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22,020
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5562
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Discharge summary
|
report
|
Admission Date: [**2144-2-26**] Discharge Date: [**2144-3-10**]
Date of Birth: [**2072-12-5**] Sex: F
Service: MEDICINE
Allergies:
Cardizem / Codeine / Optiray 300 / Heparin Agents
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 71 yo female with h/o CAD s/p CABG '[**38**], recent
hospitalization from [**Date range (1) 22383**] for UTI and CHF exacerbation, who
presents again with shortness of breath similar to previous
presention. Pt was discharged on Lasix and followed up with her
PCP, [**Name10 (NameIs) 1023**] noted that the patient had lost 8 pounds and Cr had
bumped from 2.0 -> 2.6. Her lasix was held and pt now presents
again with progressive shortness of breath. It got very bad this
AM with associated substernal chest discomfort that felt like a
pressure, and she was brought into the ED.
.
In the ED, a CXR was taken which shows pulmonary edema, but
could not exclude underlying pneumonia. EKG at the time showed
TWIs in I/aVL and ST depressions in V5-V6, only the TWI in I
being new. Initial enzymes negative x1. She was given 100 mg IV
Lasix, put out 1L, felt much better and transferred to the
floor.
.
On the floor, she notes that she has had a dry cough, feels like
there's something to bring up but cannot. No fever/chills/NS. No
chest pain currently, only mildly short of breath. She has 2
pillow orthopnea at baseline, no PND.
.
Pt also notes chronic left anterior thigh pain, for which she
has had some relief with gabapentin. Opiates were initially
tried, but she developed severe nausea/vomiting and
constipation.
.
ROS:
(+) Rhinorhea on and off for 1 year.
(-) Denies headache, sinus tenderness, or congestion. Denied
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. CAD s/p CABG in [**2138**] - Followed by Dr. [**Last Name (STitle) **]
- MI in [**2122**]
- CABG [**2138**] = LIMA-->LAD, VG-->OM, VG--->RCA
- Exercise MIBI ([**3-2**]): Interval development of moderate,
reversible distal anterior wall and apical perfusion defect,
involving the expected LAD territory. Stable, moderate,
predominantly fixed perfusion defect involving the lateral wall
and lateral portion of the inferior wall. Normal left
ventricular cavity size. Mildly depressed left ventricular
function with hypokinesis of the apex and septal akinesis, the
latter being consistent with prior CABG. EF 46%.
- TTE [**6-30**]: EF 40-45%, 2+ TR, 1+ MR
2. AAA - [**3-2**] Abd MRI showed infrarenal AAA 5 x 6 cm with
diffuse atherosclerotic change
- [**2142-7-6**] - underwent endovascular repair of abdominal aortic
aneurysm
- complicated by left external iliac artery avulsion (?apparent
intra-op rupture of iliac) s/p left iliac stent graft to left
CFA, bilateral femoral endartectomies and rt CFA patch
angioplasty [**2142-7-7**] with right groin washout [**2142-7-8**] (for ?
lymphatic leak)
3. DM type II: for 20 years typically under good control unless
she is sick
4. Cryptogenic cirrhosis (?NASH) c/b esophgeal varices and
portal gastropathy, + ttG in [**7-29**]
5. Pancytopenia, uncertain etiology
6. CRI (baseline 1.9)
7. h/o PUD
8. h/o LGIB due to AVM
9. + HIT [**7-30**]
10. Ecoli UTI resistant to bactrim and cipro
11. No prior history of blood clot per her report.
.
Social History:
Ms. [**Known lastname 22321**] [**Last Name (Titles) 22381**] worked as a hairdresser, retired ~5-10 years
ago. She quit tobacco 20 yrs ago (started smoking at 17 yo,
1-2pks/day, unfiltered), rare EtOH. She is divorced but lives
with her son, who helps manages her meds. Has 2 daughters who
work at [**Hospital1 18**] in [**Name (NI) 13042**]. Has another daughter. [**Name (NI) **] her children
and her 7 grandchildren live in the [**Location (un) 86**] area.
Family History:
Her mother had non-alcoholic liver cirrhosis and diabetes type
2. Her father had diabetes and died of lung cancer. One of her
daughters and her son have both required
pacemakers/defibrillators for heart disease. She had a brother
who died of a brain tumor and has an older sister who is
generally in good health. No family history of blood clots.
Physical Exam:
Vitals: T: 98.1 P: 60 BP: 126/50 R: 22 SaO2: 93% 2.5L
General: Awake, alert, mild respiratory distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, JVD to mandible, no carotid bruits appreciated
Pulmonary: Lungs with diffuse coarse crackles.
Cardiac: RRR, nl. S1S2, +early 2/6 systolic murmur heard equally
over all heart valves
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ patellar bilaterally.
.
Pertinent Results:
[**2144-2-26**] 06:50AM CK-MB-NotDone proBNP-8900*
[**2144-2-26**] 06:50AM CK(CPK)-30
[**2144-2-26**] 06:50AM cTropnT-0.02*
[**2144-2-26**] 06:50AM WBC-3.9* RBC-4.05* HGB-11.5* HCT-33.8* MCV-83
MCH-28.5 MCHC-34.1 RDW-17.7*
[**2144-2-26**] 06:50AM NEUTS-81.3* LYMPHS-12.4* MONOS-5.6 EOS-0.5
BASOS-0.3
[**2144-2-26**] 01:50PM CK-MB-2 cTropnT-0.09*
[**2144-2-26**] 01:50PM CK(CPK)-27
[**2144-2-26**] 10:15PM CK(CPK)-39
[**2144-2-26**] 10:15PM UREA N-60* CREAT-2.5*
[**2144-2-26**] 10:15PM CK-MB-NotDone cTropnT-0.02*
.
[**2-26**] IMPRESSION: AP chest compared to [**2143-2-4**]:
Moderately severe pulmonary edema is probably responsible for
the increasing opacification in both lower lungs since [**2-4**], taken in the setting of chronic pulmonary [**Month (only) 1106**] congestion
and baseline interstitial edema. Nevertheless the relatively
focal opacification in the right mid and both lower lung zones
could represent coexistent pneumonia. Small bilateral pleural
effusions are probably present. Heart size top normal,
unchanged.
.
Brief Hospital Course:
71 yo female with h/o CAD s/p CABG '[**38**], recent hospitalization
from [**Date range (1) 22383**] for UTI and CHF exacerbation, who presents again
with CHF exacerbation due to recent decrease in diuresis. Brief
hospital course by problem below:
.
#) Dyspnea: likely [**2-28**] failure given recent d/c of lasix. In
difficult position [**2-28**] intravascular volume depletion with Cr
remaining elevated to 2.6. Also ? of PNA given CXR findings.
Initially given Lasix 100mg IV in ED with good response,
continued to diurese as needed to keep O2 sats up and decrease
work of breathing. Ruled out MI with CEx3, and was not a
candidate for intervention anyway given HIT+ and multiple
comorbities. Unlikely component of pneumonia given unproductive
cough, absence of fever and no bump in WBC; however, given
ambiguous CXR possibly having underlying pneumonia, giving
levfloxacin 250 daily starting [**2-28**]. Gave Nitro paste prn for
chest discomfort. Consulted cards: recent echo from [**2144-2-3**] with
normal EF, mild MR. Unlikely to have changed in interim.
[**Hospital 22384**] medical management by d/c'ing nadolol, started Coreg
12.5 [**Hospital1 **], Imdur changed to 180 daily and titrated up to 240,
Hydral changed to 50mg tid and then increased to 75mg tid as
pressure tolerated. For diuresis, pt needed increasing doses to
keep her O2 level>92%, eventually up to 340mg IV lasix in one
day (120 AM, 100 afternoon, 120 PM) and still requiring 15L NRB,
so pt sent to CCU for lasix drip and closer monitoring. In the
CCU she was stabilized with a Lasix drip and then called out to
the floor with the impression that her dyspnea was
multi-factorial, including will pneumonia (levofloxacin d/c'ed
s/p 10 day course) and anemia with dyspnea improving when Hct
>30, transfusing as necessary.
.
#) Acute on Chronic Renal Failure: etiology likely related to
DM2 and chronic intravascular depletion. Lasix only as needed
above so as to avoid intravascular depletion. Helding ACE-I.
Renal consult to help manage fluid balance- added zaroxyln to
lasix initially, but changed to diuril with lasix as it is given
IV and may bypass problems if pt has bowel wall edema. After
return from CCU, pt was d/c'ed on 120mg [**Hospital1 **] PO lasix.
.
#) Pancytopenia: chronic of unknown etiology; likely [**2-28**] liver
disease (cryptogenic cirrhosis). D/c'ed on home dose of EPO.
.
#) DM2: continued Lantus 28u daily, [**1-28**] if pt not eating, SSI.
.
#) Code Status: Full, confirmed with patient [**2144-2-26**]
.
Medications on Admission:
1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day [held
since [**2-25**] AM]
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection Qweek.
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a
day).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
9. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
12. Lantus Insulin 27 units + SSI
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
2. Cholecalciferol (Vitamin D3) 400 unit 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 Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain: For
chest pain; take one every five minutes up to three times; if it
does not work, please call your PCP or come to the ED.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Four (4) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 injection* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Take with the 25mg tab.
Disp:*60 Tablet(s)* Refills:*2*
13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Take with 3.125 mg tablet.
Disp:*60 Tablet(s)* Refills:*2*
14. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*50 neb* Refills:*2*
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*50 neb* Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
Disp:*qs 1 month units* Refills:*2*
18. Home O2
Home O2 at 2L/minute continuous; pulse dose for portability
Discharge Disposition:
Home With Service
Facility:
Shouthshore VNA
Discharge Diagnosis:
Primary Diagnoses:
-CHF exacerbation
-Pneumonia
-Acute renal failure
Secondary Diagnoses:
-CAD
-AAA
-DM2
-cryptogenic cirrhosis
-pancytopenia
-CRI
-HIT
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Your
ideal body weight is 140 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200 mL
.
Return to the ED or call your PCP if you have:
-fever, chills, night sweats
-chest pain, shortness of breath, palpitations
-nausea, vomiting, diarrhea
-any new or concerning symptoms
.
Followup Instructions:
The following appointments have been made for you:
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-3-17**]
11:10
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2144-6-5**] 10:20
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
Completed by:[**2144-6-21**]
|
[
"583.81",
"585.9",
"428.0",
"584.9",
"578.9",
"284.1",
"250.40",
"V45.81",
"571.5",
"413.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12490, 12536
|
6455, 8968
|
331, 337
|
12732, 12741
|
5376, 6432
|
13138, 13677
|
3973, 4321
|
9943, 12467
|
12557, 12626
|
8994, 9920
|
12765, 13115
|
5112, 5357
|
4336, 5016
|
12647, 12711
|
272, 293
|
365, 1969
|
5031, 5095
|
1991, 3479
|
3495, 3957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,613
| 162,362
|
45887
|
Discharge summary
|
report
|
Admission Date: [**2108-11-8**] Discharge Date: [**2108-11-23**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
headache, vomiting, difficulty speaking, right sided weakness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient had L sided ICH in [**2098**] with residual R hemiparesis
(arm >> leg) and mild word finding difficulties. At recent
baseline, daughter and caregiver describe his speech as fluent,
able to answer questions appropriately, read paper. He has R
arm
>> leg weakness but was ambulatory short distances using a cane
and R leg brace but mainly used an electric wheelchair to get
around. For about the past 6 days, he has been complaining of a
"dull" bifrontal headache. For past 3 days, has been vomiting
1-2 times per day. Over past few days, speech has gotten worse
with significant word finding difficulty. His R side also seems
weaker with less ability to transfer. No fever.
Past Medical History:
HTN
Amyloid Angiopathy
Hx of stroke
s/p TURP
Social History:
Married. No T/E/D.
Family History:
No h/o amyloid angiopathy.
Physical Exam:
Vitals 98.6 BP 119/54 P 58 R 16 O2 sat 96%
General: Eldelry man curled on R side holding his head and
intermittently crying
Lungs: Clear to auscultation
CV: Regular rate and rhythm
Neurologic Examination:
Mental Status: Awake. Eyes open throughout exam, attentive
towards examiner. Oriented to person, chooses "home" as
location, gives "[**Month (only) 956**]" as date. Says days of week forwards,
not backwards. Nonfluent speech. Follows 1 but nt 2 step
commands. Labile emotions, intermittently crying for no
apparent reason. Reaches out to hug examiner throughout the
exam.
Cranial Nerves: R visual field cut based on blink to threat.
Pupils equally round and reactive to light, 3 to 1 mm
bilaterally. Extraocular movements intact, no
nystagmus. R facial droop in UMN pattern. Tongue midline.
Motor:
Spastic tone in R arm > leg. R arm with flexion contractures at
elbow and wrist. No movement in R arm seen. R leg distal >
proximal weakness. L arm and leg grossly full strength. Not
able to cooperate with detailed testing.
Sensation testing was not reliable
Reflexes: B T Br Pa
Right 3 3 3 3
Left 2 2 2 2
L toe was downgoing, R up
Coordination is normal on finger-nose-finger on L
Gait was not assessed
Pertinent Results:
[**2108-11-8**] 09:31PM PT-13.0 PTT-24.5 INR(PT)-1.1
[**2108-11-8**] 04:57PM GLUCOSE-129* UREA N-20 CREAT-0.9 SODIUM-134
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-29 ANION GAP-17
[**2108-11-8**] 04:57PM ALT(SGPT)-16 AST(SGOT)-43* ALK PHOS-111
AMYLASE-118* TOT BILI-0.5
[**2108-11-8**] 04:57PM LIPASE-15
[**2108-11-8**] 04:57PM ALBUMIN-4.5
[**2108-11-8**] 04:57PM HOLD BLUE-HOLD
[**2108-11-8**] 04:57PM GREEN HLD-HOLD
[**2108-11-8**] 04:57PM WBC-11.5*# RBC-3.93* HGB-12.6* HCT-36.1*
MCV-92 MCH-32.0 MCHC-34.8 RDW-12.7
[**2108-11-8**] 04:57PM NEUTS-80.9* LYMPHS-12.9* MONOS-2.6 EOS-3.3
BASOS-0.2
[**2108-11-8**] 04:57PM PLT COUNT-272
Brief Hospital Course:
Patient was admitted to the ICU for management of intracranial
hemorrhage due to amyloid angiopathy. He was transferred to the
floor on [**2108-11-10**]. His blood pressure was managed to keep the
systolic below 140s. He was placed on a bowel regimen,
GIprophylaxis, and a swallow evaluation, which showed no signs
of aspiration. He was given DVT prophylaxis, an anemia work up,
and sliding scale insulin to control his blood sugars. Patient
was started on dilantin for seizure prophylaxis, which was
slowly tapered off during the course of his hospitalization.
Initial head CT showed a small amount of subarachnoid blood in
left frontal and right frontal sulci, encephalomalacia, brain
atrophy, and two large intraparenchymal hemorrhages in the left
parasagittal frontal region with associated edema. He had
increased nausea and vomiting and was less responsive on
[**2118-11-12**]. Repeat head CT showed no significant change.
He also received a CT of the abdomen and pelvis which showed an
enlarged prostate with a simple cyst, but no acute processes.
He was seen by physical and occupational therapy evaluation and
treatment to help increase his range of motion on the right
side.
His course was complicated by an enterococcal urinary tract
infection, resulting in fevers and altered mental status. He
was treated with vancomycin, the infection cleared and his
mental status improved. He was seen by speech/swallow who
determined that he was unable to swallow. Multiple discussions
were held with patients family regarding continued nutritional
support. Because his mental status seemed to be improving, they
decided to treat his underlying infection and place PEG for tube
feeds. On the morning of [**11-21**], prior to PEG placement, Mr.
[**Known lastname 1787**] was noted to be unarousable with eye deviation to the
right. Repeat head CT showed a new right frontal hemorrhage.
Based on poor prognosis for neurologic recovery given bilateral
cortical hemorrhages, the family decided to readdress goals of
care and patient was made comfort measures only. Medications,
nutrition, and hydration were held. Comfort medications,
including Ativan and Morphine were prescribed on an as needed
basis though he has not required these over the last two days.
He is now being discharged to hospice for further comfort care.
Medications on Admission:
Hytrin 5mg QD,
Proscar 5mg QD,
Lipitor 5mg QD,
HCTZ 25mg QD,
Xalatan 1 drop QD
Allergies: NKDA per history but PCN in computer
Discharge Medications:
1. Morphine Sulfate 20 mg/5 mL Solution Sig: 2.5-20mg PO q 4-6
hours: PRN as needed for discomfort, respiratory distress.
Disp:*30 ml* Refills:*0*
2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO q3 hours: PRN as
needed for agitation or respiratory distress: Please give SL.
Disp:*10 Tablet(s)* Refills:*0*
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
Disp:*20 Suppository(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tibbet house
Discharge Diagnosis:
Amyloid angiopathy
Intracranial hemorrhage: multiple
UTI
Discharge Condition:
Unresponsive, right hemiplegia, no apparent distress
Discharge Instructions:
Discharged to hospice for continued comfort care.
Followup Instructions:
None.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"277.3",
"599.0",
"438.20",
"401.9",
"431",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6089, 6128
|
3107, 5446
|
284, 292
|
6229, 6283
|
2436, 3084
|
6381, 6505
|
1132, 1160
|
5625, 6066
|
6149, 6208
|
5472, 5602
|
6307, 6358
|
1175, 1358
|
182, 246
|
320, 1010
|
1779, 2417
|
1398, 1763
|
1383, 1383
|
1032, 1078
|
1094, 1116
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,984
| 165,232
|
31826
|
Discharge summary
|
report
|
Admission Date: [**2177-5-16**] Discharge Date: [**2177-5-26**]
Date of Birth: [**2092-2-27**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Ischemic colitis vs inflammatory colitis, LGIB
Major Surgical or Invasive Procedure:
[**2177-5-17**]: Extended left hemicolectomy with colostomy formation
[**2177-5-23**]: Cardiac catheterization
History of Present Illness:
85F who presented with abdominal pain, bloody diarrhea and
leukocytosis with
elevated serum lactate. She reported that as she attempted to
get out of bed on morning of admission due to rectal bleeding
her legs "gave out" on her and she fell. She was transported to
[**Hospital1 18**] for further evaluation. In the ED she was noted with
progressive tenderness over the course of her resuscitation, and
a lactate that originally went down, but then was noted to
increase. CT imaging was done showing an area of colitis most
prominent in the
area of the splenic flexure. She became intermittently
hypotensive, requiring significant fluid administration to
maintain normotension, and showed signs of
progressive abdominal tenderness. She was, therefore, taken to
the operating room for exploration and definitive management.
On POD 3, Mrs. [**Known lastname 74659**], had episode of SVT with rates of
approximately 150-170, and per her report, was symptomatic with
palpitations, chest discomfort and shortness of breath. The SVT
spontaneously broke without intervention. EKG
was performed overnight after the SVT broke which showed a rate
of ~100 in sinus rhythm with diffuse ST depressions in
I/II/AVF/V4-V6 and 1mm elevation in aVR which is all new from
baseline. No intervention was done at that time. Subsequent EKGs
showed resolution of most of these changes with subtle ST
depressions in the anterolateral precordial leads. Afterwards
she was noted to
have increasing O2 requirements and CXR this AM was consistent
with pulmonary edema and bilateral pleural effusions. She was
diuresed with 10mg IV lasix x1 with improvement in her shortness
of breath. Subsequent labs were notable for CK 489, MB 4,
Trop-T 0.28 with BNP ~22,000. The patient was admitted to ICU
for further management and closer observation.
On [**2177-5-22**], a cardiac catheterization was completed and
significant for distal left main and 3-vessel coronary artery
disease. Please see the catheterization report for further
details.
Past Medical History:
HTN, HL, CRI (baseline creat 1.3), Breast cancer, Osteoporosis,
Anx/Dep, Glaucoma
PSH:
Left breast mastectomy ([**5-12**])
Right mastectomy ([**2135**])
TAH ([**2160**])
Social History:
Lives with her son and sister
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp: 97.7 HR: 70 BP: 87/53 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, diffuse tenderness
Rectal: brbpr
On discharge:
VS: 98.9 90 122/66 16 96% RA
GEN: A&O, NAD
PULM: Lung sounds diminished at bases bilaterally, otherwise
clear, no crackles/rhonchi
CV: RRR, no m/r/g
ABD: Soft, minimally appropriately tender and midline surgical
incision site, nondistended. Surgical incision dry with
steristrips intact. RLQ stoma pink with liquid stool output.
EXTR: Trace LE edema, warm pink and well-perfused.
Pertinent Results:
[**2177-5-16**] 06:20PM BLOOD WBC-10.0# RBC-4.15* Hgb-12.7 Hct-38.3
MCV-92 MCH-30.6 MCHC-33.1 RDW-14.0 Plt Ct-185
[**2177-5-20**] 07:00AM BLOOD WBC-7.4 RBC-2.96* Hgb-9.1* Hct-26.8*
MCV-91 MCH-30.9 MCHC-34.1 RDW-14.5 Plt Ct-110*
[**2177-5-17**] 01:15AM BLOOD Neuts-89.7* Lymphs-6.9* Monos-3.1 Eos-0.1
Baso-0.3
[**2177-5-16**] 06:20PM BLOOD Neuts-91.3* Lymphs-5.3* Monos-3.0 Eos-0.1
Baso-0.3
[**2177-5-20**] 07:00AM BLOOD Plt Ct-110*
[**2177-5-16**] 06:20PM BLOOD Glucose-190* UreaN-34* Creat-2.6*# Na-139
K-4.1 Cl-101 HCO3-23 AnGap-19
[**2177-5-17**] 01:15AM BLOOD Glucose-200* UreaN-35* Creat-2.4* Na-136
K-3.6 Cl-107 HCO3-17* AnGap-16
[**2177-5-19**] 05:51AM BLOOD Glucose-95 UreaN-28* Creat-1.6* Na-142
K-3.5 Cl-112* HCO3-21* AnGap-13
[**2177-5-20**] 07:00AM BLOOD Glucose-153* UreaN-24* Creat-1.3* Na-139
K-3.4 Cl-111* HCO3-21* AnGap-10
[**2177-5-17**] 11:47AM BLOOD ALT-26 AST-40 AlkPhos-24* TotBili-1.3
[**2177-5-16**] 06:20PM BLOOD Lipase-26
[**2177-5-16**] 06:20PM BLOOD cTropnT-<0.01
[**2177-5-20**] 07:00AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.0
[**5-16**] Left wrist xray: Intra-articular, impacted, and dorsally
angulated fracture of the distal radius. Ulnar styloid fracture.
[**5-16**] CT abd/pelvis: Diffuse wall thickening extending from the
mid transverse colon to the sigmoid.
[**5-16**] CT head: no acute process
[**5-16**] CT cspine: no fracture
[**2177-5-21**] TTE:
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild to moderate regional
left ventricular systolic dysfunction with focal severe
hypokinesis of the entire septum and basal-to-mid anterior wall.
The remaining segments contract normally (LVEF = 35-40 %). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.
[**2177-5-21**] ECG:
Sinus tachycardia with atrial premature beats. Low limb lead
voltage.
ST-T wave abnormalities. Consider ischemia. Since the previous
tracing
of [**2177-5-16**] the rate is faster, the ventricular premature beat is
new, atrial premature beat is new, limb lead voltage is lower,
ST-T wave abnormalities are new. Consider ischemia. Clinical
correlation is suggested.
[**2177-5-21**] Chest x-ray:
AP chest compared to [**5-20**]:
Lung volumes are appreciably lower, and there is considerably
more
consolidation in both lower lobes as well as mediastinal and
pulmonary
vascular congestion and perihilar opacification suggesting
concurrent
pulmonary edema. Small bilateral pleural effusions are
presumed, increased since [**5-20**]. Heart size is normal. Right
internal jugular line ends in the region of the superior
cavoatrial junction.
[**2177-5-22**] Cardiac cath:
FINAL DIAGNOSIS:
1. Ostial and complex distal LMCA and severe 3 vessel coronary
artery
disease.
2. Mild systemic arterial hypertension.
3. Moderate left ventricular diastolic heart failure in the
setting of
know left ventricular systolic heart failure (presumed acute).
4. Reinforce secondary preventative measures against CAD, MI, LV
systolic dysfunction, and hypertension.
Brief Hospital Course:
Ms. [**Known lastname 74659**] was admitted to the Acute Care Surgery team and was
taken to the operating room for extended left colectomy with
transverse colostomy. In the OR she received 4.5L crystalloid
and one unit of cryoprecipitate for a fibrinogen in the 80s and
a slow ooze noted intraoperatively. IV Cipro and Flagyl along
with Vancomycin via the stoma were started. Postoperatively she
was hemodynamically stable and was admitted to the TSICU where
she remained intubated. Over the course of the day her ABG
showed a persistent metabolic acidosis which was felt to be
secondary to under resuscitation and she was bolused and her
basal fluid rate was increased to 125/hr to good effect, her
ABGs improved.
She was also seen by Orthopedics for her left wrist fracture
that was sustained during her fall at home which was what
initially brought her into the hospital. This was reduced and
splinted in the ED prior to her trip to the OR. She will follow
up in [**Hospital 5498**] clinic in a few weeks after discharge.
On HD#3/POD#1, she was extubated. Her mental status was
appropriate, she was stable off pressors and stable from a
respiratory standpoint on room air. She was transferred to the
floor and doing well overall. She was noted to have bowel
function with ostomy output by POD 3. Wound ostomy consultation
was obtained early on and teaching was initiated with patient.
She was noted with sinus tachycardia since her surgery and was
started on low dose beta blockade with some improvement in her
heart rate from the 110's to 80's-90's. Her electrolytes were
followed closely and repleted accordingly.
On [**5-20**] (POD#3) overnight into [**5-21**] (POD#4), however, she had an
episode of SVT with rates of approximately 150-170, and had
symptomatic palpitations, chest discomfort and shortness of
breath. EKG showed diffuse ST depressions in I/II/AVF/V4-V6 and
1mm elevation in aVR which is all new from baseline. Subsequent
EKGs showed mostly resolution subtle ST depressions in the
anterolateral precordial leads. Afterwards she was noted to have
increasing O2 requirements and CXR on [**5-21**] AM was consistent
with pulmonary edema and bilateral pleural effusions. She was
diuresed with 10mg IV lasix x1 with improvement in her shortness
of breath. Labs were notable for a CK of 489 a troponin of 0.28
with BNP ~22,000.
She was started on a heparin drip, aspirin and continued on
metoprolol. She was transferred to the trauma ICU for further
monitoring but remained hemodynamically stable. Cardiology
evaluated and deemed her appropriate for a catheterization. She
was taken to the cath lab on [**2177-5-22**]. Findings include distal
left main and 3 vessel coronary artery disease. No intervention
was undertaken at that time (see pertinent results section for
details). She was transferred back to the floor from the ICU s/p
catheterization.
At this time, Mrs. [**Known lastname 74659**] continues on her beta blocker and
ASA. Her home ACEI was resumed on [**5-23**]. She is currently
hemodynamically stable and feeling well. Her pulmonary edema has
resolved and her oxygenation status is stable on room air. She
is tolerating a regular diet and having output via her ostomy.
She has been started on an appetite stimulant and dietary
supplements given decreased PO intake in her initialy
postoperative course. Her foley catheter has been discontinued
and she is voiding adequate amounts of urine without difficulty.
She has been evaluated by Physical and Occupational therapy and
is being recommended for rehab after her acute hospital stay. On
[**2177-5-26**] she is afebrile, hemodynamically stable and tolerating a
regular diet. She is being discharged with follow up scheduled
with cardiology, ACS and orthopedics.
Medications on Admission:
BENAZEPRIL 20, HYDROCHLOROTHIAZIDE 12.5, LATANOPROST 0.005 %
Drops - 1 gtt ou qhs, PERPHENAZINE-AMITRIPTYLINE 2'',
ROSUVASTATIN 20 qhs, CHOLECALCIFEROL 1000
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Perphenazine 2 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Aspirin 325 mg PO DAILY
6. bimatoprost *NF* 0.01 % OU QHS
* Patient Taking Own Meds *
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES AM AND
QHS
8. benazepril *NF* 20 mg Oral daily
hold for sbp<110
9. Megestrol Acetate 400 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
Soldiers Home in [**State 350**] - [**Location (un) **]
Discharge Diagnosis:
Ischemic colitis
s/p fall: Distal left radius fracture
Non ST elevation myocardial infarction
Acute pulmonary edema
Congestive 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:
You were admitted to the hospital with abdominal pain and were
found to have ischemia (decreased blood supply) to your left
colon. You underwent a resection of this part of your colon.
During your operation you also required that a colostomy be
created so that now you have a bag that will collect any stool
that is produced.
The wound ostomy nurse saw you to provide teaching regarding
your new colostomy.
On the fourth day after your surgery, you experienced a heart
attack. You were also found to be in a rapid heart rhythm. As a
result, you were seen by cardiology and had a diagnostic cardiac
catheterization to evaluate the arteries in your heart. As
recommended, you have been started on aspirin, a beta blocker
(blood pressure medication) and continued on your home ACE
inhibitor (previously "Benezapril"). We did not resume your
home hydrochlorothiazide (diuretic). We recommend that this be
followed up by your primary care physician as well as
cardiology.
You were evaluated by the Physical therapy team and being
recommended for rehab after your hospital stay.
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] HEALTHCARE -[**Location (un) 2352**]
Address: 1000 [**Last Name (LF) **], [**First Name3 (LF) 2352**],[**Numeric Identifier 13951**]
Phone: [**Telephone/Fax (1) 1144**]
Department: ORTHOPEDICS
When: TUESDAY [**2177-6-3**] at 8:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2177-6-3**] at 8:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2177-6-6**] 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: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
When: THURSDAY [**2177-6-12**] at 1:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2177-5-26**]
|
[
"V10.3",
"365.9",
"584.9",
"428.41",
"428.0",
"557.9",
"311",
"403.90",
"414.01",
"300.00",
"733.00",
"427.0",
"410.91",
"585.3",
"813.44",
"272.4",
"276.2",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"38.93",
"45.75",
"88.56",
"46.11",
"79.02"
] |
icd9pcs
|
[
[
[]
]
] |
11530, 11612
|
7162, 10924
|
350, 465
|
11797, 11797
|
3636, 4940
|
13085, 14700
|
2769, 2786
|
11132, 11507
|
11633, 11776
|
10950, 11109
|
6778, 7139
|
11980, 13062
|
2801, 3221
|
3236, 3617
|
264, 312
|
493, 2509
|
4949, 6761
|
11812, 11956
|
2531, 2706
|
2722, 2753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,121
| 127,236
|
52728
|
Discharge summary
|
report
|
Admission Date: [**2114-6-22**] Discharge Date: [**2114-7-17**]
Date of Birth: [**2035-6-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Rt. Parietal Mass
Major Surgical or Invasive Procedure:
[**6-27**]: Stereotactic brain biopsy
History of Present Illness:
Patient transferred from OSH after head CT revealed new right
parietal brain mass. Per notes, the patient's wife called Mr.
[**Known lastname 108775**] PCP, [**Name10 (NameIs) **] reported that patient had been sleeping alot,
was unsteady on his feet and could not write his name. She also
reported that as of this morning he could walk
because his gait was shuffled and he had a hard time
understanding her. Mrs [**Known lastname **] reports that they are at their
house on [**Location (un) **] and it was recommended they go to the nearest
hospital for evaluation.
Past Medical History:
Stage IIIB nonsmall cell lung cancer s/p right lobectomy [**2113-1-4**]
Hypertension.
Hypercholesterolemia.
Arthritis.
Gout.
Status post prostatectomy.
Status post appendectomy.
Status post back and neck surgery and hernia repair.
?h/o asbestos exposure
Social History:
Recently quit smoking, smoked 1PPD or every other day for 50
years. Lives w/ wife. Used to work for navy. No alcohol use.
Family History:
Pt has 9 other siblings, 6 have died of lung CA or alzheimers.
Physical Exam:
On Discharge:
Orient to place and self
L sided neglect
PERRL
L pronator drift
5/5 strength
Face symmetric
Pertinent Results:
Labs on Admission:
[**2114-6-22**] 07:20PM BLOOD WBC-8.0 RBC-4.50* Hgb-13.7* Hct-40.0
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.8 Plt Ct-230
[**2114-6-22**] 07:20PM BLOOD Neuts-81.3* Lymphs-12.0* Monos-2.3
Eos-3.8 Baso-0.6
[**2114-6-22**] 07:20PM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0
[**2114-6-22**] 07:20PM BLOOD Glucose-112* UreaN-36* Creat-1.4* Na-142
K-3.7 Cl-104 HCO3-27 AnGap-15
Labs on Discharge:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2114-7-17**] 04:40AM 4.6 3.37* 10.3* 31.0* 92 30.5 33.3 14.6
277
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2114-7-13**] 10:27AM 87.1* 8.4* 3.7 0.6 0.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2114-7-17**] 04:40AM 89 17 0.9 135 3.9 102 24 13
Imaging:
CT Head [**6-22**]:
FINDINGS: There is a round-ovoid hyperdense mass in the right
cerebral
hemisphere, measuring 24 x 30 mm, 2:16, with a significant
amount of vasogenic edema, and enhancement of the occipital [**Doctor Last Name 534**]
of the right lateral ventricle. There is shift of midline
structures 4 mm. There is no acute hemorrhage, or large acute
territorial infarction. No blood in the ventricles. The
visualized portion of the paranasal sinuses and mastoid air
cells appear normal. There is no fracture seen.
IMPRESSION:
Hyperdense round mass in the right cereberal hemisphere, with
significant
amount of vasogenic edema, concerning for metastasis. 4 mm shift
of midline structures.
MRI Head [**6-23**]:
FINDINGS: There is diffuse edema identified in the right
parietooccipital
region extending from the periatrial right region. Mass effect
is seen on the right lateral ventricle without midline shift.
Within the area of edema there is heterogenous T2 abnormality
seen measuring approximately 3 cm, which demonstrates
enhancement following gadolinium administration. There is also
subtle subependymal enhancement seen along the occipital [**Doctor Last Name 534**] of
the right lateral ventricle. There are no other foci of abnormal
enhancement seen within the brain. There is no hydrocephalus
identified.
IMPRESSION: Right periatrial approximately 3 cm enhancing mass
with extensive surrounding edema. The mass also demonstrates
subtle subependymal enhancement along the occipital [**Doctor Last Name 534**] of the
right lateral ventricle. Chronic blood products are seen within
the mass. The differential diagnosis includes lymphoma, glioma
or metastatic disease. Given patient's history of lung cancer,
metastasis should be considered, but the appearances are not
typical.
CT Torso [**6-23**]:
CT TORSO: Prior to administration of IV contrast, helical
imaging was
performed through the level of the abdomen. Subsequently, after
uneventful
administration of 100 mL of Visipaque, helical imaging was
performed from the thoracic inlet through the pubic symphysis.
Three-minute delayed imaging was performed at the level of the
abdomen. Coronal and sagittal reformations were prepared. Oral
contrast was also administered.
COMPARISON: CT chest [**2114-6-20**], CT abdomen [**2109-12-11**].
MRI
abdomen, [**2108-4-10**].
CT CHEST:
Patient is status post prior right upper lobectomy, unchanged
since
examination from three days prior. A region of ground-glass
opacity in the
superior segment of the right lower lobe (3:11) appears
unchanged measuring 9 mm. There is an unchanged 3-mm nodule in
the left base (3:48). There are stable-appearing multiple
bilateral pleural plaques which are consistent with the
patient's history of asbestos exposure. There is no significant
axillary lymphadenopathy. There are scattered non-pathologically
enlarged mediastinal nodes, unchanged. There is no hilar
adenopathy. There is calcification of the aortic arch without
evidence for aneurysm or dissection. There is coronary artery
vascular calcification. No pericardial effusion. There are no
pleural effusions. The partially visualized lobes of the thyroid
appear normal.
CT ABDOMEN:
The spleen appears normal apart from an incidentally noted
splenule (3:59). The right and left adrenals appear
unremarkable. The pancreas is slightly fatty replaced but
appears otherwise normal. The gallbladder is unremarkable
without stones. In segment VII of the liver is a predominantly
hypodense mass measuring 3 x 2.2 cm with peripheral area of
enhancement consistent with prior diagnosis of a hemangioma
within the liver. Segment sVI small hemangioma is unchanged.
Segment II hemangioma seen in [**2108**] is not apparent today. There
are multiple smaller hypodensities throughout the liver, too
small to fully characterize but appear unchanged. No new masses
are identified in the liver. The kidneys enhance and excrete
contrast symmetrically. There is no hydronephrosis. There is a
hypodensity in the interpolar region of the right kidney (3:56),
too small to characterize. Left renal size has decreased since
[**2108**] from 10.9 cm SI to 9.2 cm SI and there is slight cortical
thinning and delayed enhancement compared to the right. There is
narrowing at the iorigin of the left renal artery with calcified
plaque and slight post-stenotic dilation that likely reflects
high-grade left renal artery stenosis, though it is not
optimally evaluated on this non- angiographic study. The
abdominal aorta is densely calcified with calcific and non-
calcific atheromatous plaque, but no aneurysm. Celiac artery
origin narrowing appears mild There are scattered non-
pathologically enlarged retroperitoneal and mesenteric nodes. No
free air or free fluid is seen in the abdomen. Stomach and
abdominal loops of small and large bowel appear grossly normal.
CT PELVIS:
The bladder is unremarkable. Patient is status post
prostatectomy with
surgical clips in the low pelvis. The rectum is normal; however,
there is
sigmoid diverticulosis without diverticulitis. Remaining pelvic
loops of small and large bowel appear normal. There is no free
air or free fluid in the pelvis. There are scattered mesenteric
nodes but none are pathologically enlarged. No inguinal
lymphadenopathy. There is extensive atherosclerosis with
apparent moderate to high grade narrowing of the left common
iliac artery at its origin and similarly at the origin of the
left external iliac artery. There is also moderate-highgrade
narrowing in the mid right external iliac artery. Assessment is
not optimal on this non- angiographic study.
BONE WINDOWS: Patient is status post laminectomy from L4 through
L5 with
nonunion of the posterior elements of the sacrum, unchanged
since [**2108**]. No
suspicious sclerotic or lytic lesions are present.
IMPRESSION:
1. No foci concerning for new primary malignancy. The patient's
multiple
pleural plaques secondary to history of asbestos exposure appear
stable.
2. Stable ground-glass opacity at the superior segment of the
right lower lobe (3:11). Chronic changes from right lower
lobectomy.
3. Left renal artery origin stenosis, likely high-grade, with
decreased size of left kidney since [**2108**], cortical thinning, and
delayed enhancement. Confirmation could be obtained with MRA if
needed.
4. Bilateral iliac artery stenoses detailed above, but not
optimally
evaluated on this non- angiographic study and because of
calcified
atherosclerosis. If not evaluated in the past MRA is recommended
because of the extent of calcification limiting CTA assessment.
5. Stable liver hemangioma. Diverticulosis without
diverticulitis.
Head CT [**6-27**](post-op)
FINDINGS: There is a hyperdense 3 x 2.5 cm mass in the right
cerebral
hemisphere causing significant vasogenic edema and approximately
6 mm of
leftward shift of the septum pellucidum, unchanged since [**6-22**], [**2113**]. There are no areas concerning for hemorrhage. The size
and configuration of the ventricles appears stable. [**Doctor Last Name **]-white
matter differentiation appears normal apart from the marked
edema around the right cerebral mass. There are no areas
concerning for an acute infarction. There is a burr hole in the
right frontal calvarium otherwise the osseous structures appear
intact. Paranasal sinuses, ethmoid and mastoid air cells are
clear.
IMPRESSION: Stable appearance to a hyperdense mass in the right
cerebral
hemisphere with stable vasogenic edema and 5 mm of midline
shift. No areas
concerning for hemorrhage postoperatively.
[**7-10**] Head CT IMPRESSION:
1. Post-surgical changes, with hemorrhage in the right parietal
resection bed
and a small amount of layering hemorrhage in the lateral
ventricles, unchanged
from study of 11 hours earlier.
2. Unchanged 7mm leftward shift of midline structures.
3. Unchanged vasogenic edema of the right cerebral hemisphere.
4. Little change in the size of the ventricles from 11 hours
prior.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after having a newly identified
right parietal mass in the setting of increased confusion and
left sided weakness. CT of the Torso was obtained and found to
have stable disease in comparison to previous imaging. In the
setting of a relatively benign CT torso; it was best thought to
biopsy the lesion in the head first to determine pathology.
Given that the patient is a left hand dominant person with a
right sided lesion; functional MRI was performed on [**6-27**] prior
to biopsy, should resection become determined course. In the
afternoon of [**6-27**], Mr. [**Known lastname **] went to the operating room for a
stereotactic brain biopsy. Preliminary pathology revealed a
likely metastatic pathology. His surgical case was discussed at
the weekly brain tumor conference on [**7-2**], and it was decided
that he should undergo a resection.
On [**7-4**] the patient went to the OR for a right parietal
craniotomy for tumor resection. Operative course was
uncomplicated. Patient was extubated in the OR and taken to the
PACU for recovery and continued monitoring. Post operative scan
which was performed within 4 hours revealed some bleeding in the
operative bed with extension to the third and lateral
ventricles. On clinical exam patient was easily arrouseable, but
had some left lower extremity weakness with planter flexion.
Given our concern for the development of hydrocephalus, the
patient was sent for a repeat CT scan within two hours, which
was not concerning for hydrocephalus.
On [**7-10**] patient was transferred from the floor back to the
Stepdown for desaturation episodes and decline in mental status.
An ABG revealed a poor PaO2 of 60%. Patient underwent a CTA of
the chest to rule out PE and a noncontrast CT. CTA was negative
for PE, and the CT of the head was unchanged from a study done
on [**7-6**]. Patient was pan cultured and had LFTs and dopplers
ordered to further work up his fevers. The bilateral lower
extremity ultrasound was negative for DVT. Pt does have h/o of
gout so colchicine given for flare.
Since that time, patient with periods of waxing/[**Doctor Last Name 688**] delirium.
Patient is oriented to self and location but has periods where
he did not orient to time and did not follow commands.
Medications on Admission:
Diovan, Crestor, ASA, Albuterol, Advair, ProAir, Propoxyphene
N-AC, Spiriva
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB,
dyspnea.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheezes.
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO TID (3 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO tid () for
2 days.
14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid ().
15. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: Five
Hundred (500) mg Intravenous Q24H (every 24 hours) for 1 days.
17. Insulin sliding scale
Please follow nursing flowsheet
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right parietal tumor
Intraventricular hemorrhage
Hypertention
Hyponatremia
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? 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.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
You have an appointment in the Brain [**Hospital 341**] Clinic on [**2114-8-1**]
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
-You have also been scheduled to see Dr. [**First Name (STitle) **] [**Name (STitle) 3929**] on
[**2114-7-23**] in the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**]. Please
call ([**Telephone/Fax (1) 70038**] with any questions.
-You will not need an MRI of the brain as this was done during
your acute hospitalization
Also; please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office(general
oncology medicine) at [**0-0-**] to schedule a follow up
appointment approximately 4wks after surgery.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2114-11-16**] 11:30
Completed by:[**2114-7-17**]
|
[
"780.09",
"431",
"198.3",
"272.0",
"573.8",
"405.11",
"440.1",
"E878.8",
"V10.11",
"997.02",
"V45.89",
"492.8",
"276.1",
"348.5",
"784.3",
"274.9",
"342.90",
"716.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.13",
"01.59",
"87.03",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
14398, 14477
|
10354, 12642
|
337, 377
|
14595, 14619
|
1615, 1620
|
16662, 17847
|
1410, 1474
|
12769, 14375
|
14498, 14574
|
12668, 12746
|
14643, 16639
|
1489, 1489
|
1503, 1596
|
280, 299
|
2009, 10331
|
405, 975
|
1634, 1990
|
997, 1254
|
1270, 1394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,030
| 105,481
|
3725
|
Discharge summary
|
report
|
Admission Date: [**2128-10-6**] Discharge Date: [**2128-10-11**]
Date of Birth: [**2068-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone / Zanaflex
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe nodule.
Major Surgical or Invasive Procedure:
[**2128-10-6**]: Video-assisted thoracic surgery left lower lobe
wedge resection.
History of Present Illness:
Admitted for scheduled VATS and left lower lobe resection.
Past Medical History:
Coronary Artery Disease s/p 1v CABG in [**2111**] (SVG -> RCA),
occluded RCA and SVG->RCA graft on Cath in [**1-20**] and RCA fills w/
collaterals; PCI to LAD(3.0x23 Cypher) in [**8-20**] and OM1(2.5x15
Vision-BMS) in [**5-/2127**]
Supraventricular tachycardia s/p ablation
Peripheral [**Year (4 digits) 1106**] disease s/p Right femoral to dorsalis pedis
vein graft, L. femoral-peroneal bypass, right femoral-DP vein
graft bypass, and left BKA, Excision of vein graft and aneurysm
of the right common femoral artery with proximal vein bypass
with interposition segment of nonreversed right basilic vein.
Cath [**8-20**] showed LSFA stents were totally occluded with
collaterals
Emphysema: Home Oxygen 2-4 Liters
Pulmonary Embolism: on coumadin [**11-20**]
Hypercholesterolemia
Total thyroidectomy for thyroid CA->Hypothyroidism
Bilateral inguinal hernia repair
CVA [**2116**] with left-sided weakness
Carotid Stenosis: Right Total occulsion
Seizure disorder
Ischemic neuropathy
Social History:
He denies alcohol use. He smoked 1 ppd for 20 years but quit in
[**2126**]. Lives alone with multiple family members living nearby.
Formerly worked as a computer systems engineer but had to retire
in [**2109**] due to multiple surgeries and medical problems.
Currently on disability. Reports asbestos exposure for 7 years
at a building he worked at.
Family History:
Noncontributory, sister with history of ruptured cerebral
aneurysm at age 48.
Physical Exam:
VS: T 97.6 HR: 87 SR BP 90/50 Sats: 88-91% 4L NC Wt 210
lbs
General: sitting up in bed no apparent distress
Neck: supple
Card: RRR
Resp: decreased breath sounds Right i/4 up, Left 1/3 up no
crackles or wheezes
GI: obese benign
Extr: warm L BKA
Incision: left VATs clean/dry intact, site ecchymotic
Neuro: non-focal
Pertinent Results:
[**2128-10-9**] 07:00AM BLOOD WBC-8.6 RBC-4.13* Hgb-13.8* Hct-40.5
MCV-98 MCH-33.5* MCHC-34.2 RDW-15.2 Plt Ct-141*
[**2128-10-7**] 03:37AM BLOOD WBC-11.2*# RBC-4.45* Hgb-15.2 Hct-43.3
MCV-97 MCH-34.1* MCHC-35.0 RDW-15.3 Plt Ct-134*
[**2128-10-9**] 07:00AM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-139
K-4.6 Cl-100 HCO3-31 AnGap-13
[**2128-10-7**] 03:37AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-138
K-4.1 Cl-100 HCO3-32 AnGap-10
[**2128-10-6**] TISSUE Site: LOBE LEFT LOWER LOBE NODULE.
GRAM STAIN (Final [**2128-10-6**]): No Growth
TISSUE (Final [**2128-10-9**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2128-10-7**]): NO ACID FAST BACILLI SEEN ON
DIRECT
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2128-10-7**]): NO FUNGAL
ELEMENTS
PA AND LATERAL CHEST ON [**2128-10-9**]
FINDINGS: Left IJ central catheter in stable satisfactory
position. Left-
sided chest tube remains as before, there is small amount of
subcutaneous
emphysema on the left. Focal opacity of the left base appears
improved when compared with the previous film of [**2128-10-8**]. There
is no specific evidence of CHF. [**Date Range **] margins are sharp.
Heart remains normal in size. Osseous structures are intact.
CXR: [**2128-10-8**]
FINDINGS: There is improvement in fluid status versus prior
study. Chest
tubes remain in place, subcutaneous emphysema again noted, and
there is slight decrease in the blunting seen at the left CP
angle. No new consolidations.
CHEST RADIOGRAPH [**2128-10-6**].
FINDINGS: As compared to the previous radiograph, the left-sided
chest tube and left-sided central venous access line are in
unchanged position. A minimal left-sided pneumothorax is
minimally better seen than on the previous examination.
Unchanged retrocardiac atelectasis, soft tissue air collection
in the left lateral chest wall.
Brief Hospital Course:
Mr. [**Known lastname 16807**] was admitted on [**2128-10-6**] for Video-assisted
thoracic surgery left lower lobe wedge resection. He was
extubated in the operating room and monitored in the PACU prior
to transfer to the floor. His [**Doctor Last Name **] drain was converted to bulb
suction. He tolerated a regular diet. His pain was managed
with a Dilaudid PCA.
On [**10-7**] the patient was found somnolent with a SP02 of 75% and
[**Doctor Last Name **] drain with air. He was administered narcan with no result.
His [**Doctor Last Name 406**] drain was converted to pleuravac to low wall suction
with a notable airleak. He was transferred to the SICU where he
spontaneously woke. A chest-x-ray showed a small pneumothorax.
He was placed on nocturnal BiPap On [**2128-10-8**] the chest tube
drained > 400cc of serosanguinous fluid. It was placed to water
seal with minimal air leak. Good pulmonary toilet continued. He
was restarted on his home medications. On [**2128-10-9**] he
transferred to the floor. He was seen by cardiology who agreed
with restarting lasix. His chest x-ray revealed no pneumothorax
and was converted to [**Doctor Last Name 406**] bulb without airleak. Physically
therapy saw the patient and cleared him for home with PT.
Medical Oncology saw the patient who deemed him not a candidate
for adjunctive therapy secondary to co-morbidity. They will
continue to follow his pathology. On [**10-10**] the [**Doctor Last Name 406**] drain was
removed and follow-up chest x-ray showed no pneumothorax. The
foley was removed and failed to void. A bladder scan showed 400
urine. On [**2128-10-11**] the foley was removed and he voided. He
continued to make steady progress and was discharged to home
with VNA and PT. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Atorvastatin 20mg qd Clonazepam 1mg TID Clopidogrel 75mg daily
ASA 325mg daily
Fluticasone-Salmeterol 250/50 1 inh [**Hospital1 **] Furosemide 20mg qAM
Gabapentin 800mg TID Hydroxyzine 25mg q4-6H PRN itch
Levetiracetam 1500mg [**Hospital1 **] Levothyroxine 150mcg daily
Metoprolol tartrate 25mg TID Nitroglycerin 0.3 mg tab SL PRN
Tiotropium 18 mcg capsule, 1 cap inh daily
Calcium carbonate 500 mg (1250mg) tablet, chewable, 1 tab daily
Cholecalciferol 400 U tablet daily Pyridoxine 50mg daily
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
4. Levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours.
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
[**Hospital1 **]:*90 Tablet(s)* Refills:*0*
15. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower lobe nodule.
Discharge Condition:
stable
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**10-26**] at 3:30pm on the [**Hospital Ward Name 5074**] Sharpiro Clinical Center [**Location (un) 24**].
Report to the [**Location (un) **] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16800**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-10-19**] 4:00
Completed by:[**2128-10-12**]
|
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"438.89",
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"443.9",
"V12.51",
"349.9",
"V45.82",
"414.01",
"433.10",
"V10.87",
"345.90",
"E878.8",
"780.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.20",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
8126, 8184
|
4281, 6105
|
313, 398
|
8252, 8261
|
2310, 2898
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8284, 8731
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1872, 1951
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1966, 2291
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3055, 3055
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3088, 4258
|
249, 275
|
426, 486
|
2934, 3022
|
508, 1488
|
1504, 1856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,301
| 178,472
|
51558
|
Discharge summary
|
report
|
Admission Date: [**2136-8-25**] Discharge Date: [**2136-8-31**]
Date of Birth: [**2060-1-15**] Sex: M
Service: MEDICINE
Allergies:
Protamine Sulfate / Ambien
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Bilateral lower extremity swelling.
Major Surgical or Invasive Procedure:
[**8-26**] knee washout, plastic removed but metal left in.
History of Present Illness:
76 yo man w/ hx of CKD, DM2, HTN, COPD, who presents to the ED
for increasing swelling and redness to b/l LE (L>R) and SOB
w/productive cough w/yellowish sputum that has been worsening
over the last 1-1.5wks. In ED patient reported weight gain of 15
pounds in last two weeks and bilateral lower extremity swelling.
In addition had fever to 101.5 at home, increased sputum, cough,
slight hemoptysis and yellow phlegm. Also had worsening DOE to
the point that he could not get out of his wheel chair.
In ED he was given Vanc and neb X 1. CXR showed CM but no PNA.
LENI's unable to r/o DVT, though unlikely.
On the floor, patient was given vanc, ctx, azithro to cover CAP
and a cellulitis/septic arthritis. Ortho planned to take patient
to OR [**8-26**] for washout and hardware change given may be septic
joint. Patient initially had low-grade fever to 99.9 with BPs
ranging 140s-170s/70a, HR 90s. Initial O2 sat was 95% on RA. He
received amytriptline (150mg), gabapentin (300mg) and a dose of
2 mg Iv morphine at 2200. At ~ 1am NF was called for
tachypnea/respiratory distress. Patient was breathing at 30 with
new O2 requirement (91% on RA 97% on 2L NC). Felt still SOB as
he did when he came in but was not initially altered. Got a neb
and labs were sent including ABG which revealed: PH 7.4/ PCO 40/
PO2 62. (abgs from [**2132**] on with O2 mas as only 70s with pH 7.4
when PCO2 is 40). Patient thought to have acute CHF exacerbation
and given 80mg IV lasix with good UOP but no improvement in
breathing. Given worry about patients MS (which had waned down
over the course of the NF evaluation) and hypoxia he was
transferred to the ICU.
Past Medical History:
Chronic renal failure, Stage IV
Hyperlipidemia
DM2
HTN
CAD
Osteoarthritis
Peripheral neuropathy [**1-31**] spinal stenosis
AAA
MGUS
Thrombocytopenia
COPD
Diastolic CHF w/ LVH
Morbid obesity
Social History:
Former history of tobacco use, [**4-2**] ppd x 40-50 years, stopped in
'[**16**]. Heavy alcohol use, though decreasing in recent months, last
drink was over a week ago. No history of withdrawal. Denies
illicit drug use.
Family History:
Father died at 96. mother died at 93. Diabetes.
Physical Exam:
Vitals: VS: Tm 98.7 111-132/70s 80-90s 98% RA
General: Alert, oriented X 3; appropriate, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: thick neck, supple, JVP difficult to assess given habitus
Lungs: short expiratory phase, anterior fields clear b/l,
decreased bs at b/l bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding,
GU: foley in place
Ext: warm, 2+ chronic venous stasis changes and multiple areas
of excoriation and surrounding erythema. Pneumoboots in place. L
knee is in immobilizer and is wrapped with Ace wrap.
Neuro: A&Ox3; CNII-XII intact; sensation grossly intact
Pertinent Results:
INITIAL LAB DATA
[**2136-8-25**] 02:45PM BLOOD WBC-15.9*# RBC-3.56* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.8 MCHC-33.3 RDW-14.6 Plt Ct-62*
[**2136-8-27**] 03:55AM BLOOD Neuts-93* Bands-1 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-8-26**] 06:08AM BLOOD Fibrino-804*
[**2136-8-27**] 03:55AM BLOOD Glucose-230* UreaN-52* Creat-3.1* Na-138
K-5.0 Cl-103 HCO3-23 AnGap-17
[**2136-8-26**] 06:08AM BLOOD ALT-10 AST-13 AlkPhos-85 TotBili-0.2
[**2136-8-25**] 02:45PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-1526*
[**2136-8-26**] 04:00AM BLOOD Type-ART pO2-62* pCO2-41 pH-7.40
calTCO2-26 Base XS-0
[**2136-8-26**] 06:44PM BLOOD Type-ART pO2-114* pCO2-62* pH-7.24*
calTCO2-28 Base XS--2
[**2136-8-27**] 03:20AM BLOOD Type-ART pO2-117* pCO2-49* pH-7.34*
calTCO2-28 Base XS-0
.
AT DISCHARGE:
CBC ([**8-30**]) 8.0/9.4/28.2/96
BMP: 137/4.0/99/26/45/2.3/79
.
MICRO:
[**2136-8-25**] 2:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CEFTRIAXONE Susceptibility testing requested by DR.
[**Last Name (STitle) **] #[**Numeric Identifier 78716**]
[**2136-8-28**]. CEFTRIAXONE = 0.19 MCG/ML.
Cefpodoxime & MINOCYCLINE SENSITIVITY TESTING REQUESTED
BY [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] #[**Numeric Identifier 14013**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- =>2 R
ERYTHROMYCIN---------- =>4 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**2136-8-26**] 7:56 am JOINT FLUID Source: Kneeleft.
**FINAL REPORT [**2136-8-29**]**
GRAM STAIN (Final [**2136-8-26**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**2136-8-26**] 4:07 pm TISSUE PERI-PORSTHETIC LEFT KNEE.
GRAM STAIN (Final [**2136-8-26**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2136-8-29**]): NO GROWTH.
Legionella Urinary Antigen (Final [**2136-8-27**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING
ECHO ([**8-27**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Pulmonary artery systolic hypertension. Mild
mitral regurgitation. Dilated ascending aorta.
Compared with the prior study (images reviewed) of [**2134-4-28**], the
findings are similar.
CXR ([**8-28**])
IMPRESSION:
1. Small bilateral pleural effusions, unchanged.
2. Mild cardiomegaly and tortuosity of the aorta, stable.
3. Mild pulmonary vascular congestion
Brief Hospital Course:
# Hypoxia/Shortness of breath: Must likely multifactorial in
etiology: with contribution from underlying COPD (wheezing and
short expiratory phase on exam), CHF given elevated BNP and
fluid on CXR, obesity-hypoventilation syndrome given body
habitus, and ?pneumonia though CXR without focal infiltrate.
Patient empirically treated for PNA given WBC count with broad
spectrum antibiotics:vanc/ctx/azithro. Given IV solumedrol and
a prednisone taper for COPD. Home lasix initially held due to
acute on chronic kidney failure. In house CXR with mild vascular
congestion. As [**Last Name (un) **] improved home lasix/metolazone restarted and
patient diuresised well. With treatment of COPD, CHF and ?PNA
symptoms improved and patient weaned off supplemental oxygen
prior to discharge; completed predisone taper. Foley was left in
place in our for rehab facility to adequately monitor I/O.
# Septic Left knee/right left extremity cellulitis. Patient
found to have erythematous and tender left knee as well as
possible cellulitis of posterior right calf. Patient taken to OR
by ortho for washout of left knee by Dr. [**First Name (STitle) **]. PRINCIPAL
PROCEDURE:1. Irrigation debridement to bone of left TKR.2.
Revision of left TKR exchange of polyethylene liner.3. Biopsy of
left knee tissue.4. Total synovectomy left knee. 2 JP drains
were placed and removed by ortho on [**8-30**], Per ortho recs patient
without need for further wash-out as they do not believe knee to
be primary source of infection; more so that the joint was
seeded hematogenously; possible sources include skin flora, or
incomplete suppression of previous group B strep infection in
[**2133**].. Fluid cultures andj oint tissue obtained with no growth
to date in house. Patient was placed on broad antibiotics and
discharge on IV ceftriaxone. Pain controlled in house with
Tylenol and oxycodone 5mg PO Q8hrs as needed. Patient maintained
on low dose narcotics with attempted to minimize use as patient
with sedative side effects as well as mild hallucinations.
.
# Group B Bacteremia. During infectious work-up blood cultures
were obtained that were positive for Grp B Strep susceptible to
CTX. Of note, positive history of Grp B Bacteremia in [**2133**].
Question if this presentation of bacteremia represents new
infection or incomplete suppressant of old. Patient initially on
vancomycin and CTX. Treatment tailored to IV CTX after
susceptibilities obtain. PICC line placed for prolonged course
of Abx tx on [**8-30**].
.
# CAD: No complaints of chest pain. EKG with no ischemic
changes. Cardiac enzymes negative. Patient continued on ASA, BB,
ace-i, statin.
.
# Thrombocytopenia: Etiology unclear. Chronic issue in patient
with known MGUS. Worked up in [**2132**] by Heme-Onc.Monitored in
house. SPEP, UPEP ordered with plan to be followed up as
outpatient. At discharge plt count at baseline: 96.
.
# Chronic Kidney Disease (stage 4) baseline creatinine 2.7.
Elevated during admission (peak 3.1) possibly secondary to
hypervolemia. Downtrended during admission with re-initiation of
diuresis, at discharge creatinine: 2.4.
.
# Hypertension. Normotensive in house. Continued on amlodipine.
Lasix initially held due to [**Last Name (un) **]. Home dose restarted in house.
.
# Peripheral Neuropathy. Gabapentin and Amitriptyline held in
house and due to sedative side effects held at time of
discharge.
.
# Depression. Continued on outpatiet Celexa.
.
# DM. Sugars well controlled on home Lantis and insulin sliding
scale.
Medications on Admission:
ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for
Nebulization - one ampule inhaled every 6-8 hours as needed for
as needed for shortness of breath Use with nebulizer machine -
No
Substitution
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
[**12-31**]
puffs by mouth every four (4) to six (6) hours as needed for
cough/wheezing
AMITRIPTYLINE - 150 mg Tablet - 1 (One) Tablet(s) by mouth hs
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DEPTH SHOES AND INSERTS - - wear daily for patient with
diabetes and neuropathy
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhales twice a day
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth hs
GEMFIBROZIL - 600 mg Tablet - [**12-31**] Tablet(s) by mouth twice a day
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen -
give
4 times a day; give sq as per sliding scale
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 76 units sq every morning
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 2 puffs inhaled four times a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
METOLAZONE [ZAROXOLYN] - 2.5 mg Tablet - 1 (One) Tablet(s) by
mouth once a day as needed for weight greater than 305 pounds
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth every four (4) - six (6) hours as needed for pain
PRAVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
.
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other
Provider; OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet
by mouth day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1
Capsule(s) by mouth once a day
GERIATRIC MULTIVITAMINS-MIN [MULTI-VIT 55 PLUS] - (Prescribed by
Other Provider) - Tablet - 1 Tablet(s) by mouth day
INSULIN SYRINGE-NEEDLE U-100 - 31 gauge X [**5-13**]" Syringe - use
twice a day as directed
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): This will be
continued for minimum 6-week course (start date was [**8-26**]).
Patient will follow-up in infectious diseases clinic on [**9-20**].
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please continue while patient is
relatively immobile. As patient regains ability to ambulate may
discontinue at rehab.
16. Insulin Glargine 100 unit/mL Cartridge Sig: Seventy Six (76)
Subcutaneous once a day: Once daily in the morning.
17. Insulin Lispro 100 unit/mL Cartridge Sig: ASDIR
Subcutaneous three times a day: Per sliding scale, with meals.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
21. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating/gas.
22. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for sob/wheezing.
23. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation every six (6) hours.
24. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
26. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for for weight greater than 305lbs.
27. Insulin Aspart 100 unit/mL Insulin Pen Sig: One (1) give 4
times a day Subcutaneous four times a day: give sq as per
sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY:
Group B Bacteremia
Septic Left Knee
CHF
COPD
SECONDARY:
Hypertension
Chronic Kidney Disease
Anemia
Thrombocytopenia
Discharge Condition:
Mental status: clear and coherent
Ambulatory status: requires assistance with ambulation, transfer
due to knee pain s/p wash-out
Discharge Instructions:
You presented to [**Hospital1 18**] with symptoms of shortness of breath and
increased pain and swelling of your right leg and left knee.
.
On admission you had a fever and elevated white blood cell count
indicative of infection. Regarding the lower extremity pain you
were treated for presumed skin infection of the right leg and
left knee. You were started on antibiotics and taken to the OR
to have your left knee washed out. During the procedure two
drains were placed in the L knee. Orthopedic surgery followed
you throughout your stay. They did not feel you needed any
additional procedures during the hospitalization. The drains
were pulled on [**8-30**]. You will follow up with Dr. [**Last Name (STitle) **] in ortho
clinic on [**9-14**].
.
Regarding your shortness of breath with oxygen requirement. It
was thought this was due to a constellation of things:
underlying COPD, congestive heart failure and possible
pneumonia. You were placed on antibiotics to treat pneumonia.
You completed treatment prior to discharge. Regarding COPD you
were started on a prednisone taper, and given breathing
treatments (with nebulizers) as needed. Your initial CXR
illustrated mild fluid overload consistent with CHF. You were
placed on home dose of Lasix and diuresed well. With these
intervention your breathing gradually improved and at time of
discharge you no longer required oxygen.
.
During the infectious work-up, blood cultures were obtained
which were positive for Group B Strep. You were placed on IV
Ceftriaxone to treat the infection. The infectious disease team
also helped work on your case and recommended continued
treatment with ceftriaxone for mininum 6weeks. A PICC line was
placed prior to discharge to faciliate IV antibiotic treatment.
You will follow up with infectious disease clinic as an
outpatient.
.
CHANGES TO MEDICATION:
START taking
Ceftriaxone IV - 6 week duration
Followup Instructions:
Department: ORTHOPEDICS
When: FRIDAY [**2136-9-14**] at 4:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2136-9-17**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],ANP-BC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: FRIDAY [**2136-9-14**] at 4:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2136-9-17**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],ANP-BC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2136-9-20**] at 8:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2136-10-12**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2136-8-31**]
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59,067
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36478
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Discharge summary
|
report
|
Admission Date: [**2101-8-17**] Discharge Date: [**2101-9-8**]
Date of Birth: [**2034-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
melanotic stool
Major Surgical or Invasive Procedure:
intubation
central venous line placement
arterial line placement
History of Present Illness:
Mr. [**Known lastname 60517**] is a 66 y.o. Male with a history of hepatic
sarcoidosis, ascites, ?cirrhosis, Grade I varicies, pulmonary
sarcoidosis, s/p recent hospitalization for melena requiring
PRBC transfusion presents for a TIPs evaluation.
.
Pt resides in [**Location (un) 3844**] and last week noted 3 days of
Melena, as well as general fatigue and weakness. Given that he
was just started on Iron supplements he decided not to come into
the hospital immediately, however after he noted some epigastric
pain on Satruday as well as a low grade temp his wife decided to
take him to the hospital.
.
Per the outside hospital notes that were faxed, on arrival to
the ED he was noted to have guaiac positive stool with no gross
frank blood. He was noted to be hypotensive at the time in the
60s (usual SBP is 90s), his Hct was 27.8 (his prior Hct baseline
is 27) and he was given IVF and transfused 2 units. He received
an upper endoscopy although it is unclear if this was performed
during his hospitalization course or whether it was done a week
prior. The upper endoscopy showed no gastric or esophageal
varicies but did show bleeding of the antrum as well as some of
the gastric body which was thought to be from gastric antral
portal hypertensive gastropathy. His bleeding was treated with
Argon plasma coagulation, and was thought to be
non-hemodynamically significant rectifiable only by liver
transplant or TIPs procedure. Following an appropriate reposnse
in his Hct from 27->32 pt was discharged with GI recommendation
of PPI therapy, follow up with his GI doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**] and
periodic transfusions. After calling the transplant nurse pt was
recommended to come into the hospital for TIPs evaluation.
.
Of note pt was recently hospitalized early last month for TIPs
evaluation. His upper endoscopy on [**2101-7-10**] at [**Hospital1 18**] for
screening purposes during a hospitalization for abdominal pain.
At the time it showed only Grade 1 Varicies and the same gastric
portal hypertensive gastropathy. His Nadolol was discontinued
but then restarted by Dr. [**Last Name (STitle) 696**] given the portal hypertensive
gastropathy. The possibility of a TIPs was discussed with Dr.
[**Last Name (STitle) 696**] which per his note was not preferred given pt's cardiac
work up showing ejection of 45% and reversible perfusion defects
on stress MIBI. After this finding Cardiology were consulted an
pt was felt to be at high risk for bleeding given his
gastropathy and the need for antiplatelet therapy during
catherization.
.
Currently pt denies any fevers, chills, congestion, sore throat,
cough, shortness of breath, chest pain. He does have some
abdominal discomfort with his hernia around the umbilical
region. He still endorses melena but denies any nausea,
vomiting, constipation, hematochezia, hematuria. +diarrhea prior
to coming to the hospital for which he took Imodium.
Past Medical History:
- [**Last Name (STitle) 7816**]-[**Location (un) **] ([**2099**]), trigger apparently a viral URI; s/p
tracheostomy, PEG, now reversed; course complicated by MSSA
ventilator-associated pneumonia, C difficile colitis, and NSTEMI
- sarcoidosis, with biopsy of a mediastinal lymph node
demonstrating noncaseating granulomata and liver biopsy
demonstrating noncaseating granulomata, nodular regeneration,
and positive reticulin staining c/w sarcoidosis of the liver
- s/p ventral hernia repair ([**3-/2101**])
- T&A as an adolescent
- grade II varices in the distal esophagus,
- Duodenitis
- Portal hyprtensive gastropathy,
- 10 mm ulcer in the antrum, anterior wall. seen on [**5-17**] EGD
- BPH
- CAD
Social History:
Lives in [**Location (un) 3844**] with wife, has 3 adult children. Never
smoked or used illicit drugs, denies current EtoH use.
Family History:
Mother died of emphysema in 70s, father died of sudden heart
attack at age 47 while refereeing a high school football game.
Physical Exam:
Vitals - T:98.0, BP: 118/65, HR: 65, RR: 18, 02 sat: 98% on RA
GENERAL: Caucasian, chronic-sick appearing pt with Dobhoff tube
in NARD.
HEENT: No scleral icterus noted, EOMI, MMM.
CARDIAC: Distant S1, S2, no m/g/r, RRR
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: Normoactive BS x 4, distended with +fluid wave.
Abdominal hernias noted, pt displays mild discomfort with
palpation of umbilical hernia, hernias are easily reducible on
examination.
Rectal: Stool noted in vault, no hemorrhoids palpated. Brown
stool noted, guaiac positive.
EXTREMITIES: No edema noted, no asterixis noted.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout.
Pertinent Results:
LABS ON ADMISSION:
[**2101-8-17**] 11:35PM BLOOD WBC-11.0# RBC-3.80*# Hgb-11.5*#
Hct-34.4*# MCV-91 MCH-30.4 MCHC-33.6 RDW-17.9* Plt Ct-136*
[**2101-8-17**] 11:35PM BLOOD Neuts-82.2* Lymphs-9.9* Monos-5.7 Eos-1.6
Baso-0.5
[**2101-8-17**] 11:35PM BLOOD PT-15.4* PTT-28.9 INR(PT)-1.4*
[**2101-8-30**] 05:39AM BLOOD Fibrino-218
[**2101-8-17**] 11:35PM BLOOD Glucose-103 UreaN-48* Creat-1.8* Na-136
K-4.7 Cl-110* HCO3-19* AnGap-12
[**2101-8-17**] 11:35PM BLOOD ALT-24 AST-35 AlkPhos-161* TotBili-2.6*
[**2101-8-17**] 11:35PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.0 Mg-1.9
TROPONIN TREND:
[**2101-8-30**] 01:14AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2101-8-30**] 05:39AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2101-8-30**] 12:25PM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2101-8-30**] 10:05PM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2101-8-31**] 04:11AM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2101-8-31**] 03:08PM BLOOD CK-MB-5 cTropnT-0.28*
Brief Hospital Course:
Discharge Summary per Floor Team
# Portal Hypertensive Gastropathy and associated melena - Mr.
[**Known lastname 60517**] was admitted to [**Hospital1 18**] after discharge from OSH in New
[**Location (un) **] for possible TIPS procedure due to documented portal
hypertensive gastropathy with chronic oozing requiring multiple
admissions and blood products. On admission, his stool was
noted to be guaiac positive, however he was not actively
stooling due to administration of immodium prior to drive from
[**Location (un) 3844**]. IV PPI was started and nadolol was continued on
admission. Patient was started on bowel regimen. Type and
screen was kept active and access was maintained for possible
resuscitation. After 2 days of admission, patient had a large
melanotic bowel movement. Hematocrit was followed closely and
noted to return to baseline (he had been s/p 2 units PRBCs at
OSH) and then noted to be stable. Due to history of portal
hypertensive gastropathy documented at [**Hospital1 18**] and recent EGD at
OSH, repeat EGD was not done. After consulting cardiology,
decision was made to undergo TIPS without prior cardiac
catheterization. TIPS was planned, however patient's renal
function declined and TIPS was postponed. During this time
patient continued to have melanotic stools. Nadolol was
discontinued on day 6 of admission due to heart rate in the low
60's so as to not mask tachycardia in setting of possible bleed.
Hematocrit continued to be stable. Renal failure improved,
however TIPS was postponed again due to diagnosis of SBP.
# Abdominal Pain - Mr. [**Known lastname 60517**] had abdominal pain on presentation
to [**Hospital1 18**]. Patient has chronic pain at baseline, but stated it
was an acute worsening. Ventral hernia was examined and
determined to be reducable without pain. Abdominal ultrasound
on admission showed cirrhotic liver, moderate-to-large ascites
and patent hepatic vasculature. There was concern for possible
obstruction after no bowel movements for first 2 days, but KUB
did not support this diagnosis. Diagnostic paracentesis on
hospital day 3 was negative for SBP. Abdominal pain was also
noted to be associated with nausea and emesis, tube feeds were
held with some resolution. Patient did have non-bloody emesis x
2. Tube feeds were re-started slowly and titrated to goal
over many days, with intermittent discontinuation due to nausea.
On day 9 of admission, paracentesis was repeated which was
positive for SBP with neutrophil count of ~1700 when corrected
for blood from traumatic introduction of needle. See below.
.
# SBP: On day 9, patient was noted to have elevated white count
and continued abdominal pain. Paracentesis was positive for SBP
(~1700 neutrophils) and patient was started on Ceftriaxone.
Patient was afebrile and hemodynamically stable. After less
than 24 hours of treatment with Ceftriaxone, white blood cell
count continued to increase and patient looked clinically worse
on exam with increased somnelance and diaphoresis. Antibiotic
coverage was changed to Cefepime and Vancomycin (Vancomycin
added due to finding on CXR in LLL). Patient showed imrpovement
with change of antibiotics with resulting decrease in white
blood cell count. IV Flagyl was added for anaerobic coverage.
On [**8-29**] days after diagnosis of SBP, patient had continued
abdominal pain with associated nausea. CT Abdomen and Pelvis
(without contrast [**1-10**] ARF) showed no acute process. Repeat
paracentesis showed increased neutrophils in ascitic fluid and
antibiotic coverage was changed to meropenem. He had a repeat
diagnostic paracentesis in the MICU on [**2101-9-3**], which was again
positive for SBP despite coverage with vanco/[**Last Name (un) 2830**]/cipro/flagyl.
Fungal coverage was considered, but ultimately not started given
his overall declining clinical status.
.
#. Acute Renal Failure - Patient admitted with creatinine of
1.8, elevated from baseline ~1.4 on previous admission.
Diuretics were held. Renal function continued to worsen over
4-5 days. Patient was given small IVF boluses intermittently,
however attempt was made not to fluid overload patient due to
history of liver disease and ascites. Patient did not respond
to albumin challenge. Urine electrolytes showed Na > 10, not
consistent with HRS. Due to tube feed hold [**1-10**] nausea and
emesis, patient was placed on maintenance fluids while not
recieving feeds. Additionally, free water was increased in tube
feeds. With worsening renal function to 2.4, patient was given
NS boluses and additional fluids which he responded to. In the
MICU, his creatinine was [**Last Name (un) 15355**] elevated. He was maintained on
octreotide and midodrine, as well as daily albumin.
#. Hypoxic Respiratory Failure - Patient aspirated and was
transferred to the MICU for hypoxic respiratory failure. He was
intubated on arrival. He was found to have a large consolidation
and started on vanco/flagyl, in addition he was maintained on
meropenem and cipro as above. Nothing was found on bronchoscopy.
He was unable to wean successfully on the vent. Therapeutic
paracentesis was attempted on [**9-3**] to improve respiratory
status, but only a liter could be taken off. Family opted not to
repeat paracentesis given overall deteriorating clinical
picture.
#. Cirrhosis: Patient has history of sarcoidosis and possible
sarcoidosis of liver, however it is felt that he most likely has
cirrhosis of the liver with ESLD. Noted to have chronic portal
hypertensive gastropathy requiring multiple admissions and blood
products. Also noted to have varices. Patiently was previously
considered for TIPS procedure at [**Hospital1 18**] about 1 month prior to
admission, but this was not done due to cardiac risk factors.
Cardiology was re-consulted during this admission and determined
that the risk of cardiac intervention was higher than with the
TIPS, so cleared patient for TIPS and to deal with any cardiac
complication as they arise. TIPS was scheduled, however
postponed due to acute renal failure and then infection.
Additionally, the prospect of possible transplant had been
discussed previously with the patient and family, however due to
his decreased ejection fraction (>45%), he is not a candidate
for transplant at [**Hospital1 18**]. At family's request, patient was to be
referred to [**Hospital1 **]-[**Location 14660**] for evaluation for possible
CABG-liver transplant upon discharge. Before patient was able
to receive TIPS procedure he was sent to the ICU for respiratory
failure after possible aspiration event.
# History of NSTEMI/EF 45% - Patient with history of NSTEMI
during prior hospitalization at [**Hospital1 2025**] with resultant EF 45%.
Initially seen by cardiology at [**Hospital1 18**] during previous admission
in [**Month (only) 216**]. Cardiology was re-consulted during this admission
for discussion on pursuing TIPS. No intervention for previous
positive stress-MIBI was done during this admission.
Summary per ICU Team
ICU Course: Vitals were monitored closely and noted to be stable
until [**8-29**] when Mr. [**Known lastname 60517**] had an acute event marked by hypoxia
with subsequent transfer to the ICU. CXR revealed a substantial
right lung white out suggestive of aspiration PNA vs. chemical
pneumonitis. He was also noted to have a continued significant
GIB with falling HCT requiring multiple transfusions of blood
products and plasma. Patient was noted to be in shock with
likely hemorrhagic and septic compononets from pneumonia and
SBP. Patient was broadly covered with Vancomycin, Meropenum,
Cipro and Flagyl. He was also intubated for respiratory failure
and started on pressors. Liver was consulted, but patient was
no longer considered a candidate for TIPS given multiple medical
comorbidities and likely mortality a/w procedure. An UGI scope
was performed demonstrating oozing gastropathy and liver
recommended reversing INR with FFP. ECG was performed showing ST
depressions in the lateral leads accompanied by cardiac enzyme
elevation. Echo was performed which showed wall motion
abnormalities in the corresponding territory suggesting
significant myocardial ischemia; however, given comorbid illness
and active GIB, patient was not candidate for intervention or
anti-coagulation. Patient also began to develop atrial
fibrillation with runs of rapid ventricular response, causing
further demand ischemia which was treated with metoprolol PRN
for rate control. A second therapeutic / diagnostic paracentesis
was performed demonstrating continued SBP despite broad spectrum
antibiotic coverage. Patient continued to deteriorate with
multi-organ system failure and no progression with aggressive
therapeutic interventions by ICU team. On [**9-7**], after extensive
conversations with family, the decision was made for CMO care.
The patient was extubated and all medical therapy was withdrawn.
The patient was started on a morphine drip. The patient passed
away at 7:54 AM on [**9-8**].
Medications on Admission:
Furosemide 20mg daily
Aldactone 50mg daily
Tamsulosin 0.4mg daily
Nadolol 20mg daily
Calcium + vit D 1 tab daily
Esomeprazole 40mg daily
MVI
Nutren Pulmonary TF
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
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40,586
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|
46819
|
Discharge summary
|
report
|
Admission Date: [**2196-11-6**] Discharge Date: [**2196-11-10**]
Date of Birth: [**2118-1-22**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Nut Flavor
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Aflutter ablation
History of Present Illness:
This is a 78 year-old male with bipolar disorder,
T2DM,hypertension, and hyperlipidemia who presented to [**Hospital **]
Hospital after a syncopal episode at home and was found to be
bradycardic and hypotensive. He was managed there for about a
day and transferred to [**Hospital1 18**] as he is a patient of Dr. [**Name (NI) 11723**]. Of note, he was recently discharged on [**2196-11-2**] after
being admitted for rate control of atrial fibrillation/flutter.
Plan during his last admission was to have a TEE and then
ablation for his atrial flutter. However, due to an esophageal
issue and inability to pass the TEE probe, he was discharged
home with medical management of his atrial flutter with plan for
flutter ablation in the near future.
Per patient's wife, he went to the bathroom, had a BM, and
immediately thereafter felt dizzy and subsequently passed out.
His wife caught him as he fell, but he scraped his ear on the
wall. No reported seizure-like activity.
OSH course: On admission, EKG was notable for atrial rate of 300
and ventricular rate of 28. He was hypotensive and was started
on dopamine. He was found to be in ARF and was hyperkalemic. He
was admitted to the CCU. He remained clinically stable there. He
was hydrated with 3L NS and BP maintained on low-dose dopamine.
He remained in atrial flutter. His Geodon and Coumadin were
held.
Upon transfer to the [**Hospital1 18**] CCU, he arrived hemodynamically
stable on dopamine gtt at 8 mcg/kg/min. His heart rate was in
the 50-60s.
ROS: Negative except as above.
Past Medical History:
Prostate Cancer s/p radiation treatment [**2193**]
T2DM with neuropathy
Hypertension
Gout
Bipolar Disorder type 1
Hyperlipidemia
Atrial flutter
CRI
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse but the patient drinks
[**1-31**] shots of vodka per week when his neuropathy is hurting.
There is no family history of premature coronary artery disease
or sudden death. Patient enjoys playing music, jazz piano in
particular.
Family History:
Noncontributory
Physical Exam:
Gen: Elderly aged male in NAD. Oriented x 3. Mood, affect
appropriate, wearing cap due to photophobia.
HEENT: Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of
the oral mucosa.
Neck: Supple with JVP of 9cm.
CV: Regular rhythym, tachycardic, normal S1, S2. No murmur
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles bilateral
bases, no wheezes or rhonchi.
Abd: Soft, NT, ND. No HSM or tenderness.
Ext: 2+ pitting edema to ankles. DP pulses 1+.
Skin: No ulcers, scars, or ecchymosis.
Neuro: CN2-12 grossly intact. Strength normal.
Pertinent Results:
[**2196-11-10**] 05:10AM BLOOD WBC-5.0 RBC-3.76* Hgb-11.2* Hct-33.3*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.2 Plt Ct-166
[**2196-11-9**] 03:20PM BLOOD PT-16.8* PTT-34.0 INR(PT)-1.5*
[**2196-11-10**] 05:10AM BLOOD Glucose-156* UreaN-35* Creat-1.8* Na-135
K-4.3 Cl-100 HCO3-28 AnGap-11
[**2196-11-10**] 05:10AM BLOOD Mg-1.8 Cholest-86
[**2196-11-9**] 03:20PM BLOOD ALT-15 AST-17 LD(LDH)-151 AlkPhos-87
TotBili-1.0
[**2196-11-10**] 05:10AM BLOOD Triglyc-108 HDL-30 CHOL/HD-2.9 LDLcalc-34
[**2196-11-7**] 05:23AM URINE Hours-RANDOM Creat-19 Na-40
[**2196-11-7**] 05:23AM URINE Osmolal-203
Barium Swallow [**11-7**]: Normal-appearing esophagus without
evidence for narrowing or obstruction. Motility not assessed.
ECHO [**11-7**]: No LA/LAA thrombus. Mild mitral regurgitation.
Simple atheroma in the descending aorta.
Brief Hospital Course:
78 M with bipolar, a-flutter/fib, T2DM who presents s/p syncopal
episode with bradycardia and hypotension and cardiogenic shock
causing renal failure and hyperkalemia.
SYNCOPE/HYPOTENSION - Most likely etiology of his bradycardia
and syncope was nodal [**Doctor Last Name 360**] overdose. Pt was recently admitted
and diagnosed with atrial flutter, with rate control on
metoprolol. Patient reported taking diltiazem and metoprolol at
home although specifically being told to stop the diltiazem. He
also reports feeling weak and lightheaded since that discharge.
Both the beta blocker and calcium channel blocker were held and
pt's heart rate improved. He required HR control for his atrial
flutter, which was successfully acheived with slowly increasing
doses of metoprolol. After normal barium swallow and TEE ruling
out vegetations, and INR decreased to acceptable, pt underwent
successful ablation of his atrial flutter. Pt was continued on
Warfarin after ablation for plan on 1 month of anticoagulation
post ablation.
PUMP - Pt had received 3L IVF at OSH for hypotension and was
diuresed successfully at [**Hospital1 18**] with several doses of IV lasix.
BIPOLAR DISORDER - Patient on Geodon as outpatient. Concern that
may be contributing to his bradycardia (known side effect of the
medication). Psychiatry was consulted and recommended holding
Geodon and starting bedtime Zyprexa.
ACUTE ON CHRONIC RENAL FAILURE - Creatinine on admission was
2.6, up from 1.4. Likely related to decreased perfusion in
setting of hypotension was improving at time of discharge 1.8.
DIABETES TYPE 2: Continued neurontin for neuropathy. BS control
with insulin sliding scale.
BPH - Terazosin was held given hypotension and restarted prior
to DC.
GOUT - Continue allopurinol
Medications on Admission:
HOME MEDICATIONS:
Metoprolol 100 mg PO TID
Warfarin 2 mg PO daily
Allopurinol 300 mg PO daily
Neurontin 300 mg PO [**Hospital1 **]
Zocor 20 mg PO daily
Geodon 20 mg QAM, 80 mg [**Hospital1 **]
Klonazipam 0.5 mg [**Hospital1 **]
Terazosin 10 mg [**Hospital1 **]
Lisinopril 20 mg daily
Cartia 240mg dialy
Glipizide 10mg [**Hospital1 **]
.
MEDICATIONS UPON TRANSFER:
Dopamine gtt
Neurontin 300 mg PO [**First Name9 (NamePattern2) **]
[**Last Name (un) **]
Protonix 40 mg IV daily
Allopurinol 100 mg PO daily
Zocor 20 mg PO daily
Geodon 20mg qAM and 80mg qPM
Tylenol PRN
Zofran PRN
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: 1.5 syringes Subcutaneous
once a day.
Disp:*2 syringes* Refills:*4*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Terazosin 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please get your INR, BUN, Creatinine and K drawn on [**2196-11-11**] and
call results to Dr. [**First Name (STitle) **] Phone: [**Telephone/Fax (1) 99363**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial flutter s/p ablation
Acute cardiogenic shock due to excess nodal blockade and
bradycardia.
Acute Renal Failure
Diabetes Mellitus
Bipolar Disorder
Discharge Condition:
stable
BUN 35
creat 1.8
INR 1.7
Hct 33.3
Discharge Instructions:
You had an ablation owithin the right atrium to treat your
atrial fibrillation. You are now in a normal rhythm. You are at
an increased risk of stroke for the next few weeks so we have
started you on Lovenox injection to be taken until your Warfarin
level is > 2.0. Please take the Lovenox until Dr. [**First Name (STitle) **] tells you
not to. You will resume Warfarin at your outpatient dose. Other
medicine changes:
1. Metoprolol has been changed to a long acting pill to be taken
once a day.
2. After discussion with the psychiatrist here and your
outpatient psychiatrist, your Geodon was changed to Zyprexa and
your clonazepam was changed to Zolpidem to be taken at night
only. Please avoid driving until you know if these medicines
will make you sleepy.
.
Only take the medicines on your list, throw out your cardiazem
(cartia), DO NOT take this medicine.
.
Please call Dr. [**First Name (STitle) **] if you have any palpitations, unusual
bleeding, nausea, dizziness, extreme fatigue or any other
concerning symptoms.
Followup Instructions:
Cardiology:
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-11-29**]
11:20
Primary care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 99363**] Date/time: [**11-25**] at
3pm.
Psychiatry:
Dr.[**Name (NI) 14539**] Phone: [**Telephone/Fax (1) 99364**] Date/time: [**11-23**] at
8:30am. In [**Location (un) **] office.
Completed by:[**2196-11-11**]
|
[
"427.89",
"V10.46",
"427.32",
"E849.0",
"785.51",
"873.0",
"584.9",
"296.7",
"403.90",
"585.9",
"274.9",
"E888.9",
"250.60",
"272.4",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"37.34",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
7504, 7553
|
3959, 5732
|
344, 364
|
7750, 7793
|
3124, 3936
|
8865, 9328
|
2473, 2490
|
6361, 7481
|
7574, 7729
|
5758, 5758
|
7817, 8842
|
2505, 3105
|
5776, 6338
|
297, 306
|
392, 1935
|
1957, 2106
|
2122, 2457
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,100
| 127,111
|
15884
|
Discharge summary
|
report
|
Admission Date: [**2124-9-28**] Discharge Date: [**2124-10-4**]
Date of Birth: [**2102-8-15**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: The patient is a 22 year old
Irish male arriving by ambulance, presented at a trauma basis
status post 30 foot fall while cutting trees at work. The
patient, on arrival, was alert and oriented times three and
denies loss of consciousness.
PAST MEDICAL HISTORY: The patient denies any significant
past medical history.
ALLERGIES: The patient answers to no known drug allergies.
MEDICATIONS: The patient takes no medications.
SOCIAL HISTORY: The patient is an Irish citizen working as
a tree worker in the United States.
On admission, the patient states that he fell from
approximately a 30 foot height, falling on his pelvis. He
denies loss of consciousness. He complained of lower back
pain, chest pain and difficulty breathing. Vitals in the
field were oxygen saturation at 100%, blood pressure 150/90;
heart rate 62; temperature 36.2 C.; respiratory rate 14. On
arrival, the patient was alert and oriented times three in a
collar and back board.
PHYSICAL EXAMINATION: Head normocephalic, atraumatic.
Pupils are equal, round and reactive to light. Extraocular
movements intact. Neck with no jugular venous distention,
patient in collar. Chest is clear to auscultation
bilaterally. Cardiovascular examination: The patient has a
II/VI systolic murmur. Abdominal examination is soft,
nontender, nondistended, with positive bowel sounds. Rectal
examination is negative for blood. The patient has upper
lumbar tenderness in his musculoskeletal back examination and
tenderness of the thoracic region. Neurological examination:
Cranial nerves II through XII intact and the patient has
normal motor and sensory function and is again, alert and
oriented times three.
LABORATORY: The patient had a white blood cell count of 9.0,
hematocrit of 48, platelets of 220, BUN of 27, creatinine of
0.8. The patient's toxicology screen was negative.
The patient had a chest CT scan which was negative. Head CT
scan negative.
Chest x-ray findings suggested a left lung contusion.
The patient's abdominal CT scan was consistent with a Grade I
kidney laceration. The patient was also found to have an L3
transverse process fracture.
In the Emergency Department, the patient was trauma basically
seen and film tests discussed and was given a fast
examination which was negative. The patient's coags were 14,
30 and INR of 1.4. Arterial blood gases of 7.39, 43, 79.
Given the patient's Grade I kidney laceration consistent with
subscapular hematoma, a Urology consultation was obtained.
ASSESSMENT AND PLAN: As patient was hemodynamically stable
and the CT scan did not show any extravasation of contrast,
the patient was unlikely to have a urine leak.
HOSPITAL COURSE: The patient was followed with serial
hematocrits and bed rest.
A further addendum to the patient's abdominal CT scan was the
finding of free fluid of unknown source in the abdomen. Due
to the unexplained source, the patient was taken to the
Operating Room for exploratory laparotomy. In the Operating
Room the operating surgeons found no intestinal injury, liver
injury or pancreatic injury. The patient continued to have
positive red blood cells in the urine. A peritoneal lavage
during exploratory laparoscopy showed 52,000 red blood cells,
amylase of 45 and white blood cell count of 178.
A Neurosurgical consultation was also obtained given the
patient's L3 left transverse process fracture with otherwise
normal alignment of his spine. As the patient has no
evidence of motor, sensory weakness, evidence of spinal
stenosis, etc., the fracture was deemed to be a stable
fracture, non-operative, not requiring brace, without limits
to patient's weight bearing status.
On or about [**2124-9-30**], the patient complained of right knee
pain. Orthopedics consultation was obtained. The patient
did have a history of an old right knee meniscal injury
status post arthroscopy. The patient is currently able to
ambulate at the time of consultation and weight bear as
tolerated, but continues to have knee pain with weight
bearing.
The patient's knee was filmed and showed old tibial fracture,
no new acute fracture. It was felt that the patient could
have new ligamentous injury. The patient was advised to
weight bear as tolerated and wear a knee brace until
follow-up in the [**Hospital 5498**] Clinic in ten days.
The question on the patient's knee film was a slight
irregularity of the patient's posterior tibial plateau as
well as showing small joint effusion.
The patient improved throughout the remainder of his hospital
course, easily switching to a regular diet, p.o. medications
and continued to get out of bed and ambulate without
difficulty. The patient was stable at the time of discharge.
DISCHARGE INSTRUCTIONS: As the patient was returning to
[**Country 4754**] permanently in two weeks, the patient was advised to
follow-up with [**Hospital 5498**] Clinic one week from discharge in
addition to Trauma Clinic one week from discharge, wear a
knee brace and weight bear as tolerated.
The patient was discharged with Percocet for pain, Colace for
bowel function.
Activity is as tolerated.
DISCHARGE DIAGNOSES:
1. Left lung contusion.
2. Grade I kidney laceration.
3. L3 transverse process fracture.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2124-10-4**] 18:06
T: [**2124-10-7**] 18:00
JOB#: [**Job Number 45617**]
|
[
"805.4",
"866.01",
"861.21",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
5299, 5667
|
2856, 4874
|
4899, 5278
|
1154, 2838
|
165, 406
|
429, 598
|
616, 1130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,940
| 130,276
|
31575
|
Discharge summary
|
report
|
Admission Date: [**2159-9-3**] Discharge Date: [**2159-9-19**]
Date of Birth: [**2083-3-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Mass
Pneumonia
Major Surgical or Invasive Procedure:
Distal Pancreatectomy with Splenectomy
Mobilization of Splenic flexure
Colectomy
Open Cholecystectomy
History of Present Illness:
This is a 76-year-old woman in excellent health overall. She
recently presented with vague left upper quadrant pain and chest
complaints. This was worked up through a chest CT scan which in
fact showed evidence of a large cystic mass in the left upper
quadrant of the abdomen upon review of the abdominal slices. She
was sent to Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for endoscopic ultrasound
evaluation and cyst analysis was performed. He saw mural nodules
and solid components to this very large cyst but the aspirate
itself was negative for malignancy. I then got involved and we
performed a dedicated CT angiogram of the pancreas to evaluate
this. What we found was a large space-filling mass with
attenuation of the stomach in front of it. This cyst had solid
components with septae within it and was very concerning for a
mucinous cyst adenocarcinoma.
I discussed the need for distal pancreatectomy and splenectomy
with her in great detail. We planned to do this operation in 2
weeks time in an elective fashion. However, she returned to me
10 days prior to this operation with evidence of pneumonia. This
was treated and she recovered and felt much
better from that. This was a left lower lobe pneumonia in the
setting of atelectasis on that side, probably from this tumor
mass. She got better from this but still had poor p.o. intake
and had a very low albumin. For this reason, I elected to keep
her in the hospital and give her TPN for a number of
days.
Past Medical History:
hydatiform mole (non-cancerous)
Social History:
lives at home with husband who has dementia. No tob, occ etoh.
Has 4 healthy children.
Family History:
Many relatives live into 90s. No FH of specific cancers.
Physical Exam:
99.2, 93, 130/60, 20, 95% 2L
Gen: NAD, A+O x3
CV: RRR
Chest: decreased breath sounds left base, dulness to percussion.
Abd: +BS, tender LUQ, nondistended
Ext: no edema, dp palp bilat.
Pertinent Results:
[**2159-9-3**] 08:26PM BLOOD WBC-11.2* RBC-3.84* Hgb-11.6* Hct-35.0*
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.4 Plt Ct-613*
[**2159-9-17**] 05:15AM BLOOD WBC-16.0* RBC-3.11* Hgb-9.5* Hct-28.7*
MCV-92 MCH-30.5 MCHC-33.1 RDW-14.1 Plt Ct-867*
[**2159-9-15**] 02:48AM BLOOD PT-14.4* PTT-35.8* INR(PT)-1.3*
[**2159-9-17**] 05:15AM BLOOD Glucose-80 UreaN-4* Creat-0.5 Na-136
K-3.8 Cl-97 HCO3-23 AnGap-20
[**2159-9-3**] 08:26PM BLOOD ALT-33 AST-44* AlkPhos-208* Amylase-32
TotBili-0.4
[**2159-9-15**] 02:48AM BLOOD ALT-35 AST-34 AlkPhos-96 Amylase-29
TotBili-0.5
[**2159-9-15**] 02:48AM BLOOD Lipase-23
[**2159-9-17**] 05:15AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.9
[**2159-9-15**] 02:48AM BLOOD Albumin-2.6* Calcium-7.7* Phos-3.0 Mg-1.9
.
CHEST (PRE-OP PA & LAT) [**2159-9-3**] 8:20 PM
IMPRESSION: Moderately large left pleural effusion with left
lower lobe consolidation/collapse
.
Cardiology Report ECG Study Date of [**2159-9-12**] 6:41:26 PM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 152 84 378/409.57 62 32 31
.
Brief Hospital Course:
76 F with LUQ pain x 2wks, CT and MRI at [**Hospital 1474**] hospital
revealed a pancreatic tail mass
Pneumonia: She presented with LUQ pain and a new dry hacking
cough, and low grade temperature. A pre-op CXR showed Moderately
large left pleural effusion with left lower lobe
consolidation/collapse - evidence of pneumonia. She was treated
with Levoquin and she recovered and felt much better.
Malnutrition: Due to her low Albumin, she remined in the
hospital on TPN while being treated for the PNA.
She then went to the OR on [**2159-9-12**] for: distal pancreatectomy,
splenectomy, cholecystectomy and bowel resection.
Post-op Hypotension: She stayed the night in the PACU for
hypotension and then was transferred to the SICU to wean off the
pressors.
She also received crystalloid bolus for low urine output and
Albumin for plasma expansion.
Post-op Blood Loss/Anemia: She received 3 units of PRBC.
Pain: She had an epidural for pain control. APS decreased the
solution to 0.05% Bupiv with Dilaudid in order to assist getting
her off pressors. The epidrual was D/C'd on POD 4 and a PCA was
started. Once on a diet, she was tolerating PO pain meds and had
minimal pain.
GI/Abd: She was NPO with a NGT. The NGT was d/c'd on POD 3. His
diet was slowly advanced, starting with sips. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] amylase
was checked on POD 6 and was 25. Her drain was D/C'd later that
evening. She continued to have drainage from the drain site and
suture was placed... Her staples were D/C'd on POD ...She was
tolerating a regular diet at time of discharge.
Pathology: Adenocarcinoma of the pancreas, arising in a cystic
mucinous neoplasm, see synoptic report. a. There is
ovarian-type stroma in the wall of the cyst. b. Focal
calcification of cyst wall.
2. The carcinoma extends into the submucosa of the attached
colon segment.
3. Focus of ossification at one end of the colon segment.
Lymph Nodes 4 of 13 involved.
Oncology was consulted and she will follow-up as an outpatient.
Vaccines: She received meningococ vaccine on [**9-16**], pneumo and
Hib were given prior.
The patient was discharged on [**9-19**] home in stable ocndition.
Medications on Admission:
Percocet 1-2 tabs q4-6h
Discharge Medications:
Tylenol 300/30 1-2 tabs q4-6h
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic mass
Pneumonia
Post-op Hypotension
Discharge Condition:
Good
Tolerating Diet
Pain well controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] 3 weeks. Call ([**Telephone/Fax (1) 2363**]
to schedule an appointment.
|
[
"263.9",
"574.10",
"486",
"280.0",
"458.29",
"157.8",
"197.5",
"197.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"51.22",
"38.93",
"99.15",
"52.52",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
5800, 5806
|
3481, 5672
|
338, 442
|
5896, 5940
|
2448, 3458
|
7029, 7156
|
2169, 2228
|
5746, 5777
|
5827, 5875
|
5698, 5723
|
5964, 7006
|
2243, 2429
|
273, 300
|
470, 1992
|
2014, 2048
|
2064, 2153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,950
| 183,468
|
11980
|
Discharge summary
|
report
|
Admission Date: [**2201-4-30**] [**Year/Month/Day **] Date: [**2201-5-6**]
Date of Birth: [**2132-3-13**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Epidural catheter placment (removed on [**2201-5-5**])
History of Present Illness:
69 YOF s/p fall on bathtub 3 days prior to coming into the ED
who presents with rib fractures [**8-4**], small pneumothorax and
pneumomediastinum.
.
Past Medical History:
HTN, ?COPD
Social History:
+ETOH us at home; recently widowed
Family History:
Noncontributory
Physical Exam:
Upon presentation:
Temp:97.9 HR:126 BP:134/78 Resp:18 O(2)Sat:100 normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
no c spine tenderness
Chest: Clear to auscultation, + crepitus to R chest
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry, + ecchymosis to R chest wall
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2201-4-30**] 06:30PM CK-MB-2 cTropnT-<0.01
[**2201-4-30**] 10:30AM GLUCOSE-140* UREA N-28* CREAT-0.8 SODIUM-131*
POTASSIUM-3.5 CHLORIDE-89* TOTAL CO2-22 ANION GAP-24*
[**2201-4-30**] 10:30AM ALT(SGPT)-126* AST(SGOT)-95* ALK PHOS-115*
TOT BILI-1.5
[**2201-4-30**] 10:30AM WBC-4.0# RBC-3.34* HGB-11.5* HCT-33.6*
MCV-101* MCH-34.5* MCHC-34.4 RDW-13.6
[**2201-4-30**] 10:30AM PLT COUNT-141*
[**2201-4-30**] 10:30AM PT-10.3* PTT-25.7 INR(PT)-0.8*
IMAGING:
-CT Torso: ([**4-30**]): Moderate right pneumothorax, pneumomediastinum
and extensive right upper chest wall soft tissue emphysema. 8th,
9th, and 10th right lateral rib fracture. Small lung contusions.
CXR ([**5-1**]): ? aspiration, no worsening PTX
[**5-2**] CXR: Stable vs sl increased R PTX, LLL atelectasis. Serial
CXRs showing improvement.
Brief Hospital Course:
She was admitted to the Trauma service for pulmonary care and
pain management related to her rib fractures. The Pain Service
was consulted for assistance with pain medication
recommendations; an epidural catheter was placed and remained in
place for several days. Her pain was only fairly well controlled
with the epidural; long and short acting narcotics were added.
it should be noted that she initially became sleepy with the
short acting narcotic and it is being recommended that the
lowest dose be used as indicated. She is also on a bowel
regimen.
Social work was consulted given her history of alcohol and
concerns voiced by her family regarding this and also for coping
related to recent death of her husband. She was provided with
information pertaining to alcohol use and treatment but refused
as noted in social work documentation. She was placed on CIWA
protocol initially but did not show any signs of active
withdrawal.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
ASA 81', albuterol 90'''' prn, Lisinopril 40', Ranitidine 150'',
Cal + D 315/200'', unknown antidepressant
[**Month/Day (4) **] Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection three times a day.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to right chest wall.
14. Oxycodone 5 mg Tablet Sig: [**12-27**] - 1 Tablet PO Q4H (every 4
hours) as needed for pain.
15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
17. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
19. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
[**Month/Day (2) **] Disposition:
Extended Care
Facility:
[**Hospital 745**] HealthCare
[**Hospital **] Diagnosis:
s/p Fall
Right rib fractures 8,9,10
Small right pneumothorax
Pneumomediastinum
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Hospital **] Instructions:
Patient will be in rehab less than 30 days.
You were admitted to the hospital following a fall where you
broke several ribs on your right side. Your injuries did not
require any operations. You remained in the hospital for ~1 week
for pain management and pulmonary care. The Physical therapists
are recommending rehab after your acute hospital stay.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery in 2 weeks for
evaluation of your rib fractures; call [**Telephone/Fax (1) 600**] for an
appointment. Inform the office that you will need a standing AP
end expiratory chest xray for this appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2201-5-6**]
|
[
"305.00",
"401.9",
"338.11",
"807.03",
"860.0",
"958.7",
"E885.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
2140, 3181
|
333, 389
|
1302, 2117
|
5805, 6203
|
672, 689
|
3207, 5242
|
704, 1283
|
285, 295
|
418, 570
|
5257, 5782
|
592, 604
|
620, 656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,573
| 136,564
|
16355
|
Discharge summary
|
report
|
Admission Date: [**2155-4-8**] Discharge Date: [**2155-4-11**]
Date of Birth: [**2116-5-16**] Sex: M
Service: NEUROMEDICINE
HOSPITAL COURSE: The patient is a 38-year-old right-handed
man, with advanced metastatic nasopharyngeal squamous cell
carcinoma, status post chemotherapy and radiation, status
post right internal jugular vein removal, who developed left
hemiplegia following an interventional radiology procedure
during which his left brachiocephalic vein was recanalized
due to a superior vena cava occlusion. One month prior to
admission, the patient developed severe swelling of his head
due to superior vena cava syndrome.
On the day of the procedure, the patient was able to move all
limbs appropriately. During the procedure, he was noted to
still be moving all of his limbs at approximately 3:30 p.m.
After the procedure in the PACU, he was noted to not be able
to move his left side. This was at approximately 6:50 p.m. He
also had a fever of 102 at the time. A neurology consult was
called, and the consult resident noted severe weakness of the
left face, arm and leg. The patient was taken to the MRI
scanner which revealed occlusion of the right internal
carotid artery and right middle cerebral artery with an
evolving right frontoparietal temporal stroke. He was taken
then to the neurological surgical intensive care unit and
placed on Neo-Synephrine to maintain his blood pressure.
PAST MEDICAL HISTORY:
1. Metastatic nasopharyngeal squamous cell carcinoma.
2. Status post tracheotomy.
3. Status post G-tube and removal.
4. Status post right neck dissection and right internal
jugular vein removal.
MEDICATIONS ON ADMISSION:
1. Roxicet 2 tsp q. 4 h.
2. Lasix 30 mg once daily.
3. Pepcid.
4. Motrin p.r.n..
5. Epivir.
6. Coumadin 1 mg once daily.
ALLERGIES: Aspirin and clindamycin.
PHYSICAL EXAMINATION ON ADMISSION: Showed a temperature of
98, blood pressure 91/46, heart rate 129, respiratory rate
25, O2 sat 99% on mechanical ventilation. In general, he was
diaphoretic and uncomfortable. His HEENT exam was notable for
a massively edematous head with swollen periorbital regions
with closed eyes. His neck exam was notable for a trache
collar. His extremities were warm with 2-plus peripheral
pulses. On neurologic exam, he was awake and alert and able
to follow commands. He was able to answer yes and no by hand
squeezing. His cranial nerve exam was notable for a left
facial droop. His motor exam was notable for flaccid weakness
in the left arm and leg with no movements. His right side
appeared to move normally. His reflexes were significantly
decreased on the left. His right toe was downgoing. His left
toe was mute. He had no response to painful stimulation on
the left, but did respond on the right. Coordination and gait
could not be tested.
HOSPITAL COURSE: The patient was admitted to the
neurological surgical intensive care unit with a diagnosis of
a large right-sided stroke from a right internal carotid
artery and right middle cerebral artery occlusion. His goal
blood pressure was set at 130s-170s using IV fluids and
vasopressors as needed. He was placed on cardiac and
respiratory monitors. Blood and urine cultures were obtained,
and he was started on antibiotics for the fever. He was also
started on Plavix for secondary stroke prophylaxis.
On [**4-9**], with an exam on propofol, he was able to
squeeze his hand once to command. His right eye could not be
opened due to the facial swelling, but his left pupil was
reactive from 3 to 2-mm. He was spontaneously moving his
right side, but had no movements on the left.
On the morning of [**4-10**], on examination on morning
rounds by the neurology team, the patient was noted to be
unresponsive. His left pupil was 10-mm and nonreactive. His
right eyelid could not be opened. He was emergently given 50
grams of mannitol for presumed cerebral herniation, and his
respiratory rate on the ventilator was increased to decrease
his PCO2. He was taken immediately to head CT which showed
diffuse edema of the right hemisphere, as well as the
occipital lobe. There was also massive leftward subfalcine
herniation with obliteration of the right lateral ventricle.
There was contralateral left temporal [**Doctor Last Name 534**] dilatation. There
was also extensive edema in the brain stem. This was felt to
be due to a malignant edema syndrome from his stroke. A
hemicraniectomy was considered but felt not to be indicated
due to the poor overall prognosis. His serum sodium and
osmolality was followed closely. His head of the bed was
elevated. He was evaluated by the neurosurgical team. The
family was notified of the change in events and the poor
prognosis. At that time, it was decided not to pursue the
hemicraniectomy given the overall poor prognosis.
His blood pressure started to drop which was maintained with
phenylephrine. He also became highly febrile. Despite
continued maximal support, the patient's clinical status
continued to decline. On [**4-11**], the patient was removed
from life support and died at 1:00 p.m. on [**4-11**]. The
chief cause of death was felt to be arterial ischemic stroke
with secondary cerebral edema and cerebral herniation.
DISCHARGE CONDITION: Death.
DIAGNOSES:
1. Stroke.
2. Cerebral edema.
3. Cerebral herniation.
4. Nasopharyngeal carcinoma.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 22585**]
Dictated By:[**Doctor Last Name 46576**]
MEDQUIST36
D: [**2157-2-3**] 11:16:13
T: [**2157-2-3**] 12:16:42
Job#: [**Job Number 46577**]
|
[
"V44.0",
"459.2",
"V15.3",
"458.29",
"V10.02",
"997.02",
"438.22",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"38.93",
"39.50",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5232, 5580
|
1680, 1867
|
2841, 5210
|
1882, 2823
|
1450, 1654
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,954
| 158,018
|
4516
|
Discharge summary
|
report
|
Admission Date: [**2153-1-16**] [**Month/Day/Year **] Date: [**2153-1-19**]
Date of Birth: [**2088-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Weakness and myalgias x 2 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 64yo woman with multiple myeloma, s/p allogeneic
transplant [**2143**] with recurrent disease and with systemic
amyloidosis(cardiac), on hemodialysis for ESRD who represents
for malaise, weakness, and generalized body aching x 2 days.
She was admitted last week [**Date range (1) 19274**]/08 with hypercalcemia and
treated with pamidronate 30mg, calcitonin, and dialysis.
Hospital course was complicated by an episode of hypotension
following dialysis on [**2153-1-12**]. She also began treatment for
myeloma and amyloidosis last week with Revlimid. Besides
generalized pain worst in back, legs, and jaw and weakness, she
also notes intermittent SOB x 2 days(at home is on 2-3LNC).
Denies cough, fever, chills, chest pain or palpitations. She was
dialyzed yesterday to dry weight of 60kg. She and her husband
note poor po intake for the past several weeks.
.
In the ED, initial vs were: T 98.7 P 68 BP 83/43 R 22 O2 sat 99%
on NRB. Her lowest systolic 60s improved to the systolic in the
80s. She was transiently on peripheral dopamine w/improvement of
systolic to mid 90s. Restarted levophed around 0900 because
tachycardia due to dopamine. Labs were notable for calcium 14.2,
INR of 7.2. CXR showed a worsening pleural effusion and CTA
chest was performed which demonstrated stable chronic changes
and no PE. TTE in the ED was w/o evidence of large pericardial
effusion. Patient was given cefepime and vancomycin. CVL was
attempted, but reportedly clotted.
.
Review of sytems:
(+) Per HPI
(-) Denied night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. No nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. Does not make urine. She
denies lightheadedness/dizzyness.
Past Medical History:
Multiple Myeloma: (Per Problem [**Name (NI) **] [**Name2 (NI) **], reconfirmed with
patient)
"1. Initial treatment with melphalan and prednisone, [**2142-2-28**]
followed by VAD [**Month (only) **], [**2142-9-25**] with autologous stem cell
transplant in 01/[**2143**]. With relapse of her myeloma, she received
thalidomide from [**Month (only) **] to [**2143-10-25**].
2. Nonmyeloablative allogeneic stem cell transplant from a
sibling donor in 11/[**2143**].
3. Noted for recurrent disease in the summer of [**2145**] and
received a donor lymphocyte infusion in [**8-/2145**] with relatively
a stable disease after this.
4. Noted for slow progression of her disease in the fall of [**2150**]
and status post a second donor lymphocyte infusion on [**2151-2-5**]
given at a dose of one x10 to the seventh T-cell/kg.
5. Admitted on [**2151-9-13**] due to worsening renal insufficiency
with creatinine of 3.4 and new lung mass causing right lower
lobe collapse. The lung mass was biopsied and thought consistent
with amyloid.
6. Following [**Year (4 digits) **], she was started on thalidomide for a
short period of time, but was readmitted on [**2151-9-28**] due to
left lower edema and new DVTs.
7. Received Cytoxan [**2151-9-30**] with Decadron 20mg X 4 days with no
change in disease.
8. Received Velcade 1.3mg/m2 D1 and D4, but then admitted due to
worsening lower extremity edema and increased creatinine.
9. Received Cycle 1 Velcade/Cytoxan/Decadron on [**2151-10-22**]. Cycle
2 started on [**2151-11-12**]. Cycle 3 on [**2151-12-3**] with D11 Velcade
held. C 4 started on [**2151-12-24**] but admitted following morning
due to dyspnea. C5 started on [**2152-1-31**] with D8 Cytoxan held and
D11 Velcade held due to low counts. Also on dialysis for renal
failure.
10. Thalidomide to start on [**2152-2-18**]. Coumadin is
anticoagulation.
11. Another admission on [**2152-3-9**] due to increasing shortness
of breath and worsening/recurrent pneumothoraces on the left
side. She
underwent pleurodesis and although had a reaction to the talc
procedure, she was discharged home after only about a one-week
stay in the hospital. She resumed her thalidomide at 50 mg
daily, and she has slowly increased this to 150 mg daily as of
[**2152-4-17**]. She was restarted on Coumadin which is being adjusted
to keep INR at 2-3.
13. Status post DLI on [**2152-4-24**]."
Other Pertinent Past Medical History - Per [**Year (4 digits) **] and Confirmed
with Pt
- s/p 3 episodes of epiglottitis/supraglottitis requiring
intubation in [**2145**], [**2149**], [**2151**]
- Amyloidosis - involvement of lungs, tongue, bladder, heart
- CKD - thought secondary to amyloid disease progression
- Diastolic dysfunction - likely secondary amyloid
- Multiple DVT's (L IJ, L popliteal, L sup femoral)-IVC
filter, due to R sided DVT propagation; on coumadin
intermittently (due to fluctuating platelet counts on Velcade)
- Pulmonary emboli in the past associated with DVT's
- Osteopenia s/p Zometa infusions
- HTN
- s/p tonsillectomy
- Hx of disseminated herpes in [**2146**]
- Urge incontinence
- Subdural hemorrhages in [**2-/2151**] in the setting of elevated INR
Social History:
Married and lives in [**Location 3786**]. She has two adult children
and one grandson. She uses alcohol occasionally. She denies
ever using tobacco or illicit drugs.
Family History:
Notable for hypertension. No family history of malignancies or
premature cardiac death
Physical Exam:
Vitals: T: 97 BP: 94/49 on 0.06 levophed P: 73 R: 13 O2: sat 96%
on NRB
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bronchial BS and crackles at left base; decreased BS on
left, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: guaiac (-)
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; +edema on right wrist, no tenderness w/passive motion
Neuro: A&O x 3, CN 2-12 in tact, [**5-29**] upper and lower extremity
strength
Skin: No rash, warm and dry.
Pertinent Results:
Images:
CTA chest on admission: Negative for PE, stable BL lung
collapse/atelactasis; stable hyperventilatory changes in RUL.
CXR:
.
EKG: NSR at 67bpm, lateral lead TWF unchanged from prior dated
[**2153-1-10**].
.
[**2153-1-16**] 06:50AM CK-MB-9
[**2153-1-16**] 06:50AM cTropnT-0.80*
[**2153-1-16**] 08:23AM LACTATE-2.8*
[**2153-1-16**] 06:50AM PT-60.7* PTT-41.7* INR(PT)-7.2*
.
Liver US [**1-18**]
1. No evidence of biliary obstruction.
2. Cholelithiasis, no evidence of acute cholecystitis.
Gallbladder wall
thickening is likely secondary to ascites and also be seen in
the setting of
chronic liver disease.
3. Splenomegaly.
.
Echo
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The myocardium appears bright which may
be due to renal failure; an infiltrative process cannot be
excluded. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion.
Brief Hospital Course:
64yo woman with multiple myeloma, s/p allogeneic transplant [**2143**]
with recurrent disease and with systemic amyloidosis(cardiac),
ESRD on hemodialysis s/p recent hospitalization for
hypercalcemia and supratherapeutic INR who represents for the
same issues as well as hypotension. Pt was started on broad
spectrum Abx for concern for sepsis resulting in hypotension.
She was also treated for hypercalcemia, supratherapeutic INR,
chronic renal failure, tachycardia. However On night of [**1-18**],
pt had an episode of bradycardia, hypotension and she passed
away within a few seconds to a couple of minutes.
.
# Hypotension: It was in the setting of poor PO intake, likely
due to hypovolemia. She was started on empiric vancomycin and
levofloxacin for borad spectrum coverage. Blood cultures were
sent. Echo showed normal EF. She was on very small doses of
levophed to maintain a MAP of 55-60. We couldnt give a lot of
fluids as she was on dialysis.
.
# Hypercalcemia: It was in the setting of diffuse, recurrent MM
c/b amyloidosis. She received IV pamidronate x 1 and calcitonin
100 U SC x 1. Gentle IV fluids were given. HD was continued.
Serum Ca came dwon from about 14 on admission to 9.8 on [**1-18**].
.
# Respiratory: Pt has chronic oxygen requirement due to
amyloidosis involvement of the lungs. Also has h/o PEs and is
s/p pleurodesis. CTA was negative for PE. CT and CXR w/stable
chronic findings. No suggesition of PNA at this point. We tried
to wean oxygen as tolerated to home level 2-3 L.
.
# Tachycardia: Pt had 2 episodes of tachycardia with drop in her
BP. initially it was thought to be ventricular tachycardia and
hence pt was loaded with Amiodarone. Cardiology was consulted
who thought that it was atrial fibrillation and not Vtach. hence
Amio was discontinued.
.
#Elevation in liver enzymes: Pt had severe rise in ALT, AST and
LDH. We thought that might be from starting the Amio. However
Liver team was consulted and did not think that Amio had enough
time to cause the rise in LFTs. Liver US didnt show any acute
changes.
.
# Coagulopathy: Pt initially presented supratherapeutic at prior
admission, had been subtherapeutic on [**Month/Year (2) **] and Coumadin
dose was increased. She came in supratherapeutic. hence we held
her coumadin and gave her vitamin K x 1 dose. her INR came down
from about 7 to 4 over the hospital course.
.
# Multiple myeloma: Recurrent; c/b hypercalcemia and
amyloidosis. hem/onc was consulted and management was as per
their recs.
.
# ESRD on HD: management per renal team.
Medications on Admission:
Sevelamer HCl 800 mg PO TID W/MEALS
Pantoprazole 40 mg PO Q24H
Trimethoprim-Sulfamethoxazole 160-800 mg PO 3X/WEEK (MO,WE,FR)
Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Nausea.
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID as needed
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Lenalidomide 5 mg PO Three times weekly the day of dialysis.
Warfarin 4 mg PO DAYS([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
[**Doctor First Name **] Medications:
none
[**Doctor First Name **] Disposition:
Expired
[**Doctor First Name **] Diagnosis:
Pt deceased on [**1-19**]
[**Month/Year (2) **] Condition:
Dead
[**Month/Year (2) **] Instructions:
none
Followup Instructions:
None
Completed by:[**2153-2-14**]
|
[
"277.39",
"458.9",
"V42.81",
"518.81",
"203.00",
"275.42",
"V45.11",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8185, 10720
|
359, 365
|
6422, 6440
|
11452, 11487
|
5570, 5659
|
10746, 11429
|
5674, 6403
|
288, 321
|
1907, 2202
|
393, 1889
|
6454, 8162
|
2224, 5370
|
5386, 5554
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,915
| 188,169
|
52544
|
Discharge summary
|
report
|
Admission Date: [**2186-9-29**] Discharge Date: [**2186-10-3**]
Date of Birth: [**2122-4-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Clindamycin / Cortisone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
-s/p Coronary artery bypass grafting x 4(left internal mammary
artery grafted to the left anterior descending artery/Saphenous
vein grafted to Diagnal/Obtuse Marginal/Posterior descending
artery)[**2186-9-29**]
History of Present Illness:
(H&P obtained via interpreter)
64 year old Cantonese speaking male who recently was seen in
preop testing for total right knee replacement that is scheduled
for [**2186-9-28**] at NEBH. His EKG was notable for a possible old
inferior infarct with T wave inversions in V4-V6. For this
reason
he was referred for stress testing with Dr. [**Last Name (STitle) **]. This was
notable for bigeminy with exercise and possible RCA ischemia. He
was referred for left heart catheterization. He was found to
have
coronary artery disease upon cardiac catheterization and is now
being referred to cardiac surgery for revascularization.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia (diet controlled),
Hypertension, prediabetes
2. OTHER PAST MEDICAL HISTORY:
Prediabetic
Gout
Osteoarthritis, requiring right knee replacement
[**2185-4-23**]: colon cancer s/p colectomy
[**2184**] CVA versus TIA: dizziness, double vision ([**Hospital 8**]
Hospital) - no specifics
Environmental allergies
Mildly hard of hearing
Social History:
Divorced. No children. Retired, previously worked in
acupuncture
Denies alcohol, tobacco or illicit drug use.
