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72,043
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24078
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Discharge summary
|
report
|
Admission Date: [**2117-9-18**] Discharge Date: [**2117-9-28**]
Date of Birth: [**2067-8-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Increased lower back pain
Major Surgical or Invasive Procedure:
1. Transpedicular decompression T11.
2. Fusion T6-S1.
3. Multiple thoracic laminotomies.
4. Multiple lumbar laminotomies.
5. Instrumentation T6-S1.
6. Autograft.
7. Epidural catheter placement.
8. Vacuum-assisted closure device placement.
History of Present Illness:
Patient is 50 Male with metastatic melanoma, mets in
brain/spine, recent ICH a few weeks ago d/c on [**9-3**], now with
worsening back pain uncontrolled on current medications. His has
trouble remembering exact dates and details about his pain as he
has had some memory impairment from his recent intracranial
hemorrhage. He currently rates his back pain as a [**2117-8-13**]. He
denies pain in his legs but says he has intermittent sensation,
particularly in the right leg. He has underlying fecal and
urinary incontinence as baseline, requiring foley and adult
brief.
.
In the ED, his vital signs were 98 120 158/66 18 99% RA, pain
was rated as a [**6-12**]. He was given dilaudid 1 mg iv x1 with good
pain control. His zxam showed right leg decreased sensation from
previous. Good rectal tone, foley in place.
Past Medical History:
Mr. [**Known lastname 61229**] was diagnosed with a 1.45 mm thick, [**Doctor Last Name 10834**] level IV
melanoma from his lower back in [**2104**]. He underwent wide local
excision and bilateral inguinal negative sentinel lymph node
biopsies. He developed left inguinal recurrence in [**12/2111**],
undergoing completion left inguinal lymph node dissection on
[**2112-2-8**] with pathology revealing melanoma in four of nine
nodes with extracapsular extension. He received radiation
therapy to the left inguinal region completing in 05/[**2111**]. He
began interferon off protocol in [**5-/2112**] with therapy
discontinued on [**2112-10-19**] due to radiation colitis. In
[**2-/2113**], he underwent biopsy of a right clavicular lesion by Dr.
[**First Name (STitle) 1022**] revealing a 0.45 mm thick, [**Doctor Last Name 10834**] level III melanoma. He
underwent wide local excision in 04/[**2112**]. In [**6-/2114**], he had
biopsy of a left mandible skin lesion revealing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10834**] level
III, 0.51 mm thick melanoma with three mitoses per mm2. On
[**2114-7-23**], he underwent wide local excision and sentinel lymph
node biopsy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] with no residual
melanoma at the primary site, but one of three lymph nodes
showed a
microscopic deposit of melanoma. He underwent modified left
neck dissection on [**2114-7-30**] with no melanoma noted in seven
additional nodes. In [**2115-6-4**], he underwent biopsy of a new
right chest wall skin lesion by Dr. [**First Name (STitle) 1022**] revealing metastatic
melanoma not seen at the margin without an epidermal component
and two mitoses per mm2. It was unclear whether this
represented an in-tranist metastasis from his right clavicle
melanoma or an epidermatrophic metastasis. He underwent right
chest wide local excision and right axillary sentinel lymph node
biopsy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] on [**2115-7-18**]. There was no evidence
of residual melanoma in the chest or in the sentinel lymph node.
Staging scans were negative and he began GM-CSF off protocol on
[**2115-9-4**], completing 13 cycles in [**2116-8-4**]. Torso CT in
[**9-11**] revealed new small bilateral pulmonary nodules and an
abnormal right kidney. CT guided biopsy of the right kidney on
[**2116-10-27**] confirmed metastatic melanoma. He began the Phase I/II
RAF 265 trial on
--[**2116-12-22**]. Therapy was held on C1W4, [**1-12**], due to visual
problems, fatigue and anorexia.
--[**2117-1-26**]: started Cycle 1 of ON-082 study
--2/25-27/10: admitted for hematuria from renal mets
--[**Date range (1) 61233**]: admitted for embolization of right renal artery
branch
--[**Date range (1) 61234**] admitted cervical spinal cord compression: treated
with anterior cervical diskectomy C3-C4, C4-C5.
--[**2117-2-16**]- taken off study ON-082 study
--3/19-23/10: admitted for Posterior Cervical Decompression and
Fusion
--[**2117-3-2**]: started cycle 1 of dacarbazine
--[**Date range (1) 61235**]: radiation to C3-T2 and L3-L5
--[**2117-5-20**]: started plexxikon study phase I DDI
--7/22-24/10: admitted for neutropenic fever
--[**Date range (2) 61236**]: admitted with left parietal hemorrhage from
bleeding left parietal cortex and left basal ganglia metastases
--[**2117-9-9**]: Whole brain radiation completed. [**2106**] cGy over five
fractions
.
Other Past Medical History:
Metastatic melanoma, mets to spine, liver, and kidneys as above
Anxiety
s/p laminectomy and cervical fusion
s/p multiple resections
Social History:
Lives with wife, daughter, 10 and son, 8 in [**Hospital1 3597**], NH. No
tobacco, no alcohol, no illicit drug use.
Family History:
noncontributory, no melanoma
Physical Exam:
ADMISSION:
VS: T: 97.0, BP: 140/80, P: 105, RR: 20, 97% on RA
GEN: thin, chronically ill appearing male, AOx3, NAD
HEENT: PERRLA. slightly dry MM. no LAD. no JVD. neck supple.
Cards: tachycardic, reg rhythm, S1/S2 normal. no
murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign, red skin marks over left groin
BACK: mildly TTP in mid back, palpable mass over lower spine at
~L3
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
GU: scrotal swelling, normal rectal tone, stool in vault, guaic
neg
Neuro/Psych: CNs II-XII intact except right CN [**Doctor First Name 81**]- weak shoulder
shrug. LUE: tri/bic [**3-8**], wrist, grip [**4-7**]; RUE: tri/bic 2-3/5,
wrist [**1-8**], grip 2-3/5. Sensation- decreased over right LE
compared to left LE, decreased over RUE.
Pertinent Results:
Hematology:
[**2117-9-24**] 03:44AM BLOOD WBC-3.8* RBC-2.95* Hgb-8.7* Hct-24.6*
MCV-84 MCH-29.7 MCHC-35.5* RDW-17.3* Plt Ct-65*
[**2117-9-23**] 01:23AM BLOOD WBC-4.0 RBC-3.34* Hgb-9.7* Hct-27.1*
MCV-81* MCH-29.0 MCHC-35.8* RDW-17.0* Plt Ct-62*
[**2117-9-22**] 12:46PM BLOOD WBC-4.3 RBC-3.61* Hgb-10.5* Hct-28.9*
MCV-80* MCH-29.1 MCHC-36.4* RDW-16.8* Plt Ct-77*
[**2117-9-22**] 09:06AM BLOOD Hct-31.1*
[**2117-9-22**] 04:01AM BLOOD WBC-4.3 RBC-3.77* Hgb-11.2* Hct-30.8*
MCV-82 MCH-29.7 MCHC-36.3* RDW-16.5* Plt Ct-78*
[**2117-9-21**] 11:06PM BLOOD WBC-3.9* RBC-4.09* Hgb-11.9* Hct-33.1*
MCV-81* MCH-29.1 MCHC-36.0* RDW-16.4* Plt Ct-73*
[**2117-9-20**] 06:25AM BLOOD WBC-8.0 RBC-4.84 Hgb-13.4* Hct-38.1*
MCV-79* MCH-27.7 MCHC-35.2* RDW-17.0* Plt Ct-65*
[**2117-9-19**] 12:14PM BLOOD WBC-8.5 RBC-4.80 Hgb-13.5* Hct-37.6*
MCV-78* MCH-28.0 MCHC-35.8* RDW-17.0* Plt Ct-68*
[**2117-9-18**] 12:10PM BLOOD WBC-8.4 RBC-4.71 Hgb-13.3* Hct-36.7*
MCV-78* MCH-28.1 MCHC-36.1* RDW-17.4* Plt Ct-78*#
[**2117-9-18**] 12:10PM BLOOD Neuts-91* Bands-4 Lymphs-1* Monos-3 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2117-9-23**] 01:23AM BLOOD PT-13.3 PTT-32.1 INR(PT)-1.1
[**2117-9-22**] 09:06AM BLOOD PT-13.6* PTT-31.3 INR(PT)-1.2*
[**2117-9-21**] 08:30PM BLOOD PT-14.6* PTT-31.6 INR(PT)-1.3*
[**2117-9-20**] 06:00PM BLOOD PT-11.9 PTT-24.5 INR(PT)-1.0
Chemistries:
[**2117-9-24**] 03:44AM BLOOD Glucose-83 UreaN-19 Creat-0.6 Na-136
K-4.3 Cl-102 HCO3-28 AnGap-10
[**2117-9-23**] 01:23AM BLOOD Glucose-116* UreaN-17 Creat-0.7 Na-134
K-4.0 Cl-104 HCO3-25 AnGap-9
[**2117-9-20**] 06:25AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-137
K-4.5 Cl-94* HCO3-34* AnGap-14
[**2117-9-19**] 12:14PM BLOOD Glucose-226* UreaN-21* Creat-0.8 Na-135
K-4.3 Cl-96 HCO3-27 AnGap-16
[**2117-9-18**] 12:10PM BLOOD Glucose-101* UreaN-20 Creat-0.8 Na-135
K-4.7 Cl-94* HCO3-31 AnGap-15
[**2117-9-24**] 03:44AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1
[**2117-9-23**] 01:23AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.7
[**2117-9-22**] 12:46PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0
[**2117-9-22**] 04:01AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2117-9-21**] 11:06PM BLOOD Calcium-8.9 Mg-1.4*
[**2117-9-21**] 01:46AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
[**2117-9-20**] 06:25AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.1
[**2117-9-19**] 12:14PM BLOOD Calcium-9.2 Phos-4.1 Mg-1.8
[**2117-9-23**] 01:35AM BLOOD Type-ART pO2-165* pCO2-30* pH-7.46*
calTCO2-22 Base XS-0
[**2117-9-22**] 04:18AM BLOOD Type-ART pO2-152* pCO2-44 pH-7.42
calTCO2-30 Base XS-4
[**2117-9-21**] 11:15PM BLOOD Type-ART pO2-227* pCO2-43 pH-7.40
calTCO2-28 Base XS-1
[**2117-9-21**] 08:57PM BLOOD Type-ART pO2-230* pCO2-38 pH-7.43
calTCO2-26 Base XS-1 Intubat-INTUBATED
[**2117-9-21**] 08:24PM BLOOD Type-ART pO2-234* pCO2-38 pH-7.43
calTCO2-26 Base XS-1 Intubat-INTUBATED
[**2117-9-21**] 07:49PM BLOOD Type-ART pO2-233* pCO2-35 pH-7.47*
calTCO2-26 Base XS-2 Intubat-INTUBATED
[**2117-9-21**] 07:13PM BLOOD Type-ART pO2-235* pCO2-32* pH-7.49*
calTCO2-25 Base XS-2 Intubat-INTUBATED
[**2117-9-21**] 06:25PM BLOOD pO2-235* pCO2-33* pH-7.53* calTCO2-28
Base XS-5
[**2117-9-21**] 08:57PM BLOOD Glucose-131* Lactate-4.6* Na-133* K-3.9
Cl-100
[**2117-9-21**] 08:24PM BLOOD Glucose-123* Lactate-4.6* Na-132* K-4.0
Cl-101
[**2117-9-21**] 07:49PM BLOOD Glucose-97 Lactate-3.8* Na-132* K-3.0*
Cl-103
[**2117-9-21**] 07:13PM BLOOD Glucose-99 Lactate-4.0* Na-131* K-3.4*
Cl-100
[**2117-9-21**] 06:25PM BLOOD Glucose-114* Lactate-3.4* Na-130* K-3.7
Cl-94*
[**2117-9-21**] MR C&T SPINE:
1. Extensive metastatic lesions involving the cervical and the
thoracic spine as described above, ribs and the sternum as well
as the liver as described above. Focal lesion along the lateral
aspect of the chest wall laterally, can be better assessed on
CT.
2. T11 moderate compression deformity, with moderate epidural
component and pre/paravertebral component with severe canal
stenosis and severe compression on the cord. Other details as
above.
3.Evaluation of the C-spine is somewhat limited due to artifacts
from
hardware. Subtle epidural component at C4 and C5 levels cannot
be completely excluded. Vague non-enhancing T2 hyperintense foci
in the cord at C4 and C5 levels- of equivocal significance.
Attention on close follow up.
.
MRI L SPINE [**2117-9-20**]:
1. Diffuse metastatic disease involving the visualized
vertebrae, the upper sacrum and the iliac bones included on the
present study.
2. Diffuse metastatic disease involving the T11 vertebra with
moderate loss of height(counting from S1 upwards), with moderate
amount of epidural soft tissue component, with severe canal
stenosis and severe degree of compression on the lower thoracic
cord. Moderate amount of pre- and para-vertebral soft tissue
component, left more than right.
.
The epidural and the pre-/para-vertebral soft tissue component
is new from the prior CT torso of [**2117-5-6**]. There is also
increased posterior bulging of the T11 vertebral body compared
to the [**Month (only) **] study with continued moderate decrease in the height
in the anterior and the mid portions.
3. Moderate L4 compression deformity, with metastatic
involvement of a
moderate-sized pre-/para-vertebral soft tissue component. No
epidural
component or significant canal stenosis at this level.
4. Multilevel, multifactorial degenerative changes in the lumbar
spine as
described above. Diffuse altered signal intensity related to
metastatic
involvement.
.
CT SPINE [**2117-9-22**]:
1. Air locules in the posterior vertebral muscle as well as
posterior
subcutaneous tissues are most likely expected postoperative
sequelae.
2. Evidence of thoracic and lumbar laminectomies at multiple
levels, with
metallic fixation rod extending from T6-S1. Removal of posterior
portion of T11 vertebral body with pedicle screws noted at L2,
L3, L5 and S1. Dural catheter noted. Compression of the L4 again
noted.
3. Portions of study are incompletely evaluated due to streak
artifact.
Within this limitation, no focal fluid collections are
identified.
4. Bilateral pleural effusions, left greater than right with
adjacent
compressive atelectasis/consolidation in the correct clinical
setting.
5. Hardware is intact.
Brief Hospital Course:
#Spinal cord compression secondary to metastatic melanoma:
Patient presented with worsening back pain. On admission, his
neuro exam was unchanged from previous with right sided weakness
and sensory deficit. His pain was controlled with MS contin 60
mg po BID and dilaudid 1-2 mg iv q1h. He was treated with iv
decadron 10 mg iv x1 then decadron 4 mg iv q6h. MRI showed new
lesion at L4, he got 1 session of radiation therapy on [**2117-9-20**].
In the evening of [**9-20**], patient had new weakness of the left
lower extremity with developing sensory deficit. Spinal MRI
showed new spinal cord compression and T11. Rad Onc, spine and
ortho were urgently consulted. Steroid dose was increased and
rest of spine MRI was obtained. The patient discussed the option
of surgery with his primary oncology outpatient team and his
family: he understood the risks of surgery, that surgery may not
improve his functional level, especially given his prior known
neurologic deficitsand that the recovery from the surgery may be
up to 3 months. T8-S1 decompression, posterior
fusion/instrumentation was performed on [**9-21**] with with the
ortho spine service. He required 15U RBCs, 10U FFP, 2xPlts, 3L
LR. He had a complicated SICU stay. Palliative care consult was
called. After discussion with the family, patient was
transitioned to comfort care only. The patient peacefully
expired with wife and family at bedside at 8:37AM on [**2117-9-28**].
Medications on Admission:
Dexamethasone 4 mg po q8h
Lorazepam 1 mg PO BID prn anxiety
Morphine SR 15 mg po q12h
Morphine 15 mg PO Q4H prn pain
Morphine 30 mg po tid prn pain
Baclofen 10 mg po bid
Heparin 5000 units tid
Bisacodyl 10 mg po prn constipation
Senna 8.6 mg po daily
Pantoprazole 40 mg po q24h
Levetiracetam 1000 mg po BID
Zolpidem 5 mg po qHS prn insomnia
Docusate 100 mg po BID prn constipation
Acetaminophen 325 mg po q4h prn pain
Famotidine 20 mg po BID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"707.25",
"300.00",
"197.7",
"V87.41",
"198.2",
"707.03",
"V66.7",
"198.5",
"197.0",
"V49.86",
"V15.3",
"198.3",
"453.81",
"788.20",
"V10.82",
"287.5",
"733.13",
"V45.4",
"198.0",
"342.90",
"599.0",
"336.3",
"285.1",
"518.5",
"338.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"81.64",
"81.05",
"92.29",
"81.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14281, 14290
|
12323, 13761
|
341, 581
|
14341, 14350
|
6186, 12300
|
14406, 14416
|
5220, 5251
|
14253, 14258
|
14311, 14320
|
13787, 14230
|
14374, 14383
|
5266, 6167
|
276, 303
|
609, 1424
|
4938, 5072
|
5088, 5204
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,102
| 115,419
|
43321+58610
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-1-11**] Discharge Date: [**2156-1-21**]
Date of Birth: [**2074-11-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2156-1-16**] Redo-Sternotomy, Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**]
Epic Bioprosthetic)
[**2156-1-13**] Cardiac Catheterization
History of Present Illness:
81 year old male that presents with two recent syncopal episodes
& loss of conciousness 5 days ago in context of progressive
fatigue and dyspnea on exertion but without chest pain.
Evaluated at [**Hospital3 **] and was ruled-out for Myocardial
infacrtion or stroke. He has known coronary artery disease and
is s/p CABG [**2134**], as well as aortic stenosis ([**Location (un) 109**] 0.5cm on echo
[**2155-12-7**]). He was transferred from [**Hospital1 **] to be evaluated for an
aortic valve replacement.
Past Medical History:
1. CAD s/p CABG, [**2135-1-26**] CABG ([**Hospital1 18**])
2. Hypercholesteremia
3. HTN
4. Aortic stenosis (dx in [**2145**])
Social History:
- Lives with wife. Married for 53 years, 2 daughters and 1
[**Name2 (NI) 12496**]
- Retired farmer (grew tomatoes)
- Denies smoking and alcohol
Family History:
Non-contributory
Physical Exam:
Pulse: 73 SR Resp: 16 O2 sat: 98/RA
B/P: 121/84
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] sternal incisional scar
Heart: RRR [x] Irregular [] Murmur III/VI @base -> neck
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x] well-perfused [x] Edema/Varicosities:
None
Neuro: Grossly intact
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit can not assess due to AS murmur
Pertinent Results:
[**2156-1-11**] WBC-9.7 RBC-5.29# Hgb-15.7# Hct-46.0# Plt Ct-276
[**2156-1-11**] PT-12.2 PTT-24.3 INR(PT)-1.0
[**2156-1-11**] Glucose-224* UreaN-33* Creat-1.4* Na-137 K-4.2 Cl-96
HCO3-27
[**2156-1-11**] ALT-45* AST-23 LD(LDH)-202 AlkPhos-73 TotBili-0.9
[**2156-1-11**] Albumin-4.3 Calcium-10.0 Phos-4.0 Mg-2.4
[**2156-1-13**] %HbA1c-6.4* eAG-137*
[**2156-1-20**] Hct-27.6*
[**2156-1-20**] WBC-11.1* RBC-2.99* Hgb-8.7* Hct-25.2* Plt Ct-152
[**2156-1-19**] WBC-13.7* RBC-2.62* Hgb-7.8* Hct-22.9* Plt Ct-137*
[**2156-1-21**] UreaN-21* Creat-1.2 K-3.6
[**2156-1-20**] Glucose-84 UreaN-22* Creat-1.1 Na-137 K-3.0* Cl-99
HCO3-32 AnGap-9
[**2156-1-19**] Glucose-101* UreaN-25* Creat-1.2 K-3.7 HCO3-31
[**2156-1-18**] Glucose-159* UreaN-23* Creat-1.3* Na-136 K-3.7 Cl-102
HCO3-28 A
[**2156-1-21**] Mg-2.4
[**2156-1-19**] Chest PA and lateral: There are small bilateral pleural
effusions. Again noted is a tortuous aorta and the sternotomy
wires, which are stable. The cardiac, mediastinal and hilar
contours are unremarkable.
[**2156-1-16**] Intraop TEE:
Pre-bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta as well as a 0.6 cm complex atheroma.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Mild
(1+) aortic regurgitation is seen. A proper annular diameter is
difficult to measure in face of heavy calcification.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-bypass:
The patient is receiving no inotropy support post-bypass. There
is a well seated bioprosthetic valve in the aortic position.
There is no aortic perivalvular or valvular leak. There is no
evidence of LVOT obstruction. The mean gradient across the
aortic valve is 8 mmHg. Biventricular function is preserved
post-bypass at >55% EF. All other findings are similar to
prebypass findings. The aorta is intact post-decannulation.
Findings were discussed in person with surgeon.
Brief Hospital Course:
Transferred from outside hospital for evaluation due to syncope.
Underwent cardiac catheterization that revealed no obstructive
coronary disease with a widely patent left internal mammary
artery to left anterior descending artery. Surgery was
consulted for aortic valve replacement and he underwent
preoperative workup and monitoring of creatinine which increased
from admission 1.4 to 1.7 on [**1-13**] preoperatively. On [**2156-1-16**] he
was brought to the operating room and underwent redo sternotomy,
and aortic valve replacement. See operative report for further
details. Given he was in the hosptial for greater than 24 hours
preoperatively, he received Vancomycin for perioperative
antibiotics. Postoperatively he was transferred to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. His CVICU course was
otherwise uneventful, and on postoperative day two, he
transferred to the SDU. He remained in a normal sinus rhythm as
beta blockade was advanced as tolerated. Postoperatively, his
renal function remained stable. Over several days, he continued
to make clinical improvements with diuresis and he was ready for
discharge to home on post operative day five.
Medications on Admission:
Amlodipine 5mg daily
aspirin 81 mg daily
atenolol 25mg [**Hospital1 **]
cilostazol 50mg [**Hospital1 **]
Fexofenadine ([**Doctor First Name **]) 60mg [**Hospital1 **]
Rosuvastatin 40mg daily
HCTZ 25mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID ().
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take for 7 days, then stop. Please take with KCL.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily):
Please take for 7 days, then stop. Take with Lasix.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p Redo-Sternotomy, Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft
??????89(LIMA/LAD only),
s/p PTCA/DESx3 ??????05(RCA)
Hyperlipidemia
Hypertension
Arthritis
Allergic rhinitis
Chronic low back pain
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2156-2-16**] 3:00
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 8098**] in [**11-29**] weeks [**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2156-1-21**] Name: [**Known lastname **],[**Known firstname 422**] B. Unit No: [**Numeric Identifier 14722**]
Admission Date: [**2156-1-11**] Discharge Date: [**2156-1-21**]
Date of Birth: [**2074-11-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 265**]
Addendum:
Addendum to discharge summary for date [**0-0-**].
It should be noted that in both the past medical history and the
discharge diagnosis section the patient has Chronic Renal
Insufficiency-baseline Creatinine 1.5.
Additionally the patient did have post operative anemia
requiring a transfusion of 2 units of packed red blood cells
after surgery. The post-operative anemia was due to a
combination of blood loss and aggressive fluid resuscitation in
the post-operative period.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2156-4-2**]
|
[
"V45.81",
"285.1",
"401.9",
"272.0",
"424.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"37.23",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9478, 9653
|
4495, 5792
|
283, 444
|
7627, 7723
|
1954, 4472
|
8263, 9455
|
1307, 1325
|
6049, 7279
|
7353, 7606
|
5818, 6026
|
7747, 8240
|
1340, 1935
|
236, 245
|
472, 978
|
1000, 1129
|
1145, 1291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,792
| 185,451
|
21444+21461
|
Discharge summary
|
report+report
|
Admission Date: [**2115-10-8**] Discharge Date: [**2115-10-17**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with baseline dementia, status post a left occipital
stroke a year ago, who presents from an outside hospital with
a large right subdural hematoma. The patient was intubated
and sedated during initial exam.
ALLERGIES: No known allergies.
MEDICATIONS:
1. Nitroglycerin 0.4.
2. Trazodone 50 q at bedtime.
3. Norvasc 5 po once daily.
4. Plavix 75 po once daily.
5. Prevacid 30 po once daily.
6. Lisinopril 20 po once daily.
7. Dilantin 15 po once daily.
8. Aspirin 81 po once daily.
CT scan shows a large right subdural hematoma and
subarachnoid with minimal midline shift.
HOSPITAL COURSE: On initial exam, the patient withdrew to
painful stimulation in the right upper extremity, very
sluggish withdrawal to pain in the left upper extremity. She
was admitted to the ICU with q 1 h neuro checks, and a repeat
head CT the following morning. The patient actually fell out
of a wheelchair at home, and was being cared
DICTATION ENDED
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 55481**], [**MD Number(1) 56557**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2115-10-17**] 11:27:28
T: [**2115-10-17**] 11:56:01
Job#: [**Job Number 56631**]
Admission Date: [**2115-10-7**] Discharge Date: [**2115-10-17**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with baseline dementia status post a left occipital
stroke 1 year ago, presented to an outside hospital with a
large right subdural hematoma after falling out of a
wheelchair. The patient was intubated and sedated on the
initial examination.
PAST MEDICAL HISTORY: Hypertension.
Stroke.
Seizure disorder.
Diabetes.
EXAMINATION: The patient, on initial examination, withdrew
to painful stimulation the right upper extremity and sluggish
withdrawal to painful stimulation in the left upper
extremity. Pupils were equal and reactive.
The patient was admitted to the ICU for close neurologic
observation. The patient had a C-spine clear with MRI scan.
She had repeat head CT which showed stable size of subdural
hematoma. She, neurologically, continued to be moving all
extremities to stimulation, right greater than left, and
localizing to pain. She was on mannitol 25 q.6h. She had a
repeat head CT on [**2115-10-10**], which was unchanged. She
continued on mannitol, continued to have her eyes open but
did not follow commands with a left hemiparesis, which was
baseline and withdrawal of her all 4 extremities.
On [**2115-10-12**], the patient was transferred to the Step-Down
Unit. She continued to remain neurologically unchanged with
a stable head CT. She was eventually transferred to the
regular floor. She was seen by Physical Therapy and
Occupational Therapy and found to be safe for discharge home
with her family with 24-hour care from her family. The
family cleared her for transfers with a [**Doctor Last Name 2598**] Lift. She also
had a swallow evaluation and remained NPO with PEG in place
for feeding. Her neurologic status remained stable, she
would localize briskly on the right. She has a left
hemiparesis, opened eyes to commands. She will have a head
CT on the day of discharge; if that is stable, she will be
discharged on [**2115-10-17**], with follow-up with Dr. [**First Name (STitle) **] in one
month with a repeat head CT.
MEDICATIONS ON DISCHARGE:
1. Dilantin 100 mg p.o. t.i.d.
2. Pantoprazole 40 mg p.o. q.d.
3 Ferrous sulfate 225 p.o. q.d.
1. Metoprolol 75 p.o. b.i.d.
2. Levofloxacin 250 p.o. q.4h. for 5 days for UTI.
3. Lisinopril 20 p.o. q.d.
4. Amlodipine 5 mg p.o. q.d.
5. Nystatin 5 cc p.o. q.i.d. p.r.n.
6. Heparin 5000 units subcutaneous, which will be
discontinued.
7. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow up with Dr. [**First Name (STitle) **] in one month with
a repeat head CT at that time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2115-10-17**] 11:33:08
T: [**2115-10-17**] 22:44:32
Job#: [**Job Number 56655**]
|
[
"780.39",
"E884.3",
"V12.59",
"250.00",
"852.20",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3519, 3885
|
750, 1455
|
3931, 4305
|
1484, 1764
|
1787, 3493
|
3910, 3919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,783
| 118,075
|
28023
|
Discharge summary
|
report
|
Admission Date: [**2187-7-29**] Discharge Date: [**2187-8-4**]
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 5295**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, stents x 2 (left main, LAD)
History of Present Illness:
81yo M with DM, HTN, CAD with recent hospitalization at [**Hospital1 5979**] for CP and SOB. At the time of this visit, he ruled out
by enzymes but was found on diagnostic cardiac catheterization
to have a 90% LAD; there was no therapeutic intervention at that
time. He was subsequently referred to Dr. [**Last Name (STitle) 11255**] who had
considered an outpatient intervention; however, Mr. [**Known lastname 68181**] had
instead opted to undergo an elective cardiac catheterization in
[**State 108**], where he could convalesce with his daughter. In
preparation for the trip to [**State 108**], the patient awoke from
sleep on at 01:30 on [**2187-7-29**] with chest pain and shortness of
breath, which resolved with SL nitro x1. He subsequently went
to [**Hospital3 **] where his first Trop-I was 0.27 and d-dimer
was negative (Cr 1.4). Given his known cardiac disease he was
started on a hep gtt, integrillin gtt, and an NG patch was
administered. In addition, the pt was given solumedrol and
ceftriaxone/azithromycin for presumed COPD/PNA. Due to his
known LAD lesion, he was transferred to [**Hospital1 18**] for further care.
In the [**Hospital1 18**] ED, he was afebrile with HR of 74, SBP of 97, but
was requiring NRB to maintain SaO2 in the mid 90s. the pt had
one episode of chest pain which resolved with SL NTG x3. He
reported SOB and DOE in associated with his CP but denied any
palpitations, PND, orthopnea, edema, presyncope or syncope. He
was started on heparin gtt and integrillin gtt and admitted to
CCU.
.
Past Medical History:
1. CAD s/p diagnostic cath at [**Hospital6 3105**] with
90% LAD
2. DM with neuropathy
3. HTN
4. Hyperlipidemia
5. COPD
6. TB s/p left lobectomy '[**44**]
7. Colon CA s/p colectomy
8. BPH s/p TURP
9. Arthritis
10. s/p hernia repair x2
[**92**]. s/p hand surgery
Social History:
Patient resides alone in a housing project for the elderly. He
admits to drinking beer, approximately 3+ beers per day. He
denies any history of DT's, seizure, or other alcohol withdrawal
symptoms. He has a history of tobacco abuse but states that he
quit in the [**2141**]'s.
Family History:
Non-contributory
Physical Exam:
VS: T: 99, HR: 79, BP: 95/49, RR: 19, SaO2: 95% on 2L NC O2
GEN: elderly male sitting upright in bed, in NAD. Conversing
appropriately in full sentences.
HEENT: EOMI, OP clear, mmm
NECK: supple, no JVD
CV: RRR, S1, S2, no m/r/g
CHEST: posterior left chest wall scar from prior thoracotomy,
lungs with expiratory wheezes, decreased breath sounds over left
upper lobe
ABD: soft, NT, ND, BS+
EXT: 1+ edema bilaterally, no clubbing or cyanosis
NEURO: A+O x3
Pertinent Results:
STUDIES:
[**2187-7-29**] 10:56PM BLOOD CK-MB-20* MB Indx-1.0 cTropnT-0.22*
[**2187-7-30**] 05:58AM BLOOD CK-MB-24* MB Indx-1.1 cTropnT-0.38*
.
CXR [**2187-7-29**]: "Heterogeneous opacification in the lower lungs,
right substantially greater than left could be due to pneumonia.
Heart size is top normal. Vascular deficiency in the upper
lungs suggests emphysema and rib deformities in the left chest
suggest previous thoracotomy."
.
ECG [**2187-7-29**]: NSR at 90, left axis, left anterior fascicular
block, TWI in L, occasional PVC.
.
[**2187-7-30**] 05:58AM BLOOD Triglyc-112 HDL-46 CHOL/HD-4.0
LDLcalc-115
[**2187-7-30**] TTE:
Conclusions: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. There is regional
left ventricular systolic dysfunction. Resting regional wall
motion abnormalities include distal LV and apical hypokinesis.
No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately 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. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction c/w CAD.
.
[**2187-7-31**] CARDIAC CATHETERIZATION:
1. The proximal LMCA lesion was predilated with a 2.5 X 12mm
Maverick
balloon, stented with a 3.0 X 08mm Cypher stent and post dilated
with a
3.5 X 12mm Maverick and a 3.0 X 15mm NC Ranger balloon with
lesion
reduction from 80 to 10%.
2. The mid LAD lesion was predilated with a 3.0 X 20mm Maverick
balloon,
stented with a 3.0 X 28mm Cypher stent and post dilated with a
3.0 X
15mm NC Ranger balloon with lesion reduction from 99 % to 0%.
FINAL DIAGNOSIS:
1. Critical LMCA lesion successfully treated with stenting (Drug
eluting)
2. Successful stenting of the LAD (Drug eluting)
.
CXR [**2187-8-3**] "Improvement of multifocal pneumonia. Stable
post-surgical changes and emphysema."
Brief Hospital Course:
A/P: 81yo M with known 90% LAD lesion, DM, and COPD p/w chest
pain and shortness of breath in setting of new PNA.
.
1. CV:
A. Coronaries: The pt presented with known h/o CAD. He had
recently undergone a diagnostic catheterization which detected
90% LAD lesion. Given the clinical presentation with symptoms
of chest pressure, SOB, and persistently elevated cardiac
enzymes, he underwent catherization with stent placement in two
vessels on [**2187-7-31**]. During his post-catheterization
convalescence integrilin and heparin drips were discontinued.
He was started on chronic anti-platelet therapy with ASA 325 mg
and Plavix 75mg. In the peri-MI setting, his outpatient regimen
of Zocor 40 mg qday was changed to Lipitor 80 mg qday. His
beta-blocker and ACEI were titrated to doses of Atenolol 75 mg
qday and Lisinopril 5 mg qday to achieve goals of heart rate<80
and BP <130/80. In the peri-MI setting his outpatient
Felodipine was discontinued for improved mortality.
.
B. Pump: Post-catherization TTE revealed diminshed EF of 45%
with distal LV and apical AK, nml valves. In the setting of
heart failure, he was diuresed with furosemide 20mg PO daily and
was discharged home on this dose.
.
C. Rhythm: The pt was maintained throughout his hospitalization
in NSR with consistent findings on exam and telemetry.
.
2. PNA: The pt was found on admission to have heterogenous
opacifications in the lung bases, suggestive of an infiltrate.
This radiographic finding was further substantiated by his
elevated WBC and oxygen requirement. Upon admission, he
received 3 days of ceftriaxone and azithromycin and then was
switched to levofloxacin 500 mg on day 4 of antibiotic therapy.
Mr. [**Known lastname 68181**] was discharged with RX for 7 additional days of
antibiotic therapy to complete 14-day course. However, even
with radiographic improvement of the pneumonia, he continued to
require supplemental oxygen, both at rest and with activity,
likely secondary to underlying lung disease and a picture of
chronic hypoxia. He had a persistent cough throughout
hospitalization and in the 48 hours prior to discharge had one
episode of coughing up a moderate amount of blood clots, and the
subsequently noted blood-tinged sputum. No changes were noted
on chest x-ray at this time, and this was considered to be most
likely secondary to his acute cough and trauma to the
oropharynx. He remained hemodynamically stable, and was advised
to return to the ER in the case of gross hemoptysis or to
follow-up with his PCP in the case of persisting blood in his
sputum.
.
3. COPD: No PFTs were available to us documenting the severity
of his likely chronic lung disease. Given his h/o TB, s/p left
thoracotomy, and h/o tobacco abuse, he was treated as if a COPD
exacerbation were part of his clinical picture. He was started
as an in-patient on a Prednisone taper and jet nebulizer
treatments with only mild improvement in his respiratory status.
He was noted by PT to desat to 83-88% with ambulation on room
air, and he was recommended repeatedly for home oxygen. He
refused the attempts to set up home oxygen for him on multiple
occasions. He was discharged with a prescription for an
Atrovent MDI and with explicit instructions to complete the
prednisone taper.
.
4. DM: His blood sugars were noted to be labile throughout the
hospitalization, likely secondary to the prednisone taper and
his chronic DM. Initially, his blood glucose was managed with
sliding scale insulin and NPH. Prior to discharge, he was
controlled on an oral hypoglycemic [**Doctor Last Name 360**] and instructed to
resume management at home with Glucophage 500 mg. He was
instructed that Glucophage was preferable to his previous
regimen of Glyburide given his episodic hypoglycemia as an
in-patient.
.
5. Arthritis/Neuropathy: The pt has pain from arthritis and
neuropathy most likely secondary to his long standing DM. He was
continued on his home regimen of Neurontin 300 mg TID during
this hospitalization.
.
6. FEN: He was fed with a cardiac heart healthy diet.
Electrolytes were repleted as needed to maintain K>4 and Mg>2.
In the setting of his CHF, he underwent daily diuresis with
Lasix 20 mg qday to maintain an even or negative fluid balance,
and he was discharged with instructions to continue this regimen
as an outpatient.
.
7. PPx: Patient received Protonix for GI prophylaxis and
heparin for DVT prophylaxis.
.
8. Code status: DNR/DNI.
Medications on Admission:
MEDICATIONS:
1. ASA 81mg once daily
2. Metoprolol 25mg [**Hospital1 **]
3. Lisinopril 10mg once daily
4. Felodipine 2.5mg once daily
5. Isosorbide Mononitrate 60mg once daily
6. Zocor 40mg QHS
7. SL Nitro
8. Nabumetone 75mg [**Hospital1 **]
9. Neurontin 300mg TID
10. Darvocet 100mg TID PRN
11. Glyburide 10mg [**Hospital1 **]
12. Albuterol PRN
13. Omeprazole 20mg [**Hospital1 **]
14. Colace
.
ALLERGIES: Demerol
Discharge Disposition:
Home
Discharge Diagnosis:
Unstable angina
Pneumonia
Discharge Condition:
Good. Patient desats into high 80's on room air with activity
but has declined recommendation for supplemental oxygen at home.
Discharge Instructions:
1) You had a cardiac catheterization and placement of stents in
the arteries that supply blood to your heart. You were started
on new medications, one of which is called clopidogrel (or
Plavix), which is important for keeping blood flowing through
the stents. It is very important that you continue to take this
medication; do not stop taking it unless you discuss it with
your cardiologist. Stopping this medication on your own may
result in death.
*
2) You will also need to complete an additional 7 day course of
levofloxacin, an antibiotic therapy for your pneumonia.
*
3) Your aspirin dose has been increased from 81 mg daily to 325
mg daily.
*
4) Your anti-lipid [**Doctor Last Name 360**] has been changed from Zocor to Lipitor.
*
5) Your Lisinopril dose has been decreased to 5 mg daily. If
you have remaining 10 mg tablets, you may break them in half.
*
6) A new medication Lasix has been added to your regimen. Take
one tablet daily.
*
7) Your beta-blockade [**Doctor Last Name 360**] has been changed. Discontinue your
previous prescription of Metropolol and start Atenolol as
prescribed in its place.
*
8) Your Felodipine was discontinued.
*
9) Instead of your previously prescribed Albuterol inhaler, you
should use the Atrovent inhaler 4x daily, as prescribed.
*
10) You were started on a steroid taper (prednisone) to improve
your respiration, which you will need to continue following your
discharge. It is important that you take this medication as
directed, since stopping this medication prior to the end of the
complete course may have adverse effects. Starting tomorrow
morning, take a dose of 30 mg for 3 days, followed by 20 mg for
3 days, then 10 mg for 3 days, then 5 mg for 3 days.
*
11) Please call your doctor or return to the emergency room if
you have recurrent chest pain, shortness of breath, if you
cannot eat drink or take your medications, if you have bleeding
from groin, or you develop any other symptoms that are
concerning to you.
Followup Instructions:
Patient was instructed to return to the ER in the case of gross
hemoptysis, chest pain, or shortness of breath. He was
instructed to follow-up with his PCP in the event of persistent
blood-tinged sputum.
|
[
"428.0",
"411.1",
"272.4",
"414.01",
"401.9",
"491.21",
"V10.05",
"250.60",
"486",
"410.71",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"00.46",
"88.56",
"00.66",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
10077, 10083
|
5152, 9598
|
225, 280
|
10153, 10283
|
2965, 4882
|
12307, 12514
|
2456, 2474
|
10104, 10132
|
9624, 10054
|
4899, 5129
|
10307, 12284
|
2489, 2946
|
175, 187
|
308, 1846
|
1868, 2142
|
2158, 2440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,209
| 173,259
|
24243
|
Discharge summary
|
report
|
Admission Date: [**2200-2-18**] Discharge Date: [**2200-3-3**]
Date of Birth: [**2148-6-15**] Sex: M
Service: MEDICINE
Allergies:
Fondaparinux
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
fever and neutropenia
Major Surgical or Invasive Procedure:
Cardiac Cardioversion
Intubation
Transjugular Liver biopsy
Extubation
History of Present Illness:
Patient is a 51yo M with history of ALL dx'd in [**2197**], treated
and went into remission (onc history below), but then relapsed.
He was recently admitted on [**2200-2-3**] for the first part of
hyperCVAD. Treatment was delayed a few days secondary to
elevated bili, but started on [**2-6**]. He was discharged on [**2-10**].
He received vincristine on days 4 ([**2-9**]) and 11 ([**2-16**]).
He returned to clinic today for follow up and was found to have
fever to 100.6 and ANC of 60. He was reports fever or chills,
no sick contacts, no NSAID or Tylenol use, but is on steroids.
PICC removed on Sunday.
At clinic patient had a negativ cxr, blood culture drawn,
received 2g IV cefepime, and was transfused 1U pRBCs.
ROS: negative for fevers, chills, sore throat, nasal congestion,
pain, abdominal pain, n/v/d/constipation, change in urinary
habits.
Past Medical History:
Pertinent Onc History: (Per OMR Notes)
He presented in spring of [**2197**] with [**Location (un) 5622**] chromosome
negative ALL and was enrolled in the ECOG E2993 protocol. His
course was complicated by arachnoiditis and spinal headache
after intrathecal methotrexate and he developed a large saddle
pulmonary embolus potentially related to his L-asparaginase. He
also developed pulmonary infarct with bloody pleural effusion
and has had several episodes of febrile neutropenia. He was
treated with heparin for the pulmonary embolus and an IVC filter
was placed. He had a trial of
fondaparinux but had an allergic reaction. In light of having a
filter in place and cyclic thrombocytopenia while on treatment,
he has not had further anticoagulation. He has received the
remainder of his protocol treatment with L-asparaginase omitted
due to the pulmonary embolism.
.
He entered a complete remission on [**2198-6-20**], and was
randomized to a standard intensification consolidation arm. He
completed his intensification with high-dose methotrexate and
underwent stem cell mobilization in the summer of [**2197**] and then
completed his radiation therapy in early [**Month (only) **] and underwent
consolidation with intrathecal ARA-C. He began cycle 1 of
consolidation on [**2198-9-10**]. He began cycle 2 of
consolidation on [**2198-10-8**], where he received 5 days of
cytarabine and etoposide last given on [**2198-10-12**].
Shortly before [**2198-10-22**], he began to experience an
ascending weakness. He was admitted to the neurology service
where nerve conduction studies revealed a Guillain-[**Location (un) **] like
syndrome as well as a polyneuropathy presumed to be from
diabetes mellitus and vincristine. He was treated with IVIG and
had improvement in symptoms. He completed cycles 3 and 4 without
further complication. Began maintenance on [**2199-2-5**].
Complicated by transaminitis requiring dose reduction of 6MP and
then a change to thioguannine and chemotherapy break in [**10-30**].
.
ROS: Denies fevers, weight loss, weight gain, chest pain,
shortness of breath, abdominal pain, nausea, vomiting,
constipation, BRBPR, change in bowel or bladder habits,
hematuria, lower extremity edema
.
Past Medical Hx:
- ALL (as per above onc history)
- Stable peripheral neuropathies in right hand and lower
legs/feet
- Pulmonary embolism
- IVC filter placement
- Guillain-[**Location (un) **] syndrome vs. CIDP
- Diabetes type 2, on insulin
- Concern for NASH
Social History:
He is married and works at [**Company 11293**]. He is a lifelong nonsmoker.
He does not drink alcohol.
Family History:
- Mom: coronary artery disease.
- Father: colon cancer.
- No family history of neurologic disorders.
Physical Exam:
VS: 99.4 83 104/83 20 100RA
HEENT: EOMI, PERRL, thrush in mouth
Neck: no LAD
CV: RRR 1/6 systolic murmur at LUSB
Lungs: CTAB
ABD: +BS, obese, NT, ND, soft
Ext: trace edema
Skin: echymosis on abd, no rashes
Neuro: AAOx3, CN2-12 intact, 5/5 strength, sensation decreased
in right hand and feet bilaterally.
Pertinent Results:
T bili trend:
4/3/07-10.1
4/4/07-11.6
4/5/07-14
Liver, needle core biopsy:
Central venular hemorrhage with focal drop out.
Lobular regeneration with scattered rare neutrophils.
Trichrome stain shows no advanced fibrosis or cirrhosis. Focal
sinusoidal fibrosis is seen.
Reticulin stain shows features consistent with nodular
regenerative hyperplasia.
Severe iron deposition in Kupffer cells and hepatocytes on
special stain.
Brief Hospital Course:
ICU course:
Patient was transferred to ICU. He was intubated, successfully
cardioverted. He went for transjugular biopsy of his liver by
IR. He was successfully extubated. He continued to be slightly
encephalopathic. He was seen by respiratory and NIFs initially
~12 returned to baseline of ~40cm.
.
Assessment: Patient is a 51yo man with ALL with [**Last Name (un) 4584**] [**Location (un) **]
like weakness and liver failure after the first part of
hyperCVAD.
.
Plan:
# Fever/Neutropenia: Patient presented with ANC of 60. Monitored
with serial cultures which were negative or no growth to date.
CXR clear. He was covered with cefepime, vanc, flagyl,
micafungin.
.
# Weakness/GBS: On hospital day #[**1-26**] patient started having
progressive muscular weakness throughout body. Neuro was
involved. Thought that presentation was most consistent with
[**Last Name (un) 4584**] [**Location (un) **] like illness. Patient completed 2g (500mg x4
doses) of IVIG and had some slow improvement, but difficult to
assess in setting of hepatic encephalopathy.
.
# Liver Disease: Patient presented with an elevated tbili which
continued to rise and today is 16.1. His INR began to rise as
well.
Liver biopsy excluded cirrhosis/end stage liver and NASH as
causes. The histology showed some vascular congestion. Based on
clinical presentation and histology not to the contrary patient
was diagnosed with probable VOD. There are case reports of VOD
after chemotherapy with vincristine and other agents. We
received approval from FDA for compassionate use of defibrutide
for a non-post transplant patient with VOD. Began treatment
with defibrutide on [**2200-2-28**]. Care transitioned to comfort.
.
# Cardiac: Patient had new onset afib with RVR on [**2200-2-23**]. He was
evaluated by cardiology (EP). He was electrically cardioverted
to NSR under anesthesia. He was started on digoxin, sotalol and
diltiazem to maintain sinus rhythm.
.
# ALL: Patient completed 1st part of hyperCVAD (on day
+14--vincristine on day +11, dexamethasone on +11, 12, 13, 14).
.
# Heme: Transfuse RBCs to goal hct of 25. Transfusion parameters
for defibrutide for INR is <2-2.5 and platelets of >50.
.
# History of PE. Stable, no signs of active clot.
- IVC filter in place.
- No systemic anticoagulation in the setting of
thrombocytopenia.
.
# Diabetes. Difficult to control glucose while taking steroids.
[**Last Name (un) **] was very involved on last admission and patient was
discharged with a detailed insulin regimen based on his changes
in decadron.
.
# Goals of Care: On night of [**2-28**]-7 patient expressed wishes to
die and wanted to be made comfortable. After discussion with
wife by primary oncologist, the collective decision was to
transistion to comfort care.
Medications on Admission:
Medications: (Meds per OMR, [**2200-1-16**])
- Ativan 1mg PO Q6 PRN
- Bactrim DS 800-160mg PO QMWF
- Dexamethasone 24mg PO daily days [**12-22**] of chemo
- Fluconazole 200mg PO daily
- Humalog Sliding scale and lantus 25units in the morning.
- Lactulose 15mL TID/QID PRN constipation
- Levofloxacin 500mg PO daily
- Methotrexate 45mg PO as directed
- Nasonex 2 sprays each nostril daily
- Prednisone 6.5mg PO daily x 5 days
- Protonix 40mg PO daily
- Thioguanine 40mg PO daily as directed
- Zofran 8mg PO Q8 PRN nausea
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
ALL
[**Last Name (un) 4584**] [**Location (un) **]
Liver Failure
Diabetes
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
None
|
[
"286.7",
"V58.67",
"112.0",
"357.0",
"250.00",
"570",
"789.5",
"572.2",
"284.8",
"V12.51",
"453.9",
"204.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"99.14",
"50.11",
"99.15",
"99.04",
"99.05",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8151, 8160
|
4796, 7551
|
302, 374
|
8278, 8289
|
4345, 4773
|
8346, 8354
|
3897, 4000
|
8122, 8128
|
8181, 8257
|
7577, 8099
|
8313, 8323
|
4015, 4326
|
241, 264
|
402, 1263
|
1285, 3758
|
3774, 3881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,672
| 164,336
|
32167
|
Discharge summary
|
report
|
Admission Date: [**2133-11-9**] Discharge Date: [**2133-11-18**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo female with dementia who lives at a nursing home was found
next to her bed unresponsive from a likely fall out of bed. She
was taken to an area hospital with a GCS initially. CT scan
there revealed SDH and SAH and right pneumothorax. A chest tube
was placed and she was transported to [**Hospital1 18**] for further care.
Past Medical History:
TIA
CVA
RBBB
Temporal arteritis
Dementia
HTN
Type II DM
Social History:
Married with a daughter
Family History:
Noncontributory
Physical Exam:
Upon admission:
O: T: 100.3 BP: 139/69 HR: 102 R 18 O2Sats 100% on NRB
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PER minimally RL EOMs intact
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 and place, not to time.
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 minimally reactive to light, at 1.5
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,
+left arm tremor. Strength full power [**4-11**] throughout. No
pronator
drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2
Left 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2133-11-10**] 03:36AM BLOOD Phenyto-0.9*
[**11-9**] CT torso: 1. Displaced fractures through the anterior
lateral portion of the third and fourth ribs with associated
mild-to-moderate sized anterior basal pneumothorax. A
right-sided chest tube is identified, however not optimally
positioned.
2. Small right-sided hemothorax with associated atelectasis.
3. Mild stranding within the anterior mesentery, which in the
setting of trauma likely represents mesenteric contusion.
4. 1 cm hypodensity within the uncinate process, which may
represent IPMN. A repeat MRI can be performed in one year to
ensure stability if clinically appropriate.
[**11-9**]: CT head 1. Small layering intraventricular hemorrhage.
2. Right subdural hematoma layering over the right tentorium.
3. Small amount of left sided subarachnoid hemorrhage within the
ambient cistern or small layering subdural hematoma.
[**11-10**] CT head: 1. Small layering intraventricular hemorrhage
without evidence of hydrocephalus.
2. Small unchanged bilateral subdural hematomas layering over
the tentorium. That the blood along the left tentorium may
represent subarachnoid hemorrhage within the left ambient
cistern cannot be entirely excluded.
Brief Hospital Course:
She was admitted to the Trauma ICU under the Trauma service.
Neuro: Her pain was controlled with PO pain medications.
Dilantin was started for her subdural hemorrhage. Neurosurgery
was consulted, and appropriate CT of the head were obtained to
monitor the bleed; serial scans were stable. The Dilantin will
need to continue for at least 4 weeks at which time she will
follow up with Dr. [**Last Name (STitle) **]. Here ASA was restarted on day of
discharge because of her history of TIA's and CVA.
CV: Her home medications were restarted, and her vital signs
were monitored. Her stay was briefly complicated by an episode
of aymptomatic hypotension which resolved appropriately with a
fluid bolus. She did have an episode of chest discomfort on day
of discharge which she was unable to recollect. ECG and serial
enzymes were cycled; her CK was 27 and troponin was <0.01. There
were no further episodes of this.
Pulm: The chest tube was eventually removed once the output had
decreased. Chest x-rays were obtained for surveillance and
evaluation and were stable.
GI/GU: Her diet was advanced and her Foley catheter removed.
Heme: Her hematocrit was monitored and remained stable.
ID: No acute ID issues.
Endo: She was placed on a sliding scale of insulin.
Physical therapy was consulted and have recommended short rehab
stay.
Medications on Admission:
ASA, prilosec, aggrenox, lisinopril, trazadone, lipitor,
levaquin, reglan, KCl
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
2. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Dilantin Infatabs 50 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO three times a day for 4 weeks.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Senna 8.6 mg Capsule Sig: Two (2) Capsule PO twice a day as
needed for constipation.
13. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**]- [**Location (un) 5089**]
Discharge Diagnosis:
s/p Fall
Intraventricular hemorrhage
Subdural hematoma
Left subarachnoid hemorrhage
Right pneumothorax
Discharge Condition:
Good
Discharge Instructions:
Continue with Dilantin until follow up with Dr. [**Last Name (STitle) **],
Neurosurgery, in 4 weeks.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 4 weeks; when you schedule
your appointment, please have the office arrange for a CT of the
head on the same day. Please call [**Telephone/Fax (1) 1669**] to make an
appointment.
You should continue taking Dilantin until your follow up
appointment.
Please follow up with Dr. [**Last Name (STitle) **] (trauma surgery) in [**12-9**] weeks;
call [**Telephone/Fax (1) 600**] to make an appointment.
|
[
"E884.4",
"294.8",
"V12.54",
"852.00",
"250.00",
"807.02",
"401.9",
"446.5",
"860.0",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6070, 6143
|
3473, 4809
|
271, 278
|
6290, 6297
|
2237, 3142
|
6446, 6902
|
771, 788
|
4938, 6047
|
6164, 6269
|
4835, 4915
|
6321, 6423
|
803, 805
|
223, 233
|
306, 635
|
1340, 2218
|
3151, 3450
|
819, 1082
|
1097, 1324
|
657, 714
|
730, 755
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,737
| 170,499
|
8963
|
Discharge summary
|
report
|
Admission Date: [**2134-7-23**] Discharge Date: [**2134-7-31**]
Date of Birth: [**2053-12-3**] Sex: F
Service: MEDICINE
Allergies:
Verapamil / Iodine; Iodine Containing / Zoloft / Atenolol
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
cough and fever
Major Surgical or Invasive Procedure:
Right internal jugular vein central venous catheter
PICC line
Cardioversion for a-fib
History of Present Illness:
Pt is an 80 yo F w/ hx of COPD, htn, and two recent admissions
for PAF and CHF exacerbation who presents with exacerbation of
chronic cough and nausea with fever for two days.
Pt. states that she has experienced a chronic cough which is
mostly dry but with occasional clear sputum production for
around 5 months. This cough, however, does not limit her ADLs or
exercise tolerance as pt states she can usually walk "as far as
I want." About 3 weeks prior to presentation ([**7-5**])the pt
presented to [**Hospital1 **] for similar dyspnea and was admitted with a dx
of a-fib, anticoagulated, and cardioverted. She was discharged
on [**7-9**] to a rehab facility where poor monitoring of INR on
coumadin resulted in an INR of 9.1 when the pt. again presented
to [**Hospital1 **] complaining of DOE. During this admission, pt. was found
to have a CHF exacerbation with BNP=1425 in the context of a TEE
from [**7-6**] which had shown diastolic dysfunction. The pt. was
discharged to home on [**7-15**] and reports feeling "back to her
usual self" until two days prior to presentation.
Two days prior to presentation, pt reports increased cough with
wheezing along with severe nausea such that she "wishes she
could throw up" and fevers with rigors up to 102 degrees
accompanied by confusion. She denies associated CP, emesis,
diarrhea, dysuria, or urinary frequnecy. She reports decreased
PO intake (both food and fluids) during this time.
On arrival to the [**Name (NI) **], pt was febrile to 100.4 with MAP = 51 and
HR= 65,RR=18 and O2 sat = 95 on RA . Sepsis protocol was
initiated; a LIJ CVL was placed, she received 5L IVF, and was
started on a levophed ggt. Blood and urine cxs were sent and pt
was subsequently broadly covered with levofloxaxin and
vancomycin.
Past Medical History:
Diastolic congestive heart failure EF>=60%
Atrial Fibrillation - s/p cardioversion. not anticoagulated.
Rate controlled on nadolol.
HTN - labile
Cardiac History:
CABG: None
Catheterizations: None
PCI: None
Cardioversion: 2x for afib - most recently [**2134-7-6**]
Pacemaker/ICD: none
Stress Tests: Not available on computer
Social History:
Lives alone in [**Location (un) **]. Smoked [**2-20**] ppd x 40 years - quit 16
years ago. Glass wine with dinner. Able to do ADLs.
Family History:
Father: lung Ca and CAD
Physical Exam:
69 134/58 25 95% on 4L NC CVP13
Gen-Pt. tired appearing, A and O x 3, coughing loudly
HEENT- NC/AT, PERRL, MMM, no LAD, no JVD, sclera anicteric
Cardio-nl S1 and S2, RRR
Pulm-exp wheezes and sparse "dry" rales throughout, increased
exp phase, no rhonchi
Abd-bs+, soft, nt, nd, no organomegaly
Ext-warm and dry, 2+distal pulses throughout, no c/c/e
Neuro- no gross lesions
Pertinent Results:
Admission hct 36.8, discharge 31.9. WBC admission 13.4,
discharge 10.6. Plts 488. INR upon discharge was 2.5
BUN upon discharge 12, Cr 0.9 sodium 128, Cl 94, K 3.8, Bicarb
28. LFTs normal. 3 sets cardiac enzymes negative.
iron 17, TIBC 140, Ferritin 234. B12 757, Folate 7.7. serum
lactate 0.5 to 1.0. U/A small blood with no RBCs otherwise
normal.
Micro
[**7-23**] Blood culture: 4/4 bottles S.aureus (MSSA) sensitive to
clindamycin, erythromycin, gentamicin, levofloxacin, bactrim,
oxacillin
[**7-24**] Blood culture no growth to date (as of [**7-30**])
[**7-25**] Blood culture no growth to date (as of [**7-30**])
[**7-27**] Blood culture no growth to date (as of [**7-30**])
[**7-23**] urine culture negative
ECHO ([**7-27**]):
The left atrium is moderately dilated. The estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Transmitral Doppler and tissue
velocity imaging are consistent with normal LV diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad. Compared with the prior study
(images reviewed) of [**2134-7-14**], estimated pulmonary artery
systolic pressures are now higher. There are no obvious
vegetations are visualized. The severity of mitral regurgitation
is slightly reduced. The other findings are similar.
Left lower extremity ultrasound ([**8-5**]):
No evidence of DVT in the left leg.
Hip X ray ([**7-27**]):
Prominent multilevel degenerative changes of the lower lumbar
spine, incompletely evaluated. Mild degenerative changes of the
sacroiliac joints and hips.
Pelvic / L spine MRI ([**7-27**])
1. No evidence of discrete fluid collections, abnormal
enhancement, or
underlying osteomyelitis.
2. Soft tissue fluid consistent with anasarca, likely from
third spacing of fluid. This may reflect underlying
hypoalbuminemia or fluid overload.
LEFT UPPER EXTREMITY ULTRASOUND ([**7-30**])
1. No evidence of DVT in the left upper extremity.
2. Non-occlusive thrombosis of the left cephalic vein within
the forearm.
Brief Hospital Course:
Sepsis: Blood cultures from [**7-23**] positive for MSSA, treated with
Nafcillin x 14 days starting [**7-26**] with end date [**8-8**]. Patient in
ICU requiring pressors and fluid boluses, then transferred to
the floor where she was afebrile and improving, she continually
diuresed much fluid. Source likely IV catheter which was placed
upon previous visit to the ER in the left antecubital fossa. No
evidence of pelvic abscess or osteo (checked given hip/groin
pain) or of seeding of valves (checked by transthoracic echo).
Blood cultures have been negative to date since [**7-23**].
Atrial fibrillation: in the setting of large fluid shifts
(diuresed negative 5 liters 1 day post ICU discharge) she
returned to atrial fibrillation rhythm after just being
cardioverted a few weeks ago. Attempted rate control with
lopressor and diltiazem had little effect, patient was
cardioverted and started on Norpace to keep her in sinus rhythm.
QTc was followed while on this drug and she showed no
significant QTc prolongation. Continue coumadin anticoagulation.
Hyponatremia: Thought to be due to CHF versus SIADH. Follow Na
as patient autodiureses. If still hyponatremic once euvolemic,
should be fluid restricted.
Medications on Admission:
diovan 80mg po bid
ASA 81 mg po daily
lasix 20 mg po daily
nadolol 10 mg po daily
xanax 0.25 mg po bid
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
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. Ipratropium Bromide Inhalation
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever.
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
15. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): continue for an additional 7
days.
17. Outpatient Lab Work
please draw PT, PTT, and INR on monday [**2134-8-2**] and fax results
to Dr. [**First Name (STitle) 1557**] at [**Telephone/Fax (1) 31123**]
18. Valsartan 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
19. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
1. Septicemia
2. Diastolic congestive heart failure
3. Hypertension
SECONDARY:
1. Sepsis with MSSA
2. Diastolic congestive heart failure
3. Hypertension
4. Atrial Fibrillation
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted to the hospital because you were experiencing
chills, fever and weakness. In the emergency department, you had
signs of severe infection and received a large amount of fluids
and needed to be admitted to the intensive care unit. During our
workup, we found you to have an infection of in your blood. A
PICC line was placed so you could finish your 14 day course of
antibiotics. You were resuscitated with a lot of fluid while in
the ICU due to your low blood pressure, and were cardioverted
back to sinus rhythm and started on a new medication (norpace)
to keep you in that rhythm.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please keep all your appointments and take all medicines as
written. If you begin to experience fever, chills, or other
symptoms that worry you please call your primary care doctor or
come into the emergency department.
Followup Instructions:
You have the following appointments:
[**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2134-8-23**]
1:40
PULMONARY BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2134-8-26**]
10:10
PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING
Date/Time:[**2134-8-26**] 10:30
Please call your PCP [**Name Initial (PRE) 176**] 2 weeks to make an appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"428.0",
"038.11",
"996.62",
"V09.0",
"427.31",
"995.91",
"428.30",
"276.1",
"401.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.21",
"38.93",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
8792, 8889
|
5798, 7015
|
333, 421
|
9119, 9139
|
3163, 5775
|
10118, 10689
|
2730, 2755
|
7169, 8769
|
8910, 9098
|
7041, 7146
|
9163, 10095
|
2770, 3144
|
278, 295
|
449, 2215
|
2237, 2564
|
2580, 2714
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,745
| 183,879
|
4337
|
Discharge summary
|
report
|
Admission Date: [**2190-10-1**] Discharge Date: [**2190-10-10**]
Date of Birth: [**2118-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute onset chest pain/shortness of
breath/hypoxia
Major Surgical or Invasive Procedure:
[**2190-10-5**]
Drainage of pericardial effusion
History of Present Illness:
71 yo s/p AVR/CABGx2 on 8/ whose post
op course was complicated by ileus, was discharged to rehab on
[**9-30**]. He states he was having a bad day, unable to eat anything
or urinate, and while straining to urinate he developed acute
onset chest pain similar to what he felt prior to his surgery
with associated shortness of breath. The rehab called 911 and
he
was brought in for further evaluateion. In the Ed he was found
to have >2mm ST elevation in leads 2,3,aVf, V4, V5 and V6 with
ST
depression in aVR. Patient was taken to the cath lab by
cardiology for evaluation of his grafts.
Past Medical History:
Pericardial Effusion, s/p re-exploration
Coronary Artery Disease s/p cabg
Aortic Stenosis s/p AVR
PMH:
Hypertension
Hyperlipidemia
Pulmonary hypertension
Diastolic heart failure
Diabetes mellitus
AAA s/p endovascular repair in [**2186**]
Gout
Obesity
Sleep apnea
Social History:
Lives with wife. Retired. Previously works as accountant. Now
volunteer as mentor on MWF. Smokes cigars occasionally. Drinks
[**2-1**] glasses of wine per week. Denies drug use.
Family History:
Mother with diabetes. No known history of MI, stroke, or cancer.
Physical Exam:
Pulse:120s AF Resp: 18 O2 sat:96% on 5L NC
B/P Right:160/76 Left:
Height: Weight:
General:
Skin:diaphoretic intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur none
Abdomen: very distended, firm, non-tender to light palpation,
some discomfort to deep palpation, hypoactive bowel sounds
Extremities: Warm [x], well-perfused [x] Edema 1+
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**2190-10-5**] Echo
Conclusions
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with depressed free wall
contractility. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
The tricuspid valve leaflets are mildly thickened. There is a
large pericardial effusion which is largest posterior to the
left ventricle and is small anterior to the right ventricle and
small to moderate anterior to the right atrioventricular groove.
There is some stranding/organization in the pericardial space,
particularly anteriorly. There is mild indentation of the right
atrium without collapse. No right ventricular collpapse is seen.
There is some phasic motion of the interventricular septum.
There is probably mild pulmonary artery systolic hypertension.
Compared to the prior study of [**2190-10-4**], the pericardial
effusion appears larger, particularly posterior.
.
[**2190-10-9**] Echo:
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is mildly dilated with borderline normal free wall
function. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis leaflets appear to move normally.
There is a tiny small pericardial effusion, primarily apical
with the patient in the supine position.
IMPRESSION: Tiny residual pericardial effusion.
Compared with the prior study (images reviewed) of [**2190-10-5**],
pericardial effusion is much smaller.
Brief Hospital Course:
Cardiac cath showed patent grafts. He was returned to the CVICU
for further observation. He was kept NPO and had an NGT placed
for an ileus on KUB, which would resolve. He tolerated a full
diet and regained bowel function prior to discharge. He went
into acute renal failure with creatinine peak of 4.9. Renal
function would recover and urine output increased. Creatinine
returned to baseline of 1.0 prior to discharge. Echo revealed
pericardial effusion and the patient was returned to the
Operating Room on [**10-5**] for exploration and evacuation of
pericardial effusion. He tolerated this well and returned to
the CVICU for observation and recovery. He continued to make
progress and was transferred to the telemetry floor on POD 2.
AFib persisted and coumadin was resumed. Follow-up echo
revealed trace pericardial effusion with EF 55%. He was
discharged to the MACU at [**Hospital 100**] Rehab.
Medications on Admission:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Amiodarone 200 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
9. Ranitidine 150 mg PO DAILY
10. Warfarin 2 mg PO DAILY16 Duration: 1 Doses
Take as directed for INR goal 2.0-2.5 for atrial fibrillation
11. Bumetanide 1 mg PO DAILY
x 7 days then resume 0.5 mg daily until further instructed by
cardiologist
12. Potassium Chloride 20 mEq PO DAILY
while on diuretics
13. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes
3. Amiodarone 200 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Bisacodyl 10 mg PR DAILY:PRN constipation
7. Colchicine 0.6 mg PO DAILY Duration: 1 Days
8. Docusate Sodium 100 mg PO BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
11. Metoprolol Tartrate 50 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
12. Milk of Magnesia 30 ml PO HS:PRN constipation
13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
14. Warfarin MD to order daily dose PO DAILY
goal INR 2-2.5 for post-op AFib
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pericardial Effusion, s/p re-exploration
PMH:
Coronary Artery Disease s/p cabg
Aortic Stenosis s/p AVR
Hypertension
Hyperlipidemia
Pulmonary hypertension
Diastolic heart failure
Diabetes mellitus
AAA s/p endovascular repair in [**2186**]
Gout
Obesity
Sleep apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with Ultram
Sternal Incision - healing well, no erythema or drainage
Left lower extremity saph site clean/dry/intact.
Trace edema bilaterally
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr [**First Name (STitle) **] on [**2190-10-26**] at 1:30p in in the [**Hospital **] Medical
office building [**Hospital Unit Name **]
Cardiologist: Dr.[**Name (NI) 3733**] on [**2190-10-15**] at 3:40pm [**Telephone/Fax (1) 62**]
and Date/Time:[**2190-11-5**] 11:40
Primary Care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2190-10-13**] 3:00pm
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2190-10-11**]
Results to phone [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) **] at Dr.[**Name (NI) 11509**] office
[**Telephone/Fax (1) 18731**]
Fax [**Telephone/Fax (1) 13238**] after dicharge from rehab
**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:[**2190-10-10**]
|
[
"428.32",
"560.1",
"416.8",
"327.23",
"272.4",
"V42.2",
"V45.81",
"584.9",
"414.00",
"428.0",
"401.9",
"274.9",
"423.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.56",
"88.42",
"88.57",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
6412, 6478
|
3944, 4857
|
363, 414
|
6785, 7007
|
2239, 3921
|
7760, 8852
|
1534, 1600
|
5607, 6389
|
6499, 6764
|
4883, 5584
|
7031, 7737
|
1615, 2220
|
272, 325
|
442, 1034
|
1056, 1321
|
1337, 1518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,318
| 198,530
|
50711+59280
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-9-21**] Discharge Date: [**2123-9-29**]
Date of Birth: [**2052-2-14**] Sex: F
Service: VSU
CHIEF COMPLAINT: Bilateral lower extremity ulcerations
(right greater than left).
HISTORY OF PRESENT ILLNESS: This is a 71-year old female
with known diabetes, congestive heart failure, atrial
fibrillation, peripheral [**Year (4 digits) 1106**] disease who presents for
pre-hydration for an arteriogram of her right lower
extremity. The patient was admitted to the medical service
last month for a UTI and is now symptomatic. She has a right
lower extremity ulcer which occurred after removal of ankle
hardware last month. Currently the patient denies chest pain,
shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **], abdominal pain, nausea, vomiting,
fevers, chills. The patient has no specific complaints other
than low leg pain.
PAST MEDICAL HISTORY: Includes type 2 diabetes (insulin
dependent), congestive heart failure (with an ejection
fraction of 50% to 55%), history of chronic atrial
fibrillation (anticoagulated), coronary artery disease,
status post angioplasty in [**2109**], [**2110**] and [**2113**], history of
pulmonary hypertension, history of hyperlipidemia, history of
COPD (with home O2), history of pulmonary embolus, history of
obstructive sleep apnea (on CPAP), history of
depression/anxiety, history of aortic endocarditis (treated),
history of chronic anemia.
PAST SURGICAL HISTORY: Includes thyroidectomy, laparoscopic
cholecystectomy, a right thoracotomy decortication, and a
right hip and ankle open reduction/internal fixation.
ALLERGIES: PENICILLIN, TEGRETOL, BEEF AND PORK INSULIN,
_______________ (manifestations unknown).
MEDICATIONS ON ADMISSION: Include Lasix 40 mg/80 mg daily,
lisinopril 5 mg daily, Celexa 60 mg daily, Synthroid 200 mcg
daily, multivitamin tablet, Zocor 20 mg daily, aspirin 325 mg
daily, Coumadin, Lopressor 25 mg t.i.d., Atrovent 2 puffs
b.i.d., Fentanyl patch, oxycodone, Dilantin, Toprol XL 50
b.i.d., Protonix 40 daily, OxyContin 10 mg daily, Neurontin
600 mg b.i.d. (Monday and Wednesday), Lantus insulin 18 units
daily.
SOCIAL HISTORY: The patient is a resident of [**Hospital 100**] Rehab.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 98.7,
pulse of 92, respiratory rate of 18, blood pressure of
110/60, O2 saturation of 95% on room air. GENERAL APPEARANCE:
Anxious elderly female in no acute distress. HEENT: Carotids
are palpable without bruits. LUNGS: Clear with diminished
[**Hospital 1440**] sounds at the bases. HEART: Regular irregular rhythm.
ABDOMINAL EXAM: Benign. PULSE EXAM: Shows palpable
carotid's/radial's bilaterally 2+, femoral's are palpable 1+,
popliteal's are monophasic dopplerable signal bilaterally. On
the left, DP is monophasic and the PT is a triphasic
dopplerable signal. On the right, the DP is triphasic and the
PT is monophasic. EXTREMITIES: Limbs show minimal dry ulcers
on the left with a small anterior leg ulcer at the Achilles
heel. All bases are clean and pink. There is no drainage.
HOSPITAL COURSE: The patient was admitted to the [**Hospital 1106**]
service. IV hydration was begun in anticipation for an
arteriogram with a creatinine of 1.5. Admitting labs included
a white count of 8.4, hematocrit of 34.0, BUN of 15,
creatinine of 1.5. An EKG showed atrial fibrillation. No Q
waves. Nonspecific ST changes. A chest x-ray revealed poor
pulmonary inspiratory effort. No CHF.
On hospital day 1, the patient had no events overnight. The
patient's anticipated angio was deferred secondary to
scheduling problems. She was afebrile. This was discussed
with the patient, and she was allowed to eat and was prepared
for an arteriogram for [**2123-9-23**]. She was continued on
vancomycin, levofloxacin, and Flagyl.
On [**9-23**], the patient underwent abdominal aortogram with
bilateral runoff and a right above-the-knee amputation. She
required a unit of packed red blood cells intraoperatively.
She was transferred to the PACU in stable condition. The
angio was done from the left common femoral with a 5 sheath,
and she had a dopplerable DP at the end of the procedure.
Immediately postoperatively, she remained hemodynamically
stable. Postoperative hematocrit was 31.2. A chest x-ray was
without pneumothorax. The tip of the Swan-Ganz was in the
SVC. There was some right lower lobe atelectasis versus
edema. Dressings were clean, dry and intact. She had no
hematoma in the groin. She required Neo-Synephrine at 0.3
units/kg/min for systolic blood pressure support. The patient
remained in the PACU overnight.
On postoperative day 1, she did have rapid atrial
fibrillation which resolved. She was weaned off her Neo-
Synephrine. She was begun on a diltiazem drip. Her enzymes
were cycled, which were negative for rule out. Her diet was
advanced as tolerated. She was transferred to the VICU for
continued monitoring and care.
On postoperative day 2, the patient required Haldol for night
confusion with an improvement. She was afebrile. She
continued on the Neo-Synephrine and diltiazem drips. Her rate
was under excellent control with atrial fibrillation of 78.
Blood pressures were 100/94. She was 100% on 3 liters. Blood
gas was 7.43/43/111/29 and 3. Vancomycin, levofloxacin, and
Flagyl were continued. A regular insulin sliding scale was
begun. A multipoultice boot to the left foot. Her IV fluid
rate was decreased, and the patient was transferred to the
VICU for continued monitoring and care. On postoperative day
2, there were no overnight events. Her hematocrit remained
stable at 30.4 with a white count of 13.1; down from 15.0.
Her creatinine improved - was 0.7 - and gases remained
stable.
On postoperative day 3, her diet was advanced as tolerated.
Fluids were hep-locked. On postoperative day 4, the patient
was transferred to the regular nursing floor. She continued
to be afebrile. Her central line was discontinued.
On postoperative day 5, physical therapy was requested to see
the patient in anticipation for discharge planning. Her white
count was 9.9. The patient will require rehab prior to
discharge to nursing facility. Antibiotics were discontinued
on [**2123-9-28**]. Her beta blockade was reinstituted. The
remaining hospital course was unremarkable.
DISCHARGE DISPOSITION: The patient was discharged to rehab.
CONDITION ON DISCHARGE: Stable condition; the wounds were
clean, dry and intact.
DISCHARGE INSTRUCTIONS: The patient is to keep a
multipoultice splint to the left heel for heel protection.
She should not have any stump shrinker's to the amputation
site. The skin clips should remain in place until seen in
followup. The patient's INR's should be monitored; and her
goal INR should be 2.0 to 3.0 and Coumadin dose adjusted
accordingly.
DISCHARGE MEDICATIONS: Lisinopril 5 mg daily, levothyroxine
200 mcg daily, citalopram hydrobromide 60 mg daily,
simvastatin 20 mg daily, methylphenidate 10 mg q.a.m. and 5
mg at lunch, aspirin 325 mg daily, fluticasone actuation
aerosol 110 mcg 2 puffs b.i.d., Fentanyl patch 75 mcg per
hour q.72h., miconazole nitrate powder to affected area,
Lasix 80 mg daily, albuterol/ipratropium bromide 103/18 mcg
actuation aerosol 1 to 2 puffs q.6h., topiramate 15 mg
b.i.d., Protonix 40 mg daily, oxycodone 10 mg sustained
release q.12h., gabapentin 600 mg b.i.d. and 900 mg at
[**Year (4 digits) 21013**], insulin glargine 18 units at [**Year (4 digits) 21013**], diltiazem 30
mg q.i.d., Nystatin swish-and-swallow q.i.d., lorazepam 0.5
mg q.8h. p.r.n., oxycodone 5 to 10 mg q.4h. p.r.n. (for
breakthrough pain), metoprolol tartrate 25 mg t.i.d.,
Coumadin 2.5 mg daily at [**Year (4 digits) 21013**].
DISCHARGE DIAGNOSES:
1. Bilateral lower extremity ulcerations; right worse than
left.
2. Postoperative blood loss anemia; transfused/corrected.
3. History of coronary artery disease.
4. Congestive heart failure (ejection fraction of 55%).
5. Status post angioplasty to coronary arteries in [**2109**], [**2110**]
and [**2113**].
6. History of atrial fibrillation; anticoagulated.
7. Pulmonary hypertension.
8. Postoperative hypotension; corrected.
9. Hypercholesterolemia (on statin).
10. Chronic obstructive pulmonary disease (with home
O2); stable.
11. History of sleep apnea (on continuous positive
airway pressure).
12. History of depression and anxiety; on antilytic
[**Doctor Last Name 360**].
13. History of aortic valvular endocarditis.
14. History of chronic anemia.
DISCHARGE FOLLOWUP: The patient should follow up with Dr.
[**Last Name (STitle) **] in 4 weeks and all for an appointment. She is status
post right AKA on [**2123-9-23**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2123-9-28**] 15:51:22
T: [**2123-9-28**] 16:57:34
Job#: [**Job Number 105499**]
Name: [**Known lastname 17151**],[**Known firstname **] Unit No: [**Numeric Identifier 17152**]
Admission Date: [**2123-9-21**] Discharge Date: [**2123-10-4**]
Date of Birth: [**2052-2-14**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn
Attending:[**First Name3 (LF) 270**]
Addendum:
Pt had extended stay, bed availability at rehab.
On discharge pt is stable, taking PO, pos BM, urinating without
difficulty, OOB to chair.
Discharge INR 2.2
OTHER:
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s) .
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET :
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - LTC
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2123-10-4**]
|
[
"518.82",
"V58.61",
"428.0",
"357.2",
"440.24",
"285.1",
"V58.67",
"458.29",
"250.60",
"427.31",
"416.8",
"496",
"997.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"99.04",
"84.17",
"00.17",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
14946, 15166
|
7673, 8470
|
6780, 7652
|
1740, 2142
|
3070, 6255
|
9503, 11283
|
1463, 1713
|
2238, 3052
|
154, 220
|
8491, 9478
|
11296, 14240
|
14264, 14923
|
249, 883
|
906, 1439
|
2159, 2215
|
6342, 6400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,513
| 153,335
|
45800
|
Discharge summary
|
report
|
Admission Date: [**2127-3-24**] Discharge Date: [**2127-4-17**]
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 80-year-old female
with a complex past medical history notable for subglottic
stenosis with a long-term tracheostomy who presented for
elective placement of tracheostomy tube on [**2127-3-24**].
The patient has been followed on an ongoing basis by the
Thoracic Service and Otolaryngology Service for chronic
laryngeal tracheitis with an associated edematous subglottic
area which has caused complete obstruction in the area of the
glottis. The patient has since been dependent on a
tracheostomy for proper respiration and has been unable to
speak secondary to her edema.
The patient requested a revision of her tracheal stoma with
attempted tracheostomy tube placement in hopes of promoting
an open airway. The patient was subsequently scheduled for
this procedure to be conducted through a combined effort of
the Thoracic Service and the Otolaryngology Service on [**2127-3-24**].
PAST MEDICAL HISTORY:
1. Aortic stenosis; status post bioprosthetic aortic valve
replacement.
2. Coronary artery disease; status post coronary artery
bypass graft in [**2125-8-20**].
3. Hypertension.
4. Status post cardiovascular with some residual left-sided
weakness.
5. Hypothyroidism.
6. Diabetes.
7. Depression.
MEDICATIONS ON ADMISSION: Medications on admission included
Lipitor, Levoxyl, Atrovent, albuterol, glyburide, and Nexium.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No history of tobacco, alcohol, or drug use.
HOSPITAL COURSE: On [**2127-3-24**] the patient underwent a
direct laryngoscopy with biopsy, tracheal stoma revision with
removal of granulation tissue, and placement of a #10
tracheostomy tube.
The procedure was a combined effort between the Thoracic
Service (represented by Dr. [**First Name11 (Name Pattern1) 951**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 952**]) and the
Ear/Nose/Throat Service (represented by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]).
The patient's tracheostomy tube was placed without major
difficulty; during which time the patient was ventilated with
the intermittent us of jet ventilation as well as ventilation
through the tracheostomy tube connector.
The patient tolerated the procedure well without any
intraoperative complications and was subsequently transferred
to the Recovery Room in stable condition.
Shortly following arrival in the Recovery Room, the patient
was noted to have diminished oxygen saturations with an
increasing oxygen requirement. On physical examination, no
breath sounds were auscultated on the patient's left side. A
STAT chest x-ray was obtained which demonstrated a left-sided
tension pneumothorax. A left-sided chest tube was placed on
an emergent basis with adequate immediate decompression of
the left hemithorax with subsequent lung reinflation
confirmed by follow-up chest x-ray.
During the course of this episode, the patient was noted to
have elevated systolic blood pressures in the 180s to 210
range with associated sinus tachycardia. The patient was
subsequently sedated and successfully bronched with
mechanical ventilation subsequently provided via her tracheal
site.
The patient was subsequently transferred to the Surgical
Intensive Care Unit for further evaluation and management.
Post episode laboratory studies demonstrated an elevated
troponin to 10.4. A follow-up electrocardiogram demonstrated
new T wave inversions in leads III, aVF, and V3 to V6. A
Cardiology consultation was obtained, and the patient was
begun on an aspirin and heparin drip; as per standard
myocardial infarction protocol.
An echocardiogram obtained on postoperative day one
demonstrated no evidence of cardiac kinetic compromise
compared to prior cardiac studies, and the patient
demonstrated gradually decreasing troponin profiles over the
ensuing days.
On postoperative day two, the patient was noted to experience
acute respiratory distress secondary to dislodgment of her
tracheostomy tube connector from her surgical site. The
patient's tracheostomy tube was subsequently removed and
replaced with a #6 Portex tracheostomy without difficulty.
The patient remained on a standard tracheostomy for the
duration of her stay without subsequent replacement of her
tracheostomy tube.
On the evening on postoperative day two, the patient was
noted to demonstrate an acute drop in her hematocrit from
29.2 to 20.8. Following placement of a nasogastric tube,
bright red blood was aspirated from the patient's epigastrium
despite vigorous lavage.
A Gastrointestinal consultation was obtained and recommended
vigorous resuscitation with fluid and blood products in
conjunction with discontinuation of the patient's aspirin and
heparin therapy.
An esophagogastroduodenoscopy conducted on the morning on
postoperative day three demonstrated erosions in the stomach
body and fundus in conjunction with blood in the fundus, but
no obvious sources of gastrointestinal bleeding. The patient
was thereafter noted to stabilize her hematocrit following
fluid and blood product resuscitation. No additional
episodes of acute gastrointestinal bleeding throughout the
duration of her stay. The patient was thereafter begun on
total parenteral nutrition secondary to her requirement for
enteral sparing during her recovery window period. With
stabilization, the patient was gradually weaned from her
sedation and successfully extubated on postoperative day
three.
Upon the weaning of the patient's sedation, it was noted that
the patient was lethargic and minimally responsive. In
addition, the patient was noted to be hypertensive with
systolic blood pressures in the 200 range.
A computed tomography scan of the head was obtained which
demonstrated findings consistent with a recent left
frontoparietal infarction which was noted to be accompanied
by moderate brain parenchymal edema and mild mass effect on
repeat computerized axial tomography two days later.
A Neurology consultation was obtained, at which point the
patient was noted to have diminished ability to move the
right side of her body and diminished right-sided sensation.
Upon evaluation, the patient's stroke was believed to be
secondary to an embolic phenomenon given her recent history
of myocardial infarction, her past history of atrial
fibrillation, and the recent reversal of her anticoagulation.
It was recommended that the patient be kept at a systolic
blood pressure of greater than 140 to maximize cerebral blood
flow and to maintain on a propofol drip to minimize possible
seizure activity. In addition, the patient was started on
low-dose aspirin therapy following consultation with
Gastrointestinal Service.
NOTE: The remainder of this dictation will be continued
under a separate dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2127-4-16**] 13:34
T: [**2127-4-16**] 15:12
JOB#: [**Job Number 97573**]
|
[
"410.71",
"518.81",
"578.9",
"512.1",
"482.41",
"519.02",
"434.11",
"478.74",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.74",
"96.04",
"31.43",
"96.72",
"45.13",
"43.11",
"97.23",
"96.6",
"34.04",
"31.5",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1381, 1516
|
1598, 7143
|
131, 1029
|
1051, 1354
|
1533, 1579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,049
| 190,664
|
10614
|
Discharge summary
|
report
|
Admission Date: [**2143-7-13**] Discharge Date: [**2143-7-18**]
Date of Birth: [**2078-1-6**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Ms Contin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo m with hx restrictive lung dz, CAD, distolic HF, OSA, HTN,
BPH, type II DM p/w progressively worsening shortness of breath
and LE edema. Pt reports that for the last 1 week has been
having worsening dyspnea both at rest and on exertion. Also with
~15 lb weight gain in 1 week. Usually weighs 265 lbs, today
280lbs. Home VNA contact[**Name (NI) **] cardiology and lasix titrated from 60
mg [**Hospital1 **] to 80 mg [**Hospital1 **] yesterday. However without improvement of
sxs.
.
Also reports worsening LE edema, left greater than right.
Apparent trauma to L toe and knee after fall. Also with dry
productive cough and nasal congestion. Denies orthopnea, PND. At
baseline with very limited ET to ~several steps, limited mostly
by chronic back and leg pain. Per wife, during recent travel to
[**Location (un) **], did not adhere to low sodium diet for several days.
Chronic L sided CP radiating to the neck, approximately 2
episodes per week. Last episode was yesterday. These episodes
are usually non-exertional, non-radiating, and self resolves
over 2-3 minutes.
.
His inital vitals were: 97.4 98/59 HR 71 75% on RA, 97% 2L NC.
In the ED he was given 80mg IV lasix and was then admitted to
the floor for treatment of CHF exacerbation.
.
Of note Mr. [**Name14 (STitle) 34888**] has had his pain medications titrated up
recently with his methadone being doubled to 10mg tid. He had
taken 2 doses at this increased dose and upon admission to the
floor was found to be somnolent, developing shallow respirations
with worsening obtundation. He then desatted to 70's on N/C and
was placed on a 100% NRB. ABG at that time was 7.03/103/241.
He was given 0.4mg IV narcan with improved consciousness and
subsequently became cold/uncomfortable with hypertension to SBP
160. He was transferred to the CCU for narcan drip and closer
monitoring.
Past Medical History:
1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and
diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, retinopathy
4) HTN
5) CRI, baseline creatinine of 1.7
6) Anemia of chronic disease.
7) Sleep apnea on BiPAP, currently 16/13 on 4L O2
8) Chronic restrictive ventilatory disease secondary to a bile
duct leak with pulmonary fibrosis requiring decortication
9) Neuropathy - hands and feet
10) Lower extremity claudication
11) BPH.
12) Glaucoma; on carbonic anhydrase inhibitor
13) Bilateral cataracts s/p surgical removal
14) Depression
15) Osteoarthritis
16) Erectile dyscunction s/p Penile implant [**11-6**]
.
.
Past surgical history:
1) [**2138**] Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
2) [**2139**] Decortication for fibrothorax complicated by
respiratory failure requiring tracheostomy.
3) Appendectomy.
4) Left knee/hip replacement
5) L shoulder AC recection
Social History:
The patient lives with his wife. [**Name (NI) **] never smoked. Only minimal
ethanol. Retired. Lives a sedentary lifestyle.
Family History:
DM, CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father
Physical Exam:
PHYSICAL EXAMINATION:
VS - 97.8 136/63 HR 79 100% on 100% NRB
Gen: WDWN middle aged male in NAD. Somnolent but arousable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 10 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were shallow, but unlabored without accessory muscle use.
+Bibasilar crackles, decreased BS in bases
Abd: Protuberant, soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Ext: 2+ edema b/l left grossly more edematous than right, FROM
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS:
BNP 7352 on admission.
WBC 9.3 on admission down to 6.0 on discharge.
HCT 33 on admission and 34 on discharge.
BUN 68 on admission down to 49 at discharge.
Cr 2.5 on admission down to 1.7 on discharge.
Blood gas on admission pH 7.03 CO2 102 O2 241.
Blood gas before discharge pH 7.38 CO3 53 O2 97.
.
CXR on admission:
The appearance of the chest is similar to [**2143-5-4**]. Mild
cardiomegaly is unchanged. Pulmonary vasculature appears similar
and remains prominent, consistent with a mild degree of edema.
Left lateral pleural thickening has not changed. There is no
evident pleural effusion or new airspace consolidation. Again
seen is prior right rib resection. Clips in the right upper
quadrant compatible with prior cholecystectomy.
.
Cardiology Report ECG Study Date of [**2143-7-13**] 12:15:04 PM
Sinus rhythm. Frequent atrial ectopy. Probable old
inferoposterior wall
myocardial infarction. Non-specific T wave changes. Compared to
tracing
of [**2143-5-4**] there is no significant diagnostic change.
.
RENAL U/S:
The right kidney measures 10.9 cm. The left kidney measures 10.7
cm. There is no evidence of hydronephrosis, nephrolithiasis or
renal mass. The corticomedullary differentiation in the kidneys
is preserved.
.
LEFT LOWER EXTREMITY ULTRASOUND:
No evidence of left lower extremity deep vein thrombosis.
.
ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
65 male w/ questionable diastolic dsyfunction CKD, CAD, DM2, HTN
admitted with dyspnea and volume overload and hypercarbic
respiratory failure from prescribed narotics.
.
# Volume Overload: Patient diuresed nicely and was 2.4L negative
in first 24 hrs of admission, with minimal rales on exam. Volume
overload improving although still with b/l pitting edema.
Presumed CHF (with scant evidence), with preserved EF >55% in
[**5-8**]. Diastolic dysfunction was not evident on echo (only echo
abnormality is altered e:a ration). Precipitant for current
decompensation not entirely clear. Possibilities include dietary
indiscretion per wife and possible URI/infectious precipitant.
Treated with lasix drip and restarted on PO lasix at more
frequent dosing of 60mg TID (up from his home dose of 60 mg [**Hospital1 **])
with good effect. O2 sat was 97% on discharge.
.
# Hypercarbic respiratory failure: Likely due prescribed
narcotic use. Presented with dangerous hypercarbia and
respiratory acidosis. His home narcotics were initially held and
then decreased on discharge. He remained on bipap over length of
stay and had good Oxygen saturation (97% on room air).
.
# CAD: With apparently chronic non-exertional self-resolving CP.
Cath in [**2138**] showed minimal dz. ROMI at admission. His
metoprolol was continued at 12.5 [**Hospital1 **]. His ASA was decreased from
325 to 81 for secondary prophylaxis because he has not had
stents. Consider stress test when symptomatically improved as an
outpatient.
.
# CKD: CKD Stage 3, secondary to diabetic nephropathy. Acute on
chronic renal failure likely due to poor forward flow which
improved greatly with diuresis. Renal ultrasound was normal.
Etiology includes pre-renal vs renal dysfunction (diabetic
complication possibly). Initially high creatinine (2.4) and was
stable at 1.7 on discharge. Nephrology followed patient during
hospitalization.
.
# HTN: Stopped his home regimen of Imdur 30 because no clear
indication given good blood pressure control and normal echo.
Metoprolol 12.5 [**Hospital1 **] and Cozzar 50 mg were continued at home
dose.
.
# LE edema: Consistent with volume overload. Was asymmetric with
left greater than right. NEG Dopplers for DVT. Cellulitis at
left great toe treated with amox / clavulanate 500mg [**Hospital1 **] (7 day
course started on [**7-14**]).
.
# DM 2: Diet controlled. Acceptable HgbA1c of 6.7 in [**12-9**].
.
# Nasal congestion/dry cough: Clinical picture suggestive of
viral URI sxs.
.
# Osteoarthritis: At baseline with severe lower back pain and LE
pain. We restarted methadone at reduced dose given his
respiratory suppression at his prior doses.
.
# OSA: BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2
continued.
.
He is full code.
Medications on Admission:
HOME MEDICATIONS:
Oxycodone 5/325 2 tabs TID
Methadone 10 mg TID
Tylenol
Lasix 80 [**Hospital1 **]-->increased on [**7-12**] from 60 [**Hospital1 **]
Lexapro [**9-16**]
ASA 325
Colace
ISS
Flomax 0.8 daily
cozaar 50 daily
Toprol xl 25 daily
Proscar 5 daily
Imdur 30 daily
Calcitriol 0.5 daily
Protonix 40 daily
Mirapex 0.125 daily
BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2
Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
Disp:*45 Tablet(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Escitalopram 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
8. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
11. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Respiratory Insufficiency due to Narcotics
Volume Overload
Left First Toe Cellulitis
Acute Renal Failure
Discharge Condition:
Good. Weight 121.7 kg. Oxygen saturation 97% on room air.
Discharge Instructions:
Please remember to take your medications as described in the
instructions. If you develop increasing shortness of breath,
increasing weight, chest pains, high fever, nausea,
palpitations, light-headedness, or loss of consciousness, or any
other concerning signs, please contact your physician
[**Name Initial (PRE) 2227**].
Followup Instructions:
Please follow up with your primary care provider [**Name Initial (PRE) 176**] 2 weeks
of discharge. Please call your primary care provider to schedule
this. The following other appointments have been made for you:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2143-9-2**]
2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2143-9-5**] 3:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2144-5-26**] 11:30
Completed by:[**2143-7-20**]
|
[
"250.40",
"412",
"404.91",
"518.81",
"600.00",
"250.60",
"357.2",
"E935.1",
"428.33",
"362.01",
"584.9",
"583.81",
"440.21",
"425.4",
"428.0",
"585.3",
"681.10",
"327.23",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10561, 10619
|
6159, 8893
|
295, 302
|
10768, 10828
|
4224, 4534
|
11200, 11904
|
3400, 3475
|
9322, 10538
|
10640, 10747
|
8919, 8919
|
10852, 11177
|
2971, 3241
|
3490, 3490
|
8937, 9299
|
3512, 4205
|
248, 257
|
330, 2176
|
4548, 6136
|
2198, 2948
|
3257, 3384
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,158
| 109,420
|
33745
|
Discharge summary
|
report
|
Admission Date: [**2191-4-30**] Discharge Date: [**2191-4-30**]
Date of Birth: [**2160-5-22**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Liver laceration
Major Surgical or Invasive Procedure:
Bedside ex-lap
Bedside clam shell thoracotomy
Bedside Pericardial window
History of Present Illness:
30yM transfered from [**Hospital6 **] s/p single stab wound
to the abdomen. At the OSH, the patient was taken to the OR for
ex-lap and was found to have an 8cm deep laceration of the right
lobe of his liver which they sutured. Per report, EBL was
estimated to be 5 liters and required ~14u PRBC, platelets, and
ffp. They then found that branches of the portal vein and
hepatic artery were bleeding so they packed his abdomen and
closed for transfer to [**Hospital1 18**]. In the PACU of OSH, the patient
was unstable and required further blood product transfusions.
Eventually, the blood pressure was reported to be ~120/80 with a
hct of 25 so the patient was transfered to [**Hospital1 18**]. No temp was
recorded at OSH. Upon arrival to [**Hospital1 18**] BP was 80/p, T was 88F,
and the patient was brought directly to the TSICU.
Past Medical History:
Unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
Intubated and sedated
Active bleeding from nares and into abdominal JP drain
Anasarcatous
RIJ in place
Abdominal JP in place with BRB
Pertinent Results:
[**2191-4-30**] 07:25AM TYPE-ART PO2-56* PCO2-106* PH-6.81* TOTAL
CO2-19* BASE XS--22
[**2191-4-30**] 07:25AM GLUCOSE-195* LACTATE-7.8* K+-4.5
[**2191-4-30**] 07:25AM freeCa-0.95*
[**2191-4-30**] 06:26AM TYPE-ART PO2-237* PCO2-65* PH-6.92* TOTAL
CO2-15* BASE XS--21
[**2191-4-30**] 06:03AM GLUCOSE-262* UREA N-7 CREAT-0.9 SODIUM-149*
POTASSIUM-4.6 CHLORIDE-117* TOTAL CO2-14* ANION GAP-23*
[**2191-4-30**] 06:03AM CALCIUM-8.5 PHOSPHATE-8.3* MAGNESIUM-1.5*
[**2191-4-30**] 06:03AM WBC-8.7 RBC-2.99* HGB-9.1* HCT-27.9* MCV-94
MCH-30.5 MCHC-32.6 RDW-14.0
[**2191-4-30**] 06:03AM PLT COUNT-103*
[**2191-4-30**] 06:03AM PT-21.2* PTT-150* INR(PT)-2.0*
[**2191-4-30**] 06:03AM FIBRINOGE-62*
[**2191-4-30**] 05:27AM TYPE-MIX PO2-222* PCO2-70* PH-6.85* TOTAL
CO2-14* BASE XS--23 COMMENTS-GREEN TOP
[**2191-4-30**] 05:27AM LACTATE-5.8*
[**2191-4-30**] 05:27AM freeCa-1.07*
[**2191-4-30**] 05:19AM TYPE-ART PO2-169* PCO2-65* PH-6.89* TOTAL
CO2-14* BASE XS--22
[**2191-4-30**] 05:19AM GLUCOSE-221* LACTATE-5.6*
[**2191-4-30**] 05:19AM freeCa-1.09*
[**2191-4-30**] 04:56AM GLUCOSE-269* UREA N-6 CREAT-1.0 SODIUM-145
POTASSIUM-4.6 CHLORIDE-118* TOTAL CO2-13* ANION GAP-19
[**2191-4-30**] 04:56AM estGFR-Using this
[**2191-4-30**] 04:56AM ALT(SGPT)-1201* AST(SGOT)-[**2170**]* ALK PHOS-77
AMYLASE-49 TOT BILI-0.3
[**2191-4-30**] 04:56AM LIPASE-31
[**2191-4-30**] 04:56AM ALBUMIN-1.8* CALCIUM-9.0 PHOSPHATE-9.3*
MAGNESIUM-1.7
[**2191-4-30**] 04:56AM WBC-14.6* RBC-3.89* HGB-11.3* HCT-35.1*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.5
[**2191-4-30**] 04:56AM PLT COUNT-86*
[**2191-4-30**] 04:56AM PT-37.0* PTT-150* INR(PT)-4.0*
[**2191-4-30**] 04:56AM FIBRINOGE-61*
Brief Hospital Course:
On arrival into our intensive care unit the patient was found to
be profoundly hypothermic with a core body temperature of 88
degree Fahrenheit. He was profusely
bleeding from the abdomen, the nares and the orogastric tube. An
arterial blood gas showed a pH of 6.8. He as aggressively
resuscitated with fluids, packed red blood cells, fresh frozen
plasma, platelets, cryoprecipitate and many attempts at warming
using a Bair Hugger device, that and room heating were
performed. The patient's core temperature eventually reached
34.9 degrees, but he became progressively more
difficult to ventilate. CXR done on admission was unremarkable,
however, when the patient had increased difficulty ventilating,
bilateral tube thoracotomies were performed. From the right
chest tube, the patient had sanguinous discharge. He had
continued difficulty with ventilation, and at this point his
abdomen was quickly prepped and the retention sutures from his
prior surgery were removed and patient was eviscerated.
Next, the patient became somewhat easier to ventilate, however,
his oxygen saturation continued to deteriorate and the patient
became bradycardic, eventually displaying only agonal complexes
with no blood pressure. The patient had
bilateral chest tubes that had been placed previously, but there
was blood clotted in the right chest tube. The team was
concerned that the patient had a right hemothorax or a right
tension pneumothorax or perhaps cardiac tamponade since the path
of the knife was largely unknown.
Preparation of the patient's chest from neck to distal abdomen
was very rapidly prepped with Betadine. Using a scalpel an
incision was made in the 5th intercostal space on the right side
from mid axilla to sternum. This incision was carried down
through intercostal space into the right pleura. Upon entering
right pleura, a small amount of blood was noted, but there was
no evidence of a gross right hemothorax
or a right tension pneumothorax. The patient continued to be in
cardiopulmonary arrest and therefore the incision was carried
across the midline into the left and a formal clamshell
thoracotomy was performed involving both the right and left
hemithoraces.
The chest wall was elevated and quickly both hemithoraces
quickly examined. There was no evidence of hemothorax on the
right or the left side. The pericardium was quickly opened and
opened cardiac massage was performed. There was no evidence of
hemopericardium or cardiac tamponade. The patient responded with
reasonable blood pressure tracings upon open cardiac massage.
While there was no spontaneous electrical activity noted, nor
was there spontaneous cardiac contraction noted. The open
cardiac massage and full code was performed for an additional 15
minutes. Multiple ampules of epinephrine, bicarbonate, calcium
and atropine were administered, none of which resulted in
resumption of a cardiac rhythm or adequate perfusion. At 7:35
p.m. the code was called and the operation was terminated.
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"276.2",
"427.89",
"427.5",
"868.13",
"300.00",
"E966",
"305.00",
"286.9",
"780.99",
"864.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.91",
"99.60",
"54.12",
"37.12",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6287, 6296
|
3218, 6205
|
311, 385
|
6343, 6353
|
1504, 3195
|
6405, 6411
|
1325, 1334
|
6259, 6264
|
6317, 6322
|
6231, 6236
|
6377, 6382
|
1349, 1485
|
255, 273
|
413, 1253
|
1275, 1284
|
1300, 1309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,566
| 139,708
|
29103
|
Discharge summary
|
report
|
Admission Date: [**2159-9-27**] Discharge Date: [**2159-10-2**]
Date of Birth: [**2108-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2159-9-27**] Cardiac catheterization
[**2159-9-28**] Coronary artery bypass grafting x3 with left internal
mammary artery to the left anterior descending coronary; reverse
saphenous vein single graft from aorta to the second obtuse
marginal coronary artery; reverse saphenous vein single graft
from aorta to posterior descending coronary artery.
History of Present Illness:
50 year-old man with PMH significant for CAD w/ stent placed in
RCA in [**2154**] by Dr. [**Last Name (STitle) **]. Patient was doing well until [**2159-8-13**] when he started having chest pain while dragging a 30lb
bucket of clams for ~[**Age over 90 **] yards. The chest pain was sub-sternal,
did not radiate, and was [**9-19**] in intensity. It self-resolved in
~5-10 minutes. Pt then had several more episodes during the
following weeks, approximately 2-3x weekly, all while pulling
cases or doing other physical activity. Pt denies pain at rest.
Pt had similar pain during his cardiac stress test, except that
it was more focused on his left chest.
.
Pt had a nuclear stress test at OSH where he exercised 8 minutes
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol reaching 85% of his max
PHR. He experienced chest discomfort at peak exercise, 0.5-1mm
ST depression in II, III, avF, V4-V6 but no perfusion defect on
imaging. LVEF was normal. Pt underwent cardiac catheterization
(Right radial) today and was found to have tight left main
lesion. Cardiac surgeons have already seen the Pt and plan for
OR tomorrow. Will start heparin drip at 3.00 pm (4 hours after
cath done). Patient with h/o heavy EtOH use. Last drink last
night.
.
On arrival to the floor, patient was stable and pain free.
Vitals were: 97.3F, 126/71, 68, 20, 99% RA.
.
REVIEW OF SYSTEMS
On review of systems, pt denies fevers, chills, night sweats,
headaches, changes in vision, or cough. Reports some dyspnea
during his chest pain episodes. Denies nausea, vomiting,
diaphoresis. No diarrhea or constipation. No neurological
symptoms.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Dyslipidemia
CAD s/p RCA stenting in [**2154**]
WPW s/p ablation at [**Hospital1 112**] in [**2139**]
Bipolar disorder
Left fourth finger amputation from traumatic accident
Social History:
Lives in [**Location 70066**] with wife and five children. He is not
currently working.
Contact for discharge: [**Name (NI) **] [**Name (NI) 70067**] (son): [**Telephone/Fax (1) 70068**]
Tobacco: 1.5 ppd x 35 years. Quit about 2 years ago
ETOH: 6 pack once a week
Recreational drugs: Denies
Home services: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother died from lung cancer at 68 (heavy
smoker). Father had a stroke at 71.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
97.3F, 126/71, 68, 20, 99% RA.
GENERAL: very tanned looking man in no acute distress. Oriented
x3. Mood, affect appropriate.
HEENT: PERL, EOMI, no LAD. normal oropharynx.
NECK: Supple with JVP of 6 cm.
CARDIAC: reg rate and rhythm, normal s1 s2, no murmurs rubs or
gallops.
LUNGS: breath sounds somewhat distant. clear to auscultation
bilaterally.
ABDOMEN: normal bowel sounds, abd soft and nontender, no masses.
EXTREMITIES: trace pedal edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2159-9-27**] CARDIAC CATHETERIZATION:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronary disease. The LMCA had a
distal
eccentric 80% stenosis. The LAD had an ostial 70% hazy lesion.
The LCx
had no angiographically apparent coronary disease. The RCA had
70%
stenosis at the ostium of the PDA.
2. Limited hemodynamics revealed normotension.
.
PREOP BLOOD WORK:
[**2159-9-27**] WBC-5.1 RBC-4.91 Hgb-15.8 Hct-44.7 Plt Ct-161
[**2159-9-27**] PT-13.2 PTT-121.9* INR(PT)-1.1
[**2159-9-27**] Glucose-119* UreaN-8 Creat-0.8 Na-146* K-3.5 Cl-108
HCO3-25
[**2159-9-27**] ALT-21 AST-20 CK(CPK)-167 TotBili-0.2 DirBili-0.1
IndBili-0.1
[**2159-9-27**] Calcium-7.4* Cholest-PND
[**2159-9-27**] %HbA1c-5.3 eAG-105
.
POSTOP BLOOD WORK:
[**2159-10-1**] WBC-8.3 RBC-3.53* Hgb-11.4* Hct-32.3* RDW-14.0 Plt
Ct-128*
[**2159-9-30**] WBC-8.9 RBC-3.61* Hgb-11.7*# Hct-32.8* Plt Ct-119*
[**2159-9-29**] WBC-11.5* RBC-4.61 Hgb-14.8 Hct-41.6 Plt Ct-154
[**2159-10-2**] Glucose-83 UreaN-20 Creat-1.2 Na-135 K-4.6 Cl-102
HCO3-26 AnGap-12
[**2159-10-1**] Glucose-79 UreaN-19 Creat-1.0 Na-137 K-4.3 Cl-96
HCO3-36* AnGap-9
[**2159-9-30**] Glucose-94 UreaN-16 Creat-1.0 Na-136 K-4.4 Cl-96
HCO3-37* AnGap-7*
[**2159-10-2**] Mg-2.2
.
[**2159-9-28**] INTRAOP TEE:
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic stenosis is seen. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was
notified in person of the results prior to incision.
POST-BYPASS: The patient is on no inotropes. Biventricular
function is unchanged. There are no segmental wall motion
abnormalities. There is trivial mitral regurgitation. No aortic
regurgitation is seen. The ascending aorta, aortic arch, and
descending aorta are intact.
Brief Hospital Course:
Mr. [**Known lastname 70067**] is a 50 year-old man with PMH significant for
coronary artery disease s/p RCA stent in [**2154**], now with
reproducible chest pain and angina on stress test. Patient was
admitted and underwent cardiac catheterization which revelaed
tight stenosis of left main coronary artery and right sided
disease. Based upon the results, cardiac surgery was consulted
for surgical revascularization. Preoperative workup was
unremarkable and he was cleared for surgery. The following day,
patient was brought to the operating room and underwent coronary
artery bypass grafting by Dr. [**Last Name (STitle) 914**]. For surgical details,
please see operative note. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home with VNA services in good
condition with appropriate follow up instructions.
Medications on Admission:
DIVALPROEX [DEPAKOTE ER] - (Prescribed by Other Provider) - 500
mg Tablet Extended Release 24 hr - 3 Tablet(s) by mouth every
evening
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 150
mg
Tablet - 1 Tablet(s) by mouth every evening
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth every evening
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth as needed
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth every evening
TESTOSTERONE ENANTHATE - (Prescribed by Other Provider) - 200
mg/mL Oil - once weekly
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth every evening
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. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
4. divalproex 500 mg Tablet Extended Release 24 hr Sig: Three
(3) Tablet Extended Release 24 hr PO QHS (once a day (at
bedtime)).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Dyslipidemia
Prior RCA stenting in [**2154**]
History of WPW s/p ablation at [**Hospital1 112**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] [**2159-11-6**] at 1:15PM [**Telephone/Fax (1) 170**]
Wound Check Clinic [**2159-10-9**] at 10AM [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) 7047**] - appt pending at discharge. Dr.
[**Last Name (STitle) 70069**] office will call in the near future with appointment.
.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 6700**] in [**5-15**] 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:[**2159-10-2**]
|
[
"V49.62",
"414.01",
"272.4",
"V45.82",
"296.80",
"412",
"V70.7",
"V15.82",
"411.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9735, 9806
|
6383, 8010
|
321, 672
|
9994, 10150
|
3924, 6360
|
10938, 11621
|
3060, 3225
|
8789, 9712
|
9827, 9973
|
8036, 8766
|
10174, 10915
|
3240, 3261
|
2435, 2493
|
271, 283
|
700, 2341
|
3275, 3905
|
2524, 2711
|
2363, 2415
|
2727, 3044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,190
| 118,980
|
19969
|
Discharge summary
|
report
|
Admission Date: [**2141-12-23**] Discharge Date: [**2141-12-26**]
Date of Birth: [**2066-1-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Shellfish
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
This is a pleasant 75 yr old male (chinese-speaking only) with
cad s/p CABG in [**2138**], PCTA [**2141-10-3**] with cyphers of LAD/D1, also
with CO of RCA and LCx, PAF on coumadin, DMII, DCM (EF 30% with
severe inferoposterior wall/inferior septum) and HTN who
presents with NSTEMI (Tn 0.57, CK 195, MB 15) in setting of
BRBPR (hct 24 with baseline 34). Pt admitted to MICU,
transfused 4U PRBC's and 1U FFP with resolution of chest pain.
INR supratherapeutic at 4.8. Aspirin and plavix continued due
to risk of in-stent thrombosis. EGD revealed Barrett's
esophagus, non-bleeding erosions and 2 non-bleeding
benign-looking duodenal polyps. Continued on PPI and scheduled
for colonoscopy [**12-25**]. No further bleeding and hct stable.
Past Medical History:
CAD s/p CABG [**3-6**] at NYU
dual chamber cardioverter/defibrillator placement [**3-6**]
DM2
Chronic Renal Insufficiency
Gout
HTN
Social History:
+tobacco history x 25years, quit in '[**38**]
No ETOH
Lives with son
Family History:
non-contributory
Physical Exam:
98.9 105/67 67 14 98%RA
Gen: NAD, A&O X 3, well-mannered, good-spirits
Heent: EOMI, L ptosis, PERRL, MMM
Neck: No JVD or LAD
Heart: RRR, no mrg. PMI non-displaced
Lungs: Clear
Abd: Soft, nt/nd. No masses. Non-tender. No rebound guarding.
NABS.
Ext: No c/c/e
Pertinent Results:
[**2141-12-22**] 09:15PM BLOOD WBC-5.1 RBC-2.59* Hgb-8.0* Hct-24.2*
MCV-94 MCH-30.8 MCHC-32.9 RDW-15.2 Plt Ct-363
[**2141-12-22**] 09:15PM BLOOD PT-26.7* PTT-60.0* INR(PT)-4.5
[**2141-12-22**] 09:15PM BLOOD Glucose-127* UreaN-104* Creat-2.6* Na-137
K-3.9 Cl-102 HCO3-22 AnGap-17
[**2141-12-23**] 05:00AM BLOOD ALT-19 AST-31 AlkPhos-66 Amylase-54
TotBili-0.7
[**2141-12-23**] 06:30PM BLOOD CK-MB-15* MB Indx-8.2* cTropnT-0.82*
Brief Hospital Course:
1. GIB: Pt was admitted with acute GI bleeding. He got a
total of 5 units of PRBC's and 1 unit FFP for his
supratherapeutic INR. His CP occured with hct of ~24 (baseline
36) and resolved with blood transfusion and his hematocrit
remained stable ~35. EGD in the MICU revealed short segement of
Barrett's esophagus, non-erosive gastritis and non-bleeding
dudenal polyps. H.pylori serology returned positive, and he
will be treated with triple therapy for this problem. [**Name (NI) **] was
maintained on IV protonix [**Hospital1 **] for gastric acid suppression. Pt
then moved to the floor where he underwent bowel prep and had a
colonoscopy which revealed 2 sessile benign-appearing polyps
7-8mm in size that were not removed given the pt's
anticoagulated state. Therefore, Mr.[**Known lastname **] cause of bleeding was
likely supratheraputic anticoagulation from an unknown site. He
is no longer bleeding and his hematocrit is stable. H.Pylori
negative. He will be discharged with protonix 40mg [**Hospital1 53837**] X [**4-11**]
weeks.
2. NSTEMI: Pt had evidence of AMI with troponin leak in
setting of acute hemmorhage. Pt is paced, so it is impossible
to definitively rule out acute STEMI, but his serial ekg's did
not meet sgarbosa's criteria. However, his history is not
suggestive of acute coronary syndrome. He was maintained on
medical management with aspirin, BB, statin. He was maintained
on asprin and plavix (even in setting of acute GIB) to prevent
acute in-stent thrombosis. Pt was discharged with his home
regimen including coreg, digoxin, and imdur.
3. PAF: Pt was VVI-paced at 75 BPM while in house. His
coumadin was held. Mr.[**Known lastname **] will not be anticoagulated so his
ascending colonic polyps can be safely removed in the near
future.
4. DM: Pt was maintained on regular insulin sliding scale
during this hospitalization. No evidence of DKA.
5. Gout: Pt with history of gout. No evidency of acute gouty
flare. Remained on [**Known firstname **] allopurinol for secondary prophylaxis.
6. Barrett's Esophagus: Found on EGD. Will need follow-up in
[**Hospital **] clinic for this problem.
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet [**Known firstname **]
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet [**Known firstname **]
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet [**Hospital1 **]
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR [**Known firstname **] DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Allopurinol 100 mg Tablet Sig: 0.5 Tablet [**Known firstname **] DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet [**Known firstname **] DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet [**Known firstname **]
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet [**Known firstname **] once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Hyzaar 50-12.5 mg Tablet Sig: One (1) Tablet [**Known firstname **] once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Coumadin 2 mg Tablet Sig: One (1) Tablet [**Known firstname **] once a day: goal
INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Lower GIB secondary to supratheraputic anticoagulation
NSTEMI
Diabetes
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L/day.
If you have these symptoms, call your doctor or go to the ER:
-blood in stool
-black stool
-chest pain
-shortness of breath
-increased lethargy
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2142-1-31**] 8:30
2. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2142-1-31**] 9:30
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2142-1-31**] 10:00
4. Please call your PCP at [**Hospital6 33**] for general
check-up within 7-10 days of discharge. She must review and
follow your INR for goal 2.0-2.5.
Completed by:[**2141-12-26**]
|
[
"414.00",
"250.00",
"280.0",
"211.3",
"427.31",
"V45.01",
"V45.81",
"410.71",
"401.9",
"578.9",
"584.9",
"790.92",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5652, 5710
|
2157, 4313
|
324, 341
|
5827, 5833
|
1707, 2134
|
6154, 6884
|
1368, 1386
|
4336, 5629
|
5731, 5806
|
5857, 6131
|
1401, 1688
|
257, 286
|
369, 1111
|
1133, 1265
|
1281, 1352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,319
| 170,118
|
13278
|
Discharge summary
|
report
|
Admission Date: [**2145-1-1**] Discharge Date: [**2145-1-8**]
Date of Birth: [**2073-7-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache, difficulty speaking
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
HPI: The patient is a 74 year old man with a history of
well-controlled hypertension and hyperlipidemia presenting with
a
severe sudden onset headache with speech difficulty. This
history
is obtained from the patient's wife who accompanied him and was
present for the onset of symptoms. The headache started at
approximately [**2132**] with an onset over seconds. It predominantly
left frontal and reportedly did not affect his neck. He did not
complain of much besides the headache and did not have any
apparent nausea or vomiting, but he did seem to have difficulty
forming his words and constructing sentences, resulting in
fragmentation of his speech. He maintained consciousness
throughout this episode and did not have any apparent deficits
to
his wife besides the speech problem. His wife brought him to an
outside hospital where the patient received an NCHCT which
revealed a large left lobar hemorrhage; a physician there
explained this to the patient, but the patient wanted to leave,
and per his wife "did not seem to understand what the doctor was
saying." He was transferred to [**Hospital1 18**] for further management with
Neurology and Neurosurgery being consulted emergently to assist
with management. He notably arrived very agitated, yelling, and
trying to leave his stretcher.
His wife reports that he has had two weeks of increasing
difficulty with formulating words and sentences without
enunciation difficulty. She also notes that over the past 6
months he has had progressive difficulty with short term memory,
often forgeting simple items and tasks. He previously was very
sharp and functional. She thinks that he has also become much
more repetitive.
The review of systems could not be obtained by the patient, but
the wife endorsed his prior headache, speech difficulty, and
memory changes without any other accompanying symptoms noted by
the patient to his wife.
Past Medical History:
HTN
HL
Hypothyroidism
Social History:
Retired, previously a police officer. Married, lives with his
wife. [**Name (NI) **] tobacco use. Occasional ETOH (one glass of wine per
week, if that). No illicit drug use.
Family History:
No siblings. Mother had a hip fracture and died of pneumonia.
Father died of an aneurysm rupture located behind his stomach.
Physical Exam:
Physical Exam on Admission:
VS T: not recorded HR: 104 BP: 135/106 RR: 24 SaO2: 98%RA
General: Agitated, held down by EMS and staff, trying to get out
of the stretcher. / Head: NC/AT, no conjunctival icterus, no
injection, no oropharyngeal lesions / Neck: Supple, no nuchal
rigidity or meningismus / Cardiovascular: Mildly tachycardic, no
M/R/G / Pulmonary: Equal air entry bilaterally, no crackles or
wheezes / Abdomen: Soft, NT, ND, +BS, no guarding / Extremities:
Warm, no edema, palpable radial/dorsalis pedis pulses / Skin: No
rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, did not answer orientation
questions but responded to his name "[**Known firstname **]." Initially kept
saying to EMS "Doctor, release me, let go of me, [**Doctor First Name **] let me
go." He initially answered my orientation questions with "I
don't
know," and then fragments of words. He followed the simple
command of looking to the left and right, but would not look up
or down. Could not assess further as he was intubated. After
sedation and intubation, he would resist examination of the
face/eyes by turning his head and straining against his
restraints.
oriented x 3. Recalls a coherent history. Registration [**2-20**] and
recall [**2-20**]. Concentration maintained when recalling months
backwards. Follows two step commands, midline and appendicular.
Language fluent with intact repetition and verbal comprehension.
Normal prosody. No paraphasic errors. High and low frequency
naming intact. No dysarthria. No apraxia or neglect.
- Cranial Nerves - [II] PERRL 3->2.5. Resists examination for
fundoscopy. [III, IV, VI] Moves eyes laterally in both
directions
to command, but does not move eyes up or down. [V] Corneal
reflexes present when brushing eyelids bilaterally. [VII] No
facial asymmetry noted at rest or when speaking.
- Motor - Normal bulk. Normal tone in the upper extremities but
increased tone (rigidity) in the bilateral lower extremities.
Unable to test with confontrational methods prior to intubation,
but he provided full strength resistance with his proximal
muscles (shoulder, elbow, hip flexors) per report of the six
EMS/ED staff members who were restraining him.
- Sensory - Withdraws to noxious stimuli equally in both arms
and
legs.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 x*
R 2 2 2 2 x*
Plantar response extensor bilaterally.
*Hypertonia at the ankles preventing accurate assessment of
reflexes.
- Coordination - Unable to assess at the time of examination.
- Gait - Unable to assess at the time of examination.
Pertinent Results:
Admission Labs:
[**2145-1-1**] 12:14PM TYPE-ART PO2-149* PCO2-40 PH-7.43 TOTAL
CO2-27 BASE XS-2
[**2145-1-1**] 12:14PM GLUCOSE-132* LACTATE-1.1 NA+-139 K+-3.7
CL--103
[**2145-1-1**] 12:14PM freeCa-1.19
[**2145-1-1**] 03:08AM %HbA1c-5.8 eAG-120
[**2145-1-1**] 03:07AM URINE HOURS-RANDOM
[**2145-1-1**] 03:07AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2145-1-1**] 02:31AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-404*
PCO2-42 PH-7.37 TOTAL CO2-25 BASE XS-0 AADO2-257 REQ O2-51
-ASSIST/CON INTUBATED-INTUBATED
[**2145-1-1**] 01:38AM PH-7.33* COMMENTS-GREEN TOP
[**2145-1-1**] 01:38AM GLUCOSE-163* LACTATE-3.8* NA+-142 K+-4.4
CL--100 TCO2-27
[**2145-1-1**] 01:38AM freeCa-1.22
[**2145-1-1**] 01:29AM GLUCOSE-172* UREA N-28* CREAT-1.2 SODIUM-141
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-19
[**2145-1-1**] 01:29AM estGFR-Using this
[**2145-1-1**] 01:29AM ALT(SGPT)-29 AST(SGOT)-30 TOT BILI-0.3
[**2145-1-1**] 01:29AM CK-MB-4 cTropnT-<0.01
[**2145-1-1**] 01:29AM ALBUMIN-4.5 CALCIUM-9.9 PHOSPHATE-2.7
MAGNESIUM-1.7
[**2145-1-1**] 01:29AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2145-1-1**] 01:29AM WBC-16.6* RBC-4.17* HGB-13.9* HCT-40.7 MCV-98
MCH-33.3* MCHC-34.1 RDW-12.1
[**2145-1-1**] 01:29AM NEUTS-88.8* LYMPHS-8.0* MONOS-2.7 EOS-0.3
BASOS-0.2
[**2145-1-1**] 01:29AM PT-11.1 PTT-25.6 INR(PT)-1.0
[**2145-1-1**] 01:29AM PLT COUNT-235
[**2145-1-1**] 01:29AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2145-1-1**] 01:29AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
CXR [**1-5**]: Persistent left basilar opacity may represent
atelectasis, aspiration or pneumonia. Feeding tube port ends
higher than the gastroesophageal junction.
MR [**Name13 (STitle) 430**]: 1. Large left temporoparietal intraparenchymal hematoma
with intraventricular extension is redemonstrated. No abnormal
enhancement is identified on the present scan to suggest an
underlying mass lesion or vascular malformation. However, a
repeat MRI with contrast may be obtained once hemorrhage
resolves to assess for underlying lesion. Multiple foci of
abnormal susceptibility are seen in bilateral cerebral
hemispheres which likely represent microhemorrhages associated
with hypertension.
