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Discharge summary
|
report
|
Admission Date: [**2165-7-13**] Discharge Date: [**2165-7-23**]
Date of Birth: [**2130-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish / Nafcillin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2165-7-13**] Re-exploration of mediastinum for cardiac tamponade
History of Present Illness:
34M with aortic insufficiency & aortic stenosis c/b
recurrent endocarditis s/p multiple repeat aortic valve
rreplacements, most recently on [**2165-6-12**] with a 19-mm Onyx
mechanical valve & replacement of ascending aorta/hemiarch with
a
26-mm Dacron graft. He presented ~two weeks post-op with
pericardial tamponade secondary to hemopericardium requiring
re-operation and evacuation of pericardial hematoma. He was
doing
relatively well since discharge with the exception of persistent
mild [**2165-1-19**] anterior chest pain and R sub-scapular pain.
Last night was abruptly awakened from sleep with acute dyspnea
and increase in his chest pain to [**7-27**], similar to his
symptomatic pain during his episode of tamponade. He was
evaluated in the ED at [**Hospital1 18**] and cardiac surgery is being
consulted for concerns about his R pleural effusion.
Past Medical History:
ESRD on HD via L AV fistula, aortic valve endocarditis with
MSSA s/p tissue AVR [**9-23**], s/p redo sternotomy, homograft redo
aortic valve and aortic root replacement with reimplantation of
coronary arteries ([**2161-9-29**]); MSSA bacteremia with recurrent
endocarditis in [**8-25**], endocarditis [**1-27**] following angioplasty of
stenotic arteriovenous fistula; CHF (systolic and diastolic
dysfunction, EF55%); B subclavian vein, left IJ and left
Brachiocephalic thromboses s/p brachiocephalic vein stent, HTN,
chronic low back pain, hyperlipidemia, chronic fatigue syndrome,
pyloric stenosis
Social History:
Originally from [**Male First Name (un) 1056**]. Has 3 sons. Drinks 2-3
drinks/month, continues to smoke 1ppd x10 years, no illicits.
Works part-time as a teacher.
Family History:
mother - breast ca at 45, survivor, aunt - died of MI at 50, no
other family hx of renal disease, no DM or other CA in the
family
Physical Exam:
Pulse:112 ST Resp:32 O2 sat: 100% on 2L
B/P Right: 115/75:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [ ] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: significantly diminished breath sounds @ R base with
inspiratory crackles
Heart: RRR [x] mechanical heart sounds; (-)murmur
Abdomen: Soft, non-distended, non-tender
Extremities: Warm [x], well-perfused [x] Edema none; L forearm
fistula w/palpable thrill; Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:1+ Left:1+
Pertinent Results:
Conclusions
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). The right ventricular cavity is
unusually small. A mechanical aortic valve prosthesis is
present. There is right atrial and right ventricular collapse
which appears mechanical by nature -- a clot appears to be
compressing on both [**Doctor Last Name 1754**]. There is significant, accentuated
respiratory variation in mitral valve inflow, consistent with
impaired ventricular filling.
IMPRESSION: A mechanical compression by what appears to be a
clot on right atrium ventricle with mitral inflow pattern
compatible with tamponade physiology.
Dr. [**Last Name (STitle) **] was notified in person of the results during
the exam.
Electronically signed by [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2165-7-13**] 08:48
[**2165-7-23**] 07:20AM BLOOD WBC-4.2 RBC-2.69* Hgb-8.5* Hct-25.2*
MCV-94 MCH-31.6 MCHC-33.8 RDW-18.4* Plt Ct-100*
[**2165-7-22**] 04:38AM BLOOD WBC-3.8* RBC-2.78* Hgb-8.2* Hct-25.9*
MCV-93 MCH-29.4 MCHC-31.5 RDW-17.7* Plt Ct-107*
[**2165-7-21**] 05:30AM BLOOD WBC-3.7* RBC-2.71* Hgb-8.3* Hct-25.2*
MCV-93 MCH-30.7 MCHC-33.0 RDW-17.9* Plt Ct-105*
[**2165-7-19**] 07:00AM BLOOD PT-14.6* INR(PT)-1.3*
[**2165-7-18**] 01:25PM BLOOD PT-14.1* INR(PT)-1.2*
[**2165-7-17**] 05:25AM BLOOD PT-15.6* INR(PT)-1.4*
[**2165-7-16**] 12:10PM BLOOD PT-17.2* PTT-22.9 INR(PT)-1.5*
[**2165-7-23**] 07:20AM BLOOD Glucose-108* UreaN-56* Creat-10.2*#
Na-139 K-4.8 Cl-98 HCO3-31 AnGap-15
[**2165-7-22**] 04:38AM BLOOD Glucose-75 UreaN-36* Creat-8.0*# Na-140
K-4.6 Cl-101 HCO3-32 AnGap-12
[**2165-7-21**] 05:30AM BLOOD Glucose-72 UreaN-24* Creat-5.9*# Na-142
K-4.0 Cl-99 HCO3-33* AnGap-14
Brief Hospital Course:
Admitted on [**7-12**] for hypotension after dialysis. Developed
tamponade and was taken to the OR for mediastinal exploration
and evacuation of clot, and drainage of left plerural effusion
by Dr. [**First Name (STitle) **] on [**7-13**]. Transferred to the CVICU in stable
condition. Followed by nephrology. Extubated later that day.
Transferred to the floor on POD # 2 to begin increasing his
activity level. Dr. [**Last Name (STitle) 914**] does not want coumadin or heparin
for his mechanical valve for one month. He is to remain on
aspirin therapy. He had continuing chest tube output that
delayed his discharge for several days. Chest tubes were
discontinued on [**2165-7-21**]. Follow up chest x-rays revealed a
stable hydropneumothorax on the right. The patient was
discharged to home on POD 10, after dialysis, with appropriate
follow-up instructions. Dr. [**Last Name (STitle) 914**] has ordered the patient to
stay off of coumadin until [**2165-9-12**].
Medications on Admission:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*200 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change for goal INR 1.8-2.5, coumadin clinic to manage.
Disp:*30 Tablet(s)* Refills:*2*
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*qs ML(s)* Refills:*0*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*0*
8. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day for 2 weeks.
Disp:*14 * Refills:*0*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
***NO COUMADIN FOR AT LEAST 1 MONTH***
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P AVR ( mechanical valve)/ replace. ascending and hemiarch
aorta) on [**2165-6-12**]
cardiac tamponade s/p re-exploration [**2165-7-13**]
ESRD on HD via L AV fistula, aortic valve endocarditis with
MSSA s/p tissue AVR [**9-23**], s/p redo sternotomy, homograft redo
aortic valve and aortic root replacement with reimplantation of
coronary arteries ([**2161-9-29**]); MSSA bacteremia with recurrent
endocarditis in [**8-25**], endocarditis [**1-27**] following angioplasty of
stenotic arteriovenous fistula; CHF (systolic and diastolic
dysfunction, EF55%); B subclavian vein, left IJ and left
Brachiocephalic thromboses s/p brachiocephalic vein stent, HTN,
chronic low back pain, hyperlipidemia, chronic fatigue syndrome,
pyloric stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid and ultram
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**8-6**] @ 2:00 pm
Please call to schedule appointments with your
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-7-24**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2165-7-31**] 11:30
Cardiologist Dr. [**Last Name (STitle) **] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
??????
****NO COUMADIN OR HEPARIN FOR ONE MONTH PER DR. [**Last Name (STitle) **]****
Completed by:[**2165-8-2**]
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|
5735, 7288
|
9948, 10836
|
2251, 2869
|
261, 282
|
418, 1281
|
1303, 1906
|
1922, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,742
| 166,584
|
28486
|
Discharge summary
|
report
|
Admission Date: [**2134-5-10**] Discharge Date: [**2134-6-11**]
Date of Birth: [**2057-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**5-12**] CABGx3 (LIMA->Ramus, SVG->LAD, SVG->RCA)/MVR(#27mm [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 9041**] Valve)
History of Present Illness:
76 yo M transferred from [**Hospital3 417**] on [**5-10**] after cardiac
catheterization showed 3 vessel disease.
Past Medical History:
HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-16**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH
Social History:
Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day
Family History:
Noncontributory
Physical Exam:
Admission
HR 81 RR 18 BP 119/81
NAD, flat after cath. Sob with talking.
Skin 3 areas at right temple where skin ca excised, some
crusting and erythema at superior area; well healed TKR, right
LE medial vein harvest incision
Lungs CTAB
Heart Irreg Systolic murmur
Extrem cool, no edema
Slight right facial droop, MAE
Discharge
VS T 98.4 HR 85 SR BP 115/52 RR 24 O2sat 100% on 50% trach
collar
Gen NAD
Neuro Alert, interactive. Follows commands, moves all
extremities
Pulm course rhonchi
CV RRR, no murmur. sternum stable incision-CDI
Abdm soft, NT midline incision w/VAC-clean margins. Colostomy
stoma-clean-healthy. G-J tube site-CDI
Ext warm, no edema
Pertinent Results:
[**2134-5-10**] 03:50PM GLUCOSE-161* UREA N-44* CREAT-2.9* SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2134-5-10**] 03:50PM ALT(SGPT)-12 AST(SGOT)-15 ALK PHOS-124* TOT
BILI-0.6
[**2134-5-10**] 03:50PM %HbA1c-6.5*
[**2134-5-10**] 03:50PM WBC-6.8 RBC-4.44*# HGB-13.0*# HCT-39.6*#
MCV-89 MCH-29.3 MCHC-32.9 RDW-19.4*
[**2134-5-10**] 03:50PM PLT COUNT-255
[**2134-5-10**] 03:50PM PT-15.3* PTT-28.1 INR(PT)-1.4*
[**2134-5-10**] 01:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2134-5-10**] 01:32PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-MOD
[**2134-5-10**] 01:32PM URINE RBC-[**3-17**]* WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2134-6-11**] 02:32AM BLOOD WBC-9.9 RBC-2.93* Hgb-8.9* Hct-30.2*
MCV-103* MCH-30.3 MCHC-29.4* RDW-20.1* Plt Ct-370
[**2134-6-11**] 02:32AM BLOOD Plt Ct-370
[**2134-6-11**] 02:32AM BLOOD PT-16.9* PTT-80.9* INR(PT)-1.5*
[**2134-6-11**] 02:32AM BLOOD Glucose-196* UreaN-55* Creat-2.6* Na-146*
K-3.8 Cl-113* HCO3-25 AnGap-12
[**2134-6-10**] 03:16AM BLOOD ALT-27 AST-37 LD(LDH)-299* AlkPhos-146*
Amylase-70 TotBili-0.9
[**2134-6-11**] 02:32AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69045**]TTE (Focused
views) Done [**2134-5-20**] at 4:48:29 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-9-22**]
Age (years): 76 M Hgt (in): 66
BP (mm Hg): 106/52 Wgt (lb): 140
HR (bpm): 110 BSA (m2): 1.72 m2
Indication: Left ventricular function.
ICD-9 Codes: 427.31, 424.0
Test Information
Date/Time: [**2134-5-20**] at 04:48 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: TTE (Focused views) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid [**7-18**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 35% >= 55%
Tricuspid Valve - Peak Velocity: 1.4 m/sec
Findings
This study was compared to the prior study of [**2134-5-10**].
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate regional LV systolic dysfunction. False
LV tendon (normal variant). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis. Paradoxic septal motion consistent with prior
cardiac surgery.
AORTA: Focal calcifications in aortic root.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve leaflets. No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Cannot assess MVR. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Significant PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm). The rhythm
appears to be atrial fibrillation. Emergency study performed by
the cardiology fellow on call.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is markedly dilated. There is moderate regional
left ventricular systolic dysfunction with anteroseptal,
anterior and anterolateral wall hypokinesis. Right ventricular
chamber size is normal with mild global free wall hypokinesis.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthesis cannot be adequately assessed. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2134-5-10**],
the focal wall motion abnormality now includes the anterolateral
wall and the mitral bioprothesis is new.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2134-6-10**] 10:44 AM
CHEST (PORTABLE AP)
Reason: assess for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
76 year old man s/p avr/cabg explor lap
REASON FOR THIS EXAMINATION:
assess for infiltrates
HISTORY: Status post cardiac surgery.
FINDINGS: In comparison with study of [**6-7**], the pulmonary
vessels are somewhat less distinct, raising the possibility of
increasing pulmonary venous pressure. Blunting of the
costophrenic angles are again consistent with pleural fluid. The
hemidiaphragms again are not well seen, consistent with some
atelectatic changes at the bases. The central catheter and
tracheostomy tube remain in place.
IMPRESSION: Little change except possibly for some increasing
vascular congestion.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**2134-6-8**] 9:14 am SPUTUM
**FINAL REPORT [**2134-6-10**]**
GRAM STAIN (Final [**2134-6-8**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2134-6-10**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
ESCHERICHIA COLI. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in MCG/Mg
________________________________________________________
STAPH AUREUS COAG +
| 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
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R
VANCOMYCIN------------ <=1 S
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] R.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] R on FRI [**2134-5-21**] 6:59
AM
Name: [**Last Name (LF) **], [**Known firstname **] M Unit No: [**Numeric Identifier **]
Service: Date: [**2134-5-20**]
Date of Birth: [**2057-9-22**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2919
PROCEDURE PERFORMED: Exploratory laparotomy, intended right
colectomy with takedown of hepatic and splenic flexure,
cholecystectomy and gastrojejunostomy tube.
PREOPERATIVE DIAGNOSIS: Mesenteric ischemia.
POSTOPERATIVE DIAGNOSIS: Mesenteric ischemia.
ASSISTANT: [**Doctor Last Name **] [**Doctor Last Name **].
ANESTHESIA: General endotracheal.
INTRAOPERATIVE FLUIDS: 4 units of FFP, 1 unit of packed
cells.
ESTIMATED BLOOD LOSS: 200.
OPERATIVE FINDINGS: Upon opening the abdomen using a
diagnostic laparoscopy, we identified normal small bowel and
gangrenous changes of the cecum with near perforation. Based
upon this, we converted to an open laparotomy.