Family History:
No family history of CAD
Physical Exam:
Physical Exam
Pulse:65 Resp:16 O2 sat:97/RA
B/P Right:166/76 Left:170/97
Height:5'4" Weight:166 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] __no___
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
Indication: intraop CABG ? Asending aortic replacement
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2186-9-29**] at 12:42 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 60% >= 55%
Left Ventricle - Stroke Volume: 100 ml/beat
Left Ventricle - Cardiac Output: 3.98 L/min
Left Ventricle - Cardiac Index: 2.20 >= 2.0 L/min/M2
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Sinus Level: *4.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.8 cm <= 3.0 cm
Aorta - Ascending: *4.6 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 0.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 2 mm Hg < 20 mm Hg
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.4 cm
Aortic Valve - Valve Area: 4.2 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. Small secundum ASD.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aorta at sinus level. Moderately
dilated ascending aorta Mildly dilated aortic arch. Mildly
dilated descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. AR vena
contracta is <0.3cm. Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
A small secundum atrial septal defect is present. Left
ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. 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 arch is mildly
dilated. The descending thoracic aorta is mildly dilated. The
ascending aorta measures 4.6 cm at it's largest point in the
distal ascending aorta. The more proximal ascending aorta
measures 3.8-4.2 cm througout its proximal course. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.
Post bypass: Patient is a paced, on phenylepherine infusion.
LVEF is preserved and normal. AI remains mild. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**].
Aortic contours intact. Remaining exam is [**Last Name (Titles) 1506**]. All
findings discussed with surgeons at the time of the exam.
[**2186-10-3**] 05:55AM BLOOD WBC-7.6 RBC-4.05* Hgb-12.9* Hct-37.5*
MCV-93 MCH-31.8 MCHC-34.3 RDW-13.8 Plt Ct-163#
[**2186-10-2**] 04:01AM BLOOD WBC-8.0 RBC-3.65* Hgb-11.7* Hct-33.1*
MCV-91 MCH-32.1* MCHC-35.4* RDW-14.2 Plt Ct-100*
[**2186-10-1**] 05:57AM BLOOD WBC-7.6 RBC-3.54* Hgb-11.3* Hct-32.1*
MCV-91 MCH-31.8 MCHC-35.1* RDW-14.3 Plt Ct-88*
[**2186-10-3**] 05:55AM BLOOD UreaN-17 Creat-0.9 Na-140 K-4.1 Cl-104
[**2186-10-2**] 12:22PM BLOOD Na-139 K-3.7 Cl-99
[**2186-10-2**] 04:01AM BLOOD Glucose-146* UreaN-21* Creat-0.9 Na-138
K-3.0* Cl-99 HCO3-30 AnGap-12
Brief Hospital Course:
64 year old male found to have abnormal EKG upon pre-op workup
for knee replacement. He was referred for left heart
catheterization. He was found to have coronary artery
disease upon cardiac catheterization was referred to cardiac
surgery for revascularization. Preoperative workup completed.
On [**2186-9-29**] Mr.[**Known lastname 724**] was taken tot he operating room and underwent
Coronary artery bypass grafting x 4(left internal mammary artery
grafted to the left anterior descending artery/Saphenous vein
grafted to Diagnal/Obtuse Marginal/Posterior descending
artery)with Dr.[**Last Name (STitle) **]. Please see operative report for further
surgical details. Cardiopulmonary bypass time= 76 minutes. Cross
clamp time= 69 minutes. He tolerated the procedure well and was
transferred to the CVICU intubated and sedated. He awoke
neurologically intact.
He was transferred to the floor in stable condition. His
antihypertensives were titrated up and his systolic blood
pressures improved. Chest tubes and pacing wires were removed
per cardiac surgery protocol. He was ambulating in the halls
without difficulty, tolerating a full oral diet and his
incisions were healing well. He was discharged home in stable
condition POD 4 with VNA services. All follow up appointments
were advised.
Medications on Admission:
ALLOPURINOL 300MG Daily
COLCHICINE [COLCRYS] 0.6 mg Daily
VERAPAMIL 240 mg, 1 Tablet(s) by mouth every morning, may take
one in evening if BP his high
CETIRIZINE 10 mg, [**12-25**] Tablet(s) by mouth daily prn
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Daily
CYANOCOBALAMIN (VITAMIN B-12) Dosage uncertain
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 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:*0*
9. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation once a day as needed for shortness of breath or
wheezing.
Disp:*1 1* Refills:*0*
10. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
14. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
-Coronary artery disease
-s/p Coronary artery bypass grafting x 4(left internal mammary
artery grafted to the left anterior descending artery/Saphenous
vein grafted to Diagnal/Obtuse Marginal/Posterior descending
artery)[**2186-9-29**]
-Secondary:
Hypertension
Hyperlipidemia, controlled with diet
Prediabetic
Gout
Osteoarthritis, requiring right knee replacement
[**2185-4-23**]: colon cancer s/p colectomy
[**2184**] TIA: dizziness, double vision([**Hospital 8**] Hospital) - no
specifics (pt does not recall)
Environmental allergies
Mildly hard of hearing
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 [**11-1**] at 2:00 PM
Cardiologist: Dr [**Last Name (STitle) **] on [**11-8**] at 2:00pm.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**12-25**] weeks [**Telephone/Fax (1) 31372**]
**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:[**2186-10-3**]
|
[
"790.29",
"414.01",
"401.9",
"411.1",
"V10.05",
"V43.65",
"272.4",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9465, 9495
|
6293, 7594
|
313, 526
|
10098, 10324
|
2444, 6270
|
11248, 11765
|
1715, 1741
|
7948, 9442
|
9516, 10077
|
7620, 7925
|
10348, 11225
|
1756, 2425
|
265, 275
|
554, 1180
|
1316, 1571
|
1587, 1699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,889
| 113,880
|
3628
|
Discharge summary
|
report
|
Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-24**]
Date of Birth: [**2080-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16330**]
Chief Complaint:
found down, xferred to OSH, then to [**Hospital1 18**]
Major Surgical or Invasive Procedure:
Central venous line placement
Intubation/extubation with invasive ventilation
History of Present Illness:
Mr. [**Known lastname 16490**] is a 69 yo with IDDM, PVD, CVA [**2138**] (no residual
deficits), ESRD [**1-9**] ([**3-12**]) DM, not on HD, with a h/o of multiple
episodes of hypoglycemia taken emergently to OSH after this wife
found him unresponsive in bed, surrounded by empty coke cans.
Blood glucose was 6. [**Name (NI) 1094**] wife states that the patient has not
been feeling well for the last couple of days prior to event,
having increased [**Last Name (LF) **], [**First Name3 (LF) 1658**] colored, foul smelling diarrhea. Pt
denieed fevers, chills, abdominal pain, but has not been eating
well. Wife reports more incontinence. Patient has had DM for
decades and is on NPH and regular insulin followed by [**Last Name (un) **].
Worsening renal fx reportely over the past year, with multiple
discussions with his nephrologist, Dr. [**First Name (STitle) 805**] about initiation
of HD. Yesterday AM, the patient was more confused, reportedly,
then was found unresponsive by his wife. with a BG of 6. Pt was
given 1 amp of dextrose in the field. The patient reportedly did
not fall, and did not complain of any CP, SOB, dizziness,
lightheadedness or diaphoresis. He does not remember feeling
shaky before the episode.
.
Pt was taken to OSH emergently, was intubated in the field.
Prior to intubation, the patient apparently vomited and
aspirated a large amount of particulate matter (witnessed by
paramedics). Particulate matter was aspirated from his ETT. When
brought to the ED, the patient was not responding to any
commands. Head CT was done at OSH was reportedly negative,
showing an old infarct, but no acute process. Blood sugar was
reportedly in the 20s. Laboratory studies revealed an non-AG
metabolic acidosis, renal insufficiency but normal lactate
levels. Per OSH records, the patient had a transient episode of
hypotension of unkown etioology, but rebounded back quickly with
500ccs bolus. Per the patient's wife, the patient did administer
his NPH this AM. Patient with h/o DM and found unresponsive with
significant hypoglycemia. Intubated for airway protection but
not waking up (Etomidate, Ativan given). Exam shows brainstem
function (gag) but not much else. Paitent HD stable, on vent. To
come TO [**Hospital1 18**] tonight to MICU green as patient is usually cared
for at [**Hospital1 18**] for DM and renal failure.
.
Prior to xfer from OSH, received a call from [**Name8 (MD) 16491**] MD
reporting that the patient was becoming more awake, following
commands. Pt unlikely able to protect airway, so kept intubated
and xferred to [**Hospital1 18**]. In the MICU, he became more awake, but
continued to have problems with aspiration. CXR noted bilateral
effusions and infiltrates c/w aspiration PNA.
Past Medical History:
1. Ischemic colitis [**2-8**], s/p ex lap and rigid sigmoidoscopy
without evidence of ischemic bowel.
2. PVD: s/p right popliteal to dorsalis pedis bypass and left
femoral-popliteal and popliteal-anterior tibial bypass, R CEA,
and right SFA stent.
3. Type I Diabetes mellitus - brittle diabetic; episodes of
severe hypoglycemia and DKA
4. Status post CVA >10 yrs ago.
5. History of CHF with preserved EF
6. COPD- no PFTs in system
7. Hypertension
8. Glaucoma
9. CKD-baseline cr 2.1-2.4 (Cr clearance of 25-30, stage 4)is
preparing for PD with Dr. [**First Name (STitle) 805**] at [**Last Name (un) **]
10. h/o Duodenal ulcer but on EGD above not seen
11. Anemia of chronic disease.
12. Esophageal dysmotility.
13. h/o VRE UTI
14. Rectal CA-dx [**2148**] no surgery due to comorbidities; s/p
palliative XRT
15. Secondary hyperparathyroidism
Social History:
Lives with his wife. [**Name (NI) **] smoked for >50yrs at most 2ppd. Now
smokes 1ppd. Remote heavy EtOH use in past (3+ drinks per day),
quit 2-3 years ago. No recreational drug use. Used to work in
greenhouse supply business, then sold real estate now disabled.
Sleeps up to 22 hours per day per wife's report. Does not allow
visitors to house. Admits to lack of motivation.
.
Wife, [**Name (NI) 4115**] [**Telephone/Fax (1) 16487**] (H), [**Telephone/Fax (1) 16488**] (C)
Family History:
Mother colon cancer. Father with throat cancer. Brother died of
colon cancer at age 62.
Physical Exam:
Vitals: Tmin 95.7; Tc95.7, HR 50-61; BP 123-182/49-57; RR 16 on
AC 550x16; FIO2 of 0.5; PEEP 5.
Gen: chronically ill appearing, somnolent elderly male,
intubated, sedated.
HEENT: pupils irregular, assymetric and non-reactive; EOMI, b/l
periorbital edema, MM dry
Neck: supple, no LAD, no JVP elevation, +linear well-healed scar
over Right cartoid
Cardio: PMI inferiorly displaced and diffuse, RRR, nl S1/S2,
no murmurs or rubs appreciated
Resp: CTAB, no exp wheezes
Abd: + BS, soft/NT/ND, no HSM, no masses
Ext: no c/c/e; b/l LE w/ significant atrophy. multiple scars.
dopplerable pulses bilat.
Neuro: intubated, sedated on boluses, but responding to commands
when waking up
Pertinent Results:
[**2150-6-23**] EKG: Sinus tachycardia. Right bundle-branch block. Left
axis deviation. Left anterior fascicular block. Compared to
previous tracing of [**2150-4-2**] heart rate is increased. Otherwise,
multiple abnormalities as previously noted persist without major
change.
.
[**2150-6-22**] CXRAY: Right internal jugular vascular catheter
terminates in the proximal superior vena cava. Cardiac contour
and vascular pedicle width have slightly increased and are
accompanied by worsening vascular engorgement, diffuse perihilar
haziness and interstitial opacities, likely due to increased
volume status and fluid overload. Superimposed secondary
process such as aspiration is difficult to exclude in the
setting of diffuse edema. Bilateral layering pleural effusions
are noted.
Brief Hospital Course:
A/P 69M,ESRD, CAD, PVD, brittle type I DM with very labile
sugars taken emergently to OSH after being found unresponsive by
his wife with a blood glucose of 6.
.
1) Hypoglycemia: This was likely the effect of NPH, lantus with
decreased clearance (worsening renal fx, decrease PO intake and
increased diarrhea). Pt has had very labile blood sugars in the
past, with multiple episodes of hypoglycemia. Patient taking
NPH/regular [**9-10**] at home in AM. [**First Name8 (NamePattern2) **] [**Last Name (un) **] notes, the patient
takes lantus as well. Patient was initially maintained on an
insulin drip whiel in the ICU, but later transitioned to Lantus
4 units with RISS coverage at meal time.
.
2) Respiratory failure: Patient was intubated for airway
protection in the field, with visible aspiration and suctioning
back of particular matter. He was extubated following transfer
to [**Hospital1 18**]. He was started on levofloxacin and flagyl as empiric
therapy for aspiration pneumonia.
.
3) PVD: Patient has known severe peripheral vascular disease,
s/p multiple bypass surgeries and vein harvesting. Patient is
due back fro R SFA angioplasty some time soon to save the
patient's right leg. There has to be a discussion between renal
and vascular surgery about risk of contrast dye and the risk of
starting the pt on HD.
He was continued on Aspirin, and Dr. [**Last Name (STitle) **] made aware of
admission.
.
4) Diabetes mellitus, type I: Patient has exocrine and endocrine
pancreatic insufficiency given type I DM, presenting with
[**Male First Name (un) 1658**]-colored stools. He was continued on pancreatic replacement
enzymes. [**Last Name (un) **] was consulted and patinet was maintained on a
regimen of Lantus 4 units + RISS.
.
5) Renal Insufficiency: Mild acute on chronic at time of
presentation, likely prerenal in the setting of poor PO intake.
Creatinine returned to baseline of ~4 with hydration. Planning
is in progress for eventual hemodialysis. Renal function is
likely declining due to progression of disease. Patient has a
non-gap metabolic acidosis, and was started on Sodium citrate
prior to discharge. He was continued on a regimen of epo,
calcitriol, lanthanum, and calcium acetate.
.
6) Nutrition: Patient underwent a speech & swallow evaluation
with report of ongoing aspiration with thin liquids with
coughing after drinking. He also appeared to have residue in
his throat of which he is unaware given that he
coughed up [**Location (un) 2452**] juice and eggs from earlier this morning when
he aspirated. Therefore, he was recommended to be put on a diet
of ground solids & nectar thick liquids if he alternates between
bites and sips and if he ends his meal w/several sips of nectar
to clear residue from his pharynx. The following
recommendations were made:
-Diet of nectar thick liquids & ground consistency solids using
the following:
a) slow rate of intake
b) small bites and sips
c) Alternate between bites and sips
d) End meal w/several sips of nectar thick liquid to clear
residue from his throat
e) PO medications crushed with purees
Patient refused thick liquids for duration of hospitalization
and subsequently had very poor PO intake of liquids.
.
7) Depression: Social work consult was obtained, and patient
was started on Lexapro 5 mg daily (renally dosed).
.
8) Code status: full code, confirmed with patient repeatedly
during this hospitalization.
Medications on Admission:
Norvasc 2.5 mg as directed 1 tab QD
Fosrenol 1000 Mg chew one with each meal.
Lasix 40mg 1 per day
Glucagon Emergency Kit 1mg
Phoslo 667mg three times a day 2 tablets
Hectorol 0.5mcg twice a day
Hydralazine Hcl 50mg twice a day
Neurontin 100mg two at bedtime.
Procrit 4000 U/ml as directed twice a week.
Ferrous Sulfate 325mg 1 time per day
Folic Acid 1mg 1 time per day
Lantus ? dose
Humulin ? dose
Lipram 20-4.5-25 four times a day 2 tabs
Metoprolol Tartrate 100mg twice a day ()
Losec 20mg 1 time per day
Foltx 1-2.5-25mg 1 time per day
ASA 325 qd
Discharge Medications:
1. Aspirin 325 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule [**Location (un) **]: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Location (un) **]: One (1)
injection Injection TID (3 times a day).
4. Lanthanum 500 mg Tablet, Chewable [**Location (un) **]: One (1) Tablet,
Chewable PO TID (3 times a day): Please give with meals.
5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) [**Location (un) **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Calcitriol 0.25 mcg Capsule [**Location (un) **]: One (1) Capsule PO DAILY
(Daily).
7. Escitalopram 10 mg Tablet [**Location (un) **]: 0.5 Tablet PO DAILY (Daily).
8. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution [**Location (un) **]:
Fifteen (15) ML PO BID (2 times a day).
9. Epoetin Alfa 4,000 unit/mL Solution [**Location (un) **]: One (1) mL Injection
QMOWEFR (Monday -Wednesday-Friday).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Four (4) units Subcutaneous
at bedtime.
12. Levofloxacin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q48H
(every 48 hours) for 2 days.
13. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 2 days.
14. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Norvasc 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
16. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: Per
sliding scale Subcutaneous QACHS.
17. Metoprolol Tartrate 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
18. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a
day: Uptitrate dose as needed
.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16492**] [**Doctor Last Name **]
Discharge Diagnosis:
Hypoglycemia
Aspiration pneumonia
Respiratory failure
Depression
Diabetes mellitus, type I
Acute renal failure
End-stage renal disease
Secondary hyperparathyroidism
Pancreatic insufficiency
Discharge Condition:
Stable glucose levels and vital signs.
Discharge Instructions:
You were admitted to the hospital with hypoglycemia. It is
important that you adhere to a diabetic diet with frequent oral
intake to prevent high/low blood glucose levels.
.
You have been treated for an aspiration pneumonia which occurred
due to respiratory failure when your blood glucose level was low
at home. You have a 9-day course of antibiotics remaining.
.
You have been started on a medication called Lexapro for
symptoms of depression.
.
You should return the hospital if you are experiencing chest
pain, shortness of breath, fevers, or uncontrolled blood glucose
levels.
Followup Instructions:
You should follow-up with your nephrologist Dr. [**First Name (STitle) 805**] at the
[**Hospital **] clinic next week, as previously scheduled.
.
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM
Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2150-7-29**] 12:45
.
Provider VASCULAR LAB
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2150-11-12**] 10:30
.
Provider [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2150-11-12**] 11:15
|
[
"403.90",
"585.4",
"443.9",
"285.21",
"V12.59",
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"428.0",
"584.9",
"250.41",
"588.81",
"507.0",
"V10.06",
"276.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12205, 12281
|
6189, 9604
|
371, 451
|
12515, 12556
|
5382, 6166
|
13188, 13738
|
4580, 4670
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|
12580, 13165
|
4685, 5363
|
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479, 3208
|
3230, 4071
|
4087, 4564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,357
| 126,703
|
10558
|
Discharge summary
|
report
|
Admission Date: [**2199-9-18**] Discharge Date: [**2199-9-28**]
Date of Birth: [**2151-11-14**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Tylenol 8 Hr
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T1, T5, T7 decompression, fusion C5-T10
History of Present Illness:
Patient is a 47 yo man who has a h/o of UC and PSC s/p Whipple
c/b pouchitis who was transferred from [**Hospital 47**] Hospital with
leg/arm parathesias, had MRI which showed cord compression at T7
from mets of unknown source. He had a month long history of
back pain, near R shoulder blade. This was followed by
numbness/tingling in the R hand, mostly the last 3 digits. Two
weeks ago, he saw his PCP. [**Name10 (NameIs) **] was referred to physical therapy.
Saturday, pt started to feel tingling in the R leg. Sunday, he
had R leg weakness, affecting his gait. On Monday, he felt
malaise. By Tuesday, he needed assistance with walking due to
weakness in both legs, R>L. No urinary or fecal incontinece, no
perianal numbness.
MRI at [**Location (un) 47**] showed mets were noted at C7, T1, T2, T5, T7
with cord compression at T7. He received morphine and decadron.
In the ED, initial VS were: 97.8 114 126/78 18 97. Labs were
notable for AP 707, WBC 13.3. The patient received cipro &
flagyl for pouchitis. Ortho-spine was consulted and rec. head
of bed <30, bedrest.
Review of Systems:
(+) Per HPI: He has lost 10 lbs in the last 6 months. Chronic
diarrhea, stable. Intermittent pain in LIQ.
(-) Denies fever, chills, night sweats. Denies headache, vision
problems. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
constipation, BRBPR, melena.
Past Medical History:
Ulcerative colitis, s/p colectomy and ileo-anal pull through
Primary sclerosing chlangitis, s/p Whipple
Chronic pouchitis, usually on rifaxmin as maintenance, takes
cipro/flagyl for rescue
Complex renal cyst
Asthma
Eczema
Social History:
Patient lives with wife and daughter. [**Name (NI) **] is a database
administrator. Quit tobacco use in [**2184**], 1ppd x 10years. 6
pack on a weekend. No recreationsl drugs since college,
marijuana, cocaine.
Family History:
Aunt with rectal cancer, dx in her 50s. Uncle with renal
cancer.
Physical Exam:
VS: 97.7, 100/66, 106, 20, 96RA
Gen: NAD, AOX3
HEENT: PERRLA, EOMI, MMM, sclera anicteric, not injected
Neck: no LAD, no JVD
Cardiovascular: RRR normal s1, s2, no murmurs appreciated
Respiratory: Clear to auscultation bilaterally, no crackles,
wheeze in LLL
Abd: normoactive bowel sounds, soft, non-tender, mildly
distended
Extremities: No edema, 2+ DP pulses
Neurological: MS [**6-12**] in BUEs, mild numbness along ulnar
distribution bilaterally, MS 5-/5 in BLEs, no numbness in legs,
upgoing babinski on R, equivocal on L, DTR's brisk but equal
throughout
Back: no TTP or percussion along spine
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Pertinent Results:
Admission labs:
[**2199-9-17**] 11:00PM WBC-13.3*# RBC-4.36* HGB-12.3* HCT-37.0*
MCV-85# MCH-28.2# MCHC-33.2 RDW-13.9
[**2199-9-17**] 11:00PM NEUTS-96.2* LYMPHS-3.2* MONOS-0.3* EOS-0.1
BASOS-0.1
[**2199-9-17**] 11:00PM PLT COUNT-317
[**2199-9-17**] 11:00PM GLUCOSE-129* UREA N-13 CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
[**2199-9-17**] 11:00PM ALT(SGPT)-52* AST(SGOT)-50* ALK PHOS-707* TOT
BILI-1.4
[**2199-9-17**] 11:00PM ALBUMIN-3.6
OSH MRI: There are mets involving the C7, T1, T2, T5, and T7
vertebrae. Tumor extends into the canal at the T1, T5, and T7
levels. There may be minimal extension into the anterior aspect
of the cancal on the left at the T2 level.
Tumor surrounds the cord and causes mild to moderate cord
compression at the T7 level. There is only a very small
impression on the anterior aspect of the cord by tumor at the T5
level.
Brief Hospital Course:
47 yo man who has a h/o of UC and PSC s/p Whipple who presented
to OSH with 1 month of back pain and increasing
numbness/weakness of extremities, found to have metastatic spine
disease and cord compression on MRI.
# Spinal cord compression with metastatic bone disease:
- Onc to see in AM
- Ortho spine - see below
# Primary sclerosing cholangitis:
- cont. ursodiol
# Chronic pouchitis: H/o UC s/p colectomy
- cont. cipro, flagyl
# Asthma: stable.
- albuterol prn
FEN: regular diet
PPx: HSQ
Access: PIV
CONTACT: [**First Name4 (NamePattern1) **] [**Known lastname 34751**] cell [**Telephone/Fax (1) 34752**], home [**Telephone/Fax (1) 34753**]
Following pre-operative staging and medical optimization,
patient presented for decompression and stabilization. He
underwent the procedure, tolerating it well. Given duration of
anesthesia and blood loss, he was transferred intubated to the
TICU in stable condition. He was extubated uneventfully.
Patient was transferred to the floor once critical care issues
were resolved.
Pain was controlled with IV followed by PO medications. Foley
was discontinued. PT was consulted for assistance with the
patient's care. He progressed with therapy and was fully
ambulatory at the time of discharge. Oncology was contact[**Name (NI) **] to
arrange follow-up. At the time of discharge, final path was
pending.
Once pain was well controlled, PO diet was tolerated, and once
pt had passed PT, he was deemed stable for D/C to home.
Medications on Admission:
Pls see attached.
Discharge Medications:
1. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
9. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QPM (once a
day (in the evening)).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Metastatic disease to thoracic spine, s/p decompression and
fusion
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:
1. Keep incision clean and dry, daily dressing change until dry
for 24hr, then may leave open to air and may shower - no bath
2. Continue PT exercises at home
3. No lifting > 10 lbs
Physical Therapy:
Activity as tolerated.
Maintain C-collar at all times, no neck ROM
Assist with mobilization, ADL training, proprioceptive training;
home-exercise program.
Treatments Frequency:
Keep incision clean and dry. Daily dressing changes until dry
for 24 hours, then leave open to air and may shower.
Followup Instructions:
Test for consideration post-discharge: CA [**08**]-9
1. follow-up with Dr. [**Last Name (STitle) 1352**] in [**8-17**] days, call for appointment
2. follow-up with oncology, call office for appointment
Completed by:[**2199-10-1**]
|
[
"198.4",
"569.71",
"E878.2",
"336.3",
"199.1",
"733.13",
"724.01",
"198.5",
"V12.79",
"493.90",
"576.1",
"338.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"77.49",
"81.05",
"77.79",
"81.64",
"03.32"
] |
icd9pcs
|
[
[
[]
]
] |
6467, 6540
|
4012, 5499
|
288, 330
|
6651, 6651
|
3085, 3085
|
7352, 7586
|
2289, 2356
|
5567, 6444
|
6561, 6630
|
5525, 5544
|
6834, 7017
|
2371, 3066
|
7035, 7190
|
7212, 7329
|
1466, 1797
|
239, 250
|
358, 1447
|
3101, 3989
|
6666, 6810
|
1819, 2042
|
2058, 2273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,696
| 186,225
|
3361
|
Discharge summary
|
report
|
Admission Date: [**2179-11-12**] Discharge Date: [**2179-12-5**]
Service: MEDICINE
Allergies:
Erythromycin Base / Vitamin K Analogues
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 82 yo woman with PMH CAD s/p CABG, s/p MV repair
(for MVP with MR) in [**2170**] who presents with c/o increased SOB
from baseline over past 3 days. Per patient and family, reports
at baseline, pt experiences SOB with exertion, including
climbing stairs. However, over the past 3 days, patient has
been experiencing increased SOB, so that she appears SOB with
talking, with sitting down, etc. Patient denies any chest
pain/pressure, orthopnea, PND, weight gain, LE swelling,
although does say she used to get those symptoms prior to her MV
repair. Other than the SOB, patient reports + diaphoresis at
night (which she reports also noting prior to her MV repair),
feeling weak and tired, decreased appetite. Family denies any
change in mental status.
.
Of note patient's recent medication changes include: HCTZ
started 1.5-2 mos ago. Otherwise no medication changes. Per
patient's family, she does not always take her medications,
including her potassium.
.
Also of note, patient and her family report patient had a
mechanical fall 3 days ago, which they also say was the onset of
her symptoms, although they do think it is coincidental. The
fall is reported as mechanical as pt tripped over the rug. No
LOC, did not hit her head, no change in MS or balance since that
time.
.
In ED, patient received in EKG which did not show any ST
changes, 1 set negative CE (trop = 0.02, CK 39). Labs notable
for CR to 1.3 from baseline 0.8, K 2.4, D dimer 997. Pt was
given ASA, started on Hep gtt (in case ACS), given 80mg PO Kcl.
.
Currently pt denies SOB (although appears tachypnic). Just c/o
weakness and feeling tired. ROS otherwise as above.
Past Medical History:
1.) CAD s/p CABG ([**2170**] - also took sample of chamber wall as
appeared to be atrial myxoma, although pathology diagnosed
organized thrombus) - c/b sternal staph infection (oxacillin
sensitive staph aereus) - therefore sternum removed w/
latissimus dorsi flap over sternal area.
2.) MV repair - Corkscrew # 30 mitral annuloplasty ring ([**2170**] at
same time as CABG above)
3.) Hx of paroxysmal A Fib
4.) Dementia (early alzheimer's)
5.) s/p cholecystectomy
6.) s/p TAH
Social History:
Lives next door to son and daughter
[**Name (NI) **] etoh No drugs No smoking
Family History:
Father died at 61 with MI
Physical Exam:
In ED:
T:95.3 HR: 92 BP: 116/66 RR: 25 O2 sat: 97% on 4L
AAO x3, hard of hearing
HEENT: PERRL EOMI
Neck: Supple
Resp: crackles 1/3 up base
CV: Systolic murmur, RR
Abd: Soft NTND +Bs
GU: No CVA tenderness
Ext: No LE edema +DP pulses B/L
Skin: No rashes
Neuro: No focal numbness or weakness
Pertinent Results:
[**11-12**] CXR: The heart is enlarged. Pulmonary vascular markings are
increased with Kerley B lines evident. There is no focal
consolidation. There is no pneumothorax. Osseous structures are
unremarkable.
IMPRESSION:
CHF.
.
[**2180-11-14**]: REnal US:
RENAL ULTRASOUND: The right kidney measures 9.3 cm. Within the
upper pole of the right kidney is a 0.7 x 1.2 x 1.1 cm simple
cyst. Within the right lobe of the liver is an 1.2 x 0.7 x 1 cm
simple cyst. The left kidney measures 10 cm. There are no renal
masses, stones, or hydronephrosis. The bladder contains a Foley
catheter is otherwise unremarkable.
IMPRESSION: Simple right renal and right hepatic cysts.
.
ECHO: [**2179-11-15**]:
Conclusions:
1. The left atrium is moderately dilated. The left atrium is
elongated. The
right atrium is markedly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal. [Intrinsic right ventricular systolic
function may be more
depressed given the severity of tricuspid regurgitation.]
4.The aortic valve leaflets (3) are mildly thickened. Moderate
(2+) aortic
regurgitation is seen.
5.The mitral valve is redundant and thick. A mitral valve
annuloplasty ring is
present. Moderate to severe (3+) mitral regurgitation is seen.
6.Moderate to severe [3+] tricuspid regurgitation is seen.
7.There is severe pulmonary artery systolic hypertension.
8.There is no pericardial effusion
.
[**2179-11-18**]: CT head with contrast:
CONCLUSION: Limited study due to motion artifact. No large
intracranial hemorrhage is identified. No gross intracranial
mass effect is evident. A 7.5-mm lytic lesion at the right
parietal bone may represent a venous [**Doctor Last Name **], although a metastatic
deposit cannot be excluded and can be considered in the
appropriate clinical setting.
.
[**11-21**]: CXR:
FINDINGS: Again seen is an endotracheal tube with tip 4.8 cm
above the carina. The tip of the endotracheal tube is pressing
against the right lateral wall of the trachea and deviating it
slightly. The NG tube is in the stomach. There is a Swan-Ganz
catheter with tip in the pulmonary outflow tract. There is
increased hazy opacity in bilateral lower lungs, left greater
than right, and also in the low left mid lung suggesting patchy
focal infiltrates. These have increased compared to the prior
day. There is no pneumothorax.
.
[**11-28**]: RUQ US
IMPRESSION:
1. Gallbladder not visualized. Is this patient status post
cholecystectomy?
2. Multiple anechoic lesions in the liver consistent with cysts
with one of these lesions suggestive of a septated cyst.
3. No biliary ductal dilatation
.
[**2179-12-3**]: CT Chest
IMPRESSION:
1. No pulmonary embolism.
2. Status post CABG with median sternotomy, with unchanged
appearance of the sternum. Marked cardiomegaly with marked right
atrial enlargement.
3. Small bilateral pleural effusions, increased compared to the
prior study.
4. Increased ground glass opacity with interlobular septal
thickening in bilateral lungs, which probably representing
worsening pulmonary edema. More confluent opacities in bilateral
upper lobes, also increased compared to the prior study, which
may represent infectious process such as multifocal pneumonia.
Please correlate clinically.
.
[**2179-12-3**]: CXR:
IMPRESSION: Increased patchy pulmonary alveolar opacities
consistent with worsening failure.
.
[**2179-12-5**]:
An ET tube is present, tip approximately 2.5 cm above the
carina. It points toward the right mainstem bronchus and close
followup is therefore recommended. An NG tube is present, tip
beneath diaphragm extending off film. Right IJ central line is
present, tip overlying SVC/RA junction.
There is moderate cardiomegaly. There are patchy interstitial
and alveolar infiltrates, diffusely throughout both lungs. These
appear somewhat less confluent than on the film from one day
earlier, particularly in the left upper zone. No effusions are
identified.
IMPRESSION: Diffuse interstitial and alveolar infiltrates, with
slight interval improvement compared with one day earlier. Lines
and tubes as described.
.
Micro Data:
[**2179-11-13**] 9:30 pm URINE
**FINAL REPORT [**2179-11-16**]**
URINE CULTURE (Final [**2179-11-16**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ORGANISM. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2179-11-12**] 05:16PM PLT COUNT-152
[**2179-11-12**] 05:16PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+
[**2179-11-12**] 05:16PM NEUTS-65.5 LYMPHS-23.4 MONOS-6.4 EOS-4.5*
BASOS-0.2
[**2179-11-12**] 05:16PM WBC-6.1 RBC-3.71* HGB-11.9* HCT-34.7* MCV-94
MCH-32.2* MCHC-34.4 RDW-16.7*
[**2179-11-12**] 05:16PM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2179-11-12**] 05:16PM CK-MB-NotDone
[**2179-11-12**] 05:16PM cTropnT-0.02*
[**2179-11-12**] 05:16PM CK(CPK)-39
[**2179-11-12**] 05:16PM GLUCOSE-83 UREA N-35* CREAT-1.3* SODIUM-143
POTASSIUM-2.4* CHLORIDE-100 TOTAL CO2-31 ANION GAP-14
[**2179-11-12**] 06:20PM D-DIMER-997*
[**2179-11-12**] 06:20PM PT-13.5* PTT-22.7 INR(PT)-1.2
Brief Hospital Course:
82F w/CAD s/p CABG, s/p MV repair (for MVP with MR) in [**2170**]
admitted to the CCU after being found in respiratory distress on
the floor. Her course in the CCU was complicated by 4 episodes
of acute pulmonary edema of unknown etiology for which she
required intubation for appropriate ventilation and oxygenation.
It was felt that her repiratory distress was most likely
secondary to cardiac issues and pulmonary hypertension. An
extensive workup was done to try to determine whether there were
reversible cardiopulmonary etiologies.
Her cardiac workup included:
- ECHO which showed- EF 50% with 2+ MR, 2+ TR, old MVR
- Cardiac Catherization which revealed PCWP: 17mmHg, LVEDP:
16mmHg, PAP: 67/25 with LVEF: 55% and CI: 3.13. In addition, her
coronary anatomy showed 60% LCx s/p stent.
- multiple attempts at cardioversion with medication and
electricity
- pressure support
# Rhythm:
The patient's heart rhythm shifted quite often during her time
here. She was originally in Afib/Aflutter on floor - tried to
control with BB. Initially delayed becaues of fluid overload;
eventually, she was cardioverted on [**2179-11-19**] to sinus and
heparinized as patient may reconvert to AFib/Flutter. She had a
long history of PAF, for which she was not anticoagulated for
because of compliance issues
Her dysrhythmias were felt that to be secondary to signals
coming from multiple foci - the shifts varied b/w a rate
80s-120s. On [**11-28**], she was restarted on amiodarone (no loading
as patient was previously on amiodarone). We also felt that
there was also some concern for amiodarone toxicity given 2 year
history of amiodarone usage- > however, felt better to restart
the amio in face of continuing arrhythmias.
Of note, the patient had an episode of bradycardia with a
junctional rate of low 40s with a drop in BP to 60s on [**11-22**] at
4am - > unclear as to the precipitant of this -> EP felt that
this was likely [**1-13**] a PAC (possibly [**1-13**] increased vagal tone) ->
would not like to do any interventions given recent
cardioversion and short episode. Nodal agents were avoided and
atropine was kept at bedside.
.
# PULMONARY:
On night of [**11-19**], patient developed tachypnea on floor and was
intubated; required pressor support with levophed and fluids.
Unclear whether patient aspirated vs acute pulmonary edema. She
was cardioverted to sinus rhythm in the CCU. She was Swanned in
the CCU and then started on dobutamine and lasix. Eventually
weaned off of levophed. She was extubated on [**2179-11-23**] -> and
tolerated this well -> and only intermittently requiring CPAP ->
reintubated on [**11-27**] for respiratory disress. There were no
clear precipitants for this last episode.
[**12-2**]
- Cath was done to assess cornary anatomy. It showed that
patient has pulm HTN - likely from valvular disease.
- developed diffuse pulmonary opacification [**12-2**] - which may
have been [**1-13**] hydration for cath and was +2.3L over 2 days. A
pulmonary consult was called to help to elucidate the etiology
of this recurrent pulmonary edema. Diuresis was held as this was
not felt to be more of an ARDS type picture.
.
- CTA on [**12-3**] ruled out chronic/subacute PEs
- During her course in the CCU, she was broadly covered with
antibiotics including Unasyn/Zosyn, vancomycin and Azithromycin.
These were discontinued on [**12-2**] with close monitoring for signs
of infection.
.
# AMS:
On night of [**11-18**], patient had episode of delirium/agitation -
THis was most likely secondary to overmedication with sedatives.
It was unclear as to whether this was due to psychotropic
medications or delirium from multiple medical problems.
.
# UTI
On admission, patient was on Cipro for Cipro sensitive E Coli
UTI -> switched to Unasyn given ? of aspiration -> on [**11-24**] ->
changed to Zosyn for Pseudomonas coverage (3 days of intubation)
- added on Vancomycin 1g q 48 given ? aspiration to cover for
MRSA
- Zosyn/Vanco transiently stopped on [**11-26**] because of Ox
sensitive sputum Cx-> restarted overnight of [**11-27**]
.
# ARF:
ARF from admission resolved with hydration
# Lytic lesion on skull:
- SPEP/Upep negative
- metastatic disease vs venous [**Doctor Last Name **] from prior comparison
.
# Withdrawl of care:
- on [**12-5**], family discusssion was held with health care team
and family of patient, including health care proxy (daughter of
patient.) During the discussion, it became clear that it was not
the patient's desire to be intubated for a long period of time;
in addition, the patient's pulmonary status had not been
improving over the course of this hospitalization. Hence, the
decision was made to withdraw care except for sedation. In
addition, the patient was made DNR/DNI.
Shortly thereafter on the night of [**12-5**], the patient passed
away peacefully with her daughter and son-in-law at her bedside.
Medications on Admission:
Ibuprofen 400 tid
potassium
HCTZ 25 QD
Namenda 10 [**Hospital1 **]
Univasc 15 QD
ASA 325 QD
Amiodarone 200mg daily
Paxil 30 QHS
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2180-3-21**]
|
[
"427.31",
"599.0",
"996.71",
"414.01",
"E942.0",
"V45.81",
"293.0",
"276.8",
"276.51",
"389.9",
"428.30",
"294.10",
"416.8",
"584.9",
"331.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"89.64",
"99.04",
"36.07",
"99.62",
"00.66",
"00.40",
"37.23",
"88.56",
"88.57",
"00.13",
"88.72",
"96.04",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
14289, 14354
|
9211, 14082
|
268, 275
|
14406, 14416
|
2936, 9188
|
14467, 14500
|
2581, 2608
|
14260, 14266
|
14375, 14385
|
14108, 14237
|
14440, 14444
|
2623, 2917
|
209, 230
|
303, 1969
|
1991, 2468
|
2484, 2565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,488
| 150,435
|
34165
|
Discharge summary
|
report
|
Admission Date: [**2104-4-7**] Discharge Date: [**2104-4-23**]
Date of Birth: [**2023-12-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
OSH transfer for severe anemia, acute renal failure, and left
leg hematoma.
.
Major Surgical or Invasive Procedure:
Left leg debridement and lavage with VAC dressing.
Right IJ central line.
Peripherally inserted central catheter (left).
Peripherally inserted central catheter (right).
Esophagogastroduodenoscopy (EGD).
.
History of Present Illness:
Ms. [**Known lastname **] is an 80 year old female with history of atrial
fibrillation, anemia of unclear etiology (baseline hct ~33) and
asthma who presented to an OSH on [**2104-4-6**] with malaise and LE
swelling after a mechanical fall one week prior. She was found
to be in ARF with creatinine 4.6 (baseline 0.9) and K of 8. Her
hct was 19, down from baseline 33. Her hyperkalemia was treated
and she was transfered to [**Hospital1 18**] ICU for ARF, anemia and
hypotension.
.
Past Medical History:
-Atrial septal defect
-Pulmonary hytpertension
-Chronic atrial fibrillation (no anti-coagulation because of
frequent bleeding, previously on digoxin but was d/c'd for
hypotension ~1y ago)
-Papillary TCC, grade II/III (dx [**6-9**])
-Chronic anemia of unclear etiology (baseline hct ~33);
colonoscopy [**5-10**] revealed 2mm benign polyp in descending colon,
diverticulitis, large internal hemorrhoids
-Barrett's esophagus with high grade esophageal dysplasia (dx by
EGD [**3-10**])
Social History:
lives with daughter, no smoking, no EtOH
.
Family History:
Non-contributory
.
Physical Exam:
PHYSICAL EXAM ON TRANSFER TO THE MEDICAL FLOOR.
VITALS: 98.7, 144/62, 65, 20, 96% RA
GEN: A+Ox3, NAD, smiling
HEENT: OP clear, MMM
NECK: JVP difficult to assess because of neck size and IJ
catheter.
CV: Irregular, II/VI SEM at upper borders, no G/R
PULM: CTAB, diffuse expiratory wheeze, no rales, speaking in
short sentences
ABD: Soft, NT, ND, +BS
EXT: 2+ pedal edema bilaterally. LLE dressed with some
serosanguinous drainage. Toes warm and well perfused.
.
Pertinent Results:
PERTINENT LABS:
[**2104-4-7**] 12:31AM BLOOD WBC-8.7 RBC-2.13* Hgb-6.9* Hct-19.8*
MCV-93 MCH-32.4* MCHC-34.9 RDW-15.0 Plt Ct-249
[**2104-4-23**] 04:34AM BLOOD WBC-3.1* RBC-2.39* Hgb-7.5* Hct-22.0*
MCV-92 MCH-31.6 MCHC-34.4 RDW-15.4 Plt Ct-171
[**2104-4-7**] 12:31AM BLOOD Neuts-78.7* Lymphs-13.0* Monos-6.4
Eos-1.6 Baso-0.3
[**2104-4-7**] 12:31AM BLOOD PT-14.7* PTT-29.1 INR(PT)-1.3*
[**2104-4-13**] 06:30AM BLOOD PT-21.5* PTT-35.6* INR(PT)-2.0*
[**2104-4-23**] 04:34AM BLOOD Plt Ct-171
[**2104-4-23**] 04:34AM BLOOD PT-13.3 PTT-27.8 INR(PT)-1.1
[**2104-4-7**] 12:31AM BLOOD Fibrino-477*
[**2104-4-7**] 12:31AM BLOOD Ret Aut-6.2*
[**2104-4-7**] 12:31AM BLOOD Glucose-66* UreaN-105* Creat-4.6* Na-132*
K-7.2* Cl-100 HCO3-14* AnGap-25*
[**2104-4-23**] 04:34AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-136
K-4.4 Cl-109* HCO3-23 AnGap-8
[**2104-4-7**] 12:31AM BLOOD LD(LDH)-293* CK(CPK)-102 TotBili-0.3
[**2104-4-7**] 12:31AM BLOOD CK-MB-8 proBNP-9575*
[**2104-4-7**] 12:31AM BLOOD cTropnT-0.27*
[**2104-4-7**] 12:31AM BLOOD calTIBC-267 VitB12-1229* Folate->20
Ferritn-297* TRF-205
[**2104-4-7**] 12:31AM BLOOD TSH-1.1
[**2104-4-7**] 12:31AM BLOOD Cortsol-36.2*
[**2104-4-22**] Epo level- pending
.
MICRO DATA:
BLOOD CX ([**4-8**], [**4-9**], /[**4-10**]): negative
URINE CX ([**4-8**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
LACTOBACILLUS SPECIES. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
LLE WOUND:
GRAM STAIN (Final [**2104-4-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2104-4-13**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed (including a screen for Pseudomonas
aeruginosa,
Staphylococcus aureus and beta streptococcus).
Susceptibility will be performed on P. aeruginosa and S.
aureus if
sparse growth or greater.
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 250-7774L [**2104-4-9**].
ANAEROBIC CULTURE (Final [**2104-4-13**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
.
H. pylori ([**4-17**]): negative.
.
.
STUDIES:
CT LLE ([**4-7**]): 1. Large hematoma of the medial calf located
within the subcutaneous fat. There is no involvement of the
underlying muscle.
2. No fracture of the tibia or fibula. Please note the study is
not tailored to evaluate the knee. If there is clinical
suspicion for fracture about the knee, then radiographs or CT
would be recommended for further evaluation.
.
CXR ([**4-7**]): Right-sided central venous line is again seen with
tip overlying the SVC. Heart size again appears enlarged. There
is unchanged pulmonary congestion compared to prior study. No
new focal consolidations are identified.
.
LLE US ([**4-7**]): Limited examination, but no evidence of DVT in the
left lower extremity.
.
TTE ([**4-7**]): The left atrium is mildly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right 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 ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic regurgitation. Dilated ascending aorta. This
constellation of findings is c/w hypertensive heart.
.
LUE US ([**4-15**]): No evidence of deep vein thrombosis in the left
arm.
.
CT ABD/PELVIS ([**4-17**]): 1. No evidence of retroperitoneal
hematoma.
2. Focal fluid density, cystic structure in the retroperitoneum
adjacent to the aorta. The lesions is incompletely characterized
without intravenous contrast, but likely benign. Possibilities
include an enteric duplication cyst or a low attenuation lymph
node.
.
EGD ([**4-17**]): Normal mucosa in the whole esophagus,
Erosions in the antrum, Normal mucosa in the first part of the
duodenum and second part of the duodenum, Otherwise normal EGD
to second part of the duodenum.
.
Brief Hospital Course:
80 year old female with asthma, anemia, and afib transferred
from an OSH s/p fall with LLE hematoma, ARF, anemia.
.
# L lower leg hematoma. Occurred s/p fall at home. Followed by
plastics in house. Underwent I+D of the wound with initial
removal of 800cc of clot. This was felt to be a large cause of
her anemia. A VAC dressing was placed. Wound culture had heavy
growth of MSSA but this was felt to be most likely a
contaminant. She was initially started on vancomycin but this
was discontinued. Went to OR today for further wound debridement
and now has VAC dressing in place. IV dilaudid was required for
pain control with dressing changes.
.
# Acute blood loss anemia: Felt to be multifactorial. In large
part her anemia was due to her LLE hematoma, as evidenced by the
fact that 800cc of clot was removed initially on her admission
here. However, her hematocrit remained low during the remainder
of her hospitalization, ranging 22-27, despite receiving 10 pRBC
transfusions during her admission. There was no evidence for
iron deficiency, hemolysis or B12 deficiency. SPEP/UPEP normal.
She was intermittently guaiac + and had one episode of a small
amount of BRBPR on [**4-8**] raising concern for a GI blood as a
potential source of blood loss. Had a colonoscopy in [**5-10**] with
only a benign polyp and internal hemorrhoids. GI felt that her
BRBPR most likely represented hemorrhoidal bleeding and there
was no indication for colonoscopy. Later during her
hospitalization she had an EGD in the setting of a self-limited
episode of small amount of coffee grounds emesis, which was only
notable for mild gastritis with no evidence of active bleeding.
Given that her hematocrit remained low, hematology was consulted
as well. They felt there was no need for a bone marrow biopsy at
this time and that her anemia is likely multifactorial, but
mostly related to her bleed. Another possibility is that her
kidneys were not able to mount a sufficient hematopoietic
response to her recent blood loss given her acute renal failure.
Epo level was checked and is pending at the time of discharge.
She is being discharged to rehab today with a hematocrit of 22.
She will receive a unit of pRBC at rehab. Hematocrit will be
monitored there with transfusions given as needed to maintain
her hct above 24.
.
# Acute renal failure (ARF): Her ARF was thought to be
multifactorial due to NSAIDs (which she had been taking high
doses of after the fall), Ace-i, lasix and hypotension/volume
depletion secondary to the hematoma. Renal US was normal. Her
creatinine gradually improved with time and fluids and her
creatinine is now 0.8 at the time of discharge. Hyperkalemia
resolved. The renal team followed her initially while she was in
house.
.
# Coagulopathy: INR was increased to 2.0 and felt likely [**1-5**]
nutritional deficiency. No history of liver disease. Not on
coumadin. INR normalized with PO vitamin K.
.
# UTI: Urine culture from [**4-8**] and [**4-10**] with >100k E coli,
resistant to cipro. She completed a 7 day course of
ciprofloxacin.
.
# Fever: Pt initially had low-grade temps, which quickly
resolved. Most likely due to the hematoma and her UTI. No
evidence for pneumonia on CXR. Blood cultures were negative.
.
# SOB/wheeze: Per the patient, she has shortness of breath and
wheezing at baseline. She reports a long history of asthma.
Denies any history of tobacco use so COPD unlikely. She had been
using her albuterol inhaler at home regularly every 4-6 hour but
was not on long-acting b-agonist or steroid as an outpatient.
She was initially on supplemental oxygen in the ICU but this was
weaned quickly on the medical floor. She was started on
long-acting inhaled steroid and beta agonist. She should have
formal testing with PFTs when she is medically more stable.
.
# Afib: She is not chronically anticoagulated. Was taking a baby
aspirin as an outpatient, which was held in the setting of her
bleed. Rate control was adequate without meds. Anticoagulation
should be considered as an outpatient. Aspirin will be restarted
on discharge.
.
# Constipation: On arrival to the medical floor she was severely
constipated. She had no BM for over one week. Symptoms became so
severe that she had several episodes of vomiting and developed
one episode of coffee grounds emesis subsequently, likely from
esophageal irritation or a small tear. She was treated with an
aggressive bowel regimen and her symptoms resolved.
.
# Thrombocytopenia: Platelets dropped from 249 to 102. Heparin
was stopped and her platelet count rose to 170 by the time of
discharge.
.
# Seizures: Pt had seizures [**1-5**] benign brain tumor in the [**2065**]
and has been on carbamazepime since. This was continued in house
but should be re-addressed as an outpatient.
.
# Hypertension: Her outpatient ACEI was held for ARF. She
remained normotensive while in house. She will be re-started on
the ACEI upon discharge.
.
# CODE: DNR DNI, confirmed with patient and her daughter [**Name (NI) **]
is her HCP.
.
# DISPO: Pt is being discharged to rehab.
.
Medications on Admission:
Tegretol 200mg PO BID
Lisinopril 10mg PO daily
Lipitor 20mg PO daily
Digoxin 0.125mg PO daily
Lasix 20mg PO daily
ASA 81mg PO daily
Pantoprazole 40mg PO daily
Multivitamin with iron daily
Ibuprofen 400-600mg PO q4-6h for past 2 weeks
.
Allergies: PCN/codeine
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
1) left leg hematoma
2) acute on chronic blood loss anemia
3) UTI
4) Acute renal failure
Secondary: gastroesophageal reflux disease, asthma, atrial
fibrillation, and seizures.
Discharge Condition:
Vitals stable. Pain controlled. Hct stable 22-24.
.
Discharge Instructions:
You came to the hospital with a left leg injury, kidney injury,
and anemia. You will be leaving the hospital and going to a
rehabilitation facility to help you continue to recover from
your left leg injury and anemia. You are being discharged with
medications to help with your left leg pain and previously
diagnosed health problems. Please take all medications and
change wound dressing as prescribed.
.
If you develop chest pain, shortness of breath, or fevers > 101,
you should return to the emergency room.
.
Followup Instructions:
You will be followed while at the rehabilitation facility.
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"E888.9",
"E935.9",
"584.9",
"E879.8",
"112.3",
"999.8",
"493.90",
"287.5",
"416.8",
"455.8",
"924.10",
"709.8",
"578.0",
"041.4",
"286.9",
"285.1",
"564.00",
"599.0",
"280.0",
"E849.0",
"530.81",
"427.31",
"585.3",
"345.90"
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icd9cm
|
[
[
[]
]
] |
[
"86.04",
"86.22",
"38.93",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
12839, 12922
|
7486, 12529
|
359, 565
|
13152, 13206
|
2174, 2174
|
13768, 13953
|
1658, 1678
|
12943, 13131
|
12555, 12816
|
13230, 13745
|
1693, 2155
|
242, 321
|
593, 1077
|
2190, 7463
|
1099, 1582
|
1598, 1642
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,238
| 116,500
|
54115
|
Discharge summary
|
report
|
Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-24**]
Date of Birth: [**2089-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB/angina for 18 months
Major Surgical or Invasive Procedure:
CABG x 4 [**2159-2-20**] (LIMA to LAD, SVG to DIAG, SVG to RAMUS, SVG
to PDA)
History of Present Illness:
69 yo male with SOB and angina to left arm with moderate
exertion. Has had sx for approx. 1 1/2 years. Cath at [**Location (un) **]
revealed LM and occluded RCA, as well as severe right external
iliac stenosis. Transferred here for CABG.
Past Medical History:
CAD
inferior myocardial infarction
hyperlipidemia
hypertension
renal calculi ( 10 years ago)
bilat. LE claudication
PSH: appy, tonsillectomy, 2 back surgeries
Social History:
lives with wife
retired [**Name2 (NI) **] worker
actively smokes one ppd
one ETOH per week
Family History:
mother with multiple MIs/CVA, died at age 82
Physical Exam:
5'9" 89.3 kg
HR 50 RR 18 136/62
well-appearing
skin unremarkable
PERRL
lower partial and imcomplete dentition
neck supple, full ROM
CTAB
RRR no murmur
soft, NT, ND, + BS
warm, well-perfused, no edema
left groin cath site c/d/i, no hematoma
neuro grpossly intact
2+ bil. fem/DP/PT/radials
no carotid bruits appreciated
Pertinent Results:
Conclusions
PRE-CPB:1. The left atrium is normal in size. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine, a-pacing. Preserved
biventricular systolic function post-cpb. Trivial mr, ai. Aortic
contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2159-2-20**] 16:43
?????? [**2153**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr. [**Known lastname 496**] was admitted from [**Hospital **] Hosp. on [**2-14**]. Heparin
was started during a plavix washout while awating surgery. He
underwent CABG with Dr. [**Last Name (STitle) **] on [**2-20**]. He tolerated the
procedure well and was transferred in critical and stable
condition to the surgical intensive care unit. His phenylephrine
and propofol drips were weaned. He was extubated that evening
and his chest tubes were removed. He was transferred to the
floor on POD #1 to begin increasing his activity level. He was
seen in consultation by physical therapy. On POD #3 his wires
were removed. By the following day he was ready for discharge
to home.
Medications on Admission:
atenolol 50 mg daily
zetia 10 mg daily
simvastatin 80 mg daily
ASA 325 mg daily
plavix 75 mg daily
prednisone 20 mg TID x 1 day for cath prophylaxis only
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
CAD s/p CABG
inferior myocardial infarction
hyperlipidemia
hypertension
renal calculi ( 10 years ago)
right external iliac stenosis
bilat. LE claudication
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 8579**] in [**2-6**] weeks
Follow up with Dr. [**Last Name (STitle) 40075**] in [**1-5**] weeks
Completed by:[**2159-2-24**]
|
[
"440.21",
"412",
"V13.01",
"272.4",
"401.9",
"414.2",
"414.01",
"440.8",
"518.0",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5260, 5323
|
2983, 3666
|
328, 410
|
5522, 5529
|
1386, 2960
|
6327, 6596
|
984, 1030
|
3870, 5237
|
5344, 5501
|
3692, 3847
|
5553, 6304
|
1045, 1367
|
264, 290
|
438, 677
|
699, 859
|
875, 968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,146
| 108,902
|
7798
|
Discharge summary
|
report
|
Admission Date: [**2133-5-13**] Discharge Date: [**2133-5-19**]
Date of Birth: [**2067-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
flail post. MV leaflet, mod.-severe MVP found on follow up echo.
known MVP/MR [**First Name (Titles) **] [**Last Name (Titles) 10718**] of endocarditis in '[**18**].
Major Surgical or Invasive Procedure:
Mitral Valve repair (#34mm CE physio ring)[**5-13**]
History of Present Illness:
65yo male with known MVP/MR diagnosed '[**18**] after an [**Year (2 digits) 10718**] of
endocarditis. He only admits to mild PND at high altitude. He
now presents for surgical evaluation. Cardiac echo [**10-30**] reveals
mod-severe MVP,3+MR with partial mitral post. flail leaflet.
DR.[**Last Name (STitle) **] was consulted for MVrepair.
Past Medical History:
MVP/MR, hyperlipidemia, endocarditis'[**18**], GERD, RLL nodule, Left
periaortic mass c/w esoph. cyst vs. bronchogenic cyst stable
since '[**19**], right knee surgery, torn left rotator cuff, ?OSA
Social History:
retired engineer, denies tobacco, 2-3 beers/week.
Family History:
father with PPM at age [**Age over 90 **], brother and son with heart
murmurs.lives in [**Location **] with wife.
Physical Exam:
Admission Physical Exam
afebrile, Pulse:72, RR:14, BP:146/78, Ht:72",Wt:188lb
General: A&Ox3, NAD
HEENT: [**Last Name (un) **], NC/AT, carotids: neg. bruits/JVD
CVS:RRR, Nl S1-S2, III/VI holosystolic murmur
Lungs:CTA
ABD:benign
EXT:0 C/C/E, no varicosities
Discharge EXAM
T:99.1, P:81,BP:136/88, RR:18, O2SAT: 96%, Wt:85.9KG
General:A&Ox3,NAD
HEENT:AT/NC, [**Last Name (un) **]
CVS:RRR
Lungs:CTA
ABD:benign
EXT: neg. C/C/E
Pertinent Results:
[**2133-5-18**] 09:00PM BLOOD WBC-8.8 RBC-3.54* Hgb-11.2* Hct-31.6*
MCV-89 MCH-31.7 MCHC-35.5* RDW-15.1 Plt Ct-242#
[**2133-5-13**] 12:22PM BLOOD WBC-18.0*# RBC-3.62* Hgb-11.2*# Hct-32.4*
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.8 Plt Ct-159
[**2133-5-17**] 02:40PM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-135
K-3.9 Cl-101 HCO3-28 AnGap-10
[**2133-5-13**] 01:18PM BLOOD UreaN-17 Creat-0.9 Cl-113* HCO3-24
Approved: FRI [**2133-5-15**] 2:59 PM
[**2133-5-18**] 09:00PM BLOOD WBC-8.8 RBC-3.54* Hgb-11.2* Hct-31.6*
MCV-89 MCH-31.7 MCHC-35.5* RDW-15.1 Plt Ct-242#
[**2133-5-18**] 09:00PM BLOOD Plt Ct-242#
[**2133-5-15**] 12:25AM BLOOD PT-15.9* PTT-29.3 INR(PT)-1.4*
[**2133-5-17**] 02:40PM BLOOD Glucose-133* UreaN-16 Creat-0.8 Na-135
K-3.9 Cl-101 HCO3-28 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 28207**], [**Known firstname 870**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3947**] [**Hospital1 18**] [**Numeric Identifier 28208**]Portable
TTE (Focused views) Done [**2133-5-14**] at 4:17:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2067-12-14**]
Age (years): 65 M Hgt (in): 70
BP (mm Hg): 118/65 Wgt (lb): 190
HR (bpm): 83 BSA (m2): 2.04 m2
Indication: LV function; status post mitral valev repair
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2133-5-14**] at 16:17 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W033-0:00 Machine: Vivid [**6-28**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.0 cm <= 5.0 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Peak Resting LVOT gradient: *12 mm Hg <= 10
mm Hg
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *25 < 15
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - E Wave: 1.6 m/sec
Mitral Valve - A Wave: 1.4 m/sec
Mitral Valve - E/A ratio: 1.14
Mitral Valve - E Wave deceleration time: *260 ms 140-250 ms
TR Gradient (+ RA = PASP): *18 to 30 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Mild resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous
mitral valve leaflets. Mitral valve annuloplasty ring.
Well-seated mitral annular ring with normal gradient. [**Male First Name (un) **] of
mitral valve leaflets. No MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Mild [1+]
TR. Borderline PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - bandages,
defibrillator pads or electrodes.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%) There is a mild resting
left ventricular outflow tract obstruction. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
are myxomatous. A mitral valve annuloplasty ring is present. The
mitral annular ring appears well seated and is not obstructing
flow. There is systolic anterior motion of the mitral valve
leaflets. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-4-30**], the mitral valve has been repaired (ring
annuloplasty); however, there is now systolic anterior motion of
the anterior mitral leaflet with mild left ventricular outflow
tract obstruction.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2133-5-14**] 17:01
Brief Hospital Course:
On [**2133-5-13**] Mr [**Known lastname **] was taken to the OR where he underwent a
Mitral Valve repair with #34mm CE physio ring. Please refer to
DrKhabbaz's operative note for further details. Cross clamp
time:49" Cardiopulmonary bypass time:64". He was transferred to
the CVICU intubated on propofol and Neo to optimize his blood
pressure and cardiac output. He was extubated without incident
and tubes and lines were discontinued in a timely fashion. POD#1
he had a near syncopal [**Known lastname 10718**] and was treated with volume for
orthostatic hypotension. EKG changes postop were evident with ST
elevations and a intermittent LBBB. Mr [**Known lastname **] was started on
Ibuprofen for pericarditis. POD #2 he was doing well and
transferred to the floor. Further tele monitoring revealed LBBB
resolved. Beta blocker was optimized and he remains
hemodynamically stable. On [**2133-5-19**] it was felt that Mr [**Known lastname **]
was doing well and was ready to be discharged to home with VNA
services.
Medications on Admission:
Lipitor 5(1),Aciphex 15(1), Lisinopril 40(1),Amoxicillin prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*1 30* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: 1 month only.
Disp:*90 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
status post Mitral Valve repair (#34mm CE physio ring)
PMH: MVP/MR,hyperlipidemia, endocarditis'[**18**], GERD, RLL nodule, L
periaortic mass c/w esophageal cyst vs. bronchogenic cyst stable
since '[**19**],torn left rotator cuff, ?OSA, right knee surgery
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
wound clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 28209**]) please call for
appointment
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2133-5-20**]
|
[
"458.0",
"401.9",
"272.4",
"424.0",
"426.3",
"423.9",
"530.81",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8522, 8556
|
6626, 7643
|
488, 543
|
8856, 8863
|
1788, 6603
|
9375, 9790
|
1214, 1329
|
7754, 8499
|
8577, 8835
|
7669, 7731
|
8887, 9352
|
1344, 1769
|
283, 450
|
571, 911
|
933, 1131
|
1147, 1198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,692
| 184,278
|
54202
|
Discharge summary
|
report
|
Admission Date: [**2187-10-29**] Discharge Date: [**2187-11-14**]
Date of Birth: [**2108-6-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo M with a history of hypertension and diabetes found at
home with altered mental status. He was last seen on Saturday
[**2187-10-27**] at work and in normal state of health. He was found by
his family at home on Monday [**2187-10-29**] lethargic and confused. He
was initially able to respond to sons saying that he was OK,
then became unable to speak or communicate. His sons gave him
juice and sugar pills as he has been like this in the past when
hypoglycemic. He was then brought to [**Hospital **] Hospital, where he
was found to have a low grade fever of 100.4, leukocytosis,
hypertension to 200s/100s, acute renal failure, and
hypernatremia. Head CT was negative for bleed. He was
intubated for airway protection and transferred to [**Hospital1 18**] for MRI
and further evaluation of his mental status.
At [**Hospital1 18**], he The underwent MRI brain which showed small areas of
restricted diffusion on DWI in right parafalcine cortex.
Neurology was consulted and did not feel the patient had a new
stroke, and they felt his presentation was more consistent with
a toxic-metabolic picture.
.
The patient was successfully extubated, however, his mental
status never returned to baseline. Possible contributing
insults, including hypernatremia and other metabolic
derangements, poorly controlled hypertension, and infection were
either corrected or ruled out. The patient remained confused
and far from his relatively highly functional baseline per his
family. No clear etiology of his mental status was found, and
he was transferred to the floor for further evaluation.
Past Medical History:
Hypertension
Type II Diabetes mellitus
Polio
S/p cath with stent placement 4 years ago
S/p renal artery stent 4 months ago.
CHF
Social History:
Works as Engineer. Non-smoker, no slcohol. Widower, lives alone.
Three sons in the area. Was working and driving prior to
admission.
Family History:
non-contributory
Physical Exam:
VS: T- 99.6 P- 76 BP- 190/70 RR- 17 O2Sat- 96% on RA
GENERAL: arousable to name, dobhoff in place, hard of hearing,
"I am at home." Pleasant. follows commands intermittently.
HEENT: PERRL, MM dry.
NECK: Supple to LAD, no JVD.
CARDIOVASCULAR: RRR, II/VI SM apex
LUNGS: Ant and lat fields clear.
ABDOMEN: ND, NABS, soft, small mass at RUQ under skin. Scar RLQ
EXTREMITIES: LLE with atrophy, RLE with rigidity
Pertinent Results:
[**2187-10-29**] 11:52PM GLUCOSE-203* UREA N-45* CREAT-1.5* Sodium
150* POTASSIUM-3.5 CHLORIDE-116* TOTAL CO2-24 ANION GAP-14
[**2187-10-29**] 11:52PM ALT(SGPT)-41* AST(SGOT)-56* LD(LDH)-265*
CK(CPK)-638* ALK PHOS-139* AMYLASE-227* TOT BILI-0.9
[**2187-10-29**] 11:52PM CK-MB-10 MB INDX-1.6 cTropnT-0.08*
[**2187-10-29**] 11:52PM TSH-1.2
[**2187-10-29**] 11:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-10-29**] 11:52PM WBC-13.5* RBC-4.60 HGB-14.6 HCT-41.8 MCV-91
MCH-31.7 MCHC-35.0 RDW-14.5
[**2187-10-29**] 11:52PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2187-10-29**] CXR: normal tube placement, no acute cardiopulmonary
process.
[**2187-10-31**] MRI/MRA brain:
1. Subacute infarcts involving paramedian right frontal cortex
and subcortical white matter, which may relate to distal
occlusion of A3 segment of the right anterior cerebral artery,
perhaps on an embolic basis. However, there is no evidence of
new infarction elsewhere in the brain.
2. Moderate chronic micro-ischemic change in bihemispheric
periventricular and subcortical white matter.
3. Moderate generalized atrophy.
4. Unremarkable cranial MRA with no flow-limiting stenosis.
[**2187-11-1**] Head CT: no mass effect or hemorrhage
[**2187-11-2**] TTE: Mild symmetric LVH with overall LVEF 50%. Increased
LV filling pressure. Mild AV, trace AR, 1+ MR. 3+ TR. moderate
PAH.
Video swallow: Various consistencies of barium were administered
through out the exam. Both the oral and pharyngeal phases were
within functional limits. No premature spillover or oral cavity
oropharyngeal residue was identified. No aspiration or
penetration was observed during the exam.
Brief Hospital Course:
1. Altered mental status: Despite multiple studies and
extensive evaluation, no clear etiology was determined. The
patient's mental status continued to wax and wane during the
hospitalization, however, never returned to baseline. He was
always able to provide his name, and was intermittently oriented
to place, but never oriented to situation or time. Per his
family, the patient was relatively highly functional prior to
this event, and given the lack of improvement, the family agreed
to long term nursing facility placement. At the time of
discharge, he was able to feed himself with supervision, and sit
in a chair safely. He needed a lot of assistance moving and
changing position, and was intermittently cooperative with PT.
All sedating medications were held and blood pressure and blood
glucose were closely monitored. The patient was very hard of
hearing, which limited effective communication. The patient
should have neuropsychiatric testing in the dementia clinic one
to two months after discharge.
.
2. Hypertension: the patient has a history of renal artery
stenosis and difficult to control hypertension. He had stenting
of his renal artery several months ago. At the time of
discharge, his regimen included Clonidine TTS 3, Lisinopril 40
mg qd, Amlodipine 10 mg qd, Metoprolol 50 mg po bid (when heart
rate would tolerate), and Hydralazine 50 mg po q6. The
patient's blood pressure was originally well controlled on
Labetalol, however, his low heart rate limited our ability to
give the drug. Per the Geriatrics Attending, clonidine is not an
optimal drug to use in elderly with dementia, therefore, if it
is ultimately possible to wean off some of the medication,
Clonidine should be the first withdrawn.
.
3. Diabetes: The patient was maintained on sliding scale
insulin. Low dose Lantus was restarted late in the admission.
The patient had high readings during the day but tended to have
a very low fasting glucose on the am labs. The patient had a
history of hypoglycemic episodes from tight diabetes control.
HbA1c is 5.6%.
.
4. CAD/CHF: LDL 67, no need for statin. Continue betablocker
and ace-inhibitor as tolerated. He had three sets negative
cardiac enzymes and his echocardiogram showed preserved LV
systolic function. He had several episodes of NSVT, and
electrolytes were repleted as necessary. At discharge, aspirin
and Plavix were restarted.
.
5. FEN: He was initially on tube feeds via the nasogastric
tube. He successfully passed a video oropharyngeal study, and
was able to eat by himself at the time of discharge.
Electrolytes repleted as necessary.
.
6. Disposition: The patient was ultimately discharged to a
skilled nursing facility. His mental status never recovered
during this admission and the chance long term recovery of
memory and function is unpredictable. His three sons and their
wives were very involved with the patient's care. He was full
code.
.
Medications on Admission:
Insulin
Plavix 75 mg qd
Lasix 30 mg qd
Lisinopril 20 mg qd
Colace
Aspirin
Potassium
Labetolol 100 mg [**Hospital1 **]
Clonidine 0.1 mg [**Hospital1 **]
Toprol XL 100 mg QD
Nifedical XL 30 mg qd
Pravachol 40 mg qd
Protonix 40 mg qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP <100, HR <55.
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
9. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous
at bedtime.
10. Insulin Lispro (Human) 100 unit/mL Solution Sig: 0-10 units
Subcutaneous four times a day: per sliding scale.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**]
Discharge Diagnosis:
Dementia
Hypertension
Diabetes mellitus
Coronary artery disease
Congestive heart failure
Renal artery stenosis
Discharge Condition:
Afebrile, hemodynamically stable.
Discharge Instructions:
Please return to the emergency department for fevers, chills,
chest pain, shortness of breath, or new neurological symptoms.
.
Followup Instructions:
Please follow up with your primary care physician within one
month of hospital discharge. Phone number for Dr. [**Last Name (STitle) 8522**] is
[**Telephone/Fax (1) 8577**].
.
Please make an appointment in the [**Hospital **] Clinic at [**Hospital1 18**] for
Neuropsychiatric testing for 2-3 months after hospital
discharge. Phone number of the clinic is [**Telephone/Fax (1) 719**].
.
|
[
"V45.82",
"276.0",
"428.0",
"250.02",
"290.41",
"437.0",
"584.9",
"397.0",
"428.32",
"414.01",
"401.9",
"599.0",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8667, 8713
|
4533, 4545
|
339, 345
|
8868, 8904
|
2745, 4036
|
9079, 9470
|
2283, 2301
|
7739, 8644
|
8734, 8847
|
7484, 7716
|
8928, 9056
|
2316, 2726
|
278, 301
|
373, 1965
|
4045, 4510
|
4561, 7458
|
1987, 2116
|
2132, 2267
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,379
| 138,237
|
24221
|
Discharge summary
|
report
|
Admission Date: [**2171-7-5**] Discharge Date: [**2171-7-13**]
Date of Birth: [**2101-5-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 70 year-old female with a history of diastolic heart
failure, CKD, and DM2 who presents with shortness of breath,
hypoxia and acute on chronic renal failure. She was placed on a
NRB in the ambulance, satting 92, and was transitioned to BiPAP
in the ED, started on nitro gtt, and received a dose of
furosemide 40mg IV. Of note, the patient was recently admitted
with acute on chronic renal failure and her furosemide was held
on discharge. She put out 600cc urine to the 40 of lasix IV, and
per ED report, the patient felt symptomatically improved after
the dose. ABG on arrival was 7.36/36/47 after being initiated on
bipap.
.
Past Medical History:
CKD, Stage IV (baseline Creat 4.3-4.[**2171-6-3**]), s/p R RAS
stent and pta (Renal MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
Diastolic HF
DM II
Hypertension
s/p CVA ([**2158**])
PVD, s/p revascularization RLE
Hypercholesterolemia
Valvular disease: mild [1+] MR & TR (echo [**2171-7-8**])
Mild symmetric LVH, mod PA syst htn, LVEF >75%, diastolic
dysfunction
CAD, coronary artery calcifications per CT
Diverticulosis
Pulmonary subpleural RUL nodule
Degenerative changes in the spine
h/o calcified gallstones
Severe small vessel ischemic changes (Head CT [**2171-6-21**])
.
PSHx:
s/p revascularization RLE
s/p hysterectomy, Fibroids ([**2147**])
s/p R RAS stent and pta/ renal: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Social History:
Notable that she had a 15-pack-year smoking history, quitting in
[**2157**]. She formerly consumed alcohol heavily but not since her
early 20s. She has no history of intravenous drug use. She is
retired.
.
ADLs - HHA assists with bathing, independent in all other; IADLs
- independent with phone, has MOW, sister/HM assists or does all
other IADLs.
.
She lives alone, [**Location (un) 9998**] apt in [**Hospital3 4634**] bldg, elevator.
Sister lives on [**Location (un) 61490**] & helps alot. Services from ETHOS (Case
Manager: [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 61491**], [**Telephone/Fax (1) 61492**]): HHA 2 x's/wk,
MOWs; [**Hospital 119**] Homecare for SN & PT.
.
Assistive Devices - Has lifeline, shower chair, grab bars in BR,
[**Last Name (LF) **], [**First Name3 (LF) **] & WC; has glasses but they are home, sister will
bring to [**Name (NI) 5595**]. Dentures: full uppers only, lost bottoms some
time ago - states she eats "OK" with only uppers. No hearing
aids.
Family History:
Family history: Notable for a sister who has hypertension and a
CVA, mother who died from an MI and had diabetes mellitus. There
is no specific history of kidney disease, no history of kidney
stones.
Physical Exam:
DISCHARGE PE:
============
VS: Tmax 99.2 HR - 80-81, BP - 127-148/56-70 o2 sat - 96%RA
GENERAL: Obese elder black female in NAD, NCAT
EYES: EOMI, PERRL, conjuntiva clear, non-icteric
ENT: MMM, some tenderness left lateral neck with rotation, no
LAD
CARDIOVASCULAR: rrr, s1 s2 s4, 2/6 systolic murmur best @ apex
RESP: [**Month (only) **] BS @ bilat bases/posterior, no wheezes
GASTROINTESTINAL: soft, , obese, +BS, nontender
MUSCULOSKELETAL-EXT: no edema, + venous stasis changes
NEUROLOGICAL: alert, oriented, engaging right-sided def s/p CVA
INTEGUMENT: healed scarred decubiti on right heel (old); no
rash, no ulceration
GENITOURINARY: foley removed today ([**7-13**])
Pertinent Results:
ADMISSION LABS:
==============
[**2171-7-5**] 08:23PM URINE HOURS-RANDOM UREA N-262 CREAT-25
SODIUM-75
[**2171-7-5**] 08:23PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2171-7-5**] 07:30AM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-1.008
[**2171-7-5**] 07:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-7-5**] 07:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2171-7-5**] 07:30AM URINE AMORPH-FEW
[**2171-7-5**] 08:19PM UREA N-85* CREAT-4.7* POTASSIUM-3.7
[**2171-7-5**] 08:19PM WBC-8.0 RBC-3.42* HGB-10.2* HCT-30.4* MCV-89
MCH-29.8 MCHC-33.6 RDW-15.1
[**2171-7-5**] 08:19PM PLT COUNT-185
[**2171-7-5**] 01:54PM TYPE-ART PO2-82* PCO2-27* PH-7.44 TOTAL
CO2-19* BASE XS--3
[**2171-7-5**] 01:54PM freeCa-1.17
[**2171-7-5**] 01:08PM GLUCOSE-158* UREA N-85* CREAT-4.7* SODIUM-139
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15
[**2171-7-5**] 01:08PM CK(CPK)-73
[**2171-7-5**] 01:08PM CK-MB-3 cTropnT-0.03*
[**2171-7-5**] 01:08PM CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-2.4
[**2171-7-5**] 01:08PM WBC-8.2 RBC-3.21* HGB-9.6* HCT-28.3* MCV-88
MCH-30.0 MCHC-34.0 RDW-15.0
[**2171-7-5**] 07:10AM TYPE-ART PEEP-5 O2-40 PO2-47* PCO2-36
PH-7.34* TOTAL CO2-20* BASE XS--5 INTUBATED-NOT INTUBA
[**2171-7-5**] 05:25AM GLUCOSE-145* UREA N-82* CREAT-4.5* SODIUM-138
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-19* ANION GAP-17
[**2171-7-5**] 05:25AM CK(CPK)-78
[**2171-7-5**] 05:25AM cTropnT-0.03*
[**2171-7-5**] 05:25AM LACTATE-1.2
[**2171-7-5**] 05:25AM WBC-11.8* RBC-4.08* HGB-11.6* HCT-36.0 MCV-88
MCH-28.5 MCHC-32.3 RDW-14.8
[**2171-7-5**] 05:25AM NEUTS-83.4* LYMPHS-11.2* MONOS-3.9 EOS-1.2
BASOS-0.3
[**2171-7-5**] 05:25AM PT-12.9 PTT-25.9 INR(PT)-1.1
.
IMAGING:
=======
[**2171-7-12**] CHEST (PA & LAT) - COMPARISON: [**2171-7-10**].
FINDINGS: There is marked improvement in degree of pulmonary
edema, with only mild pulmonary vascular congestion remaining.
Bilateral small effusions remain present, but significantly
decreased. The cardiac silhouette is mildly enlarged. There is
no focal consolidation or pneumothorax. IMPRESSION: Significant
improvement in degree of now only mild interstitial edema with
residual small bilateral effusions.
.
[**2171-7-10**] CHEST (PORTABLE AP) - IMPRESSION: AP chest compared to
[**7-8**] & 12. Severe bilateral consolidation worsened
appreciably. Perihilar distribution suggests this is edema,
although mild cardiomegaly has not worsened. Moderate right
pleural effusion has increased.
.
[**2171-7-8**] RENAL U.S. - IMPRESSION: 1. Normal right kidney; 2.
Atrophic hyperechoic left kidney with abnormal Doppler
waveforms. If clinically indicated, cross- sectional imaging
could be performed for further characterization.
.
[**2171-7-6**] CT CHEST W/O CONTRAST - IMPRESSION: 1. Multifocal
perihilar areas of consolidation and ground-glass opacity
associated with smooth septal thickening, bilateral pleural
effusion, most prominent on the right, interstitial fluid,
bronchial wall thickening and mild cardiomegaly as well as small
pericardial effusion suggesting pulmonary edema; 2.
ongravitational asymmetric ill-defined peribronchial vascular,
partly nodular and partly ground-glass, opacity with air
bronchogram suggesting multifocal pneumonia, most prominent on
the right; 3. Subpleural right upper lobe nodule. In the absence
of risk factor, no further followup is warranted. If risk factor
is present for lung cancer, chest CT is recommended in 12
months; 4. Coronary artery calcifications, aortic and aortic
annulus calcifications are scattered; 5. Calcified gallstone.
Right renal artery stent. Left renal atrophy. Diverticulosis.
.
[**2171-7-5**] BILAT LOWER EXT VEINS PORT - IMPRESSION: No evidence of
lower extremity DVT of either leg.
.
[**2171-7-8**] Cardiac Echo (TTE) - LA is markedly increased
(>32ml/m2). The left atrium is dilated. The interatrial septum
is aneurysmal, no ASD. Mild symmetric LVH with normal cavity
size. LV systolic function is hyperdynamic (EF>75%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg), no VSD. RV chamber size and free wall
motion are normal. No As or AR. Mild (1+) MR. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. IMPRESSION: Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Diastolic dysfunction. Moderate
pulmonary artery systolic hypertension. Compared with the prior
study (images reviewed) of [**2169-12-5**], the estimated pulmonary
artery systolic pressure is higher.
.
EKG:
===
[**2171-7-5**] Sinus rhythm. Non-specific inferolateral ST-T wave
changes. Compared to the previous tracing of [**2171-6-21**] the QRS
voltage is decreased. Ventricular rate is slower. QT/QTc
374/407.
.
DISCHARGE LABS:
==============
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2171-7-13**] 07:20AM 6.7 3.26* 9.9* 28.8* 88 30.2 34.3 15.3
254
Glu UreaN Creat Na K Cl HCO3 AnGap
[**2171-7-13**] 07:20AM 123* 91* 5.9* 140 4.3 103 23 18
Brief Hospital Course:
70 year old female with ESRD admitted with hypoxia in setting of
lasix being held. She was admitted to the ICU [**Date range (1) 61493**] where she
was aggressively diuresed with IV lasix.
#1. Pneumonia, multifocal pneumonia, most prominent on the right
per CT. Initially treated with vancomycin and levofloxacin but
narrowed to levo. Completed a seven day course of levofloxacin
#2. Pulmonary Edema, acute on chronic decompensated diastolic
heart failure
Aggressively treated with Lasix IV, respiratory status much
improved. After diuresis, symptoms, clinical exam & repeat CXR
appear to indicate that the patient's DRY WEIGHT TO BE ~173.5
lbs. Was treated with 100mg PO lasix [**Hospital1 **] on [**7-12**] with good
diuresis, but with weight to 171.5 on [**7-13**] and creatinine to
5.9. Lasix dose decreased to 100mg once daily on discharge. Note
that it can be changed to [**Hospital1 **] if weight increases as she
responds to it.
- recommend sleep study as outpatient to eval for obstructive
sleep apnea, as it may contribute to clinical picture.
#3. Acute on Chronic Renal Failure, Stage IV CKD
Renal consultation supported need for aggressive diuresis, given
pulmonary edema, despite rising creatinine. Renal aware
creatinine in 5's. Renal will continue to follow at [**Hospital1 5595**]/MACU.
Out-patient appointment per Renal consult set-up with [**Hospital 1326**]
Clinic (next available - [**2171-9-10**]). Please avoid all medications
that contain aluminum, magnesium. Patient on renal diet & fluid
restriction. Had vein mapping while inpatient.
#4. Urinary Retention
Foley placed ([**7-11**]) after patient did not void, despite OOB to
commode, after Lasix 60 mg IVP & bladder scan showed ~ 400 cc
retention. Foley removed on [**7-13**].
#5. Diabetes: continued with home NPH and humalog sliding scale.
FSBS running 126-215 in the 24 hrs prior to discharge.
#6. Change in Mental Status
Seen by Psych while in ICU for auditory hallucinations. Felt to
be brief episodes of delirium. Patient now A&O x's 3. Psych
recommended considering starting dementia medication such as
namenda in near future.
.
#7. Pain
Intermittent lower left lateral neck pain with movement. Needs
f/u by PCP. [**Name10 (NameIs) **] acetaminophen.
.
#8 Skin, s/p revascularization RLE
Well-healed old decubitus on right heel. Needs close attention
to skin.
# Code Status: Full
Medications on Admission:
(per [**2171-6-23**] [**Hospital1 18**] D/C Summary)
1. ECASA 325 mg PO QD
2. Calcitriol 0.25 mcg PO QD
3. Nifedipine SR 60 mg 2T PO QD
4. Toprol XL 200 mg PO QD
5. Gabapentin 300 mg PO QOD
6. Atorvastatin 40 mg PO QD
7. Insulin: 15 units Humalin N qam & 6 units Humalin N qpm
8. Tylenol 650 mg PO [**Hospital1 **] (OTC)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
=================
Multifocal pneumonia
acute on chronic decompensated diastolic heart failure
Pulmonary edema, with right pleural effusion
Acute on Chronic Renal Failure
.
Secondary Diagnosis:
===================
Chronic kidney disease, Stage IV (baseline Creat 4.3-4.[**2171-6-3**]), s/p R RAS stent and pta, (Renal: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD)
Diastolic HF
Diabetes, type II
Hypertension
s/p CVA ([**2158**])
Peripheral vascular disease, s/p revascularization RLE
Hypercholesterolemia
Valvular disease: mild [1+] MR & TR (echo [**2171-7-8**])
Mild symmetric LVH, mod PA syst htn, LVEF >75%, diastolic
dysfunction
CAD, coronary artery calcifications per CT
Diverticulosis
Pulmonary subpleural RUL nodule
Degenerative changes in the spine
h/o calcified gallstones
Severe small vessel ischemic changes (Head CT [**2171-6-21**])
.
PSHx:
s/p revascularization RLE
s/p hysterectomy, Fibroids ([**2147**])
s/p R Renal aretery stent and pta
Discharge Condition:
Stable. Dry weight is 173 lbs. Weight on discharge is 171.5.
Lasix dose decreased to once daily. Discharge creatinine 5.9.
Discharge Instructions:
You were admitted to the hospital after becoming very short of
breath. You were found to have a pneumonia, pulmonary edema from
heart failure and acute (on chronic) renal failure and were
admitted to the ICU. Your treatment has included antibiotics,
medications to control your BP & to help your heart and also
strong medicines to assist your kidneys to get rid of the extra
fluid in your body (Lasix IV). Your breathing has become much
better and you are now ready to go to a rehabilitation setting
where your kidney doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] in your care.
.
Please let your health care providers know if you have any of
the following: chest pain or pressure, trouble breathing, fever
> 100.6 and/or shaking chills, pain that is not controled by
medicines, dizzyness when standing, blood in your stool or urine
or any other health-related concerns.
.
Please follow the instructions of the Physical Therapists.
Please also take all your medications as prescribed.
.
It is important to make and keep all of your follow-up
appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2171-7-16**] 9:00
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD, Renal [**Hospital 1326**] Clinic,
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2171-9-10**] 8:50
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2171-9-10**] 1:00
Completed by:[**2171-7-13**]
|
[
"428.33",
"585.4",
"250.00",
"723.1",
"486",
"414.01",
"584.9",
"276.4",
"518.89",
"780.09",
"788.20",
"285.9",
"428.0",
"443.9",
"403.90",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13247, 13313
|
9084, 11460
|
322, 329
|
14354, 14479
|
3772, 3772
|
15610, 16084
|
2877, 3063
|
11831, 13224
|
13334, 13334
|
11486, 11808
|
14503, 15587
|
8776, 9061
|
3078, 3078
|
3092, 3753
|
275, 284
|
357, 996
|
13546, 14333
|
3788, 8760
|
13353, 13525
|
1018, 1792
|
1808, 2845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,717
| 177,972
|
51304
|
Discharge summary
|
report
|
Admission Date: [**2115-12-30**] Discharge Date: [**2116-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
HYPOXIA
Major Surgical or Invasive Procedure:
Endotracheal intubation and ventilation
Arterial Line
History of Present Illness:
[**Age over 90 **]F h/o HTN, PVD, spinal stenosis, who was transferred from
[**Hospital1 **] after presenting with calf pain and numbness x 1
day. Pt reports having left leg pain "off and on" for months.
Was diagnosed with bursitis and has been receiving steroid
injections. Yesterday pt reports pain was so severe that she
fell to the ground. EMS was called, and pt was taken to OSH
where O2sat was 82% on RA/100%on NRB. Pt denied SOB, cough, CP.
Also denied N/V/D/F/C/dysuria, or abdominal pain
W/U at OSH notable for EKG changes without ishemic changes, CXR
showing honeycombing insterstitial patterns. CTA was negative
for PE but showed patchy ground glass opacities, bibasilar
fibrosis, peripheral bullous disease and increased interstitial
markings.
Pt started on empiric CTX and zithro, given supp O2, and
transferred to the [**Hospital1 **] per pt's request.
Past Medical History:
HTN, PVD, Hypercholesterolemia, spinal stenosis, h/o pleural
empyema as child s/p surgery, bilateral cataracts, fibrocystic
breast disease; echo [**2114**]: EF 65% with mild pulmonary HTN
Social History:
Lives alone in [**Hospital3 **]. Quit tobacco 30 years ago,
40-50 pack year history prior. EtOH: 2 glasses of wine a day.
Former real estate [**Doctor Last Name 360**].
Family History:
Non contributory
Physical Exam:
At the time of death:
Pulseless, apneic
No response to sternal rub, corneal reflex, or nailbed pressure.
No heart sounds or lung sounds.
Pertinent Results:
[**2115-12-30**] 10:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2115-12-30**] 10:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2115-12-30**] 10:20PM GLUCOSE-127* UREA N-25* CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
[**2115-12-30**] 10:20PM CK(CPK)-100
[**2115-12-30**] 10:20PM CK-MB-5 cTropnT-<0.01
[**2115-12-30**] 10:20PM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.0
[**2115-12-30**] 10:20PM WBC-12.5* RBC-4.05* HGB-13.5 HCT-38.0 MCV-94
MCH-33.3* MCHC-35.5* RDW-13.4
[**2115-12-30**] 10:20PM PLT COUNT-284
[**2115-12-30**] 09:07PM TYPE-ART PO2-60* PCO2-28* PH-7.48* TOTAL
CO2-21 BASE XS-0
[**2115-12-30**] 09:07PM LACTATE-1.4
[**2115-12-30**] 09:07PM freeCa-1.12
UNILAT LOWER EXT VEINS LEFT PORT [**2115-12-31**] 9:17 AM
Left common femoral, superficial femoral, and popliteal veins
demonstrate normal compressibility, color flow, Doppler
waveforms, and response to augmentation. No intraluminal
thrombus is identified.
CHEST (PORTABLE AP) [**2115-12-30**] 9:20 PM
A mild degree of bilateral pulmonary vascular congestion and
cardiomegaly.
ECHO Study Date of [**2116-1-2**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis. Mild to
moderate ([**11-24**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**11-24**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
CT Chest - Findings consistent with possible nonspecific
interstitial pneumonitis.
Brief Hospital Course:
Upon admission to [**Hospital1 18**] MICU, patient was placed on NRB w/ nasal
cannula for additional oxygen delivery, and it was noted that
patient would desaturate with any attempt to remove mask. CT
suggested a diffuse process w/ ground-glass opacities and
differential diagnoses included LIP,IPF/UIP,AIP/ARDS,BOOP,PAP.
Nonetheless, patient appeared subjectively without distress.
However, on subsequent days, despite empiric antibiotic
treatment and diuresis for presumptive pneumonia and pulmonary
edema, patient's hypoxia continued to progress and patient
ultimately became subjectively dyspneic. In addition, patient
was also treated empirically for Pneumocystis carinii pneumonia
w/ high dose sulfamethoxazole/trimethoprim. Echocardiogram
revealed no significant only 2+TR, normal LV function, and no
findings that would explain patient's persistent progressive
hypoxia. Lower extremity doppler ultrasound revealed no
evidence of deep venous thromboses.
Hypoxia was considered to be less likely due to infectious
and/or cardiogenic causes and thought more to be secondary to a
primary pulmonary process. Radiological consultants suggested
that CT findings were consistent with nonspecific interstitial
pneumonitis. Therefore, in addition to empiric antibiotics,
patient was given high dose steroids in an attempt to reverse
any acute changes - as it was felt that patient's hypoxia was
most likely an acute exacerbation of chronic pulmonary process.
On hospital day six, given patient's continued progressive
symptomatic hypoxia (found confused whenever patient had
accidentally removed NRB mask), patient was electively intubated
by anesthesia.
At that point, open lung biopsy was considered to determine
cause of patient's pulmonary disease, however, in discussion
with family and thoracic surgery consultants, it was felt that
patient would not have been interested in such an invasive
procedure, and that yield in terms of diagnosis of a reversible
cause would be extremely low.
As patient continued to exhibit no improvedment over the next
five days, a decision was made by the patient's family and
healthcare proxy to withdraw care and extubate patient. Patient
was given comfort measures only and expired at 2:30 PM [**2116-1-10**].
Medications on Admission:
On Transfer:
Ceftriaxone 1g QD
Azithromycin 250mg QD
Lisinopril 5mg QD
Atenolol 25mg QD
Heparin 5000 SC TID
ASA 325mg QD
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Nonspecific interstitial pneumonitis
Respiratory failure
Myocardial infarction (post-mortem diagnosis)
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"443.9",
"492.8",
"584.9",
"428.0",
"251.8",
"272.0",
"518.84",
"V58.67",
"724.00",
"E932.0",
"401.9",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"99.04",
"96.72",
"00.17",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6494, 6503
|
4037, 6295
|
271, 327
|
6650, 6660
|
1829, 4014
|
6712, 6718
|
1639, 1657
|
6466, 6471
|
6524, 6629
|
6321, 6443
|
6684, 6689
|
1672, 1810
|
224, 233
|
355, 1223
|
1245, 1435
|
1451, 1623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,180
| 190,828
|
198
|
Discharge summary
|
report
|
Admission Date: [**2139-11-24**] Discharge Date: [**2139-12-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 87 year old lady with a PMH of diastolic heart
failure (EF>75%), severe lung disease and resultant pulmonary
hypertension, T2DM, obesity, who presents from home with hypoxia
and worsening somnolence.
Patient reports that since discharge from the hospital on
Saturday [**11-21**], she has had persistent increased sputum which
she has difficulty coughing up. She feels like the sputum gets
caught in her throat. It is white-clear. She denies fever or
chills. She denies worsening dyspnea, but has only ambulated in
her house as she hasn't been feeling well. She endorses mild
orthopnea. She denies worsening lower extremity edema.
Of note, patient was recently admitted for hypoxia with CXR
findings of a LUL. She had presented to her cardiologist one
week prior to initial admission with complaints of worsening
dyspnea and increased sputum production, without fever or
leukocytosis. At that time, cardiologist felt that patient was
having an acute flare of her chronic bronchitis, and placed her
on a one week course of levofloxacin. A CXR was performed at
the time to rule out pneumonia which was negative for
consolidation. She followed up with the cardiologist NP one
week later, and was found to have O2Sats ranging from 68-80% on
3L NC (baseline, home oxygen). She continued to be afebrile
without leukocytosis but reported no improvement in sputum
production or dyspnea. She was sent to the ER where a repeat
CXR showed bilateral upper lobe opacities concerning for
pneumonia. She was given ceftriaxone and azithromycin and
admitted to the medicine service. Antibiotics were not
continued as patient was afebrile, without cough or
leukocytosis. Right lower extremity ultrasound was negative for
DVT. Patient was discharged home as her oxygen saturations
returned to baseline on home 3L NC.
[**Name (NI) **] son reports that patient had BCG vaccination in
[**Country 532**]. He does not know if she was ever exposed to
tuberculosis. He does not know of anyone in his family who was
exposed to tuberculosis.
In the ED inital vitals were 97.4 70 141/47 18 100%
Non-Rebreather.
ABG 7.35/91/105/46. She was given vanc/cefepime x1. Lung exam
c/w decreased breath sounds, tachypneic to low 30s. She was
transferred to the [**Hospital Unit Name 153**] for further management.
On arrival to the ICU, vital signs were 97.6, 69, 132/56, 18 and
96% on 3LNC. Patient was comfortable and denied any pain.
Past Medical History:
1. Falls, multiple noted in OMR & D/C summaries
2. Pulmonary HTN, on 2L/nc @ home, PDA per echo [**2120-11-5**]
3. h/o exudative pleural effusion, treated with talc for
pleuredesis ([**2128-2-17**])
4. CHF per Echo ([**2136-3-26**]) - Grade I (mild) LV diastolic
dysfunction, LV inflow pattern suggests impaired relaxation, -
LVEF>55%
5. Mild (1+) AR, trivial MR, trivial TR (Echo [**2136-3-26**])
6. HTN
7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7
8. Type II DM, %HbA1c 6.3 ([**2136-2-3**])
9. Hyperlipidemia
10. Chronic low back pain,
12. Spinal stenosis, L3-4 & L4-5, per MRI ([**2134-2-27**])
13. Compression fracture of the T3-T4, per CT ([**2136-5-22**])
14. h/o Left knee medial meniscus [**Last Name (LF) 1994**], [**First Name3 (LF) **] MRI ([**2129-10-26**])
15. Obesity
16. Anemia (baseline ~ 26-30)
17. h/o Rectus sheath hematoma
18. h/o Hemorrhoids
19. h/o UGI Bleed
20. Urinary incontinence
21. Syncope
22. Gallstones, per CT ([**2136-4-4**])
23. Depression
.
<b>PSHx:</b>
- s/p IM nail right humerus ([**2134-3-2**]), secondary to fall
- s/p Open posterior treatment of cervical fractures at C3,
cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4
([**2134-3-2**]), seconadary to fall
- s/p EGD([**2129**]) gastritis/duodenitis and HP, rx recommended but
no documentation of eradication
- s/p MVA ([**12/2127**])
- s/p Colonoscopy [**2124**] (two small adenomas) & [**8-28**] (2 sessile
sigmoid polyps, path: mucosal prolapse)
- s/p TAH for fibroids.
Social History:
Russian-speaking widow (husband [**Name (NI) 1995**] died of sudden cardiac
death [**10/2127**]) who
lives alone. Has lived in the United States since ~[**2116**]. She
worked as a bookkeeper in [**Country 532**]. Son [**First Name8 (NamePattern2) 1975**] [**Name (NI) **],
[**Telephone/Fax (1) 1958**]) in area & assists. Son is only relative as
daughter died ~[**2114**] of sarcoma. She does not drink or smoke.
Ambulates with rolling walker, housing has elevator/no steps.
VNA has been involved with HM/HHA [**Hospital1 **]: [**Hospital6 1952**]
Care, Inc. [Phone: ([**Telephone/Fax (1) 1996**]; Fax: ([**Telephone/Fax (1) 1997**]] & [**Hospital1 **]
Family & Children??????s Service [[**Telephone/Fax (1) 1998**]].
Denies tobacco use (ever). Denies ETOH use.
Family History:
Negative for diabetes, cardiac disease, hypertension and cancer
with the exception of her daughter who died of a sarcoma.
Family history is notable for longevity.
Physical Exam:
Admission Exam:
Vitals: 97.6, 69, 132/56, 18 and 96% on 3LNC
General: Alert, oriented, no acute distress, speaking in full
sentences without accessory muscle use
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rales in all lung fields with good air movement
bilaterally, no prolonged expiratory phase, no wheezes, no
egophany
CV: Regular rate and rhythm, fixed split S1 with prominent S2,
holosystolic murmur best heard at RUSB radiating to bilateral
carotids.
Abdomen: +BS, soft, obese, non-tender, no hepatosplenomegaly
GU: foley draining clear urine
Ext: Warm, well perfused, 2+ DP/PT and radial pulses, 2+ pedal
edema bilaterally, no clubbing or cyanosis.
Neuro: A+O x3, strength 4/5 bilaterally in upper/lower
extremities
Discharge exam: unchanged with the exception of:
Lungs: CTAB, faint expiratory wheezes in right base
Extremeties: 3cm tender compressible lump on left medial wrist
Pertinent Results:
Admission labs:
[**2139-11-24**] 11:59AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.1* Hct-32.1*
MCV-92 MCH-28.8 MCHC-31.4 RDW-14.4 Plt Ct-188
[**2139-11-24**] 11:59AM BLOOD Neuts-81.5* Lymphs-12.3* Monos-4.2
Eos-1.7 Baso-0.3
[**2139-11-24**] 11:59AM BLOOD Glucose-185* UreaN-42* Creat-1.4* Na-143
K-4.4 Cl-92* HCO3-46* AnGap-9
[**2139-11-24**] 01:42PM BLOOD pO2-105 pCO2-91* pH-7.35 calTCO2-52* Base
XS-19
[**2139-11-24**] 08:51PM BLOOD Type-ART pO2-81* pCO2-101* pH-7.32*
calTCO2-54* Base XS-19
MICROBIOLOGY:
Blood culture x2 ([**2139-11-24**])- no growth, pending final
Urine culture ([**2139-11-24**])- no growth, final.
Sputum ([**2139-11-25**])- no acif fast bacilli seen on smear, no
legionella isolated. Acid fast culture pending
Sputum ([**2139-11-26**])- pending
[**2139-11-24**] CXR:
IMPRESSION:
1. Worsening multifocal opacification. Recommend clinical
correlation for
infection, and in the absence of concern for infection, CT of
the chest is
recommended to exclude the possibility of malignancy.
2. Pulmonary artery enlargement compatible with pulmonary
arterial
hypertension.
[**2139-11-30**] CXR:
IMPRESSION:
1. Cardiomegaly and enlargement of the pulmonary arteries
consistent with
pulmonary hypertension.
2. No consolidation. No pulmonary edema.
[**2139-11-24**] CT chest w/o contrast:
IMPRESSION:
1. Three discrete new irregularly-shaped focal opacities
demonstrated within the left upper lobe that, given multiplicity
and configuration, are likely related to an active infectious or
inflammatory proces, much less likely to be synchronous
bronchogenic carcinoma. Differential also includes organizing
pneumonia or pseudolymphoma. Recommend followup to resolution
with conventional radiographs in six weeks.
2. Moderate cardiomegaly and severe pulmonary hypertension have
progressed
since [**2135**].
3. Findings compatible with the sequelae of prior granulomatous
exposure
Discharge Labs:
[**2139-12-4**] 07:20AM BLOOD WBC-4.0 RBC-3.36* Hgb-9.6* Hct-31.2*
MCV-93 MCH-28.6 MCHC-30.9* RDW-15.1 Plt Ct-197
[**2139-12-4**] 07:20AM BLOOD Glucose-182* UreaN-49* Creat-1.3* Na-141
K-5.0 Cl-94* HCO3-44* AnGap-8
Studies pending at discharge:
None
Brief Hospital Course:
87 yo F with a history of diastolic heart failure, pulmonary
hypertension, chronic kidney disease, and chronic bronchitis
admitted with hypercarbic respiratory failure. Hospital course
notable for acute renal failure.
#Hypoxia/Atypical Pneumonia/Pulmonary hypertension/Chronic
Obstructive Pulmonary Disease/Acute on chronic diastolic heart
failure/Hypercarbic respiratory failure/Obstructive Sleep Apnea:
Patient was initially admitted to the Intensive Care Unit with
hypercarbic respiratory which was felt to be due to over
oxygenation, and most likely worsening pulmonary hypertension
from volume overload and atypical pneumonia. She was diuresed
and treated with azithromycin with improvement in her symptoms.
She was also seen by the Pulmonary service for evaluation of her
pulmonary hypertension and episodes of apnea and they
recommended an outpatient sleep study. The patient did well and
was transferred from the Intensive Care Unit to the medical
floor and improved with antibiotics and further diuresis and was
discharged on home oxygen of 2-3L NC. Given that
over-ventilation and over-oxygenation was felt to contribute to
the patient's hypercarbic respiratory failure and somnolence,
the patient should have oxygen for a target oxygen saturation of
89-93%.
#Pulmonary nodules:
Patient had sputum production and a chest CT which showed 3 left
uppe lobe lung nodules that were most likely felt to be
infectious. She was ruled out for TB with 3 negative sputa for
AFB and patient received course of azithromycin. She should have
a follow up CXR in 6 weeks. Patient and son were made aware of
this and the importance of follow up.
#Acute on chronic diastolic Heart Failure:
As above patient was admitted in volume overload. Hospital
course was notable for improvement in symptoms with diuresis,
but complicated by acute renal failure (see below). Patient was
ultimately discharged euvolemic on regimen of Lasix 80mg once
daily to keep her euvolemic and TBB even.
#Acute on Chronic renal Failure:
During diuresis for acute heart failure, patient developed acute
renal failure with probable contraction alkalosis. At this point
diuresis was stopped, gentle fluids were given, and diuretics
were stared when renal function had returned to [**Location 213**].
Lisinopril was held and should be started 3 days after discharge
at 2.5mg po daily.
# Hypertension: Blood pressure was well controlled on home
regimen. Diltiazem was continued but Lisinopril was held during
acute renal failure.
# Diabetes mellitus: HgbA1c 6.5 in 7/[**2138**]. On glipizide at
home. Patient was covered with sliding scale insulin in the
hospital. Glipizide can be restarted once renal function
stabilizes.
# Transitional issues:
AFB cultures will need to be followed-up
She will need close pulmonary follow-up for repeat imaging in
several weeks (fu of pulmonary nodules as well as follow up of
her likely COPD, severe pulmonary hypertension, and probable
sleep apnea
.
#Disposition: Patient was discharged to rehab.
Medications on Admission:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for fever or pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Solaraze 3 % Gel Sig: One (1) application Topical twice
weekly: apply to affected areas and rub in well twice weekly.
14. iron aspgly&ps-C-B12-FA-Ca-suc [**Medical Record Number 2001**]-1 mg-mg-mcg-mg
Capsule Sig: One (1) Capsule PO twice a day.
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)
Capsule PO once a day.
17. Motrin IB 200 mg Tablet Sig: 1-2 Tablets PO 2x/day for 2
weeks as needed for pain.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for fever/pain.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for sputum production/cough.
Disp:*200 cc* Refills:*0*
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for wheezing/shortness of breath.
Disp:*30 bullets* Refills:*0*
16. iron aspgly&ps-C-B12-FA-Ca-suc [**Medical Record Number 2001**]-1 mg-mg-mcg-mg
Capsule Sig: One (1) Capsule PO twice a day.
17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)
Capsule PO once a day.
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-28**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice
weekly.
Disp:*1 * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Hospital1 1559**]
Discharge Diagnosis:
Primary:
1) Acute on Chronic Congestive Heart Failure
2) COPD
3) Pulmonary Hypertension
Secondary:
1) Obstructive Sleep Apnea
2) Diabetes Mellitus, Type 2
3) Chronic Kidney Disease
4) Pulmonary nodules/Atypical pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs [**Known lastname **]:
It was a pleasure taking care of you in the hospital during your
stay; You were taken care of by a critical care team during your
ICU stay and a medicine primary team during your inpatient
hospitalization. During your stay you received treatment for
congestive heart failure and continued treatment for a possible
pneumonia. You will need to continue to restrict your salt
intake in order to prevent exacerbations of your heart failure.
Additionally, there was significant concern that you have
obstructive sleep apnea. You have appointments to see a sleep
medicine specialist and a pulmonologist.
The following changes were made to your medication regimen:
1) START guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO
Q6H (every 6 hours) as needed for sputum production/cough
2) START albuterol 0.083% neb solution, 1 nebulizer every 4
hours as needed for shortness of breath or wheezing
3) You may use saline nasal spray as needed for nasal dryness.
4) Your lasix dose was decreased to 80mg once daily (instead of
twice per day).
.
Please try to avoid ibuprofen and other NSAIDs orally if
possible because these could further damage your kidneys.
Please be sure to weigh yourself every morning and call your
primary care doctor if weight is increasing by more than 3 lbs.
You may need to have your lasix increased again.
Please be sure to keep all of your followup appointments as
listed below, including your followup with the cardiologist next
week.
.
No other changes were made to your medications and you should
continue to take all your other medications as originally
prescribed.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2139-12-8**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES/SLEEP MEDICINE
When: FRIDAY [**2139-12-25**] at 2:00 PM
With: DR [**Last Name (STitle) 2004**] / DR [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2140-2-10**] at 7:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES/PULMONARY
When: WEDNESDAY [**2140-2-10**] at 8:00 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2139-12-30**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2140-3-11**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2140-5-11**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2139-12-4**]
|
[
"793.11",
"416.0",
"584.9",
"285.9",
"428.0",
"327.23",
"496",
"276.0",
"428.33",
"585.9",
"518.81",
"250.02",
"276.2",
"403.90",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14792, 14875
|
8364, 11059
|
262, 268
|
15140, 15140
|
6186, 6186
|
16974, 19220
|
5040, 5205
|
12934, 14769
|
14896, 15119
|
11398, 12911
|
15323, 16951
|
8089, 8321
|
5220, 6001
|
6017, 6167
|
8335, 8341
|
212, 224
|
296, 2731
|
6202, 8073
|
15155, 15299
|
11082, 11372
|
2753, 4242
|
4258, 5024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,585
| 111,504
|
23288
|
Discharge summary
|
report
|
Admission Date: [**2152-7-4**] Discharge Date: [**2152-7-8**]
Date of Birth: [**2091-7-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Tracheal Intubation
CVL placement
Arterial Line placement
History of Present Illness:
Patient is a 60 year old female with a history of HepC
cirrhosis, active HepC infection on ribaviron and interferon,
complicated by pancytopenia, has been on neupogen and promacta,
initially presented to the ED earlier today from the infusion
clinic for a scheduled transfusion with SOB.
On arrival to her infusion clinic appointment, she was notably
sob after walking from the parking garage to the
Infusion/pheresis unit. Her Resp rate was 30 with an o2 sat of
97% on room air. Her bp was 78/38 on the right arm and 82/50
on the left. She apparently attributes this to taking her
lisinopril for the last 2 to 3 days, even though she was
explicitly instructed not to by her NP, [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**], last
week as her blood pressures were low. She also reports the
development of pleuritic chest discomfort 4 days ago described
as sharp and made worse upon deep inspiration. A CXR was
ordered in clinic and showed new bilateral pleural effusions
L>R. She was sent over to the ED 98.2 80 26 o2 sat 97% bp
115/70.
On arrival to the ED, initial vitals were 98.2 93 103/57 18 99%
2L. Initial vitals were notable for a Cr 2.8 up from baseline
.7, INR 2.0. An ultrasound showed a moderately sized
pericardial effusion. Cardiology was consulted, did a bedside
echo, showed no tampnnade phsyiology, a circumferential
effusion, and a pulsus of 8. Trop .05. With the pleuritic
chest pain, a D Dimer was checked which was > 6,000. She also
endorsed increased abdominal distension; a bedside ultrasound
showed no fluid to tap. While in the ED, her pressures started
to decrease to the 80s systolic. She received 2 L IVFs,
vancomycin and zosyn, and admitted to the MICU for hypotension.
On arrival to the MICU, patient is alert and comfortable with
SBPs in the 90s. She does state that for the past 4 days, she
has also had diarrhea and has not been able to take POs. She
also states she has taken advil sporadically over the last few
days to help her chest pain.
Past Medical History:
HepC Cirrhosis
Pancytopenia on neupogen
Hypertension
GERD
Depression
Asthma
Bilateral leg swelling
Social History:
Patient denies current smoking or alcohol.
Family History:
NC
Physical Exam:
Discharge physical exam: Expired
Pertinent Results:
ADMISSION LABS:
[**2152-7-4**] 03:28PM BLOOD WBC-9.4# RBC-2.69* Hgb-8.4* Hct-28.0*
MCV-104* MCH-31.3 MCHC-30.0* RDW-20.3* Plt Ct-84*#
[**2152-7-4**] 03:28PM BLOOD Neuts-85.2* Lymphs-10.5* Monos-3.2
Eos-0.9 Baso-0.2
[**2152-7-4**] 03:20PM BLOOD PT-21.3* PTT-33.5 INR(PT)-2.0*
[**2152-7-4**] 01:45PM BLOOD Glucose-85 UreaN-40* Creat-2.8*# Na-134
K-4.4 Cl-105 HCO3-19* AnGap-14
[**2152-7-4**] 01:45PM BLOOD ALT-27 AST-59* AlkPhos-164* TotBili-1.9*
[**2152-7-5**] 12:17AM BLOOD Calcium-7.1* Phos-4.2 Mg-1.9
[**2152-7-5**] 11:01AM BLOOD Type-ART Temp-36.9 pO2-93 pCO2-33*
pH-7.31* calTCO2-17* Base XS--8 Intubat-INTUBATED
CXR:
1. Bilateral pleural effusions, left greater than right.
2. Moderate-to-severe cardiomegaly.
3. Peripheral parenchymal or pleural opacities bilaterally.
4. These findings appear to be new at least since [**2150-9-18**] when the lung bases were visualized on the CT. Further
evaluation with chest CT is recommended.
5. Bilateral widening of the glenohumeral joint spaces may be
indicative of rotator cuff laxity. Correlation with history and
physical examination is recommended.
ABDOMINAL ULTRASOUND:
1. Coarsened echogenic liver compatible with cirrhosis.
2. At least two and possibly three echogenic liver lesions are
new since
[**2152-4-27**]. These are concerning in a patient with
cirrhosis. Further assessment with multi-phasic CT or MRI is
necessary once the patient's renal function improves.
3. Small pockets of right upper and lower quadrant ascites.
4. Portal and hepatic veins are patent.
TTE:
There is a small to moderate sized circumferential pericardial
effusion primarily lateral, inferolateral and inferior to the
left ventricle and anterior to the right atrium, with relatively
little effusion anterior to the right ventricle. There are no
echocardiographic signs of tamponade.
TTE:
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. 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 with probably mild mitral regurgitation (in limited
views). The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion (upto 1.4 cm
diastolic width lateral to left ventricle, smaller elsewhere).
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
TTE:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF 65%). Right ventricular
chamber size and free wall motion are normal. There is severe
mitral annular calcification. There is borderline pulmonary
artery systolic hypertension. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2152-7-5**], the size of the effusion is similar. The heart
rate is reduced.
Right Upper Quadrant Ultrasound:
FINDINGS: The liver is again noted to be coarsened and nodular
throughout consistent with the patient's known cirrhosis. Two
small slightly hyperechoic lesions are again seen in the left
lobe of the liver essentially unchanged from the prior
ultrasound. These lesions measure 1.1 to 1.2 cm in diameter
each. No cystic component is identified in either of these
lesions. Additionally, a tiny hypoechoic lesion is also seen in
segment VI of the liver measuring 1.0 cm. There is no cystic
component identified within this lesion. A small amount of
ascites is seen again in the right upper quadrant. The portal
vein is patent with hepatopetal flow. The gallbladder is normal
on limited views. There is an enlarged periportal lymph node
measuring 3.5 x 1.4 cm. No hydronephrosis is seen on limited
views of the right kidney. No biliary dilatation is seen and
the common duct measures 0.7 cm.
IMPRESSION: Nodular coarsened hepatic architecture consistent
with the patient's known cirrhosis. Three small solid liver
lesions are identified. Additional characterization of these
lesions with CT or MRI is suggested when feasible. There is no
evidence of an abscess. Small amount of ascites again seen in
the right upper quadrant.
Brief Hospital Course:
60 year old female with hepatitis C cirrhosis, treatment
complicated by neutropenia on Neupogen presenting with SOB,
pleuritic chest pain, and hypotension, managed for shock and
ARDS, subsequently intubated, who was later transitioned to
comfort measures only by her family given her worsening clinical
picture and expired during this hospitalization on [**Last Name (LF) 2974**], [**7-7**], [**2152**] at 22:08.
# Hypotension/Shock: Patients SBPs in the 80s/90s on
presentation. She received 2 L IVFs as well as one unit of
blood for a Hct 24, however reamined hypotensive. She was
covered emperically for infectious etiologies with Vanc/Zosyn,
then changed to Vanc/cefepime. Given pericardial effusion,
there was initial concern for impending tamponade, however, TTE
showed no tamponade physiology and pulsus was 8. She was
subsequently intuabted for respiratory failure, a CVL was
placed, and she was started on levophed, vasopressin, and
neosynephrine. It was also hypothesized that she may be in
decompensated cirrhosis causing her low blood pressures. An AM
cortisol was within normal limits. The patient was continued on
3 pressors, when the decision was made to transition to comfort
measures only, pressors were discontinued upon extubation.
# Respiratory failure: Patient initilly hypoxic, satting in the
low to mid 90s on 2L on admission. She had bilateral pleural
effusions on chest XRay. The morning after admission, her O2
sats were in the 90s, RR in the 40s-50s. She was subsequently
intuabted. CXR was consistent with ARDS versus TRALI versus
pulmoanry edema. She required high FiO2 and PEEP, and because
she was overbreathing on the vent, she was paralyzed and an
esophageal balloon was placed. Patient desaturated on the
ventilator to 60-70 percent. Her PEEP was increased, and her
oxygen saturation initially improved. With on-going discussion
with the family, the decision was made to transition to comfort
measures only. With this decision, paralytics were discontinued.
As paralytics were weaned, the patient was extubated, and she
died shortly there after.
# Anuric renal failure: Patient's Cr 2.8 up from a baseline .7
on admission. She was anuric. Possible etiologies included
taking lisinopril in the setting of NSAIDs and poor PO intake,
hepatorenal syndrome, ATN secondary to shock. She was started
on CVVH on HD number 2. The patient remained on CVVH until the
patient was transitioned to comfort measures only.
# Hep C Cirrhosis: On ribavirin and interferon, followed by Dr.
[**Last Name (STitle) **]. Abdominal ultrasound showed minimal ascites, 3 new
liver lesions were noted on RUQ ultrasound. Radiology felt that
these lesions likely represented hematomas as opposed to septic
emobli or abscess.
# Depression: Held sertraline.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 puffs po qid prn
ELTROMBOPAG [PROMACTA] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
EPOETIN ALFA [PROCRIT] - 40,000 unit/mL Solution - Inject 40,000
units SQ once weekly
FILGRASTIM [NEUPOGEN] - 300 mcg/0.5 mL Syringe - Inject
300mcg/0.5mL SQ once weekly
FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) -
220
mcg Aerosol - 1 puff po twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet -
one
Tablet(s) by mouth daily
PEGINTERFERON ALFA-2A [PEGASYS CONVENIENCE PACK] - (Prescribed
by Other Provider; recording only) - 180 mcg/0.5 mL Kit - Inject
180mcg/0.5mL SQ once weekly 90 mcg weekly
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq
Tablet, ER Particles/Crystals - 1 Tab(s) by mouth daily
RANITIDINE HCL - (Prescribed by Other Provider) - 300 mg
Capsule
- one Capsule(s) by mouth night
RIBAVIRIN - (Prescribed by Other Provider; recording only) -
200
mg Capsule - 6 Capsule(s) by mouth 3 capsules QAM and 3 capsules
QPM
SERTRALINE - (Prescribed by Other Provider) - 100 mg Tablet -
Tablet(s) by mouth
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply to affected
area
twice a day
Medications - OTC
BIOTIN-CALCIUM CARBONATE [BIOTIN 100+10] - (Prescribed by Other
Provider) - Dosage uncertain
CALCIUM CARBONATE [CALCIUM 600] - (Prescribed by Other
Provider)
- 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (Prescribed
by Other Provider) - 600 mg calcium-200 unit Capsule - 1
Capsule(s) by mouth daily
GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) -
Dosage uncertain
MULTIVITAMIN - (OTC) - Capsule - one Capsule(s) by mouth
daily
Discharge Medications:
Expired
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**]
|
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"571.5",
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icd9cm
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[
[]
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[
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"39.95",
"38.97",
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icd9pcs
|
[
[
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11862, 11871
|
7163, 9946
|
321, 380
|
11922, 11931
|
2696, 2696
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11987, 12133
|
2624, 2628
|
11830, 11839
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11892, 11901
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9972, 11807
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2643, 2643
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270, 283
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408, 2426
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2713, 7140
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2448, 2548
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2564, 2608
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2668, 2677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,760
| 171,946
|
2133
|
Discharge summary
|
report
|
Admission Date: [**2140-2-29**] Discharge Date: [**2140-3-4**]
Date of Birth: [**2079-8-6**] Sex: M
Service: MEDICINE
Allergies:
Iron
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
hematemesis, hyperglycemia
Major Surgical or Invasive Procedure:
-Blood Transfusion
-Esophagogastroduodenoscopy [**2140-3-3**]
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old male with PMH significant for ESRD
s/p renal transplant [**2135**] on cellcept, DMII, chronic
pancreatitis, HCV without cirrhosis, and HTN admitted with one
week of feeling ill with decrease PO intake and 1-2 days of
nausea, vomiting and abdominal pain, decreased UOP, and
hyperglycemia. He subsequently developed coffee grounds emesis
today so called 911 and was brought to ED by EMS. Patient also
reports running out of medications recently and states he has
not been able to tolerate his immunosuppressives last 2 days
secondary to vomiting. He states abdominal pain similar to prior
episodes of gallstone pancreatitis and when he used to drink
ETOH but he denies any recent ETOH intake in last 15 years. Of
note, he had similar admission in [**2139-7-30**] at which time he
declined EGD.