CT/CTA head [**1-1**]: : Stable predominantly intraaxial
temporoparietal hemorrhage with intraventricular, subdural, and
subarachnoid extension and significant mass effect. Normal CTA
of the head, specifically without evidence of vascular
malformation or aneurysm.
EEG [**1-1**]: This is an abnormal portable EEG, because of the
presence of bifrontally predominant intermittent rhythmic delta
activity (FIRDA). This finding can be seen in hydrocephalus, and
also in encephalopathy of nonspecific etiology. Background is
diffusely attenuated and slow and does not include a posterior
dominant rhythm. These findings are consistent with a diffuse
moderate encephalopathy of nonspecific etiology.
KUB: NG tube terminates in the stomach.
Echo: The left atrium is elongated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest. Patient unable to cooperate with manuevers.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. 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. There is no mitral valve
prolapse. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. No intracardiac source of
embolism identified. Normal global biventricular systolic
function. Mild pulmonary hypertension. Mild thoracic aortic
dilation.
LENIs: No evidence of DVT in right or left lower extremity. Left
posterior tibial veins could not be identified.
Brief Hospital Course:
74yoM h/o HTN, HL p/w sudden onset and severe left-sided
headache with trouble constructing sentences, found at an OSH to
have a large left lobar intracerebral hemorrhage primarily
affecting the temporal and occipital lobes. The hemorrhage has
intraparenchymal, subarachnoid, subdural, and intraventricular
components. MRI brain showed multiple chronic microhemorrhages
in the bilateral cerebral hemispheres. CTA brain did not show a
vascular malformation or aneurysm. The clinical picture and data
was most suggestive of hemorhage secondary to amyloid
angiopathy. Less likely etiologies include: hemorrhagic
conversion of ischemic infarct, ruptured AVM/aneurysm,
hypertensive hemorrhage, and hemorrhagic malignancy. He remained
on the neurology floor wards of the [**Hospital1 18**] and an NG tube was
placed. Over the course of the next several days, he developed
low to high grade fevers and spiked a significant leukocytosis
(20K). His CXR showed the presence of a pneumonia-like
infiltrate. As he developed tachypnea and hypoxia, he was
transferred to the intensive care unit and immediately
endotracheally intubated. On the day following intubation, a
family meeting was held where his wife [**Name (NI) **], expressed his
wishes that he would not be interested in prolonging life when
there would be no chance of a meaningful neurologic recovery.
She wished that he would be allowed to die with dignity, and
asked about a way to focus on his comfort. His status was
changed to comfort measures only. He was terminally extubated.
His nonessential medications were discontinued. He remained in
the ICU with his wife until he expired at 2233hrs on [**1-8**], [**2144**]. [**First Name5 (NamePattern1) **] [**Known lastname 40421**] received pastoral support by way of the
hospital's Catholic priest.
Medications on Admission:
Irbesartan 150 daily
Simvastatin 20
Synthroid 225 mcg
Niacin 750 mg q12h
ASA 325 mg daily
MVI
Calcium
Testosterone gel
Discharge Medications:
N/a (deceased)
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
N/a (deceased)
Discharge Instructions:
N/a (deceased)
Followup Instructions:
N/a (deceased)
Completed by:[**2145-1-10**]
|
[
"277.39",
"V49.86",
"437.9",
"434.91",
"486",
"431",
"518.81",
"272.4",
"401.9",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11645, 11654
|
9631, 11437
|
340, 365
|
11722, 11738
|
5349, 5349
|
11801, 11846
|
2539, 2665
|
11606, 11622
|
11675, 11701
|
11463, 11583
|
11762, 11778
|
2680, 2694
|
271, 302
|
393, 2287
|
5365, 9608
|
2709, 3232
|
3257, 5330
|
2309, 2332
|
2348, 2523
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,062
| 169,820
|
9456+9457
|
Discharge summary
|
report+report
|
Admission Date: [**2106-8-5**] Discharge Date: [**2106-8-7**]
Date of Birth: [**2050-3-11**] Sex: M
Service: NEUROSURG
HISTORY OF PRESENT ILLNESS: This is a 56-year-old man
without any significant past medical history who presented to
the emergency room after the sudden onset of headache while
he was riding a bicycle. He characterized this headache as
the worst headache of his life and had associated nausea and
vomiting times one. He also complained of dizziness at the
time of headache onset. He presented to the [**Hospital1 346**] emergency room, where an initial
head CT scan was read as negative. However, a lumbar
puncture was done, in which tube 1 showed 4800 red blood
cells and tube 4 showed 4000 red blood cells. The patient
was sent for an MRI of the head, which raised the question of
a right posterior cerebral artery aneurysm. The CT scan was
revealed and, on second analysis, it was thought that it was
suspicious for a subarachnoid hemorrhage in the suprasellar
cistern. The patient was then admitted for further
evaluation.
PAST MEDICAL HISTORY: The past medical history was
significant for left shoulder surgery in [**2106-3-4**] for
repair of a "minor rotator cuff tear" and removal of
osteophytes. Otherwise, the past medical history was
insignificant.
MEDICATIONS ON ADMISSION: The patient was on no medications.
ALLERGIES: There were no known drug allergies.
FAMILY HISTORY: The father had leukemia and the mother had
gastrointestinal cancer. There was no family history of
aneurysms.
SOCIAL HISTORY: The patient was a nonsmoker and used no
ethanol. He was married, with children, and was a church
minister.
PHYSICAL EXAMINATION: On physical examination, the patient
was resting comfortably when seen, slightly sleepy at first
but readily arousable, awake, alert, oriented and conversant.
Of note, the patient had been given 2 mg of Ativan before the
examination. The face was symmetric. The tongue was
midline. The neck was supple with full range of motion.
There was no rigidity, but the neck was slightly painful at
extreme flexion. The general examination was essentially
unremarkable, as per previous notes.
On examination of the extremities, the patient moved all
extremities and had strength of [**5-8**] in all of the muscle
groups tested in the upper and lower extremities. The
sensory examination was intact to light touch. There was a
very slight inward pronator drift of the left hand.
Finger-nose-finger testing and heel-to-shin testing were
normal. Rapid alternating movement was normal. The toes
were downgoing bilaterally. Gait was reported to be normal,
as per the emergency room staff. There was no ataxia noted.
LABORATORY: Laboratory values were as per the History of
Present Illness.
RADIOLOGY: Neurological imaging data was as per the History
of Present Illness.
HOSPITAL COURSE: The patient was admitted to the surgical
intensive care unit, where a continued cerebral angiogram was
done that was essentially normal, without evidence of any
obvious aneurysm. The patient was observed for two days with
a repeat CT scan showing no changes from the previous
examination. The headache stabilized after the patient was
transferred to the floor.
The patient continued to do well and the decision was made to
discharge him.
DISCHARGE INSTRUCTIONS: The patient was discharged with
strict instructions to return to the emergency room, should
there be an exacerbation of symptoms.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
Ruled out subarachnoid hemorrhage.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7762**]
Dictated By:[**Name8 (MD) 11440**]
MEDQUIST36
D: [**2106-8-7**] 14:04
T: [**2106-8-7**] 15:27
JOB#: [**Job Number 32236**]
Admission Date: [**2106-8-5**] Discharge Date: [**2106-8-7**]
Date of Birth: [**2050-3-11**] Sex: M
Service: NEUROSURG
ADMISSION DIAGNOSIS:
Rule out subarachnoid hemorrhage.
DISCHARGE DIAGNOSIS:
Rule out subarachnoid hemorrhage.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
white male who presented to the emergency room on [**2106-8-5**]
with "the worst headache of [his] life" since 4 PM on
[**2106-8-4**]. The patient was 20 minutes into a bicycle ride
when he developed the acute onset of this headache with
associated nausea and vomiting times one as well as
dizziness. He presented to the emergency room for
evaluation.
A CT scan of the head was initially read as negative. A
lumbar puncture was performed; tube 1 showed 4800 red blood
cells and tube 4 showed 4000 red blood cells. The patient
was sent for an MRI, which raised the question of a right
posterior cerebral artery aneurysm. A re-review of the CT
scan then was considered suspicious for a subarachnoid
hemorrhage in the parasellar and suprasellar cistern.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: The patient had left shoulder surgery
in [**2106-3-4**] for repair of a minor rotator cuff tear and
removal of osteophytes.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: There were no known drug allergies.
FAMILY HISTORY: The family history was noncontributory.
SOCIAL HISTORY: The patient was a nonsmoker with no alcohol
use. He was married and a church minister.
PHYSICAL EXAMINATION: On examination, the patient was
resting comfortably in bed, slightly sleepy but easily
aroused and then awake, alert, oriented and conversant. On
examination of the face, the smile was symmetric and the
tongue was midline. The neck was supple with full range of
motion and no rigidity, but it was slightly painful at
extreme flexion.
In all major muscle groups, strength was [**5-8**]. The patient
moved all extremities and had full range of motion. The
sensory examination was intact to light touch throughout.
There was no pronator drift. Finger-to-nose testing was
within normal limits. Rapid alternating movements were
within normal limits. Gait was reportedly normal per the
emergency room staff.
The cardiac examination was a regular rate and rhythm, S1 and
S2. The lungs were clear to auscultation bilaterally. The
abdomen was soft, nontender and nondistended with positive
bowel sounds. The extremities were warm, soft and nontender
with positive pulses.
PERTINENT EXAMINATIONS: As per the History of Present
Illness.
HOSPITAL COURSE: The patient was admitted to the surgical
intensive care unit for close monitoring with every hour
neurological checks. He remained stable in the surgical
intensive care unit. On [**2106-8-5**], the patient was taken to
the angioscopy suite for an angiogram of his brain. There
was no evidence of any aneurysm or source of bleeding. The
patient was transferred back to the surgical intensive care
unit. His femoral sheath was removed and pressure was
applied. There was no evidence of bleeding. The patient's
vital signs remained stable. His hematocrit remained stable.
On the morning of [**2106-8-6**], the patient was still complaining
of a slight headache. The patient was neurologically intact.
Intravenous fluids were continued at 100 cc/h. In the
afternoon, he was transferred to the floor for monitoring of
his headache. His intravenous fluids were decreased. He was
placed on Tylenol #3 and his headaches decreased to minimal.
CONDITION ON DISCHARGE: On the morning of [**2106-8-7**], the
patient was neurologically intact. He was stable. He was
free of headaches.
DISPOSITION: The patient was discharged home to follow up
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in the office for further evaluation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7762**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2106-8-6**] 22:16
T: [**2106-8-11**] 07:22
JOB#: [**Job Number 32237**]
|
[
"784.0",
"780.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5166, 5207
|
3542, 3959
|
4036, 4071
|
5093, 5149
|
6395, 7343
|
3356, 3487
|
4941, 5066
|
5336, 6377
|
3980, 4015
|
4100, 4887
|
4910, 4917
|
5224, 5313
|
7368, 7907
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,927
| 133,804
|
10348
|
Discharge summary
|
report
|
Admission Date: [**2193-11-7**] Discharge Date: [**2193-11-20**]
Date of Birth: [**2123-5-31**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 70 year old male with
painless jaundice. The patient has a two week history of
nausea and vomiting without abdominal pain. An ultrasound on
[**11-5**], showed poorly visualized abdominal anatomy due to the
presence of large amount of scar tissue, but no intrahepatic
ductal dilatation. Has been on TPN for eight months
secondary to poor appetite. By report, also has functioning
colostomy tube.
PAST MEDICAL HISTORY:
1. Infected aortic bypass graft [**10/2191**].
2. Femoral graft.
3. End-stage renal disease, hemodialysis on Tuesday,
Wednesday and Thursday.
4. Short-gut secondary to small bowel resection colostomy.
5. Three-vessel coronary artery bypass graft in [**2187**].
6. Hypertension.
7. L1 and L2 laminectomy.
8. Depression.
9. TPN times eight months.
10. Splenectomy.
SOCIAL HISTORY: Lives in his own house, 24 hour help.
FAMILY HISTORY: Notable for abdominal aortic aneurysm.
PHYSICAL EXAMINATION: In general, he was in no apparent
distress but was unhappy and notably jaundiced. Vital signs:
Afebrile; pulse 80; blood pressure 130/80; respiratory rate
20; O2 saturation 92% on room air. HEENT: Dry mucous
membranes, scleral icterus. Jugular venous pressure
increased to the angle of the jaw. No lymphadenopathy or
thyromegaly. There is a tracheal site that was healed.
Lungs are clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm; normal S1 and S2. Abdomen was soft,
nontender, nondistended. An ostomy site; no spider angiomata
and no hepatosplenomegaly. He was noted to have no cyanosis,
clubbing or edema. He had a right below the knee amputation
but three plus pulses on the left side. Neurologic
examination was nonfocal.
LABORATORY: On admission, white blood cell count 11.0,
hematocrit 34, platelets 217, differential within normal
limits. Coagulation studies were normal. Sodium 135,
potassium 2.9, chloride 99, bicarbonate 24, BUN 63,
creatinine 4.9. Glucose 64. AST 363, ALT 200, alkaline
phosphatase 604, total bilirubin 7.5, GT 289, albumin 2.4.
Esophagogastroduodenoscopy showed duodenal ulcers felt
secondary to possibly to a H. pylori infection; serologies
were sent.
HOSPITAL COURSE: Mr. [**Known lastname 28138**] was admitted to the [**Hospital1 1444**] on [**2193-11-7**], for a work-up
and treatment of painless jaundice. The patient was
initially placed on outpatient medications including Zoloft,
Albuterol, Atrovent and Flovent, Ativan, Imdur as well as
nausea control with Droperidol. A gastrointestinal
consultation was sought. They recommended an imaging study
with an MRI or MRCP. In addition, the patient was continued
on his TPN and the patient was scheduled for a MRCP as well
as CEA and CN8, 9 enzymes.
Since the patient has a history of end-stage renal disease on
hemodialysis, the Renal Team was consulted and followed him
throughout his hospitalization. He continued to receive his
hemodialysis at his regular scheduled intervals. On hospital
day four, he was seen by the night intern and was noted to
have desaturations. Since he was on room air or minimal
oxygen requirement, noted desaturation to 80% on room air.
His shortness of breath and desaturation was felt most likely
secondary to volume overload in the GN. The Renal Team was
originally [**Year (4 digits) 653**]. The patient was scheduled for an early
dialysis where they removed a larger amount of fluid than
normal.
After this session, the shortness of breath was noted to be
better after hemodialysis.
The MRCP results showed no ductal dilatation, no evidence of
obstruction, status post cholecystectomy in the past.
Differential diagnoses after the MRCP included cholecystitis
and cholangitis in the setting of TPN, possible virus
infection, however, this was felt to be negative Hepatitis A,
B and C in the past. A CMV antigen was sent. Also possibly
secondary to drug intoxication, auto-immune or
hemachromatosis. In the setting of a normal MRI, additional
laboratories were sent, including a CMV antigen, IgG, IgA,
IgM, IgG, [**Doctor First Name **], AMA and anti-smooth muscle antibody.
In further discussion with the GI Team, the feeling was that
the patient's painless jaundice was most likely
multifactorial in etiology, including possible effect from
his Lipitor as well as the high fat load from his TPN. In
response to this, his Lipitor was discontinued as well as the
fat content of his TPN was diminished over the next couple of
days.
Chest x-ray after his desaturation revealed a possible right
lower lobe pneumonia felt secondary to aspiration. He was
started on antibiotics including levofloxacin and Flagyl.
His liver function tests continued to stabilize, however,
over the course of the next several days, the patient
continued to feel very fatigued and very weak. His shortness
of breath continued to improve over the next couple of days
on levofloxacin and Flagyl as well as he continued his normal
dialysis.
However, the patient continued feeling weak and began to
refuse Physical Therapy over the course of the next several
days. In addition, over the course of the next several days,
the patient continued to have an increasing white blood cell
count in the setting, however, he remained afebrile during
this time. He was continued on levofloxacin and Flagyl for
his aspiration pneumonia during this time, however, his white
blood cell count continued to rise. In this setting, an
Infectious Disease consultation was obtained.
Infectious Disease consult recommended a right upper
extremity ultrasound for a clot most likely in his arm which
was felt could be possibly the source of his elevated white
blood cell count in his graft site. Mr. [**Known lastname 28138**] continued
to feel weak and have lower extremity pain. Over the next
couple of days, Mr. [**Known lastname 28138**] continued to have a rising
white blood cell count up to 25.0 and he became hypotensive
with systolic blood pressures approximately 80 to 90. He
received multiple fluid boluses and increased his antibiotics
with Vancomycin to cover more Gram positive coverage.
Over the course of the next couple of days, the patient
became progressively more hypotensive with systolic blood
pressures to the 70s and a white blood cell count to 20,000.
This was felt most likely secondary to sepsis, however, he
had a negative work-up for right AV fistula abscess, fluid
collection, with a negative ultrasound. He had a nonfocal
abdominal examination and blood cultures negative at that
time.
He was transferred to the Intensive Care Unit for invasive
blood pressure monitoring and pressors. He was started on
Neo-Synephrine to maintain his blood pressure. At this time,
extensive family discussions were held as to Mr. [**Known lastname 34341**]
prognosis. The prognosis was felt mostly to be poor. This
was discussed with the family, most notably his two sons.
The patient was made "DO NOT RESUSCITATE", "DO NOT INTUBATE",
and while he continued to show septic physiology in the
Intensive Care Unit, his prognosis remained poor. At this
time, the patient was in intensive pain and his hypotension
did not seem to be resolving and the family decided to make
the patient comfort measures only and intensive fluid
resuscitation and pressor support was withdrawn.
The patient expired at 10:32 p.m. on [**2193-11-20**]. The patient
was noted to have no cardiac activity or voluntary
respiratory effort at that time. The patient was declared
expired at 10:32 p.m. on [**11-20**]. His attending as well as his
primary care physician was notified. In addition, his family
was [**Name (NI) 653**], most notably, his son, [**Name (NI) **] [**Name (NI) 28138**] and an
autopsy was declined at that time.
CAUSE OF DEATH:
1. Sepsis.
2. Liver failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 34342**], M.D. [**MD Number(1) 34343**]
Dictated By:[**Last Name (NamePattern1) 14434**]
MEDQUIST36
D: [**2194-2-21**] 15:18
T: [**2194-2-25**] 15:53
JOB#: [**Job Number 34344**]
|
[
"507.0",
"573.3",
"579.3",
"518.82",
"996.62",
"038.9",
"E942.2",
"263.9",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"99.15",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1045, 1085
|
2355, 8208
|
1108, 2337
|
167, 577
|
599, 972
|
989, 1028
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,841
| 186,347
|
10294
|
Discharge summary
|
report
|
Admission Date: [**2172-8-3**] Discharge Date: [**2172-8-12**]
Date of Birth: [**2107-5-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old male,
who presented to the Emergency Room with an infected right
antecubital A-V graft, which had been removed [**2172-7-7**].
Since that surgery, the area has been erythematous, swollen,
and painful. Patient has had low grade temperatures to 99.5
and the night before admission the patient noticed a clot
eroding through his skin. He was seen in hemodialysis and
referred to the Emergency Room.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to diabetic nephropathy
status post left arm A-V fistula x2.
2. Status post multiple thrombectomies.
3. Status post failed central line placement for
hemodialysis.
4. Status post A-V fistula removal.
5. Patient has had diabetes mellitus x35 years.
6. Coronary artery disease status post CABG.
7. Status post cerebrovascular accident with residual left
sided weakness.
MEDICATIONS AT HOME:
1. Actos 30 mg p.o. q.d.
2. Renagel p.o. q.d.
3. Isosorbide dinitrate 20 mg t.i.d.
4. Atenolol 25 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. 70/30, 20 and 20.
7. Lasix 80 mg p.o. q.d.
8. Calcitriol 0.25 mg p.o. q.d.
9. Levaquin 500 mg p.o. after hemodialysis.
10. Zoloft 25 mg q.d.
11. Digoxin 1.25 mg Tuesdays, Thursdays, Saturdays.
ALLERGIES:
1. Keflex.
2. Vancomycin.
SOCIAL HISTORY: The patient does not smoke or drink alcohol.
PHYSICAL EXAMINATION: Patient was afebrile and vital signs
were stable complaining of pain in the right upper extremity,
in mild distress, alert and oriented times three. Lungs were
clear to auscultation bilaterally. Heart was regular, rate,
and rhythm, no murmurs. Abdomen was soft, nontender,
nondistended, positive bowel sounds. Patient had total
femoral tunneled left femoral Permacath in the left groin.
Right upper extremity was swollen, erythematous, and there
was a positive pulsatile clot eroding through the skin.
SUMMARY OF HOSPITAL COURSE: The patient was seen in the
Emergency Department by the senior transplant resident.
Patient was then emergently taken to the OR for removal of
the infected pseudoaneurysmal A-V graft stump on the right
upper extremity. For detailed accounts of report, see
operative report. Postoperatively, the patient went to the
floor with a temporary femoral catheter for hemodialysis in
the right groin. The left catheter was removed, and tip was
sent off for culture as well as a tissue culture from the
excised right A-V graft stump.
Patient was taken back to the OR in an attempt to place a
Permacath in a central vein in the upper torso either in the
left or the right IJ or the right or left subclavian. After
numerous attempts, access was not able to be obtained.
Patient returned to the floor. Following that procedure, the
patient was taken to IR for access guided by fluoroscopy and
venography. At this time, the patient was discovered very
tortuous central veins as well as a completely occluded right
IJ. Again at this time, no line was placed. Patient was
taken back to the floor and scheduled for a MR venogram. MR
venogram showed completely occluded right IJ with numerous
collaterals and possible access via the left subclavian. The
patient was scheduled for Interventional Radiology the next
day for recanalization of occluded vessels in an attempt to
place a Permacath for hemodialysis.
The day of procedure the patient and his family were informed
of the risks involved rupture of the vessel, massive bleeding
within the chest. At that time the patient declined to have
the procedure and instead requested Interventional
Radiologist to make his right femoral hemodialysis catheter a
permanent one. His right femoral catheter was tunneled, and
the patient was returned to the floor.
During his hospital course, the patient grew out MRSA from
his tissue culture as well as from his blood cultures taken
from the original tunneled left groin catheter. Patient was
placed on linezolid 600 mg b.i.d. and ID consult was
consulted throughout this hospital course. Patient underwent
extensive workup with regards to infectious disease including
transthoracic echocardiogram as well as transesophageal
echocardiogram to rule out echocardiogram.
After the infected catheter was taken out, subsequent blood
cultures were all negative. Patient was D/C'd on an
additional two weeks of linezolid 600 mg b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Infected right arteriovenous graft stump.
2. End-stage renal disease.
3. Diabetes mellitus.
4. Methicillin-resistant Staphylococcus aureus positive blood
cultures.
DISCHARGE MEDICATIONS:
1. Isosorbide dinitrate 20 mg p.o. t.i.d.
2. Atenolol 25 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Lasix 80 mg p.o. q.d.
5. Calcitriol 0.25 mcg p.o. q.d.
6. Sertraline 25 mg p.o. q.d.
7. Protonix 40 mg p.o. q.d.
8. Digoxin 125 mcg Tuesdays, Thursdays, Saturdays.
9. Linezolid 600 mg p.o. b.i.d. x3 weeks.
10. Pioglitazone 30 mg p.o. q.d.
11. Folic acid/vitamin B complex 1 mg p.o. q.d.
FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr.
[**First Name (STitle) **] in the Transplant Center [**2172-8-27**] for discussions for
more permanent access for hemodialysis.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2172-8-15**] 23:46
T: [**2172-8-19**] 07:51
JOB#: [**Job Number 34224**]
|
[
"E879.1",
"403.91",
"414.00",
"428.0",
"790.7",
"997.2",
"996.62",
"250.40",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"00.14",
"86.09",
"39.42",
"88.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
4529, 4697
|
4720, 5108
|
1028, 1401
|
2023, 4445
|
1487, 1994
|
155, 579
|
5133, 5551
|
601, 1007
|
1418, 1464
|
4470, 4508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,300
| 115,032
|
10242
|
Discharge summary
|
report
|
Admission Date: [**2151-2-3**] Discharge Date: [**2151-2-15**]
Date of Birth: [**2095-12-25**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
nausea, vomitting, abdominal pain
Major Surgical or Invasive Procedure:
[**2151-2-8**]: ex lap, sigmoid colectomy, left salpingo-oophorectomy,
diverting loop ileostomy
[**2151-2-10**]: washout and closure
History of Present Illness:
55 year old female with no known past medical history who was
admitted for abdominal pain and N/V, found to have new large
colonic mass causing bowel obstruction, now s/p resection. The
patient had been previously well until 2 weeks ago, when she
started having constipation and was started on colace. A stool
guaiac was obtained and it was positive. She underwent an EGD
and colonoscopy on [**2151-2-2**], during which a mass in splenic
flexure was found and biopsied. She then presented the following
day on [**2151-2-3**] with sudden-onset nausea and vomiting after prep
for colonoscopy.
.
On admission, she was found to have a partial large bowel
obstruction at the sigmoid colon with the transition point at
the location of her mass. She was also found on CT scan to
incidentally have four pulmonary nodules consistent with
metastatic disease. She was made NPO, given IV fluids, and NG
tube placed for decompression. Remained obstructed and
distended, so a family meeting was held regarding her prognosis,
and they opted for surgical intervention.
Past Medical History:
Hemorrhoids 20 yrs ago
Social History:
She lives with her husband, daughter and son, she works as a
cook in a local restaurant. She denies drinking, tobacco, or
illicit drugs.
Family History:
Non-contributory, no family hx of cancer
Physical Exam:
Discharge Physical Exam:
VS: Tm 98.4, Tc 97.6, HR 79, BP 105/68, RR 18, SO2 98% RA
GEN: NAD
Cards: RRR, no RMG
Pulm: CTAB
Abd: soft, nt, nd, normal bs, incision without
erythema/tenderness
Extrem: CCE
Pertinent Results:
WBC: 3.8, hgb 14.4, hct 45.2, plt 273
Na+137, K3.3, Cl 108, Bicarb22, BUN 11, Cr 0.3, Gluc 149,
Ca+6.4, Mg1.5, Phos 2.6
PT 11.2, PTT 31.6, INR 1.0
ABG: pH 7.49 pCO2 27 pO2 371 HCO3 21 BaseXS 0, K+ 2.8
(repleted), lactate 1.5
CEA 3.0
UA: Neg Leuk, Neg Nitr, WBC 10, Bact Few, 0 Epi
.
Micro: Urine culture [**2151-2-8**] pending
.
Images:
[**2-3**] CT abd/pelvis with contrast: 1. 1-cm nodule in the left lung
base should be further evaluated with a dedicated chest CT on a
non-emergent basis. 2. Dilated fluid-filled loops of small bowel
with relative transition point at the level of the sigmoid
colon. Distended large bowel. 3. Segment of the descending colon
appears thickened and irregular which may be related to recent
colonoscopy. No free air seen. 4. Ascites.
[**2-4**] KUB: Large bowel obstruction. Severe cecal dilatation to
10.9 cm. No free air or pneumatosis.
[**2-4**] CT chest: 1. Four pulmonary nodules measuring up to 11 mm
within the lungs bilaterally are most consistent with metastatic
disease. None of these are located centrally and would probably
not be amenable to endobronchial biopsy. 12 mm right hilar lymph
node, immediately anterior to the right mainstem bronchus at the
level of the right pulmonary artery. 2. Marked distention of
proximalsmall bowel loops up to 5.3 cm in diameter, unchanged.
3. Trace bilateral pleural effusions. Mild cardiomegaly.
[**2-7**] KUB: As compared to prior examination, there is interval
slight decrease in the distention of the bowel loop still
substantially dilated, up to 5.5 cm for the small bowel and up
to 6 cm for the large bowel. Again is noted paucity of the bowel
gas in the pelvis with only minimal amount of air questionably
located in the rectum. This might correspond to fluid-filled
bowel loops as opposite to air-filled. The NG tube tip is in the
stomach. The right pleural effusion is noted, appears to be
slightly increased since [**2151-2-3**].
.
EKG: [**2151-2-8**] rate 91, sinus rhythm, nonspecific twave changes
Brief Hospital Course:
55 year old female with no known PMH who was admitted for
abdominal pain, N/V, new large colonic mass causing bowel
obstruction. She underwent open left colectomy and diverting
loop ileostomy, and subsequent washout and closure of abdomen.
She tolerated this well. Her hospital course by systems is as
such:
Neurovascular: Patient required paralytics postoperatively from
her ex.lap on [**2151-2-8**], however this was weaned. While on
mechanical ventilation she was transitioned to fentanyl and
versed. After extubation, she was still quite sedated, but this
resolved within 24 hours and was thought to be secondary to
persistent effects of sedating medication.
Respiratory: Following her colectomy and ileostomy on [**2151-2-8**],
she required mechanical ventilation. After her washout on
[**2-10**]/2 she passed her spontaneous breathing trial on [**2151-2-11**] and
was extubated. She was weaned to room air and transferred to the
floor where she was stable on room air until discharge.
Cardiovascular: Patient had minimal pressor requirement after
initial surgery on [**2-8**]. This was weaned down and the patient
started autodiuresing.
GI/Nutrition: Patient was maintained on TPN for nutrition while
unable to take POs. By 36 hours after extubation, the patient
was tolerating clears. Her diet was subsequently advanced once
she was moved to the floor. Her ostomy had excellent output
postoperatively.
Electrolytes: Repleted prn
Medications on Admission:
Calcium 500mg QD
Vit D 1 tab Q day
Colace 100mg TID
Ferrous sulfate 1 tab Q day
Discharge Medications:
1. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day).
Disp:*120 Capsule(s)* Refills:*1*
2. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
3. Vitamin D Oral
4. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a
day.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
Please take this medication if the tylenol is not controlling
your pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Colonic Adenocarcinoma
Large Bowel Obstruction
Respiratory Failure
Hypotension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the [**Hospital1 18**] Colorectal surgery service where
you underwent a procedure to remove an obstructing mass in your
large bowel. At this time we feel you are safe to go home and
continue your recovery at home.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new
medications as prescribed. In particular, be sure to take the
newly prescribed loperamide 4 times daily.
Please take the prescribed analgesic medications as needed. You
may
not drive or operate heavy machinery while taking narcotic
analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,
but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and
drink adequate amounts of fluids. Avoid strenuous physical
activity
and refrain from heavy lifting greater than 10 lbs., until you
follow-up with your surgeon, who will instruct you further
regarding
activity restrictions. Please also follow-up with your primary
care
physician so they may further direct your care.
Incision Care:
*Please call your surgeon or go to the emergency department if
you
have increased pain, swelling, redness, or drainage from the
incision
site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
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.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks as the ostomy
nurses have taught you. The output from the stoma should not be
more than 1200cc or less than 500cc. If you find that your
output has become too much or too little, please call the office
for advice. The office nurse or nurse practitioner can recommend
medications to increase or slow the ileostomy output. Keep
yourself well hydrated, if you notice your ileostomy output
increasing, take in more electrolyte drink such as gatoraide.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If you notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. You may eat a regular diet with
your new ileostomy. However it is a good idea to avoid spicy
foods.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic for this week. You will
have a visiting nurse at home for the next few weeks helping to
monitor your ostomy until you are comfortable caring for it on
your own.
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Please call tomorrow to schedule an appointment in clinic with
Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3378**] for 10 days from now. Please also
call the ostomy clinic to make an appointment with the Ostomy
Nurses: ([**Telephone/Fax (1) 34123**] for this week.
Completed by:[**2151-2-16**]
|
[
"285.1",
"197.0",
"196.2",
"789.59",
"153.3",
"518.51",
"560.9",
"557.0",
"540.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.62",
"96.71",
"45.75",
"54.25",
"65.49",
"46.01",
"45.94"
] |
icd9pcs
|
[
[
[]
]
] |
6248, 6296
|
4073, 5521
|
336, 470
|
6426, 6426
|
2050, 4050
|
10342, 10650
|
1772, 1814
|
5652, 6225
|
6317, 6405
|
5547, 5629
|
6577, 7720
|
7735, 10319
|
1829, 1829
|
263, 298
|
498, 1555
|
6441, 6553
|
1577, 1602
|
1618, 1756
|
1854, 2031
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,450
| 187,815
|
39814
|
Discharge summary
|
report
|
Admission Date: [**2149-7-30**] Discharge Date: [**2149-8-5**]
Date of Birth: [**2070-1-6**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Felodipine
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
ERCP [**2149-8-1**]
History of Present Illness:
Mr. [**Known lastname 5108**] is a 79 yo M with HTN, DM II, ?AS and history of
asymptomatic gall stones who was transfered from [**Hospital3 **]
Hospital for ERCP. Patient was in his usual state of health
until today at ~5:00 am when he woke up with lower mid chest and
epigastric pain. He got up to go to the bathroom, felt
lightheaded and had 2 episodes of emesis that was non-bloody and
no coffee grounds were seen. He went back to bed and when his
pain did not get better he called his son to take him to the
hospital. He describes his pain as [**9-21**], sharp/pressure and he
has never had this kind of pain before. He had associated
chills, diaphoresis, cough productive of white sputum but no
other symptoms.
He was initially taken to [**Hospital3 **] Hospital where he was given
40 mg IV lasix, 3 g unasyn and zofran. A CT abd/pel revealed a
stone in the common bile duct and pancreatitis. He was then
transfered to the [**Hospital1 18**] ED.
In the ED, initial vs were: T 99.3 BP 129/76, HR 87, RR 18, Sat
99% 2L. Patient was given 2L IVF, 3 g unasyn and 500 mg IV
metronidazole. He was seen by the general surgery team in the ED
who recommended surgical evaluation after ERCP.
On the floor, the patient states he is doing much better and his
pain is now down to 4/10.
Past Medical History:
- Diabetes, type II
- Hypertension
- History of gallstone
Social History:
- Tobacco: 100 pk/yr history, quit 15 yrs ago
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother - gall stones
Father - unknown
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no carotid bruits
Lungs: Crackles [**12-15**] way up bilaterally
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM that
radiates to the apex and carotids, no rubs or gallops
Abdomen: soft, mild distention, TTP RUQ and epigastric area,
bowel sounds present, no rebound tenderness or guarding,
reducible umbilical hernia
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
WBC: 18.2 -> 8.5
Cr: 1.8 -> 1.3
ALT: 233 -> 57
AST: 316 -> 18
ALK PHOS: 174 -> 122
BILI: 4.2 -> 0.8
LIPASE: 5667 -> 128
TTE [**2149-7-31**]: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.8 cm2). The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
ERCP [**2149-8-1**]:
Difficult intubation with the ERCP scope as describe above.
Successful biliary cannulation
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized. The course and caliber of the
structures are normal with no evidence of extrinsic compression
and no ductal abnormalities.
The CBD was about 7mm.
There was a suggestion of a large stone or stones impacted at
the distal CBD
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Sphincteroplasty performed with 8mm dilation balloon.
Sweep of the bilary tree revealed scant sludge. No stones were
retreived.
Due to the concern for persistent impaction of a distal CBD
stone, an 8cm by 7FR Cotton [**Doctor Last Name **] biliary stent was placed in
the main duct.
Otherwise normal ercp to third part of the duodenum
C-SPINE XR [**2149-8-5**]: PENDING
CT C-SPINE [**2149-8-5**]: PRELIM FINDINGS--Large osteophyte at around
C3-C4 protruding approximately 1.75 cm anteriorly.
Brief Hospital Course:
79 M with gallstone pancreatitis and choledocholithiasis.
Initially had lipase 5667 with elevated lactate and WBC; started
on unasyn and metronidazole with aggressive IVF hydration.
Underwent ERCP on hospital day #3 with sphincterotomy and stent
placement. No stones were retrieved. Post-ERPC did well.
Problem list:
#. [**Name2 (NI) **]sis/Gallstone pancreatitis: Follow up plan is
for repeat ERCP with stent removal and possible removal of
stone; will also follow-up with surgery for cholecystectomy.
Completed 5 days of Unasyn.
#. Hypoxia at rest to 89% on room air. Family reports that the
patient's baseline is 89-90% on room air. O2 sat was check with
patient ambulating and O2 sat improved to 95%. Etiology may be
hypoventilation at rest that improves with effort. Recommend
incentive spirometry to improve breathing function at rest.
#. Moderate to severe aspiration: Pt has had long-standing
coughing while eating (reported by the son). A bedside
swallowing evaluation revealed signs and symptoms of aspiration.
Video Swallow Study was performed that showed impaired
epiglottal movements caused by obstruction from a protruding
cervical osteophyte. Cervical spine imaging obtained and
Ortho-Spine consultation requested. Patient and family did not
want to pursue further inpatient evaluation and elected to go
home and follow up with Ortho-Spine as outpatient. They
understand that left untreated, aspiration can lead to
complications such as aspiration pneumonia. The following
recommendations from speech and swallow about diet
recommendations and oral care were passed along to them:
If pt wishes to accept the risks of aspiration and return home
on PO, safest diet is thin liquids and moist pureed or ground
solids with the following aspiration precautions:
a. Water will be the safest liquid to drink
b. Take small bites and sips
c. Swallow 4-5 times for each bite
d. Take a sip of liquid after each bite
e. Crush pills and take with applesauce/yogurt/etc.
f. End meals with a sip of liquid
g. Maintain good oral hygiene especially before eating
and drinking
h. Recommend physical activity after meals as able
#. Acute renal failure: Likely prerenal with improvement after
IVF.
#. HTN: Anti-hypertensives held initially.
#. Aortic stenosis, moderate: Echo showed aortic valve area of
1.8.
#. Diastolic heart failure, acute: Occurred in the setting of
fluid resuscitation; improved with IV furosemide
#. Diabetes, type II: The patient was started on an ISS, with
appropriate blood sugar control.
#. DVT prophylaxis: Heparin subcutaneous
#. Code status: Full code
Medications on Admission:
Aspirin 325 mg daily
Atenolol 100 mg daily
Furosemide 40 mg [**Hospital1 **]
HCTZ 12.5 mg daily
Glipizide 2.5 mg daily
Glucosamine
Multivitamin
Vitamin E 400 units daily
Discharge Medications:
1. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
4. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. Glucosamine Oral
6. Multivitamin Oral
7. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: [**Month (only) **]
RESUME ON [**8-6**].
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Gallstone pancreatitis
- Aspiration
- Cervical osteophytes
SECONDARY DIAGNOSES:
- Diabetes mellitus, type II
- Hypertension
- Chronic kidney disease
- Diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICAL ISSUES:
1. Gallstone pancreatitis: It will be essential that you
follow-up with both the ERCP doctors and with the surgeons (see
information below). Aspirin was stopped for 5 days following
the ERCP. You may restart your aspirin on [**8-6**].
2. Aspiration: You were found to have aspiration on Video
Swallowing Evaluation. This problem may be caused by your
epiglottis not closing over your airway because of obstruction
from arthritic changes of the spine. You elected to leave the
hospital to pursue outpatient evaluation with Orthopedic-Spine
Surgery Clinic rather than having this assessed in the hospital.
Please call the [**Hospital 87648**] clinic to make an appointment
for follow-up for this issue. People who have aspiration are at
risk for developing complications such as pneumonia.
Alternative nutrition through methods such as tube feeds can
reduce the risk of aspiration.
You will receive a call by the Speech Therapists to go over
recommendations for safer eating habits until this issue is
fully addressed. See below for diet recommendations.
Followup Instructions:
APPOINTMENT #1:
Name: [**Last Name (LF) 7466**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Doctor Last Name 87649**], [**Location (un) 38384**],[**Numeric Identifier 87650**]
Phone: [**Telephone/Fax (1) 86465**]
Appointment: Wednesday [**2149-8-13**] 2:00pm
APPOINTMENT #2:
Clinic: SPINE CLINIC
Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
Office Phone: ([**Telephone/Fax (1) 88**]
Office Location: [**Doctor First Name **], STE 3B; [**Location (un) **] [**Numeric Identifier 718**]
Division: NEUROSURGERY
Instructions: Please tell them that you were requested to get
repeat 'Cervical XRAY 3 Views' (these XRAYS were performed
during your hospitalization and you should have them performed
again prior to your appointment).
APPOINTMENT #3:
Please call the Acute Care Surgery clinic at [**Telephone/Fax (1) 600**] to
schedule an appointment within 2 weeks. This is to consider
elective surgery to have your gallbladder removed.
APPOINTMENT #4:
The ERCP center will contact you regarding repeat ERCP for
biliary duct stent removal and removal of any residual stone in
the bile duct.
|
[
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"424.1",
"427.31",
"250.00",
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"574.91",
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"428.31",
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"276.3",
"721.8",
"584.9",
"585.9",
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icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
7881, 7887
|
4483, 4789
|
298, 319
|
8127, 8127
|
2443, 4460
|
9411, 10602
|
1827, 1866
|
7351, 7858
|
7908, 7989
|
7157, 7328
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8309, 9388
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1881, 2424
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8010, 8106
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243, 260
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347, 1630
|
4803, 7131
|
8142, 8285
|
1652, 1711
|
1727, 1811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,655
| 100,119
|
47452
|
Discharge summary
|
report
|
Admission Date: [**2117-7-22**] Discharge Date: [**2117-7-31**]
Date of Birth: [**2036-6-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
EGD
Central venous line access
History of Present Illness:
This is a 81 year old female who presented to an outside
hospital 3 weeks prior to admission with nausea, vomiting,
diarrhea, and abdominal pain. She was diagnosed with cirrhosis
of unknown etiology; she was negative for hepatitis,
hemachromatosis, and history of alcoholism. Her symptoms
improved and she was discharged. She presented to [**Hospital1 18**] with
similar symptoms. CT scan of the abdomen demonstrated complete
thrombosis of the SMV with partial thrombosis of the main PV and
intrahepatic left and right portal veins and multiple abnormal
loops of small bowel in the pelvis with wall thickening.
Patient was started on heparin drip. Foley & NGT were placed.
She received vancomycin & Zosyn in the ED, which was switched to
Cipro and Flagyl on admission to the ICU.
Past Medical History:
hypertension
cirrhosis
osteoarthritis
dyslipidemia
h/o ureteral stone
seborrheic keratosis
thrombocytopenia
appendectomy
herpes zoster
GERD
osteopenia
depression
hip replacement
cellulitis
Social History:
She denies EtOH, tobacco, and illicit drug use. She denies
herbal and over-the-counter medications.
Family History:
aunt with ovarian ca
daughter with breast ca in 50s
no family history of liver disease
Physical Exam:
per Dr. [**Last Name (STitle) **] on initial presentation:
98.1 65 145/61 20 98% 4L
gen: minimally response
CV RRR
pulm: CTAB
abd: soft, nondistended, mildley tender on right
rectal: heme pos
Pertinent Results:
Admission labs:
137 105 15
-------------< 117
3.7 21 0.7
Ca: 9.4 Mg: 1.7 P: 2.6
ALT: 25 AP: 271 Tbili: 2.0 Alb: 3.2
AST: 32 LDH: Dbili: TProt:
[**Doctor First Name **]: 52 Lip: 54
.
12.9
9.9 >-----< 165 D
41
N:85.3 Band:0 L:9.7 M:3.7 E:0.9 Bas:0.4
.
Trends and discharge labs:
[**2117-7-31**] 06:45AM BLOOD WBC-5.7 RBC-3.16* Hgb-10.1* Hct-30.7*
MCV-97 MCH-32.0 MCHC-32.9 RDW-16.2* Plt Ct-PND
[**2117-7-26**] 05:06AM BLOOD PT-19.5* PTT-67.8* INR(PT)-1.9*
[**2117-7-27**] 06:00AM BLOOD PT-21.1* PTT-62.3* INR(PT)-2.0*
[**2117-7-28**] 05:21AM BLOOD PT-21.5* PTT-93.3* INR(PT)-2.1*
[**2117-7-29**] 05:03AM BLOOD PT-20.7* PTT-33.5 INR(PT)-2.0*
[**2117-7-30**] 06:15AM BLOOD PT-20.6* PTT-33.0 INR(PT)-2.0*
[**2117-7-31**] 06:45AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-134
K-3.4 Cl-98 HCO3-33* AnGap-6*
[**2117-7-22**] 06:05AM BLOOD ALT-25 AST-32 AlkPhos-271* Amylase-52
TotBili-2.0*
[**2117-7-23**] 02:15AM BLOOD ALT-17 AST-26 LD(LDH)-231 AlkPhos-193*
Amylase-36 TotBili-0.8
[**2117-7-24**] 01:57AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-171*
Amylase-28 TotBili-0.6
[**2117-7-25**] 05:30AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-164*
Amylase-27 TotBili-0.7
[**2117-7-26**] 05:06AM BLOOD ALT-15 AST-25 AlkPhos-159* Amylase-46
TotBili-0.8
[**2117-7-27**] 06:00AM BLOOD ALT-13 AST-26 LD(LDH)-213 AlkPhos-151*
Amylase-45 TotBili-0.8
[**2117-7-28**] 05:21AM BLOOD ALT-16 AST-31 AlkPhos-156* TotBili-1.0
[**2117-7-29**] 05:03AM BLOOD ALT-15 AST-34 AlkPhos-179* TotBili-0.8
[**2117-7-27**] 06:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.8 Mg-2.1
[**2117-7-24**] 06:21AM BLOOD Lactate-1.4
.
CT Abd/Pelvis ([**2117-7-22**])
IMPRESSION:
1. Complete thrombosis of the superior mesenteric vein with
partial thrombosis of the main portal vein and intrahepatic left
and right portal veins.
2. Multiple abnormal loops of small bowel within the pelvis with
wall thickening. This likely represents venous congestion from
thrombosis of the mesenteric veins. An enterocolitis
(inflammatory/infectious) with secondary thrombosis of the
mesenteric veins is also a possibility. The mesenteric arteries
are patent; however, mesenteric ischemia from venous congestion
cannot be excluded.
3. Shrunken, nodular liver, esophageal varices and ascites, all
compatible with cirrhosis.
.
CT Abd/Pelvis ([**2117-7-27**])
IMPRESSION:
1. Stable thrombosis of the portal vasculature including partial
thrombosis of the main portal vein, complete thrombosis of the
left portal vein, partial thrombosis of the right portal vein,
complete thrombosis of the superior mesenteric vein.
2. Improving multiple small bowel loops with decreased wall
thickening and dilatation.
3. Stable cirrhotic liver.
4. Markedly increased ascites.
.
EGD:
Impression: Grade 1 varices at the lower third of the esophagus
Portal Hypertensive Gastropathy - oozing with blood and causing
melena.
Otherwise normal EGD to second part of the duodenum
Recommendations: Requires:
1) Protonix- 40mg [**Hospital1 **]
2) Carafate - 1gram qid
.
Micro:
c diff neg
stool cx neg
blood cx ngtd
Brief Hospital Course:
81yo woman with cirrhosis here with SMV thrombosis. Hospital
course by problem:
.
#Complete SMV and partial portal vein thrombosis.
SMV and portal vein thromboses demonstrated on CT of [**7-22**] which
was repeated on [**7-27**] showing little change. Hepatobiliary
Surgery was consulted urgently in the ED for management of SMV
thrombosis with ischemic bowel. Serial abdominal exams were
benign. Lactate peaked at 1.5 on [**7-22**]. She had episodes of
melena on [**7-17**], but remained otherwise asymptomatic. She was
in the ICU for close monitoring then transferred to the floor on
[**7-25**]. NGT was removed and Coumadin was started. On [**7-26**], her
diet was advanced and she was transferred to Hepatology for
further management of newly diagnosed cirrhosis. We continued
heparin and coumadin until INR was 2.0 for two consecutive days.
She received coumadin as follows: 1mg, 1mg, 1mg, 2mg, 2mg, 2mg
and discharged on 2mg daily. Her HCT remained stable. She will
followup with Dr. [**Last Name (STitle) **] in the liver clinic. [**Last Name (STitle) 18303**] INR is [**2-20**].
.
#GI Bleeding
Patient had guaiac positive stools and underwent an EGD to
assess for varices which showed no active bleeding but had
portal gastropathy which was thought to explain the patient's
melena. Melena may also have come from venous congestion in
small bowel as a result of SMV thrombosis. Repeat CT scan
showed resolving venous congestion. HCT dropped 5.5 points from
41 to 34.5 from HD0 to HD1 and then to 30 by HD4, it remained
stable after this, without further melena. Ms. [**Known lastname 73649**] had
spotting of red blood on pads and toilet paper which was thought
to be causing persistant guaiac positive stools. Exam confirmed
presence of hemorrhoids but also raised the possibility of
vaginal bleeding, which should be investigated as an outpatient.
Colonoscopy was deferred given likely friable colon in setting
of thrombosis. If BRBPR, we recommend checking hematocrit with
[**Known lastname **] >28. If less than 28, discuss with patient's PCP re
stopping coumadin and need for eval. In terms of the possible
vaginal bleeding, we recommend outpt gynecology appt. We
continued nadolol and PPI and sucralfate.
.
#Cirrhosis/Edema/abdominal pain
Etiology of cirrhosis remains uncertain. Report of
investigations at OSH ruled out common viral and autoimmune
etiologies, and genetic causes would be unlikely to present at
81years of age. NASH remains a possibility, but this should be
investigated further with outpatient hepatology follow up which
has been arranged for Ms. [**Known lastname 73649**].
She has experienced significant fluid retention with ascites and
lower extremity edema, her weight increasing approximately 4kgs.
With Lasix and Aldactone, lower extremity edema has improved
significantly but ascites is persistant.
Ascites has caused intermittent band like upper abdominal pain
which was mostly controlled with oxycodone but occassionally
required 0.5mg dilaudid IV. By time of discharge, pain was
controlled with oral medications alone.
.
# HTN: we regulated with her nadolol, spirono, and lasix. We
did not continue HCTZ
.
# Depression: sertraline
.
# Activity: seen by PT. able to ambulate with assist.
.
# Code: Full
.
# Contact: daughter [**Name (NI) **]: [**Telephone/Fax (1) 100371**]
Medications on Admission:
lorazepam, Darvocet, Fosamax, HCTZ, MVI, Propoxyphene,
ranitidine, sertraline, Zocor
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO every six
(6) hours as needed for pain.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
please adjust per recommendations from your PCP. [**Name10 (NameIs) 18303**] INR [**2-20**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Primary:
- SMV thrombosis
- Cirrhosis
- Portal gastropathy
Secondary:
- GERD
- arthritis
- HTN
- Hyperchol
- thrombocytopenia
Discharge Condition:
well. Able to ambulate with assist
Discharge Instructions:
You were admitted with abdominal pain and noted to have an SMV
thrombosis. This is a clot in the vein near your liver. You
also have cirrhosis and some fluid overload. We treated you in
the ICU and you stabilized. We continued heparin and started
coumadin to keep your blood thin. We also performed an EGD to
look for any bleeding in your stomach. You remained stable.
.
Please take all of your medications as instructed. Please keep
your followup appts. It is very important for you to have your
coumadin level checked on Monday and followed closely by your
PCP.
.
Please contact your PCP or [**Name (NI) **] if you experience worsening
shortness of breath, chest pain, abdominal pain, fevers, or
blood loss.
.
You described some possible vaginal bleeding. You should
discuss this with your PCP and possibly see a gynecologist.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) **] on Thursday [**8-5**] at
11:30am. His office is [**Telephone/Fax (1) **]
.
Please followup with Dr. [**Last Name (STitle) **] on [**8-24**] @ 12:15pm. You
may reach him at ([**Telephone/Fax (1) 1582**].
|
[
"401.9",
"535.51",
"789.5",
"557.0",
"571.5",
"452",
"623.8",
"311",
"456.21",
"455.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9434, 9520
|
4879, 8226
|
312, 345
|
9690, 9728
|
1820, 1820
|
10614, 10873
|
1505, 1593
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8361, 9411
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9541, 9669
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8252, 8338
|
9752, 10591
|
2116, 4856
|
1608, 1801
|
240, 274
|
373, 1159
|
1836, 2100
|
1181, 1371
|
1387, 1489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,728
| 101,009
|
20263
|
Discharge summary
|
report
|
Admission Date: [**2190-2-3**] Discharge Date: [**2190-2-10**]
Date of Birth: [**2140-10-11**] Sex: M
Service: Medical Intensive Care Unit, [**Location (un) **] Team
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 49 year old male
initially admitted to the Medicine Service on [**2-3**] with
shortness of breath and spontaneous pneumothorax after
several cycles of Bleomycin for testicular seminoma who was
transferred to the Medical Intensive Care Unit on [**2190-2-5**] for hypoxia.
Briefly, the patient was initially diagnosed with seminoma in
[**2189-7-20**], status post orchiectomy for testicular mass.
Patchular vascular invasion with preoperative Beta HCG 9 that
remained elevated postoperatively. Computerized tomography
scan showed metastatic evidence to chest, neck and abdomen
with both the retroperitoneal and subclavicular
lymphadenopathy. The patient was treated with Bleomycin 180
units, Etoposide and Cisplatin in [**2189-10-19**] to [**2189-12-20**]. This was complicated by pneumonia on [**11-22**] and no
normalization of LDH, acid fast bacillus and Beta GG was
admitted to [**Location (un) **] outside hospital on [**1-10**] to
[**1-15**] with shortness of breath. Chest computerized
tomography scan showed no pulmonary embolism but did show
bronchiectasis and interstitial fibrosis. Pulmonary function
tests showed decrease in his DLCO per the chart. It was
thought that he had drug toxicity. Amiodarone was stopped
and Prednisone 60 mg p.o. q. day was started. The patient
was readmitted to the outside hospital on [**1-27**] through
[**1-29**] with spontaneous pneumothorax and managed
expectantly. He was seen on [**2-1**], felt okay and could
walk [**11-22**] mile. On [**2-2**], after increasing shortness of
breath after coughing he went to the outside hospital. He
had shaking chills, nasal congestion, increased clear sputum
and central chest congestion with occasional wheezing. He
had a son at home with similar symptoms. No orthopnea,
paroxysmal nocturnal dyspnea, or edema. The patient had a
74% room air saturation and increased subcutaneous emphysema.
So, a left chest tube was placed with hemi valve.
The patient was transferred to [**Hospital6 2018**] on [**2-3**] where he had a respiratory rate of 27,
saturations 83% on 3 liters to 91%, on 6 liters with an
arterial blood gases of 754, 32 and 68, and was admitted to
the Medicine Service. The patient was started initially on
intravenous Bactrim empirically for primary care physician
given he was on Prednisone 60 as an outpatient and Prednisone
was increased to 80 mg p.o. q. day. Cultures including viral
cultures were sent that were negative to date. Chest
computerized tomography scan showed pulmonary fibrosis and
moderate left pneumothorax with pneumomediastinum emphysema,
soft tissue enlarged pulmonary artery. Cardiothoracic
Surgery was consulted and recommended an existing chest tube
placement of 20 cm of water suction. Echocardiogram was
performed and broad-spectrum antibiotics with Bactrim,
Azithromycin and Ceftriaxone were started empirically. The
patient was with deteriorating oxygen saturation, so the
patient was transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Cardiomyopathy in [**2182**], viral, also per chart from
outside hospital in [**2189-10-19**] had an ejection fraction
of 55%. No mitral regurgitation, trace tricuspid
regurgitation. PA pressure is 25 to 30.
2. Testicular cancer in [**2189-7-20**], radical
orchiectomy, pure seminoma with vascular invasion.
3. Atrial fibrillation treated on Amiodarone discontinued
[**2189-12-20**], secondary to question of pulmonary fibrosis.
4. Depression.
5. History of mild renal insufficiency, baseline creatinine
of 2.5.
ALLERGIES: Codeine.
MEDICATIONS AT HOME: Atenolol 25 mg p.o. q. day, Lipitor 20
mg p.o. q. day, Humibid LA one tablet p.o. q.h.s., Lasix 40
mg p.o. q. day, Magnesium oxide 400 mg p.o. t.i.d., Calcium
carbonate 500 mg p.o. t.i.d., Guaifenesin and Codeine 5 to 10
cc p.o. prn cough, Protonix 40 mg p.o. q. day, Haldol 2 mg
t.i.d. prn agitation, Bactrim 450 mg intravenously q. 8,
Prednisone 80 mg p.o. q. day, Tessalon pearls 100 mg p.o.
t.i.d., Morphine 5 to 10 mg q. 6 hours prn sublingual,
subcutaneous heparin 5000 mg p.o. q. 8 hours, Ceftriaxone 1
gm q. 24, Azithromycin 500 mg intravenously q. 24.
SOCIAL HISTORY: Married with three children, works in
roadside construction. Denies tobacco history.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: Temperature 97.4, blood pressure
120/80, heart rate 75, respiratory rate 27, sating 80% on 6
liters. In general, this gentleman is in moderate
respiratory distress, was able to speak. Head, eyes, ears,
nose and throat, mucous membranes moist. Neck, no
lymphadenopathy. Cardiovascular, regular rate and rhythm, no
murmurs, rubs or gallops. Lungs, positive rales and wheezes,
right greater than left. Abdomen, positive bowel sounds,
soft, nontender, nondistended, no masses. Extremities, warm
bilaterally.
LABORATORY DATA: Pertinent laboratory data revealed white
blood cell count 20.9, hematocrit 41.3, platelets 192, white
cell count differential is 97% polys, 2% lymphs, 2% monos.
INR 1.1, PTT 19.6, creatinine 1.5, potassium 4.3, LDH 362.
Nasal swab viral cultures, pending.
Chest x-ray [**2-5**], increasing left apical pneumothorax
with 20% volume loss, left lower lobe atelectasis, left
pigtail catheter in place, bilateral diffuse interstitial
opacities, blunting of the right costophrenic angle.
Chest computerized tomography scan [**2-4**], small left
pneumothorax, pneumomediastinum and subcutaneous emphysema
and intramuscular emphysema, extensive pulmonary fibrosis,
left greater than right, right predominantly lower lobe.
Pulmonary artery prominence with no consolidations.
[**2190-2-5**], echocardiogram, ejection fraction greater
than 55%, no patent foramen ovale, by Bubble study, mild
right atrial enlargement.
Electrocardiogram, sinus rhythm with a rate of 112, axis -36,
T wave inversions in 3 and 6, biphasic Ts and AVF.
HOSPITAL COURSE: 1. Hypoxia - The patient presented with
diffuse infiltrates concerning for pulmonary fibrosis and
Bleomycin lung toxicity. The patient had been on Amiodarone
which has also contributed and the patient also had a
spontaneous pneumothorax on chest x-ray which was managed
with chest tube placement as per Cardiothoracic Surgery. The
patient was maintained on antibiotic treatments for his
pneumonia, given his sick contacts, also atypical
presentation, given his previous immunosuppression and
therefore the patient was continued on Prednisone. So, the
patient was titrated oxygen. Subsequently, however, the
patient had worsening hypoxia and on [**2-6**], after
extensive discussion with the patient and his wife, the
patient was subsequently intubated given his worsening
respiratory status. The patient continued to be intubated
with worsening hypoxemia throughout the hospital course and
on [**2-10**], an extensive discussion was made with the family
and given the patient's inability to wean off of his FIO2 and
with worsening hypoxia it was agreed upon that the patient
should have comfort care as an ultimate goal for his
hospitalization, and on [**2-10**], the patient was
subsequently placed on Comfort-Measures-Only. The patient's
family was informed.
Subsequently the patient also had some hypotension which was
covered with pressors and on [**2190-2-10**], at 10:26 PM, the
patient had worsening hypoxia and after withdrawal of care,
the patient was found to be unresponsive to deep sternal rub,
no heartsounds were palpable. The patient was warm. The
pupils were fixed and dilated, and subsequently the patient
was declared dead on [**2190-2-10**] at 10:26 PM. Autopsy was
declined per family.
2. History of atrial fibrillation - The patient was
maintained on Amiodarone and Atenolol for rate control.
3. Cardiomyopathy - The patient was maintained on Lasix.
4. Seminoma - The patient was status post three cycles of
Bleomycin, Etoposide and Cisplatin. There were no acute
issues to be followed up with Oncology.
5. Renal - The patient's creatinine continued to rise,
likely due to hypotension. The patient's medications were
renally dosed.
[**Known firstname **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2190-2-24**] 12:16
T: [**2190-2-24**] 12:58
JOB#: [**Job Number 54403**]
|
[
"E933.1",
"425.4",
"512.8",
"518.1",
"515",
"486",
"198.89",
"584.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.71",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4513, 4532
|
6128, 8550
|
3830, 4392
|
4555, 6110
|
205, 227
|
256, 3241
|
3263, 3808
|
4409, 4496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,084
| 105,609
|
23442
|
Discharge summary
|
report
|
Admission Date: [**2156-12-4**] Discharge Date: [**2156-12-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R Sided weakness, confusion, and aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo RH woman who was in her usual state of health until
last night at 8pm when she began complaining of right hand
difficulty - poor grip, currently taking aleve for "arthritis".
She was at a restaurant with her family and kept repeating, "I
don't know what's going on." Repeated actions - kept eating
bread, held butter and said, "Where's the butter?" Then
suddenly
the right side of her body was weak. EMS arrived and took her to
OSH where she was found to have a left sided occipito-parietal
bleed (films not available at this time). Transferred to [**Hospital1 18**]
for neurosurgical backup. Was admitted to Neurosurgical ICU
overnight, given dexamethasone, did well and is now being called
out to the floor, neurology service.
Per daughter ([**Name (NI) 60095**]) and son [**First Name8 (NamePattern2) **] [**Name (NI) **]), there was no
preceeding headache, no history of hypertension, no tobacco
smoking. [**Name (NI) **] father died of an MI at age 54 but all other
family members have longevity. At baseline she is fully
functional, lives alone, no dementia or weakness.
Past Medical History:
tachycardia - on digoxin, atenolol, followed by Dr. [**First Name (STitle) **] [**Name (STitle) 60096**]
cardiology [**Telephone/Fax (1) 58549**]
s/p hysterectomy for "bladder pressure", not cancer
h/o skin cancer (not melanoma per daughter)
h/o "worrisome personality"
Social History:
no tob/etoh/drugs, husband deceased in [**2143**] of prostate CA,
3 kids all live in MA, very involved. Son [**Name (NI) **] [**Name (NI) **] (dentist)
Home [**Telephone/Fax (1) 60097**], cell [**Telephone/Fax (1) 60098**], beeper [**Telephone/Fax (1) 60099**],
office [**Telephone/Fax (1) 60100**]
Family History:
dad died of MI at age 54, mom lived to be [**Age over 90 **] yo, brother
in his 90's, sisters in their 80's. All 3 kids healthy.
Physical Exam:
Vitals: 98.7, HR 58-70 NSR, BP 128-148/50-60's, 19, 97% RA
I/O: [**Telephone/Fax (1) 60101**], LOS 695cc neg, FS 166-175
GEN: NAD, pleasant
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no masses
CHEST: CTA bilat
CV: RRR without mur
ABD: soft, NT/ND, +BS, no HSM
EXTREM: no edema
NEURO:
Mental status:
Patient is alert, awake, pleasant affect.
Oriented to person only, does not know place, time (year/season)
nor president.
Poor attention - names DOWF, but not backwards.
Language is fluent with intermittant comprehension, repitition
OK, no dysarthria. Names some items "My fingers", "My knuckles"
but does not name watch. + perseveration.
+ apraxia - unable to show me how she brushes teeth, ? neglect.
Unable to calculate, + left/right mismatch. Unable to test
memory.
Cranial Nerves:
I: deferred
II: Visual acuity: not tested. Visual fields: cannot test
reliably. Pupils:3->2 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or
ptosis.
V: jaw strength OK
VII: right lower face droop
VIII: hearing intact to finger rubs
IX, X: gag reflex present bilaterally. Symmetric elevation of
palate.
[**Doctor First Name 81**]: trapezius [**5-5**] on left only
XII: tongue midline without atrophy or fasciulations.
Sensory: Withdrawls in all extremities to painful stimuli,
unable to recognize objects placed in her hands bilaterally,
exam limited by inattention.
Motor:
Normal bulk, tone. No fasciculations. + right drift. No
adventitious movements.
Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP* QD Ham DF PF Toe
RT: 4 3 5 4+ 5 4+ 5 0 0 0 0 0 wigglex1
* poor cooperation for formal strength testing for right leg.
Did better with right arm.
Reflexes: No grasp, glabellar, snout, palmomental or [**Doctor Last Name **].
No
Jaw jerk.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 3 2 up
LEFT: 2 2 2 2 2 mute
Coordination: unable to test
Gait:unable to test at this time.
Pertinent Results:
[**2156-12-4**] 10:00PM BLOOD WBC-10.09 RBC-4.20 Hgb-13.5 Hct-38.3
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.2 Plt Ct-135*
[**2156-12-4**] 10:00PM BLOOD Neuts-81* Bands-3 Lymphs-10* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-12-4**] 10:00PM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1
[**2156-12-4**] 10:00PM BLOOD Glucose-151* UreaN-12 Creat-0.8 Na-131*
K-5.9* Cl-95* HCO3-27 AnGap-15
[**2156-12-5**] 03:14AM BLOOD Glucose-166* UreaN-11 Creat-0.7 Na-135
K-3.8 Cl-97 HCO3-24 AnGap-18
[**2156-12-6**] 05:33AM BLOOD Phenyto-16.0
MR HEAD W/O CONTRAST [**2156-12-5**] 1:22 AM
IMPRESSION: Recent left occipital lobe hemorrhage. No other
sites of hemorrhage identified. No hydrocephalus or shift of
midline structures.
MR CONTRAST GADOLIN [**2156-12-5**] 8:10 AM
IMPRESSION
1. No discrete focus of enhancement is identified within the
brain, though
there is probably some enhancement of the brain along the
margins of the
left parietal-occipital hemorrhage
MRA BRAIN W/O CONTRAST [**2156-12-6**]
IMPRESSION
1. Negative MRA of the circle of [**Location (un) 431**]
Brief Hospital Course:
Pt admitted on [**12-4**] from OSH with L parieto-occipital
hemorrhage. Pt initially seen and admitted by the neursurgical
service into the NSICU. Pt started on mannitol, dilantin, with
strict SBP control < 140. An MRI W and W/O contrast performed
without evidence of a mass lesion. Pt then transferred to the
Neurology service for further management on [**12-5**]. Pt was stable
overnight from admission and was therefore transferred to the
floor. Pt began to show improvement with increased strength and
decreased confusion and aphasia. An MRA was performed which was
without evidence of an AVM. Speech and swallow eval performed on
[**12-6**], Pt able to tolerate full PO intake. PT/OT consulted, and
rehabilition recommended. Pt continued improving neurologically,
PO intake well tolerated, and there were no acute events during
the hospital course. Pt discharged to rehab on [**12-8**] in stable
condition.
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 5 days.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left occipito-parietal hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Please return for all follow-up appointments
[**Last Name (un) **] all medications as directed
Return to the ER for any increased weakness, confusion, blurry
vision, numbness, nausea/vomitting, headaches, chest pain,
shortness of breath or general malaise
Followup Instructions:
Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2156-12-8**]
|
[
"342.90",
"277.3",
"784.3",
"785.0",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6658, 6728
|
5297, 6210
|
304, 311
|
6806, 6814
|
4214, 5274
|
7118, 7341
|
2056, 2187
|
6233, 6635
|
6749, 6785
|
6838, 7095
|
2202, 2497
|
224, 266
|
339, 1429
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3001, 4195
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2512, 2985
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1451, 1722
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1738, 2040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,999
| 149,804
|
41082
|
Discharge summary
|
report
|
Admission Date: [**2194-6-16**] Discharge Date: [**2194-6-27**]
Date of Birth: [**2116-11-28**] Sex: M
Service: MEDICINE
Allergies:
Ancef / Bactrim / latex / doxycycline
Attending:[**Last Name (NamePattern1) 13159**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- TEE
- Direct laryngoscopy and right neck exploration with closure of
cervical esophageal laceration and placement of drain.- PICC
line placement
- Arterial Line
- Operative G-J tube placement
- Intubation and Mechanical Ventilation
History of Present Illness:
77M with h/o CAD, PVD, a fib, on coumadin, recent dx of
Aflutter, c/o left sided chest pain for one week, generalized
weakness, SOB on exertion, increased LE edema. Pt describes
sharp, localized pain on L side of chest near axilla, somewhat
reproduceable, began at around the same time that he fell out of
bed and had to call for nurse to come and get him up. Also has
been SOB on exertion, but pain and dyspnea are independent --
either can occur without the other. SOB has also developed over
past two weeks, always w/ exertion, sometimes only minor
exertion. VNA found him w/ irregular heart rate on morning of
admission, sent him to ED. Got full ASA en route, pain improved
but still present.
Past Medical History:
Dyslipidemia
Hypertension
Nondisplaced fracture of greater trochanter of left femur
Status post skin graft
Compression fracture of L4 lumbar vertebra
Esophagitis
Depression
Peripheral Edema
Orthostatic Hypotension
Obesity
COLONIC ADENOMA
ANEMIA, UNSPEC
ATRIAL FLUTTER
ESOPHAGEAL ATRESIA/STENOSIS/TE FISTULA - CONGEN
ATRIAL FIBRILLATION
OSTEOARTHRITIS - KNEE, left
PSORIASIS
CELLULITIS (SPECIFY SITE)
PROSTATIC HYPERTROPHY - BENIGN
STASIS ULCER
THROMBOPHLEBITIS/PHLEBITIS OF DEEP VEINS
PERIPHERAL VASCULAR DISEASE
h/o ALCOHOL DEPENDENCE
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
Social History:
Pt lives alone, has VNA and home health aid to help with wound
care, ADLs. Former professional puppeteer, widowed in [**2178**].
-Tobacco history: 60 pack-year history, nonsmoker since late
[**2151**].
-ETOH: Former heavy drinker, currently sober
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS- T=97.7 BP=127/97 HR=109 RR=16 O2 sat=99%RA
GENERAL- Obese elderly man 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, no carotid bruits, JVP could not be appreciated w/
pt at 30-degree angle.
CARDIAC- faint heart sounds, tachycardic, regular. No m/r/g
appreciated. No thrills, lifts.
LUNGS- Barrel chest, no chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese NTND. No abdominial bruits.
MS- tender to palpation over L chest near axilla, no tenderness
on right.
EXTREMITIES- No c/c/e.
SKIN- Trigonal area is erythematous, well-demarcated under
pannus, malodorous. Extensive ulceration over [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**],
some w/ crusting, some open and bleeding on exposure. No
purulence, no tenderness or swelling. No heel ulcers. Toes
appear pink, well perfused.
PULSES-
Right: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
Left: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
.
MICU Transfer Exam:
General: Extubated. AOx3
HEENT: PERRL, anicteric sclera, ETT in place, bilateral neck and
upper chest subQ emphysema with crepitus ?????? similar to yesterday.
Right neck dressing c/d/i. JP drain in place.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA on anterior exam, no crackles or wheezing.
Ab: obese, NT/ND, no HSM. Normoactive BS, PEG in place
Ext: Bilateral erythematous plaques over groin, bandaged LE.
Neuro: No focal motor deficits noted.
.
Discharge exam:
VS: Tc 98.5, Tm 98.9, HR 107(97-112), BP 103/66(103-113/58-72),
RR 20, SO2 96%@2L, INS/OUT (600+300+400)/(1550+950) = -1200
GEN: pleasant, NAD, well-developed, well-nourished
HEENT: PERRLA, MMM, poor dentition, tongue has white/brown
material on dorsum, EOMI but with R eye convergence
insufficiency, sclera anicteric, no conjunctival injection
NECK: healing surgical scar with crusted blood at incision site,
no spreading erythema or purulence; no crepitance
PULM: mild crackles [**11-26**] way up on L only
CV: tachycardia, regular rhythm, normal S1/S2, no m/r/g
EXT: b/l leg atrophy (L>R), b/l leg bandages with underlying
ulcerations extending to proximal legs; no edema; dorsalis
pedis, posterior tibial, and radial pulses palpable b/l; PICC
line in L arm with no associated pain or site bleeding/bruising
ABD: G-J tube in place, surgical wound site tenderness but no
spreading erythema or purulence; mild discomfort to deep
palpation in lower abdomen, soft, protuberant, no r/g
MSK: strength 5+ grossly throughout
NEURO/PSYCH: CN II-XII grossly intact; mood: ??????all right??????,
affect: appropriate
Pertinent Results:
ADMISSION LABS:
[**2194-6-16**] 12:30PM BLOOD WBC-4.9 RBC-3.93* Hgb-11.6* Hct-35.8*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.8* Plt Ct-258
[**2194-6-16**] 12:30PM BLOOD Neuts-62.8 Lymphs-24.7 Monos-6.0 Eos-5.1*
Baso-1.4
[**2194-6-16**] 12:30PM BLOOD PT-43.2* PTT-53.2* INR(PT)-4.3*
[**2194-6-16**] 12:30PM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-141
K-4.3 Cl-106 HCO3-29 AnGap-10
[**2194-6-16**] 08:55PM BLOOD CK(CPK)-41*
[**2194-6-17**] 06:05AM BLOOD WBC-4.8 RBC-3.84* Hgb-11.4* Hct-35.4*
MCV-92 MCH-29.8 MCHC-32.3 RDW-15.8* Plt Ct-251
[**2194-6-17**] 11:31PM BLOOD WBC-5.6 RBC-3.72* Hgb-11.0* Hct-34.0*
MCV-91 MCH-29.7 MCHC-32.5 RDW-15.6* Plt Ct-260
[**2194-6-18**] 05:05AM BLOOD WBC-5.1 RBC-3.88* Hgb-11.3* Hct-35.6*
MCV-92 MCH-29.1 MCHC-31.8 RDW-15.8* Plt Ct-260
[**2194-6-18**] 02:52PM BLOOD WBC-8.3# RBC-4.13* Hgb-12.3* Hct-37.8*
MCV-92 MCH-29.7 MCHC-32.5 RDW-15.7* Plt Ct-246
[**2194-6-19**] 03:31AM BLOOD WBC-9.5 RBC-3.48* Hgb-10.2* Hct-31.3*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.6* Plt Ct-203
[**2194-6-19**] 07:47AM BLOOD Hct-30.7*
[**2194-6-19**] 02:43PM BLOOD Hct-31.8*
[**2194-6-20**] 02:45AM BLOOD WBC-9.6 RBC-3.20* Hgb-9.4* Hct-29.2*
MCV-91 MCH-29.4 MCHC-32.2 RDW-15.8* Plt Ct-192
[**2194-6-16**] 12:30PM BLOOD PT-43.2* PTT-53.2* INR(PT)-4.3*
[**2194-6-18**] 05:05AM BLOOD PT-34.1* PTT-47.6* INR(PT)-3.3*
[**2194-6-20**] 02:45AM BLOOD PT-33.6* PTT-42.2* INR(PT)-3.3*
[**2194-6-20**] 10:40AM BLOOD PT-22.9* INR(PT)-2.2*
[**2194-6-18**] 07:11PM BLOOD Type-ART pO2-129* pCO2-50* pH-7.34*
calTCO2-28 Base XS-0
[**2194-6-19**] 02:52AM BLOOD Type-ART Temp-36.7 Rates-18/1 Tidal V-500
FiO2-60 pO2-182* pCO2-43 pH-7.42 calTCO2-29 Base XS-3
-ASSIST/CON Intubat-INTUBATED
[**2194-6-19**] 08:07AM BLOOD Type-ART Temp-36.5 pO2-124* pCO2-42
pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2194-6-19**] 02:49PM BLOOD Type-ART Temp-36.6 pO2-111* pCO2-46*
pH-7.33* calTCO2-25 Base XS--1 Intubat-INTUBATED
.
EKG [**2194-6-16**]:
Underlying rhythm is likely atrial flutter with rapid
ventricular response.
Left anterior fascicular block. Compared to the previous tracing
of [**2192-12-28**]
atrial flutter is new and Q-T interval is now shorter.
.
TEE [**2194-6-18**]:
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the
procedure. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was under general
anesthesia throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The posterior pharynx was
anesthetized with 2% viscous lidocaine. No glycopyrrolate was
administered. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. Image quality was
suboptimald - poor esophageal contact.
Conclusions: [**Name2 (NI) **] thrombus/mass is seen in the body of the left
atrium. No mass or thrombus is seen in the right atrium or right
atrial appendage. Unable to visualize the LAA due to poor image
quality.
.
CT Chest [**2194-6-18**]:
IMPRESSION:
1. Extensive subcutaneous air in the soft tissues of the neck
and anterior
posterior chest wall extending into the mediastinum to the level
of the
carina. Suspected site of possible esophageal perforation is
most likely in the upper to mid esophagus given the distribution
of air, although the
definitive site cannot be delineated on this study. No large
hematoma.
2. Atelectasis at the lung bases.
3. Hypodense lesions within the liver which are most likely
cysts.
.
CXR [**2194-6-19**]:
FINDINGS: In comparison with the study of [**6-18**], there is
increasing
opacification at both bases with poor definition of the
hemidiaphragms. This suggests increasing layering pleural
effusions with compressive atelectasis. Subcutaneous emphysema
is essentially unchanged. Mild elevation of pulmonary venous
pressure is probably present.
.
CXR [**2194-6-25**]:
IMPRESSION: No significant change since prior study. Mild
pulmonary edema and possible small bilateral pleural effusions.
.
Gastrograffin Esophageal Swallow Study [**2194-6-25**]:
Surgical staples and a drain with surrounding suture material
were
noted in the right upper thorax. No subcutaenous air is
identified. In a semi-upright position, the patient was
administered multiple swallows of contrast. On images 11 through
20, a small drop of contrast is seen
overlying the left clavicle outside of the expected region of
the esophagus. This was suspected to be outside of the patient,
which was confirmed with physical exam, and disappeared after
cleaning the patient. On subsequent swallows, in the frontal and
slightly obliqued positions, there is no evidence of leak in the
hypopharynx and upper esophagus. Thin barium was not
administered per request of the ENT team.
IMPRESSION: No evidence of upper esophageal leak with Optiray
oral contrast
.
DISCHARGE LABS
[**2194-6-27**] 06:09AM BLOOD WBC-6.6 RBC-3.30* Hgb-9.6* Hct-29.8*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.2 Plt Ct-330
[**2194-6-27**] 06:09AM BLOOD Plt Ct-330
[**2194-6-27**] 06:09AM BLOOD PT-14.7* PTT-30.9 INR(PT)-1.4*
[**2194-6-27**] 06:09AM BLOOD Glucose-92 UreaN-19 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2194-6-27**] 06:09AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
Brief Hospital Course:
77M with h/o CAD, PVD, afib on coumadin c/o left sided chest
pain for one week, SOB on exertion and at rest, increased LE
edema, suspicious for ACS vs. demand ischemia [**12-26**] heart rate.
.
#Chest pain. Pt w/ multiple risk factors, admitted for lateral
L-sided chest pain. Trops neg, EKG showed no acute changes. Pain
not associated with activity, also occurs with or without SOB.
On further investigation his pain is reproduceable: pt was
tender on his L chest wall near his axilla. Pt endorsed a fall
from his bed that required his nurse to get him up, pt reports
pain started at about this time. Likely that at least some
portion of his pain was musculoskeletal in nature; also possible
is pain secondary to demand from his high heart rate.
.
#Aflutter. Pt was admitted for SOB and chest pain, r/o for MI
with neg trops and EKG as above. EKG and tele both showed
a-flutter with rapid ventricular response. Judged likely that
symptoms were caused by his arrhythmia. EP cards consulted
regarding possible ablation; pt deemed an appropriate candidate
in principle, but procedure not possible until pt clears an
intertrigonal candidal infection. Pt given metoprolol for rate
control with no effect on rate. He was prepped for cardioversion
as a bridging measure prior to ablation. TEE was not able to be
passed blindly and was done with laryngoscopy. Poor images were
obtained and cardioversion was aborted. On withdrawal of the
scope, blood was seen and concern for esophageal injury. CXR
revealed subcutaneous air in the neck with rapid progression.
Patient was transferred to MICU for close monitoring with
Thoracics and ENT consulted for managment of esophageal
perforation. Plan for a flutter was to continue amiodarone and
metoprolol.
.
MICU COURSE:
# Esophageal Perforation: Upon arrival to MICU, patient was
intubated for airway protection. ENT evaluated patient who
performed a direct laryngoscopy which revealed esophageal
performation. Patient was taken to the OR for repair and
returned to MICU for post-operative monitoring. Patient was
initially started on vancomycin, clindamycin, ciprofloxacin
however was changed to vancomycin/meropenem given persistent
hypotension (see hypotension). Patient was ultimately taken for
GJ tube placement on [**2194-6-20**] for nutrition while esophagus
healed. Patient was subsequently extubated on [**6-20**]. Patient will
need speech and swallow evaluation at direction of ENT and
thoracics.
.
# Hypotension: After perforation and upon intubation, patient
was found to be hypotensive with SBPs 80s-90s. There was initial
concern for sedation induced hypotension, however patient
remained hypotensive after removal of sedation. Patient was
initially started on vancomycin, ciprofloxacin, and clindamycin
however after persistent hypotension patient was changed to
vancomycin and meropenem. After starting meropenem, hypotension
resolved. Of note, on admission note, patient was on
fludrocortisone for orthostatic hypotension. However per PCP he
was not taking it. Adrenal Insufficency was thus ruled with a
normal cosyntropin stimulation test. On transfer BPs were
restored.
.
# Atrial Flutter: Patient remained in atrial flutter while in
MICU. Initially held po medication given esophageal performation
then restarted on amiodarone and metoprolol. Patient was
restarted on warfain without bridge post-operatively.
.
SECOND MICU COURSE:
See above for chronic medical issues.
.
# Hematemesis: Pt transferred back to MICU on [**2194-6-23**] for
hematemesis. He was hemodyanamically stable with stable Hct.
Emesis consistent with coffee ground. He was continued on
Pantoprazole 40mg [**Hospital1 **] IV. No NG lavage was done given recent
esophageal rupture and surgery. Continued Vanc and Meropenem and
repeated CXR which showed resolution of air in the neck and soft
tissues. ENT did not think sx likely [**12-26**] surgical repair but
will cont to follow. Pt remained stable so was called out the
next morning.
.
#Hypoxemia- mild oxygen requirement at 2LNC. Some mild pulm
edema on imaging. Also has a RML consolidation which could
represent aspiration vs. pneumonia especially given he has brown
sputum production. He was stable/afebrile on Vanc and meropenem
which were continued. He responded well to Lasix IV prior to
MICU transfer, and given persisting crackles up to mid lung
bases with mild JVD he was given another 20mg IV lasix. Dry
weight per patient is 238Ibs and currently was 246Ibs. Still on
2L NC on transfer out of MICU...
.
# Pneumomediastinum/esophageal repair - Pt s/p neck exploration
w/ ENT with repair of multiple perforations. Wound was clean and
dry w/o erythema, surrounding crepitus. JP draining clear fluid.
ENT and Thoracic Surgery following.
.
#Constipation- The patient had not passed any stool for more
than 1 week. He denied any abdominal pain, no tenderness to
palp. passing flatus and therefore suspicion for obstruction
low. Could be ileus though none seen on KUB today. aggressive
bowel med given
.
# A flutter/A fib - RVR to 160s, 140s on the [**Hospital1 **]. BPs remained
stable. 5mg IV metoprolol given prior to MICU stay to reduce
rate to ~110. Per cards recs, amiodarone reduced and metoprolol
increased, HR was atrial fib 110-120 at the time of transfer out
of MICU....
.
# Candidal Rash - The patient has extensive intertrigonal
candidal infection. Per wound care recs, will treat with
antifungal critic aid.
.
# Venous status dermatitis - multiple open sores on legs
bilaterally. Seen by wound care and said to be improving. cont
Betamethasone Dipro 0.05% Cream, Adaptic and Kerlix daily, wound
gel to wound beds to facilitate autolytic debridement
.
MEDICINE WARDS COURSE:
# Hematemesis: The patient was transferred to the wards on
lansoprazole for an episode of hematemesis that was thought to
be unrelated to the patient's esophageal tear per ENT. He was
continued on his lansoprazole with no further incidents.
.
# Hypoxemia- mild oxygen requirement at 2LNC. Some mild pulm
edema on imaging. He was stable/afebrile on Vanc and meropenem
which were continued (notably, these had been ordered for
mediastinitis). He was diuresed on two occasions with good
results and subsequent improvement of the mild bibasilar rales
that were noted pre-diuresis. Post-diuresis, some rales did
remain. His oxygen requirement was low and he will leave the
hospital on 2L NC which can be weaned at rehab. He should be
given 20mg PO lasix daily prn for diuresis as needed.
.
# Pneumomediastinum/esophageal repair - Pt s/p neck exploration
w/ ENT with repair of multiple perforations. Wound was clean and
dry w/o erythema, surrounding crepitus. JP drain was removed.
Esophageal gastrograffin swallow study revealed no esophageal
leakage and patient's diet was advanced to pureed foods with
supplemental tube feeds until he follows up with ENT. Patient is
being treated with vancomycin and meropenem through [**2194-7-1**].
.
# A flutter/A fib - There was a question of whether he was in
atrial flutter vs. atrial tachycardia from a low atrial focus
with 2:1 conduction. The latter was thought to be more likely
the case according to electrophysiology. His heart rate remained
elevated in the 100s and 110s on admission to the general
medical floor where his metoprolol dose was increased to 37.5
[**Hospital1 **]. He remained at approximately 100/minute with no episodes of
RVR or hemodynamic instability. The patient was restarted on his
warfarin, goal INR [**12-27**]. Patient has been receiving 3mg daily
though INR is still subtherapeutic (INR was 1.4 on day of
discharge). Recommend increasing warfarin to 4mg daily and
monitoring INR closely.
.
# Candidal Rash - The patient has extensive intertrigonal
candidal infection. He was treated with a topical miconazole
powder.
.
# Venous status dermatitis - multiple open sores on legs
bilaterally. Seen by wound care and improving. The patient did
well on bethasone Dipro 0.05% Cream, Adaptic and Kerlix daily,
and wound gel to wound beds to facilitate autolytic debridement
.
TRANSITIONAL ISSUES
# WARFARIN DOSING: INR should be checked next on [**2194-6-28**] and
adjusted to a goal INR of [**12-27**].
# VANCOMYCIN DOSING: due to high trough, dose on [**2194-6-26**] was held
and pharmacy was consulted. They recommended changing his dose
from 1000 mg q8 hours to 1250 q12 hours.
# DIURESIS: The patient should be given 20mg PO furosemide on
[**6-28**] and [**2194-6-29**]. After that, the rehab physician may decide
whether or not his volume status dictates a further need for
diuresis.
# HYPODENSE HEPATIC LESION: This should be followed-up on an
outpatient basis with an ultrasound.
Medications on Admission:
1. Warfarin 2 mg PO DAILY16
2. Multivitamins 1 TAB PO DAILY
3. Citalopram 20 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Warfarin 4 mg PO DAILY16
your INRs will be followed closely and your dose possibly
adjusted to achieve goal INR [**12-27**]
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
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. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Meropenem 500 mg IV Q6H
9. Metoprolol Tartrate 37.5 mg PO BID
hold for HR<60 and sbp<90
10. Miconazole Powder 2% 1 Appl TP TID:PRN cutaneous fungus
11. Nystatin Oral Suspension 5 mL PO QID:PRN [**Female First Name (un) **]
swish and spit
12. Ondansetron 8 mg IV Q8H:PRN nausea
13. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
hold for rr<12 and sedation. try tylenol first
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 1 TAB PO BID:PRN constipation
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
19. Ferrous Sulfate 325 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Fludrocortisone Acetate 0.1 mg PO DAILY
22. Vancomycin 1250 mg IV Q 12H
please draw next trough on [**2194-6-29**] AM.
23. Furosemide 20 mg PO DAILY
Please give for [**2194-6-28**] and [**2194-6-29**] then re-assess the need for
further diuresis.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis: atrial fibrillation
Secondary diagnosis: esophageal tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at the [**Hospital1 **]. As you know, you were admitted
with chest pain and found to have an irregular heart rate.
Unfortunately we were not able to put a catheter into your
arteries because of fungus on your skin and we had to put a
probe into your stomach. This procedure was complicated by a
tear in your esophagus which required emergency surgery and
antibiotics. You did very well and the repair was assessed and
found to be intact, allowing you to eat pureed food. You should
not eat any non-pureed food until your ENT surgeon says that it
is safe.
You are on several new medications - please see the sheet
attached for further details.
Followup Instructions:
Cardiology Appointment:
-WITH WHOM?: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**] (Dr. [**First Name (STitle) **] [**Name (STitle) 89565**] nurse
practitioner)
-WHERE?: [**Hospital **] Medical [**Hospital1 **] Associates at [**Location (un) **] ([**Location (un) 75527**], [**Location (un) 86**], [**Numeric Identifier 718**])
-WHEN?: [**2194-7-16**] at 3:00 P.M.
Name: [**Last Name (LF) **], [**First Name3 (LF) **] V. MD
Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC
Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 2349**]
Appt: [**Last Name (LF) 2974**], [**7-4**] at 10:45am
***Please arrive 20 mins early to this appt to fill out some
necessary paperwork.
Department: THORACIC SURGERY
When: THURSDAY [**2194-7-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"112.3",
"799.02",
"V12.72",
"401.9",
"998.81",
"E870.8",
"E878.8",
"427.32",
"578.0",
"311",
"707.10",
"998.2",
"518.52",
"272.4",
"560.1",
"V58.61",
"997.49",
"564.00",
"459.81",
"E879.8",
"427.31",
"110.3",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"31.42",
"88.72",
"38.93",
"42.82",
"46.32",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
21014, 21136
|
10382, 19014
|
316, 551
|
21257, 21257
|
4948, 4948
|
22206, 23349
|
2156, 2173
|
19347, 20991
|
21157, 21157
|
19040, 19324
|
21440, 22183
|
2188, 3802
|
3818, 4929
|
269, 278
|
579, 1277
|
21217, 21235
|
4964, 10359
|
21176, 21196
|
21272, 21416
|
1299, 1876
|
1892, 2140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,371
| 177,454
|
50719
|
Discharge summary
|
report
|
Admission Date: [**2143-11-16**] Discharge Date: [**2143-11-26**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 y/o m w h/o DM1, h/o DKA, h/o medication/diet noncompliance,
h/o alcohol and drug abuse, htn, CRI, presented with weakness
and fatigue and found to be in DKA in ED. Pt. reports that he
was discharged [**11-12**] and he was not able to fill his insulin
script, so he had to go to the ED for insulin. Pt. denied HA,
nausea, SOB, chest pain, abd pain, dysuria, diarrhea, sick
contacts or recent travel. While in the [**Hospital Unit Name 153**] he was treated with
an insulin gtt, and his DKA resolved, however he was found to
have slightly elevated cardiac enzymes, concerning for NSTEMI.
Cardiology was consulted, no changes were seen on ECG, but a TTE
showed an area of hypokinesis corresponding with a possible LCx
lesion. A stress test was done which showed a defect in LCx
territory. Pt. was treated with maximal medical management.
Past Medical History:
# HTN - not currently being treated
# DM - now insulin dependent
- has had multiple admissions for DKA in setting EtOH use
- currently on NPH + Regular insulin [**Hospital1 **], no sliding scale
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
Social History:
Lives w/ girlfriend, no children. Sister (?[**Doctor Last Name 2270**]) is very
supportive. Works part time as a tire-changer. No tobacco, but +
EtOH (2-3 beers/day) and cocaine use (snorted last week).
Family History:
Mother had diabetes, niece has diabetes, no coronary artery
disease, no hypertension, no cancer, no liver disease, no renal
disease in the family.
Physical Exam:
T 98.3 HR 86 BP 110/60 R 20 sat 93% RA
gen: NAD, A+OX3
HEENT: mmm
CV: RRR 2/6 hsm
pulm: CTAb
abd: s/nt/nd +BS
ext: 1+ edema bilat
Pertinent Results:
[**2143-11-16**] 08:44PM GLUCOSE-551*
[**2143-11-16**] 08:40PM GLUCOSE-657* UREA N-57* CREAT-4.7* SODIUM-133
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-11* ANION GAP-26*
[**2143-11-16**] 04:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2143-11-16**] 04:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-11-16**] 04:25PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2143-11-16**] 04:00PM GLUCOSE-718* UREA N-57* CREAT-4.6*
SODIUM-129* POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-13* ANION
GAP-26*
[**2143-11-16**] 04:00PM CK(CPK)-303*
[**2143-11-16**] 04:00PM CK-MB-18* MB INDX-5.9 cTropnT-0.28*
[**2143-11-16**] 04:00PM WBC-4.7 RBC-3.76* HGB-11.7* HCT-36.1* MCV-96
MCH-31.1 MCHC-32.4 RDW-12.5
[**2143-11-16**] 04:00PM NEUTS-62.3 LYMPHS-29.4 MONOS-3.8 EOS-3.3
BASOS-1.3
[**2143-11-16**] 04:00PM PLT COUNT-268
.
CXR ([**11-16**]): Tiny pleural effusion. Increased prominence of
bilateral hilar adenopathy. While non-specific, sarcoid and
lymphoma should be considered. No evidence of focal
consolidation. Poorly defined small nodular densities seen
projecting over the posterior right 6th and 7th ribs. Followup
imaging recommended following treatment to document resolution.
.
TTE ([**11-19**]):
IMPRESSION: Mild regional left ventricular systolic dysfunction
suggestive of
CAD (? Left dominant circulation with LCX lesion). Mild mitral
regurgitation
most likely due to papillary muscle dysfunction. Mild pulmonary
artery
systolic hypertension.
Based on [**2134**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2143-11-19**]
14:44.
[**Location (un) **] PHYSICIAN:
.
exMIBI ([**11-20**]):
IMPRESSION: Abnormal myocardial perfusion study at sub-optimal
level (57% MPHR)
demonstrating a mild reversible inferior defect, LV enlargment
and transient
cavitary dilatation.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] informed of results by Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] at
2:55pm
[**0-0-0**].
CXR ([**11-23**]):
Persistent right mid and lower lung opacity. Diagnostic
considerations include pneumonia.
Brief Hospital Course:
1. DKA- Thought to be [**3-14**] non-compliance and ? cardiac ischemia.
Came in with sugar 700 and Ag 21. Gave IVF, insulin gtt and
repleted K and now AG is 9 and sugars all less than 200. On his
normal home regimen. Needs more diabetes teaching and should f/u
with Dr. [**Last Name (STitle) **] at [**Last Name (un) **].
2. NSTEMI-cardiology was consulted . CKs and troponins trending
down, no significant ekg changes compared to [**2142**]. Started
asa/plavix and is on beta blocker. Started statin. TTE revealed
regional wall motion abnormality concerning for possible LCx
lesion. exMIBI also revealed a defect consistent with LCx lesion
but there was also some transient dilation observed raising the
question of 3VD. On the day of discharge the cardiology team was
still deciding whether he should undergo cath, and this would be
with renal involvement as his Cr is 3.5-4 at baseline. Pt. did
not want to stay for catheterization and preferred medical
management as he was tired of being in the hospital. He was told
of the risks of sudden cardiac death and heart attack and
understood this. He will follow up with Dr. [**Last Name (STitle) 1445**] of
cardiology.
3. Chronic abd pain- long-term issue. RUQ US normal. LFTs
normal. AP chronically elevated. GI consulted. Think may be PUD
or gastritis although pt denies hematochezia/melena. Also
concern for gastroparesis although pt does not report fullness,
nausea, vomit after meals. Started on PPI.
4. Acute on chronic renal failure-creatinine elevated on
admission and trended down to baseline at 3.7. Recently d/c in
early [**Month (only) **] and on that admission had acute on chronic renal
failure thought ot be [**3-14**] ATN from cocaine abuse. Chronic
component [**3-14**] DM and HTN. Pt needs outpt nephro appt. Followed
by renal in house, follow up with Dr. [**First Name (STitle) 805**].
5. ETOH/drug abuse-on CIWA scale but didnt require ativan.
Started thiamine,
MVI, folate.
6. FEN-cardiac, diabetic diet, euvolemic on d/c, kept on daily
40 mg lasix.
7. HTN- not compliant with meds. Poorly controlled BP in house.
Labetalol increased to 800 mg po tid, continued on nifedipine
120 mg, added imdur 30 mg daily. Will need to follow up with
cardiology and renal.
Medications on Admission:
Nifedipine 120 mg daily
NPH insulin 14 units sc qam, 10 units sc qpm
Lasix 40 mg po daily
Labetalol 400 mg tid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day): DO NOT TAKE IF YOU USE COCAINE, Can be fatal.
Disp:*240 Tablet(s)* Refills:*2*
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous twice a day: Please take 14 units sc qam and 10
units sc with dinner.
10. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous four times a day: sliding scale 4 times daily
with meals and at bedtime.
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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
16. Erythromycin 5 mg/g Ointment Sig: One (1) app Ophthalmic HS
(at bedtime) for 1 weeks: apply to L eye at bedtime.
Disp:*qs 1 week* Refills:*0*
17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Non-ST-Elevation Myocardial Infarction (MI)
Hypertension
Type 1 Diabetes
Polysubstance Use
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital if you have chest pain, confusion,
Inability to urinate, fever, nausea/vomitting. Please make sure
you follow up with your kidney doctor, Dr. [**First Name (STitle) 805**]. Please also
call for an appointment with the cardiologist in the next week.
You may need to have a cardiac catheterization.
Followup Instructions:
1. Please follow up with your cardiologist. Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]
[**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2143-12-9**] 11:20
2. Please schedule an appointment with Dr. [**First Name (STitle) 805**], your kidney
doctor. Please call [**Telephone/Fax (1) 3637**] for an appointment.
3. Please also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next
2 weeks. Call [**Telephone/Fax (1) 250**] for an appointment.
4. Please call toProvider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], RNC
Date/Time:[**2143-12-3**] 11:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2143-12-9**] 2:00
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2143-12-9**] 2:00
|
[
"305.90",
"403.90",
"584.9",
"585.9",
"507.0",
"250.43",
"410.71",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9610, 9616
|
5155, 7392
|
321, 328
|
9773, 9780
|
2676, 4607
|
10148, 11053
|
2357, 2506
|
7553, 9587
|
9637, 9752
|
7418, 7530
|
9804, 10125
|
2521, 2657
|
278, 283
|
356, 1196
|
4640, 5132
|
1218, 2119
|
2136, 2341
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,250
| 189,110
|
21823
|
Discharge summary
|
report
|
Admission Date: [**2193-10-2**] Discharge Date: [**2193-10-3**]
Date of Birth: [**2129-4-16**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
mechanical ventilation and intubation
History of Present Illness:
64 y.o. man with known met pancreatic CA, with mets to liver,
lungs p/w nausea/vomiting, diarrhea, abdominal pain x 1 day.
The patient usually receives care at [**Hospital1 112**]. In the emergency
department he was found to have an elevated lactate,
hypotensive, lethargic. The patient was started on sepsis
protocol. He was also noted to be in A-fib, was shocked and
entered into a wide complex tachycardia. He was then
cardioverted to a sinus rhythm. A cat scan of the abdomen
revealed multiple thromboses including the IVC,portal/splenic
veins, compression of celiac artery and concern for bowel
ischemia.
Past Medical History:
Metastatic Pancreatic CA (dx [**6-28**]) s/p pall chemo [**7-28**] c/b
gastric outlet obstruct s/p duod stent; R pleural effusion; IVC
clot
Social History:
Lives at home with wife, daughter
Family History:
non-contributory
Physical Exam:
Admission:
Gen Intubated, febrile, hypotensive, anasarcic, jaundiced man
HEENT jaundiced, chemotic, PERRL
Pulm coarse BS, equal
CVS tachycardic
Abd tense, obese, moderately distended, unable to assess
tenderness, hypoactive bowel sounds
Ext anasarcic
Pertinent Results:
[**2193-10-2**] 12:10PM PT-21.5* PTT-64.7* INR(PT)-2.9
[**2193-10-2**] 12:10PM WBC-16.1* RBC-3.21* HGB-9.6* HCT-29.4* MCV-92
MCH-29.9 MCHC-32.6 RDW-17.3*
[**2193-10-2**] 12:10PM ALT(SGPT)-107* AST(SGOT)-198* CK(CPK)-47 ALK
PHOS-176* AMYLASE-31 TOT BILI-2.6*
[**2193-10-2**] 12:10PM GLUCOSE-52* UREA N-11 CREAT-0.9 SODIUM-135
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-14* ANION GAP-23*
[**2193-10-2**] 04:40PM FIBRINOGE-231 D-DIMER-8754*
[**2193-10-2**] 04:40PM LD(LDH)-563*
[**2193-10-2**] 04:40PM HAPTOGLOB-149
[**2193-10-2**] 04:40PM FDP-40-80
[**2193-10-2**] 07:31PM TYPE-ART TEMP-36.1 RATES-16/ TIDAL VOL-600
O2-50 PO2-261* PCO2-27* PH-7.16* TOTAL CO2-10* BASE XS--17
-ASSIST/CON INTUBATED-INTUBATED
[**2193-10-2**] 07:39PM ALBUMIN-2.2* CALCIUM-6.9* PHOSPHATE-5.0*
MAGNESIUM-1.7
[**2193-10-2**] 07:39PM ALT(SGPT)-188* AST(SGOT)-373* LD(LDH)-668*
CK(CPK)-95 ALK PHOS-163* TOT BILI-2.8*
[**2193-10-2**] 09:25PM LACTATE-11.4*
[**2193-10-2**] 11:17PM TYPE-ART TEMP-36.2 RATES-30/ TIDAL VOL-600
PEEP-5 O2-50 PO2-204* PCO2-17* PH-7.33* TOTAL CO2-9* BASE XS--14
INTUBATED-INTUBATED VENT-CONTROLLED
Brief Hospital Course:
Pt was found to be septic on admission requiring pressors,
mechanical ventilation, bicarbonate infusion. On Abdominal CT
pt was found to have a pancreatic mass and metastatic lesions to
the liver (known), as well as newly diagnosed occluding thrombi
in the IVC and common iliac veins, and infiltrative tumor
occluding the celiac artery and the SMA. The patient's family
was notified of the results and the patient was made comfort
measures only. Mr [**Known lastname **] [**Last Name (Titles) **] on [**2193-10-3**] with his family
present.
Medications on Admission:
[**Date Range **]
Discharge Medications:
[**Date Range **]
Discharge Disposition:
Home
Discharge Diagnosis:
metastatic pancreatic cancer, ischemic bowel, cardiopulmonary
failure
Discharge Condition:
[**Date Range **]
Discharge Instructions:
[**Date Range **]
Followup Instructions:
[**Date Range **]
|
[
"197.7",
"785.52",
"557.0",
"038.3",
"286.6",
"157.9",
"428.0",
"197.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.62",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3338, 3344
|
2683, 3228
|
325, 364
|
3457, 3476
|
1543, 2660
|
3542, 3562
|
1239, 1257
|
3296, 3315
|
3365, 3436
|
3254, 3273
|
3500, 3519
|
1272, 1524
|
271, 287
|
392, 1008
|
1030, 1172
|
1188, 1223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,606
| 130,785
|
21938
|
Discharge summary
|
report
|
Admission Date: [**2168-10-27**] Discharge Date: [**2168-11-3**]
Date of Birth: [**2109-3-23**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman
who had a known history of coronary artery disease, status
post myocardial infarction with a left anterior descending
stent in [**2160**] following ventricular fibrillation arrest. He
reported having done very well until the past couple of
months with now increasing left neck tightness with exertion
that resolved with rest. The patient denied chest pain,
shortness of breath, fatigue, nausea, vomiting, or edema.
A stress test performed on [**10-25**] showed a large severe
anteroapical, septal, and inferior ischemia areas and apical
hypokinesis with an ejection fraction of 60 percent.
The patient was brought into the hospital on [**2168-10-27**]
and brought immediately to the Cardiac Catheterization
Laboratory. Catheterization revealed a 95 percent right
coronary artery lesion, a tight 99 percent proximal left
anterior descending lesion, and an 80 percent first obtuse
marginal lesion. The patient was referred to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] for urgent coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Myocardial infarction.
2. Coronary artery disease with a left anterior descending
stent in [**2160**].
3. Ventricular fibrillation arrest.
4. Hypertension.
5. Hypercholesterolemia.
6. Varicose veins.
PAST SURGICAL HISTORY: Includes tonsillectomy, right wrist
ganglion wound, and appendectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg by mouth once
daily, Lipitor 10 mg by mouth once daily, lisinopril 10 mg by
mouth once daily, atenolol 25 mg by mouth once daily, and
Viagra as needed.
SOCIAL HISTORY: The patient lives in [**Location 2498**] with his son.
[**Name (NI) **] works full time as a banker. He quit smoking in [**2160**] with
greater than a 10-pack-year history. He has had no alcohol
in three years.
FAMILY HISTORY: He had a positive family history with both
his father and brother dying of myocardial infarctions at
young ages and mother with mitral stenosis.
PHYSICAL EXAMINATION ON ADMISSION: He was 5 feet 11 inches,
weight was 200 pounds, in sinus rhythm at 50, with a blood
pressure of 88 systolic (diastolic not recorded), his
respiratory rate was 13, and saturating 97 percent on room
air. He was lying flat in bed in no apparent distress.
Alert and oriented times three. Appropriate and grossly
neurologically intact. He had fine rales in his right base.
The left lung was clear. Heart was regular in rate and
rhythm with S1 and S2 tones. No murmurs, rubs, or gallops.
The abdomen was soft, nontender, and nondistended. There
were positive bowel sounds. The extremities were warm and
well perfused with no edema. He had positive varicosities in
his right lower extremity. The pulses on the right were 2
plus dorsalis pedis, 2 plus posterior tibial. On the left,
pulses were 1 plus radial, 2 plus dorsalis pedis, and 2 plus
posterior tibial.
PREOPERATIVE LABORATORY DATA ON ADMISSION: White blood cell
count was 7, hematocrit was 38.4, and platelet count was
166,000. Sodium was 139, potassium was 3.9, chloride was
103, bicarbonate was 25, blood urea nitrogen was 18,
creatinine was 0.8, with a blood sugar of 143. Prothrombin
time was 12.8, partial thromboplastin time was 25, and INR
was 1. Alanine-aminotransferase was 18, aspartate
aminotransferase was 16, alkaline phosphatase was 53, amylase
was 64, total bilirubin was 0.7, and albumin was 4.2.
Hemoglobin A1C was 6.1 percent preoperatively.
RADIOLOGY: Preoperative electrocardiogram showed a sinus
rhythm at 64 with a probable old inferior myocardial
infarction. Please refer to the electrocardiogram report
dated [**2168-10-27**].
SUMMARY OF HOSPITAL COURSE: On [**10-27**], in the late
afternoon the patient was taken to the Operating Room and had
a coronary artery bypass graft times three by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 70**] with a left internal mammary artery to the left
anterior descending, a right internal mammary artery to the
right coronary artery, and a vein graft to the obtuse
marginal. He was transferred to the Cardiothoracic Intensive
Care Unit in stable condition.
On postoperative day one, the patient had been extubated
overnight. He was in a sinus rhythm at 92 with a blood
pressure of 100/66. He was saturating 98 percent on 4 liters
nasal cannula. He was on an insulin drip at 3 units an hour
and a Neo-Synephrine drip at 1.5 mcg/kg/minute. The patient
was in no distress. His heart was regular in rate and
rhythm. Chest tubes remained in place. He had decreased
breath sounds at both bases. His abdomen was soft. He had 1
plus peripheral edema.
Postoperative laboratories as follows. White blood cell
count was 11.7, his hematocrit was 28.9, and platelet count
was 169,000. Sodium was 141, potassium was 4.3, chloride was
108, bicarbonate was 25, blood urea nitrogen was 11,
creatinine was 0.6, and blood glucose was 74 (on his insulin
drip).
His Neo-Synephrine was weaned over the course of the day. He
did receive a 500-cc saline bolus to help boost his blood
pressure slightly and help wean the Neo-Synephrine. Oxygen
was weaned. Chest tubes remained in place with a plan to
transfer the patient to the floor when he was completely
weaned off his Neo-Synephrine. He remained in the Intensive
Care Unit.
On postoperative day two, the patient an episode of rapid
atrial fibrillation into the 140s with a drop in his blood
pressure to 82/30. He received an amiodarone 150-mg bolus.
He otherwise remained hemodynamically stable after that with
a normalizing blood pressure of 107/62 and a heart rate back
in a sinus rhythm at 84. Overnight, he was started on an
amiodarone drip at 0.5 mg/minute. His Neo-Synephrine was
weaned from 1.25 to 0.8 mcg/kg/minute. He remained in a
sinus rhythm. His chest tubes were discontinued. He
received 2 units of packed red blood cells which brought his
hematocrit up to 28. He was saturating 96 percent on 4
liters nasal cannula. He still had decreased breath sounds
at his bases. The incisions were clean, dry, and intact.
His pacing wires were discontinued. He was allowed out of
bed with Physical Therapy but remained in the Intensive Care
Unit as he remained on a Neo-Synephrine drip. He was alert
and oriented and was following commands appropriately.
Later that day, the patient was transferred out to the floor
on [**10-31**] to begin his ambulation and working with
Physical Therapy; which he began right away. He was
receiving oral Percocet for sternal discomfort and incisional
pain.
On postoperative day five, he had a scant amount of sternal
drainage of the distal portion of his incision and some
difficulty voiding the prior day. Flomax was started to help
assist him in this process. He had no incisional erythema,
though. His Foley catheter was discontinued. A voiding
check was performed again. A central venous line was
discontinued. Beta blockade continued with Lopressor 12.5 mg
by mouth twice daily. Lasix diuresis continued orally. The
patient was continued on amiodarone and Plavix. The patient
continued to work with Physical Therapy. Attempts were also
made to wean down his oxygen via nasal cannula. He was
ambulating with a level III on [**10-31**]. Discharge
planning was begun with the patient planning to stay with his
sister postoperatively. The patient continued to walk and
work with the nurses that evening.
On postoperative day six, he also had a slight sternal
dressing that was unremarkable. His white count was 4.9,
hematocrit was 26.5, and creatinine was stable at 0.8. He
was receiving Percocet as needed for incisional discomfort.
He did have the sternal drainage - a small amount - from the
lower pole of his sternal incision but none the following
morning, and he was encouraged to continue to ambulate, and
discharge planning continued. He was also seen by Case
Management who worked out that he would have Visiting Nurses
Association services while he was staying with his sister.
[**Name (NI) **] was also seen by the Clinical Nutrition team.
The patient was evaluated for a rash on his back and upper
buttocks. The patient said this was not uncommon. He had
experienced this before. It possibly might have been related
to one of his medications. Examination showed small diffuse
papules nonvesicular erythematous area on the superior
portion of his buttocks and mid back. It appeared to be a
probable dermatitis which was stable. The patient was seen
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43107**] and was also treated with Benadryl.
His examination was also otherwise unremarkable.
On postoperative day six, the date of discharge, he was alert
and oriented. His lungs were clear bilaterally. His heart
was regular in rate and rhythm. He had good bowel sounds.
His incisions were clean, dry, and intact with no erythema
and no sternal drainage. His amiodarone was decreased to 400
mg twice daily, and the patient was discharged to home with
Visiting Nurses Association services to stay with his sister.
DISCHARGE FOLLOWUP: Discharge instructions for followup were
given to the patient. He was instructed to follow up with
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 17025**] - his primary care physician [**Name Initial (PRE) **] [**Name10 (NameIs) **]
approximately one to two weeks post discharge. He was
instructed to follow up with Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] - his
cardiologist - in approximately two to three weeks post
discharge and to see Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 70**] in the office in
approximately six weeks post discharge for his postoperative
surgical visit.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Status post myocardial infarction with left anterior
descending stent.
3. Status post ventricular fibrillation arrest.
4. Hypertension.
5. Hypercholesterolemia.
6. Varicose veins - right lower extremity.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg by mouth once daily.
2. Potassium chloride 20 mEq by mouth twice daily (times six
days).
3. Colace 100 mg by mouth twice daily.
4. Enteric coated aspirin 325 mg by mouth once daily.
5. Plavix 75 mg by mouth once daily.
6. Amiodarone 400 mg by mouth twice daily for seven days,
then amiodarone 400 mg by mouth once daily for one week,
then amiodarone 200 mg by mouth once daily.
7. Lipitor 10 mg by mouth once daily.
8. Multivitamin one capsule by mouth once daily.
9. Polysaccharide-Iron Complex 150 mg by mouth once daily.
10. Vitamin C 500 mg by mouth twice daily.
11. Tamsulosin hydrochloride sustained-release 0.4 mg by
mouth once daily at bedtime.
12. Ibuprofen 600 mg by mouth q.8h. as needed (take with
food).
13. Percocet 5/325 one to two tablets by mouth q.4-6h.
as needed (for pain).
14. Lasix 20 mg by mouth twice daily (times seven days).
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharge home on [**2168-11-3**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2168-12-13**] 10:45:24
T: [**2168-12-13**] 11:39:44
Job#: [**Job Number 57474**]
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32,120
| 157,920
|
26493
|
Discharge summary
|
report
|
Admission Date: [**2119-5-12**] Discharge Date: [**2119-5-19**]
Date of Birth: [**2038-7-10**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Opioid Analgesics / Keflex
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
General Malaise
Major Surgical or Invasive Procedure:
Transesophageal echo
History of Present Illness:
Ms. [**Known lastname 1356**] is an 80 year old woman with history of CAD s/p CABG,
CHF (EF 25-30% with BiV ICD placement), NIDDM, hypertension,
TIA, and chronic renal insufficiency who presented on [**2119-5-9**] to
an outside hospital with chest pain, shortness of breath, fever,
fatigue, hypotension, and nausea. Upon evaluation, she was found
to be febrile to 102, lethargic and unable to provide meaningful
history. Her troponin was elevated at 2.7 and creatinine was
elevated to 2.4 (baseline 1.0), BNP of 897. Her chest x-ray
showed mild pulmonary edema.
.
On admission, blood and urine cultures were performed. She was
initially started on Unasyn given concern over a UTI (given
indwelling suprapubic catheter). She was started on oxacillin
and vancomycin when blood cultures grew back Staph aureus in [**3-10**]
bottles (resistant to penicillin and cefazolin). An
echocardiogram (TTE) on [**2119-5-11**] showed a vegetation on the mitral
valve and severe mitral regurgitation, thought to be new. A TEE
was not performed. Of note, urine culture grew E. coli 10-50,000
CFU, pan-sensitive.
.
Over the course of the OSH admission on [**5-11**], she became
hypotensive (systolic in the low 100's) with low urine output; a
right IJ central line was placed for administration of
dobutamine. Per report, CVP was 7. At the time of transfer, the
dobutamine was running at 5mcg, and urine output was
100-200cc/hr.
.
The site of the right IJ central line has been oozing since it
was placed (at the time, INR was elevated to 3.3). Her
hematocrit was 32 on admission and dropped to 27 and then 24;
she was planned to get two units of pRBC's but was a difficult
crossmatch due to antibodies.
.
On review of symptoms, she reports mild sore throat and chest
painshe denies any prior history of TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
Congestive Heart Failure; EF 25-30%
NIDDM
CAD s/p MI, 2v CABG ([**2103**])
LBBB
s/p [**Hospital1 **]-V ICD placement [**12-11**] at [**Hospital1 18**], [**Company 1543**] [**First Name9 (NamePattern2) 24118**] [**Last Name (un) 24119**]
7304
Hypertension
Hyperlipidemia
History of TIA on warfarin
Left total hip replacement
Right total knee replacement
Osteoarthritis
Has suprapubic catheter - does urinate as well
Social History:
SOCIAL and FAMILY HISTORY:
Social history is significant for the absence of current tobacco
use. There is no current alcohol abuse. Married for >60 years
with 10 children and 31 grandchildren and 28 great
grandchildren. Lives with husband.
Family History:
There is no family history of premature coronary artery disease
or sudden death that could be obtained.
Physical Exam:
VS: T 98.5F, BP 125/52, HR 81, RR 14, O2 99% on room air
Gen: WDWN elderly female in NAD, resp or otherwise. Oriented x
2. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple; unable to assess JVP on right side given right IJ.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. I/VI systolic murmur heard at apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles,
otherwise clear.
Abd: Obese, soft, non-tender, mildly distended. Normal active
bowel sounds. No HSM or tenderness. No abdominal bruits.
Suprapubic catheter in place; dressing clean/dry/intact.
Ext: No clubbing or cyanosis. Trace edema in lower extremities
bilaterally. No femoral bruits. 1+ DP pulses bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. No
stigmata of endocarditis.
Pertinent Results:
ECHO:
Mild spontaneous echo contrast is seen in the body of the left
atrium. A mass measuring 0.6cm in greatest width is adherent to
the RV pacing lead is seen within the right atrium. No atrial
septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. LV systolic function appears
depressed. There are complex (>4mm) atheroma in the aortic arch
and descending thoracic aorta. 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 a moderate-sized vegetation (09.x0.8 cm) on
the atrial surface of the posterior leaflet of the mitral valve.
It is slightly mobile and irregular in its appearance,
consistent with a vegetation or possibly a torn chordae with
mild calcification. No mitral valve abscess is seen. Mild to
moderate ([**12-7**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. No masses or vegetations
are seen on the pulmonic valve, but cannot be fully excluded due
to suboptimal image quality. There is no pericardial effusion.
IMPRESSION: Small mobile echodensity on the posterior leaflet of
the mitral valve consistent with a vegetation. Mild to moderate
mitral regurgitation. Small mass adherent to the RV pacing lead
seen with the body of the right atrium, suggestive of a fibrin
strand.
PORTABLE ABDOMEN [**2119-5-14**] 10:06 AM
PORTABLE ABDOMEN
Reason: please assess for any evidence of obstruction
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with nausea, vomiting, endocarditis
REASON FOR THIS EXAMINATION:
please assess for any evidence of obstruction
REASON FOR EXAMINATION: Nausea and vomiting in a patient with
endocarditis.
Portable AP chest radiograph was reviewed with no prior studies
available for comparison.
The overall appearance of the abdomen is unremarkable with
preserved bowel gas and contents. No dilated bowel loops were
demonstrated. Note is made of a prior left hip replacement.
Right hip pain. Sepsis.
FINDINGS: No old films available for comparison. The patient is
status post left total hip replacement with the prosthesis in
good location. There are severe degenerative changes of the
right hip with joint space narrowing, sclerosis, subchondral
cysts and osteophytes. The margins of the entire humeral head
cannot be adequately defined inferiorly and it is unclear if
this is due to osteopenia or overlying osteophytes. Infection
cannot be totally excluded and if this remains a clinical
concern, recommend followup with MRI.
Renal U/S:
FINDINGS: Grayscale evaluation of bilateral kidneys reveals no
evidence of stones, or hydronephrosis. There is a simple cyst
within the mid pole of the left kidney, measuring approximately
1.9 cm.
There is a suprapubic catheter seen coursing into the bladder.
Mild anechoic region surrounding of course of the superior
catheter likely reflects a small amount of fluid or edema. There
is no evidence for a discrete abscess. Initial images which
demonstrate a rounded heterogeneous appearance approximately 1.6
cm adjacent to the region of the bladder was not reproducible
upon re-examination, and may have reflected either a portion of
the bladder or bowel.
IMPRESSION:
1. No definite evidence of an abscess.
2. No evidence of hydronephrosis.
Brief Hospital Course:
# Mitral valve vegetation:
Patient meets criteria for bacterial endocarditis per OSH echo
and will require 6 weeks of antibiotics. She has remained
afebrile. Portal of entry thought to be suprapubic catheter
(also urine growing E. coli), but exact source unclear. She also
has history of sacral decubitous ulcer. TTE done here at [**Hospital1 18**]
which does demonstrate MV mass on posterior leaflet that appears
ehcogenic; TEE with small mobile echodensity on posterior
leaflet consistent with vegetation. Also concern over mass seen
adherent to RV pacing lead. Discussion of risks/benefits of ICD
system removal. Decision by primary team that due to inherent
risks in replacement/lead adjustment procedure, will treat
conservatively with antibiotics with close f/u. Speciation
received from OSH: Staph sensetive to Oxacillin so changed abx
from vancomycin to Nafcillin 2gm q4 hours. Culture data reveals
that MSSA sensitive to all but pencillin. Prior to discharge to
rehab, pt changed from Nafcillin to Oxacillin b/c on formulary
at the rehab center. Pt will continue Nafcillin x 6 weeks and
f/u with ID. ID added rifampin to pt's regimen after discharge
- the rehab facility was contact[**Name (NI) **].
.
# CAD/Ischemia: history of CAD s/p CABG in [**2103**]. Troponin
elevated at OSH; cardiac biomarkers flat at [**Hospital1 18**]. INR elevated
at 3.7, therefore no need for heparin.
Continued aspirin 325mg daily and beta blocker.
.
# Pump: Per initial echo, MR was noted to be severe with
anterior jet, however upon repeat TEE, was mild to moderate,
which was more consistent with her exam. She has has known CHF
with [**Hospital1 **]-V ICD in place. Previous EF 25-30%; however,
echocardiogram at OSH demonstrated EF 30-35% with mitral valve
vegetation, however with her severe MR, EF may be overestimated.
Repeat ECHO here demonstrated EF 30-35% as well with moderate to
severe MR. Pt was plced on Isordil 10mg TID and hydralazine for
afterload reduction. Her [**Last Name (un) **] was held [**1-7**] ARF but can be
restarted if renal function improves and BP tolerates in the
future.
.
# Rhythm: Has [**Hospital1 **]-V ICD placed in [**12/2116**] at [**Hospital1 18**]. Reviewed
arrythmias noted on telemetry during course of stay, could be
NSVT versus initiated from device. EP evaluated and her
additional ventricular pacing feature turned off. No other
events on telemetry adn pt will f/u with EP on discharge
.
# Acute on chronic renal failure: unclear precipitant and
baseline creatinine in th low 2.0s. Felt it may be related to
overdiuresis vs hypotension. Renal ultrasound showed no
evidnece of hydronephrosis. Pts Lasix dose decreased adn [**Last Name (un) **]
held. Her medications were dosed for renal function. She will
need ongoing monitoring of her renal function but it remained
stable.
.
.
# UTI at OSH with 10-50,000 CFU pan-sensitive E. coli: was on
Unasyn briefly as outpatient. Repeat U/A and urine culture here.
Pt was treatead with Levo for 10 day course per ID
recommendations
.
# History of CVA on warfarin: INR 3.7 on admission and thus
held, but INR improved on day of discharge. SHe will need to be
restarted on home coumadin on day after discharge, saturday
[**2119-5-20**].
.
# Anemia: Baseline HCT is 32 per PCP discussion Hematocrit at
OSH dropped but now improving and trending up. Hct stable.
Difficult crossmatch. Iron studies WNL.
.
# Bladder dysfunction s/p suprapubic catheter placement: Urology
consulted and felt suprapubic catheter not infected. They
changed it on day #2 of hopsitalization. Pt will need ongoing
urology follow up per her usual schedule
.
#Nausea-Felt to be related to constipation. KUB wnl. LFTs
trended over stay and unremarkable. Pt given bowel regimen and
nausea improved.
.
Medications on Admission:
- Potassium 10meq daily
- Isosorbide 30mg daily
- Toprol XL 12.5mg daily
- Alprazolam 0.25mg [**Hospital1 **]
- Bupropion 150mg [**Hospital1 **]
- Lipitor 40mg daily
- Warfarin 2mg daily
- Aspirin 81mg daily
- Colace 100mg [**Hospital1 **]
- Multivitamin daily
- Elavil 25mg QHS
- Lasix 40mg [**Hospital1 **]
- Starlix 120mg TID
- Allopurinol 200mg daily
- Hydroxyzine 25mg QHS
- Detrol LA 4mg daily
- Diovan 160mg daily
- Fexofenadine 60mg daily
- NTG PRN chest pain
- Tylenol PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP <100 or HR < 60.