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room and placed on the operating table in the
supine position. After general endotracheal anesthesia was
obtained, an infraumbilical incision was made. We dissected
down to the subcutaneous tissues into the peritoneal cavity
using [**Last Name (un) 24631**] technique. Pneumoperitoneum was obtained. The 10
mm scope was placed in the peritoneum. We inspected the liver
and gallbladder. The liver looked unremarkable but the small
bowel that we were able to visualize was unremarkable. The
cecum had gangrenous changes. Based upon this, we converted
to open.
A midline laparotomy incision was made. We dissected through
subcutaneous tissues and then lengthened the opening in the
fascia to the xiphoid process all the way down to the pubic
symphysis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24412**] retractor was placed on the patient's
bed. Retractors were placed in the right upper, right lower
and left medial aspect of the incision. We took down the
right colon by dividing the white line of Toldt with
electrocautery. We extended this all the way up to the
hepatic flexure and took down the hepatic flexure. In doing
this, we were easily able to identify gangrenous changes in
the gallbladder as well. We divided the terminal ileum with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 3224**] stapler and then began taking down the mesentery. We
divided the mesenteric vessels with [**Doctor Last Name 1356**] clamps and tied off
the tissue with 2-0 silk tie. As we traversed the hepatic
flexure and identified the transverse colon, we identified
multiple patchy areas in the transverse colon as well as in
the splenic flexure. The sigmoid colon and distal descending
colon were unremarkable. We took down the splenic flexure and
then divided the colon at the mid descending colon location.
The colon was divided with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler. We took the
mesentery down with 2-0 silk ties and divided the tissue.
The middle colic vessels were suture ligated with a 3-0 silk
stitch. We then turned our attention to the gallbladder. The
gallbladder was taken down in a retrograde fashion. We
incised the peritoneum over the gallbladder and took it down
off the gallbladder in a retrograde fashion. We identified
the cystic artery and duct which were individually ligated
and divided. The gallbladder was then removed. A small
circular incision just below the umbilicus over the rectus
sheath was made. We took a core of subcutaneous tissues down
to the fascia, made a cruciate incision in the fascia and
then pulled the distal ileum through the opening to create an
ileostomy.
We irrigated the abdomen with crystalloid solution. Once we
had satisfactory control of all bleeding and hemostasis was
adequate, we then identified the stomach and placed two 2-0
silk pursestring sutures in the fundus of the stomach. A
small gastrotomy was made. A GJ tube was then advanced
through the anterior abdominal wall, positioned in the
stomach. The jejunal portion of the tube was then advanced
through the pylorus into the fourth portion of the duodenum.
The pursestring sutures were tied down. The tube was everted.
The stomach was then tacked up to the anterior abdominal wall
and once this was done, the balloon was inflated and the
sutures were tied down. The disk was then left at
approximately 4 cm on the anterior abdominal wall. The disk
was secured in place with a series of interrupted 3-0 nylons
and a 0 silk suture. The G-tube was left open. The J-tube was
clamped. The fascia was closed with running #1 looped PDS.
The skin was closed with staples. The ileostomy was matured
in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] fashion using interrupted 3-0 silk sutures. An
ostomy appliance was affixed.
The patient was returned to the cardiovascular intensive care
unit in critical but stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] S.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on [**Doctor First Name **] [**2134-6-3**] 8:08 AM
Name: [**Last Name (LF) **], [**Known firstname **] M Unit No: [**Numeric Identifier **]
Service: Date: [**2134-5-28**]
Date of Birth: [**2057-9-22**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 25514**]
PREOPERATIVE DIAGNOSIS: Respiratory failure.
POSTOPERATIVE DIAGNOSIS: Respiratory failure.
PROCEDURE:
1. A surgical tracheostomy (Portex #7).
2. Therapeutic bronchoscopy.
ASSISTANT: [**First Name8 (NamePattern2) 5321**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
OPERATIVE INDICATIONS: The patient is a gentleman who
underwent a sternotomy by the cardiac service. He developed
respiratory failure postoperatively and the thoracic service
was consulted for placement of a tracheostomy.
OPERATIVE REPORT IN DETAIL: The patient was brought to the
operating room, placed supine on the operating table. After
patient identification and time-out, we performed a
therapeutic bronchoscopy through the endotracheal tube. The
purpose of this was to clean the trachea of the secretions
prior to tracheostomy insertion. There were some thick
secretions from the central airways that were suctioned free.
We then gently hyperextended the neck and prepped and draped
the anterior neck and chest in the usual sterile fashion. We
made a 3-cm collar incision one fingerbreadth above the
sternal notch. The platysma muscle was divided. The strap
muscles were retracted laterally and the thyroid isthmus
divided. The cricoid cartilage was identified and elevated
with a hook.
We made a transverse tracheotomy incision between the second
and third tracheal ring. The #7 Portex tracheostomy was
inserted without resistance into the tracheal lumen. There
was good return of CO2 and the patient's O2 saturation
remained above 90% during this portion of the procedure.
We then performed confirmatory bronchoscopy that identified
the appropriate position of the tracheostomy.
The tracheostomy was then sewn to the skin using 2-0 PDS. The
tracheostomy tape was also applied.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 32450**]
Dictated By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by renal to
continue on dialysis. He was seen by dermatology and started on
bactroban for his facial lesion. He was started on bactrim for a
UTI.
On [**5-12**] he was taken to the operating room where he underwent a
CABG x 3 and Mitral valve replacement. He was extubated later
that same day. He was confused and was started on haldol. A
dobhoff tube was placed as he was high risk for aspiration as
he could not manage his secretions. He remained in the ICU for
pulmonary toilet.
He was started on amiodarone and then digoxin and heparin and
seen by electrophysiology for atrial fibrillation. Bedside
swallow evaluation showed aspiration and he remained NPO.
Dobhoff tubes were placed but he continued to pull them out.
Sputum culture grew GNR/GPC and he was started on zosyn and
vanco. On [**5-19**] he was found to be in respiratory distress, as
well as bradycardic and hypotensive and he was reintubated.
Bronchoscopy after intubation showed large amounts of
secretions. He was started on dopamine. He was cardioverted
successfully for atrial fibrillation with hypotension. His
dopamine was dc'd, and he was started on levophed. He continued
to be acidotic and underwent abdominal CT scan which showed
ischemic bowel. He was taken to the operating room on [**5-20**] where
he underwent a Exploratory laparotomy, intended right colectomy
with takedown of hepatic and splenic flexure, cholecystectomy
and gastrojejunostomy tube. He was started on TPN. He continued
on CVVH. HIT antibody and SRA sent for thrombocytopenia were
negative. His ostomy began functioning and He was started on
tube feeds through his GJ tube on [**5-26**]. He underwent tacheostomy
on [**5-28**]. He was started on fluconazole for yeast in urine and
sputum. Zosyn was changed to ceftazidime. He was positive for
cdiff and was started on flagyl and PO vanco. His ventilatory
support was slowly weaned. The superior aspect of his abdominal
wound opened and a VAC dressing was placed by the general
surgery team. He was weaned from his pressors and ventilator
over the next several days. On POD 30/22/14 he was started on
Ceftriaxone and Vanco for VAP/tracheobronchitis.
He was ready for discharge to rehab on [**6-11**]
Medications on Admission:
coumadin 2.5', nephrocaps, terazosin 2', prilosec 20', lopressor
25", lantus 10', mirtazipine 7.5', zocor 40', dig 0.125 [**Last Name (LF) **], [**First Name3 (LF) **]
81', imdur 60', megace"
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q24H (every 24 hours).
7. Warfarin 1 mg Tablet Sig: adjust dose to INR Tablet PO DAILY
(Daily) as needed for afib: Target INR 2-2.5
last dose 5/26-1mg.
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for nose.
11. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 days.
12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous HD PROTOCOL (HD Protochol) for 7 days.
13. Ceftriaxone 1 gram Recon Soln Sig: One (1) gm Intravenous
Q24H (every 24 hours) for 7 days.
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: as directed
below ML Intravenous PRN (as needed) as needed for line flush:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Order was filled by pharmacy with a dosage form of Syringe and a
strength of 10 UNIT/ML .
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
16. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
once a day.
17. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection Q AC&HS.
18. Maalox/Diphenhydramine/Lidocaine Sig: Five (5) cc every
six (6) hours as needed.
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic PRN (as needed).
20. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-20**]
Puffs Inhalation Q4H (every 4 hours) as needed for when on vent.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD, MR now s/p CABG, MVR
perforated gall bladder, mesenteric ischemia s/p Exploratory
laparotomy, extended right colectomy with takedown of hepatic
and splenic flexure, cholecystectomy and gastrojejunostomy tube
post op respiratory failure s/p tracheostomy
PMH CRF on HD, PVD s/p fem [**Doctor Last Name **] and rt iliac stents, Afib, CVA w/
facial residual, DM, Subdural hematoma from fall, pulm HTN,
Retinal embolus, Carotid disease s/p rt CEA, HTN, lipids, bilat
cataracts, urosepsis, COPD, Chronic bronchitis, diverticulosis,
squamous cell CA, basal cell CA, colon polyp, gout
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds in 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] [**2-14**] wks after discharge from rehab
[**Telephone/Fax (1) 26190**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2 wks after discharge from rehab [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2-14**] wks after discharge from rehab
Pt has numerous actinic keratoses (precancerous lesions) which
will need to be treated as an outpatient. He agrees to follow up
with his new primary dermatologist as scheduled in [**Month (only) **].
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (General Surgery Clinic) in [**2-14**] weeks.
Patient to call for all appointments
Completed by:[**2134-6-11**]
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]
] |
21727, 21799
|
16929, 19177
|
325, 503
|
22426, 22436
|
1866, 5485
|
22748, 23505
|
1155, 1172
|
19419, 21704
|
6527, 6567
|
21820, 22405
|
19203, 19396
|
22460, 22725
|
5524, 6490
|
1187, 1847
|
282, 287
|
6596, 16906
|
531, 646
|
668, 1024
|
1040, 1139
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,055
| 166,572
|
51082
|
Discharge summary
|
report
|
Admission Date: [**2200-9-10**] Discharge Date: [**2200-9-16**]
Date of Birth: [**2161-1-23**] Sex: F
Service: CCU
DICTATING DATE [**2200-9-11**] UNTIL DISCHARGE
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
female, with risks factors of family history, and smoking,
and history of cocaine use in the remote past, who presents
with substernal chest pain that had first begun during
exercise and lasted 10 minutes and remitted with rest. The
chest pain returned the following day while at rest, was
rated as [**11-7**], crushing, substernal, radiating to the neck,
associated with nausea, diaphoresis and paresthesias of her
arms. The patient denied shortness of breath, orthopnea or
PND. She went to the ED of an outside hospital after six
hours of this pain. EKGs there were reportedly normal, and
the patient was sent home. The pain persisted, but decreased
with rest and increased with movement. The patient rested
that day, and then the following day went to see her PCP who
drew labs and checked an EKG which, again, was found to be
normal and sent her home. Her primary care physician called
her back the next day when he discovered that her troponin-I
was 10 and her CK was 400.
She was admitted to [**Hospital6 256**]
where EKGs here revealed evidence of a completed anteroseptal
infarct. The patient was pain-free and admitted to C-MED for
monitoring and elective cath. While on the floor, the
patient developed pain again. EKGs at that time revealed ST
elevations in V2 and V3, ST depressions in AVL and AVF, and
evidence of a LAD lesion persisting. The patient reports
that she exercises regularly, does yoga and cardia yoga
weekly. She denies any history of spontaneous abortion. No
history of blood clots or DVTs, has never had chest pain
prior to one week ago. Denies any palpitations, fever,
chills, nausea or vomiting, or lower extremity swelling.
PAST MEDICAL HISTORY: The patient has none.
MEDICATIONS: The patient takes none.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient's father had an MI at age 39 and
was deceased at age 52 from coronary disease. Grandfather
died of an MI at 52.
SOCIAL HISTORY: The patient is married with two children, a
homemaker and a physical therapist. She denies any use of IV
drugs. Reports occasional cocaine use over 20 years ago,
minimally uses alcohol, and had a 15-pack year of tobacco
history but quit over 10 years ago.
EXAM AT ADMISSION TO CCU: The patient was afebrile
temperature, blood pressure 90s/50s. She was admitted from
the Cath Lab on a balloon pump and dopamine. General
appearance - she was laying flat, alert, frightened, a very
thin young woman on 2 liters of nasal cannula O2. HEENT -
she was anicteric with moist mucous membranes. No carotid
bruits. Normal carotid upstroke and amplitude. No JVD or
increased JVP appreciated. Cardiovascular - heart was a
regular rate and rhythm with a normal S1, S2, no murmurs,
rubs or gallops. No abdominal or femoral bruits. Lungs were
clear anteriorly. Abdomen was scaphoid with normoactive
bowel sounds, soft and nontender. Extremities were cool, dry
with radial and DP 2+ bilaterally. The patient had a Swan in
place in her right femoral vein and a right femoral arterial
line. That catheter site had no oozing, was nontender, and
DP and PT pulses were 2+ bilaterally and equal.
LABORATORIES: Significant for normal lipid profile and CKs
that peaked at 430. Hematocrit was stable throughout the
course of admission. Renal function was stable. Chest x-ray
revealed hyperinflation with no infiltrates or infusions.
Catheterization on [**2200-9-10**] revealed a stenosis prior
to PTCA. The LAD was 100% occluded. The left circ was 100%
occluded. The left main was 100% occluded. There was heavy
thrombus burden noted. The proximal LAD was doddered with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 35064**] balloon. Upon retraction, the left main was
completely occluded. The patient complained of severe chest
pain, became hypotensive, and a stent was placed to the left
circ, the left main and the LAD. A balloon pump was placed,
and the patient was admitted to the CCU for further
monitoring.
