, and reactive to light and
accommodation. The oropharynx was clear with upper dentures.
Former left internal jugular site covered with gauze and
clean, dry and intact. Cardiovascular examination is regular
rate and rhythm, III/Vi murmur at the apex radiating to the
axilla. S1 and S2 normal. Lungs - There are a few scattered
crackles at the bases bilaterally, no wheezes. The abdomen
is distended but nontender with normoactive bowel sounds.
Extremities - The patient is status post bilateral below the
knee amputations. Stumps appear to be well healed, and no
erythema and no edema is noted.
LABORATORY DATA: Significant for a white blood cell count
9.0, hematocrit 35.6, and platelet count 158,000. Sodium
128, potassium 4.9, bicarbonate 14, chloride 94, blood urea
nitrogen 81, creatinine 8.1, glucose 91. Calcium 8.3,
phosphate 6.9, magnesium 3.4. Vancomycin level was 24.9.
Transthoracic echocardiogram showed decreased left
ventricular systolic function but no change since [**2119-10-12**].
Electrocardiogram showed normal sinus rhythm, left axis
deviation, poor R wave progression, but again no change.
An ultrasound of the previous internal jugular permacath site
showed a likely hematoma.
HOSPITAL COURSE: In summary, this is a 67 year old gentlemen
with multiple medical problems who presented with sepsis from
Methicillin resistant Staphylococcus aureus associated with
dialysis line.
1. Dialysis line was removed on [**2120-3-2**], and he was
continued on Vancomycin throughout his stay, dose one gram
for levels less than 15. Wound site was assessed very day
and repeat ultrasound was obtained showing resolution of the
hematoma and a patent right internal jugular which was the
planned site for the second dialysis catheter placement.
Blood cultures were positive on [**2120-3-3**], for coagulase
negative Staphylococcus epidermidis, one out of two bottles
which was likely a contaminant given his initial six out of
six bottles positive for coagulase positive Staphylococcus
which was identified as Methicillin resistant Staphylococcus
aureus. Surveillance cultures were drawn on [**2120-3-4**],
[**2120-3-5**], [**2120-3-6**], [**2120-3-7**], all of which were negative.
2. End stage renal disease - The patient was received
dialysis on [**2120-3-5**], and [**2120-3-6**], and then again on
[**2120-3-9**], after the placement of new right internal jugular
tunneled catheter on [**2120-3-8**]. On day eleven, he was noted
to have some itching and an anion gap likely secondary to his
uremia. The situation did not recur after dialysis was
reinstated at regular intervals.
3. Gastrointestinal - Ascites was noted to be of cardiac
origin. The patient was on a one liter fluid restriction
during his stay, status post managed by dialysis. He was
kept on a renal and cardiac appropriate diet. Initial low
sodium was likely secondary to volume overload and corrected
again when regular dialysis was reinstated.
4. Cardiovascular - The patient was continued on his
Amiodarone, sinus rhythm. There were no cardiovascular
events. He was ruled out for myocardial infarction on his
initial presentation through the Medical Intensive Care Unit.
5. Endocrine - The patient was continued on his
Levothyroxine dose.
6. Psychiatric - The patient was continued on Zoloft
through his hospital stay and seemed to have a cheerful mood
and bright outlook.
DISCHARGE STATUS: On discharge, the patient will go to
[**Hospital3 2558**] where he has been a resident with his wife.
DISCHARGE DIAGNOSES: Left internal jugular line sepsis.
MEDICATIONS ON DISCHARGE:
1. Acetaminophen 325 mg to 650 mg p.o. q4-6hours p.r.n.
2. Allopurinol 100 mg p.o. once daily.
3. Aspirin 325 mg p.o. once daily.
4. Colace 100 mg p.o. twice a day.
5. Folic acid 1.0 mg p.o. once daily.
6. Zoloft 100 mg p.o. q.h.s.
7. Amiodarone 200 mg p.o. once daily.
8. Protonix 40 mg p.o. once daily.
9. Levothyroxine 50 mcg p.o. once daily.
10. Ursodiol 300 mg p.o. three times a day.
11. Dulcolax 5 mg p.o. q.h.s. p.r.n.
12. Calcium Carbonate 1000 mg p.o. three times a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10388**], M.D.
Dictated By:[**Last Name (NamePattern1) 9128**]
MEDQUIST36
D: [**2120-3-10**] 10:28
T: [**2120-3-10**] 11:41
JOB#: [**Job Number 105741**]
|
[
"276.6",
"V45.81",
"998.12",
"414.01",
"785.59",
"996.62",
"425.4",
"585",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6041, 6077
|
6103, 6850
|
3737, 6019
|
2087, 3719
|
186, 2064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,854
| 120,290
|
52884
|
Discharge summary
|
report
|
Admission Date: [**2201-2-2**] Discharge Date: [**2201-3-17**]
Date of Birth: [**2121-8-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
AAA presents for retroperitoneal repair
Major Surgical or Invasive Procedure:
- POD 37 s/p open pararenal AAA
- POD 37 s/p takeback for retroperitoneal bleeding,
- POD 36 s/p L colectomy
- POD 35 s/p extended L colectomy
- POD 33 s/p end transverse colostomy
- POD 29 s/p attempted abd closure
- POD 26 s/p fascial closure
- POD 22 s/p bedside perc trach
History of Present Illness:
79 year old man with CAD, CHF w/EF 40%, HTN, presents for
elective retroperitoneal juxtarenal 5.5 cm AAA repair [**2-2**] with
a question of reimplantation of left renal artery.
Past Medical History:
CAD s/p MI (EF 40%), CABG [**4-/2184**], multiple PCI's/stent to circ/RCA
Hyperlipidemia
HTN
Cervical myelopathy
GERD
Schatzki's ring
Mohs surgery
Social History:
Married with three children and worked as a lawyer, rare alcohol
Family History:
NC
Physical Exam:
height 175.3cm weight 87.27 kg
Vital Signs:
98 51 148/88 14 100% RA
General: NAD
Mental/psych: A and O x 3
Airway: mallampati Class II
mouth opening adequate > 3cm
thyromental distance > 6 cm
hyomental distance > 3cm
mandibular prognatism adequate
Dental Good
HEENT: perrla, eomi full extension ofneck without pain and
supple without LAD
CARDS: RRR 1/6 SEM, no bruits
Lungs: CTAB
Abd: S, NT, ND
Ext no c/ce
other: anicteric, no thyromegally, L arm no sensory deficit.
active abduction to 120 deg, passive to 180 deg
Pulses: Fem [**Doctor Last Name **] DP PT
R 2+ 2+ - 2+
L 2+ 2+ - 2+
Pertinent Results:
[**2201-2-2**] 11:54PM GLUCOSE-111* UREA N-18 CREAT-1.2 SODIUM-138
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-19* ANION GAP-12
[**2201-2-2**] 11:54PM ALT(SGPT)-402* AST(SGOT)-492* ALK PHOS-35*
TOT BILI-2.8*
[**2201-2-2**] 11:54PM CALCIUM-9.8 PHOSPHATE-4.5# MAGNESIUM-1.3*
[**2201-2-2**] 11:54PM WBC-3.8*# RBC-3.61* HGB-11.7* HCT-31.3*
MCV-87 MCH-32.4* MCHC-37.3* RDW-15.5
[**2201-2-2**] 11:54PM PLT COUNT-147*#
[**2201-2-2**] 11:54PM PT-17.2* PTT-54.3* INR(PT)-1.6*
[**2201-2-2**] 11:54PM FIBRINOGE-184#
[**2201-2-2**] 11:49PM TYPE-MIX
[**2201-2-2**] 11:49PM O2 SAT-73
[**2201-2-2**] 11:42PM PO2-84* PCO2-47* PH-7.16* TOTAL CO2-18* BASE
XS--11
[**2201-2-2**] 11:42PM GLUCOSE-104 LACTATE-6.5*
[**2201-2-2**] 11:42PM O2 SAT-94
[**2201-2-2**] 11:42PM freeCa-1.26
[**2201-2-2**] 09:49PM HCT-28.7*
[**2201-2-2**] 09:49PM PT-18.3* PTT-58.8* INR(PT)-1.7*
[**2201-2-2**] 09:38PM HCT-7.3*#
[**2201-2-2**] 09:37PM TYPE-ART PO2-174* PCO2-40 PH-7.22* TOTAL
CO2-17* BASE XS--10
[**2201-2-2**] 09:37PM GLUCOSE-106* LACTATE-6.1* NA+-139 K+-3.3*
CL--114*
[**2201-2-2**] 09:37PM O2 SAT-98
[**2201-2-2**] 09:37PM freeCa-1.08*
[**2201-2-2**] 09:27PM CK(CPK)-2899*
[**2201-2-2**] 09:27PM CK-MB-48* MB INDX-1.7
[**2201-2-2**] 09:27PM MAGNESIUM-1.3*
[**2201-2-2**] 08:02PM TYPE-ART PO2-183* PCO2-47* PH-7.21* TOTAL
CO2-20* BASE XS--9
[**2201-2-2**] 08:02PM LACTATE-6.4*
[**2201-2-2**] 07:57PM GLUCOSE-152* UREA N-16 CREAT-1.2 SODIUM-142
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-19* ANION GAP-20
[**2201-2-2**] 07:57PM ALT(SGPT)-361* AST(SGOT)-364* CK(CPK)-[**2111**]*
ALK PHOS-31* AMYLASE-39 TOT BILI-1.5
[**2201-2-2**] 07:57PM LIPASE-48
[**2201-2-2**] 07:57PM CK-MB-30* MB INDX-1.6 cTropnT-0.06*
[**2201-2-2**] 07:57PM ALBUMIN-2.3* CALCIUM-9.1 PHOSPHATE-6.3*#
MAGNESIUM-1.4*
[**2201-2-2**] 07:57PM WBC-8.6 RBC-3.97*# HGB-12.5*# HCT-35.2*#
MCV-89 MCH-31.5 MCHC-35.6* RDW-14.9
[**2201-2-2**] 06:56PM PO2-108* PCO2-33* PH-7.30* TOTAL CO2-17* BASE
XS--8
[**2201-2-2**] 06:56PM GLUCOSE-130* LACTATE-7.3* NA+-137 K+-4.7
CL--113*
[**2201-2-2**] 06:56PM HGB-11.7* calcHCT-35
[**2201-2-2**] 06:56PM freeCa-0.94*
[**2201-2-2**] 06:20PM WBC-8.9 RBC-2.87* HGB-9.2* HCT-25.9* MCV-90
MCH-32.0 MCHC-35.5* RDW-14.7
[**2201-2-2**] 06:20PM PLT SMR-VERY LOW PLT COUNT-67*
[**2201-2-2**] 06:20PM PT-19.9* PTT-137.3* INR(PT)-1.9*
[**2201-2-2**] 06:19PM TYPE-ART PO2-70* PCO2-55* PH-7.22* TOTAL
CO2-24 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 06:19PM GLUCOSE-133* LACTATE-9.3* NA+-139 K+-5.3
CL--106
[**2201-2-2**] 06:19PM HGB-8.8* calcHCT-26
[**2201-2-2**] 06:19PM freeCa-1.00*
[**2201-2-2**] 05:51PM TYPE-ART PO2-66* PCO2-42 PH-7.12* TOTAL
CO2-15* BASE XS--15 INTUBATED-INTUBATED
[**2201-2-2**] 05:51PM GLUCOSE-140* LACTATE-7.6* NA+-135 K+-5.1
CL--113*
[**2201-2-2**] 05:51PM HGB-10.7* calcHCT-32
[**2201-2-2**] 05:51PM freeCa-1.06*
[**2201-2-2**] 04:40PM TYPE-MIX
[**2201-2-2**] 04:40PM O2 SAT-38
[**2201-2-2**] 04:33PM TYPE-ART PO2-265* PCO2-35 PH-7.27* TOTAL
CO2-17* BASE XS--9
[**2201-2-2**] 04:33PM GLUCOSE-125* LACTATE-7.2* K+-4.7
[**2201-2-2**] 04:33PM freeCa-1.10*
[**2201-2-2**] 04:03PM HCT-25.3*#
[**2201-2-2**] 03:12PM TYPE-ART PO2-189* PCO2-36 PH-7.24* TOTAL
CO2-16* BASE XS--11
[**2201-2-2**] 03:12PM LACTATE-4.7*
[**2201-2-2**] 03:12PM freeCa-1.12
[**2201-2-2**] 03:06PM GLUCOSE-115* UREA N-17 CREAT-1.0 SODIUM-141
POTASSIUM-4.5 CHLORIDE-118* TOTAL CO2-15* ANION GAP-13
[**2201-2-2**] 03:06PM estGFR-Using this
[**2201-2-2**] 03:06PM CALCIUM-6.7* PHOSPHATE-4.0 MAGNESIUM-1.6
[**2201-2-2**] 03:06PM WBC-10.7 RBC-3.67* HGB-12.0* HCT-34.4* MCV-94
MCH-32.6* MCHC-34.8 RDW-15.1
[**2201-2-2**] 03:06PM NEUTS-88.7* LYMPHS-7.0* MONOS-3.9 EOS-0.3
BASOS-0.2
[**2201-2-2**] 03:06PM PLT COUNT-119*
[**2201-2-2**] 03:06PM PT-18.2* PTT-61.6* INR(PT)-1.7*
[**2201-2-2**] 01:57PM TYPE-ART PO2-274* PCO2-33* PH-7.22* TOTAL
CO2-14* BASE XS--13 INTUBATED-INTUBATED
[**2201-2-2**] 01:57PM GLUCOSE-107* LACTATE-7.8* NA+-136 K+-4.3
CL--112
[**2201-2-2**] 01:57PM HGB-12.1* calcHCT-36
[**2201-2-2**] 01:57PM freeCa-1.10*
[**2201-2-2**] 01:32PM TYPE-ART PO2-315* PCO2-44 PH-7.10* TOTAL
CO2-14* BASE XS--15 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 01:32PM GLUCOSE-131* LACTATE-7.8* NA+-136 K+-4.9
CL--111
[**2201-2-2**] 01:32PM HGB-13.1* calcHCT-39
[**2201-2-2**] 01:04PM TYPE-ART PO2-163* PCO2-30* PH-7.26* TOTAL
CO2-14* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 01:04PM GLUCOSE-134* LACTATE-6.0* NA+-135 K+-3.6
CL--119*
[**2201-2-2**] 01:04PM HGB-10.6* calcHCT-32
[**2201-2-2**] 01:04PM freeCa-1.25
[**2201-2-2**] 12:29PM TYPE-ART PO2-175* PCO2-35 PH-7.27* TOTAL
CO2-17* BASE XS--9 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 12:29PM GLUCOSE-222* LACTATE-4.4* NA+-134* K+-4.3
CL--113*
[**2201-2-2**] 12:29PM HGB-12.3* calcHCT-37
[**2201-2-2**] 12:29PM freeCa-1.05*
[**2201-2-2**] 12:06PM TYPE-ART PO2-174* PCO2-54* PH-7.11* TOTAL
CO2-18* BASE XS--13
[**2201-2-2**] 12:06PM GLUCOSE-334* LACTATE-8.0* NA+-133* K+-3.7
CL--109
[**2201-2-2**] 12:06PM HGB-11.5* calcHCT-35
[**2201-2-2**] 12:06PM freeCa-1.05*
[**2201-2-2**] 11:53AM TYPE-ART PO2-158* PCO2-30* PH-7.41 TOTAL
CO2-20* BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 11:53AM GLUCOSE-112* LACTATE-3.5* NA+-134* K+-3.6
CL--109
[**2201-2-2**] 11:53AM HGB-12.1* calcHCT-36
[**2201-2-2**] 11:53AM freeCa-0.77*
[**2201-2-2**] 11:19AM TYPE-ART PO2-186* PCO2-38 PH-7.45 TOTAL
CO2-27 BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 11:19AM GLUCOSE-133* LACTATE-2.2* NA+-132* K+-3.8
CL--100
[**2201-2-2**] 11:19AM HGB-11.5* calcHCT-35
[**2201-2-2**] 11:19AM freeCa-0.97*
[**2201-2-2**] 08:52AM TYPE-MIX INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 08:52AM O2 SAT-79
[**2201-2-2**] 08:45AM TYPE-ART PO2-422* PCO2-40 PH-7.45 TOTAL
CO2-29 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-2-2**] 08:45AM GLUCOSE-115* LACTATE-1.5 NA+-135 K+-3.8
CL--98*
[**2201-2-2**] 08:45AM HGB-13.6* calcHCT-41
[**2201-2-2**] 08:45AM freeCa-1.12
Brief Hospital Course:
[**2-2**] Juxta renal AAA repair
The patient is a 79-year-old male with progressive increase in
size of his juxtarenal aneurysm now close to 6 cm. In addition,
he had some features that were
very concerning. He has "a double bubble sign" with two areas
of saccular-appearing aneurysm with very thin walls. We
discussed operation since endovascular repair would not be
possible even with fenestration. He understood the risk of
death, renal failure and intestinal damage due to the fact that
we would need to place the clamp above the visceral vessels.
requirement.
Intraoperatively the dissection proved to be very difficult and
there was a 50 min clamping time. Hemostasis was achieved and
due to the complex nature of the case, we just continued with
the patient intubated into the ICU and would give him volume
resuscitation and blood products as needed.
However in his immediate post-operative course Initially postop
he required a great deal of volume and was somewhat labile,
stabilized for a short period of
time with his lactate starting [**Doctor First Name **] come down from the 7 to 8
range down to the 4 range. However, then became more pressor
dependent and dropped his pressure even more. On Examination he
was much more distended and we decided to take him
urgently to the operating room for evacuation.
[**2-2**] take back for bleeding
The small bowel looked completely normal. The sigmoid was
somewhat dusky but the patient was on pressors at this time.
Dr.[**Last Name (STitle) **] from the General Surgery
Service evaluated the colon and did not think it needed to be
removed currently but since we were going to leave the patient
open and re-explore him the next day, or 48 hours, they could be
re-evaluated at that point. After we were able
to get all of the surgical bleeding that could be identified, we
re-examined the suture lines and there did not appear to be any
bleeding. The aorta where we placed the clamp was not bleeding.
The left renal artery was still patent with a
strongly palpable pulse. We then irrigated, placed several lap
pads in over the Surgicel, and then we were unable to get the
small bowel back into the peritoneum because of the distention.
We then used a [**State 19827**] patch we fashioned to
the skin circumferentially, cut some holes in the [**State 19827**] patch
and then created a suction sumping system with JP drains and
Ioban. The patient was then taken in critical condition to the
Intensive Care Unit with the plan to re-
explore the patient in the morning. At the time of transfer,
his pressor requirement had been cut in half and his acid- base
status had started to improve and he had started to make some
urine. The family was notified of the critical nature of the
situation.
Over that night the patient required very aggresive
resuscitation with massive transfusion requirments and fluids to
> 20L and lactates were stable elevated however he began to not
make urine. He also had evidence of compartment syndrome with an
open abdomen so was taken off of suction.
[**2-3**] Left colectomy
Due to his deteriorating circimstance he underwent
Re-exploration of abdominal aortic aneurysm surgery and left
colectomy for dead colon. The pt remained unstable in the CVICU
and a left IJ quentin was placed and CVVHD was started. he
remianed iun ajunctional ryhtym and was requiring three
pressors.
[**2-4**] resection of sigmoid and transverse colectomy
Due to the pt continuing to be labile and hight lactates with no
urine output
We Reopened the abdomen; drainage of intra-abdominal fluid;
resection of residual sigmoid colon and intraperitoneal rectum;
resection of a portion of
transverse colon.
[**2-5**] patient began to improve weaniung off of pressors and
stariting to make urine over the course of the day
[**2-6**] Colostomy placement
Removal of packs, placement of colostomy and
partial closure of fascia with mesh.
[**2-8**] Pt's wound was tightned at the bedside by [**2-13**] pt was ready
to have wound closed and vac dressing placed. Pt continued to
improve however was deemed that he would be vent dependent for a
while so underwent a perc trach placement on [**2-17**]
[**2-17**] PERC TRACH
By [**2-27**] patient was off all pressor
By [**2-28**] Creat was down to 2.5 and pt off of HD
On [**3-1**] patient was started on Acyclovir for preseumed herpetic
rash over face and eyes. He was also weaned to trach collar
[**3-2**] passy muir valve placed PT BEGAN COMMUNICATING
[**3-4**] creat down to 1.9
[**3-6**] taking in PO
[**3-7**] tolerating ensure shakes
[**3-8**] coag + staph from sputum chnged to nafcillin; Optho stopped
acyclovir and switched to e-mycin
[**3-9**] ready for rehab
3/3-5 pt spiked temp and also experienced a drop in SBP. Was
given IVF. Sputum culture revealed MSSA and pansens Klebsiella.
Dobhoff placed.
[**Date range (1) 81346**] Tube Feeds/ground diet. Sat->resp acidosis->back on
rate. *Klebsiella PNA/MSSA->#2 Zosyn([**3-13**])
[**3-15**] Dobhoff replaced
Medications on Admission:
ASA 325'
HCTZ 25'
Univasc 15'
Prilosec 20'
Plavix 75'
Pravastatin 20'
Aldactone 12.5'
Toprol XL 25'
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic Q2H (every 2 hours) as needed for per
opthamology.
13. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)).
14. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1)
Intravenous PRN (as needed).
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed) as needed for mag<2.
17. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed.
18. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25g
Recon Solns Intravenous Q6H (every 6 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab
Discharge Diagnosis:
AAA repair
c/b intestinal ischemia
prolonged intubation
Discharge Condition:
stable
Discharge Instructions:
please call if patient is febrile to >101.2 begins to have
nausea/vomiting unbale to tolerate PO or begins to have
hematemesis and/or blood from ostomy. Please also call for
decreased ostomy output. Please inform if pt becomes unable to
ventilate, or is failing prolonged periods of trach mask. Call
for any questions.
Followup Instructions:
f/u with opthamology at [**Hospital **] rehab
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2201-4-21**] 2:00
Please call Dr. [**Last Name (STitle) **] for Appointment for follow up
|
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[
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[
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|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,993
| 123,160
|
2328
|
Discharge summary
|
report
|
Admission Date: [**2175-9-28**] Discharge Date: [**2175-10-2**]
Date of Birth: [**2092-8-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Shellfish Derived
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old female with stage IV gastric adenocarcinoma with
recent PE diagnosis who presents with shortness of breath and
decreased abdominal Pleurx drainage.
.
She was recently admitted [**2175-9-11**] to [**2175-9-14**] with atrial flutter
and shortness of breath. She was treated for atrial flutter
with a diltiazem drip and then oral diltiazem. She also was
initially heparinized for her PE but per the discharge summary,
frequent blood draws or injections would not be consistent with
her goals of care and anticoagulation was discontinued. She
also had a Pleurx abdominal catheter placed for palliation due
to recurrent ascites.
.
She reports having intermittent abdominal pain around the site
of the Pleurx since discharge. She then had progressive
shortness of breath over the last 2-3 days which worsened this
AM and prompted her to present to the ED. She also reports that
her VNA went to drain her Pleurx today which didn't drain as
much as usual and this worried her. She does report pleuritic
left sided chest pain with deep inspiration but no baseline
chest pain. She has felt weak for the last several weeks. 20
lb weight loss since [**Month (only) 116**]. Denies current abdominal pain,
nausea, vomiting, or change in BM. Does report frequent
burping. Also has new bedsore. She can walk only with
assitance. Her Pleurx is drained every other day, about 1.5-2L
at a time. Endorses low appetite.
.
In the ED, she was found to be in Afib with RVR with HR 150's.
She also complained of abdominal pain. CTA chest and abdomen
were performed which confirmed PE but also showed gas in the
peritoneum. Surgery was consulted for the gas pattern. She was
given vancomycin, cefepime, and levofloxacin. She was given
10mg IV dilt x 2 for RVR. She was started on a heparin drip.
She was guaiac negative. Last vitals 97.8 113 90/48 20 99%RA.
She was confirmed DNR/DNI.
.
On arrival to the MICU, she reports feeling fatigued and mildly
SOB. Denies other symptoms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough or wheezing.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Gastric adenocarcinoma, stage IV, not treated
Hypertension
Hypercholesterolemia
Atrial flutter, on coumadin in the past
Ocular hypertension
Hyponatremia
Social History:
denies EtOH, tobacco, or illegal drugs
Family History:
The patient's granddaughter recently died of colon cancer at 36
years. Her father died of an MI in his 70s. Her mother died of
CHF in her 90s. She has one sister who has allergies and history
of scarlet fever. She has 12 children, 11 currently living.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Lethargic but arousable and oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry with mild thrush,
otherwise oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Irregularly irregular without no murmurs, rubs, gallops
Lungs: Scant crackles at the bases with decreased breath sounds
throughout
Abdomen: Firm with palpable masses throughout abdomen consistent
with known peritoneal metastases, no rebound/guarding. Pleurx
in place in LUQ. BS+
GU: Foley in place
Ext: Warm, well perfused with dependent pitting edema but no
calf swelling or tenderness, 1+ pulses palpable
FEX ON DISCHARGE
VS: 96.2 102/50 78 16 99% 3LNC
Gen: chronically ill appearing, cachectic
HEENT: EOMI, dry MM
Neck: supple, no cervical
CV: irreg irreg, no mrg, nls1s2
Pulm: decreased breath sounds at b/l bases with overlying
crackles
Abd: distended, non tender, distent bowel sounds, no rebound
Ext: right LE cooler than left +2 DP pulses, [**1-15**]+ edema to knees
b/l
Pertinent Results:
LABS:
On admission:
[**2175-9-28**] 12:25PM BLOOD WBC-7.7 RBC-5.06 Hgb-14.1 Hct-42.5 MCV-84
MCH-27.9 MCHC-33.2 RDW-15.2 Plt Ct-236
[**2175-9-28**] 12:25PM BLOOD Neuts-84.1* Lymphs-12.1* Monos-3.1
Eos-0.6 Baso-0.2
[**2175-9-28**] 12:25PM BLOOD Glucose-114* UreaN-21* Creat-0.8 Na-130*
K-5.8* Cl-97 HCO3-22 AnGap-17
[**2175-9-29**] 01:00AM BLOOD ALT-11 AST-7 AlkPhos-17* TotBili-0.0
[**2175-9-28**] 12:25PM BLOOD cTropnT-<0.01
[**2175-9-29**] 01:00AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0
[**2175-9-28**] 12:46PM BLOOD Lactate-2.5*
Pertinent labs:
IMAGING:
CXR: Interval development of moderate-to-large left pleural
effusion
and persistent small right pleural effusion with bibasilar
airspace opacities, likely atelectasis though infection is not
excluded. Mild pulmonary vascular congestion.