.
In ED, initial VS: HR 138 BP 157/66. On exam, he appeared dry
with diffuse non-focal abdominal pain and rectal exam was
significant for melanotic stool. He triggered for HR 130s. NGL
was attempted and induced coffee grounds emesis. Labs were
significant for lipase 196, lactate 4.2 which improved to 3.2
and BUN of 146 and Cr 3.5 with WBC 13K, HCT at baseline of , and
glucose>500. GI saw patient and he was started on PPI drip.
Renal was also contact[**Name (NI) **] given [**Name (NI) **] in renal transplant patient.
He was started on insulin drip at 8 units/hr. He also received
zosyn and vancomycin for ? fever. RIJ CVL placed for tachycardia
but he was never hypotensive. He received a total of 2L NS. VS
prior to transfer: HR 110 BP 151/69 RR 22 O2sat 100%.
.
On arrival to ICU, he denies nausea and states abdominal pain is
improved. He reports thirst and requests a glass of hot tea. He
also denies recent lightheadedness, dizziness, palpitations,
dysuria, CP, SOB, cough, sore throat, fever, chills, diarrhea.
Past Medical History:
1. ESRD s/p Renal Transplant [**6-/2135**] (baseline Cre 1.8-2.5)
- complicated by CMV Viremia
2. Erectile Dysfunction
3. Hx of detached retina - [**2132**], surgically repaired
4. h/o infected sebaceous cyst
5. Pancreatitis -chronic
6. Diabetes Mellitus Type II - on Insulin
7. h/o Knee arthritis
8. h/o Hepatitis C - followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11455**] ([**Hospital1 2177**])
9. Hypertension - controlled on metoprolol
10. Osteoarthritis
Social History:
Lives alone in apartment on [**Location (un) **] avenue. On
disability, not currently working.
EtOH: Last drink 15 yeasr ago although previously reported ETOH
intake in setting of admissions for pancreatitis in [**2139-7-30**].
Drugs: Denies illicits.
Tobacco: Denies
Family History:
Mother - Type 2 Diabetes Mellitus, hypertension, passed away
from "old age"
Father - Type 2 Diabetes Mellitus, passed away from "old age".
Also has h/o alcoholism
Physical Exam:
On admission:
VS: 117 157/61 20 100%RA
GEN: Appears comfortable, slurred speech, confused
HEENT: Dry mucous membranes, PERRL, EOMI, anicteric, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: Tachy, regular, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive b/s, soft, nt, no masses or
hepatosplenomegaly, negative [**Doctor Last Name 515**] sign
EXT: no c/c/e, atrophic skin changes LEs with 1+ DP/PT. Chronic
venous stasis changes.
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx to date, year, month, not place "[**Hospital3 9947**]" but oriented to city and state. Slurred speech as above.
CN II-XII intact. 5/5 strength in LEs and UEs with no pronator
drift. + asterixis. 2+DTR's-patellar.
RECTAL: Per ED, melanotic guaiac positive stool
.
At time of discharge:
VS: afebrile, 126-158/66-70, 88-94, 99%(RA)
GEN: NAD, slurred speech, confused seeming with some
inappropriate remarks, but AOx3 and able to attend properly
HEENT: MMM, PERRL, EOMI, anicteric
RESP: CTA b/l with good air movement throughout
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive b/s, soft, nt, no masses or
hepatosplenomegaly, scar in LRQ
EXT: no c/c/e, atrophic skin changes LEs with 1+ DP/PT. Chronic
venous stasis changes. LUE with fistula (palpable thrill)
Pertinent Results:
REPRESENTATIVE AND LAB TRENDS:
CBC:
-[**2140-2-29**] 01:30PM BLOOD WBC-13.3* RBC-4.34* Hgb-9.7* Hct-31.7*
MCV-73* MCH-22.4* MCHC-30.6* RDW-15.4 Plt Ct-225
-[**2140-3-1**] 12:26PM BLOOD Hct-29.5*
-[**2140-3-1**] 08:45PM BLOOD WBC-7.4 RBC-3.84* Hgb-8.7* Hct-28.3*
MCV-74* MCH-22.7* MCHC-30.9* RDW-16.9* Plt Ct-162
-[**2140-3-2**] 01:45PM BLOOD WBC-5.9 RBC-3.54* Hgb-8.4* Hct-25.8*
MCV-73* MCH-23.8* MCHC-32.6 RDW-17.9* Plt Ct-138*
-[**2140-3-3**] 01:37AM BLOOD WBC-6.7 RBC-3.80* Hgb-8.7* Hct-28.0*
MCV-74* MCH-23.0* MCHC-31.2 RDW-17.6* Plt Ct-150
-[**2140-3-4**] 06:12AM BLOOD WBC-6.0 RBC-3.83* Hgb-8.8* Hct-28.6*
MCV-75* MCH-23.0* MCHC-30.8* RDW-18.0* Plt Ct-134*
.
Coags:
[**2140-3-1**] 03:55AM BLOOD PT-13.8* PTT-27.0 INR(PT)-1.2*
.
Chem:
[**2140-2-29**] 07:19PM BLOOD Glucose-223* UreaN-143* Creat-3.3* Na-142
K-3.8 Cl-107 HCO3-23 AnGap-16
[**2140-3-2**] 06:24AM BLOOD Glucose-89 UreaN-62* Creat-2.2* Na-156*
K-3.8 Cl-124* HCO3-23 AnGap-13
[**2140-3-3**] 05:42AM BLOOD Glucose-89 UreaN-35* Creat-1.7* Na-147*
K-3.4 Cl-115* HCO3-24 AnGap-11
[**2140-3-4**] 06:12AM BLOOD Glucose-98 UreaN-25* Creat-1.6* Na-142
K-4.1 Cl-110* HCO3-23 AnGap-13
.
MISC:
[**2140-2-29**] 01:30PM BLOOD ALT-14 AST-20 AlkPhos-65 TotBili-0.3
[**2140-2-29**] 01:30PM BLOOD Lipase-196*
[**2140-2-29**] 01:48PM BLOOD %HbA1c-7.4* eAG-166*
[**2140-2-29**] 01:30PM BLOOD Triglyc-198*
[**2140-2-29**] 07:19PM BLOOD Acetone-SMALL
[**2140-2-29**] 01:30PM BLOOD TSH-0.95
[**2140-2-29**] 01:30PM BLOOD Cortsol-38.1*
[**2140-2-29**] 01:30PM BLOOD Glucose-463* Lactate-4.2* Na-139 K-4.0
Cl-107 calHCO3-15*
[**2140-3-1**] 06:11AM BLOOD Lactate-1.0
[**2140-3-4**] 06:12AM BLOOD tacroFK-3.0*
IMAGING:
[**2140-2-29**], CXR, IMPRESSION: No acute cardiopulmonary process.
Right IJ placement with tip at the mid SVC.
.
[**2140-2-29**], renal U/S, IMPRESSION:
1. Unremarkable evaluation of the right lower quadrant
transplant kidney, with resistive indices ranging from 0.73 to
0.77. No hydronephrosis or perinephric fludi collection.
2. Elevated post-void bladder residual of 234 cc. Recommend
clinical
correlation and consider nonurgent urology consult if concern
for bladder outlet obstruction. Please note that the prostate
was not evaluated on this study.
.
[**2140-2-29**], RUQ U/S, IMPRESSION: Cholelithiasis without secondary
findings of acute cholecystitis.
.
[**2140-3-3**], EGD: friability and erythema in esophagus c/w
esophagitis, but no varices. Small hiatal hernia.
Brief Hospital Course:
60M with ESRD s/p renal transplant [**2135**], DM2, HTN, and chronic
pancreatitis admitted with N/V, abdominal pain, hematemesis,
hyperglycemia and acute on chronic renal failure.
.
1. Hematemesis: Given history of antecedent vomiting, most
likely secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear but differential
diagnosis also included PUD, gastritis, AVM, Dielafeuoy's,
variceal bleed. Has h/o ETOH use and HCV but no known history
of varices or cirrhosis/portal HTN. GI evaluated pt and
recommended ICU admission overnight. In am, GI decided that
there was no need to perform urgent EGD given stable Hct and
resolution of symptoms. Pt was initially on a PPI drip, then
transitioned to PPI IV BID. Active T&S and PIVs were
maintained. Hct was monitored closely. Pt was transferred to
the floor, with GI still following. Pt eventually had EGD on
[**2140-3-3**] that revealed esophagitis, no varices. Bx pending at
time of discharge. Pt had no further hematemesis during
admission, and although stool remained guaiac positive, HCT
remained stable. HCT on discharge was 28.6.
.
2. N/V/abdominal pain: Likely secondary to acute on chronic
pancreatitis given prior history and elevated lipase 190 but
unclear trigger if no recent ETOH intake. Differential diagnosis
also included PUD/gastritis, mesenteric ischemia,
gastroenteritis, cholecystitis. Received vanco and zosyn in ED,
but no evidence of cholecystitis on U/S, so defered further
antibiotics. Remained afebrile during admission.
Nausea/vomiting was treated with Zofran PRN. Abd pain resolved
upon arrival to the ICU. CMV viral load was negative. Lactate
trended down with IVF. RUQ U/S was unremarkable except for
presence of gallstones.
.
3. Acute on chronic renal failure s/p renal transplant: Patient
presenting with acute on chronic renal failure, Cr 3.5 from
previous baseline 1.8-2.0 s/p prior renal transplant. Clinical
history of N/V and BUN/Cr ratio 40 consistent with prerenal
etiology. Urine lytes supported prerenal etiology. Cre
improved with IVF. Renal transplant u/s was unremarkalble.
Tacrolimus levels were monitored closely. Renal transplant is
following closely and recommend continuing home
immunosuppressives at current dose for now. Tacrolimus level,
however, was subtherapeutic at time of discharge.
.
4. DM2/Hyperglycemia: Patient has h/o Type 2DM on insulin at
home. He presented with elevated blood sugars in the days prior
to admission, likely in the setting of pancreatitis +/-
infection. Pt had AG which was likely multifactorial. Small amt
of ketones were also detected in serum and urine. Pt was placed
insulin drip per protocol for tight glucose control, goal blood
sugars 150-180 initially, then transitioned to SC insulin. Pt's
sugars trended down with insulin treatment, and was discharged
on 10units glargine qAM.
.
6. Tachycardia: Initial tachycardia was likely secondary to
hypovolemia from blood loss as well as N/V. Resolved with fluid
repletion. However, pt again was tachycardic prior to
discharge. No events on telemetry. Once beta-blocker was
re-initiated, tachycardia resolved.
.
7. Altered mental status/Delirium: Altered mental status on
admission likely secondary to uremic encephalopathy and GIB
given asterixis on exam. Differential also included infection,
ETOH withdrawal. Pt denied ETOH intake and never required PRN
valium. Pt was alert and oriented, albeit with some
inappropriate responses and bizarre beliefs prior to discharge.
.
5. Anion Gap Metabolic Acidosis: AG 19 on arrival with low
bicarb, likely secondary to elevated lactate and renal failure
+/- DKA. Resolved with fluid resuscitation.
.
8. HTN: Once HCT stable, resumed beta-blocker.
.
9. h/o hepatitis C: No acute issues; has no h/o cirrhosis.
.
10. Code: Full
Medications on Admission:
(Per PCP's office, most recently seen in [**Name (NI) 1096**], pt unable to
confirm ad ran out of medications >1 week prior to admission):
-Cellcept 250mg three tabs [**Hospital1 **]
-Prednisone 2.5mg daily
-Prograf 2mg Po qam, 1mg PO qpm
-Metoprolol 50mg PO BID
-Simvastatin 10mg PO qhs
-Omeprazole 20mg PO BID
-Percocet 1tab PO q6 hours (120 q month)
-Humalog 5units SC qac
-Vitamin D [**Numeric Identifier 1871**] units q o week
Discharge Medications:
1. mycophenolate mofetil 250 mg Capsule Sig: Three (3) Capsule
PO BID (2 times a day).
2. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. tacrolimus 1 mg Capsule, twice daily Sig: Two (2) Capsule PO
Each morning: and 1 (one) Capsule each evening.
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. omeprazole 40 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:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
8. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous qAM.
Disp:*300 units (1month supply)* Refills:*0*
9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
-[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear versus esophagitis
-Hyperglycemia
-Acute renal failure
Secondary:
-End-Stage Renal Disease s/p Renal Transplant [**6-/2135**] (baseline
Cre 1.8-2.5)
-Pancreatitis
-h/o Hepatitis C
-Hypertension
-Osteoarthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] with bloody vomit, high blood sugar,
and kidney failure. You were initially admitted to the ICU
because you needed careful monitoring, but once you were stable
enough, you were transferred to the floor. You didn't have any
further vomiting while you were in the hospital, but you
continued to have stool that tested positive for blood. You
blood level, however, remained stable after your transfusion in
the ICU. You had an endoscopic procedure
(esophagogastroduodenoscopy) that showed some inflammation of
the esophagus, but no other serious findings. You were also
able to tolerate a regular diet prior to going home.
The following changes were made to your medications:
-STOP Humalog, START glargine insulin subcutaneously each
morning
--> check your blood glucose before breakfast, befre lunch,
before dinner, and at bedtime; record the values and show your
primary physician at your [**Name9 (PRE) 702**] appointment
-INCREASE omeprazole to 40mg twice a day
Please resume all other medications as previously directed, and
make an appointment to see your primary physician [**Name Initial (PRE) 11457**] 2
weeks.
Please avoid any alcohol or NSAIDs, such as ibuprofen (Advil,
Motrin) and naproxen (Aleve). These medications can cause
further bleeding in the intestinal tract.
Followup Instructions:
Name: [**Last Name (un) 11451**]-[**Last Name (LF) **],[**First Name3 (LF) 3679**] S.
Location: [**Hospital6 **] ACC-5
Address: [**Location (un) 11452**], DEPT 1, [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 11453**]
When: Please make an appointment with your PCP [**Name Initial (PRE) 176**] 2 weeks
|
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19,851
| 137,064
|
44322
|
Discharge summary
|
report
|
Admission Date: [**2126-12-24**] Discharge Date: [**2127-1-8**]
Date of Birth: [**2061-2-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Codeine / Nortriptyline
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Femoral line
History of Present Illness:
65 year-old male with history of HIV on HAART (CD4 392 and VL
undetectable [**6-/2126**]), ESRD on HD, DM2, recently admitted with
abdominal pain [**Date range (3) 95040**] presenting with dyspnea from
his nursing home. The patient states that four days prior to
presentation he developed rhinorrhea, pharyngitis, and myalgias,
all of which have since resolved. The day of admission he
complained of shortness of breath and was noted to have oxygen
saturations in the mid-80s on room air. He was sent to [**Hospital1 18**]
for further evaluation.
.
In the ED, afebrile 82 119/61 80% RA->100% NRB. VBG 7.41/52/47.
Chest x-ray showed bilateral lower lobe effusions, cannot rule
out consolidation. Right femoral line placed for access -
complicated by arterial stick. Blood cultures sent. Given
vancomycin, levofloxacin, ceftriaxone.
.
On transfer to the MICU, the patient states his shortness of
breath is improved with NRB. He denies fevers, chills, chest
pain, cough. Review of systems otherwise negative in detail.
Past Medical History:
1) HIV: diagnosed in [**2106**], on HAART. followed by Dr. [**Last Name (STitle) 1057**] at
[**Hospital1 18**].
2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy,
charcot foot, nephropathy, and ? mild retinopathy.
2) Chronic renal failure on Hemodialysis and graft infections,
thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues,
thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] /
Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**]
3) [**Female First Name (un) 564**] esophagitis
4) Hepatitis C: genotype IB
5) Congestive heart failure: echocardiogram [**10-15**] w/ EF 50%.
6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and
circumcision during hospitalization.
7) Hypertension
8) Hypercholesterolemia
9) LE Diabetic ulcers
10) Herpes zoster of the left mandibular distribution of the
trigeminal nerve. [**2115**]
11) R suprapatellar abscess: [**2115**].
12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**]
13) Obesity
15) GI Bleed: [**2117**]. OB positive stool.
16) Anemia
18) Colonic Polyps
19) Gastritis with large hiatal hernia.
20) Lipodystrophy
21) Charcot foot: dx in [**9-13**].
22) Colonic AVM: seen on [**3-9**] colonoscopy on the ileocecal
valve. Treated with thermal therapy.
23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No
abnormalities on CT chest in [**2121**].
24) VISA/MRSA- grew out from culture from R anterior chest wound
25) L3 compression deformity
Social History:
Lives in extended care facility. Quit smoking 20 years ago.
History of IVDU and alcohol abuse. Quit both over 20 years ago.
Has a fiance who says she is the HCP.
Family History:
Patient not close to family and is thus unaware of family
history.
Physical Exam:
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : R base, Diminished: L base)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right: Absent, Left: Absent; no area of induration,
R femoral line in place
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person, place, time, Movement:
Purposeful, Tone: Normal
Pertinent Results:
Labs on Admission:
[**2126-12-23**] 11:45PM WBC-5.5 RBC-3.43* HGB-10.9* HCT-33.8* MCV-98
MCH-31.8 MCHC-32.3 RDW-21.9*
[**2126-12-23**] 11:45PM NEUTS-73.7* LYMPHS-17.4* MONOS-4.7 EOS-3.4
BASOS-0.8
[**2126-12-23**] 11:45PM PLT COUNT-159
[**2126-12-23**] 11:45PM PT-23.4* PTT-39.8* INR(PT)-2.3*
[**2126-12-23**] 11:45PM GLUCOSE-72 UREA N-21* CREAT-4.9* SODIUM-137
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-35* ANION GAP-12
[**2126-12-23**] 11:53PM LACTATE-0.9
[**2126-12-24**] 03:52AM TYPE-ART PO2-72* PCO2-59* PH-7.40 TOTAL
CO2-38* BASE XS-8
Studies:
[**2126-12-23**] CXR AP: Cardiomegaly. Interval development of bilateral
interstitial opacities as well as bilateral pleural effusions,
the findings are suggestive of interstitial edema.
[**2126-12-25**] CT CHEST/ABD/PELV:
1. Moderate-to-large bilateral pleural effusions with bibasilar
atelectasis. No evidence for pneumonia.
2. Diffuse ground-glass opacity with intralobular septal
thickening
suggestive of volume overload; however, other entities including
PCP [**Name Initial (PRE) **]/or drug reaction can provide a similar picture.
3. No retroperitoneal hematoma. Resolution of previously noted
bilateral
groin hematomas.
4. Diffuse anasarca.
5. Extensive coronary artery calcification. Extensive
calcification of the
abdominal aorta and its branches.
6. Atrophic kidneys.
7. Femoral access catheter traversing through the IVC and
terminating in the right atrium.
8. Moderate hiatal hernia.
9. Extensive degenerative changes of the thoracolumbar spine
with old
compression deformities at L4 and T9-T10.
10. Hyperdense material at the site of insertion of the right
femoral catheter concerning for skin breakdown.
[**2126-12-26**] RUE Duplex: 1. Large pseudoaneurysm just proximal to
the right antecubital fossa. 2. No right upper extremity DVT.
[**2126-12-31**] CTA RUE:
1. Large patent pseudoaneurysm arising from the brachial artery
at the
antecubital fossa.
2. Thrombus\poor opacification of the proximal and mid brachial
artery with normal distal filling of the brachial, radial and
cubital arteries.
3. Occluded kinked right subclavian vein stent.
4. Widespread atherosclerosis.
5. Bilateral kidney atrophy with multiple hypodensities, likely
cysts,
incompletely evaluated.
6. Large hiatal hernia.
7. Right pleural effusion and atelectasis.
8. Diffuse soft tissue edema, more marked in the right anterior
chest wall.
9. Dilatation of the common bile duct with no visible
obstruction.
Brief Hospital Course:
1)Respiratory distress: He initially presented with respiratory
distress which was most likely due to combination of dietary
indescretions and having to go an extra day without dialysis
over the weekend. He was initially admitted to the MICU but his
symptoms resolved quickly with dialysis. He had a CT of his
chest which did not show any evidence of pneumonia. He ruled
out for influenza with a nasal aspirate. He was transferred to
the floor where he remained stable from a respiratory standpoint
until 2 weeks into his course when he developed hypoxia and
respiratory alkalosis due to over medication with morphine. His
antibiotic coverage was expanded to include levofloxacin and
flagyl because he had some abdominal pain at the time. When his
mental status recovered the next day the levofloxacin was
discontinued. The flagyl was continued given a positive CDiff
test and will be continued on discharge.
2)Coagulase negative staph bacteremia - He was found to have
coag negative staph growth on blood cultures from admission,
unclear if contaminant or if true bacteremia, however given h/o
multiple lines and limited options for future dialysis access,
will treat with course of antibiotics for bactermia for two
weeks. All surveillance cultures since starting vanc have been
negative. He did have Lspine MRI last admission with concern
for L3/4 abnormality which could be c/w infection.
He was treated with vancomycin for a 2 week course. In
addition, he was started on vancomycin locks to his HD line. He
had a repeat MRI L spine which showed no change.
3)Right brachial pseudoaneurysm: Durin his admission he was
found to have a right brachial artery, native vessel,
pseudoaneurysm. It was thought that at one time he may have had
fistula there. He had surgical removal with graft placement for
repair. He did well following this with no complications.
4)Anemia: acute on chronic, decrease during this admission
likely [**2-9**] right fem line placed in the ED on admission which
had continued bleeding for several days until removal. Since
line removed, no further bleeding with stable HCT.
5)Acute on Chronic systolic CHF: TTE last admission showed
global hypokinesis with decreased EF from prior (35-40%).
Presenting symptoms likely at least in part due to volume
overload. Now resolving as pt's dyspnea improved, CT [**12-25**]
showed no pulm edema. Volume management with HD, he was
continued on metoprolol.
6)HIV: CD4 392 and VL undetectable 6/[**2126**]. Followed by Dr. [**Last Name (STitle) 1057**].
On admission, he was on incorrect HAART regimen. Regimen
evaluated and corrected by ID pharmacist and Dr. [**Last Name (STitle) 1057**] and was
changed as follows:
-indinavir 800mg [**Hospital1 **]
- lamivudine 150mg pm Tu, Th
-ritonavir 100mg [**Hospital1 **]
-stavudine 20mg q24
7)ESRD on HD: Tu/Th/Sa HD schedule.
- HD per renal. Last HD was [**2127-1-6**]
- Continued nephrocaps, sevelamer
- vanco locks to dialysis line after dialysis to prolong
lifespan of line
# Hypertension: Blood pressure has been well controlled,
trending toward low-normal BP rather than hypertension.
- Continued home regimen of nifedipine, metoprolol; holding
nifedipine for sbp <120 to prevent low blood pressure
- did not get home diazoxide as not on forumulary, however
likely would not be able to tolerate as has had lower SBPs in
house (100s).
# L3 compression deformity: Incidentally noted last admission. A
low-grade infection could not be ruled out on imaging, however,
Neurosurgery declined intervention at that time. Repeat MRI
showed no change.
# History of graft thrombosis: Multiple clots in grafts and IVC
in past. INR Therapeutic on admission; INR was elevated to 4.2
after antibiotic administration and thus coumadin dose was held
[**1-7**]. Will need to be restarted as o/p with goal INR [**2-10**].
# Type 2 diabetes: No acute issues
- Humalog sliding scale - no fixed dose
- Continued gabapentin for neuropathy
# Chronic draining chest wound: VISA.
- need STRICT CONTACT PRECAUTIONS
- wound throughly evaluated in past. No action for now
# FEN:regular diet (patient refusing diet restrictions),
electrolyte management per dialysis
# PPX: Therapeutic coumadin, PPI, bowel reg prn
- PT consult - increase activity level as tolerated
# Access: Left femoral dialysis line, L PICC
#CODE: DNR/DNI
# Contact: [**Name (NI) **] [**Name (NI) **], girlfriend & HCP, [**Telephone/Fax (1) 95041**]
Medications on Admission:
1. Gabapentin 200 mg PO HS
2. Ferrous Sulfate 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Indinavir 400 mg PO BID
5. Lamivudine 150 mg PO 2X/WEEK (TU,TH)
6. Diazoxide 50 mg/ml 2 mg PO TID
7. Pantoprazole 40 mg PO BID
8. Stavudine 20 mg PO 3X/WEEK (TU,TH,SA)
9. Citalopram 60 mg PO DAILY
10. Nystatin 100,000 unit/mL Suspension Five ML PO TID
11. Metoprolol Tartrate 75 mg PO BID
12. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
13. Insulin lispro sliding scale
14. Simethicone 80 mg PO QID:PRN heartburn
15. Nifedipine 30 mg PO Q8H
16. Warfarin 2.5 mg and 3 mg PO DAILY alternating
27. Percocet 5/325 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,TH).
8. Insulin Lispro 100 unit/mL Solution Sig: As indicated by
scale Subcutaneous ASDIR (AS DIRECTED).
9. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
12. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
16. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days.
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
18. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
community acquired pneumonia
acute systolic CHF
Bacteremia
Pseudoaneurysm s/p repair
Clostridium difficile infection
Discharge Condition:
The patient was afebrile, normotensive, satting 100% on RA with
resolving diarrhea on discharge
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing. Your breathing difficulty was most likely
related to eating too much salt and your kidney disease. Your
symptoms improved with dialysis.
During your hospital stay you were found to have an aneurysm on
your right arm which was repaired by the surgeons.
You also developed an infection with increased WBC and diarrhea
which was likely an infection in your colon. You are being
treated with IV antibiotics for this infection and your diarrhea
is resolving.
You had an episode of confusion that was likely because of too
many pain medications - specifically morphine - and your
infection. You had several imaging studies of your brain and
spine that were normal.
Medications:
1) Your Indinavir was increased to 800mg twice daily as
recommended by Dr. [**Last Name (STitle) 1057**].
2)Your stavudine was increased to 20mg every day as recommended
by Dr. [**Last Name (STitle) 1057**].
3)Your diazoxide was held and your blood pressure was good
throughout your admission.
4)You were restarted on ritonavir 100mg twice daily which you
should be on for HIV according to Dr. [**Last Name (STitle) 1057**].
5)You were started on Flagyl 500mg IV every 6 hours for your
colon infection (C.Diff).
You should call your doctor or come back to the emergency room
if you develop fevers, chills, headache, confusion, neck pain,
shortness of breath, cough, chest pain, abdominal pain, nausea,
vomiting, blood in your stool or black stools, diarrhea, leg
swelling, more than 3 pounds weight gain in one day or any other
concerning symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 3121**] on [**2127-1-16**]. Please call Dr.
[**Last Name (STitle) **] for the time of your appointment. He will take out
your stitches on that day.
Please keep your follow up appointment with Dr. [**Last Name (STitle) **] on
[**2126-1-12**] at 8:10 am. He should check your electrolyes and your
coumadin level and assess the need to continue the flagyl for
your diarrhea.
Completed by:[**2127-1-8**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,090
| 102,313
|
33814
|
Discharge summary
|
report
|
Admission Date: [**2187-12-10**] Discharge Date: [**2187-12-11**]
Date of Birth: [**2119-11-27**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Motrin
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Aspirin Desensitization
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 78172**] is a 68 yo male with history of dilated
cardiomyopathy, pulmonary embolism, severe asthma and severe
diffuse tracheobronchomalacia s/p tracheobronchoplasty, who
presents today for aspirin desensitization prior to RHC/LHC to
evaluate coronaries and pressures.
Based on previous cardiac MRI, there seems to be disease within
the coronaries, and possibly evidence of scar of the myocardium.
A previous ECHO showed an EF of approx 25%, but CMR EF was
approx 40%. He is being evaluated for ischemic cardiomyopathy.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, 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. he denies chest pain, DOE,
PND, Orthopnea, palpitations or presyncope. All of the other
review of systems were negative. (+) include postnasal drop
with resultant intermittent cough. neck stiffness resolving w/
movement.
Per OMR not from Dr. [**Last Name (STitle) **], "he has been working several days
in the construction business for up to 4 hours at a time without
limiting symptoms. He is also active at home, taking care of his
horses, carrying heavy hay bales, and ascending the [**Doctor Last Name **] to his
barn without chest discomfort, dyspnea on exertion, fatigue,
lightheadedness, or any palpitations." This was confirmed with
patient and is unchanged.
Past Medical History:
1. CARDIAC RISK FACTORS:
(-)Diabetes
(-)Dyslipidemia
(-)Hypertension
.
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
1. Postoperative atrial fibrillation status post tracheoplasty.
2. Severe global cardiomyopathy of unknown etiology diagnosed
on
[**2187-5-16**] with CTA revealing probable nonobstructive coronary
disease.
3. Bilateral pulmonary emboli found incidentally on CTA.
4. Gastroesophageal reflux.
5. Diffuse tracheobronchomalacia, status post tracheobronchial
stent on [**3-8**], removed on [**3-26**]. Subsequent surgical
tracheobronchoplasty on [**5-9**].
6. Severe persistent asthma.
7. Recurrent pneumonia for 30 years.
8. Chronic sinusitis status post three sinus surgeries.
9. Nasal polyps.
10. Left meniscectomy of the left knee.
11. TURP secondary to BPH.
12. Tonsillectomy.
13. Ankle plating for fracture.
14. Vasectomy.
15. Three right-sided inguinal hernia repairs.
Social History:
-Tobacco history: 34 pk/yr smoker Quit smoking: 32 yrs ago
-ETOH: up to 3 beers/day in the past, currently none
-Illicit drugs: denies
He previously worked as a carpenter and an insurance [**Doctor Last Name 360**] and
is married and lives with his wife. Now retired from insurance
x4 years.
Family History:
Parents are both deceased, father in his 80s from COPD and
throat cancer, mother in her 80s of congestive heart failure.
He has one sister who is without cardiac history. He has several
maternal uncles who died of strokes.
Physical Exam:
VS: T=98.7F BP=144/98 HR=87 RR= 22-27 O2 sat=98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No angioedema, some post nasal drip. Trachea to midline.
NECK: Supple with JVP of 4 cm, no carotid bruits.
CARDIAC: RR, occasional premature beat, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. 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+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2187-12-10**] 06:14PM GLUCOSE-104 UREA N-24* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-27 ANION GAP-10
[**2187-12-10**] 06:14PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.0
[**2187-12-10**] 06:14PM WBC-6.5 RBC-3.84* HGB-12.2* HCT-34.5* MCV-90
MCH-31.8 MCHC-35.4* RDW-13.7
[**2187-12-10**] 06:14PM PLT COUNT-215
[**2187-12-10**] 06:14PM PT-12.4 PTT-29.1 INR(PT)-1.0
STUDIES
EKG: Sinus rhyth, LAD, possible LVH. TwI V1. V1-V4 nonspecific
repolrization anl.
2D-[**Month/Day/Year **] [**2187-5-16**]:
The left atrial volume is markedly increased (>32ml/m2). The
left atrium is dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
Diastolic function could not be assessed. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. EF 20-25%.
IMPRESSION: Severe global left ventricular hypokinesis with
moderate to severe mitral regurgitation and moderate left
ventricular dilatation. Mild pulmonary artery systolic
hypertension with preserved right ventricular systolic function.
CARDIAC MRI [**2187-7-4**]:
Impression:
1. Mildly increased left ventricular cavity size with mild
global hypokinesis and more pronounced hypokinesis of the basal
to mid portion of the septum. The LVEF was mildly decreased at
41%. There was patchy mid-myocardial late gadolinium enhancement
of the basal to mid portion of the septum.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 60%.
3. Mild pulmonic regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were mildly increased and normal, respectively.
The main pulmonary artery diameter index was mildly increased.
5. Biatrial enlargement.
6. Normal coronary artery origins. There were lesions noted in
the proximal LAD, proximal LCx, and mid RCA.
Cardiac cath [**2187-12-11**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
single vessel coronary artery disease. The LMCA was normal. The
LAD was
normal, but gave of a D1 with 80% stenosis. The LCx was normal.
THe RCA
was normal.
2. Resting hemodynamics revealed normal right sided filling
presures
with a RVEDP of 9mm Hg and slightly low left sided filling
pressures
with a LVEDP of 9mm Hg. Systemic vascular resistance was
decreased at 11
[**Doctor Last Name **] unit. The PVR was also decreased at 0.9 [**Doctor Last Name **] unit.
Systemic
arterial pressures were low at 98/68mm Hg. The baseline cardiac
output
and cardiac index were 6.6 L/min and 3.3 L/min/m2, respectively.
3. Pericardial calcifications were noted.
4. Patient had a severe vagal reaction during the procedure,
requiring
atropine (2m IV) and transient dopamine support.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Low filling pressures.
Brief Hospital Course:
68 yo male with h/o h/o dilated cardiomyopathy, PE,
tracheobronchomalacia s/p tracheobronchoplasty, who presents for
aspirin desensitization and RHC/LHC to evaluate for ischemic
cardiomyopathy
# CORONARIES: Based on CMR, it seems there are lesions noted in
the proximal LAD, prox LCX and mid RCA with enhancement of the
basal to mid portion of septum which could be c/w scar. Given
these findings, and previous ECHO with EF 25%, there is a
concern for ischemic cardiomyopathy. Patient admitted for ASA
desensitization with eventual goal of LHC/RHC to evaluate
coronaries and cardiac pressures. The patient underwent ASA
densitization per protocol given his ASA allergy. His ASA
desensitization was completed without event and he underwent a
cardiac cath on [**12-11**] which showed.... He was discharged home on
81 mg of ASA daily.
# PUMP: The patient has a history of dilated cardiomyopathy 25%
on echo, then following CMR with EF 41%. Unclear etiology of
cardiomyopathy. Query ischemic cardiomyopathy. His lisinopril
and B-blocker were held given the ASA desensitization, howevr
they were restarted on discharge.
# RHYTHM: The patient has a history of post-op Afib, last holter
recordings all NSR with some ectopy, but no e/o afib. Currently
off coumadin x6wks. ECG NSR w/ LAD, LVH and nonspecific
repolarization anl. The patient was monitored on tele during
his stay.
#. Aspirin desensitization: The patient was desensitized to ASA
per protocol without event.
# Asthma: Severe persistent. No wheezing on exam. Last
exacerbation > 1year. The patient was continued on Advair and
singulair.
# Allergic rhinitis: Currently stable. Postnasal drip w/
occasional cough. The patient was continued on loratadine,
Singulair, and Flonase.
Medications on Admission:
Lipitor 10 QD
Metoprolol 50 mg QD
Lisinopril 10mg QD
Singulair 10 mg QD
Advair 100/50 1 puff [**Hospital1 **]
Flonase 50 mcg [**Hospital1 **]
Tums [**Hospital1 **]
Ergocaliferol 400u qD
MVI daily
Loratadine 10mg QD
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray
Nasal twice a day.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Coronary Artery Disease
Cardiomyopathy
Aspirin Desensitization
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters daily
You were admitted for an elective heart catheterization as well
as aspirin desensitization. You were admitted to the cardiac
ICU, and were monitored overnight and tolerated the aspirin well
without complications. You then had a cardiac catheterization
which showed one blockage of an artery but was not felt to need
intervention.
You will be discharged on an aspirin given this one blockage.
No other medication changes were made.
If you develop any of the following symptoms, please call your
PCP, [**Name10 (NameIs) 2085**], or go to the ED: chest pains, shortness of
breath, fevers, chills, bleeding or oozing from the groin site,
or loss of sensation in your foot or leg.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2188-3-4**] 11:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-3-31**]
10:00
Please call Dr.[**Name (NI) 14643**] office at [**Telephone/Fax (1) 62**] to schedule a
followup appointment in the next 4-6 weeks.
Completed by:[**2187-12-13**]
|
[
"427.31",
"519.19",
"V12.51",
"V14.8",
"425.4",
"414.01",
"530.81",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12",
"88.56",
"37.23",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
10539, 10545
|
7571, 9326
|
316, 342
|
10671, 10680
|
4264, 7464
|
11543, 11949
|
3206, 3431
|
9592, 10516
|
10566, 10566
|
9352, 9569
|
7481, 7548
|
10704, 11520
|
3446, 4245
|
1984, 2057
|
253, 278
|
370, 1871
|
10585, 10650
|
2088, 2876
|
1893, 1964
|
2892, 3190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,427
| 110,992
|
33563
|
Discharge summary
|
report
|
Admission Date: [**2150-9-9**] Discharge Date: [**2150-9-10**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
evaluation of tracheostomy
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
75y/o M with a PMH of ESRD on HD, CAD, ischemic cardiomyopathy,
PAF, morbid obesity, COPD, OSA, and chronic tracheostomy
transferred to [**Hospital1 18**] for evaluation of tracheostomy. Per [**Hospital1 **]
reports there is concern for malfunctional tracheostomy as the
patient's peak pressures have been rising on ventilator. Per
respiratory therapy notes from [**Hospital1 **], prior to [**2150-9-9**] was on
AC 14/650/+5/50%, peak pressures rising over past week to mid
30s and 40s. RT has been unable to pass the inline catheter due
to resistance. Pt taken off vent to swith to 14 fr however
unable to pass airway. He was switched to SIMV 650/12/50%/ PEEP
5 with increased comfort.
The patient underwent a recent R BKA on [**2150-8-27**]. He had episodes
of hypoxia related to mucous plugging and sputum grew MRSA and
was started on a short course of vancomycin. He has chronic
decubitous ulcers. He received a short course of linezolid,
aztreonam and flagyl during his post-op BKA course, all
discontinued on [**9-1**]. He is on dialysis for ESRD.
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)
and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers
Allergies: Penicillin and sulfonamides
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
noncontributory
Physical Exam:
99.7 97.9 96/44 77 15 99% on vent
Alert and oriented with appropriate affect.
Trach in place.
Heart regular with no murmur.
Lungs with good air entry b/l and scattered crackles.
s/p right BKA, +1 edema in LE.
Obese with soft abdomen and bowel sounds present.
No rash, no asterixis.
Pertinent Results:
[**2150-9-9**] 08:49PM BLOOD WBC-7.5 RBC-2.90* Hgb-7.4* Hct-26.0*
MCV-90 MCH-25.6* MCHC-28.4* RDW-17.8* Plt Ct-202
[**2150-9-10**] 05:38AM BLOOD WBC-6.5 RBC-3.00* Hgb-7.6* Hct-25.8*
MCV-86 MCH-25.4* MCHC-29.5* RDW-19.3* Plt Ct-216
[**2150-9-9**] 08:49PM BLOOD PT-37.6* PTT-53.2* [**Month/Day/Year 263**](PT)-4.0*
[**2150-9-9**] 08:49PM BLOOD Glucose-149* UreaN-32* Creat-3.8* Na-140
K-3.8 Cl-104 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Glucose-109* UreaN-34* Creat-4.2* Na-139
K-3.7 Cl-103 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Albumin-2.4* Calcium-7.8* Phos-1.9*
Mg-2.7*
Micro:
[**2150-9-9**] 11:34 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-9-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Preliminary):
BAL [**9-10**]:
BRONCHIAL LAVAGE RIGHT MIDDLE LOBE.
GRAM STAIN (Pending):
RESPIRATORY CULTURE (Pending):
FUNGAL CULTURE (Pending):
CXR [**2150-9-9**]:
In comparison with study of [**6-27**], there is little change in the
appearance of the tracheostomy tube. Dobbhoff tube is in place,
though the image ends above the diaphragm so the tip cannot be
seen. Central catheter tip similarly is difficult to evaluate
and appears to be in the right atrium.
Prominence of interstitial markings persists and there are
probable bilateral pleural effusions.
Brief Hospital Course:
75 y/o with chronic tracheostomy, HD-dependent ESRD, sacral/LE
ulcers, R [**Hospital 6024**] transferred to the MICU for evaluation of his
tracheostomy.
# Respiratory failure:
Mr. [**Known lastname 77792**] has a history of hypercarbic/hypoxic respiratory
failure and is s/p trachostomy earlier in [**2149**]. He was noted to
have increasing peak pressures with difficulty in passing a
catheter due to resistance and was transferred for further
evaluation of his trach. IP was consulted and performed
bronchoscopy on [**9-10**]. He was found to have diffuse airway edema
consistent with volume overload. There were no significant
secretions and a full survey of the airways reveals all airways
were patent without any endobronchial lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
He should be continued on vancomycin for treatment of MRSA
pneumonia.
Please note that the findings of the sputum culture and BAL were
pending at the time of discharge.
# ESRD:
Related to diabetic nephropathy. Patient did not receive HD at
[**Hospital1 18**] as he will be receiving it upon return to [**Hospital1 **].
Continued renagel.
# Atrial Fibrillation:
Continued metoprolol. Coumadin was held for supratherapeutic
[**Hospital1 263**] of 4. Please dose coumadin as needed to maintain [**Hospital1 263**] of
[**1-18**].
Please note that coumadin is not on the current medication list
as it should be held given that his [**Month/Day (3) 263**] is elevated. This is
most likely due to the interaction of coumadin with his current
antibiotics (levofloxacin and fluconazole). Please restart
coumadin cautiously once his [**Month/Day (3) 263**] is < 2.5 to maintain an [**Month/Day (3) 263**]
between 2 and 3.
Also note that subcutaneous heparin was stopped during your
hospital stay.
# Type II DM: continued sliding scale insulin and Lantus.
# R BKA with Sacral and leg ulcers:
Continued current wound care, no signs of active infection
# Plasma cell dyscrasia:
Found to have IgA kappa on serum electrophoresis with an
imbalance in the free kappa:lambda light chain ratio. BM biopsy
showed 5-10% plasma cells. During his work up the hematology
team felt he likely had MGUS and ordered a retroperitoneal
biopsy of a mass that was noted on his abd CT scan. His FNA was
non-diagnostic and a needle core biopsy showed fragments of
lymphoid tissue with quiescent appearing germinal centers.
Continued outpatient follow up
# Nutrition: NPO; tube feeds continued.
# Access - mid-line
# Code- full
Medications on Admission:
Fluconazole 100mg/50ml daily to end [**9-14**]
Levofloxacin 500mg IV Q24 (stop date [**9-14**])
Vancomycin 1gm IV
Epogen 20,000units QHD
Lispro SS
Heparin 5000U TID
Simvastatin 10mg daily
Docusate 100mg [**Hospital1 **]
Senna 2 tab [**Hospital1 **]
Famotidine 20mg daily
Warfarin 2mg daily
Renagel 800mg TID w/ meals
Tylenol 650mg Q6
Percocet 2 tab po Q4
Zofran 4mg IV Q6
Dulcolax 10mg po PRN constipation
Coumadin 2.5mg po daily
Metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: hold if sedated.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Fluconazole 10 mg/mL Suspension for Reconstitution Sig: One
Hundred (100) mg PO once a day for 4 days: Last dose 9/29.
9. Levofloxacin 25 mg/mL Solution Sig: Five Hundred (500) mg
Intravenous once a day for 4 days: last day = [**9-14**].
10. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
with dialysis for as directed days: per treatment course as
directed by physicians at [**Hospital1 **].
11. Epogen 20,000 unit/mL Solution Sig: 20,000 units Injection
with dialysis.
12. Insulin
Please continue insulin according to the regimen you were on
prior to transfer to [**Hospital1 18**].
13. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for sbp < 90 or hr < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis: Respiratory failure
Secondary Diagnoses: Pneumonia, End stage renal disease, Sacral
and leg ulcers, diabetes, Chronic diastolic heart failure,
Atrial fibrillation on coumadin
Discharge Condition:
On mechanical ventilation via trach. Afebrile with HR in
70s-80s and BP 98/40.
Discharge Instructions:
You were admitted for evaluation of your tracheostomy. A
bronchoscopy was performed and showed that your trach tube was
in the correct position without any obstruction.
1. Please attend all follow-up appointments as recommended by
your normal providers.
2. Please continue all medications as instructed. We stopped
your subcutaneous heparin during your stay. We also would like
you to dose coumadin carefully as the [**Hospital1 263**] is currently elevated
at 4. This is most likely from the interaction of coumadin with
fluconazole and levofloxacin.
3. Please return to the hospital if you develop fevers,
worsening respiratory status, or any other concerning symptom.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please continue to see your normal providers through [**Hospital **]
Health Care.
Completed by:[**2150-9-10**]
|
[
"V44.0",
"414.01",
"496",
"428.32",
"V49.75",
"414.8",
"250.40",
"428.0",
"482.41",
"327.23",
"707.04",
"585.6",
"V45.1",
"V09.0",
"272.0",
"707.03",
"V58.61",
"427.31",
"518.83",
"V13.02",
"V46.11",
"707.07",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8403, 8478
|
3827, 6394
|
320, 334
|
8718, 8800
|
2349, 3202
|
9630, 9743
|
2005, 2022
|
6909, 8380
|
8499, 8499
|
6420, 6886
|
8824, 9607
|
2037, 2330
|
8561, 8697
|
3238, 3804
|
254, 282
|
362, 1418
|
8519, 8539
|
1440, 1911
|
1927, 1989
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,057
| 177,832
|
41670
|
Discharge summary
|
report
|
Admission Date: [**2153-7-30**] Discharge Date: [**2153-8-24**]
Date of Birth: [**2080-5-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
C. diff diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
Colonoscopy, flexible sigmoidoscopy
Exploratory Laparotomy
History of Present Illness:
73 yo F with hypertension, asthma and newly diagnosed PUD and
Crohn's and multiple recent admissions for persistent diarrhea
and abdominal pain who is transferred from [**Hospital3 25357**] after presenting [**2153-7-25**] with abdominal pain and
diarrhea again and found to have C.diff colitis without
improvement on vancomycin and metronidazole.
.
Patient was initially admitted [**Date range (3) 90587**] at [**Hospital3 25357**] with abdominal pain, diarrhea and fever though to be
secondary to infectious gastroenteritis treated with
metronidazole and levofloxacin x 14 days. Stool cultures were
negative. Also found to have peptic ulcer disease on EGD
(duodenal and prepyloric ulcer - reportedly large and deep) and
started on PPI (biopsies negative for H.pylori or malignancy and
revealed benign gastric antral type mucosa with chronic
superficial gastritis and lymphoid folicular formation with
foveolar hyperplasia per discharge summary [**2153-7-30**]).
.
Hospitalized again at [**Hospital1 189**] from [**Date range (1) 90588**] with RLQ
abdominal pain, early satiety and weight loss. CT on admission
showed thickening of cecum and ascending colon concerning for
inflammatory versus infectious colitis. Also showed heavy
calcified plaque at the origins of the celiac artery and SMA.
Gastroenterology was consulted, colonoscopy performed [**2153-7-13**]
and per discharge summary consistent with Crohn's disease
(biopsy per [**2153-7-30**] discharge summary was negative for
malignancy but showed inflamed granulation tissue with foreign
body giant cells). Started on mesalamine. Stool studies
negative for infection (negative c.diff and O/P per discharge
summary). Of note, last colonoscopy was in [**2151**] but incomplete
study due to anatomy. Discharge summary from [**2153-7-14**] does not
mention antibiotics however discharge paperwork from today
references that patient was treated with ciprofloxacin and
metronidazole (patient unable to recall).
.
Patient re-presented to [**Hospital6 204**] on [**2153-7-25**] with
diffuse abdominal cramping (acute on chronic), rigors, low grade
fever, diarrhea and poor po intake with relative hypotension to
100/70. Her labs were significant for leukocytosis of 21.5K.
Patient was started on high dose methylprednisolone,
levofloxacin and metronidazole for presumed Crohn's flare.
C.diff was positive in the stool (per discharge summary, no
results reported) and methylprednisolone was discontinued
(unclear when d/c'ed). CT abdomen and pelvis on [**2153-7-29**] was
obtained which showed inflammatory changes in the colon
unchanged from [**2153-7-10**]. Also showed subacute infarcts of spleen.
Heme/onc was consulted which recommended MRI or doppler
ultrasound to rule out splenic vein thrombosis. Hypercoagable
work-up significant for low protein C activity. Given that
patient continued to have abdominal pain, poor po and diarrhea
and white count has not improved, decision made to transfer to
[**Hospital1 18**] for second opinion.
.
Patient reports she continues to have diffuse ache-like
abdominal pain with sitting and intermittent sharp periumbilical
pain (which is new x 3 days). Continues to have 3-4 episodes of
watery non-bloody diarrhea per day which she states has been
going on for months. Reports very poor po intake due to lack of
appetite and bad taste in mouth. Endorses weight loss however
unable to quantify (Atrius note states 28 lbs since [**Month (only) 116**]). No
nausea or vomiting. No fever or chills. No history of blood
clots. Denies history of a.fib.
.
- General: No fevers, chills, sweats, + weight loss
- HEENT: no changes in vision or hearing, no rhinorrhea, nasal
congestion, headaches, sore throat
- Lungs: no cough, shortness of breath, dyspnea on exertion
- Cardiac: no chest pain, pressure, palpitations, orthopnea, PND
- GI: + abdominal pain, no nausea, vomiting, + diarrhea, -
constipation, -BRBPR, -melena
- GU: no dysuria, hematuria, urgency, frequncey
- MSK: no arthralgias or myalgias
- Neuro: no weakness, numbness, seizures, difficulty speaking,
changes in memory.
Past Medical History:
PUD - duodenal and prepyloric ulcers on EGD [**6-11**]
HTN
Asthma
Social History:
Lives with husband - four children and four grandchildren all
healthy.
Retired 1.5 years ago - teacher aid at an elementary school
Quit tobacco 22 years ago, 1 ppd
No heavy alcohol in the past, sometimes one cocktail a day but
around the time of her granddaughter's death she reports having
'a couple' of cocktails per day. She has not had any alcohol in
the last few months since the GI symptoms worsened. No history
of
drug use or IVDU
Family History:
Father - prostate and bladder cancer
Grandmother - colon cancer
Physical Exam:
Admission Exam:
VS: 96 105/67 86P 20RR 97RA
Gen: alert, NAD, pleasant, resting comfortably in bed
Heent: anicteric, eomi, perrl, op clear s lesions, mmd
Neck: supple, no LAD, no JVD
Cv: +s1, s2 -m/r/g
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Extr: no edema, 2+ dp/pt, no calf ttp
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Discharge Exam:
VS: Tc/m 99.3, HR 106, 140/68, 16, 94% 1L and 92% on RA
General: pleasant, NAD lying in bed smiling and interactive with
dobhoff in and tube feeds running
EENT: PERRL, EOMI, dry mucous membranes, no thrush
CV: RRR, nml S1/S2, no murmurs, rubs, gallops
Pul: CTAB. good air entry, good chest expansion with
encouragement
GI: stapled 6inch incision which is clean/dry/intact with some
dried blood around staples, normoactive bowel sounds, soft,
nondistended, diffusely tender, worse around incision site
MSK: no joint swelling or erythema
Extremities: warm and well perfused, 2+ edema to the knees
bilaterally.
LYMPH: no cervical lymphadenopathy
SKIN: no rashes, no jaundice, some erythema of left forearm
improved from yesterday
NEURO: awake, alert and oriented x3
Pertinent Results:
[**8-2**]
K 3.3 after repletion, normal Bun/Creat, normal LFTs
phos low at 1.9
WBC down to 11.4, Hct 35.2, plts 460
[**Hospital1 18**] micro: neg cdiff, neg stool cx and O+P, blood cx neg to
date, H pylori serology P
.
Reviewed outside labs in chart: protein C level 72 (normal range
77-173), this value is not diagnostic or even suggestive of true
protein C deficiency, other hypercoag labs including Factor V
leidin, anti-thrombin III, lupus anticoagulant,
anti-cardiolipin, factor II mutation are negative.
.
C diff toxin positive on [**7-27**], stool cultures are negative.
albumin low to 2.1 on [**7-28**], PM cortisol level 19.4, CK 26, CRP
5.4, WBC high of 37.5 with 14% bands on [**7-28**].
.
Recent study reports:
kub with non-specific bowel gas pattern
splenic vein duplex with splenic infarcts, intact
venous/arterial flow
[**2153-7-30**] OSH Labs:
138 107 9
-----------< 76
4.2 22 0.3
29.3> 12.8/37.2 <316
WBCs: 24 -> 37.5 -> 26.8 -> 29.3
Hct: 38 -> 45 -> 36 -> 37
.
OSH Imaging:
.
[**2153-7-25**] AXR: diffuse colitis with marked mural thickening, no
pneumatosis or abnormal gaseous distension of bowel
.
[**2153-7-26**] CT abdomen and pelvis with contrast: probable subacute
splenic infarcts; inflammatory and/or infectious change of colon
unchanged or slightly improved since [**2153-7-10**] study (thickening of
the wall of ascending colon and cecum, mild to moderate wall
thickening in descending colon and splenic flexure)
.
[**2153-7-10**] CT abdomen and pelvis enterography: mural thickening
cecum and proximal ascending colon, hypervascularity in adjacent
mesentery; heavy calcified plaques at origins of both celiac
artery and SMA; no occlusion of these vessels, no venous
obstruction; no abscess or perforation; multiple peripheral foci
of transient hepatic attenuation differences consistent with
areas of shunting within liver
...
IMAGING DURING [**Hospital1 18**] ADMISSION:
[**2153-7-31**] Spleen Ultrasound:
Splenic infarcts with patent splenic vein.
.
[**2153-8-1**] KUB:
No evidence of megacolon
.
[**2153-8-3**] CXR:
Right PICC line terminates at mid SVC. Both lungs are well
expanded. Minimal pleural effusions seen bilaterally wit mild
atelectasis in the left lung base. There is no lung
consolidation. Heart size is normal.
Mediastinal and hilar contours are stable and unchanged since
prior
radiograph. Anterior wedge compression fracture of T9 vertebral
body seen
involving one-third of the vertebral height. Degenerative
changes are seen at multiple thoracic vertebral body levels.
.
[**2153-8-6**] CXR: Compared to the prior exam there is no significant
interval change.
.
[**2153-8-6**] CT ABD & PELVIS: 1. Trans-mesocolic small bowel internal
hernia without secondary signs of ischemia. 2. Watery colonic
wall thickening consistent with diagnosis of C. difficile
colitis. 3. Near-complete splenic infarction with a small viable
portion remaining medially, with associated splenic vein
thrombosis. The portal vein and SMV are patent.
4. The SMA and celiac origins are severely calcified and fill
poorly with
contrast, though this is not an arterial phase CT. 5. Abdominal
ascites.
6. Hiatal hernia. 7. Small bilateral pleural effusions with
bibasilar atelectasis. 8. Anasarca.
.
[**2153-8-6**] Portable Abdomen: Normal diameter of the transverse
colon.
.
[**2153-8-17**] Colonic mucosal biopsies, two: A. 45 cm:
Colonic mucosa with crypt regeneration and focal edema of the
lamina propria.
B. 20-35 cm:
1. Features consistent with ischemic-type colitis with focal
fibrinopurulent exudate, suggestive of early pseudomembrane
formation; see note.
.
[**2153-8-20**] Abd and pelvis CT: 1. No evidence of intra-abdominal
abscess.
2. Persistent splenic infarcts with unresolved splenic vein
thrombosis.
3. Resolved intra-abdominal ascites.
4. Mild improvement in bibasilar pleural effusions.
2. AFB stain is negative for acid fast bacilli. No viral
inclusions are identified on H&E; CMV immunostain will be
performed at the request of the clinician and results will be
reported in an addendum.
[**2153-8-22**] URINE URINE CULTURE-negative INPATIENT
[**2153-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2153-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2153-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2153-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2153-8-19**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2153-8-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2153-8-14**] BLOOD CULTURE Blood Culture,
Routine-negative
[**2153-8-14**] BLOOD CULTURE Blood Culture,
Routine-negative
[**2153-8-7**] PERITONEAL FLUID GRAM STAIN-negative; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-negative INPATIENT
[**2153-8-5**] Immunology (CMV) CMV Viral Load-negative
[**2153-8-5**] Blood (CMV AB) CMV IgG ANTIBODY-negative;
CMV IgM ANTIBODY-negative
[**2153-8-3**] STOOL FECAL CULTURE-negative; CAMPYLOBACTER
CULTURE-negative CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2153-8-1**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST negative
[**2153-7-31**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST negative
[**2153-7-31**] BLOOD CULTURE - negative
[**2153-7-31**] BLOOD CULTURE - negative
Brief Hospital Course:
73 yo F with hypertension, asthma transferred from outside
hospital to [**Hospital1 18**] on [**7-31**] for further evaluation of acute on
chronic diarrhea, abdominal pain, and weight loss.
#. DIARRHEA/ C. DIFF COLITIS: Her OSH hospital course was
significant for gastric ulcerations seen on EGD and colitis
suggestive of Crohn's on colonoscopy and biopsy. Her outside
path slides from gastric, colon biopsies performed prior to
admission were reviewed by [**Hospital1 18**] pathologist and they confirmed
colitis, but could not confirm or refute a diagnosis of Crohn's
especially as she could have had partially treated or
undiagnosed cdiff at that time. Additionally, GI states the
biopsies were taken from an ulcer, which cannot acurrately
diagnose Crohn's disease. During her most recent admission to
the OSH, she was found to have a leukocytosis of 35 and her
stool was positive for C. Diff. Her white count improved with
treatment of her C. Diff, however her stool output continued to
be at least 2 L/day. As such she was transferred to [**Hospital1 18**] for
further work-up. Here, she was continued on oral vancomycin and
IV flagyl. She underwent colonoscopy on [**8-2**] that showed
pseudomembranes and active cdiff, the [**Last Name (un) **] was not complete as
edema/inflammation resulted in a stricture through which the
colonoscopy could not pass. She was also seen by infectious
disease who agreed with her management. On [**2153-8-3**], a Dobbhoff
tube was placed in order to start tube feeds. She initially
tolerated this well and there was no change in her stool output.
However, early in the morning of [**2153-8-6**], she developed severe
abdominal pain and these were stopped. She underwent an
abdominal CT that suggested splenic vein thrombosis and a large
splenic infarct, as well as a possible internal hernia of the
small bowel. Surgery was consulted prior to the abdominal CT
results and they ultimately decided to take her to surgery, as
they felt she had an acute abdomen. Ex-lap did not show a
surgical pathology for her abdonimal pain. Acute pain may have
been [**1-3**] to her infarcted spleen. Patient was transferred back
to medicine, after a short stint in the SICU for prolonged
paralytic effect during the surgery, and her treatment for c.
diff was continued (PO and PR vancomycin, as well as a shorter
stint of IV flagyl). Repeat flex sig on [**2153-8-17**] showed improved
but persistent pseudomembranes and colonic biopsies showed crypt
regeneration, pseudomembranes, without evidence of crohn's in
the portion of the colon biopsied. Notably, celiac serologies
were performed and these were negative. At time of discharge
frequency of bowel movements was significantly improved but she
still required qod dosing of oral vancomycin which she should
continue for one week. If patient is to develop fever or
worsening idarrhea, please check Cdiff.
.
Other ACTIVE ISSUES:
#Splenic infarct: visualized on OSH imaging as well as CT
abdomen here. Hypercoag workup negative, although initially
protein C level noted to be slightly lower than normal range,
though this value is not suggestive of clinical protein C
defeciency that could cause increased risk of thrombosis.
Splenic infarcts were present on abdominal ultrasound. Repeat CT
showed persistent splenic vein thrombosis and splenic infarction
(with increased viable tissue), but no abscess. Anticoagulation
was started with LMWH and coumadin. Platelet counts continued to
rise (up to 900s), likely a result of recent spleen infarction.
Anticoagulation should continue for minimum 3 months for
treatment of splenic thrombosis and can be readdressed by
primary care/GI teams. Pt will need immunizations given new
asplenic state as outpatient, particularly meningiococcal
vaccine and Hemophilus influenza vaccination. Should she become
febrile prophylactic antibiotics should be considered though
this could further exacerbate cdiff symptoms.
.
#Anorexia/weight loss/severe malnutrtion: This is likely related
to her underlying illness, worsened by her distaste for food [**1-3**]
flagyl use. For her nutrition, she was trialed on tube feeds,
however this worsened her diarrhea and there was concern for
malabsorption given her high outout. She ultimately received
TPN, which increase her albumin from 1.9 to 3.0 over a week.
Oral nutrition was encouraged and Ensure chocolate supplements
were given. Pt continues to be week and requires rehabilitation
given deconditioning and malnutrtion as a result of her
prolonged illness. Discharge home is felt to be unsafe at this
time.
.
Chronic ISSUES:
.
#PUD: duodenal and prepyloric ulcers by EGD in [**Month (only) 205**], biopsies
negative for malignancy or h.pylori. At [**Hospital1 18**], stool h. pyroli
antigen was negative. She was continued on her proton pump
inhibitor.
.
#HTN: stopped her home enalapril on admission. She did not
require antihypertensives during her admission.
.
COPD/asthma: pt required no treatmetn during her
hosptialization.
To Do:
- Meningococcal vaccine, hemophilus influenza vaccine
- check cdiff if fevers
- monitor INR qod, adjust dose to maintain INR [**1-4**], until INR
stable. - TPN to be discontinued per GI teams.
Medications on Admission:
Meds on transfer from OSH:
Percocet 1-2 tabs q6h prn
Metronidazole 500mg IV q8h ([**2153-7-25**])
Vancomycin 250mg q6h ([**2153-7-28**])
Mesalamine 1500mg daily
Lovenox 40mg SQ daily
Folic acid 1mg daily
Thiamine 100mg po daily
Reglan prn
MVI
Protonix 40mg iv BID
Zofran prn
Acetaminophen 650mg q4h prn
Benadryl prn
Ambien prn
Discharge Medications:
1. Align 4 mg Capsule Sig: One (1) Capsule PO once a day: or
equivalent probiotic.
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for breakthrough pain.
6. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
10. vancomycin 250 mg Capsule Sig: One (1) Capsule PO twice a
day.
11. TPN
Pt will need continued TPN Most recent order at [**Hospital1 18**] on
[**2153-8-24**]:
Volume(ml/d) Amino Acid(g/d) Dextrose(g/d) Fat(g/d)
[**2141**] 110 370 40
NO Trace Elements will be added daily
Standard Adult Multivitamins
NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc
125 0 0 45 25 30 12 14
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary Diagnosis:
C. diff diarrhea
splenic infarction
Secondary Diagnosis:
PUD - duodenal and prepyloric ulcers on EGD [**6-11**]
HTN
Asthma/COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were hospitalized for treatment of an infection of your
gastrointestinal tract which causes profound diarrhea. The
infection is called Clostridium Difficile (C. Diff). At one
point, there was concern for a a serious problem in your abdomen
and you were taken to surgery for exploration. The surgery did
not show evidence of any dead tissue or infection outside of
your intestine. On imaging, we noted that you had a blood clot
in a vein causing your spleen to become infarcted. Surgery did
not feel your spleen had to be removed however. You remained in
the hospital for treatment of the c. diff infection in your
colon and for nutrition, which you largely got through your
veins.
The following changes were made to your medications:
CONTINUE to take Vancomycin by mouth for 7 days.
START Align or similar probiotic.
START Dronabinol for appetite.
Please continue to take your other home medications as
prescribed.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2153-8-28**] at 3:00 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2153-8-24**]
|
[
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"276.8",
"401.9",
"289.59",
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"275.3",
"783.21",
"562.10",
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"786.05",
"261",
"041.86",
"338.19",
"532.90",
"338.29",
"427.89",
"553.8",
"275.41",
"789.00",
"493.20",
"V16.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"54.11",
"45.25",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
18387, 18461
|
11644, 14546
|
337, 398
|
18653, 18653
|
6316, 11621
|
19787, 20155
|
5079, 5144
|
17231, 18364
|
18482, 18482
|
16880, 17208
|
18804, 19764
|
5159, 5516
|
5532, 6297
|
265, 299
|
14561, 16227
|
426, 4518
|
18559, 18632
|
18501, 18538
|
18668, 18780
|
16243, 16854
|
4540, 4607
|
4623, 5063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,855
| 115,711
|
23793
|
Discharge summary
|
report
|
Admission Date: [**2123-2-11**] Discharge Date: [**2123-3-5**]
Date of Birth: [**2049-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypoxic respiratory failure and hypotension
Major Surgical or Invasive Procedure:
1. s/p Intubation
2. s/p Tracheostomy
History of Present Illness:
73 y.o. man who presents for respiratory distress. History is
limited and is from son and [**Name (NI) **] notes. He was apparently feeling
ok yesterday. This morning, per his living facility, he was
less responsive and in respiratory distress. O2 sat was in the
50s. He may have had a mild cough over the last few days. He
was brought to the ED. He was intubated on arrival for
unresponsiveness, cyanosis. Subsequently, he was hypotensive
with SBP to 60s. A CVL was placed, he was given 2.25 L NS and
started on levophed with response in SBP up to 110s. He was
started on vanco, levo, flagyl for pneumonia after infiltrate
was seen on CXR. Then transported to [**Hospital Unit Name 153**].
Pt had CXR on [**2-4**] which showed bibasilar infiltrates. He was
started on levaquin and flagyl.
Past Medical History:
1) AAA repair--R common iliac aneursym repair in [**7-12**] with
endovascular stent
2) COPD--on home O2
3) CAD with cardiomyopathy: last TTE in [**7-12**] showed nml EF,
impaired relaxation.
4) HTN
5) CRI (bl Cr=1.2)
6) Anemia
7) chronic UTI
8) dementia
9) depression
Social History:
Spanish speaking, lives in a nursing home, ex-smoker and alcohol
user.
Family History:
noncontributory
Physical Exam:
VS: Tm 102 (Tc 101.3) -- BP 110/80 --- HR 90-100s -- RR 20
(set) --- 100% on AC 500 x 20 FiO2 0.6 PEEP 5 PIP 37.
GEN: intubated, but opens eyes and follows simple commands.
HEENT: NCAT, Pupils 3mm and min reactive but equal. Anicteric.
OP with ETT, dry MM.
Neck: supple, JVP not appreciated due to habitus.
Lungs: coarse BS b/l with anterior rhonchi and left sided
expiratory wheezing.
CV: distant HS, RRR, nml S1S2, no m/r/g appreaciated
ABD: soft, mod distended, NT, naBS, no masses.
EXT: no c/c/e.
NEURO: resting cogwheel tremor of hands R>L.
SKIN: no wounds or ulcers.
Pertinent Results:
[**2123-2-11**] 07:56AM WBC-15.2* RBC-3.67* HGB-10.9* HCT-33.7*
MCV-92
PLT COUNT-215
.
[**2123-2-11**] 08:27AM GLUCOSE-291* LACTATE-3.4* NA+-146 K+-4.3
CL--106
[**2123-2-11**] 08:27AM freeCa-1.11*
[**2123-2-11**] 09:10AM CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-2.2
.
[**2123-2-11**] 09:51AM LACTATE-3.9*
[**2123-2-11**] 10:47AM LACTATE-2.4*
.
[**2123-2-11**] 08:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2123-2-11**] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2123-2-11**] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
.
[**2123-2-11**] 08:27AM ABG#1: O2-100 PO2-277* PCO2-94* PH-7.21*
[**2123-2-11**]
ABG#2: RATES-/16 O2-100 PO2-253* PCO2-64* PH-7.29*
.
CXR: RLL patchy opacity
ECG: porr baseline but appears SR at 96bpm, nml axis, ints.
PRWP. TWI in V2, no acute ST-T changes (c/w [**7-12**])
.
[**2123-2-11**]- abdominal x-ray - No evidence of bowel obstruction.
Nasogastric tube in satisfactory position.
.
Echo [**2123-2-15**] - Suboptimal image quality. Left ventricular wall
thicknesses and cavity size are normal. Overall left
ventricular systolic function is probably mildly depressed. The
basal septum appears hypokinetic. Right ventricular chamber
size and free wall motion appear normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2122-8-5**], the degree of pulmonary hypertension
detected has increased. A mildly depressed LVEF is now
suggested, but not conclusive (poor image quality). If
clinically indicated, a repeat TTE with echo contrast (Definity)
may better define regional/global LV systolic function.
.
CT abdomen - [**2123-2-22**] - IMPRESSION:
1. No findings to explain patient's bacteremia within the chest,
abdomen, or pelvis. No abscesses.
2. Extensive bullous emphysema within the lungs. Bilateral
pleural effusions, findings to suggest loculation. Bibasilar
consolidation has the appearance of more of atelectasis. Nodules
within the lungs should be followed up by CT in [**4-12**] months after
the patient's current condition has resolved.
3. The pancreatic head cystic lesion and small pancreatic neck
cystic lesion are unchanged in appearance from [**2122-5-14**]. These
likely represent cysts, however IPMT cannot be excluded, and
attention should be paid to this on follow-up.
4. Decreased size of right common iliac artery aneurysm after
graft placement. No evidence of superinfection of this aneurysm.
No change in the aortic, left common iliac, or bilateral common
femoral aneurysms. No evidence of infection of these aneurysms.
5. Gastrostomy tube tip is within the second/third portion of
the duodenum.
6. Persistent atrophic left kidney.
.
CXR [**2123-3-4**]- No change in comparison to the prior study. No
evidence for new infiltrate
Brief Hospital Course:
73 y.o. man with h/o severe COPD, pneumonias, HTN who presents
with hypoxic respiratory failure, unresponsiveness, and
hypotension. Given fevers, infiltrate on CXR, most likely
etiology of respiratory failure is pneumonia, and this is also
the most likely cause of his hypotension/septic shock. There is
no evidence of ACS or CHF.
..
..
## Hypoxic respiratory failure: Intuabated on AC mode on
admission. Given his history of recurrent aspiration pneumonias
with MRSA and Pseudomonas he was started on broad comverate
antibiotics with vanc, zosyn and azithromycin. Urine legionella
was negative. DFA for influenza also negative. Sputum cultures
returned with MSSA and pesudeomonas ([**Last Name (un) 36**] to zosyn). He was
treated with Vanc, Zosyn and azithro for 14 day course. He was
also given albuterol/atrovent nebs given history of COPD. He
did not have much improvement in lung mechanics with 20 puffs of
bronchodilator trial and was given burst of IV steroids
(methylpred 80 IV for 7 days). Daily RSBIs were checked with
not much improvement in his respiratory status. With attempts
of weaning pt became tachycardic and tachypneic and pressure
support was unable to be weaned off. He was evaluated by
Interventional pulmonary who planned on placing a trach, this
was delayed given positive blood culture with klebsiella, see
below. After cultures were negative for 6 days, IP placed a
bedside trach. He will need to have continued mechanical
ventilation for now which should be weaned at a vent facility as
tolerated. The trach should also help pt with preventing
aspiration as he's had multiple admissions for aspiration
pneumonias.
.
## Septic shock: Likely due to pneumonia. Treated with abx as
above. Given IVF and levophed initially, with goals of CVP
10-12 corrected for PEEP, MAP>60, and UOP>30 cc/hr. [**Last Name (un) **] stim
showed appropriate response. Levophed was weaned off and he did
not require pressors thereafter.
.
## CAD/CHF: No indication of acute process. Held
antihypertensives on admission. His blood pressure remained
stable and he was not restarted on his anithypertensives. Given
his CAD, inquired with PCP and started him asa, statin.
..
## Bacteremia: Few days after admission pt had temp spike and
had blood cultures done which later grew Klebsiella. There was
no clear source of infection. So CT scan of abdomen was done
without clear source. His central line was changed and cultures
were negative thereafter. he should be treated for total 2 week
course with levofloxacin (start date [**2123-2-24**]).
## [**Doctor First Name 48**]/CRI: Likely pre-renal from sepsis and hypotension. This
resolved with initial ivf. Creatinine remained around 1.4-1.7
during the rest of the admission.
..
## Abd distention: nontender, LFTs were checked on admission
and several times during the admission and were unremakable.
KUB was done which showed no evidence of obstuction only stool
in colon. Given persistent distension he also had a CT scan of
abdomen, results above. His distention improved with prn
Lactulose during the admission.
..
## F/E/N: He was continued on TFs during the hospitilization.
Nutrition also followed pt while he was in the ICU. He was
placed on insulin gtt initially and was changed over to basal
insulin + RISS.
..
## PPx: Maintained on SC heparin, PPI. bowel regimen.
Medications on Admission:
Trazadone 25mg q6h prn
APAP prn
Flovent 110mcg 2puffs [**Hospital1 **]
Combivent 2 puffs q4h
Lopressor 25mg tid
Levaquin 500mg daily (since [**2-4**])
Flagyl 500mg tid (since [**2-4**])
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection Q8H (every 8 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) ml PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8)
Puff Inhalation Q4H (every 4 hours).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation Q4H (every 4 hours).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation Q4H (every 4 hours) as needed.
10. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous Q24H (every 24 hours) for 8 days:
Please continue until [**2123-3-10**]. thank you.
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
12. Acetaminophen 160 mg/5 mL Solution Sig: [**6-16**] ml PO Q4-6H
(every 4 to 6 hours) as needed.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
15. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Please see attached list for details Injection four times
a day: Please see attached list for details.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Sepsis due to PNA
2. COPD
3. Acute renal failure on baseline chronic renal failure
Secondary:
1. CAD
2. CHF
3. AAA repair
4. HTN
5. Dementia
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with all of your doctors.
Please take all of your medications as instructed. Please note,
several changes have been made in your medications including
antibiotics which should be continued for two weeks. See below
for details:
1. Please continue the antibiotic Levofloxacin until [**2123-3-10**]
2. Please continue the albuterol and atrovent nebulizers 8
puffs Q 4hours. Your flovent and combivent has been
discontinued and replaced with the albuterol and atrovent IH.
3. Please continue to hold the antihypertensive medications
until his blood pressure shows signs of hypertension. At this
point, the pt can be started on metoprolol 12.5mg three times a
day and titrated up to 25mg three times a day.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks after discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2123-3-7**]
|
[
"482.1",
"038.9",
"401.9",
"995.92",
"428.0",
"496",
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"403.91",
"276.52",
"996.62",
"482.41",
"414.01",
"294.8",
"425.4",
"785.52",
"584.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.22",
"96.04",
"38.91",
"00.17",
"38.93",
"33.24",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10849, 10920
|
5462, 8826
|
358, 400
|
11126, 11135
|
2269, 5439
|
11911, 12155
|
1629, 1646
|
9062, 10826
|
10941, 11105
|
8852, 9039
|
11159, 11888
|
1661, 2250
|
275, 320
|
428, 1231
|
1253, 1524
|
1540, 1613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,339
| 104,951
|
50540
|
Discharge summary
|
report
|
Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-24**]
Date of Birth: [**2071-3-16**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Percocet
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
failure to decannulate
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
66 F with history of CAD s/p CABG [**2118**], PCI recently, OSA,
bipolar, on [**1-27**] went to [**Hospital1 336**] for an elective left hip
replacement, which was complicated with post-op AFIB with RVR
that required cardioversion. She became septic, had a VAP
secondary to pseudomonas, UTI [**2-22**] VRE. She improved, was trached
and pegged, and transferred to [**Hospital **] [**Hospital **] Rehab. She was
there for 2 months, where they could not decannulate her. Bronch
was done at [**Hospital1 **] - tracheomalacia was seen in the subglottic
region to trach. She was transferred here for evaluation of
tracheal stenosis after failed attempts at decannulation.
.
She was changed from a 6 uncuffed to a 7 cuffed trach. En route
in ambulance, she had SOB with frothy secretions. She had to
stop at [**Hospital 17679**] medical center for trach management, CT chest
was done to assess for PE, she was suctioned and doing fine,
then transferred here.
.
She was admitted to the IP service. She has been trached for [**4-25**]
months. She went for bronch today and IP found severe
supraglottic edema compatible with GERD. IP decided not to do
anything with her trach until this edema was fixed first. She
was started on PPI. She had a trach change this afternoon, in
which her trach was downsized back down to 6 uncuffed. She was
going to be discharged and seen in 4 weeks by IP.
.
She decannulated herself today by coughing up her trach today,
and a respiratory code was called on [**4-23**] at 1430 when she became
hypoxemic. IP came and changed her trach to a 7 cuffed trach,
bronched her, saw frothy secretions in the trachea. She was
significantly hypoxic: 7.37 / 53 / 54 / 32, and was hypertensive
220/120 during the code. Blood / mucus was suctioned from her
bronchi, and she was sitting up and coughing. She may have
negative pressure pulmonary edema or diastolic dysfunction. She
had normal vitals and was transferred to MICU green for
monitoring.
.
Past Medical History:
s/p CABG
Left total hip replacement
Bipolar disorder
Depression
AFIB
Chronic constipation
Trach and PEG
HIT on Fragmin (Arixtra
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
VS: 99.3 / 120/65 / 90 / 34 / 97% on
PS 400 / 20 / 8 / 8 / 0.8
GEN: Alert, in good mood, communicates clearly
HEENT: Trach site clean with minimal erythema
LUNGS: Diffuse rhonchi bilaterally
HEART: RRR, no m/r/g
ABD: Soft, +BS, ND NT
EXTR: No c/c/e
NEURO: Gait not tested
Pertinent Results:
[**2137-5-24**] 08:06AM BLOOD Hct-29.8*
[**2137-5-24**] 04:30AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.6* Hct-28.7*
MCV-91 MCH-30.3 MCHC-33.4 RDW-19.3* Plt Ct-291
[**2137-5-23**] 02:49PM BLOOD WBC-8.8 RBC-3.82* Hgb-11.6* Hct-34.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-18.9* Plt Ct-349
[**2137-5-23**] 12:35AM BLOOD WBC-11.8* RBC-4.08* Hgb-12.3 Hct-36.4
MCV-89 MCH-30.0 MCHC-33.6 RDW-19.0* Plt Ct-351
[**2137-5-24**] 04:30AM BLOOD Neuts-74.7* Lymphs-17.9* Monos-3.7
Eos-3.2 Baso-0.5
[**2137-5-23**] 02:49PM BLOOD Neuts-79.7* Lymphs-14.4* Monos-3.4
Eos-2.2 Baso-0.2
[**2137-5-23**] 12:35AM BLOOD Neuts-88.5* Bands-0 Lymphs-7.4* Monos-3.3
Eos-0.6 Baso-0.2
[**2137-5-24**] 04:30AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+
[**2137-5-23**] 02:49PM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+
[**2137-5-23**] 12:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2137-5-24**] 04:30AM BLOOD Plt Ct-291
[**2137-5-24**] 04:30AM BLOOD PT-13.4* PTT-30.5 INR(PT)-1.2*
[**2137-5-23**] 02:49PM BLOOD Plt Ct-349
[**2137-5-23**] 02:49PM BLOOD PT-13.1 PTT-50.3* INR(PT)-1.1
[**2137-5-23**] 12:35AM BLOOD Plt Smr-NORMAL Plt Ct-351
[**2137-5-23**] 12:35AM BLOOD PT-12.9 PTT-30.4 INR(PT)-1.1
[**2137-5-23**] 02:49PM BLOOD Ret Aut-2.4
[**2137-5-24**] 04:30AM BLOOD Glucose-112* UreaN-22* Creat-1.0 Na-141
K-3.3 Cl-103 HCO3-32 AnGap-9
[**2137-5-23**] 02:49PM BLOOD Glucose-209* UreaN-22* Creat-1.1 Na-136
K-3.6 Cl-97 HCO3-31 AnGap-12
[**2137-5-23**] 12:35AM BLOOD Glucose-129* UreaN-26* Creat-1.1 Na-138
K-4.1 Cl-97 HCO3-33* AnGap-12
[**2137-5-23**] 02:49PM BLOOD ALT-7 AST-15 LD(LDH)-199 CK(CPK)-50
AlkPhos-87 Amylase-52 TotBili-0.8
[**2137-5-23**] 02:49PM BLOOD Lipase-31
[**2137-5-24**] 08:06AM BLOOD proBNP-2166*
[**2137-5-23**] 02:49PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2137-5-24**] 04:30AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
[**2137-5-23**] 02:49PM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.9 Mg-2.0
UricAcd-11.6* Iron-38
[**2137-5-23**] 12:35AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.0
[**2137-5-23**] 02:49PM BLOOD calTIBC-330 Ferritn-280* TRF-254
[**2137-5-23**] 02:49PM BLOOD TSH-1.8
[**2137-5-24**] 02:27AM BLOOD Type-ART Tidal V-400 PEEP-8 FiO2-80
pO2-90 pCO2-47* pH-7.43 calTCO2-32* Base XS-5 AADO2-451 REQ
O2-75 Intubat-INTUBATED Vent-IMV
[**2137-5-23**] 02:48PM BLOOD Type-ART pO2-54* pCO2-53* pH-7.37
calTCO2-32* Base XS-3 Intubat-NOT INTUBA
[**2137-5-24**] 02:27AM BLOOD Glucose-98 K-3.2*
[**2137-5-24**] 02:27AM BLOOD freeCa-1.19
Brief Hospital Course:
66 F with history of COPD with respiratory failure on
tracheostomy since [**1-27**] following L total hip replacement. She
was brought in to be evaluated by interventional pulmonary for
failure to decannulate. Bronchoscopy show supraglottic edema in
addition to tracheal stenosis. Plan was to start her on PPI and
follow up with interventional pulmonary in 4 weeks. On the
medicine floor, she coughed up her trach tube and a respiratory
code was called. She was recannulated and transferred to medical
ICU for overnight monitoring. THroughout the night, her blood
pressure was slightly low. It was likely medication related as
it resolved by itself in the morning. She also had slight
hematocrit drop, likely related to traumatic recannulation of
her trach. She was initially on SIMV +PS 400 x20, PEEP 8, PSV 8
and FiO2 of 0.80. Her CXR show interstitial edema, likely from
negative pressure during her decannulation. Her pulmonary edema
resolved w/ positive pressure and she was eventually weaned to
trach mask again.
Medications on Admission:
ASA 81 QD
Lipitor 80 QD
Zyprexa 5 [**Hospital1 **]
Paxil 10 QD
MVI
Combivent 6puff QID
Colace 100 [**Hospital1 **]
Senna 2 QHS
Lactulose 30 [**Hospital1 **]
Lasix 30 [**Hospital1 **]
Aldactone 30 [**Hospital1 **]
Metoprolol 25 [**Hospital1 **]
Ativan 1 q4 prn
Zegerid 40'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
4. Paroxetine HCl 10 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mg PO
DAILY (Daily).
5. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q6H (every 6 hours).
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
8. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2
times a day).
9. Furosemide 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times a
day).
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day): hold for BP<100.
11. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
12. Zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
15. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: Six Hundred (600) mg
PO Q8H (every 8 hours) as needed for pain.
16. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1)
Spray Nasal DAILY (Daily).
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
18. Fondaparinux 2.5 mg/0.5 mL Syringe [**Last Name (STitle) **]: 2.5 mg Subcutaneous
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**]
Discharge Diagnosis:
supraglottic edema likely from gastroesophageal reflux and
tracheal stenosis
Discharge Condition:
stable on trach mask.
Discharge Instructions:
Please call DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**] to schedule a repeat
bronchoscopy in 4 weeks. Call if you develop any problems with
your trach tube.
Continue PPI [**Hospital1 **].
Please continue all medications prior to admission.
Followup Instructions:
schedule bronch in 4 weeks( DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**])
Completed by:[**2137-5-24**]
|
[
"530.81",
"519.02",
"327.23",
"285.9",
"296.80",
"799.02",
"458.9",
"428.0",
"V45.81",
"428.33",
"564.09",
"V45.82",
"427.31",
"478.6",
"519.19",
"V43.64",
"401.9",
"518.83",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
8509, 8555
|
5306, 6327
|
308, 323
|
8676, 8700
|
2838, 5283
|
9015, 9144
|
2513, 2530
|
6650, 8486
|
8576, 8655
|
6353, 6627
|
8724, 8992
|
2545, 2819
|
246, 270
|
351, 2312
|
2334, 2464
|
2480, 2497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,040
| 182,170
|
22115
|
Discharge summary
|
report
|
Admission Date: [**2199-8-31**] Discharge Date: [**2199-9-5**]
Date of Birth: [**2147-9-23**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
On intial presentation, abdominal pain. Transferred to us for
possible stenting of L mainstem bronchus occluded by SCC of the
lung.
Major Surgical or Invasive Procedure:
Rigid bronchoscopy on [**9-4**].
Tracheal intubation [**9-4**], with extubation [**9-5**].
History of Present Illness:
This patient is a 51 y.o. male with a history of heavy alcohol
abuse, admitted [**8-27**] to [**Hospital 11485**] Hospital with abdominal pain
and found to have pancreatitis with lipase 560. The same day,
he was found to have a L lung whiteout on CXR, further evaluated
with chest CT which showed a L hilar mass with pleural effusion.
On [**8-29**] the patient was going to have a bronchoscopy, but went
into AF with RVR 180, BP 80/40. He was transfered to the ICU,
started on a diltiazem drip, and went back into NSR within a few
hours. On [**8-30**] he had a brochoscopy which showed a mass just
below the carina and a complete obstruction of the L mainstem
bronchus 2-4 cm below the mass. Tissue biopsy showed SCC, and
patient was transferred to us for possible stenting.
The patient says he drinks about 12 beers a day. His pain
resolved while at [**Hospital1 11485**] after being NPO for two days. He had
one episode of pancreatitis 15 years ago, and another in [**2195**].
The patient denies any SOB, CP, HA, N/V/D. He does note a 27
pound weight loss since the winter. No dysphagia. He has a
chronic cough with some wheezing, without hemoptysis. Clear
white sputum.
Past Medical History:
Esophagitis
Alcoholic hepatitis
Pancreatitis
Cholelithiasis
Etoh abuse
Social History:
Patient is divorced, but still lives with his wife and 3
children. They live in [**Location (un) 22201**], near [**Location (un) 5583**] Mass. He is
still working as an extruder operator. When he first moved here
from Poland in [**2162**] he worked for three years on a tobacco farm.
Drinks 12 beers a day.
Smoked 2 ppd x 30 years.
Denies IVDU
Family History:
Mother had diabetes and was blind. Deceased.
Father died of an MI.
No cancer.
Physical Exam:
VS: 98.4, tmax 101.3 at midnight, BP 96/58, HR 84, RR 20, 94% on
2L.
Gen: Patient is a slim caucasian male, poorly groomed, with poor
denitition, lying in bed, appearing comfortable, with NC in
place.
HEENT: PEARL, EOMI, anicteric.
Neck: No lymphadenopathy, supple.
Lungs: Decreased breath sounds throughout L lung. Bronchial
breath sounds and inspiratory wheezes heard at R base.
CVS: RR, normal rate, no M/R/G.
Abd: Normoactive BS, soft, NT/ND.
Extr: Clubbing of digits, no edema.
Pertinent Results:
Imaging:
CT torso [**2199-9-2**] -
1) 3.2x3.9 cm hilar mass with extension into subcarinal area,
causing complete collapse of the L lung and a large pleural
effusion. Exact borders of pulmonary mass can't be visualized
due to lack of IV contrast, but a rough estimate is given at 7.4
x 7.0 cm.
2) Subcentimeter R middle lobe lung nodule
3) Small R pleural effusion
4) Pancreatic calcifications consistent with chronic
pancreatitis
5) Chronic calcifications consisten with splenic granulomas
CT head [**2199-9-2**] -
Negative unenhanced head CT. MRI with gadolinium would be
helpful if there is clinical suspicion of metastases. Cavum
spetum pellucidum.
Bronchoscopy [**2199-9-4**] - 100% obstruction left main bronchus with
tumor.
Micro:
[**2199-9-3**] BCx: Strep pneumoniae 2/4 bottles. Sensitive to
Ceftriaxone, penicillin, erythromycin, levofloxacin,
tetracycline, TMP-SMX, vancomycin.
[**2199-9-3**] UCx: Contaminated.
[**2199-9-5**] BCx: Pending.
Hematologic:
[**2199-9-1**] 05:55AM BLOOD WBC-16.4* RBC-2.89* Hgb-9.1* Hct-28.5*
MCV-99* MCH-31.3 MCHC-31.7 RDW-12.9 Plt Ct-627*
[**2199-9-3**] 06:35AM BLOOD WBC-20.8* RBC-3.03* Hgb-9.6* Hct-29.8*
MCV-98 MCH-31.7 MCHC-32.2 RDW-13.1 Plt Ct-722*
[**2199-9-1**] 05:55AM BLOOD Neuts-79.5* Lymphs-13.7* Monos-5.9
Eos-0.5 Baso-0.4
[**2199-9-5**] 02:35AM BLOOD WBC-17.2* RBC-3.03* Hgb-9.4* Hct-30.3*
MCV-100* MCH-31.0 MCHC-31.0 RDW-13.0 Plt Ct-906*
Iron:
[**2199-9-1**] 05:55AM BLOOD calTIBC-135* VitB12-847 Folate-10.0
Ferritn-478* TRF-104* Iron-15*
[**2199-9-1**] 05:55AM BLOOD TSH-3.1
Coagulation:
[**2199-9-1**] 05:55AM BLOOD PT-13.5 PTT-32.1 INR(PT)-1.2
Chemistry:
[**2199-9-3**] 06:35AM BLOOD Glucose-91 UreaN-2* Creat-0.3* Na-134
K-4.2 Cl-94* HCO3-32* AnGap-12
[**2199-9-3**] 06:35AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1
[**2199-9-5**] 02:35AM BLOOD Glucose-103 UreaN-4* Creat-0.3* Na-138
K-3.9 Cl-100 HCO3-30* AnGap-12
GI:
[**2199-9-3**] 06:35AM BLOOD ALT-14 AST-20 AlkPhos-234* Amylase-42
TotBili-0.3
[**2199-9-3**] 06:35AM BLOOD Lipase-23 GGT-223*
Brief Hospital Course:
A/P: 51 y.o. male transferred from [**Hospital1 11485**] with L mainstem
bronchus complete obstruction secondary to SCC, originally
admitted for acute pancreatitis.
1) Airway: The patient was seen by interventional pulomonology
on arrival, who recommended a CT scan with contrast to stage the
carcinoma prior to stenting, as if the patient were low stage he
may be a surgical candidate rather than palliative, which is
what stenting would accomplish. Unfortunately, the patient has
a prior history of a contrast allergy, therefore we performed
the CT scan without contrast. It demonstrated a large pleural
effusion on the L side, with a rim of cortex, with complete
collapse of the left lung and a large hilar mass.
Interventional pulmonology attempted a thoracentesis, however
the effusion was extremely thick and bloody, and no aspirate was
obtained. He was taken to the OR for rigid bronchoscopy with
possible stenting on [**9-4**], however during the course of the
procedure the patient desaturated to 70 percent, most likely
secondary to laryngospasm, and required intubation. Stenting
was unable to be performed, as the lumen was completely
obstructed without a patent airway distally. The patient was
transfered to the MICU post intubation, and remained intubated
for less than 24 hours, being successfully extubated on the
morning of [**9-5**]. Post-extubation he was stable, with a HR in
the 80s, BP 104/57, RR in the 20s, with 93% saturation on room
air.
We have spoken with the patient about the option of thoracotomy
with decortication, however the patient is currently refusing
any operative procedures, and wants to go back to [**Hospital1 11485**] for
any further care. He may, however, consider it in the future.
It is currently unclear whether the thick material occupying his
thoracic cavity is tumor or empyema.
As far as staging goes, the CT scan performed at our hospital
did not have contrast, and therefore is not a great study for
evaluating for metastases. It showed results as described in
the Pertinent Results section. Of note, Mr. [**Known lastname 57786**] has an
elevated ALP level in the 200s, without transaminase elevation,
in addition to an elevated GGT. This could indicate hepatic
involvement.
2) Streptococcal bacteremia: The patient ran a low grade fever
multiple times duing the course of his stay, with tmax of 102.8
on [**2199-9-3**]. Additionally, wbc increased to 20, and he also
developed a thrombocytosis. Blood cultures were positive for S.
Pneumoniae, with a likely source being post-obstructive
pneumonia. He was started on ceftriaxone [**9-4**], pending
sensitivities. It is pan-sensitive, and he could be switched to
PO Levaquin if desired when he arrives at [**Hospital 11485**] Hospital. He
has remained afebrile since starting ceftriaxone. Surveillance
blood cultures were drawn on the day of discharge, and are
currently pending.
2) Pancreatitis: Patient has been without abdominal pain since
[**8-29**], and without tenderness on physical exam. He has been give
IVF at 150 cc/hr for the duration of his stay, and did not
require any analgesic medication. He has been able to tolerate
a regular house diet since the night after his arrival. IVF
were continued throughout since he was NPO for procedures for
much of the time.
3) Etoh: Patient normally drinks 12 beers per day, therefore he
was placed on a CIWA protocol. However, he never had symtpoms
of withdrawal, and it has now been more than a week since his
last drink
4) A-fib: Patient has been in NSR since episode before
bronchoscopy at [**Hospital1 11485**]. Was only in AF for a few hours,
therefore no need for anticoagulation. We continued diltiazem
30 mg PO q6 hours while he was here, and monitored him with
telemetry for the first 48 hours. His rhythm has been regular
the whole time.
5) Anemia: Mr. [**Known lastname 57786**] is anemic, but his hematocrit has been
stable. Iron studies indicate an anemia of chronic disease,
which could also be alcohol related. We have been giving him
folate, thiamine, and a MVI during his stay.
5) Prophylaxis: Heparin 5000 Units SQ TID
Medications on Admission:
SC Heparin
Famotidine
Tylenol PRN
Atrovent PRN
Diltiazem 30 mg PO q6 hours
RISS
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000 Injection TID (3 times a day).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
9. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Squamous Cell Carcinoma of the lung
Resolved episode of acute pancreatitis
Discharge Condition:
Good. Stable.
Discharge Instructions:
Patient is on ceftriaxone for strep. pneumonia bacteremia -
started on the evening of [**9-3**]. Pan-sensitive, so can be
switched to PO Levaquin if desired.
Followup Instructions:
With oncology at [**Hospital 11485**] Hospital, for discussion of further
treatment/palliation of his cancer.
Continue antibiotics for at least 14 days (he is on day 2 of
ceftriaxone as of [**9-5**], so he needs another 12 days).
|
[
"511.9",
"577.1",
"486",
"510.9",
"790.7",
"427.31",
"305.01",
"162.8",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"32.01",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9953, 9968
|
4860, 8993
|
442, 534
|
10087, 10103
|
2824, 4837
|
10310, 10543
|
2224, 2304
|
9123, 9930
|
9989, 10066
|
9019, 9100
|
10127, 10287
|
2319, 2805
|
270, 404
|
562, 1749
|
1771, 1843
|
1859, 2208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,680
| 197,232
|
32850
|
Discharge summary
|
report
|
Admission Date: [**2168-12-5**] Discharge Date: [**2168-12-7**]
Date of Birth: [**2124-9-7**] Sex: M
Service: MEDICINE
Allergies:
Reglan / Seroquel
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Peritoneal Dialysis
History of Present Illness:
44 yo M w/ PMH of metastatic testicular germinoma, PCKD on PD,
b/l PE, presents with SOB. Pt was driving with his wife to [**Name (NI) 2860**]
for an appointment when he began to develop rapid shallow
breathing and felt short of breath. The patient was unable to
alleviate his shortness of breath and felt it was progressively
getting worse over 45 minutes. He denied CP, dizziness,
palpitations, loss of conscious. He drove into the [**Hospital1 18**] garage
where EMS was called and he was taken to the ED. He reports
altering his peritoneal dialysis protocol over the past couple
days so that he was retaining fluid, rather than removing fluid.
.
In the ED he was satting 80% on NRB. He was put on bipap with
satts improving to mid-90s. His CXR showed vol overload. Pro BNP
>70,000, wbc 12.9 wihtout bandemia, lactate 5.7, INR 3.4. He was
given IV lasix and started on nitro drip. He was off bipap and
was put on O2 by NC. His satts were 99%/6L. He also received IV
CTX and IV levoflox x 1.
Past Medical History:
metastatic testicular Ca, germinoma, s/p 40 rounds chemo,
carboplatin and ifoosfamide.
PCKD on PD
PE, bilateral, s/p peritoneal biopsy
DM
Hypertension
Secondary hyperthyroidism
Renal transplant X2, [**12/2163**], [**12/2165**]
Hyperlipidemia
Appendectomy s/p MVC [**2143**]
Social History:
Social History: quit smoking 5 yr back. smoked 1 ppd x 20 yrs,
no alcohol x past 13 yrs, occa etoh before that, no drug use.
Family History:
non-contributory
Physical Exam:
96.2 100 138/99 22 100/5l NC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules. Central line
in place for administering chemo
RESP: bibasilar crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. PD
cath in place
EXT: b/l 2+ edema, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose.
Pertinent Results:
[**2168-12-5**] WBC-12.9* RBC-3.26* Hgb-10.8* Hct-35.7* MCV-110*
MCH-33.1* MCHC-30.3* RDW-18.4* Plt Ct-257 Neuts-65.8 Lymphs-28.2
Monos-2.6 Eos-2.5 Baso-0.9
PT-32.7* PTT-31.5 INR(PT)-3.4*
Glucose-234* UreaN-36* Creat-13.0* Na-139 K-4.6 Cl-98 HCO3-25
AnGap-21*
ALT-12 AST-19 AlkPhos-57 Amylase-39 TotBili-0.3
[**2168-12-5**] 12:35PM BLOOD cTropnT-0.10*CK(CPK)-48
[**2168-12-5**] CK-MB-4 cTropnT-0.14* CK(CPK)-34*
[**2168-12-6**] 04:24AM BLOOD CK-MB-4 cTropnT-0.12* CK(CPK)-30*
[**2168-12-5**] 12:35PM BLOOD Albumin-3.2* Calcium-9.4 Phos-4.7* Mg-2.2
[**2168-12-7**] 06:25AM BLOOD proBNP- >70,000
CHEST (PORTABLE AP) [**2168-12-5**] 12:43 PM
FINDINGS: Upright portable AP chest radiograph obtained. Right
IJ central line is seen with its tip in the proximate location
of the superior vena cava. The heart appears enlarged. Low lung
volume somewhat limit evaluation, as does patient motion. There
is, however prominence of pulmonary vasculature, with indistinct
pulmonary hila. Findings are compatible with congestive heart
failure. There may be right basilar atelectasis and small
effusion. No pneumothorax. Mediastinal contour is unremarkable.
IMPRESSION:
Right IJ central line in acceptable position.
Cardiomegaly, congestive heart failure.
[**2168-12-6**] ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. There is moderate to severe global
left ventricular hypokinesis (LVEF = 25-30 %). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Borderline left ventricular cavity dilation with
moderate to severe global hypokinesis c/w diffuse process
(toxin, metabolic, cannot exclude multivessel CAD). Dilated
thoracic aorta.
Brief Hospital Course:
A/P: 44 yo M w/ PMH of metastatic testicular Ca, PCKD on PD, PE
p/w pulm edema in the setting of volume overload from
inappropriate .
.
#SOB: The patient's CXR showed bilateral infiltrates. This was
likely in the setting of improper peritoneal dialysis. He was
initially in the ICU on nitro gtt until his PD could be
restarted. Once his PD was restarted, greater than 3L fluid was
removed in 24 hrs with marked improvement of his respiratory
status. He was initally on BiPap very shortly, and was then O2
by NC. Prior to transfer to the floor, the patient was satting
>95% on RA. The patient was given nebs, but did not require
them prior to discharge any longer. He had BNP>70,000 even at
the time of discharge. This could have been due to CHF
exacerbation vs volume overload from lack of PD. An ECHO showed
an EF of 25-30%, though this could be depressed with massive
volume overload from lack of PD. He should have a repeat ECHO
as an outpt by his PCP once his volume status is back to his
baseline.
.
# PCKD: Pt has h/o PCKD and is on PD chronically. He had
stopped doing his PD properly prior to coming to [**Location (un) 86**] for his
[**Hospital1 4601**] appt which probably led to his volume overload. The
patient understands that he needs to keep up with his PD.
During this hospitalization, the patient was followed by Renal
and he was restarted on his PD with a concentrated dialysate.
He will need to continue that regimen for [**12-22**] more days after
discharge, and he will f/u with [**Hospital **] clinic the afternoon of his
discharge to get the supplies he needs. He has an outpatient
nephrologist in [**State 2748**] that he follows regularly with.
.
# CAD: The patient has no past h/o CAD. He presented with trop
of 0.1 with Sr Cr of 13. EKG showed diffuse TWI. No ST changes.
He had no prior available to compare. He was chest pain free
during this hospitaliziation. A discussion of ACE and ASA was
done with the patient. He will bring these up with his PCP
since he is on neither of these medications with a h/o diabetes
and a low EF.
.
# HTN/Tachycardia: He will continue his outpatient Metoprolol
dose.
.
# DM: The pt had h/o DM. At home he is on actos and amaryl. He
was on ISS during this hospitalization, but was restarted on his
home medications at discharge.
.
# Testicular cancer: The patient was in [**Location (un) 86**] for a DF cancer
appt which he did not make given that he was unable to breathe
and presented to [**Hospital1 18**] ED. He has had many rounds of
chemotherapy in the past. He will need to f/u with his
oncologist for further followup.
Medications on Admission:
Actos 15mg PO QD
Dulcolax 100mg Capsule PO QD
Iron 325 mg PO QD
PhosLo 1334 PO TID
Famotidine 40mg PO QD
Sensipar 60mg PO QD
Glimepride 2mg Po QD
Metoprolol 25mg PO BID
Prednisone 5mg PO QD
Alprazolam .5mg PO HS:PRN
Nasonex 50mcg suspension 2 sprays each nostril QD
Coumadin 3.5mg PO QD
Procrit 24,000 Units injection, QMWF.
Discharge Medications:
1. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
2. Dulcolax Stool Softener 100 mg Capsule Sig: One (1) Capsule
PO once a day.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Sensipar 60 mg Tablet Sig: One (1) Tablet PO once a day.
7. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily): each nostril.
12. Warfarin 1 mg Tablet Sig: 3.5 Tablets PO QD ().
13. Procrit 20,000 unit/mL Solution Sig: [**Numeric Identifier 17514**] ([**Numeric Identifier 17514**]) units
Injection QMon/Wed/Fri.
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Cyanocobalamin 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
16. Peritoneal Dialysis
Please go to your [**Hospital **] clinic for dialysis as scheduled. Continue
using 4.25 dextrose dialysate for [**12-22**] more days and followup
with your [**Hospital **] clinic
17. Echocardiogram
outpatient repeat Echocardiogram- discuss with your PCP
18. Outpatient Lab Work
repeat CBC by your PCP
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Volume Overload secondary to Renal Disease
Polycystic Kidney Disease on Peritoneal Dialysis
Secondary Diagnoses:
Hypertension
Diabetes
Testicular Cancer/Germinoma
history of Bilateral Pulmonary Embolisms
Hyperlipidemia
Discharge Condition:
stable, good O2 sats on room air, ambulating without difficulty
Discharge Instructions:
You were admitted for difficulty breathing. You were found to
have lots of excessive fluids. This was likely due to improper
peritoneal dialysis. You were initally in the ICU, and once
your dialysis was restarted, your breathing improved quickly.
You also had an Echocardiogram (ultrasound of the heart) which
showed some decreased functioning of your heart. You should
have discussions with your PCP regarding repeating that test now
that most of the fluid is off.
.
Please take all medications as prescribed. Please keep all of
your scheduled appointments. Please continue with your
peritnoeal dialysis as instructed. You will need another [**12-22**]
days of 4.25 dextrose dialysate PD to help remove some more
fluid. After discharge, please go to your [**Hospital **] clinic to ensure
you get the proper supplies.
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pains, shortness of breath,
nausea, vomiting, fevers, or chills.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Tray to schedule an appointment
within the next week. Please discuss with him about repeating
an Echocardiogram, possibly a stress test, and whether starting
an Aspirin or Ace-inhibitor is appropriate.
[**Last Name (NamePattern1) 76475**] [**Apartment Address(1) 76476**],
[**State 2748**] Multispecialty Grp,
[**Location (un) **], CT
.
Please call your oncologist to schedule an appointment and to
repeat your CBC (cell counts)
|
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icd9cm
|
[
[
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icd9pcs
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20,473
| 116,479
|
21311
|
Discharge summary
|
report
|
Admission Date: [**2126-2-21**] Discharge Date: [**2126-3-2**]
Date of Birth: [**2057-3-8**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: Alcoholic cirrhosis and HCC admitted
for liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male with a history of alcoholic cirrhosis and hepatocellular
carcinoma. Cirrhosis discovered after episode of esophageal
varices bleeding approximately five years ago. Asymptomatic
until two years ago when he had another episode of bleeding.
In [**2125-5-26**] he was noted to have a 4 cm mass in the liver
which was an hepatocellular carcinoma. Had radiofrequency
ablation [**6-29**]. Presents today for liver transplant.
PAST MEDICAL HISTORY: Alcoholic cirrhosis, hepatocellular
carcinoma, esophageal varices with bleeding, history of
tuberculosis approximately 18 years ago. Mild hypertension,
coronary artery disease, status post coronary artery bypass
graft 13 years ago.
PAST SURGICAL HISTORY: Coronary artery bypass graft one
vessel and hernia repair.
MEDICATIONS ON ADMISSION: Aspirin 81 mg q day, isosorbide 50
mg q day, propranolol 40 mg B.I.D., spironolactone 25 mg q
day, folic acid 400 mg q day, iron 325 mg B.I.D. Fish oil 2
grams B.I.D.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Widowed, high school teacher in [**Hospital3 **].
Two children. Drank greater than 12 beers per day for 30
years but he quit some years ago.
REVIEW OF SYSTEMS: No cough, sore throat, upper respiratory
illness. No change in appetite or weight. No change in
bowel or bladder habits.
PHYSICAL EXAMINATION: The patient has a heart rate of 60,
temperature 96.1, blood pressure 140/70, breathing 18, pulse
oximetry 98 percent on room air. General: In no acute
distress. Awake, alert, friendly, conversant. Head, eyes,
ears, nose and throat: Normocephalic, atraumatic.
Extraocular movements are full. Cardiovascular: Regular
rate and rhythm. Negative murmur, rub or gallop. Distant
sounds. Pulmonary: Clear to auscultation bilaterally.
Chest midline, coronary artery bypass graft scar upper chest.
Abdomen soft, nontender, not distended, no masses, no rebound
or guarding. Extremities: No edema, warm, well perfused.
Dorsalis pedis and posterior tibial 1 plus bilaterally right
leg with scar from vein harvesting.
LABORATORY DATA: WBC of 10., hematocrit of 29.4, PT of 16.8,
PTT of 150 and platelets of 70. Patient has a sodium of 141,
3.2, 107, 26, BUN/creatinine of 17/0.9. ALT on the 28th was
61, AST 361, total bilirubin 1.8, direct bilirubin 0.6.
Patient had an electrocardiogram demonstrating sinus
bradycardia, 56 with questionable first degree AV block.
Slipped T waves in V6. Chest x-ray showed no acute
cardiopulmonary disease.
HOSPITAL COURSE: The patient was admitted to Transplant
Surgery, given MMF, 20 mg times 1, Solu-Medrol 1,000 mg times
one, fluconazole 400 mg times 1, Vancomycin 1,000 mg times 1,
Levaquin 500 mg times 1. Patient was typed and crossed.
Patient went to the operating room on [**2126-2-22**] and transplant
was performed by Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) 2523**] with no
complications. Patient went to the Intensive Care Unit still
intubated, sedated. On [**2126-2-22**] patient had a transplant
Doppler ultrasound postoperatively and report demonstrated
liver texture appears normal. No focal hepatic or
perihepatic masses seen. Portal vein appears normal and
patent. Inferior vena cava is patent as well as the main
hepatic vein and conclusion was normal liver, normal
vasculature. Patient had a chest x-ray on [**2126-2-23**] for
placement of right internal jugular and that demonstrated
that the right internal jugular was in the superior vena cava
and no pneumothorax. Density at the right base may represent
some pleural fluid. Left upper lung opacity consistent with
prior tuberculosis. Patient was doing well on postoperative
day two. Doing well. Pain well controlled. No nausea or
vomiting. Tolerating clears. Patient was still continuing
Solu-Medrol taper, cyclosporin and MMF. Patient was out of
bed on [**2126-2-24**] and transferred here to the floor. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] medial on [**2126-2-24**], put out 65, lateral 70 and T
tube 393. Physical therapy was consulted. Patient was out
of bed. Tacrolimus levels were closely monitored. On [**2126-2-26**]
T tube cholangiogram was performed demonstrating that there
is rapid inflow drainage into the small bowel, some reflux
into the hepatic ducts. A second canalicular structure next
to the distal bile duct must likely represent the remnant of
the cystic duct. On [**2126-2-27**] the patient T tube was capped.
Patient was placed on cyclosporin drip to increase the
cyclosporin level. His platelets were decreased slightly to
99. He continued to do well, urinating and ambulating
without difficulty. On [**2126-3-1**] he was continued on Bactrim,
fluconazole and ganciclovir. His propranolol was held which
is a medication that he takes at home because his heart rate
was in the low 50s. Electrocardiogram was performed
demonstrating no ST changes.
Patient is possibly going home on [**2126-3-2**] if patient does well
overnight. Patient should call Transplant Service
immediately at [**Telephone/Fax (1) 56342**] if any fevers, chills, nausea,
vomiting, inability to take medications, jaundice or
lethargy. Patient should have his dry sterile gauze to
capped T tube every day, observe the site for redness,
drainage or pus. [**Hospital3 **] [**Hospital6 407**] to
follow the patient. Glucose monitoring and logs every Monday
and Thursday with results faxed to Transplant Office at [**Telephone/Fax (1) 21087**]. He has an appointment with Dr. [**Last Name (STitle) **] on [**2126-3-6**] at
11:40 and also an appointment on [**2126-3-13**] at 10:30 A.M.,
[**2126-3-20**] at 10:40 and again patient should get laboratory work
every Monday and Thursday which includes the CBC, chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
cyclosporin level.
Patient is being discharged on the following medications:
Fluconazole 400 q 24 hours, aspirin 81 mg q day, cyclosporin
300 and 300 q 12 and it will be adjusted per transplant
coordinators if needed, ferrous sulfate 325 mg q day.
Patient is going to go home on Ganciclovir 400 q 24 hours,
heparin 5,000 units subcutaneously t.i.d. Patient is going
to home on MMF 1,000 B.I.D., Percocet 1 to 2 P.O. q 4 hours
PRN, Protonix 40 q 24, guaifenesin 20 mg q day and Bactrim
SSI 1 tablet P.O. q day.
Patient should follow up with his cardiologist because
medications have been held due to a low heart rate.
Otherwise patient will be discharged to home with [**Hospital6 3429**].
FINAL DIAGNOSIS: Alcohol related cirrhosis with
hepatocellular carcinoma.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2126-3-1**] 17:53:01
T: [**2126-3-1**] 18:54:19
Job#: [**Job Number 56343**]
|
[
"V45.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"50.59"
] |
icd9pcs
|
[
[
[]
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] |
1089, 1283
|
2775, 6806
|
6824, 7147
|
1002, 1062
|
1610, 2757
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1463, 1587
|
263, 721
|
174, 234
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744, 978
|
1300, 1443
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,301
| 198,545
|
37478
|
Discharge summary
|
report
|
Admission Date: [**2188-2-25**] Discharge Date: [**2188-3-11**]
Date of Birth: [**2149-10-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2188-3-4**] Tracheostomy and gastrostomy tube placement
History of Present Illness:
40yo female driver s/p motor vehicle crash with front end. Per
EMS, she was unresponsive at scene with snoring respirations and
not following commands. Intubated in ED.
.
Family History:
Noncontributory
Physical Exam:
Upon admission:
O: T:96.1 BP: 139/61 HR:82 R 20 O2Sats 100
Intubated,sedated, in hard collar
does not open eyes , Pupils 3->2, moves all 4 spontaneous and
purposeful
Head CT:no hemorrhage or fx seen but poor quality scan, needs
repeat
Labs:
NA 141
WBC RBC Hgb Hct Plt Ct
[**2188-2-25**] 6.5 4.44 12.6 38.6 313
UreaN Creat
[**2188-2-25**] 09:45AM 8 0.6
Pertinent Results:
Micro/Imaging:
[**2188-3-5**] CXR Worsening RLL consolidation, left stable
[**2188-3-4**] CXR Improvement in consolidation
[**2188-3-3**] CXR Worsening LLL consolidation
[**2188-3-2**] CXR Retrocard consolidation
[**2188-3-1**] CXR Stable from previous
[**2188-2-29**] BCx P
[**2188-2-29**] UCx Coag + staph - [**Last Name (un) **] to Levoflox
[**2188-2-29**] CXR LLL Consolidation
[**2188-2-29**] BAL Coag + Staph - [**Last Name (un) **] pending
[**2188-2-28**] Sputum cx P (stain: 3+ GPC pairs & clusters, 2+ GNRs)
[**2188-2-27**] MR [**First Name (Titles) **] [**Last Name (Titles) **] sig intensity in splenium c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Last Name (NamePattern4) **] sig
in hippo c/w hypoxia
[**2188-2-26**] CXR L basilar atalect. NGT, ETT ok
[**2188-2-26**] CT head No interval change from prior
[**2188-2-25**] CXR no acute process
[**2188-2-25**] CT Head CT no bleed, succal effacement
[**2188-2-25**] CT-torso distended stomach, Bibasilar pulmonary
opacities atelectasis
[**2188-2-25**] CT-Spine No acute intracranial hemorrhage. No fracture
[**2188-2-25**] CT Head (Rpt) - Stable from previous. No hemorrhage
[**2188-2-25**] 03:48PM TYPE-ART PO2-239* PCO2-40 PH-7.43 TOTAL
CO2-27 BASE XS-2
[**2188-2-25**] 02:13PM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-1.8
[**2188-2-25**] 02:13PM PT-12.4 PTT-22.9 INR(PT)-1.0
[**2188-2-25**] 09:45AM LIPASE-85*
[**2188-2-25**] 09:45AM WBC-6.5 RBC-4.44 HGB-12.6 HCT-38.6 MCV-87
MCH-28.5 MCHC-32.7 RDW-13.0
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
consulted given her low GCS at scene of crash. She underwent
serial head CT scans which did not reveal any intracranial
hemorrhage. MR imaging did reveal evidence of diffuse axonal
injury. No further recommendations from Neurosurgery was
offered.
She remained in the ICU vented and minimally responsive despite
sedation being discontinued. The decision was made for
tracheostomy and PEG placement after discussion with her family.
She was eventually weaned off of the ventilator. Over the course
of a couple of days following this she was noted to be
responsive to simple commands. At this point she was tolerating
her tube feeds at goal. She was transferred to the regular
nursing unit where she continued to slowly show signs of
increased responsiveness.
She was treated with a seven day course of Levaquin for a
pneumonia; course completed on [**3-9**].
She was evaluated by Physical and Occupational therapy and is
being recommended for acute head injury rehab. She is being
discharged today to rehab in stable condition.
Medications on Admission:
Unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Dose
Injection four times a day as needed for per sliding scale: see
attached sliding scale.
3. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ML's PO
Q6H (every 6 hours) as needed for fever or pain.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
8. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Traumatic Brain Injury - Diffuse Axonal Injury
Respiratory failure
Pneumonia
Discharge Condition:
Activity Status:Out of Bed with assistance to chair or
wheelchair
Mental Status/Level of Consciousness:Lethargic; intermittently
arousable.
Discharge Instructions:
*
Followup Instructions:
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for
evaluation of possible removal of tracheostomy. Call
[**Telephone/Fax (1) 600**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"518.5",
"599.0",
"482.41",
"E812.1",
"041.11",
"854.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.21",
"96.72",
"96.04",
"43.11",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
4620, 4690
|
2618, 3706
|
339, 399
|
4834, 4975
|
1094, 2595
|
5025, 5333
|
616, 633
|
3764, 4597
|
4711, 4813
|
3732, 3741
|
4999, 5002
|
648, 650
|
276, 301
|
427, 600
|
839, 1075
|
664, 831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,593
| 131,842
|
23327
|
Discharge summary
|
report
|
Admission Date: [**2139-1-16**] Discharge Date: [**2139-1-20**]
Date of Birth: [**2074-9-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
The pt. is a 64 year-old male with a history of CAD who
presented to the ED with shortness of breath. Per EMS notes,
the pt. called EMS complaining of labored breathing. During
transport, the pt. had an episode of unresponsiveness. On
arrival to the ED, the pt. had another episode of aspiration
this time with emesis and witnessed aspiration. Shortly
thereafter, he was intubated for airway protection and sedated
with propofol. The pt. was given ceftriaxone, flagyl, and 40mg
of IV lasix in the ED. He was also started on IV solumedrol.
Per notes, the pt. did complain of a one day history of fever
and cough prior to becoming unresponsive.
Past Medical History:
-CAD, S/P LAD stent, had MI in [**2131**]
-CHF, EF unknown
Social History:
Unknown; pt. had parole papers on his person.
Family History:
Unknown.
Physical Exam:
T: 99.4F P: 85 R: 22 BP: 107/47 SaO2: 96% on 60% FIO2
Vent: Mode: AC Vt: 500 RR: 10 PEEP: 5 FiO2: 0.6
General: Intubated and sedated
HEENT: Pupils 1mm and sluggishly reactive to light, MMM, ETT in
place
Neck: supple, no JVD appreciated
Pulmonary: faint inspiratory crackles throughout anteriorly and
laterally
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: obese, soft, NT/ND, active bowel sounds, no masses or
HSM
Extremities: trace bilateral pitting edema of BLE, no c/c
bilaterally, 2+ DP pulses bilaterally
Neurologic: sedated, EOMI to doll's eye maneuver, +corneal on
right, absent on left; +gag reflex; withdraws all extremities to
pain; reflexes 1+ throughout. Plantar response mute bilaterally.
Pertinent Results:
EKG: Sinus tachycardia at 100bpm, nl. intervals and axis, no
evidence of hypertrophy. Q waves in II, III, aVF, V2-V6.
.
CXR: Patchy bibasilar opacities L>R with associated pleural
effusions. Could represent early pneumonia or aspiration.
.
TTE: 1. The left atrium is mildly dilated. 2. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed. Resting regional wall motion abnormalities include
mid and apical
septal and anterior along with apical akinesis. 3. Right
ventricular chamber size is normal. Right ventricular systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5.The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-31**]+)
mitral regurgitation is seen. 6.There is no pericardial
effusion.
.
[**2139-1-16**] 12:35AM BLOOD WBC-14.6* RBC-5.28 Hgb-14.9 Hct-46.8
MCV-89 MCH-28.2 MCHC-31.9 RDW-15.0 Plt Ct-348
[**2139-1-20**] 07:00AM BLOOD WBC-7.7 RBC-4.23* Hgb-12.2* Hct-36.3*
MCV-86 MCH-28.8 MCHC-33.6 RDW-15.5 Plt Ct-194
[**2139-1-16**] 12:35AM BLOOD PT-13.7* PTT-24.1 INR(PT)-1.2
[**2139-1-16**] 12:35AM BLOOD Glucose-89 UreaN-22* Creat-1.2 Na-142
K-4.0 Cl-101 HCO3-30* AnGap-15
[**2139-1-20**] 07:00AM BLOOD Glucose-80 UreaN-22* Creat-0.9 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2139-1-16**] 04:44AM BLOOD ALT-25 AST-23 CK(CPK)-134 AlkPhos-73
Amylase-78 TotBili-0.5
[**2139-1-16**] 12:35AM BLOOD cTropnT-<0.01
[**2139-1-16**] 04:44AM BLOOD CK-MB-3 cTropnT-0.02*
[**2139-1-16**] 12:10PM BLOOD CK-MB-3 cTropnT-<0.01
[**2139-1-16**] 06:23PM BLOOD CK-MB-4 cTropnT-<0.01
[**2139-1-17**] 06:33AM BLOOD CK-MB-4 cTropnT-<0.01
[**2139-1-18**] 08:05AM BLOOD CK-MB-5 cTropnT-<0.01
[**2139-1-19**] 06:00AM BLOOD CK-MB-3 cTropnT-0.03*
[**2139-1-16**] 04:44AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.3 Mg-1.8
[**2139-1-20**] 07:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
[**2139-1-18**] 08:05AM BLOOD Triglyc-103 HDL-38 CHOL/HD-2.6 LDLcalc-41
[**2139-1-16**] 12:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-1-16**] 02:51AM BLOOD Type-ART pO2-203* pCO2-57* pH-7.32*
calHCO3-31* Base XS-1
[**2139-1-16**] 05:58AM BLOOD Type-ART Rates-[**11-4**] Tidal V-500 FiO2-60
pO2-91 pCO2-42 pH-7.36 calHCO3-25 Base XS--1
[**2139-1-16**] 08:14AM BLOOD Type-ART pO2-96 pCO2-40 pH-7.39
calHCO3-25 Base XS-0
[**2139-1-16**] 03:38PM BLOOD Type-ART pO2-74* pCO2-40 pH-7.40
calHCO3-26 Base XS-0 Intubat-INTUBATED
[**2139-1-16**] 08:14AM BLOOD Lactate-1.3
[**2139-1-16**] 02:51AM BLOOD O2 Sat-98 COHgb-1 MetHgb-0
[**2139-1-16**] 08:14AM BLOOD freeCa-1.11*
Brief Hospital Course:
ASSESSMENT AND PLAN: 64 M with history of CAD, CHF presented
with respiratory distress/failure complicated by an aspiration
event and loss of consciousness. During hospitalization the
following problems were addressed:
1. Respiratory failure: Patient presented with hypercarbic
respiratory failure. Etiology likely multifactorial and due to
aspiration pneumonitis and possible obstructive lung disease
and/or community-acquired pneumonia. The patient was intially
intubated, then extubated on day two. He was continued on
levofloxacin and flagyl for a possible aspiration pneumonia.