HOSPITAL COURSE: While in the CCU, hypercoagulable work-up
was sent, but these studies were not completed by the time of
discharge and would be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and the CCU
team, and reported to the patient after discharge. Lipid
panel was normal. On postcath day #3, the balloon pump was
pulled. The patient was given daily aspirin and Plavix, as
well as 48 hours of Integrilin. EKGs revealed
pseudonormalization of the T's. When the patient's blood
pressure increased and the dopamine was weaned off, beta
blocker and ACE inhibitor were started. EF was evaluated as
greater than 55% on echo. The patient had no evidence of
cardiac failure or cardiogenic shock. There were no
conduction concerns.
The patient was monitored on tele throughout the
hospitalization without any ectopy noted. The catheter site
healed without residual bleeds or hematoma formations.
Hematocrits were stable, and the patient received much
education regarding risk factor modification. The patient
was instructed to have a low-fat, low-cholesterol diet, to
continue taking a statin or Lipitor to keep her cholesterol
low, to always manage her weight, and monitor her blood
pressure, and to take all of her medications as directed, and
to follow-up with cardiology. On day #3, after the sheath
was pulled the patient sat up to chair, ambulated, and was
cleared by PT for discharge home without need for further
rehabilitation.
On the day of presumed discharge, [**9-15**], with ambulation
the patient complained of difficulty breathing and light
chest pressure. EKG at that time revealed T wave changes.
The patient was taken to the Cath Lab where a coronary
angiography was performed. The left main was found to have
mild residual stenosis but a patent stent. The LAD had a
patent stent with luminal irregularities. The left circ had
a patent stent with modest caliber distal vessels. The ramus
intermedius was patent, and the RCA was patent but revealed a
catheter induced spasm proximally with mild approximately 30%
ostial stenosis. There was no angiographic evidence of left
main, LAD, or left circ stent thrombosis, or compromise to
the stent lumens. The patient was instructed to continue
secondary preventative measures against coronary artery
disease, stent thrombosis and post MI care as per the CCU
team. The patient was much relieved after this
catheterization, rested well that evening, ambulated without
shortness of breath, or difficulty breathing, or further
chest pressure, and was discharged to home the following day.
FOLLOW-UP:
1. The patient was given appointments to follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in cardiology.
2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in interventional cardiology for a relook
catheterization in 4 months, and with Dr. [**First Name (STitle) **], the patient's
primary care doctor. Dr. [**First Name (STitle) **] was called, and the patient's
hospitalization was discussed. He reported that he would
call her with an appointment for her to see him within 1
week.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg qd.
2. Lipitor 10 mg qd.
3. Metoprolol 25 mg [**Hospital1 **].
4. Plavix 75 mg qd.
5. Lisinopril 2.5 mg qd.
DISCHARGE DIAGNOSES: ST elevation myocardial infarction.
CONDITION: Stable.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 900**] 12-248
Dictated By:[**Last Name (NamePattern1) 106091**]
MEDQUIST36
D: [**2200-9-17**] 14:01
T: [**2200-9-17**] 13:16
JOB#: [**Job Number 106092**]
|
[
"V17.3",
"V15.82",
"410.11",
"458.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"37.22",
"36.05",
"99.20",
"36.06",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
2054, 2180
|
7557, 7848
|
7408, 7535
|
4246, 7385
|
213, 1914
|
1937, 2037
|
2197, 4228
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,505
| 185,558
|
3552
|
Discharge summary
|
report
|
Admission Date: [**2118-9-1**] Discharge Date: [**2118-10-11**]
Date of Birth: [**2050-11-26**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Motrin / Codeine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
elevated billirubin found at clinic
Major Surgical or Invasive Procedure:
ERCP
Multiple Paracenteses
Cardiac Catheterization
Orthotopic Liver Transplant
History of Present Illness:
67 yo F with presenting from clinic complaining of 3 bloody
stools 5 days pta and 1 bloody stool on the day pta, went to
clinic today and was found to have elevated bilirubin from 11.9
on [**8-25**] to 22.8 on [**8-31**] so was admitted to evaluate for biliary
obstruction/cholangitis. Pt has mild RUQ pain, but denies,
nausea, vommiting, chest pain, shortness of breath, and husband
has not noticed any change in mental status.
.
She was recently admitted on [**8-11**] for choledocholithiasis,
diagnosed by ultrasound in ED, underwent ERCP on [**8-11**], where
sphincterotomy was performed, stones were extracted and 10 F
Cotton [**Doctor Last Name **] biliary stent was placed. Afterwarks she
complained of persistant nausea and RUQ pain radiating to back.
She underwent paracentesis on [**8-15**] and 1800 cc of fluid was
removed. Her total bilirubin rose from 5.3 at admission ([**8-11**]);
to 7.1 on [**8-17**]. She underwent repeat ERCP on [**8-18**] which
demonstrated purulent bile, sludge, and stones. The stent was
exchanged for another 10F Cotton [**Doctor Last Name **] stent and she was started
on
Zosyn. Following the procedure, her symptoms of pain and nausea
abated, but her total bilirubin continued to rise and her
diarrhea, which had resolved, returned on [**8-20**]. Stool was
negative for C.diff x 2. On [**8-24**], she underwent cardiac
catherization as part of her evaluation for liver
transplantation and was found to be 60% stenosed in her LAD and
70% stenosed in her LCX. As these lesions may be clinically
insignificant, a nuclear stress test was recommended but has not
yet been performed. By discharge her bilirubin had continued to
rise and was 11.9 on the day of discharge ([**8-25**]). Hepatology
suggested that the cause was intrahepatic cholestasis secondary
to drugs and recommending stopping Zosyn, starting Actigall, and
obtaining an MRCP. She was deemed stable for discharge, and
upon return to clinic this further elevated bilirubin was
discovered and pt was admitted for further evaluation.
Past Medical History:
1. Liver cirrhosis: Cryptogenic cirrhosis with portal
hypertension and known varices, portal gastropathy.
- Biopsy [**3-/2110**] - positive for bile duct proliferation
- History of variceal bleed - band ligation; on Propranolol
- chronic thrombosis of SMV and main PV (nonocclusive)
- Chronic ascites - no prior episodes of SBP
- is on the transplant list.
2. HTN
3. DM: c/b retinopathy s/p laser eye surgery, on insulin
4. osteoporesis
5. s/p tubal ligation.
6. colonic polyps c/w adenoma
7. chronic stable angina - s/p cath demonstrating 60% stenosis
of LAD and 70% stenosis of LCX
8. psoriasis
9. OLT [**2118-9-22**]
Social History:
Lives with husband in [**Name (NI) 86**], nonsmoker, denies ETOH, Spanish
speaking, has 7 children.
Family History:
Father died of esophageal ca at 80. Mother died of CVA/DMII at
71. Sister has breast ca. Siblings have diabetes.
Physical Exam:
VS: 97.3 105/52 68 18 95%RA FS202 W68.4kg
General: Hispanic woman in NAD
HEENT: NCAT icteric EOMI PERRLA OP clear
Neck: no bruit/thyromegally/brut, JVP at 1 cm above clavicle
CV: nml s1 s2 rrr no m/r/g
Chest: CTA no rales/rhonchi/wheeze
ABD: soft, +bs, reducible unbilical hernia, RUQ tender to deep
palp, no reboud, no guarding
EXT: +clubbing, no edema
Neuro: nonfocal
Pertinent Results:
ADMISSION LABS [**2118-8-31**]
UREA N-18 CREAT-0.9 SODIUM-136 POTASSIUM-4.1 CHLORIDE-99 TOTAL
CO2-28 ANION GAP-13 GLUCOSE-87
ALT(SGPT)-81* AST(SGOT)-148* ALK PHOS-175* TOT BILI-22.8*
ALBUMIN-3.0* CALCIUM-9.2 AFP-2.7
WBC-5.0# RBC-3.28* HGB-11.4* HCT-34.3* MCV-105* MCH-34.7*
MCHC-33.3 RDW-17.1* NEUTS-69.1 LYMPHS-17.9* MONOS-7.1 EOS-5.2*
BASOS-0.7
PT-15.2* PTT-29.9 INR(PT)-1.4*
[**2118-9-7**] 11:00AM ASCITES WBC-[**Numeric Identifier 16243**]* RBC-3375* Polys-72*
Lymphs-2* Monos-0 Mesothe-2* Macroph-24*
ASCITES TotPro-1.4 LD(LDH)-123 Albumin-<1.0
ASCITES WBC-265* RBC-1650* Polys-2* Lymphs-17* Monos-63*
Mesothe-5* Macroph-13*
Urine Culture positive for enterococcus from [**9-23**] for which she
received 10 day course of linezolid
Discharge Labs: [**2118-10-11**]
WBC-5.1 RBC-3.16* Hgb-10.2* Hct-28.5* MCV-90 MCH-32.2*
MCHC-35.7*
RDW-16.6* Plt Ct-145*
PT-12.7 PTT-24.2 INR(PT)-1.1
Glucose-112* UreaN-51* Creat-3.3* Na-133 K-3.6 Cl-92* HCO3-30
AnGap-15
ALT-19 AST-13 AlkPhos-90 TotBili-2.4*
Albumin-3.4 Calcium-8.8 Phos-3.2 Mg-1.8
FK506-6.5
Brief Hospital Course:
Repeat ERCP was performed, which showed stones in the CBD, which
were removed and stent was replaced. Pt was placed on peri-ercp
cipro. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7925**] continued to rise despite ERCP, so US and MRCP
were performed, neither of which showed stones, strictures, or
any other sign of obstrustion. Therefore, persistent
bilirubinemia was attributed to underlying liver disease.
.
Pt had persistent ascites, and received paracentesis x4 during
admission. Before the second para the pt was complaining of RUQ
tenderness, nausea, and vomiting and fluid showed culture
negative SBP, despite treatment with peri-ERCP cipro. Pt was
started on ceftriaxone and eventually switched to po cipro with
negative surveillence taps x 2 and resolution of symptoms.
.
While being teated for SBP the pt developed acute renal failure
and urine soudium < 10 indicating a diagnosis of hepatorenal
syndrome. She was treated with albumin, midodrine, and
octreotide and creatine began to fall.
.
During this admission pt recieved Stress MIBI on [**2118-9-5**] as
routine pre-transplant cardiac screening since pt has hx of
angina with recent cath on [**2118-8-24**] showing the LAD had a
60%lesion at the first diagonal and the mid LCx had 70%
stenosis. Stress MIBI was normal. However, while on midodrine
therapy, which is known to cause vasospasm, pt complained of L
scapula pain radiating to L arm, EKG with ST elevation in avR
and ST depressions in II, V2-V6 and aVL. Troponin T elevated to
0.13. Diagnosed with NSTEMI. Repeat cardiac cath was again
negative for flow limiting disease, and NSTEMI was attributed to
mitodrine-induced coronary vasospasm.
.
Renal function declined precipitously and she shortly became
anuric and required hemodialysis for volume overload. A urine
culture was positive for VRE, and linezolid was started.
.
On [**9-22**], with a MELD of 44, Ms [**Known lastname 7086**] received an orthotopic
liver transplant. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see
operative report for details. Two [**Doctor Last Name 406**] drains were placed, 1
behind the right lobe of the liver and the second
behind the hilum. A right groin temporary dialysis line was
placed for ultrafiltration during surgery. She received standard
immunosuppression per protocol.
On POD 1 an U/S was obtained showing: No diastolic flow seen
within the main hepatic artery and branches. There are low peak
systolic arterial branch velocities measured in the liver
parenchyma. The findings raise concern for hepatic artery
stenosis, particularly given the liver donor age and status.
-Patent portal and hepatic veins.
On POD 2 another U/S of the liver was obtained with findings c/w
further decrease in the main hepatic arterial flow, with no
demonstrable flow during diastole. The peak systolic main
hepatic arterial flow has decreased compared to prior study from
1 day previously. Again, no intrahepatic arterial flow is
identified.
On [**9-23**] an arteriogram was obtained at the celiac trunk
demonstrating tortuous
proximal hepatic artery with some irregularity suggestive of
web-like
narrowing. Nonvisualization of the distal hepatic branches.
-Patent hepatic and portal veins.
She spent a total of 5 days in the ICU
She did not undergo any further procedures but was watched
carefully and by [**9-30**] (POD 8) liver U/s showed substantial
improvement of the intrahepatic arteries. Normal blood flow in
the portal veins and hepatic veins. There was right pleural
effusion, but no perihepatic collections.
Patient continued to c/o diffuse abdominal pain, seemingly focal
at the area of the drains.
On [**10-6**] (POD14) an abdominal CT was obtained due to bloody
drainage found in the JP drain (JP Hct 9%). Results were as
follows:
-In this study limited by lack of IV or oral contrast, there may
be a hematoma in the region of the portahepatis in this status
post liver transplant patient.
-Decreased ascites and improved splenomegaly.
-Small to moderate right pleural effusion.
During this time of higher blood concentration in drains she
underwent transfusion of 5 units of RBC's. She was also given
platelets x 6 to keep count around 100. The drainage eventually
became less bloody again and drain output dropped, however one
drain was left in at the time of discharge.
Glucose management was somewhat problem[**Name (NI) 115**] with elevated blood
sugars. She was followed by [**Last Name (un) **].
In additian renal followed as well as she required dialysis
pre-transplant, CVVH intra-op and in the ICU. Her creatinine
continue to trend down slowly and urine output was adequeat with
Lasix which will be continued at home. She has an appointment
with Nephrology as followup and labs will be followed by the
transplant clinic as well.
She was discharged home with VNA services for Drain care, blood
sugar amangement and medication teaching.
Medications on Admission:
1. Spironolactone 100 mg PO BID
2. Nitroglycerin 0.4 mg Sublingual Sublingual PRN
3. Furosemide 40 mg PO TID
4. Propranolol 20 mg PO BID
5. Omeprazole E.C. 20 mg PO BID.
6. HISS
7. Ursodiol 300 mg PO TID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
8. PredniSONE 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units
units Subcutaneous at bedtime.
Disp:*2 bottles* Refills:*2*
11. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Disp:*2 bottles* Refills:*2*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
14. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
15. Aspirin 81 mg PO Daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p OLT
Choledocholithiasis
Secondary diagnoses: Liver cirrhosis: Cryptogenic cirrhosis with
portal hypertension and known varices, portal gastropathy.