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
TID (3 times a day) as needed.
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
17. Ondansetron 4-8 mg IV Q8H:PRN
18. 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.
19. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Hold for SBP<100.
20. Oxacillin 2 gram Recon Soln Sig: One (1) Intravenous every
four (4) hours for 6 weeks: 2grams every 4 hours
To complete 6 week course; last day [**2119-6-26**].
21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
other day for 5 days: Last day [**2119-5-23**].
22. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: To
start Saturday [**2119-5-20**].
23. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Endocarditis - MSSA
UTI
Acute kidney injury
Secondary:
Diabetes
Hypertension
Anemia
History of CVA
Chronic renal failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a bacterial infection in your blood that
spread to your heart. This infection is being treated with
intravenous anti-biotics for a total of 6 weeks.
.
Additionally, you were found to have a urinary tract infection.
You were treated with an antibiotic called Levofloxacin which
you will complete a 10 day course.
.
Medication changes: Lasix has been dose reduced to 40 mg daily
due to acute kidney damage.
Followup Instructions:
1. A followup appointment has been scheduled with your PCP:
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 65450**], MD for after you complete your rehabilitation
course. Date/Time: [**6-30**] at 10 AM. Phone: [**Telephone/Fax (1) 33129**].
Location: 1221 Main, [**Apartment Address(1) 65451**]. [**Location 65452**] [**Numeric Identifier **].
.
2. Infectious disease followup appointment:
Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Date/Time: [**2119-6-22**] at 10:00 AM
Location: [**Hospital1 69**].
[**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Office Building, Suite G.
.
3. Cardiology followup appointment:
Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date/Time: [**2119-6-30**] at 9:00 AM
Location: [**Hospital1 69**]. [**Hospital Ward Name 516**].
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**].
|
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325, 348
|
14368, 14377
|
4284, 5847
|
14854, 15852
|
3169, 3274
|
11994, 14088
|
5884, 5938
|
14204, 14204
|
11482, 11971
|
14401, 14739
|
3289, 4265
|
14759, 14831
|
270, 287
|
5967, 7674
|
376, 2455
|
14223, 14347
|
2477, 2894
|
2910, 2921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,109
| 107,574
|
54021
|
Discharge summary
|
report
|
Admission Date: [**2177-3-17**] Discharge Date: [**2177-3-23**]
Date of Birth: [**2105-4-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 M w/Hx of CVA x1 ([**2170**], residual Left sided weakness, hoarse
voice), HTN, dyslipidemia and alcohol abuse presents with
palpitations.
.
Three weeks prior to admission, in [**State 108**], patient had episode
of lightheadness with a fall in a sauna (scraped knee). Since
then he has had occasional recurrences of these symptoms. On
[**3-16**], he felt lighthead in a restaurant, fell and scraped his
chin. No history of seizure, loss of bowel/bladder continence or
tongue biting. He has no recall of this event. In the days prior
to admission, he has had sinus congestion with a 'sinus
infection'. He took Advil Cold & Sinus for several days without
improvement. Then started Nasonex and most recently Moxifloxacin
x several days. Today, [**3-17**], while driving, he felt a racing
heart. Drove to his office, called his staff to arrange an
ambulance.
.
He was taken by EMS to [**Hospital1 **]. He received Amiodarone en route.
At [**Hospital1 **], he had a rate of 250 that fell to 140 with 6 mg of
Adenosine. He then received dilt 10 x 2, metoprolol, dilt drip,
before his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] arranged transfer
to [**Hospital1 18**].
.
In the [**Hospital1 **] ED, he was afebrile, BP 114/82-125/90, HR 115-125, RR
14, SpO2 1002-3L. He was symptomless and joined by his daughter.
.
REVIEW OF SYSTEMS:
S/he denies any prior history of deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
#. CVA- history of right inferior MCA stroke in [**2170-8-3**] with
residual mild left hemiparesis
#. Ulcerative Colitis- quiescent, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2305**],
M.D.; reportedly had 4+ guaiac stools in the past.
#. Depression
#. HTN
#. History of gastritis
#. Hyperlipidemia
#. Chronic renal insufficiency- Baseline Cr 1.4, followed by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Social History:
CPA; widower, lost wife 6 months previous (cirrhosis).
-Tobacco history: 1-1.5 PPD
-ETOH: [**2-5**] large cups of Vodka; more than [**1-4**] gallon of vodka
every 10 days
-Illicit drugs: none
Family History:
Mother had CA
Father had MI
Physical Exam:
VS: , BP 114/82-125/90, HR 115-125, RR 14, SpO2 1002-3L
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.
No oral ulcers. Filled caries
NECK: Supple with non-elevated JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, globally
decreased breath sound, 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: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Let sided weakness on neuro exam.
Pulse slows with right sided carotid sinus massage.
Pertinent Results:
ADMISSION LABS
[**2177-3-17**] 03:10PM BLOOD WBC-10.2 RBC-4.30* Hgb-13.8* Hct-41.0
MCV-95 MCH-32.1* MCHC-33.7 RDW-12.8 Plt Ct-261
[**2177-3-17**] 03:10PM BLOOD Neuts-70.3* Lymphs-19.0 Monos-4.4
Eos-5.7* Baso-0.6
[**2177-3-17**] 03:10PM BLOOD Glucose-97 UreaN-23* Creat-1.7* Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2177-3-17**] 03:10PM BLOOD ALT-16 AST-27 CK(CPK)-77 AlkPhos-72
TotBili-0.7
[**2177-3-17**] 03:10PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2177-3-17**] 03:10PM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.0 Mg-1.5*
[**2177-3-17**] 03:10PM BLOOD TSH-0.46
CT Chest [**3-18**]
There are no large lung nodules that correspond to the chest
x-ray abnormality. There is bronchial wall thickening in the
lower lobes
bilaterally that might explain the abnormality and is due to
inflammatory
process.
Emphysema.
1-3 mm lung nodules. Followup in one year is recommended.
TTE 3.16
The left atrium is mildly dilated (5.4cm). Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Low normal left ventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2170-8-10**], left ventricular function may be less
vigorous. The atrial sizes are larger. Estimated pulmonary
artery pressures are now lower.
Brief Hospital Course:
SUMMARY
71 M with Hx of CVA, HTN, DL presents with 3 weeks of
lightheadedness, falls and 1 day of palpitations. He was found
with a rate of 250 that did not break with adenosine. He has
been kept at 120's with diltiazem. He is admitted for workup and
management of his narrow-complex tachyarrythmia. There was
question as to whether he had atrial tachycardia or atrial
flutter. There was evidence (flutterform waves during carotid
sinus pressure) that his rhythm was flutter. On [**3-20**], he
converted to atrial fibrillation. We attempted to manage him
with nodal agents, but these only lowered his blood pressure (to
the 90's) while his heart rate was steady in the 120's. On [**3-20**],
with low BP and afib, he was transferred to the CCU for
TEE/cardioversion complicated by hypotension requiring transient
pressors. He was started on coumadin (with heparin bridge) and
amiodarone.
BY PROBLEM
1) SVT - Atrial Flutter and Atrial Fibrillation with RVR
Hypotension
The differential for his tachycardia was fairly narrow. It was
either atrial tachycardia or atrial flutter. Right carotid sinus
massage (very light pressure was sufficient) effected a decrease
in the ventricular response with a period of just flutter waves
that also showed atrial repolarization or an "a" wave. His lack
of response to adenosine rules out PSVT. The tracings from the
OSH show a tachycardia to 260 with the same interval as the
space between p waves when he later ran at 130. A long strip
from the outside hospital additionally showed flutter waves. He
had flutter waves with carotid pressure and the interval between
QRSs is variable. He was in atrial flutter with variable
conduction. His risk factors are presumed COPD, alcoholism and
age. CHADS2 score is 3. We attempted to manage him medically
without conversion for the dual concern of stroke and bleeding
on anticoagulation (hx of UC and gastritis). After [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 102218**]
trial of betablockade from 25->75 mg [**Hospital1 **] metoprolol, his rate
did not change and he became hypotensive. The dose was halved to
37.5 and his hypotension persisted, concommittant with his
conversion to atrial fibrillation. He was transferred to the CCU
for TEE/Cardioversion. After cardioversion, he went into a sinus
rhythm with a large amount of atrial ectopy. However, his
hypotension persisted after his cardioversion with blood
pressures in the 60's to 70's systolic and after several boluses
of phenylephrine with only 10 to 20 mm Hg rise in systolic blood
pressure including well after he had been given fentanyl and
propofol for the TEE and cardioversion he remained hypotensive
requiring an arterial line and continuous phenylephrine
intravenous infusion for hypotension which persisted after large
volume of saline infusion (over 2 liters). This was continued
overnight and he remained bradycardic with rates in the 50's
with atrial ectopy and paroxysmal atrial flutter. He was given
amiodarone po the next day because of the concern of his
compromised blood pressure even in sinus rhythm. Overnight his
blood pressure improved to over 100 systolic and the pressor was
weaned and he was returned to the floor from the CCU.
FOLLOW UP: INR checks through Dr. [**Last Name (STitle) **]
FOLLOW UP: Patient placed on Amiodarone and will
need liver, pulm testing at intervals to be determined by
outpatient physicians.
2) Arterial Vasculopathy, confirmed at least by coronary
calcification in all coronary vessels on chest CT and atheroma
in the ascending aorta seen on TEE
Hx of CVA; his stroke is now considered thromboembolic
given recent events.
Peripheral Artery Disease
Hypertension, Dyslipidemia
Patient has risk factors for heart disease but no prior
documentation. He had a fairly large CVA. His TEE showed "simple
atheroma" in the aortic arch and the CT of the chest for
evaluation of a question of a nodule showed calcium in all the
coronaries. Patient has elevated troponin, in the setting of
chronic renal failure. In the hospital, ABI's were performed
where he had bilateral systolics of 60 at the DP with brachial
systolic of 90, indicating PAD. The patient was admitted on
aggrenox and aspirin, was discharged on coumadin w/o
antiplatelet agents to lessen bleeding risk given the history of
gastritis and 4+ guaiac stools in the past thought to be colonic
or related to colitis in origin. Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**].
3) Alcoholism
Patient had his last drink the night prior to admission.
He was placed on a CIWA that was never triggerred. He received
supplementation with multivitamin, thiamine, folate. Social work
saw him as well. He was counselled to stop drinking.
4) COPD/Emphysema
CXR showed hyperinflated lung fields and a LLL opacity. CT
chest non-contrast showed multiple 1-3 mm nodules. Radiology
reccommended 1 year follow up. Patient was counselled to quit
smoking
5). Chronic renal insufficiency: Baseline 1.4, as high as 1.8.
Discharged at 1.3 likely after NSAID abstinence and hydration;
he had been taking NSAIDS chronically for headache to the day
prior to this admission. He was counseled re: abstaining from
all NSAIDS and aspirin and aspirin containing OTC drugs.
.
#. Hyperlipidemia
- lipitor
.
#. H/o CVA - discharged on coumadin for presumptive embolic
source
.
#. Ulcerative colitis - stable
.
# PUMP: There is no clinical suspicion of heart failure. He does
not have electrocardiographic or echocardiographic evidence of
LVH
Medications on Admission:
ATORVASTATIN 40mg daily
DIPHENHYDRAMINE HCL 25mg daily
DIPYRIDAMOLE-ASPIRIN [AGGRENOX] 25 mg-200 mg [**Hospital1 **]
FOLIC ACID 1mg daily
LISINOPRIL 10mg daily
ASPIRIN 325 mg daily
THIAMINE HCL
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for allergy.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO once a day: Take 1
tab tonight, Take [**1-4**] tab tomorrow night and alternate the doses
thereafter.
.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Flutter
Emphysema
Alcohol Abuse
History of CVA
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2177-5-22**] 10:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2177-12-2**] 10:30
Arrange followup with Dr. [**Last Name (STitle) **]; INR on [**2177-3-24**]; results
to Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 311**].
Completed by:[**2177-3-23**]
|
[
"556.9",
"427.31",
"272.4",
"303.91",
"438.20",
"458.29",
"492.8",
"427.32",
"585.9",
"305.1",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12583, 12589
|
6010, 9242
|
336, 343
|
12687, 12687
|
4202, 5987
|
12834, 13323
|
3101, 3131
|
11837, 12560
|
12610, 12666
|
11617, 11814
|
3146, 4183
|
2304, 2377
|
9327, 11591
|
1749, 2210
|
284, 298
|
371, 1730
|
12702, 12811
|
2408, 2873
|
2232, 2284
|
2889, 3085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,580
| 151,367
|
46795
|
Discharge summary
|
report
|
Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-12**]
Date of Birth: [**2072-10-25**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Iodine / Heparin Agents
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58-year-old lady with HCV cirrhosis complicated by recurrent
ascites, status post multiple large volume paracentesis, bipolar
disorder, encephalopathy, and chronic pain, recently evaluated
by hospice by outpatient consult who was found unresponsive the
night before admission at 10pm by family. She was last seen at
her baseline at home around 8pm that night by daughter's
boyfriend. She was given 6mg of narcan by EMS, became agitated
but did not wake up. She was taken to an OSH where she was
intubated and head CT was negative. She was also note to have
hematuria and blistering of her legs.
.
Daughter notes that patient recently was told by Hepatologist
Dr. [**Last Name (STitle) 497**] that she was not a transplant candidate. She obtained
a hospice consult on Saturday, but daughter did not find out
about hospice consult until Tuesday. She was given methadone for
abdominal pain and xanax to take as needed. Family found no
liquid methodone remaining and 26/100 pills of missing
methadone; daughter feels she may have accidentally overdosed on
medication because she was unsure of how to take medications.
Son noticed that she was intermittently somnolent on Tuesday
from methadone, mentioned it to Hospice nurse who encouraged
patient to continue with medications. Daughter feels that
patient only agreed to Hospice consult to get pain medications
for abdominal pain. Patient missed her weekly outpatient
paracentesis appointment on Monday and was noted to build
increased lower extremity edema and form bullae in lower
extremities.
.
In the ED, she was initially noted to be [**Age over 90 **]F. Propofol was
turned off but she was not noted to follow commands; she was
noted to move her feet but not her upper extremities. EKG
showed QTc prologation. Vitals and Vent settings prior to
transfer were as follows: BP123/52 HR113 , Vt 450cc RR 18
(overbreathing at 30) PEEP 5 Fio2 40%. No ABG done in ED.
Past Medical History:
Hep C Cirrhosis c/b ascites, encephalopathy
Seizure disorder
Hypertension
Prior IVDU
Bipolar disorder
Migraines
Peripheral vascular disease
Peripheral neuropathy
Pulmonary nodules
Anxiety disorder
Serous cystadenomas s/p BSO [**2128**]
Prior pneumothorax after trauma
PPD+, s/p INH x6 months
GERD
Possible history of reactive RPR
? arrest [**2-21**] accidental methadone OD
Hemorrhoids
Social History:
Has a son, [**Name (NI) 12395**] who is very involved in her care. Currently not
working, on disability. She quit smoking several years ago but
has a 60+ pack year history. History of IVDU- heroin (but has
not used for past 25 yrs) and methadone therapy, now off
methadone. Denies any recent drug use. Has previously lived in
[**Hospital 2251**] Nursing Home but moved to [**Location (un) **] to live in her own
apartment in [**2130-7-20**].
Family History:
Father with prostate cancer and arthritis. mother also has
arthritis. she has multiple maternal aunts with breast cancer,
dx in their 30s.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 99.2 BP: 115/48 P: 108 100% on CPAP FiO2 40%
General: intubated, off sedation, does not withdraw to pain in
any of the four extremities
HEENT: pupils 4mm and reactively bilaterally, difficult to
evaluate inside of mouth with ETT, OG tube and neck collar
Neck: supple, JVP difficult to eval with c-collar in place
Lungs: clear to ascultation anteriorly and laterally
CV: Regular rhythm, rapid rate, no murmurs, rubs, gallops
Abdomen: very soft, no grimace to palpation, mildly distended,
hypoactive bowel sounds, + fluid-wave, no organomegaly
GU: foley in place draining dark red urine
Ext: warm, well perfused, difficult to palpate pulses through
edema; 2+ peripheral edema, 1+ edema up to hips
Skin: bilateral lower extremity bullae anteriorly with
underlying ecchymoses and petechiae with skin tear on right
anterior shin
Pertinent Results:
[**2131-1-11**] 04:15AM URINE RBC-[**6-29**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2131-1-11**] 04:15AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-75
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD
[**2131-1-11**] 04:15AM FIBRINOGE-70*
[**2131-1-11**] 04:15AM WBC-11.0 RBC-3.30* HGB-10.0* HCT-29.8* MCV-90
MCH-30.2 MCHC-33.5 RDW-18.0*
[**2131-1-11**] 04:15AM LIPASE-60
[**2131-1-11**] 04:15AM ALT(SGPT)-477* AST(SGOT)-579* ALK PHOS-124*
TOT BILI-5.8*
[**2131-1-11**] 04:15AM UREA N-79* CREAT-3.0* SODIUM-136
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-14* ANION GAP-22*
[**2131-1-11**] 04:28AM freeCa-0.90*
[**2131-1-11**] 11:57AM LACTATE-7.2*
[**1-11**] RUQ u/s: IMPRESSION:
1. Patent hepatic veins and portal venous system. No evidence of
portal vein thrombosis.
2. Coarse nodular liver consistent with history of cirrhosis.
3. Thickened gallbladder wall likely due to chronic liver
disease and
sludge in the gallbladder.
4. Enlarged spleen measuring at the upper limits of normal at
12.6 cm.
5. No significant ascites in the right or left lower quadrants.
Mild-to-
moderate amount of ascites in the right upper quadrant in the
perihepatic
region.
[**1-11**] CXR: IMPRESSION:
1. ET tube terminating 5.1 cm above the carina.
2. Mild interstitial edema.
Brief Hospital Course:
58 year old woman with ESLD secondary to HCV cirrhosis, seizure
disorder, bipolar disorder, transferred from OSH intubated with
altered mental status after being found down at home.
On presentation to MICU, patient was not responsive to noxious
stimuli, despite no sedative medications. Altered mental status
was multifactorial, secondary to narcotic overdose and sepsis of
unknown source. Patient had been recently started on Hospice,
given methadone and liquid morphine to self-titrate for pain
control. Family noted that she had become increasingly
somnolent over the previous few days and later found a
significant amount of the narcotics missing from bottles.
Patient was felt to have overdosed on narcotics, as she did have
some mild response to narcan by EMS. Additionally, she was
thought to be septic because her WBC was elevated past her
baseline, and she presented with tachypenea, tachycardia,
hypothermia, and lactic acidosis. She was started initially on
ceftriaxone for empiric treatment of presumed SBP, though no
ascites noted on exam. Antibiotics were quickly broadened
further to Vancomycin and Zosyn, as patient's blood pressures
started slowly trending downwards and lactic acidosis worsened.
CXR was clear on presentation and UA was negative for infection.
Upon discussion with patient's hepatologist, Dr. [**Last Name (STitle) 497**], it was
discovered that she had signed DNR/DNI papers with Hospice nurse
earlier in the week and had agreed to comfort measures. Her son
had been present for this meeting but had requested intubation
at OSH; Dr. [**Last Name (STitle) 497**] had been present over telephone conference for
the meeting as well and confirmed comfort measures.
Family meeting was held in the MICU to discuss patient's
prognosis and wishes, and family agreed to withdraw care and
keep comfort measures. They made the decision to extubate her
the evening of [**1-11**]. Patient passed the next morning with
family at her bedside.
Medications on Admission:
FOLIC ACID - 1 mg Tablet daily
FUROSEMIDE - 80 mg Tablet daily
GABAPENTIN - 100 mg Capsule - 2 TID
LACTULOSE - 10 gram/15 mL Solution - 30 cc(s) TID
OMEPRAZOLE - 40 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) [**Hospital1 **]
RIFAXIMIN [XIFAXAN] - (record) - 200 mg Tablet - 2 Tablet(s)
TID
SPIRONOLACTONE 100 mg Tablet daily
TOPIRAMATE [TOPAMAX] 100 mg Tablet - QHS
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth Q6HR prn Pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis of unkown source
Narcotics Overdose
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"E850.1",
"443.9",
"530.81",
"571.5",
"356.9",
"584.9",
"345.90",
"296.80",
"995.91",
"V49.86",
"518.81",
"965.02",
"789.59",
"300.00",
"276.3",
"038.9",
"286.6",
"401.9",
"276.2",
"570",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8004, 8013
|
5510, 7488
|
318, 324
|
8099, 8108
|
4203, 5487
|
8161, 8260
|
3162, 3302
|
7975, 7981
|
8034, 8078
|
7514, 7952
|
8132, 8138
|
3317, 3331
|
258, 280
|
352, 2277
|
3345, 4184
|
2299, 2686
|
2702, 3146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,756
| 116,604
|
23199
|
Discharge summary
|
report
|
Admission Date: [**2161-11-22**] Discharge Date: [**2161-11-27**]
Date of Birth: [**2109-6-15**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Transfer from [**Hospital3 15174**] for treatment of
altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 52 year old woman with past medical history
significant for chronic pain on narcotics and benzodiazepines,
malabsorption syndrome due to complications of gastric bypass
surgery, and severe osteoporosis. Three days prior to her
admission to the outside hospital, the patient presented to her
PCP's office for evaluation of ~20 pound weight loss that had
occurred over the past 6-8 weeks. The patient was found to have
a urinary tract infection, and she was prescribed Ciprofloxacin.
The patient took two doses of the antibiotic. The following
day, the patient's husband noted that his wife seemed very
nervous and agitated. He called the PCP, [**Name10 (NameIs) 1023**] advised the
patient to discontinue the Ciprofloxacin. That evening, the
patient's husband noted that the patient was laughing
inappropriately while she watched TV. She thought the TV was
"talking to her." The patient's husband called 911, but by the
time the EMTs arrived at their home, the patient was able to
answer questions correctly, and she refused to go to the
hospital. The following morning, the patient was noted to be
more agitated, paranoid, and delusional, so her huaband called
911 again. This time, the patient was taken to
[**Hospital3 15174**].
On presentation to the outside hospital, the patient was
noted to have a low grade temperature (100.2). Her neurologic
exam was reported as "non-focal," and a non-contrast head CT was
negative for bleed. The patient's tox screen was negative for
ETOH. Her other laboratory data was unremarkable. The patient
was admitted to the hospital for treatment of narcotic
withdrawal.
During her 36 hour hospitalization, the patient was given two
doses of Buprenex. Subsequently, the patient became lethargic,
confused, combative, and agitated. She was transferred to the
ICU for further management. She was given a few doses of Haldol
and Ativan for her agitation. Lumbar puncture was unsuccessful.
Given her persistent agitation and concern for narcotic
withdrawal, the patient was transferred to [**Hospital1 18**] MICU for
further management.
Past Medical History:
Motor vehicle accident, complicated by R ankle injury and rib
fractures, [**2151**]
Chronic pain syndrome since motor vehicle accident
s/p R leg BKA due to R ankle injury in above MVA, [**2154**]
Malabsorption syndrome, s/p gastric bypass surgery for morbid
obesity, ~22 years ago
Asthma. Patient has been hospitalized for asthma exacerbations,
but she has never been intubated.
Relapsing-remitting multiple sclerosis, questionable diagnosis
~8 years ago. Patient given diagnosis based on problems with
motor coordination.
Depression. Hospitalized in [**2141**] at [**Hospital3 3765**] for
psychiatric illness.
Migraine
Social History:
The patient lives at home with her husband. She has three
children. Her husband states that she does not abuse tobacco,
alcohol, or illicit drugs. The patient is currently on SSI.
Family History:
Mother with alcoholism.
Physical Exam:
GEN: Agitated, diaphoretic, cachectic appearing female lying in
bed. Patient appears tremulous.
VS: T: 98.8 HR: 122 BP: 140/69 RR: 18 O2sat: 98% RA
HEENT: NC/AT. PERRL. EOMI. Pupils dilated ~3 mm. Edentulous.
MM dry. OP clear.
NECK: Supple. No nuchal rigidity. Palpable thyroid.
CVS: Tachycardic. S1, S2. No murmurs, rubs, or gallops.
LUNGS: CTAB. No rales, wheezes, or crackles.
ABD: Scaphoid, non-tender, non-distended, +BS.
EXT: Right stump without c/c/e. Left leg without c/c/e.
Extremities warm, well-perfused.
SKIN: No rashes or lesions.
NEURO: Patient thinks the year is "[**2162**]," knows she is in a
hospital, and thinks "[**Last Name (un) 2450**]" is the president. +Tremor. Strength
[**5-13**] in all extremities. Finger-to-nose intact. Reflexes 2+
throughout.
Pertinent Results:
[**2161-11-22**] 07:36PM WBC-10.0 RBC-3.68* HGB-8.5* HCT-27.6* MCV-75*
MCH-23.1* MCHC-30.8* RDW-22.6*
Labs on admission:
[**2161-11-22**] 07:36PM NEUTS-85.8* LYMPHS-10.0* MONOS-3.8 EOS-0.3
BASOS-0.1
[**2161-11-22**] 07:36PM PLT COUNT-878*
[**2161-11-22**] 07:36PM GLUCOSE-97 UREA N-7 CREAT-0.3* SODIUM-139
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2161-11-22**] 07:36PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-89 TOT
BILI-0.2
[**2161-11-22**] 07:36PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2161-11-22**] 07:36PM PT-13.1 PTT-26.9 INR(PT)-1.1
[**2161-11-22**] 07:36PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2161-11-22**] 07:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF) PROTEIN-28
GLUCOSE-76
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-370*
POLYS-20 LYMPHS-76 MONOS-4
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-2500*
[**2161-11-23**] 02:53AM BLOOD calTIBC-384 Ferritn-7.5* TRF-295
[**2161-11-22**] 07:36PM BLOOD VitB12-GREATER TH Folate-GREATER TH
[**2161-11-22**] 07:36PM BLOOD TSH-0.62
[**2161-11-22**] 07:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EKG:
(OSH)
Sinus tachycardia, 96 bpm. Nl int, nl axis. No ST/TW changes.
CXR:
No infiltrates or consolidations.
Labs on discharge:
[**2161-11-26**] 05:59AM BLOOD WBC-9.6 RBC-3.82* Hgb-8.6* Hct-29.0*
MCV-76* MCH-22.6* MCHC-29.8* RDW-22.5* Plt Ct-657*
[**2161-11-26**] 05:59AM BLOOD Plt Ct-657*
[**2161-11-26**] 05:59AM BLOOD Glucose-108* UreaN-12 Creat-0.3* Na-142
K-4.8 Cl-108 HCO3-32* AnGap-7*
[**2161-11-26**] 05:59AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
[**2161-11-25**] 07:51AM BLOOD tTG-IgA-DONE
[**2161-11-25**] 07:51AM BLOOD ENDOMYSIAL ANTIBODIES-PND
Brief Hospital Course:
1. MICU COURSE ([**Date range (1) 12258**]): Pt had an LP and the results of
the CSF analysis were unremarkable. Her mental status improved
in ICU and she became much more alert and was oriented by the
morning of the second hospital day. While in the ICU, the
chronic pain service was consulted. Their recommendations are
noted below.
2. Altered mental status: As above, the pt. underwent a lumbar
puncture, the results of which were not suggestive of CNS
infection as the cause of her encephalopathy. A TSH, B12 and
electrolytes were sent which were all within normal limits. An
RPR was sent and was nonreactive. Upon further discussion with
the pt. when she became more alert, it was discovered that after
taking the first two doses of ciprofloxacin the week prior to
admission, the pt. became extremely nauseous and had episodes of
emesis and diarrhea. This led the pt. to stop taking her
narcotics which she is on chronically for pain. Thus, it was
believed that the pt's. altered mental status was secondary to
narcotics withdrawal. It should be noted, however, that
ciprofloxacin has been associated with acute psychosis,
seizures, and acute delirium.
3. Chronic pain: The pt. reported that she had been on large
doses of oxycontin, valium and neurontin for pain in her right
shoulder, back and legs prior to admission. In the context of
her heavy narcotics use, a chronic pain service consult was
obtained while the pt. was in the intensive care unit. They
recommended stopping oxycontin and decreasing the dose of
valium. In addition, they recommended continuing neurontin and
adding methadone. The pt. initially tolerated this regimen
well. However, on the fourth hospital day, the pt. continued to
complain of leg spasms. Baclofen was introduced with some
success in relieving her spasms.
The pain service also recommended that the pt. be started on
celecoxib for musculoskeletal pain but this was held over the
concern of possible upper gastrointestinal bleeding in the
setting of iron deficiency anemia of yet uncertain etiology.
4. Iron deficiency anemia: The pt. was found to have profound
iron deficiency anemia on admission. Further discussion with
the pt. and her PCP revealed that the pt. has known iron
deficiency and has received supplementation in the past. A
gastroenterology consult was called. They had recommended
performing both colonoscopy to examine for occult malignancy
(especially in the face of recent unintentional weight loss and
cachexia) and an EGD to evaluate the anatomy of her upper GI
tract in light of her prior gastric bypass. The pt. did not
desire to undergo these procedures during this inpatient
hospitalization, but agreed to follow-up for these studies on an
outpatient basis. The importance of following-up regarding this
issue was explicitly stressed to the pt. prior to discharge.
She was discharged on 325mg of ferrous sulfate once per day.
5. Weight loss/cachexia/?malabsorption: In light of the pt's.
~20 pounds over the 6 to 8 weeks prior to admission, a nutrition
consult was obtained. They had recommended TPN in addition to
encouraging the pt. to increase her p.o. intake. The pt. did
received three days of TPN through a PICC line in addition to a
regular diet. There was, again, concern over occult malignancy
which further prompted the desire to perform a colonoscopy. A
breast exam was also performed as a part of a malignancy work-up
and was unremarkable. The pt. stated that she has had a
"negative" mammography within the last year.
The gastroenterology service also raised the possibility of
celiac disease and tTG-IgA and endomysial antibodies were sent
and were pending at the time of discharge.
There is also the possibility that her weight loss is secondary
to her profound depression with vegetative symptoms.
6. Depression: The pt. admitted to severe depression in the
months prior to admission. As such, the psychiatry service was
consulted. They recommended re-starting fluoxetine which was
done at a dose of 20mg per day.
7. Osteoporosis: The pt. was started on calcium and vitamin D
supplementation.
8. Migraine Headaches: The pt. complained of headache suggestive
of typical (not classical) migraine. Her pain was not relieved
with acetaminophen. A trial of subcutaneous sumatriptan,
however, did provide relief. She was discharged with a
prescription for subcutaneous sumatriptan with instructions to
stop taking the medication if she experienced flushing,
dizziness, fatigue (suggestive of serotonin syndrome due to
concomitant use of fluoxetine).
Medications on Admission:
[**Doctor First Name **] 180 mg PO daily
Premarin 1.25 mg PO daily
Maxair prn
Oxycontin 160 mg PO 8x/daily
Neurontin 600 mg PO daily
Percocet 325-650 mg PO q4-6hours prn pain
Valium 20 mg qid prn pain
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Methadone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 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. Sumatriptan Succinate 6 mg/0.5 mL Kit Sig: One (1)
Subcutaneous Q1H PRN as needed for headache not controlled by
tylenol: [**Month (only) 116**] repaat after one hour if headache not controlled by
first dose. Do NOT take more than 12mg in a 24 hour time
period.
Disp:*60 syringes* Refills:*2*
12. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
-acute delirium, likely secondary to narcotics withdrawal vs.
reaction to ciprofloxacin, resolved.
-iron deficiency anemia
-depression
-chronic pain
-osteoporosis
-migraine headache
Discharge Condition:
The pt. was alert and completely oriented. She was tolerating a
p.o. diet and eating well. She was ambulating with the
assistance of a walker.
Discharge Instructions:
Please take all of your medications as perscribed. Please
notice that you have had many medication changes. Please be
sure to attend all of your follow-up appointments. If you
experience any concerning symptoms, including dizziness,
flushing or confusion, please call your primary care doctor or
come to the emergency department for evaluation.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 59655**]
at [**Telephone/Fax (1) 26677**], to schedule a follow-up appointment regarding
this hospitalization within one week. It is strongly
recommmended that you undergo a colonoscopy and
esophagogastroduodenoscopy to investigate the cause of your
anemia and weight loss.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"V49.75",
"579.3",
"292.0",
"311",
"292.81",
"997.4",
"261",
"346.90",
"733.00",
"280.9",
"304.71",
"340",
"E931.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12454, 12460
|
6102, 6449
|
351, 358
|
12686, 12832
|
4204, 4313
|
13228, 13734
|
3361, 3386
|
10915, 12431
|
12481, 12665
|
10690, 10892
|
12856, 13205
|
3401, 4185
|
236, 313
|
5654, 6079
|
386, 2495
|
4328, 5634
|
6464, 10664
|
2517, 3146
|
3162, 3345
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,066
| 158,027
|
33253
|
Discharge summary
|
report
|
Admission Date: [**2160-2-13**] Discharge Date: [**2160-2-19**]
Date of Birth: [**2104-6-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
hypoxemia, hypotension
Major Surgical or Invasive Procedure:
Mechanical ventilation
History of Present Illness:
Ms. [**Name13 (STitle) 2819**] is a 55 yo woman with a Hodgkin's lymphoma s/p chemotx
x2, hypothyroidism and a h/o chemo-induced cardiomyopathy (now
resolved) who presents as a transfer from an OSH after being
found delirious at home.
.
Per the pt's son and daughter, she seemed abnormal on the phone
2 days prior to admission, but was not confused. On the day
prior to admission, the family reports that she was quite
confused on the phone, not knowing her address. As the family
did not know her exact address, they enlisted the help of others
to find her. Her landlord was eventually reached, and she called
EMS.
.
Upon EMS arrival, the pt was found in her bed as though she had
been there for a few days. She had been incontinent of urine and
there was a bucket ofvomit. She was A&Ox2. She was taken to an
OSH, where she was intubated for hypoxemic respiratory failure
(O2 sat 87% on 15L NC). She was not febrile, but was tachycardic
and hypotensive to the 80s systolic. A CXR demonstrated diffuse
R-sided infiltrate and LLL infiltrate. An initial CBC revealed
pancytopenia (WBC 2.9, Hct 17, Plt 34). She recieved 2 units
PRBCs, azithromycin, ceftriaxone and methylprednisolone. Her
blood pressure was maintained with dopamine. She was transferred
to the [**Hospital Unit Name 153**] for further management.
Past Medical History:
Hodkin's lymphoma
Hypothyroidism
h/o chemo-induced cardiomyopathy, resolved
Social History:
Lives by herself, recently moved from [**State **], former
substitute teacher, former smoker (quit 15-25 years ago), no h/o
EtOH abuse.
Family History:
n/c
Physical Exam:
Vitals: T: 97.1 BP: 54/31 P: 107 R: 16 SaO2: 100%, ventilated
General: sedated, intubated, opens eyes to command, does not
squeeze hands to command
HEENT: Pupils small but reactive 1->0.5, no scleral icterus, MM
dry
Neck: no LAD, supple
Pulmonary: Lungs CTA anteriorly bilaterally
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
.
Pertinent Results:
From OSH:
152 | 113 | 94 /
3.7 | 20 | 1.3\ 236
.
2.9\_5.9 _/
/ 17 \34
Diff: Neuts 96%; Lymphs 3%; Monos 1%; 0 Eos, 0 Basos
.
Total protein 6.5, Albumin 2.4, Globulin 4.1, Tbili 1.4, Dbili
0.5, AST 37, ALT 24, Alk phos 113; Amylase 70, Lipase 37.
.
LDH 445
CK 54
.
Selected [**Hospital1 18**] labs
[**2160-2-13**] 10:41PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
HCV Ab-NEGATIVE
[**2160-2-13**] 10:41PM FDP-40-80 FIBRINOGEN-1316*# D-DIMER-9619*
[**2160-2-13**] 03:59PM FIBRINOGE-1138* D-DIMER-8857*
[**2160-2-13**] 09:23PM LACTATE-2.4*
[**2160-2-13**] 04:15PM LACTATE-2.5*
[**2160-2-13**] 03:59PM HAPTOGLOB-552*
.
[**2160-2-13**] 03:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
[**2160-2-13**] 03:59PM WBC-1.8* RBC-1.84* HGB-6.4* HCT-19.4*
MCV-105* MCH-34.7* MCHC-33.0 RDW-19.4*
[**2160-2-13**] 03:59PM NEUTS-60 BANDS-18* LYMPHS-14* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-6* MYELOS-2*
[**2160-2-13**] 03:59PM PARST SMR-NEGATIVE
[**2160-2-13**] 03:59PM RET MAN-.9
.
[**2160-2-13**] 03:59PM GLUCOSE-209* UREA N-86* CREAT-1.7*
SODIUM-155* POTASSIUM-3.8 CHLORIDE-119* TOTAL CO2-25 ANION
GAP-15
[**2160-2-13**] 03:59PM ALT(SGPT)-18 AST(SGOT)-29 LD(LDH)-330*
CK(CPK)-49 ALK PHOS-90 AMYLASE-62 TOT BILI-1.3
[**2160-2-13**] 03:59PM CALCIUM-7.4* PHOSPHATE-3.2 MAGNESIUM-2.6
Brief Hospital Course:
55 yo woman with h/o Hodgkin's lymphoma s/p chemo x2 and
persistent pancytopenia presents with profound pancytopenia,
hypoxemic respiratory failure and sepsis.
.
Ms [**Name13 (STitle) 2819**] arrived to the MICU brought by [**Company 16410**] helicopter
from [**Hospital6 8283**]. She required ventilatory
support and pressors, starting with norepinephrine, and using a
low tidal-volume ventilatory strategy. Blood cultures ultimately
revealed strep pneumonia, E. coli, and [**Female First Name (un) **] albicans; she had
been broadly treated from the beginning and was ultimately
treated with levofloxacin (vancomycin was discontinued once
sensitivities on strep came back from MVH showing pan-sensitive
organism), cefepime, and caspofungin.
.
She was mildly responsive at different times in the first [**3-9**]
days of her stay but was not significantly responsive
thereafter. She required increasing levels of ventilatory
support, requiring frequent up-titrations of FiO2, increased
PEEP, and showing increasingly dire P/F ratios suggesting
advancing and refractory ARDS. Though she was started on a
single pressor for the last days of her admission she was
requiring three. Again, doses varied, but in the last two days
here she was so exquisitely dependent on pressors that her
pressures would drop precipitously even as nurses changed from
one bag of a pressor to the next.
The primary insult appeared to be a set of large consolidative
regions of her lungs, likely secondary to strep pneumonia, and
followed by sepsis and ARDS. Incidental note was made of
hypodensities on the liver (of unknown etiology), and cysts in
the lungs (likely non-pathologic given location of some in
healthy-appearing portions of lung). Though an abdominal process
could have contributed to her septic presentation, further
abdominal imaging was not possible because for most of her
admission the patient was not stable enough to take to CT scan
and ultrasound was minimally helpful given abdominal distension.
.
In sum, it appears that Ms [**Name13 (STitle) 2819**] acquired an infection in the
setting of pancytopenia and bone marrow fibrosis; was unable to
fight that infection (likely strep pneumo was the original
culprit); and then began having altered mental status and
vomiting, along with superimposed infections. She became septic,
and came to us with unrelenting sepsis and ARDS.
.
Ultimately after 7 days of attempting to improve her health, it
was clear that despite occasional gains, overall we were losing
ground. Her prospects of recovery were extremely slim. The team
discussed this with her son and daughter who had been present
and involved in her care, and together all agreed on stopping
her pressors and pulling back from aggressive interventions,
emphasizing comfort instead. It was clearly understood by all
that this would mean a hastened time of death compared to
pressing on with our prior life-sustaining but not life-saving
interventions.
She died about an hour-and-a-half after pressors were
discontinued, with her children present. She was kept on a
ventilator at this time to minimize respiratory discomfort
during the last period of her life, with the assessment that
removing the ventilator and subjecting the patient to sustained
respiratory distress would likely be more difficult for patient
and family than maintaining the ventilator while discontinuing
the pressors.
.
The family refused an autopsy.
Medications on Admission:
On transfer:
Dopamine gtt
Ceftriaxone
Azithromycin
Methylprednisolone
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis/ARDS
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"038.42",
"276.2",
"V10.72",
"244.9",
"573.8",
"V58.81",
"V64.3",
"785.52",
"780.09",
"112.89",
"284.1",
"481",
"995.92",
"276.0",
"287.5",
"V15.82",
"518.89",
"584.9",
"790.29",
"276.1",
"038.2",
"276.50",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"96.6",
"38.91",
"96.72",
"86.05",
"99.21"
] |
icd9pcs
|
[
[
[]
]
] |
7606, 7615
|
4030, 7457
|
339, 364
|
7670, 7680
|
2619, 4007
|
7732, 7739
|
1975, 1980
|
7578, 7583
|
7636, 7649
|
7483, 7555
|
7704, 7709
|
1995, 2600
|
276, 301
|
392, 1706
|
1728, 1805
|
1821, 1959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,354
| 173,369
|
28971
|
Discharge summary
|
report
|
Admission Date: [**2156-10-10**] Discharge Date: [**2156-10-21**]
Date of Birth: [**2098-1-26**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 13565**]
Chief Complaint:
Dysphagia - Myasthenia crisis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 39733**] is a 58 yo woman with DM, ESRD on dialysis, DM, CHF
and diagnosis of myasthenia [**Last Name (un) 2902**] presenting with worsening
dysphagia and weakness for the past 10 days.
Patient has diagnosis of [**First Name9 (NamePattern2) 69836**] [**Last Name (un) 2902**] since [**2142**] (see below
PMH for diagnosis history), having had 2 crisis with respiratory
distress in the past and several admission for plasmapheresis.
Patient has been tried on several medications including
corticosteroids, cellcept and cytoxan. Patient is poorly
compliant to treatment, she often misses her appointments and
she has been off medications for the past 2 months.
Patient reports that for the past 10 days she has had
progressive dysphagia, she chokes drinking water and has not
been able to take pills PO. She also reports that her legs have
been weaker, not being able to walk for the past few days. She
denied diplopia, ptosis or respiratory distress.
Patient was seen in [**Hospital 69837**] clinic by Dr. [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 4638**]
and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who recommended for her admission for
plasmapherisis.
In ER, patient had NIF -20/-15, VC 1 L in ED with poor effort
Past Medical History:
1. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]: diagnosed with myasthenia [**Last Name (un) 2902**] in [**2142**]
with a presentation with ptosis and episodic double vision. She
subsequently developed dysarthria, dysphagia, and mild neck and
limb weakness, and was initially evaulated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
the [**State 1558**], [**Hospital1 1559**]. Her work-up
included
acteylcholine receptor antibodies which were positive.
Initially,
she was treated with high-dose prednisone at 80 mg a day. The
patient stated that on this dose of prednisone, she had an
increase in her serum glucoses that were difficult to control
because of her type 2 diabetes. She was then started on trials
of various steroid-sparing agents, complicated by side effects,
and has included:
a. IV Cytoxan, which she stated that she did not tolerate
because
of diarrhea.
b. CellCept, which she could not tolerate because she could not
swallow it.
c. she thinks she has tried cyclosporine in the past as well Dr.
[**First Name (STitle) **] eventually put her on Imuran, which she has been on for
the last 12 years.
2. Poorly controlled diabetes
3. ESRD
4. Neuropathy
5. HTN
6. Congestive heart failure.
Social History:
She lives by herself, smokes 1 pck cigarette per day for the
past 40 years, no alcohol use or illicit drug use. She used to
work with medical trascription.
Family History:
No hx of [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**] in the family, father died of lung
cancer and mother had DM.
Physical Exam:
T 97 BP 182/69 HR 63 RR 23
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2,
Lung: Clear to auscultation bilaterally
Abd: ascitic, nontender
Ext: ulcer on L toe; warmth and mild erythma on lower
extremities
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**3-15**], recalls [**3-15**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils: surgical on L eye and cataract on R eye. Visual fields
are full to confrontation. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1-V3. Facial
movement symmetric. Hearing intact to finger rub bilaterally.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 4- 5- 5 5 5 5 5 4- 5 5 5 5 5 5
L 4- 5- 5 5 5 5 5 4- 5 5 5 5 5 5
Neck flexor: 4-
Sensation: Decreased to touch, pinprick, vibration on lower
extremities and proprioception throughout. No extinction to DSS
Reflexes: Trace to 1+ at the biceps and knees.
Gait: Not checked, pt came in wheelchair today.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Pt could not stand up
Pertinent Results:
[**2156-10-10**] 01:50PM BLOOD WBC-10.3 RBC-4.40 Hgb-13.0 Hct-41.4
MCV-94 MCH-29.6 MCHC-31.4 RDW-16.3* Plt Ct-189
[**2156-10-10**] 01:50PM BLOOD Glucose-90 UreaN-16 Creat-3.2*# Na-140
K-4.9 Cl-97 HCO3-38* AnGap-10
[**2156-10-10**] 01:50PM BLOOD CK(CPK)-29
[**2156-10-10**] 01:50PM BLOOD cTropnT-0.22*
[**2156-10-10**] 08:00PM BLOOD cTropnT-0.19*
[**2156-10-11**] 04:23AM BLOOD cTropnT-0.22*
[**2156-10-12**] 05:00AM BLOOD cTropnT-0.20*
[**2156-10-10**] 01:50AM BLOOD %HbA1c-6.9*
[**2156-10-10**] 08:00PM BLOOD TSH-2.3
[**2156-10-10**] 06:27PM BLOOD Type-ART pO2-64* pCO2-50* pH-7.46*
calTCO2-37* Base XS-9
[**2156-10-10**] 06:27PM BLOOD Lactate-1.8
Echo [**10-11**]: Moderate left ventricular hypertrophy with preserved
regional/global biventricular systolic function (LVEF > 55%).
Moderate diastolic dysfunction with evidence of elevated filling
pressures. Right ventricular hypertrophy with normal function
and evidence of RV pressure overload. At least moderate
pulmonary hypertension (PCWP > 18mmHg). Mild aortic stenosis and
trivial regurgitation. Mild to moderate mitral and tricuspid
regurgitation. Mild functional mitral stenosis from extensive
mitral annular calcification.
Brief Hospital Course:
Patient is a 58 year old RHW with DM, ESRD on dialysis, DM, CHF
and diagnosis of myasthenia [**Last Name (un) 2902**] in [**2142**] presenting with
worsening dysphagia and weakness for the past 10 days after
being off medications for the past 2 months due to running out
of her meds. Patient reports not being able to swallow solids
nor to walk at home for the past few days but denied dyspnea,
double vision or ptosis. Patient is poorly compliant to
treatment. Neurological exam remarkable for weakness in lower
extremities and in the ER, patient had NIF -20/-15, VC 1 L in
ED with poor effort.
She was admitted to ICU initially given her serious condition
and the possibility for need for intubation. She was monitored
closely and was followed per Dr. [**Last Name (STitle) **]/[**Doctor Last Name 4638**] throughout this
admission. She was started on plasmapheresis on [**10-11**] - morning
after admission using her HD catheter and renal followed her as
well for her ESRD and HD. She was urgently dialyzed on [**10-11**]
after plasmapheresis. She tolerated both well without
respiratory distress or hemodynamic instability. She was
continued on Imuran (50mg [**Hospital1 **]) and Mestinon 15mg daily. She was
also started on prednisone (1mg/kg/day = 45mg/day). NIF and VC
were checked every 3~4 hrs and continued to improved especially
after the 1st round of plasmapheresis.
She was transferred to Neuro Step down on [**10-12**] given that she
was more stable. She received 5 cycles of plasmapheresis every
other day and continued to get HD as recommended per renal who
also recommended an echo which showed preserved ventricular
function (LVEF > 55%) but mild pulm HTN with PCWP > 18mmHg.
Upon admission to the neurology team she had improved strength
but was refusing to take her mediactions PO. He imuran and
steroids were changed to IV. She continued to have her NIF's
and VC checked on a q6-8hr basis. They continued to improve and
stabilized around normal for age and wt (with some intermitent
poor results due to poor effort.) She also began to take her
mestinon more regularly, which also improved her strength.
Towards the end of her stay she was changed back to PO meds and
her imuran was increased to 100mg in am and 50mg in PM. She
also began to take more doses of mestinon on a prn basis.
As her strength improved, she began to eat more, and this mainly
consisted of peanut butter and jelly sandwhiches. Her
fingerstick glucose checks began to consistently range in the
300-500 range. She was then started on 16 units of lantus on
top of her sliding scale of regular insulin. This succesfully
brought her to more acceptable ranges. She completed 5 sessions
of plasma exhange with no complications. While admitted she
continued her hemodialysis schedule.
By time of discharge, he strength was much improved and she had
less fatiguablilty. PT was consulted and determined she
required no outpt services. Social work was consulted as well
and helped her get set up with support services in her area.
She was scheduled to follow-up with Dr. [**Last Name (STitle) **] in clinic.
Medications on Admission:
Medications (of note, she has taken none for the last 5 days and
noted dose are what she was on when before she ran out 2 months
ago):
Insulin
Imuran 150 mg daily.
Prednisone 30 mg a day alternating with 10 mg a day.
Lasix
Mestinon 15 mg (she can't tolerate more due to severe diarrhea).
She was prescribed Levsin but has apparently not taken it.
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual [**Hospital1 **] (2 times a day) as needed for
with mestinon to prevent diarrhea.
Disp:*60 Tablet, Sublingual(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours).
7. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous once a day.
Disp:*480 units* Refills:*2*
8. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
9. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): take in the morning.
Disp:*60 Tablet(s)* Refills:*2*
11. Pyridostigmine Bromide 60 mg Tablet Sig: 0.25 Tablet PO HS
(at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) **]
Diabetes
End stage renal disease
Discharge Condition:
Improved
Discharge Instructions:
You were admitted because your myasthenia was not well
controlled. Please continue to take your medications when you
are discharged. If you start to have worsening weakness, please
call your neurologist or come to the emergency room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**12-3**] at noon in the
[**Hospital Ward Name 23**] building [**Location (un) **]
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23,933
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7538
|
Discharge summary
|
report
|
Admission Date: [**2112-1-26**] Discharge Date: [**2112-2-4**]
Date of Birth: [**2039-11-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Weakness, fatigue
Major Surgical or Invasive Procedure:
Right IJ central line
History of Present Illness:
Mr. [**Known lastname 27548**] is a 72-year-old gentleman with h/o renal transplant
in [**2104**] with a 90 pack-year smoking history recently diagnosed
with poorly differentiated adenocarcinoma of the lung (by
resection of PET positive left upper lobe nodule with no
evidence of disease dissemination) who was discharged on [**1-24**]
after being admitted for a bronchoscopy, left video thoracoscopy
with biopsy of mediastinal lymph nodes, and video-assisted wedge
resection of an upper lobe nodule which he tolerated well. He
has been feeling nauseated art home since discharge and has also
experienced anorexia, lethergy, lightheadedness. Of note, he has
not taken insulin at home x 2 days. At time of discharge on
[**1-24**], he had a rising WBC at 12.5.
.
This gentleman has significant comorbidities including
insulin-dependent diabetes mellitus, hypertension, increased
serum cholesterol, coronary artery disease status post prior
myocardial infarction and severe peripheral vascular disease
with bilateral lower extremity revascularizations. He recently
underwent a revision of this right femoral posterior tibial
graft when this lesion was detected. The patient has a
90-pack-year smoking history, having quit in [**2083**]. He has no new
pulmonary symptoms. He also has crippling arthritis that has
left him wheelchair bound. A preoperative evaluation showed no
critical coronary disease and preserved ventricular function.
.
In the ED, he was found to be in DKA with a gap of 18. In
addition, he had a UTI with 21-50 WBCs, Many bacteria, Mod
Leuks, 15 Ketones, 1000 glucose, 0-2 EPIs. His WBCs were 20 on
CBC with a HCT of 30 (last HCT 33 on [**1-20**]). CXR was unchanged
from prior on [**1-20**]. He received 400mg Cipro IV, 1g Vancomycin
and Insulin gtt with Calcium Gluconate. A renal ultrasound was
done and showed no evidence of hydronephrosis. Renal transplant
and CT [**Doctor First Name **] saw the pt in the ED. He received a total of 1L of
fluids. Prior to coming up, the patient had respiratory
compromise requiring Bipap thought secondary to acute pulmonary
edema.
Past Medical History:
- ESRD s/p living unrelated renal transplant (from wife) in
[**9-/2105**] on multiple immunosuppressants
-Adenocarcinoma of lung (T1N0M0) s/p VATs w/ wedge resection &
lymph node biopsy on [**2112-1-20**]
- CAD s/p myocardial infarction
- Severe peripheral vascular disease s/p bilateral lower
extremity revascularizations (and recent revision). Also, s/p
bilateral toe amputations. Pt is wheelchair bound b/c of this.
- 90 pack-year smoking history quit in [**2083**]
- Diabetes x 25 years on home insulin
- Hypertension
- Hypercholesterolemia
- Severe osteoarthritis effecting the hips, shoulders, knees
- Spinal stenosis which causes back pain
Social History:
Smoked cigarettes until [**2083**]. No alcohol ingestion. He lives at
home, is married with 3 grown children and was previously a
truck driver.
Family History:
Father had lung cancer, died of stroke. No history of coronary
disease
Physical Exam:
VS - Tm 100 Tc BP: 150/44 (137-172/42-86) HR: 75 (72-88)
RR 21 O2sat 96% on 3L
FSBS - 162, 188, 226, 168, 125
General: obese man, pleasant, comfortable, sitting up in chair
HEENT: PERLLA, EOMI, anicteric, no scleral icterus, MMM, OP
clear, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid
Lungs: CTAB
Heart: RR, Nml S1 and S2, no murmurs, rubs or gallops
appreciated
Abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
Extremities: 2+ b/l LE edema, pressure dressing in place around
calves. Abrasion right knee, healing. Toes amputated. Pulses
dopplerable ([**Name8 (MD) **] RN report).
Neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch.
.
Pertinent Results:
Admission labs:
[**2112-1-26**] 05:50PM GLUCOSE-377* UREA N-50* CREAT-2.7*
SODIUM-130* POTASSIUM-6.1* CHLORIDE-92* TOTAL CO2-20* ANION
GAP-24*
[**2112-1-26**] 05:50PM CK(CPK)-229*
[**2112-1-26**] 05:50PM CK-MB-3 cTropnT-0.09*
[**2112-1-26**] 05:50PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-3.7
MAGNESIUM-2.7*
[**2112-1-26**] 05:50PM WBC-20.8*# RBC-4.04* HGB-10.0* HCT-30.7*
MCV-76* MCH-24.6* MCHC-32.5 RDW-16.4*
[**2112-1-26**] 05:50PM NEUTS-95.3* BANDS-0 LYMPHS-2.0* MONOS-2.4
EOS-0.2 BASOS-0.1
[**2112-1-26**] 05:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2112-1-26**] 05:50PM URINE RBC-[**6-5**]* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
.
Discharge labs:
[**2112-2-4**] 04:55AM BLOOD WBC-8.2 RBC-3.49* Hgb-8.4* Hct-26.3*
MCV-76* MCH-24.2* MCHC-32.0 RDW-16.9* Plt Ct-711*
[**2112-2-4**] 04:55AM BLOOD Glucose-90 UreaN-42* Creat-1.9* Na-140
K-4.7 Cl-103 HCO3-30 AnGap-12
[**2112-2-4**] 04:55AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.3
.
Imaging:
[**2112-2-1**] - Ultrasound of renal transplant.
INDICATION: Difficulty voiding.
FINDINGS: The transplant kidney in the left lower quadrant is
visualized and measures 11.6 cm in maximum length. There is
normal renal cortical thickness. The resistive index measures
approximately 0.8. No evidence of any perinephric collections.
The bladder measures 7.9 cm in transverse x 7.5 cm in AP x 9 cm,
pre-voiding and is relatively unchanged post-voiding and
measures approximately 9 x 7 x 8.6 cm, representing a bladder
volume post-micturition of 334 mL.
IMPRESSION: Transplant kidney in left lower quadrant relatively
unremarkable with significant post-micturition residual volume
of 334 mL.
[**2112-1-27**] ECHO
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated athe sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is a minimally
increased gradient consistent with trivial mitral stenosis. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2111-12-15**],
no change.
Brief Hospital Course:
72yo man with multiple medical problems including renal
transplant, DM, severe PVD, CAD, recent dx of lung CA who p/w
DKA & klebsiella. Now, stable.
.
#Klebsiella Urosepsis: on admission, pt found to have
pan-sensitive Klebsiella growing in blood (2/4 bottles). His UA
was also positive, though urine culture was negative. He
receieved ciprofloxacin for the infection. It was felt his
urine was the source of the bacteremia. Surveillance blood
cultures cleared following initiation of anti-biotics.
.
# DKA: Pt was admitted to the MICU, where he was started on an
insulin drip and fluids for DKA. The trigger for his DKA was
thought to be his infection along with his non-compliance with
insulin during the days prior to admission. Once his gap
closed, he was transferred to the medicine [**Hospital1 **]. [**Last Name (un) **] was
consulted. They recommended changing his lantus to NPH and
tightening his sliding scale. His blood sugars came under
better control with this regimen.
.
# ARF: Pt had acute renal failure on admission that was thought
to be due to pre-renal etiology in setting of DKA. There was no
evidence of pyelonephritis, nor hydronephrosis. Creatinine
peaked at 3.2 and improved with fluid. Crt trended down to 1.9
at time of discharge.
.
# Renal Transplant: Pt is s/p living unrelated transplant from
his wife in 10/[**2104**]. Baseline Crt 1.7-2. Pt was followed by
renal transplant team and pt's primary nephrologist. His
immunosuppressants (Prednisone, Cellcept, Sirolimus) were
continued though his Cellcept dose was decreased in the setting
of his infection--500mg of Cellcept three times a day (rather
than 1000mg 3 times daily). He was continued on prophylactic
Bactrim.
The pt was started on Epogen for his CKD related anemia.
.
# Urinary retention: Pt has a history of BPH. During his recent
admission, he had marked difficulty voiding after having foley
removed. Alpha agonists were started with minimal improvement.
Given concern of obstruction, a foley was placed during this
admission. Pt then underwent renal US which showed no evidence
of obstruction/hydronephrosis; though it did reveal high
post-void residual (334cc). Urology was contact[**Name (NI) **] and they
recommended that the pt be discharged with a foley in place and
follow-up in the urology clinic. The pt refused this. He was
informed that he could instead perform intermittant straight
catheterization instead. He refused both interventions. The
risks of withholding home catheterization was explained. The pt
voiced understanding of potential risk to kidneys & bladder.
Post-void residual of 215cc on day of discharge.
.
# CHF: Following administration of fluids on admission, the pt
developed worsening LE edema. His lasix was restarted with good
effect.
.
# Lung CA: Pt recently diagnosed with poorly differentiated
adenocarcinoma of the lung on [**2112-1-20**]. Pt is followed by Dr.
[**Last Name (STitle) **] of CT [**Doctor First Name **].
.
# Thrombocytosis: likely reactive. To be followed up with pt's
nephrologist.
.
# Hypertension: Pt continued on home regimen.
.
# Hypercholesterolemia: Continued Lipitor, holding Niacin
.
# LE wounds: Pt has multiple superficial wounds on his LE. His
surgeon, Dr. [**Last Name (STitle) **], has seen them and recommended daily dressing
changes. These did not appear infected. The pt was diuresed to
minimize edema and promote healing.
.
# CAD: S/P angioplasty with stents in [**2103**]. MI in [**2104**]. Trop
elevated up to 0.17 on [**2112-1-27**]. CK 258, CK-MB 3. He complained
of no CP. EKG unchanged. Pt likely had mild demand ischemia w/
troponin leak in the setting of DKA. He was continued on
metoprolol, Norvasc, and ASA.
.
# OA: Ongoing, debilitating problem. Pt received Percocet PRN.
.
# CODE: FULL, confirmed with pt on admission. Does not want
long-term intubation
Medications on Admission:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 75mg PO BID
8. Gabapentin 100 mg Capsule PO BID
9. Sirolimus 2mg PO HS (at bedtime).
10. Mycophenolate Mofetil 500 mg TID (3 times a day).
11. NPH insulin 100 units [**Hospital1 **] and sliding scale humalog
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One PO
DAILY
13. Lipitor 20 mg Tablet Sig: Three (3) Tablet PO once a day.
14. Niaspan 500 mg Tablet Sustained Release One PO at bedtime.
15. Colace 100 mg Capsule One PO twice a day as needed
.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
14. Epoetin Alfa 3,000 unit/mL Solution Sig: Two (2) ml
Injection Tues and Thursday: 6000units to be injected twice a
week.
Disp:*360 ml* Refills:*2*
15. Humalog 100 unit/mL Solution Sig: based on sliding scale
Subcutaneous Brkfast, lunch, dinner, bedtime.
16. One Touch Basic System Kit Sig: One (1) kit
Miscellaneous as needed.
Disp:*1 kit* Refills:*0*
17. One Touch UltraSoft Lancets Misc Sig: with finger sticks
Miscellaneous brkfast, lunch, dinner, bedtime.
Disp:*200 lancets'* Refills:*2*
18. One Touch II Test Strip Sig: one Miscellaneous with
finger sticks.
Disp:*200 strips* Refills:*2*
19. Lasix 20 mg Tablet Sig: One (1) Tablet PO QPM as needed for
worsening leg swelling.
Disp:*30 Tablet(s)* Refills:*1*
20. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty
(60) units Subcutaneous Breakfast and bedtime.
22. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Klebsiella Urinary Tract Infection
2. Klebsiella Bacteremia - Sepsis
3. Hypoxic Respiratory Failure
4. Diabetic Ketoacidosis
5. Symptomatic Hypoglycemia/Hypothermia.
6. Acute Renal Failure
7. Diastolic Heart Failure
8. BPH - Urinary Retention--post void residual of 215cc on
discharge; pt refused foley & intermittant straight
catheterization.
9. Thrombocytosis (likely reactive)
.
Secondary:
1. ESRD s/p LURT [**2104**]
2. CKD Stage III
3. Chronic Immunosupression
4. Diabetes Mellitus Type I Controlled with Complications
5. Single-Vessel Coronary Artery Disease s/p PTCA [**2103**], MI [**2104**]
6. Mild Aortic Stenosis (AoVA 1.2-1.9cm2).
7. S/P Left Fem-Tib BPG [**2107**].
8. LUL Adenocarcinoma s/p Wedge Resection
9. Osteoarthritis
10. Spinal Stenosis
11. PVD s/p Bilateral Lower Extremity BPG
12. Bilateral Lower Extremity Toe Amputations.
13. Hypertension
14. Hypercholesteremia
15. Anemia of Chronic Kidney Disease
Discharge Condition:
Good, afebrile; post-void residual of 215cc on discharge; pt
refused foley & intermittant straight catheterization. Risks of
withholding from catheterization explained and pt voiced
understanding of potential risk to kidneys & bladder.
Discharge Instructions:
You were admitted to the hospital with a urinary tract infection
that spread to your blood. Complicating this was very high
blood sugar levels. These have both been treated--with
anti-biotics and insulin, respectively.
.
You are having urinary retention, which needs to be further
evaluated and treated by a urologist.
.
Please take your medications as prescribed.
Your diabetes medications have been adjusted. You will be
taking NPH at home along with a humalog sliding scale and keep
track of your blood sugar levels.
.
You were also started on a new medication called Epogen (Epoetin
Alfa), which is a shot that is given for anemia. You will need
to give yourself this shot twice a week.
.
You will complete a total of 2wks of antibiotics (Cipro) for
your infection.
.
You should take only 500mg of Cellcept three times a day (rather
than 1000mg 3 times daily).
.
Resume your sirolimus at 3mg daily at home.
Your lopressor (ie, metoprolol) was increased from 75mg twice
daily to 100mg twice daily.
.
Please contact your doctor or call 911 if you experience fever,
chills, rash, chest pain, shortness of breath, nausea, vomiting,
or any other concerning change in your condition.
Followup Instructions:
Please see Dr. [**First Name (STitle) 805**] in clinic in 2wks. Please call for an
appointment. You should have your Sirolimus level checked along
with a CBC (your platelet count has been elevated and should be
followed up).
.
Please call Dr.[**Name (NI) 825**] office (urology) to make the nearest
available appointment for urinary retention. ([**Telephone/Fax (1) 7707**]
Please see your primary care doctor as needed.
|
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"362.01",
"V49.71",
"788.20",
"584.9",
"041.3",
"996.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13901, 13959
|
6971, 10832
|
298, 322
|
14958, 15197
|
4107, 4107
|
16431, 16857
|
3290, 3362
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4848, 6948
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3377, 4088
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241, 260
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350, 2441
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4123, 4832
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2463, 3112
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3128, 3274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,536
| 121,055
|
54138
|
Discharge summary
|
report
|
Admission Date: [**2147-9-3**] Discharge Date: [**2147-9-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardic Catheterization with percutaneous angioplasty
History of Present Illness:
84 yo M with HTN, hyperlipidemia, PVD, CAD s/p MI [**2120**]'s, h/o L
nephrectomy admitted with inferior STEMI s/p Cath and BMS x2 to
RCA. Pt reports that he awoke at 4 AM on the morning of
admission and noted that he had substernal aching in his chest.
In addition he noted that he had L sided jaw ache, diaphoresis,
nausea and vomiting. He took NTG x3 with no relief in pain.
The aching in his chest continued until 7 AM when he called his
son and was taken to [**Name (NI) 2025**]. He reports that he was told that he
lost consciousness several times since coming to the hospital.
Nothing relieved his pain, which was finally relieved during
cardiac cath. Chest pain free on arrival to the CCU.
.
In ED given ASA 325, NTG gtt, Plavix 600mg po x1, Heparin gtt,
Integrilin gtt and transferred to ED. He was noted to be
bradycardic and vomiting with HR in 30's , hypotensive SBP 70's.
Transferred to cath lab.
.
Cardiac cath with mid occlusion of RCA with no collaterals, s/p
BMS x2 to RCA.
.
He had been in his usual state of health prior to this am. He
has had no chest pain in the past, even with his prior MI and
has never had to use his NTG prior to this AM. He has been
taking all of his medications except for his ASA which he
stopped 1 1/2 weeks ago as he ran out of his pills. He has not
had any decrease in exercise tolerance and has been able to go
up 13 steps and walk around his neighborhood without any
shortness of breath. He denies orthopnea, PND, lower extremity
edema, palpitations, dyspnea on exertion. He does report
occasional left buttock pain with exercise relieved with rest.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, joint pains, cough, hemoptysis, black stools or
red stools. He denies recent fevers, chills or rigors. All of
the other review of systems were negative.
Past Medical History:
Past Medical History:
1. Coronary artery disease; a myocardial infarction in [**2126**].
A normal stress echocardiogram in [**2142-11-9**] with left
ventricular ejection fraction of 55% and trace aortic
regurgitation. Cardiac cath,[**1-13**] stress: negative, LV normal
wall motion ,small fixed distal anterior wall defect per OMR.
2. History of hypertension.
3. Peptic ulcer disease.
4. Abdominal aortic aneurysm; status post repair.
5. Renal cell carcinoma; status post left nephrectomy.
6. Hyperlipdemia
7. Syncope in [**2143**] attributed to vasovagal reaction vs
orthostatic hypotension
*
Past Surgical History
1) Poplitial aneurym excised/bypass [**9-13**]
2) Left iliac aa [**2-13**]
3) AAA repair w bilat iliac aa repair [**11/2135**],
4) Lt. thorocoabdominal Nephrectomy [**2-/2139**],
5) Angio [**2-13**] with embolization of left hypogastric artery
6) Left inguinal hernia repari
7) Vasectomy
Social History:
Retired, worked in chemical compnay mixing compounds. Widowed 9
years ago, but has 5 children, 4 of whom live locally, and 16
grandchildren. Pt was a smoker, but quit in [**2126**]. Never drank
much alcohol and currently drinks none. Was a singer/son[**Name (NI) 110963**]
in his freetime.
Family History:
non contributary
Physical Exam:
VS: T 97.8 BP 142/86 HR 72 RR 17 96%2L
Gen: alert, lying flat, appears comfortable, answers questions
appropriately
HEENT: JVP around 7-8cm
CV: distant heart sounds, RRR no murmur auscultated
Lungs: unable to assess posterior lung fields as he is lying
flat with sheaths still in place, anterior lung fields CTAB
Abd: obese, soft, nontender BS+
Ext: no pedal edema, DP's 2+ bilaterally, Sheaths in place in R
femoral A and V, oozing around site
.
Pertinent Results:
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 GUIDE catheter, with manual
contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
bare-metal stent(s).
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2 m2
HEMOGLOBIN: 16 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 10/11/8
RIGHT VENTRICLE {s/ed} 34/10
PULMONARY ARTERY {s/d/m} 34/17/23
PULMONARY WEDGE {a/v/m} 19/25/16
AORTA {s/d/m} 144/82/104
**CARDIAC OUTPUT
HEART RATE {beats/min} 85
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 56
CARD. OP/IND FICK {l/mn/m2} 4.5/2.2
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1707
PULMONARY VASC. RESISTANCE 124
**% SATURATION DATA (NL)
PA MAIN 73
AO 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED
2) MID RCA DISCRETE 2
2A) ACUTE MARGINAL DIFFUSELY DISEASED
3) DISTAL RCA DIFFUSELY DISEASED
4) R-PDA DIFFUSELY DISEASED
4A) R-POST-LAT DIFFUSELY DISEASED
4B) R-LV DISCRETE 60
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DIFFUSELY DISEASED
6) PROXIMAL LAD DIFFUSELY DISEASED 10
6A) SEPTAL-1 DIFFUSELY DISEASED
7) MID-LAD DIFFUSELY DISEASED 10
8) DISTAL LAD DIFFUSELY DISEASED 10
9) DIAGONAL-1 DIFFUSELY DISEASED 10
10) DIAGONAL-2 DIFFUSELY DISEASED 10
12) PROXIMAL CX DIFFUSELY DISEASED 10
13) MID CX DIFFUSELY DISEASED 10
13A) DISTAL CX DIFFUSELY DISEASED 10
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 10
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 10
**PTCA RESULTS
RCA
**BASELINE
STENOSIS PRE-PTCA 100
COLLATERAL GRADE (0-2) 0
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH JR4 GUID
GUIDEWIRES CHOICE P
INITIAL BALLOON (mm) 2.0
FINAL BALLOON (mm) 4.0
# INFLATIONS 5
MAX PRESSURE (PSI) 270
**RESULT
STENOSIS POST-PTCA 0
DISSECTION (0-4) 0
SUCCESS? (Y/N) Y
PTCA COMMENTS: The initial angiography revealed a total
occlusion of
the large mid RCA with some chronic component to it and
calcifications
but no collaterals and with large thrombus burden. Heparin and
integrilin were administered for anticoagulation. The initial
stragegy
was to predilate the lesion to reestablish flow and perform
thrombectomy
given large thrombus burden and risk of no-reflow. JR4 Guide
provided
good support. Choice PT XS wire crossed the lesion with some
difficulty.
2.0 X 20 mm Voyager baloon was used to predilate the lesion
reestablishing flow. X-Sizer device could not advance past the
lesion
and despite another predilation with a 2.5 X 30 mm Maverick
baloon at 10
atms. Therefore an angiojet device was used for thrombectomy
with good
result. Pacer was placed in the RV and 1 mg of atropine was
administered
for transient bradycardia and hypotension during the angiojet.
3.5 X 28
mm bare metal Vision stent was placed in the distal RCA and
deployed at
18 atms. Subsequently a 4.0 X 16 mm Liberte baremetal stent was
placed
proximally in an overlapping fashion and deployed at 18 atms.
The
overlap was postdilated as was the proximal edge of the stent.
There was
no residual stenosis in the stented segment. TIMI flow was III
and there
was no dissection or distal embolization. The patient left the
cath lab
pain free and in stable condition to the coronary care unit.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 23 minutes.
Arterial time = 1 hour 23 minutes.
Fluoro time = 28 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 320
ml, Indications - Renal
Premedications:
integrilin 8.5 ml bolus and 14.9 ml/hr drip
Heparin 1000
1% Lidocaine subq.
Anticoagulation:
Heparin 1000 units IV
Other medication:
Nicardipine 400 mcg IC
Nitroglycerine 200 mcg IC
Atropine 1 mg IV
Cardiac Cath Supplies Used:
3.5 [**Doctor Last Name **], VISION 08MM
.014 [**Company **], CHOICE PT XS, 300CM
.014 [**Company **], CHOICE PT XS, 300CM
2.0 [**Company **], MAVERICK 20MM
2.5 [**Company **], MAVERICK 30MM
6F CORDIS, JR 4 SH
- EV3, X-SIZER
- POSSIS, ANGIOJET XMI 135CM
5F BARD, PACING WIRE
4.0 [**Company **], LIBERTE 08MM
- ALLEGIANCE, CUSTOM STERILE PACK
- POSSIS, ANGIOJET PUMPSET
- GUIDANT, PRIORITY PACK 20/30
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
mild disease in the LMCA. LAD and LCX had mild non-critical
disease
throughout. RCA was totally occluded in the mid vessel without
collaterals and large thrombus burden, as well as proximal
calcifications.
2. Left ventriculography was deferred given renal insufficiency.
3. Hemodynamic assessment showed no evidence of right heart
failure with
normal RVEDP and PCWP. Cardiac index was preserved at 2.2
L/min/M2.
4. Successful stenting of the mid to distal totally occluded RCA
with
two overlapping baremetal stents 4.0 X 16 Liberte and 3.5 X 28
Vision
without residual stenosis. Thrombectomy was also performed with
resultant TIMI III flow and no evidence of embolization (see
PTCA
commenst for detail).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Acute inferior myocardial infarction, managed by acute ptca.
4. Successful PTCA of RCA vessel with thrombectomy and baremetal
stent
placement.
Brief Hospital Course:
# CAD - IMI STEMI s/p BMS x2 to RCA most likely [**2-10**] to acute
thrombosis. He has not had any prior angina or decreased
activity tolerance making progressive occlusion less likely. In
addition, he stopped taking his ASA for the past 1.5 weeks which
may have played a role in acute MI. Patient had a peaked at
1450, and has been trending downward. He will be discharged on
plavix, aspirin, statin, metoprolol. Patient has not been
hypertensive, so home HCTZ was stopped. A follow up echo after
catherization showed mild inferior-basal hypokenesis with an EF
of 50%.
.
#Chronic Renal Insufficiency - s/p left nephrectomy for RCC,
baseline CR 1.8-2. Recieved 320ml contrast during cardiac cath
so he is at high risk of contrast nephropathy. Patient given
continued hydration after cath, and Cr at d/c is 2.0.
.
#Guiac positive emesis - became transiently hypotensive and
vomited with sheath pull, coffee ground vomitus, Guiac positive,
no bright red blood. Concerning as he was on integrilin gtt and
heparin gtt during cath and will be continued on ASA and Plavix
post cath. Patient started on protonix 40mg [**Hospital1 **]. Hct has held
steady, and patient scheduled for outpatient GI follow up.
.
#BPH - takes saw [**Location (un) 6485**] and two other herbal medications at
home. Patient with poor urinary output, and some concerns of
urinary retention. Started on fosamax.
Medications on Admission:
Lopressor 50mg [**Hospital1 **]
Zocor 40mg daily
ASA 325mg daily (hasn't taken for past 1.5wks)
HCTZ 25mg daily
NTG (took for first time on morning of admission)
Saw [**Location (un) **] (and two other herbals for BPH)
Coenzyme Q-10
Omega 3
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. 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*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
6. Protonix 40mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
Upper GI Bleed
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after an admission
for continued chest pain. Evaluation showed that you were
having a heart attack, and you underwent a cardiac
catheterization to open up your blocked coronary artery. You
had two bare-metal stents placed in one of your coronary
arteries. The stent will keep you artery open.
Please follow theese instructions as you recover:
- you must take aspirin 325mg every day and plavix 75mg every
day. You should not stop taking plavix uncless your doctor
tells you to stop. Stopping too early can cause a new clot to
form.
- You should continued to take your already prescribed
medication
- You will follow up w/ your doctor in 2 weeks.
- If you develop chest discomfort that does not go away with
nitroglycerin, sweling ,redness, or bleding at the puncture
site, a fever of 101 deg or higher, call your doctor.
- You were also noted to have bloody vomit while in the
hospital. You will need to follow up with a gastroenterologist
as an out patient to evaluate for source of bleed. If you
develop light headedness, you faint, or shortness of breath,
call your doctor.
Followup Instructions:
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2147-9-21**] 10:10
Gastroenterology: [**Hospital Unit Name 1825**] [**Location (un) 448**] [**Hospital1 18**] [**Hospital Ward Name 516**]
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2147-9-20**] 5:00
|
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icd9cm
|
[
[
[]
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[
[
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12277, 12283
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|
270, 325
|
12348, 12357
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,371
| 184,662
|
50720
|
Discharge summary
|
report
|
Admission Date: [**2143-12-5**] Discharge Date: [**2143-12-19**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
chest pain and vomiting
Major Surgical or Invasive Procedure:
upper endoscopy
left cataract removal, endocyclophotocoagulation, vitrectomy,
membranectomy, and retinal endolaser
History of Present Illness:
47 year old male with poorly controlled type I diabetes, HTN,
sarcoidosis and substance abuse who presents with chest pain
associated with swallowing liquids, nausea and nonbloody emesis.
He reports he was in his usual state of health until 2 days ago
when he began having nonradiating chest pain associated with
drinking fluids. He has not eaten solid foods in 2 days
secondary to the pain. He denies associated SOB or diaphoresis.
He denies pain with activity. He denies a h/o GERD but is on
protonix daily. In the emergency department, he was found to be
in DKA (glucose of 1199, AG of 25, 7.29/34/60). Of note, pt had
3 prior admissions this month for DKA and intermittent chest
pain. During a prior admission pt had normal cath ([**2143-11-28**]).
In the ER, his EKG showed TWI in the inferior and V5-V6 leads
and ST elevation in V2-V3, unchanged from prior. His troponin
was elevated at 0.47 in the setting of an elevated Creat to 4.9
(baseline 2.5). Vitals were significant for a BP of 204/79.
CXR was c/w CHF. He received 4 liters of NS, 12 units of
Regular Insulin and then was started on an insulin gtt. Given
initial concern for ACS he received ASA 325 mg, Lopressor 5 mg
IV x3, and was started on a heparin and nitro gtt. He was then
admitted to the medical ICU for further management.
Past Medical History:
# HTN
# Insulin dependent DM
- has had multiple admissions for DKA in setting EtOH use
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
(last use many weeks ago)
Social History:
Lives w/ a friend, no children. Works part time as a
tire-changer. Denies tobacco use. Denies recent EtOH or
cocaine use (per report daily EtOH use in past).
Family History:
Mother had diabetes, niece has diabetes. Denies FH of coronary
artery disease, hypertension, cancer, liver disease, or renal
disease.
Physical Exam:
Physical exam on admission
Tc 98.0 BP 174/66 HR 79 RR 28 Sat 100% 2L NC, 95% RA Wt
97 kgs
Insulin gtt at 12cc/hr, Heparin gtt
Gen: sleeping, easily arousable, NAD
HENNT: dry MM, anicteric, PERRL
Neck: no LAD, JVD ~7 cm
CV: RRR, nl S1S2, II/VI systolic murmur heard
Chest: left sided chest tenderness to palpation
Lungs: crackles [**2-12**] way up, diffuse wheezing
Abd: soft, minimal RUQ and epigastric tenderness to palpation,
ND, +BS, No HSM
Ext: 1+ pitting edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3, moving all extremities
Skin: no rash
Pertinent Results:
[**2143-12-5**]
D-DIMER-1188
WBC-9.2 HGB-9.7 HCT-31.9 MCV-102 RDW-12.9
ALBUMIN-3.2 CALCIUM-8.8 PHOSPHATE-7.1 MAGNESIUM-2.6
CK-MB-20 MB INDX-3.0 cTropnT-0.47
GLUCOSE-1199 UREA N-69 CREAT-4.9 SODIUM-125 POTASSIUM-5.3
CHLORIDE-84 TOTAL CO2-16
freeCa-1.14
ABG: PO2-60* PCO2-34* PH-7.29* TOTAL CO2-17*
serum tox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
urine tox: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
ECG [**12-5**]: NSR, rate 96, nl axis and intervals, S1Q3T3, normal
R wave progression, new TWI II,[**Month/Year (2) 1105**],AVF,V5,V6. Minimal ST
elevations in V2-V3 (unchanged from prior).
Radiology
CXR [**12-5**]: Interval development of bilateral small layering
pleural effusions, as well as increased perihilar haziness and
mild prominence of azygos vein, consistent with mild
failure/fluid overload. Stable hilar prominence, most consistent
with hilar lymphadenopathy.
[**12-11**] MRI/MRA brain: MRI demonstrates mild findings consistent
with small vessel ischemic changes. No acute infarction. MR
angiogram with questionable irregularity of the left M1 segment
which may be artifactual, but may be due to a fenestration.
There is also irregularity of the proximal left anterior
cerebral artery near its origin, which also may be artifactual.
[**12-12**] V/Q scan: Matched defect in right lower lobe. Low
likelihood ratio for recent pulmonary embolism.
Pathology/cytology
[**12-12**] esophageal brushings: Negative for malignanct cells.
Reactive squamous cells, inflammatory cells and [**Female First Name (un) 564**] species.
[**12-12**] esophageal biopsy: Ulceration with granulation tissue.
Special stain (methenamine silver) is negative for fungi, with
satisfactory control.
[**12-12**] antral biopsy: Chronic inactive inflammation, with focal
intestinal metaplasia. [**Doctor Last Name 6311**] stain is negative for H. pylori,
with satisfactory control.
Brief Hospital Course:
47 year old male presents with chest pain, nausea/vomiting,
found to be in DKA.
1) DKA/Type I diabetes mellitus, poorly controlled: The patient
was initially maintained on an insulin drip in the MICU,
subsequently transitioned to lantus with a humalog insulin
sliding scale. The [**Last Name (un) **] service was consulted, and his insulin
regimen was adjusted accordingly. It was difficult to engage Mr.
[**Known lastname 1683**] in his care, and he required significant urging in order
to participate in his diabetes management (fingersticks, insulin
administration). At time of discharge, he demonstrated ability
to check his fingersticks and was provided with a magnifying
device to attach to the insulin syringe in order to adequtely
draw up his insulin. He was discharged with VNA for
diabetes/medication teaching. If he is unable to comply with
this insulin regimen, transition to NPH/humalog mix twice a day
may be considered. He will follow-up with [**Last Name (un) **] following
discharge.
2) Chest pain/esophageal candidiasis: The patient's elevated
troponin on admission was attributed to poor renal clearance in
the setting of acute on chronic renal failure. Myocardial
ischemia was concerned unlikely, particularly given recent
negative cardiac catheterization. He received relief from
maalox/viscous lidocaine, raising the suspicion that his chest
pain was gastrointestinal in etiology. He underwent an EGD
[**2143-12-12**], which showed esophageal candidiasis (although brushing
fungal stain was negative), gastritis (biopsy with areas of
Barrett's esophagus), and erosions at the duodenal bulb. His
pantoprazole was increased to twice a day dosing and he began a
14 day course of fluconazole. He should follow-up with the
gastroenterology service as an outpatient given evidence of
Barrett's esophagus.
3) Lethargy: Given the patient's initial lethargy, a work-up was
pursued, which included TSH, RPR, folate, and vitamin B12, all
of which were normal. The patient declined a HIV test A head MRI
was within normal limits, not consistent with neurosarcoid. A
head MR angiogram showed a possible irregularity of the left M1
segment and the left anterior cerebral artery near its origin,
both of which the neurology service felt were artifactual. The
patient's mental status improved, although he remained difficult
to engage in his medical care. Depression is a likely
contributor, however, he declined initiation of an
anti-depressant. This can be re-addressed by his PCP as an
outpatient.
4) Acute angle glaucoma: On ophthalmology consult was obtained,
who found hiw left eye pressure was 42 (normal <21) with 20/70
vision. He underwent an avastin treatment (to reduce
neovascularization) on [**12-11**]. He subsequently underwent a left
cataract removal, endocyclophotocoagulation, vitrectomy,
membranectomy, and retinal endolaser treatment on [**2143-12-13**]. He
was followed closely by ophthalmology and started on multiple
eye drops (see discharge medications), which he demonstrated the
ability to administer. He will follow-up in ophtho 1 week
following discharge
5) Acute on chronic renal failure: Creatinine 4.9 on admission
(from 3.2 [**2143-12-1**]), improved with hydration to 3.4 on
discharge, indicating likely pre-renal component. His urine
sediment was unremarkable. The patient's creatinine has
progressively worsened over the course of the last year,
attributed to diabetic nephropathy, poorly controlled
hypertension, and cocaine use. During this admission, he was
started on Phoslo for a high phosphate, in addition to
acetazolamide. He will follow-up with his outpatient
nephrologist (Dr. [**First Name (STitle) 805**] following discharge.
6) Cardiomyopathy: EF 40-45% on recent TTE. Etiology unclear,
given clean coronaries, but was felt secondary to longstanding
hypertenstion. A CXR was consistent with mild CHF in setting of
aggressive fluid repletion for DKA. The patient was restarted on
his lasix and, at time of discharge, was stable on room air and
appeared relatively euvolemic.
7) Anemia: Pt has a component of ACD due to underlying kidney
disease and was continued on epogen. At the time of discharge,
his hematocrit was stable at 29.2. Vitamin B12 and folate levels
were normal, and an SPEP [**10-16**] was normal. An outpatient
colonoscopy may be considered by his PCP to rule out occult GI
bleeding.
8) Hypertension: The patient was continued on his home doses of
labetolol and nifedipine.
9) Polysubstance abuse: The patient has a history of cocaine and
alcohol use, although his tox screens were negative on
admission. He was treated with CIWA scale as needed, and
thiamine, folate, MVI. In addition, he was followed by the
social work/addiction service.
Full code
Medications on Admission:
1. Erythromycin 5 mg/g Ointment Sig: half inch Ophthalmic QID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Prednisolone Acetate 1 % Drops QID
6. Dorzolamide-Timolol 2-0.5 % Drops OS qid.
7. Apraclonidine 0.5 % Drops QID
8. Epoetin 8,000 units QMOWEFR
9. Nifedipine 90 mg PO DAILY
10. Insulin NPH-Regular 14 U with breakfast and 14 U with dinner
(was prescribed 35 qAM and 20 qPM).
11. Labetalol 400 mg TID
12. Ferrous Sulfate 325 mg qd
14. Lasix 40 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*1*
9. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
11. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
QID (4 times a day): to left eye.
Disp:*qs 1 month supply* Refills:*0*
12. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig:
One (1) Drop Ophthalmic QID (4 times a day): to left eye.
Disp:*qs 1 month supply* Refills:*0*
13. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic QID
(4 times a day): to left eye.
Disp:*qs 1 month supply* Refills:*2*
14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QID (4 times a day): to left eye.
Disp:*qs 1 month supply* Refills:*0*
15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): to left eye.
Disp:*qs 1 month supply* Refills:*0*
16. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)): to left eye.
Disp:*qs 1 month supply* Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous qAM.
Disp:*qs 1 month supply* Refills:*2*
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous before each meal and at bedtime: take as
directed.
Disp:*5 ml* Refills:*2*
19. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: diabetic ketoacidosis
Secondary: glaucoma, [**Female First Name (un) **] esophagitis, chronic renal
insufficiency, hypertension, anemia, diastolic congestive heart
failure
Discharge Condition:
Stable
Discharge Instructions:
1) Please take all your medications as prescribed. You have been
prescribed multiple eye drops, which you should take as
prescribed until directed to do otherwise by Dr. [**Last Name (STitle) **].
Please wear protective glasses during the day and protective
patch at night. New medications include:
- pantoprazole increased to twice a day for gastritis/reflux
- glargine (instead of NPH) with humalog sliding scale
- calcium acetate and acetazolamide (given your renal disease)
- fluconazole for yeast infection
2) Please follow-up as indicated below
3) Please check your fingersticks before each meal and at
bedtime. If your fingerstick is persistently >250, call your
primary care physician.
Followup Instructions:
1) Primary Care ([**Telephone/Fax (1) 250**])
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2144-1-7**] 7:20 p.m.
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2144-2-26**] 9:00 a.m.
2) Ophthalmology: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 253**]) [**2143-12-25**] at 9:30
a.m.
3) [**Last Name (un) **]: Dr. [**Last Name (STitle) 105514**] [**Name (STitle) 105515**] [**2143-12-30**] 1 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2143-12-19**]
|
[
"428.30",
"366.9",
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"585.9",
"365.63",
"250.13",
"428.0",
"250.53",
"584.9",
"403.90",
"112.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"14.74",
"13.41",
"12.92",
"13.71",
"45.16",
"12.73",
"14.9"
] |
icd9pcs
|
[
[
[]
]
] |
13317, 13375
|
5534, 10268
|
340, 457
|
13600, 13609
|
3567, 5511
|
14351, 15042
|
2828, 2964
|
10820, 13294
|
13396, 13579
|
10294, 10797
|
13633, 14328
|
2979, 3548
|
277, 302
|
485, 1795
|
1817, 2635
|
2651, 2812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,947
| 150,417
|
35789
|
Discharge summary
|
report
|
Admission Date: [**2115-8-2**] Discharge Date: [**2115-8-8**]
Date of Birth: [**2049-9-11**] Sex: M
Service: MEDICINE
Allergies:
Betadine / chlorhexidine
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
chills
Major Surgical or Invasive Procedure:
Removal of HD line [**2115-8-3**]
Right IJ line placement [**2115-8-3**]
Right IJ line removal [**2115-8-3**]
Tunneled HD catheter placement [**2115-8-6**]
Transesophageal echocardiogram [**2115-8-7**]
History of Present Illness:
65 y.o male with pmhx of DM type 2, COPD on 2L home O2, and CKD
(recently started on HD in [**4-/2115**]), who presents with fevers,
hypotension.The patient was at dialysis, and reported fever up
to 100.0 with chills.Approx. 75 % of the dialysis was completed
per ems and he recieved total of 1.5g of vanco at the dialysis
center. The patient does make a small amount of urine at
baseline and denies dysuria. He endorses a nonproductive cough
for a couple days, but denies chest pain, nausea,
vomiting,abdominal pain, confusion, headaches, sick contacts or
recent travel.
.
Of note in [**4-/2115**] the patient started dialysis which was
complicated by MRSA bactremia, and hypotension. He was admitted
and had his dialysis line removed, TTE at the time negative for
endocarditis, he was discharged with new HD line and 6 weeks of
Vancomycin. He has been followed by outpatient [**Hospital **] clinic for
this and completed therapy in 6/[**2115**].
.
In the ED initial vitals were: 101.4 75 130/44 16 100% 2L Nasal
Cannula and the patient recieved 500mg Meropenem and 500mg p.o
tylenol. He became tachypnic to 40s and O2 sats down to low 90s
on 4L NC after 1 liter of NS and so put on bipap and went to
100% oxygen sat. He was weaned off of bipap after less than 1
hour and now resp status stable on 4L NC once again. He was
given 0.5 mg IV ativan for comfort.For hypotension with SBP
70's, a right IJ central catheter was placed and low dose
Levophed started with SBP's in the 90's.The patient was
transferred for further care to the ICU.
.
On arrival to the MICU, the patient is off BIPAP and breathing
well. He is mentating well and the above HPI was obtained. He
says his breathing is "better." The below review of systems was
obtained including no chest pain, nausea, productive cough. He
has felt "crummy for few days" but will not elaborate.
Review of systems:
Obtained from patient
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. 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:
-diabetes mellitus type II
-HTN
-dCHF/right heart failure (EF>55%),
-s/p open chest surgery for "dot" on lung at [**Doctor Last Name 1263**]
-rheumatoid arthritis
-COPD on 2L home O2
-Depression
-Bipolar Disorder
-Schizoaffective disorder
-Glaucoma
-stage 5 chronic kidney disease
-peripheral vascular disease s/p RLE bypass
-history of pulmonary embolism on Coumadin
-Obesity hypoventilation syndrome
-OSA on bipap/cpap
-chronically elevated left hemidiaphragm
Social History:
Lives in [**Hospital3 2558**], Uses electric wheelchair at baseline.
-Tobacco history: smoked 1PPD for 43 years quit several years
ago
-ETOH: quit drinking 4-5 years ago, used to drink socially
-Illicit drugs: Denies
Family History:
Mother: [**Name (NI) 3730**] (unknown type)
Father: [**Name (NI) 3495**] disease
Physical Exam:
Admission Exam
Vitals: T:99.1 BP: 90/46 P: 96 R: 18 18 O2: 96% 4L NC
General: Alert, oriented X 3, no acute distress. Speaking in
full sentences but pursing lips when breathing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD.R-IJ in place . Has left
dialysis line with erythema 1-2cm around it, nontender with no
drainage.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sounds on the left side, mild exp
wheezing in the right lower lung field, no significant rales and
some mild diffuse ronchi
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses DP b/l, no clubbing,
cyanosis or edema , bruising on shins b/l
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Discharge Exam
VS - T 97.8, HR88, BP 134/76, RR 01, O2Sat 98% 2LNC
GENERAL - Awake, alert, NAD
HEENT - NC/AT, sclerae anicteric, OP clear
LUNGS - poor air movement bilaterally, no crackles, no wheezes
HEART - RRR, NL S1-S2, no M/R/G
NEURO - awake, CNs II-XII grossly intact
Pertinent Results:
Admission Labs
[**2115-8-2**] 08:40PM BLOOD WBC-16.6*# RBC-3.91*# Hgb-11.7*#
Hct-38.7*# MCV-99* MCH-29.8 MCHC-30.1* RDW-16.2* Plt Ct-180
[**2115-8-2**] 08:40PM BLOOD Neuts-87* Bands-2 Lymphs-3* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-3* NRBC-2*
[**2115-8-3**] 04:43AM BLOOD PT-13.4* PTT-37.2* INR(PT)-1.2*
[**2115-8-2**] 08:40PM BLOOD Glucose-103* UreaN-22* Creat-2.9*# Na-138
K-3.9 Cl-100 HCO3-28 AnGap-14
[**2115-8-2**] 08:40PM BLOOD ALT-11 AST-16 LD(LDH)-289* CK(CPK)-108
AlkPhos-66 TotBili-0.1
[**2115-8-2**] 08:40PM BLOOD Albumin-3.6 Calcium-8.9 Phos-1.1*# Mg-1.6
[**2115-8-4**] 09:00AM BLOOD Vanco-7.4*
[**2115-8-3**] 01:04AM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-67* pH-7.25*
calTCO2-31* Base XS-0
[**2115-8-2**] 09:05PM BLOOD Lactate-1.8
Other Pertinent Labs:
[**2115-8-7**] 07:20AM BLOOD Vanco-19.2
[**2115-8-6**] 08:20AM BLOOD CRP-122.8*
[**2115-8-2**] 08:40PM BLOOD CK-MB-2 cTropnT-0.07*
[**2115-8-3**] 04:43AM BLOOD CK-MB-2 cTropnT-0.07*
[**2115-8-2**] 08:40PM BLOOD ALT-11 AST-16 LD(LDH)-289* CK(CPK)-108
AlkPhos-66 TotBili-0.1
[**2115-8-6**] 08:20AM BLOOD ESR-30*
[**2115-8-5**] 04:34AM BLOOD PT-11.1 PTT-32.9
Discharge Labs:
[**2115-8-8**] 07:10AM BLOOD WBC-6.7 RBC-3.43* Hgb-10.1* Hct-34.0*
MCV-99* MCH-29.6 MCHC-29.8* RDW-16.3* Plt Ct-193
[**2115-8-8**] 07:10AM BLOOD Glucose-96 UreaN-33* Creat-2.7* Na-134
K-3.9 Cl-97 HCO3-29 AnGap-12
[**2115-8-8**] 07:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
CXR ([**2115-8-2**]): No evidence of acute disease.
CXR ([**2115-8-2**]): New right internal jugular central venous
catheter terminates at the expected junction of the superior
vena cava and right atrium, with no evidence of pneumothorax.
There is otherwise no relevant change in the appearance of the
chest since the recent study performed a few hours earlier.
[**2115-8-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2115-8-3**] CATHETER TIP-IV WOUND CULTURE-PENDING
INPATIENT
[**2115-8-3**] URINE URINE CULTURE-FINAL INPATIENT
[**2115-8-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2115-8-3**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2115-8-2**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPH AUREUS COAG +}; Anaerobic Bottle Gram
Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2115-8-2**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPH AUREUS COAG +}; Anaerobic Bottle Gram
Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2115-8-2**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPH AUREUS COAG +}; Anaerobic Bottle Gram
Stain-FINAL; Aerobic Bottle Gram Stain-FINAL
TEE ([**2115-8-7**]): No spontaneous echo contrast or thrombus is seen
in the body of the left atrium/left atrial appendage or the body
of the right atrium/right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion. IMPRESSION: No echocardiographic evidence
of endocarditis. Preserved left ventricular function. Dilated
right ventricle. Mild-to-moderate tricuspid regurgitation.
UNILAT UP EXT VEINS US ([**2115-8-6**]): IMPRESSION: No evidence of
DVT in left upper extremity veins.
Brief Hospital Course:
65 year old male with Type 2 DM, lung disease on 2L home O2, and
ESRD (recently started on HD in [**2115-5-7**]) who presents with
fever and chills at dialysis complicated by hypotension.
# HD line associated GPC Septicemia. He was admitted to the
MICU with norepinephrine gtt requirement which was weaned off
within 24 hours on [**2115-8-3**]. He was empirically covered with
Vancomycin and Meropenem which was narrowed to Vancomycin once
blood cultures grew GPC. HD line was removed on [**2115-8-3**].
Right IJ line which was placed on [**2115-8-3**] was also removed on
[**2115-8-4**]. He underwent placement of a new right-sided tunneled
IJ HD catheter on [**2115-8-6**]. He underwent TTE for evaluation of
the presence of endocarditis, which was non-diagnostic.
Subsequently, he underwent TEE, which did not show any evidence
of vavular vegitations or abscesses. Blood cultures speciated to
MRSA, and he was treated with vancomycin for a total course of 4
weeks (through [**2115-8-29**]). As an outpatient, this will be dosed
via HD protocol, and will be managed by his nephrologist. While
on antibiotics, should have weekly CBC, LFT's, and blood
chemistries for the next 3 weeks, or until instructed to stop by
PCP or Renal Doctors.
# HTN/dCHF/right heart failure (EF>55%): Held metoprolol while
hypotensive, but continued aspirin 81 mg daily. Restarted
metoprolol at 25 mg [**Hospital1 **] on [**2115-8-4**]. Blood pressures were well
controlled after restarting this medication.
# Rheumatoid arthritis: No active issues on this admisison.
Hydroxychroloquine was continued.
# Hx Pulmonary Embolism on Coumadin: Emailed Dr. [**First Name8 (NamePattern2) 7841**] [**Name (STitle) 7842**]
and told her we aren't bridging coumadin and ask if she objects
for any reason - she does not know PMH and could not get
records. Pt says only had PE once many years ago. PCP OK with
discontinuing coumadin.
# ESRD: Recieved most of dialysis session prior to MICU
transfer. Electrolytes remained stable. Following the removal of
his infected HD line, he was given an HD holiday. With placement
of a new HD line, HD was reinitiated. Upon discharge he was
restarted on his normal HD schedule on M/W/F. Next session will
be [**2115-8-9**].
# COPD: Goal SaO2 is 90-92%. Continued on home Fluticasone,
Albuterol standing and Tiotropium. He was maintained on his home
oxygen requirement and BiPAP at night.
# EKG changes: Has baseline right bundle branch block, but did
have deeper ST segments in anterolateral distribution in the
setting of hypotension and tachycardia. Likely rate related
changes vs lead placement. Patient denied any current chest
pain, pressure, nausea/vomiting. EKG similar to priors upon lead
change. CE stable. No further action necessary.
# Contact Dermatitis: Noted following exposure to chloraprep
and/or betadine. These medications were added as allergies on
his record. Follow-up with allergy as an outpatient to further
explore this issue is being arranged by care connections.
# Hypophosphatemia: Resolved. Stopped sevelamer on this
admission. Phosphate management per renal as outpatient.
# Bipolar disorder/Schizoaffective disorder: No signs or
symptoms of psychosis. Continued his home divalproex,
oxcarbazepine, and risperdone and clinically trend mental
status.
# Diabetes mellitus II: Sugars were well controlled on this
admission. He was maintained on a Humalog sliding scale. He was
discharged on the same.
# Obesity hypoventilation syndrome and OSA: Maintained on BIPAP
at night.
Transitional Issues:
-Please resume HD on Monday/Wednesday/Friday schedule. Next
session [**2115-8-9**].
-Needs vancomycin, dosed via HD protocol, through [**2115-8-29**].
-Please check weekly CBC, LFT's, and blood chemistries for the
next 3 weeks, or until instructed to stop by PCP or Renal
Doctors.
-Please only use hypoallergenic occlusive dressings with IV
therapy, and please avoid the use of chloraprep and betadyne.
-Needs evaluation by Allergy to determine if he is allergic to
betadine and/or chlorhexidine.
Medications on Admission:
. Information was obtained from .
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Divalproex (DELayed Release) 250 mg PO QAM
4. Divalproex (DELayed Release) 500 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Calcium Carbonate 1250 mg PO TID
9. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
10. Tiotropium Bromide 1 CAP IH DAILY
11. Hydroxychloroquine Sulfate 400 mg PO BID
12. Risperidone 2.5 mg PO HS
13. Tamsulosin 0.4 mg PO HS
14. Oxcarbazepine 300 mg PO BID
15. sevelamer CARBONATE 1600 mg PO TID W/MEALS
16. Warfarin 3 mg PO DAILY16
17. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Divalproex (DELayed Release) 250 mg PO QAM
4. Divalproex (DELayed Release) 500 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
7. Hydroxychloroquine Sulfate 400 mg PO BID
8. Oxcarbazepine 300 mg PO BID
9. Tiotropium Bromide 1 CAP IH DAILY
10. Calcium Carbonate 1250 mg PO TID
11. Tamsulosin 0.4 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Vancomycin 0 mg IV HD PROTOCOL
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
15. Metoprolol Tartrate 25 mg PO BID
16. Risperidone 2 mg PO HS
17. Albuterol Inhaler 2 PUFF IH [**Hospital1 **]:PRN wheezing
18. Ascorbic Acid 500 mg PO BID
19. Lactulose 15 mL PO BID:PRN constipation
20. Vitabee/C *NF* (B-complex with vitamin C) 1 tab Oral daily
21. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Methacillin Resistant Staph Aureus Septicemia
Hemodialysis catheter infection
Secondary: End stage renal disease
Chronic Obstrictive Pulmonary Disease
Hypertension
Bipolar disorder
Diastolic congestive heart failure
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 4587**],
You were recently admitted to [**Hospital1 1170**] for treatment of fevers and chills. While you were
hospitalized, you were found to have bacteria in your blood,
likely from your dialysis catheter. Your infected dialysis
catheter was removed, and you were treated with antibiotics. A
new dialysis catheter was placed, and you were restarted on
hemodialysis. During your hospitalization, you developed low
blood pressure, requiring a brief stay in the medical ICU. The
cause of this low blood pressure was likely the infection in
your blood. During your ICU stay, you were on medications to
treat your low blood pressure, and you improved. Those
medications were stopped, and you were transferred to the normal
medical floor.
When you leave the hospital, you will need to continue to have
hemodialysis, per your normal routine. You will also need to
continue to receive IV antibiotics through [**2115-8-29**]. This
will be managed by your kidney doctors.
Also, while you were hospitalized, it was observed that you
developed a rash following exposure to products used to clean
your skin, including betadine and chloraprep. Please consider
this an allergic reaction, and avoid exposure to these cleaning
agents in the future.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: RADIOLOGY
When: WEDNESDAY [**2115-9-25**] at 11:00 AM [**Telephone/Fax (1) 590**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: DIV OF GI AND ENDOCRINE
When: WEDNESDAY [**2115-9-25**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2115-10-24**] at 4:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment in Allergy and
Inflammation. It is recommended you be seen within 2 weeks of
discharge. The office will contact you at home with an
appointment. If you have not heard within 2 business days please
call the office at [**Telephone/Fax (1) 9316**].
Completed by:[**2115-8-8**]
|
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21,773
| 100,387
|
24372
|
Discharge summary
|
report
|
Admission Date: [**2147-3-14**] Discharge Date: [**2147-4-4**]
Date of Birth: [**2091-10-7**] Sex: M
Service: MEDICINE
Allergies:
Mycophenolate Mofetil
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
fever, abdominal pain, diarrhea, anorexia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
55 male who is 9 months and 26days s/p a liver [**First Name3 (LF) **] for
HCV/HCC, with mild acute rejection and recurrent HCV infection
on ribavirin and interferon, who is presenting with fever and
increasing nausea/emesis/diarrhea/malaise. Since discharge on
[**2-9**] patient has had intermittent nausea and vomiting, the last
a couple of days ago. Has had decreased PO intake d/t nausea and
feeling unwell. Also with loose stills since discharge that he
though was getting better but have now returned more recently,
stooling 5-6 times per day, no melena or hematochezia.
Increasing lethargy over the last couple of weeks. Developed a
sore throat a couple of weeks ago as well in joint discomfort
that has progressed now to frank swelling of feet, ankles, and
hands. He relates pain/myalgias in feet, ankles, calves, ant
shin, knees, hands, wrists, elbows, shoulders, forearm.
Developed a fever to 102.5 over last coupe of days. No sick
contacts, recent travel, abnormal foods, lives alone. No
dysuria, cough. Abdominal pain slightly increased from his
chronic baseline level. +HA but no neck stiffness, photophobia,
vision changes.
.
ED course: Presenting vital signs were T 98.5 HR 125 BP 116/88
RR 16 Sat 98% RA. Labs showed a mild increase in his
transaminitis, as well as a leukocytosis. Ceftriaxone 1gm,
vancomycin 1gm, morphine 4mg iv x2, tylenol 1gm, oxycodone 10mg
po. HR 137 when febrile to 101, HR fell to 125 with 3L NS. Blood
and urine cultures were sent. UOP in ED 700cc.
Past Medical History:
# Hepatitis C/alcoholic cirrhosis, c/b hepatocellular carcinoma
-dx [**2144-4-26**]
-HCC s/p radiofrequency ablation [**2143**]
-s/p liver [**Year (4 digits) **] [**2146-5-18**] with hep B core AB + liver,
received HBIG and on daily lamivudine, last HBV viral load not
detected [**10-3**])
-On [**9-15**] he had a liver biopsy per 3 month protocol that showed
early recurrent HCV and mild acute rejection - tacrolimus
increased and 500mg x 3doses of steroids
-Repeat bx [**10-3**] with fibrosing cholestatic hepatitis - -
started INF [**2146-10-12**], procrit [**10-3**], ribavirin [**2146-10-27**] for
hepatitis C
-On Save the Nephron study since [**6-3**]
Viral hepatitis C
- [**2147-3-9**] HCV viral load 5,750,000 (up from 3,150,000 in [**11-3**])
# Hypertension
# GERD
# Cholecystistitis and cholelithiasis s/p laprascopic
cholecystectomy [**2145-2-10**]
# Hx polysubstance abuse
# Alcohol use
# post [**Month/Day/Year **] DM and hypertension
Social History:
Pt lives alone in [**Location (un) 61729**], [**State 1727**], able to take care of his
ADLs. Monogamous sexual relationship with his partner, uses
[**Name2 (NI) 61730**] contraceptives. Last HIV test in [**2144-4-26**] negative,
partner status unknown. Denies EtOH use, last drink was in [**Month (only) 116**]
[**2143**]. Prior to that did have heavy ETOH. Denies current IVDU,
states he used heroin, barbiturates, cocaine in 70s,80s, 90s.
Denies current tobacco use, quit 15 years ago.
Family History:
NC
Physical Exam:
Vs- 101.1 (101.8), 113/84, 138(127-138) 20, 93%RA
Gen- Ill appearing, in pain
Heent- OP clear but mmm dry, PERRL, anicteric, wick in place of
ear
Neck- Supple, JVP flat
Cor- [**Last Name (un) **] but regular rhythm, no m/r/g
Chest- Crackles at bases bilaterally
Abd- TTP in RLQ, mild in RUQ
Ext- Joint swelling in hands with erythema, dorsal aspect of
feet swollen, nonpitting, mildly erythematou, trace ankle edema,
significant TTP in feet, ankles, calves and anterior shins
bilaterally, no knee swelling or effusions, hip without TTP
bilaterally, 1+ PE B UE/LE, no rash other than erythema in feet
and hands
Neuro- A&Ox3, 5/5 strength B UE/LE, 2+ DTR's patellar
Skin- Multiple tatoos, scattered ecchymosis
Pertinent Results:
ct abd/pel [**3-15**]
IMPRESSION:
1. No evidence of hepatic or intra-abdominal abscess.
2. New bilateral lower lobe consolidation in addition to
previous atelectasis.
3. No change in adrenal and renal lesions. Bilateral
nonobstructing renal calculi.
4. Expected appearance of liver post [**Month/Year (2) **].
[**3-16**] tte
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**3-20**] renal u/s
IMPRESSION:
1. Nonobstructing renal calculi in the right kidney. Comparison
to the [**2147-3-15**] CT, there are multiple bilateral
nonobstructing renal calculi which were not visualized in this
examination.
2. Splenomegaly
[**3-24**] u/s
GRAYSCALE AND DOPPLER ULTRASOUND OF THE LIVER: Comparison is
made to the prior ultrasound dated [**2147-3-14**]. The liver is
normal in echogenicity without evidence of focal lesion or
intra- or extra-hepatic ductal dilatation. Portal veins, hepatic
veins, and hepatic arteries are patent with appropriate
waveforms. Spleen measures 16 cm. There is new right pleural
effusion.
IMPRESSION: Patent vessels with appropriate waveforms.
Splenomegaly. New right pleural effusion.
------------------
[**3-29**] cxr
IMPRESSION:
1. New right lower lobe opacification, suspicious for pneumonia
in the appropriate clinical setting. Adjacent small right
pleural effusion.
2. Resolving linear left basilar opacities
-------------------
[**3-30**] abd u/s
GRAYSCALE AND DOPPLER ULTRASOUND OF THE TRANSPLANTED LIVER:
Comparison was made to the ultrasound dated [**2147-3-24**] and CT
scan dated [**2147-3-15**]. There is no focal liver lesion in the
transplanted liver. There is no intra- or extra-hepatic ductal
dilatation. Portal vein is widely patent. There is a ring-like
echogenic structure at the portal vein anastomosis. There is an
anechoic tubular two-compartmental structure, which initially
appeared to be bile duct, however, further scanning revealed it
to be fluid accumulating along the porta hepatis at real- time
scanning. Normal waveforms are seen in main portal vein, main
and left hepatic arteries and three hepatic veins. There is a
small amount of right pleural effusion.
IMPRESSION: No intra- or extra-hepatic ductal dilatation in the
transplanted liver. Tubular [**Hospital1 **]-lobed fluid tracking along the
porta hepatis. Small right pleural effusion. Patent portal
veins.
Brief Hospital Course:
55 yo man with hx EtOH/HCV cirrhosis s/p OLT in [**5-3**], CMV donor
+, recipient -, now admitted with abdominal pain, fever,
myalgias, headache, cough and found to have CMV viremia with
evidence of liver involvement course complicated by recurrent
HCV seen on biopsy, multifactorial acute renal failure,
microabscesses on biopsy concerning for ascending cholangitis.
.
# CMV Viremia
Original CMV VL [**3-15**] 95,800 at that time started on oral
valganciclovir, biopsy results on [**3-17**] confirmed liver
involvement and he was switched to IV ganciclovir and completed
a 2 week course. His CMV VL decreased to <600 copies on [**3-29**]. He
will need to complete 6 months of oral valganciclovir 450mg
daily for likely 6 months, follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] was
scheduled for patient. Of note he had a negative opthalmologic
examination for retinitis done by opthalmologist.
.
# Transplanted liver
Biopsy shows trichrome stain demonstrates increased portal
fibrosis with septa formation and foci of early bridging
fibrosis (Stage 2-3). Additionally, marked centrivenular
fibrosis without luminal occlusion is seen, indicative of a
component of chronic venous outflow obstruction. Moderate portal
and lobular mixed inflammation consisting of mononuclear cells
and focally prominent neutrophils (some in association with bile
ducts), with microabscess formation and foci of extensive
hemorrhagic necrosis, predominantly involving zone 3. Scattered
viral inclusions morphologically consistent with cytomegalovirus
are identified within hepatocytes and rare bile ductular
epithelial cells (confirmed by immunostain for CMV, with
satisfactory controls). Recurrent viral hepatitis C, difficult
to grade in this sample. Diagnostic features of acute cellular
rejection are not identified. Biliary findings are also likely a
result of the CMV and/or cytokine-mediated, but a concomitant
bacterial infection, sepsis, a drug effect or biliary
obstruction remain within the histopathologic differential.
Given rising alkaline phosphatase concern for cholestatic
fibrosis was high, he may need repeat liver biopsy in the near
future given his stage 2-3 fibrosis this early into his
transplantation. His Bactrim prophylaxis was switched to Dapone
given his renal dysfunction, G6PD level was normal.
.
# Acute kidney injury
Multifactorial etiology in this patient with a baseline 1-1.2,
he had component of cryoglobulinemia given positive cryos on
[**3-15**] and [**3-27**] with 3 an 2 percent crycrit respectively. He was
started back on interferon and ribavirin on [**3-25**], ribavirin was
subsequently held given rise in creatinine. His urine did not
reveal proteinuria and had nonspecific granular casts.
Tacrolimus nephrotoxicity was considered and his goal was
reduced to [**5-3**]. His creatinine peaked at 2.1 and decreased, at
discharge his creatinine was... Of note he did receive fluid
challenges with no improvement in renal function given that his
PO intake was poor. His Bactrim was switched to Dapone given his
renal dysfunction, G6PD level was normal.
.
# Superimposed bacterial infection
Had recurrent fevers while on treatment for CMV, biopsy revealed
microabscesses concerning for ascending cholangitis. Patient is
to complete 3 week course of levaquin and flagyl on [**4-6**], he did
not spike any fevers while on this regimen. initially was on
vancomycin for possible pneumonia, susbsequent radiograph was
unrevealing. Patient had recurrent headache for which he had a
negative lumbar puncture, all other cultures were negative.
.
# Normocytic anemia
Multifactorial due to chronic disease, likely small oozing from
CMV colitis (not biopsied or colonoscopy), had EGD showing
gastric erosion consistent with gastritis, no CMV. On multiple
myelosuppressive medications. He was transfused for
hematocrit<21. Hematology reviewed smear and was not concerning
for TTP. He is on Epogen during his HCV treatment.
.
# Inflammatory arthritis
Seen by rheumatology who tapped his swollen right knee, there
was no evidence of infection and the fluid was inflammatory.
This was attributed to cryoglobulinemia and his myalgias and
arthralgias resolved throughout his hospital course.
.
# Hypertension
His metoprolol was increased to 75mg [**Hospital1 **] with good effect.
.
# Communication: Daughter (HCP): [**Name (NI) 2808**] [**Name (NI) **] [**Telephone/Fax (1) 61731**].
Medications on Admission:
Lamivudine 100 mg daily
Pantoprazole 40 mg daily - not taking
Bactrim single strength
CellCept 1 gram [**Hospital1 **]
Insulin on a sliding scale (occ)
Metoprolol 50 mg twice a day.
Klonopin 0.5 mg as needed.
Pegylated interferon alpha-2a 180 mcg subcutaneously weekly
(fridays) - patient has not taken this recently, unclear for how
long
Filgrastim 300 mcg subcutaneously weekly - not taking recently
Gabapentin 300 mg twice a day.
Iron 150 mg twice a day.
Epogen 40,000 units subcutaneously weekly - not taking recently
Prograf 3 mg twice a day.
Ribavirin 200mg [**Hospital1 **]
Percocet seven and a half pills as needed for pain - per pt, but
not on Dr.[**Name (NI) 948**] med list
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO
TWICE DAILY ().
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: One (1)
Subcutaneous 1X/WEEK (SA).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
14. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
16. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
17. Outpatient Lab Work
Please check cbc, chem-10, AST, ALT, Total bilirubin, LDH, INR,
PT and have results faxed to Dr. [**Last Name (STitle) 497**] at ([**Telephone/Fax (1) 3618**]. These
labs should be checked on Monday [**4-10**].
18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
OLT
Disseminated CMV
Microabscesses in liver
HCV
Acute kidney injury
Normocytic anemia
Hypertension
Discharge Condition:
Stable
VSS
Discharge Instructions:
You were admitted and found to have an extensive CMV infection
in your liver as well as recurrent hepatitis C. You also had
renal failure and your kidney function on discharge was still
elevated. You will need to take your medications EXACTLY as you
are instructed to do so. This is really important given your
[**Month (only) **] is in danger. You have been scheduled appointments
with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] of infectious diseases.
Take all of your medications as indicated and inform the
[**Last Name (STitle) **] clinic if you have any issues obtaining your
medications.
If you develop any fever>101.5, abdominal pain, bleeding or any
worrisome symptoms call the [**Last Name (STitle) **] clinic or present to the
emeregency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-4-9**]
3:15
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-4-19**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-4-25**] 10:30
You will be contact[**Name (NI) **] by Dr.[**Name (NI) 948**] office to set up an
additional appointment. If you are not you should call them by
the end of this week.
You should also have your labs checked on friday to make sure
your blood cell counts and kidney function are stable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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|
2842, 3332
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,488
| 191,090
|
38828
|
Discharge summary
|
report
|
Admission Date: [**2112-3-6**] Discharge Date: [**2112-3-11**]
Service: MEDICINE
Allergies:
Darvon / Tramadol / Narcotic Analgesic & Non-Salicylate Comb
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
acute hypoxic respiratory failure and pneumonia
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. [**Name13 (STitle) **] is an 85 yo male with a h/o HTN, CRI, anxiety, and
recent admission in [**1-20**] at OSH for gastroenteritis, who is
transfered to the [**Hospital Unit Name 153**] from [**Hospital3 **] ICU (per his
family's request). The patient presented to [**Hospital3 **] ED
on [**2112-3-2**] with generalized weakness, fever to 103F, lethargy,
dyspnea, and was noted to have an oxygen saturation in the 70s.
He denied N/V/D, abdominal pain, change in urinary habits, but
did endorse orthopnea. He was admitted to the [**Hospital3 **]
ICU for severe respiratory failure. CXR at that time showed
evidence of bilateral pneumonia (thought to be aspiration), and
he was noted to have a leukocytosis of 14,000. Despite initial
treatment with IV ceftriaxone, azithromycin, and solumedrol, the
patient was unable to tolerate taper off nonrebreather and
required BiPAP to help maintain oxygen saturations. Given that
he appeared worse both clinically and by xray, antibiotics were
switched to levaquin, vanc, and zosyn. Concern was also raised
for fluid overload contributing to his respiratory failure, so
he was also diuresed with 20 mg IV lasix x 1 with good [**Name (NI) **] (pt
fluid status +600cc at time of transfer). An initial sputum
culture and blood cultures x2 were negative. A repeat sputum
culture, urine Legionella, and mycoplasma serology were done at
the OSH and are pending at the time of transfer.
.
The patient has no history of COPD or CHF. Per his daughter, he
has never had an echo. He had a pneumovax in [**2109**] and influenza
vaccine in [**2110**].
.
On the floor, initial vs were: BP 148/74, P 111, RR 33, with an
O2sat of 95% on CPAP 80%FiO2 and 8 PEEP. ABG was reassuring at
7.42/36/84.
.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
1. Hypothyroidism.
2. Hypertension (on Lisinopril 10 mg daily).
3. Hyperlipidemia.
4. Hyperhomocysteinemia.
5. Pernicious anemia (gets B12 injections monthly).
6. Benign prostatic hypertrophy (last PSA 2.39 [**2112-3-1**]).
7. Chronic renal insufficiency (BL creatinine:~2).
8. Testosterone deficiency (on testosterone).
9. Anxiety.
10. Vertigo.
11. Mild memory loss.
12. Chronic right bundle branch block.
Social History:
The patient is married and lives with his wife in [**Name (NI) **]. He has
very close family support. No alcohol or tobacco use.
Family History:
Father died of acute leukemia. Mother died of massive MI at 82
yo. Brother died of ruptured AAA. Sister died of gastric cancer.
Physical Exam:
Vitals: T: afebrile BP: 148/74 P: 111 RR: 33
O2sat: 95% on CPAP 80%FiO2, 8 PEEP. Notably, patient desated to
80% when lying flat. This resolved when he sat back up.
General: Alert, oriented, no acute distress, no accessory muscle
use when sitting upright.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except bibasilar
crackles, no wheezes
CV: Tachycardic, regular rhythm with occasional ectopic beats,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Pertinent Results:
[**2112-3-6**] 12:41AM TYPE-ART PO2-84* PCO2-36 PH-7.42 TOTAL CO2-24
BASE XS-0
[**2112-3-6**] 12:41AM LACTATE-1.4
[**2112-3-6**] 12:33AM PT-12.9 PTT-29.4 INR(PT)-1.1
[**2112-3-6**] 12:33AM WBC-22.7* RBC-3.23* HGB-10.6* HCT-32.8*
MCV-102* MCH-32.9* MCHC-32.3 RDW-16.2*
[**2112-3-6**] 12:41AM freeCa-1.22
Brief Hospital Course:
Mr. [**Known lastname 84385**] is an 85 yo M with a history of HTN, CRI,
anxiety, and recent admission at OSH for gastroenteritis, who
was transfered from an OSH with worsening acute hypoxic
respiratory failure and PNA.
.
# Hypoxic Respiratory Failure: Patient thought to be hypoxic
secondary to PNA from aspiration per OSH records. Given
progression, concern exists for possible [**Doctor Last Name **]/ARDS. Further
workup for causes of hypoxia (eg PE) limited given CRI so unable
to obtain CTA. Some mention of improvement with diuresis at OSH
but no record re: LV dysfunction. Patient noted to desat on exam
on admission to [**Hospital1 18**] when laying flat with resolution when
sitting up, concerning for CHF exacerbation (BNP at OSH 228,
baseline unknown). EKG showed RBBB, sinus arrythemia and echo
showed mild symmetric left ventricular hypertrophy with normal
biventricular systolic function. High estimated cardiac output.
Moderate pulmonary artery systolic hypertension. No
intracardiac shunt identified. He was diuresed with prn lasix
with good [**Hospital1 **]. He was continued on broad spectrum antibiotics
with vanc/zosyn/cipro. Culture data remained negative
throughout. Patient had received steroids at OSH for concern of
COPD exacerbation. Given that this presentation was not thought
to be a COPD exacerbation given no prior history of COPD and
lack of wheezing on admission exam, we did not continue
steroids. However, his respiratory continued to worsen and
eventually required pressors to support his blood pressure.
This was continued until the family meeting, when the family
decided to make him CMO. Patient subsequently expired.