Although no distinct infiltrate was seen on CXR, we could not
rule out a retrocardiac infiltrate. He was also started on
albuterol and atrovent MDI for a possible COPD component. He
would likely benefit from PFTs as an outpatient evaluation.
Sputum culture and gram stain pending.
3. Loss of consciousness: Possible hypoxic insult secondary to
aspiration vs hypercapneic from respiratory acidosis. Tox screen
was positive for opiates only after patient received them in ED.
Per outside reports, patient has routine parole drug screenings
and has been negative. Once sedation was weaned, his mental
status returned to baseline.
4. CHF: Pt. with known h/o of CAD and ischemic cardiomyopathy.
He was ruled out for acute MI although ECG shows Q-waves,
presumed old, and nonspecific T-wave changes in inferolateral
leads. Echo showed moderately depressed LV function and apical
and septal wall motion abnormalities. He was started on
aspirin, lipitor, metoprolol and lisinopril for secondary
prophylaxis. Monitor for tolerance to metoprolol given presumed
COPD.
The patient tolerated a po diet. PPx by SQ heparin and
pneumoboots. He is a full code. Unclear if he has a PCP, [**Name10 (NameIs) **]
should likey be referred for PFTs and stress test on discharge.
He is a full code. His sister is involved in his care and was
the source of information while he was sedated, no designated
HCP.
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): as directed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 90* Refills:*1*
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
10. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
Disp:*1 103* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
LOC
RESPIRATORY FAILURE
CHF
PNA
SECONDARY:
CAD
DM
Discharge Condition:
stable, ambulating off oxygen without difficulty
Discharge Instructions:
1) Seek immediate medical attention if experiencing fever,
chills, chest pain, shortness of breath, palpitations, abdominal
pain, nausea, vomiting, diarrhea.
2) Take all medications as prescribed
3) Follow-up on all appointments
Followup Instructions:
-Please call for a follow-up appointment w/ Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 250**] at [**Hospital6 733**].
- Recommend outpatient pulmonary follow-up for Pulmonary
Function Test to further evaluate for evidence of emphysema
- Recommend outpatient Exercise Tolerance Test (Stress test)
-You need a follow-up Chest X-ray in 6 weeks to ensure your
pneumonia has resolved. We must ensure complete resolution of
the infiltrate seen on the x-ray here to make sure there is no
evidence of a cancer underneath the infection. This is routine
practice for patients over age 50 with a pneumonia.
|
[
"491.21",
"V45.82",
"428.0",
"486",
"518.81",
"787.91",
"250.00",
"507.0",
"780.09",
"414.8",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7761, 7767
|
4645, 6633
|
334, 346
|
7870, 7920
|
1939, 4622
|
8197, 8879
|
1186, 1196
|
6656, 7738
|
7788, 7849
|
7944, 8174
|
1211, 1920
|
275, 296
|
374, 1024
|
1046, 1107
|
1123, 1170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,419
| 115,187
|
38200+58197
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-2-7**] Discharge Date: [**2199-2-25**]
Date of Birth: [**2116-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2199-2-8**] Aortic Valve Replacement(21mm Pericardial), Two Vessel
Coronary Artery Bypass Grafting(left internal mammary to left
anterior descending artery, vein graft to ramus), and Aortic
Endarterectomy.
History of Present Illness:
Mr. [**Known lastname 61512**] is a 82 year old gentleman with symptomatic
coronary artery disease and aortic stenosis. In [**2198-7-3**],
Dr. [**Last Name (STitle) **] deemed him to be too high risk for surgery due to
extensive aortic calcification. He subequently underwent aortic
valvuloplasty in [**2198-10-3**]. Due to recurrent symptoms, he
underwent repeat cardiac cathterization in [**2199-1-2**] which
revealed left main disease with an instent restenosis of ramus.
Given his severe aortic stenosis and left main lesion, he was
deemed too high risk for percutaneous intervention. He was
subquently referred to Dr. [**First Name (STitle) **] for off pump CABG, with the
possibility of aortic valve replacement. After extensive
discussion with the patient and his family, he agreed to proceed
with high risk surgery.
Past Medical History:
Severe Aortic Stenosis, s/p aortic valvuloplasty [**2198-10-3**]
Coronary Artery Disease, s/p BMS to Ramus in [**2196**]
History of TIA [**2196**]
ESRD requiring hemodialysis
Pulmonary Hypertension
Chronic Diastolic Congestive Heart Failure
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Anemia
History of Bladder Calculi
Renal Osteodystrophy
Social History:
Lives with: wife
Occupation: retired
Tobacco: denies
ETOH: social
Family History:
No family history of early MI or sudden cardiac death
Physical Exam:
Admission Physical Exam:
Pulse: 85 Resp: 18 O2 sat: 100%RA
B/P Right: Left: 144/76
Height: 5'5" Weight: 64kg
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact [X]
Left Upper Arm Fistula
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-
Pertinent Results:
Admits Labs:
[**2199-2-7**] WBC-7.2 RBC-4.52* Hgb-10.5* Hct-32.0* Plt Ct-117*
[**2199-2-7**] PT-12.7 PTT-25.3 INR(PT)-1.1
[**2199-2-7**] Glucose-187* UreaN-33* Creat-4.8*# Na-136 K-4.0 Cl-91*
HCO3-33*
[**2199-2-7**] ALT-22 AST-21 LD(LDH)-252* AlkPhos-57 Amylase-118*
TotBili-0.6
[**2199-2-7**] Lipase-53
[**2199-2-8**] Albumin-2.5*
[**2199-2-7**] %HbA1c-6.5*
.
[**2199-2-8**] Intraop TEE:
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic root and
ascending aorta have focal calcifications. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen. A guidewire is seen in the descending aorta
during femoral cannulation.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. There is
significant mitral annular calcification. There is prolapse of
the anterior mitral leaflet with a posteriorly directly MR jet
with coanda effect. At least moderate (2+) mitral regurgitation
is seen.
POST-CPB:
A bioprosthetic valve is present in the aortic position. The
leaflets appear to move normally. The peak gradient across the
aortic valve is 29mmHg, the mean gradient is 12mmHg. There is a
small paravalvular leak which improved with protamine
administration.
LV systolic function appeared severely depressed immediately
after separation from bypass and slowly improved with
administration of inotropes. Estimated EF after chest closure is
30-35%.
The MR remains an eccentric jet with coanda effect. There is
moderate to severe MR. There is no evidence of aortic
dissection.
.
[**2199-2-15**] Postop Portable TTE:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. A bioprosthetic aortic valve prosthesis
is present. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
.
Brief Hospital Course:
Mr. [**Known lastname 61512**] was admitted and underwent routine preadmission
testing and hemodialysis. On [**2199-2-8**] he was taken to the
operating room and underwent Aortic Valve Replacement(21mm
Pericardial)/Two Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending artery, vein graft
to ramus), and Aortic Endarterectomy. Cardiopulmonary Bypass
time= 245 minutes. Cross Clamp time=180 minutes. Please see
operative note for surgical details. He tolerated the procedure
well and was transferred to the CVICU intubated and sedated on
multiple pressors and inotropy to optimize cardiac function.
Renal continued to follow postoperatively for his ESRD/dialysis
needs. Mr.[**Known lastname 61512**] was kept intubated to protect his airway
while maintaining stable hemodynamics until POD# 5. Pressors and
inotropy were weaned off. Beta-blockers/Statin/Aspirin and
diuresis was initiated. Postoperative atrial fibrillation was
treated with Amiodarone and beta-blocker. Prolonged conversion
pauses and tachy-brady syndrome became apparant.
Electrophysiology was consulted and a temporary transvenous wire
was placed. Beta-blockade and Amio were held to allow for
recovery. Per EP these agents were slowly reintroduced and
tolerated. Transvenous pacing wire was discontinued on [**2-19**].
Ultimately a permanent pacemaker was deemed unnecessary.
Anticoagulation was initiated with Coumadin secondary to
paroxysmal atrial fibrillation. Supratherapeutic INR was treated
with holding anticoagulation, reversal with vitamin K and fresh
frozen plasma, and gentle dosing with Coumadin was resumed. All
lines and drains were discontinued in a timely fashion.
Antibiotics for Clostridium Difficile was initiated. A Midline
was placed for access. Speech and swallow was consulted for
swallowing evaluation. POD# 11 he was transferred to the step
down unit for further monitoring. Physical Therapy was consulted
for evaluation of strength and mobility. Hemodialysis was
conducted per Renal. He continued to progress and on POD# 17 he
was cleared for discharge to [**Hospital **] [**Hospital **] Rehabilitation at [**Doctor Last Name 1263**]
for further progress in strength, mobility, and daily
activities. Dr.[**Last Name (STitle) 85178**] to follow Coumadin dosing/INR once Mr
[**Known lastname 61512**] has been discharged from rehab. All follow up
appointments were advised.Target INR 2.0-2.5 for A Fib.
Medications on Admission:
RENAL CAPS - 1 mg Capsule - 1 Capsule(s) by mouth every morning
LABETALOL - 200 mg Tablet - 1 Tablet(s) by mouth every evening
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at night
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 Tablet(s) by mouth every
morning (held on dialysis days)
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every
morning
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Coumadin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5
Tablets PO once a day: dose today 1 mg only;all further dosing
per rehab provider;Goal INR is 2.0-2.5 for atrial fibrillation.
10. Insulin sliding Scale and Daily Dose
Please see attached sliding scale and daily insulin dose.
11. telemetry
please keep on telemetry
12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 8 days: dosing through [**3-5**]; for a 2 week course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] @ [**Hospital **] HOSPITAL
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR and CABG
Heavily Calcified Aorta
End Stage Renal Disease, requires Hemodialysis
Pulmonary Hypertension
Chronic Diastolic Congestive Heart Failure
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Anemia
Postop Sick Sinus Syndrome
postop C. difficile
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 1+ 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 resume hemodialysis on Tuesday/Thursday/Saturday
Schedule.
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**
**VNA to draw daily INR and call/fax results to [**Hospital 197**] Clinic
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-3-18**]
1:00
Cardiologist: Dr. [**Last Name (STitle) 85179**] # [**Telephone/Fax (1) 7164**], appointment arranged
for [**2199-3-5**] at 9am.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 36361**] in [**5-7**] weeks
Dr.[**Last Name (STitle) 85179**] to follow INR/Coumadin dosing via [**Hospital 197**] Clinic
**once discharged from rehab.
[**Hospital 197**] Clinic # [**Telephone/Fax (1) 85180**]
daily labs: PT/INR for Coumadin ?????? indication: Paroxysmal Atrial
Fibrillation
Goal INR 2-2.5
Please Fax- [**Telephone/Fax (1) 7165**] Coumadin doses/INR levels to the
[**Hospital 197**] Clinic upon discharge
Results to phone fax [**Telephone/Fax (1) 7165**]
**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:[**2199-2-25**] Name: [**Known lastname 13510**],[**Known firstname 422**] D Unit No: [**Numeric Identifier 13511**]
Admission Date: [**2199-2-7**] Discharge Date: [**2199-2-25**]
Date of Birth: [**2116-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
Patient extremely anxious re: discharge. BP180/80 --> 154/53
with Hydralazine 10 mg IV and Ativan 0.25 mg po x 1. Spoke with
PA Joannne at Rehab and discussed adding Hydralazine 10 mg po q
6 hrs PRN SBP>140.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] @ [**Hospital **] HOSPITAL
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2199-2-25**]
|
[
"E878.2",
"287.5",
"276.3",
"440.0",
"785.51",
"428.0",
"585.6",
"008.45",
"427.31",
"427.81",
"416.8",
"V10.83",
"428.32",
"V45.82",
"V45.11",
"997.1",
"414.01",
"403.91",
"250.00",
"588.0",
"285.21",
"426.0",
"272.4",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"38.14",
"00.40",
"36.11",
"96.72",
"39.95",
"37.78",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
12938, 13128
|
5583, 8024
|
327, 539
|
9985, 10216
|
2670, 5560
|
11200, 12915
|
1865, 1920
|
8428, 9545
|
9659, 9964
|
8050, 8405
|
10240, 11177
|
1961, 2651
|
268, 289
|
567, 1394
|
1416, 1766
|
1782, 1849
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,582
| 124,476
|
53806
|
Discharge summary
|
report
|
Admission Date: [**2185-5-13**] Discharge Date: [**2185-5-18**]
Date of Birth: [**2129-2-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / crabmeat only / Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2185-5-13**] - Coronary artery bypass grafting times 4; left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to the ramus intermedius, marginal branch,
and posterior descending.
History of Present Illness:
56 year old male with known CAD, cardiomyopathy with EF 30%
status post [**Company 1543**] ICD implantation. His most recent coronary
angiography [**2184-6-1**] revealed an occluded D1 and RCA with
extensive collaterals and normal renal arteries. Recent device
interrogation on [**2185-4-18**] by Dr [**Last Name (STitle) 11250**] revealed an episode
of nonsustained ventricular tachycardia on [**2185-2-28**] at a
rate of 214 which was self-terminating. He reports vague
episodes of left chest discomfort radiating down left arm at
rest starting about one week ago. One recent episode of
lightheadedness with postural change. He was referred for
coronary angiography. He was found to have three vessel disease
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Hypertension
Cardiomyopathy, EF 30%
ICD placed
Non-sustained ventricular tachycardia
Syncope, [**1-/2184**]
Congestive heart failure
Hyperlipidemia
Diabetes mellitus type 2
Asthma
Sleep apnea, no CPAP machine, uses oxygen concentrator
GERD
Degenerative joint disease
History of episode of 1 week of vomiting blood, 2 years ago
Anxiety, s/p trauma hit by car as child
Depression
s/p right knee replacement, [**11/2184**]
s/p umbilical hernia repair, [**2185-3-8**]
s/p colonoscopy with polyps removed
s/p Tonsillectomy
Social History:
Race:Caucasian
Last Dental Exam:2 years ago
Lives with:Lives alone. Disabled
Contact:[**Name (NI) **] [**Name (NI) **] (friend) Phone# [**Telephone/Fax (1) 110414**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:remote rare cigars
ETOH: < 1 drink/week [x] [**3-8**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- non contributory
Physical Exam:
Pulse:73 Resp:18 O2 sat:97/RA
B/P Right:145/80 Left:154/81
Height:5'[**83**]" Weight:241 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] Recent
umbilical hernia incision with appropriate mild tenderness
Extremities: Warm [x], well-perfused [x] Edema [x] with right
ankle swelling from recent trauma
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: dop Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
Note Date: [**2185-5-13**]
Signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD on [**2185-5-13**] at 10:30 am Affiliation:
[**Hospital1 18**]
Cosigned by [**Name (NI) **] [**Last Name (NamePattern4) 11899**], MD on [**2185-5-13**] at 12:33 pm
ICD INTERROGATION FORM
Reason for interrogation: Therapy Deactivation prior to CABG in
patient with single lead ICD placed for primary prevention
Device Brand: [**Company 1543**]
Model: Protecta XT VR D314VRG
Presenting rhythm: Sinus rhythm at 72 bpm
Intrinsic Rhythm: Sinus rhythm at 72 bpm
Programmed Mode: VVI with lower rate at 40bpm
FVT/VT detection/therapties off
VF therapy ATP before charging, 25J, 35J x 5
Battery Voltage: 3.18V
RV lead
Intrinsic amplitude: 14.5 mV
Pacing impedance:
Pacing threshold: 2.25V @ 0.40ms
%pacing: <0.1%
Diagnostic information: arrhythmias, morphologies, rates, Rx:
-- possible optivol fluid accumulation
-- no fast atrial or ventricualr rates
-- no therapies deliviered
Programming changes (details):
VR Detection and therapies turned off
Summary (normal / abnormal device function):
-- Normal Device function
-- No arrythmias recorded
-- VT/VF therapies turned off for surgery, please call following
completion of surgery for repeat interrogation and re-activation
of VF therapy
Addendum by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD on [**2185-5-13**] at 12:33 pm:
I personally reviewed the ICD interrogation on this patient, and
agree with Dr.[**Name (NI) 110415**] findings.
Brief Hospital Course:
Mr. [**Known lastname 110416**] was a same day admit and on [**2185-5-13**] he was brought
directly to the operating room where he underwent a coronary
artery bypass graft x 4. Please see operative note 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 he was started on beta-blockers and diuretics
and gently diuresed towards his pre-op weight. Later on this day
he was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Oxygen
therapy was continued given his preoperative home oxygen use. He
required aggressive diuresis and the plan was to discharge him
to rehab with 1 week of lasix at 120mg daily and then decrease
dose to his preoperative dose of 80mg daily. A low dose ace
inhibitor was resumed given his ejection fraction of 30%. His
renal function will be monitored closely at rehabilitation as
his creatinine was mildly elevated postoperatively at 1.2.
Potassium levels will also be followed and repeleted as needed.
He had a burst of atrial fibrillation which converted to normal
sinus rhythm with amiodarone. He will be discharged on an
amiodarone taper of 400mg daily for 1 week and then decrease the
dose to 200mg daily on [**2185-5-24**] until otherwise instructed by his
cardiologist. He continued to make steady progress and was
discharged to [**Hospital 11252**] [**Hospital 18979**] health care on postoperative day
4. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
ALPRAZOLAM 0.5 mg HS
AMLODIPINE 10 mg Daily
ATENOLOL 150 mg Daily
ATORVASTATIN 40 mg Daily
BENAZEPRIL 40 mg [**Hospital1 **]
DIAZEPAM 5 mg HS
FEXOFENADINE-PSEUDOEPHEDRINE 180 mg/240 mg- 1 Tablet HS
FUROSEMIDE 80 mg Daily
GLIPIZIDE 10 mg [**Hospital1 **]
LOSARTAN 25 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
OXYGEN CONCENTRATOR 3 L at night time
RANITIDINE HCL 150 mg Daily
SITAGLIPTIN [JANUVIA] 100 mg Daily
ASCORBIC ACID 1,000 mg Daily
ASPIRIN 325 mg Daily
BILBERRY- Dosage uncertain
VITAMIN D3 1,000 unit [**Hospital1 **]
CHROMIUM PICOLINATE - Dosage uncertain
IBUPROFEN 200 mg HS
L.ACIDOPH & SALI-B.BIF-S.THERM [ACIDOPHILUS] - Dosage uncertain
MULTIVITAMIN Daily
OMEGA 3-DHA-EPA-FISH OIL Daily
VITAMIN E 400 unit Daily
Discharge Medications:
1. Lasix 40 mg Tablet Sig: Three (3) Tablet PO once a day for 7
days: Then decrease to 80mg daily as per his preop dose.
2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. amiodarone 200 mg Tablet Sig: 400mg daily for 1 week then on
[**2185-5-24**], decrease dose to 200mg daily thereafter. Tablets PO
once a day for as instructed months: 400mg daily for 1 week then
on [**2185-5-24**], decrease dose to 200mg daily thereafter.
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
13. Insulin Sliding Scale
Please see attached insulin sliding scale. FIngersticks QAC and
HS
14. atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Multi-Vitamin HP/Minerals Capsule Sig: One (1) Capsule
PO once a day.
16. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate up as renal function and blood pressure allow.
17. Sleep Apnea
Oxygen Concentrator for sleep as per preop
Discharge Disposition:
Extended Care
Facility:
[**Hospital 18979**] [**Hospital **] [**Hospital 11252**] Rehabilitation Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Hypertension
Cardiomyopathy, EF 30%
ICD placed
Non-sustained ventricular tachycardia
Syncope, [**1-/2184**]
Congestive heart failure
Hyperlipidemia
Diabetes mellitus type 2
Asthma
Sleep apnea, no CPAP machine, uses oxygen concentrator
GERD
Degenerative joint disease
History of episode of 1 week of vomiting blood, 2 years ago
Anxiety, s/p trauma hit by car as child
Depression
s/p right knee replacement, [**11/2184**]
s/p umbilical hernia repair, [**2185-3-8**]
s/p colonoscopy with polyps removed
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
2+ Lower extremity edema
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) 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
5) No lifting more than 10 pounds for 10 weeks
6) Take lasix 120mg once daily in the morning for 7 days with
20mEq of potassium and then reduce dose to 80mg daily (preop
dose)thereafter until otherwise instructed by cardiologist.
Current weight is 118.4kg, preop weight 109kg.
7) Amiodarone 400mg daily for 1 week, then decrease to 200mg
daily on [**2185-5-24**].
8) Please monitor renal function (BUN/CREAT) and potassium.
Repelete as needed.
9) 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) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2185-6-22**] 1:00
Cardiologist: Dr. [**First Name4 (NamePattern1) 11249**] [**Last Name (NamePattern1) 11250**] [**2185-6-7**] at 9:00am
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2185-5-24**] 10:45
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Name (STitle) 110417**] in [**5-5**] weeks [**Telephone/Fax (1) 77350**]
**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:[**2185-5-18**]
|
[
"285.1",
"327.23",
"250.00",
"V43.65",
"E878.2",
"493.90",
"414.01",
"272.4",
"V53.32",
"427.31",
"401.9",
"414.8",
"411.1",
"458.29",
"428.0",
"530.81",
"428.43",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
9002, 9108
|
4706, 6512
|
319, 542
|
9752, 9976
|
3133, 4683
|
11229, 11945
|
2273, 2326
|
7288, 8979
|
9129, 9190
|
6538, 7265
|
10000, 11206
|
2341, 3114
|
263, 281
|
570, 1350
|
9212, 9731
|
1907, 2257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,208
| 127,775
|
30594
|
Discharge summary
|
report
|
Admission Date: [**2164-10-13**] Discharge Date: [**2164-10-27**]
Date of Birth: [**2109-2-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Femur fracture, respiratory failure
Major Surgical or Invasive Procedure:
Operative fixation of right distal femur
History of Present Illness:
History of Present Illness:
Ms. [**Known lastname **] is a 55yo F w/hx of MS, severe COPD presented as a
transfer from [**Hospital3 **] for R femur fracture after walking
down the stairs in her house. In the [**Hospital1 18**] ED, she was felt to
be in respiratory distress and was admitted to the ICU for
further monitoring.
.
The patient states that she was walking down her stairs on the
day PTA [**2164-10-12**] when she felt a snapping sensation. She had no
pain and was able walk down the stairs and to her chair. She
fell asleep and arose the next morning unable to stand. She
went to the [**Hospital3 **] ED where she was found to have a R
hairline femur fracture with lipohemarthrosis. She was then
transferred to the [**Hospital1 18**] ED for further management.
.
In the ED, initial vs were: T 98.3 P 81 BP 154/74 R 18 O2 sat
94% on 2L. Patient was given duonebs X 3, dilaudid 1mg IV X 1.
A CXR showed severe emphysema without acute process. She was
evaluated by orthopedics who put her R leg in a knee
immobilizer.
.
Upon arrival to ICU, the patient was in moderate respiratory
distress and using accessory muscles to breath. O2 sats
initially 80% on 2L while transporting her to the bed and with
talking. O2 sats improved over next 30 minutes to 88-90% on 3L
after not talking.
Past Medical History:
-MS, relapsing and remitting, pt states no current symptoms
-Hypertension
-COPD on 3L home O2
-Anorexia of unclear etiology
-Cardiomyopathy in [**2161**] (unclear etiology, EF recovered on echo
[**2162**])
Social History:
Lives with brother who helps to take care of her. Smoked 2ppd X
30 years, currently smokes [**2-17**] cigarrettes per day. Past EtoH
use, none recent.
Family History:
Mother and father with heart disease.
Physical Exam:
Vitals: T: 95.7 BP: 143/89 P: 90 R: 18 O2: 88-93% on 3L
General: Alert, oriented, comfortable, cachectic appearing woman
HEENT: Sclera anicteric, MM slightly dry, OP clear
Neck: JVP not elevated, no LAD
Lungs: poor air movement, difficult to exam due to lack of
subcutaneous tissue, no obvious wheezes, no rales, prolonged
expiratory phase
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, kyphoid abdomen, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. RLE in knee immobilizer. No obvious deformities.
Pertinent Results:
Labs on admission:
[**2164-10-13**] 06:02PM TYPE-ART O2 FLOW-2.5 PO2-60* PCO2-82* PH-7.42
TOTAL CO2-55* BASE XS-23 INTUBATED-NOT INTUBA VENT-SPONTANEOU
COMMENTS-NASAL [**Last Name (un) 154**]
[**2164-10-13**] 05:15PM GLUCOSE-126* UREA N-17 CREAT-0.7 SODIUM-145
POTASSIUM-2.9* CHLORIDE-87* TOTAL CO2-50* ANION GAP-11
[**2164-10-13**] 05:15PM estGFR-Using this
[**2164-10-13**] 05:15PM CARBAMZPN-2.2*
[**2164-10-13**] 05:15PM WBC-7.0 RBC-3.50* HGB-9.4*# HCT-30.6* MCV-87#
MCH-26.9*# MCHC-30.8* RDW-14.9
[**2164-10-13**] 05:15PM NEUTS-83.0* LYMPHS-11.8* MONOS-4.7 EOS-0.2
BASOS-0.3
[**2164-10-13**] 05:15PM PLT COUNT-145*
[**2164-10-13**] 05:15PM PT-13.3 PTT-23.6 INR(PT)-1.1
Micro:
[**2164-10-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2164-10-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2164-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2164-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2164-10-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2164-10-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2164-10-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2164-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2164-10-15**] URINE URINE CULTURE-FINAL INPATIENT
[**2164-10-14**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Imaging:
Femur XRAY ([**10-14**])
R femur fracture: Right femur fracture.
Proximally, a fixation plate and screw complex is noted
supporting the hip
and distally there is a minimally displaced oblique vertical
fracture at the lateral aspect of the distal metaphysis of the
femur. The distal fragment overall shows good apposition with
the proximal fragment and the distal fragment shows slight
deviation anterolaterally from its donor site. There is no
additional fracture site more proximally.
Echo ([**10-16**])
The left atrium is normal in size. There is probably mild left
ventricular hypertrophy (views are suboptimal). The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with probably normal free wall contractility. The aortic
root is mildly dilated at the sinus level. The aortic valve
leaflets are mildly thickened (probably trileaflet). There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is at least moderate to
severe pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
This is a 55 yo F w/hx of severe COPD who presents with R femur
fracture and difficulty breathing.
.
#. Respiratory Status: On admission, patient was comfortable on
3L NC which is home rate. Differential included COPD
exacerbation vs. worsening of respiratory status secondary to
pain and femur fracture. She does not signs of PNA or infection
on CXR and no other symptoms of fever or cough. Respiratory
status is most likely baseline. Unclear why she has such severe
lung disease given relatively [**Name2 (NI) 15403**] smoking history, but she
was only taking an albuterol inhaler at home. On [**10-14**], patient
developed increased work of breathing. ABG had increased PaCO2
to 100s, put on BiPAP, repeat ABG showed same PaCO2 100s, and pt
intubated. She was maintained on albuterol nebs, ipratropium
nebs, and budesonide nebs. After intubation pressures dropped
to 60/40's, started on pressors, which were soon after weaned.
Extubation was attempted on [**2164-10-20**], but patient failed and was
reintubated less than an hour later [**3-19**] hypoxia/increased work
of breathing. She became hypotensive again after reintubation
and was again started on 3 pressors, which were eventually
weaned. She was also started on steroids at that time (IV
methylpred eventually switched to PO prednisone-will require 2
wk taper). It was decided that she could not tolerate extubation
[**3-19**] poor respiratory reserve and she was taken for trach/PEG on
[**2164-10-25**]. It should also be noted that she completed a seven day
course for presumed ventilator associated pneumonia with
vanco/cefepime/ciprofloxacin.
.
#. Femur Fracture: Likely secondary to osteoporosis and possibly
from prior steroid use. Unclear why she is not on calcium and
vit D and/or bisphosphonate. She was started on these inhouse.
She was taken to the OR on [**2164-10-16**] for ORIF of right distal
femur. She was started on prophylactic lovenox 30mg [**Hospital1 **] on
POD#1. She will need her staples removed on [**10-30**] (2 weeks post
op).
.
#. Cardiac: On admission, ectopy on ECG-Likely secondary to low
electrolytes. Electrolytes were aggressively repleted. Concerned
that labile bp's could be [**3-19**] ischemia, got ekg which looked
same as priors (inflat q waves) and trop which were neg. Got
OSH records which showed that pt had recent NSTEMI in [**7-24**]
and also has cardiomyopathy c EF of 20%. Repeat Echo showed
EF>55%, mild LVH, normal LVEF, dilated RV, with moderate to
severe PA systolic HTN.
.
#. Anemia: Likely [**3-19**] iron deficiency. Hct at OSH was 37 in [**Month (only) **]
[**2164**]. Hct inhouse ranged 24-28. Vitamin B12 and folate were
normal. Iron supplementation was held on hospitalization because
of infection (VAP). She was also transfused multiple times to
keep HCT at goal in light of previous NSTEMI. Likely also some
component of bleeding after surgery.
.
# HTN: Blood pressures labile, coreg d/c'ed on this admission as
intermittently needed pressors as above and COPD not well
controlled. Lasix was used, as patient has been mostly positive
during her admission. Now that pressors weaned, BP's in 130's
systolic. Lisinopril was started at a dose of 2.5 daily.
.
#. Nutrition: Patient has history of anorexia. She was initially
started on remeron. Eventually after intubation she was
transitioned to tube feeds. She had PEG placement on [**2164-10-25**].
#. Trigeminal Neuralgia: continued carbamezepine, amitriptyline,
gabapentin
Medications on Admission:
Klor-Con 20 mEq Oral Packet Oral qday
Omeprazole 20 mg Cap 1 tab qday
Furosemide 20 mg Tab PO BID
Coreg 3.125mg PO BID
Mirtazapine 30 mg Tab PO qday
Simvastatin 40 mg Tab PO qday
Plavix 75 mg Tab PO qday for unclear etiology
Carbamazepine 200 mg Tab PO qday for trigeminal neuralgia
Neurontin 300 mg Cap PO TID for trigeminal neuralgia
Amitriptyline 50 mg Tab PO qday for trigeminal neuralgia
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Femur fracture
Respiratory failure, hypercarbic.
Pneumonia, ventillator associated
Secondary Diagnosis:
COPD
Anemia
Hypertension
Cardiomyopathy
Discharge Condition:
stable
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted to the [**Hospital1 18**] after you fell and fractured your
hip. You required intubation for respiratory failure and we
were unable to wean you off the ventillator due to you
underlying lung disease. You were also treated for a pneumonia
during this admission. You underwent a tracheostomy and PEG
tube placement during this admission.
Followup Instructions:
Please call to schedule follow up in the Ortho Trauma Clinic
with either Dr. [**Last Name (STitle) 1005**] or Dr. [**Last Name (STitle) **] in [**3-20**] weeks. The
telephone number is [**Telephone/Fax (1) 1228**].
Please make an appointment to see your primary care doctor, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1356**] 1-2 weeks after you leave the rehab facility.
Please discuss with her that we stopped your plavix and also
that we stopped your carvedilol since it can make your lung
disease worse, and instead started you on a medicine called
lisinopril.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2164-10-28**]
|
[
"733.15",
"518.83",
"263.9",
"287.5",
"491.21",
"280.9",
"340",
"401.9",
"276.0",
"276.2",
"350.1",
"997.31",
"425.4",
"799.02",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"31.1",
"96.04",
"33.23",
"96.72",
"43.11",
"96.07",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
9437, 9509
|
5535, 8993
|
353, 395
|
9717, 9726
|
2876, 2881
|
10162, 10865
|
2139, 2178
|
9530, 9530
|
9019, 9414
|
9750, 10139
|
2193, 2857
|
278, 315
|
451, 1724
|
9654, 9696
|
9549, 9633
|
2896, 5512
|
1746, 1953
|
1969, 2123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,361
| 195,794
|
49666
|
Discharge summary
|
report
|
Admission Date: [**2167-8-21**] Discharge Date: [**2167-9-8**]
Date of Birth: [**2089-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
back pain, elevated INR
Major Surgical or Invasive Procedure:
surgical fasciotomy
Right internal jugular central line placement
Left subclavian line placement
History of Present Illness:
Pt is a 77 year old male with hx of metastatic follicular
thyroid cancer with known vertebral mets admitted with elevated
INR. The patient reports that his visiting nurse checked an INR
on [**8-18**] (last dose of Coumadin) which was elevated to >4. His
Coumadin was held, and when it was checked again today it was
elevated >5 and he was instructed to come to the ED.
Incidentally he reports that he has had worsening back pain for
the last week, describes [**8-17**] pain which is usually controlled
on Percocet to [**3-17**]. The pain is sharp, constant, and is in a
band along the beltline between his hips. It does not radiate.
He has no pain, numbness or tingling in his legs. No change in
bowel or bladder function. He reports that it is usual for him
not to be able to lie flat due to pain, but this is much worse
than usual. In addition, he has been taking more Percocet than
usual - 6-8 tabs daily and subsequently began having nausea and
vomiting [**2-8**] x this week. He states that he feels well right up
until the time that he vomits (usually right after a meal). He
denies bleeding - mucosal or otherwise.
.
ROS: decreased appetite, denies SOB, CP, no fever or chills, but
reports cold intolerance. no change in bowel habits, with
regular BM daily.
.
In the ED his vitals were T 98.1 HR 104 BP 141/86 O2 - 98% on
RA. He was given percocet for pain. CT scan was done showing no
evidence of RP bleed. Nuerosurgery was contact[**Name (NI) **] and recommended
no need to reverse INR at this point.
Past Medical History:
- History of hairy cell leukemia diagnosed in [**2141**], status post
splenectomy without further treatment.
- Metastatic follicular thyroid cancer (summary below)
- History of paroxysmal atrial tachycardia
- Benign prostatic hypertrophy
- DM type 2 on oral hypoglycemic agents
- Hypercholesterolemia
- Hypertension
- Status post left hip replacement [**2166-6-2**]
- Recent DVT and PE ([**2166-5-12**])
- Status post Electrophysiology ablation of AVNRT focus
- Status post Fluoroscopic guided placement of [**Location (un) 260**] IVC
filter
.
Brief Onc Summary per last endocrine note:
"The patient was diagnosed in [**2166-4-7**] with follicular
thyroid carcinoma affecting his lungs, lumbosacral spine and
left hip. He suffered a fracture of his left hip for which he
had a left replacememt and was found to have extensive bony
lesions at the L5-S1 invading his spinal canal, this causing
severe spinal stenosis. He received external beam radiation for
spinal metastases but suffered DVT complicated by coronary
embolus while in rehab. He eventually had a total thyroidectomy
on [**2166-7-10**]. Because he had been on Amiodarone for
paroxysmal atrial fibrillation, he could not immediately be
treated with radioactive iodine for his metastatic disease. His
Amiodarone was stopped in [**2166-5-8**] and with aggressive
therapy, his iodine level eventually dropped in [**2167-4-7**]. He
was treated with Thyrogen twice as his TSH could not be
increased adequately due to topic production of thyroid hormone
by metastatic thyroid carcinoma. This allowed him to receive
200 mCi of radioactive iodine treatment [**2167-4-15**]. He was
treated with Decadron around the time of the therapy due to
known spinal metastases and concern for cord compression."
Social History:
He lives in [**Location 10022**] with his wife and son. [**Name (NI) **] has four
children, 2 sons, 2 daughters. [**Name (NI) **] denies tobacco or alcohol use.
He used to work in heavy glass manufacturing. His son [**Name (NI) **] and
one of his daughters live with him.
Family History:
He reports that his mother had breast cancer and died at 82y/o.
His father died of a stroke at 86y/o. His sister has lung
cancer.
Physical Exam:
Vitals: T 98.4 BP 129/94 HR 88 RR 17 O2 100% RA
Gen: Elderly man in mild distress - appears uncomfortable
sitting upright in bed
HEENT: MMM, no OP lesions - no mucosal bleeding, EOMI, pupils
dilated (s/p b/l cataract surgery)
Neck: Supply, no LAD, no JVD
Heart: RRR, nl S1/S2, no S3/4, no murmurs
Lungs: CTA b/l, no wheezes or rales
Abdomen: Soft, NT/ND, +BS, no masses, no HSM, no guarding or
rebound tenderness
MSK: Approx 4cm mass over vertebrae around level T10-L1 - tender
to tough, not fluctuant, non-erythematous. Otherwise generally
tender to lumbar/sacral region
Extrem: 2+ pitting edema b/l, compression stockings in place,
skin smooth and hairless. no erythema or calf pain.
Pertinent Results:
Labs on admission:
Na 139 K 4.1 Cl 101 HCO3 28 BUN 12 Creat 0.8 Glucose 130
Ca 8.6 Mg 1.6 P 2.5
.
ALT 14 AST 20 AP 119 TBili 0.4 Alb 4.3 amylase 65 lipase 18
.
WBC 5.8 Hgb 10.9 HCT 33.5 Plt 439 MCV 106 N 74.4% L 17.2%
.
PT 48.4 PTT 82.2 INR 5.7
.
U/A: Trace ketones, otherwise negative
.
[**9-6**] --> Blood, urine and tissue cx --> Pan-sensitive Klebsiella
.
MR Lumbar spine ([**8-14**]):
1. Since the previous MRI the soft tissue changes at T12-L1
level have
decreased. Signal changes indicative of metastatic disease are
still noted at this level. On the post-gadolinium images a
central area of low signal identified within the T12 vertebral
body which could be due to changes from treatment.
2. Metastatic disease to L4, L5 and S1 again noted unchanged in
extent.
3. No evidence of new bony metastatic disease or epidural mass.
4. Multilevel degenerative changes and a small arachnoid cyst
at the posterior aspect of the thecal sac at T12-L1 level are
unchanged from previous study.
.
CT Lumbar spine ([**8-18**]):
Multilevel metastatic disease within the visualized lower
thoracic and lumbar spine as described above. Specifically,
marked destruction and loss of vertebral body height of the L1
vertebral body with appearance suggesting soft tissue
infiltration extending posteriorly with an epidural component.
Additionally, marked destruction and soft tissue infiltration of
the L5 and S1 vertebral bodies. These findings suggest a
hemangioma of the L4 vertebral body with superimposed
metastasis, recommend further evaluation with an MRI of the
thoracic spine.
Approximately 2.7 x 2.5 cm low-attenuation lesion within the
interpolar aspect of the right kidney likely representing a
renal cyst, recommend further evaluation with ultrasound.
Further findings as described above.
.
CT Abdomen/Pelvis ([**8-21**]):
IMPRESSION:
1. No evidence of retroperitoneal or intraperitoneal bleed.
2. Diverticulosis.
3. Multiple lungs nodules, likely representing metastases,
smaller in size since [**65**]; however, the evaluation is limited on
this abdominal CT.
4. Multilevel thoracolumbar spinal metastasis with soft tissue
and
indentation into the spinal canal, which has been described in
detail on
recent MRI and CT of the lumbar spine.
5. Lymphadenopathy along the left iliac chain, increased in
size.
.
X-ray L Hip:
Views of the left hip show an unchanged appearance of the left
femoral
hemiarthroplasty. No acute fracture is identified.
Degenerative changes are seen in the lower lumbar spine. IVC
filter is seen. Degenerative changes are seen in the right hip.
IMPRESSION: Stable appearance of the left femoral prosthesis.
No acute change.
Brief Hospital Course:
Pt is a 77 yo man with metastatic follicular thyroid cancer with
known vertebral metastases presenting with hypotension, elevated
lactate, hypoxia concern for sepsis or bleed.
.
He was initially treated for worsening lower back pain, and
started a chronic pain regimen and restarted XRT to L hip and
lumbar spine. He spent over 1 week in the hospital when he was
transferred to ICU for hypotension and placed on pressors &
antibiotics. He was found to have a rapidly spreading infection
of both legs to the hip. Surgery immediately evaluated and took
patient to OR [**9-6**] for fasciotomy which revealed a diagnosis of
necrotizing fasciitis. He was unstable in the OR, so only his
anterior legs were debrided. He has undergone aggressive fluid
resuscitation and remained intubated with relative pulmonary
edema after his surgery. Blood, urine, and tissue cx all showed
Klebsiella. He was intially treated with cefepime, vancomycin,
and clindamycin as well as aggressive pressor support and
ventilation. However, family meeting was held [**9-7**] and family
felt that given very poor prognosis they did not wish to proceed
with another surgery. Their goal was to maintain the patient's
comfort as much as possible including extubating him, and placed
on comfort measures. He died at 9:57 pm on [**2167-9-8**]. Family
wished to proceed to autopsy.
Medications on Admission:
Calcitrol .25 mcg po daily.
Calcium carbonate 1250 mg five times daily.
Finasteride 5 mg qd.
Levothyroxine sodium 350 mcg po qThursday, other days 175 mcg.
Metformin 1000 mg po bid.
Pravastatin 20 mg po qd.
Vitamin D 800 units daily
Oxycodone w/ APAP 5/325 1-2 tabs q4-6 hours as needed for pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
necrotizing fasciitis, sepsis
hip pain
metastatic thyroid cancer
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"V12.51",
"728.86",
"584.5",
"V43.64",
"785.52",
"V58.61",
"198.5",
"197.7",
"401.9",
"038.49",
"250.00",
"E934.2",
"197.0",
"285.22",
"V10.87",
"790.92",
"600.00",
"202.40",
"733.13",
"272.0",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"92.29",
"99.07",
"83.14",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9328, 9337
|
7600, 8952
|
324, 422
|
9446, 9456
|
4912, 4917
|
9508, 9514
|
4059, 4191
|
9299, 9305
|
9358, 9425
|
8978, 9276
|
9480, 9485
|
4206, 4893
|
261, 286
|
450, 1968
|
4931, 7577
|
1990, 3752
|
3768, 4043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,862
| 199,057
|
8517
|
Discharge summary
|
report
|
Admission Date: [**2111-11-8**] Discharge Date: [**2111-11-11**]
Date of Birth: [**2041-8-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Nausea and vomiting with coffee ground emesis
Major Surgical or Invasive Procedure:
NG tube placement and lavage.
History of Present Illness:
This 70 yo woman with a history of advanced papillary serous
ovarian cancer diagnosed in [**2105**], with progressive disease
despite multiple forms of chemotherapy, now presents with two
days of nausea/vomiting with coffee ground emesis.
She was recently admitted ([**2111-9-28**] to [**2111-11-3**]) to the OB/GYN
service for small bowel obstruction, for which she had
exploratory laparotomy, lysis of adhesions and small bowel
resection. Additionally she had post-operative fever which was
found to be secondary to an intra-abdominal abscess. She was
initially treated with amp/levo/flagyl IV, and ultimately
transitioned over to a course of po levaquin/flagyl for total of
28 days of antibiotic treatment. She continued concurrently on
her antibiotics as well as her coumadin treatment for DVT.
.
In [**Hospital1 18**] Emergency department, she underwent NG lavage, which
demonstrated coffee ground material that eventually cleared with
1.5 L NS lavage. She was given 2 units FFP and 10mg vit K SC for
an elevated INR. She then developed recurrent coffee ground
emesis and had repeat NG lavage. GI was consulted
but decided that upper endoscopy was not warranted given her
elevated INR. She is now admitted for further management.
Social History:
She is married and lives with her husband on [**Location (un) **].
Denies tobacco or alcohol use.
Family History:
NC
Physical Exam:
vitals: 98.7, 92, 120/64, 18, 94% on RA
.
gen: alert; oriented and interactive. No distress. NG tube in
place and clamped.
heent: sclera anicteric; op clear, mucosa dry
neck: full range of motion, no LAD
cv: rrr, no m/r/g
resp: CTA bilaterally by anterior exam
abd: minimally distended; hypoactive bowel sounds; soft,
non-tender. dressing wet over abscess site - draining
bilious/fecal material
extr: no c/c/e
neuro: no focal deficits
Pertinent Results:
CT torso w/ contrast [**11-8**]:
1. Markedly dilated loops of small bowel extending from the
duodenum through to at least the level of the right lower
quadrant up to a small bowel-small bowel anastomotic site.
Beyond this anastomotic site (apparent side-to-side
anastomosis), there is a segment of nondilated, fluid-filled
small bowel, with a second bowel anastomosis entering a large
loop of nondescript bowel (unclear if this represents small or
large bowel). Beyond this, there is a third anastomosis with
decompressed loops of sigmoid colon present beyond this site.
These findings are worrisome for high-grade mechanical
small-bowel obstruction.
2. Multiple liver metastases, not significantly changed.
3. Persistent right-sided hydronephrosis and hydroureter.
4. Interval decrease in size in pelvic fluid collections.
.
[**2111-11-8**] 11:30AM BLOOD WBC-8.0 RBC-3.80*# Hgb-12.7# Hct-36.2#
MCV-95 MCH-33.3* MCHC-35.0 RDW-18.3* Plt Ct-444*
[**2111-11-10**] 06:58AM BLOOD WBC-6.7 RBC-3.57* Hgb-11.7* Hct-34.7*
MCV-97 MCH-32.7* MCHC-33.6 RDW-18.5* Plt Ct-424
[**2111-11-8**] 11:30AM BLOOD Neuts-71.3* Lymphs-22.1 Monos-6.1 Eos-0.3
Baso-0.2
[**2111-11-8**] 04:30PM BLOOD Neuts-65.5 Lymphs-26.4 Monos-6.9 Eos-0.8
Baso-0.5
[**2111-11-8**] 11:30AM BLOOD PT-34.6* PTT-41.6* INR(PT)-9.1
[**2111-11-10**] 06:58AM BLOOD PT-13.1 PTT-24.7 INR(PT)-1.1
[**2111-11-8**] 11:30AM BLOOD Glucose-126* UreaN-16 Creat-0.7 Na-139
K-3.6 Cl-103 HCO3-25 AnGap-15
[**2111-11-10**] 06:58AM BLOOD Glucose-119* UreaN-3* Creat-0.5 Na-133
K-4.0 Cl-108 HCO3-24 AnGap-5*
[**2111-11-8**] 11:30AM BLOOD ALT-18 AST-22 AlkPhos-57 Amylase-30
TotBili-0.3
[**2111-11-10**] 06:58AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.8
[**2111-11-8**] 04:30PM BLOOD calTIBC-114* VitB12-454 Folate-14.8
Ferritn-140 TRF-88*
Brief Hospital Course:
70yo woman with history of metastatic ovarian cancer and recent
hospitalization for small bowel obstruction and abdominal
absscess now presents with upper GI bleeding and signs of
high-grade obstruction on CT scan.
.
1. Upper GI bleeding: After FFP and vit K, the INR decreased to
1.6. She did not have further episodes of emesis, and her Hct
remained stable during this time.
.
2. Metastatic ovarian cancer: The patient received extensive
prior treatment with multiple chemotherapy regimens and has
demonstrated disease progression nonetheless. Dr. [**Last Name (STitle) **] did
not feel that additional chemotherapy would be of benefit, but
was concerned that it would compromise her already poor quality
of life. He suggested reorienting the goals of care to comfort
measures, in hopes of getting the patient home with family over
the holidays. Both the patient and her husband made the
decision to be DNR/DNI, with transition to hospice care at home.
.
3. Small bowel obstruction: Dr. [**First Name (STitle) 1022**] did not feel that surgery
was not an option given her extensive intraabdominal tumor
burden and her poor tolerance of her recent surgical procedure.
After her decision to receive hospice services, she requested
removal of NG tube. Her nausea was well controlled with
decadron 4mg po bid, compazine 25mg per rectum q8 hours prn, and
ativan as needed. She will continue to use fentanyl for pain
control, and concentrated morphine solution for breakthrough
pain.
.
4. History of intra-abdominal abscess: She completed a planned
28 day course of levaquin and flagyl. She will continue to
receive wet-to-dry dressing changes twice a day to this area.
.
5. FEN: She will continue to take clear liquids as tolerated.
.
6. Code status
- DNR/DNI
.
7. Dispo
- Home with hospice care.
Medications on Admission:
coumadin 2.5mg qhs
nifedipine 30mg qd
fentanyl patch 25mcg q72h
percocet 5/325 q4-6h prn
levaquin 250mg qD
flagyl 500mg TID
(levo/flagyl to complete total course of 28days on [**2111-11-9**])
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed.
Disp:*60 Suppository(s)* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-15 mg PO Q1-2H
() as needed for pain.
Disp:*100 mg* Refills:*2*
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Advanced and progressive ovarian cancer.
Small bowel obstruction.
History of intra-abdominal abscess
Discharge Condition:
Fair
Discharge Instructions:
Please call your hospice care provider or Dr.[**Name (NI) 29995**] office
if you have fever, chills, uncontrolled vomiting or pain or any
other symptoms that are concerning to you.
.
You may have clear liquids if you can tolerate it.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21074**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2111-12-3**] 3:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2111-12-3**] 3:30
Completed by:[**2111-11-23**]
|
[
"560.9",
"197.4",
"285.9",
"578.0",
"569.81",
"289.82",
"183.0",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6731, 6782
|
4060, 5865
|
362, 394
|
6926, 6933
|
2269, 4037
|
7215, 7527
|
1794, 1798
|
6108, 6708
|
6803, 6905
|
5891, 6085
|
6957, 7192
|
1813, 2250
|
277, 324
|
422, 1662
|
1678, 1778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,563
| 144,409
|
24068
|
Discharge summary
|
report
|
Admission Date: [**2126-9-11**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2067-1-3**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Rigors and fevers up to 105.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male status post orthotopic liver transplant complicated by
multiple episodes of increased LFTs secondary to common bile
duct stenosis treated with stents who presented with rigors
and fevers of 105. He had been seen initially at [**Hospital6 48708**] and received empiric coverage. The patient was
transferred to the [**Hospital6 256**] for
further evaluation. He became hypotensive with a base
deficit, decreased PCO2 and a hematocrit of 22.6.
PAST MEDICAL HISTORY: End-stage liver disease secondary to
alcohol, status post orthotopic liver transplant on [**2126-6-15**], complicated by portal vein thrombosis, status post
lysis and stent placement on [**2126-6-27**], also with CBD
stricture in the common bile duct with stent placement,
history of portal hypertension with esophageal varices,
insulin dependent diabetes mellitus, GERD, anxiety and
depression, and degenerative joint disease.
ALLERGIES: Ambien, the patient gets confused and overly
sedated with Ambien. No known drug allergies otherwise.
MEDICATIONS: Rapamune 1 mg once a day, Cellcept [**Pager number **] mg twice
a day, Valcyte 450 mg once a day, prednisone 7.5 mg once a
day, Bactrim single strength once a day, fluconazole 400 mg
once a day, Lopressor 37.5 mg b.i.d., Atrovent 2 puffs
p.r.n., albuterol 2 puffs q.4 hours, Paxil 20 mg once a day,
Protonix 40 mg once a day, ursodiol 300 mg p.o. t.i.d.,
ferrous sulfate 325 mg p.o. daily, regular insulin sliding
scale, Coumadin.
HOSPITAL COURSE: The patient was admitted directly into the
surgical intensive care unit. On admission, his sodium was
137, potassium 3.5, chloride 106, CO2 16, BUN 25, creatinine
1.2, glucose 147, white count 5.8, hematocrit 27.9, platelet
count 99, fibrinogen 588, PTT 34.8, lactic acid 3.2, INR 2.2,
PTT 34.8, PT 22.8. His AST was 1408, ALT was 861 on
admission, and repeat was 1164, alkaline phosphatase was 311,
total bilirubin was 1.1.
He was started on imipenem and vancomycin and fluconazole.
Blood cultures from [**Hospital3 **] were positive for gram-
negative bacilli and gram-positive cocci and anaerobes. He
was started on an insulin drip as well for hypoglycemia.
The patient was intubated for respiratory distress. An ERCP
was done, and it was noted that his biliary stent was
infected. This was removed. On retrograde cholangiogram, it
was noted that the patient had irregular filling of the
common bile duct. A new biliary stent was placed. A duplex
was done of the liver. This demonstrated normal Doppler
ultrasound. There were multiple echogenic foci within the
left lobe of the liver concerning for pneumobilia.
The patient spiked a temperature on hospital day 2 to 103.8.
An abdominal scan demonstrated underperfusion of segments 2
and 3 in the left lobe of the liver with multiple fluid and
gas collections, likely representing bile leak. There was a
wedge-shaped low attenuation region of the anterior right
lobe suggestive of compromise of the right anterior portal
vein, although the right anterior portal vein appeared
patent. There was also moderate right pleural effusion and
associated right lower lobe atelectasis with a small left
pleural effusion. There was also free fluid in the abdomen
and pelvis and nonspecific stranding within the mesentery.
He underwent a transthoracic echocardiogram given blood
cultures. The left atrium was normal in size. Overall he had
left ventricular systolic function with an EF of 70%. There
were no masses or thrombi noted in the left ventricle. There
was trivial mitral regurgitation and no pericardial effusion
or vegetations noted.
The patient underwent a hepatic arteriography on [**9-13**].
This demonstrated tight stenosis of the proper hepatic artery
just distal to the anastomosis treated with a 3 mm x 23 mm
coronary stent with good post-stent result. He also underwent
a balloon angioplasty of the distal proper hepatic artery
with good postangiographic result. There was successful snare
recovery of a dislodged unexpanded 3 mm x 23 mm stent from
the common hepatic artery.
Blood cultures on admission grew out Klebsiella pneumoniae
sensitive to imipenem, meropenem, otherwise resistant. Urine
culture was negative. Repeat blood cultures on the 5th
demonstrated Klebsiella pneumoniae with the same
sensitivities. He remained on imipenem.
On admission, the patient was confused and not at baseline.
Of note, the patient underwent placement of two 8 French
pigtail catheters and 2 liver collections on [**9-12**].
Repeat duplex of the abdomen demonstrated main and left
portal veins and hepatic arteries patent with appropriate
wave forms. His LFTs started to trend down with an AST of 52,
ALT 280 and alkaline phosphatase of 257.
His Coumadin was resumed. The patient still remained somewhat
confused although improved from admission. Unfortunately he
removed his PICC line that was placed for long-term
antibiotics, as well as the 2 pigtail catheters placed in the
liver bile leaks. He underwent replacement of 2 left hepatic
abscess collection drains.
Repeat blood cultures from [**9-12**] were positive for
enterococcus, as well as Klebsiella pneumoniae. His
antibiotics were changed per infectious disease to include
daptomycin for the VRE and meropenem for the Clostridium, as
well as the Klebsiella. He remained on daptomycin and
meropenem for the remainder of this hospital course. He had
bile cultures that grew out Clostridium.
Repeat blood cultures on the 16th demonstrated enterococcus
fecalis sensitive to daptomycin, resistant to vancomycin. He
remained on daptomycin for this. Subsequent blood cultures on
the [**9-25**] were negative.
Of note, the patient was persistently congested bringing up
large amounts of phlegm. Sputum cultures were negative. Chest
x-ray done on the 13th demonstrated an interval decrease in
the right pleural effusion without any consolidations. He was
given albuterol and Atrovent inhalers with improvement.
The patient was transferred out of the surgical intensive
care unit when stable. He remained on the medical surgical
unit where he was evaluated by physical therapy who
recommended rehab based on the slow progress of functional
activities. Nutrition saw him and evaluated him and
recommended Ensure 1 can t.i.d. for low caloric intake.
Occupational therapy evaluated the patient and recommended
rehab for inability to complete ADLs.
The patient underwent repeat abdominal CT on [**9-27**]. It
was noted that the 2 percutaneous pigtail catheters were
located in the left hepatic lobe with slight interval
decrease in size of the 2 hepatic abscesses. Again the right
pleural effusion was stable, and it was noted that he had a
small amount of ascites as well.
The PICC line was replaced after the patient self-removed. It
was noted that his liver function tests, specifically the
alkaline phosphatase remained elevated. He underwent a repeat
angiography on [**9-27**] to evaluate the hepatic artery. It
was noted that the patient had a 40% stenosis in the proper
hepatic artery. A second hepatic artery stent was placed with
good angiographic result. It was noted that there was
nonvisualization of the right hepatic vein. An MRV was
recommended. A liver duplex was done to evaluate the venous
system. This demonstrated interval improvement in the
arterial wave forms within the main, right, and left hepatic
arteries, as well as patent portal and hepatic veins with
appropriate wave forms. There was limited evaluation of the
liver parenchyma secondary to overlying bandages.
After the hepatic artery stent was placed, his alkaline
phosphatase continued to increase slightly each day from 304
up to 406. Total bilirubin remained in the 0.6 range. His AST
was 38, ALT 62. His creatinine remained stable throughout
this hospital course at 0.5.
He became ambulatory with the help of physical therapy. He
was tolerating a regular diet. Vital signs were stable. The
plan was to discharge him to [**Hospital **] Rehab for further
physical therapy, IV antibiotics and nutrition support. He
should followup in the outpatient clinic with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 9404**] to evaluate further IV antibiotic needs, specifically
meropenem and daptomycin. The length of course of antibiotics
depends on further repeat imaging to assess the resolution of
hepatic collections. The patient should have weekly CK given
IV daptomycin, given the potential side affect of
rhabdomyolysis. He should also have a CBC with differential,
LFTs, CHEM10 and trough Rapamune levels every Monday and
Thursday. Of note, the patient needs to be scheduled in the
future for biliary stent change.
DISCHARGE MEDICATIONS: Albuterol 0.083% nebulizer treatment
1 neb p.r.n. q.6 hours for dyspnea, aspirin 325 mg p.o.
daily, Plavix 75 mg p.o. daily, daptomycin 420 mg IV q.24
hours, Colace 100 mg p.o. daily, insulin sliding scale please
see printed scale, Atrovent 1 neb p.r.n. q.6 hours for
dyspnea, meropenem 500 mg IV q.6 hours, metoprolol 50 mg p.o.
b.i.d., Cellcept [**Pager number **] mg p.o. b.i.d., Paxil 20 mg p.o. daily,
Protonix 40 mg p.o. daily, prednisone 5 mg p.o. daily, Lasix
20 mg p.o. b.i.d., heparin 5000 units subcu b.i.d., heparin
flush via the PICC 200 units per port of the PICC daily
following saline flushes, Senokot 1 tab p.o. b.i.d. p.r.n.,
Rapamune 4 mg p.o. daily, Bactrim single strength 1 tab
daily, ursodiol 300 mg p.o. t.i.d.
FOLLOW UP: The patient is scheduled for followup appointment
in the outpatient transplant clinic on [**10-7**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please fax all labs to [**Hospital6 649**], [**Telephone/Fax (1) 697**], attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], nurse
coordinator.
ADDENDUM
Coumadin was stopped as noted on the medication list, and
aspirin and Plavix were used for prophylaxis for hepatic
artery stents.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2126-10-1**] 14:23:35
T: [**2126-10-1**] 15:42:45
Job#: [**Job Number 61214**]
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11,346
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8611
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Discharge summary
|
report
|
Admission Date: [**2166-1-24**] Discharge Date: [**2166-2-1**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
-L IJ central line
-AV fistulagram with recannalization attempt by Interventional
Radiology
-CT with contrast
-Echocardiogram
-Pericardiocentesis
-Thrombectomy of AV graft thrombus
History of Present Illness:
HPI: Mr. [**Known lastname 30197**] is a 57 year-old man with hx of ESRD on
hemodialysis since [**Month (only) 205**] who presented with 1 day history of
fever to 101 at home and 1 week history of cough. The patient
reports he developed a cough approximately one week ago that has
been productive of copius white sputum. He describes daily
episodes of coughing upon waking and "throwing up white stuff."
There is no evidence of food or bile in the secretions and he
believes they are coming from his lungs rather than his stomach.
He also notes that these coughing fits make him feel nauseus. 2
days prior to admission he was given Reglan for nausea and
"throwing up." He subsequently developed diarrhea, and has had
approximately 5 mushy brown, non-bloody stools daily. He has not
experienced any sore throat, chills, abdominal pain, dysuria. He
notes lightheadedness on changing positions but has been
experiencing this since begininning dialysis in [**Month (only) 205**]. He also
experiences achiness following dialysis. He denies any fever
prior to the day before admission.
.
ROS: Has DOE at baseline, cannot walk up a flight of stairs.
Denies chest pain, abdominal pain, sweats.
.
In the ED, the patient's temperature was 100.6. He underwent CXR
(clear) and CT with contrast. Blood cultures were sent and he
received Levofloxacin 500mg, Flagyl 1000mg, Vancomycin 1g
Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
3. Hypertension
4. Diabetes type 2, recently diagnoses, HbA1C 9
5. Hepatitis C infection
6. Bilateral hearing loss
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 fall [**2164**]
Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago
Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He
is unsure of any other medical problems in his family.
Physical Exam:
Physical Exam:
VS: T100.6 BP 107/76 HR 101 RR 22 O2sat 94%RA
GEN: Subdued-appearing middle-aged man in NAD
HEENT: Icteric sclera, OP clear, MMM
NECK: supple, no LAD, no JVD
CARD: Tachycardic, regular rhythm, normal S1, S2. 3/6 systolic
murmur at L upper sternal border
LUNG: Crackles on R from base to middle lung field. Crackle on L
at base only. Moving air well.
ABD: Protuberant, soft, ND, slightly tender in site of recent bx
in RUQ, no ascites. Liver edge nonpalpable. No splenomegaly
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally
Pertinent Results:
CXR [**2166-1-24**]:
The left-sided IJ central venous line has migrated slightly more
proximally and the distal tip is in the distal left
brachiocephalic vein. The cardiac size is prominent but
unchanged. There is some tortuosity to the thoracic aorta.
Some streaky density seen at the left base, best seen on the
lateral radiograph. This is likely secondary to atelectasis,
however, early infiltrate cannot be completely excluded.
Attention to this region is recommended on followup studies.
.
.
CT ABDOMEN/PELVIS W/ CONTRAST [**2166-1-24**]:
CT ABDOMEN: There is bilateral pleural thickening and bibasilar
atelectasis, which is unchanged from prior exam. There has been
interval development of a large pericardial effusion. The
effusion measures higher than fluid density at 30 Hounsfield
units and was not present previously. The liver, gallbladder,
pancreas, spleen, adrenal glands, and kidneys are stable in
appearance. The patient is status post partial left nephrectomy.
Multiple low attenuation renal foci are noted and may represent
cysts but are too small to be fully characterized. The stomach
and bowel loops are within normal limits. There is no free air
or free fluid. Of note, are prominent left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. They are
increased in size compared to prior examination.
CT PELVIS: The bladder, prostate, seminal vesicles, and rectum
are unremarkable. There is focal segment of narrowing in the
sigmoid colon, which may relate to transient peristalsis.
Contrast is seen passing beyond this point. There is no free
fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Interval development of a large pericardial effusion with
high attenuation fluid.
2. Interval increase in size of left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. These could be
inflammatory, however, given the patient's history of renal cell
carcinoma, neoplastic involvement cannot be excluded.
3. Low attenuation renal foci, which may represent cysts but are
too small to be fully characterized.
4. Pleural thickening and atelectasis at both lung bases.
.
.
CXR PA & LATERAL [**2166-1-26**]:
Cardiomegaly is unchanged. A left internal jugular central
venous catheter is in unchanged position, with the tip in the
superior portion of the SVC. No pneumothorax is identified.
There is no consolidation or evidence of congestive failure. No
pleural effusion. IMPRESSION: Cardiomegaly. No evidence of
pneumonia.
.
.
EKG [**2166-1-26**]:
Sinus tachycardia
Modest ST-T wave changes with Probable QT interval prolonged
although is
difficult to measure - are nonspecific but clinical correlation
is suggested. Since previous tracing of [**2166-1-24**], probable no
significant change
.
.
Echocardiogram [**2166-1-27**]:
Conclusions:
1.The left atrium is mildly dilated. The left atrium is
elongated. The
inferior vena cava is dilated (>2.5 cm).
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. No mitral
regurgitation seen.
6.There is a moderate to large sized pericardial effusion. The
effusion
appears circumferential. There is very mild diastolic
invagination of the
right ventricular outflow tract and there is respiratory
variation of mitral valve inflow consistent with early
tamponade.
.
.
Cardiac Cath/Pericardiocentesis [**2166-1-28**]:
1. Right heart catheterization revealed severe elevation of
right and
left sided filling pressures along with equalization of RA, RV
end
diastolic, PA diastolic and PCWP at about 20mmHG. The cardiac
index was
preserved at 3.7. There was marked respiratory variation (peak
to peak
of 30mmHG) in the femoral artery pressure tracing.
2. Pericardiocentesis was uncomplicated and revealed an opening
pressure of 20mmHG and was essentially identical to RA pressure.
600 cc
of bloody fluid were drained with improvement in RA pressure to
10mmHG.
The cardiac index remained unchanged at 3.6.
3. Echo done post procedure revealed only minimal effusion
posteriorly
(pt had 2.5cm circumfrential effusion yesterday).
FINAL DIAGNOSIS:
1. Pericardial effusion with tamponade physiology
2. Successful pericardiocentesis.
.
.
ECHO [**2166-1-29**]:
Conclusions:
There is a trivial/small pericardial effusion. There are no
echocardiographic
signs of tamponade.
.
.
LABS:
[**2166-1-24**] 01:50PM:
WBC-15.1* RBC-3.41* HGB-9.6* HCT-30.4* PLT COUNT-692
MCV-89 MCH-28.1 MCHC-31.5 RDW-16.0*
NEUTS-69.3 LYMPHS-23.3 MONOS-5.7 EOS-1.0 BASOS-0.8
PT-13.4* PTT-24.9 INR(PT)-1.2*
GLUCOSE-79 UREA N-29* CREAT-7.9*# SODIUM-138 POTASSIUM-3.7
CHLORIDE-93* TOTAL CO2-27 ANION GAP-22* LACTATE-1.6
[**2166-1-24**] 06:10PM:
URINE SP [**Last Name (un) 155**]-1.022 BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2
Brief Hospital Course:
#. Issues to be followed-up as outpatient:
1) Needs echo to assess for reaccumulation of pericardial
effusion in 4 weeks followed by appointement with Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**]. The patient has been instructed to call to schedule echo
and appointment.
2) Assymetric LAD of the left paraesophageal, diaphragmatic and
vena caval lymph nodes seen on CT chest [**1-24**]. Needs repeat CT in
[**3-20**] weeks.
3) Had one dark, guaiac-positive stool on [**1-31**]. Should have
outpatient colonoscopy.
4) RCC, PSA
.
#.Pericardial effusion: First noted on CT chest on [**1-24**]. Viral
etiology was felt to be most likely. Despite his ESRD it was
thought that this was unlikely to be a uremic effusion because
he has been well-dialyzed. On [**1-26**], the patient's SBP was in the
90's. It was unclear if this drop in BP Was secondary to the
effusion or to intravascular depletion from dialysis the day
before. He was given 3 boluses of IVF and BP improved. Pulsus
paradoxus was monitored and remained stable at 10-12mmHg.
Cardiology was consulted and the patient underwent TTE on [**1-27**]
which showed 1.5-2cm pericardial effusion. On [**1-28**] he underwent
pericardiocentesis: 600cc of fluid was removed and a pericardial
drain was placed which drained 80cc of serosanginous fluid over
24 hours. The patient tolerated the procedure well and went to
the CCU for post-procedure monitoring. Pericardial fluid was
found to be an exudate. [**2159**] WBCs were seen. Diff was: N 27%, L
41%, Mono 4%, Eos 4%, Macros 24%. Gram stain and Acid Fast smear
were negative. Fluid culture showed no growth, anaerobic
culture preliminarily no growth. Fungal cultures preliminarily
negative, Acid Fast culture pending. Cytology was negative for
malignant cells. PPD was negative. He tolerated the procedure
well and a pericardial drain was placed. On [**1-29**], drain output
was minimal and removal of the drain was attempted. Removal was
not successful and the patient underwent angiography for removal
of the drain, which was found to be incorporated into a
loculated portion of the pericardial sac. Given these findings,
this is most likely viral etiology, however, malignancy must
still be considered. On echocardiogram 24 hours post-procedure,
no re-accumulation of fluid was seen. The patient remained
hemodynamically stable until discharged. He is to schedule a
follow-up echocardiogram with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] ([**Telephone/Fax (1) 128**]) in
about 4 weeks ([**3-1**]).
.
#.Fever:
The patient presented with fever to 101 at home, in the setting
of 1 week of productive cough. His WBC was also elevated to 15.1
on admission, and he received Vancomycin, Levo and Flagyl in the
ED. Blood cultures, urine cultures and stool cultures were sent
and found to be negative. There was no evidence of pneumonia on
chest films. Given that Mr. [**Known lastname 30197**] is a hemodailysis patient,
the team's greatest concern was for infected venous access
causing bacteremia, and blood cultures were repeated x3. As
there was no evident source of infection, no further antibiotics
were given. Tylenol was held so fever curve could be monitored,
and he continued to have low grade fever until his effusion was
drained on [**1-28**]. Following drainage of the effusion the patient
continued to become febrile during/after hemodialysis
treatments, but was otherwise afebrile. Given his history of
renal cell carcinoma, this was also considered as a possible
source of fevers. RCC is being followed as an outpatient. By the
day of discharge, Mr. [**Known lastname 30197**] was afebrile and his WBC had
decreased to 9.9.
.
#.ESRD:
The patient has received hemodialysis since [**2165-6-14**], on Tues,
Thurs, Sat schedule. Dialysis was continued on this schedule
while the patient was hospitalized. On Saturday [**1-25**], 2.2kg
fluid was removed resulting in SBP in 90's. He also reported
lightheadedness with changes in position. Subsequently, he
received IV fluid boluses and his blood pressure improved. On
[**1-27**] the patient underwent fistulagram that had been scheduled
as an outpatient to work-up difficulty with fistula access. The
graft was found to be stenosed, and revision by angiography was
performed. On post-procedure imaging the graft was found to be
thrombosed, and re-cannulation was again attempted that
afternoon. Ultrasound the following morning ([**1-28**]) revealed
complete occlusion of the fistula throughout its graft portion
from the arterial anastomosis to the venous anastomosis.
Transplant surgery performed thrombectomy on [**1-29**], and
post-procedure exam revealed 2+ graft pulse and restoration of a
graft thrill. The patient missed his Tuesday hemodialysis
secondary to graft thrombosis and was subsequently dialyzed
Wednesday-Thursday-Friday-Saturday. He continued to have good
pulse and graft thrill at discharge. In addition to continuing
dialysis, the patient was continued on calcium carbonate 500mg
TID. Electolytes were monitored. The transplant service was
aware of the patient, and the renal service followed him while
inpatient.
.
#. Hypoxia: On [**1-26**] the patient became hypoxic to 88% on RA. He
was placed on 2L NC with sats 94-97%. He denied SOB or chest
pain at the time. Concern was for pneumonia of CHF, given his
reports of dyspnea on exertion at baseline. CXR was checked with
no evidence of pneumonia, pulmonary edema, or pleural effusion.
His oxygen sats were monitored and the patient was instructed to
use an incentive spirometer. Sats improved over the next two
days and supplemental oxygen was discontinued.
.
#.Anemia:
The patient has had anemia requiring transfusions in the past,
likely related to ESRD. On admission HCT was 30.4, then declined
over several days to 25.3. He was transfused 1 unit prior to
pericardiocentesis, and his HCT increased appropriately with the
transfusion. On [**1-31**] he had one dark, soft formed stool that was
guaiac positive. HCT was monitored. It remained stable and was
30.4 on the day of discharge.
Given recent negative colonoscopy ([**2-16**]) patient will simply
require regular follow-up in 5 years.
.
#.Nausea and Diarrhea:
At baseline, the patient has frequent nausea associated with
acid reflux, for which he takes prilosec 40mg [**Hospital1 **]. He also gives
a history of food "getting stuck" and being regurgitated,
suggesting gastroparesis. On admission, the patient reported
post-tussive nausea for 1 week. He has also described daily
episodes of "throwing up" upon waking up in the morning, but
these episodes were always associated with coughing, and the
description given of the secretions was suggestive of sputum
rather than emesis. On the day following admission the patient
had one episode of vomiting after eating breakfast. He noted
that he had not been eating for the week prior to adimission. He
continued to experience intermittent nausea until [**1-26**], when his
appetite improved. The patient had been started on Reglan 2 days
prior to admission for presumed nausea and vomiting and
subsequently developed soft stools, approximately 5 per day.
Stool cultures were sent, and c. difficile toxin was negative.
He continued to have guaiac-negative soft stools while
hospitalized. One guaiac-positive dark, soft formed stool was
recorded on [**1-31**]. HCT remained stable and the patient had a
normal brown colored BM prior to discharge. He was not
orthostatic on discharge.
.
#.Depression:
Patient has had ongoing discussion with his outpatient treaters
about starting an antidepressant medication. During his
hospitalization he informed the team that he now feels that he
needs to start a medication to help with depression. He was
started on Zoloft 25mg daily and advised of possible side
effects of nausea, vomiting and diarrhea. He was also advised
that the medication would most likely not have any effect on his
mood for several weeks.
.
#. Hypertension: Remained stable. Home medications (Valsartan
360mg, diltiazem 320mg, amlodipine 5mg) were continued until
[**1-26**], when the patient found to have low BP. Valsartan was then
decreased to 80mg daily and amlodipine was held. All BP meds
were held on [**1-27**] due to concern for early tamponade. Home
regimen was resumed after drainage of pericardial effusion; the
patient's BP remained stable.
.
#. Diabetes: The patient was placed on QID finger sticks and
insulin sliding scale while hospitalized. He was continued on
glipizide 5mg daily and Lantus 10 units daily except when NPO
for procedures. The majority of his finger sticks were at goal.
.
#.Gout: Remained stable, without symptoms. Allopurinol 100mg QOD
was continued.
.
#.[**Doctor Last Name 15532**]??????s Esophagus: Continued PPI 40mg [**Hospital1 **]
.
#.Hepatitis C: Viral load was sent (currently pending).
.
#.Prophylaxis: While on bed rest, the patient was maintained on
SC heparin. This was discontinued when he began to feel better
and get out of bed frequently.
.
#.Fluids, electrolytes, nutrition: The patient was maintained on
a renal/cardiac diet. Electrolytes were checked daily and the
patient received hemodialysis on his outpatient schedule plus
two additional sessions.
Medications on Admission:
Aspirin 81 mg daily
Nephrocaps 1 cap daily
Allopurinol 100 mg QOD
Valsartan 320mg daily
Amlodipine 5mg daily
Diltiazem SR 360mg daily
Glipizide 5mg daily
Lantus 10units QAM
Prilosec 40mg [**Hospital1 **]
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Prilosec 40mg one tablet twice daily
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Sertraline 50 mg Tablet Sig: half Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
New pericardial effusion
End-stage renal disease on hemodialysis
Occlusion of hemodialysis fistula graft
Anemia
Diabetes
Discharge Condition:
Good
Discharge Instructions:
1. Please call your doctor or return to the Emergency Department
if you develop fever >101, chills, vomiting, abdominal pain,
chest pain, fainting, shortness of breath at rest or lying down,
lightheadedness, or for any other concerning symptoms.
2. Please keep all of your appointments as scheduled (see
below).
3. Please keep your dialysis schedule of Tues/Thurs/Sat.
4. Restart all of your home medications, including your diabetes
medicines. We have added an antidepressant to your medications
(Sertraline 25mg); take half a tablet once a day
Followup Instructions:
1. DR. [**First Name8 (NamePattern2) **] [**2-12**] at 4PM Phone:[**Telephone/Fax (1) 250**]
2. DR. [**First Name (STitle) **] [**Name8 (MD) **], MD--[**3-5**] at 8:40AM Phone:[**Telephone/Fax (1) 673**]
3. Please call ([**Telephone/Fax (1) 19380**] to schedule an appointment with
Dr. [**Last Name (STitle) 911**] to have an echocardiogram in 4 weeks.
|
[
"403.91",
"420.91",
"V10.52",
"E878.2",
"285.21",
"070.54",
"996.73",
"250.00",
"274.9",
"530.85",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"88.55",
"99.04",
"39.95",
"00.40",
"37.0",
"39.50",
"38.93",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
19129, 19135
|
8831, 18056
|
286, 469
|
19306, 19313
|
3567, 8040
|
19908, 20266
|
2767, 2956
|
18310, 19106
|
19156, 19285
|
18082, 18287
|
8057, 8808
|
19337, 19885
|
2986, 3548
|
240, 248
|
497, 1873
|
1895, 2368
|
2384, 2751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,995
| 129,731
|
32592
|
Discharge summary
|
report
|
Admission Date: [**2189-1-8**] Discharge Date: [**2189-1-14**]
Date of Birth: [**2110-12-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
weakness in legs
Major Surgical or Invasive Procedure:
Thoracic laminectomies with resection intradural mass
IVCF placement
History of Present Illness:
HPI: 78yM with no PMH who had sudden onset back pain yesterday
afternoon resulting in a progressively worsening and ascending
paralysis and anesthesia. At 3pm, the patient noted the onset
of
his back pain. By 9pm, the patient developed BLE weakness and
numbness. He was brought to OSH and transfered to [**Hospital1 18**] ED.
Upon arrival, the patient had decreased sensation below T12 and
[**3-17**] BLE strength and decreased rectal tone. MRI showed a T5/6
intradural mass. Exam worsened recently with 0/5 BLE motor tone
and paresthesia below T8. Also of note, the patient developed
chest pain in the ED. ECG was WNL and the first set of enzymes
were negative. The patient was just given 10 IV decadron.
Past Medical History:
none
Social History:
non smoker
married
supportive family
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O:
T: 97.8 BP: 120/70 HR: 101 R: 18 O2Sats: 97% RA
Gen: WD/WN, Uncomfortable, complaining of chest pain
HEENT: Pupils: 3-->2 MM PERRL EOMs Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, distended (baseline)
Extrem: Warm and well-perfused.
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
R 5 5 5 5 5 0 0 0 0 0
L 5 5 5 5 5 0 0 0 0 0
Unable to sit up and flex abdominal muscles
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally in the upper extremities; Below T5/6 the
patient is without sensation to light touch or nociception. The
patient is sensate to deep palpation in the abdomen but not to
deep palpation below his abdomen.
Reflexes: B T Br Pa Ac
Right 1 1 1 0 0
Left 1 1 1 0 0
Propioception absent in BLE; normal in BUE
Toes downgoing bilaterally
No clonus
Normal tone on passive movement of lower extrimities
Rectal exam - no rectal tone
ON DISCHARGE HIS EXAM IS +++++++++++++++++++++++++++++++++++++
Pertinent Results:
[**2189-1-8**] 10:00AM WBC-8.8 RBC-4.12* HGB-12.9* HCT-37.1* MCV-90
MCH-31.2 MCHC-34.7 RDW-14.8
[**2189-1-8**] 10:00AM NEUTS-79.1* LYMPHS-16.6* MONOS-4.0 EOS-0.2
BASOS-0.1
[**2189-1-8**] 10:00AM PLT COUNT-224
[**2189-1-8**] 10:00AM PT-12.8 PTT-19.3* INR(PT)-1.1
[**2189-1-8**] 10:00AM GLUCOSE-155* UREA N-26* CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
MRI: Severe mid thoracic cord compression at the T5-T6 level by
intradural extramedullary mass, with mild adjacent cord edema.
RADIOLOGY Final Report
[**Numeric Identifier 3174**] INTERUP IVC [**2189-1-12**] 7:52 AM
Reason: Please place IVC filter for PE prophylaxis
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with paraplegia after cord hemorrhage (T5)
REASON FOR THIS EXAMINATION:
Please place IVC filter for PE prophylaxis
INDICATION: 78-year-old man with a thoracic cord tumor, status
post resection, complicated by hemorrhage. Please place IVC
filter for PE prophylaxis.
RADIOLOGISTS: Drs. [**First Name (STitle) 4685**] [**Name (STitle) 4686**] and [**Name5 (PTitle) **] [**Doctor Last Name **]. Dr.
[**Last Name (STitle) 4686**], the attending radiologist, was present and supervising
throughout the procedure.
TECHNIQUE/FINDINGS: The risks and benefits were discussed with
the patient's son, and written informed consent was obtained. A
preprocedure timeout was performed. The right groin was prepped
and draped in standard sterile fashion. Ultrasound was used to
identify and confirm patency of the right common femoral vein.
Under ultrasonographic guidance and after the administration of
5 cc of 1% lidocaine, a 19-gauge needle was advanced into the
right common femoral vein, and a 0.035 [**Last Name (un) 7648**] wire was advanced
into the distal IVC, through which an Omniflush catheter was
advanced into the contralateral external iliac vein. A venogram
was performed demonstrating a single patent inferior vena cava,
with no evidence of thrombosis. The renal veins were identified
at the level of L1. Based on this diagnostic findings, it was
determined that the placement of an IVC filter would be
indicated. An OptEase filter was placed below the level of the
renal veins. The vascular sheath was removed, and manual
compression was held for 10 minutes to achieve hemostasis. A
final fluoroscopic image was obtained to confirm filter
placement. The patient tolerated the procedure well with no
immediate complications.
IMPRESSION: Successful placement of an OptEase filter in the
infrarenal inferior vena cava. This may be retrieved within 14
days of placement if indicated, or left in permanently.
Cardiology Report ECG Study Date of [**2189-1-8**] 9:46:56 AM
Artifact is present. Sinus rhythm. Left axis deviation. Right
bundle-branch
block with left anterior fascicular block. There are small R
waves in the
inferior leads consistent with possible prior inferior
myocardial infarction.
No previous tracing available for comparison.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 156 142 410/457 63 -42 5
Brief Hospital Course:
Pt was brought to the OR from the ER where under general
anesthesia he underwent thoracic laminectomy T4-7 with resection
of intradural extramedullary mass. He tolerated this procedure
well , was extubated and transferred to the ICU for close
neurologic monitoring. Post op his LE motor remained 0/5. He
had sensory level at T6. His SBP was maintained > 100 for cord
perfusion. He was on decadron and tapered. His dresssing was
clean and dry and was removed post op day 2 and incision was
well healing with staples.He had IVC filter placed
prophylactically.
He weas seen by PT and PT as well as social work for his acute
change in physical exam. He is incontinent of stool at times. He
has a foley catheter in place. Post-operatively, some of the
sensation in his lower extremeities has returned, howver his
mobility and propriception have not. He is stable medically at
the time of discharge.
Medications on Admission:
Medications prior to admission: None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): while on steroids.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Sodium Phosphates Solution Sig: Forty Five (45) ML PO BID
(2 times a day) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 2 days: [**2189-1-14**] and [**1-15**].
13. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times
a day for 2 days: [**1-16**] and [**1-17**].
14. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO twice a
day: start [**1-18**] and continue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Intradural Extramedullary mass T5-6
cord compression
Discharge Condition:
NEUROLOGICALLY SLIGHTLY IMPROVED FROM ADMISSION H&P
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools for two weeks from
your date of surgery
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Have a family member check your incision daily for signs of
infection
?????? 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
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:
YOUR STAPLES SHOULD BE REMOVED ON [**2189-1-21**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2189-1-14**]
|
[
"344.1",
"192.2",
"336.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"03.4"
] |
icd9pcs
|
[
[
[]
]
] |
8046, 8116
|
5705, 6607
|
336, 407
|
8213, 8267
|
2554, 3239
|
9398, 9650
|
1247, 1251
|
6695, 8023
|
3276, 3335
|
8137, 8192
|
6633, 6633
|
8291, 9375
|
1281, 1578
|
6665, 6672
|
280, 298
|
3364, 5682
|
435, 1149
|
1593, 2535
|
1171, 1177
|
1193, 1231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,747
| 161,957
|
14083
|
Discharge summary
|
report
|
Admission Date: [**2198-6-1**] Discharge Date: [**2198-6-4**]
Date of Birth: [**2145-9-24**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with a history of coronary artery disease, status post
myocardial infarction and stent to the left circumflex in
[**2193**], diabetes, nephrolithiasis, obstructive sleep apnea,
hypertension, hypercholesterolemia who presented to outside
hospital with one day of substernal chest pressure. The
patient says that the pain started gradually over 20 minutes
and increased to [**11-8**] at 1 p.m. on [**2198-5-31**]. The chest pain
was worse with deep breath and was associated with shortness
of breath, but no nausea, vomiting or diaphoresis. No
palpitations, or lightheadedness. The patient took one
sublingual nitroglycerin with some relief. He then fell
asleep, but awoke the next morning, [**2198-6-1**], with pain again
without radiation but worse when he lifted up his arms.
The patient was taken to [**Hospital **] [**Hospital3 2063**] by his
family where CK was drawn and was negative. Vital signs were
temperature 97??????, heart rate 88, blood pressure 145/74,
saturating 97% on room air. Electrocardiogram was normal
sinus rhythm with left axis deviation, left atrial
enlargement, but no ST or T-wave changes. The patient was
treated with aspirin, sublingual nitroglycerin, morphine
which decreased his pain to 5 out of 10. He was also treated
with Lopressor, Lovenox and a nitroglycerin drip. He was
transferred to [**Hospital1 **] for a possibility of
catheterization.
REVIEW OF SYSTEMS: Positive for dyspnea on exertion x1 with
progressive worsening, no orthopnea, no paroxysmal nocturnal
dyspnea, positive for heartburn from which she gets symptoms
about 2x a week. He denies recent weight gain or weight
loss. He has no fevers or chills, no abdominal pain, no
nausea vomiting, no diarrhea, no bright red blood per rectum,
no melena, no dysuria.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Obstructive sleep apnea
4. Obesity
5. Migraine headaches
6. Coronary artery disease, status post myocardial
infarction with stent to the left circumflex in '[**93**]. ETT
[**1-30**], exercised for 9 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol reaching
95% of his maximum heart rate with no chest pain and no
electrocardiogram changes. Thallium results are not
available.
ADMISSION MEDICATIONS:
1. Metoprolol 50 mg po bid
2. Aspirin 325 mg po qd
3. Lipitor 40 mg po qd
4. Mavik 4 mg po qd
5. Glucotrol XL 10 mg po qd
6. Glucophage 850 mg po bid
7. Nitrostat prn
8. Naproxen 550 mg po bid
9. Vicodin prn for low back pain
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient works as a welder. He lives
with his wife. [**Name (NI) **] quit smoking 20 years ago. He smoked a
pack a day for about 20 years. He denies any recent alcohol
use and no history of alcohol abuse. He has been on
disability since [**1-31**] secondary to low back injury at work.
FAMILY HISTORY: No coronary artery disease, no cancer, but
positive for diabetes.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature 98??????, heart rate 93, blood pressure
118/82, saturating 93% on 4 liters nasal cannula.
GENERAL: The patient is alert, diaphoretic in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Oropharynx is clear,
mucous membranes moist. No jugular venous distention, no
carotid bruits.
HEART: Tachycardic, regular and no murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Obese, soft, nondistended, nontender with positive
bowel sounds.
EXTREMITIES: Trace edema, 2+ peripheral pulses.
NEUROLOGIC: Exam was nonfocal.
ADMISSION LABS: White count of 14.9, hematocrit of 40.8,
platelets 337. INR of 1, calcium 9.2, magnesium 1.8, sodium
138, potassium 4.1, chloride 101, bicarbonate 27, BUN 13,
creatinine 0.7, glucose 307. At outside hospital, total
bilirubin 0.4, alkaline phosphatase 170, ALT 35, AST 23.
Serial CKs 64, 47 and 40.
Electrocardiogram revealed normal sinus rhythm at 90, left
axis deviation, left atrial enlargement, no ST or T-wave
changes.
HOSPITAL COURSE:
1. CORONARY ARTERY DISEASE: The patient was admitted to the
CCU for possible catheterization and concerning symptoms of
substernal chest pain unresponsive to nitroglycerin and a
history of coronary artery disease, myocardial infarction,
diabetes, hypertension, hypercholesterolemia and obesity.
However, given the fact that his pain had been persistent for
greater than 24 hours and that cardiac enzymes remained
negative as well as no electrocardiogram changes, the CCU
team that it was unlikely that his chest pain represented
cardiac ischemia or infarction. The heparin and
nitroglycerin drips were discontinued, but the patient was
continued on aspirin, beta blocker, Lipitor and ACE
inhibitor.
2. PULMONARY: The patient had some complaint of pleuritic
chest pain, as well as an oxygen requirement. A chest x-ray
was unrevealing for etiologies. The patient had a CT
angiogram to rule out pulmonary embolus. This study revealed
no evidence of pulmonary embolism.
3. GASTROINTESTINAL: The patient continued to complain of
chest pain which radiated to his back. The patient underwent
right upper quadrant ultrasound looking for a biliary
pathology, negative for cholelithiasis, gallbladder edema or
any common bile duct pathology. Further lab testing revealed
an amylase of 285, lipase of 621. Further questioning
revealed no obvious etiology of pancreatitis, as the patient
has no evidence of gallstones and has not had any recent
alcohol use. He also has no recent medication changes. The
patient was treated with intravenous fluids and was kept npo
for 36 hours. The patient's pain resolved and he was started
back on a clear liquid diet. The patient's pain resolved on
its own and he required minimal pain medications.
The patient also complained of constipation which was treated
with Colace, Dulcolax and lactulose with good results. The
patient will be continued on Protonix for his heartburn.
4. ENDOCRINE: The patient was treated with regular insulin
sliding scale during this hospitalization with good glucose
control. He will be restarted on his outpatient regimen of
Glucotrol and Glucophage as he is tolerating po diet.
DISCHARGE DIAGNOSIS:
1. Pancreatitis
DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg po bid
2. Aspirin 325 mg po qd
3. Lipitor 40 mg po qd
4. Mavik 40 mg po qd
5. Glucotrol XL 10 mg po qd
6. Glucophage 850 mg po bid
7. Naprosyn 500 mg po bid
8. Vicodin prn
9. Prilosec 20 mg po qd
DISCHARGE STATUS: The patient will be discharged home. His
wife said she would call to make him a follow up appointment
within the next week when it is convenient for them.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12-735
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2198-6-4**] 14:48
T: [**2198-6-4**] 15:04
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 41995**]
|
[
"577.0",
"564.00",
"786.59",
"414.01",
"V45.82",
"401.9",
"272.0",
"V15.82",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.43"
] |
icd9pcs
|
[
[
[]
]
] |
3096, 3173
|
6430, 7158
|
6389, 6407
|
4208, 6368
|
2493, 2767
|
3188, 3746
|
1623, 1986
|
179, 1603
|
3763, 4190
|
2008, 2470
|
2784, 3079
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,249
| 112,028
|
8063
|
Discharge summary
|
report
|
Admission Date: [**2174-4-2**] Discharge Date: [**2174-4-9**]
Date of Birth: [**2099-2-19**] Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
75 yo M with refractory HCC on cycle 1 of 5FU, Hep B cirrhosis,
tumor obstruction of left portal vein, partial obstruction on
right followed by Dr. [**Last Name (STitle) **] for chemotherapy presents from home
via [**Location (un) 620**] ED. This morning he was found to be minimally
responsive and had flecks of blood on the pillow noted by family
the morning of admission. At [**Hospital1 **] [**Location (un) 620**] he was intubated for
airway protection in setting GCS 8, Head Ct was obtained and
negative for acute bleed, he recieved 5L IVF. Patient has HD
stable and was guiac + from rectal vault with brown stool.
On arrival to [**Hospital1 18**] ED, he was HD stable, afebrile, intubated.
Labs repeated and notable HCt 25, INR 1.7. Stools were guiac
positive [**Doctor Last Name 352**] stools, NG tube placed to suction red tinged
gastric contents without lavage. He was noted to develop
progressive abdominal distention. Given h/o ruptured hepatoma in
04 with hemoperitoneum he was sent for CT ab/pelvis prior to
trasfer to the floor which showed moderate ascites, no
intraperitoneal bleed, atelectasis vs consolidation at lung
bases and distended urinary bladder. It was also noted that his
BP was trending down and he was started on PRBCs, protonix IV,
octreotide gtt, cipro. The liver/omed teams were made aware of
the admission. At the time of transfer, vital signs: T97.5 BP
124/72 HR 76 RR 16 POx100% on AC.
Past Medical History:
-Hepatocellular CA recently treated with sorafenib (stopped
[**2174-3-2**]), planning to try 5-FU/leucovorin vs. palliative care -
he initially presented with a ruptured hepatoma in [**2168**]. He
underwent surgical resection and has had for recurrent disease,
radiofrequency ablation as well as trans arterial
chemoembolization. He tolerated the TACE poorly and has had
subsequent progression of disease and is not a candidate for RFA
or cyberknife therapy.
-Hepatitis B cirrhosis
-h/o reptured hematoma
-Prostate Ca
Social History:
-(+) EtOH/Tobacco in past; not anymore
-military (Korean/[**Country 3992**])
-Lives with 2 supportive sisters and GF from [**Name (NI) 2784**]
Family History:
Non-contributory
Physical Exam:
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-19**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
Admission Labs:
[**2174-4-2**] 06:56PM ASCITES TOT PROT-0.6
[**2174-4-2**] 06:56PM ASCITES WBC-470* RBC-85* POLYS-52* LYMPHS-6*
MONOS-0 MACROPHAG-42*
[**2174-4-2**] 03:30PM HCT-28.0*
[**2174-4-2**] 10:15AM PO2-225* PCO2-26* PH-7.46* TOTAL CO2-19* BASE
XS--2 COMMENTS-SPECIMEN T
[**2174-4-2**] 09:20AM COMMENTS-GREEN TOP
[**2174-4-2**] 09:20AM GLUCOSE-113* LACTATE-2.9*
[**2174-4-2**] 09:15AM GLUCOSE-121* UREA N-35* CREAT-1.0 SODIUM-126*
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-20* ANION GAP-13
[**2174-4-2**] 09:15AM estGFR-Using this
[**2174-4-2**] 09:15AM ALT(SGPT)-22 AST(SGOT)-36 CK(CPK)-35* ALK
PHOS-249* TOT BILI-3.4*
[**2174-4-2**] 09:15AM LIPASE-111*
[**2174-4-2**] 09:15AM cTropnT-<0.01
[**2174-4-2**] 09:15AM CK-MB-NotDone
[**2174-4-2**] 09:15AM CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2174-4-2**] 09:15AM AMMONIA-86*
[**2174-4-2**] 09:15AM WBC-7.4 RBC-3.13* HGB-8.1* HCT-25.3* MCV-81*
MCH-26.0* MCHC-32.1 RDW-24.7*
[**2174-4-2**] 09:15AM NEUTS-85.0* LYMPHS-8.7* MONOS-5.6 EOS-0.6
BASOS-0.1
[**2174-4-2**] 09:15AM PLT COUNT-168
[**2174-4-2**] 09:15AM PT-18.6* PTT-34.5 INR(PT)-1.7*
.
Labs on discharge:
[**2174-4-8**] 05:10AM BLOOD WBC-3.5* RBC-3.69* Hgb-10.1* Hct-30.9*
MCV-84 MCH-27.3 MCHC-32.6 RDW-22.6* Plt Ct-80*
[**2174-4-8**] 05:10AM BLOOD PT-18.6* PTT-64.1* INR(PT)-1.7*
[**2174-4-8**] 05:10AM BLOOD Glucose-91 UreaN-23* Creat-0.6 Na-132*
K-4.3 Cl-105 HCO3-19* AnGap-12
[**2174-4-7**] 05:35AM BLOOD ALT-19 AST-38 AlkPhos-201* TotBili-3.6*
[**2174-4-8**] 05:10AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.0
.
IMAGING:
CT Abd:
IMPRESSION:
1. Moderate-to-large amount of ascites in the abdomen. No
evidence of intraperitoneal or retroperitoneal bleeding.
2. Markedly distended urinary bladder with Foley catheter
balloon within the urethra, repositioning required.
3. Cirrhotic liver with hypoattenuating lesions consistent with
hepatocellular carcinoma, and hyperattenuating foci consistent
with prior
chemoembolization.
.
RUQ Ultrasound: ([**4-2**])
IMPRESSION:
1. Moderate ascites, spot marked for bedside paracentesis.
2. Doppler examination difficult given the abdominal ascites.
Nonocclusive
thrombus in the main portal vein, with slow flow. Hepatopetal
flow in the
left portal vein. Right portal vein not seen. Recommend repeat
Doppler
examination following paracentesis.
3. Cirrhotic liver, with limited evaluation for focal lesions.
.
RUQ U/S ([**4-6**]):
IMPRESSION:
1. Moderate ascites is slightly decreased since [**2174-4-2**].
2. No evidence of flow in the main and right portal veins,
consistent with
known thrombus, similar to [**2174-2-11**].
3. Cirrhotic liver with large infiltrative mass again seen.
.
.
MICRO:
[**2174-4-2**] 6:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2174-4-2**]):
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..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Brief Hospital Course:
In short, Mr [**Known lastname 11257**] is a 75M with metastatic
treatment-refractory HCC (Dx [**2168**]), course c/b ascites and
portal vein thrombosis, who presented with altered mental status
and concern for UGIB, s/p intubation for airway protection, now
improved to baseline. His hospital course is as follows:
.
# Altered mental status: Most likely hepatic encephalopathy.
Was given aggressive lactulose with marked improvement in his
mental status. He was also diagnosed with SBP as a possible
precipitant. CT head was unremarkable. He was extubated
without complications. RUQ ultrasound was negative for acute
thrombosis. EGD was negative for bleed. We continued his
lactulose and CTX with good effect. AOx3 on discharge.
.
# Respiratory failure: Intubated largely for airway protection.
Weaned quickly and extubated on [**2174-4-3**]. Was stable in the MICU
and on the floor thereafter.
.
# SBP: Diagnostic paracentesis on [**4-2**] with close to 250 PMNs.
Gram stain with PMNs. Given his clinical picture, pt treated
with a 5-day CTX course as well as with albumin.
.
# Metastatic HCC: s/p 5FU on [**2174-3-24**]. Poor prognosis. Discussed
possible hospice, but pt did not feel ready to make the
decision. Plan was discussed with Dr [**Last Name (STitle) **] and Dr [**First Name (STitle) 679**].
.
# Pancytopenia: Likely the result of his chemotherapy. EGD was
negative for acute bleeding.
.
# Urinary Retention: Urology was consulted for elevated bladder
scan and difficult Foley. They recommended keeping the Foley
catheter in place x2 weeks and to follow up as an outpatient. Pt
also developed low urine output, likely [**1-17**] low flow from severe
liver disease. Since pt comfortable and Cr 0.6, no intervention
done. Mild intermittent oozing at urethral meatus likely from
foley trauma.
.
# Full code
# Contact:
[**Name (NI) 28814**] (sister) [**Telephone/Fax (1) 28815**] (home), [**Telephone/Fax (1) 28816**] (cell)
[**Name (NI) **] (brother) [**Telephone/Fax (1) 28817**] (home)
[**Name (NI) 3551**] (sister) [**Telephone/Fax (1) 28818**] (cell)
Medications on Admission:
Spironolactone 25mg daily
Lactulose 15gm/15ml 1 tbsp daily
Omeprazole 20mg po daily
Prochlorperazine 10mg Q6-8hrs prn nausea
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day): Please titrate to [**2-16**] bowel movements per day.
Disp:*1350 ML(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
hepatic encephalopathy
.
metastatic hepatocellular carcinoma
hepatitis B cirrhosis
prostate cancer
Discharge Condition:
improved, mental status at baseline.
there is some oozing/bleeding at the urethral meatus [**1-17**] foley
trauma; foley flushes without any obstruction or clot to suggest
internal hemorrhage
Discharge Instructions:
You were admitted to the hospital with altered mental status
likely from hepatic encephalopathy. Please continue taking
lactulose to have [**2-16**] bowel movements a day. Take more lactulose
if you feel confused.
.
Your medications changes are as follows:
1. continue your spironolactone 25mg daily
2. continue your lactulose
3. changed your prilosec to high-dose pantoprazole (40mg twice
daily)
.
If you have any fevers, chills, chest pain, shortness of breath,
abdominal pain or any other concerning symptoms, please call
your physician.
Followup Instructions:
Please call your primary care physician for followup upon your
discharge: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 682**]
.
Please follow up with urology in 2 weeks for voiding trial and
PSA check: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] ([**Telephone/Fax (1) 5727**]) or Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**]
([**Telephone/Fax (1) 6445**]).
.
Other appointments:
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-14**] 11:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-21**] 11:00
Provider: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-4-28**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2174-4-9**]
|
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"596.0",
"E933.1",
"155.0",
"571.5",
"V10.46",
"567.23",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"58.22",
"96.71",
"57.94",
"54.91",
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] |
icd9pcs
|
[
[
[]
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|
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|
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|
6296, 6311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,160
| 105,597
|
47149
|
Discharge summary
|
report
|
Admission Date: [**2174-9-27**] Discharge Date: [**2174-10-5**]
Date of Birth: [**2096-3-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Zoloft
/ Remeron
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Increased Dyspnea
Major Surgical or Invasive Procedure:
Pulmonary intubation (at OSH)
History of Present Illness:
78 y/o woman with CAD multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulm hypertension, CVA, HTN,
NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 **] [**Location (un) 620**]
on the night of [**9-26**] with fever, severe dyspnea, wheezing,
malaise, nausea, and one episode of watery diarrhea. On
presentation, she was hypoxemic to 70% on RA. She had crackles
and wheezing on lung exam. CXR showed possible LLL infiltrate,
pulmonary edema. The patient received aspirin, 40mg IV lasix,
and 750mg IV Cipro. Initially, the patient was given metoprolol
and the rest of her home meds including losartan, aspirin,
[**Date Range 4532**], and lipitor were continued. She was placed on BiPap.
Overnight, she developed more dyspnea and hypoxemia and O2 sat
dropped to 82% on NRB. ABG was 7.32/32/54 on BiPap. The patient
was intubated started on lasix gtt, nitro gtt, and heparin gtt.
On arrival to the floor, patient was intubated but awake, able
to answer questions and follow commands, and in no acute
distress. She denied any chest pain or abdominal pain. Vitals on
transfer were 99.4, 111/49, 64, 15, 100% on 100% FIO2.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension
2. CARDIAC HISTORY:
-Extensive CAD s/p multiple stents
-CABG: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# H/o CVA [**2157**]
# Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**]
followed by [**Doctor Last Name **])
# PVD
# DM II - not on insulin
# Hypertension
# Migraine headaches
# Gastritis - no peptic ulcer disease history.
# Depression x30 years, initially reactive
Social History:
Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.
Family History:
Mother had CAD and MI. Father died at a young age of MI.
Physical Exam:
On Admission:
VS: 99.4, 111/49, 64, 15, 100% on 100% FIO2.
GENERAL: 78yo female. Intubated but awake and in NAD. Able to
answer questions and follow commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: mechanical ventilations. Decreased lung sounds at left
lung base, crackles in LLL.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema. Palpable DP pulses. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
GENERAL: 78yo female. Alert and oriented x3 and in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: trace fine bibasilar crackles, normal work of breathing,
no accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. + BS
EXTREMITIES: No edema. Palpable DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Labs on Admission:
[**2174-9-27**] 10:27AM BLOOD WBC-16.0*# RBC-2.46*# Hgb-7.5*#
Hct-23.1*# MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-266#
[**2174-9-28**] 01:57AM BLOOD PT-15.0* PTT-54.3* INR(PT)-1.4*
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-27**] 10:27AM BLOOD Glucose-191* UreaN-46* Creat-2.2* Na-141
K-4.5 Cl-111* HCO3-21* AnGap-14
[**2174-9-27**] 10:27AM BLOOD Calcium-8.2* Phos-4.7* Mg-1.9
[**2174-9-27**] 02:06PM BLOOD Type-ART pO2-69* pCO2-37 pH-7.33*
calTCO2-20* Base XS--5
[**2174-9-27**] 10:24PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-94 pCO2-28*
pH-7.42 calTCO2-19* Base XS--4 Intubat-INTUBATED
[**2174-9-27**] 02:06PM BLOOD Lactate-1.0
Hemeatology Labs:
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-28**] 05:40PM BLOOD calTIBC-140* Ferritn-842* TRF-108*
Cardiac Labs:
[**2174-9-27**] 10:27AM BLOOD CK-MB-17* cTropnT-1.17*
[**2174-9-27**] 02:28PM BLOOD CK-MB-19* MB Indx-6.9* cTropnT-1.25*
[**2174-9-27**] 02:28PM BLOOD CK(CPK)-277*
[**2174-9-27**] 07:52PM BLOOD CK-MB-19* MB Indx-7.1* cTropnT-1.32*
[**2174-9-27**] 07:52PM BLOOD CK(CPK)-267*
[**2174-9-28**] 01:57AM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-1.34*
[**2174-9-28**] 01:57AM BLOOD CK(CPK)-200
[**2174-9-28**] 09:53AM BLOOD CK-MB-11* cTropnT-1.32*
[**2174-9-28**] 05:40PM BLOOD CK-MB-9 cTropnT-1.37*
[**2174-9-28**] 05:40PM BLOOD CK(CPK)-174
[**2174-9-30**] 06:11AM BLOOD CK-MB-6 cTropnT-1.59*
[**2174-9-30**] 06:11AM BLOOD CK(CPK)-77
[**2174-10-1**] 04:03AM BLOOD CK-MB-5 cTropnT-1.55*
[**2174-10-1**] 04:03AM BLOOD CK(CPK)-51
UA:
[**2174-9-27**] 11:35PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2174-9-27**] 11:35PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
[**2174-9-27**] 11:35PM URINE CastHy-17*
[**2174-9-29**] 05:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2174-9-27**] 11:35PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2174-9-29**] 05:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
Microbiology:
[**2174-9-27**] 11:35 pm URINE Source: Catheter.
**FINAL REPORT [**2174-9-29**]**
URINE CULTURE (Final [**2174-9-29**]): NO GROWTH.
[**2174-9-27**] 10:27 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-27**] 2:27 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-27**] 11:35 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-28**] 1:00 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2174-9-30**]**
GRAM STAIN (Final [**2174-9-28**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2174-9-30**]): NO GROWTH.
Blood Culture [**2174-9-28**]: NGTD x 6 days
Images/Studies:
EKG [**2174-9-27**]: Sinus rhythm. Slight ST segment elevation with T
wave inversions in the anterior leads raises concern for
evolving myocardial infarction. Clinical correlation is
suggested. Inferior ST-T wave changes may also be due to
ischemia. Compared to tracing #1 there are now deep T waves seen
in leads V3-V6 raising concern for ischemia. Clinical
correlation is suggested.
EKG [**2174-9-28**]: Sinus rhythm. ST segment elevation with T wave
inversions seen in the anterior precordial leads raises concern
for ischemia. Inferior ST-T wave changes also raise some concern
for ischemia. Compared to tracing #2 no interim change.
EKG [**2174-10-1**]:Sinus rhythm. Left atrial abnormality. Compared to
the previous tracing of [**2174-9-28**] there is further evolution of
recent or ongoing anterolateral and apical myocardial
infarctions. Clinical correlation is suggested.
EKG [**2174-10-2**]: Sinus rhythm with increase in rate as compared to
the previous tracing of [**2174-10-1**]. There is further evolution of
acute anterolateral and apical myocardial infarctions. Followup
and clinical correlation are suggested. The Q-T interval remains
prolonged.
CXR [**2174-9-27**]: Endotracheal tube with distal tip in the right
mainstem bronchus. Unchanged bilateral pulmonary edema and left
lower lung atelectasis with possible pleural fluid.
CXR [**2174-9-28**]: The left mid and lower lung consolidation is
redemonstrated, concerning for large infectious process
associated with pleural effusion. Patient continues to be in
interstitial pulmonary edema, moderate in severity. The ET tube
tip is 4 cm above the carina. NG tube is in the stomach.
CXR [**2174-9-29**]: Small right and moderate left pleural effusions
are grossly unchanged allowing the difference in position of the
patient. Cardiomediastinal contours are unchanged, partially
obscured by the pleural and parenchymal abnormalities. Moderate
pulmonary edema is stable. Left mid and left lower lobe
consolidations are unchanged.
Labs on Discharge:
[**2174-10-5**] 06:00AM BLOOD WBC-11.3* RBC-2.40* Hgb-7.3* Hct-22.6*
MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-424
[**2174-10-5**] 06:00AM BLOOD Glucose-201* UreaN-58* Creat-1.9* Na-142
K-4.0 Cl-111* HCO3-18* AnGap-17
[**2174-10-5**] 06:00AM BLOOD Mg-2.2
Brief Hospital Course:
78 y/o woman with CAD s/p multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulmonary hypertension, CVA,
HTN, NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 18**]
[**Location (un) 620**] with dyspnea and hypoxemia c/b acute respiratory failure
requiring intubation and tranferred to [**Hospital1 18**].
# NSTEMI/CAD: Patient with significant prior history of 3 vessel
CAD s/p multiple PCIs and stents. Enzymes positive and trending
up at [**Hospital1 18**] [**Location (un) 620**], EKG upon arrival here with T-wave
inversions in V3-V6. Cardiac enzymes were trended and peaked and
plauteued on HOD 2. She was continued on a heparin gtt to
complete 48 hour treatment. Home ASA, [**Location (un) 4532**], statin, and
metoprolol were continued. On HOD 4 there was concern for
evolving changes on EKG. Cardiac enzymes at that time were
elevated to trop of 1.59, however with flat CK and CKMB. A cath
was considered, however it was determined not to be acute
evolution and not urgent. Will likely need cath as an
outpatient.
# Diastolic Heart Failure: Patient with history of diastolic CHF
with preserved ejection fraction. Initially not significantly
volume overloaded on exam, weight is similar from recent
cardiology visit. Likely flash pulmonary edema due to sustained
hypertension and tachycardia (patient with another recent
admission to [**Location (un) 620**] for flash pulmonary edema in setting of
gastritis). The patient was diuresed with IV lasix bolus prn.
She recieved 40 mg IV on HOD 1 with poor response. She recieved
80mg IV x 2 on HOD 2 with ok response. On HOD 4 she recieved
120mg IV lasix in the AM with poor UOP and then recieved 5 mg
metolazone followed by 120 mg IV lasix with good UOP response.
On HOD 6 patient appeared dry and required 500 cc of fluids. The
patient was initially managed with nitro gtt for afterload
reduction, but then was transitioned to home hydralazine,
amlodipine, losartan, and imdur. The medications were adjusted
and patient was discharged on the following regimen: hydralazine
50mg TID, isosorbide 120mg daily, and losartan 50mg daily for
afterload and 20mg lasix daily for diuresis.
# Pneumonia: Elevated WBC with LLL opacity on CXR on admission.
Patient recieved 750 of cipro at OSH and was initially started
on levofloxacin 500mg q48h upon arrival to [**Hospital1 18**]. The patient
then spiked a fever on HOD 1 and she was broadened to cefepime
and vanc to cover for HCAP given recent hospitalization. She was
treated for 8 days with day 1 of treatment 10/09/10/10, patient
completed antibiotics on day of discharge ([**10-5**]).
# Hypoxic respiratory failure: Likely due to a combination of
pulmonary edema and pneumonia. Patient was intubated on arrival.
Propofol and fentanyl were used for sedation. The patient was
successfully extubated on HOD 2.
# Gout Flair: The patient developed gout flare (right podagra)
on [**10-3**]. She was started on oxycodone 2.5 mg Q6H for pain.
Secondary to patient's renal function colchicine and NSAIDs were
avoided. She was therefore started on prednisone 30 mg x 1 day,
20 mg AM x 1 day, and then will complete slow taper over 7 days.
# Normocytic Anemia: Patient with Anemia dating back to [**2163**]. As
low as this admission previously in [**2171**]. Patient with Hct of 23
on admission. Patient with normal reticulocyte count and iron
studies consistent with anemia of chronic disease (low iron, low
TIBC, high ferritin). Patient was started on iron
supplementation and will need GI workup as an outpatient to rule
out GI loss as part of low iron. Patient's Hct was trended and
she remained stable and asymptomatic and did not require blood
transfusion. Hct on discharge of 22.6.
# CKD: The patient has a history of CKD with Cr ranging from 1.7
- 3.3 over the last 1.5 years. Baseline appears to be low 2's.
Cr on admission of 2.2. Medications were renally dosed and
nephrotoxins were avoided when possible. Cr was trended and 1.9
on discharge.
# Type II diabetes: The patient's home metformin was held and
the patient was maintained on humalog ISS.
# Hypertension: The patient's home medications were initially
held and she was on nitro gtt on arrival. She was weaned off
nitro gtt and home medications were restarted as tolerated.
Eventually she was on home amlodipine, losartan, hydralazine,
metoprolol, and Imdur.
# Hyperlipidemia: Home atorvastatin was continued.
# Depression: Home mirtazapine was continued. Patient on
desvenlafaxine at home, not on formulary at [**Hospital1 18**], gave
venlafaxine in the meantime to avoid SSRI withdrawl.
# Hypothyroidism: Home levothyroxine continued.
Transitional Issues:
- [**Month (only) 116**] need outpatient Cath.
- Needs GI work up as an outpatient.
- Patient insturcted to weigh self every morning, and call Dr
[**Last Name (STitle) 2903**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
-Patient to have chem-7 on Monday [**2174-10-10**] with results sent to
Dr. [**Last Name (STitle) 2903**]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. HydrALAzine 50 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. traZODONE 75 mg PO HS:PRN insomnia
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Zolpidem Tartrate 5 mg PO HS
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Pristiq *NF* (desvenlafaxine) 50 mg Oral daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Mirtazapine 45 mg PO HS
8. traZODONE 100 mg PO HS:PRN insomnia
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Escitalopram Oxalate 5 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. HydrALAzine 50 mg PO TID
15. Losartan Potassium 50 mg PO DAILY
16. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
17. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*2
18. Outpatient Lab Work
Please check chem-7 on Monday [**2174-10-10**] with results to Dr. [**Last Name (STitle) 2903**]
at Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
ICD9: 428
19. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST elevation myocardial precautions
Hospital Acquired Pneumonia
Acute on Chronic Diastolic congestive heart failure
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 34407**],
You were transferred to [**Hospital1 18**] a fever and trouble breathing. You
were found to have a pneumonia and were treated with 8 days of
intravenous antibiotics. You also were in heart failure with too
much fluid on board and we gave you diuretics to remove the
extra fluid.
Changes to your home medications include:
-CHANGE metoprolol to once daily formulation (metoprolol
succinate XL 150mg daily)
-START prednisone for your gout flare. You will take 3 more days
of prednisone at home. Please call Dr. [**Last Name (STitle) 2903**] if the gout returns.
-START iron for your anemia
Weigh yourself every morning, call Dr [**Last Name (STitle) 2903**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Please take all
of your medicines as directed.
It was a pleasure taking care of your during your
hospitalization and we wish you the best going forward.
Followup Instructions:
Please make an appt to see Dr. [**Last Name (STitle) **] in 1 month.
.
Department: [**State **]When: Thursday [**2174-10-13**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2174-10-6**]
|
[
"274.01",
"414.01",
"293.0",
"443.9",
"250.00",
"346.90",
"486",
"780.52",
"585.9",
"V45.82",
"333.94",
"416.8",
"280.9",
"562.10",
"410.71",
"715.90",
"428.0",
"428.33",
"447.4",
"244.9",
"296.50",
"404.91",
"518.81",
"285.29",
"V58.66"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16056, 16105
|
9216, 13858
|
351, 383
|
16276, 16276
|
3688, 3693
|
17402, 17808
|
2248, 2306
|
14977, 16033
|
16126, 16255
|
14254, 14954
|
16461, 17379
|
2321, 2321
|
1673, 1738
|
3093, 3669
|
13879, 14228
|
294, 313
|
8937, 9193
|
411, 1566
|
3707, 8918
|
16291, 16437
|
1769, 2076
|
1588, 1653
|
2092, 2232
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,206
| 128,415
|
9304
|
Discharge summary
|
report
|
Admission Date: [**2129-1-17**] Discharge Date: [**2129-1-21**]
Date of Birth: [**2093-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Decreased vision in left eye
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 35 year-old male with a history of hypertension
(not currently on medication) who presents with blurry vision in
his left eye. The patient was in his usual state of good health
until 2 weeks prior to admission, when his left eye developed
darkness in the center of the visual field and blurriness in the
peripheral visual field. Over the following two weeks, the
patient reports no improvement or worsening of the blurriness.
On the day of admission, the patient visited his PCP for
evaluation of vision, and blood pressure was found to be
264/160. The patient was given lasix (20 mg, PO) and Aspirin
(325 mg, PO) and sent by ambulance to [**Hospital1 18**]. The patient denies
dizziness, headache, changes in speech, motor deficits, tingling
or numbness, back pain, chest pain, palpitations, shortness of
breath, recent drug use, or consumption of wine/aged cheese. The
patient reports an increase in his dietary salt intake during
the 2-3 weeks prior to admission.
.
In the ED, the patient was in NAD, with T 98.4 P 100 BP 235/154
RR 18 SaO2 100 (RA). He was found to have optic disc swelling
and macular edema in his left eye. He denied CP, SOB, N/V/D. His
neuro exam was reported as normal. An EKG showed ST depression
in II,III, avf, with non-elevated cardiac enzymes. BUN/Cr
returned as 22/1.7 (baseline 1.1 from 3/[**2126**]). A CXR showed
cardiomegaly but no volume overload. CT head showed no acute
hemorrhage. He received a total of 5 L fluid in the ED. He was
started on a nitroprusside drip, and was changed to labetalol.
BP improved to 199/125 and vision improved (not back to normal),
and the patient was transferred to the ICU for further
evaluation and treatment.
.
Upon arrival to the ICU, he was in NAD. T 94.4 P 95 BP 192/109
RR 20 SaO2 100 (RA). BUN/Cr was 16/1.3. The patient was
continued on labetolol drip, and was transferred to the floor
once confirmed as stable.
.
On the floor, the patient had T 99.1 P 84 BP 178/109 RR 20 SaO2
95(RA). He reports that the visual blurriness continues to
resolve.
.
.
ROS: Three weeks prior to admission, the patient reports one
episode of headache, which was bitemporal in location, [**1-4**] in
intensity, and lasted 1 hour. Review of Systems otherwise
negative except as specified in HPI (Denies fevers/chills,
nausea, changes in hearing, chest pain, abdominal pain, blood in
stool, dysuria, tingling/numbness/neakness in limbs, new rashes,
easy bleeding).
Past Medical History:
1. Hypertension (diagnosed [**2126**], patient prescribed lisinopril.
Voluntarily discontinued medication)
2. Folliculitis keloidalis nuchae (prescribed minocycline,
hibiclens, lidex gel by dermatologist. Pt. not currently using
meds)
3. Bilateral Pterygia (chronic issue, stable)
Social History:
The patient was born in [**Country 3587**], [**Country 480**] (moved to United
States in [**2109**]). Works in shipping/receiving, office
installations. Patient lives at home with his wife and daughter
(10 months old).
Alcohol: Reports drinking 6 beers on weekend, 2 on weeknights.
Smoking: Hx of [**12-28**] cigarettes/day for < 1 yr. Quit 10 yrs ago
Drugs: Denies
Family History:
Patient's grandfather: CAD, diabetes mellitus (living, age [**Age over 90 **])
[**Name (NI) **] father: diabetes mellitus, hypertension
Reports pterygia in most of family members
Physical Exam:
Vitals T 99.1 P 84 BP 178/109 RR 20 SaO2 95(RA).
.
General: This is a healthy-appearing male in no apparent
distress. On exam, he is conversational and nontoxic appearing.
Skin: Warm and well perfused. Nails without clubbing or
cyanosis. Scattered keloidal papules along the posterior
hairline, with superficial crusting.
HEENT: Head is normocephalic and atraumatic. Sclera anicteric.
Bilateral pterygium. Oral mucosa pink. Poor dentition
(deterioration of teeth/gums, many missing teeth). Trachea
midline. Neck supple. Thyroid non-enlarged.