DM
chronic stable angina - s/p cath demonstrating 60% stenosis
of LAD and 70% stenosis of LCX
Discharge Condition:
good
Discharge Instructions:
Please call the transplant center ay [**Telephone/Fax (1) 673**] if you have
fevers >101.5, chills, nausea, vomiting, inability to take any
of your medications, jaundice, abdominal bloating, legs swollen,
shortness of breath, bleeding, incision
redness/bleeding/drainage.
Empty and record JP drain output. Bring record of output to
clinic. Change drressing once a day or more often as needed
[**Month (only) 116**] shower, pat incision dry
No heavy lifting
Labs every Monday and Thursday
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-13**] 3:20
X SUITE GI ROOMS Date/Time:[**2118-10-20**] 8:00
[**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2118-10-20**]
8:00
Nephrology, [**Hospital Ward Name 23**] Building [**Telephone/Fax (1) 60**], Wed [**11-16**], 1 PM
Completed by:[**2118-10-14**]
|
[
"414.01",
"455.5",
"428.0",
"250.52",
"567.23",
"362.01",
"574.50",
"285.1",
"571.5",
"572.3",
"572.4",
"401.9",
"569.84",
"447.1",
"998.12",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"51.87",
"51.88",
"37.22",
"54.91",
"39.95",
"99.04",
"45.24",
"88.55",
"99.06",
"38.93",
"00.14",
"99.05",
"00.93",
"38.95",
"88.47",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
11504, 11561
|
4845, 9811
|
322, 403
|
11851, 11858
|
3776, 4512
|
12394, 12844
|
3253, 3370
|
10066, 11481
|
11582, 11610
|
9837, 10043
|
11882, 12371
|
4528, 4822
|
3385, 3757
|
11631, 11830
|
247, 284
|
431, 2475
|
2497, 3119
|
3135, 3237
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,395
| 156,878
|
4752+55601
|
Discharge summary
|
report+addendum
|
Admission Date: [**2143-12-25**] Discharge Date: [**2143-12-29**]
Date of Birth: [**2081-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18988**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yo gentleman with history of DM type 2 with neuropathy,
retinopathy, gastroparesis, autonomic dysfunction, GERD, s/p
Nissen fundoplication CAD s/p CABG bought in by wife after
noting glucose greater than 900 at home. hyperglycemia. For
the past four days the patient believes his gastroparesis was
"acting up" with symptoms of epigastric abdominal pain and
nausea. No vomiting or diarrhea. Pt had poor appetite. He
also stopped taking his NPH insulin and stopped checking
fingerstick glucoses over this four day period. This AM check
his fingerstick and it was greater than 900 His finger sticks at
home were elevated bought by wife. Glucose 917, AG of 21. He
was started on insulin drip as well as D5 1/2 NS with 20 mEq
potassium. Over the next eight hours, the anion gap closed, and
glucose trended down to 406 and then to 327.
ROS: Intermittent chest pain for several years (see below for
cardiac history), worsened by exertion. Intermittent dyspnea on
exertion, gets dyspneic after crossing street and climbing
flight of stairs
No recent fevers or rash. No urinary complaints.
Past Medical History:
1. Hypertension.
2. Type 2 diabetes (last A1c 8.2 on [**8-/2142**]) complicated by
-retinopathy
-neuropathy.
-autonomic dysfunction, followed by Dr. [**First Name (STitle) **], on
fludrocortisone and midodrine
3. History of Nissen fundoplication for hiatal hernia in
[**2136**].
4. Gastroesophageal reflux disease symptoms, on proton pump
inhibitor.
5. Coronary artery disease, status post 4 vessel coronary
artery
bypass graft in [**2129**];
-last stress (pyrimadole-MIBI) in [**2139**] with no anginal symptoms
or EKG changes, no reversible defects
-echo in [**9-/2143**] LVEF>55%
-cath in [**2137-12-6**] showed native 3-vessel disease, patent
saphenous vein graft to third obtuse
marginal, first diagonal, and right posterior descending
artery, a patent left internal mammary artery with a distal
left anterior descending artery occlusion.
6. Ulcerative colitis times 15 years; recent endoscopy
showed gastritis in prepyloric region, colonoscopy was normal
to the cecum.
7. Autonomic d
Social History:
Recently retired related to health problems, lives with his wife
in [**Name (NI) **], [**First Name3 (LF) **] lives on [**Name (NI) 1456**], Distant tobacco, 2
drinks/day. No IVDU
Family History:
?
Physical Exam:
Gen: Well-appearing, speaking in full sentances, NAD
HEENT: MMM, EOM's full, PERRL
NECK: supple, no LAD, no carotid bruits
CV: normal s1 with physiologic split s2, not parvus or tardus,
no MRG
Pulm: CTAB
Abd: Firm, NT, ND, no HSM, BS+
Extrem: Warm, 1+ DP, PT pulses, [**Last Name (un) 19966**] toe deformity,
Neuro: Alert, oriented x3, CN's II-XII intact, decreased
sensation to light touch to knees Bilaterally.
Pertinent Results:
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2143-12-29**] 09:20AM 9.3 3.57* 12.2* 35.3* 99* 34.3* 34.7 12.8
283
[**2143-12-28**] 06:50AM 7.4 3.51* 12.1* 34.2* 97 34.4* 35.3* 12.4
246
[**2143-12-27**] 03:19AM 10.2 3.41* 11.9* 33.6* 99* 35.0* 35.4*
12.5 236
[**2143-12-26**] 02:31PM 32.2*
[**2143-12-26**] 06:05AM 12.1* 3.27* 11.7* 32.4*# 99* 35.8* 36.2*
13.0 247
[**2143-12-25**] 10:26AM 10.4 4.23* 14.5 43.7 103* 34.3* 33.2 12.6
311
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2143-12-29**] 09:20AM 204* 14 1.0 137 4.7 101 29 12
[**2143-12-28**] 06:50AM 89 13 0.8 137 3.8 101 27 13
[**2143-12-27**] 03:19AM 104 12 0.8 135 3.6 99 27 13
[**2143-12-26**] 02:31PM 192* 15 0.8 134 3.7 97 30 11
[**2143-12-26**] 06:05AM 133* 20 0.8 139 3.5 101 29 13
[**2143-12-26**] 12:08AM 310* 26* 1.0 139 3.9 102 32 9
[**2143-12-25**] 06:37PM 327* 31* 0.9 142 4.1 103 32 11
[**2143-12-25**] 04:25PM 420* 36* 1.0 144 4.3 104 31 13
[**2143-12-25**] 02:27PM 584* 40* 1.1 143 4.6 103 29 16
[**2143-12-25**] 10:26AM 964* 48* 1.5* 134 5.3* 86* 28 25*
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2143-12-25**] 10:26AM 20 20 358* 85 26 0.6
.
CE:
CK 358-->372
TnT .04--><.01
.
Acetone Osmolal
[**2143-12-25**] 10:26AM SMALL1 360*
.
ABD CT [**2143-12-25**]
IMPRESSION:
1. No evidence of acute pathology in the abdomen or pelvis.
2. Cholelithiasis without cholecystitis.
3. Multiple small retroperitoneal lymph nodes. Although these do
not meet CT criteria for pathologic enlargement they are new.
Six month follow up is recommended.
.
CXR:
IMPRESSION: No evidence of congestive heart failure or
pneumonia.
.
Brief Hospital Course:
62 year old diabetic gentleman with gastroparesis admitted with
extreme hyperglycemia and elevated anion gap. Differential is
hyperglycemic, hyperosmolar, non-ketotic syndrome vs. diabetic
ketoacidosis. Lack of ketones and the fact this is type II
diabetes favor the former diagnosis. No evidence of cardiac
insult or GI bleed. Pt was non-compliant with insulin over the
last five days. Currently, pt is feeling better . Other than
hyperglycemia (which is now much improved) no electrolyte
abnormalities. Pt not eating well, however, apparently from
gastroparesis
MICU Course - patient originally received 7 L fluids and started
on an insulin drip. His gap closed and he was restarted on NPH
and humalog and came off the insulin drip on day #2. His
nausea/vomiting were controlled well with ativan. His diet was
slowly advanced. He was started on a low dose captopril and
switched to lisinopril at time of discharge.
1) Hyperglycemia, pt diabetic, last A1c 8.2 in [**8-/2142**] - ,
arrived on insulin drip. This initially proved difficult to
control, got to 250 on the drip, gave 10 units humalog but then
rose to 400 after eating clears, it slowly got back t 150 a few
hours later. Gave NPH at lower dose and stopped drip. As the
patients ability to tolerate food improved, he was restarted on
his home regimen of NPH with humalog SS coverage. FS on floor
were 108-153-259(highest recorded)
.
2) Abd pain/nausea, CT of abdomen nl, likely from gastroparesis,
possibly viral. Pt c h/o gerd, nissen. Nausea controlled well
with ativan. He was restarted on his reglan. Tolerated PO diet
well.
.
3) CAD, ruled out for MI with 2 negative CE and no EKG changes.
Continue ASA and lipitor. Was not on BB on admission. Started
low dose ACE-I. Tolerated captopril 12.5 TID and switched to
Lisinopril 30mg daily at time of discharge-BP was well
controlled.
.
4) DM related complication
--Autonomic dysfunction, had been on
midodrine/fludrocortisone-these meds were held as was
hypertensive throughout his course requiring ACE-I. He tolerated
his ACE-I well. Retinopathy/neuropathy, no active issues,
however was evaluated by PT and deemed that due to his
neuropathy his gait was abnormal. PT recommended a walker for
all ambulation. PT provided walker for pt at time of discharge.
.
5) Neuropsych:Continued lamictal, venlafaxine.
.
6) Ulcerative colitis, no active issues:Continued sulfasalazine
.
.
Code: Full
.
Comm: [**Name (NI) 1123**] (wife) [**Telephone/Fax (1) 19967**]
Medications on Admission:
Meds on Transfer:
Lamotrigine 100 mg PO BID
Acetaminophen 325-650 mg PO Q4-6H:PRN
Lorazepam 0.5 mg IV Q4H:PRN nausea
Aspirin 81 mg PO DAILY
Metoclopramide 10 mg PO QIDACHS
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO Q12H
Captopril 12.5 mg PO TID
Dolasetron Mesylate 12.5 mg IV Q8H:PRN
FoLIC Acid 1 mg PO DAILY
SulfaSALAzine 500 mg PO BID
Heparin 5000 UNIT SC TID
Venlafaxine 150 mg PO DAILY
Hyoscyamine 0.125 mg SL TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual TID (3 times a day).
5. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: Please take 75U at breakfast and 35U
at dinner.
11. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
DM-Hyperglycemia
HTN
Neuropathy
gastroparesis
Discharge Condition:
Good
Discharge Instructions:
You must continue to check your finger sticks and take your
insulin daily to prevent further hospitalizations.
.
If you have any symptoms of hyperglycemia, nausea, vomiting,
sweating with significantly elevated blood sugar please call
your physician or go to the emergency room.
.
You should use the walker for all ambulation to prevent falls.
.
You were started on Lisinopril for your blood pressure. Do not
continue to take fludrocortisone or midodrine.
Followup Instructions:
Please call your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] at
[**Telephone/Fax (1) 19968**] for a follow up appointment in 2 weeks.
--Please call [**Hospital6 733**] clinic on Tuesday for a New
Patient appointment to obtain a new Primary Care Physician
[**Telephone/Fax (1) 250**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19969**], M.D. Phone:[**Telephone/Fax (1) 8139**]
Date/Time:[**2144-2-13**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2144-4-27**] 10:20
Completed by:[**2143-12-29**] Name: [**Known lastname 3297**],[**Known firstname **] Unit No: [**Numeric Identifier 3298**]
Admission Date: [**2143-12-25**] Discharge Date: [**2143-12-29**]
Date of Birth: [**2081-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3299**]
Addendum:
Pt also received the Pneumovac and Influenza Vaccine during this
hospitalization.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3300**] MD [**MD Number(1) 3301**]
Completed by:[**2143-12-29**]
|
[
"362.01",
"337.1",
"556.9",
"V15.81",
"250.52",
"V45.81",
"530.81",
"250.62",
"357.2",
"536.3",
"250.12"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10926, 11142
|
4862, 7224
|
332, 338
|
9189, 9196
|
3150, 4839
|
9700, 10903
|
2698, 2701
|
7821, 9019
|
9121, 9168
|
7372, 7372
|
9220, 9677
|
2716, 3131
|
279, 294
|
7238, 7346
|
366, 1464
|
1486, 2484
|
2500, 2682
|
7390, 7798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,179
| 181,250
|
31750
|
Discharge summary
|
report
|
Admission Date: [**2173-8-13**] Discharge Date: [**2173-8-28**]
Date of Birth: [**2107-7-1**] Sex: M
Service: SURGERY
Allergies:
Plavix / Aricept
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
1. Ischemic colitis versus necrosis versus colitis.
2. Incisional hernia.
3. Sepsis.
Major Surgical or Invasive Procedure:
1. Subtotal colectomy.
2. Ileostomy.
3. Ventral incisional hernia repair.
History of Present Illness:
Mr. [**Known lastname **] is a 66 year old Male with history of Parkinson's
disease, vascular dementia, CAD, DM, CVA, s/p suprapubic
catheter and recent SBO who was recently admitted to [**Hospital **]
hospital in both [**Month (only) 205**] and [**2173-7-21**] for UTI with lab data
revealing for Klebsiella and 2 species of Pseudomonas with
multiple resistances (see below). The patient was discharged
back to his nursing facility with ongoing treatment for
pseudomonas UTI with ciprofloxacin. Over the last 2 days the
patient has been noted to be increasingly lethargic at his
nursing facility. This a.m. the patient was very lethargic and
noted to be in respiratory distress with vomiting of coffee
ground emesis. The patient was brought to [**Hospital **] hospital where
peripheral pulses could not be detected. The patient underwent
rapid sequence intubation and was started on Levophed for
hypotension. No compressions were performed (using Versed, Succ,
Vecuronium), nadir blood pressure is not documented although SBP
of 70s with levophed reported by ED. ABG at [**Hospital **] hospital at
time of intubation/Code was 6.90/40/7/xx per report. The patient
was treated with Gentamycin 120mg IV x1, and Ceftriaxone 1gm IV
x1. The patient was transferred to [**Hospital1 18**] for ongoing management.