.
# Leukocytosis: Patient had leukocytosis on admission to OSH of
14. This has bumped to 27.9 at time of transfer. Could represent
progression of infection/PNA, but more likely a result of IV
steroids given at OSH.
.
# Chronic Renal Insufficiency: Baseline creatinine of 2 per OSH
records and and 1.9 at OSH at time of transfer. All medications
were renally dosed.
.
# Aspiration: this is likely the source of his PNA based on OSH
records and failed limited S+S eval at OSH when on bipap. Once
out of acute setting, he will need S+S eval prior to eating.
.
# HTN: Patient's BP on admission was 148/74. At home patient was
on lisinopril. As pt was at his baseline creatinine, continued
his home regimen of lisinopril 10 mg daily.
.
# Hyperlipidemia: Continued home regimen of pravastatin 10 mg
QHS.
.
#. COMM: With daughter, [**Name (NI) **] (HCP): [**Telephone/Fax (1) 86184**].
#. CODE: DNR but okay to intubate (confirmed with pt and HCP).
Medications on Admission:
Home Medications (confirmed with patient's daughter and OSH
medical records):
Levothyroxine 100 mcg daily
Lisinopril 10 mg daily
Doxazosin 4 mg daily
Paroxetine 10 mg daily
Pravastatin 10 mg QHS
Multivitamin
Epoetin alfa 10,000 mg weekly
Vit B12 injections monthly
Ambien 5 mg QHS prn insomnia
Tylenol PM prn insomnia
Calcitriol 0.25 mcg daily
Folic Acid 1 mg daily
Lactulose prn constipation
ASA 325 mg daily
.
Medications at time of Transfer:
Heparin 5000u TID
Syntrhoid 0.1 mg daily
Cardura 4 mg daily
Paxil 10 mg daily
Colace 100 mg [**Hospital1 **]
Rocaltrol 0.25 mcg daily
Folic acid 1 mg daily
Multivitamin tab daily
Zocor 5 mg QHS
Lisinopril 10 mg daily
Atropine as directed
Milk of magnesia as directed
Lidocaine prn
Nitrostat prn
Tylenol 650 mg q4 prn
Protonix 40 mg QHS
ISS
Robitussin 5-10 mg po q4H
Levaquin 500 mg IV nightly
Vancomycin 1 g IV q36H
Zosyn 2.25g IV q6H
DuoNebs inh q4H prn
IVF with NS at 75 ml/hr
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"518.81",
"276.0",
"600.00",
"E849.7",
"403.90",
"799.02",
"585.9",
"458.9",
"426.4",
"E932.0",
"244.9",
"255.8",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7899, 7908
|
4283, 6895
|
322, 329
|
7959, 7968
|
3946, 4260
|
8024, 8170
|
3031, 3161
|
7870, 7876
|
7929, 7938
|
6921, 7847
|
7992, 8001
|
3176, 3927
|
235, 284
|
2102, 2439
|
357, 2084
|
2461, 2869
|
2885, 3015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,072
| 184,787
|
14989
|
Discharge summary
|
report
|
Admission Date: [**2184-8-18**] Discharge Date: [**2184-8-21**]
Date of Birth: [**2146-10-9**] Sex: F
Service: NEUROSURG
HISTORY OF PRESENT ILLNESS: This is a 37 year old white
female with a history of decreased vision in the left eye
over the past five months who, on work-up at outside
hospital, was found to have a tuberculum sella meningioma and
was therefore admitted for surgery. She is currently on
Zoloft, Flonase and Hydrocortisone Cream for a history of
depression, allergic rhinitis and eczema respectively. Last
menstrual period was [**2184-8-7**]. She denies fevers,
chills, sweats.
PAST SURGICAL HISTORY: Tonsillectomy.
REVIEW OF SYSTEMS: She denies hypertension, diabetes
mellitus, renal or hepatic disease. She denies chest pain,
shortness of breath or palpitations.
SOCIAL HISTORY: She has a negative alcohol history and is a
nonsmoker.
ALLERGIES: She has an allergic history with reaction to
penicillin.
PHYSICAL EXAMINATION: On physical examination, she is an
overweight white female with a blood pressure of 147/80;
pulse 92; and respirations within normal limits. She is in
no acute distress. On general physical examination,
including the Head, Eyes, Ears, Nose, Throat, Heart, Lungs
and Abdomen was essentially unremarkable with the exception
of some visual changes of the left eye.
HOSPITAL COURSE: Due to the clinical findings, the patient
was taken to the operating room on the morning of admission,
the [**2184-8-18**], where under a general
endotracheal anesthetic, the patient underwent a left frontal
craniotomy and removal of tuberculum sella meningioma. The
patient tolerated the procedure well and went to the Recovery
Room stable; she stayed over in the Recovery Room for the
first postoperative night and was then transferred to the
Regular Medical Surgical Floor.
The patient's postoperative course was otherwise essentially
unremarkable and she was discharged home in stable condition
on the morning of the [**2184-8-21**].
CONDITION AT DISCHARGE: Stable. Vision was slightly
improved at the time of discharge and she was discharged
home.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg p.o. three times a day for five days in
order to complete a course of Dilantin for one week following
surgery.
2. She was also continued on Decadron in decreasing doses
over the course of the next 12 days to complete a two week
course of Decadron.
3. She was given a prescription for Zantac.
4. She was given as well a prescription for Percocet for
relief of any headache or pain.
DISCHARGE STATUS: The patient was then discharged home in
stable condition accompanied by her family.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2184-8-21**] 10:11
T: [**2184-8-26**] 15:39
JOB#: [**Job Number 43877**]
|
[
"477.9",
"692.9",
"013.25",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
2143, 2923
|
1360, 2011
|
642, 658
|
977, 1342
|
2027, 2120
|
678, 810
|
167, 618
|
827, 954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,025
| 164,878
|
24573+57401+57404
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2150-11-20**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2092-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Talwin / Nafcillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Angiogram
History of Present Illness:
58 yo F s/p TAAA stent for type B dissection in [**2150-10-26**]. She
had a long post op course and underwent tracheostomy for
respiratory failure. Is on 4 weeks course of vanco and aztreonam
for staph in blood and proteus in urine. She was dc'd to rehab
on [**11-11**] and had an asystolic arrest there. She was transferred
to Good [**Hospital 57794**] Hospital, she has been off the vent and doind
well but had a HCT drop of 6 points (31-25) and underwent CT
scan which showed question of endoleak and was transferred for
further eval.
Past Medical History:
cushings syndrome, AVR/ascending aorta [**2143**], pulmonary AVM
repair [**2143**], COPD, GERD, h/o splenic lac c/b cardiac arrest and
anoxic brain injury, bilat adrenalectomy
Social History:
unknown.
Family History:
NC
Physical Exam:
HR 76 RR 21 BP 108/94
Lungs CTAB
Heart RRR
Abdomen benign
No CCE
A&O, MAE to command
Left radial pulse absent
Pertinent Results:
[**2150-12-3**] 05:22AM BLOOD WBC-9.3 RBC-3.38* Hgb-10.1* Hct-30.9*
MCV-91 MCH-30.0 MCHC-32.8 RDW-16.9* Plt Ct-788*
[**2150-12-3**] 05:22AM BLOOD Plt Ct-788*
[**2150-12-3**] 05:22AM BLOOD PT-14.4* PTT-51.4* INR(PT)-1.3*
[**2150-12-3**] 05:22AM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-140
K-3.6 Cl-104 HCO3-27 AnGap-13
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2150-11-21**] 1:55 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: s/p thorocoabd stent, r/o endo leak
Field of view: 39 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman endovascular stent
REASON FOR THIS EXAMINATION:
s/p thorocoabd stent, r/o endo leak
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT OF THE CHEST, ABDOMEN AND PELVIS.
INDICATION: 58-year-old female status post thoracoabdominal
aortic stent. Assess for a leak.
COMPARISONS: [**2150-11-9**].
TECHNIQUE: Non-contrast MDCT axial images of the chest, abdomen,
and pelvis were acquired. Following the administration of 60 mL
of Optiray intravenous contrast, MDCT axial images were acquired
from the thoracic inlet to the pubic symphysis. Coronal and
sagittal reconstructed images were then obtained.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The patient is
status post endotracheal intubation. The patient is status post
endovascular stenting of the thoracic aorta beginning at the
level of the aortic arch and extending inferiorly to the level
of T12 approximately. A focal area of contrast extravasation is
noted anteriorly along the graft at the junction of the two
overlapping grafts and measures 3.1 x 0.8 cm (series 401B:image
39). Comparison to the previous CT examination demonstrates
increased of the size in this focal leak. Once again,
surrounding hematoma is noted concentrically around the graft
and not appreciably changed in size compared to the previous
evaluation. There is moderate-to-severe cardiomegaly. No
pericardial effusion is present. The pulmonary artery is
enlarged, measuring 3.5 cm. There is bibasilar dependent
atelectasis. The lungs are otherwise grossly clear. The patient
is status post median sternotomy. Few mediastinal lymph nodes
are noted, none of which meet criteria for pathology by CT.
CT OF THE ABDOMEN WITH IV CONTRAST: Once again, note is made of
multiple hyperattenuating nodules throughout the liver. Several
low-attenuation foci are consistent in appearance with simple
cysts. The liver is grossly unchanged compared to the previous
evaluation. A moderate-sized left pleural effusion is noted. The
kidneys, adrenal glands, spleen, pancreas, gallbladder and
abdominal portions of the large and small bowel appear grossly
unremarkable and unchanged compared to the previous examination.
There is no free fluid within the abdomen.
CT OF THE PELVIS WITH IV CONTRAST: A Foley balloon is present
within the collapsed bladder. The rectum, sigmoid colon, uterus
and adnexa appear unremarkable. There are no pathologically
enlarged inguinal or pelvic lymph nodes. No free fluid is
present within the pelvis.
OSSEOUS STRUCTURES: There is severe S-shaped scoliosis of the
thoracolumbar spine. T12 and L2 compression fractures are
unchanged.
IMPRESSION:
1. Findings consistent with an endoleak at the level of the
graft- to-graft anastomosis in the mid thoracic cavity
anteriorly. This focal area of contrast extravasation has
increased compared to the CT of [**2150-11-9**]. Relatively stable
appearance of peri-aortic hematoma.
2. Left moderate subpulmonic effusion.
These findings were discussed over the telephone with [**First Name8 (NamePattern2) 402**]
[**Last Name (NamePattern1) **] by Dr
Brief Hospital Course:
She was seen by vascular surgery and underwent repeat CT scan
which showed findings consistent with endoleak at the lower pole
of the graft to graft anastomosis with increased area of
extravasation as compared to previous CT. She was hypertensive
and her medications were adjusted. A dobhoff tube was placed and
tubefeedings were restarted. She received a nutrition consult
for increased risk of malnutrition. She awaited normalization of
INR prior to undergoing angiogram on [**11-24**] which showed no
endoleak. She was transferred to the floor on [**11-24**]. Coumadin and
heparin were restarted for mechanical AVR. She underwent speech
and swallow evaluation and aspirated. Thoracic surgery was
consulted for PEG tube which was placed on [**11-30**]. Her coumadin
and tube feeds was restarted. She was ready for discharge to
rehab on heparin on [**12-2**].
Medications on Admission:
Combivent, Aztreonam, Vanco, Solucortef, Zypreza, Lopressor,
Nedium, Heparin gtt
Discharge Medications:
1. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution [**Month/Year (2) **]:
1350 (1350) units/hr Intravenous ASDIR (AS DIRECTED): until INR
is therapeutic.
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
3. Nystatin 100,000 unit/g Cream [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2
times a day).
7. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
12. Aztreonam 1 gram Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Injection Q8H (every 8 hours) for 1 weeks: to finish 4 week
course.
13. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
g Intravenous Q 24H (Every 24 Hours) for 1 weeks: to finish 4
week course.
14. Warfarin 2 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO at bedtime:
Adjust dosing for goal INR between 2.0 - 3.0.
Discharge Disposition:
Extended Care
Facility:
sinae
Discharge Diagnosis:
Type II endoleak - s/p thoracoabdominal stent graft for ruptured
thoracic aneurysm/dissection [**10-26**], coiling of L subclavian [**10-27**],
s/p tracheal stent [**10-30**]; chronic respiratory failure - s/p Trach
[**11-4**], s/p PEG [**11-30**], severe malnutrition - started on tube
feeds, aspiration, s/p AVR(mech), COPD, GERD, h/o splenic lac
c/b cardiac arrest and anoxic brain injury, [**Location (un) 3484**], s/p
asystolic arrest [**11-14**], +MRSA bacteremia and Proteus urinary
tract infection - being treated with Vanco and Aztreonam
Discharge Condition:
Stable.
Discharge Instructions:
1)Continue IV Heparin until INR above 2.0. Monitor PT/INR
closely and adjust Warfarin for goal INR between 2.5 - 3.0.
Please arrange outpatient Warfarin followup with Dr. [**Last Name (STitle) **]
prior to discharge from rehab. 2)Tracheostomy #7 Portex -
continue trach mask with PMV as tolerated 3)Aspiration
precautions - Continue NPO and tube feedings as directed -
please reconsult speech and swallow when indicated 4)Continue
antibiotics as directed 5)Routine PICC care 6)Pulmonary Toilet
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] MD [**2150-3-2**] 1PM - Phone [**Telephone/Fax (1) 170**]
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:
[**2150-12-24**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:
[**2151-3-3**] 1:00
Provider: [**Name10 (NameIs) **] SCAN(CTA with MMS)Phone:[**Telephone/Fax (1) 327**] Date/Time:
[**2151-3-3**] 11:45
Completed by:[**2150-12-3**] Name: [**Known lastname 11167**],[**Known firstname **] F Unit No: [**Numeric Identifier 11168**]
Admission Date: [**2150-11-20**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2092-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Talwin / Nafcillin
Attending:[**First Name3 (LF) 1543**]
Addendum:
She inadvertently pulled out her PICC oine by approximately 4 cm
prior to discharge, CXR showed continued placement in SVC.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2150-12-3**] Name: [**Known lastname 11167**],[**Known firstname **] F Unit No: [**Numeric Identifier 11168**]
Admission Date: [**2150-11-20**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2092-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Talwin / Nafcillin
Attending:[**First Name3 (LF) 1543**]
Addendum:
Correction to previous discharge summary. Ms. [**Known lastname **] had
MSSA not MRSA bacteremia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2150-12-28**]
|
[
"496",
"996.09",
"V58.61",
"458.9",
"E915",
"348.1",
"790.01",
"E878.2",
"934.0",
"787.29",
"V44.0",
"255.0",
"530.81",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"88.42",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10538, 10768
|
4926, 5789
|
307, 318
|
8182, 8192
|
1277, 1802
|
8734, 9801
|
1127, 1131
|
5920, 7537
|
1839, 1876
|
7613, 8161
|
5815, 5897
|
8216, 8711
|
1146, 1258
|
256, 269
|
1905, 4903
|
346, 885
|
907, 1084
|
1100, 1111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,334
| 168,784
|
4672
|
Discharge summary
|
report
|
Admission Date: [**2115-5-15**] Discharge Date: [**2115-5-21**]
Date of Birth: [**2039-6-19**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 75yo F reports slow onset of
shortness of breath since Sunday, progressivly getting worse,
also some minimal cough, chills, no fever, chest pain, malaise
or sick contact. Pt confirms that she celebrated [**Holiday **] on
Sunday with large portion of meal. SOB developed gradually after
[**Holiday **] celebration.
.
In the emergency department, initial vitals: 98.7 87 180/80 18
94RA, pt had CxR, was thought to have PNA and was given
Ceftriaxone/Azythro
Past Medical History:
Hypertension,
Renal cell carcinoma status post left nephrectomy
Renal artery stenosis status post stenting x2,
Diabetes
Cardiomyopathy
Social History:
no sick contact, [**Name (NI) 19747**] to dietary indiscretion over the [**Holiday **]
holiday
Family History:
Both parents w/ DM, daughter w/ DM; denies any other known
family history.
Physical Exam:
On admission-
VITAL SIGNS: T 99.2 BP 140/70 HR 80 RR 16 O2 97%2L
GENERAL: Pleasant, well appearing .female in NAD
HEENT: conjunctival pallor. No scleral icterus. PERRLA/EOMI.
MMM. OP clear. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 3/6 SEM, no
rubs or [**Last Name (un) 549**]. JVP half way elevated
LUNGS: bilateral crackles half way up
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: [**2-1**]+ edema, no calf pain, well perfused and warm
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
[**2115-5-15**] 07:45PM BLOOD WBC-15.1* RBC-3.66* Hgb-10.0* Hct-30.6*
MCV-84 MCH-27.4 MCHC-32.8 RDW-15.0 Plt Ct-199
[**2115-5-15**] 07:45PM BLOOD Glucose-83 UreaN-64* Creat-2.2* Na-138
K-3.5 Cl-99 HCO3-25 AnGap-18
[**2115-5-17**] 07:17AM BLOOD Type-ART Temp-36.7 pO2-44* pCO2-31*
pH-7.50* calTCO2-25 Base XS-1 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2115-5-17**] CXR:Compared to the prior study, there is increase in
pulmonary edema in both lungs with increased bibasilar opacities
that most likely represent the lung volume overload rather than
interval development of infectious process or aspiration. The
pleural effusion has increased, but left more than right, which
is slightly unusual and that is why it should be closely
followed. Some of the lung opacities have nodular appearance but
given its rapid development are most likely representing
pulmonary edema than an infectious etiology. The evaluation of
the patient after diuresis is highly recommended to exclude the
remote possibility of underlying infection. The patient is after
left upper abdomen surgery.
[**2115-5-18**] CXR:
REASON FOR EXAM: Assess CHF after diuresis.
Comparison is made with prior study performed a day earlier.
There is mild improvement in moderate pulmonary edema, although
right upper
lobe has increasing opacity. Atelectasis in the left base,
improved. Small
bilateral effusions, increased on the right. Cardiomegaly is
unchanged.
[**2115-5-17**] Renal U/S:
FINDINGS: Right kidney measures 11.4 cm. No evidence of right
hydronephrosis. Right main renal artery and main renal vein are
patent.
Doppler evaluation is markedly limited due to continuous
respiratory motion throughout the examination. Patient is status
post left nephrectomy. The left renal fossa is unremarkable.
Bladder is not visualized due to overlying bowel gas.
IMPRESSION: No evidence of hydronephrosis. Right main renal
artery and
vein are patent. Doppler evaluation of the right kidney is
markedly limited due to continuous respiratory motion.
Brief Hospital Course:
75 yo female admitted with SOB, URI symptoms and dietary
indiscretion over the [**Holiday **] holiday now with acute worsening of
hypoxia [**3-4**] acute CHF.
# SOB: Cardiac biomakers were flat so unlikely secondary to acs.
SOB though to represent both pneumonia and acute on chronic CHF
exacerbation in the setting of dietary indiscretion over the
[**Holiday **] weekend. Patient was initially started on Azithromycin
and Ceftriazone for antimicrobial coverage. Patient was given IV
lasix on the medicine floor but only diuresed about 1 L.
Overnight on HD#2 she became progressively more hypoxic despite
diuresis. ABG revealed alkalosis and severe hypoxia. CXR was
consistent with worsening pulmonary edema and worsening
pneumonia. EKG was unchanged. Patient was transferred to the
CCU. In the CCU patient was diuresed with IV lasix after which
she was less SOB and O2 requirement trended down. She remained
AF and had no leukocytosis so antibiotics were stopped as it was
felt her SOB was likely [**3-4**] diastolic CHF exacerbation. She was
placed on lasix 120 mg PO three times daily and her fluid
balance was negative more than 2 liters in one day so the dose
was dropped to twice daily. Her O2 requirement steadily trended
down and she required no O2 prior to discharge.
# Hypertension: Patient had labile BPs while in the CCU which
may have contributed to her acute pulmonary edema and CHF
exacerbation. Her nifedipine CR was increased and she was
started on cardura at night with better BP control but still not
ideal with pressures around 160s. Her medication regimen will be
further titrated by her outpatient physicians.
# Renal artery stenosis status post stenting x2: Continued asa
and plavix. Renal U/S was non-diagnostic however her creatinine
trended down to baseline (1.8) while she was hospitalized so it
was felt unlikely that the stent was stenosed.
# Diabetes: diabetic diet and home regiment insulin were started
initially however the patient had elevated FSBS (400s) and
[**Last Name (un) **] was consulted for better diabetic regimen. The patient
was discharge on 18units of lantus as well as a sliding scale
and will follow up as an outpatient for further diabetic
management.
# CKD: Cr baseline 1.7 to 2.1. Patient remained at baseline.
REnal u/s was non-diagnostic as above.
CODE STATUS: Full cofirmed with patient
EMERGENCY CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11461**] (daughter) [**Telephone/Fax (1) 19748**]
Medications on Admission:
Atorvastatin 20 mg
Calcitriol 0.5 mcg daily
Clonidine 0.3 mg po bid
Plavix 75 mg daily
Lasix 120 mg qam, qnoon, and 40 mg qhs
Labetalol 600 mg tid
Nifedipine 90 mg daily
Omeprazol 20 mg [**Hospital1 **]
ASA 81 mg daily
Insulin NPH 18 IU qam, 16 IU qpm
Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: Twenty One (21) units
Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
2. Insulin Syringe 1 mL 30 x [**6-15**] Syringe Sig: One (1) syringe
Miscellaneous four times a day: Please substitute if pt wishes.
Disp:*1 box* Refills:*2*
3. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Diabetes Mellitus
Hypertension
Renal Artery Stenosis s/p stent
Discharge Condition:
stable, dry weight: 67.3kg
Discharge Instructions:
You had very high blood pressure and had fluid overload. We
adjusted your medicines and gave you more Furosemide to take off
the fluid. It is very important that you monitor your fluid
status at home. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
> 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
It is very important that you take all of your medicines as
Followup Instructions:
Nephrology:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2115-8-29**] 3:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-8-26**] 2:55
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: Date/time: [**6-12**] at 4:15pm.
.
Primary care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:
.
[**Hospital **] Clinic:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] [**5-28**] at 4pm. Phone: ([**Telephone/Fax (1) 4847**]. [**Last Name (un) 19749**], [**Location (un) 86**] MA
Completed by:[**2115-5-21**]
|
[
"440.1",
"V10.52",
"425.4",
"424.1",
"585.9",
"428.0",
"428.33",
"276.3",
"799.02",
"584.9",
"403.90",
"V45.73"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7840, 7898
|
3795, 6278
|
293, 300
|
8057, 8086
|
1740, 3772
|
8528, 9256
|
1100, 1177
|
6581, 7817
|
7919, 8036
|
6304, 6558
|
8110, 8505
|
1192, 1721
|
234, 255
|
356, 813
|
835, 972
|
988, 1084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,410
| 186,484
|
22306+57292+57294
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2111-5-27**] Discharge Date: [**2111-6-5**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
gentleman with a history of cerebrovascular accident and
hypertension with four to five day history of progressive
right-sided weakness who was admitted to an outside hospital
on [**2111-5-11**]. Reportedly MRI was done at the time and
was negative for an infarct. The patient was also observed
to have facial numbness and tingling at the time and
complaints of mild dysarthria and mild word finding
difficulties. He was transferred to rehabilitation on the
[**5-13**] but had intermittent worsening of the right-
sided weakness and mild dysarthria which continued and had
some lightheadedness with standing. He was transferred to
[**Hospital1 69**] for further management.
PHYSICAL EXAMINATION: Temperature was 98.1, blood pressure
160/80, heart rate 113, respiratory rate 20, sats 92 percent
on room air. He is a pleasant elderly gentleman in no acute
distress. His sclerae were anicteric. Carotids with no
bruit. Cardiovascular: Regular rate and rhythm. S1, S2.
No murmur, rub or gallop. Chest was clear to auscultation
bilaterally. Abdomen was soft, non-tender, non-distended,
positive bowel sounds. Extremities: No clubbing, cyanosis
or edema. Neurologically, his speech was fluent with mild
dysarthria. Pupils equal, round and reactive to light.
Extraocular movements intact. Visual fields full to
confrontation. Strength 5/5 in all muscle groups. Tongue
was midline. Slight right facial droop. Deep tendon
reflexes 2 plus throughout. His toes were mute. Sensation
was intact to light touch.
HOSPITAL COURSE: He was admitted to the Neurosurgery
Service. The plan was for angiogram. The patient underwent
arteriogram on [**2111-5-29**], which showed evidence of a right
ICA stenosis and left pica stroke. The patient had high
grade right ICA stenosis in the cavernous portion. There
were no complications to the procedure and it was decided
that the patient would wait for stent placement until
recovering from his most recent stroke. He had a bedside
swallow evaluation which he failed and had a feeding tube in
place for feeding. He had a repeat swallow evaluation two or
three days later and had a video swallow which, again, he was
aspirating all consistencies. Therefore, it was decided to
place a PEG feeding tube. The PEG tube was scheduled for
placement on [**2111-6-5**]. The patient's vital signs have
been stable. He has been afebrile, awake, alert and oriented
times three, moving all extremities with good strength.
Continues with right-sided weakness. Was also seen by the
Pulmonary Service for question of right lower lobe nodule
which they felt was most likely pneumonia by CT scan.
Therefore, the patient was started on clindamycin and
levofloxacin for a two week course of intravenous antibiotics
for Gram negative rods and for radiographic evidence of
pneumonia. The patient's vital signs since that time have
remained stable. He is afebrile. He has been out-of-bed
ambulating with Physical Therapy and Occupational Therapy and
will require a short rehabilitation stay prior to discharge
to home. His sodium level has also been low today down to
129. He was started on 1000 fluid restriction, salt tabs one
gram p.o. t.i.d.
DISCHARGE MEDICATIONS: Include salt tabs one gram p.o.
t.i.d., metoprolol 25 p.o. b.i.d., hold for blood pressure
less than 160, heart rate less than 60, levofloxacin
currently 500 mg IV q. 24h. which will be changed to p.o. and
clindamycin 600 mg IV q. 8h., heparin 5000 units subcu q.
12h., insulin sliding scale, hydrocodone one to two tabs p.o.
q. 4h. p.r.n. for headache, Zantac 150 p.o. b.i.d., Excedrin
aspirin-free one tab p.o. q. 6h. p.r.n. Patient takes all
medications. Aspirin 81 mg p.o. q. day, Plavix 75 mg p.o. q.
day, meclizine 25 p.o. q. 6h. p.r.n., Colace 100 mg p.o.
b.i.d., levothyroxine 125 mcg p.o. q. day, simvastatin 20
p.o. q. day, hydrochlorothiazide 25 p.o. q. day, lisinopril
20 p.o. q. day.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2111-6-4**] 17:15:39
T: [**2111-6-4**] 17:38:51
Job#: [**Job Number 58106**]
Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 10780**]
Admission Date: [**2111-5-27**] Discharge Date:
Date of Birth: [**2026-12-30**] Sex: M
Service: NSU
ADDENDUM:
HOSPITAL COURSE: On [**2111-6-5**], the patient was taken by
Interventional Radiology to the operating room for PEG
placement. He was brought back to the floor in stable
condition. However, he developed a bleed later that day and
was experiencing hemodynamic instability. Interventional
Radiology was called by Neurosurgery to deal with the problem
and they put some stitches in the wound, and hemodynamic
stability was restored. Later on [**2111-6-5**], the patient was
experiencing mental status changes as a result of relative
hypotension. It was decided at this time that the patient
would be better taken care of in the SICU. The patient was
given a fluid bolus of 1 liter normal saline and transferred
to the SICU to presumably stay over.
While in the SICU, the patient had continued semi-occlusion
of the upper airway despite a nasal trumpet. His ABG showed
he was acidotic and secretions were increasing, so it was
decided that the patient should be intubated for airway
protection. On [**2111-6-6**], the patient had a head CT that
showed no acute changes; however, he was very lethargic,
opening the eyes to voice only, inconsistently following
commands now that he is intubated; however, he does withdraw
all extremities to pain.
On [**2111-6-7**], upon examination by Neurosurgery; all his vital
signs were stable. His lab showed a white blood count of
12.6, hematocrit of 29.3, and platelet level of 4.66. He
opened his eyes to voice. He stuck out his tongue and showed
thumbs bilaterally. At this point, the patient was following
commands and neurologically stable. The plan at this point
was to keep his blood pressure greater than 150 to ensure
perfusion and keep his pCO2 between 35 and 45. Neurosurgical
exam on [**2111-6-8**] showed all vital signs were stable. The
patient was on 0.5 percent of Neo-Synephrine to maintain a
blood pressure greater than 140. He was neurologically
stable at this point.
On [**2111-6-9**], on neurosurgical progress note, the patient was
awake and oriented x1. Pupils were 4 to 3 bilaterally. No
drift; [**3-25**] grip strength bilaterally. His plan at this time
was to keep his pressure between 120 and 170, anticoagulate
with subcutaneous heparin, and was transferred out of the
SICU to the main floor on Far 5. On [**2111-6-9**], the patient
was transferred out of the unit to the main floor. However,
at this time, he pulled out his Foley catheter traumatically.
On [**2111-6-10**], the patient was neurologically stable, all his
vital signs were stable. He was awake, alert, and oriented
x1. He had no drift. His IPs were [**2-23**]. His grip was [**3-25**].
The PEG site was clear without serosanguinous fluid
discharge. There was a small hematoma, and after pulling the
Foley he has gross hematuria. He is neurologically stable;
however, today, we will get a Urology consult and a rehab
________
DICTATION ENDED
[**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**]
Dictated By:[**Last Name (NamePattern1) 10242**]
MEDQUIST36
D: [**2111-6-10**] 11:08:09
T: [**2111-6-10**] 15:03:32
Job#: [**Job Number 10781**]
Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 10780**]
Admission Date: [**2111-5-27**] Discharge Date: [**2111-6-16**]
Date of Birth: [**2026-12-30**] Sex: M
Service: NSU
The patient experienced hematuria after traumatic Foley
extraction. The patient pulled out his Foley, and then
developed gross hematuria. Urology was consulted, and a
three-way Foley was placed, and the patient was placed on
irrigation through the Foley catheter for 2-3 days with
clearing of his urine. At this point, his urine is clear
with no evidence of blood. The three-way Foley has remained
in place and should remain in place for another 2-3 days and
then be discontinued.
The patient's neurologic status is stable. He is awake,
alert, and oriented times one. He has no drift. His IP's
were [**2-23**]. Grasps were [**3-25**]. His PEG site, where he had some
bleeding earlier on was clean, dry, and intact with no
evidence of serosanguinous drainage. His vital signs and his
temperature have been stable. He is ready for discharge with
followup with Dr. [**Last Name (STitle) 365**] in [**12-23**] weeks' time.
CONDITION ON DISCHARGE: His condition was stable at the time
of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**]
Dictated By:[**Last Name (NamePattern1) 2186**]
MEDQUIST36
D: [**2111-6-15**] 13:53:29
T: [**2111-6-15**] 14:18:23
Job#: [**Job Number 10784**]
|
[
"401.9",
"867.0",
"E878.8",
"433.10",
"244.9",
"276.2",
"507.0",
"998.11",
"E928.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.6",
"96.04",
"88.41",
"44.32",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3363, 4063
|
4692, 9008
|
4110, 4674
|
849, 1671
|
117, 826
|
9033, 9338
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,770
| 196,446
|
9759+56064
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-7-14**] Discharge Date: [**2146-8-5**]
Date of Birth: [**2066-7-17**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 32912**]
Chief Complaint:
tachycardia, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79yM s/p laparoscopic cholecystectomy [**2146-6-2**] @ [**Hospital3 **]
with intraoperative drain placement for bleeding and mild bile
spillage who developed bilious drainage on POD1. He was sent to
[**Hospital1 18**] from [**Hospital1 392**] for ERCP and was found to have a duct of
Luschka leak. He was subsequently worked up and found to have
jejunal and duodenal enterotomies. Jejunal enterotomy was
repaired, and a T-tube was placed in the duodenal enterotomy. He
now has PTBD, t-tube, and [**Doctor Last Name **] drains in place, in addition to
a feeding J-tube. He presented with tachycardia and hypotension.
Past Medical History:
Past Medical History: HTN, prostate CA, duodenal ulcer
Past Surgical History: partial gastrectomy with BII
reconstruction, prostatectomy with bilateral inguinal node
dissection, laparoscopic cholecystectomy
Social History:
He lives in a long term care facility. He does not drink
alcohol, and has not smoked for 20 years.
Family History:
non-contributory
Physical Exam:
On discharge:
Vitals: T 98.2., HR 85, BP 114/61, RR 32, O2-sat 98%RA
General: Appears well, in no acute distress. Rigid.
HEENT: Moist mucous membranes, no scleral icterus, tongue
midline, no palpable lymphadenopathy
Cardiac: RRR, no M/R/G, normal S1, S2
Pulmonary: CTAB, diminshed breath sounds at the bases
bilaterally. No rales or rhonchi.
Abdomen: Soft, non-tender, non-distended, positive bowel sounds.
No palpable masses. [**Doctor Last Name 406**] drain, T-tube drain, PTBD drain, and
J-tube in place. No erythema or purulence around drain sites.
Extremities: no edema
Pertinent Results:
C. difficile DNA amplification assay ([**2146-7-15**]): negative
Urine culture ([**2146-7-14**]): no growth
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment.
Neuro: The patient was started on a trial of Sinemet for his
previously diagnosed Parkinson's Disease. He was also placed on
EEG monitoring, which revealed no seizures.
CV: Initially, the patient required a phenylephrine drip
secondary to hypotension. However, the patient was fluid
resuscitated, and was able to wean off phenylephrine
successfully. Similarly, as he was being intravascularly
repleted, his tachycardia resolved. He remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and chest physical therapy were encouraged throughout
hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Patient was
started on peptamen tube feeds, which were slowly increased a
goal rate of 55cc/hr. The patient tolerated this well.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. On presentation, he was
empirically started on vancomycin, zosyn, and cipro secondary to
concern for infection. Urine analysis and culture were negative.
Infectious disease consult recommended discontinuing
antibiotics, as there was no proven source of infection.
Endocrine: no issues
Hematology: The patient's complete blood count was examined
routinely; he was transfused with one unit of PRBC secondary to
downtrending Hct to 22.7. Patient Hct appropriately responded to
the transfusion, with a post-transfusion Hct of 29.6.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Aspirin 325', metoprolol tartrate 25''', heparin 5,000''',
insulin regular 100'''', esomeprazole magnesium 40',
saccharomyces boulardii 250'''', ascorbic acid ER 500'', DuoNeb
0.5 mg-3 mg(2.5 mg base)/3 mL Neb'''', guaifenesin 100 mg/5 mL
Syrup Oral''''
Discharge Medications:
1. Aspirin 325 mg PO DAILY
per J tube
2. Guaifenesin [**5-12**] mL PO Q6H:PRN cough
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
4. Ipratropium Bromide Neb 1 NEB IH Q6H
5. Metoprolol Tartrate 25 mg PO TID
6. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital [**Hospital1 8**]
Discharge Diagnosis:
dehydration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 32913**],
You were admitted to the general surgery service at [**Hospital1 18**]
because you were tachycardic and hypotensive. You have done
well, and it is now safe for you to continue your recovery in a
long term care facility.
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 [**5-12**] 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.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You have an appointment
with Dr. [**First Name (STitle) **] on [**2146-8-5**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2146-8-5**]
9:30
Name: [**Known lastname 5713**],[**Known firstname **] Unit No: [**Numeric Identifier 5714**]
Admission Date: [**2146-7-14**] Discharge Date: [**2146-8-5**]
Date of Birth: [**2066-7-17**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3149**]
Addendum:
EVENTS:
[**2146-7-14**]: Cipro started empirically for UTI. Patient resuscitated
with boluses of NS X 750 cc, and LR 100 cc/hr. Patient was still
hypotensive and tachycardic at 21:00; Vanc/Zosyn started in
place of cipro in view of empiric treatment for sepsis. IR on
[**7-15**] for replacement of j-tube. A-line inserted in right axilla,
patient continues to be tachy and hypotensive, Neo 1 mcg/kg/min
started to maintain pressure despite adequate fluid
resuscitation.
[**7-15**]: J-tube replaced in IR; started Peptamen for TF. Changed
fluids to maintenance. Cdiff sent. Cipro added per ID recs for
additional gram negative coverage - given organisms noted on
prior bile cx on previous admission. Given 25/100 Sinemet x 1 to
assess for response - mild improvement per neuro team, thus
started [**Hospital1 **] tx. On neo gtt. Alb 5% 12.5g x1 overnight for low
UOP.
[**7-16**] off pressors
[**7-17**]: d/c'ed R. axillary A-line; d/c'ed antibiotics given
absence of growth on cultures and likely contamination in JP
[**Month/Year (2) 5715**] (grew multiple organisms previously and at the time ID had
recommended watchful waiting); 1U PRBCs for Hct 23.4.
[**7-18**]: Improved rigidity and finger tapping on 25/100 Sinemet,
increased to TID. Decrease in urine production, bolused 500 cc
NS.
[**7-19**]: transferred on the floor. Speech and swallow evaluation
recommended NPO. Refeed with bile from t-tube started. Fluid
balance with boluses.
[**7-20**]: continued TF, 2L LR for fluid balance.
[**7-21**]: PTBD and T-tube capped, received 1L bolus. was fluid
possitive. mental status improving.
[**7-22**]: increased output from [**Doctor Last Name 4319**], slightly increase in WBC,
PTBD and t-tube unclamped. bile refeed with TF from PTBD.
Required 500cc bolus to stay even.
[**7-23**]: Clamped T-tube and [**Doctor Last Name **], refeeding 300cc of bile per day
from PTBD by mixing with TF. Required 500cc bolus to stay even.
[**7-24**]: Clamped PTBD, unclamped occasionally to allow accumulation
of bile, continued to refeed 300cc of bile per day from PTBD by
mixing with TF. Required 500cc bolus to stay even.
[**7-25**]: Clamped T-tube; Clamped PTBD x4hrs, unclamped for 2hours,
refed bile 100cc q8h by mixing with TFs.
Due to an episode of tachycardia, hypotension, and tachypnea,
the patient was transferred to the ICU. Please refer to full ICU
notes for further reference.
[**2146-7-27**]: Patient transferred to ICU, intubated, a-line placed,
phenylephrine drip, albumin 500cc x 2, NS->LR, initially c/w PE,
CT A/P was obtained
[**7-27**]: LLL PNA was diagnosed. Sputum cultures were sent. The
patient was transitioned from a phenelephrine drip to
norepinephrine drip on this day. On this day, tubefeeds were
also administered started. 2 units of PRBCs were given for
hematocrit of 19.
[**2146-7-28**]: TF were stopped as the patient was noted to have
increased [**Month/Day/Year 5715**] output upon administration of feeds. From this
point onwards, it was determined that the patient was to be
strictly NPO, with NO tube feeds. Nothing to be administrered by
J tube, with the exception of crushed Cinemet. This was the day
that TPN was started, and began weaning patient off the vent.
Stool studies were obtained, which were negative. Sputum
cultures revealed E.coli, for which the patient was started on a
course of IV Zosyn, to be complete on [**2146-8-5**]. Due to RSBI 103
and persist acidosis, were unable to extubate. Cardiovascular
status continued to improve, however, and the patient was weaned
off pressor support.
[**2146-7-29**]: On this day, the patient was weaned off propofol, and
was awake following commands, on CPAP, with IV tylenol for pain
[**2146-7-30**]: Patient was noted to be "wet" on pulmonary exam, +10
liters during [**Hospital 5716**] hospital stay. He was given 10 mg IV
Lasix, still intubated pending further diuresis.
[**7-31**] Family updated, raised the possibility of tracheostomy.
[**8-1**]: Lasix drip restarted, goal -130 to 150 cc per hour,
albumin given with lasix- IR reanchored [**Month/Year (2) 5715**].
[**8-2**]: On this day, patient was extubated without incident. 1 U
PRBC given, NG removed, cinemet administered via j-tube, and
patient was out of bed throughout the day. He would expereince
occasional desat to high 80's which improved with suctioning
[**8-3**]: Waxing/[**Doctor Last Name 2364**] mental status this morning.
[**8-4**] and [**8-5**]: Patient continues to be stable in terms of
cardiovascular and respiratory status. [**8-5**] is the day of
completion of Zosyn treatment for LLL pneumonia. The patient
requires TPN for nutrition, and is to be strict NPO, with NO
TUBE FEEDS. Nothing is to be administered by J tube except for
crushed Cinemet. The patient and family is informed and aware of
upcoming transfer to an extended care facility for further care.
Chief Complaint:
Dehydration, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yM s/p laparoscopic cholecystectomy [**2146-6-2**] @ [**Hospital3 5717**]
with intraoperative [**Hospital3 5715**] placement for bleeding and mild bile
spillage who developed bilious drainage on POD1. He was sent to
[**Hospital1 8**] from [**Hospital1 3983**] for ERCP and was found to have a duct of
Luschka leak. He was subsequently worked up and found to have
jejunal and duodenal enterotomies. Jejunal enterotomy was
repaired, and a T-tube was placed in the duodenal enterotomy. He
now has PTBD, t-tube, and [**Doctor Last Name **] drains in place, in addition to
a feeding J-tube. At [**Hospital1 49**] in [**Location (un) 50**],
he became febrile and hypotensive and was transferred to [**Hospital 5718**] Medical Center, where he continued to be hypotensive
and tachycardic with a positive UTI, and was subsequently
transferred to [**Hospital1 8**]. Upon arrival, he was tachycardic and
hypotensive. He also had a clogged J-tube. The family was not
satisfied with the care at [**Hospital **] Hospital.
Past Medical History:
Past Medical History: HTN, prostate CA, duodenal ulcer
Past Surgical History: partial gastrectomy with BII
reconstruction, prostatectomy with bilateral inguinal node
dissection, laparoscopic cholecystectomy
Social History:
He lives in a long term care facility. He does not drink
alcohol, and has not smoked for 20 years.
Family History:
non-contributory
Physical Exam:
VS:98.0 97.5 78 131/56 26 96%1L
Gen: limited responsiveness but [**Last Name (LF) 5719**], [**First Name3 (LF) **] follow commands
CV: RRR, systolic ejection murmur
Pulm: coarse breath sounds, mild/minimal basilar crackles on L
Abd: Soft, non-tender to palpation, non-distended, Inc c/d/i,
T-tube, [**Doctor Last Name **], and PTBD all bilious output
Ext: No LE edema
Pertinent Results:
UCx- No growth
[**2146-8-4**] 02:24AM BLOOD WBC-10.1 RBC-3.01* Hgb-9.1* Hct-28.4*
MCV-94 MCH-30.1 MCHC-32.0 RDW-17.2* Plt Ct-620*
[**2146-8-4**] 02:24AM BLOOD Glucose-131* UreaN-74* Creat-2.8* Na-147*
K-3.5 Cl-110*
[**2146-8-4**] 02:24AM BLOOD ALT-7 AST-24 AlkPhos-173* TotBili-0.6
[**2146-8-4**] 02:24AM BLOOD Albumin-2.8* Calcium-9.5 Phos-3.3 Mg-2.3
[**2146-8-3**] 03:27AM BLOOD Type-ART pO2-99 pCO2-45 pH-7.47*
calTCO2-34* Base XS-7
Brief Hospital Course:
EVENTS:
[**2146-7-14**]: Cipro started empirically for UTI. Patient resuscitated
with boluses of NS X 750 cc, and LR 100 cc/hr. Patient was still
hypotensive and tachycardic at 21:00; Vanc/Zosyn started in
place of cipro in view of empiric treatment for sepsis. IR on
[**7-15**] for replacement of j-tube. A-line inserted in right axilla,
patient continues to be tachy and hypotensive, Neo 1 mcg/kg/min
started to maintain pressure despite adequate fluid
resuscitation.
[**7-15**]: J-tube replaced in IR; started Peptamen for TF. Changed
fluids to maintenance. Cdiff sent. Cipro added per ID recs for
additional gram negative coverage - given organisms noted on
prior bile cx on previous admission. Given 25/100 Sinemet x 1 to
assess for response - mild improvement per neuro team, thus
started [**Hospital1 **] tx. On neo gtt. Alb 5% 12.5g x1 overnight for low
UOP.
[**7-16**] off pressors
[**7-17**]: d/c'ed R. axillary A-line; d/c'ed antibiotics given
absence of growth on cultures and likely contamination in JP
[**Month/Year (2) 5715**] (grew multiple organisms previously and at the time ID had
recommended watchful waiting); 1U PRBCs for Hct 23.4.
[**7-18**]: Improved rigidity and finger tapping on 25/100 Sinemet,
increased to TID. Decrease in urine production, bolused 500 cc
NS.
[**7-19**]: transferred on the floor. Speech and swallow evaluation
recommended NPO. Refeed with bile from t-tube started. Fluid
balance with boluses.
[**7-20**]: continued TF, 2L LR for fluid balance.
[**7-21**]: PTBD and T-tube capped, received 1L bolus. was fluid
possitive. mental status improving.
[**7-22**]: increased output from [**Doctor Last Name 4319**], slightly increase in WBC,
PTBD and t-tube unclamped. bile refeed with TF from PTBD.
Required 500cc bolus to stay even.
[**7-23**]: Clamped T-tube and [**Doctor Last Name **], refeeding 300cc of bile per day
from PTBD by mixing with TF. Required 500cc bolus to stay even.
[**7-24**]: Clamped PTBD, unclamped occasionally to allow accumulation
of bile, continued to refeed 300cc of bile per day fro PTBD by
mixing with TF. Required 500cc bolus to stay even.
[**7-25**]: Clamped T-tube; Clamped PTBD x4hrs, unclamped for 2hours,
refed bile 100cc q8h by mixing with TFs.
Due to an episode of tachycardia, hypotension, and tachypnea,
the patient was transferred to the ICU. Please refer to full ICU
notes for further reference.
[**2146-7-27**]: Patient transferred to ICU, intubated, a-line placed,
phenylephrine drip, albumin 500cc x 2, NS->LR, initially c/w PE,
CT A/P was obtained
[**7-27**]: LLL PNA was diagnosed. Sputum cultures were sent. The
patient was transitioned from a phenelephrine drip to
norepinephrine drip on this day. On this day, tubefeeds were
also administered started. 2 units of PRBCs were given for
hematocrit of 19.
[**2146-7-28**]: TF were stopped as the patient was noted to have
increased [**Month/Day/Year 5715**] output upon administration of feeds. From this
point onwards, it was determined that the patient was to be
strictly NPO, with NO tube feeds. Nothing to be administrered by
J tube, with the exception of crushed Cinemet. This was the day
that TPN was started, and began weaning patient off the vent.
Stool studies were obtained, which were negative. Sputum
cultures revealed E.coli, for which the patient was started on a
course of IV Zosyn, to be complete on [**2146-8-5**]. Due to RSBI 103
and persist acidosis, were unable to extubate. Cardiovascular
status continued to improve, however, and the patient was weaned
off pressor support.
[**2146-7-29**]: On this day, the patient was weaned off propofol, and
was awake following commands, on CPAP, with IV tylenol for pain
[**2146-7-30**]: Patient was noted to be "wet" on pulmonary exam, +10
liters during [**Hospital 5716**] hospital stay. He was given 10 mg IV
Lasix, still intubated pending further diuresis.
[**7-31**] Family updated, raised the possibility of tracheostomy.
[**8-1**]: Lasix drip restarted, goal -130 to 150 cc per hour,
albumin given with lasix- IR reanchored [**Month/Year (2) 5715**].
[**8-2**]: On this day, patient was extubated without incident. 1 U
PRBC given, NG removed, cinemet administered via j-tube, and
patient was out of bed throughout the day. He would expereince
occasional desat to high 80's which improved with suctioning
[**8-3**]: Waxing/[**Doctor Last Name 2364**] mental status this morning.
[**8-4**] and [**8-5**]: Patient continues to be stable in terms of
cardiovascular and respiratory status. [**8-5**] is the day of
completion of Zosyn treatment for LLL pneumonia. The patient
requires TPN for nutrition, and is to be strict NPO, with NO
TUBE FEEDS. Nothing is to be administered by J tube except for
crushed Cinemet. The patient and family is informed and aware of
upcoming transfer to an extended care facility for further care.
Medications on Admission:
Aspirin 325 PO qd, metoprolol tartrate 25 PO tid, heparin 5,000
subQ tid,
insulin regular SSI qachs, esomeprazole magnesium 40 PO qd,
saccharomyces boulardii 250 PO qid, ascorbic acid ER 500 PO bid,
DuoNeb
0.5 mg-3 mg(2.5 mg base)/3 mL Neb qid, guaifenesin 100 mg/5 mL
Syrup Oral qid
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Carbidopa-Levodopa (25-100) 1 TAB NG TID
please crush and give via j-tube with 60cc water to avoid j-tube
clogging
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Heparin 5000 UNIT SC TID
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
8. Pantoprazole 40 mg IV Q24H
9. Potassium Chloride Replacement (Critical Care and Oncology)
IV Sliding Scale
Only 1 dose is to be given per laboratory value. Additional
doses without new lab values require an additional order be
placed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital [**Hospital1 15**]
Discharge Diagnosis:
Dehydration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance ([**Doctor Last Name 5720**] lift) to
chair or wheelchair.
Discharge Instructions:
Mr. [**Known lastname **] and new care team,
You were admitted to the general surgery service at [**Hospital1 8**]
because you were tachycardic and hypotensive. You have done
well, and it is now safe for you to continue your recovery in a
long term care facility.
Please provide all specified medications. Please encourage
patient to get plenty of rest, continue to assist patient with
getting out of bed and into a chair, as tolerated.
Please follow-up with surgeon and Primary Care Provider (PCP) as
advised below.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised below.
[**First Name4 (NamePattern1) 4319**] [**Last Name (NamePattern1) **] Care and T-tube care:
*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).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the [**Last Name (NamePattern1) 5715**].
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the [**Last Name (NamePattern1) 5715**] frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the [**Last Name (NamePattern1) 5715**] attached securely to your body to
prevent pulling or dislocation.
.
PTBD Care:
Please keep to gravity drainage. *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).
*If the [**Last Name (NamePattern1) 5715**] is connected to a collection container, please
note color, consistency, and amount of fluid in the [**Last Name (NamePattern1) 5715**]. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the [**Last Name (NamePattern1) 5715**] frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
[**Last Name (NamePattern1) 5715**] sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the [**Last Name (NamePattern1) 5715**] attached securely to your body to
prevent pulling or dislocation.
.
J-Tube Care:
Please monitor for signs and symptoms of infection or
dislocation. You may use this tube for administration of Cinemet
(CRUSHED) only. Do NOT give other medications by this route -
please administer intravenously, as specified. Do NOT give any
tube feeds. Patient is strict NPO and nothing by tube (except
Cinemet).
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2146-8-15**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**], MD [**Telephone/Fax (1) 5721**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1826**]
Campus: EAST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**]
Completed by:[**2146-8-5**]
|
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icd9cm
|
[
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[
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[
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|
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20186, 23071
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11613, 11639
|
11712, 12730
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19988, 20162
|
12774, 12808
|
12977, 13078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,161
| 196,196
|
9984
|
Discharge summary
|
report
|
Admission Date: [**2138-8-1**] Discharge Date: [**2138-8-20**]
Date of Birth: [**2077-6-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
right craniotomy
History of Present Illness:
61 yo male with RCC s/p chemo and CK therapy on [**2138-7-17**] presents
to [**Hospital1 18**] with LUE/LLE weakness 1 week after CK therapy. He feels
that they are both equally weak. He is having a difficult time
eating with the L arm (he is left-handed) but also lifting
things. He drags his left foot when he walks. He states his
face was never involved.
He did have a headache in the back of his head, which he noticed
more in the evening, it was not present in the AM and didn't
wake
him up out of sleep. He denied any numbness on the left side,
no
dysphagia/dysarthria, no difficulty with hearing. He feels his
coordination is fine except for the weakness and that he can sit
up and stand, but his gait is off because of the left-sided
weakness. He feels that his left leg has improved after the
steroids; his headache has definitely disappeared after the
steroids. He has been taking his seizure meds and denies any
seizure activity, no AM tongue biting, no AM urinary
incontinence, no focal motor/sensory sx's, no AOC. Rest of his
ROS was negative.
Past Medical History:
ONC history:
renal cell cancer in [**2131-10-26**]. He had a right
nephrectomy that month. He also had bilateral lung nodules,
status post bilateral VATS in [**2131-12-27**]. He had IL-2
from [**2132-2-24**] to [**2133-11-25**]. This was followed by flutamide
and Epogen. He had continued disease progression and was
treated on high-dose interferon and IL-2 in [**2133**]. He switched
to Nexavar, which he took from
[**2133**]-[**2135**], and then switched to Sutent in [**2137-1-23**], had Gemzar
added to the regimen. On [**6-29**], presented with a five- to
six-week history of a left hemiparesis with some decompensation.
brain imaging including MRI showed acute hemorrhagic lesion
with contrast enhancement in the right frontal motor strip,
common, small, more anterior one. These were both consistent
with metastasis. Underwent CK therapy on [**2138-7-17**]. Currently not
on sutent.
.
PMH:
1. Seizure
2. Hypertension
3. Anemia
4. Hypothyroidism
5. Steroid induced hyperglycemia
6 metestatic renal cell
Social History:
He is married and lives with his wife. [**Name (NI) **] tobacco, alcohol, drug
use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
Temp: 100.1
HR: 110
BP: 117/52
RR: 12
Ox: 96%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. Mobile but firm mass lateral aspect of right
neck. No JVD. No thyromegaly. No carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Able to name last
three presidents. Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Speech fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors. No apraxia, no
neglect. [**Location (un) **] intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3 mm
bilaterally. Visual fields are full to confrontation. Optic disc
margins 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 on right with decreased
tone in LUE and increased tone in LLE. No abnormal movement or
tremors. Strength on right is full. On left, grip strong, WE
5-/5, FE 5-/5, triceps [**2-27**], delt 4-/5. In leg, IP [**2-27**], quad
4-/5
but full distally.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally but extinguishes left on DSS.
Reflexes: Increased in LUE with spread and adduction at patella
on left. No clonus. Left toe upgoing, right downgoing.
Coordination: Normal on finger-nose-finger, rapid alternating
movements on right. Limited by weakness on left, but no
ataxic>degree of weakness.
Gait: Deferred.
ON discharge -
pt awake alert and oriented / conversational and attentive/
motor exam full except somewhat limited [**2-27**] on left side as well
as left side ataxia which is improved s/p crani.
Pertinent Results:
CT HEAD NONCONTRAST
FINDINGS: There is slight interval increase in the size of the
right parietal lobe hyperdense mass compared with the prior CT
examination, currently measuring 1.8 cm. However, compared to
its size on MRI, it is grossly unchanged; however, accurate
comparison is difficult due to differences in modalities. There
is associated slight interval increase in the marked surrounding
vasogenic edema, causing progressive midline shift to the left
measuring approximately 1.1 cm. Apart from the hyperdensity
within the mass, there is no evidence of intra-axial hemorrhage.
The other punctate right frontal metastasis seen in prior MR
examination is not visualized. There is no uncal or cerebellar
tonsillar herniation and the basal cisterns are preserved.
.
The subcutaneous tissues and orbits are grossly unremarkable.
Calvarium is intact. The mastoids are clear, so are the
visualized paranasal sinuses.
.
IMPRESSION:
1. Hyperdense right parietal lobe metastasis, which appears
slightly larger when compared to the previous CT examination
dated [**7-2**].
2. Slight interval increase in marked right frontal, parietal
and temporal lobe vasogenic edema causing increased midline
shift to the left. Basal cisters are preserved.
3. No acute intracranial hemorrhage.
.
.
CT TORSO:
CT OF THE CHEST WITH IV CONTRAST: Small lymph nodes are noted
in the right axilla as well as in the left axilla. These do not
meet CT criteria for pathologic enlargement and are unchanged.
A right hilar lesion is again noted and is increased in size,
currently measuring 1.9 x 1.4 cm, (previously 1.3 x 1.7 cm). A
more inferior right hilar node is also increased in size and
currently measures 4.7 x 2.5 cm (previously 2.7 x 1.5 cm).
There are small pulmonary nodules bilaterally. A nodule in the
right apex (series 3, image 7)
is stable in size, however, nodule in the left lower lobe
measuring 1.0 x 0.8 cm is new as is a tiny nodule in the right
lower lobe immediately adjacent to the pleura.
.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Two hypodense
lesions in the left lobe of the liver are unchanged. The
previously noted enhancing lesions in the right hepatic lobe
demonstrate mixed response. A lesion in segment VIII currently
measures 0.4 x 0.4 cm (previously 1.6 x 1.6 cm). Immediately
adjacent to it is a new lesion, currently measuring 1.3 x 1.3
cm. A lesion in
segment VI of the liver currently measures 0.8 x 0.6 cm
(previously 2.0 x 1.7 cm) and is thus decreased in size,
however, another lesion has increased in size, currently
measuring 1.7 x 2.3 cm (previously 1.5 x 1.1 cm). The spleen is
unremarkable. In the head of the pancreas, there is a 1.7 x 1.5
cm enhancing lesion. It is in retrospect identified on the
prior study where it measured 0.7 x 0.8 cm. A right omental
lesion is also increased in size, currently measuring 11.3 x 7.1
cm (previously 10.8 x 6.4 cm). 2.2 x 2.2 cm
lesion is seen in the lower pole of the left kidney. Again,
this is increased in size, previously measuring 1.1 x 0.9 cm.
.
A conglomerate of upper lymph nodes in the retroperitoneum
currently measures 3.2 x 1.9 cm (previously 2.0 x 1.3 cm).
.
CT OF THE PELVIS WITH IV CONTRAST: The small bowel is
unremarkable. The large bowel is normal. There is right
external iliac adenopathy, currently measuring 2.3 x 2.3 cm (on
the prior study, a lymph node in this location was borderline in
size measuring 1.0 x 1.0 cm). A second lymph node anterior to
the just described one measures 1.5 x 1.2 cm and is also
increased in size. Previously, this node did not meet CT
criteria for pathologic enlargement.
.
On bone windows, there are no concerning osteolytic or
osteosclerotic lesions.
.
IMPRESSION:
1. Mixed response with predominant disease progression with
increase in size of the right hilar adenopathy, right omental
mass and one liver lesion.
2. New lesions are seen in the liver, lungs, as well as
retroperitoneum with predominantly the right external iliac
lymphadenopathy.
3. Two of the liver metastases seen on the prior studies are
decreased in size.
MRI HEAD:
Again seen is a homogeneously enhancing mass involving the left
parietal lobe which measures approximately 2.3 cm in size. This
appears to have minimally increased compared to the [**Month (only) 216**]
study. This tumor also has a tail of enhancing tissue which
appears to extend into the adjacent sulcus.
A second tiny 0.3 cm enhancing lesion is seen in the right
centrum semiovale, as before.
There is extensive surrounding T2 hyperintensity of the right
frontal,
parietal, occipital, and temporal lobes as well as the right
subinsular region as before. There is right to left subfalcine
herniation, especially posteriorly as well as right to left
shift of the normally midline structures which measures
approximately 0.5 cm. This is not significantly changed
compared to the CT scan from [**2138-8-6**] but has increased since the
MR from [**2138-7-11**].
The peritumoral edema is causing compression of the occipital
[**Doctor Last Name 534**] of the
right lateral ventricle as before. The ventricles are not
significantly
changed in size.
The visualized orbits and major flow voids are normal. The
basal cisterns are patent.
There is a mucous retention cyst within the left maxillary sinus
and mucosal thickening of the right maxillary sinus. No
suspicious bony abnormalities are seen.
IMPRESSION:
1. Since [**2138-7-11**], increase in size of the enhancing metastasis
involving the right parietal lobe with minimal leptomeningeal
extension as before. No significant change in 0.3 cm second
enhancing metastasis of the right centrum semiovale.
2. Overall, extensive peritumoral edema does not appear to be
significantly changed, but there is worsened right to left shift
of the normally midline structures and subfalcine herniation
since the [**2138-7-11**] study.
3. The above findings may represent changes of prior radiation
therapy.
MRI NECK:
FINDINGS: No prior studies are available for comparison.
In the right level II b region, medial to the
sternocleidomastoid and
posterior to the right internal jugular vein, there is an 11 x
7.6 mm
enhancing, oval lymph node. There is no evidence of cavitation
or
pericapsular infiltration.
A few other small lymph nodes are seen scattered throughout the
neck.
No definite masses are identified.
There is a mucus retention cyst within the left maxillary sinus
and mucosal thickening of the maxillary sinuses bilaterally.
There is T2 hyperintensity and enhancement of the right
maxillary molar extraction pocket.
IMPRESSION: 11 x 7.6 mm enhancing lymph node in the right level
II b region.
CT HEAD [**2138-8-11**]
COMPARISON: [**2138-8-6**].
Allowing for positional differences, the overall apperance is
little changed compared to prior study. Again seen is an
approximately 2 cm lesion consistent with metastasis in the
right parietal lobe, with extensive edema involving the right
frontal, temporal, and parietal lobes. Shift of normally midline
structures towards the left is again identified, little changed
compared to prior CT. Again seen is effacement of the sulci in
the right frontal lobe. Mass effect on the right lateral
ventricle again seen, possibly slightly increased. No new foci
of hemorrhage or mass effect identified.
Visualized paranasal sinuses appear normally aerated.
IMPRESSION:
1. 2 cm hyperdense mass again seen in the right parietal lobe
with extensive surrounding edema involving the right hemisphere.
2. Possible slight increase in mass effect on the right lateral
ventricle.
3. Relatively stable-appearing leftward subfalcine herniation.
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2138-8-19**] 8:53 AM
MR HEAD W & W/O CONTRAST
Reason: evaluate postoperative tumor residual
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p craniotomy tumor resection
REASON FOR THIS EXAMINATION:
evaluate postoperative tumor residual
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post craniotomy and tumor resection.
COMPARISON: MRI of the brain of [**2138-8-16**], [**2138-8-15**] and [**2138-7-11**].
TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain
were obtained before and after the uneventful intravenous
administration of Magnevist. Diffusion-weighted imaging was also
performed.
MRI OF THE BRAIN WITHOUT AND WITH CONTRAST: Postoperative
changes are again seen in the right parietal region. The
well-defined rounded enhancing lesion of the right parietal lobe
has been resected. T1 hyperintensity is seen at the periphery of
the resection bed, representing a small amount of postoperative
blood. Minimal peripheral enhancement is noted at the medial
aspect of the resection bed, likely postoperative.
A 3 mm focus of enhancement in the right frontal centrum
semiovale is unchanged from prior studies, possibly representing
a tiny metastasis (9:17). A second 1-2 mm focus of enhancement
is seen in the superior right parietal region (9:20, 10:22),
which is better defined today than on prior studies. This focus
could represent a vessel on end or a tiny metastasis. Edema
within the right frontal, parietal, and temporal regions appear
similar to the preoperative study. There is minimal (2-3 mm),
right-to-left subfalcine herniation that appears decreased from
[**2138-8-16**].
IMPRESSION:
1. Interim resection of the 2.5 cm metastasis of the right
parietal lobe. Minimal enhancement at the periphery of the
resection bed is thought to be postoperative, but continued
followup is recommended.
2. Unchanged 3 mm focus of enhancement in the right frontal
region, possibly representing a tiny metastasis.
3. 2 mm enhancing focus of the superior right parietal region,
possibly representing a vessel on end or tiny metastasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: WED [**2138-8-20**] 9:05 AM
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 33416**],[**Known firstname **] W [**2077-6-23**] 61 Male [**-5/3716**]
[**Numeric Identifier 33417**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/mtd
SPECIMEN SUBMITTED: Right parietal mass
Procedure date Tissue received Report Date Diagnosed
by
[**2138-8-16**] [**2138-8-16**] [**2138-8-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
Previous biopsies: [**-5/3690**] BRAIN TUMOR.
[**-4/2883**] SMALL BOWEL ENTEROSCOPY (2).
[**Numeric Identifier 33418**] CONSULT SLIDES REFERRED TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
DIAGNOSIS:
Right parietal brain tissue, resection:
Clear cell neoplasm, see note.
Note: The specimen contains a single nodule of neoplasm
composed of a uniform population of atypical cells with cleared
cytoplasm within the brain parenchyma. These features are most
consistent with renal cell carcinoma, however
immunohistochemistry staining with antibody to cytokeratin is
being performed and will be reported in an addendum.
Clinical: Specimen submitted: right parietal tumor; left-sided
weakness, brain mass.
Gross: The specimen is received fresh in the O.R. in a container
labeled with the patient's name, "[**Known firstname **] [**Known lastname **]", the medical
record number and additionally labeled "right parietal tumor"
and consists of a 2 x 1.5 x 1.2 cm firm red-tan mass that is
sectioned revealing a white homogeneous firm nodule encompassing
nearly the entire specimen. The specimen was partially frozen
with a frozen section diagnosis by Drs. [**Last Name (NamePattern4) **]/[**Location (un) 4223**]: "Mild
necrosis with highly atypical epithelioid cells. Suspicious for
metastatic neoplasm."
The specimen is represented as follows: A=frozen section
remnant, B-C=additional representative sections of tumor.
Brief Hospital Course:
A/P: 61 yo M with metastatic RCC s.p CK therapy on [**2138-7-17**] now
with LUE/LLE weakness improving on high dose dexamethasone.
#) Left sided hemiparesis: The patient was transferred to us
from the neurosurgery service. At that time, the patient was
not a surgical candidate. The patient was found to have
worsening edema and increasing symptoms, therefore he was
started on mannitol IV. As we tapered the mannitol, he would
eventually redevelop symptoms such as headache, hemiparesis, and
hiccups, so we had to increase the mannitol again. After 2
attempts at weaning, we decided he had failed a mannitol taper
and a functional MRI was ordered to further assess if the
patient is a candidate for surgical resection without too much
compromise of his physical ability given that he is left handed.
Discussions with neurosurgery were made and it was discussed
that the patient would benefit from tumor resection.
#) Steroid induced hyperglycemia: The patient had elevated
glucose levels due to his dexamethasone. He was treated with an
insulin sliding scale to control his glucose levels. Currently
he is on a steroid taper that will take approximately 2 weeks.
#) Metastatic Renal Cell Cancer: The patient has had right
nephrectomy in the past. Currently, he in on Sutent therapy,
but it was held during his hospital admission given the
possibility of surgery.
#) Seizures: The patient is currently seizure free. He will
continue Dilantin and Keppra at current dose.
#) Hypertension: The patient will continue his home regimen.
Medications on Admission:
1. Dilantin 100 mg po tid
2. Keppra 1000 mg po bid
3. CaC03 500 mg prn upset stomach
4. Dexamethasone 4 mg po tid
5. Levoxyl 75 mcg po qd
6. Protonix 40 mg po qd
7. Amlodipine 2.5 mg po TID
8. Insulin sliding scale
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Dexamethasone 4 mg Tablet Sig: Three (3) Tablet PO tid ()
for 6 doses.
14. Dexamethasone 1 mg Tablet Sig: Eleven (11) Tablet PO tid ()
for 6 doses.
15. Dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO tid () for 6
doses.
16. Dexamethasone 1 mg Tablet Sig: Nine (9) Tablet PO tid () for
6 doses.
17. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO tid () for
6 doses.
18. Dexamethasone 1 mg Tablet Sig: Seven (7) Tablet PO tid ()
for 6 doses.
19. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO tid ()
for 6 doses.
20. Dexamethasone 2 mg Tablet Sig: 2.5 Tablets PO tid () for 6
doses.
21. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO tid () for
6 doses.
22. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO tid ()
for 6 doses.
23. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid: pt
should end on and continue this dosing .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Primary Diagnosis: Left sided hemiparesis
Secondary Diagnosis: Metastatic Renal Cell Carcinoma / brain
tumor
Hypertension
Seizure
Hypothyroidism
Anemia
Steroid induced hyperglycemia
Discharge Condition:
Neurologically improved
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Brain tumor clinic appointment Monday [**8-25**] at 400 pm
please call [**Telephone/Fax (1) **] / The appointment is on the [**Location (un) **]
of the [**Hospital Ward Name **] building on the [**Hospital Ward Name **].
If you cannot make the appointment - you should call to notify
them however it is important that you go.
Your sutures should be removed on [**8-30**]
Completed by:[**2138-8-20**]
|
[
"285.9",
"197.6",
"V15.3",
"V10.52",
"251.8",
"197.7",
"401.9",
"342.91",
"E932.0",
"244.9",
"348.5",
"198.3",
"V45.73",
"348.4",
"780.39",
"781.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
20795, 20847
|
17082, 18629
|
338, 357
|
21073, 21099
|
4852, 12668
|
22485, 22887
|
2610, 2628
|
18895, 20772
|
12705, 12752
|
20868, 20868
|
18655, 18872
|
21123, 22462
|
2658, 3057
|
279, 300
|
12781, 17059
|
385, 1452
|
3446, 4833
|
20931, 21052
|
20887, 20910
|
3072, 3430
|
1474, 2493
|
2509, 2594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,064
| 172,342
|
33661
|
Discharge summary
|
report
|
Admission Date: [**2196-3-2**] Discharge Date: [**2196-3-8**]
Date of Birth: [**2143-7-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Vicodin / Keflex / Ceftin / Tetracycline / Augmentin /
Compazine / Levaquin / Percocet / Dicloxacillin / Naproxen
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
syncope with continued unresponsiveness
Major Surgical or Invasive Procedure:
Intubated on transfer to [**Hospital1 18**]
LP
History of Present Illness:
52 yr old female with hx of seizure d/o unknown details not on
medication for ~5 yrs, RA, hx of SLE presenting after syncopal
episode at church. As per witnesses, singing calmly in church
~9-10PM when reported feeling dizzy, pt then began to tremble
and shake upper extremities. Friends sat patient in chair and
she then syncopized and was put to the ground, no head trauma.
As per EMS, pt with pulse, ?not breathing, neccesitating
bagging. ?emesis, convulsions in the ambulance. Unresponsive to
painful stimuli. FS 69. Appears at this time taken to [**Hospital 77927**]. At [**Location (un) **] 02 sat initially 73% reported though
unclear, 100% prior to intubation, though continued lethargy. Pt
was intubated and sedated. Intubated with use of Etomidate,
Succinylcholine, Versed and vecuronium. Fentanyl alsoc given. 1
gram dilantin given. CT head w/o ICH. Transfer to the [**Hospital1 18**] for
further care.
.
[**Hospital1 18**] ED, vs 97.2, 89, 160/95, 20, 100% AC. EKG NS 88, no QT
prolongation, no ST changes. Sedation with propofol but
reported to be nodding to questioning, moving all four
extremities, no evidence of seizure activity. Nml rectal tone.
Tox + opiods, benzo. Trop neg. CXR w/o focal infiltrate.
Neurology consulted. Patient to [**Hospital Unit Name 153**] for further work-up.
Past Medical History:
hx of SLE
hx of seizure disorder (not on meds)
Rheumatoid Arthritis
s/p bilateral hip replacement
Social History:
on disability. Works as a nanny. Drives. No tob/etoh/illicits
Family History:
negative for seizures
Physical Exam:
99.8, 86, 165/98, CPAP 5/5 40%FiO2 100%
Gen: sedated female sedated but intermittently nodding to
questioning
HEENT: ET tube rightward, no evidence of tongue biting,
atramatic, normocephalic, PERRL 3mm. No icterus, no injection.
OP clear
Neck: non elevated JVP
CV: RRR, no murmurs, rubs or gallops
Resp: CTA anteriorly, no wheeze
Abd: hypoactive bowel sounds, appeared non tender to exam. No
rebound or gaurding
Ext: No edema, slightly cooler distally. 2+ DP, PT pulses
skin: cooler distal extremities, no mottling, not moist
Neuro: sedated, will open eyes to some questioning. Able to
relay date. Moving all four extremities, difficult to assess
given sedation but weakness RLE>LLE, LE>UE. Limited sensory
exam. Areflexic. No neck stiffness. Pt unable to perform full
cranial nerve exam, but no focal deficits noted on initial exam.
Pertinent Results:
[**2196-3-7**] 01:00PM BLOOD WBC-7.0 RBC-3.80* Hgb-12.2 Hct-35.4*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.3 Plt Ct-335
[**2196-3-2**] 02:30AM BLOOD WBC-9.4 RBC-4.06* Hgb-13.0 Hct-37.0
MCV-91 MCH-32.0 MCHC-35.1* RDW-12.9 Plt Ct-291
[**2196-3-2**] 02:30AM BLOOD Neuts-77.2* Lymphs-18.2 Monos-3.3 Eos-0.9
Baso-0.3
[**2196-3-3**] 02:42AM BLOOD ESR-32*
[**2196-3-2**] 02:30AM BLOOD PT-12.9 PTT-29.5 INR(PT)-1.1
[**2196-3-4**] 07:30PM BLOOD Lupus-NEG
[**2196-3-3**] 02:42AM BLOOD ACA IgG-11.4 ACA IgM-8.5
[**2196-3-7**] 01:00PM BLOOD UreaN-11 Creat-0.9 Na-138 K-4.2 Cl-102
HCO3-28 AnGap-12
[**2196-3-2**] 02:30AM BLOOD Glucose-133* UreaN-8 Creat-0.8 Na-137
K-3.6 Cl-101 HCO3-28 AnGap-12
[**2196-3-5**] 06:45AM BLOOD ALT-19 AST-20 AlkPhos-96 TotBili-0.2
[**2196-3-2**] 11:02AM BLOOD ALT-37 AST-40 LD(LDH)-260* AlkPhos-101
TotBili-0.5
[**2196-3-3**] 02:42AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
[**2196-3-7**] 01:00PM BLOOD Albumin-3.9
[**2196-3-4**] 07:30PM BLOOD VitB12-1157*
[**2196-3-2**] 02:30AM BLOOD VitB12-1085* Folate-17.0
[**2196-3-4**] 11:44AM BLOOD Prolact-30*
[**2196-3-2**] 02:30AM BLOOD TSH-1.7
[**2196-3-2**] 02:30AM BLOOD HCG-<5
[**2196-3-4**] 09:49AM BLOOD dsDNA-NEGATIVE
[**2196-3-4**] 06:20AM BLOOD RheuFac-10
[**2196-3-3**] 03:16PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2196-3-4**] 06:20AM BLOOD b2micro-1.7
[**2196-3-3**] 02:42AM BLOOD C3-169 C4-41*
[**2196-3-4**] 06:20AM BLOOD Phenyto-10.7
[**2196-3-7**] 01:00PM BLOOD Phenyto-9.0*
[**2196-3-2**] 04:06AM BLOOD pO2-213* pCO2-42 pH-7.42 calTCO2-28 Base
XS-3
RIBOSOMAL P ANTIBODY
Test Result Reference
Range/Units
RIBOSOMAL P ANTIBODY <1.0 NEG < 1.0 NEGATIVE
TEST PERFORMED AT:
[**Company **], [**State **], [**Hospital1 **], [**Last Name (LF) **],
[**Name6 (MD) **] [**Last Name (NamePattern4) 67457**], M.D., DIRECTOR
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY, IGG
Test Result Reference
Range/Units
CCP, IGG 6 <20 U
Interpretation
--------------
NEGATIVE: LESS THAN 20 U
WEAK POSITIVE: 20 - 39 U
MODERATE POSITIVE: 40 - 59 U
STRONG POSITIVE: 60 OR GREATER U
[**2196-3-2**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2196-3-2**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2196-3-2**] 02:30AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2196-3-4**] 12:06PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-2
Lymphs-97 Monos-1
[**2196-3-4**] 12:06PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-67
[**2196-3-4**] 12:06PM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND
[**2196-3-4**] 12:06PM
HERPES SIMPLEX VIRUS PCR
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA Not Detected Not
Detected
HSV 2 DNA Not Detected Not
Detected
[**2196-3-4**] 12:06 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2196-3-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2196-3-7**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Time Taken Not Noted Log-In Date/Time: [**2196-3-2**] 8:03 am
URINE Site: NOT SPECIFIED
[**Doctor Last Name **] TOP HOLD # 67768L [**3-2**] 8:03AM RR.
**FINAL REPORT [**2196-3-4**]**
URINE CULTURE (Final [**2196-3-4**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
RPR - nonreactive.
MR HEAD W & W/O CONTRAST [**2196-3-2**] 12:08 PM
MR HEAD W & W/O CONTRAST
Reason: to assess for intracranial lesions as per neuro
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with ?SLE, syncope with unresponsiveness now
on ventilator
REASON FOR THIS EXAMINATION:
to assess for intracranial lesions as per neuro
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 52-year-old female patient, with suspected SLE,
syncope with responsiveness, now on ventilator, to assess for
intracranial lesions.
No prior studies are available for comparison.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain
was performed without and with IV contrast.
FINDINGS:
There are a few, scattered foci of FLAIR hyperintensity in the
frontal white matter, periventricular and subcortical in
location with no associated hemorrhage, enhancement, or
restricted diffusion.
The ventricles and extra-axial CSF spaces are normal.
IMPRESSION:
A few, scattered FLAIR hyperintense lesions, small,
approximately 2-3 mm in size, in the subcortical and
periventricular white matter, with no enhancement or restricted
diffusion. These are nonspecific and can be due to post-
inflammatory, post-infectious, vasculitis related, demyelinating
or sequelae of chronic small vessel occlusive disease. To
correlate clinically and with lab findings.
CHEST (PORTABLE AP) [**2196-3-2**] 1:59 AM
CHEST (PORTABLE AP)
Reason: eval for tube placement
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with tx intubated
REASON FOR THIS EXAMINATION:
eval for tube placement
INDICATION: Intubated.
FINDINGS: A bedside semi-erect frontal chest radiograph is
reviewed without comparison. The endotracheal tube tip
terminates 3.3 cm above the carina with the neck apparently in
extension. There is a left ventricular configuration of the
heart. The pulmonary vasculature and mediastinal contours are
within normal limits. There is linear atelectasis at the left
base though there is no consolidation identified.
IMPRESSION: ETT 3.3 cm above the carina. As the neck appears
extended on this radiograph, ETT may, effectively, be more
low-lying.
ECHO - Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). No resting LVOT gradient is present.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Normal cavity sizes with hyperdynamic left
ventricular systolic function. No structural cardiac cause of
syncope identified.
Cardiology Report ECG Study Date of [**2196-3-2**] 11:05:20 AM
Sinus tachycardia. R wave diminution with low precordial voltage
is new
compared to the previous tracing earlier on [**2196-3-2**].
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 160 72 326/413 68 10 54
Cardiology Report ECG Study Date of [**2196-3-2**] 1:24:46 AM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Inter
CHEST (PORTABLE AP)
Reason: assess for pneumonia
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with lupus, seizures with dyspnea
REASON FOR THIS EXAMINATION:
assess for pneumonia
INDICATION: History of lupus, seizures and dyspnea, assess for
pneumonia.
COMPARISON: [**2196-3-2**] radiograph.
FINDINGS: An upright chest radiograph demonstrates a normal
cardiac silhouette. Mediastinum and hila are clear. No evidence
of parenchymal abnormality to suggest airspace disease. There is
no pleural effusion or pneumothorax.
Interval removal of endotracheal tube.
IMPRESSION: No evidence for pneumonia.
Neurophysiology Report EEG Study Date of [**2196-3-4**]
OBJECT: ALTERED MENTAL STATUS, RULE OUT SEIZURE.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
BACKGROUND: A well-formed 9 Hz posterior dominant rhythm was
noted in
wakefulness which attenuated appropriately with eye opening. The
anterior to posterior voltage gradient was preserved.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: The patient progressed from the waking to drowsy state
but did
not attain stage II sleep during the recording.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 72 beats per minute.
IMPRESSION: This is a normal portable EEG in the waking and
drowsy
states. There were no areas of prominent focal slowing. There
were no
epileptiform features.
SHOULDER [**1-24**] VIEWS NON TRAUMA RIGHT [**2196-3-5**] 8:36 AM
SHOULDER [**1-24**] VIEWS NON TRAUMA
Reason: shoulder pain, assess for cause
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with lupus, and joint pain, being worked up
for seizure.
REASON FOR THIS EXAMINATION:
shoulder pain, assess for cause
RIGHT SHOULDER, [**2196-3-5**]
CLINICAL INFORMATION: Lupus, joint pain, no trauma.
FINDINGS:
Four views of the right shoulder are obtained. There are mild
degenerative changes in the acromioclavicular joint. There are
small degenerative resorptive cysts in the humeral head. No
radiographic evidence of avascular necrosis.
HIP UNILAT MIN 2 VIEWS RIGHT [**2196-3-5**] 8:39 AM
HIP UNILAT MIN 2 VIEWS RIGHT
Reason: Cause of joint pain.
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with lupus, and joint pain, being worked up
for seizure. H/o jt replacement
REASON FOR THIS EXAMINATION:
Cause of joint pain.
RIGHT HIP, [**2196-3-5**]
CLINICAL INFORMATION: Lupus, joint pain.
FINDINGS:
Frontal view of the pelvis and two coned-down views of the right
hip are obtained.
There are bilateral total hip prostheses; both acetabular
components are transfixed by a single screw. There is no
radiographic evidence of hardware complication. No
periprosthetic lucency. There are mild degenerative changes of
the lumbar spine and sacroiliac joints.
IMPRESSION:
1. No radiographic evidence of right total hip complication.
2. Left total hip prosthesis, incompletely evaluated.
Cardiology Report ECG Study Date of [**2196-3-2**] 1:24:46 AM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
TRACING #1
Brief Hospital Course:
Syncope was likely due to a seizure episode. In terms of
seizure, she was initially in ICU on mechanical ventilation.
Neurology was consulted and patient was started on phenytoin and
levitiracetam. The patient had 2 episodes of possible seizures
(staring spells with transient LOC and post event fatigue,
disorienation) after extubation - one in ICU and other on the
[**Hospital1 **]. Dose of levitiracetam was increased and for many days
prior to discharge patient did not have further seizures. LP was
normal. EEG was unremarkable as above.
Given MRI findings as above, rheumatology was consulted to see
if the seizures were due to lupus cerebritis. Rheumatologic work
up was sent and results as above. Given mostly unremarkalbe
results, rheumatology team did not feel this was lupus
cerebritis and also patient improved without increasing dose of
steroids. Attempt was made to contact patient's primary
rheumatologist but was out of office.
The patient also has fibromyalgia and is in chronic pain due to
this. Morphine was continued as below in 2 spilt doses. Since
morphine may lower seizure threshold, patient was advised to
talk with PCP regarding referral to pain specialist to adjust
pain meds.
The patient had an E coli UTI. Given many allergies,
nitrofurantoin was given for 3 days. Patient was afebrile prior
to discharge.
PT evaluation recommended discharge home. Patient will need some
assistance to climb stairs. The daughter was planning to stay
with the patient for a few days. The patient also was advised to
not drive due to seizures history and also wear the lifeline
she has at all times.
Medications on Admission:
Meds confirmed with patient. This list was different that the
list obtained from PCP (latter was a med list from many months
back)
Prednisone 5 mg daily
Morphine ext release 60 mg daily
Plaquenil 200 mg [**Hospital1 **]
folic acid 1 mg daily
Neurontin 200 mg four times daily
Lasix 20 mg daily
Ambien 5 mg at bedtime
Trazodone 25 mg at bedtime
Advil prn for pain
Methotrexate
climara patch
clonazepam 1 mg at bedtime
Discharge Medications:
1. Climara 0.075 mg/24 hr Patch Weekly Sig: One (1) Transdermal
once a day.
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours): Do not take alcohol
or use heavy machinery or drive with this medication. .
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
13. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
16. Methotrexate
As instructed by your rheumatologist Dr [**Last Name (STitle) 58721**].
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
Seizures
Syncope
History of lupus, rheumatoid arthritis, fibromyalgia
urinary tract infection, bacterial
Discharge Condition:
stable
Discharge Instructions:
You were diagnosed with seizure. It is recommended that you do
not drive or use machinery. Please wear your lifeline at all
times. Follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Your medication
have been changed and you have been started on anti seizure
medications.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2196-4-4**] 9:00
Pcp appt with Dr [**Last Name (STitle) 42317**] is for [**3-21**] at 10:40am
Rheumatology appt with Dr [**Last Name (STitle) 58721**] is for Monday [**3-28**] at
11am
|
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"518.81",
"599.0",
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"345.90",
"729.1",
"714.0",
"710.0",
"780.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
18196, 18267
|
14260, 15877
|
423, 472
|
18416, 18425
|
2915, 7531
|
18780, 19076
|
2022, 2045
|
16344, 18173
|
13376, 13470
|
18288, 18395
|
15903, 16321
|
18449, 18757
|
2060, 2896
|
343, 385
|
13499, 14237
|
500, 1804
|
1826, 1926
|
1942, 2006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,334
| 115,026
|
22460
|
Discharge summary
|
report
|
Admission Date: [**2167-12-10**] Discharge Date: [**2168-2-9**]
Date of Birth: [**2097-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
LE ulcer and sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70M CAD s/p CABG, DM , HTN, severe PVD s/p LLE bypass, ESRD on
HD, EF 15% who presented to [**Hospital3 417**] hospital from rehab
with R LE nonhealing ulcer, low grade fevers, hypotension with
sBP to 50's, and L arm swelling. Was given fluid bolus and
responded and started on broad spectrum abx. Was found to have
MRSA bacteremia as well as hematuria and was transferrred to
[**Hospital1 18**] for further care and ulcer debridement.
Past Medical History:
1. DM2:insulin dependent
2. HTN
3. CRF on dialysis:AV graft first placed [**3-18**]; s/p graft clotX3
4. CAD s/p MI; CABG X5 -[**2160**]
5. Bilateral THR - [**2157**]
6. s/p pacemaker placement
7. PVD
8. LLE bypass - [**2167**]
9. B heel ulcers (never infected)
Social History:
Lives at home with long-term girlfriend. [**Name (NI) **] tobacco/ethanol
Family History:
unknown
Physical Exam:
97.2 82/42 80 96-100% on RA
NAD, lying in bed, frail appearing elderly male.
MMM, PERRL, EOMI, no icterus
FROM, no LAD, Central line- no surrounding erythema
RR with II/VI SEM
CTA- anteriorly
Soft, NT/ND, +BS
Left leg with veous stasis but DP 2+
right leg BKA wrapped in clean/dry bandage.
Pertinent Results:
Echo ([**1-18**]): EF 30% (improved from 15% 6 mo ago); new vegetation
on mitral valve.
.
CX:
[**12-9**] R foot: enterobacter, pseudomonas, MRSA,
peptostreptococcus
[**12-9**] Blood: MRSA but since then has been Cx negative.
[**12-10**] Urine: enterobact.
Brief Hospital Course:
The patient expired on [**2168-2-9**] after a long hospital
course managing the problems listed below. On the day of his
death, he underwent HD and returned without incident. Later that
day he was found pulseless in his room, after having been
reported to be fine only 10 minutes before by the nursing staff.
A code was run, and then called when he failed to respond.
Please see more details of his hospitalization below:
# R heel gangrene: R heel wound cultures grew out multiple
organisms including psuedomonas, MRSA, and VRE. Pt was seen by
vascular [**Doctor First Name **] and R BKA was performed (guillotine [**12-11**],
revision [**1-3**]). He was started on vanc and meropenem. Meropenem
was d/c'd after a 36 day course, and vanc will be continued
until [**2168-2-15**] to complete a 6 week course (levels were checked
daily after HD and pt was redosed for vanc levels <15). The pt
was initially kept on a heparin gtt and then changed to coumadin
for target INR of [**2-18**] for vascular grafts.
# Hypotension- multifactorial including low CO, MR due to MV
vegitation, failed [**Last Name (un) 104**] stim test. Pt was supported with
levophed throughout his ICU stays. Finally was able to be weaned
from pressors and was transferred to the floor. Digoxin was
continued for inotropy- goal post HD 1-1.5 (redosed with
0.0625mg). He was continued on steroids since tapering these
agents seemed to cause him to relapse with his hypotension.
Midodrine was used initially, but the pt responded better to
florinef, and this was later able to be tapered to 0.05mg qd for
presumed adrenal insuff. His BP's improved and Captopril 3.125
tid was added.
# ID/Endocarditis- An echo performed on [**2168-1-18**] showed a new
vegetation on the mitral valve. However, the only blood culture
that was positive was that from the day of admission on [**2167-12-10**]
with MRSA. Interestingly no Cx positive since that time. He was
continued on Vanc with a plan to continue for 6wks total (would
have completed [**2168-2-14**]) with redosing for levels less than 20
after HD.
.
#Low grade temps and leukocytosis: Pt had an extensive workup
for other sources of infection since WBC remained elevated and
pt continued to have low grade fevers even while on IV vanc and
meropenem. No other sources of infection were found.
.
#ESRD- Due to pt's hypotension, he required CVVHD for the first
part of his stay, and then was changed to qd ultrafiltration
with HD qod once BP improved.
.
#Chronic LUE edema: Pt was noted to have chronic LUE edema.
Workup showed a (-) U/S on [**12-29**] and [**1-31**] repeat U/S was also
(-). Pt will keep his arm elevated to avoid worsening of the
edema.
.
# Abd pain: Pt continued to c/o epigastric discomfort that was
occasionally accompanied by SOB. This was relieved with mylanta.
.
#Anemia - most likely secondary to ESRD currently on EPO and
iron per renal with dialysis.
.
#[**Name (NI) 1568**] Pt was continued on SSI and NPH. Steroids exacerbating
sugars and supposedly eats food from OSH and non-compliant with
diet.
.
9. FEN- renal/cardiac diet. Hyperkalemia - adjusting with HD.
Nutrition consult for recs re: nutrition supplement other than
Boost - i.e. sth with less K.
.
Medications on Admission:
coumadin
Vanco at HD
Epogen
Pravachol 40 qd
Nephrocaps 1 qd
Lopressor 25 [**Hospital1 **]
Asa 325 qd
Prilosec 30 qd
Lactulose 60 qd
Levofloxacin 250 qd (for presumed UTI)
Colace 100 [**Hospital1 **]
Reglan 5 qd
Lansoprazole
Albuterol/Atrovent prn
Simvastatin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
1. DM2:insulin dependent
2. HTN
3. CRF on dialysis
4. CAD
5. PVD
6. B heel ulcers
7. Endocarditis
8. anemia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"403.91",
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"255.4",
"995.92",
"440.24",
"427.5",
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"707.05",
"038.11",
"V53.31",
"730.26",
"V09.0",
"427.31",
"V58.67",
"428.0",
"293.0",
"724.5",
"421.0",
"250.40",
"250.80",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"84.15",
"96.6",
"89.45",
"99.60",
"00.17",
"38.93",
"96.04",
"38.95",
"84.3",
"00.14",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
5363, 5372
|
1818, 5024
|
335, 341
|
5524, 5533
|
1536, 1795
|
5589, 5599
|
1198, 1207
|
5334, 5340
|
5393, 5503
|
5050, 5311
|
5557, 5566
|
1222, 1517
|
276, 297
|
369, 806
|
828, 1091
|
1107, 1182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,241
| 108,107
|
42412
|
Discharge summary
|
report
|
Admission Date: [**2192-3-13**] Discharge Date: [**2192-3-23**]
Date of Birth: [**2119-9-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Hematuria, Hemoptysis
Major Surgical or Invasive Procedure:
[**2192-3-15**] Right craniotomy for tumor resection
History of Present Illness:
ADMIT NOTE
Date: [**2192-3-13**]
Time: 2200
HPI: 72 yo M with NSCLC with brain mets s/p parietal/occipital
crani for tumor resection on [**2192-2-3**], relatively new bilateral
frontal hemorrhagic mets scheduled for neurosurgical resection
next week now s/p WB XRT with progressive weakness now with
hematuria x 1 week, worsening thrombocytopenia. Per patient's
son, his father and mother have been staying with him and he has
been providing much of the care for his father. [**Name (NI) **] was unaware
that his father was having hematuria until yesterday when his
urine was noted to be dark red. He has also had hemoptysis for a
number of months but worsening in the past 1-2 weeks with
tablespoon of hemoptysis nearly every time he coughs. The cough
is associated with right sided chest pain in the front and back.
Labs are significant for worsening thrombocytopenia of unclear
etiology.
In the ED: 98.8 85 117/71 18 98% RA. foley placed. CT head with
hemorrhagic mets stable from MRI on [**3-12**] but new from [**2192-2-3**].
Currently, he denies any pain but feels very tired.
Past Medical History:
Asthma
COPD
Appendectomy
NSCLC
Oncology TREATMENT HISTORY:
[**8-/2191**] Developed hemoptysis
[**9-/2191**] Saw a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], [**Country 5881**] and diagnosed with left
lung mass
[**2192-1-20**] Bronchoscopy
[**2192-1-20**] Pathology showed non small cell lung cancer
[**2192-1-27**] Brain MRI showed two left cerebral lesions with edema
[**2192-2-3**] Stereotactic resection of left parieto-occipital tumor
[**2192-2-14**] Completed radiation to lung
[**2192-3-13**] Completed WBI
Social History:
Originally from [**Country 5881**]. Currently lives in [**Location **]. Patient is
married and has two healthy children. He is retired painter.
He smoked 1.5 packs per day for 55 years and quit a few months
ago.
He was also a heavy drinker but he quit 5 months ago. He denies
any recreational drugs use.
Family History:
Three children, one died in an accident.
Maternal uncle with lung cancer.
Physical Exam:
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, not date (baseline).
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. R VF deficit.
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: Baseline left sided weakness. LUE [**1-15**], LLE [**3-15**], RUE and
RLE are full motor.
Pertinent Results:
[**2192-3-13**] 01:10PM cTropnT-0.014*
[**2192-3-13**] 01:10PM WBC-10.4 RBC-4.61 HGB-13.2* HCT-41.6 MCV-90
MCH-28.7 MCHC-31.8 RDW-18.0*
[**2192-3-13**] 01:10PM NEUTS-93* BANDS-4 LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2192-3-13**] 01:10PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2192-3-13**] 01:10PM PT-11.1 PTT-22.0* INR(PT)-1.0
[**2192-3-13**] 01:10PM PLT SMR-VERY LOW PLT COUNT-69*
[**2192-3-13**] 11:45AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2192-3-13**] 11:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.0 LEUK-TR
[**2192-3-13**] 11:45AM URINE RBC->182* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**3-12**] MRI: Three markedly enlarged hemorrhagic metastases have
progressed
dramatically since the brain MR [**First Name (Titles) **] [**2192-2-4**]. The
largest of these
measures 35 mm in greatest diameter. Other small metastatic
lesions appear
unchanged.
[**3-13**] CT head: One right and two left frontal hemorrhagic lesions
with surrounding edema, concerning for metastasis. These lesions
were seen in the MRI of [**2192-3-12**], but new since the CT of
[**2192-2-3**]. No new hemorrhage. No midline shift. Prominent
bilateral extra-axial spaces, likely subdural hygromas.
[**3-13**] CXR: PRELIM Consolidation in the lingular segment of the
left lung, is
consistent with known diagnosis of lung cancer. No new pulmonary
pathology
identified.
Pathology Report Tissue: RIGHT PARIETAL LESION. Study Date of
[**2192-3-15**] White matter and blood clot. No tumor identified,
levels x3.
[**3-15**] MRI Brain- IMPRESSION: Previously noted enhancing lesions in
the brain on the MRI of [**2182-3-12**] again identified for WAND study
for surgical planning. No midline shift or hydrocephalus. No
change in the size of the lesion seen since the previous study.
[**3-15**] NCHCT: IMPRESSION: Status post right frontal craniotomy and
resection of right frontal hemorrhagic metastasis with expected
intralesional and intracranial post-surgical changes. Stable
appearance of left frontal hemorrhagic metastasis and left
parieto-occipital encephalomalacia from prior resection. Stable
bilateral subdural hygromas.
[**3-16**] ECG: FINDINGS: The patient has been extubated. Left upper
lobe consolidation has improved. This pattern is consistent with
an obstructive pneumonia consistent with known lingular mass.
There is no pleural effusion or pneumothorax. The heart size is
within normal limits.
[**3-21**] LENI's: IMPRESSION: No evidence of DVT.
Brief Hospital Course:
72 yo M with NSCLC with brain mets s/p parietal/occipital crani
for tumor resection on [**2192-2-3**], relatively new bilateral
frontal hemorrhagic mets scheduled for neurosurgical resection
next week now s/p WB XRT with progressive weakness now with
hematuria x 1 week, worsening thrombocytopenia.
On [**3-13**], The patient completed WBXRT- 3500 cGy over 14 fractions
and was sent to the Emergency Department. He presented with
hematuria,thrombocytopenia, and hemoptysis. The patient had a
Head CT which was consistent with multiple known hemorrhagic
metastases in bifrontal lobes. There was no new intracranial
hemorrhage. The patient was admitted to Oncology with plans to
prepare the patient for surgery on Friday with Dr [**Last Name (STitle) **] for a
craniotomy for resection of brain mass. The platlet level was
69.
On [**3-15**], The patient went to the Operating Room for an elective
craniotomy for resection of brain mass with Dr [**Last Name (STitle) **]. The
patient tolerated the procedure well and was recovered in the
intensive care unit. The goal systolic blood pressure was < 140.
The post operative Head Ct was consistent with expected post
operative changes. The patient was alert and oriented to person
and place at baseline the patient never knows date. He was
moving all extremities and exhibited his baseline level of left
sided weakness. The goal was to keep the patient platlets > 80
for 24 hours post surgery. A blood sample was sent to the lab
and the patient was found to be HEPARIN DEPENDENT ANTIBODIES
Positive. The patient was not started on prophylactic SQ
Heparin as a result. Venodyne boots were on at all times and
mobility was encouraged.
On [**3-16**], POD #2 the patient continued to have a production
productive cough/hemoptysis. He was able to independently raise
secretions and was using a hand held suction independently. A
CXR was performed in the afternoon which was consistent with
left upper lobe consolidation which had improved. The pattern
was consistent with an obstructive pneumonia consistent with
known lingular mass. There was no pleural effusion or
pneumothorax. The heart size was within normal limits. The
platlets were 67 and the patient was transfused with 1 pack of
platlets and post transfusion platlet count was 136. The
dexamethasone was weaned. The systolic blood pressure goal was <
160. A regular insulin sliding scale was initiated given the
dexamethasone. The patients diet wa advanced and physical
therapy and occupational therapy was ordered. The patient was
transferred to the floor.
On [**3-17**], The patient's hematocrit was 21.7 from 27 the day prior
and 2 units of Packed Red Blood Cells were administered with 10
mg IV lasix to avoid fluid volume overload. The patient
continued have hemoptysis although this was improved. The serum
potassium level was 3.8 and was repleated with 20 meq KCL. The
foley catheter remained in place to accuratly moniotr urine
output in the setting of transfusion of blood products and
adminitration of lasix. The platlets count was 63. Decadron was
weaned to 4mg [**Hospital1 **] per neurology oncology recommendations. The
post transfusion hematocrit was 31.3. The evening platlet count
was 37. On exam, the patient is primarily Greek speaking. He
exhibits improved hemotysis. The surgical dressing was removed
and the staples at the incision were intact and the incision was
well approximated. There was no drainage, erythema or edema.
The patient was alert, oriented to person and place. The pupils
5-4mm bilaterally. The patient was able to move all
extremitiesand exhibited baseline Left sided weakness. The left
deltoid strength was [**2-13**], bicep [**1-15**], tricep 4-/5, grip [**1-15**], IP
[**1-15**], quad /ham4-/5, AT/[**Last Name (un) 938**]/[**Last Name (un) **] [**2-13**] RLE full, RUE 5-/5.
HIT markedly positive no heparin.
[**Date range (1) 19033**] The patient remained neurologically stable but
physically continued to become weaker and have increased pain
throughout his body. Palliative Care was consulted and pain
medications were adjusted. Multiple family meetings were held
with the son and daughter in regards to discharge planning.
Their ultimate goal was to send the patient back to [**Country 5881**] which
delayed the patient's discharge in order to figure out how to
best make this happen.
On [**3-23**] the patient continued to appear more weak, refused to
eat and complained of pain. The palliative care team met with
the family again and they all agreed that it would be in the
patient's best interest to be made CMO. Medications except for
pain meds were d/c'd. Patient was kept comfortable and he passed
with family at the bedside on [**2192-3-23**] at 23:30
Medications on Admission:
dexamethasone 4mg [**Hospital1 **]
famotidine 20mg [**Hospital1 **]
advair
keppra 750 [**Hospital1 **]
oxycodone (not really using)
TMP-SMX
acetaminophen prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
NSCLCA with mets to brain
Hematuria
Thrombocytopenia
Hemoptysis
COPD
Discharge Condition:
Expired on [**2192-3-23**] at 23:30
Discharge Instructions:
Expired
Followup Instructions:
N/A
Completed by:[**2192-3-23**]
|
[
"V15.3",
"786.30",
"162.3",
"493.20",
"198.3",
"342.90",
"724.5",
"599.70",
"V66.7",
"287.5",
"348.5",
"V49.86",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
10913, 10922
|
5937, 10673
|
301, 356
|
11035, 11073
|
3279, 4339
|
11129, 11164
|
2372, 2448
|
10881, 10890
|
10943, 11014
|
10699, 10858
|
11097, 11106
|
2463, 2470
|
240, 263
|
384, 1472
|
2733, 3260
|
4348, 5914
|
2485, 2717
|
1494, 2034
|
2050, 2356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,150
| 110,218
|
45946
|
Discharge summary
|
report
|
Admission Date: [**2198-5-16**] Discharge Date: [**2198-5-22**]
Date of Birth: [**2134-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Stent re-occlusion
Major Surgical or Invasive Procedure:
1)Two vessel coronary artery bypass grafting utilizing saphenous
vein graft to left anterior descending and saphenous vein graft
to obtuse marginal
2)Re-exploration of bleeding
History of Present Illness:
This is a 64 year old female with known coronary disease who has
undergone multiple PCI/stent procedures over the past year.
Repeat cardiac catheterization in [**2198-4-18**] revealed a 40-50%
left main lesion; 90% in-stent stenosis in the LAD; 60-70%
in-stent stenosis in the circumflex and a normal right coronary
artery. Her ejection fraction was normal, estimted at 60%. Based
on the above results, she was referred for surgical coronary
revascularization.
Past Medical History:
Non-small cell lung cancer - s/p left upper lobe resection in
[**2190**] followed by chemotherapy and radiation, Thyroid cancer -
s/p thyroidectomy in [**2182**] now hypothyroid, Hypertension,
Elevated cholesterol, Former smoker, Hypopharyngeal soft tissue
mass(followed at [**Hospital3 328**]), varicose veins - s/p left leg
vein stripping
Social History:
Former smoker - quit tobacco 40 years ago. Denies excessive
ETOH.
Family History:
Non contributory
Physical Exam:
Afebrile, Vital signs stable
General: well developed female in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Chest: regular rate and rhythm, normal s1s2 without murmur or
rub
Lungs: clear bilaterally
Abdomen: benign
Ext: warm, no edema
Neuro: grossly intact; no focal deficits
Pertinent Results:
[**2198-5-20**] 04:20AM BLOOD WBC-6.7 RBC-3.51* Hgb-10.6* Hct-30.7*
MCV-87 MCH-30.1 MCHC-34.5 RDW-14.8 Plt Ct-132*
[**2198-5-20**] 04:20AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-137 K-3.9
Cl-101 HCO3-29 AnGap-11
[**2198-5-20**] 01:30PM BLOOD TSH-27.8*
[**2198-5-21**] 09:44AM BLOOD T4-3.1* T3-36*
[**2198-5-18**] 04:07PM BLOOD Cortsol-19.6
Brief Hospital Course:
Mrs. [**Known lastname 49957**] [**Known lastname **] was admitted and underwent two vessel
coronary artery bypass grafting(vein graft to left anterior
descending and vein graft to obtuse marginal) by Dr. [**Last Name (STitle) 1290**].
Following the operation, she was brought to the CSRU. On
postoperative day one, she developed hypotension with increasing
pressor requirements. Echo performed at appr.16 hours post-op
showed signs of tamponade and was taken back to the OR
emergently for re- exploration of the mediastinum. A large
amount of clot was evacuated, both pleura were irrigated and
clot also removed, and all surgical sites were inspected. There
remained only a small amount of oozing from the OM graft with no
active bleeding.
POD #2- on levophed drip at 0.08 and improving. Swan removed ,
in sinus tachycardia, received 2 units of PRBCs, and lasix
diuresis was started.HCT rose to 33 post- transfusions.Levophed
was weaned, and the pt. was transferred out to the floor.
Started working with PT on ambulation. O2 sat 95% on room
air.Alert and oriented. Continued to improive and increase
ambulation. Pacing wires pulled on POD #6, chest tubes had been
removed the day prior. Treated with benadryl and [**Doctor Last Name **] lotion
for skin itchiness.Low dose beta blockade decreased HR to 95 in
sinus and synthroid had been restarted.Had good pain control
with percocet.On day of discharge, BP 100/44, o2 sat 96% RA, T
98.3, T4 3.1, T3 36, TSH done on [**5-20**] 27.8. Discharged in good
condition with specific instructions to follow-up with PCP for
thyroid condition in the next week.
Medications on Admission:
Aspirin 325 qd, Plavix 75 qd, Toprol 25 qd, Lipitor 80 qd,
Synthroid, Vitamin D
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease - s/p CABG X2
s/p re-exploration for mediastinal bleeding
hypothyroidism
lung CA with XRT
s/p left leg vein stripping
hypertension
elev. cholesterol
thyroid cancer with thyroidectomy
Discharge Condition:
Good, stable
Discharge Instructions:
You should seek medical attention if you have increasing chest
pain, drainage from your wound, palpitation, lightheadedness or
any other concering sign. You need to see your cardiologist in
the next 1-2 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
See your cardiologist in the next week or two.
See your primary care doctor in the next week as well to have
your thyroid medication followed.
See Dr. [**Last Name (Prefixes) **] in [**1-19**] weeks. Call his office for an
appointment [**Telephone/Fax (1) 1504**]
Completed by:[**2198-6-13**]
|
[
"V10.11",
"420.90",
"401.9",
"272.4",
"996.72",
"412",
"423.1",
"414.01",
"V10.87",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.31",
"99.05",
"37.11",
"39.61",
"99.04",
"00.17",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4956, 5015
|
2183, 3787
|
340, 519
|
5266, 5280
|
1820, 2160
|
1472, 1490
|
3917, 4933
|
5036, 5245
|
3813, 3894
|
5304, 5516
|
5567, 5863
|
1505, 1801
|
282, 302
|
547, 1009
|
1031, 1373
|
1389, 1456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,302
| 159,766
|
635
|
Discharge summary
|
report
|
Admission Date: [**2128-2-9**] Discharge Date: [**2128-2-26**]
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: A 78-year-old man transferred from [**Hospital6 4874**] status post myocardial infarction,
transferred to [**Hospital1 69**] for
cardiac catheterization.
HISTORY OF PRESENT ILLNESS: A 78-year-old man with past
medical history significant for PMR, hypertension, with no
known history of coronary artery disease, who presented at
outside hospital complaining of chest pressure radiating to
neck when using a snow-blower. Pain subsided with rest, but
returned with activity.
He says three days ago he had the same symptoms when also
using a snow-blower. No dyspnea, palpitations, nausea, or
vomiting at the time of chest pressure. Reports waking up
with chest pain approximately one week ago. Had jaw pain at
that time also. Also reports that over the past month he has
had increasing chest pain with exertion. Daughter, who is a
R.N, states that he has had increased dyspnea with exertion
x1 year.
The patient was treated with Lopressor and started on Heparin
and Aggrastat at [**Hospital6 4620**]. First set of
enzymes showed a CK of 162, MB are not available, and
troponin of 40.6. He is currently pain free.
PAST MEDICAL HISTORY:
1. PMI x10 years on prednisone.
2. Hypertension.
3. Gastroesophageal reflux disease.
4. Hiatal hernia.
5. Pernicious anemia.
6. Cholecystectomy.
SOCIAL HISTORY: Smokes [**5-8**] cigars per day x40 years, but no
alcohol use, none since [**2102**]. Retired [**Location (un) 86**] police officer.
Lives with his wife in [**Name (NI) 1411**].
FAMILY HISTORY: Both parents died of strokes in their 90s.
MEDICATIONS AT HOME:
1. Zantac 100 mg [**Hospital1 **].
2. Norvasc, no dose.
3. Vioxx, no dose.
4. Prednisone 20 mg q day.
5. Neurontin 100 mg q day.
6. Flomax 0.4 mg q day.
7. Tums, no dose.
ALLERGIES: Penicillin which causes a rash.
PHYSICAL EXAM AT TIME OF ADMISSION: Heart rate 77, blood
pressure 151/93, respiratory rate 20 and O2 sat is 98% on 2
liters. General: Pleasant-elderly man well appearing in no
acute distress. HEENT: Pupils 1.5 mm. Oropharynx is moist.
Lungs are clear to auscultation bilaterally with marked
diminished breath sounds throughout. Heart: Regular, rate,
and rhythm, normal S1, S2 with no murmur. Abdomen is soft,
nontender, nondistended with positive bowel sounds.
Extremities with 2+ edema to the left ankle, 2+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA: Sodium 140, potassium 4.2, BUN 31,
creatinine 1.1, glucose 130. White count 8.7, hematocrit
35.7, platelets 196, INR 0.9. CK 162, MB 7.9, troponin 40.6.
ELECTROCARDIOGRAM: Sinus rhythm at 94, normal axis, and
normal intervals. J-point elevated in V4-5 with early R-wave
progression.
CHEST X-RAY: No effusions or infiltrates. No emphysematous
changes.
The day after admission, the patient was brought to the
catheterization laboratory, where he underwent cardiac
catheterization. Please see catheterization report for full
details. Summary of his catheterization showed 2+ mitral
regurgitation with an ejection fraction of 45%, left main 70%
lesion, left anterior descending artery, no significant
disease, left circumflex 80% at the origin, ostia 99%
proximal, 100% in the distal.
CT Surgery was consulted. The patient was seen and accepted
for coronary artery bypass grafting plus or minus mitral
valve repair/replacement. On [**2-11**], the patient was
brought to the operating room at which time, he underwent
coronary artery bypass grafting x4 with a mitral valve
repair. Please see OR report for full details.
In summary, the patient had a coronary artery bypass graft x4
with a LIMA to the left anterior descending artery, saphenous
vein graft to OM and ramus sequentially, and saphenous vein
graft to the distal right coronary artery, and a mitral valve
repair with a #28 [**Doctor Last Name 405**] ring. The patient tolerated the
operation well and was transferred from the operating room to
the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was receiving milrinone
at 0.25 mcg/kg/minute, Neo-Synephrine at 1.5 mcg/kg/minute,
and propofol at 10 mcg/kg/minute. The patient was extubated
shortly after arrival in the Cardiothoracic Intensive Care
Unit, he developed stridor after extubation, and was
immediately reintubated. He showed a respiratory acidosis.
Transesophageal echocardiogram was done at that time, which
showed the patient to be underfilled. He was given volume
and he responded well.
On postoperative day one, the patient remained
hemodynamically stable. An attempt to decrease the sedation
and wean his ventilation was unsuccessful. The patient was
resedated and remained on full ventilatory support.
On postoperative day two, the patient remained
hemodynamically stable on Esmolol, Levophed and milrinone.
He also remained stable from a respiratory standpoint. His
milrinone was weaned off. He did have a period of atrial
fibrillation, and was started on amiodarone at that time.
On postoperative day three, patient became somewhat hypoxic
as sputum production increased and he was empirically started
on ceftriaxone, and sputum cultures were sent at that time.
Over the next two days, the patient was weaned from his
cardioactive intravenous medications. Sputum culture is
being positive for Pseudomonas and his antibiotics were
changed from ciprofloxacin and ceftazidime.
On postoperative day six, the patient was weaned from his
ventilator and successfully extubated. He remained in the
Intensive Care Unit at that time. Because of continuous
respiratory status with vigorous chest PT as well as
antibiotics, the patient's respiratory status continued to
improve over the next several days.
On postoperative day nine, it was decided that he was stable
and ready to be transferred to Far Two for continued
postoperative care and cardiac rehabilitation. Over the next
several days on the floor, the patient with the assistance of
the nursing staff and physical therapy, he increased his
activity level. He remained hemodynamically stable
throughout that period.
On postoperative day 15, it was decided that the patient was
stable and ready to be transferred to a rehabilitation
facility. At the time of transfer, the patient's condition
is stable.
His physical examination was as follows: Vital signs:
Temperature 98.2, heart rate 87, blood pressure 108/58,
respiratory rate 20, and O2 sat is 94% on room air. Weight
preoperatively is 81.6 kg and at discharge it is 94.6 kg.
LABORATORY DATA: White count 7.5, hematocrit 31, platelets
388, INR of 2.5. Sodium 139, potassium 4.9, chloride 107,
CO2 15, BUN 34, creatinine 1.2, glucose 76.
On physical exam, alert and oriented times three. Moves all
extremities. Follows commands. Respiratory: Clear to
auscultation bilaterally. Cardiovascular: Regular, rate,
and rhythm, S1, S2 with no murmur. Sternum is stable.
Incision with Steri-Strips, opened to air, clean and dry.
Abdomen is soft, nontender, nondistended, normoactive bowel
sounds. Extremities are warm and well perfused with 2-3+
pedal edema bilaterally. Right leg incision with
Steri-Strips opened to air clean and dry.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q day.
2. Prilosec 40 q day.
3. Amiodarone 400 q day.
4. Prednisone 20 q day.
5. Neurontin 100 q day.
6. Metoprolol 50 tid.
7. Lasix 40 [**Hospital1 **] x2 weeks.
8. Potassium chloride 20 [**Hospital1 **] x2 weeks.
9. Megestrol acetate 40 qid.
10. Coumadin 2.5 q day.
11. Flomax 0.4 q hs.
PRN MEDICATIONS:
1. Percocet 5/325 1-2 tablets q4h.
2. Regular insulin-sliding scale.
3. Combivent two puffs q6h.
4. Ibuprofen 400 mg q6h.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft x4 with a LIMA to the left anterior descending artery,
saphenous vein graft to OM, and R and ramus sequentially, and
saphenous vein graft to distal right coronary artery.
2. Mitral regurgitation status post mitral valve repair with
a #28 [**Doctor Last Name 405**] ring.
3. PMR.
4. Hypertension.
5. Gastroesophageal reflux disease.
6. Enlarged prostate.
7. Status post cholecystectomy.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
rehabilitation. He is to have followup with Dr. [**Last Name (STitle) 70**] in
four weeks, and follow up with his primary care provider [**Last Name (NamePattern4) **]
[**4-6**] weeks.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2128-2-26**] 08:48
T: [**2128-2-26**] 08:50
JOB#: [**Job Number 2686**]
|
[
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"482.1",
"578.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"88.72",
"96.04",
"36.13",
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"37.22",
"39.61",
"88.56",
"88.53",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
1629, 1673
|
7706, 8161
|
7240, 7685
|
8186, 8682
|
1694, 7217
|
125, 280
|
309, 1247
|
1269, 1415
|
1432, 1612
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,948
| 179,684
|
13378
|
Discharge summary
|
report
|
Admission Date: [**2173-3-12**] Discharge Date: [**2173-3-18**]
Date of Birth: [**2140-8-18**] Sex: M
Service:
CHIEF COMPLAINT: Hypoxia and acute respiratory failure.
HISTORY OF PRESENT ILLNESS: The patient is a 32 year old
male with a history of asthma who presents with acute
respiratory distress. The patient has had symptoms of upper
respiratory infection/bronchitis for approximately two weeks
prior to admission and was reportedly using escalating doses
of bronchodilators. The patient then presented to the
Emergency Department and was found to be "blue" and was
emergently intubated. After intubation, gas was 7.13, 76,
246. In the Emergency Department, the patient had received
Ketamine, Morphine, Versed, Magnesium, and bronchodilators.
The patient was difficult to ventilate requiring very high
driving pressures and was therefore paralyzed with much
improvement. Vent was set at SIMV tidal volume 600,
respiratory rate 10, PEEP 5, and 60% FIO2 on admission to the
Fennard Intensive Care Unit.
PAST MEDICAL HISTORY: Asthma. The patient has been
hospitalized in the past but history is unknown. Outpatient
regimen is unclear.
MEDICATIONS ON ADMISSION: Albuterol MDI.
ALLERGIES: Unknown.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Primary language is Portuguese. No immediate
family in the U.S. The patient's family all lives in [**Location 4194**].
The patient immigrated from [**Country 4194**] one month prior to
admission.
PHYSICAL EXAMINATION: Vital signs revealed blood pressure
111/54, heart rate 95, oxygen saturation 98% on 60% FIO2,
temperature 97.2 rectally. In general, the patient is
intubated and sedated. The heart is slightly tachycardic,
normal S1 and S2. Lungs - diffuse high pitched inspiratory
and expiratory wheezes bilaterally. Prolonged I:E ratio.
The abdomen is soft, nontender, decreased bowel sounds.
Extremities - no cyanosis, clubbing or edema.
Neurologically, moving all four extremities and is sedated.
LABORATORY DATA: White blood cell count 29.0, hematocrit
49.0, platelets 470,000, 24% polys, 47% lymphocytes, 0 bands,
6% monocytes, 21% eosinophilia. Chem7 was within normal
limits. Serum toxicology was negative. Urine toxicology was
nasogastric. Arterial blood gases after intubation 7.13, 71
and 246.
Chest x-ray - no infiltrates and no effusions. Endotracheal
tube five centimeters above the carina.
HOSPITAL COURSE: The patient is a 32 year old Portuguese
speaking male with a history of asthma who presents with
hypercapnic respiratory arrest.
1. Pulmonary - asthma - Complicated by hypercapnic
respiratory arrest. The patient was placed on maximum
sedation with Propofol which was eventually changed to
Fentanyl and Ativan. The patient no longer needed to be
paralyzed after adequate sedation was given.
The patient was started on Albuterol MDI two to ten puffs
q15minutes p.r.n. and was started on Solu-Medrol 80 mg
intravenously q8hours. The patient was also empirically
started on Levaquin 500 mg p.o. q.d. with a history of upper
respiratory infection, bronchitis type symptoms. A sputum
sample was sent which was positive for Hemophilus influenzae.
The patient still required intubation several days into
admission. Therefore, Aminophylline drip was started.
Serevent, Combivent and Flovent were added to the patient's
regimen. On [**2173-3-15**], the patient's Aminophylline drip was
discontinued. Serevent, Flovent and Combivent were
discontinued and the patient was maintained on Albuterol MDI
and steroids. The steroids were tapered.
The patient extubated himself on [**2173-3-17**], and A line was
discontinued. The patient required q4hour meter dose
inhalers on [**2173-3-17**]. The patient was transitioned to
Albuterol, Flovent and Serevent meter dose inhalers and was
started on p.o. Prednisone at 40 mg p.o. q.d. The patient
was continued on Levaquin for Hemophilus bronchitis.
The patient had a blood culture that was positive for gram
positive cocci, two out of two blood cultures. The patient's
A line was discontinued and surveillance cultures were sent
which were negative. Blood cultures from [**2173-3-15**], finally
grew out coagulase negative Staphylococcus which was thought
to be a contaminant. No antibiotics were started for this at
this time.
2. Constipation - The patient had constipation secondary to
Fentanyl drip. The patient was started on a bowel regimen
and Lactulose.
3. Communication - The patient is Portuguese speaking only
and the patient's past medical history was unclear. However,
after speaking to the patient through a translator, it
appears that he is allergic to "narcotics" although it was
unclear what this meant. The patient denies any other
allergies.
After extubation, the patient was directly discharged from
the Fennard Intensive Care Unit after he was monitored for
one day. The patient's breathing and asthma symptoms
improved with treatment.
DISCHARGE DIAGNOSES:
1. Status asthmaticus.
2. Bronchitis.
3. Positive blood cultures most likely secondary to
contamination.
MEDICATIONS ON DISCHARGE:
1. Albuterol MDI.
2. Flovent MDI. The patient was given Flovent inhaler,
however, was prescribed Azmacort since this is what is
available at free care pharmacy.
3. Serevent inhaler.
4. Prednisone taper.
5. Levaquin to complete a ten day course.
CONDITION ON DISCHARGE: Stable to home.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) 40643**] [**Name (STitle) **]
one week after discharge and then will follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] a month after discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2173-5-9**] 16:07
T: [**2173-5-10**] 20:33
JOB#: [**Job Number 40644**]
|
[
"564.01",
"518.81",
"E937.9",
"493.91",
"790.7",
"041.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1247, 1257
|
4952, 5061
|
5087, 5339
|
1192, 1230
|
2414, 4931
|
1495, 2396
|
145, 185
|
214, 1030
|
1053, 1165
|
1274, 1472
|
5364, 5871
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,774
| 199,477
|
8550
|
Discharge summary
|
report
|
Admission Date: [**2139-8-22**] Discharge Date: [**2139-9-1**]
Date of Birth: [**2068-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo M with ischemic dilated cardiomyopathy, LVEF of 20%,
status post CABG (LIMA to LAD single vessel) in [**2133**] and Cypher
stent placement to left circ in [**2135**]), atrial fibrillation on
Coumadin, recent GI bleed, h/o VT status post pacer and ICD
placement in [**2135**], with recent firing of ICD in [**6-18**] who
presented with worsening shortness of breath over the past two
weeks. Mr. [**Known lastname 30057**] main heart-failure symtpoms are increasing
neck and abdominal girth, which he has noticed over the past few
weeks in addition to dyspnea on exertion. He denies PND and has
stable 3-pillow orthopnea. He also noticed black colored stools
x 1 today, but denies any BRBPR, new light-headedness (has
minimal LH with standing at baseline) or LOC.
Baseline weight is 224lbs which was noted in 8/[**2138**].
.
Mr. [**Known lastname **] also c/o a pressure sensation in his abdomen
(periumbilical, constant discomfort) and is chronically
constipated. He is on already an aggressive bowel regimen and
his abdominal symptoms improve with BM.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis,
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
presense of dyspnea on exertion, absence of paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
VS in ED T97.7, HR 75, BP 91/68 RR22 O2 99% 2L Guiac negative
In ED given ASA 325mg po x1, zofran 4mg IV x2, 600mg mucomyst,
Started on dopamine 12mcg/kg/min, lasix 80mg IV. He had a CTA of
the chest to rule out PE with 600cc IVF and CT abdomen/pelvis
with 600cc IVF.
.
In the CCU telemetry revealed AV and V pacing with several brief
episodes of SVT with HR 150 and ?anti-tachycardial pacing.
Past Medical History:
1. CAD, s/p 1-vessel CABG (LIMA-LAD) and ascending aortic arch
repair in [**2133**]. S/p cypher stent placement to LCX [**2135**]. P-MIBI
in [**1-/2139**] with moderate, predominantly fixed perfusion defects
involving the anterolateral and inferolateral walls.
2. Ischemic cardiomyopathy with EF 15%.
3. Chronic renal insufficiency, baseline creatinine around
1.5-1.7
4. Atrial fibrillation, on coumadin
5. Hypothyroidism
6. H/o VT, status post AICD and pacer placement in [**2135**],
multiple firing episodes, last at [**Hospital1 2025**] in [**9-/2137**] in setting of
hypokalemia.
7. Asthma
9. Hyperlipidemia
10. Depression
11. Dementia
12. Anemia, baseline hct around 30.
13. Barrett's Esophagus seen on [**2133**] EGD
14. s/p removal of adenomatous polyp (path with dysplasia) in
[**2134**], no polyps seen on [**2135**] colonoscopy.