CT chest/abd/pelvis:
1. Interval development of hyperenhancement and thickening of
the peritoneum with large volume loculated ascites raises
concern for peritonitis. Presence of gas within peritoneum could
be due to indwelling catheter though gas forming organism cannot
be excluded. This finding was discussed with [**First Name5 (NamePattern1) 12132**] [**Last Name (NamePattern1) 12133**]
at 19:24 on [**2175-9-28**] by [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone.
2. Small bowel wall thickening likely reactive given the concern
for infected peritoneal fluid. No bowel obstruction.
3. Unchanged bilateral pulmonary emboli.
4. Increased bilateral pleural effusions with associated lower
lobe consolidation, likely reflects atelectasis and aspiration.
5. Extensive peritoneal carcinomatosis.
Urine:
[**2175-9-29**] 02:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.047*
[**2175-9-29**] 02:20AM URINE Hours-RANDOM UreaN-402 Creat-36 Na-14
K-39 Cl-38
[**2175-9-29**] 02:20AM URINE Osmolal-386
[**2175-9-29**] 02:24PM ASCITES WBC-825* RBC-3325* Polys-65* Lymphs-7*
Monos-21* Macroph-7*
Ascites
[**2175-9-29**] 02:24PM ASCITES LD(LDH)-273 Albumin-LESS THAN
Microbiology
[**2175-9-29**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS
GROUP} INPATIENT
[**2175-9-29**] URINE URINE CULTURE-FINAL {YEAST}
INPATIENT
[**2175-9-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2175-9-28**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
Brief Hospital Course:
83 year old female with stage IV gastric adenocarcinoma who
presents with worsening shortness of breath, atrial fibrillation
with RVR, and pneumoperitoneum.
.
#. Shortness of Breath/Pulmonary Embolus: shortness of breath
and pleuritic chest pain likely related to known PE, confirmed
on CTA. She was mildly hypoxic (92% on RA) but in no
respiratory distress. After discussion with the patient and her
family, they opted to start anticoagulation (they had reportedly
declined last admission). Lovenox was started and provided to
patient upon discharge.
.
#. Atrial fibrillation with RVR: HR to 150s in the ED, given
10mg IV dilt x 2 and 30mg po dilt with some response (HR
decreased to 120s). In the MICU she was continued on home
diltiazem 90mg po qid with PRN IV dilt for rate control as well
as fluids. Anticoagulation as above.
.
#. Pneumoperitoneum/non-draining pleurex: Found to have locules
of gas within ascites on abdominal CT scan, which was initially
felt to be due to catheter placement rather than perforation
given her benign abdominal exam. A small amount of ascitic
fluid was sampled and showed 825 WBCs (65% polys), cultures were
sent, and she was started on vancomycin and ceftriaxone for
presumed bacterial peritonitis. Culture grew bacteroides
fragilis. IR re-examined the CT abdomen, and felt that the
pleurex catheter looked like it had been placed through her
colon. Therefore they say that they cannot pull the catheter for
it will leave two open holes in her colon in communication with
her peritoneum. Therefore, they said, that a functional study
of it is not worth while. The IR attending advised the ACS
attending, and decision to leave catheter in place was discussed
with family. On the floor, patient was switched to cipro and
flagyl prior to discharge.
.
#. Stage IV Gastric Adenocarcinoma: Focusing on palliation
currently as has extensive disease. Remeron was started to help
stimulate appetite.
.
#. Hyponatremia: At recent baseline. Thought to be possibly
exacerbated by poor po intake and patient was provided IVF's.
.
#. Elevated lactate: Had to lactate 2.5, trended down to 1.8 on
recheck.
OUTSTANDING STUDIES
-None
TRANSITIONAL ISSUES
-Discharged to home hospice
Medications on Admission:
Lorazepam 0.5mg po q6h prn
Omeprazole 20mg po daily
Oxyocodone 5-10mg po q4-6h prn
Oxycontin 10mg po q12h
Pravastatin 40mg po daily
Prochlorperazine 10mg po q8h prn nausea
Timolol 0.5% ophthalmic [**Hospital1 **]
Triamcinolone 0.1% ointment topical [**Hospital1 **]
Tylenol 500mg po q6h prn pain
Docusate 100mg po bid
Bisacodyl 10mg pr prn constipation
Miralax 17g [**1-15**] packet po daily prn constipation
Senna 8.6mg po bid prn constipation
NaCl 0.65% spray nasally twice daily
Zofran 4mg po q8h prn nausea
Diltiazem ER 360mg po daily
Discharge Medications:
1. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q24H (every 24 hours).
Disp:*qs 2 weeks* Refills:*4*
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every twelve (12) hours.
6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
application Topical twice a day as needed for rash.
10. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
14. sennosides 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry nose.
16. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
17. Diltzac ER 360 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
18. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Take to increase appetite.
Disp:*30 Tablet(s)* Refills:*2*
19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary: Abdominal pain
Secondary: Metastatic gastric adenocarcinoma
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:
Dear Ms. [**Known lastname 12129**],
You were admitted to the hospital because you had decreased
output from your pleurX catheter and abdominal pain. A CT scan
of your belly was concerning for either perforation of your
colon or the catheter lying very close to the colon. However,
since your abdominal pain got better and you didn't have any
fevers we decided the best approach was to not disturb the
catheter, which you can continue to use. We will give you some
antibiotics for the next several days to help prevent infection.
Additionally, your heart rate was noted to be high and in an
abnormal rhythm called atrial fibriallation. We provided you
with a continous drip of medicine to slow your heart rate, and
it resolved. We will continue on medicine to help control your
heart rate.
Please note the following medication changes:
START Ciprofloxacin 500mg twice daily through [**10-8**]
START Flagyl: 500mg three times a day [**10-8**]
START Lovenox 90mcg once daily indefinitely
START Mirtazipine 15mg every evening to help your appetite
Followup Instructions:
Please follow up with your outpatient [**Month/Year (2) 5564**], Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1852**], as needed.
Phone: ([**Telephone/Fax (1) 12134**]
Additionally, note the following appointments that have already
been scheduled.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2175-11-14**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2175-11-29**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"197.6",
"276.1",
"789.51",
"415.19",
"568.89",
"151.9",
"V58.61",
"401.9",
"V66.7",
"V49.86",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11570, 11621
|
6623, 8838
|
322, 328
|
11735, 11735
|
4222, 4229
|
12983, 13908
|
2932, 3185
|
9428, 11547
|
11642, 11714
|
8864, 9405
|
11911, 12730
|
3225, 4203
|
2362, 2682
|
12750, 12960
|
267, 284
|
356, 2343
|
4243, 4751
|
11750, 11887
|
4768, 6600
|
2704, 2859
|
2875, 2916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,827
| 148,845
|
37632
|
Discharge summary
|
report
|
Admission Date: [**2135-8-3**] Discharge Date: [**2135-8-11**]
Date of Birth: [**2081-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Accupril / Penicillins / Zyrtec / Zarontin / Codeine / Percocet
/ Demerol / Zaroxolyn / Zantac
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
recurrent angina
Major Surgical or Invasive Procedure:
[**2135-8-4**] Coronary artery bypass graft x 3 (LIMA to LAD,saphenous
vein graft to ramus, saphenous vein graft to second obtuse
marginal)
History of Present Illness:
53 yo man with 8 years of chest pain.
Was cathed 8 yrs ago and found to have single vessel disease.
No
intervention at that time. Over the past year his angina has
worsened and is now associated with SOB even at minimal
exertion.
He has cathed at [**Hospital 5279**] hospital and then refered to [**Hospital1 18**] for
surgical intervention.
Past Medical History:
DM, CRI, HTN, gout, BPH, arthritis, sleep
apnea, anxiety, depression, B corneal implants, cryotherapy for
diabetic retinopathy, remote h/o ribs fracture/fractured toes on
right foot/fractured right shoulder/fractured right leg, s/p pin
placement in right leg for fracture, s/p toe amputations on
right
foot.
Social History:
lives with wife
retired materials handler
smoked for 5 yrs, quit 30 yrs ago
ETOH : quit 25 yrs ago
Family History:
non-contributory
Physical Exam:
Pulse: 79 Resp: 12 O2 sat:
B/P Right: 116/45 Left:
Height: 5'7" Weight:230 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]thick neck
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]Hard,distended, +bowel sounds, patient says belly hard
normally
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[x]Extremities cool, good cap refill
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+1
Carotid Bruit Right: - Left:-
Pertinent Results:
[**2135-8-3**] 05:40PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2135-8-3**] 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2135-8-3**] 08:05PM PT-12.3 PTT-21.2* INR(PT)-1.0
[**2135-8-3**] 08:05PM PLT COUNT-387
[**2135-8-3**] 08:05PM WBC-6.9 RBC-3.61* HGB-11.0* HCT-32.8* MCV-91
MCH-30.4 MCHC-33.4 RDW-13.6
[**2135-8-3**] 08:05PM %HbA1c-8.1*
[**2135-8-3**] 08:05PM ALBUMIN-4.3
[**2135-8-3**] 08:05PM ALT(SGPT)-20 AST(SGOT)-25 LD(LDH)-223 ALK
PHOS-90 AMYLASE-43 TOT BILI-0.2
[**2135-8-3**] 08:05PM GLUCOSE-342* UREA N-51* CREAT-1.8* SODIUM-136
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2135-8-10**] 06:08AM BLOOD WBC-7.6 RBC-2.78* Hgb-8.4* Hct-26.0*
MCV-93 MCH-30.1 MCHC-32.2 RDW-13.8 Plt Ct-447*
[**2135-8-10**] 06:08AM BLOOD Plt Ct-447*
[**2135-8-8**] 03:20AM BLOOD PT-12.4 PTT-24.7 INR(PT)-1.0
[**2135-8-11**] 07:07AM BLOOD UreaN-61* Creat-1.7* K-4.2
[**2135-8-8**] 03:20AM BLOOD ALT-49* AST-42* AlkPhos-86 Amylase-18
TotBili-0.2
Conclusions
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with anterior and septal apical hypokinesis. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen. No mitral
regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. Bi ventricular function is unchanged.
2. Aortic contour appears intact post decannulation.
3. Other findings are unchanged.
Dr. [**Last Name (STitle) 65203**] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2135-8-4**] 15:21
Radiology Report CHEST (PORTABLE AP) Study Date of [**2135-8-7**]
9:23 AM
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p cabg
Final Report
REASON FOR EXAMINATION: Followup of the patient after CABG.
Portable AP chest radiograph was compared to [**2135-8-6**].
The left subclavian line tip is at the level of cavoatrial
junction. The mid sternotomy wires are intact. The
cardiomediastinal silhouette is stable with some additional
decrease in the mediastinal widths. The left retrocardiac
opacity is unchanged accompanied by small amount of pleural
effusion and most likely represent atelectasis, although
infection cannot be entirely excluded.
Right basal atelectasis is unchanged. There is no pneumothorax.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
Transferred in from OSH on [**8-3**] and pre-op w/u completed.
Underwent surgery with Dr. [**Last Name (STitle) 914**] on [**8-4**]. Tolerated the
operation well, please see OR report for details in summary had
CABGx3 with left internal mamary artery to left anterior
decending artery, saphenous vein graft to ramus artery,
saphenous vein graft to obtuse marginal artery. His bypass time
was 94 minutes with crossclamp of 73 minutes. He was transferred
to the CVICU in stable condition on phenylephrine and propofol
drips. He did well in immediate post-op period and extubated
later that evening. Required additional respiratory toilet and
blood glucose management so remained in the unit for 2
additional days. Transferred to the floor on POD #5. Over the
next several days his activity level was gradually advanced and
on POD 7 he was transferred to Rehabilitation at [**Doctor Last Name 84413**]Healthcare Center in [**Location (un) 5450**] NH.
Medications on Admission:
allopurinol 300, tylenol for arthritis pain,
ASA 325, lipitor 40, cilostazol 100 [**Hospital1 **], colchicine 0.6, nexium
20, pepcid 20, [**Doctor First Name 130**] 180, naserel 2 sprys [**Hospital1 **], gemfibrozil 600
[**Hospital1 **], HCTZ 25, levemir 52 u in AM and 50 u in PM, Humalog sliding
scale, lorazepam 1 HS, toprol XL 400, provigil 200 HS, flomax
0.4, torsemide 5 [**Hospital1 **], diovan 80, venlafaxine 150 [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q4H (every 4 hours) as
needed for wheezing.
19. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
20. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
22. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
23. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
25. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
26. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous q ac&hs.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **]Healthcare Center
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery bypass graft x 2
PMH: Diabetes Mellitus, Chronic Renal Insufficiency,
Hypertension, Gout, Benign Prostatid Hypertrophy, Arthritis,
sleep apnea, anxiety, depression, B corneal implants,
cryotherapy for diabetic retinopathy, remote h/o ribs
fracture/fractured toes on right foot/fractured right
shoulder/fractured right leg, s/p pin placement in right leg for
fracture, s/p toe amputations on right foot
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) You should wash incision daily with soap and water. No
lotions creams or powders to incision until it has healed. No
bathing or swimming for 6 weeks.
5) No lifting more then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 4 weeks [**Telephone/Fax (1) 1504**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in [**12-28**] weeks [**Telephone/Fax (1) 84379**]
Dr. [**First Name4 (NamePattern1) 2092**] [**Last Name (NamePattern1) 18910**] in 6 weeks [**Telephone/Fax (1) 84414**]
please call to schedule all appointments
Completed by:[**2135-8-11**]
|
[
"V49.72",
"799.02",
"600.00",
"584.9",
"458.29",
"362.01",
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"300.4",
"250.73",
"414.01",
"V58.67",
"433.10",
"274.9",
"250.63",
"403.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
8858, 8925
|
5145, 6095
|
376, 518
|
9415, 9422
|
2113, 4393
|
10084, 10518
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|
6585, 8835
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4433, 5122
|
8946, 9394
|
6121, 6562
|
9446, 10061
|
1388, 2094
|
320, 338
|
546, 891
|
913, 1223
|
1239, 1339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,187
| 164,446
|
47679
|
Discharge summary
|
report
|
Admission Date: [**2150-5-5**] Discharge Date: [**2150-5-13**]
Date of Birth: [**2084-9-11**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / Percodan
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T10-L1 anterior fusion
T10-L2 posterior fusion
History of Present Illness:
Ms. [**Known lastname 100712**] has a long history of back pain and has undergone
a previous lumbar fusion. She has a disk herniation above the
level of her previous fusion and now presents for revision
thoracolumbar fusion.
Past Medical History:
Anxiety, Arthritis: Lumbar, right knee, Depression, Diabetes,
High cholesterol, Vit D deficiency, Sciatica
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
+ anterior thigh pain on the right
Pertinent Results:
[**2150-5-10**] 10:55AM BLOOD Hct-27.7*
[**2150-5-8**] 11:00AM BLOOD WBC-10.4 RBC-3.29* Hgb-8.6* Hct-28.6*
MCV-87 MCH-26.2* MCHC-30.2* RDW-14.0 Plt Ct-230
[**2150-5-6**] 05:45PM BLOOD Hct-32.0*
[**2150-5-6**] 05:22AM BLOOD WBC-7.3 RBC-4.04* Hgb-10.4* Hct-35.0*
MCV-87 MCH-25.6* MCHC-29.6* RDW-14.3 Plt Ct-254
[**2150-5-10**] 10:55AM BLOOD Glucose-154* UreaN-9 Creat-0.7 Na-142
K-4.1 Cl-99 HCO3-35* AnGap-12
[**2150-5-8**] 11:00AM BLOOD Glucose-153* UreaN-7 Creat-0.8 Na-139
K-3.7 Cl-102 HCO3-33* AnGap-8
Brief Hospital Course:
Ms. [**Known lastname 100712**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2150-5-5**] and taken to the Operating Room for:
1. Partial vertebrectomy of T10, T11, T12 and L1.
2. Fusion T10 to L2.
3. Instrument anterior spacers x 3.
4. Autograft bone morphogenic protein and allograft.
Please refer to the dictated operative note for further details.
The surgery was without complication and the patient was
transferred to the PACU in a stable condition. TEDs/pnemoboots
were used for postoperative DVT prophylaxis. Intravenous
antibiotics were given per standard protocol. Initial postop
pain was controlled with a PCA. On HD#2 she returned to the
operating room for:
1. T12 osteotomy.
2. Multiple thoracic laminotomies from T10 to T12.
3. Fusion T10 to L4.
4. Application of instrumentation T10 to L2.
5. Removal of previous instrumentation.
6. Autograft.
7. Epidural catheter placement.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and the patient
was transferred to the PACU in a stable condition. Postoperative
HCT was low and she was transfused PRBCs with good effect. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one. She
was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#3
from the second procedure. She was fitted with a TLSO brace for
ambulation. Physical therapy was consulted for mobilization OOB
to ambulate. Hospital course was otherwise unremarkable. On the
day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
bupropion HCl
150 mg Tablet Extended Release
1 Tablet(s) by mouth twice a day
buspirone
15 mg Tablet
3 Tablet(s) by mouth three times a day
diazepam 5 mg Tablet [**12-29**] Tablet(s) by mouth three times a day
diclofenac sodium 75 mg Tablet, Delayed Release (E.C.) 1
Tablet(s) by mouth three times a day
fluocinonide 0.05 % Cream apply twice daily
gabapentin 800 mg Tablet
1 (One) Tablet(s) by mouth three times a day.
hydrocodone-acetaminophen 7.5 mg-500 mg Tablet
one Tablet(s) by mouth four times a day
metformin 500 mg Tablet
1 Tablet(s) by mouth twice a day
trazodone 100 mg Tablet
1 Tablet(s) by mouth at bedtime
venlafaxine 150 mg Capsule, Ext Release 24 hr
1 Capsule(s) by mouth once a day
calcium
multivitamin
omega-3 fatty acids-vitamin E (Fish Oil)
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
4. buspirone 10 mg Tablet Sig: 4.5 Tablets PO TID (3 times a
day).
5. diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for spasms.
Disp:*60 Tablet(s)* Refills:*0*
6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
9. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release(s)* Refills:*2*
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
12. fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Segmental disc degeneration T12-L1
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to inspect the incisions daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2150-5-29**]
|
[
"788.20",
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] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
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icd9pcs
|
[
[
[]
]
] |
5854, 5928
|
1870, 3670
|
293, 342
|
6007, 6014
|
1342, 1847
|
8167, 8247
|
768, 773
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5949, 5986
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|
788, 1323
|
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8096, 8144
|
6180, 6373
|
244, 255
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6409, 6876
|
6888, 7988
|
370, 597
|
619, 727
|
743, 752
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,292
| 192,141
|
13873
|
Discharge summary
|
report
|
Admission Date: [**2150-6-23**] Discharge Date: [**2150-7-1**]
Date of Birth: [**2092-8-23**] Sex: M
Service: CARD [**Doctor First Name 147**]
CHIEF COMPLAINT: For cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
male with a history of hypertension, hyperlipidemia, and a
family history of coronary artery disease who comes in for
cardiac catheterization due to atypical anginal symptoms and
a positive stress echocardiogram.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hiatal hernia.
3. Hypothyroidism.
4. Spastic colon.
5. Carpal tunnel syndrome.
6. Arthritis.
7. Coronary artery disease.
8. Raynaud's.
PAST SURGICAL HISTORY:
1. Right knee replacement times two.
SOCIAL HISTORY: The patient is married. He smoked two
palpated for 20 years and quit 15 years ago.
ALLERGIES: None known.
MEDICATIONS ON ADMISSION:
1. Enteric-coated aspirin 325 mg q. day.
2. Lipitor 10 mg q. day.
3. Protonix 40 mg q. day.
4. Toprol XL 12.5 mg q. day.
5. Xanax 0.25 mg four times a day p.r.n.
6. Synthroid 0.25 mg q. day.
7. Folate 1 mg q. day.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Medicine Service and underwent a cardiac catheterization on
[**2150-6-23**], which revealed a LAM 50%, left anterior
descending 70%, right coronary artery 40% with a normal
ejection fraction. Cardiac Surgery was consulted and the
decision to operate was made.
The patient was taken to the Operating Room on [**2150-6-25**],
and underwent coronary artery bypass graft times three, with
left internal mammary artery to left anterior descending,
saphenous vein graft to obtuse marginal 1 to ramus. He
tolerated the procedure well.
While coming off the BIPAP he had multiple episodes of
ventricular fibrillation/ventricular tachycardia for which he
had to be defibrillated. He went back on BIPAP to check the
grafts, which were found to be patent. He was started on
amiodarone infusion and came off BIPAP subsequently. He was
taken to the CSICU in intubated condition. He was extubated
on postoperative day zero.
He was hemodynamically stable at this point. He continued to
do well subsequently and he was hemodynamically stable. He
was transferred to the Floor on postoperative day three in
stable condition. His pacing wires were discontinued on
postoperative day four. His subsequent hospital course was
uneventful. He ambulated well and his pain was well
controlled with p.o. analgesics. He was discharged home on
[**2150-7-1**], in stable condition.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q. day for one week.
2. KCl 20 mEq q. day times one week.
3. Colace 100 mg twice a day.
4. Enteric-coated aspirin 325 mg q. day.
5. Levothyroxine 25 micrograms q. day.
6. Lipitor 10 mg q. day.
7. Protonix 40 mg q. day.
8. Amiodarone 400 mg q. day.
9. Lopressor 25 mg twice a day.
10. Percocet one to two tablets q. four to six hours p.r.n.
DISCHARGE INSTRUCTIONS:
1. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4468**]
[**Last Name (NamePattern1) 41594**], in two weeks.
2. Follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2150-7-9**] 16:25
T: [**2150-7-10**] 09:13
JOB#: [**Job Number 41595**]
|
[
"443.0",
"414.01",
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"401.9",
"427.1",
"716.90",
"997.1",
"V15.82",
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icd9cm
|
[
[
[]
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[
"38.93",
"36.15",
"88.56",
"88.48",
"88.72",
"39.61",
"36.12",
"88.53",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
2559, 2929
|
885, 1107
|
1126, 2533
|
2953, 3467
|
691, 730
|
179, 209
|
239, 482
|
504, 668
|
748, 859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,418
| 102,465
|
15581
|
Discharge summary
|
report
|
Admission Date: [**2126-9-10**] Discharge Date: [**2126-9-17**]
Date of Birth: [**2054-8-31**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 45065**] is a 71-year-old
female with a history of cerebrovascular accident in [**2106**] and
[**2122**], and a history of bradycardia and syncope. She also has
a history of hypertension and hypercholesterolemia, without
previously-documented coronary artery disease. In [**2126-3-27**], she had an echocardiogram performed for the evaluation
of her bradycardia and syncope. The echocardiogram at the
time showed a left ventricular ejection fraction of 60 to
65%, with normal wall thickness and normal regional wall
motion.
Approximately one to two months prior to admission, the
patient developed new-onset substernal chest pain that
radiated to her back and often awakened her from sleep. The
chest pain was often accompanied by diaphoresis and shortness
of breath. It would resolve spontaneously after
approximately one hour.
In [**2126-7-28**], the patient had a MIBI performed. She
developed her typical chest pain with ST segment changes as
well as dyspnea. The imaging further showed significant
anterior, septal and inferior ischemia. The patient also had
a Holter monitor placed at that time. Her chest pain
recurred at the end of [**2126-7-28**] at rest, lasting
approximately an hour. She was referred to a cardiologist
for evaluation and cardiac catheterization. The cardiac
catheterization was performed on [**2126-8-27**]. It revealed left
main coronary artery 60% stenosis, 50% proximal left anterior
descending stenosis, 95% left circumflex artery stenosis, as
well as 80% stenosis of the first obtuse marginal artery.
The left ventricular ejection fraction was estimated at 60%.
PAST MEDICAL HISTORY:
1. Three vessel coronary artery disease
2. History of cerebrovascular accidents in [**2106**] and [**2122**]
3. History of bradycardia and syncope
4. Hypertension
5. Hypercholesterolemia
6. Obesity
7. Peripheral vascular disease
MEDICATIONS ON ADMISSION:
1. Norvasc 2.5 mg once a day
2. Uniretic 7.5 mg once a day
3. Lipitor 20 mg once a day
4. Meclizine 12.5 mg once a day
5. Aspirin 325 mg once a day
6. Sublingual nitroglycerin as needed
7. Lorazepam one pill daily at bedtime as needed
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother died from myocardial infarction and
also family history of cerebrovascular accidents.
SOCIAL HISTORY: Denies use of alcohol or tobacco.
PHYSICAL EXAMINATION: Afebrile, heart rate 71, blood
pressure 144/75, weight 68 kg. General: Well-nourished,
elderly female, in no apparent distress. Skin: Within
normal limits. Head, eyes, ears, nose and throat: Within
normal limits, no jugular venous distention, no bruits.
Respiratory: Clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm, normal S1 and S2, no murmurs, rubs.
Abdomen: Very mild tenderness in the left lower quadrant,
otherwise soft, nontender, nondistended, with hypoactive
bowel sounds, no hepatosplenomegaly. Extremities: Warm and
well perfused. Pulses present bilaterally, upper and lower
extremities. Varicosities: None. Neurologic examination:
Grossly nonfocal. There is weakness of the right upper
extremity and also right lower extremity noted.
LABORATORY DATA: Hematocrit 39.5, white blood cell count
8.8, platelets 488. Glucose 83, BUN 11, creatinine 1.0,
sodium 139, potassium 3.4. ALT 16, AST 19, alkaline
phosphatase 93, total bilirubin 0.5. Electrocardiogram
performed on [**2126-9-5**] showed sinus rhythm with heart rate of
66. The ST segment abnormalities were recorded in Leads I,
AVL and V4 through V6.