.
On arrival to the [**Hospital1 18**] ED the patient was intubated and initial
labs revealed ABG as follows: 7.12/32/248/11 with WBC of 29.5
(8% bandemia), transaminitis, ARF, lactate of 7.9 and K of 6.7.
NG lavage with 500cc revealed coffee ground fluid that did not
clear, no BRB. Patient with brown guaiac stool but no melena. In
the ED the patient was treated with Vancomycin 1gm x1, levophed
for BP. For his hyperkalemia the patient was managed with
insulin/D50, Calcium Chloride, Amp Bicarb.
Past Medical History:
Parkinson's Disease
Bipolar Disorder
History of CVA
s/p suprapubic catheter - changed [**2173-7-8**]
History of UTI - see below
CAD
DM
s/p recent small bowel obstruction [**2173-6-20**]
Social History:
Patient lives in a nursing facility secondary to Parkinson's and
Vascular Dementia
Family History:
non-contributory
Physical Exam:
The patient has no palpable pulse, no corneal reflexes, no
breath sounds, no audible heart sounds. The patient was
pronouced dead at 9 pm.
Pertinent Results:
[**2173-8-13**] 09:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2173-8-13**] 09:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2173-8-13**] 09:45AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2173-8-13**] 09:45AM PT-17.4* PTT-39.5* INR(PT)-1.6*
[**2173-8-13**] 09:45AM PLT COUNT-336
[**2173-8-13**] 09:45AM NEUTS-81* BANDS-8* LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-8-13**] 09:45AM WBC-29.5* RBC-2.57* HGB-8.7* HCT-26.6*
MCV-103* MCH-33.8* MCHC-32.7 RDW-13.6
[**2173-8-13**] 09:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-8-13**] 09:45AM CALCIUM-7.8* PHOSPHATE-9.1* MAGNESIUM-3.3*
[**2173-8-13**] 09:45AM cTropnT-0.01
[**2173-8-13**] 09:45AM LIPASE-25
[**2173-8-13**] 09:45AM ALT(SGPT)-200* AST(SGOT)-798* CK(CPK)-81 ALK
PHOS-115
[**2173-8-13**] 09:45AM GLUCOSE-77 UREA N-100* CREAT-4.2* SODIUM-140
POTASSIUM-6.7* CHLORIDE-111* TOTAL CO2-9* ANION GAP-27*
[**2173-8-13**] 09:51AM LACTATE-7.9*
MICRO
[**8-13**] PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
_______________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
[**8-13**] Blood: No growth
[**8-13**] Stool: C. Diff. neg.
[**8-14**] Wound: GRAM STAIN (Final [**2173-8-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2173-8-16**]):
A swab is not the optimal specimen collection to evaluate
body
fluids.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
2ND TYPE.
ANAEROBIC CULTURE (Final [**2173-8-20**]): NO ANAEROBES ISOLATED.
[**8-15**] Blood: no growth, no fungus, no mycobacteria
[**8-16**] BAL: GRAM STAIN (Final [**2173-8-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2173-8-21**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
[**Female First Name (un) **] (TORULOPSIS) GLABRATA. 10,000-100,000
ORGANISMS/ML..
Pathology
[**8-13**] I. Terminal ileum and right colon, ileocolectomy (A-G):
A. Segment of ileum with mucosal necrosis; mucosal necrosis
extends to proximal resection margin.
B. Segment of colon with focal mucosal necrosis; distal colonic
resection margin is free of necrosis.
C. Appendix: No diagnostic abnormalities recognized.
II. Sigmoid colon, partial colectomy (H-P):
Extensive mucosal necrosis and focal transmural necrosis;
stapled margin shows very focal superficial necrosis, while open
margin shows extensive mucosal necrosis.
III. Hernial sac, site unspecified (Q):
Dense fibrous tissue and fibroadipose tissue with chronic
inflammation and cautery effect consistent with hernial sac.
Note: The changes in the ileum and colon are consistent with an
ischemic etiology.
RADS
[**8-13**] CT ABD/PELVIS: CT ABDOMEN WITHOUT CONTRAST: Bibasilar
consolidation is noted at the bases bilaterally. There is no
evidence of pleural or pericardial effusion. Non-contrast
evaluation of the liver demonstrates no definite focal hepatic
lesion. The gallbladder, pancreas, and right adrenal gland
appear unremarkable. Patient is status post splenectomy.
Non-contrast evaluation of the kidneys demonstrate
hypoattenuating small cystic lesion projecting off the mid pole
of the right kidney. Scattered vascular renal calcifications
are noted bilaterally. Nodular enlargement of the left adrenal
gland is identified with attenuation characteristics which do
not meet the criteria for adenoma. An NG tube terminates within
the body of the stomach. There is diffuse atherosclerotic
calcification of the aorta and its branches without enlargement
of the aorta. Laxity of anterior abdominal wall musculature
allows anterior migration of loops of small bowel. No free air
or free fluid.
CT PELVIS WITHOUT CONTRAST: The colon is significantly dilated,
most
prominently in the transverse colon where it measures up to 8 cm
in diameter. The sigmoid colon demonstrates wall thickening and
significant pericolonic fat stranding without focal fluid
collection identified. No definite diverticuli to suggest
diverticulitis. Stool is seen within the sigmoid colon with a
prominent large focus of stool within a capacious rectum. No
pathologically enlarged lymph nodes are identified and there is
no evidence of free air or pneumatosis. A suprapubic catheter
is present within the bladder. The prostate demonstrates some
central calcification. Atherosclerotic changes of the iliac
system and its branches are noted with a left femoral bypass
graft in place.
Bone windows reveal no worrisome lytic or sclerotic lesions.
IMPRESSION:
1. Significant dilation of the colon, likely secondary to
mechanical
obstruction due to fecal impaction within a capacious rectum.
Thickening of the sigmoid colon with pericolonic fat stranding
worrisome for colitis (i.e., infectious or inflammatory or
ischemic).
2. Bibasilar pulmonary consolidation may represent atelectasis
or an acute infectious process/ aspiration.
3. Evidence of vasculopathy with significant atherosclerotic
change of the aorta and its branches with a left femoral stent
in place.
4. Nodular appearance to left adrenal gland cannot be
classified as adenoma.
[**8-13**] CT HEAD: FINDINGS: Age-related prominence of sulci and
ventricles is seen. Asymmetric bilateral patchy areas of low
attenuation are noted in the coronal radiata and periventricular
white matter, with no definite mass effect, likely representing
microangiopathic ischemic changes, however, vasogenic edema,
especially in the coronal radiata cannot be definitely excluded.
There is no midline shift, acute intra-axial hemorrhage or
abnormal extra-axial fluid collection is seen.
The soft tissues and orbits are grossly unremarkable. The
calvarium is
intact. Mastoids are clear, so are the visualized paranasal
sinuses.
Endotracheal tube is seen coursing through the mouth. There is
bilateral
vertebral artery calcification.
IMPRESSION:
1. Asymmetric patchy areas of hypoattenuation in the corona
radiata and
periventricular white matter, likely represents microangiopathic
ischemic
disease, however, vasogenic edema cannot be excluded especially
in the coronal
radiata.
[**8-16**] ECHO
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC
diameter
(1.5-2.5cm) with <50% decrease during respiration (estimated RAP
11-15mmHg).
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Mild-moderate
regional LV systolic dysfunction. No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior- hypo; mid inferior - hypo; basal inferolateral -
hypo; mid inferolateral - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral
annular
calcification. Mild to moderate ([**12-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
11-15mmHg.. Left ventricular wall thicknesses and cavity size
are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the basal half of the inferior
and inferolateral walls. The remaining segments contract
normally (LVEF = 40%). 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. Mild to
moderate ([**12-22**]+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction
suggestive of CAD. Mild-moderate mitral regurgitation suggestive
of papillary muscle dysfunction. No discrete vegetation
identified (does not exclude).
[**8-20**] MRI Brain:
FINDINGS: There is a moderately prominent degree of high FLAIR
signal within the white matter of both cerebral hemispheres,
with extension towards the region of the right frontal
parasagittal cortex. In conjunction with the provided history
of coronary artery disease and diabetes mellitus, these findings
are consistent with multiple areas of infarction. There are
probable multiple tiny areas of chronic infarction along the
inferolateral aspects of both cerebellar hemispheres. There is
mild global cerebral atrophy. There is elevated signal along
the intracranial course of the right internal carotid artery,
suggesting a more proximal extremely high-grade stenosis or near
occlusion of this vessel. Relatively normal flow void in the
right middle cerebral artery as well as right anterior cerebral
artery likely arises from collateral flow to these vascular
territories through the circle of [**Location (un) 431**] and
possibly retrograde flow through the ophthalmic artery as well.
There is extensive high T2 signal nearly filling the sphenoid
sinus, with
small fluid levels within both maxillary sinuses, and
essentially complete
loss of aeration of both mastoid sinuses. These findings, as
well as
extensive high signal within the nasal and oropharyngeal
airways, presumably relate to the intubated status of the
patient.
CONCLUSION:
1. Multiple areas of infarction of the brain.
2. More proximally situated high-grade stenosis or near
occlusion of the
right internal carotid artery, beyond the coverage of the
present head scan. If desired, the definition of the precise
area of vascular pathology could be achieved through followup MR
angiography, or more conveniently [**Name (NI) 13416**], as the latter
study could be performed at the bedside
TECHNIQUE: Diffusion-weighted MR scan.
FINDINGS: There are no areas of elevated signal on the trace
diffusion images to suggest a region of acute brain ischemia.
Brief Hospital Course:
The patient was transferred to [**Hospital1 18**] from [**Hospital **] hospital on
[**8-13**] for severe sepsis. The patient was intubated and
resuscitated before being brought to the OR for an exploratory
lapartomy. The patient was found to have an ischemic bowel,
resulting in a total colectomy and ileostomy. The patient was
then transferred to the SICU for post-operative care.
Neuro
The patient remained sedated postoperative while intubated. On
POD3, the patient was restarted on his home dose of Sinemet.
However, the patient still remained rigid for the first post-op
week. On POD7, the patient had an MRI of the head to assess for
anoxic brain injury. The MRI was found to be negative, The
patient was extubated on POD11 and on POD 13 was out of bed.
The patient was awake, oriented, and talking on POD14.
CV
Immediately post-op, the patient remained on a levophed and
vasopressin drip to maintain MAP>55. On POD2, both levophed and
vasopressin were weaned and the patient maintained a MAP>55 by
maintaining a CVP>10. The patient did not require pressors for
the remainder of his admission. On POD3, an trans-esophageal
ECHO was performed and the patient was found to have decreased
function of the left ventricle with an LVEF of 40%. No
vegetations were found, indicating a decreased possibility of an
embolic source of his ischmic bowel. As a result, the patient's
CVP was aggressively kept at 10-12. Post-operatively, the
patient had diabetes insipidus and requiring resuscitation fluid
to mainatain his CVP. After the first post-operative week, the
patient was able to maintain a good blood pressure with less
IVF.
Respiratory
The patient remained intubated until POD11. On POD3, the
patient was weaned off assist control and placed on pressure
support. The patient had a bronchoscopy which was consistent
with many secretions. The patient's respiratory status improved
s/p bronchscopy. The patient was further weaned to minimal
pressure support but was kept intubated due to respiratory
secretions. After discussion with the [**Hospital 228**] health care
proxy, it was decided that if he failed extubation he could be
re-intubated with the intention of placing a trach. The patient
was successfully extubated on POD11 and had minimal secretions.
The patient did not have a gag reflex, so a speech and swallow
evaluation was not needed.
GI
The patient remained NPO with NGT in place. The patient was
started on TPN. Tube feeds via the NGT were started on POD4.
Once the TF were advanced to goal, TPN was stopped. On POD4, the
ileostomy began to produce black-colored stool. GI was
consulted and did not recommend an endoscopy since there was a
low risk for upper GI bleed (the NGT output was clear). The
ileostomy then began to put out brown-colored stool. On POD13,
the ileostomy began to have an increased, oily output, which
coincided with the placement of the post-pyloric Dobhoff tube.
Tube feeds were changed to Peptamen.
Renal
Post-operatively, the patient was hypernatremic and had
increased urine output. Nephrology was consulted and the
patient was found to have diabetes insipidus, possibly secondary
to his home lithium. The patient was started on D5W to correct
his sodium. D5 1/2NS was also started as maintenance fluid to
slowly correct the patient's water deficit and to keep his CVP
>10. The patient continued to have a large urine output during
his ICU course. By POD 13, the patient's urine output began to
slow and his sodium has been stable.
FEN
Postoperatively, the patient was started on TPN. on POD4, tube
feeds were started and were quickly advanced to goal. TPN was
stopped. Immediately after extubation, tube feeds were held for
aspiration precautions. On POD14, TF were restarted (Peptamen)
and were advanced to goal.
ENDO
The patient was initially started on an insulin drip immediately
post-op. The patient was then switched to an insulin SS and had
good control of his Type 2 DM.
HEME
On POD0, the patient received 2u PRBCs, another 2u PRBCs on
POD1, and 2u FFP on POD1. The patient maintained a stable
hematocrit during his admission. The patient was started on Hep
SQ for DVT prophylaxis.
ID
Post-operatively, the patient received
ampicillin/levofloxacin/flagyl. Antibiotics were changed to
meropenem, vancomycin, aztreonam, and flagyl. ID was consulted
on POD2. A TEE was performed to rule out an embolic source.
The initial urine culture was consistent with pseudomonas.
Subsequent urine cultures and blood culures were negative.
After ID consult, antibiotic coverage was changed to Zosun,
Flagyl, and Vancomycin. The initial urine psuedomonas was
sensitive to the Zosyn. The patient had a negative C. diff.
since his admission. The broncho-alveolar lavage on POD3 was
positive for [**Female First Name (un) **] (TORULOPSIS) GLABRATA. The patient
remained afebrile during his admission and antibiotics were
discontinued on POD13. The pathology for the resection colon
was consistent with ischemic bowel and not C. Diff. colitis.