Social History:
Married, lives with wife, has five children. Formerly drank
alcohol but not since [**48**] years. No smoking or illicit drug use.
Retired painter.
Family History:
Non-contributory.
Physical Exam:
VS: T97.7 , BP99/66 , HR 84 , RR 20 , O2 93% on 3L NC
Gen: elderly gentleman, appears to be breathing comfortably on
oxygen by NC. Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of [**7-19**] cm, +HJR
CV: PMI displaced laterally, RR, III/VI systolic murmur loudest
at upper sternal borders radiating to clavicle and axilla
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, faint
expiratory wheezes
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit ; DP by doppler
Left: Carotid 2+ without bruit; DP by doppler
Pertinent Results:
[**2139-8-22**] 10:31PM POTASSIUM-4.6
[**2139-8-22**] 08:00PM URINE HOURS-RANDOM
[**2139-8-22**] 08:00PM URINE GR HOLD-HOLD
[**2139-8-22**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2139-8-22**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-8-22**] 06:50PM TYPE-ART PO2-130* PCO2-46* PH-7.41 TOTAL
CO2-30 BASE XS-4
[**2139-8-22**] 06:50PM K+-4.6
[**2139-8-22**] 06:50PM HGB-11.9* calcHCT-36
[**2139-8-22**] 06:28PM GLUCOSE-97 UREA N-29* CREAT-1.7* SODIUM-141
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-31 ANION GAP-14
[**2139-8-22**] 06:28PM estGFR-Using this
[**2139-8-22**] 06:28PM CK(CPK)-179*
[**2139-8-22**] 06:28PM CK-MB-5 cTropnT-0.01 proBNP-7720*
[**2139-8-22**] 06:28PM WBC-9.2 RBC-4.06* HGB-12.3* HCT-36.5* MCV-90
MCH-30.4 MCHC-33.8 RDW-14.6
[**2139-8-22**] 06:28PM NEUTS-81.3* LYMPHS-9.8* MONOS-6.3 EOS-2.4
BASOS-0.2
[**2139-8-22**] 06:28PM PLT COUNT-196
[**2139-8-22**] 06:28PM PT-36.5* PTT-32.4 INR(PT)-4.0*
.
.
.
[**2139-8-22**] CTA CHEST, CT Abdomen and Pelvis
IMPRESSION:
1. No evidence for aortic dissection or aneurysm. No evidence of
pulmonary embolus.
2. Cardiomegaly with bilateral pleural effusions and bibasilar
septal thickening likely related to CHF/fluid overload.
3. Bilateral renal hypodense lesions likely cysts though
incompletely assessed. If needed, renal ultrasound may be
obtained to further evaluate. 4. Diverticulosis without evidence
for diverticulitis.
.
.
[**2139-8-24**] ECHO:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated with severe global hypokinesis and akinesis of the
inferior and inferolateral walls as well as the distal
anterolaeral wall (LVEF= 20 %). No masses or thrombi are seen in
the left ventricle.The right ventricular cavity is mildly
dilated. Right ventricular systolic function is normal. The
ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. There is severe aortic valve stenosis
(area =0.8cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-13**]+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is mild pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2139-6-18**], the
findings are similar (severity of mitral regurgitation may be
slightly increased).
.
[**2139-8-29**] CXR:
FINDINGS: A single portable image of the chest is compared to
the prior
examination dated [**2139-8-22**]. There is motion artifact slightly
degrading the
image quality. Allowing for differences in technique there is
no significant
interval change. An AICD is unchanged in position with intact
leads
terminating within the expected region of the right atrium and
right
ventricle. Midline sternotomy wires are again seen. The heart
remains
enlarged. The lungs are grossly clear. The bony thorax is
grossly
unremarkable.
IMPRESSION:
1. No active disease.
2. Stable cardiomegaly.
.
Brief Hospital Course:
A/P:
71 yo M with end stage ischemic dilated cardiomyopathy, LVEF of
20%, atrial fibrillation, h/o VT s/p pacer and ICD placement in
[**2135**], admitted for CHF exacerbation. Significant improvement in
symptoms following diuresis with dopamine gtt and Lasix.
.
# Cardiac:
1. Pump: Echo [**8-24**] EF 20% with aortic stenosis (valve area 0.8)
and severely dilated LV, presenting with his usual symtpoms of
heart failure being abdominal/neck distension and dyspnea. He
is symptomatically improved after diuresis with dopamine and
lasix with significant diuresis and weight reduction from 106kg
on admission to 99kg. Creatinine elevated following with
agressive diuresis but near baseline at 2.2 prior to discharge.
Coumadin initially held for several days as INR was
supratheraputic, restarted prior to discharge.
- He was discharged on Lasix 40mg po tid, with VNS and daily
weight checks
-KCL 20mg po BID, VNS to follow outpatient K levels, results to
Dr. [**First Name (STitle) 437**] who will adjust dose accordingly
- ACE inhibitor was held throughout admission and on discharge
due to increase in creatinine, Dr. [**First Name (STitle) 437**] will restart as
outpatient when appropriate
-digoxin restarted at usual dose after dopamine gtt was
discontinued
-f/u with dr. [**First Name (STitle) **] in clinic on [**2139-9-21**]
-Discharged on Coumadin 3mg qHS, level will be followed by VNS,
INR 1.7 on D/C
.
2. Ischaemia: s/p CABG (LIMA to LAD [**2133**]), s/p cypher stenting
LCX [**2135**] no symptoms of ischemia during admission. Cardiac
enzymes negative x2 in the ED.
-Continued aspirin and lipitor.
.
3. Rhythm: baseline rhythm is V pacing with frequent ectopic
beats and occasional atrial beats. Developed transient Afib
with RVR with HR up to 120's. BP was stable and he was
asymptomatic. Thought likely to be due to hypokalemia with K <4
and pain due to UTI.
-mexilitine and sotalol continued throughout admission for VT
prevention
-Metoprolol 50mg XL restarted for rate control
-digoxin continued
- electrolytes repleted as needed with goal of K4.5, Mg>2. He
required very high doses KCl daily from 80-100mEq to maintain K
>4.5.
.
# UTI - treated initially with augmentin however given
persistent symptoms and temperature on Augmentin was changed to
IV antibiotics. He was discharged on Cefpodoxime to complete a
7 day course. Choice of antibiotics was limited due to concern
for QTc prolongation.
.
#Shortness of breath - question of underlying asthma as
contributing factor, peak flow normal
-continue Advair.
.
# Periumbilical Abdominal discomfort on admission: likely [**2-13**]
rt-heart failure and bowel wall edema. No concerning source
identified on abdominal CT, transaminases, amylase, lipase all
wnl. Symptomatically improved with diuresis, tolerated regular
diet well. Resolved by time of discharge.
.
# Black bowel movement: pt noted black bowel movement on morning
of admission however, all stools were guiac negative and Hct
remained stable throughout admission.
.
# Psych: H/O depression, no acute issues during admission
-he was continued on home doses of seroquel, clonazepam,
donepezil, citalopram
.
# FEN/GI: low-salt diet, 1500 ml fluid restriction, PPI,
repleted electrolytes as needed. Discharged on KCL 20 mEq [**Hospital1 **]
with K followed by VNS as outpatient.
.
# Acute on Chronic renal failure: creatinine transiently
elevated following agressive diuresis however close to baseline
at 2.2 prior to discharge.
.
#Dispo - Discharged home with PT and VNS
.
# Code: DNR/DNI
.
# Contact: [**Name (NI) **] [**Name (NI) **] wife [**Telephone/Fax (1) 30058**]
Medications on Admission:
lisinopril 5 mg daily;
Toprol-XL 100 mg daily;
mexiletine 150 mg 3 times a day;
sotalol 80 mg twice a day;
digoxin 0.0625 mg daily;
Lasix 40 mgdaily;
potassium 20 mEq daily;
magnesium 400 mg daily;
Coumadin daily;
aspirin 81 mgdaily;
Klonopin 0.5 mg 3 times a day;
Celexa 60 mg daily;
trazodone 25 mg at bedtime;
inhalers daily;
Protonix daily;
Seroquel 50 mg in the morning, 25 mg in the afternoon, 75 mg at
bedtime;
lactulose daily;
Aricept daily;
levothyroxine 112 mcg once daily;
Lipitor 20 mg daily;
Colace and Senna daily
Discharge Medications:
1. Metoprolol Succinate 50 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:*2*
2. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Quetiapine 25 mg Tablet Sig: As directed Tablet PO three
times a day: 50mg in the morning
25mg in the afternoon
75mg at bedtime.
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
16. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
17. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
20. Outpatient Lab Work
INR, chem7. To be drawn [**2139-9-3**].
Please have the results sent to Dr. [**First Name (STitle) 437**] ([**Telephone/Fax (1) 13786**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Decompensated heart failure, systolic
2. Urinary tract infection.
Secondary:
1. Coronary artery disease
2. Chronic kidney disease
3. Atrial fibrillation
4. Hypothyroidism
5. s/p ICD placement for ventricular tachycardia
6. Asthma
7. Hyperlipidemia
8. Depression
9. Dementia
10. Anemia
Discharge Condition:
Hemodynamically stable. On room air. Weight 208lbs (94kg).
Discharge Instructions:
You were admitted with decompensated heart failure. Please be
sure to follow-up with Dr. [**First Name (STitle) 437**] on [**9-21**] at 1pm.
Please be sure to go over your medication list as changes have
been made. The following changes have been made:
1. Toprol XL. The dose has been decreased to 50mg daily; you
were previously taking 100mg daily
2. Lasix. The frequency of this medication has been increased
to THREE TIMES DAILY.
3. Potassium. The frequency of this medication has been
increased to TWICE DAILY.
4. Coumadin. The dose of this has been decreased.
5. Spironolactone. This is a new medication that acts as a
diuretic, similar to lasix.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight if your
weight increases by 3 lbs or more.
Followup Instructions:
You have an appointment to see Dr. [**First Name (STitle) 437**] on [**2139-9-21**] at 1:00pm.
|
[
"V45.01",
"428.23",
"599.0",
"V58.61",
"427.31",
"414.01",
"285.9",
"V45.82",
"428.0",
"272.0",
"311",
"244.9",
"585.9",
"425.4",
"493.90",
"290.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14012, 14070
|
7648, 10222
|
330, 336
|
14403, 14466
|
4260, 7625
|
15298, 15396
|
3372, 3391
|
11837, 13989
|
14091, 14382
|
11283, 11814
|
14490, 15275
|
3406, 4241
|
283, 292
|
364, 2328
|
10236, 11257
|
2350, 3191
|
3207, 3356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,301
| 165,768
|
54702
|
Discharge summary
|
report
|
Admission Date: [**2148-5-4**] Discharge Date: [**2148-5-7**]
Date of Birth: [**2071-7-16**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Right side weak
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 76y previously healthy woman with
hypothyroidism (denies other PMH, including HTN, see below) who
was transferred to our ED this morning from [**Last Name (un) 63261**]
Hospital
with report of NIHSS 7 (Right-sided motor and sensory deficits)
and NCHCT showing "basal ganglia" hemorrhage on the left.
She was in her USOH yesterday and recently, although her son and
daughter (at bedside in the [**Name (NI) **]) say that she has c/o
lightheadedness on occasion recently (no medical workup. no
recent med changes). When she awoke this morning, she thinks she
felt well (per her on my history -- ED history says she felt
dizzy), but she could not get out of bed on her own. She called
to her son, with whom she lives. He found her sitting on the
side
of her bed. He helped her to the bathroom, and then to their
kitchen table, noting that she could not walk, and seemed to
fall
to the Right side. She says her Right leg "isn't doing well."
She
denies any history of pain at any time, including specifically
--
no headache and no chest/belly/back discomfort. She does endorse
"numb" in her right leg, unsure about Right arm or face. Denies
tingling. She takes ASA 162/d, never any blood thinners like
warfarin/Coumadin, Lovenox, or Pradaxa/dabigatran.
He called 911. EMS brought pt to AJH. Their NIHSS was a 7. NCHCT
revealed a "4cm Left basal ganglia hemorrhage" (see below re.
location). She was transferred here for further managment.
Her BP at AJH, I am told, was up to 180 systolic, but resolved
to
?normotensive range before they could give her labetalol as they
planned (per our ED attending). Via [**Location (un) **] en route, she was
started on a nitroprusside gtt for SBPs into the ?150s, this was
stopped on arrival because her SBPs were 120s-130s. Off any BP
medications, her pressures have remained in the 110s-130s
systolic here in our ED. Her VS are otherwise unremarkable,
except for borderline tachycardia (HR high-90s / low-100s). Exam
as follows (below).
Past Medical History:
1. hypothyroidism
2. admitted to AJH ?2y ago for Tx of PNA (CAP), no complications
3. Rosacea
< DENIES h/o HTN, HL, DM, CAD, CAV/ICH, seizure, or any other
neurologic or medical condition >
Social History:
Lives with son. Active, independent per pt and
her kids. Babysits her 4y/o grandson (dtr's kid) on weekdays; he
lives in nearby town. Denies h/o tobacco, EtOH, illicits.
Family History:
denies any h/o HTN/CAD/HL/DM/ICH/stroke. Her
niece has brain tumors of some sort.
Physical Exam:
ADMISSION EXAM
General Physical Examination:
Vital signs: reportedly afebrile
[**2148-5-4**] 09:44 101 100 15 99 117 / 92
On my exam, VS were 117/92 HR-100 13/99%RA
General: Lethargic to somnolent, but always at least arousable
to
voice. Cooperative. In NAD.
HEENT: Normocephalic and atraumatic. Anicteric. Mucous membranes
are moist. No lesions noted in oropharynx.
Neck: Supple. No bruits appreciated. No lymphadenopathy.
Pulmonary: Lungs CTA. Non-labored breathing.
Cardiac: RRR, borderline tachy (high-90s), no loud M/R/G.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Warm and well-perfused. Intact DPs. RLE externally
rotated. BP cuff on RUE, which is paretic.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
* Somnolent, which is worse from before, per son.
Oriented to "nineteen eigthy... twelve," then "[**2147**]", [**5-4**],
[**Hospital 111866**] hospital. Her history is a bit confused (clarified at
several points per son), which seems attentional (somnolence).
She makes semi-frequent paraphasic errors, primarily phonemic
also word-substitution (e.g. "squeak" for speak). Speech is very
subtly dysarthric. Language is fluent. Repetition is intact.
Comprehension is grossly normal. Slightly blunted
affect/prosody.
Able to read, but slow, hesitant (and with paraphasic errors as
above). Naming is intact to both high and low frequency objects
(again, paraphasic error, this time a neologism: "hassock" for
"hammock"). Able to follow both midline and appendicular
commands, but requires frequent coaching/reorientation. No
evidence of gross apraxia or visual or sensory neglect at this
time (limited exam).
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 3 to 2mm and brisk. Visual fields are grossly full to
confrontation testing at bedside.
III, IV, VI: EOMs full and conjugate; no nystagmus.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3. She says pin may be slightly weaker ("80%") over
Right cheeck and forehead relative to the left.
VII: I cannot appreciate any flattending of the NLF or any
facial
lag or droop when she smiles. Brow-elevation and eye-closure are
strong and symmetric.
VIII: Hearing grossly intact. Definitely hears finger-rub on
Left. Not clear whether she can hear anything on the Right.
IX, X: Palate elevates symmetrically with phonation. Mallampati
IV airway.
[**Doctor First Name 81**]: Right trapezius and SCM do not contract on command (Left
trap
is full).
XII: Tongue protrusion is midline.
Motor:
- RUE is paretic. No movement except slight flexion/extension of
the fingers. Tone is flaccid except in hand/fingers.
- RLE is plegic. It lies externally rotated with flaccid tone
throughout.
- LUE and LLE have normal bulk/tone and full power in
delt/tri/[**Hospital1 **]/WE/FE. No asterixis. No tremor.
Delt Bic Tri WE FF FE IO | IP Q Ham TA [**Last Name (un) 938**] Gastroc
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 0 0 0 0 3 2 1 0 0 0 0 0 0
Sensory:
- RUE pinprick is "80%" to "same" relative to LUE in
arm/forearm/hand/fingers. JPS is absent in the fingers and at
the
wrist.
- RLE JPS is absent at the great toe and questionably present
(but impaired) at the ankle. Pinprick absent throughout the RLE.
(LUE and LLE pin, light touch, JPS all normal/intact)
-Reflexes (left; right):
Biceps (+;0)
Triceps (+;0)
Brachioradialis (+;0)
Quadriceps / patellar (++;0)
Gastroc-soleus / achilles (0;0)
Plantar response was intermittently UPgoing on the
Right(equivocal/?flexor left).
-Coordination:
No ataxia in the Left UE/LE. Cannot test Right limbs due to
weakness.
-Gait: unable
Pertinent Results:
[**2148-5-4**] 09:16AM BLOOD WBC-6.6 RBC-4.29 Hgb-12.5 Hct-38.0 MCV-89
MCH-29.2 MCHC-33.0 RDW-14.0 Plt Ct-136*
[**2148-5-7**] 04:35AM BLOOD WBC-7.6 RBC-4.39 Hgb-12.6 Hct-38.0 MCV-87
MCH-28.7 MCHC-33.2 RDW-14.1 Plt Ct-194
[**2148-5-4**] 09:16AM BLOOD PT-12.4 PTT-28.3 INR(PT)-1.1
[**2148-5-4**] 09:16AM BLOOD Plt Ct-136*
[**2148-5-7**] 04:35AM BLOOD PT-12.7* PTT-29.0 INR(PT)-1.2*
[**2148-5-7**] 04:35AM BLOOD Plt Ct-194
[**2148-5-4**] 09:16AM BLOOD Glucose-137* UreaN-20 Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-24 AnGap-15
[**2148-5-7**] 04:35AM BLOOD Glucose-123* UreaN-21* Creat-0.6 Na-136
K-3.4 Cl-99 HCO3-24 AnGap-16
[**2148-5-6**] 05:30AM BLOOD ALT-11 AST-20 AlkPhos-68
[**2148-5-4**] 09:16AM BLOOD cTropnT-<0.01
[**2148-5-5**] 02:02AM BLOOD cTropnT-<0.01
[**2148-5-4**] 09:16AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2148-5-4**] 09:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-5-5**] 02:02AM BLOOD TSH-1.3
[**2148-5-4**] 09:23AM BLOOD Lactate-2.3*
[**2148-5-4**] NCHCT
IMPRESSION:
1. Acute left frontal and subdural hematomas, with impending
intraventricular
extension. Minimal rightward deviation of the falx cerebri.
Given the
absence of hypertensive or stroke history, close clinical
followup is merited
with imaging after resolution of acute symptoms to exclude
underlying mass or
other etiology such as amyloid angiopathy.
2. Old left frontal encephalomalacia.
[**2148-5-4**] CTA Head/Neck
IMPRESSION: Unchanged left frontal hematoma and left subdural
hematoma as
described above.
The CTA is negative for aneurysm larger than 2 mm in size, there
is no
evidence of vascular dissection or AVM.
[**2148-5-5**] NCHCT
IMPRESSION:
1. Left frontovertex parenchymal hematoma appears equivocally
slightly more
prominent in comparison to prior studies, with possible
increased hyperdensity
at the vertex. N.B. The recent CTA did not reveal a convincing
"spot sign" to
herald rapid expansion of the hematoma.
2. Minimal rightward shift of normally midline structures is
unchanged.
3. Stable appearance of the thin left-sided subdural hematoma,
with minimal
mass effect.
NOTE ADDED IN ATTENDING REVIEW: The constellation of "lobar"
parenchymal
hemorrhage, with overlying subdural - and likely intervening -
subarachnoid
hemorrhage, absent a trauma history, in a patient of this age,
is strongly
suggestive of underlying cerebral amyloid angiopathy. This also
may account
for the small established encephalomalacic focus in the left
paramedian
frontal pole, if this was a site of more remote hemorrhage.
[**2148-5-5**] MRI Head
IMPRESSION:
1. No significant short-interval change in the overall
appearance of the
relatively large left frontovertex lobar hemorrhage with
adjacent vasogenic
edema and mass effect. Given the associated overlying
subarachnoid and
ventricular component, now more evident, in addition to the
known thin
subdural hemorrhage, this is strongly suggestive of underlying
cerebral
amyloid angiopathy (CAA) with leptomeningeal vascular
involvement.
2. The diagnosis of CAA is further supported by the findings of
chronic blood
products adjacent to the left paramedian frontal polar
encephalomalacic focus,
likely the site of previous lobar hemorrhage.
3. Apparently distinct punctate focus of slow diffusion in the
left
paramedian frontovertex, representing acute ischemia, of
uncertain
significance, in this context; there is no evidence of vascular
territorial
ischemia.
Brief Hospital Course:
76yoRHW h/o hypothyroidism p/w right hemibody plegia from a high
left frontal intraparenchymal hemorrhage with associated
subdural hemorrhage, likely secondary to amyloid angiopathy. She
initially presented with depressed level of consciousness as
well and some language difficulty, but this resolved by the
second day of hospitalization. Her remaining deficits are the
dense weakness and sensory loss in her right arm and right leg.
She has some preserved strength in her right hand. An MRI scan
revealed the left high frontal-temporal-parietal hemorrhage
along with an older anterior left frontal hemorrhage
(asymptomatic), strongly suggestive of amyloid angiopathy
without any other apparent lesions or enhancement. To better
control her blood pressure, she was placed on Amlodipine to keep
her SBP < 140. To prevent further bleeding, her aspirin was
stopped. She was placed on Heparin SC after 24 hours for DVT
prophylaxis (before which she was wearing pneumatic boots). She
was evaluated with a bedside dysphagia screen and subsequently
Speech therapy with no deficits. She was discharged to rehab as
recommended by PT and OT.
.
PENDING STUDIES: none
.
TRANSITIONAL CARE ISSUES:
[ ] BP - Please maintain her SBP < 140. Titrate her amlodipine
or switch to alternative therapy if needed.
[ ] PT/OT - Please continue therapy for maximal recovery.
[ ] MRI Head with and without contrast - Neurology will followup
on the MRI Head with and without contrast to evaluate for
underlying lesions.
[ ] Antithrombotics - While she can have Heparin SC for DVT
prophylaxis, please do not restart aspirin at this time given
her amyloid angiopathy and current hemorrhages.
.
[ AHA/ASA Core Measures for Intracerebral Hemorrhage ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
4. Stroke education given? (x) Yes - () No
5. Assessment for rehabilitation? (x) Yes - () No
Medications on Admission:
1. aspirin 162mg daily (two baby aspirins as primary ppx)
2. levothyroxine 125mcg daily
3. creams for rosacea
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache/pain or fever>101F.
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Intracerebral hemorrhage (intraparenchymal
hemorrhage), Amyloid angiopathy
SECONDARY DIAGNOSIS: Hypothyroidism, Hemiplegia/hemiparesis
affecting dominant side
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic: Right arm and leg plegia.
Discharge Instructions:
Mrs. [**Known lastname **],
You were hospitalized due to symptoms of (severe) RIGHT SIDED
ARM AND LEG WEAKNESS resulting from an INTRACEREBRAL HEMORRHAGE,
a bleed on the left side of your brain. The bleeding fortunately
has not progressed. You have an older, smaller bleed in the
front part of the left side of the brain that probably did not
cause any symptoms. The appearance of these bleeds and your
story is most consistent with a condition called AMYLOID
ANGIOPATHY where the blood vessels to the brain are more
delicate and prone to damage by increases in blood pressure or
blood-thinning medications. Accordingly, we would like to
control your blood pressure better and make sure that you are
not on blood-thinning medications.
We will change your medications as follows:
1. Please take AMLODIPINE 5 MG one tablet daily for blood
pressure control. This medication may cause mild ankle swelling.
If this bothers you, your PCP can consider [**Name Initial (PRE) **] different blood
pressure medication to keep your SBP < 140.
2. Please STOP taking Aspirin as this will thin your blood too
much and may predispose you to recurrent bleeding.
3. Please take your other medications as prescribed.
Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital 4038**] clinic as
listed below as well as your PCP.
If you experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing you with medical care during this
hospitalization.
Followup Instructions:
NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2148-6-12**] 2:00pm, [**Hospital1 69**],
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) 858**], [**Location (un) 830**],
[**Location (un) 86**], MA
Please call your PCP toward the end of your rehab stay to
schedule a followup appointment as discussed with your PCP.
|
[
"277.39",
"431",
"437.9",
"432.1",
"342.91",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13031, 13105
|
10102, 11260
|
328, 334
|
13327, 13327
|
6630, 10079
|
15085, 15571
|
2805, 2889
|
12295, 13008
|
13126, 13126
|
12157, 12272
|
13541, 15062
|
4621, 6611
|
2904, 2927
|
2950, 3658
|
272, 290
|
11286, 12131
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362, 2387
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13241, 13306
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13145, 13220
|
13342, 13517
|
3683, 3683
|
2409, 2601
|
2617, 2789
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,370
| 127,915
|
39574
|
Discharge summary
|
report
|
Admission Date: [**2134-10-26**] Discharge Date: [**2134-10-31**]
Date of Birth: [**2072-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Sustained Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Electrophysiology Study
Ventricular Tachycardia Ablation
ICD placement
History of Present Illness:
62 yo male with history of hypertension, dyslipidemia with
NSTEMI in [**2134-9-15**]. Cardiac cath at MWH showed
multivessel disease - s/p 3 vessel CABG [**2134-9-23**]. Post op course
complicated by atrial fibrillation and recurrent ventricular
tachycardia. Discharged on amiodarone and metoprolol with
lifewatch monitor that did not show further ventricular
arrythmias. Referred for EP study and VT ablation.
Past Medical History:
Ventricular Tachycardia
Paroxysmal atrial fibrillation
hypertension
hypercholesterolemia
asthma
coronary artery disease, s/p CABG X 3 vessels
Social History:
Lives with: significant other, [**Name (NI) 16901**] (uses wheelchair, health is
not stellar)
Occupation: laid off last year- worked as truck driver
Tobacco: quit 12yrs ago, 66pack year history
ETOH: none
Family History:
mother died at 78yo with h/o CVA
father died at 64 ?MI
Physical Exam:
Gen: Alert and oriented X 3, no apparent distress
Lungs: Diminished at bases, + acessory muscle use
Neck: No bruit, 2+ carotid pulse
CV: S1, S2, S4, no murmur. Well healed midline thoracotomy scar
Abd: Soft, nontender, nondistended + BS's
Ext: 2+ femoral pulse, no bruit
2+ pedal pulse, no edema
Pertinent Results:
ECHO [**2134-10-26**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal with inferolateral and anterolateral hypokinesis. The
distal anteroseptal segments may also be hypokinetic but views
are suboptimal. Overall left ventricular systolic function is
mildly depressed (LVEF= ?45%). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2134-9-28**],
regional wall motion abnormalities are similar. Overall left
ventricular systolic function appears slightly more vigorous in
the current study but views are suboptimal for comparison.
CARDIAC MRI [**2134-10-27**]:
1. Moderately enlarged left ventricular cavity size with
akinesis of the basal to apical inferoseptum, inferior and
inferolateral walls. The LVEF was moderately depressed at 35%.
The effective forward LVEF was moderately
depressed at 33%. CMR evidence of prior myocardial
scarring/infarction in the basal to apical inferoseptum,
inferior and inferolateral walls. Late
gadolinium contrast-enhanced CMR images demonstrating areas of
hyperenhancement as described above. The findings are consistent
with low
likelihood of functional recovery of these walls after
mechanical
revascularization. There is hyperenhancement seen in the mid to
distal
anterior septum which is likely an artifact rather than scar.
2. Normal right ventricular cavity size and systolic function.
The RVEF was mildly depressed at 43%.
3. Mild mitral regurgitation. Mild pulmonic regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Moderate left atrial enlargement. Mild right atrial
enlargement.
6. A note is made of a hemangioma in the vertebral body at T7.
PA-Lat [**2134-10-30**]
Compared with [**2134-10-28**], the ET tube has been removed. A new
left-sided
pacemaker is present, lead tips overlie the right atrium and
right ventricle.
Again seen is cardiomegaly, with sternotomy wires. Elevated
right
hemidiaphragm and atelectasis and/or scarring in the right
cardiophrenic
region as well as thickening of the minor fissure. No CHF, other
parenchymal
opacities, or effusion. Possible faint residual
pneumopericardium noted.
IMPRESSION: New left-sided pacemaker with lead tips over right
atrium and
right ventricle. Atelectasis and/or scarring in the right
cardiophrenic
region.
Discharge Labs:
[**2134-10-31**] 06:30AM BLOOD WBC-5.6 RBC-3.23* Hgb-9.3* Hct-28.7*
MCV-89 MCH-28.9 MCHC-32.5 RDW-15.8* Plt Ct-105*
[**2134-10-31**] 06:30AM BLOOD Plt Ct-105*
[**2134-10-31**] 06:30AM BLOOD Glucose-94 UreaN-18 Creat-1.1 Na-143
K-4.1 Cl-102 HCO3-38* AnGap-7*
[**2134-10-31**] 06:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
Brief Hospital Course:
62 yoM recently s/p triple-CABG [**2134-9-23**] at [**Hospital1 18**] (LIMA to the
LAD, SVG to the OM, and SVG to the RCA) whose post-operative
course was complicated by AF-RVR and sustained VT. The patient
was admitted [**10-26**] after an EP study for VT showed inducible VT
from RV which was stable and monomorphic from basal inferior
wall. He required DC cardioversion and Amiodarone loading. After
the procedure he had an EF of 45% and was admitted for EP scar
ablation.
.
# Sustained VT: On [**10-27**], Cardiac MRI was performed which showed
EF 35 % and prior myocardial scarring/infarction in the basal to
apical inferoseptum, inferior and inferolateral walls. VT
ablation on [**10-28**] was unsuccessful and he required
intra-procedure DC cardioversion for sustained VT. He was
cardioverted to NSR. He had peri-procedure hemodynamic
instability for which he was admitted to the ICU on
intra-procedure pressors with post-procedure SBPs into the 200s.
He was extubated on first day in the ICU, pressors were weaned
and his labile hypertension resolved. An ICD was placed on [**10-29**]
without event. Patient was restarted on his home dose of
Metoprolol as detailed below. Amiodarone and Warfarin were
stopped prior to discharge.
.
# CAD: No signs or symptoms of ischemia this admission;
continued medical management of CAD with aspirin and
simvastatin, and was discharged on these medications as detailed
below.
Medications on Admission:
Amiodarone 200 mg three times daily
Metoprolo tartate 50 mg three times daily
Simvastatin 80 mg daily
Wafarin 5 mg daily
Aspirin 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Ventricular Tachycardia
Chronic Systolic Dysfunction secondary to Ischemic
Cardiomyopathy
Hypertension
Dyslipidemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after having a procedure to
ablate a scar in your heart that had been causing abnormal heart
rhythms. This procedure was not successful, as you went into an
abnormal rhythm during it and had to be shocked into a normal
rhythm. Because of this, an implantable
cardioverter-defibrillator (ICD) was placed, which will shock
you out of abnormal rhythms in the future.
.
Please make the following changes to your medications:
STOP taking COUMADIN
STOP taking AMIODARONE
Take your other medications as previously prescribed to you by
your physicians.
You need to be seen in DEVICE CLINIC THIS WEEK at the Heart
Center [**Hospital1 **] and also by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] in the next [**2-17**]
weeks.
Please CALL the Heart Center at [**Telephone/Fax (2) 87352**] on MONDAY to make
those appointments.
Followup Instructions:
1) DEVICE CLINIC at the Heart Center in [**Hospital1 **] - please call
[**Telephone/Fax (1) 87352**] to schedule an appointment for the week of
[**2134-11-1**].
2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] at the Heart Center in [**Hospital1 **] - please
call [**Telephone/Fax (1) 20259**] to schedule an appointment for the week fo
[**2134-11-1**].
|
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icd9cm
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"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6659, 6722
|
4796, 6218
|
351, 423
|
6881, 6887
|
1671, 4437
|
7817, 8202
|
1272, 1329
|
6409, 6636
|
6743, 6860
|
6244, 6386
|
6911, 7337
|
4454, 4773
|
1344, 1652
|
7366, 7794
|
278, 313
|
451, 867
|
889, 1033
|
1049, 1256
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,929
| 177,290
|
20413+57158
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-11-18**] Discharge Date: [**2129-11-23**]
Date of Birth: [**2052-12-2**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Digoxin Immune Fab
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
fevers, MRSA bacteremia
Major Surgical or Invasive Procedure:
1. PICC line placement [**11-21**]
2. Sternal wound culture [**11-18**]
History of Present Illness:
76 y/o female s/p recent d/c from [**Hospital1 **] on [**11-6**] following
complicated course involving pericardial tissue AVR and MAZE for
aortic stenosis and refractory afib [**9-17**], intermittent CHF and
renal failure now being re-admitted for ?sternal cellulitis and
MRSA bacteremia. Admitted late [**8-17**] for aortic valve repair w/
surgery initially delayed secondary to acute renal failure and
volume overload, treated w/ natrecor. Underwent magna
pericardial tissue AVR for AS and MAZE for afib. Post-op course
c/b recurrent afib and tenous volume status resulting in
intermittent CHF and ARF and several episodes of respiratory
failure requiring intubation. At one point, pt treated w/
milrinone in [**9-17**] after intubated for respiratory distress and
then extubated on [**10-3**] w/ metabolic alkalosis treated w/ diamox.
Continued to revert into afib on multiple occasions and thought
to exacerbate CHF. Labile blood pressures resulting in
hypotension w/ ACEi and bradycardia w/ digoxin. During
remainder of hospital course, again managed for CHF and resp
failure and ultimately underwent trach and PEG. All told, during
hospital course, diuresed 15 liters negative.
Transferred to [**Hospital **] rehab on [**11-10**] and initially remained
stable. Apparently, spiked fever on [**11-13**] to 103.5 and was noted
to be w/ increased resp distress and WBC also increased. CXR w/
reported b/l infiltrates. Started on Zosyn for ?infiltration but
sputum, blood cultures found positive for MRSA and started on
Vancomycin [**11-16**]. On [**11-17**], c/o substernal CP and noted to have
significant erythema at sternal incision site. Transferred to
[**Hospital1 18**] for further evaluation.
Past Medical History:
1. Aortic stenosis s/p AVR [**9-17**] as above
2. Presumed diastolic dysfunction
3. Recurrent afib s/p MAZE [**9-17**]
4. Pulmonary HTN
5. Chronic respiratory failure s/p trach
6. s/p PEG
7. type 2 dm
8. CVA [**42**] years ago
9. hypothyroid
10. Chronic renal insuffiency, baseline 1.3
Social History:
coming from [**Hospital1 **] rehab
Family History:
+DM
+CV
Negative for premature coronary disease. No other obvious
etiology of cardiomyopathy per pt and family.
Physical Exam:
gen: debilitated elderly female, appearing frustrated,
comfortable on trach ventilation
heent: JVP to ear at 60 degrees, MMM, OP clear, erythema/pain to
palpation at site of sternal wound
cv: s1, s2, irregularly irregular
pulm: cta anteriorly
abd: J tube w/ mild erythema but no discharge. no tender to
palpation.
extre: 1+ pitting le edema
Pertinent Results:
[**2129-11-18**] 03:22PM GLUCOSE-57* UREA N-28* CREAT-1.2* SODIUM-146*
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-30* ANION GAP-12
[**2129-11-18**] 03:22PM CALCIUM-8.7 PHOSPHATE-2.5*# MAGNESIUM-2.1
[**2129-11-18**] 03:22PM WBC-6.5 RBC-3.16* HGB-9.1* HCT-28.5* MCV-90
MCH-28.9 MCHC-32.1 RDW-16.3*
[**2129-11-18**] 03:22PM NEUTS-65.2 LYMPHS-24.1 MONOS-6.5 EOS-3.8
BASOS-0.5
[**2129-11-18**] 03:22PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
[**2129-11-18**] 03:22PM PLT COUNT-268
[**2129-11-18**] 03:22PM PT-17.7* PTT-33.7 INR(PT)-2.0
Brief Hospital Course:
1. MRSA bacteremia: 2/2 bottles from OSH + for MRSA. Given
recent bioprosthetic aortic valve [**9-17**], concerns about potential
for endocarditis. Pt also had erythema and pain around site of
sternum. Pt followed by both ID and CT surgery. Started on iv
vanc and rifampin and gent given concerns for endocarditis.
However, blood cultures remained neg [**Hospital 54708**] hospital course.
TTE and TEE both performed which were negative for vegetations.
ID recommended d/c of rifampin and prolonged course of IV
vancomycin x 4 weeks at 1g q 48 hrs. Meanwhile, sternal incision
was cultured w/o significant growth.
1a;)?Sternal wound infection: no evidence of osteo on ct and
evaluated by CT w/o evidence of fluctuance concerning for
abscess. Cultures of deep sternal wound w/ minimal growth.
Recommended wet to dry normal saline dressing changes [**Hospital1 **].
2. Chronic respiratory failure: continued on current vent
settings of SIMV PS.
3. CHF: Continued on low dose Coreg. In addition, pt was felt to
mild overloaded on exam and diuresed w/ IV lasix 80 mg x 2 w/
good response. She will continue w/ lasix 40 mg po bid. She
should have creatinine and weight followed closely.
4. Anemia: Hct remained relatively stable [**Hospital 44644**] hospital course
w/ transfusion 1 unit prbc.
5. CRI: creatinine stable throughout hospital course.
6. AFib: rate controlled w/ coreg and continued on
anti-coagulation w/ coumadin.
7. Access: new RUE PICC placed on [**11-20**] for delivery iv abx.
8. Rash: Macular erythematous rash thought secondary to rifampin
that was d/c'd.
Medications on Admission:
lantus 10 units qhs, lumigan eye gtts. Coreg 3.12 mg by mouth
2x/day, Colace 100 mg by mouth 2x/day, Synthroid 100 mcg by
mouth 1x/day, Flagyl 100 mg IV 3x/day, Remeron 15 mg by mouth
every evening, Zantac 150 mg by mouth 2x/day, Vancomycin 1 gram
IV every day, coumadin 3.5 mg by mouth every evening, lasix 80
mg IV as needed for weight greater than 152 lbs.
Discharge Medications:
1. Warfarin Sodium 1 mg Tablet Sig: 3.5 Tablets PO HS (at
bedtime).
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
10. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: insulin
sliding scale sliding scale Subcutaneous four times a day:
please follow pre-existing insulin sliding scale.
11. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) solution
Intravenous 48 hrs for 4 weeks: to finish on [**12-16**].
12. Outpatient Lab Work
please check vancomycin trough following third dose - goal is
for trough 15-17.
Please check inr/ptt two times per week and chem 7(sodium,
potassium, bicarbonate, chloride, bun, creatinine) 2x/week
13. tubefeeding
Ultra-cal full strength at 65 cc/hour. Check residuals q 4 hours
and hold for residual greater than 100 cc. Please flush tube w/
water 100 cc every 6 hours
14. outpatient respiratory vent
SIMV respiratory rate 12
Tidal volume 500
Pressure Support 15
PEEP 5
FiO2 - 0.30
15. Outpatient Lab Work
blood cultures - 2 sets to be drawn 1 week after completion of
anti-biotics
16. wound care
please normal saline wet to dry dressing changes to sternal
wound [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
MRSA bacteremia resolved
s/p PICC line placement
CHF stable
Atrial fibrillation
Discharge Condition:
fair
Discharge Instructions:
3lbs.
2. Please continue IV vancomycin 1 g every 48 hours until [**12-16**].
Please check vancomycin trough after 3rd dose and goal for
trough 15-17. Please check blood cultures 1 week after
completiion of abx.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SURGERY LMOB 2A Follow-up appointment should
be in 2 weeks
Name: [**Known lastname **],[**Known firstname 986**] Unit No: [**Numeric Identifier 10221**]
Admission Date: [**2129-11-18**] Discharge Date: [**2129-11-23**]
Date of Birth: [**2052-12-2**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Digoxin Immune Fab
Attending:[**First Name3 (LF) 713**]
Chief Complaint:
MRSA bacteremia
Major Surgical or Invasive Procedure:
PICC placement [**11-21**]
sternal wound swab [**11-18**]
Past Medical History:
1. Aortic stenosis s/p AVR [**9-17**] as above
2. Presumed diastolic dysfunction
3. Recurrent afib s/p MAZE [**9-17**]
4. Pulmonary HTN
5. Chronic respiratory failure s/p trach
6. s/p PEG
7. type 2 dm
8. CVA [**42**] years ago
9. hypothyroid
10. Chronic renal insuffiency, baseline 1.3
Social History:
coming from [**Hospital1 **] rehab
Family History:
+DM
+CV
Negative for premature coronary disease. No other obvious
etiology of cardiomyopathy per pt and family.
Brief Hospital Course:
Addendum: Pt was found w/ new erythematous macular rash over
lower abdomen and lower extremities on hospital day 5 and 6. The
team felt that rash was secondary to rifampin which had been
d/c'ed one day earlier. However, there is possibility that
reaction could be vancomycin-induced. At this point, have
decided to continue w/ vancomycin for previous scheduled course
to complete on [**12-16**]. Dr. [**Last Name (STitle) **], the physician at [**Hospital1 10224**] rehab was notified of the rash. Should rash worsen, he
would have the option to change to Linezolid. For now, the plan
will to be cont vancomycin at 1 g iv q 48 hours.
Sternal wound - Pt's sternal wound was cultured by CT surgery.
Sparse amount of MRSA grew from culture but not felt to be
drainable fluid collection by exam or chest CT. Will cont w/
normal saline wet to dry dressing changes [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
Discharge Diagnosis:
MRSA bacteremia resolved
s/p PICC line placement
CHF stable
Atrial fibrillation
Discharge Condition:
fair
Discharge Instructions:
Please [**Name8 (MD) 233**] MD [**First Name (Titles) **] [**Last Name (Titles) 10225**], chills, increased respiratory
distress, weight gain.
Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs.
Please follow rash over abdomen and lower extremities and if
worsens, may consider switch of antibiotics from vancomycin to
linezolid
Followup Instructions:
Provider: [**Name10 (NameIs) 10226**] SURGERY LMOB 2A Follow-up appointment should
be in 2 weeks
Please arrange follow up appointment w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 2058**]) in a few weeks.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**]
Completed by:[**2129-11-23**]
|
[
"682.2",
"428.33",
"518.83",
"041.11",
"427.31",
"397.0",
"E878.2",
"416.8",
"V42.2",
"428.0",
"250.00",
"790.7",
"998.59",
"244.9",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9711, 9781
|
8809, 9688
|
8235, 8295
|
9905, 9911
|
2998, 3536
|
10312, 10728
|
8672, 8786
|
5550, 7225
|
9802, 9884
|
5166, 5527
|
9935, 10289
|
2635, 2979
|
8180, 8197
|
418, 2129
|
8317, 8604
|
8620, 8656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,413
| 128,933
|
36189
|
Discharge summary
|
report
|
Admission Date: [**2104-12-12**] Discharge Date: [**2104-12-15**]
Date of Birth: [**2045-4-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Psychosis
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
HPI: This is a 59 year-old female with history per her daughter
and HCP of admission to [**Name (NI) 16093**] hospital for what was thought to
be [**Name (NI) **] who presents with 1 week of odd behaviour, speaking in
tongues, "witnessing miracles". Per daughter, patient [**Name2 (NI) 9103**]'t
left the house in 4 days, not eating or drinking. Praying and
acting oddly. [**Name (NI) **] sister came to visit and the decision
was made to call EMS.
.
In the ED, patient was initially brought to the psychiatric
portion of ED where her vitals were noted to be T 101, HR 152,
99/47, 28, sating 99% RA. Her serum and urine tox were negative,
but WBC was elevated to 15 and lactate to 4.5. An LP was normal,
as was CXR, UA and Head CT. She was given 1 g Ceftriaxone, Vanc,
and acyclovir. Additionally, she was given 40 mg total of Valium
for agitation.
Past Medical History:
Per daughter, patient has minimal contact with medical care, but
was hospitalized in [**6-5**] at [**Last Name (un) 16093**] for "[**Last Name (un) **]" (daughter is
unsure if she was diagnosed. Also, had inpatient psychiatric
admission 20 yrs ago at [**Hospital1 **] House.
.
Other h/o elevated LFTs, HTN, asthma.
Social History:
Lives alone, volunteers at daughter's first grade class. No
T/A/D. No OTC or supplements. Only topical oils. Per daughter,
no toxic exposures such as CO or poisons.
Family History:
Significant for siblings with alcoholism. No Bipolar,
schitzophrenia or other psyiciatric illnesses.
.
Physical Exam:
Vitals: T: 98.6 BP: 132/71 HR: 114 RR: 21 O2Sat: 100% RA
GEN: well-nourished, Acutely agitated, AO x 0, making odd
statements
Neuro: Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Unable to perform rest of exam as patient non-cooperative.
Pertinent Results:
Admission Labs:
[**2104-12-12**] 07:30PM WBC-15.1* RBC-4.83 HGB-14.6 HCT-41.9 MCV-87
MCH-30.2 MCHC-34.9 RDW-12.5
[**2104-12-12**] 07:30PM NEUTS-78.9* LYMPHS-12.5* MONOS-7.4 EOS-0.2
BASOS-1.0
[**2104-12-12**] 07:30PM PLT COUNT-365
[**2104-12-12**] 07:30PM ALT(SGPT)-30 AST(SGOT)-35 CK(CPK)-195* ALK
PHOS-96 TOT BILI-0.8
[**2104-12-12**] 07:30PM LIPASE-83*
[**2104-12-12**] 07:30PM CK-MB-5 cTropnT-<0.01
[**2104-12-12**] 07:30PM ALBUMIN-4.6 CALCIUM-10.3* PHOSPHATE-4.6*
MAGNESIUM-2.0
[**2104-12-12**] 07:30PM VIT B12-999* FOLATE-GREATER TH
[**2104-12-12**] 07:30PM TSH-4.5*
[**2104-12-12**] 07:30PM PTH-60
[**2104-12-12**] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2104-12-12**] 07:30PM LACTATE-4.9*
[**2104-12-12**] 10:07PM LACTATE-1.0
[**2104-12-12**] 09:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-38
GLUCOSE-61 LD(LDH)-18
[**2104-12-12**] 09:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-0 MONOS-0
[**2104-12-12**] 07:47PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2104-12-12**] 07:45PM PT-13.6* PTT-24.7 INR(PT)-1.2*
[**2104-12-12**] 07:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2104-12-12**] 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2104-12-12**] 07:30PM GLUCOSE-104 UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-16* ANION GAP-25*
.
[**2104-12-12**] head CT:No hemorrhage or edema. However, round focal
hyperdensity in region of sella may represent pituitary lesion
or aneurysm.
.
.
Brief Hospital Course:
59 year-old female with history per her daughter of ? [**Name2 (NI) **] who
presented with 1 week of odd behaviour, pressured speech and
symptoms of psychosis.
.
Plan:
# Psychosis - Given history of psychiatric admissions, this was
likely a primary psychiatric disorder such as [**Name2 (NI) **] or
schizophrenia. However initial thoughts included Infectious
cause may also play a role (see below). SW and psychiatry were
consulted. Psychiatry recommended inpatient psychiatric
hospitalization as thought that pt was a danger to herself; she
stopped eating, going to the bathroom, and did not leave her
home for a few days. Pt was sectioned by psychiatry. [**Name2 (NI) **] and
overall mental state improved upon transfer to the floor. On
[**12-14**] pt was calm, and was not needing prn valium or haldol
anymore. She was re-evaluated by psych on [**12-15**] and given
improvement, decision made along w family to not pursue section
12 and rec inpt psych. Pt agreed to partial hospital. This was
set up and pt was discharged
.
# Fever/WBC elevation: Infectious causes for psychosis mostly
ruled out given clean LP and UA. HSV PCR is pending, however, pt
has improved since admission. Unlikely sepsis as lactate cleared
completely with fluids. Blood/urine cultures thus far have been
unrevealing, antibiotics have been discontinued as pt has been
afebrile with a stable white count.
.
. FEN - reg diet
. Dispo - home w fu at partial hospital
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Acute manic episode
Leukocytosis
Fever NOS
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a manic episode. You had no evidence of
any infection. You agreed with our psychiatrist to go to a
partial hospital to seek psychiatric help. Appt time/date is
listed below. Please attend.
.
Please call your doctor or go to the ER for fevers, chest pain,
shortness of breath, hallucinations, suicidal thoughts, or any
other concerning symptoms.
Followup Instructions:
Please go to [**Hospital **] hospital at [**Street Address(2) **], [**Location (un) 538**],
MA tomorrow, [**12-16**], Tuesday at 9AM. PH: [**Telephone/Fax (1) 23525**]
|
[
"780.60",
"296.14",
"276.2",
"285.9",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5379, 5385
|
3853, 5295
|
326, 343
|
5472, 5481
|
2182, 2182
|
5898, 6069
|
1758, 1863
|
5350, 5356
|
5406, 5451
|
5321, 5327
|
5505, 5875
|
1878, 2163
|
277, 288
|
371, 1222
|
3702, 3830
|
2198, 3694
|
1244, 1560
|
1576, 1742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,634
| 183,480
|
41581+58416+58457
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2190-2-17**] Discharge Date: [**2190-2-22**]
Date of Birth: [**2145-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Methadone / Morphine / toradol
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2190-2-17**] 1. Emergent coronary artery bypass grafting x4 with the
left internal mammary artery to the left anterior descending
artery and reverse saphenous vein grafts to the posterior
descending artery, obtuse marginal artery, ramus intermedius
artery. 2. Thrombectomy of posterior descending artery.
History of Present Illness:
45 year old male with complaint of substernal chest pain as well
as mid abdomen that started 3 hours prior to presentation at OSH
ED on [**2-16**]. Pain radiated up neck with nausea and diaphoresis. He
ruled in for myocardial infarction CK MB 6.7 and troponin 0.21 -
On [**2-17**] he underwent cardiac catheterization that revealed
significant coronary disease with chest pain that continued
until IABP placed. He is now transferred for surgical
evaluation.
Past Medical History:
Coronary artery disease previous myocardial infarction s/p
Angioplasty and stent [**2187**]
Rheumatoid Arthritis
Chronic obstructive pulmonary disease
Diabetes mellitus
Gastric esophageal reflux disease
Pancreatitis
Hyperlipidemia
Morbid obesity
Ruptured lumbar disc
Gastroparesis
Social History:
Race: caucasian
Lives with: spouse
[**Name (NI) 1139**]: 3 packs per day
ETOH: denies
Family History:
non-contributory
Physical Exam:
Height: 70 inches Weight: 300 lbs
General: Chest pain [**7-23**] and back pain [**11-22**]
diaphoretic and anxious
Skin: Dry [x] right groin with red non raised rash no odor
unable to assess posterior due to active chest pain
Bilateral lower extremity venous stasis changes
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-tender [x] bowel sounds + [x] obese
Extremities: Warm [ x], Edema bilateral LE +1 Varicosities: None
[x]
Neuro: Alert and oriented x3 MAE right = left
Pulses:
Femoral Right: IABP Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit Right: Left:
Pertinent Results:
[**2190-2-22**] 08:45AM BLOOD WBC-7.1 RBC-3.47* Hgb-9.8* Hct-28.8*
MCV-83 MCH-28.2 MCHC-33.9 RDW-14.6 Plt Ct-249
[**2190-2-17**] 01:00PM BLOOD WBC-14.2* RBC-5.52 Hgb-15.6 Hct-45.0
MCV-82 MCH-28.2 MCHC-34.6 RDW-14.6 Plt Ct-335
[**2190-2-17**] 06:45PM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1
[**2190-2-17**] 01:00PM BLOOD PT-12.1 PTT-23.1 INR(PT)-1.0
[**2190-2-22**] 06:06AM BLOOD Glucose-171* UreaN-27* Creat-0.7 Na-137
K-3.6 Cl-100 HCO3-30 AnGap-11
[**2190-2-17**] 01:00PM BLOOD Glucose-172* UreaN-18 Creat-0.6 Na-132*
K-4.4 Cl-99 HCO3-22 AnGap-15
[**2190-2-17**] 01:00PM BLOOD ALT-31 AST-96* AlkPhos-150* Amylase-23
TotBili-0.3
Brief Hospital Course:
Mr. [**Name13 (STitle) 41776**] was transferred from OSH to [**Hospital1 18**] with significant
coronary artery disease, active chest pain and on an IABP. He
was emergently taken to the operating room where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details. Following surgery he was transferred to
the CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one all his drips, including
Epinephrine were weaned off and his IABP was removed. Beta
blockers and diuretics were started and he was gently diuresed
towards his pre-op weight. Chest tubes were removed on post-op
day two and he was transferred to the step-down floor for
further care. Epicardial pacing wires were removed on post-op
day three. He continued to make good progress while working with
physical therapy for strength and mobility. On post-op day #5 he
was cleared by Dr.[**Last Name (STitle) **] for discharge to home with no VNA services
due to insurance issues. Social work was consulted. All follow
up appointments were advised.
Medications on Admission:
Medications at home:
Dilatrate SR 40 mg daily
Gabapentin 800 mg TID
Lantus 125 mg [**Hospital1 **]
Toprol 50 mg TID
Tricor 145 mg daily
Elavil 100 mg daily
Lisinopril 20 mg [**Hospital1 **]
Reglan 10 mg TID
Ambien 10 mg qhs
Prozac 20 mg daily
Aspirin 81 mg daily
Tagamet ? dose
Percocet 10/325 q4-6h
Meds OSH
lopressor 50 mg TID
Lantus 27 units HS
NTG 1" Chest wall Q6h
Dilatrate SR 40 mg daily
Gabapentin 800 mg TID
Tricor 145 mg daily
Elavil 100 mg HS
Lisinopril 20 mg [**Hospital1 **]
Reglan 10 gm TID
Ambien 10 mg HS
Prozac 20 mg daily
Protonix 40 mg daily
Lovenox 40 mg SQ daily
Plavix - last dose: 600 mg [**2-17**]
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:*1*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*1*
7. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*1*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
9. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*1*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous BREAKFAST (Breakfast): 70 units Q AM.
Disp:*qs * Refills:*1*
13. insulin glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous q PM: 20 units Q PM.
Disp:*qs * Refills:*1*
14. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
15. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
16. Novolog 100 unit/mL Solution Sig: One (1) Subcutaneous
ACHS: per sliding scale.
Disp:*qs * Refills:*1*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary artery disease previous myocardial infarction
(Angioplasty and stent [**2187**]) s/p Coronary Artery Bypass Graft x
4
Past medical history:
Rheumatoid Arthritis
Chronic obstructive pulmonary disease
Diabetes mellitus
Gastric esophageal reflux disease
Pancreatitis
Hyperlipidemia
Morbid obesity
Ruptured lumbar disc
Gastroparesis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
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) **] on [**2190-3-17**] at 1pm
Cardiologist: Dr. [**Last Name (STitle) 86177**] at [**2190-3-24**] at 11:45AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 90423**] [**Name (STitle) **] in [**5-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2190-2-22**] Name: [**Known lastname 14180**],[**Known firstname 63**] Unit No: [**Numeric Identifier 14181**]
Admission Date: [**2190-2-17**] Discharge Date: [**2190-2-22**]
Date of Birth: [**2145-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Methadone / Morphine / toradol
Attending:[**First Name3 (LF) 135**]
Addendum:
Amended Addendum:
It should be noted that the patient was evaolving an inferior
myocardial infarction at the time he was transferred from the
cardiac catheterization lab at [**Hospital6 11271**]. He had
ST changes in lead [**3-18**] and AVF and a troponin level over 4. He
required an IABP to assist his heart function, prior to
transfer. On TEE prior to incision his EF with IABP assist was
20%, post-operative EF was 40%
It should be reflected in his discharge diagnosis that the
patient had acute systolic heart failure.
Discharge Disposition:
Home
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2190-3-29**] Name: [**Known lastname 14180**],[**Known firstname 63**] Unit No: [**Numeric Identifier 14181**]
Admission Date: [**2190-2-17**] Discharge Date: [**2190-2-22**]
Date of Birth: [**2145-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Methadone / Morphine / toradol
Attending:[**First Name3 (LF) 135**]
Addendum:
It should be noted that the patient was evaolving an inferior
myocardial infarction at the time he was transferred from the
cardiac catheterization lab at [**Hospital6 11271**]. He had
ST changes in lead [**3-18**] and AVF and a troponin level over 4. He
required an IABP to assist his heart function, prior to
transfer. On TEE prior to incision his EF with IABP assist was
20%, post-operative EF was 40%
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2190-3-28**]
|
[
"536.3",
"714.0",
"414.01",
"496",
"414.2",
"305.1",
"410.41",
"278.01",
"428.21",
"530.81",
"250.00",
"V49.87",
"412",
"V45.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10697, 10860
|
2976, 4126
|
308, 617
|
7111, 7337
|
2327, 2952
|
8260, 9681
|
1527, 1545
|
4800, 6688
|
6751, 6878
|
4152, 4152
|
7361, 8237
|
4173, 4777
|
1560, 2308
|
258, 270
|
645, 1104
|
6900, 7090
|
1424, 1511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,698
| 134,584
|
22019
|
Discharge summary
|
report
|
Admission Date: [**2157-12-9**] Discharge Date: [**2157-12-13**]
Date of Birth: [**2091-1-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Ciprofloxacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
sternal pain
Major Surgical or Invasive Procedure:
[**2157-12-9**] sternal debridement /plating
History of Present Illness:
66 yo female with alcoholic cirrhosis;
underwent CABG x3 in [**2151**]. First seen in early [**2155**] for sternal
pain and dehiscence. Surgery has been delayed for more than a
year while she had treatment for GI bleeding with subsequent
banding of esophageal varices. She has also had several
paracenteses for ascites since then, but none in the past few
months. Her last EGD was in [**9-7**] and there was no evidence of
varices post-obliteration. Ascites is currently controlled on
diuretics. She is also currently undergoing treatment with
Neupogen to increase WBCs and periodic procrit for an early
dysplastic syndrome. She will likely require platelet
transfusion
at the time of surgery.She is also on home O2 at night.Referred
now for sternal plating.
Past Medical History:
CAD s/p cabg
sternal nonunion
postop A Fib
alocoholic cirrhosis
NSVT
HTN
hypercholesterolemia
PVD
NIDDM
asthma
myelodysplasia (? low grade lymphoma)
leukopenia
anemia
portal HTN
thrombocytopenia
upper GI bleed
esophageal varices (s/p banding and obliteration
Social History:
Patient lives with her husband in [**Name (NI) 57627**]. She has been sober
for about 25 years. She does not smoke cigarettes. She is
retired from a job in security.
Family History:
mother with MI in her 40's;brother died of MI at 53
Physical Exam:
Pulse:86 Resp: O2 sat: 97% RA
B/P Right: Left: 120/58
Height: 4'[**57**]" Weight:121
General:frail-appearing, somewhat weak
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [] Full ROM []no JVD; extending neck produces
sternal pain
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM radiates to
carotids
Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds +
[x]mildly distended with tenderness at RUQ and LUQ
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None []well-healed bilat. EVH scars at knees
Neuro: Grossly intact;MAE [**4-3**] strengths
Pulses:
Femoral Right:1+ Left: 1+
DP Right:1+ Left: 1+
PT [**Name (NI) 167**]:1+ Left: 1+
Radial Right:2+ Left: 2+
Carotid : murmur radiates to carotids bil.
Brief Hospital Course:
Admitted [**2157-12-9**] and underwent surgery with Drs. [**Last Name (STitle) 914**] and
[**Name5 (PTitle) **]. Please see operative note. Transferred to the CVICU and
extubated. Coagulation factors were corrected with products.
Transferred to the postop floor to begin increasing her activity
level on POD #1. Continued to make good progress and was cleared
for discharge on POD #4 to home. Mrs. [**Known lastname **] was discharged
home with her JP drain in place which will be removed in one
week at her follow up visit with Dr. [**First Name (STitle) **]. She will make all
follow up appointments as per discharge instructions.
Medications on Admission:
Albuterol 90 mcg 2 puffs IH q4h prn
citalopram 40 mg daily
clonazepam 0.5 mg daily
fentanyl patch 25 mcg/hr q 72 hours
neupogen SC inj. 3x /week
lasix 40 mg [**Hospital1 **] ( held now-restarts [**12-2**])
lactulose 15 ml TID titrated for BMs daily
metformin 100 mg [**Hospital1 **]
toprol XL 25 mg daily
singulair 10 mg daily
SL NTG 0.4 mg prn
pantoprazole 40 mg daily
simvastatin 40 mg daily
januvia 100 mg daily
spironolactone 100 mg daily
trazodone 50 mg QHS
MVI daily
procrit prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. 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*
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Succinate 25 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:*2*
10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) cc PO
three times a day.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
14. Procrit Injection
15. Neupogen Injection
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All care VNA
Discharge Diagnosis:
CAD s/p cabg
sternal nonunion s/p plating
postop A Fib
alcoholic cirrhosis
NSVT
HTN
hypercholesterolemia
PVD
NIDDM
asthma
myelodysplasia (? low grade lymphoma)
leukopenia
anemia
portal HTN
thrombocytopenia
upper GI bleed
esophageal varices (s/p banding and obliteration)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge.
Empty your drainage bulb daily and record the drainage amount
and bring to follow up appointment with Dr.[**First Name (STitle) **].
Followup Instructions:
Please call to schedule appointments:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 57628**] [**2157-12-20**] @ 8:30 AM [**Street Address(2) 57629**]. [**Location (un) **], MA
Surgeon Dr.[**Last Name (STitle) 914**] [**Name (STitle) **] [**2158-1-10**] @ 1:30 PM [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 57630**] [**Telephone/Fax (1) 40489**] in [**12-31**] weeks
Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 11554**] in [**12-31**] weeks
Completed by:[**2157-12-13**]
|
[
"285.9",
"V46.2",
"287.5",
"414.00",
"E878.2",
"572.3",
"571.2",
"493.90",
"428.0",
"250.00",
"401.9",
"998.31",
"V45.81",
"303.93",
"443.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"99.07",
"99.05",
"78.41",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
5140, 5183
|
2579, 3213
|
304, 351
|
5498, 5594
|
6353, 6891
|
1622, 1675
|
3749, 5117
|
5204, 5477
|
3239, 3726
|
5618, 6330
|
1690, 2556
|
252, 266
|
379, 1140
|
1162, 1422
|
1438, 1606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,398
| 141,807
|
49626
|
Discharge summary
|
report
|
Admission Date: [**2119-7-12**] Discharge Date: [**2119-7-17**]
Date of Birth: [**2039-7-28**] Sex: F
Service: NEUROLOGY
Allergies:
Fosamax / Zyvox / Heparin Agents
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right arm and leg weakness, slurred speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yr right wf with hx of cad with stent place on aspirin,
htn, a-fib present to ER with sudden onset of right side
weakness
and slurred speech when she was watching [**Doctor Last Name 5749**] news at home.
Symptoms became progressively worse, and she feared being unable
to call for help. She was able to pick up phone using both hands
and call friend. By the time she arrived, she could no longer
move her right hand.
patient is a retireed psychiatrist. at baseline patient patient
is wheelchair bound due to severe spinal stenosis caused
bilaterally leg weakness.
Past Medical History:
CAD with h/o anterior MI s/p stent on aspirin with low EF=30-40%
HTN
a-fibrillation
breast cancer
leg weakness
COPD
PAD
spinal stenosis with both leg weakness wheelchair bound
OA
PUD
Social History:
She is a retired psychiatrist. She lives alone, very independent
with wheelchair, former smoker - 150 pk-yrs, quit in [**2107**].
Family History:
Significant for hypertension and history of arrhythmias in her
mother. Stroke in both mother and father. Father had asthma.
Physical Exam:
ADMISSION EXAM
temp: 37.2 BP: 145/67 RR: 16 HR: 56
Gen: distressed
HENNT: EOMI, PERRL, sclera normal
neck: soft, no carotid bruit
Lung: CTAB
CV: iregular, irregular
abd: soft, nttp
ext: discolored bilaterally, slight edmematous
Neuro exam:
gen: awake and alert to time, person and place. mild aphasia,
production of speed is slow, comprehension is normal. repetition
is mild imppaired. mild dysarthria.
CN: EOMI, PERRL, VFF, tongue in ML, slightly face asymmetric,
facil drooping to right side
Motor: righ handed. [**2-3**] with RUE, 1-2/5 with RLE. 4+/5 with left
side.
sensation: normal or subtle decreased sensation
coordination: unable to test on the right side, intact with left
side.
DTR: 1+ with UE and trace with LE. toe downwarding bilaterally
gait: not tested.
NIHSS=6( 1 for aphasia, 1 for dysarthria, 3 for RUE weakness, 1
for LLE weakness, she has weakness, but worsed).
DISCHARGE EXAM:
Neuro exam is at patient's baseline.
Speech intact with normal prosody, fluency, no paraphasic
errors, no dysarthria.
Motor exam 4+/5 deltoids strength bilaterally, otherwise upper
extremities [**5-3**].
Pertinent Results:
[**2119-7-12**] 12:09AM BLOOD WBC-7.8 RBC-5.27 Hgb-14.3 Hct-43.0 MCV-82
MCH-27.1 MCHC-33.3 RDW-14.3 Plt Ct-197
[**2119-7-12**] 12:09AM BLOOD PT-11.9 PTT-25.8 INR(PT)-1.0
[**2119-7-12**] 12:09AM BLOOD Glucose-93 UreaN-28* Creat-0.7 Na-137
K-5.8* Cl-98 HCO3-28 AnGap-17
[**2119-7-12**] 09:59AM BLOOD ALT-12 AST-25 CK(CPK)-38 AlkPhos-69
Amylase-75 TotBili-0.6
[**2119-7-12**] 09:59AM BLOOD CK-MB-4 cTropnT-<0.01
[**2119-7-12**] 07:47PM BLOOD CK-MB-3 cTropnT-<0.01
[**2119-7-12**] 09:59AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.9 Cholest-206*
[**2119-7-12**] 09:59AM BLOOD %HbA1c-5.7 eAG-117
[**2119-7-12**] 09:59AM BLOOD Triglyc-112 HDL-56 CHOL/HD-3.7
LDLcalc-128
[**2119-7-14**] 02:56AM BLOOD TSH-2.1
MICRO
URINE CX: CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML
also 1000/ml gram positives c/w contamination
IMAGING:
HEAD CT/CTA- CODE STROKE
1. Findings consistent with a small infarct core in the left
external
capsule, and a large surrounding ischemic penumbra involving the
entire left MCA territory.
2. Filling defect in the left M1 segment with distal
reconstitution of the
superior division, likely via the extracranial circulation,
suggestive of a component of chronic occlusion. Reconstitution
of the inferior division is less well seen.
3. Severe emphysema in the imaged upper lungs. Nodular density
in the right lung apex measuring 10 x 3 mm, for which a PET-CT
or follow-up CT chest in 3 months is recommended.
4. Calcification of both glenohumeral joints with fluid noted in
the left
glenohumeral joint, incompletely characterized.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the distal anterior septum, distal anterior wall
and apex.. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism identified. Mild focal
LV systolic dysfunction. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2117-7-21**],
the function of the distal anterior/antero-septal segments is
slightly better.
BRAIN MRI
1. Small acute infarction in the left external capsule.
2. Chronic microvascular infarcts in the supratentorial white
matter and
right pons.
CXR
1. No pneumonia.
2. Bilateral protrusions of the humeral heads with a new
fracture of the
right clavicle.
3. Bilateral erosions of the surgical necks of humeri. Clinical
correlation
is recommended.
4. Large hiatal remains unchanged. Right upper lobe scarring
appears
unchanged.
CT HEAD (24 hours post-TPA)
Subtle hypodensity at the site of previously MRI-demonstrated
infarct is noted. No new abnormalities are seen.
Brief Hospital Course:
79 yo RHW with h/o CAD, PAF, HTN presents with acute onset right
sided weakness and slurred speech, found to have L MCA
occlusion, s/p t-PA with good recovery of deficits.
# NEURO: Patient presented with acute right sided weakness in
arm and leg, that worsened over about 1 hour prior to
presentation. She also had slurred speech.
A code stroke was called on presentation to the ED. Head CT and
CTA revealed L MCA cut-off consistent with occlusion. CT
perfusion showed increased mean transit time, with preserved
volume, consistent with salvageable brain tissue. The risks and
benefits were discussed with the patient, and t-PA was
administered at 4 hours 10 minutes. After less than 30 minutes,
patient was able to move right arm and leg. After about 45
minutes of t-PA infusion, patient c/o headache. t-PA was stopped
and repeat head CT was stable with no bleed.
Patient was admitted to neuro ICU. Her deficits on exam had
substantially improved, she remained with 4+/5 right deltoid
strength but biceps, triceps, wrist flex/ext, and finger flex/ex
all [**5-3**] and symmetric. Speech had returned to baseline.
MRI showed small area of infarct in the L MCA distribution.
Workup for stroke etiology included TTE, telemetry, fasting
lipids, HBA1c. Of note, patient was in atrial fibrillation on
presentation to the ED, and does have a history of PAF. She had
not been anticoagulated previously due to difficulty maintaining
a constant INR in the past. She remained in sinus rhythm on
telemetry. TTE showed mildly reduced EF (40-45%) and hypokinesis
inferiorly c/w prior MI.
It was thought that the etiology of stroke was likely embolic
from AF with reduced EF. Patient agreed to start coumadin. She
was bridged with ASA due to a heparin sensitivity in the past.
Once a therapeutic INR is reached patient can be lowered back to
Aspirin 81 mg PO daily for cardiovascular protection.
Fasting lipids were moderately elevated, and patient was started
on low dose statin. Hba1c was wnl.
# CV: remained in SR after initial AF. BP was 100-120/80s and at
baseline, did not require any intervention. Home lisinopril was
initially held. Lisinopril was added back. On d/c patient did
not appear fluid [**Month/Day (1) 103777**] and no lasix was added back. A beta
blocker was not introduced secondary to low heart rate. patient
did have frequent PVC's and mg, phos, ca were within normal
limits. This d/c summary will be sent to patient's PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **].
# RESP: continued home inhalers and low dose prednisone for
COPD. Patient had incidental pulmonary nodule on CTA neck, which
requires follow-up imaging in 3 months.
# HEME: no issues
# ORTHO - Was consulted for bilateral shoulder pain that has
been chronic for many years. Plain films show obliteration of
the shoulder architecture consistent with AVN versus old trauma
versus Charcot neuropathic process. She has no acute pains due
to this, nothing has changed in the last few years. She has
some contact dermatitis-type changes overlying her shoulder on
the left side but that does not appear to be related to the
underlying orthopedic issue. At this point, I see
no acute injury that we can intervene from the orthopedic
standpoint. I will refer her for followup in the
musculoskeletal
clinic at [**Telephone/Fax (1) 1228**] on an elective basis.
# ID: patient had positive UA and was started on Bactrim x 3
days. Urine cx returned with 100,000 citrobacter but also GPC so
possibly contaminated. Completed tx course regardless. A follow
up UA was negative before discharge.
# RENAL/LYTES: no issues
# ENDO: no isses
Dispo: PT evaluated patient and recommended home without PT.
Able to transfer independently
Medications on Admission:
Lisinopril 2.5
ASA 325
Prednisone 5
atrovent prn
actonel 35 once a week
colace [**Hospital1 **] prn
levoxyl 37.5
omez 20/d
omega 3 fatty acids
MVI, Zinc, Mg
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for c.
2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
3. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sroke
Urinary Tract Infection
Coronary Artery Disease
Myocardial infarction
High blood pressure
atrial fibrillation
breast cancer
leg weakness
COPD
PAD
spinal stenosis with both leg weakness wheelchair bounds
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You presented with sided weakness and slurred speech and found
to have a Left Middle Cerebral Artery occlusion
A code stroke was called on presentation to the ED. t-PA was
administered at 4 hours 10 minutes. After less than 30 minutes,
you began to move your right arm and leg. After about 45
minutes of t-PA infusion, you developed a headache. t-PA was
stopped and repeat head CT was stable with no bleed. You were
then admitted to the neuro ICU. Your deficits on exam had
substantially improved including your speech.
MRI showed small area of infarct in the L MCA distribution. A
Workup for stroke etiology included a cardiac echo which showed
a mildly reduced ejection fraction and decreased wall motion
consistant with a prior myocardial infarction. It was thought
that the etiology of stroke was likely embolic from your atrial
fibrillation and reduced ejection fraction. You were then
started on coumadin and bridged with Aspirin. Heparin was not
started due to a history of bleeding and your refusal.
Once a therapeutic INR is reached you can be lowered back to
Aspirin 81 mg daily for cardiovascular protection.
Fasting lipids were moderately elevated, and patient was started
on Zocor.
Shoulder Pain: Plain films show obliteration of the shoulder
architecture consistent with avascular necrosis versus old
trauma versus Charcot neuropathic process. You may followup in
the
musculoskeletal clinic at [**Telephone/Fax (1) 1228**] on an elective basis.
Urine: You were found to have a urinary tract infection that
was treated with bactrim for 3 days and found to have cleared
before discharge.
Lungs: A lung nodule was found on your chest x ray. This should
be followed by your Primary Care Physician [**Last Name (NamePattern4) **] 3 months time to
monitor for any changes.
You are to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thursday [**2119-7-20**]
at 11 am.
You are to follow up with VNA to have your blood drawn to check
your INR on Tuesday.
Followup Instructions:
Dr. [**Last Name (STitle) **]: [**2119-9-19**] at 2 pm office Phone: ([**Telephone/Fax (1) 7394**] Office
Location: W/[**Location (un) **] 1
Your PCP [**Name9 (PRE) **], [**Name9 (PRE) **] Thursday [**2119-7-20**] at 11 am
Completed by:[**2119-7-17**]
|
[
"518.89",
"434.11",
"599.0",
"V10.3",
"428.0",
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"427.31",
"496",
"428.23",
"414.00",
"724.00",
"719.41",
"V46.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10527, 10585
|
5660, 9385
|
346, 352
|
10838, 10838
|
2590, 5637
|
13150, 13405
|
1321, 1447
|
9593, 10504
|
10606, 10817
|
9411, 9570
|
11021, 13127
|
1462, 2350
|
2366, 2571
|
263, 308
|
380, 950
|
10853, 10997
|
972, 1157
|
1173, 1305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,903
| 121,725
|
29698+57651
|
Discharge summary
|
report+addendum
|
Admission Date: [**2165-1-17**] Discharge Date: [**2165-1-29**]
Date of Birth: [**2081-9-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
symptomatic cholelithiasis
Major Surgical or Invasive Procedure:
open cholecystectomy
History of Present Illness:
Paraphrased from Dr.[**Name (NI) 9886**] office note:
This is an 83 woman who had her first attack of significant
cholelithiasis this past [**Month (only) 404**] and probably passed a stone at
that time, given her enzyme
elevations despite a subsequent MRCP indicating no common bile
duct stones. She was very symptomatic. Removing her
gallbladder is going to be complicated by her prior
gastrectomy in the [**2104**], but she understands the implications
of
this and whether or not it is going to preclude a laparoscopic
approach. Nevertheless, because of her higher rate of recurrent
symptoms, she desires and will need her gallbladder removed.
Past Medical History:
Past Medical History: Peptic ulcer disease, reflux,
osteoporosis, hypothyroidism, history of basal cell cancers,
cataracts, and sicca syndrome.
Past Surgical History: Billroth II for PUD in [**2104**],
tonsillectomy, hysterectomy,
appendectomy, and three eye operations.
Social History:
Socially, she lives in [**Location (un) 55**] Towers. She lives alone.
She has three children and three grandchildren. She drinks
three
to four alcoholic drinks per week. She denies tobacco and she
is
a retired medical librarian.
Family History:
non-contributory
Physical Exam:
Physical exam at discharge:
VS 98.3 98 80 141/77 20 92RA
Gen NAD, AAOx3
CV RRR
Pulm mild rhonchi at bases, improved; no respiratory distress
Abd soft, NT, ND
Wound c/d/i, no erythema or induration, steri strips in place
Ext wwp, no edema
Pertinent Results:
Admission labs:
[**2165-1-16**] 08:10AM WBC-5.0 RBC-3.93* HGB-11.4* HCT-35.4* MCV-90
MCH-29.0 MCHC-32.2 RDW-13.7
[**2165-1-16**] 08:10AM NEUTS-67.6 LYMPHS-21.5 MONOS-8.2 EOS-2.3
BASOS-0.3
[**2165-1-16**] 08:10AM PT-12.1 PTT-28.6 INR(PT)-1.0
[**2165-1-16**] 08:10AM ALT(SGPT)-35 AST(SGOT)-27 ALK PHOS-112* TOT
BILI-0.6
[**2165-1-16**] 08:10AM ALBUMIN-3.9
[**2165-1-18**] 05:42AM BLOOD CK-MB-31* MB Indx-1.7 cTropnT-<0.01
[**2165-1-19**] 02:05AM BLOOD CK-MB-16* MB Indx-0.6 cTropnT-<0.01
proBNP-1548*
[**2165-1-19**] 02:05AM BLOOD TSH-8.2*
[**2165-1-19**] 02:05AM BLOOD T4-6.8
Discharge labs:
[**2165-1-28**] 06:30AM BLOOD WBC-9.4 RBC-2.71* Hgb-7.8* Hct-24.3*
MCV-90 MCH-28.8 MCHC-32.1 RDW-14.5 Plt Ct-453*
[**2165-1-28**] 06:30AM BLOOD PT-28.0* INR(PT)-2.7*
[**2165-1-28**] 06:30AM BLOOD Glucose-75 UreaN-11 Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
[**2165-1-28**] 06:30AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.1
Imaging:
ECHO [**2165-1-19**]: Normal global and regional biventricular systolic
function. Moderate tricuspid regurgitation. Moderate pulmonary
hypertension.
CTA [**2165-1-19**]:
1. Bilateral pulmonary emboli: Segmental embolus in the left
upper lobe
propagating into the anterior left upper lobe. Subsegmental
embolus in vessel supplying the right upper lobe.
2. Moderate bilateral pleural effusions, with atelectasis.
3. Patulous, fluid-filled esophagus, which may increase the
patient's risk of aspiration.
4. Postoperative changes in the cholecystectomy bed.
5. Healing rib fractures of the left ninth rib.
CXR [**2165-1-21**]: Continued low lung volumes. Blunting of both
costophrenic angles is seen with bibasilar atelectatic change.
There is some patchy opacification in the right mid and upper
lung zones.
CXR [**2165-1-22**]: Worsening opacification in the right upper and
middle lobes concerning for right upper and middle lobe
pneumonia. Worsened left basilar atelectasis compared to
[**2165-1-21**] may be secondary to worsening atelectasis or
pneumonia in the correct clinical setting.
CXR [**2165-1-23**]: The rapid progression of the parenchymal
abnormalities compared to [**1-16**] and [**2165-1-22**] are
consistent with rapid developing infection versus aspiration
(giving significantly dilated and fluid-filled esophagus on
chest CT from [**2165-1-19**]).
Chest ultrasound [**2165-10-23**]: Small bilateral pleural effusions are
seen.
CXR [**2165-1-24**]: Bilateral parenchymal opacifications have improved
since [**2165-1-23**]. Elevated hemidiaphragms likely
represent subpulmonic pleural effusions.
CXR [**2165-1-25**]: some progressive decrease in the bilateral
pulmonary opacifications
Pathology:
Gallbladder, cholecystectomy:
1. Acute and chronic cholecystitis.
2. Cholelithiasis.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
treatment of symptomatic cholelithiasis. On [**2165-1-17**], the patient
underwent a laparoscopic converted to open cholecystectomy. The
conversion was necessary due to dense adhesions. Otherwise, the
operation went well without complication (reader referred to the
Operative Note for details). The patient stayed in the PACU
overnight for monitoring due to mild hypotension without
tachycardia. She responded to fluids, and no pressors were
needed. Her hematocrit was lower than preop value, and
subcutaneous heparin was held until hcts could be trended. She
continued to have boots for DVT prophylaxis. The patient
remained stable in terms of hct and SBP overnight, and she was
brought to the floor NPO, on IV fluids, and with a foley
catheter.
The patient was doing well until [**2165-1-19**], when she developed new
onset atrial fibrillation with rapid ventricular response and
altered mental status. She failed trials of IV lopressor and
diltiazem and was subsequently transferred to the ICU. There,
she was put on an amiodarone drip. A CTA performed at that time
demonstrated bilateral pulmonary emboli, including a segmental
embolus in the left upper lobe propagating into the anterior
left upper lobe and a subsegmental embolus in the right upper
lobe. A heparin drip was started at this time. Cardiology was
consulted, and they recommended continuing the amiodarone drip
until conversion to NSR and then discontinuing it. They agreed
with the heparin drip and anticoagulation with coumadin for a
total of 6 months. An ECHO showed no structural abnormalities,
and lower extremity dopplers were deferred due to patient
noncompliance. The patient's PTT was difficult to get to goal;
she responded well when given one dose of FFP, and a diagnosis
of ATIII deficiency was made. The heparin drip was continued at
the rate needed for a PTT of 60-80, and coumadin was started on
[**2165-1-20**]. The patient converted to NSR on [**2165-1-20**], and the
amiodarone drip was switched to a PO regimen. She continued to
display intermittent episodes of altered mental status despite
trials of Haldol, and it was felt that she was sundowning. By
[**2165-1-21**], the patient was more consistently oriented. She
continued to improve until she reached her baseline mental
status, alert and oriented x 3 at all times. Regarding the
patient's pulmonary status, she had been tachypneic and
desaturating on room air since the development of the pulmonary
emboli. Serial chest xrays were performed, showing bilateral
pleural effusions (too small to tap), bibasilar atelectasis, and
patchy consolidation in the RUL and RML. She was also
intermittently wheezy throughout. Given her normal WBC and
absence of fever, antibiotics were deferred. She improved on
supplemental oxygen, nebulizers, and lasix. The supplemental
oxygen was weaned as appropriate, and her respiratory rate
normalized.
On [**2165-1-25**], the patient was transferred back to the floor. Her
heparin drip was discontinued, as her INR was newly
supratherapeutic. Her coumadin dosage was modified
appropriately, and the INR decreased to therapeutic levels.
The patient continued to do well on the floor. She remained in
NSR, and her supplemental oxygen continued to be weaned. Her
staples were removed, and her amiodarone was discontinued on
[**2165-1-28**]. She was seen by physical therapy, who felt that she
would do best with a [**Hospital 3058**] rehab stay due to
deconditioning.
On the day of discharge ([**2165-1-28**]), the patient was alert and
oriented x 3 at all times, in normal sinus rhythm, saturating
well on RA, tolerating regular diet, voiding to the toilet, and
having bowel movements.
Summary by systems:
Neuro: The patient's narcotics were initially held due to
hypotension in the PACU. She subsequently received IV morphine
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: As discussed in the hospital course above. Briefly, the
patient developed new onset rapid Afib due to pulmonary
embolism. Converted to normal sinus rhythm with an amiodarone
drip, which was transitioned to PO. Her amiodarone was
discontinued on [**2165-1-28**] per cardiology's recommendations. She
remained hemodynamically stable in normal sinus rhythm until
discharge.
Pulmonary: As discussed above. The patient desaturated at the
time of her pulmonary emboli and developed tachypnea and
wheezes. Serial CXRs showed bilateral pleural effusions,
atelectasis, and RUL and RML consolidations. She was given
supplemental O2, nebulizers, and lasix with good effect. Good
pulmonary toilet, early ambulation and incentive spirometry also
were encouraged throughout hospitalization. Her respiratory
status improved throughout her stay, and she was saturating well
on room air at the time of discharge.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. The patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her WBC remained
normal, and she was afebrile. Wound care included telfa wicks,
which were removed on POD3, followed by dry dressings and then
no dressings.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. She was given one
unit fresh frozen plasma to evaluate for ATIII deficiency.
Prophylaxis: The patient initially received subcutaneous heparin
and venodyne boots postoperatively. However, her heparin was
discontinued in the PACU due to a concern for bleeding. Boots
were continued. Following the development of the PEs, the
patient was anticoagulated on heparin until she was therapeutic
on coumadin. Then the heparin drip was stopped, and she was
maintained on coumadin. Her INR on the day of discharge was
2.7.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
omeprazole 20 mg PO daily
levothyroxine 50 PO daily
paroxetine 30 mg PO daily
MVI, calcium, and vitamin D
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheeze.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for wheeze.
7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for headache, pain.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
doses: please dose to an INR of 2.5-3.5.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
symptomatic cholelithiasis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. Please see information about
coumadin below.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-15**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
If you experience any of the following, please call your doctor
or return to the emergency room:
*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.
Coumadin information:
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 468**] in his office on [**2165-2-11**] at
9:15am. Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**]. Phone:
[**Telephone/Fax (1) 2835**].
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
as well.
Name: [**Known lastname **],[**Known firstname 1647**] Unit No: [**Numeric Identifier 11976**]
Admission Date: [**2165-1-17**] Discharge Date: [**2165-1-29**]
Date of Birth: [**2081-9-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4987**]
Addendum:
Just prior to discharge, the patient complained of some mild
lightheadedness on standing. Orthostasis was noted on BP
measurements and she was given a small fluid bolus and further
PO intake was encouraged. She stayed overnight for monitoring
and was feeling well and eating well the next morning, no longer
orthostatic, and thus thought safe for discharge to rehab.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 42**] Center - [**Location (un) 3178**]
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**]
Completed by:[**2165-1-29**]
|
[
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"574.10",
"293.9",
"574.00",
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"427.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
18984, 19209
|
4665, 11119
|
339, 362
|
12318, 12318
|
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1913, 2485
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12332, 12439
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1087, 1210
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1355, 1589
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,332
| 165,244
|
50177
|
Discharge summary
|
report
|
Admission Date: [**2117-12-17**] Discharge Date: [**2118-1-3**]
Date of Birth: [**2043-6-24**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 74-year-old
Spanish speaking man with a known history of CAD, never
revascularized, recently admitted to the [**Hospital1 346**] for chemical cardioversion due to
atrial fibrillation and home sotalol, followed by Dr.
[**Last Name (STitle) 284**] of the electrophysiology service. On [**12-17**] he was at home with friends when he had an acute loss of
consciousness with question of seizure activity. EMS was
called. The patient had an O2 saturation in the 80s when
they arrived, with a heart rate in the 130s, atrial
fibrillation at that time and blood pressure with a systolic
of 200. The patient was intubated. Once he arrived in the
Emergency Room he had a neurological workup with a CT scan
that was negative for an acute bleed, and an event that was
felt to be not likely neurological in nature. The patient
had no MI at that time, his enzymes were negative, and he was
being worked up for an electrophysiology study with a
probable ablation plus or minus a pacemaker, however, it was
felt that prior to that procedure he should have a cardiac
catheterization. He underwent cardiac catheterization on the
[**12-22**]. Catheterization showed 70 percent left
main, 30 percent proximal LAD with 70 percent diagonal, 80
percent ostial circumflex, and 40 percent RCA with 100
percent PDA and an EF of 50 percent.
PAST MEDICAL HISTORY: Significant for CAD, congestive heart
failure, mitral regurgitation, tricuspid regurgitation,
atrial fibrillation, anemia, diabetes mellitus, hypertension,
chronic renal insufficiency with a baseline creatinine 1.5 to
1.7, and left lower extremity cellulitis.
PAST SURGICAL HISTORY: Significant for AAA repair in [**2108**]
with a redo in [**2109**] and a thoracic aortic aneurysm repair
done in [**2108**].
He is allergic to amiodarone.
MEDS AT HOME: Glucotrol 10 b.i.d., Lipitor 40 every day,
Cozaar 25 b.i.d., [**Doctor First Name **], aspirin 325 every day, Lasix 20
every day, Avandia (no dose specified), Aldactone 12.5 every
day, sotalol 40 b.i.d., and Toprol 200 every day as well as
Celexa every day 20 and Coumadin (no dose given).
SOCIAL HISTORY: Married, lives in [**Location (un) 538**]. He is
currently retired, was an independent truck driver. Tobacco
remote history, quit over 10 years ago. Alcohol use is rare.
Following cardiac catheterization cardiothoracic surgery was
consulted.
PHYSICAL EXAM: At the time of consult height was 5 feet 8
inches, weight 180, heart rate 65 atrial fibrillation, blood
pressure 141/73, respiratory rate 18, O2 saturation 99
percent on two liters. In general lying flat in bed in no
acute distress. Neurologically alert and oriented x3,
appropriate with limited English. Respiratory showed
bilateral crackles in the bases, left greater than right.
Cardiovascular irregular with frequent PACs, a II/VI systolic
ejection murmur. Abdomen soft, nontender, nondistended with
normoactive bowel sounds. Neck is supple with no carotid
bruits. Extremities warm and well perfused with 1 plus edema
and bilateral varicosities. Pulses showed radial 2 plus on
the right, 1 plus on the left, dorsalis pedis 2 plus
bilaterally. Posterior tibial two plus bilaterally.
LABORATORY DATA: White count 7.1, hematocrit 30.7, platelets
337,000. PT 14.3, PTT 35.1, INR 1.3. Sodium 137, potassium
3.6, chloride 101, CO2 30, BUN 31, creatinine 1.4, glucose
195, ALT 12, AST 12, alkaline phosphatase 54, amylase 34,
total bilirubin 0.6, albumin 3.4. UA was negative. Stress
test done on [**11-24**] showed moderate reversible inferior
lateral defect and an echo done on [**12-28**] showed an EF
of 50 percent with 3 plus MR and 2 plus TR. Chest x-ray at
the time of admission showed mild pulmonary edema.
Following consult the patient underwent vein mapping as well
as carotid ultrasound. Carotid ultrasound showed no
significant stenosis on either side.
The patient continued to be followed by the medical service
until [**12-24**] when he was brought to the Operating Room
for coronary artery bypass grafting. Please see the OR
report for full details. In summary, the patient had a CABG
times four with a LIMA to the LAD, saphenous vein graft to
diagonal, saphenous vein graft to ramus, and saphenous vein
graft to the RPL. His bypass time was 89 minutes with a
cross clamp time of 76 minutes. He tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient was AV paced with a mean arterial pressure of 68
and a CVP of 90. He had Levophed at 0.04 mcg per kilogram
per minute, insulin at 2 units per hour and propofol at 25
mcg per kilogram per minute.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was successfully weaned from
the ventilator and ultimately extubated during the course of
the operative day.
On postoperative day one the patient remained hemodynamically
stable, continuing to require smaller amounts of Levophed to
maintain an adequate blood pressure. His insulin drip was
weaned off and he was started back on a sliding scale insulin
as well as his oral hyperglycemics, however, he was kept in
the Cardiothoracic Intensive Care Unit for close pulmonary as
well as hemodynamic monitoring.
On postoperative day two the patient was noted to be mildly
confused. He was also noted to have periods of atrial
fibrillation with a ventricular response rate to the 130s.
At those times he was also noted to be hypertensive. He was
initially treated with Beta blockade and ultimately his
sotalol was instituted.
On postoperative day three the patient continued to be
hemodynamically stable. He was weaned from his Levophed
infusion. He was, however, still in the ICU because of
confusion with some combativeness, and he was noted to have
short bursts of SVT versus VT rhythm. Electrophysiology was
reconsulted at that time. On the [**2117-12-18**] he was brought to
the electrophysiology lab for ablation plus or minus
pacemaker placement. Ultimately, the patient did have a
permanent pacemaker implanted. Please see the EP procedure
note for full details. Following pacemaker placement he was
returned to the Cardiothoracic Intensive Care Unit.
On postoperative day five the patient's neurological status
was noted to be less confused, however, at night he became
increasingly combative and hypertensive. He was started on a
nitroglycerin drip at that time. He was also started on
Coumadin following his permanent pacemaker placement.
On postoperative day six the patient's neurological status
had greatly improved, with no further episodes of agitation
or confusion. He was transferred to ________ for continuing
postoperative care and cardiac rehabilitation.
Over the next several days the patient remained
hemodynamically stable. His activity level was advanced with
the assistance of the nursing staff as well as physical
therapy staff. His antihypertensives were adjusted and on
postoperative day 10 it was decided that he was stable and
ready to be discharged to home.
At the time of this dictation the patient's physical exam is
as follows: Temperature 97, heart rate 75 AV paced, blood
pressure 139/74, respiratory rate 20, O2 saturation 96
percent on room air. Weight is 82 kg, on admission was 250
pounds. Laboratory data shows PT is 19.5, INR is 2.4. On
physical exam neuro is alert and oriented, moves all
extremities, follows commands, nonfocal exam. Pulmonary
shows clear to auscultation bilaterally. Cardiac shows
regular rate and rhythm, S1 and S2. Incision healing well,
clean and dry. Sternum is stable without any erythema or
drainage. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. Extremities are warm and well
perfused with no edema. Left leg incision with Steri Strips
open to air, clean and dry.
Patient's condition at time of discharge is good. He is to
be discharged home with visiting nurses.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting times four with left internal mammary
artery to the left anterior descending, saphenous vein
graft to the diagonal, saphenous vein graft to the ramus,
and saphenous vein graft to the RPL.
2. Atrial fibrillation.
3. Status post permanent pacemaker.
4. Anemia.
5. Diabetes mellitus Type 2.
6. Hypertension.
7. Chronic renal insufficiency.
8. Status post abdominal aortic aneurysm repair.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq every day times two weeks.
2. Colace 100 mg b.i.d.
3. Aspirin 81 mg every day.
4. Sotalol 40 mg b.i.d.
5. Aldactone 12.5 mg every day.
6. Warfarin, patient is to take 2 mg on [**2118-1-3**] and [**2118-1-4**],
then as directed by Dr. [**Last Name (STitle) 6680**].
7. Glipizide 10 mg b.i.d.
8. Atorvastatin 40 mg every day.
9. Lasix 40 mg b.i.d. times two weeks.
10. Amlodipine 10 mg every day.
11. Losartan 50 mg b.i.d.
12. Avandia 4 mg every day.
13. Toprol XL 100 mg every day.
Patient's follow up in the pacemaker clinic was scheduled for
[**2118-1-4**] and was carried out on the day of discharge. He is
have follow up with Dr. [**First Name (STitle) **] in two weeks, follow up with
Dr. [**Last Name (STitle) **] in four weeks, and follow up with Dr. [**Last Name (STitle) 284**]
in six weeks. He is also to have follow up with his primary
care doctor, Dr. [**Last Name (STitle) 6680**], in one week. Additionally the
patient is to have an INR checked by the visiting nurse on
[**2118-1-5**] with results called to Dr.[**Name (NI) 104690**] office.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2118-1-3**] 16:10:41
T: [**2118-1-3**] 19:02:04
Job#: [**Job Number 104691**]
cc:[**Last Name (NamePattern4) 104692**]
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
|
[
"518.81",
"780.2",
"428.30",
"428.0",
"414.01",
"401.9",
"427.1",
"293.9",
"280.9",
"593.9",
"250.00",
"424.0",
"427.31",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.13",
"37.23",
"36.15",
"37.72",
"38.93",
"96.04",
"88.72",
"37.26",
"37.83",
"88.53",
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] |
icd9pcs
|
[
[
[]
]
] |
8153, 8625
|
8648, 10083
|
1827, 2290
|
2570, 8132
|
165, 1519
|
1542, 1803
|
2307, 2554
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,242
| 195,261
|
3689
|
Discharge summary
|
report
|
Admission Date: [**2123-7-24**] Discharge Date: [**2123-8-7**]
Date of Birth: [**2070-10-2**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Latex
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
new rash
Major Surgical or Invasive Procedure:
placement of plasmapheresis line
placement of PICC line
History of Present Illness:
52 yoF with Lymphoplasmacytic lymphoma, Waldenstrom's
macroglobulinemia, hepatitis C, h/o hepatitis B, and
cryoglobulinemia, who presented on Rituxan therapy for her
lymphoma with a new rash and fever. She was in her usual state
of health until 3 days PTA she noted "red bumps" on her legs.
The following day she started lamivudine for Hep B suppression
concurrent with Rituxan therapy. On DOA she noticed the rash
spreading to her arms b/l and then to her torso. The rash was
never pruritic or painful with no involvement of mucus
membranes. The patient also had complaints of low grade
temperatures and in the ED was 100.8 and given 1 dose of
cefepime.
Past Medical History:
Hepatitis C (liver biopsy in [**2116**] as showing stage III fibrosis)
Waldenstrom's macroglobulinemia/lymphoma
history of IVDU
depression
sialolithiasis
fine tremor
peripheral neuropathy
s/p prolonged ICU stay for heroin and benzodiazepine overdose
multi-lobar pneumonia (M. cattharalis)
Social History:
Engaged; prior IVDA, per report last use [**2119**], last cocaine
[**10-31**]; smoked [**12-25**] ppd x 30 years but trying to quit, on nicotine
TD; denies currenrt ETOH use, most recently 2 months ago, when
drinks she consumes [**12-25**] glasses of wine.
Family History:
Mother had lymphoma. Otherwise, noncontributory.
Physical Exam:
VS - Tm: 100.3, Tc: 96.4, BP: 90/60, HR: 58, RR: 16, 97% RA.
Gen: NAD, no edivence of encephalopathy or asterixis.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. oropharynx clear.
Neck: Supple palpable mass left submandibular area, freely
mobile.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Systolic murmer II/VI best heard over
pulmonic area, non radiating. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. Liver palpable 2-3cm below the costal margin.
Spleen palpable. No abdominial bruits.
Ext: +pitting edema of ankles.
Skin: No jaundice. Morbiliform rash on lower extremities b/l
with confluence. Occasional "target" like lesion measureing less
than 1cm.
Pertinent Results:
[**2123-7-24**]
WBC-3.9*# RBC-4.78 HGB-13.4 HCT-40.6 MCV-85 RDW-16.5*
PT-14.0* PTT-34.3 INR(PT)-1.2*
Glucose-114* UreaN-10 Creat-1.0 Na-138 K-3.8 Cl-100 HCO3-26
AnGap-16
ALT-54* AST-73* AlkPhos-79 TotBili-0.5
Calcium-9.9 Phos-3.8 Mg-1.8
Ct-1033*
SerVisc-1.5
Cryoglb-POSITIVE
Cortsol-21.8*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE
RheuFac-+
[**2123-7-27**] BLOOD C4-3*
[**2123-7-29**] HCV VIRAL LOAD 4,060,000 IU/mL.
[**2123-7-30**] Fibrino-395 , FDP-10-40*
Blood cultures - [**2123-7-29**]
STREPTOCOCCUS MITIS.
STREPTOCOCCUS MITIS SPECIES GROUP NOT S. PNEUMONIAE.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
IDENTIFIED AS ROTHIA DENTOCARIOSA BY [**Hospital1 4534**] LABORATORIES [**2123-8-9**].
All following blood cultures were negative for growth
812/09 TEE ECHO: No mass/thrombus is seen in the left atrium or
left atrial appendage. Overall left ventricular systolic
function is normal (LVEF>55%). with normal free wall
contractility. 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 leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Skin, left medial calf, biopsy [**2123-7-26**]:
Superficial to mid-dermal perivascular lympho-eosinophilic
infiltrate with associated endothelial swelling and erythrocyte
extravasation (see note).
Skin, right lateral thigh, biopsy [**2123-7-29**]:
Vascular injury of small vessels, leukocytoclasia, and
erythrocyte extravasation consistent with leukocytoclastic
vasculitis.
Panorex - Panorex is performed. There are multiple filling in
the teeth. There are innumerable lucencies at the roots of the
lower bicuspids and also incisors. This could represent erosion
within the mandible secondary to infection. There is also one
lucency that could represent a cavity within the left-sided
bicuspid. Upper level teeth appear intact. The roots are
partially obscured by the maxilla and not well seen.
Brief Hospital Course:
52 yoF with Lymphoplasmacytic lymphoma, Waldenstrom's
macroglobulinemia, hepatitis C, h/o hepatitis B, and
cryoglobulinemia, who presented on Rituxan therapy for her
lymphoma with a new rash and fever.
# Cryoglobulinemia: Biopsy on [**7-25**] consistent with
cryoglobulinemia with leukocytoclastic vasculitis. In addition
to a palpapble purpuric rash on her lower extremities that
extended up to the back and chest. Rash self resolved then
worsened again. She was also symptomatic with arthritis and
arthralgias which improved with antiinflammatory medications.
Treatment was initially held, given limited cutaneous
involvement. However, when pt became hypotensive requiring ICU
care, she was dosed with methylprednisolone X2 days. Steroids
were d/c'd due to confirmed infection and pt received
plasmapheresis qod X 4 treatments. Her rash improved daily.
She developed no other obvious signs of cryglobulinemia.
Rheumatology, GI, and dermatology were following. There was
discussion of plan for interferon therapy at outpatient, when
patient was stable.
#Bacteremia/Sepsis - On [**7-29**], the patient was found to be
hypotensive with BP 75/45, HR in 80s. She was asymptomatic,
mentating, and ambulating without complaints of lightheadness or
dizziness. She was given IVF without improvement in BP. Labs
were remarkable for a WBC count of 0.6 and Hct 27.9 (down from
33.2) and plts 33 (down from 60). She was started on cefepime
and vancomycin given neutropenic coverage. Blood cultures were
positive for Strep virdans and Gram postive cocci and rods. TEE
showed no vegetations. Vancomycin trough levels were
exceedingly hihg >40. Cefepime was d/c'd as patient did not
require additional coverage. Dentistry was consulted, but pt's
dentition, though poor did not reveal infection. PICC line was
inserted on [**8-6**] for outpt treatment with vancomycin.
.
#Anemia - Pt's baseline throughout her admission was Hct of 25.
On [**2123-8-4**] her AM Hct was 20, she was complaining of abdominal
pain and there was concern for GI bleed. She was given two
units of pRBCs. Her vital signs remaining stable throughout. CT
scan showed no bleed. Reduced Hct was considered to be
dilutional as patient was moving significant volumes of
peripheral edema which was notable on physical exam. She was
Guiac positive but with brown stool. Her hematocrit was stable
through the remainder of her hospitalization.
.
#Acute renal failure - Pt developed brief period of acute renal
failure, prerenal in etiology, after her septic episode which
resolved without intervention.
#Neutropenia/Pancytopenia - Pt has generally low levels of
pancytopenia. Her white blood cell count improved with
Neupogen, and Neupogen was subsequently discontinued. She
received 2 units of platelets for placement of a phoresis
catheter. But otherwise cell counts remained stable.
.
#MS Changes - Pt had a brief period of confusion and worsening
of her baseline resting tremor. She had no focal neurological
signs. Concern for toxicty of antibiotics. Vancomycin levels
and Cefepime were dose adjusted given the changing renal
function. Confusion improved within 24 hrs.
# Hepatitis C: LFTs slightly elevated, likely from HCV (HCV
viral load of 4million). During her hospitalization, there was
discussion of whether or not to begin treatment for Hep C. She
was discharged with outpt GI follow up.
.
# h/o hepatitis B: Will likely require suppression therapy given
recent tx with Rituxan. Hepatology was following.
.
# lymphoplasmocytic lymphoma: Rituxan held. Some concern that
her isease course may have been initiated by Rituxan. Plan to
continue Rituxan was deferred to her primary oncology team.
Medications on Admission:
Albuterol 90 mcg 1-2 puffs q4-6H:PRN cough,wheezing
Klonopin 2 mg PO BID
Fluticasone 50 mcg 1-2 puffs NU daily
Lamivudine 100 mg PO daily
Morphine 15 mg PO QID:PRN
Morphine (MS Contin) 15 mg PO daily
Vitamin C
Calcium Carbonate + Vitamin D3
Ginkgo
MVI
Nicotine PATCH 21 mg/24 hours -> taper to 14 mg after 6 weeks
Selenium
Vitamin E
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for SOB,
wheezing.
2. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 2 weeks: it is dangerous to smoke
when on the patch.
Disp:*14 patch* Refills:*0*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours): you can not drive or
do anything requiring a fast reaction time while on this
medication.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): you can not drive or do anything requiring a fast
reaction time while on this medication.
Disp:*60 Tablet(s)* Refills:*0*
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. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Disp:*1 bottle* Refills:*1*
10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itching.
Disp:*1 tube* Refills:*1*
11. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please check Vancomycin trough on [**8-7**] and on [**8-9**] with goal of
trough level between 15 and 20. Please fax information to Dr.
[**Last Name (STitle) **] Fax:([**Telephone/Fax (1) 16667**], Phone: ([**Telephone/Fax (1) 16668**]
13. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 5 days: Please start on [**8-7**].
Instruction to check Vanco trough levels attached. Please fax
results as directed to Dr [**Last Name (STitle) **]. Last day of vancomycin [**8-11**].
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary: cryoglobulinemia
.
secondary: lymphocytic lymphoma, Hepatitis B, Hepatitis C, acute
renal failure, Staph aureus bacteremia, Staph aureus sepsis,
delirium
Discharge Condition:
afebrile, stable, with PICC
Discharge Instructions:
It was a please to care for you during your stay at [**Hospital1 18**].
You were admitted for evaluation and treatment of a rash, which
was discovered to be due to cryoglobulinemia. You were started
on treatment for cryoglobulinemia with high dose steroids
followed by 4 treatments of plamapheresis. You tolerated the
procedures well. During your stay you developed severely low
blood pressure requiring transfer to the intensive care unit.
This low blood pressure was due to an infection of the blood.
The type of infection you had is often due to bacteria in your
mouth or intravenous drug use. You require a full 14 day course
of antibiotics and therefore will continue taking them after
your discharge.
During your admission Rituxan and lamivudine therapies were
stopped. Please discuss how treatment for your lymphoma,
hepatitis B and hepatitis C should proceed with your primary
oncologist and by your gastroenterologist.
New medications started during your visit include the antibiotic
Vancomycin, which requires IV administration, which you will
continue for 5 more days after discharge. You were also started
on Celexa for depression, and several creams for symptom relief
for your rash.
Please return call your doctor or return to the emergency
deparment if you develop new fevers to 100.4, chills, nausea,
vomiting, worsening tenderness around the site of the peripheral
line, dizziness, confusion, loss of consciousness, blood in the
stool, black stool, diarrhea, abdominal pain, or any other
concerning symptoms.
Ensure
Followup Instructions:
The following appointments have been made for you:
IT IS VERY IMPORTANT THAT YOU FOLLOW UP WITH YOUR DENTIST WITHIN
THE NEXT FIVE DAYS. IF YOU CANNOT MAKE AN APPOINTMENT PLEASE
CALL YOUR ONCOLOGIST.
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 16668**]. Please make an appointment within
the next two weeks.
[**Doctor Last Name 16669**] ([**Telephone/Fax (1) 16670**]. Please make an appointment
within the next two weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-8-9**]
12:15
XUS (C4) TCC [**Month/Day/Year 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2123-8-9**]
1:15
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2123-9-8**] 12:30
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2123-10-10**]
|
[
"070.70",
"995.91",
"458.9",
"276.1",
"070.32",
"200.80",
"780.60",
"446.29",
"038.0",
"V43.64",
"E933.1",
"693.0",
"273.2",
"338.3",
"273.3",
"576.8",
"311",
"584.9",
"E849.8",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"99.71",
"38.93",
"99.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10886, 10944
|
4781, 8469
|
284, 342
|
11151, 11181
|
2611, 4758
|
12773, 13732
|
1629, 1680
|
8853, 10863
|
10965, 11130
|
8495, 8830
|
11205, 12750
|
1695, 2592
|
236, 246
|
370, 1026
|
1048, 1338
|
1354, 1613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,809
| 132,872
|
9514
|
Discharge summary
|
report
|
Admission Date: [**2193-11-27**] Discharge Date: [**2193-11-18**]
Date of Birth: [**2117-5-2**] Sex: M
Service: NEUROLOGICAL INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
gentleman status post left thalamic deep brain stimulator
placement on [**2193-10-15**]. Now presenting with worsening
mental status in the setting of a worsening subdural
hematoma. The patient initially was at a nursing home where
he was found to be less responsive and unable to walk with
his walker for over 24 hours. He has a history of multiple
falls with subdural hematoma.
PAST MEDICAL HISTORY: Hypertension, benign prostatic
hypertrophy, degenerative joint disease, Parkinson's disease.
MEDICATIONS ON ADMISSION: Sinemet, Lisinopril and Tylenol.
LABORATORIES ON ADMISSION: White blood cell count 9.6,
hematocrit 40.3, platelets 142, sodium 138, K 4.3, chloride
103, CO2 24, BUN 10, creatinine .6, glucose 113, INR 1.1.
Head CT shows left subdural hematoma. MRI from [**10-16**] shows
left convexity subdural hematoma.
HOSPITAL COURSE: The patient was admitted to the
Neurological Intensive Care Unit for close monitoring. On
physical examination the patient is awake. Mental status
alert, oriented to person. Follows commands intermittently.
Cranial nerves II through XII are intact. No drift. Not
cooperative with individual muscle testing. Decreased bulk.
Sensation intact to pain. The patient had bedside drainage
of the subdural hematoma on [**2193-11-28**]. Mental status wise
he was awake and alert, following commands, much brighter,
oriented to person with no drift. On [**11-30**] the patient had a
repeat head CT, which showed persistent subdural hematoma.
Drain was discontinued and the patient was transferred to the
regular floor. Dr.[**Name (NI) 19941**] assessment of the scan was
that the patient would need drainage of subdural hematoma in
the Operating Room. The patient was prepped for the
Operating Room and on [**2193-12-3**] had a left craniotomy for
drainage of a subdural hematoma. Postoperative the patient
was monitored in the Recovery Room overnight. He had no
verbal output. Minimally followed commands, intermittently
held up his left arm, localized to pain in the right upper
extremity, withdrew his lower extremities. He was therefore
transferred to the Intensive Care Unit for close monitoring
on postoperative day number one.
From [**2193-11-28**] the patient grew out E-coli in his urine. He
was started on Ampicillin. On [**2193-12-5**] the patient is
awake, but minimally opens his eyes, follows simple commands,
oriented to self. Left arm antigravity, withdraw bilateral
lower extremities and purposeful movement of the left upper
extremity. On [**12-5**] the patient had a repeat head CT, which
showed the drain in good placement with the subdural hematoma
collection somewhat smaller. The patient was continued to
have the drain in place. On [**2193-12-7**] the patient was alert,
opens eyes to stimulation, following commands, moving all
extremities spontaneously. Right drift improved. Held arms
off the bed. Withdrew bilateral lower extremities. Subdural
drain was removed and the patient was transferred to the
regular floor. On [**2193-12-10**] the patient had an episode of
ventricular tachycardia, which lasted about fifteen minutes
and resolved spontaneously without treatment. The patient
was seen by cardiology, enzymes were cycled. Review of
electrocardiogram showed question of flipped T waves in the
lateral leads. The patient is seen by the EPS Service.
Electrocardiogram shows old right bundle branch block with
inferior Qs and ST elevation. Enzymes were negative. They
recommended getting an electrocardiogram and starting the
patient on a beta blocker.
On [**12-12**] the patient was awake, alert, attempting to speak,
following commands, holding up his arms left greater then
right. On Vancomycin and Levo for MRSA in his sputum. No
further cardiac issues. The patient is seen by physical
therapy and occupational therapy and found to require rehab.
The patient also had PEG placement on [**2193-12-16**] without
complications. Vital signs have been stable. The patient
has been afebrile and neurologically stable and ready for
transfer to rehab.
MEDICATIONS ON DISCHARGE: Sinemet 25/100 one tab po q.i.d.,
Vancomycin 1 gram intravenous q 72 hours. Metronidazole 500
mg intravenous q 8, insulin sliding scale, Zantac 150 mg po
b.i.d., Dilantin 100 mg po q 8 hours, Levofloxacin 500 mg po
q 24 hours, Tylenol 650 po q 4 hours prn and Lisinopril 5 mg
po q day.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge. He will follow up with Dr.
[**Last Name (STitle) 6910**] in ten to fourteen days.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2193-12-17**] 09:11
T: [**2193-12-17**] 09:37
JOB#: [**Job Number 32354**]
|
[
"600.0",
"332.0",
"426.4",
"432.1",
"369.4",
"401.9",
"482.41",
"599.0",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"96.6",
"46.32"
] |
icd9pcs
|
[
[
[]
]
] |
4314, 4602
|
752, 799
|
1079, 4287
|
195, 608
|
814, 1061
|
631, 725
|
4627, 5019
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,488
| 120,156
|
29938
|
Discharge summary
|
report
|
Admission Date: [**2128-12-24**] Discharge Date: [**2128-12-29**]
Service: MEDICINE
Allergies:
Morphine / Nitrate / Cardizem
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F with with CBD stone, s/p CCY in [**11-1**] who is transferred to
[**Hospital Unit Name 153**] after arriving to ERCP suite in respiratory distress. She
initially presented to [**Hospital1 **] with worsening epigastric pain,
N/V, diarrhea, WBC 18, normal LFTs, amylase, lipase. She had a
failed ERCP there and was transferred to [**Hospital1 18**] surgical service.
On arrival to [**Hospital1 18**] on [**2128-12-24**], she was in rapid a.fib,
hypotensive, and had ST depressions on EKG. She converted after
5 IV lopressor and the hypotension resolved. Her LFTs have been
in normal range. The plan was for her to have ERCP today to
removed the retained stones. On arrival to ERCP her RR was high
and she was satting in the low 80's on 2L liters NC,
hypertensive to systolic in 200s. Her CXR from this morning
shows new pleural effusions. She was put on 100% NRB and, given
nebs, lopressor, esmolol amd IV lasix and was transferred to he
[**Hospital Unit Name 153**] for further management.
Past Medical History:
cholelithiasis, s/p lap CCY [**11-1**], ERCP in [**11-1**] s/p partial
sphincterotomy and stent placment, c/b resp distress and CHF,
repeat ERCP on [**2128-12-7**] at [**Hospital1 **] with CBD stent, ?stent placed
in pancreatic duct.
[**2128-12-7**] admitted to [**Hospital1 **] with VRE bacteremia, ERCP done, stent
changed. started on linezolid, levoflox, flagyl
?gallbladder adeno ca in situ
CAD
CHF
afib
COPD ( on prednisone 15 mg QD at home)
DM
HTN
osteoarthritis
osteopenia
c.diff colitis currently being treated
VRE and enterocacter cloacae bacteremia [**2128-12-7**] on linezolid
.
PSH:
lap CCY [**11-1**], scars from unknown previous surgeries (?appy,
?hysterectomy)
Right hip replacment
Social History:
former tobacco, no ETOH
Family History:
noncontributory
Physical Exam:
T 95.3, BP 165/63. HR 94, RR 36, 83% on RA, 98% on shovel tent
after nebs
Genl: tachypneic
HEENT: JVP about 8CM, OP dry, EOMI
CV: RRR + systolic murmur
Lungs: very tight, diffusely wheezy, no rhonchi
AbD: soft, NT, ND, +BS
Ext: no edema, 2+ pedal pulses
Neuro: following commands, answering questins, oriented to self,
place
Pertinent Results:
[**2128-12-29**] 04:44AM BLOOD WBC-5.3# RBC-2.94* Hgb-9.3* Hct-27.4*
MCV-93 MCH-31.5 MCHC-33.9 RDW-15.1 Plt Ct-79*
[**2128-12-24**] 11:25PM BLOOD WBC-14.6* RBC-3.63* Hgb-11.6* Hct-35.0*
MCV-96 MCH-31.8 MCHC-33.1 RDW-15.0 Plt Ct-126*
[**2128-12-28**] 02:06PM BLOOD Neuts-95.6* Lymphs-1.7* Monos-2.7 Eos-0.1
Baso-0
[**2128-12-29**] 04:44AM BLOOD Plt Ct-79*
[**2128-12-24**] 11:25PM BLOOD Plt Ct-126*
[**2128-12-24**] 11:25PM BLOOD PT-11.6 PTT-22.3 INR(PT)-1.0
[**2128-12-29**] 04:44AM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2128-12-29**] 04:44AM BLOOD ALT-11 AST-18 AlkPhos-77 Amylase-40
TotBili-0.4
[**2128-12-29**] 04:44AM BLOOD Lipase-17
[**2128-12-28**] 05:53AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2128-12-29**] 04:44AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9
[**2128-12-28**] 05:53AM BLOOD Digoxin-0.7*
.
.
Imaging:
Markedly dilated common bile duct containing stones and sludge.
A biliary stent is positioned in the distal extrahepatic CBD
beyond the dilation. Mild pancreatic and intrahepatic ductal
dilatation is also identified.
.
CT abd [**2128-12-24**] at [**Hospital1 **]
Catheter in small bowel likely the CBD stent. ductal dilation
within CBD.Diverticua, pericardial thikening,
.
Brief Hospital Course:
[**Age over 90 **] yo female with retained common bile duct stone, transferred
to [**Hospital1 18**] for ERPC after several failed attempts as OSH, who
became acutely SOB and wheezy en route to ERCP. She likely
develped a COPD flare and improved marginally with nebs and
solumedrol. Discussions with patient and her daughter confirmed
her DNR/DNI status and they decided ultimately to move to
hospice care. She did not have any symptoms of cholangitis but
was continued on unasyn while in house for prophylaxis, related
to her retained biliary stones. She completed a course of
linezolid for a VRE UTI. She also was diagnosed with c diff at
the outside hospital and was maintined on flagyl while in house.
She was not having any further diarrhea. We opted to discontinue
all antibiotics at discharge as she is now comfort measures
only. This is in line with goals of care per the patient and her
daughter. If she can take the prednisone it may help her
respiratory status/COPD flare.
Medications on Admission:
Meds on Admission:
cozaar 75', protonix 40', digoxin 0.125', norvasc 5', linezolid,
levoflox, flagyl, combivent, albuterol, atrovent, prednisone
15', vicodin, colace, FeSO4, MVI, vit C .
.
Meds on Tx:
lopressor 7.5 mg IV Q4
Flagyl
Linezolid
Ampicillin/sulbactam
Discharge Medications:
1. Hospice Consult
Please have hospice evaluate patient upon arrival
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
4. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours as needed for secretions.
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Oxycodone oral solution (20mg/ml) take 5-20 mg Q4 hours PO to
maintain ocmfort
7. Ativan oral solution (2 mg /ml) 0.5 mg- 2 mg Q6 PO hours to
maintain comfort
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]healthcare center
Discharge Diagnosis:
Common bile duct stone
COPD flare
Atrial fibrillation
Discharge Condition:
Stable on 50% oxygen
Discharge Instructions:
Going back to nursing home, will be set up with hospice there.
We have provided rx for oral oxycodone solution and atival oral
solution
Followup Instructions:
Follow up with hospice care
|
[
"287.4",
"427.31",
"491.21",
"E930.8",
"428.0",
"V09.80",
"574.51",
"008.45",
"401.9",
"599.0",
"576.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5638, 5698
|
3707, 4694
|
249, 256
|
5796, 5819
|
2454, 3684
|
6003, 6034
|
2076, 2093
|
5007, 5615
|
5719, 5775
|
4720, 4725
|
5843, 5980
|
2108, 2435
|
201, 211
|
284, 1298
|
4739, 4984
|
1320, 2018
|
2034, 2060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,744
| 168,656
|
12163
|
Discharge summary
|
report
|
Admission Date: [**2178-5-30**] Discharge Date: [**2178-6-9**]
Date of Birth: [**2106-2-15**] Sex: F
Service: NEUROLOGY
Allergies:
Aspirin / Tape II Disposable Liner Adhes / Coumadin / Vancomycin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
[**Known firstname 2048**] [**Known lastname **] is a 72 year-old woman sent over from [**Hospital3 38099**] after she was found seizing in her bed this morning at
her nursing home. She has a history of severe [**Hospital3 1106**] disease
with a complete occlusion of the left carotid and a left
hemispheric stroke, as well as b/l AKAs secondary to peripheral
[**Hospital3 1106**] disease. Her daughter who was present in the [**Name (NI) **] stated
that she had recovered much of her speech but still had some
difficulty getting words out. She reportedly moved both her arms
well at baseline. She has not been by her nursing home in the
last few days but had not heard any report of illness, cough,
cold, or GI problems. She has never had a seizure.
By report she was found this morning with her right arm shaking
and nonresposive. She was given ativan and valium (unknown dose)
and intubated for airway protection. She arrived at [**Hospital1 18**] and
was
on propofol and very sedated.
ROS unobtainable given intubation
Past Medical History:
1.Atrial fibrillation diagnosed [**2168-6-13**]
2.CVA 2/02,[**6-15**] with residual expressive aphasia
3.Type 2 DM since age 50,with neuropathy,retinopathy-s/p laser
ou
4.Left DVT [**2162**] treated with coumadin
5.Thyroid nodule
6.Osteoporosis
7.VRE left [**First Name9 (NamePattern2) 6024**] [**2169-5-14**]
8.Immature cataracts
9.PVD
10. sacral decubitus
PSH
1.Subtotal thyroidectomy for nodule
2.Vitrectomy left eye
3.Amputation right first toe
4.Left AKpop-peroneal NRSVG [**6-15**]
5.Left TMA [**6-15**]
6.Right AKpop-peroneal NRSVG [**1-16**]
7.Left [**Month/Year (2) 6024**] [**2-14**]
8.Revision left [**Month/Year (2) 6024**] [**5-17**]
9.Right SFA-AT composite bilateral NRSVG [**9-16**]
10.Amputation right toes 2->5 [**9-16**]
Social History:
worked as a bus driver. Lives at nursing home in [**Location (un) **].
Non-smoker. No EtOH.
Family History:
daughter does not know family history
Physical Exam:
Physical Exam on Admission:
Vitals: 97 80 90/70 14 99% vent
General: intubated and sedated
HEENT: NC/AT, ET tube
Neck: no meningismus
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: b/l AKA
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: intubated and sedated. no response to sternal
rub
-Cranial Nerves:
left pupil 2.5 and reactive, right is 1.5 and reactive, +VOR, +
corneals, gag intact
-Motor: flaccid tone throughout. No movement of either extremity
-Sensory: No response to pinprick
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**]
L 1 1 1
R 1 1 1
Physical Exam at Time of Death - 10:05am on [**2178-6-9**]
GEN: lying in bed, not moving
HEENT: mouth open, pupils fixed and dilated
CV: no heartbeat auscultated or palpated
PULM: no respirations auscultated or palpated
EXT: cold
Pertinent Results:
[**2178-5-30**] 07:09PM TYPE-ART RATES-14/ TIDAL VOL-500 PEEP-5
O2-100 PO2-414* PCO2-35 PH-7.46* TOTAL CO2-26 BASE XS-2
AADO2-274 REQ O2-52 INTUBATED-INTUBATED
[**2178-5-30**] 07:09PM O2 SAT-99
[**2178-5-30**] 06:55PM GLUCOSE-131* UREA N-20 CREAT-0.7 SODIUM-137
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2178-5-30**] 06:55PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2178-5-30**] 06:55PM WBC-12.9* RBC-4.37 HGB-12.8 HCT-38.5 MCV-88
MCH-29.2 MCHC-33.2 RDW-16.9*
[**2178-5-30**] 06:55PM PLT COUNT-297
[**2178-5-30**] 03:22PM COMMENTS-GREEN TOP
[**2178-5-30**] 03:22PM LACTATE-2.1*
[**2178-5-30**] 01:45PM GLUCOSE-118* UREA N-21* CREAT-0.7 SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2178-5-30**] 01:45PM estGFR-Using this
[**2178-5-30**] 01:45PM WBC-16.9*# RBC-4.53 HGB-13.5# HCT-40.3#
MCV-89# MCH-29.7# MCHC-33.5 RDW-16.8*
[**2178-5-30**] 01:45PM NEUTS-93.0* LYMPHS-4.3* MONOS-2.1 EOS-0.1
BASOS-0.5
[**2178-5-30**] 01:45PM PLT COUNT-341
[**2178-5-30**] 01:45PM PT-11.1 PTT-29.5 INR(PT)-1.0
[**2178-5-30**] 01:45PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2178-5-30**] 01:45PM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2178-5-30**] 01:45PM URINE RBC-97* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
[**2178-5-30**] 01:45PM URINE 3PHOSPHAT-MOD AMORPH-MOD
[**2178-5-30**] 01:45PM URINE WBCCLUMP-RARE MUCOUS-OCC
CT head [**2178-5-30**]:
IMPRESSION:
Extensive encephalomalacia of the left hemisphere with
associated ex vacuo dilatation of the left lateral ventricle.