HOSPITAL COURSE: The patient had a cardiac catheterization
performed in [**2126-8-27**] at the outside facility, which
showed three vessel coronary artery disease with acceptable
left anterior descending, diagonal and an occluded obtuse
marginal target. She was referred and accepted for coronary
artery bypass grafting. She was consequently admitted to
Cardiac Surgery service.
On [**2126-9-10**], the patient underwent coronary artery bypass
grafting x 3, with left internal mammary artery to left
anterior descending, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal. The patient
tolerated the procedure well. There were no complications.
The total cardiopulmonary bypass time was 69 minutes, and
aortic cross-clamp time was 46 minutes.
The patient was transferred to the Intensive Care Unit in
fair condition. She remained intubated. The patient
remained in sinus rhythm with stable blood pressure. She was
adequately diuresed. The patient was extubated on the same
day without any complications. The patient was briefly on
the insulin pump for elevated blood glucose levels. She was
maintained on Lopressor. Perioperative antibiotics were
administered.
On postoperative day two, the patient was transferred to the
regular floor in stable condition. Soon thereafter, she
experienced atrial fibrillation with heart rate in the 130s
to 140s. She was treated with intravenous Lopressor and also
amiodarone. She was started on oral amiodarone as well as a
standing dose. Her chest tube was removed. Her central line
was removed. Her urine catheter was removed.
The patient reverted to sinus rhythm several hours later on
postoperative day two. She otherwise remained stable.
Physical Therapy was consulted, which followed the patient
during her hospitalization, and eventually cleared the
patient to go home. The patient was ambulating with
assistance. She remained largely asymptomatic. Supplemental
oxygen was weaned off. Her incision was clean, dry and
intact. Her lungs were clear to auscultation bilaterally.
The patient experienced another episode of atrial
fibrillation on postoperative day five, which was treated
with intravenous Lopressor. She converted to sinus rhythm
again within 24 hours. The patient was discharged to home on
postoperative day seven, on [**2126-9-17**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DESTINATION: Home.
DISCHARGE DIAGNOSIS:
1. Three vessel coronary artery disease status post coronary
artery bypass grafting
2. Hypertension
3. Atrial fibrillation
4. Peripheral vascular disease
5. Hypercholesterolemia
6. Obesity
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg by mouth once daily
2. Lasix 20 mg by mouth twice a day for seven days
3. Potassium chloride 20 mEq by mouth twice a day for seven
day
4. Amiodarone 400 mg by mouth once daily for 30 days
5. Colace 100 mg by mouth twice a day as needed for
constipation
6. Percocet one to two tablets by mouth every four to six
hours as needed for pain
7. Aspirin 325 mg by mouth once daily
8. Lopressor 50 mg by mouth twice a day
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. The patient is to have VNA services for wound check,
blood pressure and heart rate checks, as well as medication
checks.
2. The patient is to see Dr. [**Last Name (Prefixes) **], her surgeon, in
approximately four weeks.
3. The patient is to see Dr. [**Last Name (STitle) 41364**], her cardiologist, in
approximately two to three weeks.
4. The patient is to see her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in approximately one to two weeks.
5. The patient is to receive outpatient occupational therapy
as instructed.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2126-9-18**] 20:32
T: [**2126-9-19**] 00:00
JOB#: [**Job Number 45066**]
|
[
"997.1",
"427.31",
"401.9",
"443.9",
"272.0",
"278.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2393, 2487
|
6364, 7685
|
6145, 6341
|
2095, 2376
|
3737, 6061
|
2562, 3215
|
177, 1810
|
3239, 3719
|
1832, 2069
|
2504, 2539
|
6086, 6124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,347
| 197,101
|
19177
|
Discharge summary
|
report
|
Admission Date: [**2135-9-21**] Discharge Date: [**2135-9-26**]
Date of Birth: [**2058-8-5**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77-year-old female with PMH of reported COPD (not confirmed by
prior PFTs), incisinal hernia following an ileostomy and
reversal, and treatment for an abdominal abscess, chronic
leukocytosis, chronic abnormal chest CT with mild bronchiectasis
and some right middle lobe opacities, presents with gradually
worsening shortness of breath over the past 3-5 months, worse on
exertion, and instructed by her PCP to present to the ED today.
Over the past few days she has become increasingly dyspneic
simply walking around her house. She has been taking combivent
qid and 2 puffs flovent [**Hospital1 **]. She has a chronic dry cough,
productive of small amounts of yellow or white sputum, and this
cough has not got worse of late. No fevers, chills, weight
loss, night sweats, chest pain, palpitations, flu-like symptoms,
hemoptysis, abdominal pain, sick contacts. Acknowledges
occasional wheeze.
In the ED, initial vitals were: 98.0 69 132/67 20 94% 3L She was
given duonebs, solumedrol 125 and started on levofloxacin for
possible COPD exacerbation. Although her breathing became
easier, she continued to be tachypneic with RR>30, and she was
transferred to the ICU for this reason. Vitals prior to
transfer were: 97.5 72 124/99 27 94% 3L
On arrival in the MICU, she is in no acute distress. Reports
that dyspnea has improved considerably since time of
presentation. RR was down to <20 by time of arrival to floor.
Vitals were: 78, 121/61, 76, 23, 89% 3L. On moving to use the
commode, her oxygen saturaton dropped to 89% and RR went up to
32, and oxygen was increased to 6L NS. She continues to
intermittently desaturate to the high 80s with minimal exertion,
but remains asymptomatic with these desaturations.
Past Medical History:
ABDOMINAL ABSCESS
ABDOMINAL WALL HERNIA
ALLERGIC RHINITIS
CAROTID ARTERY OCCLUSION
CATARACTS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DIABETES MELLITUS
GASTRITIS/HH/DUODENITIS
GASTROESOPHAGEAL REFLUX
HEADACHE
HYPERCHOLESTEROLEMIA
HYPERTENSION
INSOMNIA
KYPHOSIS
LEUKOCYTOSIS
LUNG NODULE
MITRAL INSUFFICIENCY
OBESITY
OSTEOPENIA
PROTEINURIA
RENAL INSUFFICIENCY
UTERINE FIBROIDS
Social History:
Tobacco: 47 year old smoking history, stopped smoking sveral
years ago.
Family History:
Positive for pancreatic and breast CA
Physical Exam:
ADMISSION EXAM
=================================
Vitals: 121/61, 76, 23, 89% 3L. General: Alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, no M/R/G
Lungs: Reduced air entry bilaterally, mild bibasal crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: 2+ edema to mid-calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Exam:
===================================
Vitals: 98.1/97.8F 133/77 71 24 96 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, no M/R/G
Lungs: diminished breath sounds, trace bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, large ventral hernia easily reducible
GU: no foley
Ext: [**12-6**]+ edema to mid-calf, Kyphosis
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
================================
[**2135-9-21**] 12:10PM BLOOD WBC-11.3* RBC-5.87* Hgb-15.0 Hct-49.3*
MCV-84 MCH-25.5* MCHC-30.4* RDW-14.3 Plt Ct-433
[**2135-9-21**] 12:10PM BLOOD Neuts-79.9* Lymphs-12.3* Monos-4.3
Eos-2.8 Baso-0.6
[**2135-9-21**] 12:10PM BLOOD Glucose-105* UreaN-20 Creat-0.7 Na-139
K-4.4 Cl-96 HCO3-36* AnGap-11
[**2135-9-22**] 04:17AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.1
[**2135-9-21**] 12:28PM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-63* pH-7.36
calTCO2-37* Base XS-7
[**2135-9-21**] 12:28PM BLOOD Lactate-1.2
Microbio:
================================
[**9-21**] Bcx Pending
Imaging:
================================
CXR [**9-21**]: Stable cardiomegaly. Presence of small pleural
effusions is difficult to Preliminary Reportdiscern without a
lateral projection.
EKG: Sinus rhythm, left atrial abnormality, q waves in III and
aVF, indeterminate duration. Left axis deviation. No grossly
abnormal ST/T wave changes.
Discharge Labs:
================================
[**2135-9-26**] 07:20AM BLOOD WBC-13.1* RBC-5.84* Hgb-14.7 Hct-49.5*
MCV-85 MCH-25.2* MCHC-29.7* RDW-14.0 Plt Ct-379
[**2135-9-26**] 07:20AM BLOOD Glucose-83 UreaN-23* Creat-0.7 Na-144
K-4.4 Cl-96 HCO3-42* AnGap-10
Brief Hospital Course:
77F with multiple comorbidities, presents with gradually
worsening SOB and dyspnea on exertion, without evidence of
infection; treated for likely COPD exacerbation.
Active Issues:
=====================================
# COPD exacerbation: Restrictive PFTs documented in [**2127**], but
reported history of COPD. Patient presented with gradually
worsening respiratory function over several months. She denied
fevers, chills, sick contacts, URI [**Name2 (NI) 34370**], productive cough in
addition to CXR without infiltrate made pneumonia an unlikely
diagnosis. No tachycardia, EKG changes or other clinical
findings to suspect PE. No EKG changes, chest pain to suggest
cardiac etiology. Initially in the ICU the patient was started
on azithromycin and converted to a prednisone 60mg x 10 day
taper. Her course was longer given her poor air movement on
exam. Her respiratory status was stable on 2-3L supplemental O2
and she was called out to the floor on HD#1. Pt did well on
prednisone taper and albuterol nebs, and completed 5 day course
of azithromycin on medicine floor on [**2135-9-26**]. Although she
reported improvement, she still desaturated while ambulating on
room air, and thus qualified for home O2 therapy. As pt derived
benefit from neb treatments, nebulizer machine/unit was
prescribed at discharge. Pt was discharged with VNA services,
home PT, and O2 2L NC after cleared by physical therapy. Blood
cultures were no growth to date at time of discharge. She was
instructed to follow up with her PCP for consideration of
outpatient pulmonary referral should her symptoms not resolve in
another week. She last saw a pulmonologist in [**2127**].
Chronic Issues:
======================================
# Hypertension: Patient was continued on her home clonidine
patch, amlodipine, metoprolol, valsartan. SBP at discharge 130s.
# DM: Patient was on ISS during hospital course and continued on
her home metformin at time of discharge.
# HLD: Patient was continued on her home Crestor.
# Allergic rhinitis: Continued home fexofenadine prn.
# GERD: Continued omeprazole during hospitalization. Recommend
taper off omeprazole and switch to H2 blocker.
Transitional Issues:
====================================
-Pt has followup with PCP in one week: [**2135-10-3**]
-Have recommended she speak with PCP and seek repeat outpatient
PFTs and re-establish care with pulmonologist.
-Pt has oustanding micro date: f/u blood cultures (as of [**9-26**]
No growth to date).
-Pt is complete following taper:
Prednisone 30mg once a day on [**9-27**]
Prednisone 20mg once a day on [**2133-9-27**]
Prednisone 10mg once a day on [**11-11**]
**Last day of this medication will be on [**2135-10-1**].
Tapered dose - DOWN
-Pt will benefit from home PT for deconditioning and home O2
therapy
#Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY Start: In am
2. Metoprolol Tartrate 100 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO DAILY
with dinner
4. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD 1X/WEEK (FR)
5. Amlodipine 5 mg PO DAILY Start: In am
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
1 capsule by mouth qd 1/2 hour before breakfast
8. Fexofenadine 180 mg PO DAILY
9. Ipratropium Bromide MDI 2 PUFF IH QID
10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD 1X/WEEK (FR)
3. Fexofenadine 180 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Omeprazole 20 mg PO DAILY
1 capsule by mouth qd 1/2 hour before breakfast
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Valsartan 320 mg PO DAILY
8. PredniSONE 40 mg PO DAILY Duration: 5 Days
Please follow the following taper: Prednisone 30mg once a day on
[**9-27**]
Prednisone 20mg once a day on [**11-9**]
Prednisone 10mg once a day on [**2133-9-29**]
**Last day of this medication will be on [**2135-10-1**].
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*9 Tablet
Refills:*0
9. Ipratropium Bromide MDI 2 PUFF IH QID
10. MetFORMIN (Glucophage) 500 mg PO DAILY
with dinner
11. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
12. Portable Oxygen therapy
2 Liters
Nasal Cannula
13. Home Oxygen therapy
2 Liters
Nasal Cannula
14. Nebulizer unit/machine
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB IH q6h PRN
Disp #*30 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
caregroup home care
Discharge Diagnosis:
-COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 52306**],
It was a pleasure taking care of you here at [**Hospital1 771**].
You came into the hospital because you were having difficulty
breathing and walking up steps. We think this was due to a
Chronic Obstructive Pulmonary Disease (aka COPD). This is a
chronic breathing problem related to smoking. We are treating
you with azithromycin for 5 days and treating you currently with
prednisone for 10 days. Your primary care physician will decide
if you should see a lung doctor called a pulmonologist or if you
should have further testing performed.
The following changes were made to your medications:
-Take prednisone as follows:
Prednisone 30mg once a day on [**9-27**]
Prednisone 20mg once a day on [**2133-9-27**]
Prednisone 10mg once a day on [**11-11**]
**Last day of this medication will be on [**2135-10-1**].
Followup Instructions:
Department: [**State **]When: MONDAY [**2135-10-3**] at 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
"593.2",
"V15.82",
"433.10",
"278.00",
"403.90",
"250.40",
"585.9",
"288.60",
"V16.3",
"491.21",
"272.0",
"357.2",
"593.9",
"250.60",
"276.2",
"583.81",
"793.11",
"V44.2",
"477.9",
"424.0",
"276.3",
"737.10",
"V16.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9602, 9652
|
5080, 5246
|
290, 297
|
9715, 9715
|
3830, 4791
|
10740, 11012
|
2547, 2586
|
8486, 9579
|
9673, 9694
|
7923, 8463
|
9866, 10717
|
4807, 5057
|
2601, 3173
|
3189, 3811
|
7270, 7897
|
231, 252
|
5261, 6744
|
325, 2046
|
9730, 9842
|
6760, 7249
|
2068, 2441
|
2457, 2531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,408
| 141,792
|
52265
|
Discharge summary
|
report
|
Admission Date: [**2115-1-23**] Discharge Date: [**2115-1-24**]
Date of Birth: [**2037-3-7**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Ace Inhibitors
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Referred for elective right carotid angiography and
intervention.
Major Surgical or Invasive Procedure:
Carotid angiography
Right internal carotid stent placement
History of Present Illness:
Mr. [**Known lastname **] is a 77 year-old male with a PMHx significant for CAD
s/p remote perioperative MI and s/p RCA stent in [**2112**], HTN,
hypercholesterolemia, bladder and prostate cancer s/p cystectomy
and prostatectomy, as well as carotid stenosis, now status post
elective carotid angiography and intervention to right ICA for
asymptomatic carotid stenosis. His last carotid series in
[**10/2114**] revealed 80-99% stenosis right ICA and 40% left ICA
stenosis.
Mr. [**Known lastname **] reports intermittent dizziness, most frequently
associated with getting out of bed in the morning. Per report,
it seems to occur sporadically, and appears dependent on body
position and movement. He describes it mostly as unsteadiness
and imbalance. No history of syncope, visual changes, or other
neurological symptoms. He was seen by Dr. [**Last Name (STitle) 1693**] in early
[**Month (only) 404**], with an impression of BPV. His carotid stenosis was
felt to be asymptomatic.
He denies recent anginal symptoms and notes that he has not used
his NTG for a good period of time. He also denies orthopnea, PND
or peripheral edema. He reports shortness of breath when walking
up in incline. No history of claudication.
Past Medical History:
1. CAD, status post perioperative IMI in [**2100**]. Cath in [**2112**] with
single vessel CAD with 90% RCA stenosis s/p stenting, LAD with
mild diffuse disease, LCx with 30% ostial lesion.
2. Carotid stenosis. Carotid series [**2114-11-9**] with 80-99% Rt ICA
stenosis, 40% Lt ICA stenosis.
3. Hypertension
4. Hypercholesterolemia
5. History of right DVT/PE in [**2106**] perioperative
6. Bladder cancer s/p radical cystectomy with ureteral loop
(patient straight caths QID)
7. Prostate ca s/p radical prostatectomy
8. Anxiety disorder
Social History:
He lives with his girlfriend. [**Name (NI) **] has 5 adult children. He is an
ex-smoker, quit 20 years ago (80 pack-year smoking history).
Occasional EtOH.
Family History:
Per records, family history positive for CAD. He has 3 siblings
with CABG in their 60's.
Physical Exam:
Physical examination on admission to CCU:
VITALS: Afebrile. HR 59 regular. BP 124/52, RR 18, Sat 99% on
room air.
GEN: Very pleasant, in NAD.
HEENT: PERRL, EOMI, MMM.
NECK: No carotid bruit. JVP not elevated.
RESP: Anterior chest clear to auscultation.
CVS: RRR. Normal S1, S2. No S3, S4. Last, faint SEM at RUSB,
non-radiating.
GI: Subcostal, midline scars. Umbilical stoma. BS normoactive.
Abdomen soft, non-tender.
EXT: Right groin cath site: no bruit, no hematoma. Strong pedal
pulses. No pedal edema.
NEURO: Moves all 4 extremities, strong grip.
Pertinent Results:
Relevant data in hospital:
PLT COUNT-236
POTASSIUM-3.8
CK(CPK)-49
[**2115-1-23**] Carotid angiography: Initial angiography revealed a
right internal carotid artery with a focal 90% ulcerated lesion.
We planned to treat this lesion with PTCA/stenting using distal
protection. Heparin was used prophylactically. A 6F Shuttle
sheath was placed in the common carotid artery. Then a 5.5mm
Accunet Fitler device easily crossed the lesion and was placed
distally. Then a 2.5x20mm Maverick balloon was used to predilate
the lesion at 16 atms. Stenting was with a 6-8x30mm Acculink
self expanding stent and postdilated with 4.5x20mm Maverick
balloon at
10 atms. Final angiography revealed 0% residual stenosis, no
disseciton,
and filling of the ipsilateral ACA and MCA without evidence of
distal
embolization.
EKG pre-procedure: Sinus bradycardia, rate 56 bpm. Normal axis,
normal intevals. Flat T waves in aVL, V1. No Qs, no ST changes.
Brief Hospital Course:
77 year-old male with CAD s/p RCA stent, HTN,
hypercholesterolemia, s/p cystectomy for bladder cancer, s/p
prostatectomy, known to have asymptomatic right carotid artery
stenosis, referred for angiogram.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] elective carotid angiography on [**2115-1-23**],
which revealed a focal 90% ulcerated lesion in the right
internal carotid artery, treated with PTCA and stenting with 0%
residual stenosis. Mr. [**Known lastname **] [**Last Name (Titles) 8337**] the procedure well
without immediate complications, and was transferred to the CCU
for close hemodynamic monitoring.
Antihypertensive medications were held post-procedure. He was
continued on ASA and Plavix. In the CCU, his BP was initially
between 120-150, then 90-110s, asymptomatic. No pressor was
initiated per Dr. [**First Name (STitle) **]. Mr. [**Known lastname **] did well overnight. In AM,
he reported a transient episode of right-sided facial warmth and
numbness in the setting of elevated BP 168/70. Dr. [**First Name (STitle) **]
(neurology) was called at the bedside. Slight facial asymmetry
was noted, old when compared to ID card picture. Neurological
examination was otherwise non-focal, with normal cranial nerve
examination, strength and reflexes normal throughout. His
symptoms were felt likely related to transient hypertension. No
signs of amaurosis, no headache.
Given the above, Lopressor was resumed at 1/2 dose at 25 mg PO
BID. HCTZ held. Mr. [**Known lastname **] will follow up in Dr.[**Name (NI) 3101**] office
tomorrow for a BP check, with plan to reintroduce BP meds as
[**Name (NI) 8337**].
2) CAD: No acute issues in hospital. He was continued on ASA<
Plavix and Lipitor. Lopressor resumed on the day of discharge at
lower dose, to be titrated up to pre-hospitalization dose as
out-patient.
3) s/p cystectomy: Mr. [**Known lastname **] straight caths 4 times daily. He
was provided with the necessary equipment in the CCU.
Medications on Admission:
Aspirin 325 mg daily
Metoprolol 50 mg [**Hospital1 **]
Fluoxetine 20 mg every other day
HCTZ 25 mg daily
Plavix 75 mg daily
Lipitor 20 mg QPM
Protonix 40 mg daily
Premedicated given allergy to iodinated contrast.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO QOD ().
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Note that we are restarting 1/2 dose.
7. Hold hydrochlorothiazide
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Carotid stenosis status post right internal carotid stent
placement
Hypertension
Secondary diagnoses:
Coronary artery disease
Hypercholesterolemia
Bladder cancer status post radical cystectomy with ureteral loop
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] or return to the hospital if you
experience lightheadedness, visual changes, or tingling/numbness
in your extremities.
Please call Dr.[**Name (NI) 3101**] office tomorrow ([**Telephone/Fax (1) 4022**]). We want
you to be seen in the clinic tomorrow for a blood pressure
check. We will restart Lopressor at 25 mg twice daily for now
(1/2 dose). Do not take hydrochlorothiazide for now.
You also have a scheduled appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**] on
[**2-27**] at 0900 and an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] on [**4-3**] at 08:50. Please see below.
Followup Instructions:
1) Please call Dr.[**Name (NI) 3101**] office tomorrow ([**Telephone/Fax (1) 4022**]). You
need to be seen in the clinic tomorrow for a blood pressure
check.
2) You also have scheduled appointments with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] as indicated below:
- Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2115-2-27**] 9:00
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2115-4-3**]
08:50
Other appointments:
3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2115-3-13**] 10:00
4) Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-4-23**] 3:30
Completed by:[**2115-1-24**]
|
[
"V10.51",
"401.9",
"272.0",
"V10.46",
"433.10",
"300.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"00.61"
] |
icd9pcs
|
[
[
[]
]
] |
6896, 6902
|
4036, 6003
|
349, 409
|
7179, 7225
|
3081, 4013
|
7977, 9123
|
2405, 2495
|
6267, 6873
|
6923, 7024
|
6029, 6244
|
7249, 7954
|
2510, 3062
|
7045, 7158
|
244, 311
|
437, 1656
|
1678, 2216
|
2232, 2389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,269
| 101,566
|
31119
|
Discharge summary
|
report
|
Admission Date: [**2172-8-28**] Discharge Date: [**2172-8-31**]
Date of Birth: [**2112-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Esophagoduodenoscopy with cauterization and injection duodenal
ulcer.
History of Present Illness:
The patient is a 59 yo woman s/p gastric bypass c/b bowel
obstruction and ventral hernia repairs who presents with black
tarry stools for one day. The patient was in her usual state of
health until the afternoon of [**8-27**], when she started to have
crampy abdominal pain and the urge to defecate while driving
home from work. She subsequently had 4-5 episodes of large
volume, dark brown, tarry, malodorous stool over several hours.
These bowel movements also contained small streaks of maroon
colored blood. She had some transient lightheadedness after her
first bowel movement, but no LOC, palpiations, or CP. She also
denies any nausea, vomiting, or retching. She had no changes in
her stool color, consistency, or caliper prior to the onset of
melena, and s/p gastric bypass had no symptoms dumping syndrome.
She has had no known sick contacts, or recent weight loss,
fevers or chills. She has a recent history of starting an
NSAID, Voltaren, for OA pain several months ago. She has had
EGD in the distant past, but has not ever had a colonoscopy.
.
ED Course: On arrival to the E.D., the patient had no abominal
pain, and was no longer having large-volume stools. She did
have several additional small volume black stools over the day
on [**8-28**]. She was tachycardic to the 110s, SBP to 140s, which
improved with IVF. Her Hct was found to be 31, down from a
baseline of 39 by patient report. She was found to have brown
stool, guaiac positive. She had a negative NG lavage. She was
started on an IV PPI and transferred to the floor.
Past Medical History:
PMH/PSH:
-S/p L salpingoophorectomy [**2158**]
-S/p cholecystectomy, hernia repair [**2163**]
-S/p gastric bypass [**2166**] c/b bowel obstruction, ventral hernia
requiring mesh repair, and wound infection requiring 3
reoperations in post-operative period. GERD s/p bypass.
-OA in feet and knees
Social History:
SH: Smokes occasionally, several cigarettes/week, cut down from
approx ?????? ppd for 40 years. Very occasional EtOH. No illicit
drugs. Lives at home by herself, with sister nearby. [**Name2 (NI) 1403**] for
[**Location (un) 86**] Home Infusion Company.
Family History:
FH: Breast CA in mother and aunts. Stomach CA in maternal GM.
Brother s/p colectomy for ? diverticulitis. Distant relatives
with DM2. [**Name2 (NI) **] known FH of colon CA.
Physical Exam:
PE: Vitals: T 99.3, HR 98, BP 96/50, repeat 120/80, RR 20, 98%
RA
Gen: pleasant woman in NAD
HEENT: MMM, no blood in oropharynx, sclera anicteric
Neck: Supple, no LAD
Chest: CTAB
Cor: regular rate, normal S1, S2, no m/r/g
Abd: obese with many well-healed scars, soft, NTND, +BS in all
quadrants, no HSM, no palpable masses, Rectal: guaiac positive
dark brown stool, no palpable masses.
Extr: WWP, 2+ DPs, no c/c/e
Neuro: A+O, appropriately interactive
Pertinent Results:
[**2172-8-28**] 03:00PM BLOOD WBC-12.3* RBC-3.63* Hgb-10.4* Hct-31.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-14.8 Plt Ct-267
[**2172-8-28**] 09:21PM BLOOD Hct-25.0*
[**2172-8-29**] 04:13AM BLOOD WBC-9.4 RBC-3.32* Hgb-9.9* Hct-28.9*
MCV-87 MCH-29.6 MCHC-34.1 RDW-15.1 Plt Ct-196
[**2172-8-29**] 09:30AM BLOOD Hct-30.3*
[**2172-8-29**] 03:00PM BLOOD Hct-28.7*
.
[**2172-8-28**] 03:00PM BLOOD PT-11.6 PTT-23.6 INR(PT)-1.0
.
[**2172-8-28**] 03:00PM BLOOD Glucose-102 UreaN-19 Creat-0.7 Na-142
K-4.3 Cl-106 HCO3-25 AnGap-15
[**2172-8-29**] 04:13AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-143
K-3.4 Cl-109* HCO3-28 AnGap-9
.