Pulmonary: Thorax is symmetric with good expansion. Breath
sounds clear to ascultation bilaterally. No rales/ wheezes/
rhonchi.
Cardiac: Regular rate and rhythm. Normal S1, S2. no m/r/g
Lymphatic: No cervical or supraclavicular lymphadenopathy.
GI: +Bowel sounds, abdomen soft, nontender, nondistended. No
organomegaly
Rectal: Not performed.
Neuro: PEERLA, EOMI, tongue midline, face symmetric. Moving
5/5x4.
Extremities: Warm and well perfused, radial pulse 2+, DP 2+
bilaterally. ROM intact.
Pertinent Results:
Admission Labs:
.
[**2129-1-17**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2129-1-17**] 09:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-1-17**] 09:00PM URINE RBC-0 WBC-[**1-27**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2129-1-17**] 06:45PM GLUCOSE-110* UREA N-22* CREAT-1.7* SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
[**2129-1-17**] 06:45PM CK(CPK)-165
[**2129-1-17**] 06:45PM cTropnT-<0.01
[**2129-1-17**] 06:45PM CK-MB-2
[**2129-1-17**] 06:45PM CALCIUM-10.6* PHOSPHATE-3.1 MAGNESIUM-2.2
[**2129-1-17**] 06:45PM WBC-10.0 RBC-4.96 HGB-14.2 HCT-43.4 MCV-87
MCH-28.5 MCHC-32.7 RDW-13.7
[**2129-1-17**] 06:45PM NEUTS-71.1* LYMPHS-22.4 MONOS-5.4 EOS-1.0
BASOS-0.2
[**2129-1-17**] 06:45PM PLT COUNT-264
[**2129-1-17**] 06:45PM PT-14.0* PTT-27.9 INR(PT)-1.2*
.
[**2129-1-17**] CT head: No acute intracranial process.
.
[**2129-1-18**] ECHO: The left atrium is elongated. 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). Transmitral Doppler and
tissue velocity imaging are consistent with Grade II (moderate)
LV diastolic dysfunction. 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
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. No significant valvular abnormality seen.
.
[**2129-1-18**] Renal Ultrasound:
1. No hydronephrosis. No renal stones or cysts or masses.
2. No specific sign of renal artery stenosis however this is a
limited
Doppler examination.
.
[**2129-1-19**] MRA: Normal renal MRA. No evidence of renal artery
stenosis.
Brief Hospital Course:
This is a 35 year-old male with history of hypertension, who
presents to the ED with left eye blurriness, BP 264/160, and
clinical picture consistent with Hypertensive Emergency. The
patient reports an increased salt intake during the days
preceeding onset of visual blurriness.
.
# Hypertensive Emergency: Symptoms of headache and vision
changes resolved on the medical floor. No evidence of
intracranial bleed of cardiac ischemia as a result of
hypertensive episode. Patient does have elevated creatinine
likely the result of elevated blood pressures. Blood pressure is
now better controlled. Presume poorly controlled primary HTN as
etiology but considered secondary causes given profound HTN in a
young man. Renal artery stenosis was ruled out by ultrasound and
MRI. No evidence of rib notching on CXR to suggest coarctation.
Urine and serum tox screens are negative making
intoxication/sympathomimetics a less likely cause of patient's
extreme blood pressures. Obstructive sleep apnea unlikely. TSH
is wnl (hyperthyroid is unlikely). Patient was started on
amlodipine 10mg, HCTZ 25mg, and lisinopril 10mg daily. Blood
pressure responded and fell to < 150/90 at the time of
discharge. Nutrition and social work were consulted to discuss
life style changes and the challenges of starting new medical
regimens. Patient may benefit from follow up with a dietician
and social worker. [**Name (NI) **] is instructed to follow up with his
primary care provider within three days of discharge to have his
blood pressure monitored and his regimen tailored.
.
# Acute Renal Failure: Creatinine of presentation 1.7 (baseline
1.1 from 3/[**2126**]). Most likely primary hypertension leading to
renal failure rather than the reverse. ACEI were initially held
until creatinine was trending down. Creatinine fell to 1.3 with
IVF. However, Patient experienced increased creatinine (2.0)
after simultaneously starting HCTZ and lisinopril. Doses were
adjusted and creatinine was trending down at the time of
discharge. Patient is instructed to follow up with his primary
care provider within three days of discharge to have his renal
function monitored on his new antihypertensive regimen. Patient
schedule for an appointment with renal in outpatient setting to
establish care for likely underlying chronic renal
insufficiency.
.
# Blurry Vision: Seen by Opthomology in Emergency Department.
Described as hypertensive fundus changes - severe with optic
nerve swelling and macular edema. Recommended BP control and to
call if vision worsens. Presumed manifestation of hypertensive
emergency. Patient vision returned to baseline at time of
discharge. Patient is schedule follow up with outpatient
ophthalmology.
.
# Anemia: Likely dilutional as Hct fell from 43 on admission to
33 overnight with the administration of 5 L IVF. No apparent
bleeding. Patient asymptomatic. Hct trended up after initial
IVF bolus to 39.7 at the time of discharge.
.
# EKG changes: ST depression in leads II, III, AVF. Likely
cardiac strain in setting of hypertension. Non-elevated
troponin. Normal CK-MB. No chest pain.
.
# Code: Full
.
# Communication: Patient
.
# Disposition: Home
Medications on Admission:
None
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please have your blood drawn to monitor your Basic Metabolic
Panel (K, Na, Cl, HCO3, BUN, Cr) on Monday [**2129-1-24**].
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Acute Renal Failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for extremely high blood
pressure and changes in vision in your left eye. You required
ICU level of care to get your blood pressures under control.
You were transferred to the medical floor where your blood
pressure and kidney function was closely monitored. Your vision
improved as your blood pressure was better controlled and you
were discharged home with new medications. It is very important
that you keep your follow up appointments and a low salt diet to
prevent your symptoms from returning.
.
The following changes were made to your medications:
1) START Amlodipine 10 mg by mouth daily
2) START Lisinopril 10 mg by mouth daily
3) START Hydrochlorothiazide 25 mg by mouth daily
.
Please notify your physician or return to the hospital if you
experience change in your vision, headache, loss of
consciousness, or anyother symptom that is concerning to you.
Followup Instructions:
Please follow up with your new kidney doctor Dr. [**Last Name (STitle) **] on
Thursday [**2-10**] at 9am. Clinic is located on the seventh
floor of the [**Hospital Ward Name 23**] building in the [**Hospital1 18**] [**Hospital Ward Name 516**]. If you
need to reschedule please call [**Telephone/Fax (1) 60**].
.
Please follow up with your new eye doctor Dr. [**Last Name (STitle) **] on Wednesday
[**1-26**] at 2:30pm. The clinic is located on the fifth floor
of the [**Hospital Ward Name 23**] building in the [**Hospital1 18**] [**Hospital Ward Name 516**]. If you need
to reschedule please call [**Telephone/Fax (1) 253**].
.
Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**]
on Monday [**1-24**] at 4pm. If you need to reschedule please
call [**Telephone/Fax (1) 7976**].
|
[
"V15.81",
"372.40",
"362.83",
"794.31",
"706.1",
"275.42",
"584.9",
"403.00",
"377.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10658, 10664
|
6981, 10141
|
343, 350
|
10751, 10760
|
4774, 4774
|
11710, 12557
|
3520, 3701
|
10196, 10635
|
10685, 10730
|
10167, 10173
|
10784, 11687
|
3716, 4755
|
275, 305
|
378, 2815
|
5699, 6958
|
4790, 5690
|
2837, 3120
|
3136, 3504
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,702
| 114,246
|
2680
|
Discharge summary
|
report
|
Admission Date: [**2114-11-9**] Discharge Date: [**2114-12-6**]
Date of Birth: [**2061-11-17**] Sex: F
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
History of Present Illness:
Patient intubated and history is per report and record review.
Ms. [**Known lastname **] is a 52-year-old female with ALL s/p chemo and single
cord blood transplantation complicated by CMV viremia,
streptococcal bacteremia, VRE UTI, and suspected GVHD-induced
hepatitis who presents with fever and productive cough. The
cough started 3 weeks ago and has been productive of green
sputum, and associated with mild shortness of breath,
nausea/vomiting (attributed to Gleevec), and fatigue. She saw
her oncologist on [**2114-11-6**] for a followup, was afebrile with O2
sat 91,RA, and was noted to have a WBC of 11.2. She was started
on azithromycin and advised to return to clinic in 3 days.
Today, she noted difficulty breathing and fevers/chills/night
sweats, as well as cough, with symptoms worse the past two days.
She also reports anorexia and [**7-1**]# wt loss. Her O2 sat was noted
to be 86 on RA, improving to 95 on 3L NC. Blood cultures and flu
swab were obtained and she was referred to the ED.
.
In the ED, her initial vitals were: 99.5 88 120/76 28 96% on 5L
NC. On exam, she was dry with diminished breath sounds and right
sided crackles, and tachycardia. A CT of the chest was ordered
looking for possible PCP and showed evidence of infection with
multifocal airspace opacities. She was started on vancomycin and
aztreonam, in addition to continuing her current azithromycin.
While in the ED, her respiratory status worsened, becoming more
tachypneic and hypoxic requiring intubation. Her recent vitals
(prior to intubation) show RR 32, HR 124, 127/83 and O2 sat of
76,RA -> 96,3L. She received 4L IVF in the ED. Cannot perform
ROS as pt is intubated and sedated.
Past Medical History:
ONCOLOGIC HISTORY
====================
Diagnosed with [**Location (un) 5622**] Chromosome positive pre-B cell ALL
in [**2113-11-25**]
- [**2113-12-13**]: Part A of hyperCVAD cycle 1 was started on and
imantinib 600mg po qdaily was started on [**2113-12-21**] when the Ph
chromosome came back as positive.
- [**2113-12-22**]: First LP performed by IR and cytarabine was
administered. Fluid non-diagnostic but as high suspicion for CSF
disease started on twice weekly methotrexate
---[**2113-12-28**]: CSF sample from confirmed CNS involvement of ALL
---[**2115-1-1**] CSF sample from was negative for ALL so IT MTX
discontinued
- [**2114-1-17**]: Part B hyperCVAD of cycle 1 was started (IT chemo
was
limited to D6 ara-C on [**2114-1-22**] to minimize neurotoxicity)
- [**2114-2-2**]: Cycle 2 (Part A) of hyperCVAD started
- [**2114-3-5**]: Cycle 2 (Part B) hyperCVAD chemotherapy started
- [**2114-4-5**]: IT MTX administered
OTHER PAST MEDICAL HISTORY
============================
- Latent tuberculosis: PPD with 12mm of induration in [**2111**] at
[**Hospital1 2177**] after which received [**1-26**] mos of INH discontinued due to
transaminitis, she has been on moxifloxacin suppression since
starting chemotherapy
-Hypertension
-Hyperlipidemia
-Diabetes Mellitus (not on medications)
-Vitamin D deficiency
- Hepatitis B Ab positive (core +), maintained on lamuvidine
Social History:
She is Mandarin-speaking only and immigrated from [**Country 651**] in [**2100**].
She previously worked in customer service. She denies any
history of tobacco, alcohol, or illicit drugs. She's married.
Family History:
There is no family history of cancer or blood disorders that she
is aware of.
Physical Exam:
GENERAL: Intubated, initially responsive to verbal stimuli, but
sedation increased for agitation.
HEENT: Pupils are equal and minimally reactive to light. ETT in
place.
LUNGS: R lung fields with diffuse crackles. L side clear.
HEART: RRR no M/R/G
ABDOMEN: + BS. Soft, nontender, nondistended with no
hepatosplenomegaly. There are no palpable masses.
EXTREMITIES: There is no edema. 2+ peripheral pulses. Moves all
ext spontaneously.
SKIN: No rashes. The skin is warm and dry.
Pertinent Results:
Admission Labs:
[**2114-11-9**] 01:37PM LACTATE-1.5
[**2114-11-9**] 09:15AM GLUCOSE-156* UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
[**2114-11-9**] 09:15AM ALT(SGPT)-24 AST(SGOT)-27 LD(LDH)-349* ALK
PHOS-189* TOT BILI-0.8
[**2114-11-9**] 09:15AM WBC-13.5* RBC-2.96* HGB-10.0* HCT-29.7*
MCV-101* MCH-33.8* MCHC-33.6 RDW-13.9
[**2114-11-9**] 09:15AM NEUTS-68.1 LYMPHS-17.8* MONOS-13.3* EOS-0.5
BASOS-0.3
Discharge Labs:
Radiology:
CT Chest w/o contrast:
IMPRESSION: New-onset airspace opacification with air
bronchograms of the
right upper lobes, lower lobes and middle portion of the right
middle lobe
with patchy diffusely distributed opacification in the left lung
with an
associated right pleural effusion, suggests the possibility of
an infectious process, such as multifocal bacterial pneumonia.
However, considering the patient's clinical history of recent
bone marrow transplantation, an atypical pneumonia must be
included in the differential diagnosis (fungal, mycobacterial,
viral organisms). Pulmonary edema and pulmonary hemorrhage are
less likely, as the patient's history does not have
corroborating symptoms for the same.
TTE:The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
ASSESSMENT AND PLAN: 52-year-old female with ALL s/p chemo and
single cord blood transplantation complicated by CMV viremia,
streptococcal bacteremia, VRE UTI, and suspected GVHD-induced
hepatitis who presents with pneumonia/sepsis and respiratory
failure.
.
# Respiratory failure:
Consistent with ARDS in setting on severe PNA. Very large A-a
gradient on admission. Placed on ARDS-NET protocol.
Nasopharyngeal aspirate for influenza was negative, and flu
cultures were negative. TB was ruled out with negative BAL,
despite patient's history of latent TB. Sputum cultures did not
show any bacteria. On Bronchoscopy, nothing significant was
visualized in the airways. BAL was negative for PCP; there was
some concern that inhaled pentamidine could make a BAL appear
falsely negative and diagnosis could require a tissue biopsy,
but the beta-glucan was also negative, which was reassuring for
rule out of PCP. [**Name10 (NameIs) **] patient had been started empirically on
treatment doses of bactrim for PCP until the first beta-glucan
returned negative. She was restarted on prophylactic doses of
bactrim, per BMT recommendations. Since her LFTs were beginning
to rise, bactrim was discontinued, as she has a history of
elevated LFTs in the setting of this medication.
.
Cardiac causes of respiratory failure were considered, but a TTE
showed hyperdynamic function with LVEF> 55%, mild pulm htn,
trivial pericardial effusion, and no valvular disease, so this
was not likely to cause a compromise in respiratory function.
.
The patient was very difficult to oxygenate for much of her ICU
stay. She was often desynchronous with the ventilator, often
over-breathing the ventilator on volume control but not able to
tolerate pressure control or pressure support ventilation
modalities intitially. Eventually, she was able to tolerate AC
settings with increased sedation, and only brief trials on
pressure support with less sedation. She would often desaturate
with positional changes, likely also had some mucus plugging.
Multiple attempts to wean down PEEP were unsuccessful as she
would desaturate. Muscle paralytics had to be emploted to assure
syncronized ventilation.
On [**11-25**], the patient was switched to Airway Pressure Release
Ventilation (APRV). This resulted in increased sats to ~93%, but
unable to wean FiO2 down from 100%. The patient was placed on a
RotaProne bed. Pronation resulted in some shortterm improvement
in saturation with the ability to wean oxygen to FiO2 of 80%.
On [**11-28**], the patient was switched to Triadyne II bed and was
continued on APRV. Nitric oxide was used as well with some
modest improvement in oxygenation.
On [**11-29**], the patient became hypotensive with SBP in 70s. The
patient desatted to low 70s/high 60s with IV bolus. The patient
was repositioned patient on left side and noticed decreased
breath sounds on left in new position. Adjusted ventilator
settings and started nitric oxide with no improvement in
oxygenation. Got stat CXR which showed large left pneumothorax.
Chest tube was immediately placed with vital signs improved
immediately upon chest tube placement. FiO2 was weaned to 90%.
On [**12-3**], the patient developed massive upper GI bleed. EGD was
performed at bedside which revealed massive amounts of clotted
blood in the fundus of the stomach, but no clear eveidence of
active bleed. The patient was started on IV PPI and was given
multiple blood products including pRBCs and FFP. The patient's
oxygenation worsened, and she continued to desat on FIO2 of 100%
and maximum nitric oxide. Given clinical deterioration,
extensive discussion was held with the patient's husband and
family about goals of care and a decision was made about no
further escalation in care, including no blood products or lab
draws. The patient expired the following day.
.
# Septic shock:
The patient was hypotensive requiring levophed and vasopressin
initially, likely due to septic shock secondary to multifocal
PNA, as seen on CT chest. Levophed was weaned down [**11-11**] and
vasopressin was stopped [**11-13**]. There was a wide differential
given her immunosuppression which included usual pathogens
(Strep, etc), viral (flu, CMV), PCP (esp with elev LDH),
atypicals. She was started empirically on broad antibiotic
coverage with vancomycin, aztreonam, and azithromycin. The
aztreonam was broadened to meropenem on [**11-12**] per ID
recommendations.
On admission, she was empirically started on PCP treatment doses
of bactrim and stress dose steroids with IV hydrocortisone. She
was also empirically started on oseltamivir for flu coverage
which was discontinued on the fifth day of treatment due to a
negative flu culture. The urine legionella antigen was negative,
and the patient did not grow any bacteria from her urine or
blood cultures. Once the beta-glucan was negative, the
treatment doses of bactrim for PCP were discontinued;
prophylactic doses re-started on [**11-18**] per BMT recommendations.
Serum beta-glucan and beta-galactomannan were negative on
multple occasions.
Patient was fluid overloaded after initial fluid resusciation.
Her urine output at times was low likely due to hypotension and
a component of ATN. She was given IVFs and albumin
intermittently. Urine output picked up successfully with fluids
and increases in blood pressure. After vasopressin was stopped,
she was diuresed on a lasix drip with successful output.
On [**11-24**], an inverse correlation between fever curves and
Bactrim use was found and Bactrim was re-started again. IVIG
was administered. On [**11-29**], mild CMV viremia (VL 1000) was
detected. Metropenem was discontinued on [**11-29**] per ID recs.
#Non-gap acidosis: Related to normal saline and a component of
renal failure. As renal failure improved and normal saline was
stopped, her acidosis stabilized. During her lasix drip
administration, the patient developed a metabolic contraction
alkalosis. She was started on acetazolamide.
#Ileus: Due to the high dose of fentanyl patient received, it
appeared she developed an ileus. An extensive bowel regimen plus
PO narcan alleviated her symptoms.
.
# ALL: On chronic immunosuppression s/p single cord blood
transplantation. Was not neutropenic. She was continued on
acyclovir for prophylaxis, and her tacrolimus was discontinued.
She was started on stress dose steroids of hydrocortisone 100mg
IV Q8hours; when the stress dose steroids were tapered down
slowly, the patient seemed to make less progress with her
respiratory status, so her steroid dose was increased back.
.
# Anemia: The patient intermittently needed blood transfusions
due to low Hematocrits. She received 2 units prbcs from
admission to the ICU to [**2114-11-16**]. Her anemia is likely due to
her CA, anemia of chronic inflammation and the daily blood draws
that were needed during her ICU course.
.
# Hep B: The patient was continued on lamivudine. A hep B viral
load was sent [**11-15**] and no DNA could be detected.
.
Medications on Admission:
ACYCLOVIR - 400 mg TID
AMLODIPINE - 5 mg daily
Azithromycin 500mg, then 250mg daily x5 days total, started
[**2114-11-6**]
IMATINIB 100mg daily (on hold)
LAMIVUDINE - 100 mg daily
LORAZEPAM - 0.5 mg Tablet - [**1-26**] Tablet(s) by mouth every six (6)
hours
OMEPRAZOLE - 20 mg Capsule daily
PENTAMIDINE [NEBUPENT] - (received in IP) - 300 mg Recon Soln -
1 ihnalation(s) po monthly received on [**11-6**]
PREDNISONE - 5 mg tablet daily
TACROLIMUS [PROGRAF] - 0.5 mg qAM (decreased from [**Hospital1 **] on
[**2114-11-6**])
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - 500 mg
(1,250
mg)-400 unit Tablet - 2 tabs daily
PYRIDOXINE - 100 mg Tablet two times per week
SENNA - 8.6 mg Tablet - [**1-26**] Tablet prn constipation
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2115-8-5**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
]
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14064, 14073
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6262, 13251
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291, 316
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14124, 14133
|
4248, 4248
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14189, 14226
|
3657, 3736
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14094, 14103
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13277, 14009
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14157, 14166
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4720, 6239
|
3751, 4229
|
231, 253
|
345, 2023
|
4265, 4703
|
2045, 3421
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3437, 3641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,446
| 118,319
|
41247+58429
|
Discharge summary
|
report+addendum
|
Admission Date: [**2104-2-23**] Discharge Date: [**2104-3-5**]
Date of Birth: [**2038-6-28**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache and neck pain
Major Surgical or Invasive Procedure:
[**2104-2-25**]: Cerebral angiogram
[**2104-2-29**]: Cerebral angiogram for coiling of the PICA and Basilar
tip aneurysm
History of Present Illness:
This is a 65 year old female who presents with a consistent
headache and neck pain. She is a patient of Dr.[**Name (NI) 89842**] at [**Hospital1 2025**]
and had 4 open craniotomies for
clippings of 3 R MCA aneurysms, 2 L MCA aneurysms, a R ACA
aneurysm, and a PICA aneurysm in [**2093**] and [**2095**]. According to [**Hospital1 2025**]
records, all aneurysms were nonruptured and treated intervally.
She was last seen in [**2097**] by Dr. [**Last Name (STitle) 1128**] and complained of
chronic headaches at that time. Per [**Hospital1 2025**] records, her last known
imaging was in [**2095-6-11**] which showed no remaining aneurysms or
recanalization of the treated aneurysms. A head CT at an OSH
showed no acute blood, and LP was done in the [**Hospital1 18**] ER which
appeared bloody.
Past Medical History:
Aneurysms as above
HTN
High cholesterol
Headaches
Liver Cyst
Depression
Cataracts
Cardiac Cath
Anemia
Bil TKR
Social History:
Spanish speaking primarily. Lives alone, not married, has three
children. + Tobacco- [**2-14**] cigarettes per day. Denies ETOH.
Currently unemployed.
Family History:
unknown
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 98.0 BP: 157/74 HR: 63 R 16 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Neck: Nuchal rigidity
Lungs: CTA bilaterally.
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, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-15**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
At Discharge:
Nonfocal exam.
Pertinent Results:
Head CT [**2104-2-23**]:
No [**Year/Month/Day **] blood. No acute hemorrhage.
CXR [**2104-3-2**]
IMPRESSION: AP chest read in conjunction with chest imaging on
an abdomen CT performed today, subsequently.
Lung volumes are low, exaggerating heart size and pulmonary
vascularity. At worst there is mild vascular engorgement. I see
no pneumonia. Pleural
effusion is minimal on the left. No pneumothorax.
CT abdomen [**2104-3-2**]:
FINDINGS:
The lung bases are clear with minimal atelectasis of the left
lung base.
There is 3-mm perifissural ground-glass opacity on the left (2;
1).
ABDOMEN: Within the limits of a non-contrast examination, the
liver and
spleen appear normal. Calcifications in the gallbladder neck
indicate
gallstones and otherwise normal-appearing gallbladder. The
pancreas is
unremarkable, as are the bilateral adrenal glands. The kidneys
are normal in appearance without hydronephrosis or stones. There
is mild-to-moderate
calcification of the aorta, which is normal in caliber along its
visualized course. There is mild haziness in the retroperitoneum
in the paraaortic and aortocaval regions which is likely
lymphatic.
PELVIS: The pelvic organs are normal in appearance. A Foley
catheter is seen within the bladder. No retroperitoneal hematoma
is present. Minimal
stranding around the right groin is likely the sequela of prior
catheterization. There is no fluid collection. Visualized loops
of small and large bowel appear normal, with note of
diverticulosis. There is no
intraperitoneal free fluid or free air.
BONE WINDOWS: No concerning lytic or blastic lesion. There is
facet
degenerative disease, most prominent at the L5-S1 level. No
concerning lytic or blastic lesions are seen.
IMPRESSION:
1. No retroperitoneal hematoma.
2. 3 mm ground-glass opacity in the perifissural region of the
left lower
lung. In the absence of risk factors, no further follow up is
needed. If
patient has risk factor such as smoking, recommend followup CT
in 12 months to
document stability.
3. Facet degenerative disease at the L5-S1 level in this patient
with back
pain.
Brief Hospital Course:
This is a 65 year old female who was admitted for headache and
neck pain. Although imaging showed no [**Last Name (LF) **], [**First Name3 (LF) **] LP was performed
which was equivocal. She was admitted to the Neuro-ICU for
monitoring as we continued to work-up her headaches to rule out
rupture given her complex aneurysmal history. An CTA could not
be performed given the amount of artifact and an MRA could not
be done because we could not verify the clipping's safety for
MRI. On [**2-25**] she underwent a diagnostic angiogram which showed a
basilar tip aneurysm and a partially clipped PICA aneurysm. She
remained in the ICU overnight then was transferred to the floor
on [**2-26**].
On [**2-29**], the patient was taken to the angio suite for coiling of
her PICA and basilar tip aneurysms. She tolerated the procedure
well. She was trasnfered to the PACU and she remained there on a
heprain drip as there were no SICU beds. She had a fever of
102.2F overnight [**3-1**]. Her heparin drip was stopped. A fever
work up was started. She was reporting back pain and a CT
abdomen was done and ruled out retroperitoneal hemorrhage. Her
Hct was stable. She remained afebrile and exam remained
nonfocal. She was sent home on [**3-3**].
Medications on Admission:
Amitriptyline 30mg QHS
Ibuprofen PRN
Vicodin PRN
Gabapentin 100mg TID
Lisinopril 40mg Daily
HCTZ 12.5mg Daily
Loratadine 10mg Daily
Flonase 50mcg - 2 sprays to each nostril daily
Calcium 600+D- 1 tab TID
MVI
ASA 81mg Daily
Lipitor 20mg Daily
Proair HFA 2 puffs 3-4x per day as needed
Flovent 110mcg - 1 puff [**Hospital1 **]
Vitamin C 500mg - 1 tab daily
Vitamin E 600 units
Fluticasone 1 puff [**Hospital1 **]
Cromolyn 4% opth solution - 2 gtts into both eyes TID prn
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
PICA aneurysm
Basilar tip aneurysm
L5-S1 facet djd.
Lung Nodule: 3mm LL base
Gallstones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
A CT of your abdomen was performed when you had back pain to
ensure that you did not have a hemorrhage. There was no
hemorrhage but this study showed gallstones, a lung nodule and
degenerative disease of the lumbar spine. You should follow up
with your PCP for these findings. You should have a CT chest in
12months to follow up on this.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks, no imaging is
needed at that time. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Please follow-up with your Primary Care Doctor regarding your
Lung lesion found on CT and gallstones.
Completed by:[**2104-3-3**] Name: [**Known lastname 8882**],[**Known firstname 14214**] Unit No: [**Numeric Identifier 14215**]
Admission Date: [**2104-2-23**] Discharge Date: [**2104-3-5**]
Date of Birth: [**2038-6-28**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2427**]
Addendum:
Ms. [**Known lastname 14216**] discharge was canceled and delayed on [**3-3**] when she
developed abdominal pain, nausea and vomiting. A general surgery
consult was obtained to rule out any intra abdominal process.
There was no evidence of a retroperitoneal hematoma or evidence
of bowel obstruction. Patient was on an aggressive bowel
regieman and had a bowel movement before discharge.
Brief Hospital Course:
Ms. [**Known lastname 14216**] discharge was canceled and delayed on [**3-3**] when she
developed abdominal pain, nausea and vomiting. A general surgery
consult was obtained to rule out any intra abdominal process.
There was no evidence of a retroperitoneal hematoma or evidence
of bowel obstruction. Patient was on an aggressive bowel
regieman and had a bowel movement before discharge.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2104-3-5**]
|
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icd9cm
|
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icd9pcs
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11978, 12140
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13,267
| 143,745
|
20623
|
Discharge summary
|
report
|
Admission Date: [**2157-3-18**] Discharge Date: [**2157-3-25**]
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 83-year-old male
who was transferred from an outside facility to [**Hospital6 1760**] after falling face-first down
an escalator. The patient reportedly lost consciousness at
the scene and sustained multiple facial lacerations. Initial
CT scan of the head at the outside facility revealed evidence
of intracranial hemorrhage, at which time the patient was
transferred to this facility.
On presentation to the Emergency Department at [**Hospital6 1760**], the patient was noted to
have a GCS of 15, complained of right hand and right knee
pain, as well as right-sided face pain. Per report, the
patient remained hemodynamically stable both during his stay
at the outside facility and during transport to [**Hospital3 **].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease, status post myocardial
infarction.
3. Congestive heart failure.
4. Chronic renal insufficiency.
5. Ureteral tumor.
6. History of hematuria.
PAST SURGICAL HISTORY:
1. Right inguinal herniorrhaphy.
2. Status post transurethral resection of the prostate.
SOCIAL HISTORY: No alcohol, smoking, tobacco, or
recreational drug use.
ALLERGIES: Versed.
MEDICATIONS:
1. Norvasc.
2. Proscar.
3. Coreg.
4. Terazosin.
5. Triamterene.
6. Quinine.
PHYSICAL EXAMINATION: Temperature 101.4, blood pressure
118/64, heart rate 90, respiratory rate 16, 98% on
nonrebreather mask.
NEUROLOGIC EXAM: Alert and oriented x 3, following commands,
moving all extremities, GCS 15.
HEENT: Pupils equal, round and reactive to light. Right
periorbital ecchymosis. Previously repaired right maxillary
zygomatic laceration approximately 8 cm in length. Midface
stable. Extraocular movements intact. TMs clear.
Oropharynx clear.
CARDIOVASCULAR EXAM: Regular rate and rhythm.
RESPIRATORY: Clear to auscultation bilaterally.
CHEST: Right clavicular tenderness without deformities or
abrasion.
ABDOMEN: Soft, nontender, nondistended.
PELVIS: Stable. Flank without deformities or tenderness.
BACK: TLS spine without deformities, stepoffs or tenderness.
C-spine without deformities, stepoffs or tenderness.
RECTAL: Heme negative, good tone.
EXTREMITIES: Right upper extremity with distal forearm
deformity. Minimal cyanosis right first phalanx. Right
lower extremity superficial abrasion to right knee and right
shin. Pulses 2+ bilateral upper and lower distal
extremities.
LABORATORY: CBC - white count 12.3, hematocrit 34, platelets
173. Chemistries within normal limits. Coags significant
for INR 1.1, lactate 1.4.
RADIOLOGY: CT of the head - bilateral frontal and parietal
subarachnoid hemorrhage, small left posterior parietal
subdural hemorrhage. CT of the C-spine negative. Right
wrist with intra-articular distal radius fracture and
intra-articular first phalanx fracture. CT of the face with
fine cuts - right orbital fracture of inferior and lateral
orbital walls, medial wall of the right maxillary sinus
fracture. Chest x-ray - right second rib fracture. Right
knee, tibia and fibula - no evidence of fracture. AP pelvis
- negative. [**3-18**] CT of the head - without change.
Thoracolumbar spine series - significant only for slight disk
narrowing at L5-S1 and L3-L4, without evidence of acute
fracture. MRI of the C-spine - spondylosis without evidence
of acute injury. [**3-21**] CT of the head - without significant
change.
HOSPITAL COURSE: The patient was evaluated and stabilized in
the trauma bay at [**Hospital6 256**]
Emergency Department and then transported to radiology for
the above mentioned radiographic studies. The patient then
returned to the Emergency Department and was noted to be
hemodynamically stable throughout his course, yet was
transferred to the T-SICU for frequent neurologic assessment
and hemodynamic monitoring.
Given the above mentioned findings on CT of the head, the
neurosurgery service was asked to consult on the patient in
the Emergency Department. The patient was then placed on q 1
h neuro checks, and a systolic blood pressure of less than
140 was maintained via arterial line monitoring.
Additionally, Dilantin was loaded intravenously, and the
patient's serum sodium was monitored, all per the
recommendations of the neurosurgery service. Repeat CT scans
of the head on hospital day #2 and #5, respectively, were
without significant.
Given the patient's right orbital fractures without evidence
of clinical or radiographic entrapment, both the
ophthalmology and plastic surgery services were asked to
evaluate the patient in the Emergency Department. The
plastic surgery service determined that the nature of the
fractures was nonoperative and wished to follow-up with the
patient in the outpatient setting, as described below. The
ophthalmology consultation service found no evidence of
retinal detachment, or visual deficit, and recommended cool
compresses for 48 hours, sinus precautions, and follow-up
with ophthalmology as an outpatient.
Given the patient's obvious right distal forearm fracture and
radiographically proven right thumb fracture, the orthopedic
service was asked to evaluate the patient while in the
Emergency Department. The orthopedic service felt that the
nature of the fractures were unlikely to require operative
repair, and recommended splinting of the injury with a thumb
spica cast, elevation of the affected extremity,
nonweightbearing status of the right upper extremity, and
follow-up as an outpatient with orthopedic.
After the patient's admission to the T-SICU, the patient's
course was notable only for confusion and intermittent bouts
of lethargy, without evidence of hemodynamic instability, or
worsening hemorrhage on repeat head CT. The patient was
transferred to the general surgical floor on hospital day #3,
given the hemodynamic stability and the stable neurologic
exam. The neurosurgery service at that time decided that
there was no further indication for potential surgical
intervention and requested to see the patient as an
outpatient with repeat output CT scan of the head.
On hospital day #4, the patient was found to have episodes of
decreasing responsiveness, at which time he remained
hemodynamically stable with normal fingerstick blood glucose,
an unremarkable EKG, normal chest x-ray, normal urinalysis,
and normal arterial blood gas values. Given the patient's
known intracerebral hemorrhage, a repeat head CT was
performed on hospital day #4, which showed no further
evolution from prior scans. Subsequently, the patient's
mental status began to improve to levels of alertness
previously experienced during the hospitalization.
On hospital day #6, a bedside swallowing evaluation was
performed that found the patient able to tolerate a regular
diet with 1:1 assistance. Additionally, both physical
therapy and occupational therapy evaluated the patient and
found him in need of acute level of rehab. On hospital day
#7, a nutrition consult was obtained secondary to decreased
PO intake. Recommendations were made for nutritional
supplementation, calorie counting, and 1:1 assistance with
feeds. At this time, a discussion was had with the family
and the healthcare proxy regarding potential placement of a
temporary nasogastric feeding tube. The family was adamantly
opposed to this and committed to assisted feedings with
nutritional supplementation.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To extended care facility.
DISCHARGE DIAGNOSES:
1. Status post fall.
2. Subarachnoid hemorrhage.
3. Subdural hemorrhage.
4. Right orbital fractures.
5. Right distal radius fracture.
6. Right first proximal phalanx fracture.
7. Right second rib fracture.
8. Facial laceration, repaired.
DISCHARGE MEDICATIONS:
1. Finasteride 5 mg 1 tab po qd.
2. Terazosin 2 mg 1 capsule po q hs.
3. Bisacodyl 10 mg suppository 1 suppository rectal qd prn
constipation.
4. Colace 100 mg 1 capsule po bid.
5. Heparin 5,000 U/ml solution 1 injection q 12 h [**Hospital1 **].
FOLLOW-UP:
1. Orthopedics with Dr. [**Last Name (STitle) **] in 1 week, ([**Telephone/Fax (1) 8746**].
2. Plastic surgery, Friday, [**3-25**], ([**Telephone/Fax (1) 23144**].
3. Neurosurgery with Dr. [**Last Name (STitle) 1132**] in [**1-4**] weeks, ([**Telephone/Fax (1) 88**].
4. Outpatient head CT prior to appointment with Dr. [**Last Name (STitle) 1132**],
([**Telephone/Fax (1) 6713**].
5. Eye Clinic in 2 weeks, ([**Telephone/Fax (1) 5120**].
6. Trauma Clinic as needed, ([**Telephone/Fax (1) 55118**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 28700**]
MEDQUIST36
D: [**2157-3-24**] 14:14
T: [**2157-3-24**] 14:17
JOB#: [**Job Number 55119**]
cc:[**Hospital3 55120**]
|
[
"802.8",
"801.22",
"816.00",
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"E880.0",
"807.01",
"428.0",
"593.9",
"813.42"
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icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
7547, 7786
|
7809, 8855
|
3515, 7447
|
1118, 1208
|
1416, 1521
|
129, 887
|
1539, 3497
|
909, 1095
|
1225, 1393
|
7472, 7526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,223
| 115,705
|
6848
|
Discharge summary
|
report
|
Admission Date: [**2124-12-21**] Discharge Date: [**2124-12-24**]
Date of Birth: [**2078-6-17**] Sex: F
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 46-year-old
woman with a history of deep venous thrombosis times two, not
on anticoagulation, who also has a significant family history
for coronary artery disease.
She was in her usual state of health until 10 p.m. on the
night prior to admission when she developed the acute onset
of infrascapular pressure at rest. She went to bed but was
unable to fall asleep for several hours due to this
discomfort. She finally fell asleep, but awoke at 7 a.m. on the
morning of admission with identical back pressure.
some numbness and tingling in both hands and diaphoresis and
dizziness upon rising. She awoke her daughter who brought
her into the [**Hospital3 417**] Hospital Emergency Department.
In the [**Hospital3 417**] Hospital Emergency Department, the
patient was found to have 1-mm ST elevations in lead III
along with ST depressions in I and aVL. She was given
sublingual nitroglycerin, started on heparin and Integrilin
drip and made pain free in the [**Hospital3 417**] Hospital
Emergency Department.
She was then Med-Flighted over to [**Hospital1 190**] for cardiac catheterization. En route, the
patient had the onset of chest pain and was known to have a
possible ST elevations in right-sided V4 leads.
In the cardiac catheterization laboratory here at [**Hospital1 346**], the patient was found to have a
cardiac output of 7.42, a cardiac index of 3.93, a pulmonary
capillary wedge pressure of 17, and a proximally occluded
right coronary artery. The right coronary artery lesion was
stented, but her course was complicated by temporary complete
heart block after a ballooning of the lesion with associated
hypotension. She necessitated temporary pacing and a
dopamine infusion.
The patient was then transported to the Cardiothoracic
Intensive Care Unit for further monitoring.
PAST MEDICAL HISTORY:
1. Pulmonary embolism times one.
2. Deep venous thrombosis times one.
3. Hypercholesterolemia.
4. Knee surgery.
5. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Protonix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with two daughters. [**Name (NI) 1403**] in
insurance litigation office. She has a 15-pack-year history
of tobacco but quit 15 years ago. She denies any alcohol or
drug use.
FAMILY HISTORY: Her mother had a coronary artery bypass
graft at the age of 50. Father had a myocardial infarction
at the age of 47.
REVIEW OF SYSTEMS: The patient reports six months of
postprandial epigastric pain with a sour taste rising in her
throat that has not been relieved by a proton pump inhibitor.
She also notes several weeks of weakness in both hands; worse
upon awakening. At baseline, the patient reports getting
short of breath when climbing one flight of stairs and
occasional left ankle swelling. She denies any orthopnea,
paroxysmal nocturnal dyspnea, or palpitations.
PHYSICAL EXAMINATION ON PRESENTATION: Upon arrival to the
Unit, the patient had the following vital signs. Her weight
was 77 kg, her temperature was 95, her blood pressure was
99/60, she was on 3 mcg/kg per minute of dopamine. Her heart
rate was 73, in a normal sinus rhythm. She was breathing 19
and oxygen saturation was 98% on 2 liters. In general, she
was lying in bed. She was nauseous but in no acute distress.
She was speaking in full sentences. Head, eyes, ears, nose,
and throat examination revealed pupils were equal, round, and
reactive to light. The oropharynx was moist with specks of
blood of in the mouth; but otherwise clear. The neck was
supple. No bruits. Jugular venous distention was roughly
8 cm to 9 cm. Cardiovascular examination revealed a regular
rate and rhythm, normal first heart sound and second heart
sound, no murmurs, rubs, or gallops. The lungs revealed
decreased breath sounds at the right lower lobe; but
otherwise clear to auscultation. The abdomen was obese,
soft, nontender, and nondistended. Normal active bowel
sounds. Extremities revealed she had a right groin site
without a hematoma with the sheath still in. She had good
distal pulses bilaterally. Neurologically, alert and
oriented times three. She moved all extremities. She had
4/5 strength in the left hand and left foot with normal 3+
reflexes bilaterally and symmetrically.
PERTINENT LABORATORY DATA FROM THE OUTSIDE HOSPITAL: At the
outside hospital she had the following laboratories; white
blood cell count was 4.6, hematocrit was 43.5, and platelets
were 204. PT was 12.2, PTT was 22, and INR was 1. Sodium
was 140, potassium was 4, chloride was 107, bicarbonate was
25, blood urea nitrogen was 16, creatinine was 0.8, and blood
glucose was 137. Her LDH was 161. Creatine kinase was 33.
MB was 1.5. Index was 4.5. Troponin was 0.10. She had
creatine kinases which peaked at 1068 and subsequently
declined to 759, and a MB which peaked at 145 and
subsequently declined to 196. Her total cholesterol was 211,
low-density lipoprotein was 127, high-density lipoprotein was
39, triglycerides were 227. Protein culture and sensitivity
studies were pending at the time of discharge. Hemoglobin
A1c was pending at the time of discharge as well.
RADIOLOGY/IMAGING: The initial electrocardiogram at the
outside hospital showed a normal sinus rhythm at 75, normal
axis, normal intervals, 0.5-mm asymmetric ST depressions in
aVL and I and 1-mm ST elevations in III.
Here, as previously mentioned, the patient underwent cardiac
catheterization with the previously mentioned results. She
also had subsequent laboratory values.
She had an electrocardiogram on the day after admission which
showed a normal sinus rhythm at 68, normal axis, and
intervals. She had Q waves in II, III, and aVF with flipped
T waves in III and aVF; and she had resolution of the ST
elevations in III and the ST depressions in I and aVL.
She had a chest x-ray here at [**Hospital1 188**] which showed a heart size at the upper limit of
normal, bilateral interstitial opacities consistent with mild
congestive heart failure.
PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories
on the day of discharge were as follows; her sodium was 140,
potassium was 3.9, chloride was 107, bicarbonate was 23,
blood urea nitrogen was 11, creatinine was 0.6, and blood
glucose was 110.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: As previously mentioned, the
patient had a likely inferior myocardial infarction with
possible right ventricular involvement.
She was taken to the cardiac catheterization laboratory where
a proximal right coronary artery lesion had a stent placed
and was subsequently treated with Integrilin, heparin,
aspirin, and Plavix. She was also started on a beta blocker
and ACE inhibitor in house.
She did well and was pain free throughout the duration of her
hospital stay with the exception of the day following
catheterization when she experienced mild infrascapular back
pain lasting 20 minutes which spontaneously resolved without
any change in her electrocardiogram.
Her blood pressure remained between 90 and 100 systolic, and
she tolerated the ACE inhibitor and beta blocker well. She
did have some persistent nausea and some vomiting for the 24
hours status post catheterization which was treated
successfully with Zofran.
From a rhythm standpoint, she remained in a normal sinus
rhythm throughout the duration of her hospital stay with
occasional premature ventricular contractions.
For her coronary artery disease; as previously mentioned, she
had right coronary artery lesion that was stented. She was
to remain on Plavix for one year, aspirin, beta blocker, ACE
inhibitor, and Lipitor.
2. ENDOCRINE SYSTEM: The patient had some mildly elevated
blood sugars of slightly greater than 120 during her hospital
stay. She has no previous past medical history, and her
hemoglobin A1c was pending. On discharge, she should follow
up with this with her primary care physician to ensure she
does not have diabetes which is contributing to her coronary
artery disease.
CONDITION AT DISCHARGE: The patient was in good condition at
the time of discharge.
DISCHARGE STATUS: The patient was to be discharged to her
sister's home. Her sister is a Cardiac Intensive Care Unit
nurse.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; right coronary artery stenosis,
status post stent placement, and inferior myocardial
infarction (with a peak creatine kinase of roughly 1100).
2. Hyperlipidemia.
3. Gastroesophageal reflux disease.
MEDICATIONS ON DISCHARGE: (Her medications on discharge were
as follows)
1. Lisinopril 2.5 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d. (times one year).
5. Enteric-coated aspirin 325 mg p.o. q.d.
6. Colace 100 mg p.o. b.i.d.
7. Ambien 10 mg p.o. q.h.s. as needed (for insomnia).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to call Dr. [**Last Name (STitle) **] and schedule a
follow-up appointment as a cardiologist within two weeks of
discharge.
2. The patient was also to call her primary care physician
within one week for an appointment for followup.
3. The patient was to be arranged for cardiac
rehabilitation.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2124-12-24**] 13:15
T: [**2124-12-28**] 19:46
JOB#: [**Job Number 25875**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.23",
"37.78",
"88.56",
"36.06",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
2455, 2574
|
8376, 8606
|
8633, 8944
|
2184, 2233
|
6437, 8152
|
8977, 9580
|
8167, 8355
|
6208, 6419
|
2594, 6193
|
149, 1981
|
2003, 2157
|
2250, 2438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,287
| 192,269
|
22193
|
Discharge summary
|
report
|
Admission Date: [**2179-2-10**] Discharge Date: [**2179-2-23**]
Date of Birth: [**2111-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Seizure and unresponsiveness
Major Surgical or Invasive Procedure:
Extubated (intubated at OSH)
LP
Pacemaker placed [**2-22**]
History of Present Illness:
Patient is an obese 67 yo man with complicated PMH including
HTN, hypercholesterolemia, ongoing EtOH abuse and hx of neck
hematoma, C7 fracture from MVA in [**3-22**] transferred from [**Hospital3 6265**] after being found unresponsive.
Hx if limited given no family members and unable to reach
friend/neighbor. [**Name (NI) **] medical records, patient was last seen
normal 2 days ago then was found "sleeping" in the chair
yesterday per neighbor/friend who thought that he was just
sleeping. However, the friend found him in same position today
hence called 911. EMS reports that his FSBG was 203 and was
found unresponsive but moving his L side intermittently. Either
en route or while at [**Hospital1 **], had repeated generalized seizure
which did not abate with Ativan 2mg IV hence given Valium 10mg
which stopped the seizure. He was then loaded with 2g of
fosphenytoin then intubated for airway protection. CT
reportedly
negative for acute pathology and LP was unsuccessful hence
started on Vanc/Acyclovir/Rocephin prior to transfer to [**Hospital1 18**].
Reportedly EtOH level 0 at [**Hospital3 3583**].
Here, patient is febrile to 101.8. Given hx of EtOH abuse,
patient started on banana bag.
Past Medical History:
1. HTN
2. dCHF
3. CAD s/p CABG
4. Ongoing EtOH abuse
5. Cirrhosis
6. Mild CRI
7. PUD
8. s/p total R hip replacement
9. hx of neck hematoma, rib fracture and C7 transverse process
fracture from high speed MVA in [**3-22**]
10. Depression
11. Hypercholesterolemia
Social History:
Patient reports history of extensive ETOH intake.
Lives alone - no details known. Tried to contact son, [**Name (NI) **]
[**Name (NI) 51286**] at [**Telephone/Fax (1) 57921**] but phone number no [**Serial Number 57922**].
Family History:
Non-contributory
Physical Exam:
Admission Exam:
T 101.8 BP 114/92 HR 49 RR 25 O2Sat 100%
Gen: Intubated and sedated.
Neck: Negative Kernig's sign.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly
Abd: +BS, soft, nontender
Ext: 3+ edema upto mid shin and chronic venous stasis skin
changes in both lower legs.
Neurologic examination:
Mental status: Intubated and sedated - opens both eyes to loud
name and sternal rub. Does not follow commands but moves L arm
and leg spontaneously and against gravity.
Cranial Nerves:
R pupil larger than L (3.5 R and L 2.5) but both reactive. Eyes
conjugate and midline, passes midline with OCR. Intermittently
blinks to visual threat bilaterally and +Corneals bilaterally.
+Gag. Face appears symmetric.
Motor:
No increased tone - moves L side spontaneously and anti-gravity
but nothing on RLE and some withdrawal on RUE to noxious stim.
Sensation: Appears intact to noxious stim.
Reflexes:
2s for UEs but none for patellar or Achilles bilaterally.
Toes mute bilaterally
.
Discharge exam:
VS 97.1 90 134/73 18 97% RA
GENERAL: NAD
HEENT:PEERL, EOMI, MMM
LNGS:CTA with some fine cracles at b/l bases
CARDIO:RRR, no m/r/g
ABD:soft, nt, nd bs+
MSK/EXTREMITIES:2+edema to knees, wwp
NEURO: no focal findings, AAOx with some guidance, CN 2-12,
strength 4-/5 thoughout, sensation intact
Skin: evidence of chronic venous stasis b/l shins
Pertinent Results:
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-2-23**] 06:55AM 104* 18 1.4* 140 4.0 105 26 13
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-2-23**] 06:55AM 5.4 2.16* 7.8* 23.6* 110* 36.4* 33.2
17.1* 1
[**2179-2-16**] 02:02AM BLOOD WBC-3.3* RBC-2.24* Hgb-8.1* Hct-24.7*
MCV-110* MCH-36.0* MCHC-32.6 RDW-17.9* Plt Ct-77*
[**2179-2-15**] 03:15AM BLOOD Neuts-60.0 Lymphs-27.1 Monos-9.2 Eos-3.4
Baso-0.3
[**2179-2-12**] 02:12AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Schisto-OCCASIONAL
Burr-OCCASIONAL Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
[**2179-2-16**] 02:02AM BLOOD Plt Ct-77*
[**2179-2-10**] 07:15PM BLOOD Fibrino-339
[**2179-2-16**] 02:02AM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-140
K-3.6 Cl-111* HCO3-21* AnGap-12
[**2179-2-12**] 09:43AM BLOOD ALT-20 AST-61* LD(LDH)-180 AlkPhos-108
TotBili-0.7 DirBili-0.5* IndBili-0.2
[**2179-2-11**] 09:55AM BLOOD CK-MB-5 cTropnT-0.12*
[**2179-2-10**] 07:15PM BLOOD cTropnT-0.26*
[**2179-2-13**] 01:46AM BLOOD VitB12-854 Folate-7.7
[**2179-2-12**] 09:43AM BLOOD calTIBC-233* Hapto-125 Ferritn-191
TRF-179*
[**2179-2-11**] 09:55AM BLOOD %HbA1c-6.1*
[**2179-2-13**] 01:46AM BLOOD Triglyc-197* HDL-30 CHOL/HD-4.0
LDLcalc-52
[**2179-2-12**] 09:43AM BLOOD TSH-1.7
[**2179-2-10**] 07:15PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-2-10**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-117*
Polys-56 Lymphs-26 Monos-0 Macroph-18
[**2179-2-10**] 10:45PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-30*
Polys-28 Lymphs-36 Monos-0 Macroph-36
[**2179-2-10**] 10:45PM CEREBROSPINAL FLUID (CSF) TotProt-26
Glucose-121
[**2179-2-10**] 10:45PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
[**2-19**] Abd U/S:
1. Diffuse increased echogenicity of the liver is likely related
to fatty
infiltration. However, other forms of liver disease including
fibrosis and
cirrhosis are not excluded. Please clinically correlate.
2. Ascites and splenomegaly, suggestive of portal hypertension.
However, the main portal vein does demonstrate hepatopetal flow.
[**2-18**] Hand XRay:
1. Degenerative changes as described above.
2. Soft tissue swelling adjacent to interphalangeal joint of the
left thumb in addition to a possible juxta articular erosion.
Given soft tissue swelling and possible erosion, gout should be
considered.
Imaging:
EEG [**2179-2-14**]:
This telemetry captured no pushbutton activations. Routine
sampling showed a diffusely slow and disorganized background
with low
voltage. This is consistent with a moderate encephalopathy.
There was
also prominent left hemispheric slowing. There were no
electrographic
seizures or epileptiform discharges noted on this recording.
MR head w/w/o gado: [**2179-2-14**]
There is no evidence of intracranial mass. There is a focal area
of hyperintensity in the left posterior thalamus on the FLAIR
images. This
area is hyperintense on the diffusion-weighted images and
faintly hypointense
on the diffusion coefficient maps. This most likely represents a
small area of infarction. There is no abnormal enhancement after
contrast
administration. Images of the remainder of the brain are
somewhat degraded by susceptibility artifacts at the skull base.
However, no other abnormalities are detected.
CONCLUSION: Probable subacute left posterior thalamic
infarction. No other
significant abnormalities are detected.
EKG [**2179-2-13**]:
Atrial fibrillation is now present. The QRS complex is still an
intraventricular conduction defect with right bundle-branch
block morphology and diffuse T wave abnormalities. Since the
previous tracing of [**2179-2-11**] the QRS complex is more narrow. The
axis remains leftward with an intraventricular conduction delay
that is more right bundle-branch block. Diffuse T wave changes
and ST segment changes are still present.
Hip/pelvis:
The film is somewhat underpenetrated. There is evidence of a
right total hip
replacement in a satisfactory position. No fracture is
identified, though the
upper portions of the pelvis are not adequately seen.
LENIS [**2178-2-13**];
1. No DVT of either lower extremity. Please note, however,
left-sided calf
veins are not visualized.
2. Diffuse subcutaneous edema bilaterally.
CTA neck/head [**2178-2-13**];
1. Approximately 50-55% stenosis at the origin of the left
internal carotid
artery by NASCET criteria.
2. Technically limited study demonstrating patent intracranial
arterial
vasculature without evidence of aneurysm or high-grade stenosis.
3. No acute hemorrhage or infarction.
.
Test Name Value Units Reference Range
[**2179-2-19**] 05:31PM
Report Comment:
Source: left DIP thumb
Joint Crystals, Number MANY
Joint Crystals, Shape NEEDLE
Joint Crystals, Location I/E
Intra/ExtraCellular
Joint Crystals, Birefringence NEG
Joint Crystals, Comment
c/w monosodium urate crystals
Brief Hospital Course:
The patient is a 67 year old man with a reported h/o alcohol
abuse with liver cirrhosis, HTN, CAD, brought to the hospital
after being found by his neighbor in the same position he was
seen in two days earlier. He was witnessed to have multiple
seizure like episodes en route to hospital. He was intubated at
the outside hospital and then transferred to [**Hospital1 18**]. His multiple
seizures were presumably of new onset.
He was started on broad spectrum antibiotics at the OSH, and
continued here. He had a LP in the emergency room with a normal
profile and a negative gram stain. His antibiotics were
stopped. He was loaded with dilantin at the outside hospital
and that was initially continued here. He was transferred to
the ICU for further care.
Neuro. In the ICU the patient had an EEG, which initially
showed PLEDs from the left hemisphere, in addition to a
generalized slow background. Given high frequency of PLEDs and
association with epilepsy, he was continued on AEDs, but was
changed to Keppra 1g [**Hospital1 **] given concern for liver cirrhosis.
His MRI on initial evaluation was concerning for temporal
hyperintensity on FLAIR. Out of concern for possible HSV
encephalitis, he was restarted on acyclovir. His HSV PCR was
negative, thus acyclovir was discontinued on [**2179-2-17**].
The patient was extubated. He continued to do well, and
regained awareness. His speech improved. He did remain
significantly amnestic, in addition he was noted to have
significant confabulation. He was determined to be stable for
transfer to the floor on [**2178-2-16**].
Further EEGs showed resolution of PLEDs and a moderate
encephalopathy. Final evaluation of MRI showed posterior, left
thalamic infarction. Based on neurology team evaluatoin, there
was also concern for hypoperfusion of the left temporal lobe.
Patient's neurological examination was mostly notable at this
time ([**2-16**]) for mild encephalopathy but no asterixis, amnesia and
occasional confabulation, raising some concern for a Korsakoff
type syndrome. Pt. was continued on MVI/Thiamine/Folate. He
was started on [**Month/Day (1) **] 81mg for suspected stroke. ECHO revealed nl
LVEF, no WMA or thrombus. No atrial fibrillation was noted on
telemetry. The CVA was felt to be most likely due to a small
vessel disease. A1C was 6.1 and LDL 52. Patient was continued
on a statin. No focal motor or sensory findings were present by
HD#12.
Bradycardia. Found to have bradycardia and 2nd degree block,
RBBB and AFB. He was evaluated by EP who placed external pacing
pads and placed atropine at the bedside. He returned to a
normal rhythm and did not require external pacing. He underwent
a conduction study, which showed impaired infraHis bundle
conduction and pacemaker placement was recommended. Pt.
underwent pacemaker placement on [**2-22**] without complications and
was restarted on a betablocker. He has a device clinic that he
should keep to follow up.
Pancytopenia. Hematology was consulted. It was felt that his
pancytopenia was multi-factorial, likely secondary to his
alcohol use, question of alcoholic liver disease and underlying
anemia of chronic disease. Based on his smear they did not
believe he was suffering from TTP or HIT. Platelet number
appeared to be at baseline and normalized through hospital
course. WBC recovered by [**2-19**]. He did require one unit of blood
for anemia after procdure.
Liver disease: Liver disease/cirrhosis had been documented in
tranfer records and prior hospitalization, however appeared to
have intact synthetic function (PT/PTT), but low albumin
(unclear whether this is from malnutrition, poor synthesis or
both). Previous imaging of liver not consistent with cirrhosis.
Liver ultrasound showed echogenic texture c/w fatty
infiltration, ascites and splenomegaly. Had total body anasarca
that improved with diuresis. He was started on lasix, nadolol,
and spironolactone prior to discharge. He was also counseled on
alcohol cessation. He has a liver appointment to follow up.
Inflamed bilateral DIPs. Developed by patient on [**2-18**]
unilaterally first, then by [**2-19**] with bilateral involvement. Per
hx, has had occurence of this for over 6 months intermittently.
Rheumatology was consulted and he was noted to have monosodium
urate crystals on aspiration consistent with gout. XR of
bilateral hands showed erosion. Given his renal dysfunction (see
below) he was started on a short course of steroids, with
improvement in his symptoms. Patient was treated with humalong
sliding scale while in the hospital and on steroids. It can be
discontinued at rehab if sugars consistently less than 150 as
patient is not a know diabetic. He can follow up his diabetes
and gout PCP for this.
ARF/CKD. Baseline Cr 1.0. Fluctuating Cr 1.0 to 1.5. FENA was
2.5%, but pt. was on lasix, urine urea was not consistent with
pre-renal state. Initially his home lasix was held and IVF were
started with concern for crystal nephropathy in setting of
acyclovir use, without significant improvement in his function.
He did not appear dry on exam. He had anasarca in setting of
low albumin and possible CHF. He had a history of CAD and CHF
with reported EF 20%, TTE this admission showed normal EF but
dCHF. Had anasarca thought mostly secondary to liver failure.
His lasix was restarted at 60mg daily and he diuresed to be 6 L
negative. His volume overload improved but he still had pitting
edema to bilateral knees at discharge.
Medications on Admission:
(on admission)
1. Effexor 37.5mg daily
2. Thiamine 100mg daily
3. Metoprolol 50mg [**Hospital1 **]
4. Omeprazole 20mg daily
5. Ativan 1mg TID
6. Simvastatin 20mg daily
7. Lasix 60mg qam and 40mg qpm
8. Digoxin 0.125mg daily
9. doxycycline 100mg daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): ***Please discontinue after
discharge from acute rehab or when patient ambulatory.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
13. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 doses.
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary: Seizure, Stroke (left thalamic), Sick sinus syndrome,
presumed liver cirrhosis, diastolic CHF, gout
Secondary: EtOH abuse, CAD
Discharge Condition:
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Mental Status:Confused - sometimes
Discharge Instructions:
You were admitted to [**Hospital1 18**] after being found unresponsive and
transferred from another hospital. It was suspected that you
had a seizure. You were found to have brain activity suggestive
of a seizure. You were also found to have MRI abnormalities
suggestive of a stroke. For this you were treated with an
antiseizure medication and aspirin respectively.
.
You were also found to have a problem with your heart rate. For
this, you required a pacemaker placement. You were also found
to have a flare of gout. You were treated with steroids which
improved your symptoms.
.
You were also found to be quite swollen which was thought to be
due to your liver disease. You responded quite well to
diuretics.
.
The following changes were made to your medications:
1)We started folic acid and multivitamins for your anemia
2)We have discontinued your metoprolol and started nadolol to
lower your blood pressure now that we know about your liver
disease.
3)We changed your lasix to 60mg daily and added spironolactone
help you take off water from you belly.
4)We started you on Keppra to prevent seizures.
5)We discontinued your ativan, digoxin, and doxycycline.
6)We started you on aspirin 81mg.
7)We started you on an insulin sliding scale.
.
You were discharged to a rehab.
Please follow up with all of your appointments.
Should you develop any of the signs below or any symptoms
concerning to you, please call your doctor or go to the
emergency room.
Followup Instructions:
Please follow up with the following appointments:
NEUROLOGY: Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] within 4 weeks of discharge from
the hospital. Please call the office at ([**Telephone/Fax (1) 7394**] to
arrange your follow up appointment.
.
CARDIOLOGY: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2179-3-3**] 10:00
.
LIVER: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2179-3-5**] 2:40
Completed by:[**2179-2-23**]
|
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"428.0",
"V45.81",
"584.9",
"427.31",
"272.0",
"434.91",
"459.81",
"263.9",
"V43.64",
"585.9",
"780.39"
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icd9cm
|
[
[
[]
]
] |
[
"81.91",
"96.71",
"03.31",
"37.83",
"37.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15562, 15674
|
8500, 13997
|
346, 407
|
15854, 15972
|
3593, 8477
|
17524, 18090
|
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|
14299, 15539
|
15695, 15833
|
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|
16033, 17501
|
2225, 2510
|
3231, 3574
|
277, 308
|
435, 1647
|
2721, 3215
|
15986, 16009
|
2534, 2534
|
1669, 1934
|
1950, 2176
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,859
| 150,161
|
13128
|
Discharge summary
|
report
|
Admission Date: [**2136-10-8**] Discharge Date: [**2136-10-15**]
Date of Birth: [**2071-5-21**] Sex: M
Service: CA/TH [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 65 -year-old gentleman
with a progressive dyspnea on exertion and paroxysmal
nocturnal dyspnea over the past two months. He had a
positive exercise tolerance test with some atrial and
ventricular arrhythmias noted and underwent cardiac
catheterization in [**2136-8-20**] which revealed a left
ventricular ejection fraction of 18%, three vessel coronary
artery disease, and severe global hypokinesis and he was
referred to Cardiothoracic Surgery Service for coronary
artery bypass grafting.
PAST MEDICAL HISTORY:
1. Non-insulin-dependent diabetes mellitus.
2. Hyperlipidemia.
3. Recent congestive heart failure.
4. Status post bilateral cataract extraction.
5. Status post hand surgery many years ago.
6. Status post ankle injury.
7. Transient vertigo attributed to an inner ear infection
many years ago.
PREOPERATIVE MEDICATIONS: Univasc 15 mg po q day, Lasix 20
mg po q day, aspirin 325 mg po q day, Glyburide 10 mg po bid,
Glucophage 1,000 mg po bid, Lipitor 10 mg po q day, and
Viagra 100 mg prn.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Physical examination on admission to
the hospital was unremarkable.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2136-10-8**], with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he
underwent coronary artery bypass graft times four with a left
internal mammary artery to the left anterior descending,
saphenous vein graft to the obtuse marginal artery, saphenous
vein graft to the posterior descending artery, and saphenous
vein graft to the diagonal. Postoperatively the patient was
transported from the Operating Room to the Cardiac Surgery
Recovery Unit on IV drips of propofol, milrinone, and
lidocaine. He was in normal sinus rhythm at that time.
The patient was placed on lidocaine for frequent ventricular
arrhythmias. The milrinone was weaned off by the following
morning and late in the day on postoperative day one the
lidocaine was discontinued, as was the IV Neo-Synephrine
which had been started for some transient postoperative
hypotension. The patient was transferred to the Telemetry
Floor on postoperative day one.
An Electrophysiology consultation was obtained due to
frequent ventricular arrhythmias in the light of a low
ejection fraction. It was their recommendation to begin a
beta blocker when the patient was hemodynamically stable and
to study him. Over the next few days on the Telemetry Floor,
the patient remained hemodynamically stable, continued to
have frequent premature ventricular contractions, was
progressing with cardiac rehabilitation, had been started on
low dose beta blocker and begun on diuretics. His chest
tubes had been discontinued.
The patient was taken to the Electrophysiology Lab on
[**10-12**], where he underwent placement of a dual chamber
implantable cardioverter defibrillator. The patient
tolerated the procedure well and has remained on the
Cardiothoracic / Telemetry Floor since the placement of the
device. He has remained hemodynamically stable and he is
ready to be discharged home today, on [**2136-10-15**],
postoperative day seven.
DISCHARGE CONDITION: Stable.
DISCHARGE PHYSICAL EXAMINATION: Temperature 98.6 F, pulse 75
and normal sinus rhythm, blood pressure 110/80. His weight
today is 106.2 kg, 1.0 kg above his preoperative weight of
107.2 kg. His room air oxygen saturation is 98%.
Neurologically the patient is intact. Pulmonary examination
is unremarkable. His lungs are clear to auscultation
bilaterally. His coronary examination is regular rate and
rhythm. His sternum is stable. His incision is clean, dry,
and intact and his right leg incision is also clean, dry, and
intact with no erythema or drainage.
LABORATORY DATA: His most recent chest x-ray is from
[**2136-10-13**], which revealed small bilateral pleural
effusions and left lower lobe atelectasis. Most recent
laboratory values are from [**2136-10-15**], which revealed
a white blood cell count of 10,100, hematocrit of 24.8, a
platelet count of 379,000. Urinalysis on [**10-14**]
revealed 0 to 2 white blood cells, and few bacteria. Other
laboratory values from [**2136-10-14**], are a sodium of
138, potassium 4.9, chloride 105, CO2 27, BUN 24, creatinine
1.2, glucose 110.
DISCHARGE MEDICATIONS: Lasix 20 mg po bid times one week,
potassium chloride 20 mEq po bid times one week, Colace 100
mg po bid, enteric coated aspirin 325 mg po q day, Glucophage
1,000 mg po bid, Glyburide 10 mg po bid, Captopril 12.5 mg po
q eight hours, Lipitor 10 mg po q HS, Lopressor 12.5 mg po
bid, amiodarone 200 mg po tid times one week, then amiodarone
400 mg po q day times one month, then amiodarone 200 mg po q
day, ibuprofen 400 mg po q six hours prn, Percocet 5/325 one
tablet po q four hours prn pain, and ciprofloxacin 500 mg one
tablet po bid times five days for the urinary tract
infection.
FOLLOW UP: The patient is to follow up in the Device Clinic
here at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on the [**Hospital Ward Name 8559**], seventh floor, Cardiology Department, on [**2136-10-19**], at 11 o'clock in the morning. The telephone number
there is [**Telephone/Fax (1) 21817**]. He is to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] next week. His office has been contact[**Name (NI) **]. And he is to
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one month for
postoperative wound check.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Severe left ventricular dysfunction.
3. Frequent ventricular arrhythmias, status post automatic
implantable cardioverter - defibrillator placement.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2136-10-15**] 09:53
T: [**2136-10-15**] 09:49
JOB#: [**Job Number 40077**]
|
[
"427.32",
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"458.2",
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"518.0",
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"416.8",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3364, 3383
|
5778, 6268
|
4499, 5087
|
1366, 3342
|
5099, 5757
|
1047, 1256
|
3406, 4475
|
196, 698
|
720, 1020
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,499
| 195,672
|
33869
|
Discharge summary
|
report
|
Admission Date: [**2194-5-16**] Discharge Date: [**2194-5-20**]
Date of Birth: [**2121-12-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
CABG x4 (LIMA>LAD, SVG>DIAG, SVG>OM, SVG>PDA) [**5-16**]
History of Present Illness:
72 yo F with increasing angina/DOE and + ETT in [**3-18**]. Cardiac
cath revealed severe 3 VD with preserved EF. Referred for
surgery.
Past Medical History:
lt RAS, Carotid stenosis 60-80%bilat, PVD, elevated cholesterol,
osteoarthritis
Social History:
denies tobacco, etoh
Family History:
father deceased from MI at age 63
Physical Exam:
NAD HR 80 RR 14 BP 150/76
Lungs CTAB
Heart RRR, no murmur
Abdomen Soft, NT, ND
Extrem warm, no edema
Pertinent Results:
[**2194-5-19**] 05:30AM BLOOD WBC-14.6* RBC-2.81* Hgb-8.5* Hct-24.7*
MCV-88 MCH-30.1 MCHC-34.3 RDW-14.2 Plt Ct-166
[**2194-5-18**] 03:59AM BLOOD WBC-18.8* RBC-2.92* Hgb-8.9* Hct-25.3*
MCV-86 MCH-30.6 MCHC-35.4* RDW-14.7 Plt Ct-152
[**2194-5-16**] 02:51PM BLOOD PT-16.6* PTT-53.6* INR(PT)-1.5*
[**2194-5-20**] 04:55AM BLOOD K-3.0*
[**2194-5-19**] 03:05PM BLOOD K-3.1*
[**2194-5-19**] 05:30AM BLOOD Glucose-102 UreaN-10 Creat-0.4 Na-133
K-2.5* Cl-95* HCO3-29 AnGap-12
CHEST (PA & LAT) [**2194-5-19**] 4:21 PM
CHEST (PA & LAT)
Reason: evaluate for effusion and evaluate wires
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for effusion and evaluate wires
PROCEDURE: Chest PA and lateral [**2194-5-19**].
COMPARISON: Multiple previous chest radiographs between [**5-8**]
and [**2194-5-18**].
HISTORY: 72-year-old woman with CABG, evaluate for effusion and
wires.
FINDINGS:
There is a miniscule right apical pneumothorax barely visible on
today's examination and in retrospect was seen on the [**5-16**]
examination that hasn't changed. On today's examination,
however, there is slight worsening of bilateral small pleural
effusion and the mild-to-moderate cardiomegaly remains stable.
The first sternal wire is abnormally broken but not displaced.
The patient is status post CABG. The lungs are relatively clear.
IMPRESSION:
1) Worsening bilateral small pleural effusion.
2) Stable miniscule right apical pneumothorax barely visible on
today's examination.
3) A broken first sternal wire.
Brief Hospital Course:
She was taken to the operating room on 06.06 where she underwent
a CABG x 4. She was transferred to the ICU in stable condition.
She was extubated post op. She was transferred to the floor on
POD #1. Chest tubes and wires were dc'd without incident. She
had a small burst of afib for which her beta blocker was
increased. She otherwise did well postoperatively and was ready
for discharge home on POD #4.
Medications on Admission:
Lisinopril 40', ASA 81', Amlodipine 5', Carvedilol 3.125",
Chlorthalidone 25', Simvastatin 40'
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. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for poor veins.
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Renal artery stenosis
Carotid stenosis
Peripheral vascular disease
Elevated cholesterol
Osteoarthritis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) 48633**] in 1 week [**Telephone/Fax (1) 35142**]
Dr. [**Last Name (STitle) 78274**] [**Name (STitle) 6254**] 2 weeks [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) **] 4 weeks at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**]
Wound check [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] - thrusday [**5-29**]
at 9am
Completed by:[**2194-5-20**]
|
[
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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|
2464, 2870
|
329, 388
|
4469, 4476
|
881, 1459
|
4988, 5429
|
709, 745
|
3015, 4207
|
1496, 1528
|
4310, 4448
|
2896, 2992
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4500, 4965
|
760, 862
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283, 291
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1557, 2441
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416, 552
|
574, 655
|
671, 693
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,735
| 100,381
|
46350
|
Discharge summary
|
report
|
Admission Date: [**2180-3-8**] Discharge Date: [**2180-3-13**]
Date of Birth: [**2124-4-1**] Sex: F
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
right breast cancer
Major Surgical or Invasive Procedure:
right [**Last Name (un) 5884**] flap reconstruction on [**2180-3-8**]
History of Present Illness:
Ms. [**Known lastname 52157**] is a 55-year-old Caucasian female who presented
preoperatively in consultation for right breast reconstruction.
The patient underwent right mastectomy in [**2174**] for lobular
breast cancer, but deferred reconstruction at that time. She
now desires reconstruction and prefers using autologous tissue
in the [**Last Name (un) 5884**] flap technique.
Past Medical History:
right breast cancer
hypothyroidism
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
AVSS
NAD
CTA b/l
RRR w/ S1S2
abodmen soft, NT/ND
previous right breast surgery evident with scar
extremeties warm and well-perfused
A + O x 3
Pertinent Results:
[**2180-3-9**] 03:26AM BLOOD Calcium-8.4 Phos-4.6* Mg-1.4*
[**2180-3-9**] 03:26AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-138
K-3.9 Cl-106 HCO3-29 AnGap-7*
[**2180-3-9**] 03:26AM BLOOD Plt Ct-206
[**2180-3-9**] 03:26AM BLOOD WBC-13.3*# RBC-2.99* Hgb-9.4* Hct-26.9*
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.2 Plt Ct-206
[**2180-3-9**] 04:03PM BLOOD Hct-27.1*
[**2180-3-10**] 04:29AM BLOOD Calcium-7.9* Phos-2.5*# Mg-1.6
[**2180-3-10**] 04:29AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-138
K-3.4 Cl-100 HCO3-34* AnGap-7*
[**2180-3-10**] 04:29AM BLOOD Plt Ct-187
[**2180-3-10**] 04:29AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.7* Hct-25.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.2 Plt Ct-187
Brief Hospital Course:
Ms. [**Known lastname 52157**] was admitted on [**2180-3-8**] and taken to the operating
room for a right [**Last Name (un) 5884**] flap reconstruction. She tolerated the
procedure well with only 150 mL of estimated blood loss. She
was sent to the ICU after the procedure where she underwent
frequent flap checks that revealed good doppler pulses
consistently. The right aspect of the flap appeared to be
somewhat congested the following morning and she was treated
with leech therapy to reduce this congestion. The right aspect
of her flap remained somewhat eccymotic but continued to be warm
with good doppler signals. We removed her foley on POD 2 and
she was able to void. She tolerated a regular diet and
ambulated appropriately. She was discharged home in good
condition with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 19843**] checks and dressing
changes on POD 5.
Medications on Admission:
Levothyroxine Sodium 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
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. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
Disp:*45 Tablet, Chewable(s)* Refills:*2*
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
Disp:*20 Tablet(s)* Refills:*0*
4. Levothyroxine Sodium 50 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
While taking pain medications.
Disp:*60 Capsule(s)* Refills:*2*
7. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p right [**Last Name (un) 5884**] flap reconstruction on [**2180-3-8**]
right acquired breast deformity
Right breast cancer
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Be sure to take your complete course of antibiotics.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed
from your wounds. Take a shower immediately before dressing
changes by the visiting nurse.
Followup Instructions:
In one week with Dr. [**First Name (STitle) 3228**]. Please call for appointment ([**Telephone/Fax (1) 98529**].
|
[
"401.9",
"V10.3",
"244.9",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.99",
"85.89"
] |
icd9pcs
|
[
[
[]
]
] |
3622, 3705
|
1808, 2711
|
333, 405
|
3875, 3881
|
1119, 1785
|
4826, 4943
|
924, 942
|
2834, 3599
|
3726, 3854
|
2737, 2811
|
3905, 4803
|
957, 1100
|
274, 295
|
433, 816
|
838, 874
|
890, 908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,839
| 122,377
|
48343
|
Discharge summary
|
report
|
Admission Date: [**2103-9-29**] Discharge Date: [**2103-10-9**]
Service: MED
Allergies:
Amoxicillin / Ampicillin / Diltiazem / Furosemide / Bactrim Ds
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fall, right intratrochanteric fracture
Major Surgical or Invasive Procedure:
Right DHS [**10-1**]
History of Present Illness:
80 male w/ h/o CAD s/p ptca rca several years back, severe
cardiomyopathy (ef 20%) s/p recent biv pacer [**8-12**], chronic renal
insuffiency, remote colon ca s/p resection, reported dementia
now being admitted following mechanical fall w/ resultant right
intra-trochanteric fracture. Recently d/c'd on [**8-25**] following
placement of BiV pacer. During hospital course, evaluated by CHF
service and trialed on natrecor but unable to tolerate secondary
to hypotension. Diuresed on iv bumex and d/c'd on [**8-25**]. Now
admitted after mechanical fall following unsupervised transfer
from kitchen table. Fell on right hip and hit head as well. No
LOC. No cp/sob/fevers/chills. No urinary sx/bowel sx.
In ED, afebrile, hemodymically stable but xray shows
intra-trochaneteric fx. Head ct neg for bleed.
Past Medical History:
Afib s/p avn ablation w/ pacer in '[**99**] now w/ BiV [**8-12**]
HTN
?orthostasis
hyperlipidemia
CAD s/p PTCA to RCA in '[**97**]
s/p pericardial window for tamponade '[**01**] thought secondary to ?
endocarditis/bacteremia
CHF w/ ef 20% 6/04, now s/p biv pacer [**8-12**]
colon ca s/p resection
s/p R. nephrectomy w/ ureterectomy for transitional cell
carcinoma of renal pelvis
BPH s/p prostatectemy [**7-12**]
positive PPD s/p 1 year INH therapy
reported dementia
depression
hypothyroid
cerebral vascular dz
transitional cell bladder ca in situ s/p VCB and interferon
washing
Chronic renal insuffiency baseline 1.3-1.5
Social History:
Pt is a retired dentist, lives at home with his wife
Physical Exam:
96.8 124/72 87 16 95% ra
gen: obese elderly male, lying flat on back comfortable,
oriented to hospital and date
heent: [**Last Name (LF) **], [**First Name3 (LF) **], eomi, unable to appreciate jvd
cv: rrr w/ no mrg appreciated
pulm: CTA anteriorly w/ decreased breath sounds at bases
abd: soft, ntnd,
extr: trace le edema
Pertinent Results:
[**2103-9-29**] 04:53PM URINE HOURS-RANDOM
[**2103-9-29**] 04:53PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2103-9-29**] 04:53PM URINE GR HOLD-HOLD
[**2103-9-29**] 04:53PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-9-29**] 04:53PM URINE RBC-[**4-13**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2103-9-29**] 03:45PM GLUCOSE-96 UREA N-34* CREAT-1.4* SODIUM-143
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-27 ANION GAP-12
[**2103-9-29**] 03:45PM WBC-12.5*# RBC-4.95 HGB-12.2* HCT-38.5*
MCV-78* MCH-24.7* MCHC-31.8 RDW-17.7*
[**2103-9-29**] 03:45PM NEUTS-83* BANDS-0 LYMPHS-10* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2103-9-29**] 03:45PM NEUTS-83* BANDS-0 LYMPHS-10* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2103-9-29**] 03:45PM PLT COUNT-181
[**2103-9-29**] 03:45PM PLT COUNT-181
Brief Hospital Course:
1. Intra-trochanteric fx: secondary to mechanical fall. To OR on
[**10-1**] for DHS w/o complications. Please see [**Month/Year (2) **] for further
details. He is weight bearing as tolerating and will require
aggressive physical therapy. Post op pain well controlled w/
tylenol 1 q 6. He should f/u w/ Dr. [**First Name (STitle) 1022**] in 2 weeks time. He will
be offered low dose oxycodone prior to physical therapy to
assist w/ pain control during ambulation
2. CAD: [**Name (NI) **], pt remained hypotensive in the pacu x
1 day. He was eventually transferred to the CCU for transient
pressor requirements. Pt ruled out for MI as cause of
hypotension. He will cont on ASA, statin, low dose coreg and ace
inhibitor.
3. hemodynamics: Per review of [**Name (NI) **] pt, has h/o labile blood
pressures. [**Name (NI) 101830**], pt was hypertensive w/ diastolics
frequently exceeding 100. Consequenly, his ACEi and BB were
titrated for optimal blood pressure control during the
pre-operative period. As alluded to above, pt became hypotensive
post-operatively, requiring up to 12 of dopamine and brief CCU
stay. It was postulated that pt's hypotension was secondary to
severe fluid overload (5 liters positive on pod 1) and residual
of anesthesia. As mentioned above, he was ruled out for mi, had
echo which was neg for tamponade and demonstrated unchanged lv
function. He also was cultured for potential sepsis although he
remained afebrile - these cultures were negative. Pt was found
w/ [**7-17**] point crit drop but was guiac neg. His wound was stable.
He was transfused for goal crit greater than 28. Pt was weaned
off dopamine in the ccu over 24 hours and also gentle diuresed
w/ iv lasix and then iv bumex. In addition to his diuresis, his
acei and bb have been titrated for optimal bp control. Over the
next several days, his blood pressure should be checked
regularly and his beta blocker can be gently titrated for
optimal bp control.
4. CHF: History of severe cardiomyopathy w/ ef 20% and s/p
recent BiV upgrade [**8-12**]. Despite medicine/cardiology
recommendations, pa catheter was placed in the peri-operative
period. Based upon PA cath [**Location (un) 1131**] and overall fluid balance, pt
felt to be in failure and thought to be etiology of hypotension.
Briefly requiring pressor support but during the remainder of
hospital course, diuresed approximately [**2-9**] to 1 liter neg per
day. He will be d/c'ed on standing bumex. His ACEi and Coreg
were gently restarted for maximal bp control.
5. BiV pacer: As mentioned above, ill-advised Swan catheter
placed during peri-operative period. CXR showed no displacement
of leads and still pacing on tele. Should f/u with cardiologist
dr. [**Last Name (STitle) **] as previously arranged.
6. Anemia: As mentioned above, pt was transfused 2 unit prbc in
the immediate post-operative period. It is unclear to the source
of his anemia. he was guiac neg. Pt required one additional unit
on the floor but has since remained stable.
7. Afib: continued on coumadin and coumadin should be titrated
for goal inr greater than 2.0.
8. Chronic renal insuffiency: renal fx remained stable during
the hospital course.
9. Dementia/agitation: mild agitation in the post-operative
period well controlled w/ standing pm zyprexa.
10. Prophylaxis: will be sent on aggressive bowel regimen,
calcium and vitamin d.
Medications on Admission:
wellbutrin 150 qd
lexapro 20 qd
methylphenidate 5 [**Hospital1 **]
lipitor 20 qd
lansoprazole 30 qd
levoxyl 75 qd
colace
senna
coreg 12.5 qam, 25 q pm
bumex 1 qd
enalapril 10 qam, 5 qpm
coumadin 10 qhs
kcl 20 qd
mvi qd
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QD (once a day).
2. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
3. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
12. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): hold for excess sedation.
14. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q 4HR ()
as needed for constipation: please only prn for constipation.
17. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
18. Outpatient Lab Work
please check inr and hematocrit and bun/creatinine and
potassium/bicarbonate on [**10-11**] and fax to dr.[**Last Name (STitle) **] office
19. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: please use prior to physical therapy to enhance pain
control to help ambulate.
20. medication titration
please check bp control daily and if sbp greater than 130,
[**Last Name (STitle) 7216**] greater than 80, would increase coreg to 6.125 po bid
on [**10-11**].
Please contact md [**First Name (Titles) **] [**Last Name (Titles) 7216**] greater than 100
21. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.
22. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
intra-trochanteric fracture s/p DHS
post-op hypotension resolved
anemia
CHF resolved
CAD
Discharge Condition:
fair
Discharge Instructions:
please return to ed or [**Name8 (MD) 138**] md for chest pain, shortness of
breath, palpitations, severe cough, abdominal pain, leg pain.
please take medications as directed
please weigh yourself daily and [**Name8 (MD) 138**] md if gain greater than 3
lbs
please adhere to low salt diet and 2 liter fluid restriction
Followup Instructions:
Please call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1408**] for appt in 1 week
Please call orthopaedist dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 7807**] for appt in 2
weeks.
Please call cardiologist dr. [**Last Name (STitle) **] for appt in 2 weeks.
Completed by:[**2103-10-9**]
|
[
"427.31",
"458.29",
"414.01",
"997.5",
"428.0",
"403.91",
"V45.01",
"820.20",
"E888.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8996, 9081
|
3173, 6539
|
303, 325
|
9214, 9220
|
2241, 3150
|
9588, 9932
|
6808, 8973
|
9102, 9193
|
6565, 6785
|
9244, 9565
|
1898, 2222
|
225, 265
|
353, 1156
|
1178, 1813
|
1829, 1883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,846
| 110,325
|
52694
|
Discharge summary
|
report
|
Admission Date: [**2174-8-20**] Discharge Date: [**2174-8-26**]
Date of Birth: [**2104-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
s/p EGD and colonoscopy
s/p IVC filter placement
History of Present Illness:
Ms. [**Known lastname 4886**] is a 70 year old female with history of left leg DVT
on warfarin who presented with two days of bright red blood per
rectum. She complained of weakness and dizziness for the past
couple days and when her daughter visited her noticed she was
pale and diaphoretic.
.
In the ED, initial vs were: T 98 HR 155 BP 130/57 RR 18 SaO2
99%RA.
Patient was given 2 liters NS IVF, 2 units of FFP to reverse her
INR of 2.7, and one unit pRBCs. After a 500cc bolus, her SBP
increased from 70s to 130s and HR decreased from 150 to 100s.
NG lavage was weakly positive with pink saline and small clots
at end of suction. A central line was placed, and she received
IV PPI prior to transfer. Vitals at transfer were 130/90, 80,
20, 100% RA.
.
In the [**Hospital Unit Name 153**], she reports feeling better after being treated in
the ED. Patient reports having a week of BRBPR with clots
approximately three weeks ago that spontaneously resolved. Her
current bleeding episode started yesterday with 6 bloody bowel
movements. Afterwards, she had some palpitations with exertion
and felt fatigued. She had three episodes of non-bloody, yellow
emesis last night without any abdominal pain with some
associated cold sweats. Patient has had some intermittent
constipation (baseline [**1-27**]/day) with straining occasionally but
this does not always occur prior to bloody BM. No known sick
contacts, DOE, SOB. No current N/V or abdominal pain. She does
complain of discomfort from the NG tube.
.
Review of systems:
(+) Per HPI, 20 pound weight loss over last year.
(-) Denies fever or headache. Denies cough, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies current nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
LLE Deep Venous Thrombosis, [**2170**] & [**2173**]
Hypertension
Type 2 Diabetes Mellitus A1c 6.7% 6/10
Schizoaffective Disorder
Hyperlipidemia
Social History:
Pt is widowed and lives at an [**Hospital3 **] facility. She is
a non-smoker and denies alcohol and illicit drug use.
.
Emergency Contact: [**Name (NI) 1439**] [**Name (NI) 4886**], daughter, ([**Telephone/Fax (1) 108712**],
work: ([**Telephone/Fax (1) 108713**], cell: ([**Telephone/Fax (1) 108714**]
Case Manager: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79685**], ([**Telephone/Fax (1) 108715**], cell: ([**Telephone/Fax (1) 108716**]
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.6 BP: 144/57 P: 84 R: 22 O2: 100% RA
General: Alert, oriented, pale African American female in no
acute distress
HEENT: EOMI, sclera anicteric with pale conjunctiva, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD, R IJ in place
Lungs: Clear to auscultation bilaterally with decreased BS at
bilateral bases, 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, small
reducible umbilical hernia
GU: foley in place
Ext: cool digits with normal cap refill, well perfused, 2+
pulses, no clubbing, cyanosis or edema, strength 5/5 in BLE
extremities
Pertinent Results:
WBC-9.8# RBC-2.62*# HGB-6.6*# HCT-19.8*# MCV-76* PLT COUNT-368
NEUTS-68.6 LYMPHS-24.4 MONOS-4.8 EOS-1.8 BASOS-0.3
GLUCOSE-195* UREA N-20 CREAT-1.2* SODIUM-141 POTASSIUM-3.4
CHLORIDE-106 TOTAL CO2-24
PT-27.3* PTT-25.6 INR(PT)-2.7*
.
[**8-20**] EKG: Sinus tachycardia at 117 with RBBB and LAFB (unchanged
from prior)
.
[**8-20**] CHEST X-RAY:Frontal view of the chest demonstrates
cardiomegaly. Right IJ catheter terminates in superior vena
cava. There is mild congestive failure.
.
[**2174-8-22**] Intervential Radiology IMPRESSION:
1. Normal anatomy of the IVC with a maximal caval diameter of
2.2 cm.
2. No evidence of caval thrombus or aberrant caval anatomy.
3. Successful placement of an infrarenal OptEase IVC filter.
.
[**8-23**] EGD: normal anatomy, no explanation for bleeding.
.
[**8-23**] [**Last Name (un) **]: Findings: Excavated Lesions, Multiple diverticula
were seen in the sigmoid colon. Diverticulosis appeared to be
severe.
Impression: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
.
[**2174-8-22**] 02:50PM BLOOD WBC-9.7 RBC-3.68* Hgb-9.7* Hct-29.0*
MCV-79* MCH-26.4* MCHC-33.5 RDW-15.2 Plt Ct-283
[**2174-8-23**] 05:05AM BLOOD WBC-7.5 RBC-3.28* Hgb-8.7* Hct-26.9*
MCV-82 MCH-26.6* MCHC-32.5 RDW-15.7* Plt Ct-284
[**2174-8-24**] 05:55AM BLOOD WBC-7.8 RBC-3.15* Hgb-8.3* Hct-25.0*
MCV-80* MCH-26.2* MCHC-33.0 RDW-15.9* Plt Ct-245
[**2174-8-24**] 12:34PM BLOOD Hct-28.1*
[**2174-8-23**] 05:05AM BLOOD PT-13.6* PTT-24.4 INR(PT)-1.2*
[**2174-8-25**] 12:55PM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-140 K-3.9
Cl-104 HCO3-29 AnGap-11
[**2174-8-22**] 05:00AM BLOOD ALT-11 AST-13 LD(LDH)-180 AlkPhos-65
TotBili-0.7
Brief Hospital Course:
# Acute blood loss anemia/GI bleed: Pt was admitted to the ICU,
where she remained hemodynamically stable without evidence of
ongoing bleeding. Her INR had been reversed with 2units of FFP
and 10mg Vitamin K. She was transfused with 2 more units of
pRBCs for a total of 3 and her hematocrit bumped appropriately.
She was called out to the floor and underwent bowel prep on [**8-22**]
followed by EGD/[**Last Name (un) **] on [**8-23**] which did not show any evidence of
ongoing bleeding though severe diverticulosis of the colon. Pt
was monitored in house and remained hemodynamically stable with
stable Hct and no evidence of ongoing bleeding. She was started
on Ferrous Sulfate 325mg daily and continue on Omeprazol 20mg
daily, she will need follow up with GI following psychiatric
admission.
.
# History of DVT: Pt has had two DVTs, most recent was diagnosed
at an OSH in [**2174-5-26**] and has been on warfarin since that time.
INR was 2.7 in setting of acute GI bleed and it was reversed as
above. She underwent IVC filter placement on [**8-23**] given the
risk of anti-coagulation. After discussion with daughter/GI,
decision was made to avoid restarting coumadin given her risk to
rebleed and her delay in getting care in the setting of this
bleed. Pt is scheduled to see her PCP after discharge to
further discuss this issue.
.
# Schizoaffective disorder: Pt had a recent prolonged inpatient
psych admission and was seen by psychiatry in house. After
discussion with outpatient providers, decision was made to
transfer to inpatient psych facility for further care. Pt was
continued on Fluoxetine, Donepezil, Lamotrigine and Mirtazapine.
Further discussions regarding her ability to care for self at
home to be held at that time.
.
# HTN: stable, continue on home regimen of Lisinopril
.
# DMII: Stable, will resume home regimen of Metformin 500mg [**Hospital1 **].
Please continue BS checks and pt instructed to stop if not
taking regular meals.
.
Medications on Admission:
Aricept 5 mg qHS
Fluoxetine 20 mg qday
Lamotrigine 50 mg [**Hospital1 **]
Lisinopril 20 mg daily
GlycoLax 17 gram/dose daily
Mirtazapine 45 mg qHS
Multivitamin
Omeprazole 20 mg daily
Seroquel 300 mg qHS
Warfarin 6.5mg daily
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
2. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
1. Acute blood loss anemia
2. Diverticulosis
3. DVT s/p IVC filter
.
Secondary:
DMII
Hypertension
Schizoaffective Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute blood loss anemia from a lower
gastrointestinal bleed in the setting of anti-coagulation for a
DVT.
You have been transfused with blood and your blood counts have
stabilized without any sign of further bleeding. You underwent
placement of an IVC filter to treat the DVT. Please note that
we have stopped the Coumadin. You should not take this
medication again unless you are instructed by a physician.
.
We have restarted your home regimen including Metformin 500mg
twice daily and two new medications
1. Ferrous Sulfate 325mg daily (in place of Multivitamin)
2. Omeprazole 40mg daily
.
Please continue to monitor your blood sugars at home, you should
not take the Metformin if you are not eating regular meals.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
Appointment: Thursday [**2174-9-1**] 11:00am
.
Please call the [**Hospital **] clinic at ([**Telephone/Fax (1) 2233**] after discharge to
schedule a follow up appointment with them.
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,909
| 104,427
|
49708
|
Discharge summary
|
report
|
Admission Date: [**2182-7-16**] Discharge Date: [**2182-7-25**]
Date of Birth: [**2125-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Gentamicin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
atrial fibrillation
Major Surgical or Invasive Procedure:
Cardiac catheterization
Colonoscopy
History of Present Illness:
56M w/ multiple medical problems including CAD s/p multiple PCI,
CHF with EF 45%, PAF, DM Type I, ESRD on HD s/p [**First Name3 (LF) **] transplant
x2 who presented to [**Hospital1 18**] on [**2182-7-16**] after several episodes of
atrial fibrillation and hypotension during HD and is now
transferred to medicine for GI bleed.
.
He was originally admitted to [**Hospital3 3765**] on [**2182-7-13**] with
complaints of R knee pain after a fall to his right side. He
was seen by Rheumatology and there was a concern for possible
gout or pseudogout. During that admission, he underwent HD per
his normal schedule and during HD on [**7-15**] he went into a fib
with a ventricular rate of 130-140. He had severe chest pain
across his entire chest w/ radiation to his shoulders, jaw, and
back. He also noted SOB and a need to move his bowels during
this episode. He was given IV amiodarone during this episode but
remained in a fib for several hours before spontaneously
converting to sinus rhythm. He was hypotensive to the 80's with
elevated JVP and was given IVF and stress-dose steroids for
possible adrenal insufficiency. An echocardiogram revealed EF
55% with possible inferior HK. His cardiac enzymes were checked
and were normal.
.
On the day of transfer on [**7-16**], during HD he again had an
episode of a fib associated with the same chest discomfort and
hypotension. He received 200mg of amiodarone, 2.5mg iv lopressor
x2, dilaudid, and ativan for this episode but remained in a fib
up until the time of transfer to [**Hospital1 18**]. He was also briefly
hypotensive to the 80s and started on neosynephrine in the ICU
there. On transfer, the pt reported dull chest pain that was
pleuritic. He denied other symptoms.
.
On admission to [**Hospital1 18**] CCU, the patient stated that he had been
on 200mg of amiodarone since last [**Month (only) 205**] when his colostomy was
reversed. He had mild chest pain during HD for the past few
weeks but the episodes during his previous hospitalization had
been much more severe. There were no recent changes in his
dialysis treatment. He had a mild non-productive cough over the
week prior to admission but denied fever, diarrhea,
constipation, nausea, decreased PO intake, or HA. He has had
chronic abdominal pain for the past year. His knee pain began
about 2 weeks ago and had responded well to NSAIDs. He stopped
his NSAIDs because he was told that they can cause GI bleeds if
taken for too long.
Past Medical History:
1. ESRD: status pancreas-kidney transplant [**2164**], status post
cadaveric [**Year (4 digits) **] transplantation in [**2172**], now requiring dialysis
3x/wk
2. CAD: s/p myocardial infarction in [**2164**], s/p LCX stenting in
[**2174**], s/p LCX and OM3 stenting in [**2175**], s/p mid-LCX stenting on
'[**78**], s/p OM3 restenting in '[**78**]
3. DM
4. Hypothyroidism
5. Hypercholesterolemia
6. Hep C (dx in '[**75**]), viral load
7. CVA in [**2174**] with residual left-sided weakness
8. PVD
9. Diverticulitis, status post colostomy and Hartmann's pouch in
[**2175**],
status post reversal in [**6-3**], last Colonscopy ([**12-4**]): Erythema,
friability and granularity in the very distal portion of the
colon, just inside the afferent limb of the stoma, with
overlying clot. Brown stool with no bleeding proximal to this.
10. PVD s/p multiple digit amputations
11. GERD
12. Wheelchair bound after gentamicin related vertigo
13. PAF: diagnosed in [**2175**], continued on CCB and started on Amio
at that time
14. Benign prostatic hypertrophy, status post transurethral
resection of the prostate.
15. SBP [**1-31**]
Social History:
Patient lives with his wife. They have two children who live
nearby. He previously worked as a plummer but is now retired. He
has a 30pk year smoking hx but quit 10 years ago. He denies IVDU
and alcohol use.
Family History:
[**Name (NI) 1094**] father died at age 56 of MI, with DM and a "big heart".
Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister
has Grave's dz and brother died of 56 with DM.
Physical Exam:
Vitals: T 97.5 BP 106/39 (92-135/27-65) HR 58 (58-73) 18 98% RA
Gen: well-appearing man, laying flat in bed, NAD
HEENT: PERRL, EOMI, mmm, OP clear
Neck: supple, no JVD or LAD
Lung: crackles at left base, otherwise CTA bilaterally
Cor: RRR, nml S1S2, 2/6 systolic ejection murmur heard best at
the LSB w/out radiation
Abd: large midline scar, well-healed, hyperactive bowel sounds,
mildly distended with mild TTP in bilateral flanks, +
splenomegaly
Ext: changes of chronic venous insufficiency, no edema, could
feel distal pulses, right knee without effusion, mild medial
joint line tenderness, no pain on passive movement, pain on
active movement
Pertinent Results:
IMAGING:
Cath ([**2182-7-17**]): The left anterior descending coronary artery
has mild diffuse disease in the proximal, mid, and distal
portions. The ramus is a branching vessel that has a 70-80%
stenosis at the upper pole. The left circumflex artery is the
dominant vessel and is patent in the proximal portion. There is
60% in-stent restenosis in the mid-circumflex artery and the
distal circumflex has diffuse disease. OM1 and OM2 are small
vessels. OM3 has a 100% occlusion that is likely chronic. The
right coronary artery is non-dominant and has a 70% proximal
occlusion, the mid and distal vessel is without significant flow
limiting disease. Left heart catheterization revealed normal
diastolic filling pressures.
.
Echo ([**2182-7-17**]): Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Elevated LVEDP. Pulmonary artery systolic hypertension. Mild
mitral regurgitation.
.
Femoral Vascular US ([**2182-7-18**]): No evidence of arteriovenous
fistula or pseudoaneurysm.
.
KUB ([**2182-7-19**]): Limited study. Mild ascites.No acute pathology
is demonstrated.
.
Abd CT ([**2182-7-20**]): Liver heterogenous attenuation throughout with
two discrete foci of increased attenuation. One anteriorly in
segment 8, the other more posteriorly in segment 6 and
laterally. Splenomegaly and the spleen measures nearly 16 cm in
craniocaudad direction. In addition, peripherally there is a
wedge-shaped area of hypoattenuation. This likely reflects the
vascular phase of enhancement, but would also be consistent with
a splenic infarct. Both native kidneys are markedly shrunken and
atrophic. There is evidence of marked osteopenia. In addition,
multilevel fractures are identified, including the pelvic bones,
left iliac bone and left femur.
Brief Hospital Course:
1. Atrial fibrillation: The patient was transferred to the CCU
from the OSH with a recent history of atrial fibrillation and
hypotension complicating his hemodialysis treatments. This was
considered potentially related to his coronary artery disease
and ischemia. On hospital day 2, he underwent cardiac
catheterization, which revealed disease in LCx and OM3. The plan
was for medical management, without intervention. The pt was
then evaluated by EP for possible ablation. EP recommended
increasing amiodarone and not doing ablation at this time. His
amiodarone and beta blocker doses were titrated and he remained
in normal sinus rhythm throughout the remainder of his
hospitalization, with the exception of one episode of atrial
fibrillation during dialysis.
.
2. CAD: As noted previously, the patient underwent cardiac
catheterization on transfer from the OSH. The left main was
calcified and widely patent. The left anterior descending
coronary artery had mild diffuse disease in the proximal, mid,
and distal portions. The ramus had 70-80% stenosis at the upper
pole and the left circumflex artery was patent in the proximal
portion with a 60% in-stent restenosis in the mid-circumflex and
diffuse disease in the distal circumflex. OM3 had a 100%
occlusion that is likely chronic. The right coronary artery is
non-dominant and had a 70% proximal occlusion. The decision was
made for medical management and the patient was continued on
aspirin, statin and beta blocker with nitro prn for chest pain.
He remained chest pain free throughout his admission.
.
3. GIB: During his CCU stay, he had several episodes of
maroon-colored stools with BRBPR, which were guaiac positive.
His Hct was stable and he remained hemodynamically stable. His
heparin and coumadin were discontinued and GI was consulted.
Given his multiple comorbidities and need for long-term
anticoagulation as an outpatient, it was decided to perform a
colonscopy while the patient was in-house and his
anticoagulation held. The patient was transferred to the
medicine [**Hospital1 **] service for this procedure. Colonoscopy was
performed on [**2182-7-25**] and revealed esophageal varices and portal
hypertensive gastropathy. For this reason, Coumadin will not be
restarted as an outpatient.
.
4. Abdominal pain: During his stay in the CCU, the patient also
developed severe diffuse abdominal pain and distension on
[**2182-7-20**]. A KUB showed a possible small bowel obstruction. The
patient was evaluated with an Abdominal CT which showed possible
hypoattenuation in the liver and a possible splenic infarct,
without evidence of obstruction, though it was an inadequate
study because the pt refused to finish the contrast. The
patient's abdominal pain subsequently improved. An MRI was
performed to further evaluate the areas of hypoattenuation and
revealed peripheral wedge shaped areas of arterial
hyperenhancement within the liver consistent with perfusion
abnormalities without a focal hepatic mass identified. Continued
follow up is recommended because of the patient's known history
of liver disease. It also revealed a cirrhotic liver with
evidence of portal hypertension and splenomegaly, with an area
of T1 hypointensity in the spleen which most likely represents
an area of splenic hypoperfusion in combination with focal iron
deposition
.
5. ESRD: The patient was followed by [**Date Range 2793**] throughout his stay
and had scheduled hemodialysis.
.
6. Knee pain: During his hospitalization at the OSH and here,
the patient has had persistent right knee pain which improved
with NSAIDs and steroids at the OSH. His physical exam was
significant for pain on active movement and not passive
movement, with medial joint tenderness. This suggests a possible
MCL injury vs. tendonitis vs. anserine bursitis. RICE was
recommended and the patient received Percocet for pain. NSAIDs
were held in the setting of his GI bleed.
.
7. Hypothyroidism: His TSH was within normal limits on admission
and his synthroid was continued.
.
8. Hepatitis C: Patient has a known history of hepatitis C.
Colonoscopy revealed portal hypertensive gastropathy and
varices. Coumadin will not be continued due to varices. His
Toprol XL was continued rather than switching to nadolol. He
will be seen by a gastroenteritis as an outpatient.
Medications on Admission:
Meds: (At OSH)
1. Amitriptyline 10mg qhs
2. Liptitor 10mg qd
3. Phosphorus 167mg tid
4. Lantus 14u qhs
5. Imdur 30mg qd
6. Synthroid 0.2mg qd
7. Protonix 40mg qd
8. Prednisone 30mg qd
9. Renagel 800mg tid
10. Bactrim DS 1tab q Mon/Wed/Fri
11. Amiodarone 200mg qd
12. ASA 160mg qd
13. Toprol 25mg qd
Discharge Medications:
1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MON/WED/FRI ().
Disp:*12 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for CHEST PAIN.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed: Do not exceed more than
six tablets in one day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary diagnoses:
1. Atrial fibrillation
2. Coronary artery disease
3. GI bleed, likely secondary to esophageal varices
Secondary Diagnoses:
1. End-stage [**Date Range 2793**] disease on Hemodialysis
2. Knee pain
3. Diabetes Mellitus
4. Portal Hypertensive gastropathy
5. Esophageal ulcer
6. Peripheral vascular disease
7. Hypothyroidism
8. Hypercholesterolemia
Discharge Condition:
Good, stable hematocrit
Discharge Instructions:
You are discharged to home and should continue all medications
as prescribed. Please contact your physician or present to the
ER if you experience chest pain, palpitations, lightheadedness,
fevers, chills, maroon-colored stools, blood from your rectum or
other concerns. Please keep all follow-up appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Followup Instructions:
You have a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] on [**2182-8-28**] at 3:20pm. You should call his
office to see if you can schedule something sooner. Office
number [**Telephone/Fax (1) 2936**]
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2182-8-13**] 10:30
Please call Gastroenterologist Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] [**Telephone/Fax (1) 682**] to
schedule an outpatient appointment in one month after discharge.
|
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82,904
| 115,169
|
35057
|
Discharge summary
|
report
|
Admission Date: [**2175-8-8**] Discharge Date: [**2175-8-17**]
Date of Birth: [**2132-3-23**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**Known firstname 30**]
Chief Complaint:
Fever of 103 on HD, abd pain, N/V
Major Surgical or Invasive Procedure:
ERCP on [**2175-8-8**] with stent placement
ET Intubation on [**2175-8-8**]
ERCP on [**2175-8-14**] with stent placement
Extubation on [**2175-8-14**]
Hemodialysis
Central venous catheter - RIJ
Arterial line
Echocardiogram
History of Present Illness:
This is a 43 yo man transferred from MICU [**Location (un) 2452**] for ERCP in the
setting of presumed biliary sepsis. Patient was transferred on
[**2175-8-7**] from [**Hospital3 **] ED with fever found at HD [**2175-8-7**] to
103. He reports symptoms started the evening of [**8-6**] with sharp
abdominal pain, nausea, vomitting, and diarrhea. At HD he was
febrile with rigors to temp of 103. He had blood cultures and
was given vanco/ceftazidime and sent to [**Hospital3 **]. At
[**Hospital3 3583**] he was given benedryl 25mg iv, reglan 10mg iv,
morphine 6mg iv, zosyn 2.25gm iv. He had an abdomen/pelvis CT
that preliminarily showed gall bladder hypodensity without signs
of acute cholecysitis. He was transferred here for ERCP given
elevated amylase, lipase and transaminases. AT [**Hospital1 18**] ED he was
given 3L IVF for SBP 77-111 with HR 100's with Tm 101.5. He was
given tylenol 1gm. He was admitted to MICU [**Location (un) 2452**] overnight
where a right IJ central line was placed and he received 2L NS,
IV vancomycin and zosyn. Patient was transferred to the [**Hospital Unit Name 153**] for
planned ERCP intervention on the [**Hospital Ward Name **].
Past Medical History:
CAD s/p stent [**1-6**] at [**Hospital1 2177**] in the setting of pna
HTN
gout: no active symptoms for several years, does not take ppx
ESRD on HD x9 years, ? [**12-31**] post-strep infection as a child?, on
M/W/F schedule, last HD [**8-7**], at Forsinius in [**Location (un) 3320**] where he
reportedly normally gets 5kg removed
OSA on CPAP, pressure 17mmHg?, but is unable to tolerate at home
Social History:
Lives with children (age 19, 22), denies past or current
tobacco, drinks etoh only on special occaisions (less than
once/month) but drank more heavily prior to HD, occaisional MJ
but no IVDU or cocaine.
Family History:
Father with hypertension, mother with DM, sibs healthy, children
healthy.
Physical Exam:
VS: T 99.5 HR 101 BP 117/75 RR 28 Sat 93% on 4L NC
Gen: NAD, obese man, speaking in full sentances, mild labored
breathing, drowsy but arousable, witnessed apnic episodes while
sleeping
HEENT: PERRL, OP clear, MM dry, mild scleral icterus
Neck: Supple, Right IJ in place, no LAD
CV: Reg, Tachy, III/VI SEM best at RUSB, heard throughout, no
r/g
Resp: Decreased BS at both bases with scattered rales R base
Abdomen: Obese, distended but soft, NT, no obvious masses but
very protuberant, white striae, no fluid wave, tympanic to
percussion throughout, unable to palpate liver or spleen; no
periumbilical ecchymosis
Ext: 1+ PE to thigh bilaterally; 2+ DP's B, left UE fistula
+palpable thrill
Neuro: A&Ox3, CN II-XII intact, strength 5/5 B UE/LE, sensation
intact to light touch
Skin: no rashes, lesions or ecchymoses
.
Pertinent Results:
[**2175-8-8**] 10:22PM TYPE-ART TEMP-38.2 RATES-20/1 TIDAL VOL-700
PEEP-5 O2-60 PO2-79* PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-8-8**] 10:22PM LACTATE-1.2
[**2175-8-8**] 10:22PM O2 SAT-95
[**2175-8-8**] 08:56PM TYPE-ART TEMP-38.2 RATES-[**10-30**] TIDAL VOL-700
PEEP-5 O2-60 PO2-86 PCO2-63* PH-7.28* TOTAL CO2-31* BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-8-8**] 08:56PM LACTATE-0.9
[**2175-8-8**] 08:56PM freeCa-1.03*
[**2175-8-8**] 08:49PM GLUCOSE-101 UREA N-45* CREAT-10.1* SODIUM-140
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-20
[**2175-8-8**] 08:49PM CK(CPK)-534*
[**2175-8-8**] 08:49PM CK-MB-5 cTropnT-0.29*
[**2175-8-8**] 08:49PM CALCIUM-7.6* PHOSPHATE-5.9* MAGNESIUM-2.1
[**2175-8-8**] 02:22PM TYPE-MIX PO2-44* PCO2-54* PH-7.39 TOTAL
CO2-34* BASE XS-5
[**2175-8-8**] 02:22PM LACTATE-1.4
[**2175-8-8**] 01:55PM GLUCOSE-125* UREA N-38* CREAT-9.1* SODIUM-139
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-30 ANION GAP-17
[**2175-8-8**] 01:55PM ALT(SGPT)-70* AST(SGOT)-50* LD(LDH)-198 ALK
PHOS-200* AMYLASE-241* TOT BILI-4.5*
[**2175-8-8**] 01:55PM LIPASE-236*
[**2175-8-8**] 01:55PM ALBUMIN-3.5 CALCIUM-7.8* PHOSPHATE-5.1*
MAGNESIUM-2.1
[**2175-8-8**] 01:55PM WBC-6.9 RBC-3.60* HGB-11.2* HCT-33.2* MCV-92
MCH-31.2 MCHC-33.8 RDW-14.2
[**2175-8-8**] 01:55PM NEUTS-92.5* LYMPHS-3.1* MONOS-4.0 EOS-0.2
BASOS-0.2
[**2175-8-8**] 01:55PM PLT COUNT-179
[**2175-8-8**] 01:21PM LACTATE-1.7
[**2175-8-8**] 04:10AM GLUCOSE-127* UREA N-32* CREAT-8.8* SODIUM-140
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-32 ANION GAP-21*
[**2175-8-8**] 04:10AM ALT(SGPT)-87* AST(SGOT)-66* CK(CPK)-80 ALK
PHOS-213* AMYLASE-376* TOT BILI-3.7* DIR BILI-2.3* INDIR BIL-1.4
[**2175-8-8**] 04:10AM LIPASE-459*
[**2175-8-8**] 04:10AM CK-MB-NotDone cTropnT-0.21*
[**2175-8-8**] 04:10AM ALBUMIN-3.9 CALCIUM-7.6* PHOSPHATE-4.4
MAGNESIUM-1.2*
[**2175-8-8**] 04:10AM TRIGLYCER-236*
[**2175-8-8**] 04:10AM CORTISOL-34.3*
[**2175-8-8**] 04:10AM VANCO-10.4
[**2175-8-8**] 04:10AM ASA-NEG ACETMNPHN-7.0 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2175-8-8**] 04:10AM WBC-10.3 RBC-3.63* HGB-11.2* HCT-32.5* MCV-90
MCH-30.9 MCHC-34.4 RDW-14.7
[**2175-8-8**] 04:10AM NEUTS-94* BANDS-4 LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2175-8-8**] 04:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2175-8-8**] 04:10AM PLT COUNT-240
[**2175-8-8**] 04:10AM PT-15.5* PTT-28.7 INR(PT)-1.4*
[**2175-8-8**] ERCP FINDINGS: The common bile duct was adequately
opacified with contrast medium after the cannulation of the
biliary duct. No apparent extrahepatic or intrahepatic biliary
duct dilatation or irregularity is seen. No filling defects
consistent with stones were noted. As per report, in subsequent
images, biliary stent was successfully placed. IMPRESSION:
Successful placement of biliary stent.
[**2175-8-9**] Transthoracic Echo: The left atrium is moderately
dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. 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.] There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
[**2175-8-14**] ERCP FINDINGS: Comparison is made with CT from [**8-12**], [**2174**] and prior ERCP from [**2175-8-8**]. There is
removal of a plastic stent. A retrograde cholangiogram shows
multiple filling defects, some of which likely represent stones,
within otherwise normal- appearing biliary tree. A biliary stent
was then placed.
Brief Hospital Course:
#Hypotension/Sepsis: On admission, patient met SIRS criteria
with fever, tachypnea, tachycardia and lactate of 2.5 consistent
with sepsis. Infectious source was likely biliary tract vs. HD
line infection, however also considered was pulmonary source w/
new O2 requirements although more likely from capillary
leak/CHF. Patient has remained fluid responsive intially without
need for pressors. The underlying infection was treated with IV
vancomycin/unasyn/gentamycin for synergy until cultures at OSH
grew enterobacter at which point only zosyn was continued with
appropriate coverage. The patients lactate level, fevers and WBC
were trended and returned to [**Location 213**]. Zosyn was switched to
Ciprofloxacin after the patient developed a drug rash.
.
#Mechanical ventilation: Patient came to the ICU intubated s/p
ERCP, on a propofol drip. Initially he was hypotensive which was
treated with IV fluids and discontinued propofol, switching to
fentanyl/versed for sedation. Shortly thereafter the patient
became restless, agitated and continued to be hypotensive. He
was given 10mg vecuronium and paralyzed for arterial line
placement and foley placement. His labile blood pressures also
exacerbated his already fluid-overloaded state, making it
difficult to wean off the vent. The initiation of hemodialysis
effectively controlled his BP and fluid status, and on day 7,
after his second ERCP, he was extubated and started on CPAP
overnight.
.
# Gallstone Pancreatitis: On admission the patient had elevated
LFTs, pancreatic enzymes, bilirubin and alk phos. His levels
slowly trended down post-ERCP except bilirubin and AP, which
continued to rise. The patient experienced intermittent
epigastric discomfort which prompted a RUQ US, which showed a
fatty liver but the common bile duct non-well visualised. CT
scan of abdomen showed no intrahepatic biliary dilatation,
cholelithiasis, and a subtle hypodensity in pancreatic head.
Hepatology and ERCP were consulted prompting a second-look ERCP,
which showed sludge drainage in the major papilla, stent
migrated to major papilla and several stones in the cystic duct.
The stent was replaced, antibiotics were continued, and the
patient's enzymes and bilirubin were trended.
.
# ESRD: Initially the nephrology service felt HD was not
appropriate early during admission, in setting of patient
becoming hypertensive to 200s with volume resusitation for
pancreatitis. Beta-blockers were started however the patient did
not respond and O2 sats started trending down with worsening
acidemia and low PaO2. The following day HD was initiated with
good response in blood pressure. The patient received HD
throughout his course, with the day before D/c the final time.
.
# Hypoxia: Suspected capillary leak in the setting of sepsis vs.
CHF as pt with known CAD. The patient was weaned off his O2
requirement prior to discharge.
.
# Drug Rash: Patient developed a diffuse petticheal/macular rash
on his chest and legs which was pruritic. Dermatology was
consulted who felt consistent with a drug rash. Offending [**Doctor Last Name 360**]
was felt to be Zosyn. [**Doctor Last Name **] was discontinued and rash improved.
He will continue hydoxyzine, sarna and fluocinonide.
.
# CAD: An echo was performed to rule out endocarditis as a cause
of fever. This showed extensive calcification of cardiac
skeleton, mild calcific aortic stenosis, and no definite
vegetations . His ECG had some ischemic changes of unclear
duration, and the patient had no active symptoms. Cardiac
enzymes were stably elevated on admission and, in the setting of
ESRD, this was unlikely to be acute event. His aspirin and
plavix were continued and the patient remained on telemetry for
the duration of his stay.
.
# OSA: Witnessed apneic episodes while asleep. Known history of
OSA on CPAP as outpatient but has not been tolerating of recent.
Once patient was extubated he was started on CPAP overnight.
.
# Anemia: Normocytic with normal RDW. Unclear baseline. [**Month (only) 116**] be
low related to ESRD (not on epo as outpatient that we know of).
D. bili not consistent with hemolysis. Hematocrit was trended
and continued to improve with HD and management. Renal recs: use
epo during HD.
.
Medications on Admission:
fish oil daily
sensipar 120mg daily
ativan 0.5mg prn (rare)
percocet prn (rare)
nifedipineER 90 daily (last [**8-7**])
minoxidil-dose unable to verify but pt states rx for 2 tabs and
only takes 1
renagel 2400mg tid ac
phoslo 1334mg (?) tid ac
simvastatin 20mg daily
plavix 75mg daily
aspirin 325mg daily
toprolXL 50mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
Disp:*1 tube* Refills:*0*
6. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Take this at least one hour before you take Renagel.
Disp:*5 Tablet(s)* Refills:*0*
7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for itching: Only take this as long as
your rash is itching.
Disp:*21 Tablet(s)* Refills:*0*
8. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash for 12 days: Only use while you
have the rash.
Disp:*1 tube* Refills:*0*
9. Cinacalcet 30 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Biliary Sepsis
Gallstone Pancreatitis
Secondary Diagnoses:
ESRD with hemodialysis
CAD
Drug rash
OSA
HTN
Anemia
Discharge Condition:
Good, tolerating regular diet, ambulating with walker for
deconditioning, able to climb a flight of stairs, no oxygen
requirement, VSS
Discharge Instructions:
You were seen and treated at the hopital for a blockage in the
area of your gallbladder, which caused you to become infected.
You were treated with intravenous fluids, antibiotics and ERCP
(Endoscopic Retrograde Cholangiopancreatography) twice. A small
tube called a stent was placed near your gallbladder so that it
will drain bile into your intestine.
Please take the antibiotics (Ciprofloxacin) until it is
finished. You may also use the skin cream for your rash as long
as you need it. You may take all of your home medications, and
none of the dosages were changed.
Call your doctor or come to the Emergency Department right away
if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow again.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please make an appointment to follow up with your PCP:
[**Name10 (NameIs) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 80088**] in the next week or two to further
evaluate your response to treatment.
You will also need to follow-up with the Gastroenterology team
to have a repeat ERCP 6 weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please
call his office at ([**Telephone/Fax (1) 2306**] M-F 8:30am-4:30pm.
The Dermatologists would also like you to make an appointment
for some areas of skin that require follow-up. You may call
their office at ([**Telephone/Fax (1) 8132**] to schedule the appointment.
Completed by:[**2175-8-17**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,855
| 111,891
|
23792+57375
|
Discharge summary
|
report+addendum
|
Admission Date: [**2122-7-12**] Discharge Date: [**2122-8-7**]
Date of Birth: [**2049-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
72 year old male admitted on [**2122-7-12**] with right iliac stent
artery aneurysm with a cheif complaint of back pain and mild
shortness of breath.
Major Surgical or Invasive Procedure:
[**2122-7-13**]- Endovascular stent graft repair of right common iliac
artery with extender stend into external iliac artery and
hypogastric artery embolization.
History of Present Illness:
The pt is a 72 year old male s/p AAA orininally presented on
[**2122-5-19**] for SOB, and a CTA of the A/P at that time demonstrated
a RCI aneurysm. Pt was instructed to follow up at a later date,
as this was not deemed an emergent issue. On [**2122-6-11**], he
presented for a CAT and IV fluids for his RI. He was then
discharged and told to follow up with Dr. [**Last Name (STitle) **]. On [**2122-7-12**],
the pt arrived to have his RCI aneurysm endvascularly repaired.
Past Medical History:
AAA repair
COPD
CAD
anemia
HTN
CRI
CHF
chronic UTI
dementia
depression
Social History:
Spanish speaking, lives in a nursing home, ex-smoker and alcohol
user.