No definite acute intracranial hemorrhage
EEG [**2178-5-31**]:
IMPRESSION: This is an abnormal routine EEG in the awake and
asleep
states due to the presence of intermittent right mid-temporal
epileptiform discharges. These findings are indicative of an
active
epileptogenic focus in the right temporal region. In addition,
the
background activity is diffusely slow indicative of a moderate
encephalopathy which suggests widespread cerebral dysfunction
but is
non-specific as to etiology. No electrographic seizures are
present.
Note is made of an irregularly irregular cardiac rhythm
consistent with
atrial fibrillation.
EEG [**2178-6-2**]:
IMPRESSION: This telemetry captured two pushbutton activations.
It
showed no evidence of seizures. Throughout the recording, the
background rhythm remains slow and indicative of an
encephalopathy.
There were no prominent focal abnormalities but encephalopathies
may
obscure focal findings. There were no epileptiform features or
electrographic seizures.
MRI head [**2178-6-2**]:
IMPRESSION:
1. Acute infarction of the right basal ganglia with very slight
mass effect on the adjacent right lateral ventricle and evidence
of recent hemorrhagic conversion.
2. Acute infarction of the right posterior temporal and right
medial parietal lobe.
3. Absence of the flow void in the left internal carotid artery
indicating probable occlusion, likely chronic.
4. Stable encephalomalacia in the left temporal and left
cerebellum,
suggestive of prior infarctions.
CXR [**2178-6-1**]:
Lung volumes are appreciably lower. Increase in opacification
in the left lung is attributable to very mild edema, but on the
right the change is more pronounced with a more nodular
component which suggests developing aspiration pneumonia. The
endotracheal tube ends above the upper margin of the clavicles,
no less than 7 cm from the carina and it should be advanced [**1-16**]
cm for more secured seating. Nasogastric tube is coiled in the
stomach. The heart is mildly enlarged. There is no
pneumothorax or appreciable pleural effusion.
CXR [**2178-6-3**]:
Patient is rightward shifted which projects the large heart over
the right lower lung, but nevertheless, there is clearly
progressive opacification of the right lung and decrease in
volume of the right hemithorax suggesting a large component of
atelectasis, conceivably obscuring pneumonia, but not
necessarily. Left lung is grossly clear. As before, the
endotracheal tube is too high, 2 cm above the upper margin of
the clavicles and no less than 6 cm above the carina. It should
be advanced at least 3 cm for more secured seating and improved
aeration. Moderate cardiomegaly is stable. At least a small
right pleural effusion, new or increased since [**6-2**], is
presumed. Nasogastric tube is looped in the stomach. Right PIC
line ends at the junction of brachiocephalic veins. A new lead
runs parallel to the left clavicle ending in the midline, but I
do not recognize it. Clinical
correlation is needed. There is no left pleural effusion or
pneumothorax.
EEG [**2178-6-4**]: IMPRESSION: This telemetry captured no pushbutton
activations. The background remained markedly suppressed
throughout. Nevertheless, there were no clearly epileptiform
features or electrographic seizures.
Brief Hospital Course:
72 year-old woman with a history of hemispheric L MCA stroke, L
carotid occlusion, severe PVD s/p b/l AKA's who presented after
being found seizing in bed at her nursing facility. She has no
prior history of seizures. She was given ativan and valium
(unknown doses) at an OSH and intubated prior to transfer to
[**Hospital1 18**]. Upon arrival here she was intubated and sedated with no
further signs of seizure activity. Initial exam revealed intact
brainstem reflexes but was otherwise very limited due to her
sedation. CT showed encephalomalacia of the left hemisphere, and
UA was grossly positive. She was loaded with Keppra and started
on Ceftriaxone IV and admitted to the neuro ICU.
Neuro:
She remained quite obtunded and was unable to be weaned from
ventilatory support. On exam she was noted to be moving her
right side more than left, inconsistent with her prior large L
hemispheric stroke. Routine EEG on [**5-31**] also showed R temporal
spikes without clinical correlate. She was continued on Keppra
and connected to LTM, which showed an encephalopathic background
in delta-theta frequences without further evidence of
epileptiform activity.
An MRI was performed on [**6-2**] which showed multiple new strokes
in R MCA distribution with hemorrhagic conversion in R basal
ganglia. Most likely source was presumed to be embolic from
atrial fibrillation, but may also be related to [**Month/Year (2) 1106**]
stenosis/occlusion given hx of L carotid occlusion and severe
PVD. Aggrenox was discontinued in the setting of hemorrhage and
she was switched to aspirin. She was continued on simvastatin.
Vessel imaging and TTE were considered for further work-up but
were deferred after discussion with family regarding goals of
care when patient was made CMO.
CV:
She was maintained on telemetry monitoring during her admission
which revealed atrial fibrillation. She was continued on
Metoprolol 25mg [**Hospital1 **] and Simvastatin 10mg daily. Aggrenox was
switched to aspirin after she was found to have hemorrhagic
conversion of new infarct. This was stopped when she was made
CMO.
Endo:
She was maintained on fingersticks and sliding scale insulin for
blood glucose control. TSH was found to be high at 6.1, T3 56,
T4 5.3. Her FSs and ISS were stopped when she was made CMO.
ID:
She continued to have intermittent fevers throughout her
admission. UA was positive upon admission and she was initially
started on ceftriaxone for empiric treatment. CXR subsequently
began to show evidence of aspiration pneumonia vs. VAP and her
antibiotic coverage was broadened to linezolid/cefepime. Sputum
culture showed GPC in pairs and clusters. Her ABx were stopped
when she was made CMO.
Pulm:
She was maintained on mechanical ventilation and was unable to
be weaned due to her poor mental status and lack of gag reflex.
She was terminally extubated and passed away on [**2178-6-9**].
Prophylaxis:
She was maintained on SC heparin and a bowel regimen, which were
stopped when pt was made CMO.
Code status:
Ms. [**Known lastname **] was initially full code upon admission as confirmed
with her husband and son. After she was found to have new R
sided strokes and continued to deteriorate, a family meeting was
held on [**6-3**]. They acknowledged her poor prognosis agreed that
she would not want to live with the deficits she would be left
with. She was made DNR/DNI on [**6-3**] and subsequently her family
decided to transition her care to CMO on [**6-4**]. She was extubated
and passed away on [**2178-6-9**].
Medications on Admission:
Aggrenox
Insulin
Metoprolol
Zoloft
Zocor
Trazadone
MVI
Vitamin D
Discharge Medications:
N/A, pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
R MCA infarcts
Seizures
Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
Ms. [**Known lastname **] was admitted to [**Hospital1 1170**] on [**2178-5-30**] after being found seizing at home. She
was taken to an outside hospital and given medications to stop
her seizures. A breathing tube was placed to protect her airway.
She was then transferred to [**Hospital1 18**]. Her seizures stopped with
medication but she was still not waking up appropriately. An MRI
of her brain was then performed which showed multiple strokes in
the right side of her brain, in addition to her previous large
area of stroke in the left side of her brain. She also developed
a severe pneumonia which was treated with antibiotics. Given her
poor prognosis and low likelihood of recovery, her family
decided to make her care focused on comfort measures only. The
breathing tube was removed and she passed away peacefully on
[**2178-6-9**].
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"V49.76",
"V49.71",
"443.9",
"250.60",
"275.2",
"438.11",
"V49.86",
"362.01",
"V49.72",
"294.20",
"431",
"434.11",
"733.00",
"250.50",
"427.31",
"507.0",
"V12.51",
"275.3",
"276.8",
"E879.8",
"780.39",
"997.31",
"357.2",
"599.0",
"288.60",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6",
"00.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11852, 11861
|
8175, 11697
|
333, 345
|
11939, 11949
|
3243, 8152
|
12841, 12959
|
2288, 2327
|
11812, 11829
|
11882, 11918
|
11723, 11789
|
11973, 12818
|
2724, 3224
|
2342, 2356
|
286, 295
|
373, 1399
|
2370, 2641
|
2656, 2707
|
1421, 2163
|
2179, 2272
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,889
| 124,357
|
43538
|
Discharge summary
|
report
|
Admission Date: [**2172-7-13**] Discharge Date: [**2172-7-17**]
Date of Birth: [**2091-6-30**] Sex: F
Service: SURGERY
Allergies:
Rifabutin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal distension, pain. Hypotension and tachycardia.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 year old cachectic female with chief complaint of ileus
versus mechanical obstruction. History [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
rehabilitaion physician. [**Last Name (NamePattern4) **] [**7-11**] had little oral intake and an
IV was started. Then experienced urinary retention and a foley
was inserted, which immediately drained almost a liter.
Yesterday abdomen again distended and KUB revealed ileus vs
mechanical obstruction. She remained hypotensive and
tachycardic with BP 98/69, and HR 100-20s. According to the
family, they have noted increasing abdominal distension and poor
appetite over the past week. Has not had a bowel movement in
1week per the family despite suppositories. The patient only
began to notice abdominal discomfort over the past day.
Past Medical History:
1. Bronchiectasis.
2. Moderately severe emphysema.
3. Mycobacterium avium intracellular treated with 26 months of
antibiotics, which stopped 9/[**2169**].
4. Well compensated cardiomyopathy, (EF 30% 4/04)
5. Cachexia and failure to thrive.
6. Depression/anxiety.
7. HTN.
8. Cataracts (B).
9. Hearing deficit.
10. Thyroid nodule.
11. Cervical dysplasia [**2161**].
12. (L)BBB [**2166**].
13. Mild hyperlipidemia.
14. s/p appy (? ruptured)-40years ago.
Social History:
Resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Rehab. Smoked two packs per day times
15 to 20 years, however, quit 30 years ago. No alcohol use.
Says is independent with most ADLs.
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: 99.6 107 100/58 40 100
GEN: Cachetic appearing elderly female, no acute distress
COR: Sinus tachycardia
LUNGS: CTA b/l
ABD: Distended, soft, very mildly TTP (R)UQ.
DRE: Soft brown stool in vault, no gross blood, guiaic negative.
EXTREM: No LE edema.
Pertinent Results:
[**2172-7-13**] 09:41PM LACTATE-2.6*
[**2172-7-13**] 09:00PM GLUCOSE-98 UREA N-42* CREAT-0.6 SODIUM-140
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-11
[**2172-7-13**] 09:00PM CALCIUM-7.3* PHOSPHATE-3.6# MAGNESIUM-2.6
[**2172-7-13**] 09:00PM WBC-4.6 RBC-3.77*# HGB-11.1*# HCT-34.7*#
MCV-92 MCH-29.4 MCHC-31.9 RDW-13.8
[**2172-7-13**] 09:00PM PLT COUNT-308
[**2172-7-13**] 09:00PM PT-11.3 PTT-25.0 INR(PT)-0.9
[**2172-7-13**] 12:15PM ALT(SGPT)-21 AST(SGOT)-43* CK(CPK)-56 ALK
PHOS-81 TOT BILI-0.5
[**2172-7-13**] 12:15PM LIPASE-11
[**2172-7-13**] 12:15PM cTropnT-0.03*
[**2172-7-13**] 12:15PM CK-MB-NotDone
[**2172-7-13**] 12:15PM DIGOXIN-1.0
[**2172-7-13**] 12:15PM ALBUMIN-3.4
[**2172-7-14**] 05:01PM BLOOD cTropnT-<0.01
[**2172-7-15**] 03:34AM BLOOD cTropnT-<0.01
.
[**2172-7-13**] ECG:
Sinus tachycardia with atrial premature beats and possible
ventricular
premature beat. Left bundle-branch block with left axis
deviation. Consider left ventricular hypertrophy. Compared to
the previous tracing of [**2172-6-27**] QRS voltage appears more
prominent but there may be no significant change.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
128 130 118 334/453 93 -78 103
.
[**2172-7-13**] KUB/upright: Dilated loops of small bowel measuring up
to 5 cm consistent with bowel obstruction.
.
[**2172-7-13**] ABD/PELVIC CT W/CONTRAST:
1. Multiple dilated loops of small and large bowel consistent
with ileus.
Filling defect in the proximal SMA consistent with occlusive
thrombus with
filling distal to thrombus. Findings concerning for early
mesenteric ischemia. No pneumatosis, bowel wall thickening, or
portal venous gas identified.
2. Airspace densities noted at the lung bases bilaterally with
small bilateral pleural effusions. Findings may represent
sequelae of aspiration. Clinical correlation is recommended.
3. 8-mm hypodense cystic lesion in the body of the kidney. A
follow up CT is recommended in [**5-8**] months.
.
[**2172-7-16**] Abdominal X-ray: PENDING.
Brief Hospital Course:
The patient was admitted to the SICU under the management of the
General Surgical Service on [**2172-7-13**] for evaluation of an ileus
versus mechanical obstruction. The patient was also hypotensive
and tachycardic upon admission. She was made NPO, received IV
fluid rescusitation and electrolyte repletement, and an NGT and
foley catheter were placed. An ABD/Pelvic CT with contrast was
performed, which was maily remarkable for multiple dilated loops
of small and large bowel consistent with ileus and a filling
defect in the proximal SMA consistent with occlusive thrombus
with filling distal to thrombus. Findings concerning for early
mesenteric ischemia. No pneumatosis, bowel wall thickening, or
portal venous gas was identified. The Vascular Service was
consulted for the finding of the SMA filling defect; no vascular
intervention was recommended, but lifetime anticoagulation with
warfarin was recommended. She was started on a Heparin infusion
at that time.
The patient improved with conservative measures. Hypotension and
tachycardia resolved with hydration and adjustment of
metoprolol. Abdominal distension improved with NGT decompression
and bowel rest. The patient experienced a return of bowel
function after an enema and manual stool disimpaction on
[**2172-7-15**]. The NGT was discontinued, and she was started on sips
of clears with good tolerability. The foley catheter was also
discontinued on [**2172-7-17**]; she was able to void without problem.
She was transferred to the floor on [**2172-7-15**] in good condition,
continued on the Heparin infusion. Her diet was advanced to
regular with good tolerability, and IV fluids discontinued. On
[**2172-7-16**], the IV Heparin infusion was discontinued, and she was
started on Warfarin 1mg in the evening and Lovenox Sub-Q daily.
The plan is to discharge her on a Lovenox-Warfarin bridge until
her INR is therapeutic, at which time it has been recommended
that she continue on Warfarin anticoagulation for lifetime. INR
goal 2.5; therapeutic range 2-3.
On [**2172-7-17**], unable to wean the patient off supplemental oxygen
as the patient became tachycardic and experienced desaturation
to 84-86% on room air only. Returned to 93-95% on 4-5L O2 via
NC. An EKG was unchanged from baseline. A CXR revealed bibasilar
atelectasis. The patient received albuterol nebulizer treatments
PRN and vigorous respiratory toilet with good response. No
contraindication to planned [**Hospital1 1501**] discharge. She will be
transferred on oxygen therapy.
At the time of discharge on [**2172-7-17**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet with fair intake, ambulating with assistance,
voiding without assistance, and pain was well controlled. She
was discharged back to a skilled nursing facility on the
Lovenox-Warfarin bridge and supplemental oxygen. She will
follow-up with Vascular in 8 weeks. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
7. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for anxiety.
8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: 15-30 mL PO
Every other day.
10. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty
(20) mL PO once a day.
11. Nestle VHC 2.25 Nutritional supplement 60mL PO BID
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
7. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for anxiety.
8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: 15-30 mL PO
Every other day.
10. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty
(20) mL PO once a day.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Q4PM.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Hypovolemic shock
2. Failure-to-thrive
3. Superior mesenteric artery (SMA) filling defect
4. Small bowel obstruction
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain 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 [**4-5**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Please call ([**Telephone/Fax (1) 11814**] to schedule follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] (Vascular) in [**6-3**] weeks.
Please call ([**Telephone/Fax (1) 30577**] to schedule a follow-up appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) in 2 weeks.
Other Appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2172-10-29**] 1:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2172-11-16**]
10:00
Completed by:[**2172-7-17**]
|
[
"557.0",
"518.0",
"401.9",
"300.4",
"494.0",
"788.20",
"799.4",
"492.8",
"428.0",
"785.59",
"425.4",
"560.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9260, 9333
|
4276, 7339
|
325, 332
|
9497, 9506
|
2257, 4253
|
14333, 15021
|
1934, 1953
|
8200, 9237
|
9354, 9476
|
7365, 8177
|
9530, 14310
|
1968, 1968
|
229, 287
|
360, 1201
|
1982, 2238
|
1223, 1684
|
1700, 1918
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,163
| 159,364
|
27039
|
Discharge summary
|
report
|
Admission Date: [**2130-7-31**] Discharge Date: [**2130-8-12**]
Date of Birth: [**2052-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2130-8-3**] Coronary Artery Bypass Grafting x4: left internal mammary
artery to left anterior descending with saphenous vein grafts to
ramus, obtuse marginal and PLV.
[**2130-7-31**] Cardiac Catheterization with Intra aortic ballon pump
placement
History of Present Illness:
78 y.o man with history of DM, CKD and hyperlipidemia who
presented to [**Hospital3 4107**] with stuttering chest pain of 3
days duration. The patient's pain was intermittent, squeezing
in nature, and radiated to his neck and he initially felt that
it was gastrointestinal in nature. When the pain became worse
he presented to the [**Hospital1 **] emergency room. There, he was found
to have an EKG concerning for an anterior STEMI with ST
elevations in V1-V3 as well as in aVR. He was then transferred
to [**Hospital1 18**] for further therapy.
.
He was brought to the cardiac catherization lab and
catheterization demonstated severe multivessel disease. No
intervention was performed. An intra aortic balloon pump was
placed. Cardiac surgery was contact[**Name (NI) **] for evaluation for
coronary bypass grafting.
Past Medical History:
Past Medical History:
Peptic Ulcers
Insulin Dependent Diabetes Mellitus x 20 years
High Cholesterol
Chronic renal insufficeny
Diabetic neuropathy
Past Surgical History:
Right thigh cyst removal
Social History:
Lives alone. Sexually active with a girlfriend. Monogamous
relationship.
Retired French/Spanish teacher.
Denies heavy ETOH, one beer occasionally,
+tobacco/ 1 PPD for 60years.
No regular exercise.
Family History:
No CAD.
Positive for DM in mother.
Physical Exam:
ADMISSION EXAM
Tmax: 36.4 ??????C (97.6 ??????F)
Tcurrent: 36.4 ??????C (97.6 ??????F)
HR: 63 (63 - 73) bpm
BP: 126/51(80) {126/41(71) - 150/59(100)} mmHg
RR: 12 (11 - 15) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
GENERAL: WDWN man 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 2 cm.
CARDIAC: Quiet heart sounds with background noise from IABP.
Normal s1/s2, no murmurs, rubs gallops.
LUNGS: clear to auscultation bilaterally in axillae and
anteriorly.
ABDOMEN: Soft, non-tender, non-distended with bowel sounds
present.
PULSES: Bilateral DPs dopplerable
GROIN: IABP sheath in Right groin. No evidence of hematoma or
bleeding from site.Neurologic: Responds to: Not assessed,
Movement: Not assessed, Tone: Not assessed
Pertinent Results:
admission labs:
[**2130-7-31**] 09:30AM BLOOD WBC-6.4 RBC-4.84 Hgb-13.3* Hct-41.2
MCV-85 MCH-27.5 MCHC-32.3 RDW-15.4 Plt Ct-185
[**2130-7-31**] 09:30AM BLOOD Neuts-77.9* Lymphs-15.2* Monos-3.4
Eos-2.9 Baso-0.6
[**2130-7-31**] 09:30AM BLOOD PT-12.5 PTT-52.8* INR(PT)-1.1
[**2130-7-31**] 09:30AM BLOOD Glucose-294* UreaN-38* Creat-2.3* Na-139
K-4.6 Cl-103 HCO3-24 AnGap-17
[**2130-7-31**] 09:30AM BLOOD Albumin-4.0 Calcium-9.1 Phos-2.5* Mg-2.
[**2130-7-31**] 09:30AM BLOOD ALT-18 AST-20 LD(LDH)-171 AlkPhos-28*
Amylase-7 TotBili-0.1
[**2130-7-31**] 03:20PM BLOOD %HbA1c-7.3* eAG-163*
Cardiac Enzymes:
[**2130-7-31**] 06:15PM BLOOD CK(CPK)-315
[**2130-8-2**] 12:59AM BLOOD CK(CPK)-318
[**2130-8-2**] 07:50AM BLOOD CK(CPK)-430*
[**2130-7-31**] 09:30AM BLOOD cTropnT-0.19*
[**2130-7-31**] 06:15PM BLOOD CK-MB-15* MB Indx-4.8 cTropnT-0.73*
[**2130-8-1**] 05:10AM BLOOD CK-MB-13* cTropnT-1.02*
[**2130-8-2**] 12:59AM BLOOD CK-MB-15* MB Indx-4.7 cTropnT-0.75*
[**2130-8-2**] 07:50AM BLOOD CK-MB-23* MB Indx-5.3 cTropnT-0.99*
discharge labs:
[**2130-8-8**] 04:40AM BLOOD WBC-6.7 RBC-3.43* Hgb-9.9* Hct-28.5*
MCV-83 MCH-28.9 MCHC-34.7 RDW-14.8 Plt Ct-213
[**2130-8-8**] 09:33AM BLOOD PT-13.0 INR(PT)-1.1
[**2130-8-8**] 04:40AM BLOOD Plt Ct-213
[**2130-8-8**] 04:40AM BLOOD Glucose-221* UreaN-92* Creat-4.3* Na-140
K-4.3 Cl-101 HCO3-26 AnGap-17
[**2130-8-12**] creat 3.7; INR 1.9 (rec'd 2.5 mg coumadin)
CARDIAC CATH ([**2130-7-31**])
1. Selective coronary angiography in this right dominant system
demonstrated left main and three vessel coronary artery disease.
The
left main coronary artery had 50% stenosis. The LAD had a 70%
ostial
and 90% mid vessel stenosis. The LCx had a 70% proximal
stenosis. The
ramus had an ostial 80% stenosis. The RCA had sequential mid
and distal
80% lesions.
2. Limited resting hemodynamics demonstrated elevated left sided
filling
pressures with LVEDP 18 mmHg. There was normal systemic
arterial
pressure with central aortic pressure 110/63 with a mean of 57
mmHg.
3. Successful placement of IABP.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Successful placement of IABP.
=====================================
ECHO ([**2130-8-1**])
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with mid to distal anteroseptal akinesis,
apical akinesis, mid to distal anterior hypokinesis/akinesis and
basal inferior hypokinesis. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
CAROTID ULTRASOUND ([**2130-8-1**])
Impression: Right ICA <40% stenosis. Left ICA <40% stenosis.
Brief Hospital Course:
78 yo man with hx of DM, CKD and HLD presents from OSH with
chest pain x3 days found to have STEMI (ST elevations in V1-V3),
brought for cardiac catheterization and found to have 3VD. No
stents were placed. An IABP was placed to improve cardiac output
in the setting of hypotension. The pt was medically managed with
Aspirin 325 mg daily, metoprolol 12.5 [**Hospital1 **], rosuvastatin 40 mg
daily, and heparin gtt. Given severe 3VD, cardiac surgery was
contact[**Name (NI) **] for evaluation for coronary bypass grafting. No plavix
was given in anticipation for revascularization. The following
day the intra aortic balloon pump was successfully weaned and
removed with stable blood pressures. A small hematoma developed
in the right groin which slowly resolved, the hematocrit
remained stable. Coronary bypass workup was completed, however
surgery was delayed 2 days due to elevated Creatinine which
returned to baseline prior to procedure. The patient remained
chest pain free since cardiac catheterization with the exception
of fleeting chest pain on [**8-2**]. EKG showed findings similar to
presenting EKG. Chest pain spontaneously resolved without
intervation.
On [**8-3**] the patient was brought to the operating room for
coronary bypass grafting, please see the operative report for
details. In summary he had:
Coronary bypass grafting x4 with left internal mammary artery to
the left anterior descending artery and reverse saphenous vein
graft to the posterior left ventricular branch artery, obtuse
marginal artery, ramus intermedius artery.
His bypass time was 100 minutes with a crossclamp time of 89
minutes. He tolerated the operation well and post-operatively
was transferred to the cardiac surgery ICU.
Hemodynamically he was somewhat labile in the immediate post-op
period and was kept sedated on the day of surgery to provide
opportunity for transfusion/volume resuscitation and
stabilization. Attempted to wake patient on morning of POD1, at
that time he was very agitated and sedation was switched to
precedex without much effect. He was weaned from the ventilator
but remained agitated and was not extubated until later in the
afternoon. Following extubation he required additional pulmonary
support, additionally his creatinine which was elevated post
cardiac catheterization was again elevated, consistant with
acute on chronic renal failure. The creatinine peaked at
**4.3*** from his baseline of 2.0. At the time of discharge on
POD#9 his creat was trending downward and was 3.7 on day of
discharge.
He was hemodynamically stable but remained in the ICU to monitor
his pulmonary and renal status until POD4. All tubes lines and
drains were removed per cardiac surgery protocol.
The patient was started on Coumadin because of low EF, he
continues to exhibit signs of systolic heart failure by cardiac
echocardiogram done [**2130-8-4**].
The patient worked with the nursing staff and physical therapy
to increase his strength and endurance and was making slow
progress however he will likely benefit from short
rehabilitation stay prior to returning to his home environment.
On POD # 9 he was discharged to [**Hospital3 13990**] health center in
[**Location (un) 5110**]
His affect is a bit eccentric and impatient occasionally calling
out- wears dark glasses with claims that he is sensitive to
light. In general he is calm and cooperative. His pain is
managed with low dose neurontin and tylenol- no narcotics.
Medications on Admission:
Insulin 75/25 50U qam, 50U qpm
Gabapentin 300mg tid
Rosuvastatin 10mg daily
terazosin 0.4mg qhs
Aspirin daily
Vitamin D3 400mg daily
Omeprazole 40mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. 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. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. warfarin 1 mg Tablet Sig: dose per INR Tablet PO DAILY
(Daily): indication - low EF
goal INR 2.0-2.5.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
15. insulin 75/25
30 units qam
16. insulin
regular insulin per sliding scale based on finger stick
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center - [**Location (un) 5110**]
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Graft x 4
Past medical history:
Dyslipidemia
Chronic Renal Insufficiency
Insulin Dependent Diabetes Mellitus
Benign Prostatic Hypertrophy
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating independently with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - 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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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**] on [**8-30**] at 1:00pm in the [**Hospital **]
medical office building [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-24**] at 3:15pm
Coumadin Indication: Low EF. Goal INR 2.0-2.5
Check INR mon/wed/fri until therapeutic then weekly.
Please arrange follow up for coumadin upon discharge from rehab.
**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:[**2130-8-12**]
|
[
"250.61",
"585.9",
"530.81",
"357.2",
"272.4",
"427.69",
"427.31",
"285.1",
"584.5",
"600.00",
"V58.67",
"305.1",
"250.41",
"410.11",
"414.01",
"428.21",
"998.12",
"428.0",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"36.15",
"37.22",
"39.61",
"36.13",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
11026, 11120
|
5911, 9353
|
321, 574
|
11368, 11607
|
2830, 2830
|
12410, 13149
|
1875, 1911
|
9558, 11003
|
11141, 11204
|
9379, 9535
|
4876, 5888
|
11631, 12387
|
3864, 4859
|
1618, 1644
|
1926, 2811
|
3429, 3848
|
271, 283
|
602, 1427
|
2846, 3412
|
11226, 11347
|
1660, 1859
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,921
| 147,824
|
29929
|
Discharge summary
|
report
|
Admission Date: [**2114-2-21**] Discharge Date: [**2114-2-26**]
Date of Birth: [**2047-3-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
66 y/o male s/p MVC rollover, hit rail at 50mph, + LOC,
unrestrained.
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of open right forearm
fracture.
2. Open reduction and internal fixation of radial shaft.
3. Open reduction and internal fixation of distal radial
ulnar joint.
4. Open reduction and internal fixation of patella fracture
with patella tendon avulsion and resection of the distal
pole.
History of Present Illness:
66 y/o male s/p MVC rollover, hit rail at 50mph, + LOC,
unrestrained. Patient was sent to an OSH where he was noted to
have an open right wrist fx, mulitple rib fx's and a patellar
dislocation of his left knee. CT head was reportedly negative
and he was sent to [**Hospital1 18**] for further evaluation and definitive
care.
Past Medical History:
none
Social History:
No Tob, Occ EtOH
Family History:
N/C
Physical Exam:
Gen: NAD, AAOx3
HEENT: in hard c-collar
CV: RRR
Pulm: CTAB
Abd: soft, NT, ND
RUE: in volar splint, incision c/d/i
LUE: wound on elbow c/d/i dressed with DSD
LLE: incision c/d/i in [**Doctor Last Name 6587**] brace locked in extension
Pertinent Results:
[**2114-2-23**] 06:35AM BLOOD WBC-8.2 RBC-3.35* Hgb-10.0* Hct-29.4*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.7 Plt Ct-219
[**2114-2-22**] 08:25AM BLOOD Hct-34.1*
[**2114-2-22**] 02:57AM BLOOD WBC-8.7 RBC-3.74* Hgb-11.4* Hct-32.8*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.7 Plt Ct-264
[**2114-2-21**] 03:40PM BLOOD WBC-10.6 RBC-3.66* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.5 Plt Ct-296
[**2114-2-23**] 06:35AM BLOOD Plt Ct-219
[**2114-2-22**] 02:57AM BLOOD Plt Ct-264
[**2114-2-21**] 03:40PM BLOOD Plt Ct-296
[**2114-2-21**] 03:40PM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1
[**2114-2-23**] 06:35AM BLOOD Glucose-126* UreaN-14 Creat-0.8 Na-138
K-3.6 Cl-103 HCO3-28 AnGap-11
[**2114-2-22**] 02:57AM BLOOD Glucose-170* UreaN-12 Creat-0.8 Na-133
K-3.7 Cl-99 HCO3-25 AnGap-13
[**2114-2-21**] 03:40PM BLOOD Amylase-50
[**2114-2-23**] 06:35AM BLOOD Calcium-8.2* Phos-1.8* Mg-2.1
[**2114-2-22**] 02:57AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
[**2114-2-21**] 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
66 y/o male s/p MVC rollover, hit rail at 50mph, + LOC,
unrestrained. Patient was sent to an OSH where he was noted to
have an open right wrist fx, mulitple rib fx's and a patellar
dislocation of his left knee. CT head was reportedly negative
and he was sent to [**Hospital1 18**] for further evaluation and definitive
care.
At the [**Hospital1 18**] radiographic studies and physical exam revealed and
open galleazi fracture dislocation of the RUE, Multiple rib
fractures on the left side, both anteriorly and posteriorly, a
small left pleural effusion, acute comminuted oblique-sagittal
fracture through the right lateral mass of C1, entering the
spinal canal, but sparing the foramen transversarium, and a left
patellar fx. CT of the head revealed only a small subgaleal
hematoma. The patient was seen by neurosurgery who recommended a
hard collar for 12 weeks. The patient was then taken to the OR
with ortho for a 1. Irrigation and debridement of open right
forearm fracture. 2. Open reduction and internal fixation of
radial shaft.3. Open reduction and internal fixation of distal
radialulnar joint. 4. Open reduction and internal fixation of
patella fracturewith patella tendon avulsion and resection of
the distal pole.
He tolerated the procedure well and was transferred to the
floor. He was advanced to a regular diet and his pain was
controlled with IV then PO pain meds. He was able to be WBAT on
the LLE with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6587**] brace locked in extension and was
assisted by PT. The small wound on his left elbow was dressed
with dry [**Last Name (un) 71507**] dressing and a volar splint was fashioned for
his right upper extremity. He continued to gain mobility and on
POD # 5 was cleared to go home with PT by PT. He will followup
with ortho trauma, ortho hand, neurosurgery, and trauma surgery.
He will remain in the LLE brace in extension, int he RUE volar
splint, and in the C-collar.
Medications on Admission:
ASA 81'
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Discharge Disposition:
Home With Service
Facility:
VNA Southeastern MA
Discharge Diagnosis:
s/p MVC
1. RUE open galeazzi fx
2. left patellar fx s/p ORIF
3. 8/9th rib fx
4. lat mass C1 fx
Discharge Condition:
Stable
Discharge Instructions:
[**Name8 (MD) **] M.D. if fever > 101.5, nausea, vomiting, shortness of
breath, chest pain, increased redness around incision or
drainage from incision. Keep knee immobilized in [**Doctor Last Name 6587**] brace
for 8 weeks. Change dressing to left elbow once a day with dry
sterile dressing and keep right arm in splint, non-weight
bearing. Remain in hard cervical collar for 12 weeks total.
Please followup with ortho trauma, ortho hand, trauma surgery,
neurosurgery, and your PCP.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] of trauma surgery to schedule a followup
in 2 weeks ([**Telephone/Fax (1) 22750**].
Please call Dr. [**Last Name (STitle) 1005**] of ortho trauma to schedule a followup
in 10 days ([**Telephone/Fax (1) 2007**].
Please call Dr. [**Last Name (STitle) **] of hand to schedule an appointment
([**Telephone/Fax (1) 2007**].
Please call Dr. [**Last Name (STitle) 548**] of Neurosurgery to schedule a followup in
2 weeks ([**Telephone/Fax (1) 88**].
Completed by:[**2114-2-26**]
|
[
"813.52",
"E812.0",
"822.0",
"807.09",
"780.09",
"805.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.62",
"79.36",
"79.32",
"83.64"
] |
icd9pcs
|
[
[
[]
]
] |
4893, 4943
|
2467, 4424
|
384, 718
|
5082, 5091
|
1424, 2444
|
5623, 6139
|
1150, 1155
|
4482, 4870
|
4964, 5061
|
4450, 4459
|
5115, 5600
|
1170, 1405
|
275, 346
|
746, 1072
|
1094, 1100
|
1116, 1134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,630
| 111,653
|
51684
|
Discharge summary
|
report
|
Admission Date: [**2189-8-22**] Discharge Date: [**2189-9-7**]
Date of Birth: [**2137-12-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2189-8-26**] Drainage of peri sigmoid abcess
[**2189-8-28**] PICC line placement
History of Present Illness:
50 year-old gentleman with history of HTN, hyperlipidema,
ETOH abuse,pancreatitis, and recent legionella PNA presents as
transfer from OSH for diverticular abscess. The patient has had
an MVR/AVR and had been on coumadin until hep gtt was started
for
potential intervention off the abscess. The patient had been
NPO
on IV abx at [**Hospital 5871**] hospital for the past week, however he was
transferred to [**Hospital1 18**] in case surgical intervention needed to be
performed on the abscess. At the current time, he reports
persistent pain and bloating of his abdomen. No N/V. He has
been
passing minimal amounts of flatus.
Past Medical History:
PMHx: colonoscopy >10 yrs ago, HTN, hyperlipidemia, ETOH abuse,
pancreatitis, legionella PNA, diverticulosis
[**Doctor First Name **] Hx: AVR/MVR
Social History:
Tobacco: Current 1PPD
ETOH: daily though able to stop at any point without
consequences
Family History:
non contributory
Physical Exam:
VS: 98.8, 98, 108/68, 16, 98%2L
GEN: NAD, A&O x 3
LUNGS: Clear B/L
CV: RRR, nl S1 and S2
ABD: Soft, distended, slight diffuse tenderness to palpation, no
guarding, no rebound, no hernias
EXT: 1+ edema of LE B/L
Pertinent Results:
[**2189-8-22**] 05:50PM WBC-13.7*# RBC-3.53* HGB-10.6* HCT-32.0*
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.9
[**2189-8-22**] 05:50PM PLT COUNT-380
[**2189-8-22**] 05:50PM PT-29.0* PTT-38.1* INR(PT)-2.9*
[**2189-8-22**] 05:50PM GLUCOSE-107* UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2189-8-26**] Abd. CT: IMPRESSION:
1. Large fluid collections within the abdomen and pelvis
containing gas and
amenable to percutaneous drainage. This fluid collection appears
grossly
larger than previous study.
2. Left renal calculus within the proximal ureter, mild
hydronephrosis.
[**2189-8-26**] CT guided drainage of colonic fluid collection:
IMPRESSION: Successful drainage of the prior colon abscess and
50 ml of the
Small amount of fluid was sent to laboratory as requested. The
catheter was
left in place.
[**2189-8-29**] Abd CT : 1. Interval decrease in size of abscess in the
superior aspect of the pelvic
cavity. A percutaneous drain remains in situ, with tip at the
left lateral
aspect of the collection. The collection appears partly
loculated.
[**2189-9-1**] Cardiac Echo : The left atrium is moderately dilated.
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is top normal/borderline dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is mildly dilated. A bileaflet aortic valve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. Trace aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] A bileaflet mitral valve
prosthesis is present. The gradients are higher than expected
for this type of prosthesis. No mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: Bileaflet mitral and aortic valve prostheses.
Trivial aortic regurgitation. Elevated transmitral valve
gradients. Mild left ventricular systolic dysfunction. Mildly
dilated and hypokinetic right ventricle. Moderate pulmonary
hypertension.
Compared with the prior report (images not available for review)
of [**2187-7-23**], the gradient across the prosthetic valve is
higher. Left ventricular systolic function is less vigorous. The
right ventricle is now mildly dilated and hypokinetic. The
estimated pulmonary artery pressures are slightly higher. If
there is a clinical suspicion of valve dysfunction, a TEE may be
indicated.
[**2189-8-31**] Abd CT for drain reposition :
IMPRESSION: Successful CT-guided repositioning of the drainage
catheter
2. Focal fluid collection adjacent to the distal portion of
sigmoid colon has
also decreased in size.
3. Persistent distention of the ascending and transverse colon
with gas and
fluid, which is slightly more prominent than on previous CT.
[**2189-9-5**] Abd CT :
. Decrease in size of pelvic collection with drain in situ and
in good
position.
2. Improving acute diverticulitis of the sigmoid colon.
3. New diffuse mild thickening of the wall of the entire colon,
indicating a
superimposed colitis. Differential considerations include C.
difficile, given
that the patient is on antibiotics, however, and other
differentials such as
inflammatory bowel disease and ischemia are much less likely.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted to the hospital, continued NPO , hydrated
with IV fluids and placed on Flagyl and Ciprofloxacin. His
abdomen was very distended and tympanic and remained that way
for many days despite the fact that he was passing flatus. He
was placed on IV heparin for his prosthetic heart valves and
after 6 days of bowel rest and no significant improvement he was
placed on TPN via a PICC line.
A repeat Abd CT was done on [**2189-8-26**] which showed the same large
fluid collection from a diverticular abscess which was
subsequently drained. His partial large bowel obstruction
remained the same. The drainage grew out 2 strains of Ecoli and
coag negative staph. His antibiotics were eventually changed to
Bactrim DS and Ciprofloxacin orally. Over time the drainage was
very minimal, prompting a repeat scan on [**2189-8-29**]. On [**2189-8-31**] he
returned to Radiology to have his drain manipulated as there was
an un drained fluid collection. There was some decreased
distention of the large bowel and on exam his abdomen started to
appear less distended and he gradually had much less pain.
From a cardiac standpoint he had problems with severe DOE and 3+
leg edema requiring concentration of his fluids and vigorous
diuresis. Due to his cardiac history he had a cardiac echo
which revealed an EF of 45-50% and a slight increase in the
gradient across the mitral valve. The Cardiology service was
then consulted to address the need for a TEE. Mr. [**Known lastname 10881**]
symptoms improved after vigorous diuresis and the Cardiology
service felt that a TEE could be done on an out patient basis if
it was needed and he should have a TTE in 3 months anyway. His
cardiologist Dr. [**Last Name (STitle) **] will follow him after discharge.
His diet was very slowly increased from clear to regular as he
was having bowel movements and passing alot of flatus. His TPN
was weaned on [**9-3**] and his PICC line was eventually removed.
Coumadin was finally started after complete resolution of his
partial large bowel obstruction and his tolerance of a regular
diet.
After a protracted hospital course he was discharged home on
[**2189-9-7**] with VNA services as he was sent home with his drain in
place and will be on Lovenox 90 mg sc BID until his INR is
greater than 2.0. I spoke with Dr. [**Last Name (STitle) **] who will follow his INR
and regulate his Coumadin dose.
Mr. [**Known lastname 1968**] will follow up with Dr. [**Last Name (STitle) **] in 3 weeks and he will
have a colonoscopy in 6 weeks which will be arranged by Dr.
[**Last Name (STitle) **] office.
Medications on Admission:
Meds on transfer:zosyn, metoprolol, pantoprazole, odansetron,
albuterol, morphine
[**Last Name (un) 1724**] Coumadin 4.5', simvastatin 40', vit D 1.25q oweek,
benazepril 20'
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours): thru [**2189-9-17**].
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*28 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:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
[**Hospital1 **] (2 times a day).
Disp:*10 syringes* Refills:*1*
8. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*20 Tablet(s)* Refills:*1*
9. Coumadin 5 mg Tablet Sig: 1 [**1-9**] Tablet PO once a day.
10. Outpatient Lab Work
11. Outpatient Lab Work
draw INR every MON-Wed-Fri
Results to Mr. [**Known lastname 1968**] who will in turn contact Dr. [**Last Name (STitle) **]
12. Outpatient Lab Work
INR every M-W-F
Results to Mr. [**Known lastname 1968**] who will in turn call Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis: Diverticulitis, partial LBO, and abscess
formation
Secondary Diagnosis: HTN, Asthma, pancreatitis, Etoh abuse,
mitral valve replacement.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-17**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*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).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2189-9-25**] 1:15
You need a colonoscopy in 6 weeks...dr.[**Doctor Last Name **] office will
call you with a day and time tomorrow
Call Dr. [**Last Name (STitle) **] tomorrow to follow up INR ([**Telephone/Fax (1) 7728**])
INR Mon-Wed-Fri at [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] lab. call results to Dr. [**Last Name (STitle) **]
Completed by:[**2189-9-7**]
|
[
"401.9",
"285.9",
"560.9",
"569.5",
"493.90",
"V58.61",
"562.10",
"272.4",
"V43.3",
"577.1",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9490, 9539
|
5295, 7920
|
327, 412
|
9739, 9748
|
1631, 5272
|
12009, 12539
|
1366, 1384
|
8146, 9467
|
9560, 9560
|
7946, 7946
|
9772, 11986
|
1399, 1612
|
273, 289
|
442, 1074
|
9651, 9718
|
9579, 9630
|
1096, 1245
|
1261, 1350
|
7963, 8123
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,121
| 156,708
|
11497
|
Discharge summary
|
report
|
Admission Date: [**2197-6-20**] Discharge Date: [**2197-6-26**]
Service: CARDIOTHORACIC
Allergies:
cats and beef
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE, orthopnea
Major Surgical or Invasive Procedure:
[**2197-6-20**]
Redo Sternotomy, AVR (19mm St. [**Male First Name (un) 923**] Tissue)
Flexible cystoscopy, Foley catheter placement
History of Present Illness:
[**Age over 90 **]M w h/o tissue MVR w Dr. [**Last Name (STitle) **] in [**2187**]. He has done well
since this time. Over the last several months he has noted some
dyspnea with exertion and did have one episode of orthopnea. He
is able to walk 1 mile daily and row at the gym w/o difficulty.
Climbing stairs and bending over to tie his shoes will
occasionally elicit dyspnea. He denies chest pain or syncope.
He was initially referred for percutaneous AVR, but does not
qualify given his prosthetic mitral valve. He has come to
discuss his surgical option.
Past Medical History:
Aortic Stenosis
PMH:
Aortic Stenosis
Conduction System Disease- 1st deg. AV block/RBBB/LAFSB
Raynaud's
Diverticulosis
BPH
Lyme Disease (remotely)
Dyslipidemia
Mild carotid art dz-by US in [**2186**]
Past Surgical History
Mitral Valve Replacement (27 tissue) [**2187-11-5**]
Resection of necrotic small bowel and repair of strangulated
right inguinal hernia [**2195-12-6**]
left herniorrhaphy [**2196**]
Right thyroidectomy [**2176**]
Bilateral cataract extraction
Social History:
Lives with: alone, widower- lives in [**Location 47**] near daughter
spends [**Name2 (NI) **] in a cabin in NY without electricity- he uses a
wood stove- for which he cuts all his own wood and is quite
independent in ADLs
Occupation: retired physics professor [**First Name (Titles) 767**] [**State 36677**]
Tobacco: none
ETOH: none
Activity: walks 1 mile per day without rest, rows 15min. at gym
Family History:
mother died of pancreatic cancer at 81yo
father died at 84yo
Physical Exam:
Pulse:90 Resp: 16 O2 sat: 98%-RA
B/P Right: 126/80 Left: 130/82
Height: 62" Weight: 123.4lb
General: NAD,
Skin: Dry [x] intact [x]
right fourth fingernail- onychomycotic
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: spider veins and minor varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2197-6-20**] Intraop TEE
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed.
(LVEF 45 - 50%). with borderline normal free wall contractility.
There are simple atheroma in the descending thoracic [**Month/Day/Year 5236**].
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
A bioprosthetic mitral valve prosthesis is present. Residual
mean gradient = 3. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV Paced, on no inotropes.
There is a well-seated prosthetic aortic valve with no leak and
no AI. Residual mean gradient = 11 mmHg.
There is preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 18350**]t.
The SGC is at the PA bifurcation.
[**2197-6-25**] 06:25AM BLOOD WBC-7.9 RBC-3.64* Hgb-10.7* Hct-32.6*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.6 Plt Ct-130*#
[**2197-6-25**] 06:25AM BLOOD Glucose-95 UreaN-34* Creat-0.9 Na-142
K-3.6 Cl-100 HCO3-34* AnGap-12
[**2197-6-23**] 04:35AM BLOOD Glucose-102* UreaN-22* Creat-1.1 Na-135
K-4.0 Cl-97 HCO3-32 AnGap-10
[**2197-6-24**] 06:00AM BLOOD WBC-8.6 RBC-3.75* Hgb-11.3* Hct-34.3*
MCV-91 MCH-30.2 MCHC-33.0 RDW-14.7 Plt Ct-86*
Brief Hospital Course:
The patient was brought to the operating room on [**2197-6-20**] where
the patient underwent redo sternotomy and Aortic Valve
replacement with a 19mm St. [**Male First Name (un) 923**] tissue valve. Urology was
consulted for difficult Foley placement pre-operatively.
Cystoscopy was performed and Foley placed. He was maintained on
antibiotic prophylaxis for this. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery. He
developed atrial fibrillation and was started on amiodarone and
coumadin. He had two episodes of 3 second conversion pauses,
and pacing wires were left in for this. Chest tubes and pacing
wires were discontinued without complication. His foley was
removed on post operative day 5 and he voided after removal
without difficulty. 5 day course of prophylatic antibiotics was
completed. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Nursing and Rehab in [**Location (un) 47**] in good condition with
appropriate follow up instructions.
Medications on Admission:
Vitamin C 500 [**Hospital1 **]
Vitamin D 400 qd
Iron Supplement 325 qd
Multivitamin qd
Florastor- scheduled to stop [**6-15**]
Amoxicillin prophylaxis prn
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Check INR in Am [**6-27**] - dose as directed for INR goal 2-2.5 for
Afib.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Aortic Stenosis
PMH:
Aortic Stenosis
Conduction System Disease- 1st deg. AV block/RBBB/LAFSB
Raynaud's
Diverticulosis
BPH
Lyme Disease (remotely)
Dyslipidemia
Mild carotid art dz-by US in [**2186**]
Past Surgical History
Mitral Valve Replacement (27 tissue) [**2187-11-5**]
Resection of necrotic small bowel and repair of strangulated
right inguinal hernia [**2195-12-6**]
left herniorrhaphy [**2196**]
Right thyroidectomy [**2176**]
Bilateral cataract extraction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
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**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] at [**Hospital1 **] on [**7-13**] at 9am, [**Telephone/Fax (1) 6256**]
Cardiologist Dr. [**Last Name (STitle) 1295**] on [**7-13**] at 10am
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) 9959**] [**Name (STitle) 9960**] in [**5-9**] 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**
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by rehab
Completed by:[**2197-6-26**]
|
[
"426.11",
"V42.2",
"458.29",
"427.31",
"426.52",
"424.1",
"599.4",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"39.61",
"35.21",
"58.22",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
7122, 7262
|
4093, 5823
|
243, 377
|
7771, 7940
|
2697, 4070
|
8728, 9478
|
1890, 1953
|
6029, 7099
|
7283, 7750
|
5849, 6006
|
7964, 8705
|
1968, 2678
|
188, 205
|
405, 970
|
992, 1459
|
1475, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,690
| 142,965
|
53823
|
Discharge summary
|
report
|
Admission Date: [**2160-3-20**] Discharge Date: [**2160-3-26**]
Date of Birth: [**2095-1-25**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
[**2160-3-21**] Exploration, small bowel resection, primary anastomosis
[**2160-3-20**] exploratory laparotomy, detorsion, small bowel
resection
History of Present Illness:
65M with a history of HTN, nephrolithiasisis, and BPH who
presents upon transfer from an OSH with severe abdominal pain,
back pain, and nausea. Pt reports to have been in his usual
state of health until last evening at 8PM when he had onset of
vague, diffuse crampy abdominal pain which he attributed to gas
pains. He had a bowel movement, which was normal, however, had
no
relief. His pain progressed in severity, became very sharp in
nature, and began to radiate through to his mid-back. He became
severely nauseated with dry heaves, however, he denies emesis.
He additionally denies fevers, chills, diarrhea, or BRBPR. He
denies sick contacts, recent travel, or prior episodes. His
last colonoscopy was 2 years ago, which he reports to have been
normal.
Past Medical History:
Past Medical History:
-Hypertension
-Nephrolithiasis w/ associated hematuria s/p cystoscopy w/ stent
placement
-Benign prostatic hypertrophy
Past Surgical History:
-Bilateral inguinal herniorraphy, open
-Cystoscopy w/ ureteral stent placement
-Cataract surgery, R eye
Social History:
Lives at home with wife. Trained as a physicist; currently
employed in sales for tech firm. Denies tobacco. Minimal social
EtOH. Denies illicits.
Family History:
Denies history of IBD or GI cancers.
Physical Exam:
Physical Exam: upon admission [**2160-3-20**]
Vitals: 97.9 81 160/91 20 97% 2L
GEN: NAD. Alert, oriented x3.
HEENT: No scleral icterus. Mucous membranes mildly dry.
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, mildly distended with moderate diffuse tenderness to
palpation. No R/G. No masses.
RECTAL: Normal tone. Enlarged prostate, somewhat firm. No gross
blood. Heme-occult negative.
EXT: Warm without LE edema.
Physical examination: discharge [**2160-3-26**]
Vital signs: t98.2, hr=88, bp=99/52, rr=18, oxygen sat=99%
CV: Ns1, s2, -s3, -s4
LUNGS: Crackles bases bil
ABDOMEN: soft, staples line clean, mild tenderness,bulging
lower aspect of wound, no wound exudate
EXT: mild edema ankles, no calf tenderness bil.
NEURO: alert and oriented x 3, speech clear, no tremors.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2160-3-26**] 10:50 6.6 4.11* 11.8* 37.0* 90 28.8 32.0 13.2 382
[**2160-3-25**] 05:55AM BLOOD WBC-4.6 RBC-3.55* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.1 Plt Ct-260
[**2160-3-24**] 10:30AM BLOOD Hct-34.9*
[**2160-3-24**] 07:15AM BLOOD WBC-5.6 RBC-3.65* Hgb-10.9* Hct-33.3*
MCV-91 MCH-29.9 MCHC-32.8 RDW-12.9 Plt Ct-241
[**2160-3-20**] 01:45AM BLOOD Neuts-87.8* Lymphs-8.6* Monos-2.7 Eos-0.3
Baso-0.6
[**2160-3-25**] 05:55AM BLOOD Plt Ct-260
[**2160-3-25**] 05:55AM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-142
K-3.4 Cl-109* HCO3-25 AnGap-11
[**2160-3-24**] 07:15AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-138
K-3.7 Cl-109* HCO3-26 AnGap-7*
[**2160-3-20**] 01:45AM BLOOD Glucose-269* UreaN-26* Creat-1.2 Na-143
K-3.4 Cl-105 HCO3-21* AnGap-20
[**2160-3-21**] 12:10AM BLOOD ALT-13 AST-26 LD(LDH)-166 AlkPhos-28*
TotBili-0.8
[**2160-3-25**] 05:55AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.9
[**2160-3-24**] 07:15AM BLOOD Calcium-7.5* Phos-1.4* Mg-2.0
[**2160-3-22**] 05:07AM BLOOD Type-ART pO2-141* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
[**2160-3-22**] 05:07AM BLOOD Lactate-1.5
[**2160-3-22**] 05:07AM BLOOD freeCa-1.00*
[**2160-3-20**]: EKG:
Normal sinus rhythm with sinus arrhythmia. One ventricular
premature complex.
Intra-atrial conduction abnormality. Prominent U waves in the
prcordial leads.
Abnormal tracing. No previous tracing available for comparison.
[**2160-3-22**]: chest x-ray:
1. Nasogastric tube is seen coursing below the diaphragm with
the tip
projecting over the stomach. An endotracheal tube remains in
place with the tip approximately 4.5 cm above the carina. There
is a worsening area of focal opacity at the right lung base
which may represent an evolving pneumonia, although patchy
atelectasis would also be in the differential. The lungs are
otherwise clear. No pulmonary edema, pleural effusions or
pneumothorax is appreciated. Cardiac and mediastinal contours
are stable.
[**2160-3-23**]: x-ray of the abdomen:
Nonspecific bowel gas pattern without definite signs for
obstruction. No free intra-abdominal gas.
Brief Hospital Course:
65 year old gentleman presented with abdominal pain, nausea and
back pain. Imaging showed mid-gut volvulus. Upon admission,
he was taken to the operating room for an exploratory
laparotomy, 80 cm of jejunal resection for midgut volvulus. He
was left in discontinuity while resuscitated until POD 2 when he
was taken back to the operating room for further resection of 60
mc of proximal small bowel followed by stapled anastamosis and
abdominal closure. Intraoperatively he was resuscitated with 4
liters of crystalloid and maintained on neosynephrine for
hypotension. He was monitored in the intensive care unit.
Review of systems:
NEURO: Patient initially on propofol but given hypotension he
was switched to versed and fentanyl. He remained neurologically
intact and was able to follow commands when the sedation was
weaned. He has remained alert and oriented.
CV: Patient was initially on neosynephrine postoperatively for
blood pressure support. This was weaned off as he was
adequately resuscitated with fluid and albumin. A tran-thoracic
echo was done on POD #1 which showed good biventricular
function and improved volume status; and he remained off
pressors throughout the rest of his intensive care unit stay.
On the surgical floor, his vital signs have been stable.
Pulm: Patient remained intubated on minimal sedation while his
abdomen was open. He was extubated on HD #2 after abdominal
wound closure. His oxygenation remained stable and he was
encouraged to use the incentive spirometer. His pulmonary
status has been stable.
GI: He remained NPO until his [**Last Name (un) **]-gastric tube was removed.
On HD #4, he underwent a KUB which showed no evidence of
obstruction. He was started on clear liquids with advancment to
a regular diet. He has been tolerating his diet without nausea
or vomitting. The patient reported onset of black diarreal stool
on POD #6. A c.diff culture was sent. His hematocrit was
repeated at 37.0. His hemodynamic status was stable.
GU: His urine output was closely monitored after the procedure.
His foley catheter was removed and he has been voiding without
difficulty.
Heme: Patient's hematocrit remained stable and he was maintained
on subcutaneous heparin throughout his hospital stay.
DISPO: His vital signs have been stable and he has been
afebrile. He was evaluated by physical therapy and
recommendations made for discharge home. He is preparing for
discharge home with follow-up in the acute care clinic.
Of note: c.diff results pending
Medications on Admission:
HCTZ 25, Flomax 0.4
Discharge Medications:
1. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
2. ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q6H
(every 6 hours): left eye.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
7. diclofenac sodium 0.1 % Drops Sig: One (1) drop Ophthalmic
three times daily ().
Discharge Disposition:
Home
Discharge Diagnosis:
mid-gut volvulus with SMA/SMV torsion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain, nausea,
and back pain. You underwent a cat scan of the abdomen and
there was concern for twisting of your bowel. You were taken to
the operating room for an exploratory laparotomy and a small
bowel resection. You returned to the operating room the
following day for closure of your abdomen. You are slowly
recovering from your surgery. Your vital signs have been stable
and you are tolerating a regular diet. You are preparing for
discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-8**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
*We are working on a follow up appt with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17029**] in
the 2 weeks. You will be called at home with the appointment.
If you have not heard or have questions, please call
[**Telephone/Fax (1) 17030**].
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: TUESDAY [**2160-4-8**] at 3:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2160-3-26**]
|
[
"560.2",
"600.00",
"401.9",
"557.0",
"V70.7",
"447.1",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
8047, 8053
|
4762, 5382
|
325, 474
|
8136, 8136
|
2602, 4739
|
10128, 10920
|
1738, 1776
|
7356, 8024
|
8075, 8115
|
7312, 7333
|
8287, 9758
|
1452, 1558
|
1806, 2215
|
2238, 2583
|
5403, 7286
|
263, 287
|
9770, 10105
|
502, 1265
|
8151, 8263
|
1309, 1429
|
1574, 1722
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,725
| 140,604
|
31838
|
Discharge summary
|
report
|
Admission Date: [**2192-10-25**] Discharge Date: [**2192-11-5**]
Date of Birth: [**2167-6-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Back pain fall out of window
Major Surgical or Invasive Procedure:
T12-L1 Laminectomies
T11-L3 Fusion
History of Present Illness:
25 y/o female became worried that intruder was breaking into
her house so she tried to escape via a bathroom window and fell
2
stories on to back. She had immediate back pain.
Past Medical History:
None
Social History:
Hx:works as a waitress, lives with boyfriend in
[**Name (NI) 23962**]. Non smoker, [**3-17**] drinks per week, no drugs
Family History:
2 Brothers with brain tumors
Physical Exam:
O: T: 96.7 BP:124 /65 HR:96 R 18 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: neck in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Right ankle swelling.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
Sensation: Intact to light touch, propioception,
Reflexes: B T Br Pa Ac
Right 2+---------
Left 2+---------
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control per ER resident
Pertinent Results:
[**2192-11-5**] 11:05AM BLOOD WBC-10.0 RBC-2.92* Hgb-9.1* Hct-26.9*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.1 Plt Ct-633*
[**2192-11-5**] 11:05AM BLOOD Plt Ct-633*
[**2192-11-5**] 11:05AM BLOOD Glucose-104 UreaN-8 Creat-0.7 Na-137
K-4.0 Cl-98 HCO3-30 AnGap-13
[**2192-10-25**] 05:31AM BLOOD Amylase-90
[**2192-11-5**] 11:05AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
[**2192-10-30**] 06:40AM BLOOD TSH-2.3
[**2192-10-25**] 05:31AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Ms [**Known lastname 410**] was admitted to the Neurosurgery service into the
trauma ICU for close observation of her neurological
funcitioning specifically her motor strenght. She underwent an
MRI which showed: Burst fracture of L1 with retropulsion and
25-50% narrowing of the spinal canal with mild extrinsic
indentation on the anterior aspect of the distal spinal cord. No
evidence of abnormal signal within the cord. She also underwent
multiple trauma view X-Rays which were negative. On [**10-25**] she
had emergent surgery for thoracic/lumbar decompression and
instrumented fusion with laminectomies at T12-L1 and pedicle
screw fusions at T11-T12, L2-L3. Post operatively she remained
full strenght with no deficits. On POD#2 she was transferred to
the surgical floor and received a TLSO brace and began to work
with physcial therapy. On 914 she had a spinal angiogram to
assess her spinal arteries for the second stage of her surgery.
While on the surgical floor the patient was noted to be tearful
and emotionally labile psychiatry was consulted and treated her
for PTSD which they recommended discussing her anxieties. A CT
was also done as her brother and sister have both had brain
tumors.
On [**11-1**] she underwent a anterior fixation of T12 to L2. Post
operatively she had a chest tube in place for approximately 24
hours. Again she was noted to be full strenght throughout
without any parastesias. She began working with PT and was
found safe to be discharged on [**11-5**]. She was tolerating a
regular diet and voiding without anything difficulty. She was
cleared to wear brace only when out of bed.
Medications on Admission:
BCP
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: use while on Percocet.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L1 Burst Fx
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do
not pull them off. They will fall off on their own or be taken
off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? You may shower briefly without the collar / back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
Have staples out on [**2192-11-12**] between 0900-1200
Follow up with Dr [**Last Name (STitle) **] in 4 weeks with CT of lumbar spine
Completed by:[**2192-11-9**]
|
[
"E882",
"806.4",
"E849.0",
"309.81",
"E935.2",
"E849.7",
"998.2",
"861.22",
"E870.0",
"292.12",
"E937.8",
"297.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.05",
"03.09",
"81.62",
"34.04",
"81.06",
"84.51",
"99.79",
"34.93",
"81.04"
] |
icd9pcs
|
[
[
[]
]
] |
3938, 3944
|
1955, 3589
|
349, 386
|
4000, 4024
|
1440, 1932
|
5653, 5818
|
773, 803
|
3643, 3915
|
3965, 3979
|
3615, 3620
|
4048, 5630
|
818, 1034
|
281, 311
|
414, 592
|
1049, 1421
|
614, 620
|
636, 757
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,723
| 122,002
|
53281
|
Discharge summary
|
report
|
Admission Date: [**2171-10-4**] Discharge Date: [**2171-10-13**]
Date of Birth: [**2108-12-10**] Sex: F
Service: VSURG
Allergies:
Ceftriaxone / Rocephin
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
transfer from OSH for shortness of breath and ?NQWMI
Major Surgical or Invasive Procedure:
s/p angiography with removal of left femoral sheath
s/p left groin exploration with thrombectomy of left
aorta-bifemoral limb
History of Present Illness:
The patient is a 62 year old female with history of CAD status
post two MIs, severe PVD s/p multiple vascular surgeries
(AO-bifem [**2160**], SWA bypass, L fem [**Doctor Last Name **] [**2168**], thrombosed right
femoral graft s/p thrombectomy/produndoplasty [**2171-9-10**], renal
artery stent), VI, AAA, left CVA, ICD placed [**2-/2164**] who was
admitted to [**Hospital1 1474**] on [**2171-9-29**] for shortness of breath. The
patient states that she has experienced three episodes of
extreme shortness of breath while at rest over the last 3
months. The episodes always occur while at rest and are
accompanied by diaphoresis. She denies chest pain,
palpitations, lightheadedness, or radiating discomfort. For
each episode, which last hours throughout the entire night until
the next morning, she never takes any medications and merely
waits for the dyspnea to resolve on its own. Before her
admission to the OSH, she had an episode as described, this time
lasting three days. On the third day, the patient had mental
status changes and she was brought into the OSH ED for immediate
evaluation. There she was treated with asa, nitro, and oxygen,
at which point her shortness of breath resolved. EKG did not
reveal any ST elevations, but there was a notation of elevated
Troponin (?type) at 2.5. CK was not reported to be elevated.
From the ED, she was admitted to the CCU where she was treated
with nitro iv, betablocker, aspiring, captopril, coumadin
(stopped and switched to lovenox), and plavix. Her code status
was determined to be DNR/DNI. A decision was made to send her
to the [**Hospital1 18**] for further evaluation for cath.
Past Medical History:
* Coronary artery disease
* Mycardial infarction x2 (EF=35%)
* Mesenteric Ischemia
* Peripheral vascular disease s/p multiple vascular surgeries
(AO-bifem [**2160**], SWA bypass, L fem [**Doctor Last Name **] [**2168**], thrombosed right
femoral graft s/p thrombectomy/produndoplasty [**2171-9-10**], renal
artery stent)
* V-Tach
* Chronic renal insufficiency
* Renal stenosis
* Abdominal Aortic Aneurysm
* Polycythemia
* Atrophied R kidney
* L CVA
* ICD placed [**2-/2164**]
* DVT [**2156**]
Social History:
smoked 2 packs per day for many years, then quit 7 years ago.
no ethanol, no drugs. retired legal secretary. lives with
husband. two children without cardiac/vascular disease
Family History:
sister with severe cardiac disease. dad died of MI
Physical Exam:
On admission to the floor
VITALS: 98.4 135/58 82 20 96%RA
GEN: lying in bed, no acute distress, appearing older than
stated age
HEENT: EOMI, MM slightly dry, OP clear, PERRL bilaterally, JVP
flat @base neck
COR: RRR, 3/6 systolic murmur RUSB, to and fro murmur at apex,
left carotid bruit, right carotid with dressing, pos abd bruit,
femoral bruits L>>>[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: clear to auscultation bilaterally
ABD: soft, nontender, non distended, bowel sounds present
EXT: no edema lower extremities, no dp/tp pulses palpable
NEURO: II-XII intact, alert and oriented x 3
Pertinent Results:
[**2171-10-4**] 05:56PM CK(CPK)-12*
[**2171-10-4**] 05:56PM CK-MB-NotDone cTropnT-0.20*
[**2171-10-4**] 05:56PM HCT-26.7*
[**2171-10-11**] 03:51AM BLOOD WBC-9.4 RBC-4.06* Hgb-11.9* Hct-34.0*
MCV-84 MCH-29.3 MCHC-35.0 RDW-17.5* Plt Ct-107*
[**2171-10-13**] 09:59AM BLOOD PT-18.8* PTT-38.7* INR(PT)-2.2
[**2171-10-11**] 03:51AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-140
K-3.8 Cl-100 HCO3-30* AnGap-14
Brief Hospital Course:
Pt admitted to cardiology service on [**2171-10-4**]. Underwent cardiac
cath via L groin sheath on [**2171-10-7**]. During procedure, she had
mental status changes--the procedure was stopped, and she had
symptoms of L sided neglect and L extremity motor dysfunction
(weakness of L arm). She was taken to the neuro-angio suite and
had R cerebral lysis with resolution of the symptoms. Pt had L
groin arterial sheath pulled on [**2171-10-8**]. Prior to the pull, whe
had a palpable pulse--after the pull, pressure developed, and
patient experienced pain, pallor, and loss of the L femoral
pulse. Vascular surgery was emergently consulted for occlusion
of the L femoral artery. The L groin was emergently explored,
with thrombectomy of the L aorto-bifem limb, with patch
angioplasty of the L common femoral artery and profunda. The
patient's heparin drip was continued. On [**2171-10-9**], the patient
was stable enough to be transferred from the ICU to the VICU.
The patient received 1 unit packed red blood cells for a falling
hematocrit (27.3). She was restarted on coumadin, plavix and
aspirin, and transferred to the floor on [**2171-10-10**]. Physical
therapy was consulted and the patient was encouraged to get out
of bed to a chair. On [**2171-10-12**], the heparin drip was
discontinued, as the patient was therapeutic on coumadin. On
[**2171-10-13**], the patient was discharged to home with physical
therapy to follow the patient at home.
Medications on Admission:
* lipitor 80 mg once a day
* percocet
* asa 81 mg once a day
* folate 1 mg once a day
* clonazepam
* lasix 80 mg once a day
* coumadin
* plavix 75 mg once a day
* metoprolol 100 mg thrice daily
* captopril 25 mg thrice daily
* nitro sublingual as needed
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Left leg ischemia
cerebral vascular accident
s/p angiography with removal of left femoral sheath
s/p left groin exploration with thrombectomy of left
aorta-bifemoral limb
chronic renal insufficiency
s/p patch angioplasty
CAD
chronic renal insufficiency
anemia requiring blood transfusion
Discharge Condition:
Good
Discharge Instructions:
Please [**Name8 (MD) 138**] MD for temp >101.5, persistent nausea/vomiting or
pain, redness or drainage from wound, or any other questions.
Followup Instructions:
In 2 weeks with Dr. [**Last Name (STitle) **]. Please call office for appt.
Pt will follow-up with the primary care physician regarding her
coumadin dosing.
|
[
"997.2",
"V45.02",
"997.02",
"416.0",
"593.9",
"428.0",
"410.71",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"99.10",
"39.57",
"88.41",
"99.04",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
6372, 6427
|
4004, 5463
|
335, 463
|
6759, 6765
|
3574, 3981
|
6953, 7114
|
2869, 2922
|
5767, 6349
|
6448, 6738
|
5489, 5744
|
6789, 6930
|
2937, 3555
|
243, 297
|
491, 2142
|
2164, 2658
|
2674, 2853
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,304
| 168,787
|
30789
|
Discharge summary
|
report
|
Admission Date: [**2194-7-13**] Discharge Date: [**2194-7-28**]
Date of Birth: [**2116-9-29**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides) / Vancomycin / Ciprofloxacin
Attending:[**First Name3 (LF) 2962**]
Chief Complaint:
Transferred from [**Hospital 1474**] Hospital after syncope in the setting
of atrial fibrillation, bradycardia, s/p v fib arrest treated w/
DCCV.
Major Surgical or Invasive Procedure:
cardiac catheterization
electrophysiology study
permanent pacemaker placement
History of Present Illness:
77-yo-woman w/ MMP including atrial fib and valvular heart
disease initially had unwitnessed syncope this AM while
toileting. Before using the bathroom, she had been feeling
nauseated and fatigued. Awoke on the toilet after LOC of
uncertain duration and called EMS, who arrived to find the pt
nauseated, dizzy, and mildly dyspneic, w/ HR 30 and BP 140/80.
EMS treated w/ atropine 0.5 mg IV x 2, resulting in HR increased
to atrial fib in the 70s, BP increased to 160/100. She was then
transported to [**Hospital 1474**] Hospital ED.
.
At [**Hospital 1474**] Hospital ED, her HR was again in the 40s w/ BP
210/90, and she was reportedly mentating well. Fifteen minutes
later, she was found to be unresponsive w/ telemetry interpreted
as ventricular fib. No documentation regarding pt's BP or pulse
status at that time, but CPR was started, pt was intubated, and
amiodarone 150 mg IV given as bolus dose. After "a few seconds"
the rhythm converted to ventricular tach and then to atrial fib
w/ PVCs. She was then admitted to the CCU.
.
In the [**Hospital1 1474**] CCU, she was extubated easily. Amiodarone gtt
was started, but stopped soon after because HR decreased to 30s.
Pt was transfused 2 units FFP in prep for placement of
transvenous pacing wire. Before the procedure, she had episode
of v tach --> v fib treated w/ DCCV at 200 joules, resulting in
return to atrial fib. The pacing wire was then placed through
right femoral vein. After the pacer demonstrated appropriate
capture and paced rhythm at 70 bpm, amiodarone gtt was resumed
at 1 mg/hr. She is now transferred to the [**Hospital1 18**] CCU for further
care.
.
Currently, she c/o mild right sided chest pain w/ no cough,
dyspnea, palpitations. ROS reveals increasing DOE over past 2
months requiring wheelchair for excursions outside the home;
otherwise unreliable given acute delirium.
Past Medical History:
- Atrial fibrillation: on coumadin
- Valvular heart disease: mild to mod AR, mild MR, mod to severe
TR
- HTN
- Bradycardia: in setting of concurrent beta blockade and
calcium channel blockade
- Pulm HTN: TTE [**8-8**] w/ LVEF 65-70%; PA pressure 65 mm Hg
- COPD: FEV1 0.97 --> 1.12 after bronchodilators
- Lung CA: bronchoalveolar CA s/p L lobe resection [**9-7**]
- Colon CA: T3N1 adenoCA s/p right hemicolectomy [**7-8**]
- Hypothyroidism
- Anxiety disorder
- MRSA bacteremia after thoracotomy
- s/p cholecystectomy
Social History:
Smoked 60 pack-years, but quit 2 years ago. There is no history
of alcohol abuse.
Family History:
Non contributory
Physical Exam:
VS: T 97.1, BP 143/68, HR v paced at 70, RR 23, O2 sat 100% 2L/m
NC
Gen: elderly woman lying flat in bed, speaking in full sentences
in NAD, w/ visual hallucinations.
HEENT: anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with no JVD.
CV: faint reg s1/s2, + 2/6 systolic murmur at LLSB, no s3/s4/r
Pulm: poor breath sounds anteriorly, no wheezes or crackles
Abd: +BS, soft, NTND, + 2cm supraumbilical surgical scar
Ext: warm, no edema, faint right radial and strong left radial
pulses, strong right DP, no palpable left DP, strong left
femoral pulse.
Neuro: alert, oriented to person only, CN 2-12 intact, strength
[**6-7**] throughout except RLE not tested because of indwelling temp
pacer, sensation to fine touch intact throughout.
Pertinent Results:
EKG initially demonstrated atrial fib w/ rate 50, nl axis, nl
int, TWI diffusely, ST depression V4-V6.
.
Admission labs:
138 102 16
-------------< 167
3.7 21 1.3
Ca: 9.3 Mg: 2.0 P: 3.2
TSH:3.7 Free-T4:1.2
Dig: <0.2
Cholesterol:117
Triglyc: 87
HDL: 56
LDLcalc: 44
.
10.7
14.7 >----< 241
32
.
PT: 37.4 PTT: 50.9 INR: 4.1
.
Dishcarge Labs:
WBC 23 (stable in low 20's after onset of infectious diarrhea)
Hct: 30.7 on discharge (stable in low 30's throughout)
INR: 4.1 - 3.7 - 1.3 - 1.5 - 1.8 --1.9 ([**7-26**])
Creatinine: 1.6 (stable 1.6-1.8)
CK 159 - 138 - 156
MB 8 - 7 - 21
Trop 0.13 - 0.10 - 0.19
Na: 138 - 131 - 128 - 126 - 126 - 127 ([**7-28**])
.
Micro:
Blood 6/13 x 2: no growth
Urine [**7-16**]; [**7-17**]: Klebsiella pan sensitive.
Urine [**7-22**]: no growth
.
***Stool [**7-25**]: C.diff positive
.
Radiology:
[**7-14**] Carotids: Minimal plaque with bilateral less than 40%
carotid stenosis.
.
[**7-14**] Echo: There is moderate to severe regional left ventricular
systolic dysfunction with mid to distal septal akinesis and
apical dyskinesis/akinesis.. There is focal hypokinesis of the
apical free wall of the right ventricle. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderateto severe pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade.
.
[**7-15**]: Cardiac cath:
1. Selective coronary angiography of this right dominant system
revealed
no obstructive CAD. The LMCA, LCX and LAD had no
angiographically
apparent flow limiting stenoses. There was a fistula from the
LAD to the
LV. The RCA was a dominant vessel with a large embolus in the
distal
vessel. there was a small embolus in the AV nodal branch.
2. Limited resting hemodynamics revealed systemic hypertension.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. No obstructive coronary artery disease.
2. Embolus in distal RCA and AV nodal branch.
.
[**7-16**] Echo: The left ventricular cavity size is normal. LV
systolic function appears depressed. There is mid septal
akinesis/hypokinesis and apical septal hypokinesis. Right
ventricular chamber size is normal. There is focal hypokinesis
of the apical free wall of the right ventricle. The aortic valve
leaflets (3) are mildly thickened. Mild to moderate ([**2-4**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is at least mild-moderate mitral
regurgitation (not fully assessed). The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2194-7-14**],
left ventricular systolic function appears improved.
.
[**7-17**]: RUQ ultrasound: 1. No biliary dilatation.
2. Distention of the central right renal collecting system,
likely indicating a UPJ obstruction. CT may be performed for
further evaluation if clinically indicated. Ultrasound cannot
exclude pyelonephritis.
.
[**7-17**]: CT Abd:
1. Moderate-sized right pleural effusion and adjacent airspace
disease which may represent compressive atelectasis, however,
infection cannot be excluded.
2. Extrarenal pelvis on the right. No evidence of obstruction.
3. Left posterolateral hernia containing retroperitoneal fat, of
uncertain cause given the lack of evidence of surgery in that
region.
4. Partial right colectomy with post-surgical changes.
5. Sigmoid diverticulosis without evidence of diverticulitis.
6. Presacral edema, which may be related to fluid overload given
the presence of diffuse subcutaneous edema.
.
[**7-17**]: CXR: mild cardiac failure and right pleural effusion with
associated atelectasis
.
[**7-22**]: CT Chest:
1. Moderate right pleural effusion with associated compressive
atelectasis.
2. Ill-defined patchy opacity with air bronchograms in the
superior posterior aspect of the left lower lobe. It would be
helpful to compare with old studies to assess for interval
change. In this patient post-cardiac arrest, this could
represent a focus of aspiration or infiltrate. Neoplasm cannot
be excluded, and followup by CT (after treatment within three
months) is recommended.
3. 7 mm right middle lobe nodule. Three-month CT followup is
recommended.
4. Multiple bilateral rib fractures.
5. Centrilobular emphysema, mild-to-moderate.
6. Cardiomegaly and coronary artery disease.
7. Extensive subcutaneous edema, without evidence of pulmonary
edema.
Brief Hospital Course:
Ms. [**Known lastname **] is a 77-year-old woman w/ atrial fib, valvular heart
disease including severe TR, pulm HTN, COPD, HTN,
hypothyroidism, lung CA s/p LUL resection, colon CA s/p
hemicolectomy, now transferred from [**Hospital1 1474**] CCU w/ temporary
pacer after syncope in the setting of bradycardia and v fib
arrest s/p DCCV. Hospital course by problem:
.
#) Rhythm: Afib at baseline, was being worked up for pacer by
outpatient cardiologist (Dr. [**Last Name (STitle) **], syncope, now with episodes at
OSH of polymorphic V-tach and ventricular fibrillation. Given
patient's month long increased shortness of breath, there was
concern that the patient had a painless ischemic event that
resulted in decompensated cardiac function and worsening heart
failure. We checked CE and performed echo to assess for poor EF
and did not find this. We monitored the patient on tele and
interrogated the temp pace daily. She had a slow intrinsic
rate/rhythm in the 40s. The pacer was confirmed by CXR.
Ultimately (after rx of infection) the patient had a pacer
placed without an AICD given her relatively normal EF. This was
performed on [**7-25**] without complication.
.
#) ID: The patient had a rising WBC and was treated with
macrobid for UTI. Her white count continued to rise and she was
transitioned to zosyn for broader coverage. Ultrasound was
worrisome for possible hydronephrosis on the right kidney.
Followup CT abd showed an extrarenal pelvis and no evidence of
hydronephrosis. Urine culture grew pansensitive klebsiella and
she was changed to to Augmentin and completed a 10 day course of
antibiotics. Once her infection seemed appropriately treated, a
pacer was placed as above. She then was noted to have diarrhea
and although initial stool cultures were negative for C.diff
patient had a positive culture on [**7-25**]. She is currently on a 14
day course of flagyl. Her WBC remains elevated at 20 however she
remains afebrile and clinically improved. Her stool out put is
approximately [**3-8**] loose stools per day.
.
#) CAD: Recently failed an outpatient stress test. CE and cath
as above. Echo as above. We treated with ASA and statin. We
also treated with a heparin gtt given her afib but also embolic
disease seen on cath and was then started on Coumadin without a
heparin bridge. She did not experience chest pain, and there
was no obstructive coronary disease on cath save for the embolic
event to the AV nodal branch and distal RCA which remains of
questionable clinical significance. Per cardiology consultation,
patient remained on anticoagulation likely for the long term
given her underlying A.fib.
.
#) PUMP: As above. Pump function initially impaired but this
was thought [**3-7**] vfib arrest, compressions, and DCCV. Repeat
echo was improved. AICD not recommended. CXR showed mild/mod
failure so the patient was initially diuresed. She is
discharged off lasix and ACEI due to dehydration and
hyponatremia. She may eventually require prn lasix and and ACEI
may be added once her remain function remains stable. Her weight
should be measured daily to follow her volume status and lasix
given should her weight increase by [**3-8**] Kgs over a 2 day period.
.
#) COPD: Well controlled w/ spiriva and albuterol as an outpt;
We continued these interventions.
.
#) Tachynpnea: Patient was often tachypneic ranging from 20-30s
but with no hypoxia. Given her history of both colon and lung
cancer, a CT scan of the chest was obtained which was as above.
We recommend a followup CT in three months to assess interval
change of 7mm right middle lobe opacity and LLL patchy opacity.
She was tachypnic at baseline, thought to be multifactorial =
chest bruising, anxiety, effusion. Her oxygen saturations
remained stable on room air. Diuresis was held as above given
dehydration.
.
#) Hyponatremia: Reached a nadir of 126. This was thought to be
secondary to aggressive diuresis. Her urine lytes were
consistent with pre-renal azotemia and not SIADH. We also
considered pulmonary process given her tachypnea and history of
lung cancer thus obtained the CT chest as above. Her sodium is
stable on discharge at 127 however she requires close monitoring
of her electrolytes.
.
#) HTN: Controlled w/ diltiazem and lisinopril as outpt. We
treated with BB, Spironolactone and lasix in house. Upon
discharge she is on a beta blocker alone with good blood
pressure control. Lisinopril may be added back as an outpatient
if needed.
.
#) Anxiety: Diazepam at low doses as needed.
.
#) Hypothyroidism: Controlled w/ levothyroxine
.
#) Communication: HCP [**Name (NI) 553**] [**Name (NI) 4702**] [**Telephone/Fax (1) 72894**]
.
#) Full code.
Medications on Admission:
ALLERGIES:
- sulfa
- vancomycin
- Cipro
- codeine
.
MEDICATIONS AT HOME:
- diltiazem 120 mg qam, 60 mg qpm
- lisinopril 5 mg daily
- coumadin 4 mg alternating w/ 2 mg every other day
- lasix 100 mg po every other day
- synthroid 75 mcg daily
- valium 2 mg po qhs prn
- spiriva daily
- albuterol INH prn
Discharge Medications:
1. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours.
Disp:*1 inhaler* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a week as
needed for weight gain more than 2 kgs.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 11 days: start date [**7-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 27838**] Rehab &[**Hospital **] Care Center
Discharge Diagnosis:
Primary:
- C.diff diarrhea
- syncope
- urinary tract infection
- polymorphic VT
- chronic atrial fibrillation
- pacer dependent bradycardia
- transient ischemic attack, resolved
- long QT in setting of bradycardia
- congestive heart failure, systolic
- hypertension
- COPD
- hyponatremia
- persistent right pleural effusion
Secondary:
- valvular heart disease: mild to mod AR, mild MR, mod to severe
TR
- pulmonary HTN
- bronchoalveolar lung ca s/p left lobe resection [**9-7**]
- colon cancer: T3N1 adenoca s/p right hemicolectomy [**7-8**]
- hypothyroidism
- anxiety disorder NOS
- hx of MRSA bacteremia after thoracotomy
- s/p cholecystectomy
Discharge Condition:
Fair - stable O2 saturation, able to get out of bed to chair,
needs ongoing physical therapy and rehabilitation, no further
episodes of malignant tachyarrythmias s/p permanent pacemaker
placement.
Discharge Instructions:
You came in after having syncope in the setting of atrial
fibrillation, bradycardia and having a polymorphic ventricular
tachycardia arrest, felt secondary to bradycardia and consquent
long QT. You developed a urinary tract infection and we treated
with IV antibiotics. You required a temporary pacer and
ultimately had a permanent pacemaker placed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] once the infectious issues were felt to be resolved.
.
Please take all of your medications as instructed. Please
followup with your PCP and cardiologist as instructed. If you
notice any significant palpitations, chest pain, worsening
shortness of breath, abdominal pain or leg swelling, please
contact your PCP or come to an emergency department for an
evaluation.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2194-8-5**]
10:30
.
Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24522**] on [**8-8**] @ 10:45AM
.
Please have a followup CT of your chest within 3 months to
assess interval change.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]
Completed by:[**2194-7-28**]
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32,512
| 136,799
|
26155
|
Discharge summary
|
report
|
Admission Date: [**2157-8-15**] Discharge Date: [**2157-9-1**]
Date of Birth: [**2126-9-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
PICC line placement
Intubation and extubation
Bronchoscopy
History of Present Illness:
This is a 30 year-old female with a history of spina bidifida,
suprapubic catheter, recurrent UTIs who presents with fever,
hypotension and mental status changes. Per report, patient was
found unconscious one day PTA in [**Location (un) **] on her wheelchair
and was brought in by ambulance. Patient reports that she had
had 5 drinks prior to this episode. She denies any other
substance use at the time. Her main complaint is back pain that
she says has never really gotten much better compared with her
prior admission. She denied any symptoms that typically occur
for her VP shunt if it has a problem, such as headache, nausea,
or vomitting.
.
Of note, patient was recently discharged after an admission for
back pain and fevers. She was treated with a 5-day course of
ceftriaxone for presumed complicated urinary tract infection.
.
In the ED, patient was febrile to 102, with a blood pressure of
96/50, and tachycardic to 129, O2Sat:96% on RA. She received 4
litres normal saline IV fluids for tachycardia and borderline
low-blood pressure, and was given 1 gram of ceftriaxone and 1
gram of Vancomycin after blood and urine cultures were sent.
She also received Lorazepam and haloperidol for agitation on
initial presentation. Later in the ED course, patient was given
total of 25mg diazepam IV for concern that tachycardia was
related to EtOH withdrawal. The tachycardia did not improve
substantially.
Past Medical History:
PMH:
1. Spinabifida with hydrocephalus, VP shunt, Chiari malformation
2. Seizures ?
3. UTIs/Pyelonephritis with suprapubic cath
4. Ovarian Cysts
5. Sacral decubitus ulcer
6. Atypical Chest Pain
7. Hx of PE with vena cava filter
Social History:
The patient current lives with her mother and cousin in
[**Location (un) 686**] who help her with her activities of daily living. She
reports she is predominantly wheel chair bound and cannot
ambulate.
Tobacco: 1 PPD
ETOH: 5-6 beers at a time approximately once a week when
"feeling depressed"
Illicits: Reports no use current or ever
Family History:
Non-contributory
Physical Exam:
ICU Physical Admission:
.
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Suprapubic
catheter
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person place and time, Movement: Not
assessed, Sedated, Tone: Not assessed
Pertinent Results:
Labs on admission:
[**2157-8-15**] 06:40AM WBC-8.0 RBC-4.94 HGB-9.7* HCT-35.2* MCV-71*
MCH-19.7* MCHC-27.7* RDW-16.8*
[**2157-8-15**] 06:40AM NEUTS-39.0* BANDS-0 LYMPHS-49.3* MONOS-3.2
EOS-7.4* BASOS-1.1 PLT SMR-VERY HIGH PLT COUNT-690*#
[**2157-8-15**] 06:40AM GLUCOSE-139* UREA N-7 CREAT-0.5 SODIUM-146*
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-18
[**2157-8-15**] 06:40AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2157-8-15**] 06:40AM URINE RBC-18* WBC-7* BACTERIA-FEW YEAST-MOD
EPI-1
[**2157-8-15**] 06:40AM URINE MUCOUS-FEW
.
Labs on discharge:
[**2157-9-1**] 05:46AM BLOOD WBC-14.9* RBC-3.61* Hgb-7.7* Hct-26.7*
MCV-74* MCH-21.3* MCHC-28.8* RDW-22.0* Plt Ct-539*
[**2157-9-1**] 05:46AM BLOOD Glucose-81 UreaN-5* Creat-0.4 Na-141
K-4.5 Cl-102 HCO3-32 AnGap-12
[**2157-9-1**] 05:46AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
.
EKG [**2157-8-15**]
Sinus tachycardia
QRS changes V3/V4 - probably due to LVH but consider anterior
infarct
ST-T wave abnormalities
Since previous tracing of [**2157-7-28**], heart rate faster
Intervals Axes
Rate PR QRS QT/QTc P QRS T
138 144 76 298/434 33 38 41
.
Microbiology:
[**2157-8-15**] Urine cx - mixed flora
[**2157-8-16**] Urine cx - enterococcus
[**2157-8-20**] Urine cx - yeast
[**2157-8-24**] Urine cx - yeast
[**2157-8-24**] Urine legionella Ag - negative
.
[**2157-8-15**], [**2157-8-19**] Blood cx - negative
.
[**2157-8-24**] Cryptococcal Ag (blood) - negative
.
[**2157-8-24**] BAL - gram stain 3+ PMNs, cx negative, PCP negative,
[**Name9 (PRE) 9277**] smear negative, acid fast culture pending, cytology
negative for malignant cells
.
Imaging:
[**2157-8-15**] CXR
IMPRESSION: Visualized portion of the ventriculoperitoneal shunt
appears
intact.
.
[**2157-8-21**] Chest CT:
IMPRESSION:
1. Interval worsening of bilateral ground-glass opacities
predominantly in the upper and mid lung zones. Multiple discrete
nodules measuring up to 4 mm within both lungs are identified.
These findings are concerning for an
infectious process and possible ARDS.
2. Multiple subcentimeter lymph nodes are identified within the
bilateral
axilla, left supraclavicular region, and pericardium as
described above.
3. Small hiatal hernia.
4. 4-mm hypodense lesion in the right lobe of the liver which is
too small to characterize.
5. Left breast soft tissue density (2,67) measuring 9x13 mm of
unclear
significance.
.
[**2157-8-24**] ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). Diastolic function could not be assessed.
Right ventricular chamber size and free wall motion are normal.
The number of aortic valve leaflets cannot be determined. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: sub-optimal technical quality due to poor echo
windows. Left ventricular function is hyperdynamic, a focal wall
motion abnormality cannot be fully excluded. No pathologic
valvular abnormality seen. Pulmonary artery systolic pressure
could not be determined.
.
[**2157-8-25**] Bilateral LE U/S:
IMPRESSION:
No evidence of DVT bilaterally.
.
[**2157-8-29**] CXR:
IMPRESSION: Improved aeration of lungs with persistent
multifocal patchy
opacities and interval decrease in bilateral pleural effusions.
Brief Hospital Course:
Patient is a 30 year old female with history of spina bifida,
suprapubic catheter, recurrent UTIs who initially presented with
mental status changes, with a subsequent prolonged hospital
course including sepsis, respiratory failure.
1. Sepsis: On presentation, the patient was noted to have
fever, hypotension, and altered mental status. She was
initially given broad spectrum antibiotics for presumed sepsis
from a urinary tract infection. She also had a cortisol
stimulation test to rule out adrenal insufficiency which was
negative. Urine cultures grew vancomycin resistent
enterococcus, and she was eventually placed on linezolid and
completed a course of antibiotics. Her hypotension resolved with
IV fluids and antibiotics. The patient had continued fevers
with treatment, so blood, urine and sputum cultures were sent.
She was noted to have a new oxygen requirement as well, and was
started on broad spectrum antibiotics with vancomycin,
ceftriaxone and aztreonam for presumed infectious, ?aspiration
pneumonia. See below under respiratory failure for remainder of
events
2. Respiratory failure: As above, the patient developed
increased oxygen requirement, along with fevers, so suspected
pulmonary infection was entertained, and she was started on
broad spectrum antibiotics. She developed hypercarbic
respiratory failure requiring transfer to the intensive care
unit and intubation. She had a BAL performed which was
unrevealing with negative cultures. Her respiratory status
slowly improved and her antibiotics were tapered down to
azithromycin alone to complete a 7 day course. Infectious
disease service was involved in her care. She was successfully
extubated and weaned to room air by time of discharge. She had
completed her course of azithromycin and was discharged on
ipratropium nebulizers.
3. Mental status changes: The patient was initially admitted to
the intensive care unit with mental status changes, and sepsis
as above. Her mental status changes were also attributed to
alcohol intoxication as her EtOH level was elevated on
admission. Her mental status quickly resolved to baseline
during hospital course.
4. Supraventricular tachycardia: Throughout her stay in the ICU
she had sinus tachycardia with heart rate 110-120s. This did
not respond to fluid bolus or pain control. Her lower extemity
dopplers were negative for DVT and she has IVC filters due to
previous PE, so we decided PE was an unlikely cause. She
remained stable during remainder of her hospital course.
5. FEN: Due to concern for aspiration causing her lung
pathology, she received a swallow study which showed silent
aspiration. She had difficulty clearing her own secretions
after intubation. She was re-evaluated once stabilization on
floor and was noted to have continued aspiration with thin
liquids. She was given instructions on how to pre-thicken her
liquids at home, and how to obtain liquid thickener from the
pharmacy.
6. ?Obstructive sleep apnea: The patient was also noted to have
episodes of apnea on her first visit to the the ICU, so she was
maintained on CPAP at night during her hospital course. She
should have a formal sleep study performed as an outpatient,
arranged by her primary care physician.
7. Chronic pain: The patient was maintained on her outpatient
neurontin, lidocaine patch, fentanyl patch, and morphine
(extended and immediate release) with good pain control.
8. VP Shunt: The patient has a known VP shunt which was noted
on CT scan during admission and felt to be functional. She
should follow up with her neurosurgeon at [**Hospital6 13185**], Dr. [**Last Name (STitle) **], on discharge. This was communicated with
the patient.
9. GERD: The patient was maintained on a PPI.
10. Tobacco: The patient was maintained on nicotine patch.
11. Mixed iron-deficiency anemia and anemia of chronic disease:
Continued ferrous sulfate.
12. Left breast tissue mass: This was noted on CT chest, of
unclear significance. This should be followed up with further
outpatient testing per her PCP.
13. Social issues: The patient was noted to have some home
stressors and social work was involved during her hospital
course. She also became quite focused on certain things during
her hospital stay, for example, she was adamant that she wanted
a CPAP machine at home. I explained to her that she needed to
have formal testing for obstructive sleep apnea, which could be
set up, and if positive, then she could have that arranged. It
appears as though she may have stolen the CPAP machine from her
room on discharge.
Medications on Admission:
#. Gabapentin 600mg TID
#. Docusate Sodium 100mg [**Hospital1 **]
#. Senna 8.6mg [**Hospital1 **]
#. Omeprazole 20mg [**Hospital1 **]
#. Heparin 5,000 unit TID
#. Nicotine 21 mg/24hr q24H
#. Acetaminophen 500mg TID PRN
#. Lactulose 10gram/15mL q8H PRN
#. Miconazole Nitrate 2% Powder Topical [**Hospital1 **]
#. Ferrous Sulfate 325mg daily
#. Morphine 15mg Tablet q3H PRN
#. Ibuprofen 600mg TID
#. Lidocaine 5% daily
#. Ceftriaxone-Dextrose x 2 days
Discharge Medications:
1. Wheelchair
Motorized wheelchair. Please dispense one. No refills.
2. Gabapentin 300 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*120 Capsule(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
5. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
6. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for to back and legs.
7. Morphine 15 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) as needed for pain.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
8. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for back pain.
Disp:*15 Patch 72 hr(s)* Refills:*0*
9. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for severe breakthrough pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer
Inhalation three times a day.
Disp:*90 nebulizer treatments* Refills:*2*
13. Fexofenadine 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Nebulizer
1 nebulizer machine. Please include nebulizer mask.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Urinary tract infection
2. Sepsis
3. Aspiration pneumonia
4. Chronic low back pain
Secondary:
Spina Bifida
Recurrent UTIs
History of PE
Sacral decubitus ulcer
Discharge Condition:
Stable. Oxygenating well, mentating well.
Discharge Instructions:
If you develop increased shortness of breath, fevers, chills, or
pain in your back, you will need to call your primary care
doctor or go to the emergency room.
Please take medications as directed.
Please follow up with appointments as directed.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 7537**] ([**Telephone/Fax (1) 58249**] on thursday [**9-22**] at 10AM (will be seeing his
nurse practitioner). He will need to schedule you for a sleep
study to see if you have obstructive sleep apnea and would
benefit from a CPAP machine at home.
Please follow up with neurosurgery doctor, Dr. [**Last Name (STitle) **]. Please
call to make an appointment with this physician in the next [**1-12**]
weeks.
|
[
"305.1",
"285.29",
"741.00",
"V12.51",
"530.81",
"427.0",
"724.2",
"599.0",
"280.9",
"518.81",
"507.0",
"995.91",
"707.03",
"038.9",
"305.01",
"V45.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
13973, 14030
|
6940, 11521
|
290, 351
|
14237, 14282
|
3228, 3233
|
14577, 15064
|
2417, 2435
|
12022, 13950
|
14051, 14216
|
11547, 11999
|
14306, 14554
|
2450, 3209
|
232, 252
|
3863, 6917
|
379, 1797
|
3247, 3844
|
1819, 2049
|
2065, 2401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,190
| 157,524
|
27958
|
Discharge summary
|
report
|
Admission Date: [**2143-10-27**] Discharge Date: [**2143-10-30**]
Date of Birth: [**2070-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
fevers, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 52-year-old male with a past medical history of
CAD (s/p BMS x 2 [**6-3**]), chronic systolic HF, polycythemia [**Doctor First Name **],
and CRI (baseline Cr~2.0), and recent inguinal hernia repair who
presents with coplaints of chest pain. The patient underwent a
cardiac cath [**2143-6-3**] after an abnormal stress test, showing 2VD.
He had BMS x 2 place to his D1 and OM1. His course had been
complicated by the development of a right groin hematoma, s/p
evacuation, and 3-cm femoral artery pseudoaneurysm, which was
treated by IR. The patient had developed increasing right
inguinal groin pain, and was found to have an inguinal hernia.
He underwent an open inguinal hernia repair on [**10-15**].
On the day prior to presentation, the patient was feeling
increasing fatigue and mild dynpea on exersion. As the day
progressed began to feel chilled and had rigors. He was unable
to sleep that night, experiencying orthopnea, and increasing
dysnpea. He reports that the feeling of SOB was similar to a
prior CHF exacerbation. He also began to experience mild chest
tightness, which persisted for hours, even upon arrival to the
ED.
.
He denies any recent infecious symptoms. No sinus pain, cough,
abdominal discomfort, diahrea, dysuria. He has not noted any
erythema or increasing tendernss of right groin surgical site.
He has noted a slight increase in ankle swelling, but no pain
with passive movement.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
.
In the ED, vitals were 101.2 145/69 130 99%on 3L. EKG showed
sinus tach with STD in V3-V6. CXR showed ?CHF. He was given asa,
nitro, plavix, and heparin. Became hypotensive to 90's with
nitro and morphine. No BB was given secondary to CHF. He was
additionally given 40mg IV lasix, and put out 1L. He has been
seen by gen surgery in ED, was seen at [**Location (un) 620**] ED by vascular
per ED report they are ok with anticoag. They felt that there
was no clinical suspicion of right groin infection. Had fever
to 101 got vanc and zosyn for PNA, and admitted to the CCU for
further manegment.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS x 2 to D1/OM1 [**6-4**]
3. OTHER PAST MEDICAL HISTORY:
.
Systolic chronic CHF
Hypertension
Hyperlipidemia
Myeloproliferative disorder, essential thrombocythemia
Paroxysmal atrial fibrillation
Chronic renal insufficiency (baseline creatinine 1.8-2.0)
Testicular lymphoma, status post orchiectomy, radiation and
chemo completed [**2132**]
status post y-plasty of kidney 38 years ago
Hernia repair
bilateral meniscus tears
Gout (had flare in [**5-5**] with CHF admission, was started on
allopurinol)
Chronic systolic HF
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Retired liquer distributor, married with three children.
Family History:
Father with CAD, sister died of CVA age 77.
Physical Exam:
VS: T=98.4 BP= 107/65 HR=100 RR=20 O2 sat= 100% on 4L
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 *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic with APCs, normal S1, S2, with ? of systolic
murmur. No rubs. 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,mild inguinal tenderness, with palpable right
groin hematoma and surrounding abdominal ecchymosis, no
erythema. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: Mild left ankle edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2143-10-27**] 05:10AM BLOOD WBC-25.8*# RBC-3.44* Hgb-8.9* Hct-27.0*
MCV-79* MCH-25.8* MCHC-32.9 RDW-13.7 Plt Ct-801*
[**2143-10-27**] 05:10AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-5 Eos-1
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2143-10-27**] 05:10AM BLOOD PT-17.0* PTT-36.3* INR(PT)-1.5*
[**2143-10-27**] 05:10AM BLOOD Glucose-156* UreaN-28* Creat-2.0* Na-132*
K-4.9 Cl-100 HCO3-20* AnGap-17
[**2143-10-27**] 05:10AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 68079**]*
[**2143-10-27**] 05:10AM BLOOD cTropnT-0.53*
[**2143-10-27**] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.67*
[**2143-10-28**] 04:18AM BLOOD CK-MB-NotDone cTropnT-0.72*
[**2143-10-30**] 05:22AM BLOOD CK-MB-5 cTropnT-0.39*
[**2143-10-27**] 05:10AM BLOOD CK(CPK)-76
[**2143-10-27**] 04:20PM BLOOD CK(CPK)-89
[**2143-10-28**] 04:18AM BLOOD CK(CPK)-53
[**2143-10-30**] 05:22AM BLOOD CK(CPK)-67
[**2143-10-28**] 04:18AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.3 UricAcd-7.1*
[**2143-10-27**] 05:21AM BLOOD %HbA1c-5.7
[**2143-10-30**] 05:25AM BLOOD Vanco-16.6
[**2143-10-27**] 07:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2143-10-27**] 07:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
Blood cultures [**2143-10-27**]: No growth to date
Urine Cultures [**2143-10-27**]: No growth to date
.
Chest X-ray [**2143-10-27**]: Mild interstitial edema. No evidence of
pneumonia.
.
ECG [**2143-10-27**]: Sinus tachycardia w/ APCs @ 110, 1mm ST
depressions in v3-v5, TWI v1-v2 (unchanged.) Left anterior
fasicular block, LVH
.
Pelvic CT [**2143-10-27**]:
1. Mixed-density moderate-sized collection within the right
inguinal canal, consistent with postoperative hematoma. No
regions of air locules are present within this collection to
suggest superinfection. Right scrotal hydrocele.
2. More discrete air-containing collection is noted superiorly
adjacent to
the surgical mesh. This is presumably related to adjacent
bioabsorbable plug which was placed per operative report. Focal
abscess thought to be less likely.
3. Colonic diverticulosis without evidence of acute
diverticulitis.
.
Femoral Artery Ultrasound [**2143-10-27**]: Large right groin hematoma.
No evidence of pseudoaneurysm or AV fistula.
.
Transthoracic Echo [**2143-10-28**]: The left atrium is mildly dilated.
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Right ventricular chamber size is
normal. with borderline normal free wall function. The ascending
aorta is mildly dilated. The aortic valve leaflets appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild mitral regurgitation. Dilated ascending aorta.
.
V/Q Scan [**2143-10-28**]: Low likelihood ratio for recent pulmonary
embolism.
.
Persantine Mibi [**2143-10-28**]: Predominantly fixed distal anterior
wall and apical defect. 2. Markedly dilated left ventricular
cavity. 3. Global hypokinesis and apical akinesis with depressed
LVEF of 39%.
Brief Hospital Course:
Mr. [**Name13 (STitle) 41519**] was admitted to the hospital with fevers, chest
tightness and shortness of breath after recent inguinal hernia
repair and significant R groin hematoma. He was evaluated by
surgery in the emergency room who felt that he did not need
further surgical procedures. He was given put on a
nitroglycerin drip and heparin drip in the ED and these were
weaned off upon arrival to the floor. He was treated with
broad-spectrum antibiotics initially with Vancomycin and Zosyn
for possible groin infection and this was changed to Vancomycin
alone on [**2143-10-29**]. He was initially given Lasix for possible CHF
exacerbation and recieved Lasix 40mg PO. His cardiac enzymes
were cycled and CKs were flat with an elevated Troponin felt to
be due to his renal function. He had a pelvic CT and ultrasound
for concerns for groin infection with recent surgery and these
studies were reassuring that he did not have an infection, but
he was kept on the antibiotics for a total 10 day course. The
vancomycin was changed to Augmentin upon discharge.
.
He was evaluated by both vascular surgery and by his general
surgeon, Dr. [**First Name (STitle) **]. He has a follow-up appointment with Dr. [**First Name (STitle) **]
on [**2143-11-1**]. For his tachycardia, he underwent a V/Q scan for
concern for pulmonary embolism which was low probability. He
had a persatine thallium study to evaluate his coronaries which
showed a fixed lesion and normal stress portion. He will
follow-up with his PCP and with cardiology as an outpatient.
His Metoprolol was increased to 75mg PO TID for heart rate
control and Toprol XL was stopped. He was continued on his
Niacin and Simvastatin for hypercholesterolemia. He was
continued on aspirin and Plavix for his coronary disease and
history of recent stent.
.
For his renal function, his creatinine was checked daily and he
was given no further Lasix. He experienced joint swelling and
was evaluated by rheumatology who did not feel that this was a
gout flare. He was continued on his Allopurinol for gout. He
was continued on Anagrelide for his essential thrombocytosis.
He was given a blood transfusion of 1 unit on [**2143-10-30**] prior to
discharge. He should follow-up with his primary care doctor
regarding his polycythemia [**Doctor First Name **] and essential thrombocytosis.
.
He was discharged on [**2143-10-30**] with follow-up with his general
surgeon and instructions to follow-up with his PCP and
cardiologist. He was given prescriptions for Metoprolol and
Augmentin. On discharge, his final blood cultures were still
pending.
Medications on Admission:
Allopurinol 100 mg Tablet daily
Anagrelide 1.5 mg [**Hospital1 **]
ASA 325mg daily
Clopidogrel 75 mg Tablet daily
Docusate Sodium [Colace] 100 mg Capsule [**Hospital1 **]
Furosemide 40 mg daily
Toprol XL 50mg daily
Niacin 500 mg Capsule daily
Simvastatin 20 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Anagrelide 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
8. Augmentin 500-125 mg Tablet Sig: Five (5) Tablet PO twice a
day for 6 days.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. R Groin Hematoma
2. Coronary Artery Disease
3. Chronic Kidney Disease
4. s/p Inguinal Hernia Repair
Secondary Diagnoses:
5. Polycythemia [**Doctor First Name **]
6. Essential Thrombocytosis
7. Gout
8. Hypertension
9. Hyperlipidemia
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
were felt to have a possible infection in your right groin with
a hematoma. You were treated with antibiotics for this. You
were seen by your surgeons who did not recommend further
intervention on your groin. Your heart was evaluated and it was
determined that you did not have a heart attack. You had an
echocardiogram showing normal heart function.
Your Metoprolol dose was increased to 75mg PO twice a day. You
were given an antibiotic, Augmentin and should take this for 6
more days.
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68080**], in the next 2
weeks. You should see Dr. [**Last Name (STitle) **] within the next month. You
should follow-up with your surgeon, Dr. [**First Name (STitle) **] as scheduled on
[**2143-11-1**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: [**2134**] ml.
You should call your doctor or seek medical attention for any
fevers > 100.4, chills, night sweats, vomiting, worsening of
your hematoma at your surgery site, severe pain at your surgery
site, worsening of the swelling in your legs or feet,
palpitations, shortness of breath, chest pain, chest tightness
or pressure, or any other symptoms that concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2143-11-1**]
11:45
.
You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68080**] in the next 2
weeks. You should see your cardiologist, Dr. [**Last Name (STitle) **], within 1
month.
|
[
"998.12",
"428.23",
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"V45.82",
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"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11914, 11920
|
8247, 10858
|
328, 335
|
12219, 12254
|
4591, 8224
|
13651, 14012
|
3482, 3528
|
11175, 11891
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11941, 11941
|
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|
12278, 13628
|
3543, 4572
|
12085, 12198
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2773, 2840
|
277, 290
|
363, 2679
|
11960, 12064
|
2871, 3334
|
2701, 2753
|
3350, 3466
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,477
| 109,929
|
43120
|
Discharge summary
|
report
|
Admission Date: [**2113-1-12**] Discharge Date: [**2113-1-15**]
Date of Birth: [**2033-5-6**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Fatigue, Anuria
Major Surgical or Invasive Procedure:
Intraaortic Balloon Pump Placement
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
79 year old man with diastolic heart failure, chronic afib, CHF,
CRI, male breast cancer s/p masectomy with two recent admissions
presents with anuria and malaise. He was hospitalized from
[**Date range (1) 18845**] with a CHF exacerbation, and was diuresed 30 lbs (to
dry weight of 155 lbs). He was then hospitalized from [**11-29**]-
[**12-6**] with e coli urosepsis, treated with 4 weeks IV
ceftriaxone. Recent echo concerning for endocarditis due to ?
endocarditis. Seen in [**Hospital **] clinic [**1-10**]. No evidence of active
infection at time of visit. Culture neg endocaritis panel
pending at this time - sent as pt had persistent fever after
treatment for e.coli infection. At cardiology visit on [**1-11**] pt
found to be in ARF with Cr of 3.3 and evidence of worsening
volume overload. He was advised to come into the hospital.
Metolazone was discontinued and he was advised to hold his
torsemide. His digoxin and allopurinol were also held.
On admission today the patient reports increased edema of LE as
well as increasing abdominal distention. No urine output today.
His wife notes he has become increasing somnulent. The patient
denies dyspnea and states he has been able to walk around his
home. Does not climb stairs - utilizes chair lift. His wife adds
that he has required a walker for ambulation over the past few
days. He has had increased loose stools [**2-28**] daily for past days,
worse than his baseline. He is complaining of thirst and reports
good appetite.
On arrival to the ED the patient has an intial SBP in 90s and HR
60s, then pressure dipped to mid 70s but he continued to mentate
well. He was started on lasix gtt at 20mg/hr and received diuril
250mg.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative. Complains of fatigue and loose
stools as above.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations. The patient does report intermittent
lightheadedness with standing.
Past Medical History:
diastolic CHF
atrial fibrillation
male breast cancer s/p R mastectomy in [**2104**]
hypertension
dyslipidemia
gout
.
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: No prior CABG. No history of PCI.
Social History:
Social history is significant for the absence of current tobacco
use, last smoked [**2069**]. There is no history of alcohol abuse, he
currently drinks 1 drink per night. Prior [**University/College **] professor.
.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PHYSICAL EXAMINATION
VS - Tc 97.4, HR 61, BP 88/42, RR 14, 95%RA, 0
Gen: Elderly male in NAD. Oriented x3. Irritable. Dyspneic with
speaking
HEENT: Sclera anicteric. PERRL, EOMI. Dry MM, clear OP.
Neck: Supple with JVP at earlobe
CV: Irregularly irregular, normal S1, S2. 2/6 SEM at RUSB. [**3-2**]
systolic murmur over mitral area with radiation to axilla. No
thrills, lifts. No S3 or S4.
Chest: Resp were slightly labored. decreased BS at RLL with
dullness to percussion.
Abd: Soft, +distention and fluid wave
Ext: 1+ ankle edema, 3+ thigh edema b/l. DP and PT dopplerable
Skin: + stasis changes bilateral LE. No ulcers, scars, or
xanthomas. Warm extremities
Pertinent Results:
EKG demonstrated atrial fibrillation with ventricular rate
60bpm. LAD. QRS126 - IVCD. Low voltage in leads II,III, AVF with
q waves in III and AVF. Poor R wave progression. Non specific
diffuse twave flattening. No ST changes with no significant
change compared with prior dated [**2113-12-1**].
.
[**2113-1-12**] 03:30PM WBC-6.3 RBC-4.27* HGB-13.3* HCT-40.2 MCV-94
MCH-31.1 MCHC-33.0 RDW-17.9*
[**2113-1-12**] 03:30PM NEUTS-74.2* LYMPHS-17.2* MONOS-7.8 EOS-0.4
BASOS-0.3
[**2113-1-12**] 03:30PM PLT COUNT-108* LPLT-3+
[**2113-1-12**] 03:30PM PT-28.2* PTT-37.8* INR(PT)-2.8*
[**2113-1-12**] 03:30PM CALCIUM-8.6 PHOSPHATE-8.5*# MAGNESIUM-3.3*
[**2113-1-12**] 03:30PM CK-MB-8 cTropnT-0.04*
[**2113-1-12**] 03:30PM ALT(SGPT)-17 AST(SGOT)-48* CK(CPK)-104 ALK
PHOS-167* AMYLASE-91 TOT BILI-0.4
[**2113-1-12**] 03:30PM LIPASE-123*
[**2113-1-12**] 03:30PM GLUCOSE-167* UREA N-169* CREAT-4.5*#
SODIUM-127* POTASSIUM-5.4* CHLORIDE-85* TOTAL CO2-28 ANION
GAP-19
[**2113-1-12**] 03:43PM LACTATE-1.7 K+-4.8
[**2113-1-12**] 05:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-1-12**] 05:07PM URINE RBC-[**3-1**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2113-1-12**] 05:07PM URINE GRANULAR-0-2 HYALINE-[**6-6**]*
[**2113-1-12**] 05:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
.
CXR [**2113-1-12**] - AP UPRIGHT CHEST: There has been interval removal
of a left-sided PICC. Moderate enlargement of the cardiac
silhouette is stable. Mediastinal and hilar contours are
unchanged. Mild vascular engorgement and redistribution is again
identified, consistent with mild volume overload. There is a
stable moderate right pleural effusion with chronic right volume
loss and right basilar opacity, likely atelectasis. No
pneumothorax is identified. Visualized bony structures of the
thorax are stable.
IMPRESSION:
1. Enlarged cardiac silhouette with pulmonary vascular
redistribution consistent with mild volume overload.
2. Stable moderate right pleural effusion with right basilar
opacity, likely atelectasis, although underlying pneumonia is
not excluded.
.
Renal US [**2113-1-13**]
FINDINGS: The right kidney measures 12.3 cm and the left kidney
measures 13.4 cm. Again seen are multiple simple cysts on each
of the kidneys. The largest cyst on the right kidney measures
6.3 x 7.0 x 7.8 cm. The largest cyst on the left kidney measures
14.0 x 12.4 x 11.6 cm. There is no hydronephrosis seen and no
solid masses or stones are identified in either kidney. There is
ascites noted within the abdomen and a right pleural effusion is
also seen. A Foley catheter is identified within the minimally
distended bladder. The bladder wall is noted to be thickened.
IMPRESSION:
1. No hydronephrosis.
2. Multiple simple renal cysts.
3. Ascites with right pleural effusion.
4. Thickened bladder wall.
.
Cath [**1-13**]:
FINAL DIAGNOSIS:
1. Severe left and right ventricular diastolic dysfunction.
2. Severe pulmonary arterial hypertension.
3. Successful insertion of an intra-aortic balloon pump, albeit
with
minimal systolic unloading.
4. Atrial fibrillation.
5. Catheter-induced ventricular tachycardia.
.
TTE [**1-14**]:
The left atrium is markedly 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 70%). There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is partial anterior mitral
leaflet flail. There is small vegetation on the mitral valve
(remnant of prior endocarditis). An eccentric, posteriorly
directed jet of Moderate (2+) mitral regurgitation is seen (due
to the eccentric nature of the mitral regurgitation, the
volumetric assessment (based on color flow imaging) of mitral
regurgitation may be underestimated. The tricuspid valve
leaflets are mildly thickened. The supporting structures of the
tricuspid valve are thickened/fibrotic. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. Significant pulmonic regurgitation is seen. The
main pulmonary artery is dilated. The branch pulmonary arteries
are dilated. There is a small pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade.
Compared to the previous study of [**2112-12-28**], the mitral
regurgitation is reduced, the forward stroke volume is
increased, and the aortic regurgitation is unchanged.
Brief Hospital Course:
79M with diastolic heart failure, 4+ TR and 3+ MR afib, RF in
past related to obstruction, prostate ca, CKD (baseline Cr ~1.5)
admitted with hypotension and anuria.
.
1. Decompensated Diastolic Heart Failure/Valvular Heart Disease:
The patient presented with severe decompensated diastolic heart
failure; likely precipitated by multivalvular disease. He was
anuric on admission and was started on a lasix gtt overnight
with minimal improvement in urine output. Renal consultation was
obtained and anuria felt to be prerenal in etiology. Lasix gtt
was discontinued. The patient underwent IABP placement on [**1-13**]
with subsequent improvement in urine output and Cr. The patient
then underwent TTE and evaluation for valvular surgery as his
condition was unlikely to resolve without repair of TR and MR.
The patient refused consideration for surgery and also elected
to have the IABP removed. After discussion with the patient and
family, the patient requested to transition his care to comfort
measures. He expired on [**1-15**] at 15:15, shortly after IABP
removal.
.
2. Rhythm - Atrial fibrillation; induced Vtach during placement
of balloon but no intervention required and returned to Afib. Pt
remained well rate controlled.
.
3. Valves - Moderate (2+) AR, Moderate to severe (3+) MR,
Severe [4+] tricuspid regurgitation. Pt declined consideration
of valvular repair/replacement.
.
4. ARF: Pt presented with anuria. Cr 4.5 from 1.9 on [**1-5**].
Etiology consistent with prerenal. Treatment with lasix gtt and
IABP as above.
Medications on Admission:
CURRENT MEDICATIONS: (Per wife's medication list)
Torsemide 100 mg Tablet [**Hospital1 **]
Metolazone 5 mg T/Th/Sat - stopped
Losartan 25 mg daily
MAGNESIUM OXIDE 400 mg daily
Toprol XL 100 mg SR daily
Finasteride 5 mg daily
Tamsulosin 0.4 mg daily
Warfarin 2 mg daily T,W,Th,Sat, 1mg M,F
Femora 2.5mg daily
Gemfibrozil 600mg daily
Allopurinol 75mg daily - stopped
Lipitor 5mg daily
Digoxin 0.4mg daily - stopped
Discharge Disposition:
Expired
Discharge Diagnosis:
Diastolic Congestive Heart Failure
Valvular Heart Disease
Discharge Condition:
Expired
|
[
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"427.1",
"789.59",
"428.0",
"593.2",
"272.4",
"287.5",
"799.1",
"416.8",
"585.9",
"274.9",
"403.90",
"397.0",
"V66.7",
"584.9",
"427.31",
"600.00",
"V10.3",
"997.1",
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icd9cm
|
[
[
[]
]
] |
[
"37.61",
"37.21",
"99.05",
"99.07",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11041, 11050
|
9044, 10577
|
298, 334
|
11151, 11161
|
4007, 6919
|
3228, 3310
|
11071, 11130
|
10603, 10603
|
6936, 9021
|
3325, 3988
|
243, 260
|
10624, 11018
|
362, 2718
|
2740, 2978
|
2994, 3212
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,083
| 120,427
|
28992
|
Discharge summary
|
report
|
Admission Date: [**2200-8-18**] Discharge Date: [**2200-8-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
HPI: 84 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] w/ a PMH of severe MR, HTN, and a recent
diagnosis of cryptogenic PNA who was transferred to the ICU in
the setting of abdominal pain and elevated lactate/wbc. He was
originally admitted following a lung bx (diagnosing COP) when he
presented with dyspnea and hemoptysis. He was managed on the
floor for these complaints with supplemental oxygen and steroid
therapy. In the setting of this therapy, the patient became
tachypneic and tachycardic. His CXR showed worsening
infiltrates and he was started on empiric antibiotics
(levo/flagyl/vanco). On this regimen he remained tachycardic
and mildly hypotensive but his fever curve trended down and his
CXR improved.
On the AM of consult, the patient noted [**8-31**] diffuse abdominal
pain most intense in the epigastric area. He denied any
diarrhea (had been constipated x3d) but did endorse nausea w/out
emesis. He received laxatives w/ temporary relief of his pain
but it recurred later in the day and into the night. He
described the pain as occuring constant throughout the day but
denies radiation of the pain into the back or groin. He denies
any dysuria currently and denies any change in the pain with
eating, passing gas, or medications. He was evaluated by the
floor team and found to have a lactate of 5.6 and a dirty UA.
He developed a worsening anion gap and was evaluated by surgery
who suggested an upright CXR to exclude free air (negative) and
a CT abdomen w/ oral contrast to eval the bowel (pending). They
wished to follow the patient clinically for the time being
pending the results of the CT scan.
Past Medical History:
HTN
4+ MR
Cryptogenic organizing pneumonia
Social History:
He is married for 62 years. He has two children who live nearby.
He is a retired orthotist.
.
Family History:
no family history of pulmonary disease.
Physical Exam:
Gen: Elderly [**Male First Name (un) 4746**] lying in bed appearing uncomfortable and mildly
tachypneic
HEENT: EOMI, MMM, OP clear
Lungs: crackles RLL, decreased breath sounds and dullness to
percussion LUL and RLL
CV: RRR, III/VI SEM
Abd: Non-distended, soft, moderate tenderness to palpation in
the epigastric area, no rebound/guarding, mild BS, guaiac
negative
Extrem: No c/c/e
Pertinent Results:
136 103 38 / 91 AGap=17
4.7 21 1.4 \
CK: 70 MB: Notdone Trop-*T*: <0.01
proBNP: 1664
.
86
9.7 \ 11.1 / 432 D
/ 31.1 \
N:76.9 L:12.9 M:4.3 E:5.5 Bas:0.4
.
[**8-19**] CT chest:
1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal
interstitial abnormalities are either progression of organizing
pneumonia or edema.
2. New bilateral pleural effusions, larger in the left side.
.
[**8-27**] renal u/s:
1. No evidence of hydronephrosis.
2. Left pleural effusion.
.
[**8-28**] CT abd:
No evidence of any ischemic bowel given that this is a
non-contrast CT.
Multiple lesions in the liver which are unchanged.
Some minimal presacral fluid and some minimal fluid in the
pelvis of unknown etiology.
Sigmoid diverticula.
Scarring right base and bilateral effusions.
.
[**8-28**] CXR:
There is no evidence of free air on the supine views. The bowel
gas pattern is nonspecific, with air seen within non-dilated
loops of small bowel and throughout the colon to the rectum. No
evidence of obstruction. There are surgical clips in the right
upper quadrant, likely related to cholecystectomy.
.
Brief Hospital Course:
A/P: 84 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with h/o HTN, severe MR, and [**Hospital **] transferred to
the ICU for abdominal pain and rising lactate/wbc. Please HPI
for details of admission prior to ICU:
.
1. Abdominal pain- on transfer, ddx includes perforated viscus
and mesenteric ischemia. recent CTA showed no evidence of AAA.
possible gastritis/ulcer dz w/ high dose steroids and
hospitalization. surgery following and KUB w/out evidence of
colonic obstruction or free air. lactate continued to rise
following ICU transfer, despite elevated CVP and lack of
respiratory variation, both indicative of volume repletion.
patient continued to have minimal abdominal pain but did have
other signs of poor cardiac output including a mixed venous sat
of 42%. on the day of the patient's demise, his lactate was
8.6.
.
.
2. crpytogenic organizing pna- seen on prior needle biopsy and
some improvementon high dose steroids (radiographic). O2 sats
stable on NC but significant desaturation with any activity. on
[**8-29**] in the process of being rolled, the patient became acutely
SOB and subsequently became apneic. per his family's documented
request, a Code was not called. he subsequently expired.