[**2172-8-28**] 03:00PM BLOOD ALT-22 AST-27 CK(CPK)-68 AlkPhos-49
TotBili-0.5
Brief Hospital Course:
GI: On transfer to the floor, the patient had initially had a
SBP of 100 down from 140 in the ED, but repeat was 120/80, and
she remained hemodynamically stable. However, Hct trended down
from 31 to 25, and she was transferred to the ICU for closer
monitoring and EGD. She recieved 2 units PRBCs, with Hct bump
to 28.9. EGD was remarkable for a single cratered 15mm ulcer
with oozing from the edges just distal to the gastrojejunal
anastomosis, which was injected with epinephrine and cauterized
successfully for hemostasis. Post-procedure, she was
hemodynamically stable, her Hct was 30.3, and she was
transferred back to the floor. Once back on the floor, she did
very well, and remained hemodynamically stable. She had no
abdominal pain, nausesa or vomiting. Her Hct at discharge was
stable at 32.2, and her diet was advanced to regular. She had
not yet had a bowel movement post-procedure, but was passing
gas. She was discharged on hige dose PPI to follow-up with her
PCP [**Name Initial (PRE) 176**] 2 weeks and GI for repeat EGD and biopsy in 1 month.
Medications on Admission:
Protonix [**Hospital1 **]
Wellbutrin [**Hospital1 **]
Volataren 100mg [**Name (NI) 244**]
(unclear on doses)
Discharge Medications:
1. Wellbutrin Oral
2. 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:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Jejunal Ulcer
Discharge Condition:
The patient is hemodynamically stable with stable hematocrit.
She is tolerating a regular diet.
Discharge Instructions:
You came to the hospital because of blood in your stools. Your
stomach was examined with a camera, and you were found to have
an ulcer in the beginning of your small intestine that was
bleeding. The bleeding was stopped.
.
Please call your doctor or come to the emergency room if you
have continued blood in your stools, vomiting, blood in your
vomit, abdominal pain, fever>101, chills, dizziness, fainting,
chest pain, shortness of breath, or any other concerns.
Followup Instructions:
Please schedule follow-up with [**Hospital1 18**] gastroenterology for repeat
EGD in 1 month with Dr. [**Last Name (STitle) **]. The number to call is
[**Telephone/Fax (1) 2799**]. Please also follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**]
[**Last Name (NamePattern1) **] in 2 weeks. The number to call is [**Telephone/Fax (1) 18145**].
Completed by:[**2172-8-31**]
|
[
"285.1",
"534.40",
"V45.86",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.98",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5390, 5396
|
3947, 5017
|
291, 362
|
5454, 5552
|
3236, 3924
|
6066, 6486
|
2565, 2743
|
5176, 5367
|
5417, 5433
|
5043, 5153
|
5576, 6043
|
2758, 3217
|
245, 253
|
390, 1952
|
1974, 2273
|
2289, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,862
| 195,800
|
27243+57532
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-6-23**] Discharge Date: [**2165-6-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
respiratory failure, hypotension
Major Surgical or Invasive Procedure:
Placement of Central Venous Line
Placement of PICC line
History of Present Illness:
Per records, this is an 83 y/o M w/CAD s/p CABG, afib on
coumadin, Parkinson's, who last night at his nursing home
developed respiratory distress with tachypnea and hypoxia to the
70s, with PNA and WBC of 24, hypoxic. Also noted to be febrile
to 101.7, hypotensive in the 70s/30s, and tachypneic. He was
intubated for " hypoxic resp distress"; no ABG. His hematocrit
was 17 there (unclear prior HCT), and he was having melena. His
INR was 2.9. He received 2 L IVF, 2 U PRBCs, clindamycin and
ceftriaxone, and was transferred here for further management. On
transfer, his systolic was in the 90s, and he was not on
pressors or sedation.
*
In our ED, he was hypotensive (89-98/45 in RN notes) but did
not require pressors. + Melena. He received FFP. A right IJ
central line was placed and he was sent to the MICU. An NG tube
could not be passed, and no NG lavage was done. Lactate 2, HCT
24.
.
In the MICU: Placed on vancomycin and zosyn for broad coverage
of presumed aspiration pneumonia. PEG lavage was neg. HD
stable. He received a total of 7 units P RBCs (2 at the OSH, 5
here) and FFP x3 units. GI was consulted and becuase of
elevation of INR, did not scope. An EGD was discussed with the
patient and he refused. This was reviewed with his HCP. On
[**6-25**], patient extubated. Yesterday noted to be tachypneic and
felt to be vol overload. Received lasix 20mg IV x2 and diresed 1
L. Currently afebrile and HD stable.
Past Medical History:
1. Parkinson's
2. chronic aspiration with g-tube
3. AFib on coumadin (had been evaluated by cardiologist in
[**12-22**], and it was decided not to place him on coumadin given
history of multiple falls, but to rate control him with
metoprolol. Had been on sotalol in the past)
4. CAD s/p CABG [**2157**], 4 coronary vein grafts
5. frequent falls
6. GERD
7. Hyperlipidemia
8. Myelodysplastic syndrome
9. Urinary obstruction (?BPH)
10. HTN
11. Antral gastritis
12. malignant melanoma right ear excised
13. multiple polyps (from ascending, transverse and sigmoid
colons - hyperplastic tubulovillous adenomas) seen on
colonoscopy [**3-/2164**]
14. Restrictive lung disease [**3-21**] to asbestos exposure
15. chronic vit B12 deficiency
16. BPH
Social History:
Patient lives in a nursing home. Quit smoking in [**2128**] after 20
years. Quit alcohol in [**2154**].
Family History:
diabetes in brother
Physical Exam:
T 96.1, Tm 98.7, has been afebrile since admission, 101 120/56
28 96% on 2LNC, CVP 6
Gen: NAD, lying in bed, very hard of hearing R worse than L
HEENT: PERRL, EOMI, OP clear, MMM, scar in back of OP
Neck: R IJ in place, no erythema, tenderness
Lungs: R rhonchi and crackles halfway down back, decreased BS on
Left, rhonchi,
CV: irreg irreg, no m/r/g
Abd: soft, nt/nd. g-tube site intact. NABS.
Ext: 1+ edema, toes cold, 1+ DP bilaterally, PT not felt
Neuro: CN 2-12 intact, [**6-21**] UE and LE strength except [**5-27**] IPs
bilaterally
Pertinent Results:
afib at 82, nl axis, nl QRS, QT 466 msec, no st-t changes (had
lateral ST depressions v4-6 with RVR at OSH which are resolved
here)
[**2165-6-23**] 06:35AM BLOOD WBC-24.2* RBC-2.15* Hgb-7.0* Hct-20.9*
MCV-97 MCH-32.4* MCHC-33.2 RDW-24.6* Plt Ct-391
[**2165-6-23**] 02:11PM BLOOD Hct-21.4*
[**2165-6-23**] 07:33PM BLOOD Hct-24.5*
[**2165-6-24**] 12:40AM BLOOD Hct-24.3*
[**2165-6-24**] 04:45AM BLOOD WBC-17.4* RBC-3.02*# Hgb-9.9*# Hct-27.4*
MCV-91 MCH-32.8* MCHC-36.2* RDW-23.0* Plt Ct-301
[**2165-6-24**] 11:54AM BLOOD Hct-30.8*
[**2165-6-24**] 04:00PM BLOOD Hct-30.6*
[**2165-6-24**] 08:08PM BLOOD Hct-29.8*
[**2165-6-25**] 04:50AM BLOOD WBC-16.1* RBC-3.19* Hgb-10.6* Hct-29.0*
MCV-91 MCH-33.3* MCHC-36.6* RDW-22.3* Plt Ct-306
[**2165-6-25**] 02:08PM BLOOD Hct-30.7*
[**2165-6-25**] 09:13PM BLOOD Hct-30.8*
[**2165-6-26**] 04:45AM BLOOD WBC-13.2* RBC-3.37* Hgb-10.7* Hct-31.1*
MCV-92 MCH-31.6 MCHC-34.3 RDW-20.8* Plt Ct-328
[**2165-6-26**] 05:47PM BLOOD Hct-33.2*
[**2165-6-28**] 07:34AM BLOOD WBC-12.1* RBC-3.68* Hgb-11.9* Hct-34.2*
MCV-93 MCH-32.2* MCHC-34.7 RDW-19.1* Plt Ct-511*
[**2165-6-23**] 06:35AM BLOOD Neuts-90.7* Bands-0 Lymphs-6.6* Monos-2.5
Eos-0 Baso-0.3
[**2165-6-27**] 06:00AM BLOOD Plt Ct-355
[**2165-6-28**] 07:34AM BLOOD Plt Ct-511*
[**2165-6-23**] 06:35AM BLOOD PT-21.6* PTT-31.4 INR(PT)-2.1*
[**2165-6-23**] 02:11PM BLOOD PT-17.1* INR(PT)-1.6*
[**2165-6-28**] 07:34AM BLOOD PT-15.4* PTT-30.0 INR(PT)-1.4*
[**2165-6-23**] 06:35AM BLOOD Glucose-85 UreaN-37* Creat-0.8 Na-140
K-4.4 Cl-103 HCO3-29 AnGap-12
[**2165-6-28**] 07:34AM BLOOD Glucose-84 UreaN-9 Creat-0.6 Na-140 K-4.0
Cl-98 HCO3-32 AnGap-14
[**2165-6-23**] 06:35AM BLOOD ALT-22 AST-43* CK(CPK)-41 AlkPhos-89
Amylase-200* TotBili-0.5
[**2165-6-23**] 02:11PM BLOOD CK(CPK)-53
[**2165-6-23**] 07:33PM BLOOD CK(CPK)-50
[**2165-6-24**] 11:54AM BLOOD CK(CPK)-43
[**2165-6-23**] 06:35AM BLOOD Lipase-70*
[**2165-6-23**] 06:35AM BLOOD CK-MB-2 cTropnT-0.03*
[**2165-6-23**] 02:11PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2165-6-23**] 07:33PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2165-6-24**] 04:45AM BLOOD proBNP-6450*
[**2165-6-24**] 11:54AM BLOOD CK-MB-NotDone
[**2165-6-23**] 06:35AM BLOOD Albumin-2.3* Calcium-7.1* Phos-4.6*
Mg-2.0
[**2165-6-27**] 06:00AM BLOOD TotProt-5.7* Albumin-2.2* Globuln-3.5
Calcium-7.9* Phos-2.3* Mg-2.1
[**2165-6-26**] 09:39AM BLOOD Iron-12*
[**2165-6-28**] 07:34AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
[**2165-6-26**] 09:39AM BLOOD calTIBC-172* VitB12-1249* Folate-14.4
Ferritn-696* TRF-132*
[**2165-6-23**] 06:35AM BLOOD Cortsol-23.6*
[**2165-6-23**] 06:35AM BLOOD CRP-57.2*
[**2165-6-23**] 09:45AM BLOOD Type-ART pO2-512* pCO2-40 pH-7.47*
calHCO3-30 Base XS-5
[**2165-6-23**] 08:05PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-51* pH-7.38
calHCO3-31* Base XS-3
[**2165-6-24**] 04:44AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-54* pH-7.37
calHCO3-32* Base XS-3
[**2165-6-24**] 08:13AM BLOOD Type-MIX pO2-37* pCO2-58* pH-7.30*
calHCO3-30 Base XS-0
[**2165-6-25**] 12:52PM BLOOD Type-ART Temp-37.1 pO2-95 pCO2-40 pH-7.43
calHCO3-27 Base XS-1
[**2165-6-23**] 06:43AM BLOOD Lactate-2.0
[**2165-6-24**] 08:13AM BLOOD Lactate-1.1
[**2165-6-23**] 06:43AM BLOOD Hgb-7.9* calcHCT-24
[**2165-6-23**] 08:23AM BLOOD Hgb-6.0* calcHCT-18 O2 Sat-93
[**2165-6-23**] 09:45AM BLOOD Hgb-6.1* calcHCT-18
[**2165-6-23**] 06:35AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2165-6-23**] 06:35AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2165-6-23**] 06:35AM URINE RBC-21-50* WBC-[**4-21**] Bacteri-FEW Yeast-NONE
Epi-0-2
.
[**2165-6-23**] 9:30 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2165-6-25**]**
GRAM STAIN (Final [**2165-6-23**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2165-6-25**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**8-/2465**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
[**2165-6-24**] 10:54 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2165-6-26**]**
GRAM STAIN (Final [**2165-6-24**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2165-6-26**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 207-9207T
[**2165-6-23**].
.
URINE CULTURE (Final [**2165-6-24**]): NO GROWTH.
[**6-23**] blood cultures x 2 NGTD
.
**FINAL REPORT [**2165-6-24**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2165-6-24**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2165-6-24**] 2:48 pm URINE
**FINAL REPORT [**2165-6-25**]**
URINE CULTURE (Final [**2165-6-25**]): NO GROWTH.
.
[**2165-6-28**] 9:12 am CATHETER TIP-IV Source: Right IJ.
WOUND CULTURE (Pending):
Brief Hospital Course:
83 year old man with Parkinson's and chronic aspiration who
presents with GI bleed and sepsis.
.
#. Multilobar pneumonia/SIRS: The patient was intubated at the
OSH for hypoxia per their reports. A chest x-ray on admission
showed bilateral focal airspace opacities. Sputum was positive
for MRSA at OSH and here. He was started on vancomycin and
zosyn for broadspectrum coverage of nosocomial pneumonia, and
started on a sepsis protocol with aggresive IVF rehydration,
transfusions and transient use of levophed. He was successfully
extubated on [**6-24**], but found to be tachypneic. A repeat CXR
showed worsened pulmonary edema and small bilateral pleural
effusions right > left. This was felt to be secondary to his
aggressive fluid resuccitation and transfusion with 5 units of
RBCs here + 2 units of RBCs at the OSH + 3 units of FFP here.
On transfer from the MICU, he was positive 5.5 L for length of
stay. He was diuresed aggressively ~ 1 L per day for 2 days
with a marked improvement in his pulmonary edema and bilateral
pleural effusions, but with continued multifocal opacities
bilaterally. He may benefit from occasional diuresis with
20-40 mg PO lasix. His antibiotic coverage was narrowed to
vancomycin, and he was started on flagyl to cover for anaerobes
given his history of chronic aspiration. His WBC trended down
and he remained afebrile. He had occasional desaturations, but
these resolved with aggressive chest PT and expectoration of
large mucus plugs. On the day of discharge, he was switched to
vancomycin and levofloxacin for broader coverage of gram
negative organisms, given his recent hospital stays. The flagyl
was discontinued as it was felt that his lack of teeth made
anaerobes less likely a factor in his pneumonia. A PICC line
was placed on the day of discharge for administration of his
vancomycin, but he pulled this out accidentally because he was
curious how it worked. A repeat PICC was placed on the day of
discharge and is ready for use.
.
#. GI bleed: The patient was noted to have frank melena on
admission. His INR was found to be elevated to 2.1 on admission
secondary to coumadin therapy for his atrial fibrillation. His
hematocrit at the OSH was reportedly 18, with a baseline
hematocrit in [**12-22**] at 39 per VA records. He had received 2
units of pRBCs at the OSH with an improvement in his hematocrit
to 20.9 on admission. He was transfused with 3 units of FFP for
emergent INR reversal as well as another 5 units of pRBCs. An
NG lavage was not performed in the ED secondary to difficulty
with passing an NG tube. However, a lavage through his PEG tube
was negative. Gi was consulted and was planning to perform an
EGD on him while he was intubated, but he and his family refused
the test at that time. On transfer to the floor, an EGD was
pursued again, but his respiratory status was felt to be too
poor to pursue an EGD without intubation. He may benefit from
an elective EGD once his respiratory status has completely
improved. He had a recent colonoscopy at the VA which showed
multiple polyps but was otherwise negative for a source of
bleeding. His hematocrit steadily increased after transfer to
the floor out of the MICU, and was 34.2 at time of discharge.
He will need to continue on lansoprazole 30 mg per G-tube Q12.
.
#. CAD: The patient did not appear to be having active ischemia
and never complained of chest pain. His EKG at the OSH showed
ST depressions in setting of atrial fibrillation with RVR and
hct 17. These were resolved on ECG. He was ruled out for an MI
with 3 sets of negative cardiac enzymes. He was restarted on
aspirin 81 mg QD and started on metoprolol which was titrated up
to 50 mg [**Hospital1 **], and restarted on simvastatin at 20 mg QHS. He
should be restarted on an ACE-I as an outpatient if he remains
hypertensive.
.
#. Atrial Fibrillation: He has chronic atrial fibrillation, and
was on amiodarone on admission. His INR was reversed with FFP
and vitamin K, and his coumadin was held secondary to his GI
bleed. Per old records, he had been evaluated by a cardiologist
earlier in the year and the decision had been made to rate
control him, but avoid anticoagulation given his past history of
falls and antral gastritis. He should not be restarted on
coumadin, given his clear propensity to bleed. He will be
continued on a baby aspirin for CVA prophylaxis. His amiodarone
was discontinued because of his history of restrictive lung
disease secondary to asbestos exposure and because he did not
appear to have any rhythm benefit from it. Additionally, he had
no symptomatic benefit from it. Instead, he was restarted on
metoprolol, and this was titrated up to his outpatient dose of
50 mg [**Hospital1 **] with good rate control. This may be titrated up as an
outpatient as tolerated by his blood pressure.
.
#. Parkinson's: The patient has a history of chronic aspiration
secondary to gradual deterioration from his parkinson's disease.
He has a PEG tube in place and was continued on his tube feeds.
He was continued on carbidopa-levodopa and requip.
.
#. Low anion gap: The patient was found to have a low anion gap
of 5. A serum calcium level was normal, and the total protein
to albumin ratio was found to be 5.7/2.2, which was not
especially high. He could be further worked up as an outpatient
with an SPEP and UPEP to screen for multiple myeloma, though his
UA had only trace protein and he has no bone pain.
.
#. Anemia - The patient has a history of myelodysplasia and
chronic Vitamin B12 deficiency. Baseline hct at OSH was 39 in
[**12-22**]. Iron studies were consistent with anemia of chronic
disease, and he had a normal Vitamin B12 level and folate during
this admission. He was restarted on his outpatient dose of
cyanocobalamin 1000 mcg PO QD.
.
#. Hematuria - The patient was noted to have microscopic
hematuria on this admission, which was followed by macroscopic
hematuria seen in his foley after he was seen to pull on his
foley. Given his elevated INR, this was felt to be due to foley
trauma. However, he should have a follow-up urinalysis as an
outpatient to evaluate for hematuria, and may need an outpatient
work-up. He will be discharged with his foley in place, and
will need a voiding trial at his [**Hospital1 1501**].
.
PCP [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) 9780**], NP [**Telephone/Fax (3) 66809**]
.
Communication: [**Name (NI) **] [**Name (NI) **] (nephew and HCP) [**Telephone/Fax (1) 66810**];
[**Telephone/Fax (1) 66811**]
Medications on Admission:
Medications on transfer:
Lisinopril 2.5 mg daily
Prevacid 30 mg daily
Requip 1.0 mg tid
Vitamin b12 100 micrograms daily
Colace [**Hospital1 **]
Aspirin 81 mg daily
Zocor 20 mg daily
Senna 2 tabs daily
Coumadin (had been held last 3 days as INR was 6.1 on [**6-20**] and
3.2 on [**6-22**])
Carbidopa/Levodopa 25/100 2 tabs q8h
Neurontin 300 mg tid
Amiodarone 200 mg daily
Terazosin 2 mg po qhs
Free water flushes 250 cc via g tube tid
.
Meds from PCP [**Last Name (NamePattern4) **] [**12-22**]:
Cyanocobalamin 1000 mcg PO Qd
Oxybutinin xl 5 mg TID
MVT QD
Metamucil PRN
Sotalol 80 mg [**Hospital1 **] - d/c'ed at 11/05 visit, metoprolol 50 mg [**Hospital1 **]
started
lisinopril 20 mg QD
Simvastatin 20 mg QHS
terazosin 8 mg QHS
Gabaopebtub 399 ng /TID
sinemet 25/100 2 tabs TID
aspirin 81 mg QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
3. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 10 days.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY:PRN as needed: 10 ml NS followed by 2
ml of 100 Units/ml heparin (200 units heparin) each lumen Daily
and PRN. Inspect site every shift.
.
11. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection TID (3 times a day).
12. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
14. Terazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
Parkinson's Disease
MRSA pneumonia with sepsis
Congestive Heart Failure
Gastrointestinal bleeding
Hematuria
Discharge Condition:
fair
Discharge Instructions:
1. Please make sure that the patient takes all medications as
prescribed.
2. If he desaturates, please consider a mucus plug and give him
chest PT and vigorous suction if indicated.
3. Please have him seek medical attention if he develops fevers,
chills, worsened shortness of breath, chest pain, recurrent
melena or has any other concerning symptoms.
Followup Instructions:
Please do a follow-up Urinalysis on the patient to evaluate for
hematuria.
Please have the patient follow-up with his primary care doctor
at the VA within 2 weeks of discharge if he is discharged.
Completed by:[**2165-7-3**] Name: [**Known lastname 9582**],[**Known firstname **] A. Unit No: [**Numeric Identifier 11603**]
Admission Date: [**2165-6-23**] Discharge Date: [**2165-6-29**]
Date of Birth: [**2082-2-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 406**]
Addendum:
Addendum - His Vitamin B12 dose was 100 mcg once a day on
admission, and he was discharged on the same dose.
Medications on Admission:
Addendum - His Vitamin B12 dose was 100 mcg once a day on
admission, and he was discharged on the same dose.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Landing
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 408**] MD [**MD Number(2) 409**]
Completed by:[**2165-7-3**]
|
[
"038.9",
"332.0",
"600.01",
"995.92",
"V58.61",
"785.52",
"285.29",
"V10.82",
"482.41",
"518.81",
"867.0",
"427.31",
"V45.81",
"507.0",
"E928.9",
"238.7",
"V44.1",
"401.9",
"530.81",
"578.9",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.71",
"99.07",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
19589, 19798
|
9413, 15952
|
295, 352
|
18302, 18309
|
3309, 9390
|
18709, 19430
|
2715, 2736
|
16799, 18070
|
18171, 18281
|
19456, 19566
|
18333, 18686
|
2751, 3290
|
223, 257
|
380, 1811
|
16003, 16776
|
1833, 2576
|
2592, 2699
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,301
| 197,122
|
1981+55339
|
Discharge summary
|
report+addendum
|
Admission Date: [**2131-2-13**] Discharge Date: [**2131-2-21**]
Date of Birth: [**2078-7-13**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Meperidine / Morphine
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
1) C5-6 corpectomy / cage / ACDF for abscess [**2-13**] (White/[**Doctor Last Name 1352**])
2) C6-T1 lami / C4-T2 PSF [**2-14**] (White)
History of Present Illness:
52F with PMH of hypothyroidism and depression who presents with
6 days of progressive neck pain and spasms. Neck pain started on
[**2-7**] and is described as spasms L>R. She initially attributed
pain to sleeping position and took flexeril with minimal relief.
Pain persisted and was associated with increased fatigue,
decreased appetite and PO intake. She called PCP and was
prescribed Tylenol #3 with also minimal relief. 2 days PTA, she
noted progressive lightheadedness, dizziness and fatigue as well
as subjective fevers and night sweats. On day of transfer, she
felt so weak she was unabel to stand, was concerned she was
going to pass out and had weakness in her hands bilaterally.
Denies headache, photophobia, dysuria, sick contacts, cough,
sore throat, abdominal pain, sinus pain or congestion, or recent
travel.
.
She was initially seen at OSH ED where she had CT head, C spine
and chest which were all unremarkable. She had LP with 4 WBC, 0
RBC, 300 protein, 40 glucose. Prior to LP, she received Vanco,
CTX, and decadron. She looked well but had asympomtatic
hypotension with SBP in 60s-80s so received 6L [**Month/Year (2) 10899**] at OSH and
was transferred to [**Hospital1 18**] ED.
.
In our ED, initial VS 99.9 87/60 80 18 98%RA. She was evaluated
by neuro who recommended CTA. MRI also performed which was
limited but revealed prevertebral edema C2-C6. Patient was
evaluated by [**Hospital1 **] spine who felt this required medical
management with antibiotics and was nonoperative. Neuro exam
normal except for mild weakness triceps B/L. She received an
additional 2L NS with improvement in SBP to 90s-100s. She did
not receive further antibiotics. She was also noted to
desaturate with sleeping. VS prior to transfer 71 112/60 17
98-99%2L
.
On arrival to ICU, she reports thirst and denies LH, dizziness.
Neck pain currently 0/10.
Past Medical History:
Past Medical History:
Hypothroidism
Depression
GERD
Hyperlipidemia
.
Past surgical history
s/p appendectomy, hysterectomy, breast augmentation
Social History:
Nurse [**First Name (Titles) **] [**Last Name (Titles) 10899**]. Drinks wine with dinner, smokes ~ [**1-14**] ppd x >30
years. Denies any other drug use. Lives with husband. has 2 sons
in college. Has 2 cats, no other pets. No recent travel. Denies
recent dental work.
Family History:
Brother with DM2. Father with ALS. Mother healthy. [**Name2 (NI) **] FH
neurological disease, recurrent infections, malignancy.
Physical Exam:
GEN: pleasant, comfortable, NAD, sitting up in bed
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits
RESP: Bibasilar crackles. Otherwise CTA b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters hemorrhages or stigmata
of endocarditis. Incisions c/d/i
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout UES and
LES except at triceps where L [**3-17**], R [**4-17**]. Interossei stregth
intact. Biceps, brachioradialis and patellar DTRs 2+. [**Name2 (NI) **] focal
neck TTP.