Post-operatively, the patient's lactate levels fell back to
normal.
On [**8-29**] the patient was noticed to have a large upper GI bleed.
The Gi team saw the patient and performed an endoscope,
identifying active bleeding. The family was contact[**Name (NI) **] and
agreed to no further aggressive measures. The patient was made
CMO and eventually passed away at 9pm.
Medications on Admission:
Medications: at nursing facility
Lithium 300mg PO bid
Exelon 3mg PO bid
Glyburide 2.5mg PO daily
ISS
Sinemet 25/100 PO tid
ASA 81mg PO daily
Lopressor 25mg PO bid
Ciproflox 500mg daily x 7 days
Namenda 5mg qah
Lisinopril 10mg PO qhs
Bupropion SR 150mg daily
Dulcolax PRN
Discharge Disposition:
Expired
Discharge Diagnosis:
Duodenal ulcer
Discharge Condition:
expired
Discharge Instructions:
Patient has passed away
Followup Instructions:
none
|
[
"557.9",
"785.52",
"599.0",
"250.00",
"553.21",
"332.0",
"532.40",
"253.5",
"038.9",
"584.9",
"414.01",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.79",
"53.51",
"46.21",
"96.6",
"33.24",
"96.72",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
19491, 19500
|
13768, 19169
|
360, 436
|
19559, 19569
|
2790, 8722
|
19641, 19649
|
2597, 2615
|
19521, 19538
|
19195, 19468
|
19593, 19618
|
2630, 2771
|
235, 322
|
464, 2271
|
8731, 13745
|
2293, 2481
|
2497, 2581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,655
| 135,245
|
37629
|
Discharge summary
|
report
|
Admission Date: [**2168-1-12**] Discharge Date: [**2168-1-16**]
Date of Birth: [**2120-12-21**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin-D5w / Tegaderm Hydrocolloid
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
PICC removal with Interventional Radiology
History of Present Illness:
46M s/p MVC complicated by R tibial fracture [**9-21**] with non-[**Hospital1 **]
of fracture s/p multiple revisions and flap closure on IV
Daptomycin 600mg Qdaily at home (for isolated MRSA and
Enterobacter). He was to be switched to ORAL abx today in [**Hospital **]
clinic and but PICC line was not able to be removed at bedside.
He was sent to IR and per Dr. [**First Name (STitle) 6330**] (IR attending), the IR team
cannot remove the PICC line b/c there is adherent clot from site
of insertion at distal upper arm to axillary vein. Subclavian
vein is patent. Distal tip of the PICC was in the RIGHT
VENTRICLE upon initial eval today. It is now in the distal SVC,
and appears kinked which according to Dr. [**First Name (STitle) 6330**] is rather
atypical.
.
Per Dr. [**First Name (STitle) 6330**], Mr. [**Known lastname 449**] requires admission overnight to
initiate
UFH gtt because of the clot. Dr. [**First Name (STitle) 6330**] will ask her team to let
primary Medicine team know when to turn off heparin gtt tomorrow
in anticipation of repeat IR procedure to remove PICC. He may
require Vascular Surgery consultation.
.
Currently the patient is complaining of mild right sided
pleuritic chest pain. He does not feel short of breath, but does
say that he has been having this mild persistent chest
discomfort for several days now.
.
Past Medical History:
chronic pancreatitis
GERD
Right tibia fracture [**9-/2166**]
Social History:
Construction worker
Stopped smoking prior to non-[**Hospital1 **] repair on [**3-/2167**]
Family History:
non-contributory
Physical Exam:
Gen: AAOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: DPs, PTs 2+, the patient otherwise had a leg that
was bandaged and in external fixation w/ hardware in place and
not draining. picc in right upper extremity with erythema
sorrounding
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL..
Pertinent Results:
[**2168-1-12**] 08:49PM GLUCOSE-116* UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
[**2168-1-12**] 08:49PM estGFR-Using this
[**2168-1-12**] 08:49PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-1.5*
[**2168-1-12**] 08:49PM WBC-5.2 RBC-3.70*# HGB-11.4* HCT-32.9* MCV-89
MCH-30.7 MCHC-34.5 RDW-14.5
[**2168-1-12**] 08:49PM PLT COUNT-132*#
[**2168-1-12**] 08:49PM PT-13.0 PTT-24.1 INR(PT)-1.1
[**2168-1-16**] 07:00AM BLOOD WBC-2.8* RBC-3.52* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-129*
.
CTA [**1-12**] IMPRESSION: No pulmonary emboli. Non-occluding
thrombus surrounds central
cathether in SVC. Involvement of right brachiocephalic vein or
right atrium,
best evaluated son[**Name (NI) 5326**]
.
Echo [**2168-1-15**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. No
pulmonary hypertension seen.
Brief Hospital Course:
# DVT: The patient was discovered to have a DVT in the right
basilic vein circumferential to the right sided PICC line. This
was likely secondary to the patient recently having orthopedic
surgery. Even though the patient had been on lovenox for DVT
prophylaxis post surgery, the patient had approximately 2 weeks
where he was not on any anticoagulation prior to presentation.
Given bedside removal of the PICC was unsuccessful the patient
went to interventional radiology to have the PICC removed.
Orginally they were not successful, thus the patient was
admitted for a heparin drip while the interventional radiology
team consulted with the vascular surgery team as to the best
approach for PICC removal. Pt was taken down to the IR suite for
a subsequent attempt at removal of the PICC on [**1-14**] which was
again unsuccessful. At this time, a catheter was placed just
adjacent to the PICC for IV TPA infusion and after a third
attempt at removal, pt was admitted to the ICU for continued IV
TPA infusion and Q1 neuro checks. After receiving TPA overnight,
the patient was taken back to the IR suite and at this point the
PICC was removed without any problems. The patient went back to
the ICU for Q 1 hour neuro checks which were all negative. The
patient was eventually transferred back to the floor and was
observed overnight without any further events. The patient was
discharged on lovenox, for bridge to coumadin. Coumadin was
started and primary care doctor appointment was established for
Monday [**1-18**]. Patient was made aware as well as primary care
doctor office aware that coagulation panel would need to be
checked.
.
# Chest Pain: The patient had an ekg checked which was sinus
tachycardia. Given that the patient had pleuritic chest pain as
well as a known DVT that had undergone manipulation, the patient
had a CTA of the chest done and PE was ruled out. The patient
had resolution of the pain once he was placed back to his home
pain medication regimen of po dilaudid.
.
# Tib Fracture: The patient's tibia fracture was not an active
issue during this admission. Orthopedic team came by to evaluate
there patient. They checked a tib-fix x-ray which was stable
with slight increase in the callus formation across the bridging
fibular graft at the large gap fracture of the tibia.
.
# Leukopenia: Pt was noted to have a mild leukopenia that may be
related to new medication (Bactrim) started at [**Hospital **] clinic and his
ID provider was notified to ensure that this continues to be
monitored.
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily) for 4 weeks.
3. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
4. amitriptylin 25mg po qhs
5. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
Disp:*7 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*20 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
11. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): PLEASE FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR
FOR YOUR COAGULATION LABS.
Disp:*14 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
Deep Vein Thrombosis
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:
Deep Venous Thrombosis (DVT)
You have been diagnosed with a deep venous thrombosis (DVT). A
deep venous thrombosis is a blood clot that develops in one of
your veins. DVT??????s most commonly occur in your legs, but can
occur in other parts of your body. A DVT can partially or
totally prevent blood flow in the vessel and may cause other
serious complications.
Treatment
DVT??????s are treated with anticoagulants medications responsible
for thinning the blood and preventing further clot formation.
Initially, most patients are treated with coumadin and lovenox.
Coumadin is an oral medication that is typically taken daily and
is used for long-term prevention of blood clots. Lovenox is an
injectable medication taken either once or twice a day that is
used in the short-term while the coumadin level rises to an
effective level. Once the coumadin level is in the appropriate
range, the lovenox may be discontinued
Lovenox (enoxaparin)
* Lovenox (enoxaparin) is an injectable medication that treats
or prevents blood clots. You should take this medication as
prescribed by your doctor. This medicine is injectable and
should be given under the skin but not directly into the blood
stream. When injecting the medicine, use a different body area
each time. Use a new needle and syringe each time and dispose
of the needles/syringes properly.
* If you miss a dose, call your doctor [**First Name (Titles) **] [**Last Name (Titles) 57**]
* Follow the instructions given to you by your [**Last Name (Titles) 57**] on how
to properly store the medication.
Coumadin (warfarin)
* Coumadin is an oral mediation that treats or prevents blood
clots. You should take the medication as prescribed by your
doctor. You may take this medicine with or without food.
* If you miss a dose, take it as soon as you can unless it is
almost time for your next dose.
* When taking coumadin, you will need to have periodic blood
tests done to see if the medication is working properly to thin
your blood. You should contact your primary care provider as
soon as possible to schedule the necessary test.
Warnings for anticoagulant medications
You are at increased risk for bleeding and bruising while taking
these medications since they act to thin the blood.
Call your doctor or go to the emergency department for any of
the following:
* Blood in your urine
* Black or bloody stools
* Chest pain, shortness of breath or coughing up blood
* Fever
* Numbness or weakness in your arm or leg or on one side of you
body
* Sudden sever headache, problems with vision, speech or walking
* Vomiting up blood or coffee ground appearing material
arnings
Call your doctor or return to the emergency department for any
of the following:
* You begin bleeding that does not stop after holding pressure
on the source
* You experience new chest pain, pressure, squeezing or
tightness or develop difficulty breathing
* You have shaking chills, or a fever greater than 102 degrees
(F)
* New or worsening cough or wheezing or pain with taking deep
breaths.
* Abdominal (belly) pain, vomiting, severe headache.
* Dizziness, confusion or change in behavior.
* Any new symptoms that concern you.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Apartment Address(1) 84408**], STRATHAM,[**Numeric Identifier 84409**]
Phone: [**Telephone/Fax (1) 84410**]
Appointment: Monday Decemeber 6th, [**2167**] 11:30am
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR TO CHECK YOUR INR
AND YOUR COUMADIN LEVELS.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2168-2-3**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"287.49",
"996.74",
"E931.0",
"577.1",
"453.81",
"530.81",
"288.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.66"
] |
icd9pcs
|
[
[
[]
]
] |
8391, 8461
|
4164, 6687
|
304, 349
|
8526, 8526
|
2621, 4141
|
11902, 12689
|
1932, 1950
|
7180, 8368
|
8482, 8505
|
6713, 7157
|
8709, 11879
|
1965, 2602
|
261, 266
|
377, 1724
|
8541, 8685
|
1746, 1808
|
1824, 1916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,976
| 176,016
|
35272
|
Discharge summary
|
report
|
Admission Date: [**2199-1-31**] Discharge Date: [**2199-2-14**]
Date of Birth: [**2136-7-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
General surgery was consulted for sepsis, colitis
Major Surgical or Invasive Procedure:
[**2-1**]: Total abdominal colectomy with end ileostomy.
[**2-1**]: Reopening of recent laparotomy, oversewing of mesenteric
venous bleeder, placement of a vacuum dressing of about 50 cm2.
[**2-4**]: Re-exploration with removal of packs, replacement of GJ
feeding tube and closure of abdomen.
History of Present Illness:
Pt is a 62M with multiple medical problems who was recently
hospitalized (1/25-28/09) in the MICU for pneumonia, sepsis, and
C-Diff colitis. He was discharged on a course of Vancomycin IV
for MRSA pneumonia as well as PO vanco for the C Diff. [**1-31**] he
was noted to be febrile at his nursing home with mental status
changes. He was also hypotensive. He was transferred to the
[**Hospital1 18**] ED where he initially had a blood pressure of 66/38. His
IV access is extremely difficult and a R femoral CVL was placed.
He was volume resuscitated with 7L IVF and pressors were
started. Once he somewhat stabled a CT of the abdomen was
obtained demonstrating worsened distal colonic wall thickening
and edema.
The ED then requested this surgical consult.
No other HPI can be obtained given the patient's inability to
answer questions. Family reports the patient normally is able
to speak Spanish and understand English. The ED reports patient
answers questions in English by blinking eyes. Reportedly
patient had endorsed abdominal pain and was tender in the LLQ
for
the ED resident exams. Of note, a discharge summary is not yet
available from the recent hospitalization.
Past Medical History:
-Hypertension
-CVA: bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**]
-Type II Diabetes mellitus
-Peripheral neuropathy
-Constipation
-Dysphagia
-Depression
-Hypothyroidism
-h/o DVT
Social History:
Resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Family very involved in patient's
care. Patient does not take anything by mouth due to history of
aspiration. Spanish-speaking.
tobacco: quit [**2183**]. 30+ yrs, 2ppd.
alcohol: denies
drugs: denies
Family History:
mother - died, DM
father - died, Pneumonia
other - brother - heart disease
No family history of cancer.
Physical Exam:
On day of consultation:
Dopa 20mcg/kg/min Levo 0.27 mcg/kg/min
101.8 80 107/43 21 98% 4L ED I/O: 7L IVF/1L UO
Snoring. Does not arouse to voice or sternal rub
No jaundice or icterus
CTA B/L
RRR
Abd soft, non distended. unknown tenderness
R femoral groin line in place
Ext: All 4 extremities with severe contractures, cool, clammy
Pertinent Results:
[**1-31**] CT Abd / Pelvis
Interval worsening of distal colonic wall thickening and bowel
wall edema, which now extends from the rectum proximally to the
splenic flexure, compatible with proctocolitis. Findings are
likely secondary to an
infectious cause, especially in the context of the patient's
clinical history, but an inflammatory etiology is not excluded.
No evidence of perforation, or obstruction.
.
[**1-31**] Colonic Pathology
Pseudomembranous colitis involving the distal 25 cm of colon and
margin, consistent with C. difficile infection
.