.
3. [**Name (NI) 10271**] pt /w baseline creatinine of ~1.4 but elevated to 2.7 on
micu admission. renal ultrasound today w/out evidence of
obstruction/hydronephrosis. continued to worsen in the setting
of poor cardiac output.
.
4. Severe MR: pt in the process of preparing for a MVR prior to
this admission. major contributor to the patient's poor forward
flow.
.
5. Coagulopathy: Initially likely [**1-23**] poor nutritional status
but now concern for DIC in setting of mesenteric ischemia
.
Medications on Admission:
.
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
cryptogenic organizing pneumonia
mesenteric ischemia
severe MR
Discharge Condition:
deceased
Discharge Instructions:
.
Followup Instructions:
.
|
[
"251.8",
"276.7",
"401.9",
"584.9",
"424.0",
"276.2",
"516.8",
"428.0",
"557.0",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5572, 5581
|
3751, 5494
|
269, 274
|
5688, 5698
|
2613, 3728
|
5748, 5752
|
2155, 2196
|
5546, 5549
|
5602, 5667
|
5520, 5523
|
5722, 5725
|
2211, 2594
|
221, 231
|
302, 1960
|
1982, 2027
|
2043, 2139
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,603
| 132,068
|
40664
|
Discharge summary
|
report
|
Admission Date: [**2166-7-5**] Discharge Date: [**2166-7-8**]
Date of Birth: [**2095-4-28**] Sex: F
Service: MEDICINE
Allergies:
amlodipine / Cephalosporins / Codeine / lisinopril /
pioglitazone
Attending:[**Doctor First Name 3298**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with removal of temporary plastic stent and placement of
fully covered metal stent for biliary stricture
History of Present Illness:
71 yo F with new diagnosis of pancreatic adenocarcinoma with
liver mets in [**4-/2166**], HTN, DMII, and recent admission for septic
shock/klebsiella bacteremia who presented with abdominal pain
and was found to be hypotensive in the ER. She initially went
to [**Hospital3 **] ER initially and was transferred to [**Hospital1 18**]. She
stated that she woke up at 2am on the day of presentation with
severe pain. The pain felt "like gas" and was in the
distribution of "a circle" around lower abdomen and lower back.
She also had pain in the epigastrium radiating around to the
back and between the shoulder blades. The pain was [**9-8**],
nothing made it better. She denied fevers, chills, nausea,
diarrhea. Last bowel movement was the day before presentation,
well formed, not [**Male First Name (un) 1658**] colored. Reported having dark brown
colored urine on the day before presentation. In addition to
her abdominal symptoms she reported a "soreness" between her
breasts just above the incision line. This soreness did not
radiate and was not accompanied by SOB. She had had this pain
in the past and prior to the surgery. She stated that she
usually had this pain with exertion and it resolved with rest.
In the ED, initial vs were: T 97 HR 100 BP 88/46 O2 98% ra.
Patient briefly de-satted to 80s on RA but on 2L NC her O2
saturations increased to 98%. She received 4L of IVF with good
blood pressure response. Her labs demonstrated leukocytosis,
transaminitis, stable hematocrit. CXR did not show an effusion
or consolidation. CTA ruled out PE, and CT abdomen/pelvis did
not demonstrate an acute process. There was moderate
intrahepatic biliary dilation increased from prior studies, but
biliary stent position was unchanged. Patient was evaluated by
surgery. Bedside TTE did not demonstrate an effusion. Blood
cultures were drawn. She was empirically started on
Vancomycin/Zosyn given concern for ascending cholangitis in the
setting of leukocytosis and elevated LFTs.
On arrival to the ICU she reported no pain in her abdomen but
continued chest "soreness."
ROS:
(+) Per HPI
(-) Denied fever, chills, night sweats, recent weight loss or
gain. Denied headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
All other systems reviewed and negative.
Past Medical History:
-Pancreatic AdenoCA presented with pancreatic jaundice and s/p
initiation of a Whipple procedure during which metastatic
disease to the liver was discovered
-DM2 with neuropathy
-Glaucoma
-[**Male First Name (un) **], with history of Myxedema
-[**Male First Name (un) 88948**] Hernia
-Hypercholesterolemia
-HTN
-Anemia
-Bipolar affective disorder
-Clostridium Perfrigens Infections
-History of PUD/Gastritis/Duodenitis
-Renal Mass: [**2162-5-1**]
-Limb cramps
-Leiomyoma of uterus
Social History:
Lives with her partner of 31 years. She has 2 children, a son
and daughter. She previously smoked for 13 pack years and quit
in [**2143**]. Denies EtOH or illicits. She is a teacher's aide for
grades [**12-4**].
Family History:
Mother: brain cancer at age [**Age over 90 **].
Father: metothelioma - 75 first in his testes.
Brother in good health.
Sister with superficial melanoma on his breast. Sister with
stomach tumor which was removed 40 years ago and now in good
health. Tumor assumed to be benign.
No h/o GI disorders of GI cancers.
2 maternal aunts with [**Name (NI) 2481**] disease.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.9 BP:122/65 P: 77 RR:22 SpO2: 100% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: well healing, non erythematous incision across abdomen
along epigastrium, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place, urine is yellow
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
All vital signs stable and within normal limits, compared to
presentation RR has normalized and patient no longer requiring
oxygen supplementation. Exam notable for very mild epigastric
tenderness without guarding or rebound. Otherwise exam
unchanged and within normal limits.
Pertinent Results:
====================
LABORATORY RESULTS
===================
On Admission:
WBC-19.0* RBC-3.37* HGB-10.0* HCT-30.5* MCV-91 RDW-15.4 PLT-334
--NEUTS-86* BANDS-9* LYMPHS-3* MONOS-1* METAS-1*
HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
ALT(SGPT)-617* AST(SGOT)-651* ALK PHOS-403* TOT BILI-3.3*
ALBUMIN-3.8
LIPASE-30
GLUCOSE-151* UREA N-34* CREAT-1.0 SODIUM-139 POTASSIUM-4.1
CHLORIDE-104 TOTAL CO2-22
PT-14.3* PTT-25.3 INR(PT)-1.2*
UA: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 Blood-NEG
Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-NEG
RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
On Discharge:
WBC-17.4* RBC-3.56* Hgb-10.6* Hct-32.2* MCV-90 RDW-14.9 Plt
Ct-301
--Neuts-81.0* Lymphs-10.6* Monos-4.6 Eos-3.4 Baso-0.5
Glucose-158* UreaN-16 Creat-0.9 Na-140 K-3.9 Cl-106 HCO3-26
ALT-180* AST-25 AlkPhos-298* TotBili-1.4
Other Important Labs
[**2166-7-5**] 09:18PM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-7-6**] 05:05AM BLOOD CK-MB-2 cTropnT-<0.01
=============
MICROBIOLOGY
=============
[**1-30**] Blood Cultures from [**2166-7-5**] with gram negative rods:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2166-7-6**]):
GRAM NEGATIVE ROD(S).
Blood Cultures*2 [**2166-7-7**]: NGTD
===============
OTHER STUDIES
===============
ECG [**2166-7-5**]:
Normal sinus rhythm. Tracing is within normal limits and
unchanged from the
previous tracing of [**2166-6-9**].
Chest Radiograph [**2166-7-5**]:
IMPRESSION: Minimal bibasilar atelectasis.
CT Chest/Abdomen/Pelvis with CT angiogram of chest:
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology. Moderate
atherosclerotic disease. Bibasilar atelectasis, but no focal
airspace consolidations. Borderline enlarged mediastinal lymph
node.
2. Fatty liver and splenomegaly. Interval resolution of
geographic
hyper-enhancement in segment II reflecting resolved cholangitis.
3. Interval increase in now moderate degree of intrahepatic
biliary ductal
dilatation. Biliary drain appears appropriately positioned.
4. Status post open cholecystectomy and liver biopsy. Trace
amount of
perihepatic and perisplenic fluid.
5. Known hypoenhancing pancreatic head mass compatible with
adenocarcinoma
incompletely assessed in this single-phase study, but grossly
similar to the CTA abdomen study one month ago.
6. Bulky uterus for age may be secondary to fibroids. Pelvic
ultrasound can
be performed if clinically indicated.
7. No intra- or retro-peritoneal hemorrhage. No intra-abdominal
abscess.
ERCP [**2166-7-6**]:
Impression:
Plastic stent removed
3 cm long distal Biliary stricture noted
Large amount of pus/debris noted
Metal stent inserted as above
.
Brief Hospital Course:
71 year old female with metastatic pancreatic adenocarcinoma
presenting with cholangitis, likely due to displacement of
previous biliary stent, complicated by sepsis and GNR bacteremia
with marked improvement with replacement of biliary stent and
antibiotic therapy.
1) Cholangitis c/b gram negative bacteremia: The patient
presented with abdominal pain and an elevated bilirubin with no
other obvious source of infection and discovery of displaced
stent and pururlent material from her biliary tree. This is all
consistent with acute cholangitis. Likely inciting event was
displacement of previously placed stent. She was treated
initially with piperacillin-tazobactam and vancomycin that was
narrowed to just piperacillin-tazobactam once blood cultures
returned with gram negative rod bacteremia. She had replacement
of her stent on [**7-6**] with rapid improvement in her bilirubin and
resolution of most of her pain. Surveillance cultures remain
negative and on the day of discharge she was transitioned to PO
ciprofloxacin with plans to complete a total of 14 days of
antibiotics with day 1 being [**7-7**] (the day after stent
replacement). Of note, the patient did have a significant
leukocytosis that remained after her procedure but given her
overall improvement and the disappearance of bands this was
thought likely due to leukemoid reaction. She will follow up
with her PCP [**Last Name (NamePattern4) **] [**2-3**] days and have this rechecked.
2) Sepsis: She presented with septic shock due to cholangitis
and gram negative bacteremia but pressures normalized with
fluids and antibiotics. She remained normotensive from [**2166-7-6**]
onward.
3) Hypoxic respiratory distress: Pt desatted in the ED but
rapidly improved and CT chest without PE or pulmonary process.
Likely due to splinting and decreased lung volumes. She
remained off supplementary O2 from starting on [**2166-7-7**].
4) Atypical chest pain: The patient presented with atypical
chest pain but had unchanged, normal ECG and normal cardiac
enzymes *2. Her pain resolved with abdominal pain and was
thought to be radiation of cholangitis pain.
5) DMII, uncontrolled, with complication: She kept on insulin
sliding scale in the hospital. She will restart her [**Hospital1 **] NPH
insulin at discharge.
6) Metastatic Pancreatic Adenocarcinoma: Unfortunately, the
patient was discovered to have metastatic disease and not be a
surgical candidate in the midst of her Whipple. She has plans
to follow up with [**Hospital3 **] [**Hospital3 328**] Affiliate for medical
oncology care.
7) [**Hospital3 **]: We continued her home levothyroxine
8) BPAD: We continued her home lithium. The patient was
euthymic and a pleasure to care for throughout her
hospitalization.
9) Code Status: Code Status was DNR/DNI
Transitional Issues:
-The patient will follow-up with her PCP [**Last Name (NamePattern4) **] [**2-3**] days to recheck
WBC count and see how she is doing
-The patient has follow up with Dr. [**Last Name (STitle) 468**] in surgery
-The patient will follow up with oncology on the [**Hospital3 **]
-The patient will cancel previous appointment with ERCP given
this was for follow up from temporary stent with possible
replacement as stent was replaced during this procedure
Medications on Admission:
Levothyroxine 125 mcg Tablet PO QD
Lithium carbonate 300 mg PO QHS
Diovan HCT 80mg-12.5mg qd
Humulin 24 u qAM, 32 qPM
Dorzol/timolol 2-0.05%OP PID
Lumigan
Calcium carbonate-Vitamin D3 600 Ca-400U D
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
3. Diovan HCT 80-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Humulin N 100 unit/mL Suspension Sig: Twenty Four (24) units
Subcutaneous QAM.
5. Humulin N 100 unit/mL Suspension Sig: Thirty Two (32) units
units Subcutaneous QPM.
6. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) drop
Ophthalmic twice a day.
7. Lumigan 0.01 % Drops Sig: One (1) drop
drop Ophthalmic at bedtime.
8. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 12 days.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Cholangitis complicated by gram negative bacteremia and sepsis
Secondary Diagnoses:
Metastatic pancreatic adenocarcinoma
Atypical Chest Pain
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain that we think was due to
an infection of your bile ducts. This was likely due to the
stent previously placed to keep these ducts open becoming
displaced. You had a new stent put into place and received
antibiotics with improvement in your symptoms. You are being
discharged to complete your course of antibiotics.
Your medications have been changed. You have been started on
ciprofloxacin 500 mg twice a day for an additional 12 days after
discharge.
Please continue your other medications as previously prescribed.
Followup Instructions:
You should schedule a follow up with your PCP toward the end of
this week or beginning of next week to have your white blood
cell count rechecked and make sure you are doing well before any
trip.
You have the following appointments scheduled after your first
ERCP that you can likely cancel now that you had another ERCP.
Department: ENDO SUITES
When: MONDAY [**2166-7-28**] at 7:30 AM
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2166-7-28**] at 7:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Please keep your previously scheduled appointment with Dr.
[**Last Name (STitle) 468**]
Department: SURGICAL SPECIALTIES
When: MONDAY [**2166-9-29**] at 10:15 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"576.1",
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"785.52",
"357.2",
"365.9",
"296.80",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
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8563, 11365
|
340, 452
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13097, 13097
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3451, 3664
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4735, 5015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,649
| 187,782
|
40373
|
Discharge summary
|
report
|
Admission Date: [**2172-11-22**] Discharge Date: [**2172-12-7**]
Date of Birth: [**2126-2-28**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with embolization
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 88527**] is a 46-year-old man with no significant PMH who
presented on [**2172-11-20**] to an OSH with a chief complaint of
hemoptysis. He reported that on [**2172-11-19**] he was woken up by
coughing and coughed up about half a cup of bright red blood. He
had a second episode of hemoptysis on [**2172-11-20**] and presented to
OSH ED. Because the pt had several episodes of hemoptysis (and
one in the ED) the pt was admitted for bronchoscopy. On [**2172-11-20**]
the pt was taken for bronchoscopy which was unable to be
performed due to difficulties with sedation, and a significant
amount of periglottic edema. The pt was then taken to the OR for
bronchoscopy under genearal anesthesia and endotracheal
intubation, and during the procedure a fresh clot was visualized
in the left lingula, which, when gently disturbed, produced
brisk bleeding. Due to the extent of bleeding patient was left
intubated and transfered to [**Hospital1 18**] for further evaluation.
Past Medical History:
None.
Social History:
Common law wife of 25 [**Name2 (NI) 1686**]. Works installing security systems. No
drug use, pets, travel, hobby exposures. Tobacco: 1.5pack/d x
5yrs, previously had quit for 20yrs. EtOH: one 6 pack per day
plus vodka.
Family History:
Unable to obtain
Physical Exam:
Admission:
VS: Temp: afebrile BP:114/69 HR: 52 RR: 18 O2sat 96% on A/c
GEN: intubated, appears comfortable
HEENT: PERRL, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement anteriorly
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Intubated, moving all extremities
Discharge:
VS:99.4 84 120/62 18 99%RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, 1+ edema b/l ankles. DPs, PTs 2+.
Skin: maculopapular rash on extremities, back and chest
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait deffered. Mildly confused but oriented.
Pertinent Results:
Admission labs:
[**2172-11-22**] 01:19PM HCT-39.0*
[**2172-11-22**] 10:41AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2172-11-22**] 10:41AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2172-11-22**] 10:41AM URINE RBC-[**2-14**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2172-11-22**] 10:41AM URINE MUCOUS-MOD
[**2172-11-22**] 05:38AM GLUCOSE-133* UREA N-11 CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2172-11-22**] 05:38AM ALT(SGPT)-50* AST(SGOT)-23 ALK PHOS-51 TOT
BILI-0.6
[**2172-11-22**] 05:38AM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2172-11-22**] 05:38AM WBC-12.7* RBC-4.72 HGB-15.1 HCT-42.3 MCV-92
MCH-31.9 MCHC-34.7 RDW-12.7
[**2172-11-22**] 05:38AM NEUTS-92.1* LYMPHS-5.4* MONOS-2.3 EOS-0.1
BASOS-0.2
[**2172-11-22**] 05:38AM PLT COUNT-270
[**2172-11-22**] 05:38AM PT-12.5 PTT-22.3 INR(PT)-1.1
[**2172-11-22**] 02:40AM TYPE-ART PO2-81* PCO2-42 PH-7.36 TOTAL CO2-25
BASE XS--1
[**2172-11-22**] 02:40AM LACTATE-1.3
[**2172-11-22**] 12:52AM TYPE-ART PO2-64* PCO2-60* PH-7.27* TOTAL
CO2-29 BASE XS-0
[**2172-11-22**] 12:52AM LACTATE-1.5
Discharge labs:
[**2172-12-7**] 08:30AM BLOOD WBC-8.5 RBC-3.74* Hgb-11.9* Hct-32.2*
MCV-86 MCH-31.9 MCHC-37.0* RDW-12.5 Plt Ct-687*
[**2172-12-7**] 08:30AM BLOOD Glucose-98 UreaN-20 Creat-1.1 Na-138
K-4.1 Cl-104 HCO3-23 AnGap-15
[**2172-12-7**] 08:30AM BLOOD ALT-54* AST-35
[**2172-12-7**] 08:30AM BLOOD Lipase-637*
[**2172-12-6**] 06:00AM BLOOD VitB12-1259*
[**2172-12-6**] 06:00AM BLOOD TSH-2.5
Imaging:
Radiology report [**2172-11-22**]:
IMPRESSION:
1. Aortogram and left bronchial arteriogram demonstrating the
anatomy.
2. Left bronchial arteriogram demonstrated active contrast
extravasation from both superior and inferior branches. These
branches were successfully
catheterized with a microcatheter and embolized using 500-700
micron
Embospheres. No spinal arterial contribution was noted from
either branch of the left bronchial artery. Post embolization
arteriogram showed satisfactory angiographic result.
3. Deployment of Angio-Seal closure device for the right common
femoral
arterial access site.
CT head [**12-6**]:
No acute intracranial pathology. MRI scanning is more sensitive
than CT imaging in detecting numerous brain parenchymal
abnormalities,
including acute brain ischemia.
12/26 L ankle xray: no frx
[**12-5**] CXR: As compared to the previous radiograph, the patient
has been
extubated. The nasogastric tube and the right internal jugular
vein catheter have also been removed. There is a marked
improvement in ventilation of the right lung base. At the left,
some small areas of retrocardiac atelectasis persist. No newly
appeared focal parenchymal opacities suggesting pneumonia.
[**12-1**] LENI: IMPRESSION:
No evidence of DVT.
Micro:
[**2172-12-2**] 4:22 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2172-12-4**]**
GRAM STAIN (Final [**2172-12-2**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2172-12-4**]):
Commensal Respiratory Flora Absent.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
Hospital Course:
46 yo M with history of ETOH abuse transferred to MICU from OSH
for hemoptysis, now s/p lingular AVM bleed and IR embolization,
with ICU course complicated by MICU [**Hospital 16630**] transferred to floor
with resolving fever and confusion.
Active Issues:
# Hemoptysis: PE ruled out on CTA at OSH. Fungal markers
negative. Evidence of bleeding on bronch after two evaluations
thought [**1-14**] AVM. Pt is s/p IR embolization of left bronchial
artery without hemopytysis since the [**11-23**]. [**Hospital1 1562**] rheum
testing: all negative ([**Doctor First Name **], ANCA, ESR, CRP). Anti GBM negative.
He was transferred to the floor on [**12-5**]. He will need to have
IP follow up in 1 month.
# Respiratory distress/MRSA VAP: Patient transferred intubated
because of hemoptysis. Patient self-extubated on [**2172-11-25**] and
continued to oxygenate well, but on morning rounds [**11-26**] pt
tachypneic, with pO2 on gas 74 on 6L NC O2 and required
reintubation. Concern for multifocal pneumonia on CT. Patient
was initially covered with Vanc/Zosyn. The zosyn was changed to
Aztreonam given rash. Scopalamine patch trialed on [**11-30**] for
copious oral secretions, but this was ineffective. Sputum
culture + for MRSA. Successfully extubated on [**12-3**]. Vancomycin
course completed in [**2172-12-7**] after 14 days.
# Delirium: Active in MICU, out of window for ETOH withdrawal.
Two days after extubation, there was no evidence of withdrawal
but still had mild confusion with confabulation. Pt continued on
thiamine. CT head, TSH, B12, RPR normal. He continued to perform
poorly on his mental status examination, however this was felt
most likely secondary to his long and heavy alcohol abuse.
# Diarrhea: Started in MICU in setting of abx, cdiff negative,
resolved on own.
# Maculopapular rash: over extremities, chest and back, thought
[**1-14**] zosyn which has been discontinued, mother with [**Name2 (NI) **] allergy,
consider [**Name2 (NI) **] an allergy.
#Thrombocytosis: Likely reaction to infection.
# Alcoholism: drinks 6 beers/day, did not withdrawl, no desire
to quit, started on mvi, folate, thiamine.
# elevated INR: Likely in setting of poor nutrition, improved to
1.3 on discharge.
#. [**Last Name (un) **]: Likely secondary to dye load received with IR for
embolization. Improved throughout hospitalization with IVF.
# Anemia: Likely [**1-14**] to blood loss from hemoptysis, should be
followed as outpatient
# ALT elevation: Likely chronic, outpatient f/u.
***********
Inactive Issues:
# Smoking: cessation counseling performed, patient does not
desire to quit
************
Faxed discharge summary to PCP.
Transitional Care:
1) Anemia/Thrombocytosis: recheck CBC as outpt
2) Elevated Lipase: No clinical signs of pancreatits but at risk
bc of alcohol, if abd pain develops consider CT abd/pel
3) Elevated ALT: Likely chronic from ETOH vs NASH, consider w/u
as outpatient
Medications on Admission:
Propofol gtt
Fentanyl gtt
Protonix 40 IV daily
MVI daily
Thiamine 100mg daily
Senna 1 tab [**Hospital1 **]
Artificial tears
Discharge Medications:
1. Outpatient Physical Therapy
Please assess and treat for deconditioning from hospitalization
and left ankle pain. Diagnosis: Pneumonia. Please give results
to Dr. [**Last Name (STitle) **],[**First Name3 (LF) 88528**] R. [**Telephone/Fax (1) 39876**]. Ok to sign off.
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hemoptysis, ? AVM in lingula
Ventilator-associated pneumonia
Anemia
Confusion possibly from Wernicke's
Secondary Diagnosis:
Alcohol Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the ICU after coughing up blood. You
needed to have a breathing tube placed in [**Hospital1 1562**] in order to
protect your airway. You were then transferred to [**Hospital1 18**]. You
underwent a procedure in the OR to stop the bleeding, called
embolization. Following the procedure, you were monitored in
the ICU for recurrent episodes of bleeding, which you did not
have. You developed a pneumonia while in the hospital, and
received antiobiotics to treat the pneumonia. You improved and
were transferred to the floor. On the floor, you had some low
grade fevers that improved on their own. You also had some
confusion that was improving upon discharge. You were seen by
the physical therapist who felt you were safe to go home.
Medication changes:
1)We started you on a multivitamin, folic acid, and thiamine to
take every day.
Followup Instructions:
Please call to schedule an appointment with the interventional
pulmonologists within the next month. Phone: ([**Telephone/Fax (1) 17398**]
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1955**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] FAMILY MEDICINE
Address: 5 INDUSTRIAL DR [**Last Name (STitle) **], [**Location (un) **],[**Numeric Identifier 84441**]
Phone: [**Telephone/Fax (1) 56653**]
Fax: [**Telephone/Fax (1) 88529**]
Appt: This Thursday, [**12-10**] at 1:45pm
Completed by:[**2172-12-7**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,887
| 183,486
|
48708
|
Discharge summary
|
report
|
Admission Date: [**2180-3-8**] Discharge Date: [**2180-4-12**]
Date of Birth: [**2105-3-21**] Sex: F
Service: MEDICINE
Allergies:
Zestril / Hydrochlorothiazide
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
Lumbar Puncture
Exisional Biopsy of Neck mass
History of Present Illness:
The Pt is a 73y/o. F with a PMH of metastatic adrenal ca s/p
adrenalectomy, R hepatic resection, rectal adenocarcinoma,
parathyroid adenoma and hypothyroidism admitted with mental
status changes. Pt is alert, oriented X1. Unable to relate HPI.
Per ED notes her husband reported that the patient has been
sleepy and fatigued for last few days. She has not been taking
her usual po intake. Possible fever at home but temp was not
taken. EMS called by son. The patient reports fatigue but denies
n/v/d, no abdominal pain, no diarrhea or dysuria.
.
Pt has a history of metastatic adrenal carcinoma of the left
adrenal gland s/p adrenalectomy in [**2157**] with debulking of tumor
mass. Pt was then treated with Lysodren. In [**2175-4-25**] pt was
found to have hepatic metastases and underwent a right hepatic
resection and cholecystectomy. In [**2178-2-25**] pt underwent excision
of a left retroperitoneal mass - path consistent with a
malignant neoplasm compatible with metastatic adrenal cortical
carcinoma. Pt is also s/p
right hip arthroplasty [**2178-7-29**] secondary to AVN. Hosptalized
[**12-30**] with bleeding peptic ulcer.
.
In ED Vitals T 99.8 rectal, HR 88, BP 115/65, RR 27, O2sat 99%
RA. FS 89. Pt was reported to have a cough. CXR negative. CT
Head negative. Found to have a Ca of 11.6. UA positive. Pt given
Levaquin 500mg X1. Dexamethasone 4mg.
Past Medical History:
Metastatic adrenal cortical carcinoma
Primary hyperparathyroidism
Hypothyroidism
Hypertension
Drainage of left knee for septic arthritis in [**2167**]
Low anterior resection for stage II rectal adenocarcinoma
Resection of parathyroid adenoma X2
Cholecystectomy
Total hip arthroplasty [**7-30**]
Laparotomy with excision of left retroperitoneal metastatic
adrenal carcinoma
Osteoarthritis
Social History:
Pt unable to give history. Per DC summary of [**12-30**] pt denied
tobacco use and alcohol use. She lives in [**Location 2312**] with her
husband and one son. She has three children, two sons and one
daughter and four grandchildren.
Family History:
Pt unable to give history. Per DC summary of [**12-30**]: Father died
in his 70s of an aneurysm in his abdomen. Mother died in her 90s
of a stroke. She has one sister who died of a heart attack in
her 50s and three brothers, one of whom has had bypass surgery
and two others who are alive and well.
Physical Exam:
Vitals: T 97.2, BP 123/59, HR 88, RR 18, O2 sat 97% RA
Gen: alert, oriented to self only
HEENT: PERRLA, EOMI, dry MMM, no oropharyngeal erythema
CV: RRR, nl s1/s2, no m/r/g
Resp: CTAB, no w/r/r
Abd: multiple surgical scars, NT/ND, NABS
Ext: no edema
Neuro: speech - minimal, answering only "yup" or "no". No clear
slurred speech. Moving all extremities. No facial droop. Pt
unable to comply with full sensory but withdrawals all ext.
Pertinent Results:
[**2180-3-8**] 10:30AM WBC-6.5 RBC-5.18 HGB-14.7 HCT-46.4 MCV-90
MCH-28.4 MCHC-31.7 RDW-12.9
[**2180-3-8**] 10:30AM NEUTS-68.8 LYMPHS-19.0 MONOS-9.1 EOS-2.7
BASOS-0.4
[**2180-3-8**] 10:30AM PLT COUNT-228
[**2180-3-8**] 10:30AM PT-14.3* INR(PT)-1.2*
[**2180-3-8**] 10:30AM GLUCOSE-108* UREA N-26* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
[**2180-3-8**] 10:30AM ALT(SGPT)-12 AST(SGOT)-23 ALK PHOS-85 TOT
BILI-0.7
[**2180-3-8**] 10:30AM ALBUMIN-3.7 CALCIUM-11.6* PHOSPHATE-5.1*#
MAGNESIUM-1.6
[**2180-3-8**] 10:52AM LACTATE-2.5*
[**2180-3-8**] 01:30PM URINE RBC-[**3-29**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**3-29**] TRANS EPI-[**3-29**] RENAL EPI-<1
[**2180-3-8**] 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2180-3-8**] 01:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2180-4-8**]
Na 135, K 4.1, Cl 103, Bicarb 22, BUN 21, Cr 0.6,
WBC 6.0, HCT 28.3, Plt 300, Ca 8.5
.
[**2180-3-15**] Spinal Fluid
[**2180-3-15**] 11:00 am CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final [**2180-3-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
CXR [**2180-3-8**]
FINDINGS: The lungs are well expanded and clear. There is a
right apical pleural thickening. No consolidation or edema is
evident. Again noted is a tortuous atherosclerotic aorta. The
cardiac silhouette is within normal limits for size. Minimal
linear atelectasis is seen laterally in the left lung base. No
effusion or pneumothorax is evident. The bones are diffusely
osteopenic with a stable lower thoracic compression fracture as
previously demonstrated. Surgical clips are again noted within
the left upper quadrant.
IMPRESSION: Stable radiographic examination with known thoracic
compression fracture and no acute pulmonary process
.
CT HEAD [**3-8**]
FINDINGS: There is no edema or shift of normally midline
structures to suggest the presence of an intracranial mass. No
intracranial hemorrhage is seen. There is no evidence of major
vascular territorial infarct. Periventricular white matter
hypodensities indicate the presence of chronic small vessel
ischemia. Slight prominence of the ventricles and sulci are
consistent with age-appropriate atrophy. No fractures are
identified.
IMPRESSION:
1. No evidence to suggest the presence of intracranial masses.
However, if indicated, MRI is more sensitive for the detection
of metastatic lesions.
2. Chronic small vessel ischemia.
.
[**2180-3-11**] MRI OF THE BRAIN:
Multiple FLAIR hyperintense foci are noted in the cerebral white
matter on both sides, likely related to sequelae of chronic
small vessel occlusive disease, given the patient's age. No
enhancement is noted in these lesions.
There is no acute infarction or intracranial hemorrhage.
There is a small dural-based enhancing lesion, in the right
frontal region (series 11, image 14), best seen only on the
axial post-contrast sequences, due to artifacts on the coronal
plane, measuring 0.8 x 0.6 cm. This can represent a small
meningioma or less likely a focus of dural-based metastasis.
However, retrospective evaluation of the CT scan done on
[**2178-5-2**], demonstrates a similar lesion, in the right frontal
region, in a slightly different plane (likely related to the
angulation of the gantry, which is different from the MR
angulation) and this is seen on the post-contrast CT done on
[**2178-5-2**], series 4, image 8. This lesion is not significantly
changed on the present study, allowing for the technical
differences. Hence, this is more likely to be a small
meningioma.
The coronal post-contrast sequence is limited due to motion
artifacts and a small focus of enhancement noted anteriorly in
the right frontal region (series 12, image 5) could not be
identified with a corresponding abnormality on the axial
post-contrast sequence.
The major vascular flow voids are noted.
Mildly prominent ventricles and extra-axial CSF spaces are
slightly prominent, consistent with age-appropriate involution
of the brain parenchyma.
[**3-11**]: MRI OF THE PITUITARY:
On the pre-contrast sequences of the pituitary, there is no
enlargement of the sella or the pituitary gland, the
infundibular stalk is almost in the midline. The post-contrast
sequences are limited due to motion artifacts, hence, assessment
for small focal lesions is limited. The posterior-pituitary
bright spot is not definitively identified but the significance
of this is uncertain.
IMPRESSION:
1. No definite enlargement of the pituitary gland or no
significant displacement of the infundibular stalk of the optic
chiasm.
2. Multiple FLAIR hyperintense lesions in the cerebral white
matter on both sides likely represent sequelae of chronic small
vessel occlusive disease.
3. Small, 0.8 x 0.3 cm enhancing extradural lesion in the right
frontal region, likely representing meningioma, retrospectively
noted on the CT scan done on [**2178-5-2**], with no significant change.
Study is significantly limited due to motion artifacts on the
post-contrast sequences of the pituitary. Hence, evaluation for
focal lesions is limited. To consider repeating dedicated
imaging of the pituitary, if clinically necessary, with
sedation.
Findings were discussed with the treating physician by Dr. [**Last Name (STitle) **]
on [**2180-3-10**].
.
[**2180-3-13**] MRI Pituitary
CONCLUSION: Limited study due to motion artifact. No significant
changes since the MR [**First Name (Titles) **] [**2180-3-9**]. No evidence of
pituitary abnormality on this limited examination.
.
[**2180-3-14**] CT Chest/Abd/Pelvis
CT CHEST WITH CONTRAST: Moderate-high grade stenosis of left
subclavian artery beyond its origin is slightly worse than
[**2178-12-30**]. Heart size is normal. There is no pericardial effusion.
Bilateral pleural effusions are minimal, the lungs are otherwise
clear. There is no central or axillary lymphadenopathy. The
airways are patent to the subsegmental level.
CT ABDOMEN WITH CONTRAST: The spleen, pancreas small and large
bowel are unchanged since [**12-30**]. 1.4 cm hypodensity on the left
lobe liver (3:38, 5:3), new since [**12-30**], is suspiscious for
metastatic focus. Post left adrenalectomy, retroperitoneal mass
resection and hepatectomy changes are again noted. There is no
free fluid or free air. The right kidney is atrophic, unchanged
since [**12-30**]. The left kidney has several subcentimeter well
circumscribed hypodense that likely represent simple cysts. A
focal calyceal diverticulum is more prominent than [**2180-5-2**],
likely secondary to scarring. There is no hydronephrosis. There
are no enlarged mesenteric or retroperitoneal lymph nodes.
CT PELVIS WITH CONTRAST: There is no free fluid, free air or
evidence of obstruction. Fibroid uterus is unchanged since
[**2178-5-2**], with thickenedd endometrium similar to taht seen on most
recent ultrasound. The adnexa are unremarkable, although the
exam is limited by streak artifact from a right hip
arthroplasty. Bladder is likely adherent to anterior abdominal
wall with diastatsis of the rectus abdominus noted.
Bone windows demonstrate no suspicious blastic or lytic lesions.
A chronic compression fracture is noted at T11.
IMPRESSION:
1. New 1.5 cm hypodensity in the left lobe of the liver is
suspicious for metastasis. MRI is recommended for further
evauation.
2. Otherwise unchanged appearance of partial hepatectomy, left
adrenalectomy and left retroperitoneal mass resection.
3. Post-right hip arthroplasty changes are noted.
4. Atrophic right kidney, unchanged since [**2178-5-16**].
5. Tiny bilateral pleural effusions.
6. Endometrial thickening is similar to [**12-30**]
.
MR [**Name13 (STitle) **] [**2180-3-29**]
IMPRESSION: Since the previous MRI examination, there is
increased signal identified within the spinal cord with
enhancement in its central portion suspicious for cord ischemia
versus infarct. Soft tissue changes are seen from recent
surgery. A small right-sided metastatic lesion seen at C2-3 disc
level.
.
MR/MRA Head [**2180-3-29**]:
IMPRESSION: No significant change since the previous MRI
examination of [**2180-3-9**]. Small extra-axial mass in the right
frontal region consistent with meningioma is again identified.
No enhancing intraparenchymal brain lesions are seen. Moderate
changes of small vessel disease. No evidence of acute infarct.
Head MRA demonstrates normal flow signal in the arteries of
anterior circulation with prominent posterior communicating
artery. There is a consequent small size of the basilar artery
identified. No vascular occlusion is seen.
IMPRESSION: No significant abnormalities on MRA of the head.
Pathology:
Right Neck Mass:
Malignant neoplasm consistent with metastatic adrenal carcinoma,
(3.5 x 3 x 0.7 cm) with extensive necrosis and focal vascular
invasion.
Brief Hospital Course:
# Acute on subacute mental status changes - The patient was
admitted with acute MS changes at home. On admission she was
found to be alert but oriented only to self. After review with
her family members, they reported a subacute decline since
[**Holiday 1451**]. She was brought to the ED with reports of
increased fatigue and refusal to take po at home. She also had
increased lethargy and intermittently was not recognizing her
family members at home. CT head negative for evidence of acute
CVA. Neuro exam non-focal but she was with marked memory and
attention deficits. Her chemistry panel was significant for
hypercalcemia - Ca level 11.6 and she was also found to have a
UTI. Given her PMH of adrenal insufficiency concern was given
for acute adrenal insufficiency in the setting of an underlying
infection. It is unclear if the patient had been taking her
replacement steroids properly at home. She received aggressive
IVF repletion with subsequent correction of her hypercalcemia
and received a course of ceftriaxone for her UTI. Endocrine
consultation was obtained and the patient was placed on stress
dose steroids. Despite her correction of electrolytes and
treatment for UTI the patient continued to have a waxing and
[**Doctor Last Name 688**] mental status. Further workup demonstrated an
inappropriately low TSH, elevated prolactin and lower than
expected FSH and LH. The patient underwent an MRI of her
pituitary to evaluate for stalk compression vs. metastatic
disease. MRI of the head was negative but incidentally found
small R meningioma. Neurology consultation was obtained, who
felt symptoms unlikely to be caused by small meningioma. Given
her persistent MS changes and history of malignancy and
immunosuppression on steroids she underwent lumbar puncture. CSF
was negative for evidence of infection. Per neuro recs, Lyme
serology was also sent and was negative. CSF cytology to
evaluate for metastatic disease was also negative. A CT torso
was performed and on final exam of the imaging the patient was
found to have a new 1.5 cm hypodensity in the left lobe of the
liver, suspicious for metastasis. A CT of the spine noted a
cervical paraspinal mass. Neurosurgery was consulted and
performed an excisional biopsy. Pathology of the mass was
positive for Metastatic adrenal cancer. The patient continued
with worsening Mental status during her hospitalization with
bouts of paranoia and agitation. On [**2180-3-24**] she became
unresponsive and was intubated and sent to the ICU. She was
hypotensive and required pressors. CT of the Head was done and
was negative for ICH or stroke. She was extubated and
transferred back to the medical floor. Upon transfer, she was
noted to have new bilateral upper extremity paresis and was
unable to move her arms. An MRI of the C-spine was performed
and showed likely C2-C7 ischemia. Ms. [**Known lastname 1729**] has continued with
her AMS and currently is AAOx1 to self. She speaks only in one
word responses to yes and no questions. Several Family meetings
have occurred with the primary team, along with her oncologist,
endocrinologist and Pain and Palliative Care. The decision was
to transition to hospice given her very poor prognosis.
Ultimately, it is believed that her AMS may be due to
leptomeningeal spread of her adrenal carcinoma. Objective tests
have not shown this to be true but a 2nd Lumbar puncture may
have sealed the diagnosis. The family has opted against lumbar
puncture as it would cause discomfort to Ms. [**Known lastname 1729**]. The final
plan is to send to Hospice with plan for comfort care.
# Metastatic Adrenal Carcinoma - The patient is adrenally
insufficient following adrenalectomy for metastatic adrenal CA.
She was placed on stress dose steroids as above given concern
for acute adrenal insufficiency in the setting of an underlying
infection. Endocrinology was consulted and her dose of
hydrocortisone was slowly tapered and then the patient was
transitioned back to her home dose of dexamethasone 2.5mg [**Hospital1 **].
The patient's mitotane has been discontinued as recommended by
Dr. [**Last Name (STitle) **]. A new neck mass was found on CT of the neck.
She underwent surgical resection as above. The mass was
positive for recurrence of her metastatic adrenal cancer.
# Hypothyroidism - The patient was maintained on her home dose
of Synthroid 75mcg daily.
# UTI - On admission the patient was found to have a UTI, urine
culture grew >100,000 cfu/ml. She completed a seven day course
of ceftriaxone.
# Hx of rectal adenocarcinoma - Patient is s/p Anterior
resection of the sigmoid and proximal rectum in [**2169**].
# HTN - Antihypertensives have been discontinued.
# Post-menopausal bleeding - PAP and documented pelvic exam of
[**12-1**] by PCP [**Name Initial (PRE) **]. US demonstrating thickened endometrium, no
adnexal mass. Patient has had several small bleeding episodes
while in the hospital. No current issues.
# Nutrition - The family has decided to allow oral nutrition as
tolerated. NGT was discontinued per family's request prior to
transfer to Hospice.
Medications on Admission:
DEXAMETHASONE 0.5 mg--5 tablet(s) by mouth twice a day
Fludrocortisone 0.1 mg--1 tablet(s) by mouth twice a day
LEVOXYL 75 mcg--1 tablet(s) by mouth daily
Lysodren 500 mg--8 tablet(s) by mouth every day
NORVASC 10 mg--1 tablet(s) by mouth everyday
PROTONIX 40 mg--1 tablet(s) by mouth once a day
VALSARTAN/HCTZ 80/12.5 mg--1 tablet(s) by mouth once a day
Per OMR note Pt started on Fosamax 70mg weekly on [**12-13**] - pt
does not remember if she is taking this medication
Aspirin 81mg 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. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Dexamethasone 0.5 mg Tablet Sig: Five (5) Tablet PO Q12H
(every 12 hours).
5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Mitotane 500 mg Tablet Sig: Per Oncology recommendation
Tablet PO once a day: You should continue to take your mitotane
as directed. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Primary:
1. Metastatic Adrenal Cancer
2. Acute on Subacute Mental Status Changes
3. Urinary Tract Infection
Discharge Condition:
Sleeping comfortably
Discharge Instructions:
You were admitted into the hospital for altered mental status.
You were found to have a neck mass which was malignant. The
mass was a recurrence of your adrenal cancer. Your mental
status has not improved and your family has decided to
transition to hospice care.
You will continue on your Dexamethasone and Levothyroxine.
You will be started on Hospice medications for your comfort as
needed.
Followup Instructions:
None
|
[
"255.41",
"733.90",
"518.81",
"041.4",
"437.1",
"194.0",
"276.51",
"198.89",
"276.2",
"401.9",
"997.3",
"252.01",
"244.9",
"458.9",
"733.13",
"433.30",
"627.1",
"294.9",
"433.10",
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"V43.64",
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"584.9",
"336.1",
"344.2",
"197.7",
"599.0",
"276.8",
"785.52",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"83.32",
"89.14",
"03.31",
"87.09",
"38.93",
"96.04",
"96.71",
"87.03",
"99.23",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18975, 19027
|
12521, 17624
|
311, 359
|
19179, 19201
|
3197, 4561
|
19646, 19654
|
2427, 2727
|
18167, 18952
|
19048, 19158
|
17650, 18144
|
19225, 19623
|
2742, 3178
|
4647, 4755
|
4788, 12498
|
250, 273
|
387, 1750
|
1772, 2161
|
2177, 2411
|
4593, 4608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,712
| 115,181
|
4152+55548
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-5-3**] Discharge Date: [**2159-5-7**]
Date of Birth: [**2084-7-29**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18051**]
Chief Complaint:
malignant ascites
Major Surgical or Invasive Procedure:
Bilateral salpingo-oophorectomy,
omentectomy, total abdominal hysterectomy, radical dissection
for debulking.
History of Present Illness:
74 P0 referred for ascites. Presented with vague GI sxs and
constipation. Colonscopy wnl. US demonstrated large ascites
that contained malignant cells on paracentesis. CT previously
negative. Nl [**Last Name (un) 3907**]. Nl renal US. Elevated CA125 and CA [**73**]-9
Past Medical History:
OB: nulliparous
Gyn: nl [**Last Name (un) 3907**], nl pap, last period [**2134**]
PMH: HA, asthma, spastic colon, scoliosis
PSH: back [**Doctor First Name **], cosmetic
Social History:
quit tobacco, occasional alcohol
Family History:
paternal first cousin with breast ca
no ovarian, colon, endometrial
Physical Exam:
Initial exam notable for:
No LAD
Abdomen distedned with ascites, no masses
nl vulva, vagian, cervix
Biman limited no masses
nl rectum/cul-de-sac
Pertinent Results:
[**2159-5-6**] 06:20AM BLOOD WBC-12.0* RBC-3.68* Hgb-10.0* Hct-30.8*
MCV-84 MCH-27.2 MCHC-32.5 RDW-12.0 Plt Ct-529*
[**2159-5-6**] 06:20AM BLOOD UreaN-5* Creat-0.4 K-4.3
[**2159-5-6**] 06:20AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
Brief Hospital Course:
The patient was admitted to the SICU following her procedure on
[**5-3**]. Her surgery was complicated by laryngeal edema and
intraoperative hypertension requiring ICU admission. Otherwise
the surgery was uncomplicated - see operative report for
details. Her ICU course was unremarkable, she was extubated and
transferred to the floor on post op day 1 without complication.
The remainder of her post operative course was uncomplicated.
She advanced to regular diet without difficulty. On day of
discharge she was voiding and ambulating without assitance. Her
pain was well controlled with oral medication.
Medications on Admission:
flovent, atrovent
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
adenocarcinoma
Discharge Condition:
good. stable
Discharge Instructions:
no heavy lifting, no exercise, nothing in vagina 6wks
no driving 2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/GYN NON-PPS CC8 Where: [**Hospital 4054**] OBSTETRICS & GYNECOLOGY Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2159-5-28**] 1:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5777**] Call to schedule
appointment
Name: [**Known lastname **],[**Known firstname 2770**] A Unit No: [**Numeric Identifier 2919**]
Admission Date: [**2159-5-3**] Discharge Date: [**2159-5-7**]
Date of Birth: [**2084-7-29**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2920**]
Addendum:
The patient's discharge diagnosis is stage IIIC papillary serous
adinocarcinoma, most likely primary peritoneal in origin.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2921**] MD [**MD Number(1) 2922**]
Completed by:[**2159-5-16**]
|
[
"997.5",
"198.6",
"478.6",
"158.8",
"493.90",
"198.82",
"564.1",
"788.20",
"530.81",
"511.9",
"737.30",
"518.81",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"65.61",
"54.4",
"93.90",
"68.4"
] |
icd9pcs
|
[
[
[]
]
] |
3647, 3810
|
1521, 2134
|
345, 457
|
2556, 2570
|
1267, 1498
|
2691, 3624
|
1018, 1087
|
2202, 2468
|
2518, 2535
|
2160, 2179
|
2594, 2668
|
1102, 1248
|
288, 307
|
485, 760
|
782, 952
|
968, 1002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,836
| 119,239
|
31716
|
Discharge summary
|
report
|
Admission Date: [**2153-8-21**] Discharge Date: [**2153-9-26**]
Service: MEDICINE
Allergies:
Fluoxetine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Large R PICA stroke.
Major Surgical or Invasive Procedure:
Suboccipital craniotomy
tracheostomy
PEG tube placement
Placement and removal of central line
History of Present Illness:
83F h/o DM, CAD p/w n/v & lethargy, found to have large R
PICA stroke at [**Hospital 6138**] Hospital. USOH until today when she
complained of nausea and vomiting, with generalized weakness.
She
presented to OSH and CT showed R PICA stroke. She became
increasingly lethargic and was intubated for airway protection.
Transferred to [**Hospital1 18**] ED.
.
83 yo f with PMH positive for CAD, strokes, NIDDM, Asthma
presented to OSH with lethargy and cc of weakness, n/v on
[**2153-8-21**]. Was found to have right cerebellar stroke and was
transferred to [**Hospital1 18**]. At [**Hospital1 **] ED she was intubated for airway
protection due to increased lethargy and put on neosynephrine
drip due to hypotension.
Review of Head CT showed large right PICA cerebellar infarct
with midline shift and pressure on the 4th ventricle. She has
chronic left MCA stroke, left PCA stroke, and right MCA stroke.
She was given Mannitol 50grams iv once. Patient was
hyperventilated. Neurosurgery performed suboccipital craniotomy
to relieve intracranial pressure.
Past Medical History:
NIDDM
CAD
Strokes
Right MCA infarct
Left MCA infarct
Left PCA infarct
Asthma
Social History:
Patient is a housewife, has two daughters and a son lives with
son
Family History:
[**Name (NI) **] mother died at 19 due to infectious disease, father
died in mid 30s, cause unknown.
Physical Exam:
O: T: afeb BP: 72/20 on Levophed HR: 77 R: 22 O2Sat
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Unresponsive to voice, grimaces to painful
stimuli. Follows no commands.
Cranial Nerves: Has positive gag, corneal, and oculocephalic
reflexes.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Purposeful movements antigravity of bilateral UE,
withdrawal of right LE, no movement of Left LE.
Sensation: NT.
Toes up on left, down on right
Pertinent Results:
CT from OSH (images reviewed): Large R cerebellar infarct with
some mass effect on midline of cerebellum, enlarged 3rd
ventricle, mass effect on 4th ventricle but not fully
compressed.
No hemorrhage. Old L PCA infarct. Multiple small cortical
infarcts.
Non-contrast Head CT:
1. No acute intracranial hemorrhage.
2. Hypodensity consistent with edema and infarction involving
most of the right and possible a small part of the left
cerebellar hemisphere, producing mass effect with almost
complete effacement of the fourth ventricle.
3. Hypodensity in the watershed zones bilaterally may represent
chronic infarcts.
4. Small hypodensities in the periventricular and deep white
matter, likely representing sequela of chronic microvascular
ischemia.
5. Osteoma arising from the right temporal bone.
MRI:
1. Acute right posterior inferior cerebellar artery infarct with
blood products. Post-surgical changes are seen in the region.
Chronic right and left cerebellar infarct.
2. Chronic cortical infarcts in the left frontoparietal region.
3. Severe changes of small vessel disease and moderate brain
atrophy.
4. Small incidental calcified meningioma right temporal region
Head CT [**8-23**]:
-new cerebellar bleed
Brief Hospital Course:
# Strokes/Mental Status: Ms. [**Known lastname **] presented with a large
cerebellar stroke with evidence of compression of her fourth
ventricle and hydrocephalus of the 3rd ventricle. She was given
a 6-pack of platelets (as she had been on aspirin and Plavix)
and was taken emergently from the ED to the OR by neurosurgery
where she underwent a suboccipital craniotomy for decompression.
She tolerated the procedure well and was admitted to the
NeuroICU following the procedure. A TTE showed a large PFO with
an Atrial septal aneurysm therefore her mechanism was felt to be
likely thromboembolic. LENI's were checked and were negative.
Mentation greatly improved during the patient's stay,
correlating with treatment of her pneumonia and tracheostomy
placement. At time of discharge from the ICU, she was much more
interactive. The patient continued to be interactive when
examined with a translator. She would follow basic commands,
such as moving her extremities and squeezing her hands. She
would deny pain or discomfort. She was re-started on coumadin
for anticoagulation for her thromboembolic stroke. Her INR will
need to be monitored and coumidin increased with a INR goal of
[**12-22**].5.
.
# Respiratory Distress: Patient received tracheostomy on
[**2152-11-30**], and her chest x-ray has demonstrated much improvement,
only notable for persistent lll collapse. Patient was treated
for ventilator associated pneumonia twice with courses
vancomycin and zosyn. Ultrasound was used to evaluate for
potential effusion for thoracentesis, but there was not enough
fluid to tap. Patient underwent several bronchoscopies with
removal of mucoid material. Patient was unable to be weaned off
of the ventilator, and failed trials of extubation, aggressive
pulmonary toilet, and had repeated atelectatic collapse of of
lung. Daily pressure support trials were initiated after
trachestomy, and she did well. Normal saline nebs were used to
hydrate the airway, and she was given inhaled corticosteroids
for her history of asthma/COPD. Gentle diuresis was attempted
but limited by hypotension.
Plans were made to transition the patient to pulmonary rehab.
Given her repeated collapse noted on chest x-ray and on repeat
bronchoscopies, patient may be candidate for stent placement
from interventional pulmonology in the future. On the floor,
the patient was saturating well on her trach mask. In the
future, she should be weaned down as she tolerates. A few days
before discharge, she had a sputum sample taken that grew
pan-sensitive klebsiela. However, she remained afebile and her
WBC was not increased. And chest xray did not suggest a
pneumonia. If her clinical condition were to change, would
consider covering klebsiela with antibiotics.
.
# Clonus: Patient was noted to have a new finding of bilateral
cloni of the feet on exam, and mild serotonin syndrome was
suspected. Neurology, who was involved throughout the patient's
stay, felt this was more likely residual from prior stroke. As a
result, fluoxetine was discontinued, and fentanyl IV was weaned
and transitionned to a patch. A repeat head CT shows no new
bleeding or lesions, but increased size of pseudomeningocele.
.
# Fever: Patient continued to have low grade fevers and
leukopenia, however no systemic signs of infection were noted,
and cultures remained negative. It was suspected that her was
possibly due to suspected serotonin syndrome. At the time of
discharge she was afebile and her WBC was stable. If her
clinical picture should change, as noted above in respiratory
section, she should be covered for the klebsiela found in her
sputum. At the time of discharge there was not clinical
indication to start treatment.
.
# Blood pressure: Patient had highly variable blood pressure
while in the intensive care unit. She was initially
hypertensive, and then became hypotensive, which was typically
responsive to fluids. At time of discharge from the MICU, she
was normotensive, and her home blood pressure medications were
held. Her lisinopril was restarted at a low dose of 2.5mg and
her blood pressures were stable at the time of discharge. He
blood pressure should be monitored and medications titrated as
needed to maintain good blood pressure control.
.
#Metabolic Alkalosis: Patient noted to have small metabolic
alkalosis, pH 7.44 HCO3 36 at the time of discharge. It was
stable.
.
# Anemia: Hct 28-32 during this admission, and was stable in
mid-20s during ICU stay. Iron studies consistent with anemia of
chronic disease.
.
# CAD: Stable. ASA, Plavix and BB were held, ACEI was restarted
at low dose. Statin was continued. She was not restarted on
ASA and plavix at the time of discharge because of bleeding
risk. Her primary care physician will need to follow up these
medications in the future and reevaluate risks and benifits of
these medications.
.
# Aortic stenosis: Patient has history of aortic stenosis,
therefore we were cautious with afterload reduction
.
# DM blood sugars at goal at this time on NPH 13 units in AM
and PM. Will be continued on sliding scale. Her blood sugars
should be followed at rehab and insulin titrated as needed.
.
# Depression: d/c 'd fluoxetine, as noted above given suspected
serotonin syndrome. Patient would likely benefit from an [**Doctor Last Name 360**]
to replace her fluoxetine, and further psychiatric evaluation
during her rehabilitation stay.
.
# Asthma: Continued on nebs PRN and inhailed steroids.
.
# PPX: Continue heparin SQ while she is being started on
heparin. Can stop heparin once therapeutic on coumidin.
.
# FEN: Continue tubefeeds
.
# CODE: Full CODE
Medications on Admission:
Plavix 75 daily
ASA 81 daily
Prevacid 30 daily
Duonebs
Colace 100 mg daily
Glyburide 2.5 daily
Lopressor 50 [**Hospital1 **]
Fluoxetine 10 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain / fever.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day): hold for diarrhea or >1BM per day.
4. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day): please stop when patient's
INR is stable at 2.0-2.5 on the coumidin.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed.
8. Fluticasone 44 mcg/Actuation Aerosol [**Last Name (STitle) **]: Eighty Eight (88)
mcg Inhalation twice a day: can titrate dose higher as directed
by physician if needed.
9. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: Thirteen
(13) units Subcutaneous at breakfast and at bedtime.
10. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: As
directed by sliding scale Subcutaneous As directed by sliding
scale.
11. Fentanyl 50 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day
(at bedtime)): please titrate dose to achieve INR of [**12-22**].5.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Date Range **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
14. Lisinopril 5 mg Tablet [**Date Range **]: 0.5 Tablet PO DAILY (Daily):
hold for SBP<95.
15. Ipratropium Bromide 0.02 % Solution [**Date Range **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation: hold for diarrhea or >1 BM per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Stroke
Ventilator Associated Pneumonia
Diabetes
COPD
Discharge Condition:
stable
Discharge Instructions:
Patient was seen in the hospital for a stroke. She underwent a
neurosurgical procedure to relieve pressure on the brain. She
was followed in the intensive care unit for most of her
hospitalization. The course was complicated by ventilator
associated pneumonia and a difficult extubation course. A
trachiostomy was placed and she will be followed at rehab.
.
Please follow up with the recommended appointments listed below.
.
See attached list for most up to date medications
.
Either return to the emergency room or call your primary care
physician if the patient develops any difficulty breathing,
increasing oxygen requirement, any change in mental status or
new neurological deficits, or with any concerning symptoms.
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**First Name (STitle) **] from neurosurgery TO BE SEEN IN 2 WEEKS.
.
Please call Neurology [**Hospital 4038**] clinic at [**Telephone/Fax (1) 44**] to schedule
an appointment to be seen in 4 weeks.
.
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15170**] at [**Telephone/Fax (1) 9674**] to set
up a follow up appointment within 3 weeks.
Completed by:[**2153-9-26**]
|
[
"486",
"331.4",
"285.9",
"250.00",
"434.91",
"518.5",
"349.2",
"997.3",
"518.0",
"493.20",
"424.1",
"999.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.59",
"96.6",
"93.99",
"31.1",
"33.24",
"43.11",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11530, 11582
|
3579, 3589
|
239, 335
|
11679, 11688
|
2343, 2610
|
12462, 12974
|
1621, 1723
|
9401, 11507
|
11603, 11658
|
9231, 9378
|
11712, 12439
|
1738, 1942
|
178, 201
|
363, 1415
|
2047, 2324
|
2619, 3556
|
3604, 9205
|
1437, 1521
|
1537, 1605
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,217
| 161,582
|
38900
|
Discharge summary
|
report
|
Admission Date: [**2166-8-6**] Discharge Date: [**2166-8-22**]
Date of Birth: [**2104-2-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
new diagnosis of SCC of base of tongue
Major Surgical or Invasive Procedure:
EGD w/ Biopsy
History of Present Illness:
62 yo man with h/o CAD, heavy smoking and new diagnosis of SCC
of base of tongue with lymph node involvement.
Pt was referred to Dr [**Last Name (STitle) 86316**],ENT, in [**11-1**] for a rt neck
mass. At that time a 2.5 cm rt cervical lymph node was palpated
and fiberoptic laryngoscopy showed a 1.5 cm rt base of tongue
mass. A CT and biopsy were recommended. Pt did not show -up fo
rf/u adn could not be reached. Eventually, in [**4-2**] he had the
neck CT scan which showed a mass in teh rt oropharynx, rt
cervical mass , bilateral LAD and compression of the rt internal
jugular vein.Pt again did not show -up for f/u. He presented to
the [**Hospital1 2025**] ED with hemoptysis. After multiple attempts to perform a
fiberoptic intubation, pt underwent a tracheotomy for airway
protection. An FNA of the rt neck mass was also done and
positive for poorly differentiated SCC.Post procedure he
required pressors for a short time. Pt was transferred to the
ICU at [**Hospital1 18**] for further care. At the ICU pt monitored closely
adn remained stable.pain manged with a morphine PCA. ENT
evaluated the pt and performed a laryngoscopy and biopsy of
mass.
On arrival on the floor, pt reports that his neck pain is well
controlled. He has a persistent cough and thick secretions from
trach. He has lost 20 lbs over teh past 3 weeks adn has been
increasingly fatigued over the past several months. He denies
HAs, n/v, chest pain, sob, palpitations, abdominal pain,
diarrhea, dysuria/frequency.All other ten point ROS is negative.
Past Medical History:
1. CAD s/p STEMI s/p stents x 3 to mid LAD [**4-1**]
2. Hypercholesterolemia
3. s/p ankle surgery
Social History:
Pt lives alone, works in food service at [**Hospital1 778**].
Tob: 40+ year pack history, currently [**11-24**] ppd. Denies chewing
tobacco use.
Etoh: one six packs/week
Illicits: denies
Family History:
No known cancer diseases in the family
Physical Exam:
T 99.8 P 81 BP 113/72 RR 24 O2 sat 93% RA
General: Unable to talk, writes to communicate, appears
comfortable in no respiratory distress, coughing copious
secretions from trach during interview
HEENT: Pupils equal and reactive, sclerae non-icteric, o/p
clear, MM dry, good movement of tongue but fullness of OP.Poor
dentition.NGT in place.
Neck: Supple,trach in place, rt cervical mass extending to
supraclavicular region,left cervical enlarged lymph node
measuring 3 cm palpated.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No edema, good pedal pulses.
DERM: No rash.
Neuro: Cranial nerves [**1-4**] grossly intact, muscle strength 5/5
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
[**2166-8-9**] 04:39AM BLOOD WBC-10.0 RBC-3.63* Hgb-10.8* Hct-30.3*
MCV-84 MCH-29.8 MCHC-35.7* RDW-12.8 Plt Ct-322
[**2166-8-9**] 04:39AM BLOOD Neuts-76.2* Lymphs-11.8* Monos-8.8
Eos-2.6 Baso-0.6
[**2166-8-9**] 04:39AM BLOOD PT-15.3* PTT-32.4 INR(PT)-1.3*
[**2166-8-9**] 04:39AM BLOOD Glucose-108* UreaN-6 Creat-0.4* Na-134
K-3.5 Cl-98 HCO3-28 AnGap-12
[**2166-8-8**] 12:02AM BLOOD ALT-27 AST-24 LD(LDH)-213 AlkPhos-67
TotBili-1.5
[**2166-8-9**] 04:39AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0
[**2166-8-7**] 12:29PM BLOOD TSH-0.54
[**2166-8-7**] 07:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2166-8-7**] 07:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
GRAM STAIN (Final [**2166-8-7**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2166-8-9**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2166-8-9**] 3:37 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2166-8-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary): sparse growth
.
Recent study reports:
[**2166-8-10**]:portable CXR: bilateral atelectasis, no infiltrate.
.
[**2166-8-4**] CT chest [**Hospital1 2025**] : There is some patchy groundglass opacity
in the posterior segment of the right upper lobe. There also
some
airspace opacities in both lower lobes in the basal segments
just
above the hemidiaphragms. The thyroid gland is normal. There
is
subcutaneous air in the lower neck and upper mediastinum
probably
related to placement of the tracheostomy tube. There is also
some fluid in the retrosternal area. There is a 1.1-cm right
paratracheal lymph node. No other significant mediastinal, hilar
or axillary lymphadenopathy is seen. Limited contrast-enhanced
views of the upper abdomen show no abnormality within the
visualized liver, spleen, pancreas, or kidneys. The adrenal
glands are normal.
.
[**2166-8-4**] CT NECK from [**Hospital1 2025**]: There is a large peripherally
enhancing irregular right tongue base mass with internal air and
low density material likely representing necrosis and secretions
which extends across midline into the left tongue. This mass
measures 6 cm AP by 4 cm TV by 3 cm SI, though these
measurements are approximate as the mass is difficult to measure
given irregularity and lobulation. A right retropharyngeal lymph
node measuring 1.4 cm x 1.19 m is seen posterior to the mass.
Mass effect displaces the larynx and hyoid bone slightly to the
left and there is effacement of the upper airway. Multiple
enlarged lymph nodes are seen bilaterally with central low
density likely representing necrosis. The largest right level
II
conglomerate measures on the order of 5.5 cm x 3.4 cm. The
largest left level II lymph node conglomerate measures on the
order of 3.8 cm. Enlarged nodes are seen extending inferiorly
on
the right to the supraclavicular region. Additional rounded
1.7-cm right paratracheal node is identified. These masses
result in extrinsic compression of the internal jugular veins,
though the vessels remain patent without evidence of thrombosis.
There is opacification of left ethmoid air cells with air fluid
level in the left maxillary and sphenoid sinuses possibly
representing hemorrhage. Periapical lucencies are noted in the
remaining maxillary teeth probably representing dental caries.
Defect is noted in the anterior nasal septum. Degenerative
changes are seen throughout the cervical spine which are worse
at
C6-7. There is no severe stenosis at the origins of the right
brachiocephalic artery or at the origins of the bilateral
subclavian, vertebral or common carotid arteries. There is
mixed
calcified atheromatous plaque of the bilateral carotid
bifurcations resulting in mild bilateral internal carotid artery
narrowing. Remaining cervical carotid arteries are
unremarkable.
There is mild stenosis of the right vert origin from calcified
plaque. No other significant stenosis is noted in the cervical
vertebral arteries. There is normal enhancement of the
visualized intracranial circulation. Calcified plaque is noted
in
the carotid siphons and intradural vertebral arteries in which
there is minimal narrowing of the left intradural vertebral
artery.
.
Path:[**2166-8-7**] SPECIMEN SUBMITTED: Right base of tongue biopsy,
RIGHT Base of Tongue Biopsy #2.
DIAGNOSIS:
1. Base of tongue, right, biopsy (A-B):
Non-keratinizing squamous cell carcinoma, poorly differentiated,
seen only on frozen section slides.
2. Base of tongue, right #2, biopsy (C):
Non-keratinizing squamous cell carcinoma, poorly differentiated,
see note. Note: Immunohistochemical staining shows that the
tumor cells are positive for cytokeratin cocktail, CK5/6, p63,
and p16, and are negative for chromogranin, synaptophysin, NSE,
and LCA. The findings support the diagnosis of squamous cell
carcinoma. Additional studies for HPV will be requested and
results will be reported as an addendum.
.
[**2166-8-10**] CT of neck :1. No discrete fluid collection.
2. Slight decrease in size of base of tongue mass with
improvement in central hypodensity since [**2166-4-17**].
3. Phlegmonous change or soft tissue swelling with associated
narrowing of the oropharynx or hypopharynx, new from [**2166-4-17**].
4. Enlarged necrotic bilateral cervical lymph nodes, essentially
stable, aside from a slightly enlarged left cervical node.
5. Sinus disease as described above is new from [**2166-4-17**].
.
[**2166-8-10**] CT chest:1. Mild biapical and left lower lobe focal
ground glass opacities are new from [**2166-8-4**] and nonspecific.
These could represent focal asymmetric pulmonary edema or
atypical infection and aspiration cannot be excluded.
2. Bilateral pleural effusions, right greater than left and new
or increased compared to [**2166-8-4**], with adjacent atelectasis.
3. Enlarged mediastinal lymph node to 13 mm is stable from
[**2166-8-4**]. Known cervical lymphadenopathy is better assessed on
accompanying CT of the neck.
3. Coronary artery calcifications in the LAD.
.
[**2166-8-12**] PET/CT scan: 1. Bilateral floridly FDG-avid soft tissue
conglomerate in the neck, right much worse than left. 2.
FDG-avidity in the soft tissues around the tracheostomy site, in
keeping with recent procedure. 3. Mildly FDG-avid, patchy
opacity in the lingula, likely infectious in etiology. 4.
Bilateral non-FDG-avid pleural effusions, right worse than left.
5. Left maxillary, frontal and ethmoid sinus disease.
.
[**2166-8-14**] Cardiac echo:The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of [**2165-6-6**],
regional wall motion abnormalities are no longer appreciated.
.
[**2166-8-16**] pCXR: IMPRESSION: Lung fields are clear.
.
Discharge labs:
136 | 104 | 14
---------------<103
4.6 | 26 | 0.7
.
3.0 > 30.1 < 184
.
Ca 803
Mg 2.0
P 3.1
.
Alt 24
Ast 21
AP 43
TB 0.2
Brief Hospital Course:
62 yo man with new diagnosis of SCC of the oropharynx Stage IVB
s/p tracheotomy transferred from [**Hospital1 2025**] for further management.
Admitted to the [**Hospital Unit Name 153**] for initial management and subsequently
transferred to the floor to start his chemotherapy with TPF
which he tolerated well [docetaxel 75 mg/m2 day1 , cisplatin 100
mg/m2 day1, and continuous infusion 5FU 1000mg/m2 per day days
[**11-26**]]. His course was complicated by upper airway infection with
fever and purulent trach secretions and bleeding/skin breakdown
around his trach site. He had transient changes in mental status
attributed to the high dose steroids that he received as
premedication for the docetaxol in his chemo regimen which were
treated with haldol and DC of steroids. HE WILL REQUIRE NEULASTA
INJECTION ON [**2166-8-23**].
.
# SCC of the base of tongue: Rad onc and ENT consulted in the
ICU. Path from base of tongue finalized as poorly diff. SCC
(HPV study pending). Cytology from FNA of rt LAD-positive for
SCC per pathology at [**Hospital1 2025**]. Side effects of chemotherapy were
reviewed with the patient and he was consented with
chemotherapy. Plan for 3 cycles in-house q3 weeks. Side effects
reviewed and include, but not limited to pan-cytopenia, febrile
neutropenia, sepsis, death, neuropathy, kidnay failure, hearing
loss, skin rashes, cardiac toxicity, diarrhea. Pt expressed his
understanding and had the opportunity to ask questions. Received
full dose TPF from [**Date range (1) 23681**].
Pt started on decadron 8 mg [**Hospital1 **] x4 days [**2166-8-15**] and DC'd for
agitation [**2166-8-18**]. Protocol reviewed with pt, chemothrapy to
include docetaxel day1 , cisplatin day1 and continuous 5fu
infusion days [**11-26**]. Fitted with Passy-Muir valve [**2166-8-21**]. Treated
with allopurinol because of large tumor burden. Peg tube placed
[**2166-8-11**].
-Will need neulasta support in AM of [**2166-8-23**] ~ 24 hours after
chemo has completed late night [**2166-8-21**].
-Will need dental eval in preparation for xrt in the
future-after completion of induction chemo.
.
#CAD: MI in [**3-/2165**] with stent placement. Continued metoprolol,
aspirin and simvastatin. Metoprolol at home was 100mg metoprolol
succinate. However, given hypotension at OSH and sinus
bradycardia dose decreased to 6.25 [**Hospital1 **]. D/C'd plavix per
cardiology recommendations since patient is more than a year
from stent placement and requiring peg tube placement and
chemotherapy in the near future as well as recent hemoptysis and
continued evidence of blood in trach secretions.
Cardiac echo with Nl LVEF and improvement in wall motion
abnormalities seen after MI.
.
#Sinus bradycardia: Asymptomatic just prior to initiation of
chemotherapy. Seen in consultation with cardiology and treated
with decrease in metoprolol and transient DC of fentenyl patch
used for his cancer pain and trach site pain. Normal TSH.
Metoprolol decreased to 6.25 mg [**Hospital1 **]. Restarted fentanyl patch
[**8-19**] since this does not seem to be the culprit med and no
further bradycardia on telemetry.
.
# Hyperglycemia: transient, mild, likely due to steroid
premedication for chemotherapy.
.
# Agitation/delerium: likely due to decadron for taxotere, age
and sleep deprivation.
DC'd decadron and treated with Haldol QHS and prn.
.
#Pain:- Not as good control since restarting fentanyl patch and
morphine per G tube. Restarted fentenyl 75 mcg patch [**2166-8-19**] and
increased to 112 mcg just prior to transfer to [**Hospital1 **].
Increased morphine to 30-60 mg per G tube Q2H prn pain just
prior to transfer. Had been on a morphine PCA with good control
prior to starting fentenyl patch at basal rate of morphine at 2
mg /hr with 2 mg bolus doses Q10 minutes.
.
#Fever: Patient had fever, leukocytosis, and purulent trach
secretions in the ICU. Sputum cx, urine cx and blood cxs all
negative. Fever again on the floor. Source of fever include
possible aspiration pneumonia/trach- sinusitis. Afebrile last 48
hrs
Received unasyn [**Date range (3) 86317**] with resolution of fever, WBC
normalized and secretions cleared.
.
#Rash: Skin exfoliation due to erosion by the trach. Most recent
wound consult includes:
Goals: Protection of skin inferior to tracheostomy to allow
healing Recommendations:
Please discontinue Aquaphor Ointment to this site.
1. Cleanse skin with normal saline gently. Pat dry.
2. Apply No Sting Barrier Film to the skin around the erosion
and
air dry for 30 seconds.
3. Apply Allevyn Trach Foam around the Trach to prevent pressure
over the eroded site.
4. Change daily and prn.
.
#Nutrition: Peg tube placed. D/C's NGT used in [**Hospital Unit Name 153**]. Tolerating
peg tube feedings. Have changed to bolus feeds, 2 cans TID.
.
DVT PPX: restarted heparin [**2166-8-17**] following DC due to episode
of bleeding around trach.
.
Full code
.
Line:picc line placed [**2166-8-11**]-will need port placed prior to
next cycle.
.
precautions: Aspiration
.
.
Contact: no family/close friends. .
Medications on Admission:
home meds:
1. ASA 325mg daily
2. Plavix 75mg daily
3. Simvastatin 80 mg
4. Metoprolol 100 mg
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): per G tube.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): per G tube.
3. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day): Per PEG tube.
4. morphine 10 mg/5 mL Solution Sig: 30-60 mg PO Q2H (every 2
hours) as needed for pain: Per G tube.
5. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal Q72H (every 72 hours): Use with 12 mcg/hr patch for
total dose 112 mcg/hr.
6. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) 12 mcg
Transdermal every seventy-two (72) hours: please use with 100
mcg/hr patch for a total dose of 112 mcg/hr dose.
7. pegfilgrastim 6 mg/0.6mL Syringe Sig: Six (6) mg Subcutaneous
once for 1 doses: Give as a single dose SC on [**2166-8-23**].
8. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Per G tube.
9. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): Per G tube.
10. senna 8.8 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2 times a
day) as needed for constipation: Per G tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for continuing medical care
Discharge Diagnosis:
Squamous cancer base of tongue
CAD
Bradycardia
Hyperglycemia (mild with steroids)
Pain
Upper respiratory infection
Skin breakdown at trach site
PEG for nutrition
Mental status changes (transient with steroids)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred from [**Hospital1 2025**] after undergoing urgent
tracheostomy for bleeding from your tongue cancer that was
causing you to have problems breathing. [**Name2 (NI) **] were initially seen
in the intensive care unit and then transferred to the floor
where you got TPF chemotherapy for your cancer. You tolerated
your chemotherapy well and will need a neulasta shot when you
get to [**Hospital6 **]. While you were in the
hospital you had a slow heart rate that was treated with
decreasing your metoprolol and stopping your fentenyl patch.
Your fentenyl patch was then restarted without further heart
rate problems. [**Name (NI) **] also had an upper airway infection that was
treated with IV antibiotics. Because you cannot swallow well,
you have been receiving nutrition though your g-tube. You were
treated with dexamethasone steroid medication during your
chemotherapy which caused you to be confused. Your confusion was
treated with haldol and stopping the dexamethasone. After
discussion with the heart doctors, your plavix was stopped
because you had some bleeding around your tracheostomy site and
also needed your PEG tube placed for nutrition. You will
continue to take a low dose aspirin daily.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2166-8-28**] at 11:00 AM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"427.89",
"141.0",
"276.52",
"790.29",
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
"42.23",
"25.01",
"99.25",
"38.93",
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icd9pcs
|
[
[
[]
]
] |
17378, 17457
|
11099, 16123
|
341, 356
|
17711, 17711
|
3210, 4629
|
19110, 19414
|
2257, 2297
|
16266, 17355
|
17478, 17690
|
16149, 16243
|
17862, 19087
|
10951, 11076
|
2312, 3191
|
4664, 10934
|
263, 303
|
384, 1914
|
17726, 17838
|
1936, 2036
|
2052, 2241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,771
| 146,648
|
30007
|
Discharge summary
|
report
|
Admission Date: [**2149-1-6**] Discharge Date: [**2149-1-15**]
Date of Birth: [**2106-10-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
NG tube placement
PICC placement
History of Present Illness:
Mr. [**Known lastname **] a 42M alcoholic who initially presented on [**1-6**] after
falling. Per chart, patient stumbled over friend after drinking
3-4 beers but did not lose consciousness.
.
In the ED, vitals were 99.2 115 118/80 16 96% on room air. He
was given valium and admitted to the medicine service. CT head
was negative for bleeding, and plain films of the left shoulder
were negative for fracture (patient had complained of left
shoulder and elbow pain). CXR revealed a left sided pleural
effusion.
.
On the medical floor, he was given 40mg prednisolone for
alcoholic hepatitis, but this was subsequently discontinued. An
abdominal ultrasound was performed showing ascites and patent
portal vein. He underwent a diagnostic paracentesis that
revealed no evidence of SBP (3+ polys no organisms on gram, 73
WBC on cell count). He was continued on a CIWA scale, receiving
8mg of lorazepam on [**1-7**] last at 21:30. Lactulose was
adminstered, but held at 14:00 that day. At 23:00 he was
triggered for altered mental status with confused speech. Per
signout, patient had been conversant previously. Was found to be
hypoglycemic to 50, given D50 without significant improvement.
NGT placed and lactulose administered. He is transferred to the
MICU due to need for more intensive nursing care that available
overnight on the medical floor.
.
On MICU evaluation, patient denies pain and mumbles
unintelligably.
Past Medical History:
Alcohol abuse
humeral prosthesis
Social History:
Originally from [**Country 3400**]. Lives with housemates, worked as cook
at [**Last Name (un) 71619**] until about 2 years ago, has been unemployed
since. Has been drinking 5-12 beers daily for twenty years but
lately cut back to [**2-19**]. Smokes about 1ppd x 16 yrs, now down to
1/3 ppd. Denies any illicit or injection drugs.
Family History:
Mother and father deceased per records
Physical Exam:
Admission Exam:
Vitals 97 130 120/60 18 96% on RA
HEENT PEARL, sclera icteric, does not open eyes to voice
Neck Supple
Pulm Lungs clear bilaterally decreased L base
CV Tachycardic regular S1 S2 no m/r/g
Abd Soft distender +fluid wave with +liver edge nontender
Extrem Warm 1+ bilateral edema, palpable distal pulses
Neuro Opens eyes to voice and squeezes hands to command, poor
attention and falls asleep again quickly, moving all extremities
without any gross focal deficits. Not cooperative with asterixis
testing. Slightly tremulous.
Derm Jaundiced, no peripheral stigmata of endocarditis
Death Exam:
Patient unresponsive, pupils fixed and dilated. Bright red
blood from nose/mouth with dark blood draining into NG tube
suction. No heart/lung sounds, no carotid pulses.
Pertinent Results:
Admission Labs:
[**2149-1-6**] 06:53PM BLOOD WBC-5.0 RBC-3.07* Hgb-12.0* Hct-34.3*
MCV-112* MCH-39.0*# MCHC-35.0 RDW-16.1* Plt Ct-29*#
[**2149-1-6**] 06:53PM BLOOD PT-30.8* PTT-52.8* INR(PT)-3.2*
[**2149-1-6**] 06:53PM BLOOD Glucose-90 UreaN-5* Creat-0.6 Na-129*
K-2.9* Cl-91* HCO3-23 AnGap-18
[**2149-1-6**] 06:53PM BLOOD ALT-77* AST-384* AlkPhos-137* Amylase-77
TotBili-7.6* DirBili-4.6* IndBili-3.0
[**2149-1-6**] 06:53PM BLOOD TotProt-7.7 Albumin-1.8* Globuln-5.9*
Calcium-7.4* Phos-2.0*# Mg-1.6
[**2149-1-6**] 06:56PM BLOOD Glucose-91 Na-131* K-3.1* Cl-93*
calHCO3-23
Labs on Last Hospital Day:
[**2149-1-15**] 02:35AM BLOOD WBC-7.7 RBC-1.85* Hgb-7.3* Hct-21.7*
MCV-117* MCH-39.5* MCHC-33.7 RDW-17.3* Plt Ct-39*
[**2149-1-15**] 02:35AM BLOOD PT-53.7* PTT-90.8* INR(PT)-6.2*
[**2149-1-15**] 02:35AM BLOOD Glucose-80 UreaN-40* Creat-4.2* Na-144
K-3.8 Cl-110* HCO3-23 AnGap-15
[**2149-1-15**] 02:35AM BLOOD ALT-28 AST-68* LD(LDH)-403* AlkPhos-67
TotBili-18.4*
[**2149-1-15**] 02:35AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.3
Microbiology:
Peritoneal Fluid: GRAM STAIN (Final [**2149-1-9**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count.
Blood Culture, Routine (Final [**2149-1-13**]):
STAPH AUREUS COAG +. Pan SENSITIVITIES.
Relevant Imaging:
CT Head [**2149-1-6**]: IMPRESSION: No acute intracranial hemorrhage.
Advanced atrophy due to alcoholism.
[**2149-1-6**]: Liver U/S:
IMPRESSION:
1. Cirrhosis.
2. Ascites.
3. Gallbladder with sludge.
4. Patent portal vein.
[**2149-1-9**]: TTE: No signs of vegitation.
[**2149-1-11**]: Renal U/S
IMPRESSION:
1. No hydronephrosis.
2. Moderate-to-large ascites.
[**2149-1-12**]: Portable CXR
As compared to the previous radiograph, a nasogastric tube has
been
inserted. The course of the tube is unremarkable, the tube is in
correct
position. No complications. Otherwise, the radiograph is
unchanged.
Brief Hospital Course:
Mr. [**Known lastname **] is a 42 year old gentlmen that presented to the ED
following a fall and unknown quantity of alcohol consumption.
He was transfered to the MICU for persistent agitation/altered
mental status. Given his End-Stage liver disease from cirrhosis
complicated by Acute alcoholic hepatitis, his brother in [**Name (NI) 3400**]
was reached via telephone with his friend/roommate [**Doctor First Name **]
translating. A decision was reached to make him DNR/DNI. He
developed bradycardia in the setting of an acute Upper GI bleed
followed shortly by apnea and pulseless electrical activity.
The circumstances of his death warranted contact of the medical
examiner. Dr. [**Last Name (STitle) **] has accepted jurisdiction of his case.
1. Altered mental status: The patient's altered mental status
was attributed to fulminant liver failure complicated by
possible alcohol withdrawal and sedating benzodiazepines to
prevent such withdrawal. His status did not clear during this
hospitalization but he did become more agitated and vocal
towards the end of his stay.
2. Acute Alcoholic Hepatitis/End Stage Liver Disease: The
patient was found by liver function enzymes to be in acute
hepatitis, secondary to alcohol abuse with a history of chronic
alcohol induced liver disease. He was monitored for alcohol
withdrawal on a CIWA protocol, given vitamin therapy and tube
feeds. He was maintained on lactulose and rifaximin to attempt
to clear his mental status. The hepatology team was consulted
and the patient was not a transplant candidate despite a MELD
score of 49. He remained peristently tachycardic and
coagulopathic, not responding to several units of FFP.
3. MSSA Bacteremia: Blood cultures grew 1/4 bottles of
Methicillin sensitive Staph Aureus. TTE was negative and no
repeat cultures grew any organisms. The patient was treated
with Nafcillin, hepatically dosed. Source unknown.
4. Acute renal failure: The patient??????s renal failure and urine
output declined during his admission. The etiology was likely
acute tubular necrosis versus possible hepatorenal syndrome.
Renal was consulted and the patient was not considered a
dialysis candidate given his liver status. Lactated Ringers,
normal Saline and Albumin were given; however, these failed to
stimulate urine output. He was also trialed on midodrine and
octreotide without effect.
5. Hypernatremia: Given the patient's renal failure and
excessive diarrhea he developed hypernatremia to 148. He was
given free water boluses via his NG tube which resolved his Na.
6. Spontaneous Bacterial Peritonitis: On a diagnostic
paracentesis the patient was found to have polys without
organisms (post treatment for MSSA with Vancomycin & Nafcillin).
He was started on Ceftriaxone but then switch to Ciprofloxacin
for treatment.
7. Anemia, thrombocytopenia: The patient was found to be
anemic/thrombocytopenic secondary to chronic alcohol-induced
bone marrow suppression. No sources of bleeding were found
until his final hospital day when he developed what appeared to
be a brisk upper GI bleed. At that time his thrombocytopenia
rapidly progressed with concurrent increase in INR.
Patient communication was maintained with his roommate, [**Doctor First Name **]
([**Telephone/Fax (1) 71620**]), responsible for first bringing the patient to
medical attention. The patient's brother [**Name (NI) **] was reached in
[**Name (NI) 3400**] via [**Doctor First Name **] at 011 [**Numeric Identifier 71621**].
Medications on Admission:
None
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant Liver Failure secondary to Acute Alcoholic Hepatitis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
Medical Examiner: Dr. [**Last Name (STitle) **] will take jurisdiction of the case.
|
[
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icd9cm
|
[
[
[]
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[
"54.91",
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icd9pcs
|
[
[
[]
]
] |
8734, 8743
|
5152, 5915
|
336, 370
|
8849, 8858
|
3087, 3087
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8910, 8996
|
2236, 2276
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8706, 8711
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8764, 8828
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8882, 8887
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2291, 3068
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275, 298
|
4526, 5129
|
398, 1815
|
3103, 4508
|
5931, 8651
|
1837, 1872
|
1888, 2220
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,720
| 131,169
|
47183
|
Discharge summary
|
report
|
Admission Date: [**2121-5-1**] Discharge Date: [**2121-5-8**]
Date of Birth: [**2064-1-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Increased Headache
Major Surgical or Invasive Procedure:
[**5-2**]: Left Craniotomy for Subdural Hematoma
History of Present Illness:
57 year old male with known SDH presented on [**5-1**] with acute
worsening of headache with 10/10 pain that woke him up from
sleep. The patient reports that he did have a period with no
pain that was brief but that his pain when he came in today was
much worse than it has been all week. The patient has no gait
disturbance, no dizziness, no visual changes. He had a repeat
head CT that shows increased midline shift.
Past Medical History:
known SDH from previous admission
Social History:
Married has 5 sons youngest is 5 months, lead guitarist for
popular [**Doctor Last Name **] band, 0.5 pack per day smoker, drinks 4-6 beers
every day
Family History:
Mother 83 and healthy; Father died at 78 of liver cirrhosis
Physical Exam:
On Admission:
T:98 BP:147/100 HR:92 RR:18 O2Sats:99% RA
Gen: Patient was sleeping prior to exam.
HEENT: Pupils:PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-1**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Exam upon discharge:
The patient is oriented x 3. PERRL, EOMS intact. Face symmetric,
tongue midline.
Full strength and sensation throughout. No pronator drift.
Pertinent Results:
Labs On Admisson:
[**2121-5-1**] 04:15AM BLOOD WBC-14.1* RBC-4.49* Hgb-14.2 Hct-40.4
MCV-90 MCH-31.6 MCHC-35.1* RDW-12.7 Plt Ct-562*
[**2121-5-1**] 04:15AM BLOOD PT-12.0 PTT-24.8 INR(PT)-1.0
[**2121-5-1**] 04:15AM BLOOD Glucose-109* UreaN-8 Creat-0.8 Na-135
K-4.2 Cl-100 HCO3-25 AnGap-14
[**2121-5-2**] 11:28AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8
Labs on Discharge:
[**2121-5-8**] 06:40AM BLOOD WBC-14.4* RBC-3.55* Hgb-11.1* Hct-31.6*
MCV-89 MCH-31.4 MCHC-35.3* RDW-12.4 Plt Ct-680*
[**2121-5-8**] 06:40AM BLOOD Plt Ct-680*
[**2121-5-8**] 06:40AM BLOOD PT-12.9 PTT-24.9 INR(PT)-1.1
[**2121-5-8**] 06:40AM BLOOD Glucose-105 UreaN-10 Creat-0.7 Na-137
K-4.6 Cl-102 HCO3-26 AnGap-14
Imaging:
Head CT [**5-1**]:
COMPARISON: CT head [**2121-4-27**] and multiple priors.
A left cranial subdural hematoma demonstrates expected evolution
of blood
products, measuring 14 mm in greatest axial thickness, not
significantly
changed compared to the recent prior, however, there are shift
of normally
midline structures, 10 mm today, compared to 7 mm on [**4-27**]. No
new
intracranial hemorrhage has developed in the interval. The
basilar cisterns remain patent. There is no evidence for acute
major vascular territorial infarction. Mucosal thickening
involves the maxillary sinuses and ethmoid air cells
bilaterally. The mastoid air cells are well aerated. The
calvarium is intact.
IMPRESSION:
1. While there is no significant change in size of the left
hemispheric
subdural hematoma, there appears to be more rightward subfalcine
herniation compared to the recent prior.
Head CT [**5-2**]:
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting upright position. The heart size is within normal
limits. No typical configurational abnormality is seen. Thoracic
aorta and mediastinal structures are unremarkable. The pulmonary
vasculature is normal. No signs of acute or chronic parenchymal
infiltrates are present, and the lateral pleural sinuses are
free. No pneumothorax in the apical area. Our records do not
include a previous chest examination available for comparison.
IMPRESSION: Chest findings within normal limits on AP single
view
examination.
Head CT [**2121-5-4**]:
FINDINGS: There is evidence of prior left craniotomy. A left
extra-axial heterogeneous collection containing multiple areas
of higher attenuation and foci of air, compatible with the
patient's history of recently evacuated subdural hematoma, has
not changed compared to the CT performed earlier the same day.
There is persistent sulcal effacement involving the left
cerebral convexity and shift of normally midline structures to
the right of approximately 10 mm, probably not changed compared
to the previous evaluation. Likewise, subfalcine herniation is
unchanged. Mass effect on the left lateral ventricle including
obliteration of the posterior [**Doctor Last Name 534**] and partial compression
of the temporal [**Doctor Last Name 534**] is probably unchanged. No new areas of
hemorrhage are
evident. The region of the pituitary gland appears unremarkable.
Aside from mucosal thickening within the frontal sinuses,
anterior ethmoid cells and maxillary sinuses, right greater than
left, the visualized paranasal sinuses and mastoid air cells are
well aerated.
IMPRESSION: Stable left subdural hematoma with no new foci of
hemorrhage.
Persistent, unchanged rightward shift and subfalcine herniation.
Head CT [**2121-5-7**]:
FINDINGS: There is stable-to-slightly improved 9 mm rightward
shift of normally midline structures with minimal subfalcine
herniation. There is evolution of a left convexity subdural
hematoma causing mild gyral and sulcal effacement along this
convexity. There has been no expansion of this evolving subdural
hematoma without new foci of hemorrhage. The [**Doctor Last Name 352**]-white matter
differentiation remains well preserved. There is slight
asymmetery of the ventricles, right greater than left, which may
reflect slight obstruction at the formaen of [**Location (un) 9700**], also
unchanged. No areas concerning for acute infarct are present.
Patient is status post left frontal craniotomy with residual
foci of pneumocephalus and gas in the subcutaneous tissues,
improved since the prior examination. Otherwise, osseous
structures are intact. There is mild mucosal thickening of the
maxillary sinuses and ethmoidal air cells. The frontal and
sphenoid sinuses and the mastoid air cells are well aerated.
IMPRESSION:
1. Unchanged minimal rightward shift of normally midline
structures with
minimal subfalcine herniation.
2. Evolution of left convexity subdural hematoma without
evidence for
expansion or foci of rebleeding.
3. Status post right frontal craniotomy with resolving
pneumocephalus.
Brief Hospital Course:
57M admitted to the [**Hospital1 18**] on [**5-1**] after increased headache in the
setting of a known SDH. He was transferred to the SICU for
monitoring. On the morning of [**5-2**] he was taken to the OR for
left sided craniotomy for subdural evacuation and subdural drain
placement. He was readmitted to the ICU for overnight
monitoring. Post-op head CT was done and showed appropriate
decompression of SDH. His foley was removed but he had urinary
retention and needed replacement of catheter by urology. Pt was
started on flomax. He was also managed by pain service. His diet
was advanced and he was transferred to stepdown unit [**5-5**]. The
patient continued to improve and was transferred to floor status
on [**5-7**]. The foley was removed and he was able void on his own.
The patient was discharged with a plan for outpatient physical
therapy on [**2121-5-8**].
Medications on Admission:
Keppra, Dilaudid, Fioricet
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO QID (4 times a day) as needed for acid
reflux.
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*14 Capsule, Sust. Release 24 hr(s)* Refills:*0*
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6h () for 2
days: Please take 5 more doses. Then on Sat taper to 2mg [**Hospital1 **] x 3
days.
Disp:*12 Tablet(s)* Refills:*0*
9. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 3 days: Start on Tues and take for 3 days. On
Friday [**5-16**] taper to 1 mg [**Hospital1 **] x 3 days. On Monday [**5-19**] taper to
1mg daily for 3 days and then stop.
Disp:*22 Tablet(s)* Refills:*0*
10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Do not take more than 4
grams per day!.
11. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q 3 -4 HOURS
PRN () as needed for headache: No driving while on this
medication. Please stop if you become too lethargic.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Subdural Hematoma
Urinary retention
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after your sutures have been
removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????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.
***You have been sent home on a steroid taper. Please take as
prescribed and take famotidine until you complete the steroids.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office next Tues. [**2121-5-13**] for removal of
your sutures and a wound check. Please make this appointment by
calling [**Telephone/Fax (1) 1669**]. You also need to have a non-contrast head
CT that day.
Completed by:[**2121-5-8**]
|
[
"305.1",
"276.1",
"338.29",
"E878.8",
"530.81",
"285.9",
"600.01",
"E849.7",
"432.1",
"788.29",
"339.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
9810, 9816
|
7232, 8107
|
320, 371
|
9901, 9925
|
2479, 2825
|
11622, 11885
|
1062, 1124
|
8185, 9787
|
9837, 9880
|
8133, 8162
|
9949, 11599
|
1139, 1139
|
262, 282
|
2844, 7209
|
399, 821
|
1660, 2297
|
1153, 1408
|
1423, 1644
|
843, 878
|
894, 1046
|
2318, 2460
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,831
| 198,018
|
31544
|
Discharge summary
|
report
|
Admission Date: [**2103-9-21**] Discharge Date: [**2103-9-29**]
Date of Birth: [**2035-10-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue with decreased activity
Major Surgical or Invasive Procedure:
[**2103-9-25**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
OM, SVG to PDA to PLB)
History of Present Illness:
67 y/o male with positive ETT. Underwent cath which revealed
severe three vessel disease. Referred for surgical intervention.
Past Medical History:
Hypertension, Diabetes Mellitus, Hypercholesterolemia,
Peripheral Vascular Disease, ?TIA, s/p C-section
Social History:
Denies tobacco and ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 70 14 188/70 62" 160lbs
Gen: 67 y/o obese female in NAD
Skin: W/D intact
HEENT: EOMI, PERRL NC/AT
Neck: Supple, FROM -JVD, -bruit
Lungs: CTAB -w/r/r
Heart: RRR 1/6 early systolic
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, 1+ edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2103-9-21**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by
2D or color Doppler. 2. There is mild symmetric left ventricular
hypertrophy. 3. Overall left ventricular systolic function is
normal (LVEF>55%). 4. There are simple atheroma in the aortic
root. There are simple atheroma in the ascending aorta. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. 5. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. 6. The mitral valve
leaflets are mildly thickened. 7. Trivial mitral regurgitation
is seen. 8. The tricuspid valve leaflets are mildly thickened.
There is mild tricuspid regurgitation. POST-BYPASS: 1. Preserved
biventricular function. 2. Aortic contours are intact.
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing all pre-operative
work-up as an outpatient. On day of admission she was brought to
the operating room where she underwent a coronary artery bypass
graft x 4. Please see operative report for surgical details.
Following surgery she was transferred to the CSRU for invasive
monitoring in stable condition. She did require several blood
transfusions for post-op bleeding and low HCT. She was weaned
from sedation within 24 hours, awoke neurologically intact and
extubated. On post-op day one she was started on beta blockers
and diuretics and gently diuresed towards her pre-op weight. On
post-op day two her chest tubes were removed. On post-op day
three she was transferred to the SDU for further care. She had
episode of atrial fibrillation and was started on Amiodarone
with titration of beta blockers. She was also eventually started
on Coumadin and titrated to a therapeutic INR. On post-op day
four she had sternal drainage and was started on antibiotics.
Stopped [**9-26**]. She worked with physical therapy for strength and
mobility during his entire post-op course. On
post-op day eight she appeared suitable for discharge to home
with VNA services and the appropriate follow-up appointments.
Medications on Admission:
Avapro 300mg qd, Atenolol 25mg qd, Felodipine 5mg qd, Crestor
20mg qd, Cilastalol 100mg [**Hospital1 **], Humulin, Aspirin 325mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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:*1*
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
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:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*1*
6. Pletal 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: tapering dose to QD after 5 days of 400 [**Hospital1 **] dosing.
Disp:*7 Tablet(s)* Refills:*0*
10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days: take this dose first.
Disp:*10 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
this will be your final dose.
Disp:*30 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: take
this dose for [**9-30**] and [**10-1**]. Have INR checked and have results
sent to your cardiologist before resuming.
Disp:*30 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
CBC, INR
Please fax results to your Cardiologist on Tuesday [**2103-10-2**]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Post-op Atrial Fibrillation
PMH: Hypertension, Diabetes Mellitus, Hypercholesterolemia,
Peripheral Vascular Disease, ?TIA, s/p C-section
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increasing pain. Please contact surgeon ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Please shower daily. You may wash incision and gently pat
dry. You may have steri-strips on incisions which should fall
off on their own. If still intact after 3 weeks, you mat remove
them. No lotions, creams or powders to incision until it has
healed. No swimming until wound has healed. Use sunscreen on
incision when out in sun after it has healed.
3) No lifting greater then 10 pounds for 10 weeks from the date
of surgery.
4) No driving for 1 month.
5) Report any fever greater then 100.5.
6) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 29070**] in [**3-3**] weeks
Dr. [**Last Name (STitle) **] in [**1-30**] weeks
Completed by:[**2103-9-29**]
|
[
"998.11",
"997.1",
"414.01",
"362.01",
"413.9",
"440.21",
"272.0",
"733.00",
"E878.2",
"401.9",
"599.0",
"250.50",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"99.04",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5290, 5373
|
1917, 3182
|
317, 411
|
5614, 5620
|
1078, 1894
|
6449, 6624
|
755, 773
|
3364, 5267
|
5394, 5593
|
3208, 3341
|
5644, 6426
|
788, 1059
|
246, 279
|
439, 566
|
588, 693
|
709, 739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,566
| 195,127
|
12320
|
Discharge summary
|
report
|
Admission Date: [**2101-4-9**] Discharge Date: [**2101-4-26**]
Date of Birth: [**2046-4-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
gentleman with a past medical history significant for
untreated hypertension. He was in his usual state of health
until the morning of admission when he complained of a severe
headache and also vomited and fell on the bathroom with no
apparent head injury and no loss of consciousness. He was
taken to [**University/College **] Health Clinic where a CT scan was done and
it showed a 3 x 3 cm thalamic bleed with no midline shift and
no hydrocephalus. The patient was transferred to [**Hospital6 18075**] and from there to [**Hospital6 649**].
PAST MEDICAL HISTORY:
1. Hypertension
ALLERGIES: CIPROFLOXACIN
MEDICATIONS: None
PHYSICAL EXAM:
GENERAL: He was somnolent.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light, 2 to 3 mm.
NEUROLOGIC: He was alert and oriented x2. He did not know
the months of the year. Moving all four extremities. Had
good strength in all extremities. Was unable to follow
commands. Moves the left lower extremity spontaneous.
Reflexes were equal and symmetric bilaterally. Sensation was
grossly intact.
ADMISSION LABS: His white count was 13.4, hematocrit 40.4,
platelets 259. PT 13.2, INR 1.2, PTT 30.2. Sodium 139,
potassium 4.5, chloride 99, CO2 26, BUN 17, creatinine 1.3,
glucose 155.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit where he was closely monitored. On arrival to the
Emergency Room, the patient's blood pressure was 230/140. He
was started on a Nipride drip. He became somnolent in the
Emergency Room. He had a repeat head CT which was
essentially unchanged and the patient was transferred to the
Intensive Care Unit.
On arrival to the Intensive Care Unit, the patient had a
ventricular drain placed and patient's mental status did
improved. He was awake, more alert, following commands
intermittently, had a slight left direct purposeful movement
and withdraw to pain with some delay. CT scan shows acute
right thalamic hemorrhage with extension of the bleed into
the right lateral ventricle and third ventricle with no
evidence of hydrocephalus.
The patient failed three attempts to wean the ventricular
drain over a course of a week's time. On the fourth try, he
did eventually tolerate having the drain elevated then
clamped and then removed. His mental status improved where
he was able to follow commands. He was oriented x2, moving
all extremities strongly. He was transferred out of the
Intensive Care [**Hospital 14010**] transferred to the floor on the [**4-23**] after vent drain being discontinued on the 29th. He
was seen by physical therapy and occupational therapy and
found to require a short subacute rehabilitation stay prior
to discharge to home. He presently is awake, alert, oriented
x2, moving all extremities strongly. Still has some trouble
with word finding difficulties at times. Speech is much
clearer. He is in stable condition and ready for transfer.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg po bid
2. Tylenol 650 po q4h prn
3. Colace 100 mg po bid
4. Lopressor 100 mg po tid
5. Captopril 37.5 po tid
His systolic blood pressure should remain under 140. His
vital signs have been stable.
FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) 1132**] in two to three
weeks' time. He was in stable condition at the time of
discharge.
[**Location (un) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2101-4-26**] 10:25
T: [**2101-4-26**] 10:56
JOB#: [**Job Number 38426**]
|
[
"431",
"780.6",
"305.1",
"401.9",
"272.0",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
3129, 3350
|
1473, 3106
|
837, 1264
|
3362, 3792
|
159, 735
|
1281, 1455
|
757, 822
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,375
| 145,743
|
38348
|
Discharge summary
|
report
|
Admission Date: [**2194-8-31**] Discharge Date: [**2194-9-8**]
Date of Birth: [**2139-7-23**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Lumbar puncture [**9-2**]
History of Present Illness:
55F with Stage IV NSCLC c/b brain metastases, s/p total brain
and right hip irradiation, last chemo [**8-21**] who presents to the
ED from home with lethargy. Per the family the patient was
diagnosed with a UTI 3 days ago and was started on
ciprofloxacin, this morning the family noted that she spike a
fever to 100.9 and became concerned. Per history she denies any
CVA tenderness or suprapubic tenderness, nausea, vomiting or any
other constitutional symptoms. Family was concerned that she had
become lethargic, being unusually slow to answer questions and
staring off into space.
Upon arrival to the ED the patient was found to be afebrile at
98.9 80 104/58 14 100%. She was noted to be non-focal
neurologically but simply staring off into space and slow to
answer questions. A head CT was done that revealed possible
brain edema vs acute infarct. Serum Na is 122. After
communicating the findings with Dr. [**Last Name (STitle) 724**] (Neuro/Onc) he
recommended dexamethasone 10mg PO, Keppra 500mg once, increasing
dexamethasone to 4mg q6H, EEG and an MRI. Patient was admitted
to the [**Hospital Unit Name 153**] for further management of hyponatremia.
Past Medical History:
- Stage IV NSCLC c/b Brain Metastases, Concurrent
Intraparenchymal and Leptomeningeal Metastases on carboplatin
and pemetrexed
- PVD (s/p angioplasty at age 36, and underwent subsequent
angioplasties until eventual aortobifemoral bypass graft done in
[**2185**] with success)
- HTN
- HLD
- s/p knee repair i1974
- s/p CCY [**2190**]
Social History:
Worked as an employer specialist in a firm. Lives with daughter
and husband. 40-pack-year smoking history. No significant etoh
intake.
Family History:
Mother: died @ 46 from
metastatic lung cancer at age 46. Father: died @ 60s from lung
cancer. Has two sisters and a brother who are healthy.
Physical Exam:
GEN: diaphoretic, NAD, lethargic but arousable
HEENT: atraumatic, EOMI, PERRL, right gaze preference, dry MM,
neck supple, JVP difficult to assess [**12-31**] body habitus
CV: RRR, nl S1+S2, III/VI holosystolic murmur heard best at
LLSB, no rubs or gallops
LUNG: CTAB anteriorly & laterally
ABD: soft, NT/ND, hypoactive bowel sounds, no HSM
EXT: W/WP, no C/C/E, 2+ DP/PT pulses bilaterally
GU: foley in place
SKIN: positive skin tenting in lower extremities, stage I ulcer
on buttocks, no rashes or lesions appreciated
NEURO: A+Ox2 (person, ??????hospital??????), CN II-XII intact with no
focal deficit, face symmetric, no dysarthria, patient with R
gaze preference and head turned preferentially to right although
will turn head L to command. strength, sensation and movement of
extremities symmetric, 2+ patellar reflexes bilaterally, no
clonus, flexor plantar response
Pertinent Results:
Admission labs:
[**2194-8-31**] 11:30AM BLOOD WBC-4.1 RBC-4.12* Hgb-13.0 Hct-36.7
MCV-89 MCH-31.6 MCHC-35.5* RDW-17.3* Plt Ct-125*
[**2194-8-31**] 11:30AM BLOOD Neuts-83.4* Lymphs-7.5* Monos-8.0 Eos-0.3
Baso-0.9
[**2194-8-31**] 05:30PM BLOOD PT-13.3 PTT-27.3 INR(PT)-1.1
[**2194-8-31**] 11:30AM BLOOD Glucose-113* UreaN-12 Creat-0.5 Na-122*
K-3.5 Cl-84* HCO3-23 AnGap-19
[**2194-8-31**] 09:49PM BLOOD ALT-67* AST-25 LD(LDH)-453* AlkPhos-160*
TotBili-0.5
[**2194-8-31**] 11:30AM BLOOD cTropnT-0.03*
[**2194-8-31**] 05:41PM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1
[**2194-9-1**] 07:10AM BLOOD Type-ART pO2-81* pCO2-26* pH-7.47*
calTCO2-19* Base XS--2
Micro
[**8-31**] bcx: pnd
[**9-1**] fecal cx pnd
[**9-1**] ucx: neg
[**9-2**] CSF gram stain: 1+ PMNS, no organisms
Radiology
[**8-31**] head CT:
1. Increased hypoattenuation in the right temporal lobe may
represent
increased edema from the known right temporal metastasis, an
acute infarct, or an infectious process. Clinical correlation
recommended. An MRI could be helpful for further evaluation.
2. Small amount of fluid in the right mastoid air cells.
[**9-1**] head MRI:
1. Abnormal signal in the right temporal lobe, corresponding to
the
hypodensity seen on recent CT, with imaging characteristics
concerning for
herpes encephalitis, or less likely vasculitis.
2. Multiple bilateral small metastatic lesions, stable in size
and appearance
compared to most recent MRI. No new lesions seen.
3. No hydrocephalus. No subfalcine or uncal herniation.
[**9-2**] TTE: NO change from prior: The left atrium and right
atrium are normal in cavity size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
EEG: showed abnormal sz activity in right temporal lobe but
final read pnd
Brief Hospital Course:
#Hyponatremia: Na 122 on admission, most consistent with
hypovolemic hyponatremia, but also concern for SIADH given
intracranial pathology from mets and worsening edema. This
improved with hydration to 132 upon transfer. Most Consistent
with hypovolemic hyponatremia. However, given known brain
metastases with CT changes concerning for worsening edema as
well as NSCLC, SIADH could also be contributing to hyponatremia
but given response to fluids less likely
#Altered mental status: Likely secondary to hyponatremia vs
herpes/malignant encephalitis given MRI and EEG changes. MRI did
not show new mets, but did show abnormal signal in right
temporal lobe, as well as EEG showing abnormal activity in that
region so pt started on keppra. Concern was most for malignant
menengitis. LP showed 34 WBCs and gram stain showed 1+PMNs.
Mental status has been stable and she is a/o x3. CSF positive
for HSV encephalitis. Was On Acyclovir prior to being made CMO.
Nonconvulsive status-- Frequent electographic seizures from
right temporal region, as well as right temporal periodic
lateralized epileptiform discharges. She was started on
levetiracetam with initial control of seizures on the evening of
[**9-1**], and mental status improved. Electrographic seizures
recurred on [**9-3**] and were refractory to increased levetiracetam
and loading dose of phenytoin. On morning of [**9-4**], again had
increased seizures, and was given additional phenytoin and
intravenous lorazepam. She became obtunded and was transferred
to neuro ICU for closer monitoring of seizures. Discussion with
the family indicated that her wishes were to be DNR/DNI, but we
wanted to be able to monitor her respiratory status closely
while beginning new AEDs. On [**9-4**] PM, she was given loading
dose of IV lacosamide, and seizures stopped.
Family met on evening of [**9-4**] and decided that comfort measures
were most appropriate given her overall poor prognosis for
recovery and her wishes. She was transferred to the floor on
[**9-5**], to private room. Acyclovir was discontinued, but
lacosamide and levetiracetam were continued to prevent recurrent
seizures. On the morning of [**9-5**], she was briefly able to nod
head in response to questions, and followed simple commands.
She then became unresponsive later in the day and remained so
for the remainder of her course.
# Tele abnormalities: Unclear if this was true abnormality vs
tele malfunction. Cardiology curbsided who recommended echo
which showed no change from prior. Troponin??????s were negative x3
# UTI: Patient presented with complicated UTI for which she had
taken 4 of 6 doses of ciprofloxacin. UA neg for leuk esterase
and nitrites but partially treated & bacteria/WBCs present.
Given ongoing fevers and immunosuppression, we continued abx
with CTX 1g daily, (d/c cipro given risk to decrease seizure
threshold). Will tx for total 7 day course for complicated UTI
# Stage IV NSCLC: C/b metastases to brain and right ilium, s/p
XRT. Patient receiving carboplatin (AUC 5) and pemetrexed
(500mg/m2) ?????? plan for 4 cycles (next cycle 3wk after 3rd). Last
chemo [**8-21**] (cycle 3). Oncologist/PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. Patient
is currently denying any hip pain.
# Thrombocytopenia: Etiology unclear but stable. Last chemo
[**8-21**]; while both carboplatin & pemetrexed can cause
myelosuppression, patient??????s platelets have been WNL until this
admission.
Patient was made CMO on thursday [**9-5**] after discussions with her
husband and daughter. She was placed on a Morphine drip for
comfort care. On [**9-8**] at 840am, she was reported by nursing to
longer have respirations and heart rate. Upon physical exam, it
was confirmed that she did not have a pulse, heart sounds or
lung sounds. She did not respond to verbal or noxious stimuli.
Her time of death was called at 846am. Her cause of death was
most likely respiratory failure secondary to her primary
diagnoses of metastatic lung cancer and HSV encephalitis. Her
husband and daughter were present at the bedside who both
declined an elective autopsy. The attending on record, Dr.
[**First Name (STitle) **] was notified.
Medications on Admission:
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth Daily Start
7days
before your next chemotherapy.
LORAZEPAM - 0.5 mg Tablet - [**11-30**] Tablet(s) by mouth q4-6hrs as
needed for nausea
METOPROLOL - - daily
MORPHINE - 15 mg Tablet - 1 Tablet(s) by mouth q4-6 hours as
needed for Severe pain not controlled with long acting MSCONTIN
No Driving on this medication
MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by mouth
twice a day No driving on this medication
ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 2 Tablet(s) by mouth
three times a day as needed for nausea
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram Powder in Packet - 1 pack by mouth daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every eight (8) hours as needed for nausea or vomiting
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient had metastatic lung cancer, HSV encephalitis, Seizure
Disorder
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
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150
| 108,732
|
22276
|
Discharge summary
|
report
|
Admission Date: [**2161-7-9**] Discharge Date: [**2161-7-14**]
Date of Birth: [**2123-9-14**] Sex: F
Service: MED
Allergies:
Iodine; Iodine Containing / Dilantin / Percocet
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
chest discomfort and shortness of breath x 2 months
Major Surgical or Invasive Procedure:
Mediastinoscopy with lymph node biopsy - pathology pending
History of Present Illness:
The patient is a 37 year old female with PMH endometrial cancer
s/p TAH w/ R oopherectomy who presented to a [**Hospital 11074**] clinic with
two month history of shortness of breath and chest pain. She
describes the chest pain as "like an elephant standing on her
chest". She notes that it is associated with dyspnea,
diaphoresis, and lightheadedness. She was referred to a
cardiologist for a nuclear stress test about 6 weeks ago which
was normal per pt. Symptoms persisted over last three weeks with
increased fatigue and weakness. She also notes waxing and [**Doctor Last Name 688**]
feversv(Tm 100-101), productive cough and 18 pound weight loss
during this time. At the [**Hospital 11074**] clinic on [**7-8**], a chest x-ray
was done which was significant for mediastinal widening. She was
immediately taken by ambulance to Falumouth ED. At [**Hospital1 1562**], a
Chest CT showed diffuse mediastinal adenopathy and multiple
pulmonary nodules and splenomegaly. An echo showed small-
moderate pericardial effusion and increased tuerculation in RV
apex c/w RVA thrombus. NL EF/valves. Doppler US LE - Left
popliteal DVT. V/Q scan - indetermingate - 50% chance of PE.
Patient was stable during one day admission at [**Hospital1 1562**] and was
transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] for further work up of the pulmonary
nodules and lymphadenopathy. While in the [**Hospital Unit Name 153**], the patient was
seen by pulmonary and oncology. She was sent for a chest and
abdominal CT which suggested a 5x4 cm mediastinal mass with
precarinal lymph nodes, multiple smaller nodules throughout both
lungs and a small-moderate pericardial effusion. She was
hemodynamically stable in the [**Hospital Unit Name 153**] and transferred to the floors
on [**7-10**] pm.
The patient denies headaches/abdominal pain/melena/hematochezia/
change in bowel movements/dysuria.
The patient does note 10 year history of perimenopausal symptoms
- fatigue, myalgias, hot flashes, low grade temps.
Past Medical History:
1. ?Endometrial Cancer - age 25 - s/p TAH and RO, no chemo/xrt
(encapsulated tumor)
2. Migraine headaches - since age 8. Takes tylenol and motrin.
3. Cesarean Section x 3
4. History of fibrocystic breast disease - s/p multiple
mammograms and 7 negative biopsies
5. Per path report -Cervical cancer in situ [**2149**]
Social History:
The patient works as a bar manager. She has 3 children and is
separated
Tobacco -(+) [**12-19**] -3 ppd x 22 years (~40 pack-year)
Alcohol - Rare
IVDA - none
Family History:
Ancestry - scandinavian, english
Mother - [**Name (NI) 58056**]
Sister - Similar symptoms of fatigue, weakness, "perimenopausal"
on testosterone supplement
Great aunt - breast cancer
aunt - cervical cancer
"history of clotting in legs" in family
Physical Exam:
Temp max 99.6; Tcurrent 98.6, BP 109/58, HR 86-100, RR 17-21,
93-94%RA
Gen - Alert, no acute distress, anxious, thin
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - supple, no JVD, positive R shotty cervical LAD,
Chest - diffuse expiratory wheezes, some scattered crackles;
otherwise Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes; Left paraspinal (C7),
firm rubbery mass (+)tender to palpation
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally. no axillary LAD
Neuro - Alert and oriented x 3, cranial nerves [**1-29**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
[**2161-7-9**] 07:16PM WBC-7.5 RBC-3.63* HGB-10.9* HCT-33.2* MCV-92
MCH-30.1 MCHC-32.9 RDW-12.7 PLT 211 NEUTS-75* BANDS-0 LYMPHS-21
MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2161-7-9**] 07:16PM calTIBC-216* FERRITIN-142 TRF-166*IRON-17*
[**2161-7-9**] 07:16PM GLUCOSE-91 UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
[**2161-7-9**] 07:16PM ALT(SGPT)-3 AST(SGOT)-9 LD(LDH)-153 ALK
PHOS-74 TOT BILI-0.3 ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-3.7
MAGNESIUM-2.0
[**2161-7-9**] 07:16PM FSH-3.4 LH-4.8
[**2161-7-10**]
CT OF THE CHEST WITHOUT CONTRAST: There is no axillary
lymphadenopathy. Small
axillary lymph nodes do not meet the criteria for pathologic
enlargement and
measure up to 6 mm in size. A large mediastinal mass, which
measures up to
5.4 x 4.7 cm in axial dimension, which extends from the right
paratracheal
region at the level of the thoracic inlet to the precarinal
lesion is present
with central regions of hypodensity suggesting necrotic change.
In addition,
there is an enlarged 4.5 x 2.5 cm subcarinal lymph node.
Bulkiness in the
right hilum is present as well. Evaluation of the central
airways demonstrate
patency to the segmental bronchi bilaterally. Examination of the
lung windows
demonstrate a dominant 13 x 11 mm nodule within the right upper
lobe, with a
satellite lesion in the subpleural right apex measuring 7 mm in
size. Most of
these lesions show some characteristics of spiculation. In
addition, there is
a 5 mm nodular region in the subpleural right lower lobe, which
has well-
defined forbers. The right lower lobe demonstrates mild
atelectasis, possibly
with a smaller degree of consolidation as well. There is a trace
right-sided
pleural effusion. The left lung is essentially clear, without
evidence of
pleural effusion. There are some peripheral blebs suggestive of
paraseptal
emphysema. Note is also made of a hypodense appearance of the
blood relative
to myocardium suggestive of anemia. There is a small pericardial
effusion.
CT OF THE ABDOMEN WITHOUT CONTRAST: Allowing for the noncontrast
technique,
the liver, gallbladder, spleen, kidneys, stomach, and small
bowel appear
unremarkable. The pancreas is grossly unremarkable as well.
Adrenal glands
are not clearly visualized due to the lack of IV contrast, and
no bulky
lymphadenopathy is the retroperitoneum or mesentery is noted.
There is no
abdominal free fluid present.
CT OF THE PELVIS WITHOUT CONTRAST: The large bowel and bladder
are
unremarkable. Distal ureters are not well visualized without IV
contrast. The
uterus is not seen, and the ovaries appear unremarkable.
Examination of the osseous structures show no suspicious lytic
or blastic
lesions.
IMRESSION:
1. Large mediastinal mass with precarinal and subcarinal lymph
nodes. These
have hypodense central regions suggestive or necrosis. These
would be most
ammenable for transbronchial biopsy.
2. Multiple lung nodules, two of which are spiculated at the
right lung apex.
3. There is a small pericardial effusion.
[**2161-7-11**]
MRI BRAIN.
CLINICAL INFORMATION: Patient with history of cervical cancer
with pulmonary
nodule and mediastinal mass and patient allergic to IV contrast
for CT, for
further evaluation to exclude metastatic disease.
TECHNIQUE: T1 sagittal and axial, and FLAIR, T2 and
susceptibility axial
images of the brain were obtained before gadolinium. T1 axial,
sagittal and
coronal images were obtained following the administration of
gadolinium.
FINDINGS: In the right posterofrontal lobe, there are two small
areas of
signal abnormality seen within on the FLAIR images, one
laterally along the
anterior aspect of the central sulcus and the second superiorly
to the
posterior frontal lobe near the midline. Both of these foci
demonstrate
enhancement following the administration of gadolinium. No other
focal
abnormalities are identified. Specifically, no evidence of
periventricular
signal abnormalities are seen. No other areas of enhancement are
noted. The
ventricles and extraaxial spaces are normal in size. No evidence
for midline
shift, mass effect or hydrocephalus is seen.
IMPRESSION: Foci of signal abnormalities in the right frontal
lobe with
enhancement. The differential diagnosis includes metastatic
disease and
demyelinating process, given patient's age. However, given the
clinical
history and the location of the lesions, metastatic disease is
considered more
likely.
Brief Hospital Course:
37 year old female with h/o cervical cancer s/p TAH transferred
from outside hospital with progressive chest discomfort, SOB,
and weight loss with Left popliteal DVT, possible PE and chest
xray/ CT evidence of mediastinal mass and multiple bilateral
nodules with mediastinal lymphadenopathy.
1. Pulmonary nodules - On admission a chest xray suggested a
small focal opacity in right upper lobe and right paratracheal
opacity. A chest CT the following day suggested a large
mediastinal mass with precarinal and subcarinal lymph nodes with
hypodense central regions suggestive of necrosis. It also showed
multiple nodules, two spiculated lung nodules at right lung
apex. These lesions were most consistent with lung cancer versus
lymphoma so a mediastinoscopy was planned. Other things
originally on the differential were: TB -PPD negative,
histoplasmosis -antigen still pending, coccidoiomycoses,
nocardia, sarcoidosis (scandinavian) - ACE-normal. On [**7-11**] she
had a MRI-brain, which showed two foci of signal abnormalities
in the right frontal lobe with enhancement. No edema or mass
effect was seen secondary to the brain lesions. On [**7-13**], she had
a mediastinoscopy. The frozen section was positive for non-small
cell lung cancer; paratracheal lymph nodes were sent for
pathology (still pending).
2. Non-small cell lung cancer - Multiple necrotic lymph nodes
radiographically and grossly, MRI of the brain with focal right
frontal brain mets; and a 1 by 1 inch paraspinal hard, rubbery
lesion on her Left upper back; presentation consistent with
metastatic NSCLC. Patient was told her diagnosis with her mother
and grandfather in the room. She seemed to take the news well,
appropriately becoming teary eyed. She was then seen by a social
worker and told the social worker that she was coping well and
did not need to be seen anymore. She was seen by oncology
consult and set up for
an outpatient follow up with multidisciplinary oncology team on
thursday [**7-16**]. During that time she will discuss chemo vs
biologic therapies vs palliation.
She will also have a bone scan to evaluate for bone mets also on
thursday as an o/p. On the last day of admission, the patient
noted blurriness in left periphery; no deficit on visual fields
or neuro exam; the patient was advised to have a head ct to
reevaluate for mass effect or bleeding in the brain lesions, but
she refused and wanted to go home with no further treatment. She
was counseled to go to the ED if she had worsening vision
deficits, headaches. The patient's shortness of breath was
stable during the admission; she required 2L oxygen especially
during long conversations; the patient will be sent home on home
oxygen.
2. Hypercoagulable state - DVT/PE/?RV thrombus - echo at outside
hospital also with possible thrombus in RV; pt obviously
hypercoagulable most likely secondary to primary lung
malignancy; she was maintained on heparin throughout the
admission and was switched to Lovenox and underwent Lovenox
administration teaching prior to discharge
3. Pericardial effusion - found on echo at [**Hospital1 **]; stable on
chest CT at [**Hospital1 18**].Most likely secondary to the primary lung
malignancy; patient did not experience any decreases in blood
pressure, increased shortness of breath, or increased chest pain
during the admission. SHe was monitored throughout the admission
for tamponade physiology and did not present with any.
4. Fevers - low grade throughout admission; most likely
secondary to the malignancy; fungal, blood cultures were
negative; lyme antibody was negative; patient never mounted an
increased white blood cell count.
5. Pain/Nausea - The patient had back and chest (pleural) pain
throughout the admission well controlled PRN dilaudid q 3-4
hours. She was started on a fentanyl patch for pain on [**2161-7-13**]
with dilaudid for breakthrough. SHe also noted increased nausea
with the dilaudid which was well controlled with phenergan.
After the mediastinoscopy, she had increased throat pain which
was relieved with viscous lidocaine.
6. 10 year hisory of perimenopausal symptoms - FSH, LH within
normal limits; no further work-up during the admission
7. PPX - She was maintained on a multivitamin and zantac during
the admission with colace and senna to releive constipation in
the setting of narcotics.)
8. Code Status - Full Code
Medications on Admission:
Tylenol
(Heparin gtt from outside hospital)
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): please place new patch on
Thursday [**7-16**].
Disp:*10 Patch 72HR(s)* Refills:*2*
4. Promethazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q3-4H ()
as needed.
Disp:*84 Tablet(s)* Refills:*0*
5. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
Q3-4H () as needed for throat pain.
Disp:*112 ML(s)* Refills:*0*
6. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
Disp:*30 subcutaneous injection* Refills:*2*
7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*60 Tablet(s)* Refills:*2*
8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
9. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-small cell lung cancer
Left popliteal deep vein thrombosis/pulmonary embolus
Discharge Condition:
stable
Discharge Instructions:
Please go the the emergency department if you have increasing
shortness of breath or chest pain or if you have worsening
blurry vision or headaches.