Family History:
noncontributory
Physical Exam:
Gen: cachectic male
HEENT: PERRLA, EOMI
Lungs: rhonchi b/l bases
Cardiac: RRR, no murmurs
Abd: PEG tube site clean, slightly distended, soft, nontender
Ext: No C/C/E
Neuro: AxOx3
Palp PT bil
Pertinent Results:
[**2122-8-6**]
WBC-13.4* RBC-3.59* Hgb-10.2* Hct-32.2* MCV-90 MCH-28.3
MCHC-31.6 RDW-17.1* Plt Ct-219
[**2122-8-5**]
Neuts-75.9* Lymphs-16.6* Monos-5.0 Eos-2.2 Baso-0.3
[**2122-7-31**]
PT-13.4* PTT-32.4 INR(PT)-1.2
[**2122-8-6**]
Glucose-156* UreaN-48* Creat-1.2 Na-140 K-4.6 Cl-100 HCO3-30*
AnGap-15
[**2122-8-6**]
Calcium-10.3* Phos-4.3 Mg-2.1
[**2122-7-13**]
CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVIC
Reason: Locate central and r/o pneumo
AP SUPINE CHEST: Comparison to AP upright chest of 8 hours
prior. There has been interval intubation with the ETT tip 5 cm
above the carina. Right IJ line seen with its tip distal SVC. No
pneumothorax is identified, though limited assessment due to
severe emphysema and overlying tubes. Severe upper lobe bullous
emphysema. There remains bibasilar opacities, which may be
secondary to chronic emphysema, however, it is difficult to
exclude an element of mild CHF/volume overload superimposed on
background emphysematous changes. No pneumonia is seen. There is
a persisting left retrocardiac opacity, which is unchanged
dating back to multiple prior chest x-rays.
IMPRESSION:
1) ETT and right IJ in satisfactory position; no pneumothorax
identified, though limited assessment due to emphysema and
overlying tubes.
2) Equivocal mild CHF/volume overload superimposed on background
emphysema. No new pneumonia. Unchanged appearance of left
retrocardiac opacity. Follow-up again recommended to ensure
resolution is recommended.
ECHO
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 60% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.50
Mitral Valve - E Wave Deceleration Time: 252 msec
TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg)
Findings:
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%). No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on mitral valve. Trivial MR. LV inflow pattern c/w
impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic
function is probably normal. 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 masses or vegetations are
seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2122-7-14**], there is probably no change.
IMPRESSION: No valvular vegetations seen. If clinically
indicated, a TEE would better to exclude a small valve
vegetation.
[**2122-8-5**]
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: SOB
PROCEDURE: CT of the chest.
INDICATION: Tachycardic and tachypnic with shortness of breath.
TECHNIQUE: Multidetector noncontrast low-dose images of the
chest, and contrast-enhanced images of the chest following rapid
bolus administration of 100 cc of IV Optiray were performed.
Images are reformatted in the sagittal and coronal planes.
IV CONTRAST: Nonionic IV Optiray contrast was used for rapid
bolus administration.
CT OF THE CHEST WITH AND WITHOUT CONTRAST: There is severe
emphysematous change throughout the lungs, with marked bullous
formation in the upper lobes as well as anteriorly towards the
lung bases. No pulmonary embolism is identified. There are no
areas of consolidation. There are no pleural effusions. There is
a focal 1.2 cm opacity seen in the periphery of the lingula, not
seen on prior study of [**2122-5-11**]. The aorta is markedly
tortuous, and is seen to have mass effect on the left atrium as
before, which might compromise venous return. There is mild
dilatation of both main pulmonary arteries indicative of
pulmonary hypertension. The right pulmonary artery measures 2.5
cm, and the left 2.2 cm. There is no pneumothorax. No
pericardial effusion. Within the imaged portions of the upper
abdomen, no abnormalities are identified.
Bone windows show no suspicious lesions.
Some secretions are noted within the trachea and right main stem
bronchus.
MULTIPLANAR REFORMATTED IMAGES: Images reformatted in the
sagittal and coronal planes show no evidence of pulmonary
embolism. No aortic aneurysm or dissection identified.
IMPRESSION:
1. No pulmonary embolism identified.
2. Severe emphysema with marked bullous changes particularly at
the upper lobes and in the lower thorax anteriorly.
3. Focal 1.2 cm opacity in the periphery of the left lingula,
not seen previously. While this may represent atelectasis or an
inflammatory opacity, short-term followup in one to two months
is recommended to ensure stability or resolution.
[**2122-7-17**]
SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2122-7-17**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2122-7-19**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
ACID FAST SMEAR (Final [**2122-7-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Brief Hospital Course:
The patient was admitted on [**2122-7-12**]
PCP followed patient while in hospital
The patient is an elderly male who underwent treatment of a
ruptured aortic aneurysm at an outside hospital. He recovered,
but was left with a greater than 6 cm
right common iliac artery aneurysm. Although the aneurysm was
very large and the iliac artery proximal and distal was very
tortuous, there appeared to be a suitable proximal and distal
cuff zone for endovascular repair.
Pt pre-op'd cleared for surgery.
[**2122-7-13**]
Pt underwent a endovascular stent graft repair of right common
iliac artery aneurysm.
extender stent graft into external iliac artery and embolization
of right hypogastric artery.He tolerated the procedure well.
There were no complications. He was transfered to the PACU in
stable condition.
[**2122-7-14**]
Pt remained in PACU overnight. He was extubated this day. He was
also diuresed post procedure.
Pt had to reintubated for failed extubation. Pt has a history of
02 dependent COPD / aspiration pna. When extubated pt dropped
his o2 sats and had labored breathing.
[**2122-7-15**] - [**2122-7-27**]
Pt transfered to SICU.
Pt CRI/CHF remained stable.
Pt on CPAP/PS. recieved inhalers. Tube feeds through PEG, foley
remained, hct stable, SSI, lines remained in place. Pt
experienced low grade temps. Yellow secretions. Required no BP
control. Pt experienced low grade temps.
Pt pan cx'd. Found to have increase WBC.
Pt given zosyn for pna. Also pt started on Vancomycin for pos
blood cx.
Pt weaned to BIPAP. While in the SICU pt [**Last Name **] problem was the
inability extubate. He recieve Antibiotics for PNA. He
experienced some minor dementia. This was thought to be due sun
downing. Pt also reqiured a variety of IV medications for BP
support
Steroids were started for COPD flare. Pt extubated
[**2122-7-28**] - [**2122-7-30**]
Pt transfered to the VICU in stable condition.
Zosyn was Dc'd / Vancomycin Dc'd.
Steroids were tapered
CVL dc'd. Pt still required some diuresis.
[**2122-7-31**] -[**2122-8-3**]
Foley [**Name (NI) **]
PT WBC remained elevated. A CT scan was obtained. This was
negative.
[**2122-8-4**]
Pt transfered to Medicine for on going leukocytosis.
Medications on Admission:
FS Jevity
Tylenol 325'
Lipitor
ASA
Lopressor 6.25''
Protonix
SQ heparin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Right common iliac artery aneurysm
CRI
CHF
PNA
Discharge Condition:
Stable
Discharge Instructions:
Follow-up with Dr [**Last Name (STitle) 3407**] in two weeks. Please call [**Telephone/Fax (1) 1241**].
Completed by:[**2122-8-7**] Name: [**Known lastname 11072**],[**Known firstname 11073**] Unit No: [**Numeric Identifier 11074**]
Admission Date: [**2122-7-12**] Discharge Date: [**2122-8-7**]
Date of Birth: [**2049-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 107**]
Addendum:
See the brief hospital course below for the addendum.
Brief Hospital Course:
#1. leukocytosis: Pt transferred to the medicine service on
[**8-4**] for w/u of persistent leukocytosis. He had been afebrile,
completed a 10 day course of Zosyn for pseudomonas pneumonia,
and had been on steroids for a COPD flare from [**Date range (1) 11075**]. His
WBC increased from 6.8 on [**7-25**] and peaked to 22 on [**7-31**]. CXR,
blood cultures, PPD, TTE all negative. ESR was elevated; WBC
trending down from 22 - last checked on [**8-6**] with result of
14.1. Infectious disease service was consulted, and they
recommended testing for C. diff given that they did not find
other sources of infection. C. diff was tested once during pt's
hospitalization -- negative and pt w/out diarrhea. Plan to test
at the rehab facility.
.
#2. SOB: On [**8-4**], pt had episode of SOB/tachypnea/tachycardia
with hypotension that responded with a fluid bolus, nebs and
suction. Although pt had been on SC heparin during his
admission, ruled out PE with a CXR and CTA. EKG and cardiac
enzymes were also negative. He has had several similar episodes
in the SICU but had not been worked up for PE. It is most
likely that these have been COPD flares that are responsive to
neb treatments. Would continue to provide supplemental O2,
chest PT, suction, and nebs.
.
#3. CAD: Please refer to issue #2 above - given his history of
CAD, we checked his cardiac enzymes, ECHO, and EKG. All were
negative, and we made no changes to the current cardiac meds.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily): G TUBE DAILY.
Disp:*30 * Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 * Refills:*2*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 * Refills:*2*
10. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed for delirium.
Disp:*30 * Refills:*2*
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*30 * Refills:*2*
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please adhere to the insulin
sliding scale.
Disp:*1 mL* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 474**]- [**Location (un) 164**]
Discharge Diagnosis:
Primary:
AAA repair
Pseudomonas pneumonia
COPD exacerbation
leukcocytosis
Secondary:
CAD
anemia
HTN
CRI
CHF
chronic UTI
dementia
depression
Discharge Condition:
Good
Discharge Instructions:
Please make sure to see Dr. [**Last Name (STitle) **] within the week at [**Hospital 11076**].
Notify Dr. [**Last Name (STitle) **] with fever, worsening shortness of breath,
chest pain, persistent diarrhea, green or bloody sputum,
dizziness, back pain, or bleeding from your groin.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in the upcoming week at [**Hospital3 474**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 108**] MD [**MD Number(1) 109**]
Completed by:[**2122-8-7**]
|
[
"593.9",
"442.2",
"285.9",
"482.1",
"491.21",
"414.01",
"311",
"294.8",
"V13.09",
"458.9",
"428.0",
"401.9",
"293.0",
"564.00",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.29",
"96.72",
"39.79",
"96.6",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
15142, 15213
|
11807, 13272
|
464, 627
|
15397, 15403
|
1576, 8654
|
15735, 15977
|
1332, 1349
|
13295, 15119
|
15234, 15376
|
10917, 10990
|
15427, 15712
|
1364, 1557
|
275, 426
|
655, 1133
|
1155, 1228
|
1244, 1316
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,440
| 111,528
|
2310+2311
|
Discharge summary
|
report+report
|
Admission Date: [**2168-2-9**] Discharge Date: [**2168-2-22**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This is a 41 year old man with
end stage renal disease, dementia, hypertension, type II
diabetes, change in mental status five days prior to his
admission. At hemodialysis, the patient was noted to have
low grade fevers. Blood cultures were drawn and he was given
Vancomycin and Gentamycin doses times one. On arrival to the
Emergency Room, the patient was found to have a right lower
lobe consolidation and he was given one dose of Levaquin.
The patient was found to be in altered mental status.
Subsequently, his psychiatric medications were held. His
Levofloxacin was started on hospital day number two for
possible pneumonia. By hospital day number three, the
patient became increasingly lethargic and febrile to 101.5.
At this time, the patient became hypotensive his systolic
blood pressures dropped to the 70's. The patient's blood
pressure responded to intravenous fluids and he was given
Vancomycin and Flagyl. On hospital day number four, the
patient again became hypotensive and was sent to the
Intensive Care Unit and given aggressive hydration. In the
Intensive Care Unit, the patient was given Vancomycin and
Flagyl for suspected aspiration pneumonia. At that time, the
patient also had increasing rigors and muscle tone, thought
to possibly be secondary to his psychiatric medications.
In the Medical Intensive Care Unit, the patient was placed on
pressors and intravenous fluids. He was given Vancomycin,
Levofloxacin and Flagyl. A lumbar puncture was performed
without evidence of infection. Once the blood pressure was
stabilized, the patient was transferred to the [**Hospital1 139**]
Medicine Floor.
PAST MEDICAL HISTORY: 1.) Hypertension. 2.) End stage renal
disease, on hemodialysis. 3.) Arteriovenous fistula with a
history of pseudoaneurysm, status post repair in [**10-23**]. 4.)
Dementia. 5.) Gout. 6.) Questionable history of positive
PPD. 7.) History of Methicillin resistant Staphylococcus
aureus. 8.) Anemia of chronic disease. 9.) History of
hospitalization for syncope and mental status changes. 10.)
Dialysis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
Risperdal 0.5 mg p.o. three times a day.
Phos-Low two tablets with medications.
Remeron 30 mg once a day.
Zestril 40 mg once a day.
Hydralazine 50 mg four times a day.
Aspirin 81 mg once a day.
Imdur 60 mg once a day.
Nephro-Caps one tablet q. day.
Hytrin 2 mg p.o. q h.s.
Colchicine 0.6 mg p.o. q. day.
Allopurinol 100 mg p.o. q. day.
PHYSICAL EXAMINATION: Upon transfer, temperature was 98.9; T
maximum was 102; blood pressure was 125/70; pulse 88;
respiratory rate 20; oxygen saturation 96% on four liters.
On general examination, he is unresponsive to verbal stimuli.
He was lethargic but responded to pain. Cardiovascular:
Neck examination revealed jugular venous distention of about
6 cm. Cardiovascular: Distant heart sounds, regular rate and
rhythm. Pulmonary: Poor inspiratory effort. Abdomen was
nontender, nondistended. Positive bowel sounds, no masses.
Extremities: The patient is in multi-poultice boots for bed
sore blisters on feet. Neurologic: He is unresponsive;
decreased tone.
LABORATORY DATA: Sputum culture showed Methicillin resistant
Staphylococcus aureus, positive but consistent with
oropharyngeal flora. Cerebrospinal fluid showed one white
blood cell count, total protein of 44, glucose of 64. LDH of
39. White blood cell count was 10.9; troponin T of 0.30.
TSH of 0.94. All blood cultures were negative. Urine
cultures were negative. Cerebrospinal fluid cultures
negative.
HOSPITAL COURSE: 1.) Mental status changes: The patient was
thought to have poor mental status, secondary to his
infection. The patient during the earlier part of the
hospital course had hyponatremia which was repleted
cautiously with free water. Meningitis was ruled out by
lumbar puncture. His psychiatric medications were held as a
potential cause for his change in mental status. However, as
the patient's febrile illness subsided, the patient's mental
status increased. By the end of the hospital stay, the
patient was able to verbally respond to questions.
The patient continued to have elevated fevers after his
transfer from the Intensive Care Unit. Initially, the
patient was on Ceftriaxone and Flagyl for antibiotics. Given
the high likelihood of the patient's gram negative infection,
with the possibility of anaerobic infection from aspiration,
the patient was switched to Cefepime and Flagyl to also
include pseudomonal coverage. Given that the patient had a
Methicillin resistant Staphylococcus aureus positive sputum,
he was also continued on the Vancomycin.
The patient's fever curve continued to improve and the
patient became afebrile for over 72 hours. At this time, the
Flagyl was discontinued to prevent the selection of
Vancomycin resistant to enterococcus.
The patient's blood pressure remained stable during his
hospital course, after Medical Intensive Care Unit transfer.
The patient became hypertensive and his antihypertensive
medications were added gradually. The patient continued
hemodialysis on Monday, Wednesday and Friday. The patient
was given phosphate binders.
The patient had remained n.p.o. for several days. An
nasogastric tube placement was attempted but was
unsuccessful. Initial placement of nasogastric tube was
pulled out by patient. Subsequently placement was
unsuccessful. After discussion with the family, it was
decided that the patient would be a candidate for
percutaneous endoscopic gastrostomy placement, to receive
enteral nutrition. The patient had percutaneous endoscopic
gastrostomy placement by gastroenterology without
complications and tube feeds were started several hours after
placement of the tube.
The patient was evaluated by speech and swallow for
possibility of aspiration. A video swallow was performed
which showed that food of all consistencies were aspirated
down the trachea. The patient was deemed unable to take p.o.
and was made n.p.o. In addition, to prevent further
complications from tube feeds, the patient was kept upright
at 30 degrees during all times of tube feeds.
The patient had anemia of chronic disease. The patient was
given Erythropoietin.
The patient was immobile and chronically in bed. The patient
began to develop bed sores. The patient was placed in
multi-poultice boots for formation of new ulcers on the heels
of both feet, as well as a sacral ulcer, grade one.
The patient was given First Step air mattress and wounds were
managed with wet to dry dressings daily. The patient was
turned twice a day to avoid formation of bed sores.
The patient never complained of chest pain; however, the
patient's troponin T levels trended upwards. Despite this,
the patient's creatinine kinase and MB fractionation remained
stable. The patient's peak troponin T was 0.78. The patient
was given aspirin p.r. and intravenous beta blocker prior to
his percutaneous endoscopic gastrostomy placement.
Subsequent to percutaneous endoscopic gastrostomy placement,
the patient was given betablocker and aspirin via
percutaneous endoscopic gastrostomy tube. The patient's
cardiac enzymes were monitored.
CONDITION ON DISCHARGE: Afebrile; no hypoxia; good.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Ischemia.
3. End stage renal disease.
4. Delirium.
5. Dementia.
6. Hypernatremia.
7. Hypotension.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once a day.
2. Isosorbide 60 mg once a day.
3. Terazosin 2 mg once a day.
4. Colace liquid.
5. Bisacodyl 10 mg once a day.
6. Subcutaneous heparin q. eight hours.
7. Allopurinol 100 mg p.o. q. day.
8. Senna 8.6 mg p.o. twice a day.
9. Sovalimir 1600 mg p.o. three times a day.
10. Bactroban ointment twice a day to scrotal sores.
11. Isosorbide dinitrate 30 mg p.o. three times a day.
12. Lisinopril 40 mg p.o. q. day.
13. Metoprolol 12.5 mg p.o. twice a day.
14. Acetaminophen.
15. Flumotadine 20 mg intravenous q. 24 hours.
16. Cefepime 500 mg intravenously once a day for seven days,
given after hemodialysis on Monday, Wednesday and Friday.
17. Vancomycin one gram dosed by Vancomycin levels daily for
the next seven days; if less than 15, then give 1 gram
dose and repeat the dose the next day.
18. Humalog sliding scale.
FOLLOW-UP PLANS: The patient is to follow-up with his
primary care physician. [**Name10 (NameIs) **] patient should get hemodialysis
every Monday, Wednesday and Friday. The patient should have
cardiac enzymes, white blood cell count and Vancomycin levels
followed on a regular basis. The patient should have tube
feedings, Nepro full strength, with a goal rate of 30 ml per
hour. 60 grams of ProMod should be added to the tube feeds
daily. Tube feeds should be flushaed with 200 ml of water
every four hours.
[**First Name11 (Name Pattern1) 402**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7463**]
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2168-2-22**] 01:42
T: [**2168-2-22**] 08:18
JOB#: [**Job Number 12096**]
Admission Date: [**2168-2-9**] Discharge Date: [**2168-2-29**]
Date of Birth: [**2093-5-16**] Sex: M
Service:
ADDENDUM
HOSPITAL COURSE: After placement of the patient's NG tube on
[**2-19**], he did well; however, it was noted that he had an
increased white blood cell count to approximately 20. This
continued over several days, and there was concern for a
possible second source of pneumonia. Therefore, the patient
was not discharged as planned on [**2-22**].
Blood cultures and urine cultures remained negative. The
patient continued with a severe aspiration pneumonia,
although chest x-ray did not show any worsening of the
pneumonia.
During this time, the patient remained with only very
low-grade fevers of approximately 99??????. He was continued on
his Cefepime and Vancomycin.
As the white count remained elevated for several days,
Infectious Disease was consulted, and they recommended the
addition of Flagyl for better coverage of anaerobes.
Despite the addition of this third antibiotic, the patient's
white count remained elevated in the 18-20 range. He also
however remained afebrile and did not show any clinical
worsening of his hypoxemia or cough.
Additionally, the patient's mental status worsened, and he
was no longer communicative in correlation with this
increasing white count. Repeat head CT was negative for any
new changes. It was felt that his waxing and [**Doctor Last Name 688**] mental
status was most likely a combination of his underlying
dementia, as well as secondary to toxic metabolic process
from his infection.
The patient's mental status did improve slightly by the day
of discharge, so that he was awake and would open his eyes,
but was not following simple commands or speaking.
Communication was maintained with his daughter [**Name (NI) 1154**]
[**Name (NI) 12097**], who was also his healthcare proxy throughout his
hospitalization, and it was decided that since he is
currently stable, and it seemed unlikely that he will show
significant improvement from his current status, given that
little change had been seen over the last week, he was sent
to a skilled nursing facility for further care.
Discussions with his daughter have been ongoing as to whether
his code status should be changed to CMO and hospice care
should be pursued. Currently he is still DNR/DNI, and
antibiotics and dialysis will be continued.
CONDITION ON DISCHARGE: The patient is stable with a 3 L
oxygen requirement. He also has significant dementia. He
opens his eyes to voice but does not communicate and does not
follow commands well.
DISCHARGE STATUS: To nursing home.
DISCHARGE DIAGNOSIS:
1. Aspiration pneumonia.
2. Ischemia.
3. End-stage renal disease on hemodialysis.
4. Delirium.
5. Dementia.
6. Hypernatremia, resolved.
7. Hypotension, resolved.
DISCHARGE MEDICATIONS: Please note that unless specified
otherwise, all medications are to go through the patient's
G-tube.
Aspirin 81 q.d., Colace 100 mg b.i.d., Bisacodyl 10 mg
p.r.n., Heparin 5000 U subcue q.8 hours, Allopurinol 100
q.d., Senna 1 tab b.i.d. p.r.n., .................. 1600 mg
t.i.d., Bactroban creme applied topically to scrotal ulcers,
Isosorbide Dinitrate 30 mg t.i.d., Lisinopril 40 mg q.d.,
Metoprolol 12.5 mg b.i.d., Tylenol p.r.n., Insulin sliding
scale, Lansoprazole 30 mg q.d., Nephrocaps 1 cap q.d.,
Cefepime 500 mg IV q.d. through [**3-6**], give every day
but on days of dialysis give after hemodialysis,
Metronidazole 500 t.i.d. through [**3-3**].
FOLLOW-UP: The patient is to follow-up with his primary care
physician [**Last Name (NamePattern4) **] [**1-22**] weeks, and he is to continue dialysis three
days a week. Additionally, his white count should be checked
in approximately four days to ensure that it is stable.
[**First Name11 (Name Pattern1) 402**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7463**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2168-2-29**] 11:06
T: [**2168-2-29**] 11:22
JOB#: [**Job Number 12098**]
|
[
"038.9",
"276.5",
"276.3",
"507.0",
"041.11",
"728.88",
"995.90",
"276.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"03.31",
"96.6",
"43.11",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7425, 7559
|
12102, 13317
|
11908, 12078
|
9408, 11648
|
2629, 3690
|
8466, 9390
|
151, 1784
|
1807, 2606
|
11673, 11887
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,415
| 172,309
|
39345
|
Discharge summary
|
report
|
Admission Date: [**2118-3-7**] Discharge Date: [**2118-3-11**]
Date of Birth: [**2063-1-16**] Sex: F
Service: MEDICINE
Allergies:
Strawberry / Watermelon / [**Location (un) **] Peel Tincture,Sweet / Carrot
Attending:[**First Name3 (LF) 10323**]
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 55 yo woman with progressive metastatic RCC s/p IL2,
s/p cardiac arrest earlier this year, CHF with EF 35-40%, who
presents weakness and an episode of syncope earlier today. She
describes that she felt tired yesterday and got up and attempted
to go to work this morning. On the way to work she felt very
tired and dizzy and then when she was in the elevator at work
fell over. She denies any preceding palpitations or chest pain,
and denies every feeling confused. No incontinence. She did hit
her head but does not think that she lost consciousness.
.
She does state that in retrospect she had some urgency with
urination over the last few days but no increased frequency or
dysuria. No hematuria. Otherwise, she has been in her normal
state of health. No fevers or chills at home. Has had a dry
cough for the past few weeks, non-productive.
.
In ED she was mentating well throughout but with systolic BPs in
the 50s. She received 4L NS with transient rise in SBP to low
100s, then dropped again to 70s. CVL was placed and
norepinephrine was started. Labs were significant for WBC 16.9,
lactate 3.2, UA moderate bacteria, 13 WBC, small leuk, negative
nitrites. Given concern for urosepsis; she was given
levofloxacin 750mg x1 and BCx were drawn. She had a CTA that was
negative for PE. Head CT was not done given no focal findings.
Of note, the patient's oncologist was notified in the ED.
.
Ms. [**Known lastname **] was recently admitted the the hospital at the beginning
of [**Month (only) 404**] for high dose IL2 biotherapy. She developed
hypotension and [**Last Name (un) **] in the setting of high-dose IL-2 biotherapy
initiation. She was transferred to the MICU after she devloped
IL-2 myocarditis and ventricular tachycardia that progressed to
pulseless VT. She was resuscitation but her post arrest ECHO
showed depressed global left ventricular systolic function. She
was started on Amiodarone prior to discharge. Of note, she was
also treated for a pansensitive Klebsiella and E.Coli UTI during
that admission with Cetriaxone and then Cefpodoxime.
.
Since discharge, she has been following with Dr. [**Last Name (STitle) **] and
[**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 17265**]; she is not currently on chemo but has plans to
start a clinical trial. She has also been following with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; they discontinued her
amiodarone because of transaminitis and she was started on
Toprol 3 days ago and her cardiolgists are considering ICD.
.
On arrival to the ICU, the patient was comfortable, without any
pain or complaints. She was initially on oxygen but this was
easily weaned off.
Past Medical History:
Metastatic RCCA
-- [**2117-7-28**] revealed metastatic RCC clear cell origin
-- CT showed b/l pulmonary nodules
-- Right nephrectomy [**2117-9-6**]
-- right forearm mass resected on [**2117-10-26**]
-- left clavicle soft tissue mass
HTN
Parathyroid Adenoma
Hyperlipidemia
Anxiety
Internal Hemorrhoids
Social History:
Married and lives with her husband in [**Name (NI) **]. She has 2
daughters, 16 and 19yo. No smoking, occasional EtOH. No IVDU
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: BP 101/42, 70, 16 98% 2L-> RA
GEN: Well appearing, awake and alert, A+Ox3
HEENT: Small abrasion with scab over L forehead with 3 cmx3cm
area of swelling. EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM. Throat non-erythematous, no lesions or
exudate
NECK: No JVD
CHEST: left clavicle soft tissue mass 5cm, Right IJ CVL
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses; small well healed
surgical scars
EXT: No LE edema, palpable pedal pulses.
NEURO: awake, oriented to person, place, and time. CN II ?????? XII
intact on direct testing. Moves all 4 extremities. Strength 5/5
in upper and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
SKIN: No jaundice, no rashes, no open lesions. Occasional
scarred acne-like lesions across back. No ecchymoses.
DISCHARGE EXAM:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Pertinent Results:
ADMISSION LABS:
[**2118-3-7**] 09:25AM PT-15.0* PTT-28.8 INR(PT)-1.3*
[**2118-3-7**] 09:25AM PLT COUNT-984*
[**2118-3-7**] 09:25AM NEUTS-75.0* LYMPHS-17.9* MONOS-3.7 EOS-2.7
BASOS-0.7
[**2118-3-7**] 09:25AM WBC-16.2* RBC-3.76* HGB-8.7* HCT-28.8*
MCV-77* MCH-23.1* MCHC-30.1* RDW-16.7*
[**2118-3-7**] 09:25AM CORTISOL-44.5*
[**2118-3-7**] 09:25AM ALBUMIN-2.7* CALCIUM-9.6 PHOSPHATE-3.6
MAGNESIUM-2.2
[**2118-3-7**] 09:25AM cTropnT-0.02*
[**2118-3-7**] 09:25AM ALT(SGPT)-64* AST(SGOT)-58* LD(LDH)-459* ALK
PHOS-299* TOT BILI-0.3
[**2118-3-7**] 09:25AM GLUCOSE-141* UREA N-26* CREAT-1.1 SODIUM-134
POTASSIUM-5.9* CHLORIDE-98 TOTAL CO2-22 ANION GAP-20
[**2118-3-7**] 09:45AM URINE RBC-2 WBC-13* BACTERIA-MOD YEAST-NONE
EPI-1 TRANS EPI-<1
[**2118-3-7**] 09:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
[**2118-3-7**] 09:45AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2118-3-7**] 01:12PM GLUCOSE-142* LACTATE-0.9 K+-4.1
.
DISCHARGE LABS:
[**2118-3-11**] 06:15AM BLOOD WBC-14.6* RBC-3.53* Hgb-8.1* Hct-26.6*
MCV-76* MCH-23.0* MCHC-30.4* RDW-17.6* Plt Ct-879*
[**2118-3-9**] 03:14AM BLOOD PT-14.4* PTT-32.2 INR(PT)-1.2*
[**2118-3-11**] 06:15AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-138
K-4.7 Cl-102 HCO3-27 AnGap-14
[**2118-3-11**] 06:15AM BLOOD ALT-48* AST-35 AlkPhos-269* TotBili-0.2
[**2118-3-9**] 03:14AM BLOOD CK-MB-2 cTropnT-0.04*
[**2118-3-11**] 06:15AM BLOOD Albumin-2.6* Calcium-9.5 Phos-3.7 Mg-2.4
.
IMAGING:
[**2118-3-7**] CXR: IMPRESSION: Allowing for differences in technique,
mild interval increase in the known largest metastatic nodule in
the right lung base.
[**2118-3-7**] CT-A:
IMPRESSION:
1. No pulmonary embolism.
2. Interval increase in the size and number of multiple
metastases.
[**2118-3-8**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with
borderline normal free wall function. 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. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2118-3-10**] CXR:
IMPRESSION: Slight increase in size of small right-sided pleural
effusion
with new consolidation at the base of the right lower lobe which
could
represent pneumonia in the appropriate clinical setting.
Brief Hospital Course:
54 year-old female with a history of metastatic renal cell
carcinoma who presented after a pre-syncopal event and
hypotension in ED.
[**Hospital Unit Name 13533**]:
# Hypotension: Initially thought to be urosepsis and exacerbated
by recent initiation of B-blocker. On initial presentation, she
briefly required a pressor, but SBPs resolved. Admission lactate
3.2, which improved with IVF. Of note, other possible
explanations could be adrenal tumor invasion knowing metastatic
RCC, but recent CT of Ab/Pelvis did not show any evidence of
this and patient had a normal cortisol. The patient was
initially on Levophed but this was quickly weaned. She was given
4L IVF in the ED and then 500 cc IVF in the [**Hospital Unit Name 153**]. Her BB was
held and she was treated with Zosyn. Her Urine culture came
back negative despite a positive U/A and treatment of her UTI
was discontinued. It is likely that her hypotension was in the
setting of her initiation of metoprolol succinate 25mg PO Daily.
EP saw her and recommended stopping the BB and not to restart
amiodarone at this time. SHe was sent home on no medications
for her underlying heart arrhythmias and will follow up in the
outpatient setting for further management.
.
# CHF w/ hx VT: Patient developed O2 requirement in the [**Hospital Unit Name 153**] in
the context of fluid resuscitation. EKG unchanged with Trop
negative x 2. Echo showed EF30% which was decreased from her
last echo in [**11-30**]. Her cardiologists, Dr. [**Last Name (STitle) **] and Dr. [**Name (NI) 11723**] were contact[**Name (NI) **]. [**Name2 (NI) **] beta-blocker was held on
discharge from ICU. She was not restarted on any medications,
nodal agents nor antiarrhythmics,and will follow up with her Dr. [**Name (NI) 16434**] in the outpatient setting.
.
# Pre-syncope: Likely due to hypotension given her history of
pre-syncopal symptoms. Could consider VT that was self-resolving
but this seems unlikely from history. Could also consider brain
metastasis causing this but imaging was deferred during her ICU
stay. PE was ruled out on CT-A.
.
# Hx head trauma during syncope: The patient had a non focal
neurological exam on admission, with no headache. No imaging
performed.
# RCC: No treatment at moment, plan for clinical trial in the
future.
# Anemia: HCT dropped slightly after IVF administration but was
stable. Workup on last admission consistent with anemia of
chronic disease. Her anemia was not worked up further during
this hospitalization.
.
# Transaminitis: LFTs elevated but trending down from prior.
This was thought to be [**12-22**] amiodarone, which was stopped one
week prior to admission. Her LFT continued ot trend down and
her LFT were no longer trended.
.
# Hypoalbuminemia: Chronic, likely due to RCC. Nutrition
consult.
.
# Depression: Continued Zoloft, hold Ambien for now given
stablization of pressures
Medications on Admission:
Vit D 50,000U once weekly
Zoloft 100mg daily
Ambien 10 mg qhs
Toprol 25 mg qhs
Discharge Medications:
1. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
4. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
6. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Congestive Heart Failure
Hypotension secondary to Beta Blocker use
.
Secondary Diagnosis:
Metastatic Renal Cell Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you in the hospital. You were
admitted after fainting and we found that you had very low blood
pressure. We think this was due to your heart failure and the
administration of your metoprolol. We gave you fluid to treat
this and held your Metoprolol. Your blood pressures improved
and you were sent to the regular floor. We also did an echo
while you were here that showed that you continue to have heart
failure. While on the floor you had a fever and were found to
have pneumonia. We started you on antibiotics and you will
complete a course of antibiotics at home.
.
We made the following changes to your medications.
START Cefpodoxime 200mg by mouth every 12 Hours for 6 days
START azithromycin 250mg x4 days
.
STOP Metoprolol 25mg PO Daily
.
Please go to the followup appointments listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2118-3-15**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2118-3-15**] at 3:00 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2118-3-29**] at 3:00 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
|
[
"V10.52",
"599.0",
"995.92",
"276.52",
"038.9",
"428.0",
"428.22",
"785.52",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11244, 11250
|
7675, 10555
|
348, 354
|
11432, 11432
|
4584, 4584
|
12561, 13439
|
3624, 3642
|
10685, 11221
|
11271, 11271
|
10581, 10662
|
11583, 12538
|
5630, 7652
|
3657, 4515
|
4531, 4565
|
297, 310
|
382, 3138
|
11380, 11411
|
4601, 5614
|
11290, 11359
|
11447, 11559
|
3160, 3463
|
3479, 3608
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,137
| 145,984
|
6331
|
Discharge summary
|
report
|
Admission Date: [**2195-5-29**] Discharge Date: [**2195-6-5**]
Date of Birth: [**2135-2-18**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin / Codeine / Nitrofurantoin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Called by Emergency Department to evaluate
IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 RHW with significant PMH of DM, HTN, Old left CVA with
baseline right hemiparesis who uses walker at baseline was
transfered from OSH for evaluation of IPH.
She lives alone and has a visiting nurse who comes to help her.
per patient, on [**2195-5-28**] ( yesterday) she was watching TV and
suddenly had headache. She thinks it was severe headache and
diffuse. After headache she felt that her tongue felt heavy
thought that " mouth was sore and speech was slurred." The
slurred speech was noted bt caregiver [**First Name (Titles) 3**] [**Last Name (Titles) 24511**]. She is poor
historian and is not sure whether she had difficulty walking ,
more than baseline at the onset, however later in the day she
was
noted to have difficulty in walking due to weakness on the right
side. this weakness became worse over time, more so this am. She
did have some mild frontal dull headache throughout the day. She
denies any nausea, vomiting or visual disturbances. When asked
why didnt you go to doctor, she told me that " I dont like to go
to doctors." This am she was forced to go to OSH, presumably by
the caregiver. She was taken to OSH ([**Hospital1 **] FH). At OSH,
vitals 97.3, 137/71, 79, 20, 100 RA. She was noted to have
"slurred and thick speech" and right lower leg weakness.
OSH labs, CBC- Hb 14.6, hcy 43.8, wbc 8.6, plt 284, CPK 66,
glucose 214, BUN 27, Na 141, K 4, cl 104, Co2 26, Cr 0.93, Trop
less than 0.03, INR 4.6, PTT 34.9, BNP 296. She underwent CT
head which showed bleed in anterior corpus callosum in the
midline, with mild edema, size of bleed was 4 cm by 0.7 mm. She
was transfered to [**Hospital1 18**] after giving her 2 units if FFP and 10
mg
of vitamin K , SC.
At [**Hospital1 18**], 1334 pm, 97.3, BP 145/76, 76, 24, sat 99 RA. Neurology
as well as Neurosugery was consulted.
On neuro ROS, the pt denies , loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, or tinnitus. Denies difficulties comprehending speech.
Denies, numbness, parasthesiae. No bowel or
bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
diabetes
coronary artery disease, s/p PTCA OM3 [**2182**], of note, left AMA
from CCU after placement of stent.
MI [**2185**]? - working on obtaining records from [**Hospital1 **] (faxed
release form evening of [**2192-5-17**])
Per outpatient PCP office records:
CVA - patient endorses, says she couldn't walk, has residual
?right hemiparesis. Is still ambulatory
Major Depression
Psychotic disorder (does not appear to be on medications)
HTN
hypercholesterolemia
PSH:
chole
appy
Ovarian Tumor removal @ age 19
Social History:
Lives alone, has visiting nurse from ?Wayside Family Works - .
Unemployed, disabled, on "food stamps". no
Etoh use, denies drug use. Patient smoked
1PPD x 26 not smoked for several years.
Family History:
Mother: [**Name (NI) **] at death: 62
DM-type 2
Cause of death: CVD
Father: [**Name (NI) **] at death: 38
Cause of death: homicide
Brother: age 65
DM-type 2
Comments: 8 siblings total
Physical Exam:
Physical Exam:
Vitals: 97.3, BP 145/76, 76, 24, sat 99 RA.
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: distant, RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Some what inattentive, able
to name [**Doctor Last Name 1841**] backward but makes mistakes and is slow, Language -
she is dysarthric, is mostly fluent but makes some mistakes ,
Grossly intact repetition but makes mistakes with complex
commands, Has some difficuly naming low frequency objects but
grossly intact. Normal prosody. Refuses
to read or write. follow both midline and appendicular commands.
Pt. was able to register 3 objects and recall [**2-25**] at 5 minutes.
There was no evidence of apraxia or
neglect - when asked to show how to demonstrate brushing his
teeth, proceeds to then show it. has some DSS on right.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pain
VII: Face symmetric, no droop.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift but not
very cooperattive.
No adventitious movements, such as tremor, noted. No
asterixis noted. give away at many muscles due to ? arthritis
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 4 5 4+ 4+ 4 4 4 4 5 4 5 5 4 5
-Sensory: subjective less sensation to light touch, cold
sensation , pain on the right but she is inonsistent and not
very
cooperative with the exam.
Decreased proprioception and vibration in lower extremities to
the level of the knees.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 -
R 1 1 1 1 -
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
-Gait: deferred
-Romberg - deferred
Pertinent Results:
[**2195-6-1**] 07:40AM BLOOD WBC-5.4 RBC-4.84 Hgb-12.3 Hct-38.4
MCV-79* MCH-25.3* MCHC-31.9 RDW-14.3 Plt Ct-203
[**2195-5-31**] 07:45AM BLOOD WBC-6.3 RBC-4.82 Hgb-11.9* Hct-38.3
MCV-79* MCH-24.7* MCHC-31.1 RDW-14.4 Plt Ct-208
[**2195-5-30**] 02:06AM BLOOD Neuts-74.0* Lymphs-18.8 Monos-4.9 Eos-2.3
Baso-0
[**2195-5-31**] 07:45AM BLOOD PT-14.1* PTT-23.0 INR(PT)-1.2*
[**2195-5-30**] 02:06AM BLOOD PT-17.2* PTT-22.8 INR(PT)-1.5*
[**2195-5-29**] 02:15PM BLOOD PT-22.9* PTT-25.8 INR(PT)-2.2*
[**2195-6-1**] 07:40AM BLOOD Glucose-297* UreaN-7 Creat-0.7 Na-137
K-4.2 Cl-105 HCO3-27 AnGap-9
[**2195-5-31**] 07:45AM BLOOD Glucose-175* UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2195-5-30**] 02:06AM BLOOD Glucose-173* UreaN-23* Creat-1.0 Na-142
K-3.3 Cl-105 HCO3-26 AnGap-14
[**2195-5-30**] 02:06AM BLOOD ALT-305* AST-849* CK(CPK)-41 AlkPhos-508*
TotBili-1.8*
[**2195-6-1**] 07:40AM BLOOD ALT-114* AST-47* AlkPhos-494* TotBili-0.5
[**2195-6-2**] 12:50PM BLOOD ALT-70* AST-17 AlkPhos-428* TotBili-0.3
[**2195-5-30**] 02:06AM BLOOD CK-MB-2 cTropnT-<0.01
[**2195-5-29**] 02:15PM BLOOD cTropnT-<0.01
[**2195-6-1**] 07:40AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.9 Mg-1.4*
[**2195-5-31**] 07:45AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.5*
[**2195-5-30**] 02:06AM BLOOD %HbA1c-8.3* eAG-192*
[**2195-5-30**] 02:06AM BLOOD Triglyc-68 HDL-46 CHOL/HD-2.1 LDLcalc-37
[**2195-5-31**] 05:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2195-5-30**] 02:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2195-5-31**] 05:20PM BLOOD HCV Ab-NEGATIVE
Imaging:
CTA [**2195-5-29**]:
No aneurysm is identified in the region of the hemorrhage or
elsewhere. The left internal carotid artery is occluded below
the inferior
level of the field of view of the study. There remains a
filiform appearance
to the internal carotid extending into the head. The bilateral
anterior
cerebral arteries appear normal, reconstituted via collateral
flow. The right
vertebral artery terminates as the posterior inferior cerebellar
artery. There
are scattered calcifications of the left vertebral artery.
IMPRESSION:
1. Intraparenchymal hemorrhage within the genu of the corpus
callosum.
2. Occlusion of the left internal carotid artery, inferior to
the field of
view of this examination.
3. No aneurysm identified.
MRI/MRA head and neck recommended for further evaluation.
MRI/A [**2195-5-30**]:
MRI OF THE HEAD: Again visualized is an ovoid area of increased
T1 and iso-
to hypo-intense T2 signal intensity, in the genu of the corpus
callosum
representing early subacute hemorrhage. Extensive FLAIR
hyperintense areas
are noted in the cerebral white matter, in the frontal and the
parietal lobes
in the periventricular and subcortical location as well as in
the centrum
semiovale, which can be seen with sequelae of small vessel
ischemic changes or
prior infarcts; a larger area noted in the left frontal lobe can
relate to the
known old infarct per Careweb notes. There is no associated
decreased
diffusion in these areas to suggest acute infarcttion.
Assessment of the area of hemorrhage in the genu of the corpus
callosum on the
diffusion-weighted sequences confounded by the presence of
hemorrhage. On the
post-contrast images, there is no focus of abnormal enhancement
elsewhere in
the brain parenchyma with assessment in the genu being limited
to the
pre-contrast T1 hyperintense appearance.
The visualized portions of the paranasal sinuses and the mastoid
air cells are
clear.
3D TOF MR ANGIOGRAM OF THE HEAD:
There is decreased signal in the right distal vertebral artery.
The left
vertebral artery is patent. The Basilar and the posterior
cerebral arteries
are patent. The right internal carotid artery is patent with
atherosclerotic
changes and mild narrowing, without flow limitation. The right
anterior and
middle cerebral arteries are patent. The left internal carotid
artery is
occluded, with reformation of the A2 segment, from the anterior
communicating
artery and very faint visualization of the left MCA and the A1
segments.
POST-CONTRAST MR ANGIOGRAM OF THE NECK: There is a long segment
severe
narrowing of the left cervical internal carotid artery, after
its origin with
occlusion, at the petrous portion and reformation, after the ICA
termination,
with flow noted in the anterior and the left middle cerebral
arteries.
The right common carotid artery is patent, with atherosclerotic
changes
without flow-limiting stenosis. The vertebral arteries are
patent on both
sides.
Distal vertebral artery is not completely included in the field
of view ; on
the prior CTA Head, there appears to be effective PICA
termination of the
right vertebral artery with very diminutive caliber after the
origin of the
posterior inferior cerebellar artery.
IMPRESSION:
1. Ovoid area of early subacute hemorrhage, in the genu of the
corpus
callosum. No aneurysm noted on the MR angiogram.
2. Nonvisualization of flow in the right distal vertebral
artery- see CTA
Head report
On the prior CT angiogram, there appears to be effective PICA
termination of
the right vertebral artery.
3. Long segment severe narrowing of the left cervical internal
carotid artery
after the origin, with occlusion of the petrous and the
intracranial portions,
which may relate to atherosclerotic disease/dissection.
Reformation of the
left ICA termination, anterior and the middle cerebral arteries.
Reformed
arteries better seen on the prior CT angiogram. Long segment
severe narrowing
of the left cervical internal carotid artery, with occlusion of
the distal
petrous and the cavernous segments.
Wet read was entered soon after the study on [**2195-5-30**].
Liver US:
The liver is normal in echotexture, without evidence of a focal
lesion. The main portal vein is patent with hepatopetal flow.
The
gallbladder is surgically absent, as noted on CareWeb clinical
notes. There is no intra- or extra-hepatic biliary ductal
dilatation with the CBD measuring 6 mm. The spleen is normal in
size measuring 10 cm. The pancreas is not well visualized due to
overlying bowel gas.
IMPRESSION:
1. No evidence of intra- or extra-hepatic biliary ductal
dilatation.
2. Gallbladder surgically absent, as noted on CareWeb.
Lower extremity dopplers:
- No evidence of DVT of the left lower extremity.
Brief Hospital Course:
Ms. [**Known lastname **] is a 60-year-old right-handed woman with a previous
medical history that is remarkable for diabetes, hypertension,
left-sided old stroke with residual right-sided weakness and
using a walker at baseline, DVT two years prior, and in [**Month (only) **] a
superficial DVT (patient was still on Coumadin) who is
presenting with an intracranial hemorrhage.
She was taken to an outside hospital where an intraparenchymal
hemorrhage was diagnosed at the anterior corpus callosum level.
There is no previous medical history or family history of brain
aneurysms, brain bleeds or AV malformation. The patient was on
Coumadin 4 mg once daily. Her INR was 2.2 at the time of
presentation.
She was initially admitted to the neuro-ICU for one day to
ensure the bleeding did not progress. She had a follow up head
CT which did not show any extension. Her blood pressure was
controlled and kept below SBP of 160. She was then transferred
out the floor.
Neuro
- the patient had an MRI to explore the underlying cause of this
bleed. There was no underlying mass seen to explain the
bleeding, there did not appear to be any vascular abnormalities
either
- the patient Coumadin was held and her INR was allowed to drift
down to normal
- the patient BP was controlled and she was placed back on her
home doses of anti-hypertensive.
- the patient continued to have slurred speech with slight
improvement. There was improvement in her leg weakness, her
right leg remained weak (residual from an old stroke) but she
had significant improvement in her left leg
- she initially passed speech and swallow however had an episode
where she choked on a pancake. While she did pass a speech and
swallow re-eval, she was downgraded to ground solids. She again
had an episode of mild choking, and it appears she is eating her
food too fast, although she does have an intact swallow.
Swallow downgraded her to puree, and she should have observation
while she eats. As she improves she can be upgraded to a full
diet
- the patient's Coumadin is being held and she was placed back
on her Plavix, her last DVT was over a year ago, in [**Month (only) **] she
was noted to have an superficial thrombosis. We would prefer
that the patient have her follow up imaging before she restarted
her Coumadin. If it needs to be restarted we would wait [**1-28**]
weeks from the initial event, so around the end of [**Month (only) **]. In
addition she had an Doppler of her lower extremity because of a
complaint of left calf pain and there was no evidence of DVT
- she will be followed up with an MRI in [**6-1**] weeks, to evaluate
any underlying lesions that were obscured by the bleeding.
- She will be followed up in our stroke neurology clinic.
CV
- she will continue on her Plavix for secondary prevention
- c/w her sotalol, lisinopril for BP control
- patient was in sinus rhythm on telemetry while here
Endo
- the patient had elevated blood sugars and initially was
treated with an Insulin Sliding Scale
- her NPH (20 U in am / 10 U in pm) was added back.
- Her blood sugars should be monitored and her NPH and sliding
scale can be adjusted
Pulm
- patient with asthma continue with albuterol PRN and Advair
Psych
- continue with all medications, her psychiatric issues were
stable while she was in the hospital
- continue with Wellbutrin, Nortriptyline, and Topiramate and
Paroxetine
GI
- the patient on routine LFTs was noted to have elevated levels.
She had a US of her liver which was normal, and normal
hepatitis serologies. On further testing the levels trended
down to normal
- continue with Prilosec
- continue with bowel regimen
ID
- the patient had a positive urine and was treated with 3 days
of Bactrim
- she remained afebrile and did not have a leukocytosis
Medications on Admission:
Lisinopril 20 daily
Mortriptiline 50 QHS
Paxil 40 daily
Prilosec OTC 20 PO daily
Simvastatin 40 at bedtime
sotalol 80 mg PO BID
Novolin N insulin 20 units SC in am, changed from 32 on [**5-26**]
Novolin N insulin 10 units SC in pm, changed from 30 on [**5-26**]
Insulin sliding scale , humalog
Nitroglycerine 0.4 SL prn chest pain
Topiramate 100 Po daily
Coumadin 4 PO daily
O2 prn 2 l per min prn SOB
Bupropion 150 QHS
Advair diskus 250/50, 2 puffs [**Hospital1 **]
Albuterol 90 mcg Q 4-6 H prn SOB
Plavix 75 (need to reconfirm with the VNA )
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QHS (once
a day (at bedtime)).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
15. Novolin N 100 unit/mL Suspension Sig: One (1) Subcutaneous
as directed: 20 units SC in am
10 units SC in pm.
16. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous as
directed - sliding scale: please see attached sliding scale
chart.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Care & Rehab-Wood Mill
Discharge Diagnosis:
Corpus Callosum Hemorrhage - possibly hypertensive
Discharge Condition:
MS: awake, alert, slighlty inattentive, not able to reliable [**First Name8 (NamePattern2) **]
[**Doctor Last Name 1841**] backward, language intact but not able to write or read
reliably (apparently due to education), follows commands
CN: dysarthric, EOMI, PERRL, activates face equally on both
sides
Motor: decreased strength on RLE (old stroke) in UMN pattern
(just antigravity at IP, LLE also weaker but 4+ at IP and ham,
full other muscles. UE - full bilaterally, no drift.
[**Last Name (un) **]: reports intact to LT, pinprick
Gait: can barely walk with two person assist
Discharge Instructions:
You were admitted with an episode of slurred speech and headache
and increased difficulty with both your legs (you have old
weakness in your right leg from an old stroke). On imaging you
were found to have an area of bleeding in the front part of your
brain in an area called the corpus callosum. The cause of this
bleed is not clear, it may be related to your high blood
pressure. We did a follow up MRI scan to determine if there was
an underlying mass but did not see one. We are having you
repeat an MRI in [**3-31**] weeks. While you were here PT evaluated
you and determined you did not need any further inpatient rehab.
Speech and swallow cleared you for a diet, but you appeared to
have difficulty with swallowing large solid foods. You were
backed to a dysphagia diet and will need to be watched while you
eat for the next few days. You will follow up with our
neurology department as an outpatient. You agreed to be
discharged to rehab.
Your medications were changed as follows:
Your coumadin was stopped
You were placed on plavix
Your other medications were not changed
We will consider started coumadin again at a later date but you
have not had a DVT in over a year (there was a superficial
thrombosis in [**Month (only) **] - but she was still on coumadin) It will be
addressed when you follow up with us in clinc.
Please take all medications as prescribed. Please make all
follow up appointments. If you have any worsening of your
symptoms or any of the symptoms listed below please call your
doctor or return to the nearest emergency room.
Followup Instructions:
Please follow up with an MRI:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-7-14**]
11:40
Please follow up with:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2195-7-21**] 3:00
[**Hospital Ward Name 23**] 8, [**Hospital1 18**] - [**Hospital Ward Name 516**]
Please follow up with PCP: [**Name10 (NameIs) 24512**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 24513**] after
your discharge from rehab
|
[
"272.0",
"416.8",
"286.9",
"787.20",
"414.01",
"438.82",
"433.10",
"427.31",
"V45.82",
"250.00",
"403.90",
"585.9",
"431",
"V58.61",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18612, 18678
|
12723, 16505
|
365, 372
|
18773, 19354
|
6397, 12700
|
20974, 21551
|
3597, 3783
|
17100, 18589
|
18699, 18752
|
16531, 17077
|
19378, 20951
|
4996, 6378
|
3813, 4311
|
278, 327
|
400, 2840
|
4326, 4979
|
2862, 3375
|
3391, 3581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,855
| 141,673
|
18967
|
Discharge summary
|
report
|
Admission Date: [**2180-9-2**] Discharge Date: [**2180-9-19**]
Date of Birth: [**2107-4-8**] Sex: M
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51840**] was a 73-year-old
gentleman who had received no medical care for the past 50
years. He presented to the emergency room approximately
three weeks after hitting his left foot. After that initial
trauma he did not look at his foot again for two weeks, and
when uncovered found that it was very discolored. He ignored
the foot for another week longer before the pain became
enough that he sought medical attention. He denied any
associated symptoms besides pain in his left foot. He denied
chest pain, shortness of breath, fevers and chills, nausea,
vomiting or diarrhea.
PAST MEDICAL HISTORY: His only past medical history that is
known is that he was an ex-smoker.
ALLERGIES: The patient had no known drug allergies.
MEDICATIONS: 1. Aspirin. 2. Multivitamins.
PHYSICAL EXAMINATION: On presentation to the emergency room
he was afebrile at 97.2 degrees. His heart rate was 96,
blood pressure 118/55, respiratory rate 18, and he had a 98%
saturation on room air. He was a disheveled cachectic male,
who spoke in stream of consciousness. He was in no acute
distress. His heart was regular rate and rhythm. Lungs were
clear. His abdomen was benign. His left leg was cool from
the mid calf distally with soft compartments. His left
third, fourth, and fifth toes were mummified and malodorous.
LABORATORY DATA: His white count was 19.2, his hematocrit 42
and his platelet count 450. His BUN and creatinine were 22
and 0.8, and he had an INR of 1.8.
HOSPITAL COURSE: The patient was admitted and given vitamin
K and IV vancomycin, levofloxacin and Flagyl with the
intention of working him up for lower extremity ischemia.
Medicine and cardiology consultations were obtained and
Persantine MIBI was negative. On [**2180-9-5**] he underwent a
right common iliac artery angioplasty and stent. This was
followed on [**2180-9-12**] with an aortobifemoral bypass and
left femoropopliteal above the knee bypass with vein graft.
Postoperatively his lactates inexplicably rose to a maximum
of 9. He was taken back to the operating room on [**2180-9-13**]
for debridement of his mummified left foot. Following that
surgery he got somewhat better however was maintained on
Levophed for his pressures and was kept intubated and
obviously housed in the intensive care unit.
Over the ensuing several days he was unable to wean off of
Levophed. He was noted to be losing copious fluids through
both groin wounds and the lower aspect of his abdominal
wound. He also had a decubitus ulcer noted, however blood
cultures, urine cultures and sputum cultures remained
negative. His lactate returned to [**Location 213**] at 1.1. His foot
culture grew Enterococcus which was sensitive to levofloxacin
that he was on. By the evening of postoperative day five Mr.
[**Known lastname 51841**] lactate started rising an his blood pressures were
more difficult to maintain. His urine output started to
fall. Out of concern for ischemic bowel, the green service
and Dr. [**Last Name (STitle) 1888**] did a colonoscopy at bedside. While his
mucosa looked slightly friable, on the whole it was viable
and not ischemic at any point. As he progressively got worse
and erythema was noted across his abdomen, it was decided to
take him back to the operating room for exploratory
laparotomy and left foot amputation. This was indeed done.
The laparotomy was negative with normal-appearing colon and
small bowel. The gallbladder and appendix were also normal.
His left foot was amputated just above the ankle with
normal-appearing tissues at the stump. He was brought back
to the intensive care unit and over the course of the night,
progressively declined, ending up on vasopressin, dopamine
and Levophed drips. His lactate continued to rise again to
almost 8. Peritoneal cultures and blood cultures grew
Gram-negative rods.
Infectious disease consulted and he was started on meropenem
and fluconazole as well as vancomycin. However by the
morning of postoperative days seven and one, it was clear
that his situation was deteriorating past any point of
survivability. It was decided not to shock him in the case
of cardiac arrest given the medical futility. He passed away
at 8:10 AM on [**2180-9-19**].
The Medical Examiner declined the case, and while the Legal
Department is looking into the possibility of a court-ordered
autopsy, at this point there are no plans for a postmortem
examination.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2180-9-19**] 08:57
T: [**2180-9-19**] 09:20
JOB#: [**Job Number 51842**]
|
[
"707.0",
"276.7",
"V70.7",
"038.42",
"263.9",
"567.2",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"86.22",
"39.50",
"84.11",
"84.14",
"45.24",
"39.90",
"54.11",
"39.25"
] |
icd9pcs
|
[
[
[]
]
] |
1692, 4869
|
1001, 1674
|
176, 781
|
804, 978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,519
| 140,610
|
31318
|
Discharge summary
|
report
|
Admission Date: [**2196-8-3**] Discharge Date: [**2196-8-24**]
Date of Birth: [**2168-9-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
[**2196-8-3**]
1. Flexible bronchoscopy, right thoracotomy and right lower
lobectomy.
2. Simple repair of diaphragmatic laceration.
[**2196-8-4**]
1. Exploratory laparotomy, damage control.
2. Hepatorrhaphy.
[**2196-8-6**]
1. Wound wash-out and closure of open abdomen
[**2196-8-10**] operation for T12 fracture/dislocation & kyphosis
1. Fusion T8-L3.
2. Multiple thoracic laminotomies.
3. Open reduction of dislocated segment of T12.
4. Instrumentation, T8 to L3.
5. Autograft.
6. Epidural catheter placement.
[**2196-8-11**] operation for Right open Gustilo II both bones open
forearm fractures & Right mid shaft humeral shaft fracture,
closed.
1. Irrigation and debridement of forearm, volar open wound.
2. Open reduction and internal fixation radial shaft fracture.
3. Open reduction and internal fixation ulnar comminuted
fracture.
4. Open reduction and internal fixation humeral shaft fracture.
5. Examination and neuroplasty radial nerve.
[**2196-8-14**] thoracolumbar fracture dislocation
1. Total vertebrectomy of T12.
2. Fusion T11-L1.
3. Anterior cage placement.
4. Anterior instrumentation T11-L1.
5. Autograft.
[**2196-8-14**] operation for T11-T12 burst fracture &
fracture/dislocation
1. Removal of previous segmental instrumentation.
2. Reinsertion of segmental instrumentation.
3. Incision and drainage.
4. Debridement.
History of Present Illness:
28 yo M MVC at about 30 mph with side-impact. Pt was ejected 10
feet from car and unconcious at the scene.
Past Medical History:
None
Social History:
Married
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: HR 84 BP 100/50 RR 12 O2: 91% Face Mask GCS 6 prior to
intubation
Gen: Unresponsive
HEENT: Abrasion to forehead, nose and left cehek
Chest: Bilateral and equal breath sounds
Back: No stepoffs
Musculoskeletal- pelvis stable. Deformity and open fracture of
right arm
Skin: Abrasion to forehead, nose, left cheek, right chest, right
hip, right arm
Vascular: + right radial pulse by Doppler
Physical Exam on Discharge:
T: 98.4 HR: 90 BP: 136/68 RR: 18 95% 35% trachmask
Gen: no apparent distress
HEENT: normocephalic, atraumatic, anicteric, neck supple, no
masses
Card: regular rate and rhythm, without murmurs, rubs, or gallops
Lungs: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
Chest: Left chest wall incision well-healed with staples intact,
left chest tube insertion site well-healed, 2 right chest tube
sites remain open & are covered by a dry sterile dressing
Abd: soft, nontender, nondistended, midline abdominal incision
well-healed
Ext: no clubbing, cyanosis, mild b/l lower extremity edema,
steri strips intact over R upper extremity incisions
Neuro: CNII-XII grossly intact
Pertinent Results:
CT head [**8-3**]
1. No intracranial hemorrhage or mass effect.
2. Mild effacement of [**Doctor Last Name 352**]-white differentiation, possibly
related to mild
cerebral edema.
3. Small amount of fluid in the ethmoid and right frontal
sinuses but no
fracture identified. If there is concern for facial bone
fracture, CT of the facial bones could be performed.
Ct C-spine [**8-3**]
No fracture or malalignment of the cervical spine.
CT c/a/p [**8-3**]
1. Multiple traumatic injuries of the torso as detailed below.
2. Large right hemothorax secondary to multiple displaced
posterior right-
sided rib fractures.
3. Multifocal pulmonary contusion, small right pneumothorax,
bilateral lower lobe airspace consolidation likely due to
aspiration.
4. Hepatic laceration, right posterior, with capsular extension.
5. Bilateral renal lacerations.
6. Iliac [**Doctor First Name 362**] fracture extends into the right sacrum with
surrounding
subcutaneous soft tissue hematoma.
7. Subluxed fracture of T12 with apparent mass effect upon the
spinalcord. Evaluation with MR is suggested to assess spinal
cord injury.
8. Possible left superficial femoral artery pseudoaneurysm,
likely related to catheter insertion attempt. Doppler ultrasound
evaluation could be performed
for further evaluation to exclude possibility of pseuoaneurysm.
9. Right upper extremity fractures involving the humerus, radius
amd ulna
seen only on scout image.
10. Left scapula fracture, inferior edge.
.
RUE X-ray [**8-3**]
There is a complete transverse fracture of the right mid shaft
humerus with approximately one-half shaft width medial
displacement of distal fragment. There is no apposition of
fracture fragments. In addition, there is an oblique comminuted
fracture of the mid diaphysis of the right ulna. The proximal
ulna overrides the distal fragment by approximately 10 mm. There
is medial displacement of the distal ulna fracture fragment by
approximately one- half shaft width.
.
There is a transverse fracture of the distal diaphysis of right
radius. There is medial displacement of the distal fragment by
approximately one and one- half shaft widths. The proximal
radius overrides the distal fracture fragment by approximately 8
mm. There is associated soft tissue swelling.
.
Serum Ethanol 37
.
T-SPINE [**2196-8-14**] 12:12 PM
Reason: T11,L1 FUSION
Four intraoperative radiographs are submitted for
interpretation. Please note these are not of diagnostic quality
and are for intraoperative views only. Please refer to the
operative note for details. Pedicle screws are identified in L3,
L2, L1. An interbody fusion device is present at T12. Pedicle
screws are also identified in T11. Fixator rods traverse L1
through T11 levels as well as from the lower thoracic to upper
lumbar levels.
Brief Hospital Course:
Mr. [**Known lastname 4553**] was admitted to the trauma service and was treated
for the following conditions:
.
1) Right lower lung lobe and diaphragm laceration- On hospital
day 1, Mr. [**Known lastname 4553**] was taken to the operating room for a
flexible bronchoscopy, right thoractomy, and right lower
lobectomy for the the traumatic laceration to his right lower
lung lobe. Also, a simple repair of the diaphragmatic laceration
was performed. Dr. [**Last Name (STitle) **] of thoracic surgery performed
these surgeries.
.
2)Ruptured liver, pelvic hematoma and renal lacerations- After
the above-mentioned thoracic surgery, Mr. [**Known lastname 4553**] continued to
be unstable and required high pressures to ventilate. He was
taken to the operating room by Dr. [**Last Name (STitle) **] who performed an
exploratory laparotomy and hepatorrhaphy. Findings at the time
of surgery included about a unit of blood in the abdomen, a
liver laceration in the right posterior lobe. No major renal
lacerations were identified but gross hematuria which was
indicative of renal lacerations. His abdomen was left open for
concern of increased abdominal pressures. Over the next several
days, he did reasonably well and underwent significant diuresis.
His intra-adbominal pressures decreased and he underwent
abdominal closure on hospital day 4.
.
3)Spinal Fractures- On hospital day 8, Mr. [**Known lastname 4553**] had a fusion
of T8-L3, multiple thoracic laminotomies, attempted open
reduction of dislocated segment of T12, instrumentation of T8 to
L3, autograft and an epidural catheter placement performed by
Dr. [**Last Name (STitle) 363**]. On HD 12, he returned to the OR for for repair of
thoracolumbar fracture dislocation total vertebrectomy of T12,
fusion T11-L1, anterior cage placement, anterior instrumentation
T11-L1 and autograft, removal of previous segmental
instrumentation, reinsertion of segmental instrumentation,
incision and drainage, debridement. Anticoagulation has been
achieve using lovenox.
.
4) Right Upper Extremity Fractures- On hospital day 9, Dr.
[**Last Name (STitle) 1005**] [**Name (STitle) 45299**] irrigation and debridement of forearm down to
bone with volar open wound, open reduction and internal fixation
of the radial shaft fracture, open reduction and internal
fixation of the comminuted ulnar fracture, open reduction and
internal fixation of the humeral shaft fracture and examination
and neuroplasty of the radial nerve. His right upper extremity
has been non-weightbearing and RUE activity has been passive
elbow ROM as tolerated and passive pronation & supination as
tolerated.
.
5) Enteral Nutrition- On [**2196-8-16**], given the need for enteral
nutrition a percutaneous endoscopic gastrostomy tube was placed.
His enteral nutrition has been maintained on replete w/fiber,
full strength at 80 ml/hr.
.
6)Ventilation- Mr. [**Known lastname 4553**] was initially intubated on
admission and a tracheostomy was performed on [**2196-8-16**]. He was
gradually weaned off the vent. He has been mainained on trach
mask. He was evaluated by speech and swallow for a Passy-Muir
valve but was unable to tolerate the valve. It was recommended
to attempt to place PMV at rehab, with TLSO on, upright in
chair, if possible. It was also recommended that if he still can
not tolerate the PMV, consider downsizing the trach.
.
7) Physical Therapy- Mr. [**Known lastname 4553**] was seen by physical therapy
who recommended rehabilitation. He will be transferred to
[**Hospital3 **] Center.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day): for narcotic-induced constipation.
Disp:*600 mL* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
3. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every 4
hours) as needed for breakthrough pain: through G tube.
Disp:*200 mL* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. heparin Sig: 5000 (5000) Units Subcutaneous three times a
day.
Disp:*90 dosages* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Large right hemothorax and small right pneumothorax
2. Multiple displaced posterior right- sided rib fractures.
3. Multifocal pulmonary contusion
4. Hepatic laceration, right posterior, with capsular extension.
5. Bilateral renal lacerations.
6. Iliac [**Doctor First Name 362**] fracture extends into the right sacrum
7. Subluxed fracture of T12 with apparent mass effect upon the
spinal cord
8. Left scapula fracture, inferior edge.
9. Displaced transverse fracture of right mid-shaft humerus
10. oblique comminuted fx right ulna
11. transverse fracture of the distal diaphysis of right radius
Discharge Condition:
stable
Discharge Instructions:
You have suffered spine fractures. Please wear your TLSO brace
at all times when out of bed as directed by the spine surgery
service.
.
You should continue to use subcutaneous heparin 5000 units 3
times daily as directed. You should address when to finish this
heparin therapy with your surgeons at your follow-up
appointments.
.
Your left chest and back staples should be removed by the
nursing staff at [**Hospital3 **] on Sunday, [**2196-8-28**].
.
You have suffered right arm fractures. You should wear a sling
for comfort. You should not bear weight on your right arm. You
may move your right elbow with passive range of motion, and you
may passively pronate and supinate your right forearm as
instructed by the orthopaedic trauma service.
.
Please return to the hospital if you experience any worsening
neck pain, concerning neurological symptoms such as new
numbness, tingling, shooting pains or decreased strength or
paralysis. Also, please seek medical attention if you
experience fevers greater then 101.4, chills, or other signs of
infection. Also return to the hospital if you experience chest
pain, shortness of breath, redness, swelling. Return if you
experience worsening pain or any other concerning symptoms.
.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
Please follow up with your trauma surgeon, Dr. [**Last Name (STitle) **]. Call his
office at ([**Telephone/Fax (1) 6449**] to set up an appointment.
Please follow up with your orthopaedic surgeon, Dr. [**Last Name (STitle) 1005**],
in 2 weeks. Call his office at ([**Telephone/Fax (1) 2007**] to schedule an
appointment.
Please follow up with your spine surgeon, Dr. [**Last Name (STitle) 363**]. Call his
office at ([**Telephone/Fax (1) 11061**] to schedule an appointment.
Please follow up with your thoracic surgeon, Dr. [**Last Name (STitle) **].
Call his office at ([**Telephone/Fax (1) 1504**] to schedule an appointment.
|
[
"E812.0",
"812.21",
"866.12",
"805.6",
"E849.7",
"910.0",
"805.2",
"860.5",
"808.41",
"811.00",
"807.05",
"864.11",
"861.32",
"E849.5",
"813.93",
"958.7",
"780.01",
"864.12",
"E878.1",
"996.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"54.62",
"33.22",
"79.31",
"96.04",
"03.90",
"79.62",
"43.11",
"78.59",
"84.51",
"81.63",
"96.72",
"50.61",
"79.32",
"03.53",
"38.91",
"38.93",
"31.1",
"32.4",
"77.79",
"34.04",
"99.07",
"81.04",
"81.05",
"54.72",
"81.62",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
10636, 10706
|
5858, 9389
|
316, 1661
|
11350, 11359
|
3063, 5835
|
13128, 13762
|
1867, 1885
|
9444, 10613
|
10727, 11329
|
9415, 9421
|
11383, 13105
|
1900, 1914
|
2352, 3044
|
273, 278
|
1689, 1798
|
1928, 2324
|
1820, 1826
|
1842, 1851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,523
| 171,392
|
6059
|
Discharge summary
|
report
|
Admission Date: [**2191-2-14**] Discharge Date: [**2191-2-23**]
Date of Birth: [**2130-7-8**] Sex: F
Service: SURGERY
Allergies:
Compazine / Pepcid / Nitroglycerin / Dicloxacillin /
Methylprednisolone / Neurontin / Bactrim
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Placement of Port-a-cath central venous access device
Cholecystectomy
History of Present Illness:
Pt is a 60 yo female w/ multiple medical problems, who requires
long-term narcotic treatment for chronic pain issues, and has
been recently treated for a retained stone in the common bile
duct/cholangitis, which was relieved by ERCP, who now presents
with RUQ pain. After detailed clinical work-up, she was
diagnosed with symptomatic cholelithiasis and scheduled for
cholecystectomy and port-a-cath placement for long term central
venous administration of narcotics.
Past Medical History:
1. MRSA
2. Metastatic thyroid CA s/p iodine and now on synthroid
3. Right lower extremity cellulitis
4. Nuerogenic bladder- Pt self caths.
5. Chronic low back pain- Pt is on continuous morphine PCA.
6. Depression
7. Type 2 DM
8. Chronic arachnoiditis
9. Esophageal dysmotility
10. DVT and PE s/p placement of IVC filter
11. Chronic UTIs.
12. OSA
13. Osteoarthritis
14. CHF- Last echo was [**2189-2-26**] with a LVEF of 60%.
15. HTN
16. Anemia of chronic disease
17. Right ankle graft
18. Seizure [**2190-8-14**]
19. s/p Klebsiella line infection [**1-1**]
20. s/p ERCP for retained stone [**1-1**]
Social History:
Pt lives with her husband. [**Name (NI) **] ETOH or tobacco use. Not working
Family History:
Father - CAD, Mother - CVA
Physical Exam:
Gen- alert, oriented, obese, no distress
HEENT- PERRLA, anicteric; no JVD or LAD
CV- RRR
Chest- CTA bilaterally
Abd- obese, soft, TTP RUQ
Brief Hospital Course:
As above, pt presented to [**Hospital1 18**] from a long-term care facility
with c/o RUQ pain on [**2191-2-14**]. Recent history of cholangitis.
Pt afebrile and stable. Pt admitted to surgery service. Pt on
chronic coumadin dose for Hx of DVT/PE- started on heparin drip
at [**Hospital1 18**]. PTT would be followed and heparin dose adjusted to
achieve PTT between 50 and 70. Pt scheduled for cholecystectomy
and pre-op completed accordingly. Pt underwent open
cholecystectomy on [**2191-2-16**]. Pt tolerated procedure well. After
recovery in the [**Name (NI) 13042**], pt was transferreed to the floor in stable
condition. Pain control would be managed in partnership with
the pain service. On POD 2, pt was transferred to the SICU
after being found unresponsive, secondary to over-sedation with
narcotics. She was administered Narcan, narcotics were held,
and she quickly regained concsiousness. Neurology was consulted
to rule-out an intracranial process. A CT scan was obtained
which revealed no abnormal findings and she was ruled-out for an
intracranial process. She would remain on a narcan drip in the
SICU. She was transferred back to the floor on POD 3 in stable
condition on a low-dose morphine PCA for pain control. She
continued to remain stable. She began passin flatus and her
diet was advanced to regular on POD 4, which she tolerated well.
She was transferred back to her long-term care facility in good
condition on POD 7. She will continue to require a heparin drip
until her INR is within therapeutic range. She also will remain
on a low-dose morphine PCA for chronic pain relief.
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO QHS (once a day (at bedtime)).
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Citalopram Hydrobromide 20 mg Tablet Sig: Four (4) Tablet PO
DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
11. Amitriptyline HCl 25 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)) as needed for anxiety/insomnia.
12. Tizanidine HCl 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Tizanidine HCl 2 mg Tablet Sig: Two (2) Tablet PO QHS (once
a day (at bedtime)).
14. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO qhs () as needed for constipation.
15. Fleet Enema 19-7 g/118mL Enema Sig: One (1) ML Rectal q48
hours () as needed for constipation.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
17. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
18. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
19. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
20. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
22. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed for Nausea.
23. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1300 units per hour heparin drip Intravenous ASDIR (AS
DIRECTED): Continue until INR is between 2 and 3. Please check
PTT daily, and ensure that PTT is between 50 and 70 when on
heparin drip.
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
25. Morphine Sulfate 10 mg/mL Solution Sig: PCA- 1 mg every 6
minutes. NO basal rate. Maximum dosage is 10 mg per hour.
Intravenous once a day: Lockout is 1 mg every 6 minutes, with a
maximum of 10 mg/hr. NO basal rate.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Symptomatic cholelithiasis
Discharge Condition:
Good
Discharge Instructions:
Please keep wound area clean and dry. Take all medications as
prescribed. Heparin drip should be adjusted to keep PTT between
50 and 70. Heparin drip should be dc'd when INR therapeutic
(between 2 and 3). INR and PTT should be checked daily until
INR is therapeutic and guaranteed to remain therapeutic.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office at [**Telephone/Fax (1) 1231**] within one week
after discharge to schedule a follow-up appointment.
|
[
"311",
"349.82",
"724.2",
"428.0",
"575.11",
"723.1",
"250.00",
"780.39",
"V10.87",
"707.07",
"V58.83",
"V58.61",
"719.41",
"V12.51",
"V58.69",
"285.29",
"401.9",
"E935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
6161, 6240
|
1865, 3487
|
360, 431
|
6311, 6317
|
6673, 6819
|
1660, 1688
|
3510, 6138
|
6261, 6290
|
6341, 6650
|
1703, 1842
|
312, 322
|
459, 928
|
950, 1549
|
1565, 1644
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,264
| 105,341
|
47588
|
Discharge summary
|
report
|
Admission Date: [**2136-8-15**] Discharge Date: [**2136-8-24**]
Date of Birth: [**2079-8-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfatrim / Sulfa (Sulfonamide Antibiotics) / Tape [**1-9**]"X10YD
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy/EGD [**8-18**]
IJ CVL [**8-17**]
Intubation [**8-17**]
History of Present Illness:
56 y.o female with pmhx of HCV/ETOH cirrhosis decompensated in
the past with grade 1 varices in [**2129**], small amount of ascites,
and encephalopathy with recent diagnosis of metastatic
adenocarcinoma ( thought to be a pancreaticobilliary source) who
recieved a [**8-2**] EUS with FNA and now presenting with
hematochezia and altered mental status. The husband accompanies
the patient reports that she seemed to be more confused the last
2 days. Yesterday they noted that she had dark-colored stools
that appeared to be like blood. The patient is uncooperative
with exam right now and has no specific complaints.
.
Initial Vitals in the ED was 97.3 92 97/76 16 97% and she was
given Octreotide drip, Pantoprazole drip and Ceftriaxone.
Patient was noted to have SBP's into the 80's, given IV NS and
BP stablized with SBP at approx. 110. Patient had 1 20 G PIV and
left IO placed because of difficult access.
On arrival to the MICU, the patient is sleeping and does not
want to answer questions. She denies pain, and says she has
noticed dark blood in her stools for a couple of "days." She
refuses to answer further questions and denies confusion. "Just
leave me alone."
Review of systems:
Patient will not answer, could not be fully obtained
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hep C
EtOH abuse
Depression
Cirrhosis
L humerus fracture s/p ORIF [**2129-1-12**]; s/p removal of hardware and
repair of left humerus nonunion w/ bone graft and locking plate
[**2129-7-13**] s/p washout and debridement on [**7-22**] and [**7-25**].
Social History:
Did not drink alcohol for 3 years until a recent admission in
6/[**2136**]. Smokes abou5-6 cigarettes/day. Lives with her husband
in [**Location (un) 686**].
Family History:
NC
Physical Exam:
Admission
Vitals: T:99.0 BP:110/80 P:95 R:12 18 O2:87% RA
General: Sleeping, oriented X2-3, no acute distress. Does not
want to answer questions, wants to sleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: does not comply with neurologic exam. Spontaneously
moving all limbs.No asterxis
Rectal: dark red/maroon blood in the rectal vault
.
Discharge Exam:
General: Lethargic, one word responses, appeared to be in no
acute distress. Oriented x0
HEENT: Sclera anicteric, MM moist, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM heard best
at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Pertinent Results:
Admission Labs
[**2136-8-15**] 07:06PM HGB-9.3* calcHCT-28
[**2136-8-15**] 06:57PM GLUCOSE-85 UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2136-8-15**] 06:57PM ALT(SGPT)-41* AST(SGOT)-81* ALK PHOS-122* TOT
BILI-2.7*
[**2136-8-15**] 06:57PM ALBUMIN-3.0*
[**2136-8-15**] 06:57PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2136-8-15**] 06:57PM WBC-7.7 RBC-2.84* HGB-9.1* HCT-27.5* MCV-97
MCH-31.9 MCHC-33.0 RDW-16.1*
[**2136-8-15**] 06:57PM NEUTS-74.9* LYMPHS-17.2* MONOS-4.8 EOS-2.8
BASOS-0.4
[**2136-8-15**] 06:57PM PLT COUNT-103*
[**2136-8-15**] 06:57PM PT-17.5* PTT-32.1 INR(PT)-1.6*
[**2136-8-15**] 05:25PM GLUCOSE-88 UREA N-19 CREAT-0.7 SODIUM-129*
POTASSIUM-GREATER TH CHLORIDE-105 TOTAL CO2-23
[**2136-8-15**] 05:25PM GLUCOSE-88 UREA N-19 CREAT-0.7 SODIUM-129*
POTASSIUM-GREATER TH CHLORIDE-105 TOTAL CO2-23
[**2136-8-15**] 05:25PM ALT(SGPT)-65* AST(SGOT)-213* ALK PHOS-117*
TOT BILI-2.7*
[**2136-8-15**] 05:25PM ALBUMIN-3.2*
[**2136-8-15**] 05:25PM WBC-11.2*# RBC-3.05* HGB-9.8* HCT-29.6*
MCV-97 MCH-32.3* MCHC-33.2 RDW-16.0*
[**2136-8-15**] 05:25PM NEUTS-74.9* LYMPHS-17.2* MONOS-4.8 EOS-2.9
BASOS-0.2
[**2136-8-15**] 05:25PM PLT COUNT-148*#
.
Studies:
EGD [**2136-8-17**]: 4 cords of grade III large esophageal varices were
seen starting at 20 cm from the incisors in the upper third of
the esophagus and gastroesophageal junction. The junctional
varix had red whale signs. The varices were not bleeding.
Severe portal hypertensive gastropathy seen throughout the
stomach with cherry red spots without signs of active bleeding
or oozing. retroflexed revealed small hiatal hernia with small
gastric varices on lesser curvature left undisturbed. Normal
duodenal bulb and second portion
.
Colonoscopy [**2136-8-17**]: Moderate left sided diverticulosis without
signs of active bleeding, otherwise normal colonoscopy to the
cecum. Retroflexion in the rectum revealed hyertrophy of anal
papila and one cord of rectal varices without signs of active or
recent bleed, moderate internal hemorrhoids left undisturbed.
.
Micro:
[**2136-8-17**] URINE CULTURE-Neg
[**2136-8-16**] URINE CULTURE-neg
Brief Hospital Course:
56 y.o female with pmhx of HCV/ETOH cirrhosis decompensated in
the past with grade 1 varices in [**2129**], small amount of ascites,
and encephalopathy with recent diagnosis of metastatic
adenocarcinoma ( thought to be a pancreaticobilliary source) who
received a [**8-2**] EUS with FNA and who presented with
hematochezia and altered mental status.
.
Active Issues
#Hematochezia- Rectum revealed maroon stools. Patient placed on
Octreotide, Pantoprazole drips and started on Ceftriaxone ppx.
Differential included variceal bleed, diverticulosis. Hct
dropped from 35 to 28. Intubated without complication and
underwent EGD which revealed severe esophageal and gastric
varices with diverticulosis on colonoscopy. No role in TIPS per
hepatology given underlying malignancy. CT torso also carried
out which verified malignancy metastases, with enlarged nodes by
liver and pancreas unknown primary. Pt was transferred to the
floor, where her symptoms were controlled with oral morphine for
pain and SL zydas for agitation. There was no blood noted
.
Pain: See above. After being transferred to the floor, patient
was controlled on IV and PO morphine. Eventually switched to all
PO meds. Standing morphine has had to be uptitrated, and at
discharge she was receiving 7.5mg of concentrated SL MS q2h,
with an additional [**5-17**] q1h:breakthrough pain. It is difficult
to assess patient as she is usually sedated, however, she can
become anxious/agitated in the morning and when prompted, will
occasionally report that she has abdominal pain.
.
#Confusion-thought to be multifactorial including hepatic
encephalopathy and delirium post sedation. Was extubated on [**8-17**]
and patient remained agitated and delirious pulling out her
central line placement. A family meeting took place with the
patient's sister and husband who were health care proxies. Poor
prognosis due to underlying malignancy and cirrhosis were
explained to them. Reported that she has weeks to months to
live. Systemic chemo was offered but cons outweighed pros given
that the main concern for the health care proxies were the
comfort of the patient. Therefore, on [**8-18**] she was placed as
comfort care only and lactulose, rifaximin,ceftriaxone, PPI, lab
draws were stopped.
.
#Adenocarcinoma- thought to be from pancreatic- biliary source.
.
Transitional Issues:
#Stymptom control: Pt has been transitioned to all PO meds. Will
need to uptitrate PO morphine and SL zydas as needed
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluoxetine 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Lactulose 30 mL PO TID
5. OxycoDONE (Immediate Release) 5-10 mg PO Q8H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7.alprazolam 0.25 mg tablet 1 tablet(s) QHS
8.cholestyramine-aspartame 4 gram Packet 1 packet by mouth
qdaily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] nursing care center
Discharge Diagnosis:
Primary Diagnosis:
Metastatic pancreatic adenocarcinoma
Anemia
Gastrointestinal bleed
chronic pain
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the ICU because you had blood in your stool
and you were confused. You were treated with blood transfusions
and medicine to make you stop bleeding. A camera was used to
look at your esophagus, stomach, and your colon. This showed
many areas that could potentially bleed, though none were
bleeding at the time. When your blood count was stable, you were
transferred to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] service.
Your pain was well controlled while you were here. You were
comfortable and your symptoms were controlled. We are sending
you on medication to take by mouth for your pain, and a seperte
medication for any confusion/anxiety or agitation.
Medications to START:
Morphine Concentrate 7.5mg q2h
Morphine Concentrate 5-10mg q1h PRN:Pain
Olanzapine 5mg q8h
Olanzapine
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"303.90",
"572.3",
"571.2",
"456.21",
"530.81",
"311",
"780.09",
"493.90",
"572.2",
"456.8",
"562.10",
"285.1",
"V66.7",
"157.8",
"196.2",
"070.70",
"518.81",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8830, 8892
|
5999, 8315
|
356, 424
|
9035, 9035
|
3784, 5976
|
10016, 10146
|
2614, 2618
|
8913, 8913
|
8481, 8807
|
9171, 9993
|
2633, 3333
|
3349, 3765
|
8336, 8455
|
1647, 2148
|
288, 318
|
452, 1628
|
8932, 9014
|
9050, 9147
|
2170, 2420
|
2436, 2598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,487
| 133,381
|
15140
|
Discharge summary
|
report
|
Admission Date: [**2156-1-3**] Discharge Date: [**2156-1-10**]
Date of Birth: [**2129-8-8**] Sex: M
Service: SURGERY
Allergies:
Droperidol
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
left forearm abscess
Major Surgical or Invasive Procedure:
s/p incision and drainage left forearm abscess
History of Present Illness:
26 y/o male wih h/o of IVDA, s/p L brachial to radial bypass
with revised GSV an ligation of brachial artery secondary to
abscess. Last U/S on [**9-17**]/6 showed excellent flow in graft. For
past one week patient has been experiencing increasing erythema,
swelling of left antecubetal fossa. No fevers or chills, no n/v,
no numbness or pain in hand. Has been injecting.
Past Medical History:
IVDA (heroin), Recurrent pancreatitis-Last episode 2yr ago
No surgical history
Social History:
The patient denies any tobacco use, but is IVDA/Heroin.
Past h/o marijuana and cocaine.
Past h/o ETOH abuse, stopped [**8-20**] after diagnosed with chronic
pancreatitis.
Lives with mother.
Family History:
no bleeding diatheses
Physical Exam:
On discharge:
Vitals: 97.9 70 100/56 18 96 (RA)
Gen: NAD
CV: RRR, no murmurs appreciated
Chest: CTAB
LUE: wound in antecubetal fossa loosely approximated. No pus, no
erythema. Pink, well perfused tissue visible. Fingers warm,
palpable radial and ulner pulses.
Pertinent Results:
[**2156-1-9**] 05:48AM BLOOD WBC-4.8 RBC-4.14* Hgb-9.6* Hct-30.5*
MCV-74* MCH-23.3* MCHC-31.6 RDW-17.4* Plt Ct-402
[**2156-1-6**] 06:20AM BLOOD WBC-4.8# RBC-3.93* Hgb-9.2* Hct-28.4*
MCV-72* MCH-23.4* MCHC-32.3 RDW-16.7* Plt Ct-445*
[**2156-1-4**] 02:04AM BLOOD WBC-15.1* RBC-4.06* Hgb-9.6* Hct-28.7*
MCV-71* MCH-23.8* MCHC-33.6 RDW-17.0* Plt Ct-533*
[**2156-1-4**] 12:48AM BLOOD WBC-13.8*# RBC-3.89* Hgb-9.7* Hct-27.5*
MCV-71* MCH-24.8* MCHC-35.1* RDW-16.8* Plt Ct-527*
[**2156-1-3**] 07:05AM BLOOD WBC-9.1 RBC-4.06* Hgb-9.8* Hct-29.0*
MCV-72* MCH-24.1* MCHC-33.6 RDW-16.8* Plt Ct-495*
[**2156-1-2**] 08:00PM BLOOD WBC-8.4# RBC-4.40*# Hgb-10.7*# Hct-31.3*#
MCV-71* MCH-24.3* MCHC-34.1 RDW-17.0* Plt Ct-524*#
[**2156-1-2**] 08:00PM BLOOD Neuts-79.8* Lymphs-15.4* Monos-4.2
Eos-0.4 Baso-0.2
[**2156-1-3**] 12:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-POS
Brief Hospital Course:
The patient was admitted on [**1-3**] and taken back for an I and D
of the left antecubital fossa on [**1-4**]. Blood cultures were also
obtained and broad spectrum antibiotics were started
(vancomycin, ciprofloxacin, flagyl). His blood cultures were
shown to grow MSSA, and per infectious disease recommendations
nafcillin was started, and a TTE was obtained. The swab from his
arm was negative for MSSA. The TTE was negative for vegetations.
Nafcillin was recommended for 6-8weeks. Due to the patient's
history of IVDA, placing a PICC line was considered only if the
patient was able to go to rehab on discharge. The patient was
unwilling to go to rehab, or stay in the hospital, for
additional antibiotic treatment. He was informed that he had an
infection in his blood stream, from which he could potentially
die, and that there was no good oral antibiotic coverage for his
infection. Both the primary surgical service, infectious
disease, and PCP were involved in conversing with the patient at
length about his decision. The patient insisted on leaving, and
was discharged against medical advice, with linezolid if his
insurance company will fill the prescription, and if not he was
also given prescriptions for levofloxacin and bactrim.
Appropriate follow-up was arranged.
Otherwise post-operatively the patient did well, he tolerated
good PO intake, made good urine output, was afebrile, his wound
was loosely approximated without any pus or erythema and pink,
well perfused tissue was visible. He was given methadone and
ativan on admission to help with his drug withdrawal from which
he was subsequently successfully weaned. He was discharged in
stable condition. The patient was fully aware of the risks he
was incurring upon discharge.
Medications on Admission:
None
Discharge Medications:
1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left forearm wound infection
Discharge Condition:
Stable.
Discharge Instructions:
-You may resume your regular diet
-You may shower
-No tub baths until further instructed
-You will need to change your left arm dressing once a day,
using a wet to dry dressing change. The visiting nurse can help
you with this. This will begin after the [**Holiday **] holiday.
Until then, please change your dressing as taught by your nurse.
-Please do not do any heavy physical activity with your left arm
until the wound is properly healed
-Please take your antibiotic medication as prescribed. It is
advisable that you try to fill out the prescription for
linezolid first. If your insurance company will not cover that
prescription, then fill out the prescriptions for Bactrim and
Levoquin.
-You are leaving against medical advice, and understand that the
antibiotics being prescribed to you are sub-optimal for your
care. You are at risk of having a serious infection, and
potentially death. Please make sure you keep all of your
follow-up appointments, and return to the emergency room should
you experience fevers, foul smelling drainage from your wound,
increasing redness of your left arm wound, any chest pain,
changes in vision, rashes on your body.
Followup Instructions:
Provider: [**Name10 (NameIs) 6811**] STONE, RVT Date/Time:[**2156-2-27**] 8:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2156-3-3**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1393**] Appointment should be
in [**7-28**] days
Please call your primary care doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] M.D., to
arrange for a follow-up appointment. His office phone number is
[**Telephone/Fax (1) 10492**].
Completed by:[**2156-1-10**]
|
[
"997.2",
"790.7",
"041.11",
"304.01",
"998.12",
"E879.9",
"998.59",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"39.52"
] |
icd9pcs
|
[
[
[]
]
] |
4458, 4507
|
2300, 4050
|
289, 338
|
4580, 4590
|
1382, 2277
|
5799, 6453
|
1064, 1087
|
4105, 4435
|
4528, 4559
|
4076, 4082
|
4614, 5776
|
1102, 1102
|
1116, 1363
|
229, 251
|
366, 738
|
760, 840
|
856, 1048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,580
| 100,211
|
49516
|
Discharge summary
|
report
|
Admission Date: [**2180-11-12**] Discharge Date: [**2180-11-15**]
Date of Birth: [**2126-3-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Transferred from [**Hospital3 **] with GI bleed, and obstructive
jaundice
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
54yo m w/hx metastatic [**Hospital3 499**] ca s/p colectomy, chemo/XRT,
cholangitis s/p multiple stents, basal cell CA presented to
[**Hospital3 **] [**2180-11-10**] after sudden onset maroon colored stool
w/clots in ostomy bag. States ostomy bag filled with blood clots
but there was no abdominal pain or cramping associated with
output. Some lightheadedness, but pt feels that was more related
to anxiety over the output vs. blood loss. Pt has been taking
ibuprofen prn x2 weeks for low grade fevers. No shortness of
breath, no chest pain, no nausea, vomiting. Has not noticed
increasing jaundice. Was started on lasix several weeks ago for
leg swelling. Abdomen has been distended but has been improving
since starting Lasix.
At OSH, pt had several episodes of 500-1000ml bloody stools
w/clots out of stoma, SBP 90-120, HR 90's, Hct 23, INR 1.5.
Given 7U PRBC and 1U FFP, vitamin K 10mg for one dose. Had
gastroscopy [**11-11**] which showed no evidence of bleeding.
Colonoscopy was also done on [**11-12**] that showed bleeding only
near site of stoma, and some ? changes consistent with ischemic
colitis at right transverse [**Month/Year (2) 499**]. His bilirubin has been slowly
increasing to max of 22. No fevers documented butstarted on
levofloxacin empirically. Today, has only had 150-200cc blood
via ostomy bag. Transferred to [**Hospital1 18**] for further management.
Upon transfer to [**Name (NI) 153**], pt denies any current complaints.
Tolerating clears without any nausea, vomting or abdominal pain.
Past Medical History:
1. Metastatic [**Name (NI) **] Cancer: Diagnosed in [**6-1**], treated with
colectomy, with adjuvant chemo, XRT from [**Date range (1) 103587**]; second
course of chemo ended [**3-1**]. Known meastatic disease.
2. Cholangitis: s/p ERCP, multiple biliary stents, last placed
[**10-2**] ([**Doctor Last Name **])
3. Basal Cell Skin Cancer: Benign. Present since pt in his
20's. Over 100 resections.
Social History:
Married, retired lawyer. Quit [**Name2 (NI) **] 15 years ago, with 30 years
at 1 PPD prior. Prior heavy alchol use, roughly 10 beers/day.
Family History:
Father with [**Name2 (NI) 499**] cancer, died at 64. No CAD/CVA.
Physical Exam:
T 98, HR 88 (NSR), BP 103/57, RR 24, O2 99% RA
Gen: jaundiced male in NAD, alert, awake and oriented x 3
[**Name2 (NI) 4459**]: MM slightly dry
Lungs: R basilar crackles
Heart: S1, S2, RRR, no murmurs, rubs, gallops heard
Abdomen: distended, slightly firm, NT, NABS; ostomy bag in place
with minimal pink-tinged liquid
Extrem: 1+ bilat edema
Skin: multiple basal cell carcinomas, upper back and R LE with
lesions non-bleeding, covered by dressings
Pertinent Results:
Labs from OSH [**2180-11-10**]:
WBC 15.7, Hgb 8.2, Hct 23.6 (b/l 27-34), Plt 352
Pt 14.4/PTT 30.9/INR 1.5
Na 132, K 3.6, Cl 97, CO2 23, BUN 15, Cr 1.3 (0.8), Gluc 121, Ca
8
Alb 1.8, TP 6.2, Tbili 17.0 (was 5 in [**10-2**]), dbili 10.1, APhos
769, ALT 100, AST 158
-
Labs from OSH [**2180-11-12**]:
WBC 14.1, Hct 32.1, INR 1.26
Na 135, K 3.8, Cl 101, CO2 24, BUN 16, Cr 1.3, Gluc 95
TBili 22, Dbili 14.4, Alk Phos 607, ALT 102, AST 190
-
[**Hospital1 18**] labs:
[**2180-11-12**] 04:34PM GLUCOSE-88 UREA N-21* CREAT-1.1 SODIUM-136
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-12
[**2180-11-12**] 04:34PM ALT(SGPT)-114* AST(SGOT)-216* LD(LDH)-184 ALK
PHOS-736*
[**2180-11-12**] 04:34PM ALBUMIN-2.7* CALCIUM-8.7 PHOSPHATE-2.8
MAGNESIUM-1.7
[**2180-11-12**] 04:34PM WBC-13.0* RBC-3.59* HGB-11.6* HCT-32.0*
MCV-89 MCH-32.3* MCHC-36.2* RDW-16.2*
[**2180-11-12**] 04:34PM NEUTS-88.3* LYMPHS-5.2* MONOS-4.5 EOS-1.5
BASOS-0.4
[**2180-11-12**] 04:34PM ANISOCYT-1+ POIKILOCY-1+
[**2180-11-12**] 04:34PM PLT COUNT-280
[**2180-11-12**] 04:34PM PT-13.4 PTT-25.2 INR(PT)-1.1
Brief Hospital Course:
54yo m w/metastatic colorectal cancer complicated by multiple
episodes of ascending cholangitis secondary to tumor obstruction
and is s/p several stents who presents with GI bleed and
obstructive jaundice.
1. GI Bleed: Patient's HCT remained relatively stable throughout
the hospital course, and he was seen by the GI team who decided
not to pursue any invasive tests given that he recently had a
coloscopy and gastroscopy both of which were negative. He was
also seen by the stoma nurse who noted that he had some variceal
veins at the edge of his stoma and that could be the cause of
his bleed. Recommended some pressure applications during oozing.
His HCT remained stable, and he was tolerating po well and so it
was decided to hold off on any intervention
2. Obstructive Jaundice: Has had history of multiple cholangitis
secondary to obstruction from his metastatic cancer. Patient
presented jaundiced but did not have any fevers, and no
leukocytosis. Decided to go ahead for ERCP and tolerated the
procedure well. During the procedure, they performed a balloon
sweep and found some hemobilia and pus in his ducts. It was
re-canulated. His LFTs continued to slowly trend down after the
procedure. Given the hemobilia, it was thought that his bleed
could have been secondary to that. To complete a 7 day course of
Levofloxacin.
3. Metastatic colorectal cancer: Known end stage disease and he
is currently DNR/DNI. We had introduced the idea of the
palliative team consult but patient was not interested but the
wife was. Palliative team notified and discussed with wife as
per her request. He also has some abdominal distension but we
decided to hold off on the Lasix given his rise in Creatinine.
4. Acute Renal Failure: Patient's creatinine has been stable
through most of his hospital course but on the day of discharge,
it had bumped to 2.0. Unclear etiology but there was a call from
the lab about ? anicteric sample. A repeat creatinine was
checked and it was found to be 1.5. At that time, his PCP was
notified and made aware, and we informed his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
that we were going to have [**Last Name (STitle) 269**] come out and draw his blood on
Friday and fax him the results of his Creatinine. Case managers
were also notified regarding [**Last Name (STitle) 269**] setup. His Lasix was held
during discharge, and we dosed his antibiotics based on his
renal clearance.
5. Code: DNR / DNI
Medications on Admission:
Levoflox 500 daily
Ambien 5 qhs
Was on lasix prior to admission at OSH
Discharge Medications:
1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary:
1. Cholangitis
2. GI Bleed
Secondary
1. Metastatic Colorectal Cancer
Discharge Condition:
Fair
Discharge Instructions:
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**7-8**] days.
Please complete your antibiotic course.
Please have your blood drawn by [**Date Range 269**] services on Friday [**11-17**] and results sent to Dr. [**Last Name (STitle) **] Fax # [**Telephone/Fax (1) 103589**]
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2181-1-18**] 3:15
|
[
"276.5",
"584.9",
"197.7",
"V10.05",
"578.9",
"576.1",
"576.8",
"285.1",
"173.7",
"V44.3",
"197.0",
"173.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
7006, 7105
|
4200, 6659
|
389, 396
|
7228, 7234
|
3095, 4177
|
7591, 7814
|
2543, 2610
|
6780, 6983
|
7126, 7207
|
6685, 6757
|
7258, 7568
|
2625, 3076
|
276, 351
|
424, 1945
|
1967, 2370
|
2386, 2527
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,958
| 104,406
|
10250
|
Discharge summary
|
report
|
Admission Date: [**2158-8-6**] Discharge Date: [**2158-8-18**]
Date of Birth: [**2090-11-5**] Sex: F
Service:
CHIEF COMPLAINT: This 67-year-old white female presents with
a 5-day headache and nausea and vomiting for two days.
HISTORY OF PRESENT ILLNESS: This is a 67-year-old woman with
a headache for five days which increased to an intensity of
[**8-14**] three days prior to admission after chemotherapy. She
noted a throbbing in the midline and frontal parietal area
with no exacerbating factors, and she noted partial relief
with analgesics, and the pain is now [**2-11**]. The patient also
noted the onset of nausea and vomiting two days prior to
admission with a report that she had vomited approximately 10
to 15 times on the day of admission but denied any projectile
vomiting. She also complained of a brief blurring of vision
in the right eye lasting for a few minutes four days prior to
admission but denies any diplopia or photophobia. She denied
any motor, sensory, bowel or bladder dysfunction.
She presented to the [**Hospital6 6640**] in [**Location (un) 8545**]
where a CT scan of the head was done and showed a small right
occipital hypodensity 1 cm X 1 cm near the surface of the
brain and right-sided 2-cm X 1.5-cm area of hypodensity in
the right parietal paramedian region. There was also a left
hypodensity of 1 cm X 0.5 cm in the left parietal convexity.
The patient was then transferred to the [**Hospital1 190**] for further neurosurgical and neurologic
evaluation. The patient received 10 mg of Decadron and 1 g
of Dilantin at the [**Hospital6 6640**].
PAST MEDICAL HISTORY: (Previous medical history includes a
history of)
1. Hypertension.
2. Migraine with no reported migraine headaches in the
preceding two years prior to admission.
3. Gastroesophageal reflux disease
4. Laryngeal carcinoma and status post radiotherapy for
this.
5. Prior history of colon cancer.
6. Left subclavian clot with a Port-A-Cath in the past.
PAST SURGICAL HISTORY: (Previous surgical history includes)
1. Transverse colectomy for colon cancer.
2. History of appendectomy.
3. Prior dilatation and curettage.
4. Port-A-Cath placement.
ALLERGIES: Allergy history includes PENICILLIN and a
reported allergy to YELLOW DYE.
MEDICATIONS ON ADMISSION: Medications at the time of
admission included Toprol 50 mg p.o. q.d., Lasix 1 tablet
every two days (the patient was uncertain of the dose),
potassium supplement 20 mEq p.o. q.d., Zantac 150 mg p.o.
q.a.m., Coumadin 2 mg p.o. q.d., and Compazine p.r.n.
PHYSICAL EXAMINATION ON ADMISSION: The patient was seen
while sitting comfortably in bed, in no obvious distress.
Temperature was 98.2, blood pressure 143/56, heart rate 91,
respiratory rate 21, oxygen saturation 93% on room air. She
was alert and oriented times three. Conjunctivae were moist.
Pupils were 4 mm, briskly reactive to 2 mm bilaterally. The
tympanic membranes and oropharynx were not inflamed. There
was no jugular venous distention, and no lymphadenopathy.
The chest was clear to auscultation. Cardiovascular
examination showed a left Port-A-Cath site with S1 and S2
normal, and no added sounds. The abdomen was soft and
nontender with no organomegaly. There was no tenderness over
the spine, and no flank or costovertebral angle tenderness.
The patient was noted to move all four limbs. Rectal
examination was deferred. Neurologic examination revealed
she was alert and oriented times three with fluent speech.
Cranial nerve I was deferred; II was normal visual acuity and
fields; III, IV, and VI revealed extraocular movements were
intact, no nystagmus; nerves V and VII revealed motor and
sensory modalities in the face were normal; cranial nerves
VIII, IX, X and XII were normal uvula and palatal movement,
tongue was central, no fasciculations, and lateral movement
was normal; cranial nerve [**Doctor First Name 81**] revealed the trapezius was with
good motor strength. The motor strength of all major muscle
groups of the bilateral upper and lower extremities was [**4-8**],
and there was no pronator drift. Sensory examination was
within normal limits to light touch and pinprick, and the
biceps, triceps, ankles, and knees were 2+ bilaterally.
Finger-to-nose movement was normal.
LABORATORY DATA ON ADMISSION: White blood cell count 11.6,
hematocrit 45.1, platelet count 200. PT 17, PTT 44, INR 2.
Sodium 137, potassium 3.3, chloride 103, bicarbonate 25,
BUN 11, creatinine 0.8, glucose 190. Calcium 9.
HOSPITAL COURSE: Due to the clinical findings the patient
was admitted with a history of hypertension, gastroesophageal
reflux disease, and a history of colon cancer and laryngeal
cancer, and being on Coumadin for subclavian thrombosis.
The patient was begun on Decadron 4 mg q.8.h., sliding-scale
regular insulin, Dilantin 100 mg t.i.d., 2 units of fresh
frozen plasma were given with 10 mg of Lasix, and
vitamin K 10 mg subcutaneous times three days.
MRI with contrast and MR venogram were done to rule out sinus
thrombosis, and coagulations were repleted after the fresh
frozen plasma, and the patient was admitted to the Surgical
Intensive Care Unit. The patient remained in the Surgical
Intensive Care Unit for approximately four days and was
discharged to the floor after the MRI was felt to be stable
and consistent with the CT scan findings, and the patient
went to the hospital floor on [**2158-8-8**].
The patient was noted to be stable on [**8-9**] as well as
early on [**8-10**], but in the late afternoon of
[**8-10**] and early evening of [**8-10**] she complained
of recurrent increased headache. She was sent down for a
repeat CT scan which showed a slight increased bleed, and the
patient was readmitted to the Surgical Intensive Care Unit.
The patient's neurologic examination was stable. She was
maintained again in the Surgical Intensive Care Unit for 48
hours with neurologic status stable. She went for an
angiogram on [**8-12**] in the early morning hours, and this
showed an occluded left internal jugular vein with drainage
through collateral circulation, and the superior sagittal
sinus with good drainage. There was a patent severe sagittal
sinus, transverse sinus, and internal jugulars on the right.
There was focal stenosis at the junction of the left
subclavian vein with Port-A-Cath tip present at that level.
The patient was subsequently returned to the Surgical
Intensive Care Unit with no sequelae from the angiogram, and
a head CT was scheduled for the following day. The head CT
showed no significant change from the prior head CT of
[**8-11**], and the patient subsequently was returned to the
floor on the morning of [**2158-8-14**]. The remainder of
her postoperative hospitalization was essentially
unremarkable and stable.
DISCHARGE DISPOSITION: The patient was seen during this
hospitalization with Neurology/Oncology as well as
Physiotherapy and Occupational Therapy. It was felt that the
patient would benefit from a short stay in an acute
rehabilitation center, and arrangements were made for this to
occur at the time of discharge with arrangements for the
patient to be directly transferred to an acute rehabilitation
center with plan for discharge on [**2158-8-18**].
MEDICATIONS ON DISCHARGE:
1. Toprol 50 mg p.o. q.d.
2. Lasix 20 mg p.o. q.d.
3. Potassium supplements.
4. Decadron.
5. Zantac.
6. Tylenol.
7. Zofran.
8. Percocet.
9. Depakote.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33505**], M.D. [**MD Number(1) 33506**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2158-8-17**] 12:32
T: [**2158-8-18**] 09:39
JOB#: [**Job Number 34138**]
|
[
"432.1",
"V10.05",
"401.9",
"197.7",
"453.8",
"996.74",
"197.3",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"88.41",
"38.29",
"88.61",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6806, 7237
|
7263, 7695
|
2303, 2578
|
4521, 6782
|
2016, 2276
|
148, 248
|
277, 1613
|
4306, 4502
|
1636, 1991
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,502
| 196,973
|
44785
|
Discharge summary
|
report
|
Admission Date: [**2174-10-17**] Discharge Date: [**2174-10-21**]
Date of Birth: [**2119-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Found down, hypothermic, alcohol intoxication
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 95814**] is a 55 year-old man with a history of alcohol abuse
with prior episodes of delirium tremens and withdrawl seizures,
homelessness, hepatitis C, and bipolar disorder who was brought
in to the Emergency Department today after being found in a
dumpster. He reports that he was drinking throughout the day
yesterday and consumed about a quart of vodka followed by an
undetermined about of Listerine; he recalls that he then got
into a dumpster to sleep since it was cold outside. He is
unsure of the time of his last drink.
.
By report, when he was assessed by EMS, he was noted to be
hypothermic. He reportedly had a seizure in the ambulance on
the way to the hospital, though there was no documentation of
this and the patient did not recall it. He does report having a
seizure 2-3 days ago, but he does not recall the circumstances
surrounding this either; he is unsure whether or not he was
drinking or withdrawing at the time.
.
Upon arrival in the ED, his temperature was 98.0, HR 107, BP
140/75, RR 19, Sat 95% on room air. His fingerstick blood
glucose was 115. Initially, he was responding to voice but not
following commands; within a few hours, he was answering
question appropriately. His clothes were noted to be grossly
soiled with stool. He had a serum alcohol level of 77 with
toxicology screen also positive for benzodiazepines; his anion
gap was 13. He received a total of 30mg IV diazepam and 2mg IV
lorazepam.
.
At time of admission to the MICU, he was thirsty but otherwise
denied complaints. He denied any auditory or visual
hallucinations, but reports that he has had visual
hallucinations in the past (in the setting of alcohol
withdrawl). He denied any SI or HI. He has been intermittently
noncompliant with his medications and is not entirely sure of
the dosages.
.
Review of Systems:
He reports some dark urine. Recent seizure, per his report. He
denies any melena or hematochezia. He denies any abdominal
pain, fevers, or dysuria.
Past Medical History:
- alcoholism with history of delirium tremens
- hepatitis C, never treated
- bipolar disorder; history of self-inflicted lacerations and
benzo overdoses
- reported history of seizure disorder
- Hepatitis B, per OMR serology appears to be chronic infection
- History of subdural hematoma
Social History:
Mr. [**Known lastname 95814**] has been homeless for several months now. He has a
long history of alcohol abuse. He denies current tobacco use
and denies any history of any intravenous drug use; he admits to
using marijuana "back in the 70's." He was recently in
[**Location (un) 260**], Mass, where he had a job with the Chamber of
Commerence, but then lost his job, resumed drinking, and moved
to [**Location (un) 86**] where he has been homeless.
Family History:
He reports that both parents had esophageal cancer. He has a
sister with breast and skin cancer. He denies any family history
of alcohol abuse.
Physical Exam:
T 100.1 BP 138/86 HR 112 RR 13 Sat 96% on 2L n.c.
General: generally tremulous; answering questions appropriately,
but with his eyes closed; smelling of Listerine
HEENT: (+) scleral injection; no icterus; OP clear
Neck: no cervical/clavicular lymphadenopathy
Chest: clear to auscultation throughout with no wheezes, rales,
or ronchi
CV: tachycardic, regular, no murmurs or rubs
Abdomen: soft, NTND, normal bowel sounds, no hepatosplenomegaly
Extr: no edema, 2+ PT pulses
Skin: warm, no jaundice
Neuro: alert, appropriate, tremulous; CN 2-12 intact; [**3-19**]
strength in both arms and legs
Pertinent Results:
Laboratory Studies:
Serum EtOH 77
Anion gap 13
for rest of laboratory results, see below
.
.
Other Studies:
ECG ([**2174-10-17**]):
Sinus tachycardia with ventricular rate of 135 bpm. Normal axis,
normal intervals. Incomplete RBBB Old Q waves in I, aVL. Q waves
in V3-V5
.
CXR ([**2174-10-17**]):
Single bedside AP examination labeled "supine at 5:07 p.m." is
compared with remote study dated [**2169-9-22**]. Allowing for the
lower lung volumes and unchanged in positioning, the overall
appearance is probably not much changed. There is no focal
consolidation, and no overt edema or pleural effusion.
Prominent right paratracheal soft tissues likely represent
ectatic brachiocephalic vessels.
.
CT Head ([**2174-10-17**]):
There is no evidence of hemorrhage, shift of normally midline
structures, mass effect or hydrocephalus. No vascular
territorial infarct is identified. The density values of the
brain parenchyma are within normal limits. Ventricles and sulci
are normal in caliber and configuration. No fractures are
identified. There is moderate polypoid mucosal thickening in
the bilateral maxillary sinuses with opacification of several
anterior ethmoid air cells. The visualized mastoid air cells
appear clear.
.
Blood culture ([**2174-10-17**]): Coagulase negative staph ([**11-20**])
([**2174-10-19**]): Gram positive cocci, preliminary
.
Hepatitis B: Viral load- none detected
Hepatitis C: Viral load- 4,890,000 IU/mL
HIV Antibody- Negative
.
Toxocology Screen: Positive for alcohol and benzos
Brief Hospital Course:
Patient is a 55 year-old man with a history of alcoholism with
prior delirium tremors and seizures, possibly in the setting of
withdrawal who presented with alcohol intoxication. He reported
Listerene use, but denied any antifreeze or rubbing alcohol
intake; he had a normal anion gap. He currently denies any
hallucinations.
.
#) Alcohol intoxication/withdrawal:
Patient was admitted to the intensive care unit due to his
history of hypothermia, and possible seizure on route to the ED.
He was monitored carefully and a CIWA scale was used. He
received Valium for withdrawal symptoms as needed per the CIWA
scale, and did not need any after two days of admission. His
tremulousness improved and his heart rate and blood pressure
remained stable as he was transferred out of the intensive care
unit to the regular medical floors. He was given a
multivitamins, thiamine, and folic acid. He was kept on fall and
seizure precautions.
.
Given his long standing history of alcohol abuse, social work
was consulted and assisted with his care. Patient has long
standing history of pattern of decompensation after not taking,
or having trouble obtaining, his psychiatric medications, and
then relapsing into drinking alcohol.
.
#) Hypothermia/Found down: Patient had hypothermia per EMS
report, but all temperatures while hospitalized have been
normal. He was ruled out for a MI, and no arrhythmias were noted
on telemetry. Patient reports history of sleeping in garbage
dumpster in past, and it was felt that he was found down
secondary to alcohol intoxication.
.
#) Bipolar disorder:
Patient has long standing history of bipolar disorder.
.
Social work and psychiatry assisted with his care while he was
hospitalized.
.
With the assistance of the social work consult, it determined
that patient has history cutting, as well as prior attempts to
overdose on his psychiatric medications, reportedly about 3
attempts over the last 6 months. His most recent attempt was
approximately three weeks ago. He states he has tried to OD on
Valium but states he is "terrible" at it. He has had several
prior hospitalizations. He denies any current suicidal
ideations, but states he would like help.
.
He was evaluated by the psychiatric team who felt he wsa
severely depressed. He was continued on trileptal and lexapro at
his outpatient doses. He was given 25-50 mg of seroquel [**Hospital1 **] as
needed with good response for anxiety related to his social
stressors.
.
It was also felt that he did have some mild cognitive deficits,
mainly some confabulation, which were felt to be possibly
related to Korsakoff or depressive syndrome, or resolving
delirium. An outpatient MRI was recommended at some point to
further assess this.
.
The psychiatry team felt the patient would be best managed in a
psychiatric inpatient setting. He was cleared for medical
discharge to an inpatient psychiatric unit.
.
#) Seizure disorder: Details of his seizure disorder are
unknown; it is unknown if his seizures were in the setting of
alcohol withdrawal.
- Oxcarbazepine at 300 mg daily was continued. Of note,
convetional dosing is twice daily, but it is hepatically
metabolized. Seizure precautions were followed.
.
#) Hepatitis C and B infection: Patient had has significant
transaminitis dating back at least two years. It is likely that
his transaminitis is from alcohol abuse in setting of background
hepatitis. His hepatitis B serologies are consistent with a
chronic carrier state, and his hepatitis B viral load was
undetactable.
His hepatitis C viral load was 4,890,000 IU/mL. In light of his
viral diseases, HIV testing was completed which was negative.
.
#) Positive blood culture: Patient was noted to have 1/6 bottles
positive for coagulase negative staph on day of admission, which
was felt to be contaminant. Surveillance culture demonstrated
gram positive cocci on [**10-19**], however this was drawn off of a
peripheral IV. Patient had no clinical evidence of infection.
Additional cultures were drawn on day of discharge to be
followed.
.
#) Patient was seen and evaluated by physical therapy and felt
to be safe for discharge.
Medications on Admission:
oxcarbazepine 300mg daily (misses doses)
escitalopram 40mg daily
trazodone 100mg daily
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxcarbazepine 600 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnosis:
- Alcohol intoxication
- Bipolar disorder
Secondary Diagnoses:
- Alcohol abuse
- Hepatitis C
- Hepatitis B
- History of subdural hematoma
- Seizure disorder
Discharge Condition:
Stable, cleared by physical therapy as safe for discharge. Vital
signs stable.
Discharge Instructions:
You were admitted after being found down and hypothermic, with
alcohol intoxication. You were monitored carefully in the
intensive care unit and given medications for your withdrawal
symptoms. You are being transferred to another institution for
further management and assistance with your bipolar disorder.
.
Please contact your primary care physician or psychiatrist if
you experience any fevers, chills, chest pain, shortness of
breath, nauesa, vomiting, worsening depression, thoughts of
harming your self or others, or any other concerning symptoms.
.
It is strongly recommended that you stop drinking alcohol, and
seek medical attention for any thoughts of harming yourself.
Followup Instructions:
Please follow up with your psychiatric care providers as
directed.
Please take all medications as directed.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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10,661
| 139,315
|
16003
|
Discharge summary
|
report
|
Admission Date: [**2159-1-27**] Discharge Date: [**2159-2-2**]
Date of Birth: [**2112-8-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 46-year-old male with
a history of hypercholesterolemia. The patient also with a
history of migraines. For one week prior to admission the
patient had increased confusion and two days of left upper
extremity weakness, decreased coordination, and falls. He
also had pressure behind his right eye.
He presented to [**Hospital6 3872**] where a computed
tomography revealed a large right brain mass with shift.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed heart rate was 92, blood pressure was 160/107,
respiratory rate was 18, and oxygen saturation was 100%. In
the Emergency Department, temperature was 99 degrees. The
patient was in no acute distress; however, he had a delayed
response to questions. He had a positive left facial droop.
Pupils were equal and reactive bilaterally. He had a
positive left pronator drift. He had weak upper extremities.
The lower extremities were [**4-16**] bilaterally. The lungs were
clear bilaterally. Heart revealed a regular rate and rhythm.
The abdomen was soft and nondistended. Bowel sounds were
present.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 15.
RADIOLOGY/IMAGING FINDINGS: The magnetic resonance imaging
showed a right-sided mass with shift.
HOSPITAL COURSE: The patient was admitted to the Neurologic
Intensive Care Unit where blood cultures were drawn. The
patient was on a Nipride drip for blood pressure control. He
was also placed on Decadron, and systolic blood pressures
were kept below 160.
The patient was brought to the operating room on [**2159-1-27**]. He had a right temporal craniotomy for drainage of a
necrotic cystic mass and an open biopsy of the wall. The
findings included a swollen temporal lobe, and cystic mass
that drained a creamy white materia. Gram stain showed 3+
polys, no organisms. Frozen section was difficult to tell if
it was an abscess versus a reactive gliosis or tumor. The
surgical impression looked most likely like an abscess.
The patient was started on triple antibiotics with
ceftriaxone, vancomycin, and Flagyl after the blood cultures
were obtained.
The patient was monitored in the Neurologic Intensive Care
Unit. While in the Intensive Care Unit, the patient remained
stable. He slowly improved neurologically each day. He did
remain disoriented to place at times. He continued with a
left facial droop.
The patient was also followed by Infectious Disease Service
who continued him on triple antibiotics. The patient was
placed on mannitol and Dilantin postoperatively, along with
his antibiotics.
On [**1-29**], a peripherally inserted central catheter line
was placed for long-term antibiotic treatment. Also, on
[**1-30**], there was positive gram bacterium from the
brain; 1/2 blood cultures were positive. The brain abscess
was thought to be likely of a sinus etiology; awaiting
organisms to be identified.
Also, a Dental consultation was obtained due to the patient
complaining of dental pain prior to admission. On [**1-30**], vancomycin was increased to 1250 q.12h. The Dental
consultation revealed no evidence of dental infection;
however, the dentist was not able to look at Panorex views at
this time. They recommended starting Peridex p.o. b.i.d.
Also on [**1-30**], the patient had a cardiac echocardiogram
done. No vegetation was seen. This was to rule out
endocarditis. On [**1-30**], the patient was transferred to
the floor. He continued to be monitored closely. He
continued to improve neurologically. He was awake, alert and
oriented times three.
On the day of discharge, the patient did continue to have a
facial droop and left drift. He has been stable
neurologically.
MEDICATIONS ON DISCHARGE:
1. Decadron wean 3 mg p.o. q.8h. for today ([**2-2**]);
then 2 mg p.o. q.8h. on [**2-3**]; then 2 mg p.o. b.i.d. on
[**2-4**]; and 2 mg p.o. q.d. on [**2-5**]; and 1 mg p.o.
q.d. on [**2-5**].