[**2199-2-12**] 04:48AM BLOOD WBC-17.9* RBC-3.05* Hgb-9.0* Hct-27.0*
MCV-89 MCH-29.5 MCHC-33.3 RDW-16.2* Plt Ct-415
[**2199-2-10**] 04:14AM BLOOD Neuts-88* Bands-1 Lymphs-2* Monos-4 Eos-2
Baso-0 Atyps-1* Metas-1* Myelos-1*
[**2199-2-12**] 04:48AM BLOOD Glucose-148* UreaN-11 Creat-0.3* Na-137
K-4.3 Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
The patient was admitted to the ICU with a foley catheter in
place, IVF, NPO, central venous line, vasopressors as needed, IV
flagyl. There were increased pressor requirements and the
patient was taken emergently to the operating room for the above
procedure. He tolerated the procedure and was transferred to
the ICU intubated, on pressors, foley catheter in place, and IV
flagyl. He had increasing pressor requirements unresponsive to
fluid and packed red blood cells and the decision was made to
take him back to the operating room for re-exploration. A
bleeding vessel was noted, oversewn and the abdomen was left
open. He was again transferred to the ICU, intubated, on
minimal pressors, IV Flagyl, vanc enemas, zosyn, and sedation as
needed.
He continued intubated, on vanc, zosyn, and flagyl, IVF, NPO,
and supportive care in the ICU. Diuresis began [**2-4**] with IV
lasix. He returned to the ICU [**2-4**] for placement of a J tube
and closure of his abdominal wound. He remained intubated, IVF,
NPO, NGT and foley catheter in place, antibiotics.
[**2-5**] trophic tube feeds started
[**2-6**] continued abx, tube feeds, ventilatory management, NPO,
IVF, started lasix drip
[**2-7**] extubated, continued tube feeds, antibiotics, NPO, IVF
[**2-8**] advanced tube feeds towards goal of 70ml/hr, continued
diuresis with IV lasix prn, antibiotics, patient refused speech
and swallow evaluation
[**2-11**] transferred to the surgical floor for continued monitoring,
restarted coumadin dose, patient refused speech and swallow
consultation again
[**2-12**] discontinued antibiotics, continued tube feeds at goal
Medications on Admission:
1. Warfarin 5mg daily
2. Simvastatin 20mg daily
3. Cymbalta 60mg daily
4. Colace 150 mg/5 mL Liquid [**Hospital1 **]
5. Gabapentin 600mg TID
6. Morphine 15 mg q4hrs
7. Baclofen 20 mg QID
8. Mirtazapine 7.5 mg qHS
9. Lisinopril 5 mg daily
11. Insulin Sliding Scale with Novolin R 100 units/Ml Vial
12. milk of magnesia 30ml every other day
13. senna daily
14. Clopidogrel 75 mg daily
15. miralax 17gm daily
16. fentayl patch 25mcg q72 hrs
17. levothyroxine 25mcg daily
18. Multivitamin
19. reglan 5mg qhs
Vancomycin, both IV & PO completed on [**2199-1-22**]
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary:
Clostridium Difficile colitis s/p Total abdominal colectomy with
end ileostomy complicated by intra-abdominal hemorrage requiring
re-exploration
Secondary:
1. Multiple cerebral vascular accidents (dysarthria, dysphagia
[purees +TF] inability to walk)
2. Atrial fibrillation
3. Hypertension
4. Diabetes Mellitus
5. Depression
6. Neuropathic pain
7. Hyperlipidemia
8. GERD
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] to arrange a follow up
appointment in [**1-22**] weeks at [**Telephone/Fax (1) 80453**]
Previously Scheduled Appointments:
Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2199-3-11**] 8:30
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2199-3-11**] 10:00
Completed by:[**2199-2-14**]
|
[
"787.20",
"584.9",
"438.82",
"707.22",
"357.2",
"401.9",
"530.81",
"707.03",
"998.11",
"995.92",
"250.60",
"244.9",
"008.45",
"518.81",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"54.12",
"38.93",
"99.15",
"45.82",
"44.39",
"96.6",
"46.23"
] |
icd9pcs
|
[
[
[]
]
] |
6033, 6129
|
3793, 5424
|
364, 659
|
6562, 6571
|
2894, 3770
|
8503, 8942
|
2422, 2528
|
6150, 6541
|
5450, 6010
|
6595, 7741
|
7756, 8480
|
2543, 2875
|
275, 326
|
687, 1872
|
1894, 2106
|
2122, 2406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,856
| 189,083
|
42812
|
Discharge summary
|
report
|
Admission Date: [**2154-3-10**] Discharge Date: [**2154-3-22**]
Date of Birth: [**2118-7-7**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Spontaneous SAH
Major Surgical or Invasive Procedure:
[**2154-3-10**]: Cerebral angiogram with coiling
[**2154-3-10**]: Left EVD placement
[**2154-3-21**]: Left VP shunt placement
History of Present Illness:
35yoM with HA started 2d ago, seen at OSH ED yesterday dx
with sinusitis, headache had resolved per OSH records, negative
CT scan, pt refused spinal tap, sent home on amoxicillin. Today
sudden severe b/l frontal HA with LOC in bathroom, wife states
convulsive sz type activity few minutes. Ambulating when EMS
arrived per report. CTA at OSH today with ACA aneurysm +blood,
xfr to [**Hospital1 18**]. + emesis yesterday.
Past Medical History:
Unknown
Social History:
Unknown
Family History:
Unknown
Physical Exam:
On admission:
O: T: BP: 149/95 HR: 42 R O2Sats
Gen: lethargic, alert to name
HEENT: Pupils: equal, round, [**5-21**] b/l, disconjugate gaze
Not cooperative with exam
Moving all 4 extremities, antigravity
Remainder deferred for rapid intubation
Upon discharge:
Alert, oriented x3, following commands, MAE, affect-
frontal/childlike at times. Although oriented, has had times of
not knowing where he is. Difficulty with complex commands at
times- needs prompting. Incision is C/D/I.
Pertinent Results:
CTA Head [**2154-3-10**]:
There is a 6-mm aneurysm arising from the A2 segment of the left
anterior
cerebral artery. The neck of this aneurysm meausures 2-mm. The
petrous,
cavernous, and supraclinoid internal carotid arteries are of
normal course and caliber. The bilateral internal carotid
arteries as well as the middle and posterior cerebral arteries
are of normal course and caliber. The basilar and the vertebral
arteries are of normal course and caliber. No evidence of other
aneurysm, dissection or stenosis.
Interval development of right frontal intraparenchymal
hemorrhage
extending along the pericallosal region posteriorly as well as
intraventricular into the lateral ventricles, third ventricle,
and fourth
ventricle. There is mass effect over the frontal [**Doctor Last Name 534**] of the
right lateral
ventricle and a 7-mm midline shift to the left. Diffuse cerebral
edema, worse at the brainstem. Bilateral subarachnoid
hemorrhage.
CT Head [**2154-3-10**]:
IMPRESSION:
1. Stable right frontal and posterior pericallosal
intraparenchymal hemorrhage with worsening associated edema and
intraventricular extension with blood products more evident in
the lateral and fourth ventricles as well as into the
subarachnoid space.
2. Obliteration of supracellar cisterns concerning for
herniation.
ECHO [**2154-3-11**]:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified.
Head CT [**2154-3-11**]:
IMPRESSION:
1. Unchanged left transfrontal ventriculostomy drain. Persistent
large
amount of intraventricular hemorrhage, without evidence of
developing
hydrocephalus.
2. Persistent large amount of intraparenchymal hemorrhage along
the right
frontal lobe and also the pericallosal region. Slightly
decreased leftward
shift. Persistent mild effacement of the suprasellar cisterns,
again raising concern of possible herniation.
3. Interval placement of metallic aneurysmal coil in the
expected location of the left anterior cerebral artery. Please
refer to the operative note for further details.
Head CT [**2154-3-13**]:
IMPRESSION: Study, quite limited by poor vascular opacification,
with:
1. No specific evidence of vasospasm.
2. Stable right frontal parenchymal hemorrhage with
intraventricular
extension.
3. Minimal decrease (from 5 mm to 4 mm) in the leftward shift of
the midline structures.
4. Stable effacement of the suprasellar cisterns.
CXR [**3-16**]:
Cardiac size is normal. Widened mediastinum has improved.
Pulmonary edema
has resolved. There is no pneumothorax or large pleural
effusion. Right PICC tip is in the lower SVC. There is mild
vascular congestion.
LENIS [**3-18**]:
IMPRESSION:
1. No features to suggest thrombosis within the deep venous
structures of both lower extremities.
2. Note is made, however, of non-occlusive thrombus within
the right great saphenous vein which is classified as a
superficial vein.
Head CT [**3-21**]:
IMPRESSION:
1. Expected evolution of the right frontal intraparenchymal
hemorrhage
without evidence of new hemorrhage.
2. Redistribution of blood within the intraventricular and
subarachnoid
space.
3. Stable mass effect with sulci effacement and approximately 4
mm of
leftward shift of the midline structures.
Head CT [**3-22**]:
IMPRESSION:
1. No significant change in extent of right frontal
intraparenchymal
hemorrhage, intraventricular hemorrhage, and subarachnoid
hemorrhage.
2. Mild decrease in mass effect with leftward shift of the
normal midline
structures.
3. Stable opacification of the maxillary and ethmoid sinuses.
[**2154-3-22**] 06:04AM BLOOD WBC-15.4* RBC-4.31* Hgb-13.7* Hct-40.7
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.3 Plt Ct-271
[**2154-3-20**] 07:35PM BLOOD WBC-12.3* RBC-4.42* Hgb-14.2 Hct-41.5
MCV-94 MCH-32.2* MCHC-34.2 RDW-13.4 Plt Ct-250
[**2154-3-20**] 02:14AM BLOOD WBC-12.4* RBC-4.30* Hgb-13.7* Hct-39.8*
MCV-93 MCH-31.8 MCHC-34.4 RDW-13.4 Plt Ct-261
[**2154-3-19**] 02:28AM BLOOD WBC-13.6* RBC-4.53* Hgb-14.6 Hct-41.7
MCV-92 MCH-32.2* MCHC-35.0 RDW-13.6 Plt Ct-264
[**2154-3-22**] 06:04AM BLOOD Plt Ct-271
[**2154-3-19**] 02:28AM BLOOD PT-13.3* PTT-29.4 INR(PT)-1.2*
[**2154-3-22**] 06:04AM BLOOD Glucose-134* UreaN-14 Creat-0.5 Na-136
K-4.3 Cl-98 HCO3-29 AnGap-13
[**2154-3-20**] 07:35PM BLOOD Glucose-137* UreaN-15 Creat-0.6 Na-139
K-4.3 Cl-102 HCO3-29 AnGap-12
[**2154-3-20**] 02:14AM BLOOD Glucose-130* UreaN-19 Creat-0.5 Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
[**2154-3-19**] 02:28AM BLOOD Glucose-117* UreaN-16 Creat-0.6 Na-139
K-4.4 Cl-101 HCO3-30 AnGap-12
[**2154-3-22**] 06:04AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.1
[**2154-3-20**] 07:35PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1
[**2154-3-20**] 02:14AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1
[**2154-3-19**] 02:28AM BLOOD Calcium-9.7 Phos-4.9*
Brief Hospital Course:
35 y/o F with sudden onset of headache and LOC, ? of seizure.
CTA at OSH showed SAH and L ACA aneurysm. Patient was
transferred to [**Hospital1 **] for further neurosurgical intervention. On
arrival, patient was intubated for airway protection and EVD
placed for hydrocephalus. Patient was then taken to angiogram
where 3 coils were placed. He was taken to the ICU post
procedure for close monitoring. SBP was liberalized and cardiac
enzymes and ECHO were ordered to evaluate for sympathetic surge.
EF > 55% on ECHO.
Because of the difficulty of obtaining access in angio, Vascular
was involved and removed the sheaths on [**3-11**]. On [**3-12**], spiked
fever, cultures sent. TCDs from [**Date range (1) 23501**] have shown no
vasospasm. His exam has remained stable. On [**3-15**], his EVD was
raised to 15cm from 10cm.
[**Date range (1) 25049**] patient passed a speech eval for ground soulids and
thin liquids, his EVD was raised to 20cmo of water and he
tolerated that well.
[**3-18**] Evd clamping trial was initiated and he failed wihtin the
first hour.
VPS placement was arranged for [**3-21**] with general surgery to
assist. CSF was sent in preperation for the procedure which
remained negative. On [**3-20**] he was transferred to the Step Down
Unit where he remained stable.
On [**3-21**], he went to the OR for placement of his VP shunt. Post-op
he remained stable without changes. Post-op head CT was stable
with no hemorrhage and cath tip placement in the L lateral
ventricle. He was seen by PT/OT and rehab was recommended.
On [**3-22**], his exam was improved as he appeared clearer. A head CT
was done in preparation for discharge to once again confirm
placement of his shunt catheter. The CT head was stable. He was
discharged to rehab in the late afternoon.
Medications on Admission:
amoxicillin
ibuprofen
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours): Started on [**3-10**], please continue for total of 21 days.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache/pain.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-18**]
Tablets PO Q4H (every 4 hours) as needed for pain.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP>160.
11. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 92478**]
Discharge Diagnosis:
SAH
Left anterior cerebral artery aneursym
Hydrocephalus
Interventricular hemorrhage
Fever
Confusion
Intracerebral hemorrhage
Intraventricular hemorrhage
Venous thrombus / Right greater saphenous
Respiratory failure
Dysphagia requiring modified diet
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with an MRI/MRA
[**Doctor Last Name **] protocol. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Staple removal 14 day post-op.