Pertinent Results:
[**2131-2-16**] 06:00AM BLOOD WBC-8.0 RBC-3.26* Hgb-10.1* Hct-28.8*
MCV-88 MCH-30.9 MCHC-35.0 RDW-13.8 Plt Ct-378
[**2131-2-16**] 06:00AM BLOOD Neuts-73* Bands-2 Lymphs-16* Monos-3
Eos-2 Baso-1 Atyps-2* Metas-1* Myelos-0
[**2131-2-16**] 06:00AM BLOOD Glucose-101* UreaN-2* Creat-0.4 Na-140
K-3.0* Cl-99 HCO3-32 AnGap-12
[**2131-2-13**] 06:49AM BLOOD ALT-58* AST-66* LD(LDH)-256* AlkPhos-66
TotBili-0.2
[**2131-2-16**] 06:00AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.2
[**2131-2-13**] 06:49AM BLOOD calTIBC-165 VitB12-1462* Folate-15.5
Hapto-502* Ferritn-1806* TRF-127*
MICROBIOLOGY
Time Taken Not Noted Log-In Date/Time: [**2131-2-13**] 6:08 pm
TISSUE DISC C5.
GRAM STAIN (Final [**2131-2-13**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10900**] [**Last Name (NamePattern1) 10901**] @ 9PM [**2131-2-13**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING
Radiology Report MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of
[**2131-2-13**] 1:00 AM
[**Last Name (LF) 10902**],[**First Name3 (LF) **] EU [**2131-2-13**] 1:00 AM
MR [**Name13 (STitle) **] W& W/O CONTRAST Clip # [**Clip Number (Radiology) 10903**]
Reason: ? abscess
Contrast: MAGNEVIST Amt: 15
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with fever, four days of neck pain, seen at
OSH with negative
LP, CT head/neck, CXR, UA. Persistently low BP's after fluid
resuscitation.
REASON FOR THIS EXAMINATION:
? abscess
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: IPf TUE [**2131-2-13**] 2:58 AM
Very limited scan due to motion; patient unable to cooperate.
Prevertebral edema C2-C6.
Increased signal in C5-C6 disk concerning for inflammation. High
signal in C5-
and C6 vertebral bodies.
Although some of changes might be degenerative cannot exclude
C5-C6 discitis
osteomyelitis complex at level C5-C6; however very subotimal
scan due to
motion and most of post-contrast sequences are non-diagnostic.
Signal in the cord is preserved.
Scan should be repeated when patient able to cooperate.
Final Report
CERVICAL SPINE MRI WITH AND WITHOUT CONTRAST, [**2131-2-13**]
INDICATION: 52-year-old woman with fever and neck pain for four
days. Seen
at an outside hospital with a negative lumbar puncture and
negative CTs of the
head and cervical spine. Persistently low blood pressure after
fluid
resuscitation. Evaluate for an abscess.
COMPARISON: Cervical spine CT obtained at [**Hospital3 **] on
[**2131-2-12**]
is available for correlation.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of
the cervical
spine were obtained, with axial gradient echo and T2-weighted
images.
Following intravenous gadolinium administration, sagittal and
axial
T1-weighted images of the cervical spine were obtained.
FINDINGS: The study is limited by motion artifacts, despite
repetition of
multiple sequences. STIR images demonstrate abnormal high signal
in the C5-6
intervertebral disc, and in the marrow of the C5 and C6
vertebral bodies.
There is a large prevertebral collection from C2 through C6,
with prevertebral
edema extending inferiorly to T1. This collection demonstrates
high signal on
T2-weighted images and intermediate signal on pre- and
postcontrast
T1-weighted images, more consistent with a phlegmon than an
abscess. There is
an anterior epidural collection from C4 through C6, which
enhances on
post-contrast images, consistent with a phlegmon. This
collection moderately
narrows the spinal canal and deforms the spinal cord. There is
also a small
left posterior epidural rim-enhancing fluid collection at C7-T1
(series 13,
image 6, and series 14, image 27) consistent with an abscess,
which also
moderately narrows the spinal canal and deforms the left
posterolateral spinal
cord. Evaluation of spinal cord signal is limited due to motion
artifacts.
There is edema in the interspinous ligaments from C3-4 through
C6-7, as well
as edema in the posterior subcutaneous soft tissues.
Multilevel degenerative changes are present, but are
suboptimally assessed due
to motion artifacts.
IMPRESSION:
1. Findings consistent with discitis and osteomyelitis at C5-6.
2. Anterior epidural phlegmon from C4 through C6, moderately
narrowing the
spinal canal and deforming the spinal cord. Small left posterior
epidural
abscess at C7-T1, moderately narrowing the spinal canal and
deforming the
spinal cord. Evaluation of cord signal is limited by extensive
motion
artifacts.
3. Large prevertebral collection from C2 through C6, more
consistent with a
phlegmon than an abscess.
Radiology Report MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of
[**2131-2-14**] 1:14 PM
WHITE,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] TSICU [**2131-2-14**] 1:14 PM
MR [**Name13 (STitle) **] W& W/O CONTRAST; MR [**Name13 (STitle) **] W &W/O CONTRAST; MR
[**Name13 (STitle) 6452**] W & W/O CONTRAST Clip # [**Clip Number (Radiology) 10904**]
Reason: epidural abscess
Contrast: MAGNEVIST Amt: 16
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with epidural abscess
REASON FOR THIS EXAMINATION:
epidural abscess
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: NATg WED [**2131-2-14**] 5:11 PM
1. Interval C5-6 corpectomy and C4-7 anterior reconstruction
with debridement
of discitis/osteomyelitis. A residual fluid collection anterior
to the spine
at the C5-6 level most likely represents a postoperative seroma,
recommend
attention on followup.
2. Moderate-sized intracanalicular, epidural collection, which
is
intermediate in signal intensity on T1- and T2-weighted imaging,
and shows
peripheral enhancement with central low signal on T1-weighted
post-contrast
images, results in moderate canal narrowing and in this setting
is concerning
for infectious phlegmon/early abscess.
3. Heterogeneous marrow with numerous foci of T1/T2
hyperintensity without
abnormally high signal on STIR or post-contrast images most
likely represent
hemangiomas as well as reconversion of red marrow in the setting
of patient's
known anemia.
Final Report
CLINICAL INFORMATION: 52-year-old female who presented with an
epidural
abscess and is status post C5-6 corpectomy and anterior
reconstruction.
COMPARISON: MR performed [**2131-2-13**].
TECHNIQUE: Multisequence multiplanar MR images were acquired of
the entire
spine, before and after the administration of contrast.
FINDINGS:
CERVICAL SPINE: The patient is intubated, status post C5-6
corpectomy with
placement of interbody spacer device. The overall aligment
appears preserved.
A residual fluid collection is seen anterior to the spine
extending from the
midline rightward and measuring 3.0 x 2.2 x 0.9 cm. More
widespread edema and
induration in this area is likely post-operative. Posterior to
the thecal
sac is a dorsal epidural space collection which is intermediate
in T2 signal
and low in T1 signal which extends from the C3-4 disc space to
the upper T2
vertebral body level, measuring 10 cm (CC) and producing
moderate narrowing of
the central canal (3;8, 6;20). This collection does enhance
peripherally with
a residual low-T1-signal center following contrast
administration (13; 8).
Otherwise, no significant abnormal enhancement is noted. The
cervical spinal
cord and the cranio-cervical junction are unremarkable in
appearance.
THORACOLUMBAR SPINE: The visualized spinal cord and conus
medullaris are
normal in appearance and terminate normally at the L1 vertebral
body level.
The cauda equina nerve roots are unremarkable. There is no
significant disc
degenerative disease or neural foraminal narrowing. Vertebral
body disc
height and alignment is preserved. Edema seen in the posterior
lumbar soft
tissues is likely related to the patient's recent debilitated
state.
The bone marrow is diffusely heterogeneous with scattered
T1-/T2-hyperintense
foci, likely representing hemangiomas (or "fatty rests"), the
largest of which
within the T5 vertebral body, abutting the superior endplate,
measures
approximately 1 cm. Throughout the spine, these foci demonstrate
no increased
and predominantly decreased STIR-signal and no abnormal
enhancement,
consistent with their non-aggressive nature.
IMPRESSION:
1. Interval C5-6 corpectomy and C4-7 anterior reconstruction
with debridement
of discitis/osteomyelitis. Moderate-sized dorsal epidural
collection, which
shows peripheral enhancement with central low-signal on
T1-weighted
post-contrast images, results in moderate canal narrowing; in
this setting,
this finding likely represents persistent infectious
phlegmon/abscess.
Apparently, the patient is already scheduled for posterior
decompression and
debridement.
2. Residual fluid collection anterior to the spine at the C5-6
level most
likely represents post-operative seroma; attention should be
paid to this
region on any follow-up study.
3. Heterogeneously hypointense bone marrow signal likely
represents
reconversion of red marrow in response to the patient's known
anemia, with
several scattered hemangiomas.
Brief Hospital Course:
The patient was admitted to the [**Hospital1 18**] with neck pain and fever.
MRI was concerning for cervical epidural abscess and the patient
was taken to the OR for anterior C5-6 corpectomy / cage / fusion
on [**2131-2-13**] and C6-T1 lami / C4-T2 PSF with ICBG on [**2131-2-14**] without
complication. For details please refer to the dictated
operative note. Postoperatively the patient was taken to the
ICU intubated. She was extubated on POD#1 and transferred to
the floor that same day. TEDs / pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
administered in the form of nafcillin + vancomycin followed by
nafcillin alone once cultures returned MSSA. An echo performed
[**2131-2-15**] revealed no evidence of vegetation. A PICC line was
placed for long term antibiotics. The patient's pain was
controlled with IV pain medications followed by oral analgesics
once tolerating POs. The patient's diet was advanced as
tolerated. The foley was removed on POD#3 following the second
procedure. Physical therapy was consulted for mobilization. The
[**Hospital 228**] 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.
The patient was discharged with instructions to follow up in
clinic as directed. She is to continue taking nafcillin via
PICC as recommended by the infectious disease consult service.
Medications on Admission:
Levothyroxine 175mcg daily
Celexa 20mg PO daily
Omeprazole 20mg PO daily
Simvastatin 20mg Po daily
Flexeril x 1 dose
Discharge Medications:
1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, headache, fever.
7. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours).
Disp:*[**Numeric Identifier 961**] cc* Refills:*3*
8. 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.
9. Outpatient Lab Work
Please check ESR, CRP, WBC chem7, LFTs weekly while on nafcillin
and fax to [**Telephone/Fax (1) 1419**]. Thanks.
10. PICC dressing kit Sig: One (1) PICC dressing kit once a
week for 6 weeks.
Disp:*6 week supply* Refills:*0*
11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush for 6
weeks.
Disp:*6 week supply* Refills:*0*
12. Saline Flush 0.9 % Syringe Sig: Two (2) ml Injection three
times a day for 6 weeks.
Disp:*6 week supply* Refills:*0*
13. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
cervical epidural abscess
Discharge Condition:
Stable
A&O x3
Ambulatory - independent
Discharge Instructions:
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for 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 Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after this
type of surgery. This should resolve over time. Please take
small bites and eat slowly. Removing the collar while eating can
be helpful ?????? however, please limit your movement of your neck if
you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times. You may remove the collar to take a shower. Limit
your motion of your neck while the collar is off. Place the
collar back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time. If you have
an incision on your hip please follow the same instructions in
terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed to
your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We
are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Weight bearing as tolerated
Cervical collar at all times
Treatments Frequency:
IV antibiotics
wound checks
physical therapy
dressing changes
Followup Instructions:
Call to schedule follow up appt with Dr [**Last Name (STitle) 1007**] in [**10-26**] days.
Please also call to schedule follow up appt with infectious
disease in 6 weeks.
Name: [**Known lastname 1520**],[**Known firstname 1049**] Unit No: [**Numeric Identifier 1521**]
Admission Date: [**2131-2-13**] Discharge Date: [**2131-2-21**]
Date of Birth: [**2078-7-13**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Meperidine / Morphine
Attending:[**Doctor Last Name 147**]
Addendum:
Addendum: On [**2131-2-21**] the patient underwent upper extremity
ultrasound for concern of DVT which revealed only a superficial
thrombosis but no DVT. Treatment is to be symptomatic only with
warm compresses as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**]
Completed by:[**2131-2-21**]
|
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"336.1",
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"285.1",
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"041.11",
"311",
"112.0",
"530.81",
"730.08",
"272.4",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"81.02",
"81.63",
"80.51",
"77.79",
"83.21",
"88.72",
"77.49",
"80.99",
"03.4",
"84.51",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
20801, 21051
|
13758, 15234
|
297, 436
|
17097, 17138
|
3608, 5529
|
20013, 20778
|
2786, 2916
|
15402, 16907
|
9769, 9809
|
17048, 17076
|
15260, 15379
|
17162, 17162
|
2931, 3589
|
19848, 19905
|
19927, 19990
|
5599, 5944
|
19271, 19830
|
17195, 17417
|
247, 259
|
9841, 13735
|
18219, 19260
|
464, 2316
|
5566, 5566
|
2360, 2483
|
2499, 2770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,108
| 116,098
|
29558
|
Discharge summary
|
report
|
Admission Date: [**2187-12-1**] Discharge Date: [**2188-1-2**]
Date of Birth: [**2118-3-31**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Cephalosporins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
[**2187-12-28**]: Flexible bronchoscopy
[**2187-12-1**]: Open abdominal aortic aneurysm repair
[**2187-12-17**]: Percutaneous tracheostomy placement
History of Present Illness:
69 year old woman with multiple medical problems now presenting
on transfer from an OSH with a C-2 cervical fracture. She
suffered a fall from standing. She did not lose consciousness.
Immediately after the fall, she felt a pain
in the back of her neck. Her daughter discovered her and called
EMS. She was taken to an OSH where a CT scan of the neck
revealed a C2 fracture. She was placed in a hard collar and
transferred to [**Hospital1 18**] ED for further management. Neurosurgery
evaluation at [**Hospital1 18**] recommended conservative management.
Initial
trauma workup revealed widened mediastinum on chest x ray.
Follow-up CT of the torso was consistent with leaking infrarenal
AAA. In further questioning of the family, we found she also was
complaining of abdominal pain increasing in intensity radiating
to the back.
Past Medical History:
-diabetes
-COPD
-anxiety
-high blood pressure
-s/p knee replacement
-s/p abdominal hernias and surgery
-h/o pneumonia
-h/o recent leg cellulitis
Social History:
-lives by self
-walks with walker
-no tobacco or alcohol use
Physical Exam:
Admission exam
97.5 66 153/98 28 96%ra
General: no acute distress
Neck: in hard collar, trachea midline
Lungs: decreased breath sounds at the bases
CV: regular rate and rhythm; no murmur/rub
Abdomen: mildly tender to palpation diffusely, multiple
reducible incisional hernias no rebound. Multiple healed
abdominal scars
Ext: warm, no edema. DP 2+ Left/ 1+Right. Faint femoral pulses.
Hemosiderin deposits bilaterally in lower extremities.
Sensation decreased b/l LE distally in stocking distribution.
Pertinent Results:
Day of discharge~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
[**2188-1-2**] 01:48AM BLOOD WBC-15.1* RBC-2.48* Hgb-7.9* Hct-23.8*
MCV-96 MCH-31.8 MCHC-33.0 RDW-19.0* Plt Ct-379
[**2188-1-2**] 01:48AM BLOOD Plt Ct-379
[**2188-1-2**] 01:48AM BLOOD PT-13.6* PTT-31.7 INR(PT)-1.2*
[**2188-1-2**] 01:48AM BLOOD Glucose-116* UreaN-24* Creat-0.8 Na-137
K-3.8 Cl-103 HCO3-29 AnGap-9
[**2187-12-2**] 10:01PM BLOOD CK-MB-3 cTropnT-0.01
[**2188-1-2**] 01:48AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.4
[**2188-1-2**] 03:59AM BLOOD Type-ART pO2-107* pCO2-53* pH-7.37
calTCO2-32* Base XS-3
ADMISSION LABS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
[**2187-12-1**] 01:35PM BLOOD WBC-14.5* RBC-4.00* Hgb-12.4 Hct-36.9
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.4 Plt Ct-260
[**2187-12-1**] 01:35PM BLOOD PT-13.0 PTT-29.8 INR(PT)-1.1
[**2187-12-1**] 01:35PM BLOOD Glucose-173* UreaN-8 Creat-0.4 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2187-12-2**] 02:23AM BLOOD ALT-18 AST-38 LD(LDH)-388* AlkPhos-48
Amylase-27 TotBili-0.7
[**2187-12-1**] 01:35PM BLOOD CK-MB-16* MB Indx-3.8 cTropnT-<0.01
[**2187-12-1**] 01:35PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9
[**2187-12-1**] 11:15PM BLOOD Type-ART pO2-210* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
RADIOLOGY STUDIES~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CTA ABD W&W/O C & RECONS [**2187-12-1**] 8:23 PM
IMPRESSION:
1. 5.8 x 6.3 cm infrarenal abdominal aortic aneurysm measuring
approximately 10 cm in length. Blood in the retroperitoneal
cavity is consistent with leak. There is at least one focus of
extraluminal contrast which is likely contained in the wall. All
branches of the abdominal aorta remain patent. The inferior
mesenteric artery originates from the inferior aspect of the
aneurysm.
2. Normal intrathoracic aorta. Mediastinal widening on previous
chest x-ray was likely related to an overabundance of
mediastinal fat and bilateral dependent atelectasis.
3. Left lower quadrant abdominal hernia as described above.
Small amount of fluid at the hernia apex.
4. Gallstones.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT C-SPINE W/O CONTRAST [**2187-12-1**] 1:04 PM
IMPRESSION: Mildly displaced acute C2 fracture extending through
both lateral masses and into the posteroinferior portion of the
odontoid.
NOTE ADDED AT ATTENDING REVIEW: The fracture extends into the
left transverse foramen, raising the possibility of vertebral
artery injury. If this is a clinical concern, then an MR
examination with axial T1 images and an MRA are recommended.
This is more reliable than CTA for this purpose.
Osteophyte formation at C [**1-27**] and [**3-30**] narrow the spinal canal.
CT lacks soft tissue contrast resolution to exclude ligamentous
injury or disk or hematoma compromising the canal.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT HEAD W/O CONTRAST [**2187-12-1**] 1:04 PM
IMPRESSION: No fractures, no acute intracranial hemorrhage
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2187-12-1**] 7:40 PM
IMPRESSION:
Marked widening of the mediastinum concerning for mediastinal
hematoma and possible aortic injury in the setting of trauma.
CTA of the chest is recommended for further characterization.
Small right pleural effusion and adjacent lung opacity.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT PELVIS W&W/O C [**2187-12-4**] 3:23 PM
IMPRESSION:
1. In this patient that is post open repair of a ruptured
abdominal aortic aneurysm, there is absent perfusion of the
right kidney.
2. No evidence of pneumatosis, as clinically questioned. Mild
left colonic wall thickening and mildly dilated loops of small
bowel, which are nonspecific findings, however, can be seen in
the setting of bowel ischemia. Recommend close interval followup
and clinical correlation.
3. Gallstones.
4. Small bilateral pleural effusions and adjacent atelectases
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2187-12-13**] 8:12 AM
IMPRESSION:
1. Cholelithiasis without cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease including severe hepatic
fibrosis/cirrhosis cannot be excluded on this examination.
3. No biliary duct dilatation
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT CHEST W/O CONTRAST [**2187-12-26**] 10:42 AM
IMPRESSION:
1. Tracheomalacia. Assessment of likely tracheal stricture
around tracheostomy tube would require extubation. Bronchi
normal.
2. New, nonhemorrhagic pericardial effusion; no evidence of
tamponade.
3. Small, nonhemorrhagic, left pleural effusion.
4. Bibasilar atelectasis.
5. Atherosclerotic aortic arch ulcer; aortic contour unchanged
since [**2187-12-2**].
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT HEAD W/O CONTRAST [**2187-12-26**] 10:42 AM
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Evidence of chronic microvascular infarction.
3. New, partial opacification and possible fluid level within
the left mastoid air cells. This could represent mastoiditis in
the appropriate clinical setting.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Cardiology Report ECHO Study Date of [**2187-12-27**]
IMPRESSION: Moderate-sized pericardial effusion without
echocardiographic
signs of tamponade. Symmetric LVH with preserved global systolic
function.
Mild aortic regurgitation. Mildly dilated thoracic aorta.
Compared with the focused TEE study of [**2187-12-2**] (images reviewed),
the LV
systolic function has improved, and there is now a pericardial
effusion, as
described above.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2188-1-1**] 8:19 AM
IMPRESSION:
1. Increased left-sided basilar/retrocardiac opacity. Given the
lack of deviation of the left main stem bronchus it is felt to
likely represent an underlying consolidation with superimposed
pleural effusion.
Brief Hospital Course:
Patient was admitted after initial evaluation in trauma ED for
emergent ruptured abdominal aortic aneurysm repair by Dr.
[**Last Name (STitle) **] of vascular surgery. Please see operative note for
details of procedure. The patient tolerated this procedure well
and was taken to the surgical intensive care unit still
intubated and in critical, but stable condition. Her course in
the intensive care unit was remarkable for development of
ischemic colitis following the operation that resolved with
conservative management. A flexible sigmoidoscopy was performed
that confirmed this diagnosis intially and general surgery
followed the patient as she resolved from this condition. She
remained ventilator dependent and the decision to perform a
tracheostomy was made. She underwent a bedside percutaneous
tracheostomy on [**2187-12-17**]. Since that time she was weaned on the
ventilator to the current status of alternating trach mask and
CPAP+PS as tolerated.
Tube feedings were intitiated via NGT (PEG deferred secondary to
abdominal operations). She tolearated this at goal.
Infectious issues were a ventilator associated pneumonia with
respiratory cultures revealing proteus from [**12-7**]. She completed
a course of zosyn and flagyl on [**12-17**] (on abx from day of
surgery). Later in her hospitalization urine cultures revealed
yeast, proteus and klebsiella for which she was treated as well.
A mild leukocytosis developed the week of planned discharge with
no evident source on work-up. The WBC was decreasing at the
time of discharge.
Retention sutures placed in the OR were removed on [**2187-12-31**] when
her nutritional status had improved. Her wounds were healing
well without complications.
Cardiology evaluated the patient on [**2187-12-28**] for a small
pericardial effusion seen on echocardiography. The patient was
asymptomatic from this and it was deemed that no further work-up
was necessary unless hypotension developed. The patient
remained stable throughout. A repeat echocardiography was
recommended as follow-up (1week).
The patient was out of bed frequently and had been seen by
physical therapy prior to discharge.
Medications on Admission:
glucophage, glyburide, advair, xanax, zestril, amitriptyline,
lasix, vicodin, lipitor, lopressor
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4-6H (every 4 to 6 hours).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Insulin Sliding Scale
Fingerstick QACHSInsulin SC Fixed Dose Orders
Q12H
70 / 30 30 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**11-27**] amp D50 [**11-27**] amp D50 [**11-27**] amp D50 [**11-27**] amp D50
61-120 mg/dl 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 4 Units 4 Units 4 Units 4 Units
141-160 mg/dL 7 Units 7 Units 7 Units 7 Units
161-180 mg/dL 10 Units 10 Units 10 Units 10 Units
181-200 mg/dL 13 Units 13 Units 13 Units 13 Units
201-220 mg/dL 16 Units 16 Units 16 Units 16 Units
221-240 mg/dL 19 Units 19 Units 19 Units 19 Units
241-260 mg/dL 22 Units 22 Units 22 Units 22 Units
261-280 mg/dL 25 Units 25 Units 25 Units 25 Units
281-300 mg/dL 28 Units 28 Units 28 Units 28 Units
301-320 mg/dL 31 Units 31 Units 31 Units 31 Units
321-340 mg/dL 34 Units 34 Units 34 Units 34 Units
341-360 mg/dL 37 Units 37 Units 37 Units 37 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Abdominal aortic aneurysm
Ischemic colitis
Diabetes Melitus
COPD
Ventilatory Reqirement s/p tracheostomy
Discharge Condition:
Stable
Discharge Instructions:
Please call with any concerns or questions.
Ventilator weaning for trach per protocols.
C-collar to remain in place at all times with follow-up for open
MRI needed when stable for transport and study.
Please follow intermittent CBC to monitor mild leukocytosis and
stable anemia.
Followup Instructions:
Follow-up needed:
Open MRI on [**Hospital Ward Name 516**] of C-spine in 1-2weeks or when stable
off vent consistently
Appointments with
Dr. [**Last Name (STitle) **]. Please call for appointment in [**12-29**] weeks. ([**Telephone/Fax (1) 16580**]
Neurosurgery appointment needed following MRI. Please call for
appointment with Dr. [**Last Name (STitle) 739**]. ([**Telephone/Fax (1) 88**]
General surgery for trach. Please call for appointment when off
ventilator support. Dr. [**Last Name (STitle) **]. ([**Telephone/Fax (1) 1483**]
Please obtain echocardiography to assess pericardial effusion on
[**2188-1-4**] (approximately). Follow-up with cardiology. Call for
appointment ([**Telephone/Fax (1) 7437**]
|
[
"112.2",
"806.00",
"423.9",
"997.4",
"496",
"441.3",
"599.0",
"278.01",
"519.19",
"482.83",
"401.9",
"311",
"250.00",
"E888.9",
"518.81",
"112.3",
"999.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.44",
"99.15",
"33.21",
"99.05",
"89.60",
"38.93",
"33.22",
"31.1",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12747, 12821
|
7850, 10015
|
312, 463
|
12970, 12979
|
2115, 7827
|
13310, 14035
|
10162, 12724
|
12842, 12949
|
10041, 10139
|
13003, 13287
|
1585, 2096
|
254, 274
|
491, 1324
|
1346, 1492
|
1508, 1570
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,662
| 123,848
|
51764
|
Discharge summary
|
report
|
Admission Date: [**2122-12-4**] Discharge Date: [**2122-12-7**]
Date of Birth: [**2072-5-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD s/p banding of varices
History of Present Illness:
50y/o F with metastatic breast cancer to liver, patient of Dr.
[**Last Name (STitle) 88694**] who has been treated with 8 cycles of CAF, alternating
Xeloda/Taxotere, Caboplatin and Gemcitabine and recently has
been treated with Taxol for last month. Avastin was added as
well, first and only dose [**2122-11-20**]. She as seen in Heme/[**Hospital **]
clinic today by Dr. [**Last Name (STitle) 3274**] who sent her to the ED for c/o one
week of black stools.