2. Flagyl 500 mg p.o. t.i.d.
3. Dulcolax suppository p.r. q.h.s. as needed.
4. Protonix 40 mg p.o. q.24h.
5. Heparin 5000 units subcutaneously q.12h.
6. Peridex rinses 15 mL p.o. b.i.d.
7. Dilantin 150 mg p.o. t.i.d.
8. Vancomycin 1250 mg intravenously q.12h.
9. Ceftriaxone 2 g intravenously q.12h.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to continue on the current triple
antibiotic regimen until further notice or until follow up
with Dr. [**Last Name (STitle) 1774**]. The patient did have a peripherally
inserted central catheter line in place for the intravenous
antibiotics.
2. The patient should have weekly vancomycin troughs. Those
troughs should be faxed in care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1774**] (telephone
number [**Telephone/Fax (1) 1419**]) on the week prior to his follow-up
appointment which is scheduled for [**3-1**]. He should have
a complete blood count and sedimentation rate done prior to
this appointment.
3. The patient had a follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1774**] (in Infectious Disease here [**Hospital1 **]) on
[**3-1**] at 10 o'clock; and that will be on [**Hospital Ward Name 1827**] eleven.
4. The patient was to follow up with Dr. [**Last Name (STitle) 1906**] (the
neurosurgeon) in one month; and that would be at [**Hospital 8503**]. The patient can call telephone number
[**Telephone/Fax (1) 14023**] for an appointment.
5. The patient needs to have his staples removed on [**2-6**].
6. If there are any questions regarding his antibiotics or
his infection status, please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1774**] at telephone
number [**Telephone/Fax (1) 457**].
DISCHARGE STATUS: The patient was to be discharged to
[**Hospital 21585**] Rehabilitation in [**Location (un) 1294**], [**State 350**]. The
patient was to be discharged today, [**2-2**].
[**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**]
Dictated By:[**Last Name (NamePattern4) 36958**]
MEDQUIST36
D: [**2159-2-2**] 11:08
T: [**2159-2-2**] 11:25
JOB#: [**Job Number 45812**]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,053
| 193,287
|
53212
|
Discharge summary
|
report
|
Admission Date: [**2121-7-2**] Discharge Date: [**2121-7-3**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
65 yo M with severe COPD on 4 L home O2 (FEV1 19%, FEV1/FVC 43%
in [**7-23**]), chronic systolic CHF (EF >55% on [**3-24**]), and h/o PE in
[**2-/2121**] on coumadin who presents with worsening shortness of
breath and hypoxia. The patient has had multiple hospital
admissions for COPD exacerbation and pulmonary infections. He
was most recently at [**Hospital3 1443**] Hospital from [**5-5**] -
[**5-9**], and at [**Hospital **] Rehab after discharge. He was just
discharged from rehab yesterday. He states he was acutely more
DOE this morning while walking to the bathroom. While he had
mild DOE at rehab, he states this was worse than usal. No direct
sick contacts. [**Name (NI) **] snores at night, and states he has been sleepy
during the daytime. He has never been evaluated for sleep apnea
in the past. His VNA came to evaluate him at home and noted that
he was more dyspneic with worsening hypoxia ([**Name (NI) 20358**] sats at
82%-79% that did not improve despite some chest PT and getting
patient out of bed.) His [**Name (NI) 20358**] saturations are usually in the
mid 80s on 4 L NC. His PCP was called, who advised him to go to
the ED for further evaluation.
In the ED, initial vs were: 99.2 103 152/75 20 88 Patient was
given albuterol and ipratroprium nebs x3, methylprednisolone 125
mg IV x1, azithromycin 500 mg PO x1. CXR showed small LLL
infiltrate, so was given IV Vancomycin 1 gram x1 and Zosyn IV
x1. He was noted when transferring rooms off of [**Name (NI) 20358**] to have
sats in the low 60%. He did not require BiPap in the ED. On
transfer, VS were afebrile, 96 125/57 24 85% on 5 L NCVS - 85%
on 5 L NC, HR 96 24 afebrile 125/57.
On the floor, patient is sitting in bed on nasal canula,
watching TV. He denies any recent fevers or chills. He denies
any palpitations, syncope, orthopnea or PND. He states his lower
extremity swelling is worse, and that he may have had some
weight gain since discharge from rehab. He admits to chronic
greenish sputum that has not changed in amount, consistency.
Denies hemetemesis. Denies chest pain, abdominal pain, diarrhea
or constipation, dysuria. He has chronic psoriasis and sebbhoric
dermatitis. He has some mild venous stasis changes in his LLE
which he states is chronic after an infection in his leg in
[**2-/2119**] and has not spread, but he states that recently it has
been slightly more red and painful. He vehemently denies that
'there is anything wrong with my heart'. He is chronically
hoarse from previous intubation attempts.
Past Medical History:
1. Severe COPD: followed by Dr. [**Last Name (STitle) **], on prednisone and home
[**Last Name (STitle) 20358**] (4L NC) at baseline, recently he has been having monthly
admissions for COPD: [**Last Name (STitle) 1570**]'s [**7-23**]: FEV1 19%, FEV1/FVC 43%
2. Chronic Systolic CHF: TTE [**3-24**] LVEF>55%, although patient
denies this
3. Gastritis/GERD
4. h/o SBO
5. Tobacco Abuse: Previous 5PPD, now [**3-19**] cigs/day
6. Diabetes Mellitus type 2
7. Diverticulosis
8. C6-C7 HERNITATION
9. B12 Deficiency- on monthly injections
10. Obesity with possible OSA, but pt refuses sleep study or
CPAP
11. Psoriasis
12. Hypertension
13. Glaucoma
14. LLE cellulitis [**2-21**]
Social History:
Lives with his wife [**Name (NI) 319**] [**Name (NI) **] and his son. His
[**Name2 (NI) 8526**] has cystic fibrosis
Tobacco: previous heavy smoking history of 5 PPD, states he
recently quit smoking during [**11-22**] hospital admission
EtOH: previous history of heavy EtOH, now rarely drinks.
Drugs:
Family History:
Mother - died of lung cancer in 60s
Father - died of lung cancer in 60s
Sister- died of lung cancer in 50s
Physical Exam:
Vitals: 98.6 93 130/52 25 90% on 5 L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, slightly
elevated JVP
Neck: supple, no LAD
Lungs: increased expiratory time noted, diffuse wheezes noted in
bilateral lower lobes
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
Skin: scaly, flaky skin noted over T-zone area of face.
Ext: 1+ pitting edema BL, patch of erythema/chronic venous
stasis changes on LLL
Pertinent Results:
ADMISSION LABS:
[**2121-7-2**] 12:59PM WBC-12.7* RBC-3.12* Hgb-8.8* Hct-28.6* MCV-92
Plt Ct-306
[**2121-7-2**] 12:59PM Neuts-93.9* Lymphs-3.8* Monos-1.8* Eos-0.3
Baso-0.2
[**2121-7-2**] 12:59PM PT-23.9* PTT-26.9 INR(PT)-2.3*
[**2121-7-2**] 09:06PM Gluc-433 UreaN-30* Creat-1.0 Na-139 K-5.5*
Cl-97 HCO3-35*
[**2121-7-2**] 09:06PM proBNP-389*
[**2121-7-2**] 09:06PM Calcium-7.5* Phos-2.5* Mg-2.2
[**2121-7-2**] 02:01PM Type-ART pO2-66* pCO2-68* pH-7.34* calTCO2-38*
Base XS-7
[**2121-7-2**] 01:05PM Glucose-378* Lactate-1.6 Na-141 K-4.7 Cl-93*
calHCO3-37*
URINE:
[**2121-7-2**] 02:00PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2121-7-2**] 02:00PM Blood-NEG Nitrite-NEG Protein-75 Glucose-1000
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-7-2**] 02:00PM RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-<1
[**2121-7-2**] 02:00PM CastHy-[**4-18**]*
MICRO:
[**2121-7-2**] BCx: ***
[**2121-7-2**] [**Last Name (un) **] Legionella Ag: ***
STUDIES:
[**2121-7-2**] CXR:
****
DISCHARGE LABS:
****
Brief Hospital Course:
65 yo M with COPD on 4 L home O2, CHF, PE on coumadin who
presents with worsening shortness of breath.
# Shortness of breath: Likely multifactorial from recurrent COPD
exacerbation, volume overload from worsening CHF, possibly
worsening pulmonary hypertension. Patient with severe COPD, but
current [**Month/Day/Year 20358**] saturations are not far from his baseline of mid
80s on 4 L NC. ABG consistent with a possible acute on chronic
respiratory acidosis with some metabolic compensation. Patient
with increased weight gain and worsening [**Location (un) **] while at rehab. CXR
with ?LLL infiltrate, but patient has had multiple PNAs in the
past, without fever or increased sputum production, so CXR
finding could be resolving previous PNA. Suspicion for ACS/MI
low given no evidence of EKG changes and no chest pain. Patient
may also have worsening pulmonary hypertension from his severe
COPD contributing to his DOE. Pulmonary embolism was thought to
be unlikely given chronic therapeutic anticoagulation with
coumadin. The patient did complain of increased LLE pain and
swellling, likely from pre-existing venous insufficiency and
LENI was negative.
Overnight, the patient was maintained on face tent [**Location (un) 20358**], and
clinically improved. Saturations trended in the low 90's with
transient dips into the high 70s and 80s, primarily with
exhertion, talking and eating. In the morning the patient
received a second dose of azithromycin and prednisone was weaned
down to 60 mg po. He felt back to baseline from a respiratory
status at the time of transfer.
.
# COPD: Severe (FEV1/FVC 43%) on 4 L home O2. Home [**Location (un) 20358**] sats
are in mid 80% range. Followed by Dr. [**Last Name (STitle) **]. Continued inhalers
and spirava as above and prednisone with plan to rapidly tape to
baseline of 20 mg daily.
.
# CHF: EF > 55% in [**2119**]. Patient reports worsening SOB, [**Location (un) **], and
with weight gain (dry weight appears to be ~210, currently 220
lbs on admission). The patient was diuresed overnight with net
negative about 1L. TTE was obtained which showed EF >55% and
moderate pulm arterial hypertension. Of note the echo did show
a prominent anterior fat pad versus a loculated pericardial
effusion anteriorly. This does not correlate clinically and on
lateral CXR there was a very prominent retrosternal space that
this finding may represent. This may be followed up as an
outpatient.
.
# LLE erythema: Pt with cellulitis in this leg in [**2-21**] and with
chronic venous stasis changes. Reports slightly increased
erythema without spread and some pain in this leg. DDx includes
worsening cellulitis vs. DVT (although latter unlikely given INR
is therapeutic). As mentioned, LLE LENI was negative. Erythema
did not progress overnight, the patient remained afebrile, and
the leg was not particularly warm. We chose to not continue
treating for cellulitis. Likely changes of chronic venous
stasis.
.
# PE: Diagnosed in [**2-/2121**], on coumadin. continued coumadin 5 mg
PO daily
.
# HTN: Continued home anti-hypertensives (amlodipine, lasix)
.
# HLD: Continued statin
.
# DM: Held glyburide. Started on RISS. Transiently required
insulin gtt overnight, FSGs improved to 100s. Spiked to 499
after eating late breakfast, covered with 12U humalog. Likely
poor control due to high dose steroid requirement.
.
# Psoriasis: topical steroids.
Medications on Admission:
Coumadin 5mg PO daily
Vitamin B12 1000mcg SC qmonth (on the 16th)
Fosamax 70mg PO qSunday
Lasix 80mg PO daily
Prilosec 40mg PO daily
Norvasc 10mg PO daily
ASA 325mg PO daily
Caltrate 600mg with VitD 1tab PO daily
Flonase 0.05% 2sprays each nare daily
Spiriva 18mcg 1cap inh daily
Advair 500/50 1puff [**Hospital1 **]
Mucinex ER 1200mg PO BID
Colace 100mg PO BID
Enulose 10g PO BID
Ferrous Sulfate 325mg PO BID
Alphagam 0.2% 1gtt both eyes TID
Senna 2tabs PO qhs
Zocor 5mg PO qhs
Zantac 300mg PO qhs
Xalatan 0.005% 1gtt both eyes qhs
Mylanta 30mg PO q4h prn GI upset
Prednisone 20mg PO daily
Glyburide 10mg PO daily
Humalog 4units SC with lunch
Flomax 0.4mg PO qhs
Albuterol nebs [**Hospital1 **] and q1h prn SOB
HISS TID (no bedtime dose):
200-250 2units
251-300 4units
301-350 6units
351-400 8units
401-450 10units
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) for 7 days.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) for
7 days.
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-15**] Sprays Nasal
Q2H (every 2 hours) as needed for nasal dryness/congestion.
5. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily). Tablet(s)
13. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for GI upset.
18. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
19. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
20. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
[**Month/Day (2) **]:*3 Tablet(s)* Refills:*0*
21. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2
times a day).
22. Prednisone 20 mg Tablet Sig: 2.5 Tablets PO once a day for 3
days: Please take 2.5 tabs tomorrow (50 mg), then 2 tabs on day
2 (40 mg), then 1.5 tabs on day 3 (30 mg) then return to your
usual standing 20 mg daily.
[**Month/Day (2) **]:*7 Tablet(s)* Refills:*0*
23. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
24. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
[**Month/Day (2) **]:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD exacerbation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital overnight for an exacerbation
of your COPD. You improved with close monitoring and extra
[**Location (un) 20358**].
Your medications have changed in the following ways:
1. Add azithromycin 250 mg daily for 3 more days.
2. Add prednisone 40 mg po tomorrow, then 30 mg po the following
day, then back to your usual 20 mg po daily.
Please go to all of your outpatient appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please seek urgent medical advice or obtain transport to the ED
if you experience any of the following:
- Worsening shortness of breath, chest pain, intractable cough,
fever or chills, fainting, any other new or concerning symptoms.
Followup Instructions:
Please follow up with your pulmonologist, Dr. [**Last Name (STitle) **], in 1 week
for a repeat examination. If you can't get an appointment you
may also follow up with your primary doctor, Dr. [**Last Name (STitle) 4894**], in that
time.
|
[
"530.81",
"428.22",
"535.50",
"V58.65",
"733.00",
"280.9",
"305.1",
"V58.61",
"428.0",
"416.8",
"250.00",
"V58.67",
"V12.51",
"401.9",
"486",
"V16.1",
"491.21",
"722.0",
"365.9",
"276.4",
"V46.2",
"327.23",
"690.10",
"278.01",
"459.81",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12218, 12289
|
5618, 9015
|
270, 278
|
12352, 12352
|
4574, 4574
|
13251, 13494
|
3845, 3953
|
9881, 12195
|
12310, 12331
|
9041, 9858
|
12487, 13228
|
5589, 5595
|
3968, 4555
|
227, 232
|
306, 2818
|
4590, 5573
|
12367, 12463
|
2840, 3512
|
3528, 3829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,634
| 120,924
|
2867
|
Discharge summary
|
report
|
Admission Date: [**2182-3-7**] Discharge Date: [**2182-3-14**]
Service: MEDICINE
Allergies:
Penicillins / Egg / Chlor-Trimeton / Seroquel / Quinolones /
Milk / Peanut / Neurontin / Ambien / Lunesta / chloramphenicol /
Sulfamethizole
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
septick shock
Major Surgical or Invasive Procedure:
central line placement
arterial line placement
History of Present Illness:
Dr. [**Known lastname **] is a [**Age over 90 **]y/o gentleman with dementia (bedbound, chronic
foley for BPH) and recent [**Hospital1 18**] admission [**Date range (1) 13926**] for fecal
impaction and volume depletion who initially presented to an OSH
earlier this AM due to hypoxia and is transferred here due to
concerns for septic shock.
.
After his recent admission, he was discharged to a Nursing Home.
Family notes that he has been "miserable" without his pain meds,
which were d/c'd after his fecal impaction. He has severe right
heel pain from a decubitus ulcer. Also, they noted him to be
confused and difficult to understand all day on [**3-6**], until the
evening at which point he seemed to be short of breath. He was
noted to be hypotensive 86/52, with HR 82, temp 98.8. He was
encouraged to drink fluids and his BP improved but he became
short of breath with O2 sat 86%. He was sent to an OSH.
.
At the OSH, his VS were: T 100.7 rectal, HR 84, BP 99/55, RR 32.
ABG on 100%NRB was 7.36/35/62 (O2 sat 91%). His presentation was
initially concerning for CHF exacerbation and she was treated
with Lasix, Nitro, and CPAP, as well as IV Diltiazem for
Afib/RVR. He dropped his SBP to the 70's, which was up to SBP
100 after 5L IVF. CXR suggested possible consolidation so he was
given Vancomycin and Ertapenem. Due to concern for pulmonary
infection in the setting of hypotension, he was intubated. Was
given Versed for sedation, after which he dropped pressure to 70
again. PIVx3 were placed, BP improved with IV fluids and he was
transferred to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] ED, initial VS were: HR 88, BP 107/52, POx 94% on
A/C TV 500, RR 16, PEEP 5, FiO2 50%. He was agitated and bucking
the vent so he received Midazolam 2.5mg IV after which point his
BP dropped from 112/60 to 65/45, not fluid responsive. RIJ was
placed and NE 0.1mg/kg/min was started. VS prior to transfer
were BP 105/57, HR 73, RR 14, POx on 100% on A/C, TV 600, FiO2
60%, rate 14, PEEP 5.
.
On arrival to the MICU, he is intubated and sedated.
Past Medical History:
- Dementia
- Hypertension
- Left UQ abdominal pain
- BPH: with chronic indwelling foley and macrobid QOD
- Hypotestosteronism
- Right glenohumeral osteonecrosis: MRI on [**2179-6-1**]
- Left thigh pain: MRI [**2179-10-28**] demonstrated significant flat
back syndrome and marked arachnoiditis; s/p decompression from
L1-S1; also with bilateral foraminal stenosis at L5-S1
- Dysphagia secondary to esophageal stricture: esophageal
perforation s/p repair
- Gastroesophageal reflux disease
- Constipation
- Incontinence of both stool and urine
Social History:
-Retired pediatrician
-Lives alone, with 24 hour aid care, son is HCP
-[**Name (NI) 1139**] history: smoked pipes and cigars, now none
-ETOH: none
-Illicit drugs: none
Family History:
[**Name (NI) 13925**] cousin with lung ca, aunt with cervical ca, mom with
ovarian ca, 2 sisters with breast ca, others with lymphoma and
pancreatitis. Father with CAD, died in his 90s of an arrythmia
Physical Exam:
Vitals: T 98.8, HR 75, BP 92/51
A/C, TV 600, RR14, PEEP 8, FiO2 60%
General: well-nourished elderly gentleman, intubated/sedated
Skin: superficial abrasions on sprain of right foot, 4cm x 2cm
pressure ulcer on right heel,bone not visible
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles, L>R rales at left mid-lung field
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: VOR intact, PERRL, 1+ patellar reflexes
Pertinent Results:
ADMISSION LABS:
[**2182-3-7**] 02:31AM WBC-18.6* RBC-3.99* HGB-12.9* HCT-37.2*
MCV-93 MCH-32.4* MCHC-34.7 RDW-13.4
[**2182-3-7**] 02:31AM NEUTS-94* BANDS-3 LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-3-7**] 02:31AM GLUCOSE-122* UREA N-9 CREAT-0.8 SODIUM-125*
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-20* ANION GAP-15
[**2182-3-7**] 02:42AM LACTATE-2.0
[**2182-3-7**] 02:31AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2182-3-7**] 02:31AM URINE RBC-22* WBC-49* BACTERIA-FEW YEAST-NONE
EPI-0
.
CXR [**2182-3-7**]
IMPRESSION:
1. Endotracheal tube is no less than 5.2cm above the carina.
Given that the patient's chin is down on the radiograph, the ETT
could be advanced 2-3cm for better seating.
2. Bilateral lower lobe opacification, concerning for pneumonia.
3. Mild congestive heart failure
Brief Hospital Course:
Mr. [**Known lastname **] is a [**Age over 90 **]y/o gentleman with dementia, BPH with chronic
foley, pressure ulcers, and recent hospitalization for fecal
impaction who presents with septic shock from pneumonia.
.
He was admitted to the MICU and intubated for respiratory
failure with septic shock from pneumonia. Patient was fluid
resuscitation and started on levophed. A family meeting was held
and the decision was made to continue treating the present
infection but not to escalate care and to make the goal of care
comfort. He was weaned off pressors and extubated. He completed
a course of vancomycin and meropenem. Despite treatment he
continued to have respiratory distress so he was started on a
morphine infusion. This was increaseed to maintain his comfort.
he was also treated with ativan and a scopolamine patch. He
expired on [**2182-3-14**] at 16:15. The patients wife was offered an
autopsy but she declined.
Medications on Admission:
Expired
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"294.20",
"564.00",
"427.31",
"482.42",
"276.1",
"790.01",
"288.60",
"781.0",
"707.24",
"995.92",
"785.52",
"038.9",
"518.81",
"401.9",
"V49.86",
"707.07",
"733.41",
"600.00",
"530.81",
"V15.82",
"507.0",
"257.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6096, 6105
|
5078, 6006
|
361, 409
|
6157, 6167
|
4169, 4169
|
6223, 6234
|
3277, 3480
|
6064, 6073
|
6126, 6136
|
6032, 6041
|
6191, 6200
|
3495, 4150
|
308, 323
|
437, 2508
|
4185, 5055
|
2530, 3075
|
3091, 3261
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,296
| 153,734
|
42994
|
Discharge summary
|
report
|
Admission Date: [**2195-12-7**] Discharge Date: [**2195-12-16**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Motrin / Ampicillin / Lactose
/ Latex / Adaptic / Amiodarone
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
[**Hospital Unit Name 92798**]:[**CC Contact Info 92799**]
Major Surgical or Invasive Procedure:
none in [**Hospital Unit Name 153**]
History of Present Illness:
[**Hospital Unit Name 92800**]:
86F with CAD s/p CABG, AS s/p valvuloplasty [**11-3**], diastolic
CHF, AF who is POD 3 s/p R hemicolectomy for adenocarcinoma
sessile polyp seen on colonoscopy. Her post op course was
notable for re-intubation in the TICU on [**12-8**] and extubation on
[**12-9**]. She has been hypercarbic over the last few days (50s-60s
since extubation) with minimal urine output (15-20 cc/hr), which
was treated with fluid bolus. Her O2 sats have been ok during
this time.
.
She is one month s/p valvuloplasty for critical AS
(valvuloplasty increased her aortic valve from 0.5cm2 to
1.0cm2). Shortly following the valvuloplasty, pt developed GI
bleed and had a EGD/colonoscopy, which revealed the large cecal
mass.
REVIEW OF SYSTEMS:
(+)ve: as per HPI
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
PAST MEDICAL HISTORY:
CAD: CABG [**9-/2189**] for LM disease (LIMA to LAD and saphenous
vein graft to the OM
Severe AS s/p recent valvuloplasty
Atrial fibrillation on coumadin
Hypertension
Hyperlipidemia
Osteoarthritis, s/p right THR and spinal stenosis
Squamous cell carcinoma
Chronic venous stasis with ulcerations
Hypothyroidism
Peripheral neurophathy
Raynaud??????s syndrome
R Retinal VA clot, w/ mild loss of vision
Diastolic heart failure
Shingles [**11-2**]
Social History:
Lives with husband of 65 years. 2 children, 9 grandchildren 14
great grandchildren. No alcohol, tobacco or other drugs.
Family History:
From OMR:
Mother - CHF
Father - [**Name (NI) 5290**] x ~6, starting in 60's
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
97 89 118/50 15 89-97% on 2-4L
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing in NAD, asleep but easily
arousable.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: irregular rhythm, normal rate. Normal S1, S2. 2/6 SEM >
at RUSB. No rubs or [**Last Name (un) 549**]. JVP=12cm
LUNGS: bilateral crackles to mid lung bilaterally and upper lung
on left, mild diffuse wheeze.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: bilateral mild pitting edema but erythema
suggestive of chronic venous stasis. Healing wounds on lower
extremities bilaterally.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-28**]+ reflexes,
equal BL. Normal coordination.
PSYCH: sleepy but easily arousable and listens and responds to
questions appropriately, pleasant
Pertinent Results:
[**2195-12-7**] 03:40PM BLOOD WBC-10.9 RBC-3.46* Hgb-8.5* Hct-30.4*
MCV-88 MCH-24.7* MCHC-28.1* RDW-17.1* Plt Ct-362
[**2195-12-8**] 05:41PM BLOOD WBC-14.1*# RBC-3.54* Hgb-9.0* Hct-30.1*
MCV-85 MCH-25.4* MCHC-29.8* RDW-17.2* Plt Ct-364
[**2195-12-9**] 04:00AM BLOOD WBC-13.2* RBC-3.31* Hgb-8.4* Hct-28.3*
MCV-85 MCH-25.2* MCHC-29.5* RDW-17.1* Plt Ct-330
[**2195-12-11**] 07:55AM BLOOD WBC-8.9 RBC-3.49* Hgb-8.4* Hct-30.0*
MCV-86 MCH-24.2* MCHC-28.1* RDW-17.6* Plt Ct-409
[**2195-12-16**] 07:15AM BLOOD WBC-10.0 RBC-3.36* Hgb-8.4* Hct-29.1*
MCV-87 MCH-25.2* MCHC-29.0* RDW-17.6* Plt Ct-386
.
[**2195-12-7**] 03:40PM BLOOD Glucose-134* UreaN-25* Creat-0.8 Na-141
K-3.8 Cl-102 HCO3-30 AnGap-13
[**2195-12-11**] 07:55AM BLOOD Glucose-99 UreaN-27* Creat-1.3* Na-138
K-4.0 Cl-99 HCO3-31 AnGap-12
[**2195-12-12**] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-1.2* Na-137
K-3.7 Cl-99 HCO3-32 AnGap-10
[**2195-12-13**] 06:25AM BLOOD Glucose-99 UreaN-25* Creat-1.1 Na-139
K-4.3 Cl-100 HCO3-33* AnGap-10
[**2195-12-14**] 06:25AM BLOOD Glucose-110* UreaN-27* Creat-1.3* Na-138
K-4.6 Cl-99 HCO3-33* AnGap-11
[**2195-12-16**] 07:15AM BLOOD Glucose-105* UreaN-27* Creat-1.0 Na-139
K-4.6 Cl-98 HCO3-36* AnGap-10
.
TEE ([**2195-12-8**]):Initial exam:
The left atrium is markedly dilated. No spontaneous echo
contrast is seen in the left atrial appendage.
There is mild global biventricular hypokinesis.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Mild
(1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
By the end of the procedure there had been no significant
changes
.
Chest X-Ray ([**2195-12-13**]):FINDINGS: In comparison with study of
[**12-12**], there is again substantial cardiomegaly with some [**Month/Year (2) 1106**]
congestion and bibasilar atelectasis. The small-to-moderate
bilateral pleural effusions are again appreciated. Broken
sternal wires are again seen.
.
[**2195-12-8**] Colon mass:
Adenocarcinoma, 3.0 cm; see synoptic report.
Brief Hospital Course:
Initial Surgical Course: Admitted to TICU for pre-op bowel prep.
Required ICU monitoring due to extensive cardiac disease. Pre-op
admission coordinated with patient's cardiologist, Dr. [**Last Name (STitle) **].
Patient's operative course uncomplicated. Extubated in OR,
reintubated in TICU, now on PSV. Admitted to TICU for continued
monitoring. [**12-9**]-extubated. Early in day, pt had some
hypercarbia that improved modestly. Urine output trended down.
Given lasix 40mg IV x 2, and bolused conservatively. Responded
appropriately. Bowel function resumed. Diet advanced slowly.
Tolerating a regular diet and oral medications. Respiratory
status stable. Patient transferred to [**Hospital Ward Name 1950**] 5 on [**Hospital Ward Name 516**]
however continued to have persistent hypercarbia, and
somnolence. Creatinine continued to rise. Transferred to [**Hospital Unit Name 153**]
for closer respiratory monitoring, and hemodynamic monitoring.
She was then tranferred to Cardiology service on [**Wardname 13764**].
.
[**Hospital Unit Name 153**] Course: Patient was transferred for further management of
hypercapnia and her volume status. She was seen by cardiology
in consultation who felt that she needed gentle diuresis, and
that when she was ready to leave the [**Hospital Unit Name 153**] should be transferred
to the cardiology service for further management of her volume
status.
#. hypervolemia: patient has known dCHF and systolic dysfuction
with EF 45-50%. In addition, she still has AS with valve area
about 0.8. With fluid boluses for low UOP, strongly suspect
cardiogenic edema and hypervolemia. CXR shows consistent
pulmonary edema. Crackles and JVD on exam. Received 60 then 40
IV Lasix with good UOP.
.
#. low UOP/ARF: Cr up to 1.3. UOP low for past couple days.
likely from poor forward cardiac flow and prerenal physiology.
.
#. hypercapnea: Thought to be due to increased work of
breathing from CHF from her AS and diastolic CHF, Patient likely
had mild CO2 retention at baseline as reflected in elevated
bicarb on prior labs, acute worsening may have occurred in
setting of peri-op sedatives/pain meds, atelectasis and volume
overload. ABGs have been stable throughout course and there was
no acute worsening to precipitate ICU transfer, upon arrival to
ICU, patient??????s mental status was at her baseline.
.
#. AS: recently underwent valvuloplasty, still with valve area
of 0.8cm2.
.
#. atrial fibrillation: rate controlled on metoprolol.
.
Cardiology Course: Patient was transferred to the cardiology
service on [**2195-12-12**] for further management of her volume status.
.
#) Acute Diastolic Heart Failure: most recent echo from [**11-3**]
showed diastolic dysfunction with an overall preserved EF.
Based on clinical exam with findings of crackles in her lungs,
LE edema and CXR with volume overload, she likely received too
much fluid in the setting of post-op low urine output. She was
diuresed with with IV lasix as needed with a goal of taking off
about 1L per day for to help maintain her BP since she is very
preload dependent with her severe AS, with most recent valve
area of 0.8cm2. Her blood pressure tolerated the diuresis well.
At rehab she should receive LASIX 40 IV BID AND BE EVALUATED
DAILY IN TERMS OF VOLUME STATIS. THIS SHOULD BE TITRATED DOWN TO
HER HOME DOSE OF LASIX 60MG DAILY. When getting lasix her blood
pressures should be monitored every 4 hours during the day, with
a goal of getting about 1L of fluid off per day. She should NOT
be given lasix if her systolic blood pressure is under 100 as
she has severe aortic stenosis. If she becomes hypotensive, she
will need small IV fluid boluses since she is very preload
dependent with her severe AS. If given IV lasix she should have
her electrolytes checked to make sure potassium is above 4 and
her magnesium is above 2.
urrently she has crackles in her lungs left>right and some
wheeze for which she is receiving ipratropium nebs. She has
difficulty completing sentences due to mild SOB. She also has
edema in her LE bilaterally.
.
#) Severe Aortic Stenosis: patient is s/p valvuloplasty with
report of valve area of 1cm2 on catheterization, but recent TEE
shows that the valve area is 0.8cm2 or less. As stated above
her volume status is very tenuous and needs close monitoring
since her AS makes her preload dependent.
.
#) CAD s/p CABG: currently stable, she was continued on her
outpatient regimen of atorvastatin and metoprolol. She was
restarted on aspirin 81mg daily during her stay.
.
#) Atrial Fibrillation: patient has been chronically in AF on
coumadin, her coumadin was held prior to her surgery, and
restarted post operatively. Since she has no history of stroke,
TIA, DVT or PE she did not have an indication for bridging so
she has been on her home coumadin dose, and we have been
allowing her INR to increase slowly especially in the post
operative setting. She was continued on her home metoprolol for
rate control, however her rate control was suboptimal so she was
also loaded with digoxin and started on .0625mg daily, for
better rate control with less blood pressure effects.
.
#) Hypercapnia: patient was extubated then reintubated post
operatively due to hypercapnia. After her eventual extubation,
she was transferred to the [**Hospital Unit Name 153**] for increasing somnolence, which
has been improving during her stay. SHE IS CURRENTLY ON 0-1/2L
OF OXYGEN AND THIS SHOULD BE TITRATED DOWN AS QUICKLY AS
POOSSIBLE TO KEEP HER O2 SATS BETWEEN 90-94% to help prevent her
from retaining more CO2
.
#) S/P Right Hemicolectomy: patient had a right hemicolectomy
for a sessile polyp found on colonoscopy after a GI bleed after
her valvulplasty for her severe AS. Pathology showed low grade
adenocarcinoma, per surgery T2N0, so no further treatment needed
at this time.
.
#) Venous Stasis with Ulcerations: patient with chronic venous
stasis ulcers, wound care evaluated the patients and provided
the following recommendations:
Recommendations: Pressure relief per pressure ulcer guidelines
Support surface: Atmos Air
Turn and reposition every 1-2 hours and prn
Heels off bed surface at all times
Waffle Boots to B/L LE's
If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion, Gaymar Cushion
.
Elevate LE's while sitting as tolerated (has pain due to
arthritis)
Moisturize B/L LE's, periwound tissue and feet [**Hospital1 **] with Aloe
Vesta Moisture Barrier Ointment
.
Commercial wound cleanser or normal saline to irrigate/cleanse
all open wounds B/L LE's.
Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each drg change.
Apply Aquacel dressings over the wound beds to absorb drainage
Cover with dry gauze, Sofsorb sponge
Secure with tubular stocking (she states she does not tolerate
Kling or Kerlix
Dressing changes were increased to twice daily due to large
amounts of drainage on the dressings.
.
#) Acute Renal Failure: patient with baseline Cr of 0.8 to 1.0,
creatinine elevated in the setting of hypervolemia. Her
creatinine continued to improve and was back to her baseline
with further diuresis, making the cause of her renal failure
likely poor forward flow from volume overload.
.
#) Hypertension: blood pressure remained well controlled on home
metoprolol
.
#) Hyperlipidemia: continued home statin
.
#) Code: Full
Medications on Admission:
MEDICATIONS upon transfer to [**Hospital Unit Name 153**]:
Insulin SC (per Insulin Flowsheet) Sliding Scale
Atorvastatin 40 mg PO/NG DAILY
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Levothyroxine Sodium 75 mcg PO/NG DAILY
Docusate Sodium 100 mg PO BID
Metoprolol Tartrate 75 mg PO/NG TID
Famotidine 20 mg PO/NG Q12H
Metoclopramide 10 mg PO/NG Q8H
Furosemide 60 mg IV ONCE Duration: 1 Doses
Gabapentin 300 mg PO/NG Q12H
Timolol Maleate 0.5% 1 DROP BOTH EYES HS
Heparin 5000 UNIT SC TID
Warfarin 2.5 mg PO/NG ONCE Duration: 1 Doses Start: 1600 Order
date: [**12-11**] @ 1100
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): hold for SBP<100.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
12. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Venous stasis ulcers
Recommendations:
1.Pressure relief per the following
-Support surface: Atmos Air
-Turn and reposition every 1-2 hours and prn
-Heels off bed surface at all times
-Waffle Boots to B/L LE's
-If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion, Gaymar Cushion
- Elevate LE's while sitting as tolerated (has pain due to
arthritis)
-Moisturize B/L LE's, periwound tissue and feet [**Hospital1 **] with Aloe
-Vesta Moisture Barrier Ointment
.
-Commercial wound cleanser or normal saline to irrigate/cleanse
all open wounds B/L LE's.
-Pat the tissue dry with dry gauze.
-Apply moisture barrier ointment to the periwound tissue with
each drg change.
-Apply Aquacel dressings over the wound beds to absorb drainage
-Cover with dry gauze, Sofsorb sponge
-Secure with tubular stocking (she states she does not tolerate
-Kling or Kerlix
-Dressing changes were increased to twice daily due to large
amounts of drainage on the dressings.
14. Lasix
Pt should receive lasix 40mg IV BID and be re-evaluated daily.
Currently goal is 1L negative. SBP>100 prior to administration
(is preload dependent due to severe AS). Evaluate volume statis
daily and titrate down to lasix 60mg daily as appropriate which
is home dose. 1st dose of 40 IV lasix should be evening of
[**2195-12-16**].
15. *** SPECIAL OXYGEN ORDER
PATIENT IS C02 RETAINER. She should be on as minimal dose of
oxygen as possible to maintain o2 sats between 90-94% BUT NOT
HIGHER AS IT CAUSES SOMNOLENCE.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: Hold for sedation or RR<12.
17. INR Check
pls check INR on [**2195-12-18**] and adjust coumadin dose as needed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Right hemicolectomy for low grade adenocarcinoma
Severe aortic stenosis
Diastolic CHF
Atrial Fibrillation
Hypercapnea
Venous stasis ulcers
Acute renal failure
.
Secondary diagnosis:
CAD s/p CABG
HTN
Hyperlipidemia
Glaucoma
Discharge Condition:
Alert and oriented x3. Cough. Occasional wheeze.
Discharge Instructions:
You were admitted for a colectomy for a colon mass. After the
surgery you required admission to an intensive care unit because
you were having trouble with your breathing (due to retaining
carbon dioxide which caused sleepiness) and because you needed
to have lasix due to having extra fluid in your body. You were
then transferred to the cardiology floor where you required
additional doses of lasix to help get extra fluids off your
lungs. You will likely need additional doses of lasix at rehab.
Three days ago you also had an increased heart rate and you
received some extra medications by mouth and by IV to slow your
heart rate down. Your atrial fibrilation is now well controlled
on your home dose of metoprolol and we also started a new
medication called digoxin.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
The following medications were started:
digoxin 0.0625mg daily
ipratropium neb 1 every 6 hrs prn sob or wheeze
Aspirin 81mg daily
Colace 100mg twice a day
heparin sc 5000 units three times a day
oxycodone 5mg po q8hrs prn leg pain- need to monitor for
sedation
.
The following medications were continued:
levothyroxine 75mg po daily
lantoprost 0.0005% drops qhs
timoptic 0.5% drops qhs
lipitor 40g by mouth daily
gabapentin 300mg po daily
warfarin 4mg daily
metoprolol 75mg by mouth three times a day
.
The following medications were changed in dose:
tylenol increase to 1g every 8 hours
your lasix dose will be determined by your doctor at rehab
.
The following medications were discontinued:
Ativan
Followup Instructions:
You should follow up with your primary care physician [**Name8 (MD) **],
[**Name9 (PRE) **] after you are discharged from [**Hospital 100**] Rehab [**Telephone/Fax (1) 2660**].
.
You should follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**] on Tuesday
[**1-13**] at 10:40.
|
[
"584.9",
"274.9",
"428.33",
"V45.81",
"424.1",
"707.19",
"428.0",
"553.1",
"153.4",
"414.00",
"365.9",
"272.4",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"17.33"
] |
icd9pcs
|
[
[
[]
]
] |
16308, 16374
|
5595, 12952
|
361, 399
|
16660, 16711
|
3332, 5572
|
18327, 18625
|
2217, 2380
|
13585, 16285
|
16395, 16395
|
12978, 13562
|
16735, 18304
|
2395, 3313
|
1184, 1573
|
264, 323
|
427, 1165
|
16596, 16639
|
16414, 16575
|
1617, 2061
|
2077, 2201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,283
| 118,721
|
46661
|
Discharge summary
|
report
|
Admission Date: [**2105-1-17**] Discharge Date: [**2105-1-23**]
Service: NEUROLOGY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
shaking her upper extremities.
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
The pt is an 86 year-old woman with PMH s/c PVD, HTN,
hypercholesterolemia, and remote hx of upper GI bleed who
presents aftre being found by her husband shaking at 6pm. EMS
was
called and the patient was given 5mg of valium en route. When
the
patient arrived she recieved 6mg of ativan before she stopped
shaking. The shaking is characterized as right upper extremity
shaking. The patient is also not responsive though clearly
awake.
Unable to perform NIHSS as the patient is totally unresponsive.
A rapid first assessment revealed a woman with a shaking right
arm and unresponsive to voice. She withdrew all extremities
except for the right upper extremity. As the patient hasn't been
to this hospital since [**2094**] it was uncertain if she had a
history
of stroke or seizure and a code stroke was called. The patient
was intubated and taken to the ct scanner where a Ct/CTA
revealed
no vessle cut off, but large old left MCA strokes.
ROS
Patient is too obtunded to provide a ROS
Past Medical History:
PVD
NIDDM
HTN
Cholesterol
osteo
Hemorrhoids
Arthrtis
PUD C/B Remote hx of Upper GI bleed
Dementia
Social History:
per [**2090**] discharge summary: She lived with her husband, did not
smoke
cigarettes or drink.
Family History:
NC
Physical Exam:
T:97.3 P:80 R:24 BP:200-247/100-118 SaO2:97%.
General: Unresponsive and shaking.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: unable to assess before intubation as patient was shaking
the right shoulder so vigorously.
Pulmonary: Lungs clear anteriorly.
Cardiac: regular.
Abdomen: soft, NT/ND,
Extremities: No C/C/E bilaterally, poor peripheral pulses.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: unresponsive to voice, doesn't follow commands.
Withdraws to noxious. Was clearly awake when she arrived.
-Cranial Nerves: pupils initially demonstrating hippus. After
intubation pupils were ERRL - 3->2 bilaterally. Corneals intact.
Gag intact. Right facial droop.
-Motor: Doesn't withdraw the RUE to noxious. Withdraws the other
extremities to noxious.
-Sensory: Able to sense noxious stimuli in all four extremities.
Uses the left upper extremity swat away noxious stimul applied
to
the RUE.
-Coordination: untestable.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 3 3 3 1 0
Plantar response was extensor on the left and flexor on the
right.
-Gait: untestable.
Pertinent Results:
CTA - head [**2105-1-17**]
IMPRESSION:
Mild narrowing of the distal M1 segment and relative paucity of
left [**Name (NI) **] branches, which may be related to prior ischemia. No
hemodynamically significant stenosis.
Left lung apical airspace disease.
CXR - [**2105-1-19**]
Endotracheal tube remains low with tip terminating about a
centimeter above the carina with the neck in a flexed position.
Nasogastric tube terminates below the diaphragm. A very large
hiatal hernia is again demonstrated and appears slightly less
distended than on the recent study. Unchanged opacity in the
left retrocardiac region probably represents a combination of
the large hiatal hernia and adjacent atelectasis but aspiration
or infectious process is difficult to exclude on this single
projection. New patchy and linear opacity at the right base may
be due to either atelectasis or aspiration. Small pleural
effusions are present. No pneumothorax is evident.
Carotid ultrasound [**2105-1-20**]
IMPRESSION: Less than 40% stenosis in both internal carotid
arteries.
ECHO - TEE [**2105-1-20**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. There is mild (non-obstructive) focal hypertrophy of
the basal septum. 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 valve leaflets are moderately thickened. There is mild to
moderate aortic valve stenosis (area 1.1 cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is mild
functional mitral stenosis (mean gradient 3 mm Hg) due to mitral
annular calcification. Moderate to severe (3+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is at least moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No intracardiac source of embolism identified. Mild
to moderate aortic stenosis. Moderate to severe mitral
regurgitation with mild functional mitral stenosis due to mitral
annular calcification. Preserved biventricular systolic
function. Impaired diastolic relaxation. At least moderate
pulmonary hypertension.
EEG - [**2105-1-20**]
IMPRESSION: Abnormal EEG due to diffuse and marked slowing with
an
accentuation anteriorly and the suggestion of blunted sharp and
slow
activity at times in a semi-rhythmic fashion. While the record
overall
would suggest a moderate to moderately severe diffuse
encephalopathy,
the possibility of some element of anteriorly predominant
discharging
cannot be absolutely excluded. Should the patient's condition
change, a
repeat tracing in two to three days might be of clinical
benefit.
Brief Hospital Course:
The pt is an 86 year-old vasculopath with a history of HTN, DM,
hypercholesterolemia, and dementia who presents with focal
seizure in volving the right upper extremity accompanied by an
inability to attend and systolic blood pressure in the mid 200s.
Physical exam reveals right upper extremity pelegia with normal
sensation. CT exam suggestive of remote left hemisphere strokes.
After intubation the patient had no further shaking suggestive
of a seizure. The patient was taken off of sedation on the
second day of admission, but never arroused sufficiently to
ensure a safe extubation. The patient was maintained on
dilantin and keppra. The old strokes seen on the CT scan were
the only clear provcation identified. There was no metabolic
derrangement and though the patient had a low grade fever and
some suggestion of a pneumonia on chest x-ray a clear infectious
source was never identified. The patient never produced sputum
and required minimal ventilatory support, pointing to
atelectasis as the cause of the opacities on her CXR. Regading
the patient's old strokes we examined her risk factors. Her
total cholesterol was 297 and her LDL was 171. We started her on
simvastatin 40. Her hemoglobin A1C was 7.8. She was noted not
to be on a lipid lowering [**Doctor Last Name 360**] or an oral hypoglycemic or
insulin on admission. In fact she was only on aricept and paxil.
She was maintained on an Insulin sliding scale. Routine EEG was
not demonstrative of a seizure
In the end it was hypothesized that the patient's decreased
arousal was related to an underlying dementia and minimal
cortical reserve ill equipped to recover from a 45 minute
seizure. She was made CMO by her family.
Medications on Admission:
Aricept and Paroxetine
Discharge Medications:
1. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [**2-19**] Sublingual
Q4H PRN as needed for Secretions.
2. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q4H
PRN () as needed for pain.
3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q2H
(every 2 hours) as needed for pain.
4. ativan Sig: [**2-19**] Sublingual every six (6) hours: FOR SEIZURE
PREVENTION.
5. ativan Sig: [**2-19**] Sublingual Q1H as needed for Seizure or
aggitation: PRN for SEIZURES or aggitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Prior stroke
Seizure
HTN
DM
Discharge Condition:
CMO
Discharge Instructions:
CMO
Followup Instructions:
CMO
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"V12.71",
"V85.1",
"294.8",
"443.9",
"396.2",
"348.30",
"272.0",
"780.39",
"438.89",
"553.3",
"416.8",
"518.0",
"V66.7",
"250.00",
"433.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7949, 8021
|
5657, 7362
|
246, 259
|
8093, 8099
|
2741, 5634
|
8151, 8250
|
1532, 1536
|
7435, 7926
|
8042, 8072
|
7388, 7412
|
8123, 8128
|
2131, 2722
|
1551, 1990
|
176, 208
|
287, 1279
|
2005, 2114
|
1301, 1401
|
1417, 1516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,551
| 124,244
|
24955+57432
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-11-30**] Discharge Date: [**2135-12-3**]
Date of Birth: [**2088-5-3**] Sex: M
Service: SURGERY
Allergies:
Morphine / Penicillins / Ciprofloxacin / Clindamycin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastroparesis
Major Surgical or Invasive Procedure:
Laparoscopic J-tube placement
History of Present Illness:
47 M with a h/o uncontrolled DMII and severe gastroparesis. He
has lost aover 100 lbs over the past year due to the inability
to tolerate eating. He was admitted for a laparoscopic placement
of a J-tube.
Past Medical History:
Diabetes
Leg amputation (post-trauma)
Neuropathy
Esophagitis on EGD [**8-15**]
Seizures - stated his most recent seizure was 2 days ago, has
been vomiting his dilantin for the past few days
PVD
HTN
s/p appy
h/o DVT
Social History:
Lives with his wife and two children. Has worked on a hog farm
for 25 years. Smokes 1 ppd for past 3 years. Heavy EtOH use 3+
years ago. Heavy drug use 25+ years ago.
Family History:
Sister with [**Name (NI) 4522**] Disease
Physical Exam:
At time of discharge:
A&O X 3, NAD
PERRL, EOMI
RRR
CTAB
Abd soft, mild diffuse tenderness, no guarding or rebound, +bs,
J-tube in place, wound c/d/i
Ext without c/c/e, L BKA
Pertinent Results:
Glucose-198* UreaN-14 Creat-0.8 Na-139 K-3.3 Cl-103 HCO3-27
AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 6330**] was admitted on [**2135-11-30**] to the surgical service under
the care of Dr. [**Last Name (STitle) **]. He was taken to the OR for a
laparoscopic J-tube placement. For details of the operation
please see the operative report. Post-operatively he did well.
He was tolerating clears on the evening of POD 0. His pain was
controlled with his home regimen of Oxycontin 80 [**Hospital1 **] plus
dilaudid for breakthrough pain. He was discharged home on POD1
with recommendations from the nutritionist regarding tube feeds.
He will follow-up with Dr. [**First Name (STitle) 2643**] from GI and Dr. [**Last Name (STitle) **].
Medications on Admission:
captopril, atenolol 20, dilantin 300', oxycontin 80", [**Last Name (STitle) **],
lantus 95 in am 55 in pm
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. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily).
5. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. OxyContin 40 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO twice a day as needed for pain.
9. Lantus 100 unit/mL Cartridge Sig: 95 units in am, 55 units in
pm Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
DMII
BKA
h/o DVT
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or go to the ER if you experience any of
the following: severe pain uncontrolled by your medications,
high fevers >101.5, increasing nausea/emesis, pus from your
wound, or the inability to tolerate your tube feeds.
Tube feed recs: Probalance at 10 cc/hr initially, increasing by
10 cc Q6hrs as tolerated to a goal of 70 cc/hr (will provide
[**2145**] kcals and 91 grams of aa). Signs and symptoms of
intolerance include abdominal cramping, bloating, and diarrhea.
Eventual goal would be 120 cc/hr CYCLED over 14 hrs. This can be
adjusted based on amount of po's at home.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**1-13**] weeks. Please call [**Telephone/Fax (1) 2981**] for an
appointment.
Dr. [**First Name (STitle) 2643**] (GI) - Please call tomorrow morning in regards to your
tube feeding.
Name: [**Known lastname 1511**],[**Known firstname 63**] Unit No: [**Numeric Identifier 11253**]
Admission Date: [**2135-11-30**] Discharge Date: [**2135-12-3**]
Date of Birth: [**2088-5-3**] Sex: M
Service: SURGERY
Allergies:
Morphine / Penicillins / Ciprofloxacin / Clindamycin
Attending:[**First Name3 (LF) 203**]
Addendum:
Mr. [**Known lastname **] experienced some nausea and emesis on the evening of
POD 1. He stayed overnight for IV fluids. He finally agreed to
have a foley catheter placed and over 900 cc of urine was
obtained. He will be discharged on POD 2 with a leg bag and
instructions for its care.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2135-12-2**]
|
[
"V49.75",
"412",
"496",
"780.39",
"536.3",
"443.9",
"780.57",
"401.9",
"997.5",
"250.82",
"263.9",
"250.62",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
4746, 4907
|
1376, 2028
|
326, 358
|
3180, 3187
|
1283, 1353
|
3831, 4723
|
1030, 1073
|
2184, 3076
|
3126, 3159
|
2054, 2161
|
3211, 3808
|
1088, 1264
|
273, 288
|
386, 591
|
613, 829
|
845, 1014
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,803
| 128,439
|
36496
|
Discharge summary
|
report
|
Admission Date: [**2106-2-23**] Discharge Date: [**2106-3-2**]
Date of Birth: [**2067-7-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Heroin overdose.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 48 year old male with history of DM; admit from ED
following heroin overdose. Patient was found blue and
unresponsive in a car by EMS, maintained a pulse. Total of 1 mg
narcan given by EMS and woke up. Patient states he believes
someone called EMS for him, not sure who did or how he was
found. Admits to taking one valium and two vicodin for neck pain
earlier in the day. Then snorted heroin; unsure events of what
lead him to be found in the car. Denies other ingestions. No
EtOH x 3+ days. No APAP or other OTCs. Denies current of past
IVDU - only snorting heroin.
In the ED, vitals 94 PO (later 98), 141/90, 109, 10, 100% 3L.
Initially awake then became sleepy; at times emotionally labile.
Serum tox + for benzos, urine tox still pending. Toxicology
consult following. Started narcan gtt at 0.5/h. Labs notable for
leukocytosis to 20K, fingerstick glucose 480. Initial VBG
7.17/77/27; later ABG 7.29/59/109.
ROS: + HA since arrival to ED. + neck pain since post op. No
recent HA, visual change, fevers, CP, palps, SOB, cough, abd/GI
symptoms, rash, bleeding.
Past Medical History:
- Diabetes Mellitus (DM)
-Chronic neck pain with h/o C7 neck surgery ?fusion 3 weeks ago
-Anxiety
-Heroin abuse - reports snorting only; no IVDU
-Obstructive sleep apnea (OSA) - has CPAP at home which uses
rarely, only when "short of breath"
-Asthma
Social History:
Lives with wife and her children. Not currently employed; has
worked in construction in the past. Smokes about 1 cig/today.
Other drug use as per HPI. EtOH use only on special occasions
during last month, last drink Friday. No history of problems
related to EtOH withdrawal.
Family History:
multiple family members with DM. Sister with renal disease of
some type. Brother with HTN and hyperlipidemia.
Physical Exam:
On admission:
Vitals: Tmax: 35.7 ??????C (96.3 ??????F), Tcurrent: 35.7 ??????C (96.3 ??????F),
HR: 95 (94 - 95),
BP: 133/90(100) {129/77(87) - 133/90(100)} mmHg, RR: 14 (9 - 14)
insp/min, SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 71 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: slight pupil asymmetry with R pupil slightly
irregular; both reactive 3->2
Head, Ears, Nose, Throat: Normocephalic, MM slightly dry
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: S1/S2 Normal, Systolic murmur, soft SM at LUSB
Respiratory / Chest: Expansion symmetric, Breath Sounds clear,
few crackles at L base, diffuse wheezes, slightly diminished
Abdominal: Soft, Non-tender, bowel sounds scant
Skin: Warm, no rash , no jaundice, well healed incision
posterior Cspine
Neurologic: Attentive, Follows simple commands, Responds to
verbal stimuli, Movement: Purposeful, Tone: Not assessed, CN
II-XII intact. distal UE and LE strength 5/5
Pertinent Results:
Labs on admission:
[**2106-2-23**] 04:15PM BLOOD WBC-19.9* RBC-4.35* Hgb-12.8* Hct-36.9*
MCV-85 MCH-29.4 MCHC-34.6 RDW-13.2 Plt Ct-365
[**2106-2-23**] 04:15PM BLOOD Neuts-89.4* Lymphs-5.5* Monos-4.5 Eos-0.4
Baso-0.2
[**2106-2-23**] 04:15PM BLOOD PT-14.7* PTT-22.3 INR(PT)-1.3*
[**2106-2-23**] 04:15PM BLOOD Glucose-293* UreaN-17 Creat-1.0 Na-139
K-5.3* Cl-102 HCO3-28 AnGap-14
[**2106-2-23**] 04:15PM BLOOD ALT-61* AST-24 AlkPhos-62 TotBili-0.2
[**2106-2-23**] 04:15PM BLOOD Lipase-24
[**2106-2-23**] 04:15PM BLOOD Albumin-4.7
[**2106-2-23**] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2106-2-23**] 03:59PM BLOOD pO2-27* pCO2-77* pH-7.17* calTCO2-30 Base
XS--3
Chest x-ray [**2106-2-23**]: No acute cardiopulmonary process.
ECHO [**2106-2-24**]: Normal biventricular systolic function. No
vegetations identified.
Blood culture [**2106-2-24**], (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2106-2-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Brief Hospital Course:
This is a 48 year old male with history of DM, recent neck
surgery, history of heroin abuse; now admit after found altered
and cyanotic in car likely due to heroin overdose.
# Overdose (OD): Admits to heroin, vicodin, and valium use
without other abuses. No EtOH, sedatives, OTC meds, other
illicits. This is supported by toxicology screen. Some concern
initially of APAP OD if possible Vicodin use, however this was
negative on tox and not supported by history. Mental status
significantly improved on Narcan gtt which was weaned and
discontinued on the morning of [**2106-2-24**]. Patient was seen by
social work and was given the contact information for substance
abuse rehabilitation programs.
# Hyperglycemia. History of DM with poor medicine compliance.
The hyperglycemia was likely related to stress response from
hypoxia/respiratory acidosis plus poor baseline control. No
evidence of ketones, metabolic acidosis. He was managed with
insulin sliding scale, with Metformin held on admission.
# Leukocytosis. Also likely stress response from acute hypoxia
and acidosis. Other possibilities include infection (aspiration
pneumonia or CAP but CXR negative; UA clean; no evidence of
surgical site infection; denies h/o IVDU), alcoholic hepatitis.
This improved dramatically the morning following admission. His
vlood cultures turned positive for peptostreptococcus and we
felt this was likley due to tooth surgery. HIs cultures cleared
on antibiotics.
# Respiratory acidosis/hypercarbic respiratory failure. Likely
overmedication effect from heroin. Improved on Narcan gtt.
# Tachycardia. Sinus with normal ECG otherwise, and improved
with minimal IV fluids. This was likely related to above
episode.
# Wheezes. History of asthma; poor air entry and mild wheezing
on exam. He was started on flovent MDI (patient unsure of name
of inhaled steroid) and albuterol nebulizers.
# Heroin abuse. The patient denied any suicidal ideation and
expressed clearly that this was an accidental overdose. He
stated that he was amenable to a discussion with social
work/addiction specialists.
Medications on Admission:
-Valium prn
-Vicodin prn
-Metformin 500 mg (taking on average daily; prescribed as [**Hospital1 **])
-Omeprazole 20 mg daily
-Albuterol prn
-Steroid inhaler, unknown name
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for PAIN.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
5. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12 hr
Sig: Two (2) Tablet Sustained Release 12 hr PO twice a day for
14 days.
Disp:*56 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Heroin Overdose
Bacteremia
Paraspinal fluid collection
Anemia
SECONDARY
Asthma
Diabetes Mellitus
Patent foramen ovale
genital condyloma
Discharge Condition:
Good
Discharge Instructions:
You were admitted with heroin overdose. You were treated with a
medication, narcan, in the intensive care unit to counteract the
effects of the overdose.
.
You were found to have bacteria growing in your bloodstream and
you were treated with intravenous antibiotics. An MRI of your
neck was done to look for a source of infection. A small amount
of fluid was seen around the C-7 neck bone, the site of your
surgery and this was sampled. This fluid did not show signs of
infection. A syphillis test done was negative. A chest xray was
done to look for infection in your lungs and this was also
negative.
.
We also did an MRI of the rest of your spine which showed no
sign of infection. You have degenerative disk disease in your
lumbar spine
.
An echocardiogram of your heart was done. It showed no infection
on your heart valves but you do have a small hole in your heart
called a "Patent Foramen Ovale". It is important for you to let
your primary care doctor about this as it places you at higher
risk for having a stroke. Please call your doctor
.
Your metformin was stopped while you were admitted. You may
continue to take metformin as you were prior to your admission.
Followup Instructions:
Please make a follow up appointment with your primary care
doctor as soon as you are discharged. You will need to follow up
with him as soon as possible about the issue mentioned above.
.
Please make an appointment with your dentist as soon as
possible. Your teeth may have been the source of your blood
infection so you should be seen as soon as possible.
.
Please keep your follow up appointment with the neurosurgeons at
[**Hospital3 **] for your post-surgery check.
Completed by:[**2106-5-29**]
|
[
"E850.0",
"250.00",
"041.84",
"493.90",
"324.1",
"998.59",
"965.01",
"790.7",
"304.01",
"285.9",
"745.5",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
7471, 7477
|
4284, 6374
|
331, 338
|
7665, 7672
|
3193, 3198
|
8896, 9397
|
2025, 2136
|
6595, 7448
|
7498, 7644
|
6400, 6572
|
7696, 8873
|
2151, 2151
|
275, 293
|
366, 1443
|
3212, 4261
|
1465, 1717
|
1733, 2009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 153,716
|
3368
|
Discharge summary
|
report
|
Admission Date: [**2120-1-29**] Discharge Date: [**2120-2-6**]
Date of Birth: [**2046-3-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Senna / Iodine
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
left paraspinal mass
Major Surgical or Invasive Procedure:
Left thoracoscopic resection of mediastinal mass by Dr. [**Last Name (STitle) 952**]
in combination with facetectomy, left T11-12, with resection of
nerve sheath tumor. Laminectomy at T11-12 on the left side by
Dr. [**Last Name (STitle) **] on [**2120-1-29**]
History of Present Illness:
73yo woman with an incidentally discovered left paraspinal
lesion at the level of the T12 vertebral body and rib with
follow-up CT due to the pacemaker placement in [**2119-11-15**]
showing slight increase in the size of that mass and
questionable extension to the neural foramen was evaluated by Dr
[**Last Name (STitle) 739**] as operable. Also with increasing back pain
requiring ED visit
Past Medical History:
1. Coronary artery disease status post coronary artery bypass
graft times one, saphenous vein graft to posterior descending
coronary artery, aortic valve replacement with a porcine valve
on [**2119-1-31**]. Coronary catheterization from [**Month (only) 956**]
[**2118**] showed a 70% right coronary artery occlusion.
2. Diabetes mellitus type 2.
3. Hypertension.
4. History of severe aortic stenosis with a valve area of 0.7
status post AVR with a porcine valve.
5. Hypercholesterolemia.
6. T11 to T12 paravertebral mass.
7. Anemia.
8. Bilateral subclavian stenosis.
9. History of subdural hemorrhage after motor vehicle accident.
Social History:
She is primarily Russian speaking although she does understand
some English. She lives with her husband. She does not smoke
or drink.
Family History:
Family history is significant for a brother who died of an MI at
the age of 65.
Physical Exam:
GEN: elderly woman NAD
HEENT: anicteric, OP clear
CV: RRR with II/VI SEM
LUNGS: decreased BS at bases o/w clear
ABD: soft, NT, NABS, no masses
EXTREM: no edema, warm
Neurologic exam (per recent neurology examination):
MS: limited by language barrier (Russian speaking) but appears
normal
CN: normal
MOTOR: 4/5 weakness on bilateral IP, 4+ left TA, and left large
toe extensor. Otherwise full strength
SENSATION: No sensory level. Fine touch, pin prick/temperature,
and vibration intact bilaterally. Romberg test: negative
COORDINATION: No tremor. FTN normal. [**Doctor First Name **] normal.
REFLEXES: Symmetric in LE and UE. No clonus.
TOES: Downgoing on right but up on the left.
GAIT: Patient can rise from bed without assistance. The
initiation of the gait is normal. Patient does have a wide-based
and antalgic gait. No dragging of feet. No shuffling or magnetic
gait. The posture is normal. The turning is fast
and steady.
Pertinent Results:
Please see hospitalization course.
Brief Hospital Course:
Mrs. [**Known lastname 15615**] was admitted on [**2120-1-29**] for removal of the left
paraspinal mass via combo surgery performed by Dr. [**Last Name (STitle) 952**] and
Dr. [**Last Name (STitle) 739**]. Final pathology reveals this mass was a
schwaanoma. Her course was complicated by respiratory
decompensation, dropped oxygen saturations. CTA was negative
for PE, but showed LLL collapse with effusion. Recieved
aggressive pulmonary toilet in the ICU. Antibiotics were not
needed. SHe did well and upon discharge is satting 97% on RA.
Transfused a total of 3 units pRBCs for anemia.
She did well with PT and will be discharged home with her
pre-hospitalization services.
Medications on Admission:
protonix
isorsorbide
atenolol
diovan
nifedipine
diabetes medication ?
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyclobenzaprine HCl 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily). Tablet Sustained
Release(s)
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
15. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Resection of Left paraspinus mass - Schwaanomma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please take all your medications. Please attend all followup.
Please call your doctor or return to the ED if you experience
difficulty breathing, pain, weakness, or other concerning
symptoms.
Watch incision for redness, drainage, swelling. Do not get
staples wet, keep dry until removed
Followup Instructions:
Please followup with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in 2 weeks. ([**Telephone/Fax (1) 4044**]. Your appointment time is: [**2127-2-20**]:30pm [**Hospital Ward Name 23**]
[**Location (un) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2120-4-17**] 1:00
- Remove staples on [**2-12**] you can come to Dr [**Name (NI) 14075**] office or go to your Primary care's office
-Follow up with Dr [**Last Name (STitle) 739**] in 6 weeks
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"V45.81",
"272.0",
"V42.2",
"250.00",
"997.3",
"511.9",
"285.9",
"414.00",
"511.8",
"E878.8",
"401.9",
"215.4",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.07",
"38.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5086, 5092
|
2925, 3609
|
299, 562
|
5184, 5207
|
2866, 2902
|
5544, 6255
|
1818, 1899
|
3729, 5063
|
5113, 5163
|
3635, 3706
|
5231, 5521
|
1914, 2847
|
239, 261
|
590, 984
|
1006, 1649
|
1665, 1802
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,575
| 142,849
|
7355
|
Discharge summary
|
report
|
Admission Date: [**2204-9-21**] Discharge Date: [**2204-9-24**]
Date of Birth: [**2154-5-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50M s/p OSA, COPD and chronic pain on narcotics, presenting to
the emergency department with shortness of breath. His mother
has noticed that over the last two weeks he has had increasing
sleepiness. He says he has felt fine, except for a cough over
the last two days. This morning while trying to get out of bed
he slipped backwards onto the floor without any trauma. His
mother was worried about him and [**Last Name (un) 4662**] him into the ED. Patient
denies any chest pain or pressure. No abdominal pain. No fever
or chills. Patient is on chronic opiate medications for pain,
but denies taking extra medication. He notes that since changing
from Percocet to oxycodone his pain has been poorly controlled.
Denies any orthopnea or PND. Patient does have a history of
obstructive sleep apnea and uses a BiPAP machine at home. No
f/c, some cough.
In the ED, initial vitals were 98.6 104 129/50 16. ABG showed
PCO2 over 70, hypercapneic respiratory failure. Started on BiPAP
with improvement in mental status. Duonebs. Expiratory wheeze on
exam. IV solumedrol and Azithromycin. BiPAP set at PSV 10, PEEP
10 and FiO2 40%. CXR clear w/o pulmonary edema. EKG with sinus
tachycardia. Has one peripheral IV. Complaining of chronic pain
in his hips.
On the floor, the patient is drowsy but arousable. He falls
asleep between sentences. He complains of his chronic pain in
his lower back. He had trouble urinating this morning, but has
not since. He has been having auditory hallucinations for about
4 years now that have been worsening, but does He can walk up
one flight of stairs without resting, but not further. Other ROS
negative.
On further questioning, patient admits to taking [**4-24**] extra Xanax
tablets last night because his auditory hallucinations were
"getting to him". He refers to his auditory hallucinations as
"[**Doctor First Name **]", and says that [**Doctor First Name **] tells him bad things about himself.
He does see a therapist, but Seroquel doesn't seem to be
helping. His therapist is Dr. [**Last Name (STitle) **] at [**Location 8391**] Community
Health Center. He denies wanting to hurt himself currently.
Past Medical History:
- Type 2 DM has been followed at [**Last Name (un) **]
- OSA on CPAP at home
- Hepatits C - s/p aborted course of interferon
- Major depressive disorder, ? of schizophrenia and bipolar
disorder
- Hypertension
- Bilateral avascular necrosis of femoral heads s/p hip
replacements in '[**79**] and '[**85**]
- s/p L1/L2 kyphoplasty after fall [**6-24**]
- s/p left distal radius fracture after fall [**6-24**]
- Bilateral lower extremity edema, thought to be secondary to
venous stasis
- DJD of his back
- Osteoporosis
- Morbid Obesity
- Schatski's ring
Social History:
On disability, lives with his mother, attends a day program.
- Tobacco: Smokes [**12-22**] ppd for > 10yrs
- Alcohol: no EtoH for 15 years
- Illicits: Stopped IVDA in [**2186**] after 3 years of use, did take
cocaine with heroine. Has not used since then.
Family History:
father with DM and CAD
Physical Exam:
ADMISSION EXAM:
General: Drowsy, falling asleep between questions. A&O
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP difficult to assess, no LAD
Lungs: Basilar crackles that improve with cough, diffuse
expiratory wheezes.
CV: Distant heart sounds, tachy, regular.
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs [**12-31**] intact, strength and sensation grossly
nl.
DISCHARGE EXAM:
O: VS: 96.9, 130/80, 88, R20, 97% RA
HEENT: PERRLA, EOMI. MMM
CV: RRR w/o m/r/g.
PULM: CTAB. no crackles, rales or wheezing.
ABD: soft, nt/nd. +BS
EXT: 1+ nonpitting edema bilat LE. 1+DP pulses bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2204-9-21**] 01:35PM BLOOD WBC-4.5 RBC-3.78* Hgb-12.0* Hct-36.1*
MCV-96 MCH-31.8 MCHC-33.2 RDW-12.9 Plt Ct-129*
[**2204-9-21**] 01:35PM BLOOD Neuts-73.2* Lymphs-19.2 Monos-5.7 Eos-1.7
Baso-0.3
[**2204-9-21**] 01:35PM BLOOD PT-11.0 PTT-25.3 INR(PT)-0.9
[**2204-9-21**] 01:35PM BLOOD Glucose-234* UreaN-22* Creat-0.9 Na-135
K-4.1 Cl-99 HCO3-29 AnGap-11
[**2204-9-21**] 01:35PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.3*
[**2204-9-21**] 01:42PM BLOOD Type-ART pO2-133* pCO2-71* pH-7.26*
calTCO2-33* Base XS-2
[**2204-9-21**] 01:42PM BLOOD Lactate-2.3* K-4.0
[**2204-9-21**] 06:24PM BLOOD freeCa-1.27
URINE:
[**2204-9-21**] 06:17PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MICROBIOLOGY:
[**2204-9-21**] BCx: pending
[**2204-9-21**] MRSA screen: No MRSA isolated.
STUDIES:
[**2204-9-21**] CXR:
No acute intrathoracic process.
DISCHARGE LABS:
[**2204-9-23**] 06:20AM BLOOD WBC-6.6# RBC-3.91* Hgb-12.4* Hct-37.1*
MCV-95 MCH-31.8 MCHC-33.5 RDW-12.9 Plt Ct-151
[**2204-9-23**] 06:20AM BLOOD Glucose-236* UreaN-21* Creat-0.8 Na-138
K-4.6 Cl-95* HCO3-35* AnGap-13
[**2204-9-23**] 06:20AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 14323**] is a 50M with h/o OSA, COPD and chronic pain on
narcotics, who was admitted with hypercarbic respiratory
failure.
#. Hypercarbic respiratory failure: Etiology of respiratory
failure is likely multifactorial - obesity hypoventilation,
pulmonary HTN from OSA, COPD exacerbation, pulmonary edema, in
the setting of taking increased sedating medications ([**4-24**] extra
Xanax pills on the day of admission). Patient was originally
admitted to the ICU for respiratory failure requiring BiPAP in
the ED. On arrival to the MICU, the patient was drowsy but
arousable, falling asleep between sentences. Pt continued on
bipap. and was also given lasix 10mg IV x2 for suggestion of
mild volume overload on examination and chest xray and had 1L of
urine output. The patient was treated for COPD exacerbation
giver decreased air movement and some wheezing on examination
with pulse dose steroids, Azithromycin, nebulizer treatments,
and continued home BiPAP at night. Patient's respirtory status
improved significantly over the first hopsital day and patient
was transferred to the floor. On the floor, treatment was
continued and patient's respiratory status improved with satting
at 98-100% on room air at time of discharge. Patient will
continue azithromycin and steroid course for a total of five
days, with PRN inhaler treatment and continuation of CPAP
overnight for OSA.
# Auditory hallucinations: Pt has hx of schizophrenia vs.
depression w/psychosis. He endorses auditory hallucinations for
about 4 years now that have been worsening. His therapist is Dr.
[**Last Name (STitle) **] at [**Hospital 8391**] Community Health Center. On admission,
patient admitted to taking [**4-24**] extra Xanax tablets last night
because his auditory hallucinations (which are called "[**Doctor First Name **]")
were "getting to him". Psych evaluated the patient and
recommended Xanax taper, decreasing Seroquel, and starting
Risperidone. Patient was sectioned given concern that his
hallucinations caused him to overdose on xanax resulting in
respirtory distress. Once medically cleared patient was
discharged to psychiatry for inpatient psychiatry evaluation.
# Chronic pain: He has severe, debilitating chronic pain.
Continued home Morphine and Oxycodone PO regimen.
# Diabetes: Continued home novolog 70/30, but held home
metformin and oral hypoglycemics while an inpatient. Given
stable creatinine, these were restarted on discharge. His blood
sugars were notably higher into 300s morning of discharge given
recent corticosteroids.
# Hypertension: BP well controlled on home metoprolol,
lisinopril, and losartan/hctz.
Transitional care:
1. pending studies: blood cultures
2. Code: full
3. medical management:
started prednisone, azithromycin to complete 5 day course
decreased xanax dosing, started risperidone, decreased seroquel
per psychiatry recs
held temazepam, and this should be readdressed with psychiatry
Medications on Admission:
- alprazolam 2mg QID
- buspirone 15mg [**Hospital1 **]
- glipizide ER 10mg [**Hospital1 **]
- metformin 850mg TID
- metoprolol ER 100mg daily
- lisinopril 40mg daily
- oxycodone 10mg Q3-4hours PRN
- OxyContin 80mg tablets TID
- OxyContin 20mg tablets TID
- quetiapine 600mg QHS
- Magnesium oxide 400mg [**Hospital1 **]
- losartan/HCTZ 100/12.5mg daily
- temazepam 30mg QHS
- novolog 70/30mg 40 units QAM and QPM
- multivitamin
- nicotine patch
- vitamin D2 50,000 weekly
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 1 days.
2. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
5. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily):
HOLD for SBP<100, HR<55.
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 days.
9. quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. oxycodone 80 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours): to be
taken with 20mg for total of 100mg TID; hold for sedation,
confusion, RR<12.
11. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: hold for sedation, RR<12.
12. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO three times a day: HOLD for
sedation, RR<12.
13. losartan-hydrochlorothiazide 100-12.5 mg Tablet Sig: One (1)
Tablet PO once a day: HOLD for SBP<100.
14. alprazolam 1 mg Tablet Sig: 1.5 Tablets PO QID (4 times a
day): HOLD for sedation, confusion, RR<10.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
16. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
17. risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): in am.
18. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
19. multivitamin Tablet Sig: One (1) Tablet PO once a day.
20. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: 40 units Subcutaneous twice a day: 40 units in am with
breakfast, 40 units in pm with dinner.
21. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 **]
Discharge Diagnosis:
Primary: COPD exacerbation, pulmonary edema
.
Secondary: Hallucinations, Psychosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14323**],
It was a pleasure taking care of you during this
hospitalization.
You were seen in the hospital for drowsiness and trouble
breathing. Your drowsiness improved with time as your sedating
medications began to wean off. You were thought to also be
having a COPD exacerbation given your labored breathing. You
were given nebulizer treatments, antibiotics and steroids which
improved your ability to breath. You were initially admitted to
the ICU and then transferred to the floor once you were feeling
better. You were evaluted by psychiatry given that you were
complaining of increase hallucinations which lead you to take
more of your xanax than usual. Psychiatry thought you required
inpatient psychiatric treatment to help improve these symptoms
and to establish an optimal drug regimen.
.
The following medications were added to your home regimen:
- START Prednisone 60mg by mouth for one more day (last day is
tomorrow [**2204-9-25**])
- START Azithromycin 500mg by mouth for one more day (last day
is tomorrow [**2204-9-25**])
- START Albuterol inhalers 1-2puffs every 6hrs as needed for
shortness of breath or wheezing
- START Ipatropium inhalers 1-2puffs every 6hrs as needed for
shortness of breath or wheezing
- START Risperidone 1mg in the morning and 2mg at night
- DECREASE the dose of Alprazolam to 1.5mg four times daily
- DECREASE the dose of Quetiapine to 400mg by mouth at night
- STOP the Temazepam for now. We held this in the hospital, and
you should discuss with the psychiatrists whether this should be
restarted.
** Your psychiatrists may be making changes to some of the
medications while you are in the psychiatric facility.
Followup Instructions:
You were found to require impatient psychiatry. Please follow up
with psychiatry as discussed.
Please follow up with your PCP once you are discharged.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"298.9",
"514",
"401.9",
"518.81",
"250.00",
"327.23",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11034, 11104
|
5351, 8289
|
287, 294
|
11231, 11231
|
4164, 4164
|
13094, 13379
|
3325, 3349
|
8810, 11011
|
11125, 11210
|
8315, 8787
|
11382, 13071
|
5053, 5328
|
3364, 3920
|
3936, 4145
|
228, 249
|
322, 2462
|
4180, 5037
|
11246, 11358
|
2484, 3036
|
3052, 3309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,836
| 173,783
|
41779
|
Discharge summary
|
report
|
Admission Date: [**2184-2-21**] Discharge Date: [**2184-3-6**]
Date of Birth: [**2156-2-6**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Bleeding from Right eye
Major Surgical or Invasive Procedure:
[**2184-2-23**]: Cerebral Angiogram with coiling and sacrafice of
right Carotid artery
History of Present Illness:
This is a 28 year old female status post high speed MVA
evening of [**2184-1-14**] who is well known to the neurosurgery
service
and is status post interventional Neuroradiology Angiogram and
Coiling carotid cavernous fistula on [**2184-2-13**].This patient was
at her rehabilitation facility when at 1000 this morning a
trickle of blood came from her right eye. The patient had been
followed by opthomology as at the time of her initial injury on
[**2184-1-14**] she had multiple injuries which included right orbital
compartment syndrome and lateral canthotomy. The patient wears
a
right eye patch and has irritated, edematous conjunctiva.
Past Medical History:
Post C2 body fx, bilat preseptal hemorrhage, small bilateral
PTX, splenic injury s/p splenectomy, L squamous temporal bone
fx, bilat anterior acetabular fx, R inferior pubic ramus fx, fx
ant tibial cortex, Carotid->cav sinus fistula s/p embolization.
Annular tear C2/3 disk, Prevertebral hematoma, skull base -> C4
Social History:
Before the accident was living independently, was recently in
acute rehab prior to her readmission to Neurosurgery, + history
IVDA
Family History:
non-contributory
Physical Exam:
Upon discharge:
EO, alert and oriented x3, L pupil reactive, R gaze deficit
which has been improving, MAE with full motor, walking
independently. Tolerating PO intake without issue.
Pertinent Results:
[**2184-2-21**] 12:11PM GLUCOSE-109* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-32 ANION GAP-15
[**2184-2-21**] 12:11PM estGFR-Using this
[**2184-2-21**] 12:11PM CALCIUM-10.8* PHOSPHATE-5.3* MAGNESIUM-2.1
[**2184-2-21**] 12:11PM WBC-9.7 RBC-4.41# HGB-13.0# HCT-40.2# MCV-91
MCH-29.5 MCHC-32.3 RDW-13.5
[**2184-2-21**] 12:11PM NEUTS-62.7 LYMPHS-21.5 MONOS-7.3 EOS-7.5*
BASOS-1.0
[**2184-2-21**] 12:11PM PLT COUNT-613*
[**2184-2-21**] 12:11PM PT-11.9 PTT-33.9 INR(PT)-1.1
CXR [**2-22**]: Pleural effusions have resolved. Free air has also
resolved. A
tracheostomy is again noted. The heart is normal in size. The
mediastinal
and hilar contours appear unchanged. The lungs appear clear. The
bony
structures are unremarkable.
IMPRESSION: No evidence of acute disease.
CT head [**2184-2-25**]
1. Status post coiling of right ICA for carotid cavernous
fistula, with
subarachnoid hemorrhage in the right sylvian fissure and the
suprasellar
cisterns.
2. Diffuse swelling/edema in the right cerebral hemisphere.
Pelvis Xray [**2184-2-28**]:
IMPRESSION: Single frontal view of the standing pelvis shows
substantial bony healing of fractures of the lesser ring of the
right pelvis. Bony fusion is not complete in the right
ischiopubic junction, and if this as a potential source of
concern, oblique views should be obtained.
Tib/Fib Xray [**2184-2-28**]:
Scanning of the anterior cortical margin of the right tibia, at
the level of a small cortical defect, shows an indication of
healing at the site of the pretibial laceration.
Cspine Xrays [**2184-3-1**]:
FINDINGS: Two lateral views of the cervical spine. No AP view
provided.
Halo device is present. Patent airway. Tracheostomy present.
Normal
prevertebral soft tissues. Prior C2-C3 ACDF with anterior
instrumentation and intervertebral disc spacer. The hardware is
unchanged in position. No change in alignment. The known C2
periprosthetic frature is not seen on these radiographs.
IMPRESSION: No change from the most recent radiographs.
Brief Hospital Course:
Ms. [**Known lastname 1968**] presented to the ED on [**2-21**] from rehab and
neurosurgery was consulted for c/o bleeding from right eye. She
has no neurological complaints at that time. She was admitted to
the step down unit for q 2hr neuro checks. Optho was consulted
and on examination she was noted to have elevated occular
pressure to 28. Per their recommendation she was started on
additional eye drops, Dorzolamide 2%/lacrilube TID, for the
bleeding from her cracked conjuntiva.
On [**2-22**] she was pre-oped for a cerebral angiogram on monday and
was cleared for transfer to the floor with tele. On [**2-23**] she
underwent the cerebral angiogram angio with coil and sacrafice
of right carotid. Both groin sites had angioseal. She was
transfered to the ICU on [**2-25**] with headache, nausea and CT
showed some SAH. Decadron was started for headaches and some
cerebral edema. She was seen by opthomology again on [**2-26**] and
she needs to follow up with oculoplastics. OMFS recommedned a
soft diet and mouth exercises. Outpatient follow up was made.
Orthopedic surgery was consulted in the hospital for follow up
of her tib/fib fractures and pelvic injury. Images were ordered
and reviewed by their team and the timing of follow up was
confirmed for 8 weeks in clinic with Dr. [**Last Name (STitle) 1005**].
The trach was removed on [**2184-3-5**] at bedside. PEG remained in
place with plans for removal with Dr [**Last Name (STitle) **].
A family meeting was held on [**2184-3-5**] in which discharge planning
was discussed, some major points:
- Follow-up / signs to look for were discussed
- Patient teaching on SAH and normal course of recovery
- Cognitive therapy resources were pointed out
- Pain management and Methadone taper:
- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90747**] manages opioid withdrawl, weaning
Methadone, but can not be on Vivitrol until off dilaudid. She
can be contact[**Name (NI) **] at [**Telephone/Fax (1) 90748**] (o), [**Telephone/Fax (1) 90749**] (c).
- In collaboration with [**Location (un) **], Neurosurgery will supply
methadone taper to off over the next few days. We will also
provide narcotic Rx for 7 days. At this point, the patient will
discuss her readiness to stop Dilaudid for pain and use
non-opoid forms of pain management so she may restart her
Vivitrol. Neurosurgery will provide a refill at that time if
patient feels she is not ready but our main goal would be to
provide a Rx for a non-opoid medication that will be accepted by
the protocol [**First Name8 (NamePattern2) **] [**Location (un) **] can restart the Vivitrol.
- [**Hospital **] rehab was offered but declined
- Patient and family agreed on plan to discharge home on
Saturday 12 noon.
- VNA will make a couple of home visits to follow-up and provide
additional support.
- Halo is not removed in the OR under general
- Trach will be removed.
She was discharged home on [**2184-3-6**].
Medications on Admission:
artificial tears, asa 325, plavix 150, baci/poly eye [**Doctor Last Name **] tid,
colace, pepcid, methedone 7.5 [**Hospital1 **], senna, timolo 1 drop [**Hospital1 **] to r
eye
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-2**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*QS QS* Refills:*2*
5. 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*
6. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
Disp:*QS QS* Refills:*2*
7. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q 8H (Every 8 Hours).
Disp:*QS QS* Refills:*2*
8. benzocaine (pectin-carboxymcl) 20 % Paste Sig: One (1) Appl
Mucous membrane QID (4 times a day) as needed for tooth pain.
Disp:*QS QS* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*QS QS* Refills:*2*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Continue while on steroids.
Disp:*60 Tablet(s)* Refills:*0*
15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-7**]
hours as needed for pain: 7 day supply.
Disp:*42 Tablet(s)* Refills:*0*
16. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: 2mg (1 tab) every 12hrs for 4 doses then 1mg
(0.5 tab) every 12hrs for 2 doses then 1mg (0.5 tab) once a day
for one dose, then discontinue.
Disp:*QS Tablet(s)* Refills:*0*
17. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Steward Home Care
Discharge Diagnosis:
Carotid Cavernous Fistula
Subarachnoid hemorrhage
Cerebral edema
Post C2 body fx w/ C2-3 flex-distraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? No driving until you are no longer taking pain medications
*** Because of your cervical fractures/ Halo- no heavy lifting,
10 lb weigh restriction. ****
* Neurosurgery will continue to provide you pain medications
until you begin your outpatient medication protocol as discussed
at our family meeting.
* Follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90747**] regarding your weaning
process/ beginning outpatient protocol. In collaboration with
[**Location (un) **], we have decided to wean your Methadone to 2.5mg twice
daily for a few more days then discontinue. At that time, please
evaluate your level of pain/ comfort- if you are able to stop
Dilaudid then [**Location (un) **] can work with you on restarting your Vivitrol
and help with non-opoid pain manangement. As long as you are on
opoids, you cannot restart Vivitrol. [**Location (un) **] can make
recommendations to you and Neurosurgery on what pain medications
are allowed with the protocol.
* Neurosurgery may decline to write for narcotic prescriptions
if the following happens: Multiple providers supplying pain
medications without Neurosurgery knowing, suspected abuse or
mis-use of the pain medications, and not using the medication as
specefically prescribed.
* Neurosurgery will not provide replacement pain medications if
pills are stolen or lost.
* Neurosurgery may ask for urine analysis to confirm proper use
of medication or rule out use of illicit medications if abuse or
mis-use is suspected.
Decadron (Dexamethasone- steroid) Taper:
2mg (1 tab) every 12hrs for 4 doses then
1mg (0.5 tab) every 12hrs for 2 doses then
1mg (0.5 tab) once a day for one dose, then discontinue.
Team Contact [**Name (NI) **]:
Neurosurgery Dr [**First Name (STitle) **] [**Telephone/Fax (1) 4296**]
Spine Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 3736**]
Trauma Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 600**]
Eye Oculoplastics [**Telephone/Fax (1) 88077**]
Facial fractures Dr [**Last Name (STitle) 54446**] [**Telephone/Fax (1) 68463**]
Followup Instructions:
Neurosurgery Follow-up:
* Please follow-up with Dr [**First Name (STitle) **] in 4 weeks for follow-up with
a MRA of the brain. At that time we can discuss whether a
follow-up angiogram is needed. Please call [**Telephone/Fax (1) 4296**] to make
this appointment or call with any questions.
OMFS (facial fractures):
* F/u with Dr. [**Last Name (STitle) 54446**] on [**2184-3-12**] at 10am at [**Hospital 40530**] clinic at
[**Hospital6 **]. They are located at [**Last Name (NamePattern1) **],
[**Hospital 30433**]
[**Hospital **] Care Center, [**Location (un) 442**]. Please call [**Telephone/Fax (1) 68463**] with
any questions or concerns.
**They have recommended that you see your general dentist to
address decayed unrestorable teeth.
Opthamology (Eye):
*You will need to be seen at [**Hospital 13128**] with with
occulplastics. The phone number to make this appointment is
[**Telephone/Fax (1) 88077**].
Trauma Service (Feeding tube/splenectomy)
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2184-2-17**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment. Please arrive
there at 1:30pm.
Orthopedics (fractures, NOT SPINE)
Department: ORTHOPEDICS
When: [**2184-4-20**] at 9:20 AM (Xrays before)
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS - Xrays
When: [**2184-4-20**] at 09:10 AM
Where: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Spine (Halo):
You will need to follow up with Dr. [**Last Name (STitle) 1352**] in 2 weeks for care
of your halo. Please call for appointment. Tje office was
notified to set this appointment up with you in the next few
days.
|
[
"V44.1",
"348.5",
"V44.0",
"238.71",
"V70.7",
"430",
"900.82",
"V45.79",
"E812.0",
"372.30",
"V54.16",
"285.9",
"V54.17"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"97.37",
"39.75"
] |
icd9pcs
|
[
[
[]
]
] |
9338, 9386
|
3884, 6837
|
328, 417
|
9536, 9536
|
1831, 3861
|
12255, 14503
|
1596, 1614
|
7065, 9315
|
9407, 9515
|
6863, 7042
|
9687, 12232
|
1629, 1629
|
265, 290
|
1645, 1812
|
445, 1091
|
9551, 9663
|
1113, 1432
|
1448, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,129
| 184,147
|
2968+55430
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-8-18**] Discharge Date: [**2167-8-25**]
Date of Birth: [**2103-5-30**] Sex: F
Service: CARDIOTHORACIC SURGERY
DATE OF SURGERY: [**2167-8-20**].
ADMITTING DIAGNOSIS:
1. Angina.
2. Hypercholesterolemia.
3. Osteopenia of the spine.
4. Osteoarthritis.
5. Status post bilateral cataract surgery.
6. Status post total abdominal hysterectomy/bilateral
salpingo-oophorectomy.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft x3.
2. Hypercholesterolemia.
3. Osteopenia of the spine.
4. Osteoarthritis.
5. Status post bilateral cataract surgery.
6. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
ADMITTING HISTORY AND PHYSICAL: This patient is a
64-year-old female with a history of hypercholesterolemia and
a family history of myocardial infarction, who presented to
her primary care physician's office on [**8-18**] with a three
month history of atypical chest pain which occurred on and
off and even occurred at rest. She was noted to have some
electrocardiogram changes and sent to the Emergency Room to
rule out myocardial infarction, where subsequently she
underwent an ETT which was found to be positive. She
underwent cardiac catheterization on [**8-19**], which showed
a 60% narrowed LMCA and severe proximal and mid left anterior
descending artery disease. The right coronary artery had a
severe proximal to distal disease before the PDA.
LABORATORIES AT TIME OF ADMISSION: Her hematocrit was 32.9
when she was admitted with a platelet count of 278. At time
of admission, initial coag times were PT 12.0, PTT 22.5, and
INR of 1.0. Her BUN and creatinine at the time of admission
were 18 and 0.7. Her initial potassium was 3.6. Patient's
lowest hematocrit during the course of her hospitalization
was 21.4, but as mentioned previously, she did receive 2
units of packed red blood cells.
She was placed in the Intensive Care Unit, started on medical
management for her cardiac symptoms, and intra-aortic balloon
pump was inserted. Given the nature of her disease, it was
determined that coronary artery bypass graft would be the
best course to treat her and she was taken to the operating
room on [**8-20**] by Dr. [**Last Name (STitle) 70**], where she underwent a
CABG x3 with LIMA to LAD, and saphenous vein graft to PDA,
and saphenous vein graft to PL. She was on bypass for 76
minutes with cross-clamp time of 46 minutes. No note of any
operative complication. She was transferred to the CSRU in
normal sinus rhythm on a Neo-Synephrine and propofol drip.
She was extubated without difficulty.
On postoperative day one, she was started on diuresis regimen
with Lasix and beta blocker therapy. She notably did receive
1 unit of platelets and 2 units of packed red blood cells.
Due to limited beds, the patient remained in the CSRU.
On postoperative day three, where she received Physical
Therapy and aggressive pulmonary toilet, and incentive
spirometry, and ambulation, the patient did well. Patient
continued to do well as her blood pressure medications were
adjusted, and on postoperative day five, she was ready for
discharge to home, where her electrocardiogram showed a sinus
rhythm, chest x-ray without any notable abnormality, and a
good sternal alignment.
At the time of discharge, her hematocrit was 31.2 with
platelet count of 273. Her BUN and creatinine were 15 and
9.7 respectively with a K of 4.3.
CONDITION ON DISCHARGE: She is discharged to home in good
condition.
FOLLOW-UP INSTRUCTIONS: She has been asked to followup with
Dr. [**Last Name (STitle) 70**] in six weeks and Dr. [**Last Name (STitle) **] in one week.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid prn.
2. Aspirin 325 mg po q day.
3. Tylenol 650 mg po q4 prn.
4. Percocet 5/325 take 1-2 tablets po every four hours as
needed for pain.
5. Bisacodyl 10 mg rectal suppositories one per day as needed
for constipation.
6. Lipitor 10 mg po q day.
7. Conjugated estrogen 0.625 one po q day.
8. Folate 1 mg one po q day.
9. Metoprolol 50 mg po bid.
10. Lasix 20 mg po bid for seven days along with 20 mEq of
potassium po bid for seven days.
11. One multivitamin per day.
12. Naproxen 500 mg every eight hours as needed for pain.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 3363**]
MEDQUIST36
D: [**2167-8-25**] 12:12
T: [**2167-8-25**] 12:15
JOB#: [**Job Number 14203**]
Name: [**Known lastname **], [**Known firstname 1463**] [**Last Name (NamePattern1) 2229**] Unit No: [**Numeric Identifier 2230**]
Admission Date: [**2167-8-18**] Discharge Date: [**2167-8-25**]
Date of Birth: [**2103-5-30**] Sex: F
Service:
PHYSICAL EXAMINATION: Patient's height 155 cm, weight 63 kg,
pulse 70 and regular, blood pressure 126/63, and 99% on room
air O2 saturation. HEENT was unremarkable. There were no
carotid bruits. Carotid pulses were [**3-10**]. No
lymphadenopathy. Lungs were clear to auscultation
bilaterally. The heart was regular, rate, and rhythm with
S1, S2, no murmurs or rubs appreciated. Abdomen was soft,
nontender, and nondistended. Extremities were warm and well
perfused with no edema. Pulses were all 2+/4 except for the
right femoral which was not assessed secondary to the
presence of the intra-aortic balloon pump. Neurologically,
she was alert and oriented times three with a nonfocal
neurologic examination.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Name8 (MD) 2231**]
MEDQUIST36
D: [**2167-8-25**] 12:19
T: [**2167-8-25**] 12:51
JOB#: [**Job Number 2232**]
|
[
"411.1",
"272.0",
"V17.3",
"794.39",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.53",
"37.61",
"36.15",
"39.61",
"37.22",
"88.72",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
437, 3455
|
3703, 4818
|
4841, 5751
|
212, 416
|
3551, 3680
|
3480, 3526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,828
| 161,430
|
8482+55951
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-4-20**] Discharge Date: [**2140-4-26**]
Date of Birth: [**2056-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
AVR (27mm [**Company 1543**] Mosaic porcine)/ CABG x3 (LIMA to LAD, SVG
to DIAG, SVG to OM)/ closure ASD [**2140-4-21**]
History of Present Illness:
83 yo female who initially presented to [**Hospital1 18**] with syncope and
epistaxis in [**3-21**]. Re-presented to NEBH on [**4-14**] with exertional
angina. Cath there revealed tight left main /CX disease.
Transferred to [**Hospital1 18**] for surgery.
Past Medical History:
- Syncope, negative tilt-table testing [**5-/2138**]
- Aortic stenosis
- Hyperlipidemia
- Perninious anemia
- Left bundle branch block
- History of tachycardia - recent evaluation during
hospitalization [**2140-3-3**] with initial concern for SVT, however,
there was no response to adenosine x 3 and the conclusion was
inappropriate sinus activity due to anxiety
Social History:
Widow, lives with brother. Lifetime nonsmoker. Denies alcohol or
other drug use.
Family History:
father died of MI at 65
Physical Exam:
HR 107 RR 18 BP 134/72
5'6" 181#
resting in bed
skin unremarkable
PERRL
neck supple with full ROM/ no carotid bruits, 2+ pulses
CTAB
RRR no murmur
soft, NT, ND, + BS
warm, well-perfused, left ankle edema
no obvious varicosities
neuro grossly intact
right femoral sheath, left 2+ fem
2+ bil. DP/PT/radials
Pertinent Results:
Conclusions
PRE-BYPASS:
1. A left-to-right shunt across the interatrial septum is seen
at rest. A secundum atrial septal defect is present.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with apical,
septal, anterior and lateral apical hypokinesis. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is moderately dilated. There are focal
calcifications in the aortic arch. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and was
initially AV paced and then in sinus rhythm.
1. A well-seated bioprosthetic valve is seen in the Aortic
position with normal leaflet motion and gradients (mean gradient
= 10-15 mmHg). No aortic regurgitation is seen.
2. LV Apex is less hypokinetic. RV function is unchanged.
3. Aorta is intact post decannulation.
4. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2140-4-21**] 14:41
FINDINGS: On the right side, occlusion of the internal carotid
artery was
noticed. A peak systolic velocity of 30 cm/sec was seen in the
right common
carotid artery. On the left side, a peak systolic velocity of 85
cm/sec was
seen in the internal carotid artery, 61 cm/sec in the common
carotid artery,
and 70 cm/sec in the external carotid artery. The left ICA/CCA
ratio was 1.4.
Both vertebral arteries presented antegrade flow.
COMPARISON: None available.
IMPRESSION:
1. Occlusion of the right internal carotid artery.
2. Less than 40% stenosis of the left internal carotid artery,
with mild
plaque seen.
DR. [**First Name (STitle) **] [**Name (STitle) **]
Approved: WED [**2140-4-20**] 7:18 PM
?????? [**2134**] CareGroup IS. All rights reserved.
[**2140-4-25**] 07:10AM BLOOD WBC-6.2 RBC-2.52* Hgb-8.7* Hct-25.8*
MCV-102* MCH-34.5* MCHC-33.8 RDW-15.1 Plt Ct-129*
[**2140-4-25**] 07:10AM BLOOD Glucose-99 UreaN-24* Creat-1.2* Na-140
K-3.6 Cl-105 HCO3-27 AnGap-12
[**2140-4-25**] 07:10AM BLOOD Mg-2.0
Brief Hospital Course:
Admitted from NEBH on [**4-20**] and pre-op workup completed.
Underwent CABGx3, AVR, and closure of 2 ASDs with Dr. [**Last Name (STitle) 914**] on
[**4-21**]. Please refer to separate operative note. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. By POD 1 the patient was extubated, alert and
oriented and breathing comfortably. She was neurologically
intact and hemodynamically stable and found suitable for
transfer to telemetry at this time. On the evening of POD 1 the
patient developed some confusion/sun-downing upon transfer to
the floor. She was treated with haldol and symptoms resolved.
She remained neurologically appropriate throughout the hospital
course. Chest tubes remained until POD 4 for large output.
They were discontinued without complication. The patient was
gently diuresed toward her preoperative weight. Creatinine
increased on POD 2 and lasix and zantac were decreased.
Creatinine improved. The patient did develop postoperative
atrial fibrillation and received IV amiodarone. She converted
to sinus rhythm and was maintained on oral amiodarone as well as
beta blockade. The physical therapy service was consulted for
assistance with post-operative strength and mobility. The
patient made good progress and was discharged home on POD 5.
Medications on Admission:
crestor 5 mg daily
ASA 81 mg daily
iron poly sachharide 150 mg daily
psyllium packet daily
MVI daily
Vit. B 12 1000 mcg SC monthly
colace 100 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 1 months: TID x6 days then [**Hospital1 **] x7days then one daily
for the remainder of month.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
aortic stenosis
coronary artery disease
atrial septal defect s/p AVR/CABG x3/ ASD closure
hyperlipidemia
pernicious anemia
left bundle branch block
tachycardia
anxiety
post-op atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, drainage, redness or weight
gain of 2 pounds in 2 days
Followup Instructions:
see Dr. [**Last Name (STitle) 11679**] in [**2-12**] weeks
see Dr. [**Last Name (STitle) **] in [**3-15**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
please call for all appts.
Completed by:[**2140-4-26**] Name: [**Known lastname 5236**],[**Known firstname 1194**] Unit No: [**Numeric Identifier 5237**]
Admission Date: [**2140-4-20**] Discharge Date: [**2140-4-26**]
Date of Birth: [**2056-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Mrs. [**Known lastname **] had a transient rise in creatinine likely due to
bypass, diuresis and other medicatons. Diuretics were decreased
and other nephrotoxic meds were discontinued.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2140-5-10**]
|
[
"427.31",
"426.3",
"433.10",
"413.9",
"745.5",
"424.1",
"414.01",
"E878.2",
"272.4",
"281.0",
"511.9",
"997.1",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.71",
"36.12",
"35.21",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8999, 9216
|
4484, 5804
|
338, 463
|
7849, 7856
|
1617, 4461
|
8146, 8976
|
1249, 1274
|
6005, 7528
|
7630, 7828
|
5830, 5982
|
7880, 8123
|
1289, 1598
|
281, 300
|
491, 748
|
770, 1134
|
1150, 1233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,929
| 193,046
|
55131
|
Discharge summary
|
report
|
Admission Date: [**2165-9-10**] Discharge Date: [**2165-9-20**]
Date of Birth: [**2123-3-7**] Sex: M
Service: MEDICINE
Allergies:
metoclopramide
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Chest tube placement
lung decortication
pericardial window
Picc line
History of Present Illness:
Mr. [**Known lastname **] is a 42 year old male with medical history only
significant for migraines initially presented to [**Hospital 1263**] Hospital
on [**2165-9-3**] with dyspnea, right flank pain, watery diarrhea, and
low-grade fever, s/p visit to their ED 1 day prior for the same,
sent home on Augmentin and inhalers, 1 week after seeing his PCP
about [**Name Initial (PRE) **] sore throat. He was admitted with persistent
tachycardia, tachypnea, and leukocytosis to 16 with leftward
shift with normal blood pressure. He was initally admitted to
the floor where a CT-PA showed RLL consolidation and small
pleural effusion, but no PE. He was continued on CTX and
azithromycin (started in the ED), later broadened to CTX and
levofloxacin out of concern for Legionella (despite negative
antigen) with non-bloody watery diarrhea. He complained of
substernal chest pressure and EKG was mildly concerning for
isolated ST elevation in [**Last Name (LF) **], [**First Name3 (LF) **] he was ruled out for MI with
serial troponins. Work-up of his presentation included HIV
serology, [**Doctor First Name **], "collagen vascular disease panel", dsDNA, which
were all negative. Leukocytosis worsened and imaging showed
progression of a pneumonic process to include all right lung
fields, along with evidence of volume overload with bibasilar
crackles and worsening hypoxia, requiring NRB. He was diuresed
with furosemide 120mg IV, but patient's high oxygen requirement
continued, so he was transferred to the ICU with sat drops to
80s on NRB.
In the OSH ICU, he was unable to lay flat and antibiotics were
broadened to vanc, Zosyn, and levoflox. Repeat chest CT showed
a large, loculated empyema with significant associated right
lung atelectasis. Thoracentesis yielded 20 cc of purulent
pleural fluid. Following the procedure, he desatted again and
was intubated for increased WOB and hypoxia with 7.5 ETT. Chest
tube was placed with purulence initially, now serosanguinous.
Pleural fluid studies were consistent with an exudative process
with elevated LDH to 7072. To decrease the loculations of the
empyema, they had TPAing the chest tube. Drainage was a total of
1L in 3 days. 4L of IVF were given and he briefly required
peripheral norepinephrine for hypotension stopped hours prior to
transfer. Antibiotic course is currently vanc (day 4), Zosyn
(day 3), and levoflox (day 6). Current vent settings on
transfer were AC 450/14/5/40% (decreased from 80%). He did not
arrive with central access, but does have 2 peripheral IVs. He
continues to have good urine output and is neurologically intact
and following commands when awake. He has not been fed yet.
The family requested transfer to a larger hospital for further
care.
On arrival to the MICU, he is sedated but arouses to voice and
follows commands. Satting well on AC ventilation.
Review of systems: unable to complete on admission directly with
patient. Per family, as below.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies palpitations, or
weakness. Denies nausea, vomiting, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
migraines
Social History:
Social History: Lives independently. 25 pk-yr smoking history
(1 ppd), no IV druge use or EtOH abuse). No recent inhalational
exposure, but was recently in Cincinatti for a family reunion.
Works helping set up and take down American Red Cross blood
drives. No exposure to prisons.
Family History:
Family History: Recent diagnosis of lung/stomach cancer in uncle
Physical Exam:
Admission Exam: Vitals: T: 98.7 BP: 102/63 P: 103, AC
450/14/5/40%, O2 sat 96%
General: intubated, sedated, arouses to voice
HEENT: Sclera anicteric, MMM, pinpoint pupils, oropharynx not
visualized
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, + rub throughout
(cleared on repeat exam), no murmurs or gallops
Lungs: decreased BS over RML and RLL, otherwise CTAB without
wheezes, rales, or rhonchi; right-sided chest tube in place with
saturated dressing, now changed; no crepitus, + serosanguinous
drainage
Abdomen: soft, tender over RUQ (with wincing/grimacing),
non-distended, bowel sounds present, no organomegaly appreciated
GU: foley in place
Rectal: good tone, guaiac negative
Ext: warm, well perfused, 2+ pulses, 1+ edema bilaterally and
symmetric, no clubbing or cyanosis
Neuro: nonfocal, follows commands and moving all extremities,
could not evaluate strength/sensation in upper/lower extremities
Pertinent Results:
[**2165-9-10**] 04:04PM RET AUT-1.2
[**2165-9-10**] 04:04PM NEUTS-79.8* LYMPHS-14.2* MONOS-4.2 EOS-1.0
BASOS-0.8
[**2165-9-10**] 04:04PM WBC-14.5* RBC-3.37* HGB-9.2* HCT-28.7* MCV-85
MCH-27.2 MCHC-31.9 RDW-13.9
[**2165-9-10**] 04:04PM HAPTOGLOB-465*
[**2165-9-10**] 04:04PM ALBUMIN-2.1* CALCIUM-8.2* PHOSPHATE-3.3
MAGNESIUM-2.1
[**2165-9-10**] 04:04PM ALT(SGPT)-29 AST(SGOT)-30 LD(LDH)-227 ALK
PHOS-59 TOT BILI-0.2
[**2165-9-10**] 04:23PM LACTATE-1.2
[**2165-9-13**] FLUID,OTHER GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY
[**2165-9-13**] TISSUE GRAM STAIN-FINAL;
TISSUE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-PRELIMINARY
[**2165-9-13**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-PRELIMINARY
[**2165-9-11**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP};
ANAEROBIC CULTURE-PRELIMINARY
[**2165-9-11**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2165-9-20**] 06:03AM BLOOD WBC-17.0* RBC-2.80* Hgb-7.5* Hct-24.0*
MCV-86 MCH-26.8* MCHC-31.3 RDW-14.2 Plt Ct-694*
[**2165-9-20**] 06:03AM BLOOD Glucose-98 UreaN-6 Creat-0.5 Na-136 K-3.8
Cl-100 HCO3-31 AnGap-9
[**2165-9-20**] 06:03AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.9
[**2165-9-14**] 03:06PM BLOOD calTIBC-129* Ferritn-536* TRF-99*
[**2165-9-19**] 02:02PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**Last Name (LF) **],[**First Name3 (LF) **] MED FA2 [**2165-9-19**] 11:48 AM
CT CHEST W/CONTRAST Clip # [**0-0-**]
Reason: Pneumonia, additional loculations
Contrast: OMNIPAQUE Amt: 75
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with empyema s/p VATS, 3 chest tubes, 1
removed.
REASON FOR THIS EXAMINATION:
Pneumonia, additional loculations
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION:
Patient with empyema, decortication, three chest tubes, one
removed,
pneumonia, additional loculation?
COMPARISON: Outside hospital CT of [**2165-9-7**] and chest
CT of
[**2165-9-11**].
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal
notch to the
upper abdomen with administration of IV contrast and 1.25-mm
slice
collimation. Multiplanar reformatted images in coronal and
sagittal axes were
generated.
LUNGS AND AIRWAYS:
Bilateral pneumonia consisting of left lung ground glass
opacities and right
lower lung consolidation have improved since last exam. For
example, right
lower lobe consolidation has significantly improved. The
airways are patent
until subsegmental levels. Multiple bulla are seen in the apex
and
unchanged.
MEDIASTINUM:
Surgical decortication and pericardial drainage has been done.
Right
loculated pleural effusion has significantly improved. Two
chest tubes enter
the pleural space between 9th and 10th ribs. The first one goes
posteriorly
and ends at the apex without significant residual pleural
effusion. The
second one ends in posterior right basal pleural space. Minimal
air is seen
inside the pleural effusion. Anterior pleural effusion has
significantly
improved and the thickness of the residual pleural effusion is 2
cm.
Pericardial effusion has been drained and is improved and the
residual one is
small. Reactive lymph nodes have also decreased in size. For
example, right
upper paratracheal lymph node went from 18 x 11 mm to 18 x 8 mm.
The esophagus and the thyroid are unremarkable.
Right-sided lateral chest wall muscles are still edematous.
Right-sided PICC
line ends in lower SVC.
UPPER ABDOMEN: This study is not tailored for assessment for
intra-abdominal
organs. The upper abdomen appears unremarkable.
OSSEOUS STRUCTURES: There is no bony lesion concerning for
malignancy or
infection.
CONCLUSION:
1. Right-sided empyema and pericardial effusion has been
drained surgically.
There is significant improvement of both. There is no new
loculation.
2. Bilateral pneumonia has also improved.
This has been discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36413**], Intern.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] SOM [**Doctor First Name **] LE
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: [**Doctor First Name **] [**2165-9-19**] 10:39 PM
Brief Hospital Course:
Assessment and Plan: 42 year old with evidence of emphysematous
changes and remarkable smoking history, presenting with RLL
pneumonia complicated by loculated empyema, transferred to [**Hospital1 18**]
for further ICU management.
# Pneumonia with empyema: He had recently presented to his PCP
with sore throat,presumed to be viral. He presented to OSH ED
with dyspnea with CT showing RLL consolidation and small pleural
effusion with thoracentesis at OSH and IV antibiotics given. He
developed rapid progression of pneumonic process despite IV abx
to all right lung fields and development of a loculated empyema
and was transferred to [**Hospital1 18**] for further care. He had no known
pre-existing pulmonary disease.three chest tubes placed with
improvement in his respiratory status. He was also noted to have
a pericardial effusion, with pulsus ranging [**9-9**]. He had
extensive testing to determine the nature of the pericardial
effusion, including HIV, [**Doctor First Name **], ANCA, RF which were all negative.
CRP was noted to be greater than assay and ESR was also
elevated. He went to the OR for VATS and pericardial window.
Multiple pleural fluid aspirates and pleural tissue growing out
strep anginosis although pericardial fluid has remained sterile.
It is likely that he had initially had a strep anginosis throat
infection, aspirated the strep with subsequent development of
the PNA and empyema, with a pericardial effusion developing as
part of an inflammatory reaction. He remained intubated briefly
following his OR procedures. His respiratory status improved
markedly, with patient on 2LNC at time of ICU d/c. Repeat CXR
showed consideral improvement. His chest tubes were put to water
seal. He will have repeat CXR on [**2165-9-16**] with subsequent
removal of chest tubes by thoracics. Per infectious disease he
will require 4-6 weeks of IV ceftriaxone and oral flagyll. He
should follow up with ID on discharge to refine the course. He
received a PICC line. Before discharge, ID recommended
switching the ceftriaxone and flagyl to ertapenem for ease of
administration for the patient as he is being discharged home
and not to a rehab facility at teh patient's request. Being
sent home with [**Name (NI) 269**], PT, home O2. ID, a new PCP, [**Name10 (NameIs) **] thoracic
[**Doctor First Name **] followups are arranged. Prior to discharge one of the
chest tubes was removed and the remaining two chest tubes were
pulled back 5cm each and put on pleurastats. Pt's pain initially
controlled with IV medications and switched to long and short
acting oxycondone, which he was sent home on.
.
# Anemia of acute inflammation: Baseline HCT is 43 with HCT
28.7 on admission. Hemolysis was negaitve. Thought to be BM
response to acute infection. Transfusion threshold set at HCT
21. His Hct had no precipitous drops while on the floor.
# Pericardial effusion: No signs of tamponade. Has pericardial
window. Etiology is thought to be severe systemic inflammation
from above.
- Follow. Bedside echo in ICU [**9-15**] showed no pericardial fluid,
no vegetation, mitral valve looks okay
Medications on Admission:
Medications at home (family to bring in doses/frequencies
tomorrow):
- Verapamil 240mg
- Imitrex
- Divalproex
- vitamin D
- Cepacol (sore throat)
Medications on transfer:
- Vancomycin 1250mg IV q8h
- Levofloxacin 750mg daily
- Piperacillin/tazobactam 2.25gm IV q6h
- Alteplase 10mg IV TID to chest tube
- Morphine sulfate 2mg IV q4h PRN
- Acetaminophen 650mg q6h PRN
- Famotidine 20mg IV q12h
- Propofol gtt
- Lorazepam 1mg IV q4h PRN
- Heparin 5000 units SC TID
- Albuterol 6 puffs q4h PRN
- Albuterol 2.5mg nebs q6h PRN
Allergies: metoclopramide
Discharge Medications:
1. Verapamil SR 240 mg PO Q24H
hold for sbp<90
2. ertapenem *NF* 1 gram Injection Q24H Duration: 16 Days
Last dose 10/8
RX *ertapenem [Invanz] 1 gram 1 gram intravenously through PICC
Q24H Disp #*16 Vial Refills:*0
3. Oxygen
2-3 liters continuous via NC. Pulse dose for portability.
DX: Empyema, Pneumonia. Ambulation SPO2 of 87%
4. Acetaminophen 650 mg PO Q6H
5. Albuterol Inhaler [**12-31**] PUFF IH Q4H:PRN wheezing
RX *albuterol 1-2 puffs every four (4) hours Disp #*1 Inhaler
Refills:*0
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
8. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
9. Bisacodyl 10 mg PO DAILY
hold for loose bowel movements
Discharge Disposition:
Home With Service
Facility:
Art of Care
Discharge Diagnosis:
bilateral pneumonia
right-sided empyema
pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with a lung infection.
Surgery was done and chest tubes placed to remove the
collections of pus in your right lung and the fluid around your
heart. You were started on IV antibiotics for the infection and
will continue to take them for several weeks. A nurse will come
to your home to administer these medications.
You are also being given oxygen to help you breathe.
We are giving you two prescriptions for pain.
You should take the oxycontin every day as directed. This is a
long acting pain medication.
The oxycodone is a short acting medication used for break
through pain only.
Do not drive or operate heavy machinery while on these
medications.
These medications can make you constipated so take the
medications listed for constipation.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2165-9-26**] 2:00
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray. Dr. [**Last Name (STitle) **] will evaluate the xray
and adjust your chest tubes.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2165-9-25**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 28089**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Notes: Dr [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 112475**] is your new physician at [**Name9 (PRE) 191**]. He works
closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your
care. Please call your insurance and name Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as
your PCP. [**Name10 (NameIs) **] MUST BE DONE BEFORE YOUR APPOINTMENT.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2165-10-8**] at 3:00 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2165-9-22**]
|
[
"492.0",
"276.52",
"482.39",
"423.9",
"518.81",
"305.1",
"346.90",
"510.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"34.20",
"37.24",
"34.52",
"37.12",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14442, 14484
|
9822, 12933
|
281, 351
|
14588, 14588
|
5072, 7091
|
15578, 17244
|
4040, 4090
|
13533, 14419
|
7131, 7196
|
14505, 14567
|
12959, 13106
|
14739, 15555
|
4105, 5053
|
3252, 3673
|
234, 243
|
7228, 9799
|
379, 3233
|
14603, 14715
|
13131, 13510
|
3695, 3706
|
3739, 4008
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,586
| 138,648
|
49042
|
Discharge summary
|
report
|
Admission Date: [**2134-3-21**] Discharge Date: [**2134-3-30**]
Date of Birth: [**2079-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Type A dissection
Major Surgical or Invasive Procedure:
[**2134-3-21**] Emergency repair of complex type A aortic dissection
with total arch replacement with size 28 Gelweave graft
History of Present Illness:
This 54 year old male was seen at [**Location (un) **] Hospitla earlier
today with complaints of back pain and chest pain. His blood
pressure at that time was in the 200s systolic. A CT scan done
there showed a type A dissection. He was transferred here on a
Nipride dripand emergently taken to the Operating Room.
Past Medical History:
ascending aortic dissection
hypertension
h/o prostate cancer
s/p knee surgery
Social History:
35 pack year smoking history.
Drinks 1 gallon of vodka per week (1-2 drinks per night - very
large drinks)
Family History:
Non contributory
Physical Exam:
Admission:
General: NAD, alert and cooperative
HEENT: EOMI, PERRLA
Neck: FROM, supple
Cardio: no murmur
Neuro/Psych: Abnormal: Intubated and anesthetized.
Gastrointestinal: No masses.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. DP: D. PT: P.
LLE Femoral: P. DP: N. PT: N.
Pertinent Results:
[**2134-3-29**] 06:00AM BLOOD WBC-7.2 RBC-3.36* Hgb-10.2* Hct-29.9*
MCV-89 MCH-30.3 MCHC-34.0 RDW-14.1 Plt Ct-220
[**2134-3-28**] 04:00AM BLOOD WBC-6.6 RBC-3.19* Hgb-9.4* Hct-27.1*
MCV-85 MCH-29.4 MCHC-34.6 RDW-14.7 Plt Ct-160
[**2134-3-29**] 06:00AM BLOOD Glucose-95 UreaN-42* Creat-1.5* Na-133
K-4.0 Cl-98 HCO3-26 AnGap-13
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
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.
There are focal calcifications in the aortic arch. The
descending thoracic aorta is mildly dilated. A mobile density is
seen in the aortic arch consistent with an intimal flap/aortic
dissection. A mobile density is seen in the descending aorta
consistent with an intimal flap/aortic dissection. 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. Physiologic
mitral regurgitation is seen (within normal limits). There is no
pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on
[**Known lastname 3311**],[**Known firstname 91429**] before surgical incision.
Impression: There is an arch dissection from the mid level
extending all the way down to the thoracic aorta visualized.
Post_bypass:
Preserved biventricular systolic function.
LVEF 55%.
All other valves similar to prebypass.
The residual tear is seen just distal to the left subclavian and
extending down to the entire thoracic aorta. The mid arch is
clear. The aortic graft looks fine. The aortic valve is intact
with no residual regurgitation.
Brief Hospital Course:
The patient was admitted to the hospital and brought emergently
to the Operating Room on [**2134-3-22**] where the patient underwent
emergent replacement of ascending aorta and subtotal arch
replacement under circulatory arrest. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU on Neo Synephrine and Propofol
infusions in stable condition for recovery and invasive
monitoring. Cefazolin was used for surgical antibiotic
prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on titrated nitroglycerin. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. His blood pressure was problem[**Name (NI) 115**] and
required multiple agents to achieve adequate control. He did
experience alcohol withdrawal and developed delerium tremens in
the CVICU. He became combative and confused and pulled out his
own cordis. He was placed on the CIWA scale. Agitation was
controlled with Ativan and Haldol. Withdrawal symptoms improved
on the CIWA scale. He also developed rapid atrial fibrillation
which was treated with Amiodarone. He did convert to sinus
rhythm.
Post-operatively, the patient remained hypertensive, requiring
several agents for adequate blood pressure control. 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 he was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. Antihypertensives
were titrated down as his blood pressure was a bit low. The
patient was discharged in good condition with appropriate
follow up instructions.
Arrangements were made for a repeat CT of the aorta before his
one month follow up visit.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*6 Disk with Device(s)* Refills:*2*
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*4 Patch Weekly(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 weeks: take 2 tablet twice daily for two weeks,
then one tablet twice daily for two weeks, then stop medicine.
Disp:*112 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for PAIN for 4 weeks.
Disp:*60 Tablet(s)* Refills:*0*
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane Q4H (every 4 hours) as needed for SORE THROAT.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for TEMP/PAIN.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 weeks.
Disp:*30 Tablet(s)* Refills:*0*
10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
12. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Type A aortic dissection
hypertension
alcohol abuse
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram prn
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram prn
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram 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**]
take all medications a prescribed
Followup Instructions:
Surgeon Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2134-4-19**] at 1pm
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 4283**] ([**Telephone/Fax (1) 100250**]) in [**1-16**] weeks
Cardiologist Dr. [**Last Name (STitle) **] [**1-16**] weeks
Dr.[**Name (NI) 11272**] office will call with date for repeat CT of the
aorta
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2134-3-30**]
|
[
"799.02",
"511.9",
"443.22",
"V10.46",
"443.29",
"427.31",
"441.01",
"276.3",
"278.00",
"443.23",
"584.9",
"997.1",
"291.0",
"276.6",
"443.21",
"E878.2",
"285.9",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7046, 7109
|
3327, 5321
|
295, 426
|
7205, 7488
|
1369, 3304
|
8062, 8544
|
1017, 1035
|
5376, 7023
|
7130, 7184
|
5347, 5353
|
7512, 8039
|
1050, 1350
|
238, 257
|
454, 773
|
795, 876
|
892, 1001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64
| 172,056
|
253
|
Discharge summary
|
report
|
Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-18**]
Date of Birth: [**2116-6-27**] Sex: F
Service: ACOVE
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old
woman with a history of IV drug abuse, who initially
presented to an outside hospital on [**2143-3-2**] from a
drug and detoxification facility with a chief complaint of
headache, abdominal pain, and fever. At the outside
hospital, the patient was found to be febrile to 104.6
degrees F, and she subsequently developed hypotension with a
systolic blood pressure in the 80s.