Followup Instructions:
Please go for bone scan on Thursday, [**7-16**] at 9:30 am. Main
entrance [**Hospital Ward Name **] - by [**Hospital Ward Name 2104**] elevators.
Please follow up with Dr. [**Last Name (STitle) **] in the Thoracic Oncology Center
this Thursday, [**7-16**] at 10:30 am.
|
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29,861
| 109,283
|
4277
|
Discharge summary
|
report
|
Admission Date: [**2135-8-22**] [**Month/Day/Year **] Date: [**2135-8-30**]
Date of Birth: [**2064-2-24**] Sex: F
Service: MEDICINE
Allergies:
Streptomycin / Versed / Fentanyl
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 18536**] is a 71F with hypothyroidism, DM, afib, pulm HTN,
and h/o urinary retention who was brought to the ER for
evaluation of confusion.
.
On the afternoon of presentation, she was out with her relatives
when she complained of chills and became confused. EMS was
called and they report her glucose was in the 20s. She was given
an amp of D50, with glucose in the 200s after. She was brought
in the ED where her initial vs were T 95 HR 79 BP 87/47 SaO2
97%, fingerstick 264. She was given intravenous fluids and her
blood pressure improved to 89-95/ 50-70. She received a total of
5L of IVF. Her INR was 4.0 and a central line was not placed. A
bedside ultrasound showed mild pericardial effusion. CTA torsoe
was without evidence of dissection. ECG showed Afib with rate in
the 70s. No evidence of block. She was given vancomycin and
piperacillin/tazobactam. Head CT was negative.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Atrial fibrillation.
2. Hypertension.
3. Dyslipidemia.
4. Obstructive sleep apnea with secondary pulmonary HTN (uses
CPAP but does not know settings)
5. Chronic diastolic heart failure.
6. Diabetes mellitus type 2; [**2135-1-31**] HbA1c 7.9
7. Chronic kidney disease (baseline Cr ~1.2)
8. S/p lap appy ([**9-12**])
9. Diabetic neuropathy
Social History:
She lives with her husband. She does not use tobacco and has no
history of alcohol abuse. She already has VNA and home-health
aid weekly. She has a supportive family in the [**Location (un) 86**] area and
at baseline walks with a cane
Family History:
There is no family history of premature coronary artery disease
Physical Exam:
H&P Per Admitting Resident
General: Alert, oriented x self
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NE: CN2-12 intact, PERRL, EOMI
Pertinent Results:
Admission Labs:
WBC-5.1 RBC-3.75* Hgb-10.4* Hct-33.6* MCV-90 MCH-27.7 MCHC-31.0
RDW-16.3* Plt Ct-119*
Neuts-67.2 Lymphs-24.9 Monos-4.9 Eos-2.5 Baso-0.6
PT-38.7* PTT-33.7 INR(PT)-4.0*
Glucose-199* UreaN-39* Creat-1.6* Na-138 K-3.8 Cl-99 HCO3-28
AnGap-15
ALT-24 AST-36 CK(CPK)-76 AlkPhos-46 TotBili-0.3
Lipase-113*
Calcium-9.0 Phos-3.5 Mg-2.5
cTropnT-<0.01
TSH-8.8*
Lactate-1.3
.
[**Location (un) **] Labs:
WBC-4.5 RBC-2.56* Hgb-7.2* Hct-23.3* MCV-91 MCH-28.3 MCHC-31.1
RDW-15.1 Plt Ct-141*
PT-23.0* PTT-29.5 INR(PT)-2.2*
Glucose-93 UreaN-41* Creat-1.3* Na-141 K-4.2 Cl-98 HCO3-37*
AnGap-10
Calcium-8.4 Phos-3.7 Mg-2.7*
Misc Labs:
VitB12-292
calTIBC-300 Ferritn-126 TRF-231
Hapto-135
%HbA1c-7.7*
TSH-8.8*
T4-5.7
Cortsol-9.2
PEP-NO SPECIFIC ABNORMALITIES
Cardiac Biomarkers:
[**2135-8-21**] 09:50PM BLOOD CK(CPK)-76 CK-MB-NotDone cTropnT-<0.01
[**2135-8-22**] 03:38AM BLOOD CK(CPK)-71 CK-MB-NotDone cTropnT-<0.01
[**2135-8-22**] 11:19AM BLOOD CK(CPK)-
.
IMAGING:
.
CXR ([**8-21**]) - IMPRESSION: Low lung volumes with basilar likely
atelectasis.
CXR ([**8-24**]) - IMPRESSION: AP chest compared to [**3-30**] and
[**8-21**], read in conjunction with chest CTA [**8-21**]: Mild
cardiomegaly and mediastinal vascular engorgement have both
increased since [**8-21**], suggesting volume overload. No clear
pulmonary edema. Pleural effusion if any is small, on the
right. No pneumothorax.
.
CXR ([**8-26**]) - IMPRESSION: Bilateral lower lobe atelectasis can be
explained by low lung volumes. New consolidation in the left mid
lung.
.
CT Torso - IMPRESSIONS:
1. No findings to account for the patient's symptoms.
Specifically, no aortic dissection or aneurysm. No pericardial
effusion. No definite large pulmonary embolus.
2. No definite acute intra-abdominal pathology is seen, although
assessment
is slightly limited due to tailoring of the study towards
assessment of the aorta. Perihepatic ascites is decreased.
Cholelithiasis. Mild splenomegaly. Diastasis of the rectus
muscles, with small fat-containing paraumbilical hernia.
Brief Hospital Course:
# AMS, Hypothermia, Hypotension - Although initially concerning
for SIRS, the patient's altered mental status was likely
secondary to her hypoglycemia. She was given an amp of D50 in
the field when she was hypoglycemic and her glucose responded
appropriately. She was started on vancomycin and zosyn
empirically at admission, but these were d/c'ed when her blood
and cultures remained negative. She also ruled out for ACS with
three sets of negative cardiac enzymes. Her cortisol level was
normal. She was found to have an elevated TSH with a normal FT4.
On the day of [**Month/Year (2) **] from the MICU, the patient developed a
episode of oxygen desaturation and was started on levofloxacin
(see below). By the time she was transferred to the floor, the
patient was alert and oriented to person, place, and time, and
her hypothermia and hypotension had resolved. She remained that
way for the remainder of her hospital course.
.
# Pneumonia - The patient was intially started on broad coverage
with vancomycin and zosyn at admission. However, because
cultures were negative and the patient was stable, these
antibiotics were stopped on [**8-23**]. However, on [**8-24**], the patient
developed a episode of oxygen desaturation. CXR was done and was
suspicious for a new opacification in the right lower lung. She
was started on levofloxacin to complete a 7 day course (3 doses
of levofloxacin q48 hours). She had some low-grade fevers in
her initial days on the floor. However, her fevers improved and
she was afebrile at [**Month/Year (2) **]. Of note, during her hospital
stay, the patient continued to require 2 L of O2. There were
some discrepancies as to whether she actually uses oxygen at
home. She denied any dyspnea over her baseline, however. It is
likely that some of this oxygen requirement was secondary to her
frequent refusal to use neb treatments, her insistence to lay
flat in bed, and her refusal to use the hospital CPAP machine.
She was discharged on home O2.
.
# Hypoglycemia - Seems that patient's hypoglycemia on admission
was likely secondary to taking exogenous insulin, glipizide, and
possibly poor PO intake. On admit, her glipizide was
discontinued and she was placed on sliding scale insulin. Once
she was on the floor, [**Last Name (un) **] was consulted and placed the
patient on a regimen of 75/25 [**Hospital1 **] with an insulin sliding scale
to cover for hyperglycemia. Her [**Hospital1 **] dosing was adjusted during
her hospitalization and she was discharged on a regimen of 70/30
[**Hospital1 **] with an insuling sliding scale. She was also scheduled for
follow-up with the [**Hospital **] clinic.
.
# Atrial Fibrillation - On admission to the MICU, the patient's
nodal blocking agents were intially held. She did develop some
episodes of RVR, which responded to IV metoprolol and diltiazem.
Her PO metoprolol and diltiazem were restarted prior to
transfer to the floor. Of note, her metoprolol dose was
increased to 37.5 mg [**Hospital1 **]. On the floor, she did have a few
episodes of RVR, but they were all in the setting of her
dilatizem having been held secondary to hypotension. She was
discharged on her diltiazem and the new dose of metoprolol. Of
note, on admission, the patient's INR was supratherapeutic at 4.
Her warfarin was held and was later restarted. Initially, her
warfarin was restarted at a lower dose because she was on
levofloxacin. However, the patient was discharged on her
regular dose of 5 mg of warfarin
.
# Hypertension - While on the floor, the patient was mantained
on diltiazem, lasix, lisinopril, and metoprolol. Her blood
pressures remained stable and she was discharged on this
regimen.
.
# OSA - The patient had a history of obstructive sleep apnea
with home CPAP. She refused to use the hospital CPAP machine.
Attempts to have her home CPAP machine brought in were
unsuccessful (her family brought in the mask only, which did not
work with the hospital machine).
.
# Dyslipidemia - While in-house, the patient was continued on
her home dose of atorvastatin. Her TriCor was held on admission
but was restarted at [**Hospital1 **].
.
# Chronic Kidney Disease - Through her hospitalization, the
patient's creatinine ranged between 1.3 and 1.7. This appeard
to be consistent with the range that the patient had recently
been running.
.
# Anemia - The patient's Hct ranged between 23.3 and 33.6. The
patient's baseline appeared to be around 27 to 30. Stool were
guaiac-negative.
.
# Diastolic Heart Failure, Diabetic Neuropathy, Osteoarthritis -
There were no acute issues during this hospitalization.
Medications on Admission:
Diltiazem SR 240 mg p.o. b.i.d.
lisinopril 10 mg half q.d.
glipizide 5 mg 2 in the morning and one at night
Synthroid 88mcg p.o. q.d.
Lasix 40 mg b.i.d.
folic acid 1 mg q.d.
amitriptyline 20 mg at night
Lipitor 10 mg q.d.
TriCor 145 mg p.o. q.d.
insulin 70/30 38 in the morning and 22 at night
Coumadin
Colace 100 mg p.o. b.i.d.
Prilosec 20 mg p.o. q.d.
senna p.r.n.
Estrace vaginal cream
oxygen 2 L /min via NC prn.
metoprolol 25 mg in a.m. and 12.5 in p.m.
[**Hospital1 **] Medications:
1. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO twice a day.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for constipation.
14. Estrace Vaginal
15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous As
Directed: Please measure your blood sugars four times a day and
use the sliding scale provided at [**Hospital1 **].
Disp:*1 month's supply* Refills:*2*
16. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Home Oxygen
Oxygen at 2 liters via nasal cannula continuously pulse-dosed to
keep oxygen saturation above 90%.
Diagnosis: pulmonary hypertension
18. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: As Directed Subcutaneous twice a day: Please administer 38
units with breakfast and 22 units with dinner.
Disp:*1 month's supply* Refills:*2*
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
[**Hospital1 **] Diagnosis:
Primary:
Pneumonia
Acute hypoglycemia
Altered mental status
Atrial fibrillation with rapid ventricular response
Secondary:
Diabetes mellitus
Hypertension
Obstructive Sleep Apnea
Pulmonary hypertension
[**Hospital1 **] Condition:
Afebrile, Hemodynamically Stable.
[**Hospital1 **] Instructions:
You were admitted because of low blood sugar and low body
temperature. Your symptoms were likely secondary to a reaction
to insulin. We monitored your body temperature and blood
sugars. You also had some low oxygen levels, fevers, and
changes on your x-ray that were concerning for pneumonia.
Therefore, you were started on an antibiotic to treat this.
Changes to your medications:
START Levofloxacin 750 mg every 48 hours for three doses (last
dose on [**8-28**])
STOP Glipizide
CHANGE Metoprolol to 37.5 mg twice a day
CHANGE Levothyroxine to 100 mcg daily
Also, CHANGE your insulin regimen to the following:
Humalin 70/30: 38 units at breakfast and 22 units at dinner
Humalog Sliding Scale (follow the sliding scale provided by your
nurse [**First Name (Titles) **] [**Last Name (Titles) **])
Please return to the emergency department for any fevers greater
than 101.5, shortness of breath, chest pain, confusion, or any
other concerning symptoms.
It was a pleasure taking part in your medical care.
Followup Instructions:
Scheduled Appointments:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**2135-9-1**] at 11:30 am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP ([**Hospital **] Clinic) [**2135-9-2**] at 8:30 am
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ([**Telephone/Fax (1) 62**]) [**2135-11-23**] at 2:20 pm
|
[
"327.23",
"244.9",
"250.82",
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"428.0",
"428.32",
"416.8",
"403.90"
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icd9cm
|
[
[
[]
]
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[
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] |
icd9pcs
|
[
[
[]
]
] |
4964, 9575
|
326, 332
|
2912, 2912
|
13255, 13630
|
2297, 2363
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2378, 2893
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11808, 11894
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10091, 11778
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1285, 1664
|
360, 1267
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2928, 4941
|
11922, 12190
|
1686, 2028
|
2044, 2281
|
12221, 12578
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,148
| 171,422
|
9374
|
Discharge summary
|
report
|
Admission Date: [**2149-3-18**] Discharge Date: [**2149-3-21**]
Date of Birth: [**2102-11-16**] Sex: F
Service: PSU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 32025**] is a 46 year-old
female with invasive right breast cancer. Mammogram
demonstrated microcalcifications and a core biopsy was
positive for cancer. She, therefore, presents for a simple
right mastectomy and [**Last Name (un) 5884**] flap reconstruction. Of note, she
has a history of deep venous thrombosis and pulmonary
embolism and has been on Lovenox and Coumadin.
PAST MEDICAL HISTORY: Significant for Crohn's disease and a
history of deep venous thrombosis and PE in [**2144**].
PAST SURGICAL HISTORY: Significant for placement of an
inferior vena cava filter in [**2149-2-4**] as well as a
sentinel lymph node biopsy in [**2149-2-4**]. Surgical history
is also significant for tonsillectomy.
ALLERGIES: Imuran and Remicade.
MEDICATIONS AT HOME: Imodium, Lovenox and Coumadin.
PHYSICAL EXAMINATION: Temperature 97.0, heart rate 95.
Blood pressure 109/71, heart rate 17, 95 percent on room air.
The patient is alert and oriented in no apparent distress.
Heart is regular rate and rhythm with no murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally.
Abdomen has a moderate amount of subcutaneous fat with
moderate skin laxity. There are no masses. Breast
examination: There is bilateral grade II ptosis with left
greater than right. There is resolving left outer quadrant
ecchymosis and edema. Her back has good muscle bulk and skin
laxity.
BRIEF HOSPITAL COURSE: The patient was admitted to the
plastic surgery service on [**2149-3-18**]. She underwent a
right simple mastectomy by Dr. [**Last Name (STitle) 10656**] and a right breast
reconstruction using [**Last Name (un) 5884**] flap by Dr. [**First Name (STitle) 3228**]. For further
information on the surgeries please see associated operative
notes. The patient was observed overnight in the ICU on the
day of surgery. The pulses in her flap were checked every
half an hour to hour. Her flap remained pink and well-
perfused. On postoperative day number one, her pain was well
controlled, and her flap looked very healthy. She was
started on Lovenox 30 mg subcutaneous b.i.d. for her history
of DVT and pulmonary embolism since her Coumadin had to be
held for the surgery. A hematology consult was called and,
throughout her stay, they helped to manage her
anticoagulation. On postoperative day number one, the
patient was feeling well enough to be sent to the floor. She
was able to ambulate and tolerate a regular diet. On
postoperative day number two, the patient continued to do
well. There was no evidence of hematoma or excessive
drainage from her JP drains. Therefore, she was restarted on
her Coumadin and her Lovenox was increased to 60 mg
subcutaneous twice a day. On postoperative day three, the
patient looked exceptionally well. Her flap was well
perfused with good capillary refill. Her JP drainage was
serosanguineous. She was ambulating without difficulty. She
was tolerating a regular diet and her pain was well
controlled. Therefore, the decision was made to discharge
her to home. She will continue on her Lovenox until her
Coumadin is therapeutic. She will go home with VNA services
to assist with drains and with INR draws.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with services.
DISCHARGE DIAGNOSES:
1. Right breast cancer.
2. Crohn's disease.
3. History of DVT and PE.
DISCHARGE MEDICATIONS:
1. Vicodin 5/500 mg tablet one to two tablets p.o. q.4 to 6
hours p.r.n. for pain.
2. Colace 100 mg capsule, one capsule p.o. b.i.d.
3. Duricef 500 mg capsule, 1 capsule p.o. b.i.d. times ten
days.
4. Coumadin 8 mg p.o. q.d., to be adjusted based on INR.
5. Lovenox 60 mg subcutaneous b.i.d.
FOLLOW-UP PLANS: The patient will follow up with Dr. [**First Name (STitle) 3228**]
in one week. She will call and schedule an appointment. She
will also follow up with Dr. [**Last Name (STitle) 10656**] in one to two weeks.
She will also follow with her regular physician who monitors
her Coumadin levels.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2149-3-21**] 10:22:38
T: [**2149-3-24**] 04:36:50
Job#: [**Job Number 32026**]
|
[
"V58.61",
"174.8",
"289.81",
"555.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.89",
"85.34"
] |
icd9pcs
|
[
[
[]
]
] |
1600, 3361
|
3454, 3526
|
3549, 3849
|
958, 990
|
709, 936
|
1013, 1576
|
3867, 4435
|
166, 567
|
590, 685
|
3386, 3433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,320
| 111,772
|
19076
|
Discharge summary
|
report
|
Admission Date: [**2190-8-29**] Discharge Date: [**2190-9-4**]
Date of Birth: [**2108-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Fistulogram and failed thrombectomy
IJ dialysis catheter
Tunnelled dialysis catheter
History of Present Illness:
82 yo M with history of CAD s/p NSTEMI, ESRD on HD, DM2, HTN,
HL, Hep C, presents with sudden onset of shortness of breath.
In the ED, he received lasix 40 mg IV, morphine, and was placed
on a nitro drip with improvement of his symptoms. He put out
small amounts of urine to the lasix. At home he is able to
produce some urine. Patient was also noted to be hypertensive
and was given metoprolol 25 mg PO and 5 mg IV, but without much
response from his blood pressure.
.
Initial EKG in the ED showed ST elevations and there was concern
for STEMI. Cardiology reviewed his EKG and read them as J point
elevations, which were similar to his previous EKGs. On
transfer to the CCU, patient's vitals were T 75, BP 166/81, RR
16, O2sat 97% on 4L.
.
Past Medical History:
- Hypertension.
- NSTEMI in [**2183**].
- Hypercholesterolemia.
- Hepatitis C virus
- Glaucoma
- Type 2 diabetes mellitus, diet-controlled.
- Chronic renal insufficiency, now on hemodialysis; stage IV CKD
secondary to hypertension and FSGS
- Status post nephrectomy right-sided for suspected cancer,
pathology benign.
- Status post appendectomy.
- Status post hernia repair.
- Status post rotator cuff surgery in [**2182**].
Social History:
Mr. [**Known lastname **] lives in [**Location 2268**] with his son and grandson. [**Name (NI) **] is a
retired court officer. Admits to distant history of tobacco use
while he was in the service; about 1PPW x 5 years. Prior
marijuana use admitted to other OMR providers. Denies other
illicit drug use. No alcohol use. The patient is separated from
his wife, has 2 sons and one is deceased.
Family History:
Father with cancer of unknown origin per patient. Brother with
cirrhosis, another brother who recently had a massive CVA.
Sister w/[**Name2 (NI) 499**] cancer in her 70s.
Physical Exam:
Discharge physical exam
Temp current: 98.8 HR: 69-85 RR: 18 BP: 100-143/58-88 O2
Sat:98% RA
Physical Exam:
Gen: alert, oriented, NAD. Lying in bed during dialysis
HEENT: supple, no JVD at 20 degrees.
CV: RRR, II/VI holosystolic murmur, no thrills. No S3-4
RESP: CTAB, no audible wheezes.
ABD: flat, NT, hypoactive BS, no tenderness.
EXTR: tunneled line c/d/i, papule in sacral area, no erythema,
no open wound, no drainage noted. Feet warm with barely palp
pulses DP/PT. No penile lesions noted.
NEURO: A/O, speech clear, seems to have good recall of meds and
hospital course
Pertinent Results:
[**2190-8-29**] 03:40AM BLOOD WBC-14.5* RBC-3.42* Hgb-11.6* Hct-35.3*
MCV-103* MCH-33.9* MCHC-32.8 RDW-15.5 Plt Ct-207
[**2190-8-30**] 05:59AM BLOOD WBC-9.4 RBC-3.00* Hgb-9.8* Hct-30.8*
MCV-103* MCH-32.8* MCHC-31.9 RDW-15.2 Plt Ct-208
[**2190-8-31**] 05:24AM BLOOD WBC-8.1 RBC-3.23* Hgb-10.4* Hct-33.0*
MCV-102* MCH-32.3* MCHC-31.6 RDW-15.0 Plt Ct-212
[**2190-9-2**] 05:10AM BLOOD WBC-8.6 RBC-3.22* Hgb-10.6* Hct-32.9*
MCV-102* MCH-33.0* MCHC-32.3 RDW-14.8 Plt Ct-222
[**2190-9-3**] 06:35AM BLOOD WBC-9.1 RBC-3.02* Hgb-9.8* Hct-30.7*
MCV-102* MCH-32.6* MCHC-32.1 RDW-14.9 Plt Ct-303
[**2190-9-4**] 06:00AM BLOOD WBC-8.7 RBC-2.83* Hgb-9.2* Hct-28.9*
MCV-102* MCH-32.4* MCHC-31.7 RDW-15.2 Plt Ct-296
[**2190-8-29**] 03:40AM BLOOD PT-15.1* PTT-31.0 INR(PT)-1.3*
[**2190-8-30**] 05:59AM BLOOD PT-15.3* PTT-38.4* INR(PT)-1.3*
[**2190-9-2**] 05:10AM BLOOD PT-14.2* PTT-78.2* INR(PT)-1.2*
[**2190-9-3**] 06:35AM BLOOD PT-14.0* PTT-33.4 INR(PT)-1.2*
[**2190-8-29**] 03:40AM BLOOD Glucose-241* UreaN-42* Creat-9.0* Na-142
K-5.4* Cl-98 HCO3-27 AnGap-22*
[**2190-8-30**] 05:59AM BLOOD Glucose-110* UreaN-64* Creat-12.1*#
Na-139 K-5.8* Cl-97 HCO3-29 AnGap-19
[**2190-8-31**] 05:24AM BLOOD Glucose-102* UreaN-31* Creat-7.4*# Na-140
K-4.7 Cl-96 HCO3-33* AnGap-16
[**2190-9-2**] 05:10AM BLOOD Glucose-83 UreaN-33* Creat-7.8*# Na-141
K-4.5 Cl-98 HCO3-31 AnGap-17
[**2190-9-3**] 06:35AM BLOOD Glucose-110* UreaN-52* Creat-10.2*#
Na-138 K-4.7 Cl-94* HCO3-32 AnGap-17
[**2190-9-4**] 06:00AM BLOOD Glucose-116* UreaN-23* Creat-6.7*# Na-140
K-4.2 Cl-95* HCO3-35* AnGap-14
[**2190-9-1**] 06:05AM BLOOD CK(CPK)-240
[**2190-9-1**] 03:00PM BLOOD CK(CPK)-202
[**2190-9-1**] 09:35PM BLOOD CK(CPK)-198
[**2190-9-2**] 05:10AM BLOOD CK(CPK)-159
[**2190-9-2**] 09:21PM BLOOD CK(CPK)-140
[**2190-8-29**] 03:40AM BLOOD cTropnT-0.06*
[**2190-9-1**] 06:05AM BLOOD CK-MB-4 cTropnT-10.13*
[**2190-9-1**] 03:00PM BLOOD CK-MB-3 cTropnT-10.81*
[**2190-9-1**] 09:35PM BLOOD CK-MB-3 cTropnT-12.09*
[**2190-9-2**] 05:10AM BLOOD cTropnT-11.88*
[**2190-9-2**] 09:21PM BLOOD CK-MB-3
[**2190-8-29**] 03:40AM BLOOD Calcium-9.2 Phos-7.3* Mg-2.0
[**2190-8-30**] 05:59AM BLOOD Calcium-9.0 Phos-7.1* Mg-2.0
[**2190-8-31**] 05:24AM BLOOD Calcium-8.7 Phos-6.3* Mg-2.0
[**2190-9-2**] 05:10AM BLOOD Calcium-9.3 Phos-6.2* Mg-2.1
[**2190-9-3**] 06:35AM BLOOD Calcium-9.3 Phos-7.5* Mg-2.3
[**2190-9-4**] 06:00AM BLOOD Phos-5.4*# Mg-2.0
[**2190-9-3**] 09:55PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2190-9-3**] 09:55PM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-MOD
[**2190-9-3**] 09:55PM URINE RBC->1000* WBC->1000* Bacteri-FEW
Yeast-NONE Epi-0
[**2190-9-3**] 9:55 pm URINE Source: CVS.
URINE CULTURE (Pending):
[**8-29**]: Baseline artifact. Borderline resting sinus tachycardia at
a rate of
about 100 beats per minute. Left ventricular hypertrophy. Left
atrial
abnormality. Non-specific ST-T wave changes. Slow R wave
progression with
possible underlying anteroseptal myocardial infarction. Compared
to the
previous tracing of [**2190-7-21**] heart rate is faster. ST-T wave
changes are more
apparent. Clinical correlation is suggested.
CXR [**8-29**]: PORTABLE AP CHEST RADIOGRAPH: There are bibasilar hazy
opacities, compatible
with increased interstitial edema, atelectasis and pleural
effusions. There
is minimal pulmonary vascular prominence. The cardiomediastinal
silhouette is
within normal limits. There is no pneumothorax. A left cervical
rib is
incidentally noted.
IMPRESSION: Mild-to-moderate congestive failure. Re-evaluate
after diuresis
can be helpful to exclude superimposed infectious process.
Echo [**9-1**]: The left atrium is elongated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The aortic valve leaflets (3) are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a small pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Minimal aortic valve stenosis. Small circumferential pericardial
effusion without evidence of hemodynamic compromise. Increased
PCWP.
Compared with the prior study (images reviewed) of [**2189-4-27**],
minimal aortic valve stenosis is now present. Biventricular
systolic function remains preserved. The estimated PA systolic
pressure is now lower (but was overestimated on the prior
study).
IR thrombectomy: IMPRESSION: Thrombosis of a left upper
extremity AV graft with recurrent
stenosis at the venous anastomosis of the graft. Flow could be
restored
temporarily, but rethrombosis occured twice, despite mechanical
thrombectomy,
chemical thrombolysis, balloon angioplasty, [**Doctor Last Name **] embolectomy
and stenting
of the venous anastomosis.
Left IJ access was obtained for dialysis.
Cardiac Cath [**9-2**]:
COMMENTS:
1) Selective coronary angiography in this right dominant system
demonstrates three vessel coronary artery disease. The right
coronary
artery is a heavily calcified vessel with serial 50-60%
stenoses. The
posterior left ventricular branch is involved in a 60% stenosis.
The
left main coronary artery has a 20% lesion. The LAD isheavity
calicified. The previously placed stent was patent. The first
diagonal
had diffuse 50-60% disease. The circumflex artery had a 70%
ostial
lesion. The midvessel had a 60% focal stenosis. The first obtuse
marginal bifurcated, and one of these branches was totally
occluded with
a lesion believed to be the culprit lesion.
2) Hemodynamics measurements demonstrate normal cardiac output,
and
biventricular filling pressures.
3) lesion. Unsuccessful vascular closure with Mynx device.
Recommend
secondary prevention of CAD including plavix 75mg daily for 6
months,
and medical management of the patient's ACS.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Unsuccessful PCI to Cx/OM lesion
3. Unsuccessful vascular closure with Mynx
Tunneled Cath pending
Brief Hospital Course:
82 yo M with history of CAD s/p NSTEMI, ESRD on HD, DM2, HTN,
HL, presents with shortness of breath due to volume overload
#Shortness of breath/volume overload: Likely due to ESRD with
insufficient volume removal on HD. TTE in [**2189-4-27**] shows normal
systolic function with LVEF of 55%. Symptoms improved once
given lasix and placed on nitro drip in the ED; nitro drip was
gradually weaned off. He was continued on metoprolol 25 mg PO
BID and lisinopril 40 mg PO daily. He was given lasix 120 mg IV
but did not make significant urine so lasix was discontinued.
His fistula for dialysis was found to be clotted so an IR
fistulogram and thromectomy was attempted but failed with
immediate reclotting so an IJ temporary dialysis catheter was
placed with plan for tunneled catheter in 2 days. Dialysis was
done twice in the CCU with 1.8 L removed each time. The patient
had a tunneled HD catheter placed in IR.
.
# CAD: patient has history of CAD with NSTEMI in [**2183**] requiring
DES to mid LAD. He is not on aspirin or plavix at home. Patient
reports that he was on aspirin previously but was told to stop
it approximately 5 months ago. Troponin on admission was
slightly elevated at 0.06 but in setting of chronic renal
insufficiency. Ekg from [**2190-8-31**] 0800 showed marked T wave
inversions in precordial leads, concerning for anteroseptal MI,
different from prior EKGs. Repeat EKG on [**2190-9-1**] showed
consistent changes. CE's were trended. Troponin was 10.13, up
from 0.06 on admission, however both CK and MB were flat.
Patient remained CP/SOB-free, however reported some
dizziness/lightheadedness upon standing. Cards was consulted and
a heparin gtt was started. ECHO was completed showing no wall
motion abnormality and preserved LVEF. The patient had a
cardiac catheterization which showed a distal lesion in his OM
that was unable to be intervened upon due to the vessel being
too small. He was medically managed for his NSTEMI with
carvedilol, aspirin, plavix.
.
# DM2 - diet controlled at home. Managed with ISS.
.
# HTN - elevated BP on admission, was given metoprolol in the ED
without much effect, but also in setting of volume overload.
Continued on metoprolol and higher dose of lisinopril; HD x 2 in
CCU. He was started on carvedilol and lisinopril 40mg with good
control of his BP.
.
# ESRD - history of right nephrectomy for suspected malignancy,
but found to be benign pathology. ESRD thought to be secondary
to HTN and FSGS, is currently on HD qMWF at home. Baseline
creatinine ranging from [**5-21**], creatinine of 9 on admission.
Renal consulted and found fistula to be clotted. IR attempted
thrombectomt but failed due to reclotting so a temporary IJ
catheter was placed for dialysis. This was replaced by a
tunneled HD cath placed in IR. His phosphorous was climbing so
the patient was started on sevelamer.
.
#UTI: was on cipro on admission, started [**8-26**]. continue for
total 10 day course. The cipro was stopped by the medical team
on the floor after 1 week of therapy. He developed hematuria
the day before discharge. This was monitored, the patient was
able to urinate without difficulty and did not pass any clots.
His hematocrit was stable and the patient was discharged with
instructions to follow-up with Urology as an outpatient.
.
# Herpes - The patient had a lesion on his buttocks that was
felt to be a herpes lesion. He was started on valtrex which
gave relief to his discomfort.
Medications on Admission:
Simvastatin 20 mg daily
Metoprolol Tartrate 25 mg [**Hospital1 **]
B Complex-Vitamin C-Folic Acid 1 mg 1 capsule daily
Docusate Sodium 100 mg [**Hospital1 **]
Senna 2 tablets qhs
Lisinopril 10 mg daily
Brimonidine 0.1% 1 drop OU
Ciprofloxacin 500 mg [**Hospital1 **] x 10 days - prescribed [**2190-8-26**]
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal DAILY (Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
11. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute Pumonary Edema, NSTEMI
Secondary Diagnosis:
CAD with NSTEMI in [**2183**] requiring DES to mid LAD
End Stage Renal disease
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization.
You were admitted with shortness of breath. You were found to be
volume overloaded and you were treated with diuretics and
dialysis. Your dialysis fistula was not working properly. The
IR doctors tried to restore the blood flow, but were unable to,
so you received a temporary catheter through a vein in your neck
and a more permanant tunnelled catheter that was placed on [**9-3**].
There were some EKG changes seen that were concerning for a
blockage in one of your heart arteries. You had a cardiac
catheterization which showed a small blockage in one of the
arteries that supply the heart. This was too small to be
intervened on so you were treated medically. An echocardiogram
showed no changes in your heart function. Your blood pressures
were running high and we adjusted your medicines.
We started the following medications:
START Aspirin 325 mg daily
START taking labetalol 200mg twice daily to lower your blood
pressure and heart rate (this medication will be instead of
metoprolol)
START taking calcium and Sevelamer with meals to lower your
phosphate level
We increased the following medication:
INCREASE Lisinopril to 40 mg daily
INCREASE Simvastatin to 40 mg daily
We stopped the following medication:
STOP taking Metoprolol
STOP taking ciprofloxacin as you have finished the course of the
antibiotic.
You may take one more day of pyridium to treat burning in your
bladder and penis.
Because you had blood in your urine, you will need to follow-up
with the Urologists to find out where this is coming from.
Please call their office at ([**Telephone/Fax (1) 772**] to schedule an
appointment.
Followup Instructions:
Please call the Urology department at ([**Telephone/Fax (1) 772**] on Monday
to schedule an appointment to evaluate the blood in your urine.
You should try to schedule an appointment to be seen as soon as
possible.
Department: CARDIAC SERVICES
When: MONDAY [**2190-10-11**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2190-9-10**] at 2:35 PM
With: [**First Name8 (NamePattern2) 5478**] [**Name8 (MD) 5479**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is a follow up of your hospitalization. You will be
reconnected with your primary care physician after this visit.
Department: COGNITIVE NEUROLOGY UNIT
When: TUESDAY [**2190-10-19**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18365**], PHD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: PODIATRY
When: TUESDAY [**2190-11-23**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2190-9-10**]
|
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"E879.1",
"276.6",
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icd9cm
|
[
[
[]
]
] |
[
"39.50",
"99.10",
"39.90",
"38.95",
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icd9pcs
|
[
[
[]
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] |
14274, 14332
|
9431, 12894
|
334, 445
|
14602, 14602
|
2880, 9246
|
16496, 18379
|
2094, 2266
|
13250, 14251
|
14353, 14353
|
12920, 13227
|
9263, 9408
|
14753, 16473
|
2389, 2861
|
275, 296
|
473, 1221
|
14423, 14581
|
14372, 14402
|
14617, 14729
|
1243, 1669
|
1685, 2078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,632
| 128,004
|
8739
|
Discharge summary
|
report
|
Admission Date: [**2142-5-22**] Discharge Date: [**2142-6-5**]
Date of Birth: [**2073-12-28**] Sex: M
Service: NEUROLOGY
NOTE: Dictation is partial and will be addended.
PRIMARY DIAGNOSIS: Intraventricular hemorrhage,
status post drain
CHIEF COMPLAINT: Frontal headache and nausea
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old man
with peripheral vascular disease, insulin dependent type II
diabetes, coronary artery disease and hypertension who was
transferred to the [**Hospital6 256**]
Neurologic Intensive Care Unit on [**5-22**] from [**Hospital3 29718**] with a right interventricular plate. The patient woke
up three days prior to admission complaining of a severe
headache which worsened over the next two days. The morning
of admission, the patient vomited twice. He reports that the
headache is non throbbing, generalized and frontal in
location. ............. called the primary care physician
and sent the patient to the Emergency Department at [**Hospital3 29718**] where he was reported to be awake, oriented and moving
all extremities normally. His blood pressure at the time was
180/90. His INR was 1.9. His PTT was 42.8. The patient was
given 2 units of fresh frozen plasma prior to transfer. The
patient denies any weakness or numbness, any changes in
vision and changes in speech or language. On arrival at [**Hospital3 **], the patient still was complaining of a frontal
headache, nausea and felt tired.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes x2
2. Hypertension
3. Coronary artery disease
4. Chronic renal insufficiency with a baseline creatinine of
1.9.
5. Peripheral vascular disease status post right AKA [**10-5**]
6. Chronic obstructive pulmonary disease, status post
coronary artery bypass graft, four vessel, in [**2133**].
7. Left femoral bypass in '[**34**]
8. Right common femoral AK [**Doctor Last Name **] '[**34**]
9. Left transmetatarsal amputation [**3-5**]
HOME MEDICATIONS:
1. Lasix 60 q day
2. Enteric coated aspirin 1 per day
3. Coumadin 3 mg q day
4. Insulin NPH 32 units q a.m., 32 units q hs
5. Digoxin 0.125 mg q day
6. Zantac 150 mg po q day
ALLERGIES: PENICILLIN WHICH CAUSES A RASH AND ERYTHROMYCIN
PHYSICAL EXAM ON PRESENTATION TO NEUROLOGIC INTENSIVE CARE
UNIT:
VITAL SIGNS: Blood pressure 178 to 209/76 to 103, pulse 78
to 84, respiratory rate of 18, saturating 100% on room air.
GENERAL: The patient appeared comfortable and closes his
eyes frequently and is sleeping during the exam.
NECK: Supple without bruit, no meningismus.
CARDIAC: Normal S1, S2, regular rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Status post right AKA with no edema.
NEUROLOGIC: The patient was awake, sleeping, oriented to
self and [**Hospital3 **]. He stated that date was [**5-25**]
rather than the 18th and that the year was '[**43**]. His speech
was fluent without paraphasic errors, normal repetition,
naming. Patient was intermittently inattentive. The patient
was able to say the months of the year forward with one skip.
He was unable to say the months of the year backwards. The
patient drew a clock which was poorly organized.
CRANIAL NERVE EXAM: The patient's pupils were equal, round
and reactive to light, 1.5 to 1. Extraocular movements were
full. The patient was inattentive on formal testing with the
exception that the patient did have slight restriction of up
gaze bilaterally. He was inattentive to visual field
testing, but positive blink reflex bilaterally. Strength and
sensation intact and symmetric. Tongue and uvula in the
midline. Shoulder strength is strong. Motor exam: The
patient was without drift. He has increased bulk in the left
lower extremity, status post right AKA, status post left
first toe amputation. Strength was full throughout. There
were positive fasciculations in the left calf. Deep
tendon reflexes were depressed throughout.
The patient gets painful cramp in left calf during exam.
Left toes were equivocal. Sensation was intact to light
touch, pain, sensation and temperature throughout. Absent
vibration on the left toes. The patient had a positive
action tremor on finger to nose bilaterally. Rapid
alternating movements were intact in both upper extremities.
LABS: Chem-7 142, 4.3, 101, 30, 39, 2.2, 77. CBC - white
blood cell count 11.0, 14.4, platelets 149. CK 61, troponin
negative. PT 16.3, INR 1.9, PTT 36.6. Head CT showed blood
on deep [**Doctor Last Name 534**] of the right lateral ventricle
with small anterior secondary edema, questionable blood in
the right thalamus.
HOSPITAL COURSE: The patient was admitted to the Neurologic
Intensive Care Unit. He was noted to be awake, but
disoriented to date. On [**5-24**], the patient became
aggressively less responsive and a ventricular drain was
placed. After that time, the patient was noted to have some
improvement in his mental status, but was still not oriented
to the date. An MRI was done on [**2142-5-25**] which showed right
periventricular hemorrhage along the margin of the atrium
with the right lateral ventricle with extension to the
lateral ventricle with no definite evidence of abnormal
enhancement to indicate underlying mass. An angiogram was
planned for [**5-28**], however the patient was noted to be more
lethargic and the study was not done. He also had a rise in
his BUN and creatinine. The ventricular drain was cleansed
on [**6-1**] in the morning and a repeat CT scan showed a minimal
increase in the front ends of the frontal and temporal horns
of the bilateral lateral ventricles as compared to the
previous CT on [**2142-5-28**].
On the morning of [**6-2**], the patient was still complaining of
bifrontal headache, but denied nausea or vomiting and was
transferred to neurology floor. On the neurology floor, the
patient continued to wax and wane in attentiveness and level
of orientation. On [**2142-6-4**], the patient had two episodes of
emesis in the morning, but had no further episodes and his
nausea and headache returned to their baseline levels. The
patient was noted over the course of his stay to have a
consistently low sodium with its nadir being 127 and on
[**2142-6-5**] he had a second nadir of 132.
DISCHARGE INSTRUCTIONS will be added at a later date, as well
as condition on discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7499**]
Dictated By:[**Numeric Identifier 30575**]
MEDQUIST36
D: [**2142-6-5**] 20:09
T: [**2142-6-6**] 10:57
JOB#: [**Job Number 30576**]
|
[
"401.9",
"530.81",
"431",
"250.00",
"443.9",
"496",
"331.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
4652, 6659
|
1983, 4634
|
278, 307
|
336, 1473
|
212, 260
|
1495, 1965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,646
| 171,681
|
28491
|
Discharge summary
|
report
|
Admission Date: [**2180-8-18**] Discharge Date: [**2180-8-24**]
Date of Birth: [**2123-4-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Sepsis.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
57 y.o. M with anuric ESRD [**1-20**] polycystic kidney disease, CVA -
non verbal at baseline, past hx of bacteremia presents from HD
with hypotension and fever.
.
In the ED, patient was found to have a rectal temperature of
104.8 and a code sepsis was called. He received 1 gram tylenol,
2 grams Ampicillin, 1 gram Ceftriaxone, 500 mg Metronidazole,
and 10 mg of dexamethasone. Of note, he is reported to have
gotten 1 gram of Vancomycin at HD before transfer. He was also
fluid resuscitated amd started on a levophed gtt for SBP as low
as 50's systolic. An LP was performed and was negative. He had
an abdominal CT with findings as described below.
.
ROS: Unable to obtain.
Past Medical History:
End-stage renal disease
Hypertension
Gastroesophageal reflux disease
History of septicemia
History of cerebrovascular accident
Dysphagia
Degenerative joint disease
s/p G-tube placement
Diabetes mellitus, type 2
Social History:
History of cocaine abuse.
Family History:
NC.
Physical Exam:
VS: Temp: 96.9 BP: 119/76 HR: 115 RR: 35 O2sat: 100% on RA
weight: 63
GEN: man lying in bed, contracted, NAD
HEENT: PERRLA, EOMI, would/could not open mouth for exam
RESP: coarse breath sounds in all lung fields
CV: regular, nl s1, s2, no m/r/g
ABD: soft, diffusely tender to deep palpation, tympanic, ND, +
BS, no rebound, no guarding
Rectal: guiac - per ED, ?tenderness to palpation of prostate, +
enlarged
EXT: no edema, +1 DP pulses, fistula on L arm with + thrill, no
evidence of thrombophlebitis
Neuro: seems alert, occaisionally responds with grunts and nods
appropriately to question, other times stares and will not
answer
Pertinent Results:
Labwork on admission:
[**2180-8-18**] 01:30PM WBC-27.0* RBC-3.52* HGB-10.0* HCT-30.8*
MCV-88 MCH-28.4 MCHC-32.5 RDW-14.3
[**2180-8-18**] 01:30PM PLT COUNT-387
[**2180-8-18**] 01:30PM NEUTS-90.7* LYMPHS-5.3* MONOS-3.9 EOS-0.1
BASOS-0.1
[**2180-8-18**] 01:30PM PT-13.9* PTT-30.0 INR(PT)-1.2*
[**2180-8-18**] 01:30PM GLUCOSE-129* UREA N-42* CREAT-5.2* SODIUM-139
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-31 ANION GAP-17
[**2180-8-18**] 01:30PM CALCIUM-9.0 PHOSPHATE-1.0* MAGNESIUM-1.8
[**2180-8-18**] 03:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* POLYS-0
LYMPHS-72 MONOS-0 MACROPHAG-28
[**2180-8-18**] 03:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-75*
GLUCOSE-98
[**2180-8-18**] 02:52PM LACTATE-2.0
.
CT ([**2180-8-18**]): no definite source for sepsis identified;
prominent left perirenal lymph nodes; polycystic kidneys. some
in the left kidney are hyperdense which could represent
hyperdense cysts but cannot exclude neoplasm especially with
adjacent adenopathy; multiple liver lesions likely cysts related
to polycystic kidney disease; the presence of multiple
microabscesses would be quite unlikely; thickened rectal wall
which may be chronic. no associated inflammatory stranding.
metallic density in anus. ? thermometer.
.
CXR ([**2180-8-18**]): Ill-defined opacity in the right lower lobe
which may be secondary to patient's low lung volumes vs
summation of overlying structures; however, it should be
formally evaluated with a PA and lateral chest radiograph. No
pneumothorax.
.
[**2180-8-22**] 02:21PM BLOOD calTIBC-122* Hapto-413* Ferritn-GREATER
TH TRF-94*
[**2180-8-22**] 02:21PM BLOOD PTH-127*
.
Labwork on discharge:
[**2180-8-24**] 03:17AM BLOOD WBC-16.0* RBC-3.14* Hgb-9.6* Hct-28.9*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.2 Plt Ct-396
[**2180-8-24**] 03:17AM BLOOD Glucose-115* UreaN-16 Creat-3.3*# Na-143
K-3.7 Cl-102 HCO3-30 AnGap-15
[**2180-8-24**] 03:17AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.1*
Mg-1.7
Brief Hospital Course:
57 yoM with anuric ESRD [**1-20**] polycystic kidney disease, CVA (non
verbal at baseline), past hx of bacteremia and UTIs presents
from HD with resolved sepsis secondary to UTI. Now with C. diff
likely secondary to levofloxacin.
.
1. Sepsis. Resolved. The patient required pressures initially
during admission, but had been off pressors >24h on discharge.
Most likely secondary to urinary tract infection per urinalysis.
The patient was originally treated with vancomycin and
levofloxacin. Urine culture [**8-19**] grew E. coli sensitive to
ceftriaxone and bactrim but resistant to levofloxacin.
Levofloxacin and vancomycin were discontinued and the patient
was treated with bactrim for a 10-day course for treatment of
UTI as well as good penetration into an infected cyst if
present. Urine gram stain [**8-21**] positive for 5000 GNR,
10,000-100,000 gram+ cocci with culture showing coagulase
negative Staphylococcus species (most likely S. epidermis or S.
saprocyticus, should be covered with current regimen). Chest
X-ray was negative for pneumonia. LP negative as above. CT
abdomen showed no obvious signs of infection as above, but
infected renal cyst could not be excluded. No signs of skin
breakdown or phlebitis.
.
2. C. difficile. The patient spiked fever the third day of
hospitalization and was positive for C. difficile infection.
This was likely secondary to treatment with levofloxacin. The
patient was started on flagyl to complete a 14-day course.
.
3. Renal Failure. The patient was followed by the renal team. On
HD [**8-21**], the machine clotted and dialysis was stopped
prematurely. The patient was dialyzed the next day and then per
routine.
.
4. Hypernatremia. The patient was hypernatremic to 148 the sixth
day of admission. He was given free water boluses and this
resolved.
.
5. Sinus tachycardia. The patient's blood pressure regimen was
originally held for hypotension but was restarted at half his
outpatient doses. His blood pressure regimen can be increased to
home doses as tolerates.
.
6. Anemia. Secondary to renal failure. Hemolysis labs negative.
Anemia of chronic disease per iron studies. Received 2U PRBC [**8-22**]
with HD after losing blood with machine malfunction [**8-21**]. Epogyn
dose reviewed at HD.
Medications on Admission:
1. Lactulose 10 g/15 mL Syrup [**Month/Day (4) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
2. Labetalol 200 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day:
Hold for SBP < 90, HR < 60.
3. Diltiazem HCl 60 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO four times
a day: Hold for SBP < 90, HR < 60.
4. Reglan 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day.
5. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (4) **]: One (1) PO once a
day.
6. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
7. Ativan 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHD: PRN as needed
for anxiety.
8. Crestor 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. Rocaltrol 0.5 mcg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Procrit Injection
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
2. Labetalol 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day:
Hold for SBP < 90, HR < 60.
3. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times
a day: Hold for SBP < 90, HR < 60.
4. Reglan 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
5. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO once a
day.
6. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
7. Ativan 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHD: PRN as needed
for anxiety.
8. Crestor 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. Rocaltrol 0.5 mcg Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Procrit Injection
12. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution [**Last Name (STitle) **]:
Two [**Age over 90 11578**]y (280) mg Intravenous Q24H (every 24 hours)
for 6 days: On dialysis days, give post-dialysis. Started [**2180-8-21**]
for 10 day course.
13. Metronidazole 500 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO Q6H (every 6
hours) for 12 days: On dialysis days, give post-dialysis.
Started [**2180-8-22**] for 14 day course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Primary:
Sepsis
.
Secondary:
End-stage renal disease
Hypertension
Gastroesophageal reflux disease
History of septicemia
History of cerebrovascular accident
Dysphagia
Degenerative joint disease
s/p G-tube placement
Diabetes mellitus, type 2
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
Please contact a physician if you experience fevers, chills, or
any changes with urination.
.
Please take your medications as prescribed.
Followup Instructions:
Please follow-up with your primary care physician at [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,577
| 108,738
|
51084
|
Discharge summary
|
report
|
Admission Date: [**2119-6-26**] Discharge Date: [**2119-7-17**]
Service: MEDICINE
Allergies:
Amoxicillin / Verapamil / Univasc
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Lower extremity swelling
Major Surgical or Invasive Procedure:
Right internal jugular line placement with replacment over a
guidewire
PICC line placement
History of Present Illness:
[**Age over 90 **] year old female with asthma, atrial fibrillation on
Dabigatran and s/p dual-chamber (RA-RV) PPM in [**5-31**],
hypertension, and heart failure with preserved EF (EF 55% on
[**2119-6-28**] TTE but normal E wave, low deceleration time 133 msec)
and moderate pulmonary hypertension by TTE (TR Gradient + RA =
PASP: 44 mm Hg) who presented to the ED with lower extremity
edema. She reported considerable problems with lower extremity
edema over the weeks preceding admission with an approximately
12-lb weight gain and [**2-23**] pillow orthopnea. She further reported
dyspnea on exertion but not at rest. She has also had two
admissions within the last six weeks for AF with RVR. She had
been doing reasonably well despite persistent lower extremity
edema until the day prior to admision when she tripped and was
unable to get herself off the floor for a few hours due to
weakness.
She denies having any shortness of breath, chest pain, dyspnea
on exertion or palpitations in association with this. She
denies striking her head. Her grandson eventually was able to
help her to her feet and she seemed well without confusion so no
additional assistance was pursued at that time. She did report
three days of persistent cough, intermittently productive of
whitish sputum but denied any fevers. The morning after her fall
(the morning of admission), her family decided to bring her in
for further evaluation given her persistent cough and leg
swelling.
Past Medical History:
-Coronary artery disease
-Paroxysmal atrial fibrillation on dabigatran with dual-chamber
PPM (RA/RV)
-Hypertension
-Hyperlipidemia
-Mild Aortic insufficiency
-Chronic kidney disease (stage III)
-Asthma
-Osteopenia
-Diverticulosis
-Gallstones
-Cataracts
-Internal hemorrhoids
-Allergic rhinitis
-Impaired glucose tolerance
-Breast cancer s/p RIND '[**94**]
-sp TABHSO for dysfunctional bleeding
Social History:
Retired book-keeper at a diamond merchant. She lives with her
sister, who is 14 years younger. Mobilizes with cane, exercise
tolerance 25 meters. Smoking/Tobacco: Never smoked. EtOH: none.
Illicits: none.
Family History:
Mother died from a myocardial infarction at 65 y/o but had T2DM,
PVD, and CHF. Father had Hodgkin's disease and laryngeal
carcinoma. Brother died from pancreatic cancer. Sister has CAD
c/b by MI x2 s/p PCI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98, P 76, BP 90/51, RR 18
General: Mildly uncomfortable appearing female in NAD
HEENT: atraumatic, normocephalic, MMM, OP clear
Neck: supple, JVP not able to be assessed due to right sided CVL
with some surrounding blood
Lungs: Bilateral expiratory wheezes, mild respiratory distress
on speaking
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound, tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 3+ edema in lower extremities to knee
bilaterally, left lower extremity with 4*4 area of ecchymoses
followed by nontender, slightly indurated red area that is
nontender
DISCHARGE PHYSICAL EXAM:
Gen: alert and resting in bed, pleasant, oriented x 4, NAD
CV: RRR (AV paced) with audible S1/S2, no murmurs or S3
Pulm: poor ae bilaterally due to kyphosis but clear without
rales or wheezes
Abd: soft, NT, ND
GU: no dysuria, no foley
Ext: 2+ radial pulses, 1+ DP pulses bilateral. 1+ bilateral
pitting edema in legs with L stasis dermatitis on the shin
Skin: dry skin throughout, worse on trunck and face with
flaking. Left lower back with 7x4 cm erythematous patch--non
raised, no tenderness or pruritis
Pertinent Results:
Admission Labs:
[**2119-6-26**] 12:30PM BLOOD WBC-13.4* RBC-4.10* Hgb-11.5* Hct-34.0*
MCV-83 MCH-28.1 MCHC-33.9 RDW-16.0* Plt Ct-265
[**2119-6-26**] 12:30PM BLOOD Neuts-83.8* Lymphs-10.9* Monos-4.5
Eos-0.6 Baso-0.2
[**2119-6-26**] 07:13PM BLOOD PT-32.9* PTT-83.2* INR(PT)-3.3*
[**2119-6-26**] 12:30PM BLOOD Glucose-107* UreaN-59* Creat-2.1* Na-130*
K-4.3 Cl-86* HCO3-28 AnGap-20
[**2119-6-26**] 08:15PM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
Cardiac Labs:
[**2119-6-26**] 12:30PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-8710*
[**2119-6-27**] 01:53AM BLOOD CK-MB-5 cTropnT-0.02*
[**2119-7-3**] 03:21AM BLOOD proBNP-[**Numeric Identifier 106093**]*
[**2119-7-9**] 06:30AM BLOOD proBNP-5233*
.
Thyroid Studies:
[**2119-7-10**] 07:00AM BLOOD TSH-6.9*
[**2119-7-11**] 04:15AM BLOOD T3-56* Free T4-1.3
.
EKGs:
1. [**2119-6-26**]: Ventricular paced rhythm with a seven-beat run of an
irregular intrinsic wide complex rhythm of uncertain mechanism
but may be atrial fibrillation. Intermittent atrial pacer
activity also appears to be present. Clinical correlation is
suggested. Since the previous tracing of [**2119-5-27**] uniform atrial
pacing has been replaced by rhythm as outlined.
2. [**2119-7-11**]: Atrial paced rhythm. Left ventricular hypertrophy.
Diffuse ST-T wave abnormalities are non-specific but cannot
exclude myocardial ischemia. Clinical correlation is suggested.
Since the previous tracing of [**2119-6-26**] atrial pacing is now
present throughout and ventricular pacing is not seen.
.
Tib/Fib XRay ([**2119-6-26**]): No acute fracture or dislocation in
either tibia or fibula.
.
Right Shoulder XRay ([**2119-6-26**]): No acute fracture or dislocation.
Findings suggestive of underlying rotator cuff disease.
.
Relevant CXR:
1. [**2119-6-26**]: Mild congestive heart failure with small bilateral
pleural effusions. Opacities within the lung bases may represent
atelectasis but infection or aspiration cannot be excluded.
2. [**2119-6-27**]: Bilateral pleural effusions blunt the pleural sinuses
and obliterate the diaphragmatic contours. They also conceal
major portions of the cardiac silhouette which undoubtedly
represents marked cardiac enlargement. The pulmonary vasculature
is congested with perivascular haze and hazy peripheral
densities in the mid lung field which have now increased in
comparison with the last study and suggest development of
pulmonary edema. No pneumothorax has developed. There is no
evidence of central airway occlusion and occlusion atelectasis
related to mucus airway plugging. Comparison is made with
multiple chest examinations obtained during the last week and
they disclose findings consistent with CHF, continues
progression of pulmonary congestion.
3. [**2119-7-5**]: There is no pulmonary edema or appreciable pulmonary
vascular engorgement. Bilateral pleural effusions,
moderate-to-large on the right and moderate on the left are
stable, obscuring cardiac silhouette, which is probably enlarged
but not changed in the interim. Right PIC line can be traced to
the upper right atrium. No pneumothorax.
.
TTE ([**2119-6-28**]):
Suboptimal image quality. The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). There is
no ventricular septal defect. The 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. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-22**]+)
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. Compared with the prior study
(images reviewed) of [**2119-5-9**], the estimated PA systolic
pressure is lower.
.
TTE ([**2119-7-11**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. 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. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal global and regional biventricular systolic function.
Mild aortic and mitral regurgitation. Compared with the prior
study (images reviewed) of [**2119-6-28**], severity of tricuspid
regurgitation and degree of pulmonary hypertension have both
decreased.
.
Discharge Labs:
Creatinine 1.9
Potassium 4.7
Sodium 140
Brief Hospital Course:
[**Age over 90 **] y/o female with CAD, atrial fibrillation c/b tachy-brady
syndrome s/p PPM placement, CKD, asthma and heart failure with
preserved EF, who presented with cough, lower extremity edema
and hypotension. Patient was initially treated with
Norepinephrine for hypotension and diuresed on a Lasix drip,
with a loss of approximately 12 pounds. Chest radiography
revealed a possible infiltrate and the patient received 8 days
of antibiotics for a health-care associated pneumonia
(Vancomycin plus Zosyn, which was switched to Cefepime, and,
finally, Levofloxacin to complete the course). No definitive
cause of her initial hypotension was identified, though
interrogation of pacemaker early in her hospitalization revealed
several prolonged episodes of atrial tachycardia (one lasting
approximately 50 hours). Such episodes may have lead to a loss
of atrial kick with subsequent drop in cardiac output. Though
she was treated for an infection, the ICU team did not feel that
septic physiology was to blame for her presentation. Serum AM
cortisol of 26.4 argued against adrenal insufficiency. TSH was
elevated but did not indicate significant hypothyroidism (see
discussion below).
The patient was subsequently transfered to the inpatient
cardiology service to continue care for her hypotension and
acute on chronic kidney disease. Diuresis had been held for 48
hours prior to transfer. Diuresis was intermittently continued
on the cardiology service with little improvement in her
peripheral edema. Patient developed a persistent metabolic
alkalosis and her serum creatinine remained elevated at
approximately 2, up from a baseline of 1.5, which was concerning
for overdiuresis. Urine lytes were not helpful in assessing for
intravascular volume depletion (FEUrea ~ 43%, UNa 33). A TTE did
not reveal evidence of worsening cardiac function or valvular
disease but did reveal a near-normalization of pulmonary artery
pressures as well as loss of a TR gradient, which fit with a
clinical picture of overdiuresis. A diuretic regimen of
torsemide 20 mg PO daily was eventually restarted and patient
was discharged on this regimen.
Other Issues by Problem:
1. Atrial Fibrillation c/b Tachy-Brady Syndrome: Patient had
dual-chamber (RA/RV) [**Company 1543**] pacemaker placed on [**2119-5-26**] for
Tachy-Brady Syndrome. Pacemaker interrogation on admission
revealed frequent and prolonged episodes of atrial fibrillation.
Patient was continued on her Dabigatran throughout admission.
Her Amiodarone was dose reduced from 200 mg PO TID to 200 mg PO
daily as review of records indicated that she may have received
a load as high as 25 grams. She will need to take 200 mg
amiodarone daily for 10 days, then dose reduce to 100 mg daily
for maintenance. Metoprolol required dose reduction due to
hypotension and at discharge was prescribed as metoprolol
succinate (Toprol XL) 25 mg PO daily. Patient was continued on
dabigatran at the time of discharge.
2. Acute on Chronic Kidney Disease: Baseline creatinine in
recent months was ~ 1.5. Her serum creatinine peaked at
approximately 2. Urine lytes did not help in differentiating the
etiology (FEUrea ~ 43%, UNa 33) but other data suggested
overdiuresis. On discharge her Cr stabilzed in the range of
1.8-1.9 after several days of regular diet with oral fluids and
torsemide 20 mg PO daily to maintain treatment of lower
extremity edema.
3. Left Lower Extremity Erythema: Patient was treated for
cellulitis during a recent admission in [**5-1**]. At that time a
LLE US was without evidence of DVT to explain the asymmetry
between the LLE and RLE. She was evaluated for fracture in the
ED but imaging was negative. Her erythema gradually improved
throughout the hospitalization and at the time of discharge
looked like the chronic changes of stasis dermatitis.
4. Leukocytosis: Patient presented with WBC count of 13.4 with
neutrophil predominance though no bands or atypicals. WBCs
intermittently as high as 19.2. Blood cultures negative on
admission. UA negative on admission (no urine culture
performed). Cough and CXR suggestive of consoliation concerning
for HCAP, for which she received 8 days of appropriate
antibiotics. C. difficile toxin negative by EIA once. Patient
remained afebrile following transfer to the cardiology service.
Her leukocytosis resolved prior to discharge. Ultimately, it was
likely due to possible infection or stress response.
5. Metabolic Alkalosis: Patient developed elevated serum
bicarbonate (peak of 45) in setting of diuresis. She received
three days of Acetazolamide while diuresis was pursued. Her
serum bicarbonate at discharge was normalized. This was likely
due to volume contraction/overdiuresis.
6. Abnormal Thyroid Function Tests: Baseline TSH 1.5 prior to
initiation of Amiodarone. TSH on [**2119-7-10**] is 6.9. Elevated TSH
may reflect a consequence of significant iodine load from
Amiodarone though it is difficult to interpret in the setting of
an acute illness. T4 is within normal limits and T3 is reduced
which is more consistent with a sick euthyroid state in the
setting of an ICU stay. No treatment was initiated in the acute
setting, especially as TSH < 10, but TFTs should be closely
monitored following discharge.
7. Asthma: Patient initially managed with Levalbuterol however
was transitioned to salmeterol given concern for worsening
tachycardia and compromising hemodynamics.
8. Normocytic Anemia: Hematocrit 34 on admission and remained
stable in the low 30s.
9. Hyperglycemia/Impaired Glucose Tolerance: Patient was
maintained on a Humalog insulin sliding scale for hyperglycemic
correction though only required this very infrequently and did
not need to be continued at discharge.
10. Right Shoulder Pain: In ED patient complained of right
shoulder pain in the setting of a recent fall. Shoulder xray
revealed no fracture but did indicate chronic rotator cuff
disease.
Transition Issues:
1. Close monitoring of thyroid function tests as above
2. Close monitoring of creatinine and BUN as above. D/C Cr 1.9
3. Close monitoring of symptoms of diastolic heart failure. See
D/C physical exam.
4. Daily standing weight, if greater than 3lbs change, call Dr.
[**Last Name (STitle) **].
Ppx: The patient was maintained on SQ heparin throughout the
hospital course
Code status: Full code
Contact: [**Name (NI) **] (sister), H:[**Telephone/Fax (1) 106094**], C:[**Telephone/Fax (1) 106095**]
Lines: none
Access issues: difficult but possible with peripheral sticks
Dispo: extended stay rehab facility
Medications on Admission:
1. Dabigatran etexilate 75 mg PO twice a day.
2. Simvastatin 20 mg PO DAILY
3. Vitamin D 50,000 unit PO once a month.
4. Travoprost Z 0.004 % Drops : One ophthalmic at bedtime.
5. Psyllium powder once a day.
6. Furosemide 80 mg QAM, 40 mg QPM DAILY
7. Amiodarone 200 mg TID
8. Metoprolol succinate 100 mg PO daily
9. Acetaminophen 650 mg PO every six hours as needed for pain
Discharge Medications:
1. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CHF: Hold for SBP < 95.
Disp:*30 Tablet(s)* Refills:*1*
8. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*50 ML(s)* Refills:*2*
9. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours): Inhale once in the
morning and once at night.
Disp:*60 Disk with Device(s)* Refills:*2*
10. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day:
For ten days, take 2 tablets each day in the morning. After ten
days decrease to one tablet each morning. Hold for SBP < 95 or
HR < 50.
Disp:*30 Tablet(s)* Refills:*2*
11. miconazole nitrate 2 % Powder Sig: One (1) Topical once a
day as needed: Apply once a day to area under breasts if moist
or painful.
Disp:*2 tubes* Refills:*2*
12. docusate sodium 50 mg Capsule Sig: [**1-22**] Capsules PO twice a
day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Primary
1. Congestive Heart Failure
2. Hypotension (Low Blood Pressure)
3. Acute on Chronic Kidney Disease
4. Healthcare Associated Pneumonia
5. Atrial tachycardia
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:
1. You were admitted to [**Hospital1 18**] with low blood pressure and leg
swelling, likely due to heart failure. Fluid was removed with a
diuretic called Lasix but the amount of fluid that could be
taken off was limited by your blood pressure. You will need to
continue diuretics as an outpatient.
2. The following changes were made to your medications:
CHANGE Amiodarone 200 mg by mouth daily x 10 days. Patient is
scheduled to follow-up with Dr. [**Last Name (STitle) **] (PCP) in 10 days, and
amiodarone dose will be adjusted as necessary then.
START Torsemdie 20 mg daily
CHANGE Metoprolol succinate (Toprol XL) 25 mg daily
START Salmeterol disukus twice daily
STOP Furosemide (lasix)
3. It is very important that you keep the appointments with your
doctors including Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
Followup Instructions:
You will be discharged to a rehab facility.
1. Please keep your appointment with your primary car doctor,
Dr. [**Last Name (STitle) **] on [**2119-7-27**] at 1:30 pm. His phone number is [**Telephone/Fax (1) 7728**].
His address is: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
|
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"585.3",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17584, 17658
|
8998, 15528
|
275, 367
|
17867, 17867
|
4026, 4026
|
18909, 19233
|
2520, 2728
|
15954, 17561
|
17679, 17846
|
15554, 15931
|
18043, 18886
|
8934, 8975
|
2768, 3473
|
210, 237
|
395, 1864
|
4042, 8918
|
17882, 18019
|
1886, 2281
|
2297, 2504
|
3498, 4007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,459
| 142,033
|
47911
|
Discharge summary
|
report
|
Admission Date: [**2124-5-5**] Discharge Date: [**2124-5-8**]
Date of Birth: [**2066-6-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Pulmonary Embolus
Major Surgical or Invasive Procedure:
Inferior vena cava filter placement.
History of Present Illness:
57 year old male with recent admission for dural AV fistulas
s/p embolization ([**4-18**] and [**4-21**]) and recent treatment for
pneumonia (bibasilar infiltrates on CTA) who presented to [**Hospital1 2519**] on [**5-4**] with calf pain and found to have bilateral LE
clots, pulmonary saddle embolus (bilateral) had 2 coil
embolizations and was transferred to [**Hospital1 18**] MICU on [**5-4**]
Past Medical History:
1. Left parietal intraparenchymal hemorrhage
2. Left Dural AV Fistulas x 2: Embolized at [**Hospital1 1774**] on [**2124-4-18**] and
[**2124-4-21**] by Dr [**Last Name (STitle) **] [**Name (STitle) **]. According to [**Hospital1 1774**] records they are
syncronous with one at left distal transverse sinus and proximal
left sigmoid sinus with cortical venous reflux toward left side
vein of [**Last Name (un) 70890**] and another at the left side skull base around the
foramen magnum level mainly supplied from the left ascending
pharyngeal [**Last Name (un) **] with cortical venous reflux.
3.Recent [**Hospital1 **]-basilar pna on levo/flagyl
4.Recent abdominal pain s/p exlap which was unrevealing within
last several days (admission [**Date range (3) 101093**])
5.dyslipidemia
6.elevated PSA
7.cervical radiculopathy
Social History:
lives alone in home in [**Hospital1 **], had been at rehab prior to this
admission follwoing his ICH. Denies any h/o tob/etoh/drug use.
Works as a music teacher.
Family History:
Father had lung ca. Mother had Gyn ca of some sort.
Physical Exam:
VS: T:98.6 BP: 104/68, HR: 84, RR: 20, 02 sat: 98%RA
Gen: Pleasant male, A&O x3, NAD
HEENT: PERRL, EOMI
CV: RRR, no murmur
Chest: CTAB, no wheezing, no crackles.
Abd: soft, NT ND BS+
Ext: no edema, no calf pain on palpation, DP's palpable
bilaterally. Upper extremities also no edema or pain.
Pertinent Results:
[**2124-5-5**] 01:05AM BLOOD WBC-11.8* RBC-3.98* Hgb-11.9* Hct-35.2*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.7 Plt Ct-152
[**2124-5-8**] 06:35AM BLOOD WBC-5.4 RBC-3.70* Hgb-11.3* Hct-32.6*
MCV-88 MCH-30.6 MCHC-34.8 RDW-13.8 Plt Ct-218
[**2124-5-5**] 01:05AM BLOOD PT-16.8* PTT-33.0 INR(PT)-1.5*
[**2124-5-8**] 06:35AM BLOOD Glucose-94 UreaN-8 Creat-0.9 Na-139 K-4.3
Cl-105 HCO3-25 AnGap-13
[**2124-5-5**] 01:05AM BLOOD ALT-76* AST-47* LD(LDH)-413* AlkPhos-82
TotBili-0.4
[**2124-5-5**] 01:05AM BLOOD Phenyto-3.3*
[**2124-5-7**] 08:15AM BLOOD Phenyto-13.2
.
STUDY: CTA of the head with and without contrast.
TECHNIQUE: Following a no contrast head CT, axial multidetector
CT images of
the head were obtained during the intravenous contrast
administration of
nonionic contrast material. Multiplanar two-dimensional
reformatted images
and volume-rendered three-dimensional reformatted images were
obtained.
COMPARISON: Prior CT of the head without contrast dated [**5-5**], [**2124**].
NON-CONTRAST HEAD CT: Again, left temporal and parietal
vasogenic edema and
effacement of the sulci is demonstrated. Areas of high density
likely
consistent with embolization material in a previously known and
reported
vascular malformation.
HEAD CTA: On the left temporal lobe, there is a subtle area of
thin
enhancement, measuring approximately 27.2 x 27.8 mm in size,
vasogenic edema
is demonstrated extending superiorly and producing effacement of
the sulci. No
frank evidence of vascular malformation is identified or
aneurysm. Normal
pattern of enhancement is demonstrated in major arterial
vascular structures.
There is no evidence of significant midline shifting or
deviation of the
normally midline structures. In the multiplanar two-dimensional
and volume-
rendered reformatted images, there is no evidence of vascular
stenosis or
flow-related abnormality, hypoplasia of the A1 segment on the
right is
demonstrated. No aneurysms are identified. The vertebrobasilar
system is
patent with dominance of the left vertebral artery. No vascular
malformation
is identified and the embolization cast is unchanged.
IMPRESSION: Persistent vasogenic edema with a faint and subtle
area of thin
ring enhancement identified on the left temporal lobe as
described above,
correlation with MRI and MRA is recommended for further
characterization.
.
INDICATION: DVT, assess for DVT in the bilateral upper
extremities.
COMPARISON: None available.
BILATERAL UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and color
Doppler
son[**Name (NI) 493**] images were obtained that demonstrate wall-to-wall
flow in the
right subclavian with normal response to respiration. There is a
nonocclusive
clot in the left subclavian which does not compress. The left
internal
jugular appears clear and demonstrates compression. There is
nonocclusive clot
in the left axilla, and one of the brachial veins. In the SCV
the clot is
more echogenic and retracted and in the more distal SVC and
axillary vein the
less echogenic material is wall-to-wall.
The right internal jugular, axillary, and both brachial
demonstrate wall-to-
wall flow with normal compression. The right cephalic and
basilic are patent.
IMPRESSION: Nonocclusive, likly subacute DVT of the left
subclavian vein
extending to the axillary and one of the brachial veins.
.
INDICATION: DVT on the left lower extremity, evaluate for one on
the right.
COMPARISON: None available.
PORTABLE RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: The left
common femoral
demonstrates low flow. On the right, there is normal response to
respiration.
The right common femoral, superficial femoral and popliteal
veins compress and
show wall-to-wall flow with normal response or augmentation.
Right calf veins
demonstrated.
IMPRESSION: No DVT of the right lower extremity.
Brief Hospital Course:
PATIENT initially presented to [**Hospital3 4107**] on [**5-4**] with calf
pain and found to have bilateral LE clots, pulmonary saddle
embolus (bilateral) had 2 coil embolizations and was transferred
to [**Hospital1 18**] MICU on [**5-4**]. In the ICU the patient remained HD stable
and had good 02 sats on room air. IVC filter placed yesterday
and following CTA head showed no new areas to intervene on.
Patient evaluated by neurosurgery and he was put on dilantin.
Prior to transfer to the floor the patient's dilantin level was
low, he received increased dose.
.
#Pulmonary Embolus/DVT: Per MICU team and neurosurgery, the risk
of anticoagulation given his recent intraparenchymal hemorrhage
outweights the benefit of anticoagulation for PEs. Patient
continued to sat well on room air. He was found to have a LUE
clot as well but per MICU no plans for SVC filter as clinically
insignificant.
-Hold aspirin, hold heparin SQ, absolutely no anticoagulation
for 1 month.
-f/u outpatient neurosurgery in 4 weeks.
-tylenol for pain.
.
#Recent left parietal intraparenchymal hemorrhage:likely [**2-21**]
vascular malformation with dural AVM's and aneurysm reported on
OSH CTA head/MRI. s/p embolization of dural AVM's x2. Dilantin
level low initially, given load in the MICU and now on increased
dose.
-continue dilantin (increased to 200 [**Hospital1 **])
.
Medications on Admission:
Baclofen 10 PO TID
Tylenol 650 prn
Vicodin prn
Dilantin 100 PO TID
Protonix 40
Levaquin 500 PO daily
Flagyl 500 PO Q8 hrs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Maximum dose 4 g daily.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left lower extremity and left upper extremity deep venous
thrombosis
Bilateral pulmonary emboli
Recent left parietal intraparenchymal hemorrhage tatus post AV
dural fistula embolization X 2 at [**Hospital3 2358**]
.
Secondary:
Dysplipidemia
History of cervical radiculopathy
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
You have been evaluated for your leg pain. You were found to
have a blood clot in the leg and in the arm as well as blood
clot that had travelled to the lungs. Due to your recent
neurosurgical procedures, you cannot take blood thinners for
these clots. You had a filter put in the inferior vena cava in
order to protect you from further blood clots travelling to the
lung.
.
You SHOULD NOT TAKE aspirin or ibuprofen for the next month due
to your recent neurosurgery. Please discuss this at your visit
with the Neurosurgeons in one month.
.
We increased your dilantin to 200 mg twice per day. Please
discuss your need for this medication at your [**Hospital 4695**]
clinic visit.
.
Please contact your primary care physician or return to the
emergency room should you develop any of the following symptoms:
fever > 101, chills, difficulty breathing, coughing up blood,
chest pain, increased leg pain or swelling, slurred speech,
numbness, tingling or weakness of either arm or leg, or any
other concerns.
Followup Instructions:
You can obtain a new primary care physician at [**Hospital **] at [**Hospital1 18**]. Please call our office at [**Telephone/Fax (1) 250**] to
make an appointment. You can make an appointment with Dr.
[**First Name (STitle) **] [**Name (STitle) **] or another male provider of your choice; it
would be ideal to be seen within the next 1-2 weeks.
.
Please contact your Neurosurgeon at the [**Hospital3 2358**] for a
follow up appointment within the next 3-4 weeks. If you prefer,
you can follow up with the Neurosurgery Department at [**Hospital1 18**]. To
follow up at [**Hospital1 18**], call the Neurosurgery Department at ([**Telephone/Fax (1) 18865**] to make a follow up appointment within the next [**3-22**]
weeks.
|
[
"453.40",
"437.3",
"V12.54",
"415.11",
"272.4",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"88.67",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8041, 8098
|
6018, 7376
|
331, 370
|
8417, 8467
|
2224, 3216
|
9520, 10245
|
1842, 1895
|
7549, 8018
|
8119, 8396
|
7402, 7526
|
8491, 9497
|
1910, 2205
|
274, 293
|
399, 798
|
3225, 5995
|
820, 1647
|
1663, 1826
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,110
| 186,231
|
44745
|
Discharge summary
|
report
|
Admission Date: [**2131-12-26**] Discharge Date: [**2132-1-29**]
Date of Birth: [**2077-2-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**12-27**]: Ex lap, no bowel/mesentery injuries, ? lymphatic injury.
[**12-28**]: ORIF T4, lami T3, T4, post fusion T2-6, L ICBG. No
hematoma.
[**12-31**]: IVC filter
[**12-27**]: Echo: EF 45%, 2+ MR, 2+ TR, 1+ AR
[**1-9**]: Tracheostomy
History of Present Illness:
54 yo male s/p fall from scaffolding, ~ 20ft. Reportedly walked
into referring hospital emergency room, confused. Rapidly
deteriorated and was intubated. Radiologic imaging at referring
hosptial revealed subdural and epidural hematomas. Patient was
then transported to [**Hospital1 18**] for continued trauma care. En route
patient intermittently hypotensive.
Past Medical History:
CAD s/p CABG
Hypertension
Social History:
Lives with wife
[**Name (NI) **] in [**Name (NI) 11150**]
Family History:
Noncontributory
Physical Exam:
VS upon admission to trauma bay:
98.6 HR 120 BP 122/61 99%
intubated/sedated on arrival
TM clear
+ R orbital ecchymosis
RRR
CTAB no crepitus
rectal
soft, NT, ND
+ 2 DP's B,
MAE UE> LE
Pertinent Results:
01/Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2132-1-20**] 05:05AM 12.7* 3.22* 9.7* 28.9* 90 30.1 33.6 15.1
380
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2132-1-15**] 03:56AM 73.1* 16.1* 7.1 3.3 0.4
RED CELL MORPHOLOGY Hypochr
[**2132-1-8**] 03:19AM 1+
ADDED DIFF [**2132-1-8**] 9:21AM
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2132-1-20**] 05:05AM 380
[**2132-1-20**] 05:05AM 13.11 27.4 1.1
1 NOTE NEW NORMAL RANGE AS OF 12:00AM [**2132-1-2**].;ABNORMAL
PROTHROMBIN TIME (PT) INCREASED DUE TO;LABORATORY CHANGE TO A
MORE SENSITIVE PT [**Name (NI) 25013**].;INR VALUES REMAIN THE SAME. MONITOR
WARFARIN BASED ON INR ONLY!
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2131-12-30**] 08:09AM 314
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2132-1-20**] 05:05AM 148* 16 0.7 134 4.4 98 251 15
1 NOTE UPDATED REFERENCE RANGE AS OF [**2131-6-8**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2132-1-7**] 08:00AM 42*1 51*1 132* 120* 0.5
Source: Line-arterial/SPECIMEN SLIGHTLY HEMOLYZED
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
OTHER ENZYMES & BILIRUBINS Lipase
[**2132-1-7**] 08:00AM 51
Source: Line-arterial/SPECIMEN SLIGHTLY HEMOLYZED
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2132-1-2**] 02:22AM 2 0.09*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2132-1-20**] 05:05AM 8.9 3.8 1.9
LIPID/CHOLESTEROL Cholest Triglyc
[**2131-12-27**] 02:37PM 214*1
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
ANTIBIOTICS Vanco
[**2132-1-9**] 08:36PM 14.2*
@Trough
NEUROPSYCHIATRIC Phenyto
[**2132-1-7**] 04:18AM 2.8*
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2131-12-26**] 05:30PM NEG NEG1 NEG NEG NEG NEG
TRAUMA
1 NEG
80 (THESE UNITS) = 0.08 (% BY WEIGHT)
LAB USE ONLY EDTA Ho HoldBLu
[**2131-12-30**] 01:58AM HOLD1
1 HOLD
DISCARD GREATER THAN 24 HRS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2132-1-15**] 04:57AM ART 30/ 40 88 38 7.48* 29 4
NOT INTUBA1
1 NOT INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2132-1-11**] 02:32AM 0.9
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2132-1-15**] 04:57AM 98
CALCIUM freeCa
[**2132-1-15**] 04:57AM 1.17
Miscellaneous
HEPARIN DEPENDENT ANTIBODIES
[**2131-12-30**] 05:28PM TEST
CHEST (PORTABLE AP) [**2132-1-22**] 9:20 PM
CHEST (PORTABLE AP)
Reason: r/o PNA. check trach position.
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with trach, reinserted after dislodgement.
copious secretions.
REASON FOR THIS EXAMINATION:
r/o PNA. check trach position.
CHEST, ONE VIEW, PORTABLE
INDICATION: 64-year-old man with tracheostomy secretion, rule
out pneumonia.
COMMENTS: Portable semi-erect AP radiograph of the chest is
reviewed, and compared with the previous study of [**2132-1-14**].
The tracheostomy tube is seen in place. There are fixation dots
overlying the upper thoracic spine. The patient has prior CABG
and median sternotomy.
The lungs are clear. The heart is normal in size.
IMPRESSION: No evidence for pneumonia.
CT CHEST W/CONTRAST [**2132-1-16**] 3:12 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: please do ct abd and pelvis with iv contrast r/o
abscess. Pt
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
54 year old man s/p fall, multiple fractures, VAP . Now with
persistent fever
REASON FOR THIS EXAMINATION:
please do ct abd and pelvis with iv contrast r/o abscess. Pt
with persistent fevers
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old man status post fall with multiple
fractures. Evaluate for persistent fever. Rule out abscess.
COMPARISON: CT torso [**2132-1-3**].
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were obtained with intravenous contrast. Multiplanar
reformations were performed.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Bilaterally there has been
an interval decrease in size of pleural effusions. The
previously seen bilateral patchy opacifications, predominantly
within the lower lobes are markedly reduced, suggesting
resolution of prior infectious process/aspiration pneumonia. The
mediastinum is unchanged, the patient is intubated with
tracheostomy. Multiple surgical clips are again noted along the
anterior mediastinum and anterior chest wall.
There is a small amount of perihepatic fluid. The liver is
otherwise unremarkable. The gallbladder, pancreas, spleen, right
adrenal gland, and kidneys are within normal limits. There is a
punctate low-attenuation lesion within the lower pole of the
right and left kidneys, too small to characterize. There is a
1.3 x 1.1 cms soft tissue density nodule within the left adrenal
gland. The small bowel and large bowel are unremarkable. A PEG
is in place within the stomach. No abscesses or focal fluid
collections are seen within the peritoneum. An IVC filter is
again noted in place.
CT PELVIS: The urinary bladder is catheterized and unremarkable.
The prostate, sigmoid colon are within normal limits. There is
no free fluid. There are no pathologically enlarged lymph nodes
within the abdomen and pelvis.
BONE WINDOWS: Within the left iliac bone adjacent to the SI
joint, there is a focal low-attenuation mass, likely
representing prior location of bone graft. Interval decrease in
attenuation of this lesion, suggests likely resolving hematoma,
however, cannot rule out infectious etiology. Spinal rods are
again noted in the upper thoracic spine.
IMPRESSION:
1. Interval reduction in bilateral pleural effusions with small
residual left pleural effusion.
2. Interval reduction in patchy airspace consolidation
bilaterally especially within the left lower lobe, suggesting
resolution of prior infectious etiology/aspiration pneumonia.
3. Small left adrenal nodule, unable to completely characterize,
due to lack of noncontrast exam.
4. Left iliac low-attenuation lesion, most likely site of bone
graft, now with interval decrease in attenuation, likely
resolving hematoma, cannot rule out infection.
CT ABDOMEN W/CONTRAST [**2132-1-16**] 3:12 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: please do ct abd and pelvis with iv contrast r/o
abscess. Pt
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
54 year old man s/p fall, multiple fractures, VAP . Now with
persistent fever
REASON FOR THIS EXAMINATION:
please do ct abd and pelvis with iv contrast r/o abscess. Pt
with persistent fevers
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old man status post fall with multiple
fractures. Evaluate for persistent fever. Rule out abscess.
COMPARISON: CT torso [**2132-1-3**].
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were obtained with intravenous contrast. Multiplanar
reformations were performed.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Bilaterally there has been
an interval decrease in size of pleural effusions. The
previously seen bilateral patchy opacifications, predominantly
within the lower lobes are markedly reduced, suggesting
resolution of prior infectious process/aspiration pneumonia. The
mediastinum is unchanged, the patient is intubated with
tracheostomy. Multiple surgical clips are again noted along the
anterior mediastinum and anterior chest wall.
There is a small amount of perihepatic fluid. The liver is
otherwise unremarkable. The gallbladder, pancreas, spleen, right
adrenal gland, and kidneys are within normal limits. There is a
punctate low-attenuation lesion within the lower pole of the
right and left kidneys, too small to characterize. There is a
1.3 x 1.1 cms soft tissue density nodule within the left adrenal
gland. The small bowel and large bowel are unremarkable. A PEG
is in place within the stomach. No abscesses or focal fluid
collections are seen within the peritoneum. An IVC filter is
again noted in place.
CT PELVIS: The urinary bladder is catheterized and unremarkable.
The prostate, sigmoid colon are within normal limits. There is
no free fluid. There are no pathologically enlarged lymph nodes
within the abdomen and pelvis.
BONE WINDOWS: Within the left iliac bone adjacent to the SI
joint, there is a focal low-attenuation mass, likely
representing prior location of bone graft. Interval decrease in
attenuation of this lesion, suggests likely resolving hematoma,
however, cannot rule out infectious etiology. Spinal rods are
again noted in the upper thoracic spine.
IMPRESSION:
1. Interval reduction in bilateral pleural effusions with small
residual left pleural effusion.
2. Interval reduction in patchy airspace consolidation
bilaterally especially within the left lower lobe, suggesting
resolution of prior infectious etiology/aspiration pneumonia.
3. Small left adrenal nodule, unable to completely characterize,
due to lack of noncontrast exam.
4. Left iliac low-attenuation lesion, most likely site of bone
graft, now with interval decrease in attenuation, likely
resolving hematoma, cannot rule out infection.
MR CERVICAL SPINE [**2131-12-30**] 1:11 PM
MR CERVICAL SPINE
Reason: ? spinal cord injury
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with worsening neurologic exam
REASON FOR THIS EXAMINATION:
? spinal cord injury
MRI SCAN OF THE CERVICAL SPINE
HISTORY: Worsening neurological exam. Assess for spinal cord
injury.
TECHNIQUE: Sagittal T1, T2, gradient echo, and STIR images of
the cervical spine were obtained with axial gradient echo scans
of the C2-3 through C7-T1 interspaces.
NOTE: This study was retrieved from the PACS system on [**2132-1-1**],
at which time it was immediately interpreted, with the findings
communicated by telephone to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], resident physician
caring for the patient.
FINDINGS: There is no evidence for cervical spinal cord
compression or abnormal signal within this portion of the spinal
cord. There is no evidence for subluxation of the component
vertebrae.
Since the prior examination, a moderate-sized upper cervical
retropharyngeal fluid collection has developed, extending from
the C1-2 articulation as far caudally as the C4-5 disc space.
Regarding the thoracic spine injury site, obviously this
cervical spine study was not optimized to cover this area in its
entirety. Additionally, the images are degraded due to extensive
metal artifact from the internal fixation device which appears
to consist of multiple pedicle screws, which upon review of
prior plain films obtained through intraoperative fluoroscopy,
appear to span the fracture site at T4. To more definitively
image this area, a focused, thin-section MRI scan could be
attempted, and if unsuccessful followup CT or CT myelography
could be considered.
CONCLUSION: No evidence for new cervical spine injury to account
for worsening neurological examination. Please see above report
for additional discussion and recommendations.
COMMENT: The intracanalicular hemorrhage seen within the
cervical region on the prior [**12-26**] study has subtotally
regressed.
Brief Hospital Course:
Patient was admitted to the Trauma Service.
Injuries: C6-T3 Spinous process fx, Trans. process fx C7, R 1st
rib fx, L nondisplaced occipital fx, Multiple intracranial
hemorrhages (including L frontal convexity/mid cranial
intracranial hemorrhage), Depressed R skull fx (4 mm), Skull
base fx sphenoid/clivus
The patient arrived to the Trauma SICU with hypotension, SBP
70-80's. Given his spinal cord injuries and questionable
compression, he was bolused with hydrocortisone and started on a
drip. The hypotension was thought to be due to spinal shock,
patient was resuscitated appropriately. His blood pressure
returned to [**Location 213**] and he was brought down to CT to evaluate his
abdomen for intra-abdominal bleed as the source of his
hypotension. The CT was negative and serial Hct were followed.
He required RBC, FFP, and cryo on admission. His Hct continued
to drop on HD2 and his lactate started to climb. Based on this,
the pt was brought to the OR for exploration. No
bowel/mesentery injuries were found, but there was a ? lymphatic
injury. Propofol drip was stopped secondary to a presumptive
diagnosis of propofol infusion syndrome given his rising
lactate/CK/Creatine. His laboratory values stabilized
thereafter on HD3.
On HD3, the pt was started on TF's which he tolerated throughout
his hospital stay. He had a Repeat head CT which showed stable
multiple intraparenchymal hemorrhages, epidural hematoma,
widened anterior CSF spaces.
In addition, he developed a small troponin leak post trauma
which was thought to be due to demand secondary to his initial
hypotension. His enzymes normalized and there was no evidence
of ECG changes. He was started on a beta blocker and aspirin
and underwent TTE which showed an EF 45%, 2+ MR, 2+ TR, 1+ AR.
Because of his spine injuries he was brought to the OR on
[**2131-12-28**] with Ortho Spine where he underwent an ORIF T4, lami T3,
T4, post fusion T2-6, L ICBG. No hematoma was observed.
On HD4, the pt spike a temperature and a CXR was obtained which
showed a new L retro cardiac opacity and B effusions.
Levofloxacin was started for GNR in sputum and new infiltrate.
On HD 5, the pt was brought to the vascular lab and had an IVC
filter placed for DVT prophylaxis and immobility. The pt
started spiking temperatures. His CVL's were DC'd for a line
holiday. A L SCL CVL was placed on [**1-4**]. The pt continues
spiking temperatures and a TEE was obtained and showed no
evidence of endocarditis. A tracheostomy was done [**1-9**].
Due to the persistent nature of the fevers, repeat CT scans were
obtained ([**1-16**]). The head CT revealed improvement of the sinus
collections (ENT reviewed these films), chest CT shows
improvement of the effusions and consolidation. There was no
evidence of abscess on abdominal CT. Repeat sputum cultures
grew staph aureus and we elected to not treat since we finished
a 14 course of vancomycin.
The patient was transferred to the floor on HD 24 and had
remained afebrile until [**1-24**] when he did spike a fever; he was
re cultured. His urine was negative; sputum with Staph Aureus
Coag positive; and final blood cultures are pending at time of
this dictation. His fever source likely sputum given the color,
amount and consistency of his sputum. He is currently being
treated with Vancomycin which will need to continue for 9 more
days. His last trough level on [**1-26**] was 15.0.
Speech and swallow has evaluated patient for Passy-Muir valve. A
bedside swallowing evaluation was performed on [**2132-1-28**],
recommendation by SLP are to keep patient NPO with tube feedings
for nutrition and hydration and to repeat bedside swallowing
evaluation in about 7 days to assess for improvement in
swallowing. Physical therapy and Occupational therapy have
worked with patient throughout his hospitalization nd have
recommended a rehab stay to improve function. Instructions have
been provided regarding patient's follow up with Orthopedic
Spine Surgery in the next 2-3 weeks. Patient will need to wear
the TLSO brace while out of bed.
Medications on Admission:
Unknown
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-10**]
Puffs Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
6. Milk of Magnesia 800 mg/5 mL Suspension Sig: [**12-10**] PO twice a
day as needed for constipation.
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
8. Sliding Scale Regular Insulin Sig: One (1) Subcutaneous
four times a day: Dose per sliding scale based on fingersticks
(see attached).
9. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 9 days.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR <55 and/or SBP<110.
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed: Swish and spit.
14. Neomycin-Bacitracin-Polymyxin Ointment Sig: One (1) Appl
Topical QID (4 times a day): Please apply to blister on
sternum.
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP <110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall ~20 ft
C6-T3 Spinous process fx, Trans. process fx C7
R 1st rib fx
L nondisplaced occipital fx
Multiple intracranial hemorrhages (including L frontal
convexity/mid cranial intracranial hemorrhage)
Depressed R skull fx (4 mm)
Skull base fx sphenoid/clivus
Discharge Condition:
Stable
Discharge Instructions:
HOB to be elevated at 30 degrees at all times for sinus
precautions.
You must continue to wear your cervical collar until you follow
up with Dr. [**Last Name (STitle) 95726**] in [**1-11**] weeks.
Please call physician if experiencing chest pain/shortness of
breath, dizziness, abdominal pain, nausea/vomiting, increasing
redness/drainage from the incision.
Follow up with Orthopedic Spine, Trauma and Neurosurgery as
instructed.
Followup Instructions:
Please follow up w/ Trauma clinic in 4 weeks, call [**Telephone/Fax (1) 6439**]
for an appointment.
Please follow up with Ortho Spine, Dr. [**Last Name (STitle) 95727**], in [**1-11**] weeks,
call [**Telephone/Fax (1) 3573**] for an appointment
Please follow up with Neurosurgery in 4 weeks, call [**Telephone/Fax (1) 1669**]
for an appointment; inform the office that you will need a
followup head CT scan for this appointment
Completed by:[**2132-1-29**]
|
[
"806.05",
"286.9",
"E881.1",
"803.21",
"482.41",
"806.20",
"V45.81",
"861.21",
"518.5",
"414.8",
"807.01",
"868.03",
"401.9",
"V45.82",
"802.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"88.72",
"03.53",
"54.11",
"96.6",
"43.19",
"99.07",
"96.72",
"99.05",
"81.05",
"31.1",
"81.63",
"38.93",
"38.7",
"99.04",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
18368, 18438
|
12703, 16767
|
324, 567
|
18746, 18754
|
1340, 4136
|
19236, 19697
|
1097, 1114
|
16827, 18345
|
10778, 10825
|
18459, 18725
|
16793, 16802
|
18778, 19213
|
1129, 1321
|
276, 286
|
10854, 12680
|
595, 956
|
978, 1006
|
1022, 1081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
240
| 159,468
|
22139
|
Discharge summary
|
report
|
Admission Date: [**2144-8-5**] Discharge Date: [**2144-8-13**]
Date of Birth: [**2087-8-25**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Sulfa (Sulfonamides) / Epinephrine
Attending:[**Location (un) 1279**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**Hospital1 **]-V/ICD Left Lead Placement Adjustment
History of Present Illness:
56F h/o HTN, LBBB, Card Cath WNL ([**3-29**]), post-viral
Cardiomyopathy (of 10 yrs; EF=20%) s/p [**Hospital1 **]-V/ICD Pacer ([**2144-7-20**])
and surgical LV lead placement, RV lead revision on [**2144-8-5**].
Reportedly tolearted procedure well and was extubated on
[**2144-8-6**]. Placed on Keflex for periprocedural PPx. After
extubation, pt complained of pleuritic substernal chest pain rad
to right lower chest, SOB, DOE, occ cough, and one episode of
hemoptysis (<1tsp bld w/ mucous). Of note, there was reported
laryngeal injury during intubation. She reported subjective
fevers (but had been on Ibuprofen/Percocet; no objective fevers)
and malaise.
ROS: "hot flashes," had mild epigastric pain, had mild nausea
w/o vomiting. Last BM [**2-27**] prior. Had gas.
Past Medical History:
1) Post-Viral Cardiomyopathy (of 10 yrs; EF=20%)
2) s/p [**Hospital1 **]-V/ICD Pacer ([**2144-7-20**]) and L Lead Adjustment on
[**2144-8-5**].
2) HTN
3) LBBB
4) OSA on CPAP
5) Fibromyalgia
6) Depression
7) Recurrent UTIs
8) Tonsillectomy
Cardiac Cath ([**3-29**]): No CAD.
Social History:
Works as dental office manager. Lives with parents, of whom she
takes care of her father. Divorced. [**Name2 (NI) **] illegal drugs or tobacco.
Rare ETOH.
Family History:
Mom81 - s/p CABG/AVR. Dad88 - ESRD/HD, DM.
Physical Exam:
T98.4 BP94/50 HR79 RR20 OS96%3L
GEN - NAD
HEENT - OP CLEAR, ANICTERIC.
PULM - DECR BS AT L>R; BASES WITH FAINT BIBAS CRACKLES.
CV - RRR, NO M/G/R.
ABD - S/NT/ND, NO HSM.
EXT - NO PITTING EDEMA, BUT L>R ASYMMETRY AND SWOLLEN APPEARANCE
OF BOTH LEGS. 1+ DPs.
NEURO - A&OX3. PERRL. EOMI.
Pertinent Results:
[**2144-8-5**] 06:59PM TYPE-ART RATES-10/0 TIDAL VOL-600 PEEP-5
O2-50 PO2-150* PCO2-51* PH-7.39 TOTAL CO2-32* BASE XS-5
INTUBATED-INTUBATED VENT-IMV
[**2144-8-5**] 06:59PM GLUCOSE-116* K+-4.1
[**2144-8-5**] 06:59PM HGB-10.7* calcHCT-32 O2 SAT-99
[**2144-8-5**] 01:07PM TYPE-ART PO2-295* PCO2-46* PH-7.43 TOTAL
CO2-32* BASE XS-5
[**2144-8-5**] 01:07PM GLUCOSE-127* NA+-138 K+-3.3* CL--103
[**2144-8-5**] 01:07PM freeCa-1.18
[**2144-8-5**] 12:47PM GLUCOSE-122* UREA N-24* CREAT-0.8 SODIUM-143
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2144-8-5**] 12:47PM WBC-10.6# RBC-3.14* HGB-10.1* HCT-27.5*
MCV-87 MCH-32.0 MCHC-36.6* RDW-14.2
[**2144-8-5**] 12:47PM PLT COUNT-177
[**2144-8-5**] 12:47PM PT-13.8* PTT-28.3 INR(PT)-1.2
[**2144-8-5**] 09:22AM TYPE-ART RATES-8/ TIDAL VOL-800 PO2-342*
PCO2-49* PH-7.39 TOTAL CO2-31* BASE XS-4 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2144-8-5**] 09:22AM GLUCOSE-90 NA+-140 K+-4.0
[**2144-8-5**] 09:22AM HGB-10.1* calcHCT-30
[**2144-8-5**] 09:22AM freeCa-1.15
[**2144-8-11**] 06:30AM BLOOD WBC-8.7 RBC-3.99* Hgb-12.6 Hct-36.1
MCV-91 MCH-31.5 MCHC-34.8 RDW-13.9 Plt Ct-314
[**2144-8-11**] 09:10PM BLOOD UreaN-46* Creat-1.8*
[**2144-8-11**] 06:30AM BLOOD Glucose-96 UreaN-35* Creat-1.3* Na-144
K-4.5 Cl-98 HCO3-35* AnGap-16
[**2144-8-10**] 09:40PM BLOOD UreaN-33* Creat-1.4* Na-145 K-4.5
[**2144-8-10**] 06:20AM BLOOD Glucose-103 UreaN-29* Creat-1.1 Na-146*
K-4.2 Cl-97 HCO3-34* AnGap-19
[**2144-8-6**] 09:26AM BLOOD Type-ART pO2-92 pCO2-52* pH-7.36
calHCO3-31* Base XS-2
[**2144-8-6**] 10:29AM BLOOD Type-ART pO2-95 pCO2-49* pH-7.38
calHCO3-30 Base XS-2
Brief Hospital Course:
Mrs. [**Known lastname 2643**] was admitted to [**Hospital Unit Name 196**] s/p [**Hospital1 **]-V/ICD Pacer placement
([**2144-7-20**]) and L Lead Adjustment on [**2144-8-5**] to evaluate her
SOB/decr OS and pleuritic chest pain/chest tenderness which were
deemed likely related to CHF/L Pleural Effusion (vs Atelectasis)
and with pain from surgery, respectively.
1. DOE/CHF. Upon transfer to [**Hospital Unit Name 196**], the patient had SOB, which
was mainly exertion (comfortable at rest, but was very
fatigued). Initialy, her O2 requirement was 3-4L to maintain
OS>93: Likely CHF-related along with possible left pleural
effusion (vs. atelectasis). CXR was read as 'large left pleural
effusion.' Of note, the loudness of her voice was diminished
upon transfer, presumed seconday to laryngeal injury during
intubation. Over the course of her hospital stay, her exercise
tolerance, dyspnea, and energy level improved with diuresis
(Lasix PO and IV) along with incentive spirometry and physical
therapy. Her voice quality was drastically improved by
discharge. The procedure team saw the patient on [**8-10**] to eval
for possible therapeutic thoracentesis, but felt the CXR along
with U/S + exam findings were more consistent with atelectasis
and not effusion. Thus, there was no intervention. Pt had mild
O2 requirement on DC and was sent home with VNA and home O2
(93-94% on 1-2L; 89%-93% on RA). Her CHF drug regimen included
Carvedilol 12.5 mg PO BID, Digoxin 0.125 mg PO QD, Losartan
Potassium 75 mg PO QD, along with Lasix 60-80mg daily and
Spironolactone 25 mg PO QD, which were both held on her day of
DC secondary to rising creatinine (1.8 from 1.3). The patient
was encouraged to ambulate as well as to use her IS. She was
seen by PT.
2. Acute Renal Insufficiency. Likely prerenal after diuresis.
Held meds as above and rechecked Cr: trended down to 1.1 on day
of DC.
3. Chest Tenderness/Pain. Pt was tender near incision site and
initially had chest pain with breathing. Chest tenderness was
secondary to CT surgical procedure. It was well controlled with
Ibuprofen 400-600 mg q6-8h. She was also on Oxycodone PRN and
Cyclobenzaprine HCl 5 mg PO QD and again, encouraged ambulation,
IS, and PT. Her pleurisy and chest pain/tenderness all had
drastically improved upon DC.
4. HTN. SBPs 90s-110s. Appeared to be normotensive to
hypervolemic, yet had somewhat low SBPs, but stable. We
continued Carvedilol 12.5 mg PO BID, Digoxin 0.125 mg PO QD,
Losartan Potassium 50 mg PO QD, and Spironolactone 25 mg PO QD.
5. Anemia. HCT was 28.6-28.7 upon transfer; Pt was transfused 1U
PRBC on [**2144-8-9**] to allievate her symptoms in face of CHF. Her
HCT then rose to >35 and remained at that level for the
remainder of her hospital course. The etiology of the anemia was
unclear, although it may have been peri-operative. Fe studies
showed low iron, high ferritin and nml TIBC (low end of nml):
thus, likely inflammation in setting of Fe-deficiency anemia.
6. Depression/Anxiety. Continued Escitalopram Oxalate 20 mg PO
QD.
7. FEN. Low salt/Heart healthy diet.
8. PPx. Colace, Senna, Lactulose. SQ Heparin. Pantoprazole 40 mg
PO Q24H (used PPI because of Ibuprofen use and recent epigastric
pain).
9. Code. Full.
10. Dispo. DCed to home with VNA and home O2.
Medications on Admission:
Transfer Meds:
Losartan 50mg [**Hospital1 **], Carvedilol 12.5 mg [**Hospital1 **], SQ Heparin 5000 units
[**Hospital1 **], Spironolactone 25mg [**Hospital1 **], Escitalopram 20mg daily, Digoxin
12.5mg daily, Cyclobenzaprine 5mg daily, Tylenol PM, Percocet
PRN, Ranitidine 150mg [**Hospital1 **], Ibuprofen 400 q6h
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*0*
2. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Cyclobenzaprine HCl 10 mg Tablet Sig: 0.5 Tablet PO QD (once
a day).
Disp:*15 Tablet(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Losartan Potassium 25 mg Tablet Sig: Three (3) Tablet PO QD
(once a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1) Post-Viral Cardiomyopathy (of 10 yrs; EF=20%)
2) s/p [**Hospital1 **]-V/ICD Pacer ([**2144-7-20**]) and L Lead Adjustment on
[**2144-8-5**].
2) HTN
3) LBBB
4) OSA on CPAP
5) Fibromyalgia
6) Depression
7) Recurrent UTIs
8) Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as prescribed. Furosemide
(Lasix) has been added to your regimen. Your losartan (Cozaar)
dose has been changed to 75 mg PO QD.
Please weigh yourself daily. If you gain more than 3 lbs, call
your cardiologist.
Pleasy notify your physician if you have any worsening chest
pain, shortness of breath, fevers, chills, or any other
concerning symptoms.
Followup Instructions:
1) Primary care: Please see your primary care physician
([**Doctor Last Name **],[**Doctor First Name 57825**] [**Telephone/Fax (1) 22984**]) within the next 1-2 weeks.
2) Please call to schedule an appointment with your cardiologist
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**] ([**Telephone/Fax (1) 57826**]) or Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**]
([**Telephone/Fax (1) 6256**]) to be seen within 1 week following discharge.
Your electrolytes (K/Na) and renal function (BUN/Cr) should be
checked at this visit to ensure that they are stable. At time of
discharge, your creatinine was 1.1.
|
[
"464.51",
"593.9",
"428.0",
"425.4",
"401.9",
"285.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"33.23",
"00.51"
] |
icd9pcs
|
[
[
[]
]
] |
8741, 8790
|
3684, 6960
|
331, 386
|
9073, 9079
|
2036, 3661
|
9509, 10175
|
1672, 1716
|
7325, 8718
|
8811, 9052
|
6986, 7302
|
9103, 9486
|
1731, 2017
|
272, 293
|
414, 1186
|
1208, 1484
|
1500, 1656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,344
| 165,369
|
42171
|
Discharge summary
|
report
|
Admission Date: [**2145-12-3**] Discharge Date: [**2145-12-10**]
Date of Birth: [**2122-7-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Nausea/Vomiting/Diarrhea/Fever
Major Surgical or Invasive Procedure:
transesophageal echocardiogram
History of Present Illness:
23M, ho Aortic Valve/pulmonic valve replacement ([**Doctor Last Name **] procedure)
at age 12, presented with 3 days of GI symptoms with fever and
chill. Pt reported that three days prior to admission, he felt
nausea and had several nonbloody / nonbilious emesis. He
subsequently developed diarrhea, which was watery but
non-bloody. Diarrhea persisted for two days, but has waned down
today. He also complained of headache, that started after
emesis, which primarily located in the neck/occipital region,
described as throbbing ([**8-22**]), positional. The headache is
better now. Pt had subjective fever with chills in the past
three days, and has not been able to tolerate much po other than
water. He also felt unsteady while walking. Pt denies
photophobia, chest pain, shortness breath, cough, sore throat,
sneezing, abdominal pain at rest or new rash. Pt was on a bus
tour to [**Country 6607**] over the weekend, and had many seafood, but
otherwise no recent travel history. Pt did not recall any other
unusual food intake prior to the illness. Pt had a dental
procedure in [**Month (only) 547**], but he had antibiotics for that.
.
In the ED, initial VS were: 102.6 118 98/63 16 100% RA. The
patient underwent an LP, which showed WBC 3, poly 36, lymphs 25,
monos 39. His SBP dropped to 80s in the ED. He received 4 L
NS, right IJ was placed, and levophed was started. Pt also
received vancomycin, ceftriaxone, gentamycin and Oseltamivir.
.
On arrival to the MICU, pt's VS were 100.6, 110, 112/63, 22, 97%
on RA.
Past Medical History:
Aortic valve calcification s/p balloon angioplasty &
bioprosthetic aortic valve replacement ([**Doctor Last Name **] procedure) [**3-17**]
bicuspid aortic valve
Social History:
Pt came to US 4 months ago from [**Country 26232**] to work in a lab at
[**Hospital3 **]. Pt works on a melanoma research project
that deals with fish. Pt lives in an apartment in [**Location (un) **] by
himself. He is current not in a relationship and not sexually
active.
Pt denies smoking or iv/illicit drug use. He is a social
drinker, and last alcohol consumption was three weeks ago.
Family History:
Prostate cancer in grandfather, no [**Name2 (NI) **] hematologic malignancy,
heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.2 BP: 96/55 P: 77 R: 16 O2: 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera mildly icteric, dry oral mucosa, oropharynx clear,
EOMI, PERRL, petichiae on the soft palate
Neck: supple, JVP not elevated, no LAD, no tenderness over
occipital or neck
CV: Regular rate and rhythm, [**4-18**] crescendo/decrescendo murmur
throughout the precordium
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, RUQ tenderness with ? [**Doctor Last Name **]
sign, (no resting tenderness), no rebound, guarding, bowel
sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.7 BP: 92/56 P: 82 R: 18 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, no o/p lesions, no mucosal
petechiae
Neck: supple, JVP not elevated, no LAD, no tenderness over
occipital or neck
CV: Regular rate and rhythm, 3/6 systolic murmur throughout the
precordium
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, non-tender
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
ADMISSION LABS:
[**2145-12-3**] 11:55AM BLOOD WBC-8.2 RBC-4.79 Hgb-14.8 Hct-45 MCV-88
MCH-30.8 MCHC-35.1* RDW-11.9 Plt Ct-24*
[**2145-12-3**] 11:55AM BLOOD Neuts-92.4* Lymphs-5.0* Monos-2.5 Eos-0
Baso-0.1
[**2145-12-3**] 11:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
Burr-OCCASIONAL
[**2145-12-3**] 02:42PM BLOOD PT-13.0 PTT-30.4 INR(PT)-1.1
[**2145-12-3**] 02:42PM BLOOD Fibrino-1214*
[**2145-12-3**] 06:25PM BLOOD Parst S-NEG
[**2145-12-4**] 05:50PM BLOOD Parst S-NEG
[**2145-12-5**] 06:00AM BLOOD Parst S-NEGATIVE
[**2145-12-3**] 06:25PM BLOOD Ret Aut-0.8*
[**2145-12-3**] 11:55AM BLOOD Glucose-123* UreaN-42* Creat-1.5* Na-130*
K-3.5 Cl-94* HCO3-25 AnGap-15
[**2145-12-3**] 11:55AM BLOOD ALT-16 AST-17 LD(LDH)-201 AlkPhos-95
TotBili-2.4* DirBili-0.7* IndBili-1.7
[**2145-12-3**] 11:55AM BLOOD Lipase-19
[**2145-12-4**] 03:35AM BLOOD CK-MB-1 cTropnT-<0.01
[**2145-12-3**] 06:25PM BLOOD Calcium-7.0* Phos-0.8* Mg-1.4*
[**2145-12-3**] 11:55AM BLOOD Hapto-267*
[**2145-12-3**] 06:25PM BLOOD Ferritn-1005*
[**2145-12-3**] 06:25PM BLOOD HIV Ab-NEGATIVE
[**2145-12-3**] 02:42PM BLOOD Type-MIX pO2-54* pCO2-30* pH-7.39
calTCO2-19* Base XS--5 Comment-GREEN TOP
[**2145-12-3**] 12:15PM BLOOD Lactate-2.4*
[**2145-12-3**] 02:42PM BLOOD Lactate-1.3
[**2145-12-3**] 02:42PM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-86
PERTINENT INTERVAL LABS:
[**2145-12-5**] 06:00AM BLOOD Fibrino-588*#
[**2145-12-5**] 06:00AM BLOOD Ret Aut-0.3*
[**2145-12-4**] 03:35AM BLOOD ALT-71* AST-75* LD(LDH)-144 AlkPhos-65
TotBili-3.1* DirBili-2.7* IndBili-0.4
[**2145-12-5**] 06:00AM BLOOD ALT-42* AST-23 AlkPhos-55 Amylase-27
TotBili-2.1* DirBili-1.3* IndBili-0.8
[**2145-12-5**] 06:00AM BLOOD Lipase-33
[**2145-12-5**] 06:00AM BLOOD calTIBC-159* Ferritn-515* TRF-122*
[**2145-12-5**] 06:00AM BLOOD Triglyc-269*
[**2145-12-4**] 03:35AM BLOOD Cortsol-15.9
[**2145-12-4**] 03:35AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2145-12-3**] 06:25PM BLOOD HIV Ab-NEGATIVE
DISCHARGE LABS:
[**2145-12-10**] 05:11AM BLOOD WBC-10.3 RBC-3.83* Hgb-12.2* Hct-35.1*
MCV-92 MCH-31.9 MCHC-34.8 RDW-12.9 Plt Ct-240
[**2145-12-10**] 05:11AM BLOOD Neuts-79* Bands-0 Lymphs-11* Monos-6
Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2145-12-10**] 05:11AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-133
K-4.5 Cl-99 HCO3-27 AnGap-12
[**2145-12-10**] 05:11AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
URINE:
[**2145-12-4**] 12:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2145-12-4**] 12:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-5.5 Leuks-NEG
[**2145-12-4**] 12:00AM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
[**2145-12-4**] 12:00AM URINE CastGr-3*
CSF:
ANALYSIS WBC RBC Polys Lymphs Monos
[**2145-12-3**] 12:36 31 02 36 25 39
TUBE#4
CLEAR AND COLORLESS
TUBE #1 NOT COUNTED
Chemistry
CHEMISTRY TotProt Glucose
[**2145-12-3**] 12:36 35 69
MICRO:
Positive blood cultures from 2 bottles from ED and one [**Hospital1 **]
collection on [**12-3**]. All other subsequent surveillance blood
cultures NGTD.
Blood Culture, Routine (Preliminary):
THIS IS A CORRECTED REPORT [**2145-12-9**].
Reported to and read back by DR. [**Last Name (STitle) **] ([**Numeric Identifier 91464**]) 2:20PM
[**2145-12-9**].
HAEMOPHILUS PARAINFLUENZAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
333-1490V
[**2145-12-3**]. PRESUMPTIVE IDENTIFICATION.
IDENTIFICATION BEING CONFIRMED.
PREVIOUSLY REPORTED AS HAEMOPHILUS INFLUENZAE [**2145-12-7**].
Negative influenza, lyme, MRSA. Positive IgG CMV and EBV
(negative for IgM). Negative legionella urinary antigen.
Negative urine cx. Negative anaplasma, leptospira and RMSF
serologies.
FECAL CULTURE (Final [**2145-12-7**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2145-12-7**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2145-12-6**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2145-12-7**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2145-12-7**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2145-12-7**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-12-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
RADIOLOGY:
TEE [**12-8**]:
IMPRESSION: Poorly visualized pulmonic prosthesis with pulmonic
regurgitation. No mass or vegetation seen on mitral, tricuspid
or aortic valves. Dilated right ventricle with preserved
systolic function. Moderately dilated aortic root with a trivial
amount of central aortic regurgitation.
MRCP [**12-4**]:
IMPRESSION:
1. Contracted gallbladder with mild pericholecystic fluid,
likely related to third spacing. No gallbladder wall thickening
identified.
2. Trace intra-abdominal ascites, stable in volume since prior
CT examination.
3. Bilateral lower lobe atelectasis and bilateral pleural
effusions.
CTA Chest [**12-4**]:
1. No pulmonary embolus detected to the subsegmental levels.
2. No dissection.
3. Small bilateral pleural effusions with adjacent compressive
atelectasis. Areas of ground-glass and tree-in-[**Male First Name (un) 239**] opacities of
the right upper, middle, and bilateral lower lobes may represent
an atypical pneumonia.
4. Splenomegaly.
5. Moderate amount of intrapelvic free fluid, however no acute
intra-abdominal or intrapelvic processes detected. The appendix
is not
visualized.
TT ECHO [**12-4**]:
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. The right ventricular cavity is
dilated with borderline normal free wall function. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic valve leaflets appear normal.The transaortic
gradient is normal for this prosthesis. No masses or vegetations
are seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. An eccentric, posteriorly directed
jet of mild to moderate ([**2-14**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. No masses or vegetations
are seen on the pulmonic valve, but cannot be fully excluded due
to suboptimal image quality. A pulmonic valve bioprosthesis is
suggested. The pulmonic prosthesis is abnormal with thickened
leaflets and mildly increased gradients. No pulmonic valve
vegetation is seen. Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
RUQ US [**12-3**]:
IMPRESSION:
1. Mild intrahepatic biliary duct dilation without common bile
duct dilation. MRCP is recommended for further evaluation.
2. Nondistended gallbladder with severe gallbladder wall
thickening. This
could be due to underlying hepatic dysfunction such as in the
setting of
hepatitis and correlation with LFTs is recommended. Third
spacing could also cause a similar appearance. This appearance
would not be compatible with acute cholecystitis.
3. Splenomegaly.
Brief Hospital Course:
===========================
BRIEF HOSPITAL SUMMARY
===========================
Mr. [**Last Name (Titles) **] [**Last Name (Prefixes) **] is a 23M w/ hx sig for bicuspid aortic valve s/p
[**Doctor Last Name **] procedure over a decade ago (non-native aortic and pulmonic
valves) who presented in septic shock, found to have H.
parainflunza bacteremia and likely prosthetic valve endocarditis
(pulmonic) in the setting of a new pulmonic valve regurgitation.
The patient stabilized and was discharged on 6 weeks of
antibiotics (ceftriaxone) with ID and cardiology follow-up.
============================
ACTIVE ISSUES
============================
# # H. influenza sepsis / prosthetic valve endocarditis: Pt
initially presented w/ fever to 102, GI symptoms and generalized
ill feeling. In the ED, the patient underwent an LP, which
showed WBC 3, poly 36, lymphs 25, monos 39. His SBP dropped to
80s in the ED. He received 4 L NS, right IJ was placed, and
levophed was started. Pt was admitted to the MICU, where he was
started on vancomycin, zosyn, and doxycycline. He had a RUQ US
which showed mild intrahepatic biliary duct dilation without
common bile duct dilation. ID was consulted and they recommended
recommended CT torso, parasite smears x 3, stool cultures
(smears and stool negative). He had an MRCP, which was largely
unremarkable. Urine legionella antigen, lyme serology and
ehrlichiosis serology were all sent out in addition to EBV, CMV,
and HIV, all of which were negative (EBV/CMV IgG pos, but not
IgM). An ECHO was done out of concern for endocarditis and it
showed a preserved ejection fraction (>55%) and no vegetations.
He had a CT torso which showed no PE, no dissection, small
bilateral pleural effusions, splenomegaly and moderate
intrapelvic free fluid but with no intra-abdominal or
intrapelvic process. Over the course of his stay in the MICU,
his clinical symptoms improved. The patient then was transferred
to the floor, had a second TTE that again showed no vegetations
but significant pulmonic regurgitation. The patient's primary
cardiologist was contact[**Name (NI) **] in the [**Country 26232**], Mrs.[**Last Name (STitle) **]. [**Last Name (STitle) **].S.
Hoendermis. She confirmed the patient's condition and that the
patient had never had significant PR on prior echos. Blood
cultures from the ED grew originally H. influenza that were then
classified as H. parainfluenza. Pt transiently had shortness of
breath that resolved throughout the hospital stay (likely [**3-17**]
large infusion of IVFs to stabilize pt initially). Over the
course of the hospitalization, no further e/o organisms on
surveillance cxs. The patient's antibiotics were narrowed to IV
ceftriaxone for presumptive pulmonic valve endocarditis. A TEE
was unable to visualize the PV well. A PICC was placed and the
patient will complete a 6 week course of ceftriaxone (2g q24hrs)
(day 1 ceftriaxone = [**12-7**]). While hospitalized, we appreciated
the recommendations of our ID and cardiology colleagues. The pt
will f/u in [**Hospital 4898**] clinic for abx surveillance and in cardiology
clinic upon completion of abx.
.
# Thrombocytopenia: pt's initial platelets were only 13.
Heme-onc was consulted in the ICU, reviewed his smears, and
agreed to wait to further trend the platelets. The platelets
slowly rose to over 200 by time of discharge. It is likely this
could have been secondary to bone marrow suppression while the
patient was in septic shock.
.
# [**Last Name (un) **]: Pt presented w/ Cr 1.5, most likely prerenal secondary to
dehydration. Improved to 0.8 on discharge with rehydration.
.
# Dyspnea: see above, likely [**3-17**] third spacing/pulmonary edema
[**3-17**] aggressive fluid rehydration while in septic shock.
Resolved without intervention in the course of 48 hrs.
.
#NSVT: 20 beat run of VT, with some palpitations in the middle
of hospital stay, isolated. Pt has had palpitations before in
life. [**Month (only) 116**] be from underlying structural abnl in setting of
transposition/valve replacements, vs. electrolyte abnl. None in
past 72 hours prior to discharge. We appreciated our
cardiologist's input and repleted electrolytes to K>4 and Mg>2.
.
LFTs Elevated: Very mild ALT/AST and tbili elevation. mild
intrahepatic biliary duct dilation on US. Resolved by discharge.
=========================
INACTIVE ISSUES
=========================
NONE
=========================
TRANSITIONAL ISSUES
=========================
1. F/u in [**Hospital 4898**] clinic [**12-24**]. Pt has scripts for outpt lab work.
2. F/u with cardiology [**1-13**]. Pt should get echo prior to visit.
3. Pt should get record (CD) of echos from cards at cardiology
appt [**1-13**] to take back to [**Country 26232**].
Medications on Admission:
none
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
2. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) dose Intravenous Q24H (every 24 hours) for 6 weeks: Six
weeks starting from [**12-7**].
Disp:*42 dose* Refills:*0*
3. Outpatient Lab Work
CBC w/ differential, BMP, LFTs each week, and fax to
[**Telephone/Fax (1) 1419**] (ID outpatient office).
Discharge Disposition:
Home With Service
Facility:
Home soulutions
Discharge Diagnosis:
Primary diagnoses:
H. influenza septic shock
prosthetic valve endocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) **] [**Last Name (Prefixes) **],
It was a pleasure taking care of you. You were admitted to the
hospital for fevers, nausea, vomiting which was the result of
bacteria in your blood. You initially had a low blood pressure
and were stabilized in the medical ICU, and then were taken care
of on the general medicine [**Hospital1 **]. We were able to identify the
bacteria, and have tailored our antibiotics to this organism.
You had three echocardiograms while you were in the hospital,
and they demonstrated that there was some decreased function of
your pulmonic valve. It is probable that this is endocarditis,
which is an infection of your valve. We are treating you with
intravenous antibiotics for a six week course. You will have
support at home for the IV antibiotics.
Fortunately, your shortness of breath and your low platelets
resolved while you were in the hospital.
You will be followed in approximately five weeks in the
outpatient cardiology clinic. Please call the cardiology office
and have them schedule an echocardiogram to be performed before
this appointment. You will also be followed by the infectious
disease specialists.
Medications:
- ADD ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback.
One (1) dose Intravenous Q24H (every 24 hours) for 6 weeks: Six
weeks starting from [**12-7**]. Final dose will be [**2146-1-18**].
- CONTINUE all other medications as you had previously been
taking.
Followup Instructions:
You should call the number below to have an echocardiogram
scheduled for the last week of [**Month (only) **] (done before your
cardiologist's appt).
Department: CARDIAC SERVICES
When: THURSDAY [**2146-1-13**] at 9:00 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
Department: INFECTIOUS DISEASE
When: FRIDAY [**2145-12-24**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2146-1-13**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"427.1",
"E878.1",
"996.61",
"995.92",
"038.41",
"287.5",
"785.52",
"584.9",
"284.19",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"03.31",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
17299, 17345
|
12044, 16785
|
336, 369
|
17464, 17464
|
4129, 4129
|
19101, 20126
|
2541, 2633
|
16840, 17276
|
17366, 17443
|
16811, 16817
|
17615, 19078
|
6162, 7264
|
2648, 4110
|
7308, 12021
|
266, 298
|
397, 1932
|
4145, 6146
|
17479, 17591
|
1954, 2116
|
2132, 2525
|
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