She has been having [**12-25**] stools per day that have been soft,
black and sticky. She usually has [**12-25**] stools per day. No
diarrhea, no hematochezia. She denies any lightheadedness of
dizzyness but states that just yesterday she noted SOB with
walking up one flight of stairs. No chest pain. No vomiting, no
hematuria, +intermittent nausea and axiety. Last week she also
had one episode of confusion and forgetfullness which resolved,
has not had any other episodes since. No c/o morning HA's, she
does get tension headaches frequently which have not changed in
character. She denies any visual changes or blurryness, no
dysphagia, no odynophagia, no epistaxis, no sob at rest, no abd
pain, no ruq pain, no back pain, no dysuria, no hematuria.
Patient does have external hemorrhoids which cause her pain
often with her BM's. She has noticed increased abd girth over
the past week.
In Dr. [**Last Name (STitle) 88694**] office her hct was 16, baseline mid 30's. Guiac
positive in office. In ED she was guiac negative, NGL was
negative with 600cc. Last dark stool yesterday. She was given 4
Units of blood in the ED, started on protonix 40mg, given ativan
1mg x2, and annusol cream.
Past Medical History:
1. Breast cancer:
-breast augmentation in 79 w/ silicone implants, implants
replaced 2 years ago with saline implants.
-diagnosed [**2120**] w/ breast cancer after noted sharp pains in L
breast, skin color changes, and mass appreciated by PCP in [**Name Initial (PRE) **]
breast.
-ER negative, PR negative, HER2/neu negative
2. ADHD
Social History:
no tob, occ etoh. Financial consultant, lives with her husband
and 4 children
Family History:
Lung ca in sister at age 29, Father died of prostate cancer at
age 84, Maternal grandparents both died of throat cancer.
Physical Exam:
PE:
T: 98.4, P: 107, BP: 116/70, R: 20, Sats: 100%
GEN: pale thin lady, NAD
HEENT: alopecia appreciated, EOMI, PERRLA, sclera anicteric,
conj clear, MMM, o/p clear
CV: RRR, no m/r/g
PULM: CTA b/l, crackles appreciated at bases but clear with
cough. Good insp effort.
ABD: Distended, round, +BS, mild ascites(+fluid shift), NT/ND,
unable to appreciated liver or spleen.
EXT: no c/c/e, DP/PT +2 b/l.
NEURO: CN II-XII grossly intact, sensation grossly intact to
light touch, strenght [**3-26**] in all four ext flex/ext. Cerebellar:
FTN/[**Doctor First Name **] intact.
Pertinent Results:
Admit Labs:
[**2122-12-4**] 11:35AM BLOOD WBC-4.5# RBC-1.56*# Hgb-5.2*# Hct-16.2*#
MCV-104* MCH-33.6* MCHC-32.4 RDW-17.2* Plt Ct-160#
[**2122-12-4**] 01:10PM BLOOD Fibrino-252
[**2122-12-4**] 11:35AM BLOOD Gran Ct-2780
[**2122-12-4**] 03:50PM BLOOD Ret Aut-2.6
[**2122-12-4**] 11:35AM BLOOD Glucose-123* UreaN-10 Creat-0.4 Na-137
K-3.8 Cl-105 HCO3-25 AnGap-11
[**2122-12-4**] 11:35AM BLOOD ALT-45* AST-48* LD(LDH)-424* AlkPhos-142*
TotBili-0.5
[**2122-12-4**] 02:30PM BLOOD calTIBC-217* Hapto-126 Ferritn-585*
TRF-167*
[**2122-12-4**] 11:35AM BLOOD CA 27.29-88
.
D/C CBC:
[**2122-12-7**] 07:15AM BLOOD WBC-3.1* RBC-4.14* Hgb-13.6 Hct-38.3
MCV-93 MCH-32.8* MCHC-35.5* RDW-17.9* Plt Ct-107*
.
Hepatitis W/U:
HBsAb-POSITIVE
HBcAb-PND
.
Liver U/S w/ duplex:
IMPRESSION:
1. Portal vein patent, demonstrating hepatopetal flow.
2. Liver diffusely infiltrated with metastatic disease.
3. Large amount of ascites.
.
EGD:
Varices at the lower third of the esophagus
Erythema and congestion in the stomach compatible with Portal
Gastropathy
.
MRI Brain:
Final read pending at discharge
Brief Hospital Course:
# Bleeding esophageal varices: Patient was noted to have a
hematocrit of 16 on admission to the ICU. She received 6 units
of PRBCs. Her NG lavage was negative. She had a EGD which
showed esophageal varices which were then banded. She had no
further bleeding, her hct remained stable, and her dyspnea
resolved. She was started on Nadolol, Protonix, and a 10 day
course of levofloxacin given risk for SBP with esophageal
varices. The patient will follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an
outpatient in approximately one week and will need to be
rescoped in a few weeks for further banding. Hct at discharge
was 38.
.
# Ascites - Patient had noted increased abdominal distention
prior to admission. U/S noted a large amount of ascites, but no
hepatic vein thrombosis. Most likely cause of her ascites was
the liver metastasis. Given a remote hx of IVDU, hepatitis
serologies were sent, HepBsAb(+) and HepC pending at dischage.
Patient had a diagnostic paracentesis with no microorganisms
seen, no growth to date at dicharge, final results pending.
Patient was started on Lasix and Aldactone and will follow up
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to address the need for therapeutic
paracentesis as an outpatient.
.
# Breast cancer - Patient did not receive any chemotherapy
during this admission. She will follow up with Dr. [**Last Name (STitle) 3274**]
regarding further treatment. Due to difficulty in obtaining IV
access in this patient she may benefit from placement of a
port-a-cath depending on future treatment plans.
.
# Previous mental status changes - Patient did not exhibit any
further difficulty with word finding or any other significant
mental status changes during her hospitalization. A brain MRI
was performed on the morning of discharge to evaluate for
leptomeningeal carcinomatosis. Patient will follow up with Dr.
[**Last Name (STitle) 3274**] to obtain the results from this study.
Medications on Admission:
Medications on Admission
1. concerta 54mg'
2. wellbutrin 150mg [**Hospital1 **]
3. lactulose 30ml'
4. ativan
5. phenergan.
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
2. Methylphenidate 20 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO daily ().
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Prochlorperazine 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for nausea.
5. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. 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*
12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
13. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal bleed
Esophageal varices
Metastatic breast cancer
Discharge Condition:
Good, stable hematocrit
Discharge Instructions:
If you develop fevers, chills, lightheadedness, dizziness,
shortness of breath, or if you notice bright red blood in your
stool or dark tarry stools, call your primary care doctor or
return to the emergency room immediately.
.
You will need to be seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Gastroenterology within one week. Please call ([**Telephone/Fax (1) 107211**] to
make a follow up appointment.
.
You have a follow up appt with Dr. [**Last Name (STitle) 3274**] on [**2122-12-11**] at 11:30
AM.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2122-12-11**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2122-12-11**]
12:30
Provider: [**Name Initial (NameIs) 4426**] 17 Date/Time:[**2122-12-11**] 12:30
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2122-12-13**]
|
[
"789.5",
"197.7",
"284.8",
"535.40",
"456.0",
"174.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"54.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7806, 7812
|
4319, 6320
|
319, 348
|
7917, 7943
|
3219, 4296
|
8531, 9047
|
2494, 2616
|
6494, 7783
|
7833, 7896
|
6346, 6471
|
7967, 8508
|
2631, 3200
|
276, 281
|
376, 2027
|
2049, 2383
|
2399, 2478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,373
| 180,327
|
33693
|
Discharge summary
|
report
|
Admission Date: [**2113-4-2**] Discharge Date: [**2113-4-18**]
Date of Birth: [**2045-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] Valve Replacement(23mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]./Mitral Valve
Replacement(31mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **].)/Coronary ARtery Bypass Graft x
1(SVG->OM) [**4-6**]
History of Present Illness:
This is a 67 yo M presenting with multiple medical problems
including severe MR [**First Name (Titles) **] [**Last Name (Titles) 8813**] stenosis, who presents with
worsening DOE. He was recently hospitalized at [**Hospital1 18**] from [**3-8**] to
[**3-15**] for bilateral lower lobe PNA's, and during that hospital
course, he was found to have worsening severe MR (4+ with
partial flail leaflet and possible cord prolapse). His [**Month/Day (4) 8813**]
stenosis had a valve area of 0.8. He was also cathed and was
found to have 3VD not amenable to PCI. In the acute setting of
fevers/PNA, CT surgery was deferred until outpatient setting. He
did undergo thoracentesis of his pleural effusion on that
admission which was transudative. He was treated with a 7 day
course of CTX/azithro for the PNA. He was discharged on [**3-15**] and
was to follow up with Dr. [**Last Name (STitle) 2230**] in CT surgery for CABG/MVR/?AVR.
He got surveillance cultures subsequent to discharge that have
been negative to date. However, he was readmitted from [**Date range (1) 6098**]
with fever, diarrhea, and cough, and was found to be
hypotensive. He was treated empirically for C diff despite 3
negative stool toxin A assays. He was briefly on pressors in the
ICU. All stool cultures to date have been negative for C diff,
and pt is to complete his course of flagyl on [**2113-4-6**].
.
He states that beginning yesterday, he noted worsening DOE.
Normally he is able to walk many blocks without becoming SOB,
but yesterday he was quite exhausted even climbing the stairs to
his house. He also noted a 5 lb weight gain and paroxysmal
nocturnal dyspnea. However, denies worsening LE edema or new
orthopnea. No CP. Defintiely feels more lethargic and weaker
than usual. No F/C/night sweats, no N/V. His diarrhea has
completely resolved. Denies unual salt intake and has been
taking his medicines religiously. He called Dr.[**Name (NI) 77980**] office
who prescribed lasix 20mg po daily x 2 days. He noted no benefit
from this and so was advised to present to the ED.
.
In the ED, intial vitals were 98.3, 90, 117/83, 20, 97% RA. CXR
was read as stable cardiomegaly with no acute intrathoracic
pathology. EKG was unchanged from prior. Labs revealed slightly
elevated creatinine of 1.2 (b/l 0.9-1.1), and a proBNP of 4475
(up from 3587 on [**2113-3-8**]). 2 sets of cardiac enzymes were
negative. Cardiac Surgery was consulted for evaluation and
recommended admission to [**Hospital Unit Name 196**] for management of SOB.
Past Medical History:
Congestive Heart Failure, Hypercholesterolemia, Gastroesophageal
Reflux Disease, Pneumonia, s/p appendectomy, s/p Inguinal Hernia
Repair
Social History:
1-2 beers per day. No tobacco use. no IVDU Married, lives with
wife. [**Name (NI) **] 2 adult children and 1 five year old child. Works as
the interim executive director of the Mass. Teachers Association
Family History:
No history of premature CHD or SCD. Father passed from ALS at
age 57. Mother passed from Lung Cancer in her 70s. Brother is
61 and healthy.
Physical Exam:
VS - 98.7 123/54 18 100%RA
Gen: WDWN elderly appearing male in NAD. Oriented x3. Mood,
affect appropriate. Slightly breathless with long sentences.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Distended EJs, JVP of 12 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Loud III/VI holosystolic murmur at apex
radiating to axilla. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NT/ND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**4-6**] Echo: PRE-BYPASS: The left atrium is moderately dilated. The
left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. Mild spontaneous echo contrast is seen in the body of
the right atrium. The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. There is mild
tricuspid regurgitation. The [**Month/Day (4) 8813**] valve leaflets are
moderately thickened. There is moderate [**Month/Day (4) 8813**] valve stenosis
(area 1.0-1.2cm2) by planimetry and continuity equation c/w low
gradient AS. No Dobutamine stress test was done as it was
already done in the cath [**Month/Day (4) **] with the [**Location (un) 109**] going up to 1.67cm2.
Trace [**Location (un) 8813**] regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is partial mitral leaflet flail at
the P2 region. Anterior leaflet looks normal. There is an
eccentric jet c/w with Moderate to severe (3+) mitral
regurgitation is seen. There is a moderate sized pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results
[**First Name9 (NamePattern2) 77981**] [**Known lastname **] at 8AM in the OR before surgery start.
POST-BYPASS: Patient is on milrinone 0.25mcg/kg/min, levophed
0.07 mcg/kg/min, epinephrine 0.03 mcg/kg/min RV has moderate
systolic dysfunction. Mild to moderate TR. LVEF is 35 ro 40%.
There is a mechanical prosthesis in the mitral position well
positioned with a mean gradient of 2mm of HG. The prosthesis is
stable and functioning well. There is a mechanical prosthesis in
the [**Known lastname 8813**] position well seated and a peak of 20mm of HG. There
are no pathological leaks in both the prosthesis.
Thoracic [**Known lastname 8813**] contour is intact.
[**4-15**] CXR: Small right pleural effusion has decreased
substantially, left pleural effusion nearly resolved since [**4-7**]. Mild-to-moderate enlargement of the cardiac silhouette is
stable postoperatively. Aside from mild bibasilar atelectasis,
lungs are clear. No pneumothorax.
[**2113-4-2**] 10:30AM BLOOD WBC-10.3 RBC-4.32* Hgb-12.0* Hct-36.7*
MCV-85 MCH-27.9 MCHC-32.8 RDW-14.7 Plt Ct-372
[**2113-4-17**] 05:55AM BLOOD WBC-8.0 RBC-3.10* Hgb-9.0* Hct-27.2*
MCV-88 MCH-29.0 MCHC-33.2 RDW-15.7* Plt Ct-527*
[**2113-4-3**] 06:45AM BLOOD PT-18.6* PTT-31.3 INR(PT)-1.7*
[**2113-4-17**] 05:55AM BLOOD PT-24.1* PTT-84.9* INR(PT)-2.3*
[**2113-4-2**] 10:30AM BLOOD Glucose-129* UreaN-15 Creat-1.2 Na-137
K-5.4* Cl-103 HCO3-22 AnGap-17
[**2113-4-17**] 05:55AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-133
K-4.6 Cl-100 HCO3-24 AnGap-14
[**2113-4-5**] 07:25AM BLOOD ALT-73* AST-55* LD(LDH)-241 AlkPhos-74
TotBili-0.8
[**2113-4-17**] 05:55AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.9
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] presented to the ED c/o
worsening DOE. He was admitted under the cardiology service for
medical management. He was given vitamin K for an elevated INR
and continued on empiric Flagyl. He was seen by hepatology for
elevated transaminase and INR, and given more vitamin K for
vitamin K deficiency. He underwent an Echo on [**4-5**] which
revealed severe MR along with [**Month/Year (2) **] Stenosis. He was taken to
the operating room on [**4-6**] where he underwent a Coronary Artery
Bypass Graft x 1, Mitral and [**Month/Year (2) **] Valve Replacement. Please
see operative report for surgical details. Following surgery he
was transferred to the CVICU for invasive management in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. Post-operatively he was
seen by cardiology for ventricular ectopy. Also required blood
transfusion for decreased HCT and post-op bleeding. He was
started on Coumadin and heparin for his mechanical valves. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-op day five he was transferred to the telemetry floor for
further care. He remained relatively stable for the remainder of
his post-op course and worked with physical therapy for strength
and mobility. He remained on Heparin while receiving Coumadin
until his INR was therapeutic. This was finally achieved on
post-op day 12 and he was discharged home with VNA services and
the appropriate follow-up appointments. The coumadin clinic at
[**Hospital1 18**] while follow him as outpatient with first draw [**4-20**].
Medications on Admission:
Pantoprazole 40 mg daily, Metoprolol 12.5 mg twice daily, ASA
325 mg daily, Atorvastatin 40 mg daily, Metronidazole 500md tid
until [**2113-4-6**], MVI
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. 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*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Warfarin 5 mg Tablet Sig: goal INR 3.0-3.5 Tablets PO once a
day: please take dose as indicated - you are being given
prescription for two different doses of coumadin.
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 2 mg Tablet Sig: goal inr 3-3.5 Tablets PO once a
day: please take dose as indicated - you are being given
prescription for two different doses of coumadin.
Disp:*60 Tablet(s)* Refills:*2*
10. warfarin
please take 7.5 mg of coumadin [**4-18**] and [**4-19**]
VNA to draw [**Month/Year (2) **] [**4-20**] with coumadin clinic to further dose
medication
11. Outpatient [**Month/Year (2) **] Work
[**Name (NI) **] PT/INR for mechanical valve goal 3.0-3.5 first draw [**4-20**]
thrusday with results to [**Company 191**] coumadin clinic phone #
[**Telephone/Fax (1) 2173**] fax [**Telephone/Fax (1) 3534**]
12. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] [**Hospital **] homecare
Discharge Diagnosis:
[**Hospital **] Stenosis, Mitral Regurgitation, Coronary Artery Disease
s/p [**Hospital **] Valve Replacement, Mitral Valve Replacement, Coronary
Artery Bypass Graft x 1
PMH: Congestive Heart Failure, Hypercholesterolemia,
Gastroesophageal Reflux Disease, Pneumonia, s/p appendectomy,
s/p Inguinal Hernia Repair
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2113-5-9**] 3:00
Dr [**Last Name (STitle) 73**] 2 weeks [**Telephone/Fax (1) 902**]
Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
[**Telephone/Fax (1) **] draws PT/INR for mechanical valve goal 3.0-3.5 first draw
[**4-20**] thrusday with results to [**Company 191**] coumadin clinic phone #
[**Telephone/Fax (1) 2173**] fax [**Telephone/Fax (1) 3534**]
Completed by:[**2113-4-18**]
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,726
| 137,085
|
14468
|
Discharge summary
|
report
|
Admission Date: [**2144-1-12**] Discharge Date: [**2144-1-14**]
Date of Birth: [**2099-5-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
PICC line placement, [**2143-1-14**], Interventional Radiology
History of Present Illness:
Mr. [**Known lastname **] is a 44 year old male with quadriplegia following a
MVC in [**2125**] who presents for with a fever of 102. Events are
unclear but it seems that pt was d/c to [**Hospital1 **], checked
himself out because he was unhappy with how they turned him/took
care of him there and he could feel his "ulcers were getting
bigger." He went home and then re-presented to [**Hospital1 **] for
wound care. At [**Hospital1 **], his temp was found to be high (T 102)
with BP of 87/54, so he was sent to [**Hospital1 18**].
.
.
He was recently treated at [**Hospital1 2177**] (admitted [**Date range (1) 42768**] at [**Hospital 42779**] transferred to [**Hospital1 2177**] [**Date range (3) 42770**]). He was
recently admitted to [**Hospital1 18**] from [**Date range (1) 42780**].
.
During his most recent [**Hospital1 18**] admission, his ischial decubitus
ulcers with chronic osteomyelitis were evaluated by general
surgery who determined pt did not need debridement at that time.
Plastic surgery will not do flap closure as pt is not ambulatory
and flap will break down. Given
that he remained afebrile, without leukocytosis, without
purulent drainage, was not bacteremic, and he was treated with
antibiotics for 4 months from [**Month (only) **] - [**2143-10-10**], ID felt that it
is unlikely he has acute osteomyelitis and there is no
superinfection of ulcers. He was not started on chronic
suppressive therapy, both because no appropriate oral regimen
exists that would cover his known microbiology, and oral
suppression could [**Doctor Last Name **] more resistant microorganisms in the
future.
.
.
In the ED, initial vs were: T 97.8 HR 99 BP 95/56 RR 16 O2 97%.
Patient complained of abdominal pain, though it was unclear if
this was worse than his chronic pain. No BM for a few days. SBP
dropped to 87, but responded to IV fluids. Continued to drop SBP
to low 90s.
Patient was given IV fluids, one dose of Vancomycin and Zosyn.
UA was positive, but patient has a history of chronic
colonization with ESBL Ecoli. Urine culture was sent. CT Abdomen
and pelvis was performed which showed osteomyelitis chronic vs.
acute. Surgery was consulted to evaluate large decubitus
ulcers. They had not evaluated the patient yet on sign out. VS
at transfer: T 99.5 BP 92/54 P94 R11 96% RA.
.
.
On the floor, he mentions that he had fevers multiple times at
home for the days prior. Complains of back pain and leg pain,
though these aren't new for him. He has a cough productive of
some white sputum.
.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Quadriplegia following a MVC in [**2124**] or [**2125**]; Injury at C4-C5
level. Pt was driving from police at high speed (up to 160mph)
and car flipped.
2. History of decubitus ulcers and osteomyelitis of the sacrum
and ischial tuberosity- followed by Dr. [**Last Name (STitle) 42772**] (ID) at [**Hospital1 2177**]
([**Telephone/Fax (1) 42773**])
3. s/p flap repair of ischial and sacral decubitus ulcers
4. [**2143-6-22**] - Sacral decubitus ulcer debridement at [**Hospital1 2177**]
5. [**2143-6-24**] - Creation of diverting transverse loop colostomy to
divert stool away from sacral ulcers at [**Hospital1 2177**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42774**],
[**Telephone/Fax (1) 42775**]); colonic obstruction and colostomy revised
[**2143-6-29**]; ex-lap with revision of ostomy on [**2143-6-30**]
6. Neurogenic bladder with suprapubic catheter and history of
frequent UTIs
7. Depression
8. Anemia
9. DM type II on metformin
10. HTN
11. History of intubation secondary to narcotic overuse -
approximately [**Month (only) 116**]/[**2143-6-10**] per pt but [**Hospital3 417**] records
suggest it may have occurred more recently (possibly [**11/2143**] as
there is Head CT done for "overdose"), no documents of this
hospitalization available
Social History:
Lives at home with family (sister, brother-in-law, brother, and
their children). No tobacco, alcohol, or illicit drugs per
patient. OSH indicates prior history of marijuana and cocaine
use. Per discussion with PCP, [**Name10 (NameIs) **] is concern amongst some of
his prior PCP's in the area that he has sold some of his
narcotics.
Family History:
Mother - cancer, type unknown
Father - diabetes, pacemaker in place
Physical Exam:
Vitals: T:99.2 BP:85/50 P:90 R: 14 O2: 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Dentures in
place.
Neck: supple, unable to assess JVP given body habitus, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness. Patient has intermittent voluntary
guarding. No organomegaly. Colostomy bag in place. Site looks
clean. With small amount of brown stool present.
GU: foley in place
Ext: warm, 2+ CP pulses. No edema. Bandages over heels.
Pertinent Results:
Labs on Admission:
[**1-12**]: WBC-12.2* RBC-4.01* Hgb-10.1* Hct-31.2* MCV-78* MCH-25.3*
MCHC-32.5 RDW-16.0* Plt Ct-359
[**1-12**]: PT-15.1* PTT-28.2 INR(PT)-1.3*
[**1-12**]: ALT-16 AST-71* AlkPhos-142*
[**1-12**]: Calcium-7.9* Phos-4.0 Mg-1.7
[**1-12**]: Lactate-2.0 K-5.4*
Labs on Discharge:
Micro:
Source: Sacral decubitus ulcer.
GRAM STAIN (Final [**2144-1-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Preliminary):
***************PENDING****************
Source: supra pubic cath insert site.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
BLOOD CULTURE
Blood Culture, Routine (Pending):
******************PENDING*************
Studies:
CXR: Right middle lobe subsegmental atelectasis. No acute
process identified.
CT ABD/PELVIS: 1. Unchanged right basilar opacity, which may be
a chronic abnormality. Correlation with more remote prior
imaging, if available, is recommended. Otherwise CT follow-up
is recommended in 3 months to assess further. 2. Similar large
ulcerations extending to each ischial tuberosity. The sclerotic
appearance of each tuberosity is essentially diagnostic of
chronic osteomyelitis. No discrete fluid collection is
demonstrated.
Brief Hospital Course:
44 year old male with history of quadriplegia and recurrent
decubitus ulcers who presents with fevers in the setting of
chronic bilateral ischial and heel ulcers.
# Fever and Hypotension: On presentation patient with relative
leukocytosis with WBC of 12 (8.4 on discharge), hypotension,
responsive to fluids, and fever at [**Hospital3 **] to 102.
Sources of fever include large decubitus and heel ulcers and
with secondary chronic osteomyelitis. Abdominal exam was
benign, with no obvious source of infection seen on CT. Patient
also has positive UA, though asymptomatic, with history of
colonization with ESBL Ecoli. No cough or increasing oxygen
requirement currently. No indwelling lines. Given patients
hypotension and fever patient was started on Vancomycin and
Meropenum given past sensitivities. Further patient was bolused
with IV fluids with appropriate response in blood pressure.
Despite systolic blood pressures in the 80s during admission the
patient maintained a stable heart rate without tachycardia,
appropriate urine output, and normal mentation. During
hosptialization it was felt low blood pressures were stable and
not secondary to infection or sepsis. BP noted to be low when
sleeping and patient would wake up without symptoms. Likely not
from sepsis at this time. Blood, urine, wound cultures are
pending. These cultures should be followed by [**Hospital3 **]
and antibiotic therapy should be tailored to the results. At
this time the MICU team would favor a prolonged course of
antibiotics at 6 weeks with the first day of antibiotics on
[**2144-1-12**]. A PICC was placed on [**2144-1-14**]. During hosptialization
surgery evaluated the patients chronic wounds and felt
debridement was not indicated at this time. Further wound care
provided recommendations regarding care of chronic ulcerations.
.
# Positive UA - > 50 WBC. Patient likely chronically colonized
due to suprapubic catheter and neurogenic bladder. Urine culture
with E. Coli sensitive to Meropenum. Meropenum as above.
Suprapubic catheter was changed by urology on [**2144-1-13**].
.
# Abdominal pain: Pt with intermittent abdominal pain. Appears
to be related to constipation. Had intermittent abdominal pain
on last admission also. PPI was restarted for possible
PUD/gastritis. Bowel Regimen was started with multiple bowel
movements during admission. LFTS/Lipase were normal
.
# Chronic pain: During admission patient was continued on
regimen of Fentanyl patch 125mcg/hour, Diazepam 10mg po q6h PRN
muscle spasms, and Morphine 15-30mg po q4h PRN pain. MS contin
115mg po q12h was held during admission. Rehab facility can
determine the need to restar this medication. During admission
patients pain was controlled and need for PRN morphine was
minimal.
.
# DM2: Hold metformin given CT with contrast. Starte on Insulin
Sliding Scale. Metformin should be restarted at the rehab
facility on [**2144-1-19**].
.