During this initial evaluation, the patient was confused and
only intermittently answering questions. There was concern
for possible headache, neck stiffness, and photophobia, so
given the concern for meningitis, a spinal tap was done.
This study demonstrated 50 white blood cells (84%
neutrophils), 10 red blood cells, protein of 23, glucose of
86, and 0-5 yeast per high power field. Given these findings
and concern for meningitis, the patient received Vancomycin,
ceftriaxone, metronidazole, and gentamicin at the outside
hospital. Given the lack of Intensive Care Unit beds at the
outside hospital, the patient was therefore transferred to
the [**Hospital1 69**] for further
evaluation.
On arrival to the Emergency Department at the [**Hospital1 346**], the patient was found to have
icteric sclerae, a 2/6 systolic ejection murmur, abdominal
guarding, and right upper quadrant tenderness. Given the
concern for an abdominal process, the patient was given
levofloxacin and metronidazole; she was also given Ambisome
given the finding of yeast in her CSF at the outside
hospital.
In the Emergency Department, she had an abdominal ultrasound
that was negative for the presence of gallbladder or ductal
dilatation. Also at this time, the patient began to deny the
report that she was HIV positive; this report has been
obtained only by report and not by documented laboratory
testing from the outside hospital.
PAST MEDICAL HISTORY:
1. Intravenous drug abuse.
2. Cholelithiasis.
3. Cholecystectomy.
4. Spontaneous abortion x2.
5. Therapeutic abortion x1.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: The patient is a single mother of three
children ages 9, 8, and 2 years old. She is unemployed. She
last used heroin 3-4 days prior to admission; she began using
heroin one year prior to admission. The patient smokes a
third of a pack of cigarettes a day and denies any history of
alcohol abuse. She denies any history of providing sexual
favors for drugs or money. She says her only lifetime
partner is her husband.
INITIAL PHYSICAL EXAMINATION: Temperature 97.6, heart rate
95, blood pressure 113/71, respiratory rate 20, and oxygen
saturation 100% on room air. During this initial evaluation,
the patient was not reliable as a historian. She appeared to
be a well dressed well-nourished female in moderate distress
from "not feeling well", lying in bed, and subsequently
having emesis x1. HEENT exam: Extraocular movements are
intact. There was mild scleral icterus. Mild conjunctival
edema. Pupils are equal, round, and reactive to light.
There were small conjunctival hemorrhages on the right
greater than on the left. Her face was symmetric. Her neck
was stiff with pain with flexion half-way down towards the
chest. The right IJ central venous catheter was in place. A
small posterior cervical lymph node is palpable. Her
oropharyngeal examination was remarkable for upper dentures
with eroded mucosa and white plaques consistent with thrush
underneath. Her tongue was coated with a whitish film, and
she had a few petechiae on her upper palate. Her heart was
regular, rate, and rhythm, and there was a [**3-28**] holosystolic
murmur throughout the precordium that radiated to the axilla.
Her lungs were clear to auscultation bilaterally. Her
abdomen was soft, there were normoactive bowel sounds, she
had bilateral upper quadrant guarding, and mild abdominal
distention. The patient notes that her abdominal discomfort
has been present for the past five months. She had bilateral
upper extremity tract marks in her right forearm and in her
bilateral antecubital fossa that were clean. Scattered dark
macules were seen on her palms bilaterally. She had mild,
but not true CMT on pelvic examination. She was moving all
extremities freely and equally and had full strength on
neurologic examination.
Her laboratories from the outside hospital included the
following: Urinalysis was essentially negative. One out of
two blood culture bottles were growing gram-positive cocci in
clusters initially. Her CSF demonstrated 0-4 neutrophils and
0-5 yeasts per high power field, 10 red blood cells, 50 white
cells (80% neutrophils, 3% lymphocytes, 13% monocytes), 23
protein, and 86 glucose. Her complete blood count showed a
white count of 13.3, hematocrit 35.5, and platelets 110,000.
Differential for white count demonstrated 77 neutrophils, 14%
bands, 2% lymphocytes, and 6% monocytes. Her INR was 1.28
and her PTT was 49. Serum chemistries demonstrated a sodium
of 133, bicarbonate 21, BUN 34, creatinine 2.0. Of note, her
creatinine was 0.5 in [**2143-1-23**]. Her total bilirubin
is 3, direct bilirubin 2.3, ALT 967, AST 396, GGT 125,
alkaline phosphatase 156; her LFTs had been normal at
baseline one month prior.
Her electrocardiogram at the outside hospital demonstrated
sinus tachycardia at 112 beats per minute, normal axis, and
normal intervals.
Her head CT scan from the outside hospital demonstrated
motion artifact and normal volumes to the ventricles. An
abdominal ultrasound demonstrated increased echotexture to
the bilateral kidneys, and no evidence of hydronephrosis.
At the [**Hospital1 69**], her laboratories
demonstrated sodium 140, potassium 3.8, chloride 113,
bicarbonate 16, BUN 26, creatinine 1.5, and glucose of 204.
Her calcium was 5.8, magnesium 1.2, and phosphate 3. Her
white count was 12.2, hematocrit 29.7, and platelets of
60,000. Differential of her white count demonstrated 68%
neutrophils, 19% bands, 9% lymphocytes, and 4% monocytes.
Her fibrinogen was 477, FDP 10-40, and D dimer was pending.
Her ALT was 529, AST 150, alkaline phosphatase 97, amylase
46, lipase 23, and albumin 2.3. Her urinalysis had greater
than 50 red blood cells, [**7-2**] white blood cells, and
leukocyte esterase and nitrate were negative. Her PTT was
36.7 and her INR of 1.6.
Her abdominal ultrasound demonstrated minimal new
intrahepatic ductal dilatation and small pneumobilia. A HIV
test was done on admission to the [**Hospital1 190**] and was pending.
HOSPITAL COURSE BY SYSTEMS:
1. Infectious Diseases: While the patient was reported to be
HIV positive upon her arrival to the Emergency Department at
the [**Hospital1 69**], her HIV test
subsequently returned negative. She also informed her
caretakers that she had multiple HIV tests in the past, all
of which had been negative.
The report of "yeast" found in her CSF at the OSH was also
found to be false-positive. No yeast or fungal organisms
grew out the culture of her CSF, and a CSF Gram stain was
repeated twice at the outside hospital and found to be
negative both times. The patient received several doses of
Ambisome at the [**Hospital1 69**], but
once it had been confirmed that the finding of yeast was a
false-positive, her Ambisome was discontinued.
By hospital day three, the gram-positive cocci in clusters
that ultimately grew out from [**2-26**] blood culture bottles at
the outside hospital had been speciated as
methicillin-sensitive Staphylococcus aureus (MSSA). Once
this definitive speciation was made, the patient's antibiotic
regimen was tailored to include oxacillin and gentamicin; the
gentamicin was used for only four days in order to aid in the
clearance of her bacteremia. Given the finding of this
bacteremia and her alarming concert of symptoms on admission,
a transthoracic echocardiogram was performed on hospital day
two.
This study demonstrated a thickened posterior mitral leaflet
with a question of prolapse and at least mild-to-moderate
mitral regurgitation consistent with possible endocarditis.
Biventricular systolic function was preserved. Pulmonary
artery systolic hypertension was seen. Given these findings,
a transesophageal echocardiogram was performed on hospital
day three. This study demonstrated a moderate sized mitral
valve vegetation consistent with a diagnosis of bacterial
endocarditis.
Given this finding, it was felt that all of the patient's
initial signs and symptoms were consistent with bacterial
endocarditis. Given that the finding of yeast in the CSF was
found to be a false-positive, and given that all subsequent
Gram stain and culture data from the CSF remained negative,
the patient was not felt to have had bacterial meningitis at
any point (of note, two colonies of gram-positive cocci in
clusters were isolated from the patient's CSF culture;
however, these colonies were subsequently speciated as
coag-negative Staph, and were therefore thought to be a
contaminate.
Given the patient's LFTs abnormalities on admission, an
abdominal CT scan was done on hospital day two. This study
demonstrated a focal area of low attenuation in the contrast
enhanced right kidney, that was ultimately attributed to a
septic embolus to the right kidney. Also seen were large
bilateral pleural effusions with compressive atelectasis,
ascites, and free abdominal fluid, and a large amount of
pelvic fluid. These fluid collections were all thought to be
secondary to a systemic inflammatory response syndrome
secondary to the patient's underlying bacterial endocarditis.
In order to rule out the possibility of an epidural abscess,
a spinal MRI was done on hospital day four. This study
demonstrated no evidence of epidural abscess. Also of note,
a MRI of the head had been done on hospital day two in order
to further evaluate for the possibility of meningeal
inflammation. This study did not demonstrate any definite
evidence of a focal lesion in the third ventricle or a focal
mass within the brain.
Following the initiation of the appropriate antibiotic
therapy as noted above, the patient slowly began to improve
clinically. She initially continued to spike high fevers,
but she gradually defervesced. Her white count also
initially remained elevated, but this too gradually began to
trend down while on appropriate antibiotics. She did develop
reactive arthridities in both her left ankle and her left
hand. The Department of Rheumatology was consulted given
these reactive arthridities and recommended supportive care
to the area.
The patient's LFTs abnormalities present on admission
gradually normalized. Of note, however, the patient did
develop mild elevations in her alkaline phosphatase, amylase,
and lipase following the initiation of oxacillin therapy. It
was thought that these elevations may have been secondary to
oxacillin, but the elevations did not persist and had begun
to trend towards normal at the time of discharge. Given
these normalizations, and given that the patient's hematocrit
had been remaining stable (thus indicating that there was no
significant myelosuppression as a result of oxacillin
therapy), the patient was discharged with a plan for six
weeks of continued oxacillin therapy.
In order to rule out the possibility of mycotic aneurysm in
the brain, a MRI of the head was obtained on hospital day
seven. This study demonstrated no evidence of acute infarct
from septic emboli, and a subtle increased signal in the
right temporal region that could be within the sulcus. A
similar, but less apparent abnormality was also seen along
the sulcus of the left occipital region. These abnormalities
were nonspecific in nature, but were thought to possibly have
been due to a high protein content of the CSF. Given the
patient's overall clinical stability, however, the decision
was made to clinically follow the patient as an outpatient
following her discharge from the hospital.
Also of note, the patient had a cervical chlamydia probe
return positive during this hospitalization. She received
azithromycin 1,000 mg once during her hospitalization for
treatment of this chlamydia.
2. Cardiovascular: Given that the patient had significant
endocarditis, a Cardiology consult was obtained early in the
patient's hospitalization for evaluation of whether or not
the patient was a surgical candidate for her endocarditis.
Given that the patient did not have clinically significant
congestive heart failure or valvular dysfunction with
persistent infection after 7-10 days of appropriate
antibiotics, the patient was deemed not to be a surgical
candidate. She subsequently developed no significant
congestive heart failure, and she had no further embolic
phenomena following the septic embolus sheath to her right
kidney.
Given her bilateral pleural effusions and mitral
regurgitation, the patient was transiently on furosemide
during this hospitalization, but had no signs or symptoms of
congestive heart failure at the time of her discharge from
the hospital.
3. Rheumatology: As noted above, the patient initially
developed a left ankle reactive arthritis on hospital day
six. Given the asymmetric edema in her left ankle, a
Rheumatology consult was obtained. The Rheumatology service
agreed that the swelling in her left ankle was reactive
arthritis. The patient subsequently developed left hand
swelling later in her hospitalization, at which point the
Rheumatology service was reconsulted. They again felt that
the swelling in the patient's left hand was due to a reactive
arthritis that would be best managed with supportive care.
She was started on a 14 day course of naproxen for treatment
of the inflammation and swelling in her hand.
By the time of discharge, the patient's swelling in both her
left hand and her left ankle had improved dramatically, and
were nearly at their baseline.
4. Hematology: Soonafter admission, the patient manifested a
significant anemia with a hematocrit in the low 20s. The
etiology of this anemia was ultimately thought to be
multifactorial due to a combination of anemia of chronic
disease, recurrent phlebotomy, menstruation, and oxacillin
induced myelosuppression. There was no evidence of hemolysis
either by laboratory evaluation or by direct evaluation of
the peripheral smear. Given that the patient's hematocrit
was low, she was started on iron supplementation during this
hospitalization.
At the time of discharge, however, the patient's hematocrit
had been consistently stable for over one week, and the
decision was made to continue her on oxacillin for the time
being with twice weekly hematocrits following her discharge
from the hospital.
5. Psychiatry: By hospital day eight, the patient began
threatening to leave the hospital against medical advice due
to inadequate pain control. Given the concern for the
patient possibly leaving the hospital against medical advice
without plans for continued intravenous antibiotics, a
Psychiatry consult was requested. The Psychiatry service
felt that the patient had poor coping mechanisms given the
severity of her illness, and recommended initiation of an
atypical antipsychotic. In addition, they recommended
analgesia as necessary, including with narcotic medications
if necessary, in order to adequately control the patient's
pain. The patient was subsequently started on an atypical
antipsychotic, and her narcotic medication dosing regimen was
increased, with excellent therapeutic affect.
DISCHARGE CONDITION: Good.
DISCHARGE PLACEMENT: [**Hospital **] Hospital.
DISCHARGE DIAGNOSES:
1. Methicillin-sensitive Staphylococcus aureus endocarditis
complicated by right renal septic embolus.
2. Chlamydia.
3. Systemic inflammatory response syndrome.
4. Multifactorial anemia.
5. Reactive arthritis.
6. Intravenous drug abuse.
DISCHARGE MEDICATIONS:
1. Oxacillin 2 grams IV q4h through [**2143-4-15**].
2. Naproxen 500 mg po bid through [**2143-3-29**].
3. Pantoprazole 40 mg po q day.
4. Ferrous sulfate 325 mg po q day.
5. Quetiapine 25 mg po tid.
6. Hydromorphone 1 mg IV q4h prn pain.
FOLLOWUP:
1. The patient should have her hematocrit, alkaline
phosphatase, amylase, and lipase all checked twice a week
while at [**Hospital1 **]. The results of these blood tests should
be faxed to Dr. [**Last Name (STitle) 2504**] at fax #[**Telephone/Fax (1) 1419**] in the
Department of Infectious Diseases at [**Hospital1 190**].
2. The patient should arrange for a follow-up appointment
with Dr. [**Last Name (STitle) 2504**] by calling [**Telephone/Fax (1) 457**]. She should
arrange for this appointment during the week after she leaves
[**Hospital1 **].
3. The patient should call [**Telephone/Fax (1) 250**] to arrange for a
follow-up appointment with Dr. [**First Name (STitle) 2505**] during the week
following her release from [**Hospital1 **].
4. Note that the patient should receive the hepatitis A and
hepatitis B virus vaccines as an outpatient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2143-3-18**] 04:37
T: [**2143-3-18**] 07:17
JOB#: [**Job Number 2508**]
|
[
"511.1",
"304.00",
"112.0",
"421.0",
"995.91",
"711.04",
"038.11",
"711.07",
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] |
icd9cm
|
[
[
[]
]
] |
[
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"88.72"
] |
icd9pcs
|
[
[
[]
]
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15633, 15689
|
15710, 15948
|
15971, 17335
|
2228, 2235
|
6699, 15611
|
2706, 6671
|
155, 163
|
192, 2018
|
2040, 2201
|
2252, 2683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,888
| 150,295
|
3406
|
Discharge summary
|
report
|
Admission Date: [**2154-8-8**] Discharge Date: [**2154-8-14**]
Date of Birth: [**2106-8-11**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / Epinephrine / Percocet / Codeine / Latex
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Left hip avascular necrosis
Major Surgical or Invasive Procedure:
[**2154-8-8**] Left total hip arthroplasty
History of Present Illness:
Pt is a pleasant 48 yo F who has suffered from progressive
bilateral hip pain over the past 3 years. The pain in the left
hip is worse than that in the right hip. The etiology of the
AVN is unclear, however the pt is now having [**8-27**] pain with
activity. She would like to proceed with a left total hip
replacement at this time.
Past Medical History:
[**Doctor Last Name 15769**] cardiac valve anomaly (congenital)
Junctional rhythm with reentry
Right heart dilatation with h/o syncopal events and palpitations
Thalassemia minor
Hypothyroidism
Hypertension
Depression
Low back pain
Polycystic ovaries
Glaucoma
Hypertriglyceridemia
Social History:
Pt smokes [**11-19**] ppd. Rarely consumes alcohol
Family History:
Non-contributory
Physical Exam:
Gen: Alert and oriented, No acute distress
Neck: R anterior 0.5x 1.5 mass secondary to central line
placement, slightly tender to palpation, no
ecchymosis/swelling/drainage
Lungs: CTA bilaterally
Abd: benign
Extremities: left lower
Incision: no swelling/erythema/drainage
Dressing: clean/dry/intact, steri strips intact
+[**Last Name (un) 938**]/FHL/AT
+SILT
2+ pedal edema, moves toes
NVI bilaterally
Left hip - full extension, flexion to 70 degrees, 10 degrees
IR/ER, 20 degrees abduction
Right hip - flexion to 100 degrees, 30 degrees abduction
Pertinent Results:
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] K. on TUE [**2154-8-13**]
11:15 AM
Name: [**Known lastname 15770**], [**Known firstname 15771**] Unit No: [**Numeric Identifier 15772**]
Service: ORT Date: [**2154-8-8**]
Date of Birth: [**2106-8-11**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 15773**]
ASSISTANT: [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **], PA-C
PREOPERATIVE DIAGNOSIS: Avascular necrosis, left hip.
POSTOPERATIVE DIAGNOSIS: Avascular necrosis, left hip.
PROCEDURE PERFORMED: Primary left total hip arthroplasty.
ANESTHESIA: Epidural plus local.
COMPLICATIONS: None.
INDICATIONS: This is a 47-year-old woman with multiple
medical co-morbidities and the diagnosis of idiopathic
avascular necrosis. Preoperatively, we had discussed the
possibilities of unipolar versus total hip. Given her
morbidities, it was determined that irregardless of the
amount of remaining acetabular cartilage we would move ahead
with a total hip replacement since the future is hard to
predict in terms of her overall medical health and we wanted
to get as pain free a situation established for her as
possible.
COMPONENTS IMPLANTED: [**Doctor Last Name 3389**] Osteonics Trident PSL
acetabular shell size 50E secured by 2 vertical cancellous
bone screws, Trident X3 crosslink 10-degree hooded
polyethylene insert 36-mm E series, Accolade TMZF hip stem
size 2.5 Press-Fit x 132-degree neck shaft angle with a V40
femoral head low-friction size 36 mm x +5.
PROCEDURE IN DETAIL: The patient was brought to the
operating room and given an epidural and 2 grams of Ancef,
and Foley catheterized. Prior to the procedure, we put her
out supine on the bed and discussed our findings with her
that the left side, that is the operative side, was short by
approximately 1.5 cm. She apparently was unaware of this. She
also has a positive Galeazzi on the left. With these
considerations in mind, we had greater opportunity to
lengthen her to equalize her leg lengths. It also be noted
that she had a markedly high neck shaft angle. Therefore, we
chose the 132 series.
After the patient was adequately given an epidural, she was
put over in the lateral decubitus position, padded, the hip
immobilizers placed and sterilely prepped and draped. A
posterior lateral approach. The patient has a fair amount of
obesity. Therefore, the incision had to be lengthened
accordingly. We came down to the deep fascia which was split.
We then used electrocautery to take down the short external
rotators along with the capsule and piriformis which were
anatomically replaced through bone at the end of the case.
The femoral head was amputated with the oscillating saw 1 cm
proximal to the lesser trochanter. Bone quality was good. She
did still have a fair amount of residual cartilage in the
acetabulum, but we elected to go ahead with complete THR for
the above-mentioned reasons. On the acetabulum, she measured
out to 45 mm on her native head. We initialized medial
reaming at 46 mm and went up sequentially to size 50 at which
time we had a good bleeding base. The above-mentioned
components were impacted in at 45 degrees of abduction and 20
degrees of matched native anteversion with a good rim fit
secured by 2 cancellous screws. The liner was placed with the
[**Doctor Last Name **] at the 03:00 p.m. position for maximal stability
posteriorly. On the femoral side, standard reaming and
broaching with an osteotome was performed. We put a cerclage
wire in prophylactically at the level of the lesser
trochanter. We never did see any crack. Final seating of the
broach performed. A 2.5 fit her very well with certainly no
opportunity to go higher than that given her anatomy. We then
press fit in the above-mentioned stem. We found that a +5
more equalized her leg lengths and provided excellent
stability. She was quite stable even with the zero. She had
no tendency to come out in anterior testing. Posteriorly, she
could be brought out at about 75 or 80 degrees of internal
rotation at 110 degrees of flexion and 20 degrees of
adduction. We closed over a Hemovac drain, a 2 level, with 0
Vicryl closure in multiple levels and skin staples. The
patient tolerated the procedure well. There were no
complications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 20AA
Brief Hospital Course:
On [**2154-8-8**] patient was brought to the operating room and
underwent left total hip replacement. The case was uneventful.
Please see Dr. [**Last Name (STitle) **] operative note for details.
Post-operatively, the patient was treated with 24 hours of
antibiotic for prophylaxis of infection. Lovenox was given for
DVT prophylaxis and TEDS and pneumoboots were used. The patient
was made 50% PWB on the operative extremity with posterior hip
precautions and physical therapy assisted with mobilization.
Home medications were restarted.
On POD 1 she was oliguric and developed hypotension, nausea and
vomiting. She was evaluated by the medical service who felt she
would benefit from transfer to the ICU for closer monitoring.
She was placed on pressors to help increase blood pressure and
perfusion to her kidneys. A central line was placed.
On POD 2 she had some bladder spasm and her foley remained.
Cipro was started for UTI prophylaxis.
On POD 3 her hematocrit dropped from 26.6 to 23.8. She was
transfused 1 unit of PRBC. Her creatinine improved to 1.1 from
1.8 pre-admission. She was transferred back to the floor.
POD [**2-20**] she worked with physical and occupational therapy. She
had an episode of chest pain on exertion, which resolved within
a minute. And EKG showed no change compared to her previous
studies. She stated that this is an [**Last Name 15774**] problem.
Prior to discharge the patient was afebrile with stable vital
signs. Her hematocrit was stable and her pain was adequately
controlled on a PO regimen. The operative extremity is
neurovascularly intact and the wound was benign. Patient was
discharged home POD 6 with physical and occupational therapy
services in stable condition.
Medications on Admission:
Levoxyl 100 mcg daily
Verapamil 240 mg daily
Hydrochlorothiazide 25 mg daily
Celexa 60 mg daily
Timoptic twice daily each eye
Prilosec 40 mg b.i.d.
Potassium chloride 40 mEq daily.
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 3 weeks.
Disp:*42 syringe* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Take while on Lovenox injections.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Commode
Commode for home
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left hip avascular necrosis
Postoperative anemia
Discharge Condition:
Stable
Discharge Instructions:
Wound: Keep wound clean and dry. Cover with dry sterile
dressing until dry x 72 hours and then open to air. You may
shower, but keep all water off of wound until 1 week post-op.
Medications: take all medications as prescribed.
Call Dr. [**Last Name (STitle) **] for fevers >101, chills, sweats, redness or
discharge around your wound or any other changes that are
concerning to you.
Physical Therapy:
50% partial weight bearing
Posterior hip precautions
Treatments Frequency:
Wound: Keep wound clean and dry. Cover with dry sterile
dressing until dry x 72 hours and then open to air. You may
shower, but keep all water off of wound until 1 week post-op.
Medications: take all medications as prescribed.
Call Dr. [**Last Name (STitle) **] for fevers >101, chills, sweats, redness or
discharge around your wound or any other changes that are
concerning to you.
Followup Instructions:
BROWN,[**Doctor First Name **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-8-23**] 1:30
Completed by:[**2154-8-14**]
|
[
"733.42",
"285.9",
"786.50",
"401.9",
"458.29",
"584.9",
"365.9",
"244.9",
"746.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
9088, 9137
|
6300, 8035
|
340, 385
|
9230, 9239
|
1740, 6277
|
10152, 10280
|
1138, 1156
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8266, 9065
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9158, 9209
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8061, 8243
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1171, 1721
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9667, 9720
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9742, 10129
|
273, 302
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413, 750
|
772, 1054
|
1070, 1122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,346
| 148,059
|
8612
|
Discharge summary
|
report
|
Admission Date: [**2166-4-25**] Discharge Date: [**2166-4-27**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex
Attending:[**First Name3 (LF) 30198**]
Chief Complaint:
Syncope x 3 in 2 days prior to admission
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo M h/o ESRD on HD on tx list, s/p L partial nephrectomy for
RCC in [**2164**], diastolic CHF, HTN with recent addition of
Carvedilol, Hep C, DM2, Gout, past pericardial tamponade of
viral etiology who presents after 3 episodes of syncope over the
past 2 days.
.
The pt has HD on T,Th,Sat. His dry wt is thought to be 86kg. On
Tues he went for HD and had a full run. He returned on Wed for
more HD as he was felt to be fluid overloaded. At the end of the
extra run of HD he stood to leave, felt LH, tunnel vision, sat
down, and lost consciousness. Some of his fluid was returned.
The pt then returned for Thursday HD and was run even (wt 86.3
prior and 86.1 post). He went home and that night he stood from
bed at ~1am and had a syncopal episode. This happened again
later in the evening. He is unsure if he hit his head, but he
did fall from a stand. He notes increasing DOE (always present,
but now present when climbing 4 stairs), L jaw pain and chest
tightness reminiscent of his pericardial effusion.
.
In the ED he was noted to have a BP of 70's systolic, no
significant pulsus. He was seen by renal and received 3.5L NS, a
full aspirin, had CE's with a trop 0.02 and CK 269. Bedside US
revealed no signif pericardial effusion.
.
In addition, the pt notes that he has had increasing DOE, 3
pillow orthopnea, no PND, no [**Location (un) **], no fever, but + NS and chills.
Prior to the last week he had been eating more than normal.
Since passing out on Wednesday, he has been eating very little,
has vomitted x 2. He has chronic diarrhea up to 6x per day at
baseline and this has not changed. He has been very thirsty over
the past three days. He usually makes small amounts of urine,
but has made none since wednesday.
.
Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
(HD T,Th, Sat)
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
2. CHF (stage II) - diastolic - followed by Dr. [**First Name (STitle) 437**]. Recently
started on carvedilol (end of [**Month (only) 547**])
3. Hypertension
4. DM2, HbA1C 9
5. Hepatitis C
6. HOH
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 [**2165**]
11. Viral Pericardial effusion - [**1-20**]. [**Month (only) 958**] seen by echo to
have resolved. Not thought to be uremic effusion.
Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago
Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He
is unsure of any other medical problems in his family.
Physical Exam:
VS: T 98 BP 124/70 HR 80 RR 14 O2sat 100% RA
BG 99
GEN: NAD, conversant, oriented
HEENT: Anicteric sclera, OP clear, MM mod dry with dry/cracked
lips
NECK: supple, no LAD, no JVD
CARD: RRR, normal S1, S2. 2/6 systolic murmur at L USB
LUNG: Good air movement, clear lung fields laterally and
posterior
ABD: Protuberant, soft, ND, no tenderness. No HSM
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally. No edema
Pertinent Results:
ADMISSION LABS:
[**2166-4-25**] 08:05AM BLOOD WBC-10.4 RBC-5.43# Hgb-15.0# Hct-46.5#
MCV-86 MCH-27.6 MCHC-32.2 RDW-18.6* Plt Ct-382
[**2166-4-25**] 08:05AM BLOOD Neuts-55.0 Lymphs-34.8 Monos-8.0 Eos-1.5
Baso-0.8
[**2166-4-25**] 08:05AM BLOOD Plt Ct-382
[**2166-4-25**] 08:15AM BLOOD PT-12.0 PTT-23.0 INR(PT)-1.0
[**2166-4-25**] 08:05AM BLOOD Glucose-170* UreaN-34* Creat-8.0*# Na-139
K-4.3 Cl-95* HCO3-23 AnGap-25*
[**2166-4-25**] 08:05AM BLOOD ALT-35 AST-45* CK(CPK)-269* AlkPhos-132*
Amylase-130* TotBili-0.5
[**2166-4-25**] 08:05AM BLOOD Lipase-108*
[**2166-4-25**] 08:05AM BLOOD CK-MB-1 cTropnT-0.02*
[**2166-4-25**] 07:53PM BLOOD CK-MB-1 cTropnT-0.02*
[**2166-4-25**] 07:53PM BLOOD CK(CPK)-201*
[**2166-4-25**] 08:05AM BLOOD Calcium-10.0 Phos-1.7* Mg-1.5*
[**2166-4-25**] 06:38PM BLOOD Type-ART pO2-65* pCO2-40 pH-7.42
calHCO3-27 Base XS-0
[**2166-4-25**] 08:17AM BLOOD Lactate-3.0* K-4.4
[**2166-4-25**] 06:38PM BLOOD Lactate-1.4 Na-143 K-4.3 Cl-101
.
IMAGING: CXR - clear
Brief Hospital Course:
# Hypotension: Pt had aggressive dialysis the week prior to
admission. He had an extra run and then felt lightheaded on
standing, and lost consciousness. He was thought to have a dry
wt of 86kg, however he has been eating more than normal over
recent wks, and believes he has been putting on weight. Dry
weight likely 88-89kg. After transfer to the floor, Mr.
[**Known lastname 30199**] BP remained stable overnight. He was restarted on
carvedilol 6.25mg PO bid without complication. He was slightly
orthostatic in the morning, and was given 1L NS over two hours.
He ambulated without difficulty or symptoms of dizziness. His AM
sodium came back as 126, but was thought to be dilutional, and
recheck was 138. He was d/c'ed on his home BP regimen with
instructions to continue hemodialysis as before. The
hemodialysis service will inform Mr. [**Known lastname 30199**] outside
nephrologist that his clothed dry weight should now be
considered 88-89kg.
.
# CHF: Followed by Dr. [**First Name (STitle) 437**]. At baseline has DOE on flat ground
and with stairs. EF intact, not volume overloaded in-house on
exam or radiographically. As above, d/c'ed on [**Last Name (un) **] and
carvedilol.
.
# HTN: At home on norvasc 5, carvedilol 6.25 [**Hospital1 **], valsartan 320,
dilt 180. As above, restarted these meds while in-house, and
d/c'ed on home regimen.
.
#.Anemia:
Likely related to ESRD, has required transfusions in the past.
On Aranesp as an outpatient. Held in-house per renal.
.
#.Nausea and Diarrhea: Chronic issue. C. diff and stool cultures
sent in [**Hospital Unit Name 153**], pending at time of discharge.
.
#.Depression: Continued home dose of Zoloft.
.
#. Diabetes: Lantus 10U qHS and SSI at home. This was continued
while in-house.
.
#.Gout: Continued allopurinol 100mg QOD.
.
#.[**Doctor Last Name 15532**]??????s Esophagus: Continued PPI 40mg [**Hospital1 **]
.
#.Hepatitis C: Last viral load [**2166-1-30**]: 5,780,000 IU/mL. No
active cirrhosis, was not addressed during this admission.
.
#.Prophylaxis: Maintained with subcutaneous heparin, PPI
Medications on Admission:
1. Allopurinol 100 mg qod
2. Prilosec 40mg [**Hospital1 **]
3. Calcium Carbonate 500 mg tid
4. Diltiazem HCl 180 mg daily (Ext Release)
5. Valsartan 320 mg daily
6. Amlodipine 5 mg daily
7. Sertraline 50mg daily
8. Insulin Glargine 10 daily plus SSI
9. Carvedilol 6.25 [**Hospital1 **]
Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
4. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO once a day.
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. DILT-XR 180 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
8. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Insulin
Lantus 10U SC qHS
10. Sliding Scale Insulin
Per home regimen
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
12. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Good
Discharge Instructions:
You were admitted after fainting, and were found to have had too
much fluid taken off during dialysis. You should take all of
your medicines as directed. You should call your physician or go
to the ED if you experience more lightheadedness or fainting,
fever, chills, or for any other problems that concern you. You
should continue to go to your dialysis sessions before, and
should tell your dialysis doctor that your dry weight should now
be considered 88-89kg while clothed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2166-5-14**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2166-5-19**] 3:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2166-7-25**] 9:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30200**] MD, MSC 12-AIE
|
[
"458.21",
"274.9",
"403.91",
"285.21",
"V49.83",
"250.00",
"428.32",
"276.2",
"428.0",
"V10.52",
"585.6",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8211, 8217
|
4881, 6949
|
322, 328
|
8269, 8276
|
3878, 3878
|
8802, 9373
|
3211, 3400
|
7285, 8188
|
8238, 8248
|
6975, 7262
|
8300, 8779
|
3415, 3859
|
242, 284
|
356, 2090
|
3894, 4858
|
2112, 2812
|
2828, 3195
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,490
| 104,573
|
48299
|
Discharge summary
|
report
|
Admission Date: [**2184-12-27**] Discharge Date: [**2185-1-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: [**Age over 90 **] y/o lady with CAD multiple PCI, chronic diastolic heart
failure, hypertension, hypothyroidism, chronic renal failure
presents after a syncopal episode and melena. Patient is a poor
historian with memory trouble per family. Most of the history
was obtained from grand daughter and daughter over the phone.
Patient daughter visited her this morning and found her to be in
usual health. Her grand daughter went during the evening and
patient was in bath room. She took her to the bedroom and
patient felt week. Patient slipped along her bed to the floor
but without trauma to the head or body. She had breif episodes
of loss of consciousness for 7-10secs and family decided to call
EMS. Patient was noted to be cold, clammy with stiffened
extremities during this episode. When they moved her, found to
have really dark stool. She also vomitted once, very dark
coloured vomit. Patient denied any chest pain or shortness of
breath.
In the ED vitals were: T 95.7 HR 71 BP 134/44 RR 19 100% in
RA. Patient received 80 mg IV pantoprozole. Patient was found
to have left retrocardiac opacity and was given 1 gm of IV
ceftriaxone and levofloxacin 750 mg IV.
On arrival to MICU her vitals were T 97.2 HR 73 BP 111/80 RR
18 100% in RA. Patient is asymptomatic. Patient and family
denied any recent fever, chills, nightsweats, cough, cold,
abdominal pain, diarrhea, constipation, dysuria, hematuria,
focal numbness or weakness.
Past Medical History:
CAD s/p multiple PCIs, stenting and restenting of LCx
Chronic diastolic heart failure
HTN
Hyperlipidemia
CRI: creatinine 2.0 on [**5-3**] (while reportedly on ACEi)
Hypothyroidism
Social History:
hx: Lives alone; former seamstress; widowed; Has children that
live close by and assist her with foodshopping; otherwise she is
totally independent. Never smoker, no ETOH
Family History:
NC
Physical Exam:
Vital: T 97.2 HR 73 BP 111/80 RR 18 100% in RA. Patient is
asymptomatic.
Gen: Alert and oriented to person and place. NAD. Pleasant
lady following commands.
HEENT: EOM-I, MM dry, JVP not elevated
Heart: S1S2 II/VI holosystolic murmur heard throughout the
precordium but best at RUSB.
Lungs: crackles at left base.
Abdomen: BS present, soft NTND.
Ext: WWP, no edema
Neuro: Following commands. CNII-XII grossly intact. Strength
[**5-31**] bilaterally.
Pertinent Results:
[**2184-12-27**] 08:10PM BLOOD WBC-14.4*# RBC-3.39* Hgb-10.8* Hct-31.6*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.2 Plt Ct-401#
[**2184-12-28**] 12:56AM BLOOD WBC-13.4* RBC-3.13* Hgb-10.1* Hct-28.7*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.3 Plt Ct-366
[**2184-12-27**] 08:10PM BLOOD Neuts-89.5* Lymphs-6.2* Monos-3.4 Eos-0.7
Baso-0.3
[**2184-12-27**] 08:10PM BLOOD PT-14.7* PTT-23.3 INR(PT)-1.3*
[**2184-12-27**] 08:10PM BLOOD Plt Ct-401#
[**2184-12-27**] 08:10PM BLOOD Glucose-176* UreaN-161* Creat-4.5*#
Na-137 K-5.2* Cl-99 HCO3-22 AnGap-21*
[**2184-12-28**] 12:56AM BLOOD Glucose-170* UreaN-162* Creat-4.6* Na-137
K-5.1 Cl-101 HCO3-22 AnGap-19
[**2184-12-27**] 08:10PM BLOOD CK(CPK)-50
[**2184-12-28**] 12:56AM BLOOD CK(CPK)-48
[**2184-12-27**] 08:10PM BLOOD CK-MB-NotDone
[**2184-12-27**] 08:10PM BLOOD cTropnT-0.07*
[**2184-12-27**] 08:10PM BLOOD Calcium-8.8 Phos-5.6* Mg-2.7*
[**2184-12-28**] 12:56AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.5
[**2184-12-28**] 01:20AM URINE Hours-RANDOM UreaN-706 Creat-114 Na-10
[**2184-12-27**] 10:20PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2184-12-27**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
.
Radiographic studies:
[**12-27**] CXR:
IMPRESSION: Increased left retrocardiac opacity suspicious for
pneumonia or aspiration. Correlate clinically.
.
EKG [**2184-12-27**]: sinus rhythm. rate 60s. PVC. Borderline left axis
deviation. Mildly prominent q waves in I and aVL with biphasix
T wave in I and TWI in aVL. No sig change since [**2184-12-13**].
.
EGD ([**12-28**]): Schatzki's ring
Medium hiatal hernia
Ulcers in the stomach body and antrum
Erosions in the fundus
Ulcers in the first part of the duodenum and second part of the
duodenum
Otherwise normal EGD to second part of the duodenum
.
[**2184-12-31**] 07:30AM BLOOD WBC-11.7* RBC-3.59* Hgb-11.1* Hct-32.6*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.7 Plt Ct-320
[**2184-12-31**] 07:30AM BLOOD Glucose-102 UreaN-118* Creat-3.7* Na-144
K-4.3 Cl-113* HCO3-18* AnGap-17
[**2184-12-31**] 07:30AM BLOOD CK(CPK)-62
[**2184-12-28**] 12:19 pm SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2184-12-29**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2184-12-29**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**2184-12-31**] CXR
FINDINGS: In comparison with the study of [**12-27**], there is further
increase in
opacification at the left base with slight silhouetting of the
hemidiaphragm.
The appearance is suggestive of aspiration or pneumonia.
[**2185-1-2**] UA
SpecGr 1.013
pH 5.0
Urobil Neg
Bili Neg
Leuk Tr
Bld Neg
Nitr Neg
Prot Tr
Glu Neg
Ket Neg
RBC 1
WBC 7
Bact Few
Yeast None
Epi 1
Brief Hospital Course:
Assessment and Plan: [**Age over 90 **] yo F with CAD, chronic distolic heart
failure, hypertension, hypothyroidism, chronic renal failure
presents after a gastrointestinal bleeding, syncope and acute
renal failure.
.
1. GIB: Baseline HCT > 34. On admission 31 in the setting of
dehydration. Remained hemodynamically stable. Repeat hct of
26.2 prompted transfusion of 1U PRBCs. EGD on [**12-28**] showed
multiple gastric and duodenal ulcers, not actively bleeding. H
pylori was positive. Patient was started on [**Hospital1 **] PPI,
Clarithromycin, and Amoxicillin. HCT stable at 32 on discharge.
Aspirin and Plavix were held. GI recommended holding plavix for
total of 2 weeks, and Aspirin for 4-5 days. Restarted ASA on
discharge. Plavix to be resumed on [**1-11**]. Please monitor HCT.
Please continue PPI [**Hospital1 **] for total of 6 weeks (started [**12-28**]).
Patient was found to be H. pylori positive, and was started on
Amoxicillin and clarithromycin on [**2184-12-30**].
.
2. Left retrocardiac opacity: Crackles on exam and elevated
white count. T 96.6, has been low for several days, with HCO3 of
17. CXR [**12-31**] showed worsening infiltrate.
-continue amoxicillin and clarithromycin from H.pylori therapy
for pneumonia. Patient's GFR is 7.
.
3. Syncope: Thought to be secondary to GI bleed and dehydration.
EKG without any acute ischemic changes. Three sets of cardiac
enzymes negative.
.
4. Acute on chronic renal failure: Cr up to 4.5 but recent
baseline 1.7-2.2. However has been slowly trending up.
Nephrology was consulted. Thought to be prerenal. Seemed to be
improving on discharge, with creatinine down to 2.9 with IV
fluids. This will need continuous monitoring as an outpatient.
Continues to have good urine output. - send urine lytes
.
5. UTI: Developed urinary urgency and frequency, UA consistent
with UTI. Started on 7 day course of ciprofloxacin on [**1-3**].
6. CAD: Known CAD s/p multiple PCI. Inferior NSTEMI on
[**2184-12-11**]. Last PCI in [**2179**]. Held Asa and plavix in the
setting of GI bleed. Carvedilol was held briefly, and restarted
prior to discharge.
Medications on Admission:
Current Medications: Confirmed with family
Levothyroxine 75 mcg daily
Aspirin 325 mg daily
Nitroglycerin 0.3 mg prn
Atorvastatin 80 mg daily
Docusate Sodium 100 mg [**Hospital1 **] prn
Clopidogrel 75 mg daily
Carvedilol 12.5 mg [**Hospital1 **]
Furosemide 20 mg [**Hospital1 **]
Indomethacin 75 mg daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] in [**Last Name (un) **] [**Doctor Last Name **]
Discharge Diagnosis:
Primary diagnosis:
1. Gastric and duodenal ulcers
2. H. pylori infection
3. Syncope
4. Acute renal failure
5. Urinary tract infection
6. Aspiration pneumonia
Secondary diagnosis:
Coronary artery disease
Chronic diastolic heart failure
Hypertension
Hyperlipidemia
Chronic kidney disease
Hypothyroidism
Discharge Condition:
Stable. HCT 32.6.
Discharge Instructions:
You were admitted because you were passing blood in your stool.
You had an endoscopy performed that showed ulcers in your
stomach. You are on a medication and several antibiotics to
treat this. You received several blood transfusions because your
blood count was low. We have stopped your plavix and Aspirin
temporarily because they can increase GI bleeding. Your
indomethacin was stopped, as this can worsen ulcers. Your
Carvedilol was stopped while you were in the hospital. Next time
you see Dr. [**Last Name (STitle) **], you can discuss restarting it.
Your kidneys weren't functioning well during your
hospitalization. We are closely monitoring your kidney function,
and this will need to be monitored in clinic as an outpatient.
If you have lightheadedness, fevers, bright red blood in your
stools, black stools, or vomiting blood, please call your
primary doctor or go to the emergenc room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] Thursday [**1-6**]
at 3:15pm.
You will need to have some labs checked on Monday.
You have an appointment with Dr. [**Last Name (STitle) 80026**] on [**2-15**] at 1pm.
The clinic number is [**Telephone/Fax (1) 9557**].
Completed by:[**2185-1-3**]
|
[
"428.0",
"276.51",
"532.70",
"531.70",
"428.32",
"584.9",
"585.4",
"553.3",
"486",
"530.3",
"414.01",
"244.9",
"578.9",
"041.86",
"403.90",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8720, 8819
|
5437, 7559
|
284, 290
|
9164, 9184
|
2698, 5414
|
10131, 10440
|
2193, 2197
|
7914, 8697
|
8840, 8840
|
7585, 7585
|
9208, 10108
|
2212, 2679
|
222, 246
|
7607, 7891
|
318, 1784
|
9019, 9143
|
8859, 8998
|
1806, 1988
|
2004, 2177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,765
| 141,920
|
11592
|
Discharge summary
|
report
|
Admission Date: [**2151-10-29**] Discharge Date: [**2151-11-16**]
Date of Birth: [**2081-4-18**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Gemfibrozil
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
RUQ abdominal pain
Reason for MICU admission: respiratory failure
Major Surgical or Invasive Procedure:
fiberoptic intubation with anesthesia
PICC line placement
Arterial line placement
IJ central venous catheter placement
History of Present Illness:
This is a 70yo female, with DM, HTN, and asthma, who presented
to the ED with RUQ abdominal pain, and was admitted to the ICU
for respiratory failure. History was obtained from ED and
husband as patient now intubated. Per report, she developed
shortness of breath over three days and aches throughout her
body. Pain had some radiation to right shoulder and was
generally worse in RUQ. No cough or rhinorrhea. She also
endorsed subjective fevers and mild shortness of breath with
wheezing at home. No sick contacts. Presented to PCP today and
was noted to be dyspneic in waiting room, with O2 sats in the
low 80s on room air. She was given ASA 325 mg at clinic.
.
In the ED, initial CXR showed RLL pneumonia. Patient was given
ceftriaxone, levofloxacin, and 2L NS. Ipratropium and albuterol
nebs given. Refused flu swab but received 75 mg tamiflu.
Became more short of breath with desaturations and was then 90%
on NRB. The patient was a very difficult intubation - at least
5 unsuccessful attempts with glidescope; eventually required
stat fiberoptic intubation with anesthesia. Got succ x2 doses,
10 mg vecuronium, etomidate, ativan. On transfer, patient
satting 94% on FiO2 1 with PEEP 5.
.
On arrival to MICU, patient intubated and sedated with residual
effects of paralytics. Given solumedrol 125, mag, vanco 1 gram,
and albuterol.
Past Medical History:
- Diabetes Type II
- Hypertension
- Asthma: O2 sats at baseline low 90s on RA
- Hypertriglyceridemia
Social History:
From [**Country 3587**] in [**2142**]. Married, lives with husband of 50
years, independent in ADLs. 5 children. No EtOH, no smoking.
Family History:
Non-contributory
Physical Exam:
On presentation to the ED: 98.2, 128/60, 86, 20, 100% on 10L NRB
On arrival to the ICU: 96.7, 77, 106/48, 22, 86% on 100% FiO2
General: Intubated, sedated and paralyzed.
HEENT: PERRL, sclera anicteric, MMM, ETT and OGT in place.
Neck: obese, supple, difficult to appreciate JVD elevation.
Lungs: Bilateral wheezes with very poor air entry - improving
with albuterol.
CV: Minimal ability to hear heart sounds beneath lung sounds.
Abdomen: soft but very distended, tympanic throughout, bowel
sounds present. No rebound tenderness or guarding.
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: sedated and paralyzed.
Pertinent Results:
[**2151-10-29**] ADMISSION LABS:
WBC-12.1, Hct-30.0, Plt Ct-250
Neuts-77.4, Lymphs-15.0, Monos-6.2 Eos-1.0 Baso-0.4
PT-14.2, PTT-20.4, INR(PT)-1.2
Glucose-326, UreaN-30, Creat-1.8, Na-130, K-4.5, Cl-90, HCO3-25
ALT-19, AST-21, CK(CPK)-214, AlkPhos-96 TotBili-0.6
CK-MB-2 cTropnT-<0.01
Calcium-7.1, Phos-5.6, Mg-1.9
D-Dimer-1556
Acetone-NEG, Acetmnp-10.3
Lactate-2.3*
[**2151-10-29**] ADMISSION ABG, on NRB Mask:
Type-ART pO2-46* pCO2-47* pH-7.39 calTCO2-30 Base XS-2
Intubat-NOT INTUBA Comment-NON-REBREA
[**2151-11-16**] DISCHARGE LABS:
WBC-5.9, Hct-30.3, Plt Ct-280
Neuts-90.6, Lymphs-5.5, Monos-3.5 Eos-0.3 Baso-0.2
Glucose-64, UreaN-58, Creat-1.6, Na-150, K-4.1, Cl-108, HCO3-30
ALT-59, AST-57, LD(LDH)-363, AlkPhos-74, TotBili-0.7
Calcium-9.8 Phos-4.2 Mg-2.5
IMAGING:
[**2151-10-29**] ADMISSION CXR:
1. Right lower lobe and right middle lobe consolidation,
atelectasis, and
likely right pleural effusion.
2. Streaky left basilar retrocardiac opacity may reflect
atelectasis and/or consolidation.
[**2151-11-1**] TTE:
The left atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses and
cavity size are normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are simple atheroma in the aortic root. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH with hyperdynamic left
ventricular systolic function. Mildly dilated/hypokinetic right
ventricle. Mild mitral regurgitation. Moderate pulmonary artery
systolic hypertension. No evidence of PFO/ASD with agitated
saline.
Compared with the report of the prior study (images unavailable
for review) of [**2143-10-11**], LV function appears hyperdynamic and
the right ventricle appears mildly dilated/hypokinetic.
Pulmonary artery systolic pressures could not be determined on
the prior study.
[**2151-11-4**] CT SINUS:
The patient is intubated. There is mild mucosal thickening of
the
left maxillary sinus. The right maxillary sinus demonstrates a
fluid level. There is opacification of many of the right-sided
ethmoid air cells. Aerosolized secretions are noted in
left-sided ethmoid air cells. There is mild mucosal thickening
of the ethmoid air cells bilaterally. There is near
opacification of the sphenoid sinus, with only small foci of
air. Frontal sinuses are absent. The ostiomeatal units are
patent bilaterally. There is [**Last Name (un) 36826**] type II of the fovea
ethmoidalis bilaterally. There may be slight demineralization of
the cribiform plate. The sphenoid sinus septum is midline with
insertion on the clivus. An impacted canine tooth is noted in
the left maxilla.
IMPRESSION: Extensive sinus disease as described above with
fluid levels and aerosolized secretions. This may represent an
acute on chronic sinusitis.
[**2151-11-4**] CT TORSO:
1. Large right basal effusion and small left basal effusion with
atelectasis in the lower lobes bilaterally. The heart is
enlarged. Scattered ground-glass opacities seen throughout both
lungs, the appearances may represent fluid overload versus
infection.
2. 5-mm nodular opacity in the right middle lobe should be
followed up with a chest CT in three months if the patient is at
increased risk or has prior history of malignancy, otherwise
followup chest CT in one year is recommended as [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
guidelines.
3. Abdominopelvic ascites and fatty liver.
4. No abscess or collection present in the abdomen or pelvis.
MICROBIOLOGY:
BLOOD CULTURES: all negative
[**10-30**], [**11-1**], [**11-2**], [**11-4**], [**11-6**], [**11-7**], [**11-8**], [**11-9**], [**11-11**]
URINE CULTURES:
[**2151-10-29**]: Gram negative rods [**2141**] CFU's; not speciated
[**2151-11-1**]: negative
[**11-2**], [**11-4**], [**11-8**], [**11-11**]: yeast greater than 100,000; foley
changed after each culture returned yeast
[**2151-10-30**] DFA FLU: negative
[**2151-10-30**] RRP negative for parainfluenza, adenovirus and RSV
SPUTUM:
[**11-1**], [**11-5**], [**11-9**], [**11-11**]: yeast
[**2151-11-1**] STOOL: negative
Brief Hospital Course:
70F with DM, HTN, asthma; presenting to ED with RUQ pain with
development of hypoxic respiratory failure and ARDS, possible R
pneumonia, had increasing vent requirements, and evolving
metabolic lactic and respiratory acidosis and shock picture,
with evidence of liver and renal organ damage. Had several
episodes of PEA arrest requiring shocks. Currently, she has been
more stable for the past several days, was weaned off the vent
and been afebrile x 3 days (Tm 101.5 [**2151-11-11**]).
ACTIVE ISSUES:
# Respiratory failure/ARDS. Patient presented with evidence of
lobar R-sided pneumonia with rapid progression to severe ARDS
requiring maximal ventilatory support. Pt is now s/p 7 PEA
arrests. We were unable to find a fluid collection amenable to
thoracentesis on ultrasound. Patient extubated on [**11-14**] after
long intubated course. Has completed levaquin and vancomycin and
meropenem and cefepime 15-day antibiotic course for severe
pneumonia. Asthma management with albuterol MDIs; off of
systemic steroids. Diuresis also helped with respiratory
distress.
.
# Persistent fevers: Unknown source, possibly R sided PNA from
admission. Not enough fluid on thoraco to tap. Nothing seen on
abd/pelvis CT done on [**11-4**] to suggest a source. IJ has been
replaced, foley has been replaced multiple times. Patient has
had blood cultures, sputum, stool, and urine. Not sure what
other source is possible. Could be a drug [**Month/Year (2) **]. Will see if
afebrile when all antibiotics are stopped. Afebrile x 3 days.
.
#Tachycardia and HTN: The tachycardia has been responsive to
fluid boluses. She was on a significant home regimen of HTN
meds, which were restarted s/p hypotension. Her HTN and
tachycardia are currently controlled. Now taking Labetalol 800
TID and amlodipine 10mg, as pt is tolerating POs. Could
consider continued diuresis as this will also help control blood
pressure.
.
#Yeast in urine/vagina: Foley catheter replaced [**2151-11-6**]. Still
yeast in urine. Now yeast in vagina. S/p 5-day course of
fluconazole 200 IV qd.
.
#Anemia: patient Hct has been low for length of stay and
interval blood transfusions given. Patient has been responsive
to blood transfusions. Cause of her low Hct is now known, but
there does not seem to be a GI bleed per NG tube suctioning and
bowel movement examination. Loss could be due to being
critically ill.
.
# Hyperglycemia. Patient takes 180 units of insulin daily at
home, and has been difficult to control. Adjusted glargine and
sliding scale for better blood sugar control while inpatient.
.
# Repeated PEA arrests/shock: (ie: [**11-1**] and [**11-2**]) Patient
decompensates precipitously in setting of hypoxia, presumably
due to vagal vasodilation. Responds well to epinephrine (but
very sensitive, does not require large epinephrine doses as they
send her too hypertensive). She did have evidence of end-organ
damage on labs, with rising Cr and transaminitis, then improved.
On multiple occasions, spoke to family and she is full code.
Optimizing respiratory status was key to preventing further PEA
arrests.
.
# Elevated Troponins ?????? Almost definitely due to global ischemia
rather than ACS, as there is widespread evidence of
hypoperfusion of multiple organs. Her echo did not show any
focal wall-motion abnormalities. Has stabilized with her
improvement.
.
Code: Full code, confirmed with family on multiple occasions.
Okay with trach and PEG if necessary.
Communication: Daughter [**Name (NI) 36827**] speaks English and understands
the situation, has been kept informed and been key family
contact.
Medications on Admission:
Medications (per OMR, not verified):
- Advair 250/50 [**Hospital1 **]
- Albuterol MDI prn
- ASA 325 mg daily
- Hydrochlorothiazide 25 mg daily
- Nifedepine 90 mg daily
- Metoprolol XL 200 mg daily
- Valsartan 320 mg daily
- Simvastatin 10 mg daily
- Metformin 500 mg [**Hospital1 **]
- Humulin N 100 units QAM, 80 units QPM
- Paroxetine 30 mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-11**] PO BID (2 times a
day).
3. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 3 days.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Olanzapine 5 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for agitation.
15. Medication
Insulin per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pneumonia.
ARDS.
Vaginal and urinary tract yeast infection.
Discharge Condition:
Stable. Afebrile. Breathing comfortably. Extubated.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Take inhalers for wheeze or shortness of breath.
.
Return to the hospital or call your doctor [**First Name (Titles) **] [**Last Name (Titles) **], shortness
of breath, lightheadedness, chest or abdominal pain, rash.
.
3 days more of cream for vaginal yeast infection.
.
Consider lasix if SOB.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2151-11-23**]
1:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2152-1-19**] 9:00
Completed by:[**2151-11-16**]
|
[
"250.00",
"486",
"785.50",
"564.00",
"276.0",
"789.01",
"790.5",
"272.1",
"276.1",
"112.2",
"276.4",
"570",
"789.59",
"571.8",
"493.20",
"275.41",
"518.81",
"285.9",
"427.5",
"401.9",
"584.9",
"112.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.04",
"99.60",
"38.91",
"38.93",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12974, 13044
|
7582, 8072
|
357, 477
|
13148, 13202
|
2832, 2849
|
13635, 13975
|
2149, 2167
|
11594, 12951
|
13065, 13127
|
11221, 11571
|
13226, 13612
|
3372, 7559
|
2182, 2813
|
252, 319
|
8089, 11195
|
505, 1855
|
2865, 3356
|
1877, 1979
|
1995, 2133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,955
| 142,432
|
25489
|
Discharge summary
|
report
|
Admission Date: [**2128-11-23**] Discharge Date: [**2128-12-28**]
Date of Birth: [**2103-10-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
leg lesion, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
25 yo F with refractory AML s/p allo BMT (day +222), s/p dacogen
(d+27), ARA-C and lymphocyte infusion, h/o VRE bacteremia, h/o
c. diff, recently admitted ([**Date range (1) 63693**]) referred for admission
from clinic today with generalized weakness, new lesion on her
shin.
She reports that she has been feeling fairly well. According
to [**Date range (1) **] note from today, she had a "bad weekend" but she did not
elaborate but has been feeling fine physically. She reports that
yesterday, she noted a nodule that developed on her posterior
right calf. She notes that it is slightly tender. She has not
had any lesions like this before. She denies fevers, chills,
sweats, abdominal pain, diarrhea. She does endorse mild,
non-productive cough that is unchanged from her previous
admission. She has been eating and drinking well although her
appetite is somewhat diminished.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [x ] Fatigue [ ] Malaise
[x ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
HEENT: [x] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [] All Normal
[ ] SOB [ ] DOE [ ] Can't walk 2 flights [ x] Cough
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Angina [ ] Palpitations [ ] Edema [ ] PND
[ ] Orthopnea [ ] Chest Pain [ ] Other:
GI: [x] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ ] Diarrhea [ ] Constipation [] Abd pain [ ] Other:
GU: [x] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [x] R calf nodule
MS: [x] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [] All Normal
[x ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[x]all other systems negative except as noted above
Past Medical History:
ONCOLOGIC HISTORY
[**2128-2-3**] dx with AML after presenting to EW with vaginal
bleeding. Treated with "7&3" + Plerixafor (protocol 09-383).
Found to have a underlying MDS on post induction BM bx. MUD allo
SCT on [**2128-4-15**] (Flu/Bu/ATG)- complicated by VRE bacteremia and
anthracycline induced cardiomyopathy. She was admitted to
hospital on [**2128-7-7**] with fevers. BM bx confirmed relapsed AML.
[**2128-7-13**] - [**2128-7-17**]: Dacogen
[**2128-8-5**] - [**2128-8-9**]: Cytarabine
[**2128-9-9**] - [**2128-9-13**]: Dacogen
[**2128-9-21**] - [**2128-10-8**]: Admitted for a liver biopsy and evidence of
iron overload was found, likely secondary to transfusions in the
past. Question GVHD from recent transplant vs other toxic effect
of possible medications versus likely transfusion related
hemosiderosis which is supported by biopsy.
Liver MRI consistent with hemosiderosis and biopsy cannot rule
out GVHD due to mild bile duct dilation.
Ground glass opacities on CXR and CT and bronchial washings done
to investigate etiology. Cytology negative for malignant cells.
BAL cultures negative.
- d/c'd on posaconazole and cefpidoxime.
[**2128-10-5**]- DLI
.
PAST MEDICAL HISTORY
# Anemia
-- long standing prior to AML diagnosis
-- did not take iron supplements due to GI distress
# VRE bacteremia -- post transplant
# C diff -- completed treatment course
# Anthracycline induced cardiotoxicity
-- managed on Digoxin, Metoprolol, Lisinopril, and Torsemide
-- ([**2128-2-4**]) initial echo with normal LVEF >60%
-- ([**2128-2-25**]) routine echo with LVEF 35%
-- ([**2128-3-3**], [**2128-3-9**]) periodic echoes with LVEF 25%
-- ([**2128-3-18**]) improving with LVEF 35%
-- ([**2128-4-26**]) improving with LVEF 45%
-- ([**2128-6-2**]) most recent echo with LVEF 45-50%
Social History:
[**Known firstname **] is living in [**Location (un) 3786**] with boy-friend [**Female First Name (un) 63692**] and their
1 yo baby son [**Name2 (NI) 26580**]. She also has a 3 year old daughter ([**Name (NI) **])
who is being raised by her father/step-mother (see [**Name (NI) **] notes
from M.Saganov LICSW).
Family History:
Mother and father both alive and well. 2 half-brothers, both of
whom are healthy. Father has HTN and is on BP meds. No family
history of bleeding or cancer/leukemia. Grandfather with some
type of cancer, h/o MI s/p CABG.
Grandmother with DM, deceased [**2128-10-21**]. Aunt has CHF.
Physical Exam:
T 98.2 P 106 BP 108/64 RR 18 O2Sat 100% RA
GENERAL: non-toxic, chronic-ill appearing, NAD, mentating
clearly
Eyes: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Genitourinary: no flank tenderness
Skin: 1cm x 1cm mildly erythematous, mildly tender
induration/subcutaneous nodule on R posterior calf, dry skin
changes on ankles bilaterally (unchanged per pt)
Extremities: No clubbing, cyanosis, edema bilaterally, 2+
radial, DP and PT pulses b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, tremor,
dysdiadochokinesia noted.
.
Discharge Exam:
deceased
no spontaneous respirations, no pulse (jugular and radial), no
heart sounds auscultated, pupils fixed and dilated, no corneal
reflex, no reaction to painful stimuli
Time of death 6:55pm
Pertinent Results:
[**2128-11-23**] 08:30AM WBC-2.4* RBC-3.03* HGB-8.9* HCT-26.1* MCV-86
MCH-29.5 MCHC-34.2 RDW-14.3
[**2128-11-23**] 08:30AM NEUTS-1* BANDS-2 LYMPHS-32 MONOS-24* EOS-0
BASOS-0 ATYPS-7* METAS-0 MYELOS-8* PROMYELO-2* BLASTS-24*
OTHER-0
[**2128-11-23**] 08:30AM PLT SMR-VERY LOW PLT COUNT-31*#
[**2128-11-23**] 08:30AM GRAN CT-220*
[**2128-11-23**] 08:30AM GLUCOSE-109* UREA N-17 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2128-11-23**] 08:30AM ALT(SGPT)-157* AST(SGOT)-89* LD(LDH)-490* ALK
PHOS-261* TOT BILI-0.3
[**2128-11-23**] 08:30AM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-1.9
[**11-23**] Blood cx: pend
[**11-23**] mycolytic blood cx: pend
.
Discharge Labs:
************
.
Microbiology:
- BCx [**2128-11-24**] Blood Culture, Routine (Final [**2128-11-28**]):
STAPHYLOCOCCUS LUGDUNENSIS. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS LUGDUNENSIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 2 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
.
BCx, UCx, Tissue Cx and PICC Cx negative
C.Diff Negative
.
Pathology:
.
Lung, core needle biopsy:
- Organizing pneumonitis with features of BOOP/COP
(bronchiolitis obliterans-organizing pneumonia/cryptogenic
organizing pneumonia), see Hemepath addendum.
.
Hematopathology review: (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]).
- Patchy infiltrate within pulmonary interstitium
morphologically and immunophenotypically consistent with
involvement by patient's known acute myeloid leukemia in a
background of organizing pneumonitis as described above
.
Reports:
- Nodule US [**2128-11-24**]: No abscess
.
- CXR [**2128-11-24**]: . Slight progression of AML nodules or concurrent
infection.
PIC line ends in the right atrium, approximately 3 cm past the
superior
atriocaval junction
.
- CTA CHest [**2128-11-25**]: . No pulmonary embolism.
2. Marked increase in size and number of multiple pulmonary
nodules, many of which are now confluent. It is unclear whether
this is the same process seen on the prior studies (i.e., biopsy
proven AML nodules) or areas of new infection.
3. Stable mild cardiomegaly. Small pericardial effusion has
slightly increased in size since the prior study.
4. Stable splenomegaly
.
TTE [**2128-11-26**] The left atrium is normal in size. The coronary sinus
is dilated (diameter >15mm). Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with borderline normal free
wall function. There is abnormal septal motion/position
associated with ventricular interaction. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
.
TTE [**2128-12-3**] IMPRESSION: Small circumferential pericardial
effusion without evidence for hemodynamic compromise. Normal
left ventricular cavity size with low normal global systolic
function.
.
RUQ US [**2128-12-6**] Normal right upper quadrant ultrasound.
.
TTE [**2128-12-9**] Mildly depressed global left ventricular systolic
function. Mild mitral regurgitation. Small circumferential
pericardial effusion without echocardiographic evidence of
tamponade. Normal pulmonary artery systolic pressure
.
CT Pelvis [**2128-12-12**]
1. Possible minimal or early proctitis without evidence for
abscess.
2. Focus of superficial left gluteal subcutaneous fat stranding.
Clinical
correlation is recommended.
.
CXR [**2128-12-16**] In comparison with the study of [**12-4**], the left PICC
line again
extends to the lower portion of the SVC. Continued enlargement
of the cardiac silhouette without definite vascular congestion.
The multifocal areas of opacification have substantially
decreased. Mild retrocardiac opacification could reflect
atelectatic change.
.
CT Chest and Neck [**2128-12-17**]: Pending Read
.
Brief Hospital Course:
Patient was a 25 yo F with refractory AML s/p allo BMT [**2128-4-15**],
s/p dacogen [**2128-10-26**], ARA-C and lymphocyte infusion, h/o VRE
bacteremia, h/o c. diff admitted from clinic with subcutaneous
nodule on her R posterior calf found to have GPC and GPR
Bacteremia, rising blast counts and received 5 doses of MEC
during admission complicated by severe mucositis and neutropenic
fevers. Upon presentation to the intensive care unit, the
patient had a severe multifocal pneumonia and septic shock,
requiring intubation to facilitate bronchoscopy. Throughout
course in intensive care unit, patient required pressors to
sustain blood pressure and sedation for intubation. Patient was
covered very broadly with antibiotics. Multiple units of
platelets were given for dropping platelet counts < 10. Patient
clearly not clinically improving, based upon medication
requirements (pressors), clinical evaluations, laboratory
studies.
Multiple family meetings were held in the ICU. During a family
meeting [**12-28**] (with health care proxy present), it was decided
that care would begin to be withdrawn the next day.
The patient self-extubated herself on [**12-28**] evening. The father
(health care proxy) was called and determined prudent to
re-intubate considering was self-extubated not in controlled
setting. Patient was semi-lucid while self-extubated and
clearly did not want re-intubation. When father arrived,
communicated these with him, and he determined the patient
should be removed from life support, including pressors and
intubation, and the patient be made comfort measures only. The
patient was extubated and was anxious, in respiratory distress
and pain. Significant amounts of morphine and midazolam were
given to comfort and relieve pain, respiratory distress. Family
and friends arrived at bedside and the patient passed peacefully
at 6:55pm on [**2128-12-29**].
===================
===================
PRE-ICU COURSE
# Neutropenic Fever: Patient never recovered her counts and was
taking PO antibiotics prophylactically as an outpatient while
neutropenic. During admission her ANCs remained consistently
<500 and after MEC plummeted to 0. She was febrile during first
week of admission and after treatment remained afebrile for
sometime before becoming febrile again end of [**Month (only) 404**]. On
admission BCx grew S. Lugdunensis pan-sensitive and
Corynebacterium in BCx from [**11-24**] drawn in clinic. Serial BCx have
and UCx remained negative since [**11-25**]. TTE negative for
endocarditis, PICC Cx negative, Pulm biopsy Cx negative. She was
treated with Vancomycin to 750mg IV Q12hours ([**2128-11-25**]), CefePIME
2 g IV Q8H which was then converted to Meropenem aftetr she
began spiking fevers through Cefepime. She was taking
Posaconazole 400mg PO BID as an outpatient which was converted
to Micafungin when she developed prolonged QT syndrome from high
dose Zofran. After QT shortened with holding Xofran Mica changed
to Voriconazole since patient not tolerating POs. She was also
continued on Atovaquone for PCP prophylaxis and Acyclovir for
HSV prophylaxis. CT searching for source revealed organizing
pneumonia consistent with biopsy results but improving.
.
# Mucositis: Oropharynx and rectal involvement, related to MEC.
CT pelvis with proctitis without abscess. Unable to tolerated
POs but patient refused TPN. She was put on a morphine PCA but
pain still uncontrolled, dose titrated up to 5mg/hr infusion and
bolus 1mg Q10mins. She also received Amicar 5mg PO x1 for
bleeding [**12-23**] mucositis. CT neck showing edema of esophagous,
retropharynx and hypopharynx but without abscess formation.
Mouth care with Gelclair, Caphasol and Viscous Lidocaine
maintained. Rectal care with Tucks, [**Last Name (un) **] baths and topical
lidocaine creams.
.
#. AML: Relapsed s/p C3 decitabine/hydrea and 7+3 allo BMT as
above. After acute febrile illness resolved patient received 5
days of MEC with half dose of Mitoxan given history of
cardiomyopathy. Blasts improved with MEC though persistant and
she developed profound pancytopenia requiring multiple
transfusions. Course also complicated by mucositis with
esophageal and rectal involvement. Pulmonary nodule and skin
nodule biopsies likely AML. Hydroxyurea initially titrated up to
2 grams PO BID prior to MEC but then held during MEC because of
Pancytopenia. She received Acyclovir, Atovaquone for prophylaxis
and neutropenic fever treated as above.
.
# LFTs: Has history of transfusion related hemosidersosis based
on Liver biopsy in [**Month (only) **], on ursodiol. While receiving MEC
AST and ALT increased and downtrended following completion of
course. Likely Hepatocellular toxicity reaction [**12-23**] MEC
treatment. RUQ US negative
.
#. Subcutaneous nodule: Admitted from clinic with nodule on RLE.
US negative for abscess. Derm consulted who biopsied nodules
which showed AML involvement, culture negative.
.
CHRONIC ISSUES:
.
#. Adrenal insufficiency. On hydrocortisone [**3-31**] as an
outpatient. Doubled hydrocortisone in setting of fever to
Hydrocortisone 10/20 mg PO QPM/AM but then reduced back to [**3-31**]
after fever resolved
.
#. Oral candidiasis: Stable during admission
.
# Cardiomyopathy: Hemodynamically stable though tachycardic
during admission. TTE without change from prior. Patient became
bradycardic during MEC and was receiving 24mg Zofran prior to
chemo doses. EKG showed QT prolongation to 600 which improved to
QT of 380 after Zofran held. While on tele she had one run of 4
beat NSVT. Nausea treated with Dex and Ativan and continued
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
.
# Depression/anxiety: stable. Continued celexa, lorazepam prn
Medications on Admission:
cefpodoxime 400mg [**Hospital1 **]
citalopram 40mg daily
clotrimazole troches
folic acid
hydrocortisone 10mg qAM, 5mg qPM
hydroxyurea 1000mg daily
lorazepam 0.5mg qid prn
metoprolol 12.5 mg [**Hospital1 **]
ondansetron prn
oxycodone 5mg q4 hours prn
posaconazole 400mg [**Hospital1 **]
prednisone 10mg daily
ursodiol 300mg [**Hospital1 **]
MVI
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
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Discharge summary
|
report
|
Admission Date: [**2139-2-7**] Discharge Date: [**2139-2-11**]
Date of Birth: [**2055-5-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
lower gastrointestinal bleed
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
83 year old man with a history of CAD s/p CABG ([**2104**]) on aspirin
and plavix, AAA s/p repair ([**2121**]), diverticulosis, autonomic
dysfunction, and recent fracture of L hip s/p repair on [**2139-1-21**],
who presents from OSH with lower GI bleed. Patient was
discharged to rehab after L hip repair where had experienced
some nausea, decreased appetite and lethargy over one week.
Symptoms were beginning to improve. Early on morning of
admission, patient experienced abdominal cramping and had BRBPR,
approximately 500 cc of liquid and clots. He went to [**Hospital **]
Hospital
.
In the OSH ED, initial VS were T 97.4 HR 78, BP 124/72, RR18 O2
sat 98% on RA. The patient had two more bowel movements of
liquid blood/stool and clots. Hct was 32.1 and he was given 2
units pRBCs for active bleed. He was given 1 LNS and 80 mg IV
protonix. There was concern for an aorto-enteric fistula given
history of AAA repair so a CT Abd/Pelvis w/ contrast was
performed. No fistula was noted, but the patient was noted to
have extravasation of blood in his descending colon. He was
transferred to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] ED, initial VS were: 62 127/76 18 92% RA. The
patient had two more BMs, bloody w/ clots, about 250 and 50 cc's
each. Repeat HCT after completion of unit #[**Unit Number **] (from OSH) was
34.8. Given brisk bleed and concern for diverticular origin
based on CT finding, the patient was seen by IR and general
surgery. He was admitted to the MICU with a plan for urgent IR
embolization. VS on transfer were: HR 77 120/70 15 99%.
.
On arrival to the MICU, the patient is alert, oriented and in
good spirits. He denies any abdominal pain, nausea, or vomiting.
He notes [**2136-12-22**] pain in his left hip with certain movements.
Past Medical History:
Past Medical History:
Hyperlipidemia
CAD s/p 2 Vessel CABG in [**2103**]
AAA s/p repair in [**2121**]
Polymyalgia rheumatica and temporal arteritis
Chronic anemia
BPH s/p TURP (h/o urinary retention w/ chronic catheterization
previously)
Chronic urinary tract infections
Salmonella enteritis in [**2123**]
Diverticulosis
Colonic polyps
Atrial and ventricular ectopy
Osteoarthritis
Cholelithiasis
Autonomic dysfunction
Chronic hyponatremia
Osteoporosis, multiple fractures (pelvis, ribs)
Mild cognitive dysfunction
NSTEMI x 2 in [**2136**] - underwent cath with good FFR and no stents
placed
.
Past Surgical History:
Open AAA repair ([**2121**])
CABG ([**2104**]); angioplasty
s/p TURP
s/p Umbilical hernia repair
s/p Inguinal hernia repair
s/p R hip hemiarthroplasty in [**8-/2138**]
Social History:
Was a nuclear physicist who worked for navy, retired over 13-14
years ago. He is a widower. Currently in rehab, but was
previously living in elder housing. He denies alcohol. He smoked
[**12-22**] ppd until age 49. No history of illicit drug use.
Family History:
H/o CAD in both parents, mother with CHF, father died of brain
hemorrhage [**1-22**] trauma.
Physical Exam:
Admission Physicial Exam:
Vitals: BP: 119/65 P: 81 R: 14 O2: 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: insp crackles 1/4 up bilateral lung fields; no rhonchi or
wheezes Abdomen: soft, non-tender, non distended; bowel sounds
present; no organomegaly; well healed surgical incision
GU: No foley
Ext: 2+ pitting edema to the upper thigh on the LLE; ecchymosis
of L lateral hip; surgical site w/ steri-strips in place- c/d/i
without erythema; palpable DPs b/l; no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
except 5-/5 in Left hip [**Last Name (un) 87165**], grossly normal sensation,
.
Discharge Physical Exam:
Vitals: 97.5 139/84 99 18 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild bibasilar crackles; no rhonchi or wheezes
Abdomen: soft, non-tender, non distended; bowel sounds present;
no organomegaly; well healed surgical incision
Ext: ecchymosis of L lateral hip, receding; surgical site c/d/i
without erythema; palpable DPs b/l; no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
except 5-/5 in Left hip [**Last Name (un) 87165**], grossly normal sensation; able
to ambulate to comode
Pertinent Results:
Admission Labs:
[**2139-2-7**] 08:38AM BLOOD WBC-12.1* RBC-3.82* Hgb-12.6* Hct-34.8*
MCV-91 MCH-33.0* MCHC-36.1* RDW-16.7* Plt Ct-363
[**2139-2-7**] 08:38AM BLOOD Neuts-82* Bands-1 Lymphs-3* Monos-10
Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2139-2-7**] 08:38AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Acantho-1+
[**2139-2-7**] 08:38AM BLOOD Glucose-91 UreaN-24* Creat-0.6 Na-126*
K-4.5 Cl-93* HCO3-24 AnGap-14
[**2139-2-7**] 02:27PM BLOOD ALT-24 AST-32 AlkPhos-106 TotBili-1.1
[**2139-2-7**] 02:27PM BLOOD Calcium-7.5* Phos-3.3 Mg-2.0
.
Discharge Labs:
[**2139-2-10**] 07:00AM BLOOD WBC-8.2 RBC-4.10* Hgb-12.8* Hct-37.2*
MCV-91 MCH-31.3 MCHC-34.4 RDW-17.4* Plt Ct-290
[**2139-2-10**] 07:00AM BLOOD Glucose-80 UreaN-11 Creat-0.7 Na-135
K-3.7 Cl-99 HCO3-23 AnGap-17
[**2139-2-10**] 07:00AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.9
.
CT abdomen pelvix with contrast (uploaded from OSH): 1.
Evidence of a small diverticular bleed in the descending colon.
2. Extensive streak artifact limiting assessment of the pelvis,
but within that limitation, no drainable fluid collection.
3. Ventral abdominal wall seroma.
4. Post-surgical changes of bilateral hips as described above.
.
Mesenteric Angiogram [**2139-2-7**]: 1. No angiographic evidence of
active arterial bleeding from the superior mesenteric artery or
the inferior mesenteric artery.
2. Origin occlusion of the inferior mesenteric artery with
collateral filling from the superior mesenteric artery via the
arc of Riolan.
.
Bilateral Hip X-ray [**2139-2-8**]: No previous images. There is a
total hip arthroplasty on the right and a metallic fixation
device on the left. Heterotopic bone is seen on the left. No
definite fracture is appreciated on conventional radiographs,
which are much less sensitive than CT.
.
Left hip X-ray [**2139-2-9**]: In comparison with the study of [**2-8**],
there is little change in the appearance of the total hip
arthroplasty on the right and metallic fixation device on the
left. Extensive heterotopic new bone is again seen on the left.
.
Colonoscopy [**2139-2-10**]:
No active source of bleeding found. Though given the severity of
diverticulosis, diverticular bleeding is likely. Diverticulosis
of the whole colon, most pronounced in the descending and
sigmoid colon. Multiple small polyps in the colon. Grade 1
internal hemorrhoids.
Otherwise normal colonoscopy to cecum.
Brief Hospital Course:
83 year old man with a history of CAD s/p CABG, recent L hip
fracture s/p repair on [**1-21**], and diverticulosis admitted with
BRBPR; found to have likely diverticular bleed.
.
#) GI Bleed: Patient transferred from OSH with BRBPR in setting
of known history of diverticulosis and contrast blush in
descending colon on CT Abd/Pelvis. He was admitted to the ICU,
where he was stabilized with 4 units of PRBCs. He underwent
angiography that did not localize the source of bleed. He was
also noted to have significant occlusion of [**Female First Name (un) 899**]. His HCT
remained stable, and he was transferred to the floor. The
patient was evaluated by gastroenterology, and underwent
colonoscopy that showed diverticulosis of the whole colon with
multiple small polyps. There was no evidence of recent bleed.
The patient should discuss repeat colonoscopy with his
outpatient provider for polyp removal in the future. Of note,
the patient remained off of aspirin and Plavix for much of his
admission secondary to bleed. He was resumed on aspirin one day
prior to discharge. He will remain off of Plavix per discussion
with his outpatient cardiologist.
.
#) Left hip fracture s/p repair: Patient status post fall and
left hip fracture with repair on [**1-21**]. Prior to admission, he had
been doing well in rehab, working with PT and walking. The
patient experienced minimal pain throughout admission. Ortho
was consulted to evaluate hip stability, and determined by exam
and left hip X-ray that the patient is experiencing a normal
post-operative course. The patient was maintained on DVT
prophylaxis with pneumoboots given active bleed.
.
#) Gastric distention: Patient admitted with a recent history
of "upper GI symptoms" and CT with large amount of gastric
contents without sign of obstruction. Final CT read also
showed a ventral abdominal wall seroma, which may need to be
followed up as an outpatient. The patient denied abdominal
pain, nausea, vomiting throughout admission. He underwent
normal bowel prep for colonoscopy. He should follow up with
gastroenterology in regards to his symptoms as an outpatient.
.
#) Autonomic dysfunction: Patient has a history of orthostasis
and positional dizziness. Has been evaluated by Dr. [**Last Name (STitle) **] at
[**Hospital1 18**]. Regimen has involved encouraging Na intake,
discontinuation of antihypertensives, and recently adding
florinef. The patient remained normotensive throughout
admission on his home regimen.
.
#) Atrial fibrillation: Patient in and out of atrial
fibrillation throughout admission with normal ventricular
response. CHADS score 1. The patient remained hemodynamically
stable throughout admission. He was resumed on home aspirin
following colonoscopy. The patient is not on a beta blocker due
to history of hypotension.
.
#) CAD: Status post two-vessel CABG in [**2104**] and angioplasty.
Had NSTEMI x 2 in [**2136**], s/p cath but no PCI for adequate FFR.
Per outpatient cardiologist, ASA and Plavix were started after
cath in [**2136**] for indication of NSTEMI. The patient was
continued on ranexa and atorvastatin throughout admission. He
is not on a beta blocker or ACEI due to history of hypotension
prior to admission. Aspirin and plavix were held secondary to
GI bleed. Discussion was held with the patient's outpatient
cardiologist and the decision was made to resume aspirin after
colonoscopy, but permanently discontinue plavix. The patient
should follow up with his outpatient cardiologist on discharge.
.
#) PMR: The patient was continued on home prednisone.
=======================================================
TRANSITIONAL ISSUES
# Patient should discuss repeat colonoscopy with his primary
care physician and gastroenterologist for polyp removal
# Patient should f/u with PCP regarding abdominal wall seroma
# Plavix stopped on admission per discussion with outpatient
cardiologist. Patient should follow up with cardiologist as
scheduled on discharge.
Medications on Admission:
plavix 75 mg
aspirin 81 mg
ranexa 1000 mg [**Hospital1 **]
prednisone 5 mg daily
omeprazole 20 mg
levothyroxine 50 mcg daily
fludrocortisone 0.1 mg daily
atorvastatin 10 mg
vitamin D [**2126**] units daily
calcium 1000 mg [**Hospital1 **]
colace 100 mg daily prn
oxycodone 2.5 mg q4hr prn
alendronate 70 mg daily?
multivitamin
fish oil 1000 mg daily
ibuprofen 400 mg TID prn pain
lactobacillus 1 cap daily
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ranexa 1,000 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 390 mg (1,000 mg) Tablet Sig: One (1)
Tablet PO twice a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
14. lactobacillus acidophilus 500 million cell Tablet Sig: One
(1) Tablet PO once a day.
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
16. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehab and Nursing Center
Discharge Diagnosis:
PRIMARY DIAGNOSIS: lower gastrointestinal bleed
SECONDARY DIAGNOSES: s/p left hip fracture with recent repair,
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
*Patient with difficulty getting out of bed secondary to recent
left hip fracture
Discharge Instructions:
Mr. [**Known lastname 805**],
.
You were admitted to the hospital with GI bleed, noted to be
coming from your colon in a CT scan from an outside hospital.
You were stabilized in the intensive care unit with 4 units of
packed red blood cells. You underwent angiogram that showed no
active bleeding, and were transferred to the medical floor. You
underwent colonoscopy that showed continued diverticuli, but no
other evidence of recent bleed. You were noted to have polyps
in your colon, for which you should follow up as an outpatient.
You were seen by physical therapy, and were discharged back to
rehabilitation for your left hip. You should follow up with
gastroenterology and orthopedics as an outpatient.
.
During your admission, your plavix was stopped. You should
follow up with your cardiologist on discharge from rehab.
.
MEDICATIONS CHANGED THIS ADMISSION:
STOP plavix
STOP ibuprofen for pain
START tylenol for pain. If tylenol not effective, discuss
ibuprofen use with your primary care doctor.
Followup Instructions:
Please follow up with your primary care physician on discharge
from rehab.
.
Follow up with your orthopaedist as scheduled.
.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: ONE [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 73009**]
Phone: [**Telephone/Fax (1) 58158**]
Appointment: Monday [**2139-2-23**] 2:00pm
.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2139-3-4**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
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"285.1",
"272.4",
"412",
"276.2",
"294.20",
"998.13",
"715.90",
"276.1",
"562.12",
"V45.81",
"414.00",
"725",
"V43.64",
"557.1",
"E878.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
13138, 13209
|
7361, 11343
|
330, 344
|
13390, 13390
|
4921, 4921
|
14658, 15451
|
3256, 3350
|
11799, 13115
|
13230, 13230
|
11369, 11776
|
13623, 14635
|
5528, 7338
|
2806, 2976
|
3365, 4173
|
13301, 13369
|
262, 292
|
372, 2168
|
4937, 5512
|
13250, 13279
|
13405, 13599
|
2212, 2783
|
2992, 3240
|
4198, 4902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
808
| 158,423
|
3844+55508
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-12-2**] Discharge Date: [**2181-12-14**]
Date of Birth: [**2126-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
respiratory distress and tachycardia
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
History of present illness: Ms. [**Known lastname 13621**] is a 55 yo woman with
metastatic adenocarcinoma of unknown primary, hypertension, h/o
DVT s/p IVC filter and recently discharged after having acute
shortness of breath thought [**1-12**] atrial fibrillation with rapid
ventricular response who presented to the [**Hospital1 18**] ED today with
acute-onset shortness of breath at about 6 p.m. on the day prior
to admission.
.
She denies fever, chills, sweats, cough, increased sputum
production.
.
Of note, two days prior to admission, the pt had a CT scan of
her torso that revealed progression of her disease throughout,
including
interval progression in abnormal pulmonary densities involving
all lobes. They now have a more interstitial and consolidative
appearance, greatest in the lower lobes.
.
In the ED, her initial VSs were 132 100/70, 28-32, 97% with neb.
She received continuous nebs, methylprednisolone 125 mg IV,
furosemide 20 mg, levofloxacin and ceftriaxone. She was admitted
to the [**Hospital Unit Name 153**] for further management.
Past Medical History:
- Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in
[**2162**].
- GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age
50, normal pap's per patient
- Hypertension.
- History of mild asthma, inhalers not used for several years.
- normal mammogram less than one year ago.
- normal colonoscopy 2/[**2178**].
- recent pericardial effusion/tamponade
- right pleural effusion
- large common femoral DVT
- adenocarcinoma of unclear primary
Social History:
She worked as a nursing assistant. Lives with her husband. [**Name (NI) **] 2
Children.
Family History:
Her father died of stomach cancer at age 72. Mother died of
colon cancer at age 63. She is the 10th of 13 children. She has
lost 3 siblings to motor vehicle accidents.
Physical Exam:
GENERAL: Tachypneic, speaking in [**3-16**] word sentences, pain
well-controlled, lying in bed
HEENT: dry MM,
CARD: Tachycardic
RESP: Using accessory mucles
ABD: Mildly distended and tympanic, nontender, decreased bowel
sounds
EXT: Warm, well-perfused, 2+ DP pulses bilaterally; no pedal
edema.
NEURO: Alert & appropriate
Pertinent Results:
[**2181-12-2**] 01:08AM WBC-10.0 RBC-4.28 HGB-14.7 HCT-43.9 MCV-103*
MCH-34.3* MCHC-33.4 RDW-20.9*
[**2181-12-2**] 01:08AM NEUTS-89.7* LYMPHS-6.4* MONOS-3.6 EOS-0.2
BASOS-0
[**2181-12-2**] 01:08AM PLT COUNT-194
[**2181-12-2**] 01:08AM PT-16.7* PTT-33.3 INR(PT)-1.5*
[**2181-12-2**] 01:08AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2181-12-2**] 01:04AM LACTATE-2.5*
[**2181-12-2**] 01:08AM GLUCOSE-193* UREA N-12 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
[**2181-12-2**] 01:08AM proBNP-338*
[**2181-12-2**] 01:08AM CALCIUM-8.1* PHOSPHATE-3.3 MAGNESIUM-1.8
[**2181-12-12**] 12:00AM BLOOD WBC-7.0# RBC-3.67* Hgb-12.5 Hct-38.8
MCV-106* MCH-34.1* MCHC-32.2 RDW-20.1* Plt Ct-147*
[**2181-12-2**] 01:08AM BLOOD Neuts-89.7* Lymphs-6.4* Monos-3.6 Eos-0.2
Baso-0
[**2181-12-12**] 12:00AM BLOOD PT-14.9* PTT-23.9 INR(PT)-1.3*
[**2181-12-12**] 12:00AM BLOOD Plt Ct-147*
[**2181-12-3**] 11:31AM BLOOD Glucose-119* UreaN-14 Creat-0.5 Na-131*
K-4.5 Cl-97 HCO3-29 AnGap-10
[**2181-12-12**] 03:21PM ASCITES WBC-11* RBC-[**Numeric Identifier 17260**]* Polys-15* Lymphs-46*
Monos-0 Macroph-37* Other-2*
[**2181-12-12**] 03:21PM ASCITES TotPro-2.6 Glucose-102 LD(LDH)-274
Albumin-1.4
.
Reports:
CHEST (PORTABLE AP) [**2181-12-1**] 11:49 PM
SINGLE AP UPRIGHT BEDSIDE CHEST RADIOGRAPH: As seen on CT of the
chest from one day prior, there are multiple large loculated
pleural effusions, which appear roughly stable compared to one
day prior. There are bibasilar fluffy opacities, right greater
than left, consistent with pneumonia as seen on CT from one day
prior. The pulmonary vasculature is engorged and there is
perihilar haziness and increased interstitial markings,
consistent with mild- to-moderate pulmonary edema. Right
subclavian catheter terminates at the SVC- cavoatrial junction.
Cardiomediastinal silhouette is stable with prominence of the
left hilum due to a component of loculated effusion.
IMPRESSION:
1. Bibasilar opacities, consistent with pneumonia as seen on CT
from one day prior.
2. Mild-to-moderate interstitial edema.
3. Persistent large loculated pleural effusions.
.
Study Date of [**2181-12-1**] 11:45:12 PM
Sinus tachycardia. Peaked P waves with rightward P axis. Low
limb lead
voltage. Compared to the prior tracing of [**2181-11-22**] atrial ectopy
is no longer precorded. The rate has increased. Otherwise, no
diagnostic interim change
.
Study Date of [**2181-12-2**] 8:40:58 PM
Baseline artifacat. Sinus tachycardia. Rightward axis. Delayed R
wave
progression with late precordial QRS transition. Non-specific T
wave
abnormalities. Findings are non-specific but clinical
correlation is
suggested. Since previous tracing of [**2181-12-1**] no significant
change.
.
TTE [**2181-12-1**]
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is a moderate sized
(partially echo filled anterior to the right ventricle;
echolucent anterior to the right atrium and inferior/lateral to
the left ventricle) pericardial effusion. No definite right
atrial or right ventricular diastolic collapse is seen.
Compared with the prior study (images reviewed) of [**2181-11-16**],
the findings are similar (heart rate is slower).
Brief Hospital Course:
Assessment and MICU course: This is a 55 y.o. female with
metastatic adenocarcinoma of unknown primary first diagnosed in
[**2181-5-10**] from percardiocentesis fluid cytology, recent cycle of
capcitabine/irinotecan, history of PE/DVT s/P IVC filter and
enoxparin therapy, and SVT secondary to malignancy, who was
admitted from the ED to ICU for recurrent respiratory distress
and tachycardia. Despite diuretic therapy, antibiotic therapy,
nebulizer treatments, heart rate control, and corticosteroid
therapy, she did not improve substantially. Given this, along
with progression of disease on CT imaging in spite of receiving
chemotherapy, it was eventually determined by primary oncology
team and patient's family to pursue comfort measures only.
.
#) Dyspnea. Secondary to disease progression, pleural &
pericardial effusions.
She was continued nebulizers and Morphine elixir prn for
comfort. Avoid morphine IV unless necessary, per patient
wishes. Continue lorazepam for anxiety
.
# leaky foley, dysuria, and groin rash: She was briefly on
cipro, but it was discontinued as her UCx was negative. She had
a significantly irritated urethra, likey from a reaction to the
original foley. She was switched to a silicon foley and given
urojet, pyridium, and antibiotic ointment which resulted in mild
symptomatic improvement. These measures should be continues.
She was given ditropan with minimal improvement and the caliber
of her foley was increased with no improvement. The next step
may be removing the foley, but she has been resistent to this so
far both because of the dysuria and because of reluctance to
wear adult diapers. In addition, she has what looks like an
incontinence rash in her groin, which should be treated with
barrier cream (mupirocin [**Hospital1 **]), sarna prn, and keeping her as dry
as possible. She may need an antifungal if her rash begins to
look fungal.
.
#) Tachycardia. Secondary to malignancy, was on diltiazem for
heart rate control to help with dyspnea. Managed as per her
dyspnea as above.
.
#) Adenocarcinoma. Per Dr. [**Last Name (STitle) **] and patient and family,
goals of care addressed and patient is comfort measures only.
S/p paracentesis of 2L on [**2181-12-13**]. Fluid bloody, fluid not
indicative of SBP. Pain control has been with fentanyl patch 25
mcg/hr, oral morphine 2.5-10mg po q2h prn. She has also
benefited from scopolamine patch and saliva substitute.
.
#) Thrush. given nystatin oral 5ml po qid prn.
.
#) F/E/N. Regular diet. Megace 400mg po daily for appetite.
.
#) Prophylaxis. Discontinued enoxaparin, continue bowel regimen
for comfort - senna prn, po colace [**Hospital1 **] and pr colace prn.
.
#) Communication. With patient and family.
Husband: [**Name (NI) 17261**] [**Name (NI) 13621**] [**Telephone/Fax (1) 17262**]
.
#) Access. Port. PIV x 1.
.
#) Code Status. DNR/DNI. CMO
Medications on Admission:
Calcium Carbonate 500 mg qid
Cholecalciferol (Vitamin D3) 800 unit daily
Fentanyl 25 mcg/hr Patch 72 hr
Lidocaine patch
Capecitabine 1500 mg [**Hospital1 **]
Loperamide 2 mg qid prn
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg Tablet [**Hospital1 **]
Megestrol 400 mg daily
Hexavitamin daily
Enoxaparin 60 mg/0.6 mL syringe [**Hospital1 **]
Levalbuterol HCl nebs prn
Ipratropium Bromide nebs
Diltiazem HCl 120 mg daily
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. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Lorazepam 0.5 mg Tablet Sig: 1-4 Tablets PO Q4H (every 4
hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q4H (every 4 hours) as needed.
9. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal every seventy-two (72) hours as needed.
10. Morphine 10 mg/5 mL Solution Sig: [**12-15**] mL PO Q2H (every 2
hours) as needed.
11. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five
(5) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
5 ml of 10 Units/ml heparin (50 units heparin) each lumen Daily
and PRN. Inspect site every shift.
.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
13. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
14. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
15. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
17. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO DAILY
(Daily) as needed for Appetite Stimulation: For appetite
stimulation.
18. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
19. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous
membrane QID (4 times a day) as needed.
20. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical twice a day as needed for itching: please apply to groin
rash prn.
Discharge Disposition:
Expired
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Adenocarcinoma, metastatic, of unknown primary
.
Secondary diagnosis:
HTN
Asthma
DVT s/p IVC filter placement
h/o pleural and pericardial effusions
Discharge Condition:
Good. Pain is under control. Urethritis stable.
Discharge Instructions:
You were admitted with shortness of breath. You were in the ICU
originally and were treated empirically for pneumonia, volume
overload and COPD/asthma exacerbation as it was unclear what was
causing your symptoms. Your symptoms are most likely due to
disease progression. After discussion with you and your family,
given the poor prognosis of your disease, the decision was made
to focus on comfort and you are being discharged to a hospice
facility for further care.
.
You were noted to have urethritis and pain, likely partially due
to your foley cathether. Urology made recommendations about the
type of foley catheter to use and this was implemented prior to
discharge.
.
You had a paracentesis performed for comfort prior to discharge.
There was no evidence of infection.
.
Please call Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **] if you have any further
questions regarding your care.
Followup Instructions:
None
Name: [**Known lastname 2717**],[**Known firstname **] Unit No: [**Numeric Identifier 2718**]
Admission Date: [**2181-12-2**] Discharge Date: [**2181-12-14**]
Date of Birth: [**2126-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2719**]
Addendum:
She was not expired upon discharge from this admission.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2720**] MD [**MD Number(1) 2721**]
Completed by:[**2182-2-23**]
|
[
"597.89",
"197.8",
"197.0",
"423.9",
"486",
"197.6",
"V12.51",
"789.59",
"799.4",
"401.9",
"493.22",
"198.5",
"V66.7",
"427.31",
"199.1",
"511.9",
"785.0",
"285.22",
"196.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
13224, 13453
|
5989, 8849
|
353, 368
|
11739, 11789
|
2613, 5966
|
12747, 13201
|
2086, 2255
|
9327, 11441
|
11549, 11549
|
8875, 9304
|
11813, 12724
|
2270, 2594
|
277, 315
|
424, 1457
|
11638, 11718
|
11568, 11617
|
1479, 1964
|
1980, 2070
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,129
| 163,788
|
5713
|
Discharge summary
|
report
|
Admission Date: [**2148-11-17**] Discharge Date: [**2148-11-21**]
Date of Birth: [**2124-11-2**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Augmentin
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
24F s/p gastric bypass (roux-en-Y) in [**7-2**] c/b PE and UGIB with
IVC fliter placement, presents with 3 days of progressive
worsening abdominal pain. The pain was most severe last night,
when the patient became nauseous and lightheaded, and almost
passed out. She had no LOC, vomiting, F/C/D. In the ED,
underwent EGD that showed evidence of ulceration with overlying
clot at the gastrojejunostomy site, with surrounding erythema,
friability, and few erosions. The area was injected with 5cc of
epinephrine and electrocaudery was applied. She had several
tarry BMs in the ED, had a Hct drop to 24, and was transfused
PRBCs.
*
Of note, the patient was previously hospitalized in [**3-3**] for
acute abdominal pain, with EGD that showed para-anastomotic
ulceration and concern that residual gastric antrum was
remaining from the bypass. She was followed medically, which
required high doses of narcotics.
Past Medical History:
Gastric bypass--c/b PE and UGIB, IVC filter placed
Asthma
Back pain
Obesity
Fibroadenoma
Peri-rectal abscess
Social History:
Ms. [**Known lastname 6633**] has a 2 year-old daughter who is
currently staying with her mother. She denies any alcohol or
drug use. She is on disability. She use to a [**Company 22795**].
She reports that she denies any smoking, although D/C summary
from past admission notes that she was going outside to smoke
during the admission.
Family History:
Noncontributory.
Physical Exam:
V: T 97.7 BP 110/64 HR 78 R 18
*
PE: G: Obese female, resting in NAD, AAOx3
HEENT: MMM
Lungs: CTA, BL BS, No W/R/C
CV: RRR, S1S2, No M/R/G
Abd: Soft, tender to deep palpation, no rebound/guarding, BS
active
Ext: No E/C/C Pulses palable throughout
Pertinent Results:
Admission labs:
[**2148-11-17**] 07:00AM BLOOD WBC-8.3 RBC-3.73* Hgb-9.2* Hct-28.9*
MCV-77* MCH-24.8* MCHC-32.0 RDW-15.6* Plt Ct-354
[**2148-11-17**] 07:00AM BLOOD Neuts-51.0 Lymphs-40.6 Monos-4.5 Eos-3.5
Baso-0.4
[**2148-11-17**] 07:00AM BLOOD Hypochr-2+ Microcy-2+
[**2148-11-17**] 07:00AM BLOOD Plt Ct-354
[**2148-11-17**] 02:50PM BLOOD PT-14.1* PTT-30.2 INR(PT)-1.3
[**2148-11-17**] 07:00AM BLOOD Glucose-101 UreaN-27* Creat-0.5 Na-137
K-5.4* Cl-104 HCO3-26 AnGap-12
[**2148-11-17**] 07:00AM BLOOD ALT-10 AST-29 AlkPhos-57 Amylase-55
TotBili-0.5
[**2148-11-17**] 07:00AM BLOOD Lipase-22
[**2148-11-18**] 10:40AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
CT A/P ([**11-17**]): No evidence of obstruction or leak. The extruded
stomach is distended and fluid filled, which is an abnormal
finding in this post-operative patient.
Discharge labs:
[**2148-11-21**] 05:10AM BLOOD WBC-6.4 RBC-3.74* Hgb-9.9* Hct-30.0*
MCV-80* MCH-26.6* MCHC-33.1 RDW-16.1* Plt Ct-259
[**2148-11-21**] 05:10AM BLOOD Plt Ct-259
[**2148-11-20**] 05:20AM BLOOD Glucose-75 UreaN-5* Creat-0.4 Na-141
K-4.0 Cl-107 HCO3-25 AnGap-13
[**2148-11-20**] 05:20AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.0
Brief Hospital Course:
1. GI bleed: Pt admitted to floor, started on IVFs, protonix,
with close Hct monitoring. On the floor, she had a large BM and
BRBPR that was concerning for rebleeding. Her Hct was not
appropriately increasing following transfusions, and she was
evaluated for possible MICU transfer. During this time, she was
followed by surgery, who did not intervene, and GI, who felt
that the bleed was likely from para-anastamotic ulcers, and took
her to the endoscopy lab for EGD. She spent 1 night in the MICU
for observation, and was then transferred back to the floor.
Her Hct was stable following, and her abdominal exam was benign
throughout the admission. GI ultimately decided to have pt go
out on [**Hospital1 **] protonix and sucralfate, with trial of ursodiol and
encouraged to stop smoking. Per GI, she may ultimately a
surgical revision.
2. Pain control: Felt to have a possible element of anxiety.
She was given morphine, as well as oxycodone and oxycontin
throughout.
3. Anxiety: Persistent insomnia unrelieved with ambien or
ativan.
4. Hx of PE: No events. Placed on pneumoboots.
Medications on Admission:
Advair diskus, Albuterol INH, Ferrous Sulfate, Axert, Loratidane
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for allergy symptoms.
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed for pain.
Disp:*112 Tablet(s)* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Discharge Condition:
Stable
Discharge Instructions:
If any blood in stool, dark or black stools, severe abdominal
pain, lightheadedness, or loss of consciousness, go to the
Emergency room.
Followup Instructions:
Follow up with Dr. [**First Name4 (NamePattern1) 12589**] [**Last Name (NamePattern1) 12590**] or with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] in [**2-1**]
weeks (Call [**Telephone/Fax (1) 1954**] for appt)
Follow up with primary care clinic in 2 weeks, re-check Hct at
that time.
Please re-contact your [**Hospital6 13753**] surgeon about
re-evaluation.
|
[
"998.89",
"E878.9",
"534.40",
"E878.2",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
5452, 5458
|
3284, 4377
|
296, 301
|
5511, 5519
|
2104, 2104
|
5705, 6096
|
1774, 1792
|
4493, 5429
|
5479, 5490
|
4403, 4470
|
5543, 5682
|
2944, 3261
|
1807, 2085
|
242, 258
|
329, 1243
|
2120, 2927
|
1265, 1401
|
1417, 1758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,227
| 135,349
|
4254
|
Discharge summary
|
report
|
Admission Date: [**2116-8-10**] Discharge Date: [**2116-8-17**]
Date of Birth: Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 66-year-old woman with
autoimmune hepatitis and secondary cirrhosis who presented to
[**Hospital1 69**] on [**2116-8-5**] on advice
from her PCP who noted [**Name Initial (PRE) **] sodium of 124, potassium of 6.4 on a
scheduled appointment. She has been admitted and found to
have also an increased bilirubin. Over her hospital stay,
the patient as per the printout, the sodium remained in the
mid 120s, potassium was reduced with Kayexalate, and
aldactone was held. Coagulopathy PT of 18.6, INR of 2.4 on
admission, was treated with fresh-frozen plasma and vitamin
K.
Prior to this admission in [**2116-3-9**], the patient
developed lower extremity edema, fatigue, and decreased
mobility. She was found to have increased LFTs and was
started on Imuran, Lasix, and aldactone with some improvement
of symptoms. MRI revealed cirrhosis. It was confirmed by
biopsy one week prior to admission. Approximately one month
ago, the patient is evaluated for transplant, and was given
an increase in aldactone, and subsequently admitted for
pyelonephritis. Then she was given levofloxacin and also an
esophagogastroduodenoscopy was performed which revealed Grade
I varices, and colonoscopy revealed multiple diverticulosis
and two polyps.
During this current hospital stay, the patient began
developing low blood pressures systolics in the 80s-90s for
approximately 24 hours before transfer to the MICU. Urine
culture grew two species of Gram-negative rods. O2 sats
remained in the mid 90s and mental status decreased with
orientation only to person.
PAST MEDICAL HISTORY:
1. Autoimmune hepatitis.
2. Cirrhosis secondary to chronic hepatitis.
3. History of pyelonephritis one month ago.
4. Breast cancer status post lumpectomy and radiation therapy
in [**2107**].
5. Perirectal abscess.
6. Hypertension.
MEDICATIONS:
1. Prednisone 40 mg q day.
2. Norvasc 5 mg q day.
3. Imuran 100 mg q day.
4. Lasix 40 mg q day.
5. Aldactone 50 mg tid.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother deceased from colon cancer at 70.
Father deceased in the 70s from stroke. Siblings with heart
disease.
SOCIAL HISTORY: Lives with husband in [**Name (NI) 5110**]. Has four
children. No alcohol, or smoking, or drugs.
PHYSICAL EXAMINATION: Temperature of 98.0, heart rate 92,
blood pressure 94/47, and O2 sat is 97% on 2 liters nasal
cannula. In general, the patient is alert, responds to
questions, knows she is in a hospital, and knows her name,
follows simple commands. HEENT: Pupils are equal, round,
and reactive to light. Positive scleral icterus bilaterally.
Neck is supple. Lungs: Decreased breath sounds at the
bases. No wheezes. Heart is regular, rate, and rhythm.
Heart sounds soft. Abdomen is soft and nondistended with
fluid wave. Extremities edematous. Hematomas in upper
extremities and venous stasis changes in the lower
extremities bilaterally. Skin jaundiced. Positive actinic
keratoses on face and back, multiple hematomas at puncture
site.
LABORATORIES: Hematocrit of 25.6, potassium of 3.4, sodium
of 130, PT 16.7, PTT 35.2, INR of 1.9, ALT 77, AST 99,
alkaline phosphatase 132, total bilirubin 30.9, albumin 2.3.
Cultures grew Klebsiella.
HOSPITAL COURSE: The patient was consulted by Transplant
Surgery, and Hepatology, as well as Renal. Patient was
transfused with 1 unit of packed red blood cells on [**2116-8-10**].
On [**2116-8-12**], the patient had a difficult to control blood
pressure with blood pressures in the 70s-80s, and was started
on a Neo drip. The patient was transfused with 2 units of
packed red blood cells and given normal saline maintenance
fluid. There was a plan for a right IJ to be placed in the
morning.
Urology saw the patient concerning a left renal mass which
appeared to be renal cell carcinoma per MRI. ERCP fellow
asked to evaluate for ERCP. Indications for cystic
pancreatic lesions, but there is no biliary dilatation on
MRCP and no urgent indication for ERCP. The patient should
await medical stabilization to arrange ERCP.
On [**2116-8-13**], the patient had received several boluses of
normal saline to decrease blood pressure and responded well.
The patient had dyspnea overnight with high O2 sats and
stable vital signs. The patient then subsequently began to
require more and more pressors including vasopressin and
Neo-Synephrine. The patient was continued on lactulose and
Renal was consulted stating that the patient likely had
hepatorenal syndrome. Started on Octreotide, midodrine, and
continued on the vasopressin in an attempt to increase
perfusion to the kidneys. Was also continued on a prednisone
taper.
The patient appeared to have urosepsis as well as perhaps
hemolysis.
Condition began to deteriorate throughout the admission, and
was then deemed not a transplant candidate or an operative
candidate per the Hepatology service. Renal mass remained
highly suspicious for renal cell carcinoma and the patient
was deemed not a transplant candidate due to infection, her
need for pressors, and her respiratory and renal condition.
Then began to also develop abdominal pain suspicious for
pancreatitis versus ascites with SVP. It is also question
that the vasopressin was causing ischemic bowel.
On [**2116-8-16**], there was a family meeting [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] and
the family, and the family agreed to hold resuscitation and
nutrition, and to keep the patient comfortable. At [**2116-8-16**],
the patient's O2 sats decreased to the high 80s and low 90s
on 4 liters nasal cannula.
Chest x-ray showed congestive heart failure, and the patient
had no response to Lasix. Patient's stool was guaiac
positive at this point, and the BUN was increasing. There
was likely slow bleed in the gastrointestinal tract. In
addition, the patient developed atrial fibrillation, and
spontaneously cardioverted. The patient additionally runs of
NSVT.
On [**2116-8-17**], the patient was changed to DNR/DNI, and placed
on Morphine drip for comfort. The Neo-Synephrine was
continued, but there is no titration for systolic blood
pressure. The vasopressin was discontinued due to question
of ischemic bowel, and the patient's systolic blood pressure
slowly decreased overnight. The patient was unresponsive at
that point. At 10:35 am on [**2116-8-17**], the patient became
apneic and passed away. The patient was without heart sounds
and no respirations. Pupils were dilated and fixed. The
family refused postmortem examination.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 4525**]
MEDQUIST36
D: [**2116-12-19**] 13:42
T: [**2116-12-22**] 06:28
JOB#: [**Job Number 18481**]
|
[
"427.31",
"557.0",
"428.0",
"584.9",
"570",
"286.6",
"276.2",
"038.9",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"96.34",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2163, 2275
|
3370, 6949
|
2415, 3352
|
157, 1720
|
1742, 2146
|
2292, 2392
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,875
| 194,463
|
1168
|
Discharge summary
|
report
|
Admission Date: [**2189-5-23**] Discharge Date: [**2189-5-26**]
Date of Birth: [**2137-9-19**] Sex: F
Service: SURGERY
Allergies:
Morphine And Related / Dilaudid / Codeine / Cat Hair Std Extract
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Epidural catheter placement
History of Present Illness:
51 yo female s/p car vs. pole reportedly fleeing from police, +
EtOH, GCS 3 @ scene. She was transported to [**Hospital1 18**] for further
care. Her Blood alcohol level was 165 on admission. She was
intubated in the field for respiratory failure and a low GCS.
Past Medical History:
Depression, ADHD
Social History:
+EtOH
Family History:
Noncntributory
Physical Exam:
On Admission:
VS: 98.9 100 154/103 15 100% on ventilator
Gen: intubated, sedated
HEENT: pupils 3-->2 bilaterally, no obvious facial lacerations
CV: sinus tachycardia
Pulm: CTA bilaterally
Chest: + crepitus over ribs anteriorly
REctum: normal tone, no gross blood
Pertinent Results:
[**2189-5-23**] 11:49PM GLUCOSE-98 UREA N-8 CREAT-0.6 SODIUM-137
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-29 ANION GAP-10
[**2189-5-23**] 11:49PM ALT(SGPT)-20 AST(SGOT)-32 CK(CPK)-221* ALK
PHOS-66 TOT BILI-0.5
[**2189-5-23**] 11:49PM CK-MB-5 cTropnT-<0.01
[**2189-5-23**] 11:49PM WBC-4.1 RBC-3.28* HGB-10.9* HCT-31.7* MCV-97
MCH-33.2* MCHC-34.3 RDW-14.1
[**2189-5-23**] 11:49PM PLT COUNT-304
[**2189-5-23**] 11:49PM PT-12.0 PTT-25.9 INR(PT)-1.0
[**2189-5-23**] 09:00AM ASA-NEG ETHANOL-165* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-5-23**] CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Fractures involving the anterior left second through sixth
ribs.
Nondisplaced fracture involving the right fourth rib.
2. Dilatation of the IVC and mild periportal edema likely
related to vigorous
fluid resuscitation.
3. Fluid-filled and slightly dilated cecum of doubtful clinical
significance.
4. Mild induration noted adjacent to the right common femoral
artery and
vein. This is likely the sequela of an arterial or venous
puncture. Please
correlate with patient's history. No vascular injury is
identified.
5. Small soft tissue hematoma anterior to the mid sternum with
no underlying
fracture.
Brief Hospital Course:
She was admitted to the Trauma Service for pain control and
pulmonary care related to her rib fractures. She was extubated
on HD 2 in the morning once her mental status was able to clear
significantly. Pain service was consulted given her multiple rib
fractures for epidural analgesia. An epidural catheter was
placed for pain management. The epidural remained in place for
approximately 24 hours and was removed. She was started on an
oral pain regimen of Dilaudid which patient did not find helpful
and so she was changed to Percocet which provided better relief.
She is hemodynamically stable; her laboratory values are stable.
She is tolerating a regular diet and her pain is adequately
controlled.
She was evaluated by Physical therapy and is independent with
ambulation.
She was also evaluated by the psychiatry service who believed
that she warranted an inpatient psychiatric admission.
Medications on Admission:
Adderall 30mg SR, Wellbutrin 150', Neurontin 800', Tizanidine 4'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
3. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr Sig: Three (3) Capsule, Sust. Release 24 hr PO Q Daily ().
4. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for loose stools.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 511**] Medical Cemter
Discharge Diagnosis:
s/p Motor vehicle crash
Left rib fractures [**1-16**]
Right rib fractures 4th
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled, ambulating independently.
Discharge Instructions:
It is importnat that you continue to take deep breaths, cough
and use the incentive spirometer every hourthat you are awake.
You will need to return to the Emergency room if you develop any
fevers, chills, productive cough, shortness of breath, pain not
relieved by the pain medication, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up in [**1-13**] weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for
evaluation of your rib fractures. You will need to have an end
expiratory chest xray for this appointment.
Completed by:[**2189-5-26**]
|
[
"780.09",
"303.93",
"807.09",
"296.30",
"E815.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
4272, 4337
|
2304, 3201
|
348, 377
|
4458, 4564
|
1065, 2281
|
4981, 5203
|
747, 763
|
3317, 4249
|
4358, 4437
|
3227, 3294
|
4588, 4958
|
778, 778
|
285, 310
|
405, 667
|
792, 1046
|
689, 708
|
724, 731
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,374
| 137,853
|
14286
|
Discharge summary
|
report
|
Admission Date: [**2170-4-20**] Discharge Date: [**2170-4-27**]
Date of Birth: [**2106-2-25**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 64 year-old
gentleman with complaints of severe headache over the last
two to three weeks. Head CT shows a possible right intracranial
hemorrhage. A diagnostic cerebral angiogram was performed at an
outside institution during which the patient became aphasic and
hemiplegic. There was a question of left internal carotid
dissection and the patient was started on a heparin drip and a
repeat MRI revealed multiple left cerebral emboli and decreased
flow in the ACA and MCA on the left and no flow in the proximal
left ICA with distal reconstitution. The patient transferred to
[**Hospital1 69**] for further management.
PAST MEDICAL HISTORY: Hypertension, glaucoma, emphysema.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure 150/66. Heart rate 85.
He was in no acute distress. He was aphasic. He had a left
facial droop and left eyelid lag. Pupils are equal, round
and reactive to light 3 down to 2 mm. Extraocular movements
intact. Palpable carotid pulses. His cardiac status was
regular rate and rhythm. S1 and S2. Lungs were clear to
auscultation. Abdomen soft, nontender, nondistended. His
pulses were palpable. Rectal examination was deferred. He
had 5 out of 5 muscle strength on the left. He was 0 to 5 on
the right upper and lower extremity.
LABORATORIES ON ADMISSION: White blood cell count 7.7,
hematocrit 42.6, platelets 316, PT 11.7, PTT 31.5, INR 9.9,
BUN and creatinine were 13 and .6 on admission. Urinalysis
was negative.
HOSPITAL COURSE: The patient was admitted to the Neuro/Surgical
Intensive Care Unit and then underwent microcatheter-based
recanalization and stenting of the left ICA, a procedure which he
tolerated well and was successful. The patient was continued to
be monitored in the Intensive Care Unit post stenting. He was
awake, alert, aphasic, but following simple commands, showing two
fingers, opening his mouth, wiggeling his toes on the left and
right and had some movement of the right upper and lower
extremity on the bed.
His neurological status improved where he had antigravity
strength in the right upper extremity and 4- strength in the
right lower extremity. He continued to be somewhat confused
and disoriented, but following commands. He was transferred
to the regular floor on post procedure day number five. He
was followed by the stroke team and the Neurosurgery Service.
He had a vagal episode on [**2170-4-25**]. Blood pressure dropped
to the 80s when the patient was in the bathroom having a
bowel movement. It resolved with intravenous fluids. he was
seen by physical therapy and occupational therapy and found
to require rehab prior to discharge home.
MEDICATIONS ON DISCHARGE: Trandolapril 1 mg po q day, ASA
325 mg po q day, Plavix 75 mg po q day, Zalatan one drop OU
q.h.s., Zantac 150 po b.i.d.
The patient's condition was stable at the time of discharge.
He will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D., Ph.D. 14-133
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2170-4-26**] 09:32
T: [**2170-4-26**] 10:33
JOB#: [**Job Number 42431**]
|
[
"458.9",
"342.90",
"434.11",
"496",
"E878.9",
"998.12",
"997.02",
"E879.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2882, 3386
|
1695, 2855
|
931, 1499
|
172, 812
|
1514, 1677
|
835, 908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,814
| 129,183
|
46341+58905
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-1-16**] Discharge Date: [**2123-1-26**]
Date of Birth: [**2055-2-27**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old
gentleman transferred from an outside hospital with an
intraventricular hemorrhage into the left third lateral
ventricle.
PAST MEDICAL HISTORY: Squamous cell lung CA status post
lobectomy and XRT, hypertension, coronary artery disease,
peripheral vascular disease, COPD, left carotid occlusion,
right carotid stenosis.
MEDICATIONS ON ADMISSION: Aspirin, diltiazem, lovastatin,
Combivent, amitriptyline and metoprolol.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile. Vital signs were stable. The patient was
sleepy, awake, alert and oriented times two, following
commands in all four extremities. Pupils are equal, round and
reactive to light 3 down to 2 mm. Grasps were full. His
strength was [**5-13**] in all muscle groups.
HOSPITAL COURSE: He was admitted to the ICU and had an
MRI/MRA of the head with and without gadolinium that showed
no underlying lesion. The patient had a ventriculostomy drain
placed at admission. The patient also had CTA which showed no
obvious vascular malformation and also an angio which again
showed no obvious vascular malformation. The angio did show
left subclavian steal syndrome, left carotid occlusion and
left subclavian stenosis. Post-angio, the patient was awake,
alert and following commands. Grasps were full. Pupils are
equal, round and reactive to light. EOM's were full. His
right groin was clean, dry and intact with no evidence of
hematoma. The patient was extubated on [**2123-1-19**] and
following commands. Drain was decreased to 10 cc an hour for
24 hours to help drain large amounts of blood from the CSF.
The patient had a chest x-ray on [**1-19**] that showed interval
increase in prominence of the parenchymal opacities within
the left mid and lower lung zones, small left pleural
effusion and increased left retrocardiac densities which
could reflect atelectasis. The patient's vital signs remained
stable and he remained neurologically stable. On [**2123-1-21**],
the patient had a bedside swallow evaluation and was felt to
be safe for thin liquids with pureed solids. The patient was
told that he should sit bolt upright for all meals and
upgrade to soft solids once he was more awake. He was seen by
Physical Therapy and Occupational Therapy and felt to require
a short rehab stay. He had repeat head CT that was stable
with stable size ventricles. The drain was discontinued by
the patient himself on [**2123-1-18**]. The patient was
transferred to the regular floor on [**2123-1-20**]. He remains
neurologically stable, awake, alert and oriented times three.
Repeat head CT showed no increase in size of the ventricles.
The patient is awake. His incision is clean, dry and intact.
His repeat head CT on [**2123-1-26**] results are pending. He
remained neurologically stable and is felt to require a short
rehab stay prior to discharge to home.
DISCHARGE MEDICATIONS: Famotidine 20 mg po q12h, metoprolol,
folic acid one po daily, ferrous sulfate 325 po daily,
heparin 5000 units subcutaneously tid, insulin sliding scale,
Tylenol, Lopressor 50 mg po bid, hold for heart rate less
than 60, SBP less than 105.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
DISCHARGE INSTRUCTIONS: He will follow up with Dr.
[**Last Name (STitle) 739**] in two weeks with repeat head CT .
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2123-1-26**] 11:19:33
T: [**2123-1-26**] 11:52:25
Job#: [**Job Number 98512**]
Name:[**Known lastname 15731**],[**Known firstname **]
Unit No: [**Numeric Identifier 15732**]
Admission Date: [**2123-1-16**]
Discharge Date: [**2123-1-29**]
Date of Birth: [**2055-2-27**]
Sex: M
Service: NSU
ADDENDUM: He was discharged to the [**Hospital **] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 7808**]
Dictated By:[**Last Name (NamePattern1) 15733**]
MEDQUIST36
D: [**2123-3-12**] 13:40:56
T: [**2123-3-13**] 08:10:57
Job#: [**Job Number 15734**]
|
[
"496",
"435.2",
"414.01",
"401.9",
"431",
"433.10",
"433.20",
"447.1",
"V10.11",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.93",
"96.04",
"96.71",
"38.91",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
3059, 3301
|
543, 617
|
970, 3035
|
3413, 4264
|
640, 952
|
165, 317
|
340, 516
|
3326, 3388
|
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