# Microcytic anemia: Baseline HCT 27. Iron studies from last
admission suggest anemia of chronic disease. He required no
transfusions. He was continued on iron [**Hospital1 **].
.
Follow UP:
1. Blood, Urine, Wound Cultures [**Hospital1 1170**] - adjust antibiotic regimen and duration as needed.
2. Restart Metformin [**2144-1-19**]
3. Assess need for MS Contin while at rehab facility, this was
stopped during admission secondary to CT scan with contrast
Medications on Admission:
Medications (per d/c summary on [**1-1**])
1. Fentanyl 100 mcg/hr Patch q72 hr
2. Fentanyl 25 mcg/hr Patch q72 hr
3. Diazepam 10-20 mg po q6h
4. Ascorbic Acid 500 mg po bid
5. Docusate Sodium 100 mg po bid
6. Bisacodyl 10mg po daily
7. Ferrous Sulfate 325 mg (65 mg Iron) po bid
8. Baclofen 20 mg po qid
9. Senna 8.6 mg po bid
10. Tizanidine 2 mg po qhs
11. Calcium 500 + D 500 mg(1,250mg) -200 unit po bid
12. Capsaicin 0.1 % Cream Topical three times a day: Please
apply to neck and shoulders.
13. Morphine 15-30 mg PO Q4H PRN for breakthrough pain
14. Oxybutynin Chloride 5 mg po q8h
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two
(2) Drop Ophthalmic QID (4 times a day).
16. Multivitamin po daily
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY
18. Omeprazole 20 mg po daily
19. Morphine 100 mg po q12h
20. Morphine 15 mg [**Month/Year (2) 8426**] Sustained Release Sig: One (1) [**Month/Year (2) 8426**]
Sustained Release PO twice a day
21. Metformin 500 mg po daily
22. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal
three times a day.
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Diazepam 10 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO Q6H (every 6
hours) as needed for muscle spasms.
4. Ascorbic Acid 500 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg [**Month/Year (2) 8426**], Delayed Release (E.C.) Sig: Two (2)
[**Month/Year (2) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) [**Month/Year (2) 8426**] Sig: One (1)
[**Month/Year (2) 8426**] PO DAILY (Daily).
8. Baclofen 10 mg [**Month/Year (2) 8426**] Sig: Two (2) [**Month/Year (2) 8426**] PO QID (4 times a
day).
9. Senna 8.6 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2 times a
day).
10. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day).
11. Morphine 15 mg [**Month/Year (2) 8426**] Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Oxybutynin Chloride 5 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO TID
(3 times a day).
13. Multivitamin [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO DAILY
(Daily).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
16. Acetaminophen 325 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO Q6H
(every 6 hours) as needed for pain, fever.
17. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for contipation.
18. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed for Gas or
indigestion.
19. Vancomycin 1000 mg IV Q 12H
day1 = [**1-12**]
20. Meropenem 500 mg IV Q6H
day 1 = [**1-12**]
21. Humolog Insulin
Per Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
spau
Discharge Diagnosis:
Primary: Chronic Osteomyelitis, Sacral/Heel Ulcerations,
Quadrapelegia
Secondary: Diabetes
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Bedbound
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you while you were hospitalized
with fever. During your stay blood, urine, and wound cultures
were drawn and antibiotics were started. Antibiotics were
started and you remained stable and afebrile during this time. A
PICC line was placed to provide antibiotics for approx. 6 weeks.
Please see attached list for most up to date medication list.
Followup Instructions:
We will contact you further regarding changes in your antibiotic
regimen as we obtain results from your culture data.
Please follow up with PCP as needed.
|
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icd9cm
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,446
| 106,252
|
1857
|
Discharge summary
|
report
|
Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-9**]
Date of Birth: [**2037-8-15**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Pravastatin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Delerium and Hypoxia
Major Surgical or Invasive Procedure:
UF [**Last Name (NamePattern4) 2286**]
History of Present Illness:
Mr. [**Known lastname 10369**] is an 86 year-old man with wegener's c/b ESRD,
DM2, atrial fibrillation and chronic right pleural effusion who
was found to be delerious at [**Known lastname 2286**] today with hypoxia to 89%
on RA that corrected to 93% on 2L. Patient also complained of
loose stools for the past several days while at rehab. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] referred the patient to the ED for further
evaluation. Of note, the patient was admitted from [**Date range (1) 10375**] for
the treatment of PNA.
In the ED, initial vitals were 98.5 120 128/76 24 95% 2L. Labs
notable for WBC 4.9 90.6%N, HCT 29.9, INR 2.9, proBNP [**Numeric Identifier 10376**],
Lactate 1.9, Vanco 28.2. Blood cultures were sent. CXR showed
pulmonary edema with persistence of RLL>RML,RUL opacities (also
seen was known R-sided effusion that has been worked up
extensively by Interventional
Pulmonology). Given concern for HCAP, patient already had a
therapeutic Vanco level and received ceftriaxone 1g IV,
azithromycin 500mg IV, and flagyl 500mg IV.
On arrival to the floor, patient was sleeping but easily
aroused and was able to answer questions appropriately. Denied
any
pain, felt comfortable. Coughing with ronchorous breathing and
slightly tachypnic.
Past Medical History:
- Wegener's Granulomatosis, dx [**12/2121**] c-anca + and bx +, on
cytoxan/steroids
- DM 2 on insulin since [**2082**], typical A1c around 7.5%
- ESRD on HD (M/W/F via LUE AVF)
- Monoclonal gammopathy most likely a smoldering multiple
myeloma
- HTN, well-controlled
- Bronchiectasis with baseline grossly abnormal CXR
- SSS with intermittent afib and bradycardia
- Mitral Regurgitation
- Chronic anticoag (indication: AF) on coumadin
- Prostate cancer --> radiation therapy [**2118**], normalized PSA
- Radiation proctitis with rectal bleeding --> laser rx
- GI bleed [**3-9**] radiation proctitis
- Malignant melanoma left thigh s/p excision
- Anemia attributed to CKD
- R ingunal hernia
- S/p appy
- S/p L inguinal hernia repair
- hyperlipidemia
- Fe deficiency
- TB: latent, Patient had a history of TB with treatment in
sanitarium in [**2052**]'s, h/o INH toxicity so no treatment of latent
TB
- MAC: Bronchoscopy with BAL was performed on [**12-23**], and AFBs
found on smear c/w MAC per lab results/ID consult. Patient opted
to forego MAC therapy
- hx of pericardial effusion, no drainage needed
- TIA [**2124-3-8**], no residual deficits
Social History:
Lives with wife who is his caregiver. [**First Name (Titles) **] [**Last Name (Titles) **] son. Retired,
was employed as an international business consultant, has a PhD
in industrial engineering. Born in Eastern [**Country 10363**]. Came to the
United States in [**2068**]. Very active individual before onset of
Wegener's in [**2120**] - former mountain climber, tennis player, and
skier.
- Tobacco history: during WWII, stopped [**2057**]
- ETOH: [**2-7**] glass of wine with dinner nightly
- Illicit drugs: none
Family History:
Grandmother: DM
Father: kidney infection
Sister: TIA x 2 (80s)
Physical Exam:
Physical Exam on Admission
GENERAL - Elderly man lying in bed, A&Ox3, NAD, AOx3
HEENT - NCAT EOMI MM dry OP clear
NECK - supple, JVP flat ~ 10cm H2O
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - decreased breath sounds bilateral bases; rhonchorous
left base; breathing unlabored, no apparent respiratory distress
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no CVAT
EXTR - cool, 2+ DP pulses; LUE AVF with bruit/thrill
SKIN - scattered ecchymoses
LYMPH - no cervical LAD
NEURO - AOX3 and although some responses are inappropriat
Physical Exam on Discharge
Expired
Pertinent Results:
Admission Labs
[**2124-6-5**] 07:05PM LACTATE-1.9
[**2124-6-5**] 07:00PM GLUCOSE-151* UREA N-19 CREAT-2.6*# SODIUM-145
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-31 ANION GAP-17
[**2124-6-5**] 07:00PM ALT(SGPT)-20 AST(SGOT)-43* CK(CPK)-158 ALK
PHOS-123 TOT BILI-0.6
[**2124-6-5**] 07:00PM LIPASE-42
[**2124-6-5**] 07:00PM CK-MB-6 cTropnT-0.21* proBNP-[**Numeric Identifier 10376**]*
[**2124-6-5**] 07:00PM VANCO-28.2*
[**2124-6-5**] 07:00PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-2.7
MAGNESIUM-1.7
[**2124-6-5**] 07:00PM WBC-4.9 RBC-2.61* HGB-9.5* HCT-29.9* MCV-114*
MCH-36.3* MCHC-31.7 RDW-19.0*
[**2124-6-5**] 07:00PM NEUTS-90.6* LYMPHS-4.9* MONOS-4.3 EOS-0.2
BASOS-0
[**2124-6-5**] 07:00PM PLT COUNT-65*
[**2124-6-5**] 07:00PM PT-30.1* PTT-46.8* INR(PT)-2.9*
[**2124-6-5**] 03:00PM VANCO-13.0
[**2124-6-5**] 01:15AM PT-30.2* INR(PT)-2.9*
Pertinent Labs
[**2124-6-7**] 04:20AM BLOOD WBC-5.7 RBC-2.77* Hgb-9.5* Hct-31.9*
MCV-115* MCH-34.4* MCHC-29.9* RDW-18.3* Plt Ct-66*
[**2124-6-6**] 07:30AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-OCCASIONAL Polychr-NORMAL Spheroc-OCCASIONAL
Ovalocy-3+ Schisto-1+ Burr-1+ Ellipto-OCCASIONAL
[**2124-6-7**] 10:18AM BLOOD PT-33.5* PTT-52.4* INR(PT)-3.3*
[**2124-6-6**] 07:30AM BLOOD ESR-110*
[**2124-6-8**] 04:44AM BLOOD Glucose-328* UreaN-48* Creat-3.6*# Na-137
K-5.3* Cl-94* HCO3-24 AnGap-24*
[**2124-6-6**] 04:18AM BLOOD CK-MB-5 cTropnT-0.21*
[**2124-6-8**] 04:44AM BLOOD Calcium-8.2* Phos-7.5* Mg-2.1
[**2124-6-6**] 12:14PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2124-6-6**] 05:00PM BLOOD CRP-212.4*
EKG [**2124-6-5**]
Minimally irregular supraventricular tachycardia, most likely
atrial fibrillation. Left axis deviation. Left anterior
fascicular block. QS deflection in leads V1-V2 consistent with
prior anteroseptal myocardial
infarction. 0.5 millimeter ST segment depression in leads V4-V6
with T wave inversion in lead aVL and to a lesser degree in lead
I. Compared to the previous tracing of [**2124-5-27**], ventricular rate
is much faster. T wave inversion is more pronounced in lead aVL
but less pronounced in leads V4-V5, with similar left precordial
ST segment depression. An ongoing lateral ischemic process
cannot be excluded. Clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
131 0 96 304/428 0 -55 173
CXR portable [**2124-6-5**]
FINDINGS: Single AP upright portable view of the chest was
obtained. The
right costophrenic angle is not included on the images. Again
seen is a large area of right mid-to-lower lung opacity which is
better assessed on prior CT from [**2124-5-29**]. There is a moderate
right pleural effusion with overlying atelectasis, an underlying
consolidation cannot be excluded. Streaky and fibrotic opacities
are seen in the right lung involving the upper, mid and lower
lung fields, most noted in the left mid lung field, also seen on
the prior study. Left apical pleural thickening and
calcifications are again seen, consistent with chronic change.
No large left pleural effusion is seen. There is no
pneumothorax. The cardiac and mediastinal silhouettes are
stable. Multiple old right-sided rib deformities/fractures are
again seen. A left sided [**Year (4 digits) 1106**] stent is again partially
imaged.
IMPRESSION:
1. Right costophrenic angle not fully included on the images.
Given this,
large area of right mid-to-lower lung opacity is again seen,
likely
representing combination of pleural effusion, atelectasis and
possible
underlying consolidation. Increased right perihilar opacity.
Areas of patchy and fibrotic opacities in the left lung again
seen, may be chronic.
TTE [**2124-6-6**]
The left atrium is mildly dilated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). Mild (1+) 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 to severe [3+] tricuspid regurgitation is
seen. [Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-4-11**],
tricuspid regurgitation is now more prominent.
UE fistulogram
Patent AV fistula in the left upper extremity with areas of
aneurysmal
dilatations in the upper and mid portion of the left arm. The
arteriovenous anastomosis is patent however increased velocities
were noted. The peak systolic velocity at the level of the
arteriovenous anastomosis is 716 cm/sec. Within the fistula,
peak systolic velocities ranged between 120 and 143 cm/sec. In
the distal fistula there is a patent stent however increased
velocities were noted at the level of the proximal end of the
stent. Peak systolic velocities at this level were between 689
and 505 cm/sec. Within the stent, the peak systolic velocities
ranged between 58 and 244 cm/sec. Distally to the stent and
within the subclavian vein peak systolic velocities ranged
between 47 and 360 cm/sec. Peak systolic velocity in the
brachial artery proximal to the arteriovenous anastomosis was 47
cm/sec. Distally to the anastomosis, the peak systolic velocity
was 69 cm/sec.
IMPRESSION: Patent AV fistula in the left upper extremity with
increased peak systolic velocities at the level of the arterial
anastomosis and within the proximal margin of the stent.
Velocities were recorded up to 716 cm/sec in the arteriovenous
anastomosis.
Brief Hospital Course:
86M w/ wegener's, ESRD, Afib, DM2, recent TIA /w delirium,
presenting with delerium and hypoxia admitted for possible PNA,
expired on [**2124-6-9**]
# Dyspnea/SIRS- Patient was recently admitted from [**5-25**] to [**6-2**]
for the treatment of HCAP and was discharged on
Vanc/Levofloxacin. At HD today, patient was noted to be hypoxic
to 89% on RA and was referred to the ED for further evaluation.
In the ED, CXR showed continued evidence of right sided
opacities. WBC 4.9 is elevated from 3.5 on recent discharge.
Patient was tachycardic to the 110-120s (in the setting of Afib)
and tachypnic to the 20s with a concern for PNA confering the
diagnosis of sepsis. The patient had a therapeutic Vanc level in
the ED and received 1L NS, ceftriaxone, flagyl and azithromycin
for possible PNA. The antibiotics were continued overnight, but
then d/c'd on HD 2 after repeat CXR showed evidence of pulmonary
edema. Despite this finding that patient was relatively
euvolemic on exam and did not have elevated JVP or marked
periperal edema. It is possible that the patient has pulmonary
edema in the setting of AF with RVR. There is also the
possibility of worsening of GPA given recent discontinuation of
azathioprine and elevated ESR/CRP. Patient was unfortunately
unable to tolerate [**Month/Year (2) 2286**] given hypotension down to the 70s at
each subsequent session. His prednisone was increased with
rheumatology recommendation but respiratory status did not
improve significantly over the subsequent days. Midodrine was
started as patient's family did not wish to pursue any heroic
measures. Stress does steroid was not pursued because the
patient's family utlimately decided to transition patient to CMO
given his progressively worsening respiratory status and
hypotension.
# GPA/Wegner's granulomatosis. Patient was initially kept on
prednisone 10 mg daily and bactrim prophylaxis. However, given
the concern of vasculitis flare with recent discontinuation of
azathioprine, it was increased in the setting of his worsening
respiratory status as well as elevated CRP/ESR.
# Delerium: Patient was found to be delerious at HD on day of
admission and continued to have an element of delerium on
admission the to the MICU. Delirium improved slightly when
seroquel wore off. However, patient continued to have a degree
of delirium that is likely [**3-9**] underlying inflammatory process
and hypoxia.
# Afib. He initially did not require any rate control. He was
kept on home warfarin initially. However, he later required low
dose metoprolol for rate control. Patient does not require rate
control. Warfarin was discontinued given supratherapeutic
level.
# ESRD, HD-dependent: On HD qMWH, kidneys affected by Wegener's
vasculitis. Patient had very limited HD sessions given
hypotension.
# GOC. Patient and his family were updated daily. His
outpatient PCP, [**Name10 (NameIs) 10368**], and nephrologist were updated on
a regular basis. Palliative care was consulted. His HCP was
clear about no heroic measures for the patient and ultimately
decided that patient would transition to CMO given persistent
hypoxia and hypotension, inability to tolerate [**Name10 (NameIs) 2286**].
Patient passed away on [**2124-6-9**].
Chronic Issues:
# Chronic right pleural effusion. Stable on imaging.
# Diabetes. He was on insulin sliding scale.
# Elevated TropT, LFTs: Troponins and LFTs were downtrending
since recent discharge.
# Anemia: Patient with iron studies suggesting anemia of chronic
disease with macrocytosis likely multifactorial from ESRD
(though on epo), bactrim, MGUS, and aging marrow.
#. Hypothyroidism. He was continued on levothyroxine 137 mcg
daily & 25 mcg QOD
#. MGUS / smoldering myeloma: At baseline patient is
pancytopenic with WBC in the 3s and Hct low 30s with
macrocytosis (also noted to be on immunosuppression as described
above).
#. Hyperlipidemia. He was continued on statin and ASA.
Medications on Admission:
- senna 8.6 mg QHS
- docusate sodium 100 mg [**Hospital1 **]
- atorvastatin 40 mg daily
- pantoprazole 40 mg daily
- sulfamethoxazole-trimethoprim 800-160 mg 3X/WEEK (MO,WE,FR)
- aspirin 81 mg daily
- cholecalciferol 800 unit daily
- sevelamer carbonate 400 mg daily
- acetaminophen 1000 mg Q8H
- levothyroxine 137 mcg daily
- levothyroxine 25 mcg QOD
- prednisone 10 mg daily
- folic acid 1 mg daily
- warfarin 1 mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
End Stage Renal Disease
Wegner's granulomatosis
Delirium
Atrial fibrillation
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2124-6-9**]
|
[
"244.9",
"V49.86",
"V58.67",
"511.9",
"V45.11",
"486",
"427.81",
"458.9",
"494.0",
"250.00",
"403.91",
"790.5",
"V10.82",
"V15.82",
"427.31",
"585.6",
"V66.7",
"285.21",
"293.0",
"272.4",
"V10.46",
"V12.01",
"446.4",
"424.0",
"794.8",
"518.81",
"273.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14494, 14503
|
10056, 13299
|
313, 353
|
14643, 14652
|
4070, 10033
|
14708, 14881
|
3393, 3457
|
14465, 14471
|
14524, 14622
|
14017, 14442
|
14676, 14685
|
3472, 4051
|
252, 275
|
381, 1674
|
13315, 13991
|
1696, 2844
|
2860, 3377
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,116
| 190,670
|
31209
|
Discharge summary
|
report
|
Admission Date: [**2193-5-12**] Discharge Date: [**2193-5-17**]
Date of Birth: [**2116-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
drug overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
76 yo M admitted on [**2193-5-12**] with Vicodin overdose requiring a
MICU stay and intubation. He was given Narcan by EMS which
caused a seizure that resolved with Valium. An extensive neuro
work up including Head CT, LP, Head MRI, and EEG was
unrevealing. There was an initial concern for alcohol withdrawl
and he was maintained on a CIWA scale, however, he did not
require much ativan. He has not received Ativan in the last 3
days and has required one dose of Haldol for agitation.
.
He is able to answer questions appropriately. He notes ongoing
back pain and is requesting his gabapentin. He recalls that he
accidently used two fentanyl patches instead of one. He denies
Vicodin use, however, a bottle of Vicodin was found in his home
per report. He also reports diarrhea.
Past Medical History:
- Back pain, long-standing
- "Emotional problems" per son
- History of prescription drug abuse in remote past.
Social History:
Married, lives with wife and son who has schizophrenia. The
patient has 4 children. Used to work as an electrical technician
at [**University/College **]. Tobacco: never. EtOH daily 3 large beers per day on
average. No IVDU. Daughter is RN at [**Hospital1 2177**]. He is independent of
his ADL's. He does his finances with his wife. [**Name (NI) **] does not
drive. His son does the grocery shopping.
Family History:
NC
Physical Exam:
Vitals: T:98.4 BP:120/p P:64 R:16 SaO2:98%
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Pulmonary: Lungs CTA bilaterally (anterior exam)
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No edema, 2+ radial, DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented to hospital and name. Not sure
what town he lives in. Believes it is [**2189**].
Pertinent Results:
[**2193-5-12**] 01:30PM PLT SMR-NORMAL PLT COUNT-254
[**2193-5-12**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2193-5-12**] 01:30PM NEUTS-90.6* BANDS-0 LYMPHS-5.9* MONOS-3.1
EOS-0.3 BASOS-0.2
[**2193-5-12**] 01:30PM ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2193-5-12**] 01:30PM VIT B12-369
[**2193-5-12**] 01:30PM ALT(SGPT)-8 AST(SGOT)-15 LD(LDH)-151 ALK
PHOS-74 TOT BILI-0.4
[**2193-5-12**] 01:37PM LACTATE-0.9
[**2193-5-12**] 04:47PM COMMENTS-GREEN TOP
[**2193-5-12**] 07:56PM freeCa-1.18
[**2193-5-12**] 07:56PM TYPE-ART PO2-398* PCO2-42 PH-7.48* TOTAL
CO2-32* BASE XS-7
[**2193-5-12**] 08:58PM URINE HOURS-RANDOM
[**2193-5-12**] 11:27PM CEREBROSPINAL FLUID (CSF) PROTEIN-30
GLUCOSE-69
[**2193-5-12**] 11:27PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1*
POLYS-15 LYMPHS-75 MONOS-10
EEG
This is a mildly abnormal portable EEG due to the slow and
disorganized background with bursts of generalized slowing
suggestive of
an encephalopathy. Infection, metabolic disturbances, and
medications
are among the most common causes. No clear epileptiform
discharges or
electrographic seizures were seen.
MR head
Normal time-of-flight MRA of the circle of [**Location (un) 431**].
CXR
Comparison to earlier the same day. The endotracheal
tube again terminates approximately 6 cm above the carina.
Although a
nasogastric tube terminates in the upper stomach, a sidehole
remains in the distal esophagus. The cardiac and mediastinal
contours are unchanged. The lungs are clear. There are no
pleural effusions or pneumothorax.
Brief Hospital Course:
76 YOM who presents after narcotics overdose. called out from
MICU.
.
#Overdose- Accidental per patient and wife's discussion with
MICU team. No suicidal ideation. narcotics were held in setting
of delerium. pain was treated with standing tylenol and prn
motrin.
.
# Delerium- was on one to one sitter. neuro work up including
CT, MR head, EEG and LP was unrevealing. narcotics were held.
Geriatrics was consulted who recommended that being at home
would help the pt get back to his baseline mental status.
.
#Seizure- In setting of narcotics overdose and narcan. no
further seizure. EEG shows no ongoing focus.
.
Prophylaxis: pepcid, sc heparin, bowel regimen
.
FEN: soft diet
.
#Access: PIVs
.
#Code Status: Full
Medications on Admission:
-neurontin 300mg PO BID
-vicodin 1-2 tabs PO q 4hrs
-Buspar 15 mg PO BID (lowers sz threshold)
-trazodone 100mg PO q HS
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] vna
Discharge Diagnosis:
Drug overdose
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. You should not take
any narcotic pain medications including fentanyl patchs and
vicodin.
.
If you have chest pain, shortness of breath, nausea, vomitting,
diarrhea, pain in abdomen please call your primary care provider
or go to the emrgency room
Followup Instructions:
Please make a follow up appointment with your primary care
provider [**Name Initial (PRE) 176**] 2 weeks of discharge. We suggest that you
consider changing your provider to [**Name Initial (PRE) **] Geriatrician. You have an
appointment with Dr. [**First Name (STitle) **] in Gerontology on Monday [**2193-6-10**] at
9am. If you like you can call ([**Telephone/Fax (1) 6846**] to reschedule this
appointment.
Completed by:[**2193-5-17**]
|
[
"780.39",
"965.09",
"724.5",
"E850.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5575, 5626
|
4006, 4723
|
328, 341
|
5684, 5693
|
2347, 3983
|
6031, 6472
|
1719, 1723
|
4894, 5552
|
5647, 5663
|
4749, 4871
|
5717, 6008
|
1739, 2214
|
275, 290
|
369, 1150
|
2229, 2328
|
1172, 1285
|
1301, 1703
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,856
| 136,921
|
6920
|
Discharge summary
|
report
|
Admission Date: [**2200-1-6**] Discharge Date: [**2200-1-11**]
Date of Birth: [**2116-2-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
SOBX 3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83yo M with history of NSTEMI in [**2198**] complicated by rapid AF
and CHF (followed by Dr. [**First Name (STitle) 437**], and chronic aspiration thought
[**2-5**] progressive neurologic disease which he has had for 20years
(followed by Dr. [**First Name (STitle) 951**] and on nebs TID at home plus 2L O2 at
night at home for unclear reasons p/w respiratory distress x 3
days. Per the patient's wife the patient has had progressively
worsening SOB over the last few days so that now even at rest he
is SOB. He has also had increased weakness and fatigue,
including difficulty with walking which happens when he becomes
ill. His wife notes reduced secretions and increased
congestion. This has not been associated with CP, palps, PND,
orthopnea, or fevers however he has had a cough.
.
On admission to ED triggered for respiratory extremis. Etomidate
nebulizer made sats come up to 98% on 2-4L NC O2.
On physical exam patient's admission vitals: T:96.8 HR:69
BP:122/109 RR:28 O2Sat:92%. Noted to be tachypneic, somnolent
but able to respond when questioned. Lungs with wheezing and
crackles. Dry MM and cachectic. EKG: NSR, NA, 1AVB (old), no
STE. Labs notable for lactate 2.1. PCXR - no fluid overload on
ED's read despite crackles in lungs. Covered broadly with Vanco
1gm and Levofloxacin 750mg. Also received 2 combivent nebs and
325mg ASA.
.
Initially trops and BNP delayed on [**Hospital Ward Name **] because machine
broken, however then BNP came back elevated to [**Numeric Identifier 3301**] range (same
as prior admission during NSTEMI) and trop 0.86 with CKMB 23, CK
291. When these labs came back ED consulted cardiology who did
not call back. They also started a hep gtt for both NSTEMI as
well as presumed PE given hypoxia, clear CXR and elevated
cardiac markers without ST/TW changes on ECG. PE was ruled out
with CTA. Vital signs on transfer were 98.2 97 128/64 32
100% NRB.
.
On arrival to the floor patient c/o respiratory distress but
denies any chest pain, shortness of breath, palpitations, or
lower extremity edema.
Past Medical History:
- NSTEMI [**2198**] with hospital course complicated by AF with RVR.
At the time EF was 35% on TTE with LV apical aneurysm and
mild-mod MR.
- Progressive Neurologic disease with ataxia for 20years and now
progressive dysphagia and difficulty with secretions resulting
in at least 2 aspiration PNA events.
-Peripheral neuropathy
- GERD s/p funcoplication in [**2175**]
- Laminectomy
- herniarrhaphy
Social History:
Married. Retired engineer. non-smoker. Is dependent for his ADLs
and uses a scooter to get around for long distances but was able
to walk with walker prior to [**4-12**].
Family History:
mother having died with [**Name (NI) 5895**] like
disease, a sister died with [**Name (NI) 309**] body dementia in her 70s, and a
son with atypical multiple sclerosis as well as a maternal aunt
institutionalized with psychiatric issues from age 17. He is of
Ashkenazi [**Hospital1 **] background
Physical Exam:
VS: Temp:98.1 BP: 108/55 HR: 73 RR: 68 O2sat: 100%NRB
GEN: pleasant, wearing a face mask, in respiratory distress,
accessory muscles in use
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits
RESP: rhonchorous breath sounds diffusely with bilateral
crackles at the bases.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c. 1+ edema
SKIN: no rashes/no jaundice
NEURO: AAO to person, place, year. Cn II-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
.
[**2200-1-6**] 05:15PM BLOOD WBC-4.7 RBC-3.29* Hgb-10.5* Hct-30.7*
MCV-93 MCH-31.9 MCHC-34.2 RDW-16.8* Plt Ct-187
[**2200-1-6**] 05:15PM BLOOD PT-15.0* PTT-26.1 INR(PT)-1.3*
[**2200-1-6**] 05:15PM BLOOD Glucose-146* UreaN-33* Creat-1.2 Na-141
K-4.3 Cl-104 HCO3-25 AnGap-16
[**2200-1-6**] 05:15PM BLOOD CK-MB-23* MB Indx-7.9* proBNP-[**Numeric Identifier 26054**]*
[**2200-1-6**] 05:15PM BLOOD cTropnT-0.86*
[**2200-1-7**] 01:57AM BLOOD Calcium-9.2 Phos-4.9*# Mg-2.2
[**2200-1-7**] 12:43AM BLOOD Type-ART pO2-340* pCO2-31* pH-7.52*
calTCO2-26 Base XS-3
.
CXR: Low lung volumes but clear fields. No acute intrathoracic
process.
.
CTA:
1. No Pulmonary Embolus or acute aortic syndrome.
2. Evaluation of lungs limited by respiratory motion, though no
focal
consolidation or pneumothorax. There is minimal bibasilar
atelectasis.
3. Stable appearance of small hiatal hernia s/p fundoplication.
.
ECG: NSR at 85, Normal axis, normalization of anterolateral T
wave inversions noted on prior dated [**2199-8-23**]. No Q waves. No
ST changes. TW flattening V1-V4, similar to prior.
.
ECHO [**2200-1-7**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
mildly to moderately depressed with mid to apical hypokinesis
(LVEF= ?40 %). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2198-2-9**], left ventricular sysotlic function is
probably similar to slightly better but views are suboptimal for
comparison.
.
VIDEO SWALLOW STUDY:
INDICATION: Dysphagia.
FINDINGS: A video oropharyngeal swallow study was conducted in
conjunction
with the speech language pathologist. Various consistencies of
barium were
administered to the patient under intermittent fluoroscopic
imaging. The
patient aspirated a large volume of thin liquids. There was
significant
premature spillover of material during the oral phase of swallow
for other
consistencies.
IMPRESSION: Aspiration of thin liquids. Please refer to the
official speech
language pathology report in OMR for complete details of the
findings.
Brief Hospital Course:
83yo M with h/o NSTEMI, AF with RVR, CHF (EF 40%) admitted to
CCU with hypoxic respiratory failure.
.
#. Hypoxic Respiratory Failure: Initially thought to be
secondary to both acute decompensated heart failure in the
setting of an NSTEMI and mucus plugging seocndary to chronic
aspiration. Patient diuresed well to IV Lasix on the first day
of admission and CXR showed no signs of an aspiration pneumomia.
He continued to have episodes of witnessed aspiration events
after becoming euvolemic, see below. He was not given any more
doses of lasix throughout his admission.
.
#. Aspiration: Patient has chronic aspiration and dysphagia
secondary to neurologic disease. He continued to have several
episodes of hypoxia assocated with aspiration events. He was
kept NPO. A speech and swallow evaluation showed that he is at
high chronic risk for aspiration, especially thin liquids. He
was cleared for thick, nectar liquids. After a meeting with
him, his wife, and his primary care physician, [**Name10 (NameIs) **] was determined
that a feeding tube would not be desirable and care initiatives
were transitioned to CMO (see below). Patient does still
require frequent sunctioning at the time of discharge, however,
is eating whatever he wishes.
.
#. NSTEMI/CHF: Patient with elevated troponin in setting of
normal creatinine (although likely decreased GFR given age and
degree of cachexia) as well as elevated CK and CKMB. ECG notable
for prior infact, though no acute change. Patient was
asymptomatic. Decision was made for medical management, and
patient was placed on aspirin, continued on a beta blocker, and
a heparin drip for 48 hours. He was initially diuresed with IV
lasix, however, his lasix continued to be held as he was thought
to be euvolemic to slightly hypovolemic. His aspirin, lasix,
and beta blocker were discontinued once the decision was made
for CMO.
.
#. Chronic lung disease - continued home nebulizer treatments
and discharged on Combivent nebulizers every 4-6 hours as needed
.
#. Hypothyroidism - continue home Levothyroxine.
.
#. CMO: A family meeting was held with the CCU team, patient's
wife and daughter, and patient. Decision was made to make the
patient CMO. Discontinued all meds except nebs, levothyroxine,
bowel regimen, and changed morphine to liquid suspension.
Medications on Admission:
Aspirin 81mg daily
Coumadin 1mg daily
DuoNeb prn
Furosemide 20mg daily
KlorCon 20mEQ daily
Levothyroxine 50mcg daily
Megace 40mg daily
Omeprazole 40mg [**Hospital1 **]
Simvastatin 40mg daily
Discharge Medications:
1. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation every 4-6 hours as needed
for shortness of breath or wheezing.
2. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
5. morphine concentrate 20 mg/mL Solution [**Last Name (STitle) **]: 5-10 mg PO Q3H
(every 3 hours) as needed for pain/discomfort/resp distress.
6. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
Chronic Aspiration
Coroanry Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. Your blood tests showed that you had a mild heart
attack and you were medically managed for 2 days with a blood
thinner called heparin. It was also found that you have chronic
aspiration, and that sometimes, when you swallow, mouth contents
can go into your lungs. This likely lead to your shortness of
breath.
.
We made the following changes to your medications:
STOPPED Coumadin
STOPPED Aspirin
STOPPED Furosemide
STOPPED KlorCon
STOPPED Simvastatin
STOPPED Omeprazole
STARTED Morphine Sulfate 5-10 mg PO Q3H:PRN pain/discomfort/resp
distress
STARTED Bisacodyl 10 mg [**Hospital1 **]:PRN for constipation
STARTED Lansoprazole 30 mg Daily
STARTED Duonebs Q6 as need for shortness of breath/wheezing
Followup Instructions:
Please make an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) 410**], as needed at [**Telephone/Fax (1) 1408**].
|
[
"518.89",
"410.71",
"428.23",
"276.0",
"414.01",
"933.1",
"584.9",
"356.9",
"427.31",
"244.9",
"518.81",
"E915",
"428.0",
"V45.89",
"414.8",
"356.1",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9894, 9979
|
6527, 8840
|
314, 321
|
10075, 10075
|
3915, 3915
|
11004, 11144
|
3023, 3324
|
9082, 9871
|
10000, 10054
|
8866, 9059
|
10210, 10614
|
3339, 3896
|
10643, 10981
|
263, 276
|
349, 2397
|
3931, 6504
|
10090, 10186
|
2419, 2819
|
2835, 3007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,135
| 177,552
|
30826
|
Discharge summary
|
report
|
Admission Date: [**2185-8-7**] Discharge Date: [**2185-8-11**]
Date of Birth: [**2105-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
HYPOTENSION
Major Surgical or Invasive Procedure:
Right internal jugular central venous catheter placement
History of Present Illness:
Patient is a 79 yo M with a history of respiratory failure and
chronic vent dependence who presented from OSH with hypotension
coupled with history of fever and leukocytosis.
Per report the patient was at his facility and found to have
febrile and congested treated with lasix as CXR showed fluid
overload with possible pneumonia. However, he became hypotensive
and required pressor support. There were no MICU beds at OSH and
was transferred to [**Hospital1 18**].
While in the [**Hospital1 18**] ED, the patient was treated with pressors
(levophed) and ceftazadime as well as kayexelate for
hyperkalemia.
.
Upon arrival to the MICU, the patient was asymptomatic without
shortness of breath, chest pain, headache, fever, chills, nausea
or vomiting. He was able to communicate with mouthing words.
He became tachycardic to the 140s with atrial flutter with
persistent hypotension. For this he was changed to phenylephrine
and given IV fluids
Past Medical History:
Pulmonary hypertension, COPD, CVA, Gout
Social History:
history of tobacco x 50 years, quit 22 years ago, no current
alcohol use, prior to admission in [**Month (only) 205**] lived at home with his
wife.
Family History:
NC
Physical Exam:
T 100.1 BP:116/56 RR: 26 02 98% Vent (AC 550x12 Fi02 0.65 PEEP
10)
GEN: alert and oriented to hospital, person
HEENT: OP clear, MMM
Neck: right IJ placed
CV: tachycardic, regular
Pulm: rhonchi bilaterally with decreased breath sounds on the
right
Abd: soft, nd, nd, PEG with slight drainage around are with mild
erythema
Ext: 1+ edema LE, RUE 2+ edema, LUE 1+ edema
Neuro: moves all extremities on command
Psych: appropriate
Pertinent Results:
[**2185-8-7**] 03:03AM BLOOD WBC-20.5* RBC-2.65* Hgb-8.6* Hct-26.6*
MCV-101* MCH-32.3* MCHC-32.2 RDW-19.4* Plt Ct-153
[**2185-8-11**] 05:06AM BLOOD WBC-22.8* RBC-2.84* Hgb-9.2* Hct-27.9*
MCV-98 MCH-32.2* MCHC-32.8 RDW-20.9* Plt Ct-147*
[**2185-8-7**] 03:03AM BLOOD Neuts-88* Bands-3 Lymphs-1* Monos-6 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-8-7**] 03:03AM BLOOD PT-24.1* PTT-33.9 INR(PT)-2.4*
[**2185-8-7**] 03:03AM BLOOD Plt Ct-153
[**2185-8-9**] 05:05AM BLOOD Ret Aut-1.5
[**2185-8-7**] 03:03AM BLOOD Glucose-139* UreaN-64* Creat-1.5* Na-147*
K-5.7* Cl-110* HCO3-30 AnGap-13
[**2185-8-11**] 05:06AM BLOOD Glucose-165* UreaN-33* Creat-1.2 Na-142
K-4.0 Cl-109* HCO3-26 AnGap-11
[**2185-8-7**] 03:03AM BLOOD ALT-26 AST-20 CK(CPK)-24* AlkPhos-57
Amylase-90 TotBili-0.4
[**2185-8-7**] 03:03AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2185-8-7**] 01:02PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2185-8-7**] 03:03AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.2
Mg-2.9*
[**2185-8-8**] 03:53AM BLOOD calTIBC-129* VitB12-453 Folate-11.5
Ferritn-1587* TRF-99*
[**2185-8-10**] 04:50AM BLOOD Vanco-14.2
[**2185-8-11**] 05:06AM BLOOD Vanco-22.0*
[**2185-8-7**] 03:33AM BLOOD Lactate-2.4*
[**2185-8-10**] 08:46AM BLOOD Lactate-1.8
Initial KUB:
FINDINGS: Nonspecific dilated loops of small bowel are seen,
extending up to approximately 4 cm in diameter, which is similar
in degree when compared to the study of [**2185-7-26**]. A gastrostomy
tube is again seen, with the balloon at the tip projecting over
what is presumed to be the gastric bubble. No contrast was
administered through the tube to verify tube location. There is
a somewhat unusual appearance of the left femoral head,
presumably secondary to patient positioning.
IMPRESSION: Gastrostomy tube balloon and tip projects over what
is presumed to be the gastric bubble. Higher confidence in
localization could be obtained by obtaining a radiograph after
injecting the tube with contrast.
.
CT CHEST W/CONTRAST [**2185-8-8**] 2:55 PM
CT CHEST W/CONTRAST
Reason: eval for interstitial lung disease vs chf
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with unclear history asbestosis and COPD, recent
PEA arrest, difficult to wean vent, readmitted with VAP, need to
further delineate lung disease
REASON FOR THIS EXAMINATION:
eval for interstitial lung disease vs chf
CONTRAINDICATIONS for IV CONTRAST: None.
CT CHEST
REASON FOR EXAM: Difficult to wean from vent.
TECHNIQUE: Multidetector CT through the chest following
administration of IV contrast. Five, 1.25 mm collimation images
and coronal reformations were provided and reviewed.
FINDINGS: Tracheostomy tube is in standard position. Multiple
lymph nodes in the prevascular, pretracheal, subcarinal and in
the hila bilaterally measure up to 11 mm in the subcarinal
station. Layering moderate - size bilateral pleural effusions
are nonhemorrhagic and associated with adjacent relaxation
atelectasis. There is no pneumothorax. The airways are patent to
segmental level. Very dense calcifications are in the left main,
LAD, left circumflex and right coronary arteries. There is
moderate cardiomegaly. There is no pericardial effusion. The
aorta is normal in caliber. Ground glass opacity, and
interlobular septal thickening in the upper lobes are consistent
with interstitial pulmonary edema. Ill-defined multifocal areas
of consolidation in the right upper lobe are likely infectious
in origin. There is paraseptal emphysema.
There are no bone findings of malignancy.
The imaged portion of the upper abdomen shows no abnormalities.
IMPRESSION:
1. CHF.
2. Multifocal areas of consolidation in the right upper lobe are
likely due to infectious process.
3. Bilateral pleural effusions.
3. Coronary calcifications.
4. Moderate cardiomegaly.
5. Reactive lymphadenopathy.
.
Last CXR [**8-10**]
CHEST, SINGLE VIEW: Again there is a right internal jugular
catheter with its tip projecting over the distal SVC and
tracheostomy tube in unchanged standard position. Persistent
cardiomegaly. Nontypical interstitial edema suggesting
coexisting emphysema. Layering effusions, right greater than
left, appear marginally increased on today's study.
IMPRESSION: Equivocally increased layering bilateral pleural
effusions. Essentially unchanged nontypical interstitial edema
with likely underlying emphysema.
Brief Hospital Course:
79 yo M with COPD, vent dependence who presents with pressor
dependent hypotension
Sepsis: Patient with persistent hypotension and not responsive
to pressors. Given leukocytosis with left shift and history of
fever, infection is likely. Was initiall treated with broad
spectrum antibiotics and improved however, pressor requirement
again increased several days later and antibiotics were
continued.
Patient was given fluids but began to develop volume overload
.
#) ID: Likely secondary to infection in lungs, though other
sources of infection cannot be ruled out especially given that
the chest x-ray was no significantly different than [**7-30**].
Sputum culture showed pansensitive PSEUDOMONAS AERUGINOSA
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHIDA.
.
#) Cardiac:
- Rhythm:A fib/ flutter: appears to go in and out of this.
Continued on amiodarone.
- Pump: Has likely diastolic dysfunction at baseline. Does have
signs of fluid overload on exam though with low CVP and likely
low filling pressures. Also with possible HOCM on last echo.
Therefore, may be very preload dependent explaining why patient
is sensitive to hypotension.
Diuresis was attempted but patient did not tolerate it and
required fluid boluses
- CAD: no signs CAD currently though does have slight troponin
leak. Will continue to follow ECGs.
.
#) Pulmonary hypertension/vent dependence: Unclear etiology and
treatment. Appears to be on sidenifil at baseline though
pulmonary pressures are not significantly elevated on echo.
Likely has multifactorial lung disease given appearance of
asbestos exposure, pulmonary hypertension and smoking history.
Suspect COPD component as well. These issues ultimitely
worsened and given his overall status was difficult to treat
.
#) Anemia: Chronically anemic suspect secondary to chronic
disease and poor nutrition status.
No clear signs bleeding
.
#) ARF: slight increase in creatinine, likely seconary to
hypovolemia with prerenal azotemia.
.
#) History of thrombus: per records, the patient has a left IJ,
SCV clot. Was on anticoagulation on admission
.
#) FEN: intravascularly hypovolemic, lytes ok now but was
hyperkalemic, will check serially, no tube feeds for now as the
patient has poor PEG treatments.
.
#) PPX: therapeutic on coumadin, pneumoboots
#) Access: right IJ, right PICC
#) DNR: as discussed with patient, no shocks, no cpr, ok with
pressors.
#) Comm with patient, wife.
Patients overall status continued to decline and the decision
was made with the family and patient (who remained intact for
most of the end of his life). The decision was made not to
escalate care (from vent and 1 pressor). Infortunately the
patient died on [**8-11**]
Medications on Admission:
([**First Name8 (NamePattern2) **] [**Hospital1 487**] gen record)
Atrovent
Albuterol
Beclomethasone 80 mcg [**Hospital1 **]
Pepcid 20 mg [**Hospital1 **]
Nystatin
Percocet 5/325
Sildenafil 25 mg tid
reglan 10 mg QID
Coumadin 1 mg daily
amiodarone 400 mg daily
metoprolol tartrate 12.5 mg daily
Linezolid 70 mg sc daily
lasix 40 mg daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
- COPD w/pulmonary hypertension, chronic vent (since [**7-18**])
- PEA arrest
- CHF (EF >75%, diastolic)
- Anemia with previous transfusions
- PAF with occasional flutter and MAT; s/p cardioversion x3,
currently rhythm controlled with amiodarone and on coumadin
- Asbestosis
- gout
- stroke in [**2178**] (patient reports no persistent deficits)
Discharge Condition:
expired
Discharge Instructions:
N/a
Followup Instructions:
N/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"274.9",
"995.91",
"V44.0",
"285.29",
"518.81",
"428.30",
"427.31",
"428.0",
"V64.2",
"416.8",
"038.43",
"425.1",
"V46.11",
"427.32",
"441.4",
"496",
"276.0",
"486",
"501",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9542, 9551
|
6451, 9125
|
333, 392
|
9941, 9951
|
2075, 4164
|
10003, 10146
|
1610, 1614
|
9514, 9519
|
4201, 4362
|
9572, 9920
|
9151, 9491
|
9975, 9980
|
1629, 2056
|
282, 295
|
4391, 6428
|
420, 1364
|
1386, 1429
|
1445, 1594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,968
| 186,901
|
9680
|
Discharge summary
|
report
|
Admission Date: [**2101-6-20**] Discharge Date: [**2101-6-26**]
Date of Birth: [**2041-3-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
1. Laparoscopic adjustable gastric band.
2. Repair of hiatal hernia.
History of Present Illness:
[**Known firstname **] has class II/class III borderline severe/morbid obesity
with weight of 230 lbs as of [**2101-5-19**] (initial screen weight on
[**2101-4-20**] was 225.6 lbs), height of 64 inches and BMI of 39.6. His
12 weeks of exercise program in [**2099**] losing 15 lbs that he
maintained for 6 months, Weight Watchers in [**2098**] without much
results, 12 weeks of the South Beach diet in [**2097**] losing 15 lbs
that he regained after 6 months and 12-14 weeks of HMR in [**2094**]
losing 25 lbs that he kept off for 8 months. He has tried both
hypnosis and acupuncture for weight loss without any results. He
has not taken prescription weight loss medications or used
over-the-counter ephedra-containing dietary aids/appetite
suppressants or herbal supplements. He weighed 120 lbs at age 21
his lowest adult weight with his highest weight being his
current
weight of 230 lbs. He weighed 212 lbs one year ago. He stated he
developed significant [**Last Name 4977**] problem in his 20's and cites as
factors contributing to his excess weight large portions,
inconsistent meal schedules, frequent eating out, emotional
eating, bingeing out of habit not due to hunger and lack of
exercise. He denied history of eating disorders. He has h/o
depression as well as attention deficit disorder followed in
counseling by a therapist and on psychotropic medications.
Past Medical History:
His medical history is significant for coronary artery disease
s/p non-ST elevation MI in [**2095**] with cardiac catheterization
demonstrating borderline 60% LAD lesion, type 2 diabetes,
hypertension, sleep apnea on BiPAP, dyslipidemia, GERD with
hiatal hernia and h/o Schatzki's ring s/p dilation in [**2092**] and
several previously ([**2083**] and [**2087**]), diverticular disease with
sigmoid sessile polyp s/p colonoscopy in [**2098**], psoriasis,
osteoarthritis of finger joints and back pain.
Social History:
He does not smoke and has not used
recreational drugs, has occasional glass of wine, no caffeinated
beverages, drinks carbonated beverages 5 times a week.
Family History:
Family history is noted for father deceased age [**Age over 90 **] of MI with
h/o
hyperlipidemia, diabetes, stroke, arthritis and cancer; mother
deceased age 82 with asthma, diabetes and obesity; younger
siblings with h/o skin cancer; family h/o colon cancer.
Physical Exam:
His skin was warm and dry. Pupils were equal, round, and
reactive to light, sclerae were anicteric, conjunctivae clear.
Oropharynx was pink and moist. The trachea was midline and
there was no jugular venous distension or bruits. His lungs
were clear to auscultation bilaterally with no crackles,
wheezes, or ronchi. Heart sounds were regular rate and rhythm
with no murmurs, gallops, or rubs. Abdomen was obese, soft,
nontender, nondistended, with bowel sounds. His extremities
were without cyanosis, clubbing, or edema, and peripheral pulses
were 2+ at all four extremities. There were no focal
neurological deficits.
Pertinent Results:
STUDY: Barium esophagram upper GI study with KUB.
INDICATION: 66-year-old male status post gastric banding. Please
assess for passage of contrast exam.
COMPARISONS: None.
FINDINGS: A single scout view demonstrates no free air beneath
the diaphragms. There is marked distension of the dtomach distal
to the band. The gastric band can be seen in the left upper
abdomen.Watewr soluble contrast followed by thin barium was used
in this examination. Contrast was demonstrated to flow freely
through the esophagus and through the region of the gastric
band. There is no evidence of obstruction or leak.
IMPRESSION: Status post gastric banding. No evidence of leak or
obstruction. Distended stomach distal to band
[**2101-6-21**] 04:35PM BLOOD WBC-9.9 RBC-4.53* Hgb-13.0* Hct-37.9*
MCV-84 MCH-28.7 MCHC-34.3 RDW-14.6 Plt Ct-239
[**2101-6-21**] 04:35PM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-138
K-3.9 Cl-98 HCO3-29 AnGap-15
[**2101-6-22**] 09:33AM BLOOD Type-ART pO2-63* pCO2-56* pH-7.39
calTCO2-35* Base XS-6
Brief Hospital Course:
See post-operative report dictated [**2101-6-20**] for details of the
procedure. Mr. [**Known lastname 32729**] was admitted to the floor from the
PACU postoperatively in stable condition. On POD 1, he
underwent a swallow study which showed no evidence of leak or
obstruction, but there was gastric distension distal to the
band. Radiology attempted passage of a pediatric NG tube under
fluoroscopic guidance, but this was unsuccessful. Soon after
the patient returned to the floor, he began to develop increased
abdominal distension and tenseness, and complained of feeling
"funny", was diaphoretic, restless, and anxious. That evening,
his O2 saturation dropped to 81% on 4L NC, so he was switched to
a mask with 10L O2, on which he was still satting only 89-91. A
trigger was called, he was placed on NRB on which he satted up
to 98%, and the decision was made to transfer him to the SICU.
GI was consulted to perform upper endoscopy, which was notable
only for stomach dilated with air. No Schatzki's ring was seen,
and the scope passed readily into the duodenum. Subsequently an
NG tube was inserted blindly by Dr. [**Last Name (STitle) **] and placed to wall
suction, with immediate relief of the patient's abdominal
discomfort. He pulled out his own NGT the next day, but as he
was passing flatus and no longer distended, the decision was
made to transfer him back to the floor.
Back on the floor, Mr. [**Known lastname 32729**] [**Last Name (Titles) 27836**] quite well, and he
was advanced through to stage III diet by POD 5. He tolerated
his diet well, was urinating well, and had rapid return of bowel
function, so the decision was made to discharge him to home in
good condition on POD 6.
Medications on Admission:
ASA 81, Toprol XL 100', Altace 2.5', Lipitor 20', Norvasc 5',
Glyburide 15', Metformin 1g'', Celexa 40', Adderall XR 20', MVI
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*250 ML(s)* Refills:*2*
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Morbid obesity
Discharge Condition:
good.
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 in 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 will be given a prescription for pain medication, which
may make you drowsy. Do not drive while taking pain medication.
2. You should begin taking a Flintstones chewable complete
multivitamin. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**10-3**] 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. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 15645**] office to schedule a followup appointment
if you do not already have one
Completed by:[**2101-6-26**]
|
[
"V85.4",
"414.01",
"250.00",
"530.3",
"E878.2",
"E849.7",
"553.3",
"278.01",
"997.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.22",
"53.7",
"44.95",
"45.13",
"96.07",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6607, 6613
|
4424, 6138
|
284, 356
|
6672, 6680
|
3391, 4401
|
8124, 8275
|
2468, 2729
|
6314, 6584
|
6634, 6651
|
6164, 6291
|
6704, 7270
|
2744, 3372
|
230, 246
|
7894, 8101
|
384, 1755
|
7296, 7882
|
1777, 2280
|
2296, 2452
|
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