Completed by:[**2154-3-22**]
|
[
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"431",
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"278.01",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.41",
"39.75",
"96.04",
"02.34",
"02.21",
"54.21",
"38.97",
"96.71",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
9886, 9933
|
6987, 8774
|
322, 450
|
10227, 10227
|
1513, 6964
|
12313, 12556
|
973, 982
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9954, 10206
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11397, 12290
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266, 284
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1271, 1494
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478, 901
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1011, 1255
|
10242, 10378
|
923, 932
|
948, 957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,453
| 147,041
|
1311+1312+55271+55272
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2112-1-26**] Discharge Date: [**2112-2-8**]
Date of Birth: [**2064-6-17**] Sex: M
Service: Medicine
DISCHARGE ADDENDUM: This is a 47 year-old Caucasian male with
history of HIV, hepatitis C, depression with suicidal ideation,
polysubstance abuse including alcohol, Klonopin and cocaine who
presents to the ED after being found beside a two foot wall in
[**Hospital1 8**], [**State 350**]. The patient apparently fell from the
wall and became unresponsive and was brought to the ED. He was
noted to have at that time a generalized tonic, clonic seizure.
The patient was treated with 14 milligrams of Ativan, Vecuronium,
Ceftriaxone and Dilantin. He was intubated also for airway
protection.
Head CT scan at that time demonstrated small left frontal and
lateral temporal subdural hematoma with left sylvian fissures,
subarachnoid hemorrhage as well as multiple facial fractures. The
patient was loaded on Dilantin, treated with Mannitol for
associated edema. At that time he was started on Neo-Synephrine
for transient post intubation hypertensive and admitted to the
ICU.
The patient was maintained on Ativan drip, Morphine drip,
Mannitol, and Dilantin. He was noted to be febrile and was
initiated on Levofloxacin and Flagyl for presumed aspiration
pneumonia on [**2112-1-27**].
The patient was seen by ophthalmology and plastic surgery for
orbital fractures and noted to have unequal pupils. Neurosurgery
had been consulted. There were no new changes on head CT scan.
The patient remained tachypneic, alkalotic on CPAP and he was
extubated with success on [**2112-1-29**].
The patient continued to have persistent fevers and
Infectious Disease consult was obtained.
PAST MEDICAL HISTORY:
1. HIV positive with CD4 count on [**2112-1-30**] of 96. The
patient known to be medically non-compliant but previously on
Nelfinavir.
2. HCV positive.
3. History of endocarditis related to cocaine approximately
17 years ago.
4. History of seizures felt secondary to benzodiazepine
withdraw.
5. Polysubstance abuse times 18 years including IV heroin,
cocaine, alcohol and Klonopin.
6. History of right deltoid abscess secondary to IM illicit
drug infection.
7. Depression with history of suicidal ideation.
8. Recent otitis media treated with Augmentin on admission.
9. Cognitive impairment at baseline.
MEDICATIONS ON ADMISSION:
1. Tylenol.
2. Klonopin prn.
SOCIAL HISTORY: Mr. [**Known lastname 8071**] is homeless and lives at [**Location 8072**]
House in [**Location (un) 86**] for now.
FAMILY HISTORY: Significant for alcohol abuse in father.
Differential diagnoses include drug seizure, alcohol
withdraw, myositis, sinusitis, meningitis, otitis media. The
patient also noted to be somnolent with impaired communication
status post extubation. Dilantin was temporarily discontinued on
[**2112-1-31**] for possible drug fever but on the following day the
patient had transient right sided arm and leg twitching
consistent with transient seizures. Dilantin was restarted per
neurology and neurology consult was obtained.
The patient continued to require high flow oxygen to maintain
saturations in the upper 90s and frequent suctioning for
respiratory secretions. At that time he was transferred to
the MICU service for persistent mental status changes, seizures
and oxygen requirement.
MICU course significant for LP on [**2112-2-2**] which showed the
following: Tube 1 had 700 red blood cells with 19 white blood
cells. Tube 4 with 550 red blood cells, 22 white blood cells,
protein was 57 with glucose 45. Gram stain fluid was negative
for organisms and crypto antigen was negative. Cultures following
were negative as well. It is unlikely that the LP findings were
more typical for possible subarachnoid hemorrhage rather than
acute meningitis.
Infectious Disease - Mr. [**Known lastname 8071**] continued to spike fevers up
to 102 degrees. On [**2112-1-27**] sputum grew the following sparse
grow of staphylococcus aureus coag positive which was resistant
only to penicillin. Cultures [**2112-2-2**] continued to grow
staphylococcus aureus and he was started on IV Oxicillin for
further gram positive coverage. Infectious Disease consult at
that time recommended Unasyn which was started on [**2112-2-6**] for
further broad range coverage.
On [**2112-2-7**] Mr. [**Known lastname 8071**]' BAL culture from his previous began to
grow methicillin resistant staphylococcus aureus. Oxicillin was
discontinued and Vancomycin was started at that time.
Respiratory - Mr. [**Known lastname 8071**] required high flow oxygen as stated
before. On [**2112-2-6**] he had acute hypoxic episode and was
emergently re-intubated. On [**2112-2-7**] oxygen saturation had
improved and he was extubated successfully. Overnight he has
required minimal suctioning.
Neurology - Neuro consult had the following: After seizures
that were present on day of admission with repeated seizures
on [**2112-1-31**] shortly after phenytoin was weaned secondary to
the possible drug fever.
On [**2112-2-5**] Mr. [**Known lastname 8071**] suffered another seizure which was
thought secondary to low Dilantin levels. Dilantin was reloaded
and serum levels of Dilantin have been followed since then.
Orthopedics / Plastics - Mr. [**Known lastname 8071**] is known to have several
facial fractures including right zygomatic, right interior
temporal, low lateral wall orbit and greater pterygoid [**Doctor First Name 362**]
fractures. Plastics has been following and is deferring further
surgeries at present. Mr. [**Known lastname 8071**] also wears a hard collar
secondary to inability to clinically clear his neck since
admission. MRI was not done for ligamentous injury within
the first three days of admission and thus he will require six
weeks of C-spine stabilization.
Access - A PIC line was placed on [**2112-2-2**]. At this time
he will be transferred to [**Location (un) 2655**] Medicine Firm for further
management of his multiple problems.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2112-2-8**] 14:09
T: [**2112-2-10**] 10:11
JOB#: [**Job Number 8074**]
Admission Date: [**2112-1-26**] Discharge Date: [**2112-2-18**]
Date of Birth: [**2064-6-17**] Sex: M
Service: [**Hospital1 212**]
NOTE: This is a discharge addendum from [**2112-2-8**] to [**2112-2-18**].
As a brief review, this is a 47-year-old Caucasian male with
a history of human immunodeficiency virus, hepatitis C,
depression with suicidal ideation, polysubstance abuse who was
found down at the side of a 2 foot wall with non responsiveness.
He was in the Medical Intensive Care Unit for approximately two
weeks, at which time he was transferred on [**2112-2-8**] to CC7 for
further management.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: Mr. [**Known lastname 8071**] continues treatment with
Staphylococcus aureus pneumonia as well as sinusitis in human
immunodeficiency virus setting. The Vancomycin was started
on [**2112-2-7**] and it will be continued for two weeks. The
Unasyn was started two days prior to that and will need to be
continued for 21 days. In the interim, Mr. [**Known lastname 8071**] continues
to spike fevers up to 102.8??????. All blood, urine, fungal
isolators have been negative. CT of the head was repeated x2
which showed mild resolution of the sinusitis. LP was
attempted on [**2112-2-16**], but no fluid was able to be procured.
His fevers have been attributed to possible Dilantin drug
fever and he was thus changed to Trileptal for his seizures.
However, he continues to spike fevers every two to three days.
Other sources of fever include his subdural hemorrhage which is
like the current source. His fever could also be because of
subdural hematoma, Methicillin resistant Staphylococcus aureus
pneumonia or sinusitis which are the likely the sources at this
time.
2. NEUROLOGIC: As stated above, Mr. [**Known lastname 8071**] was weaned off
Dilantin and changed to Trileptal for seizure prophylaxis. He
has had no further seizures. His neurologic exam has remained
unchanged with the exception of occasional purposeful movement.
He remains talkative, but it seems that his language is
complicated with some degree of dysarthria. Mr. [**Known lastname 8071**]' speech
is garbled and incoherent.
3. RESPIRATORY: Mr. [**Known lastname 8071**] continues to be unable to protect
his airway against his secretions. He continues to have no gag
reflex. He does occasional desaturate on room air and on oxygen
secondary to mucous plugging, but improved significantly with
deep suction. Chest x-ray on [**2112-2-15**] showed marked improvement
of his Methicillin resistant Staphylococcus aureus pneumonia.
There was interval involvement of the costophrenic angles with
new possible bilateral pleural effusions. Decubitus chest x-rays
were done which showed no layering of the fluid and thus
thoracentesis was not attempted. He is currently saturating 97%
on room air.
4. FLUIDS, ELECTROLYTES AND NUTRITION: Mr. [**Known lastname 8071**] has
nasogastric tube for tube feeds. He may need PEG placement at
some point in the setting of his sinusitis. However, this has
been deferred secondary to the lack of guardianship.
DISPOSITION: Mr. [**Known lastname 8071**] is full code. He is undergoing
application for a medical guardianship. The first hearing will
be on [**2112-2-19**].
DISCHARGE MEDICATIONS:
1. Scopolamine patch 1.5 mg TP q 72 hours
2. Colace 100 mg po bid
3. Trileptal 900 mg po bid
4. Unasyn 3 gm intravenous q6h until at least [**2112-2-27**]
5. Vancomycin 1 gm q 12 hours until [**2112-2-20**]
6. Respalor 55 cc per hour every hour for 24 hours a day
7. Albuterol nebulizers q 2 to 4 hours prn
8. Atrovent nebulizers q 2 to 4 hours prn
9. Haldol 1 to 2 mg intravenous q 6 to 8 hours prn
10. Tylenol 325 to 650 mg po q 4 to 6 hours prn
11. Ativan 0.5 to 1 mg intravenous/po q 4 to 6 hours prn
12. Nystatin swish and swallow 10 cc po qid
DISCHARGE DIAGNOSES:
1. Subdural hematoma
2. Subarachnoid hematoma
3. Human immunodeficiency virus positive
4. HCV positive
5. History of endocarditis
6. History of seizures
7. Polysubstance abuse
8. History of right deltoid abscess
9. History of depression with suicidal ideation
10. Altered mental status
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2112-2-18**] 11:52
T: [**2112-2-18**] 12:40
JOB#: [**Job Number 8075**]
Name: [**Known lastname 1028**], [**Known firstname **] Unit No: [**Numeric Identifier 1029**]
Admission Date: [**2112-1-26**] Discharge Date: [**2112-3-1**]
Date of Birth: [**2064-6-17**] Sex: M
Service:
ADDENDUM: Over the weekend of [**2-27**] and [**2-28**],
Mr. [**Known lastname **] continued to have altered mental status but was
otherwise stable.
On [**Last Name (LF) 228**], [**2-29**], he went to the Endoscopy Suite where a
percutaneous endoscopic gastrostomy feeding tube was placed.
During the evening of [**2-29**] the feeding tube was used for
medications without incident.
On the morning of [**3-1**], the Gastrointestinal team advised
that the tube was okay for feeding. Mr. [**Known lastname **] was now
stable for discharge to a nursing facility.
DISCHARGE STATUS: To nursing facility.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE: (As detailed in previous Discharge
Summary).
[**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**]
Dictated By:[**Last Name (NamePattern1) 1032**]
MEDQUIST36
D: [**2112-3-1**] 23:39
T: [**2112-3-1**] 16:17
JOB#: [**Job Number 1033**]
Name: [**Known lastname 1028**], [**Known firstname **] Unit No: [**Numeric Identifier 1029**]
Admission Date: [**2112-1-26**] Discharge Date: [**2112-3-1**]
Date of Birth: [**2064-6-17**] Sex: M
Service: Medicine
DISCHARGE SUMMARY ADDENDUM: The patient will not be discharged
for at least a few more days. This is a discharge addendum from
previous discharge summary completed one week prior. In the
intervening week Mr. [**Known lastname **] has remained stable.
REVIEW: This is a 47 year-old Caucasian male with HIV who was
found down near a wall and found to have subdural and
subarachnoid hemorrhages present. The patient seized in the ED
and since has had an eventful ICU course. The patient was called
out to the medical service in early [**Month (only) 880**] and has remained on
this service for the past three weeks.
1. INFECTIOUS DISEASE - Mr. [**Known lastname **] has been afebrile since the
Dilantin has been discontinued. His fever was likely secondary
to drug fever rather than infectious etiology. However other
sources of fever have included his subdural / subarachnoid
hemorrhage, sinusitis and MRSA pneumonia. He has completed a two
week course of Vancomycin for MRSA pneumonia and a three week
course of Unasyn for sinusitis.
2. NEUROLOGIC - Mr. [**Known lastname **] continues to have altered mental
status which waxes and wanes. He is occasionally increasingly
agitated which requires Ativan, Haldol and occasional Trazodone.
His altered mental status is likely secondary to his intracranial
bleed with closed head injury, seizures, recent infection, and
possibly HIV encephalopathy.
3. PULMONARY - Mr. [**Known lastname **] has been treated for a MRSA
pneumonia. He is currently stable on room air.
4. GASTROINTESTINAL - Mr. [**Known lastname **] will require PEG tube
placement by GI. He failed swallow study on [**2112-2-25**] and was
noted to frankly aspirate without coughing. He currently has NG
tube and gets tube feeds at goal - 55 cc an hour.
DISPOSITION: Mr. [**Known lastname **] had a guardianship hearing on
[**2112-2-26**] and a guardian was appointed. This guardian will need
to be contact[**Name (NI) **] for further procedures such as PEG tube
placement. At this time he will need to undergo a screening for
nursing home placement. He is currently full code.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Name8 (MD) 1037**]
MEDQUIST36
D: [**2112-2-27**] 14:54
T: [**2112-2-29**] 09:42
JOB#: [**Job Number 1038**]
|
[
"802.4",
"802.8",
"507.0",
"780.39",
"V08",
"E884.9",
"305.90",
"801.26",
"473.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"96.71",
"43.11",
"96.04",
"03.31",
"96.56",
"33.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2556, 6852
|
10094, 11480
|
9514, 10073
|
11558, 14473
|
2372, 2404
|
6870, 9491
|
11495, 11531
|
1732, 2346
|
2422, 2539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,410
| 100,771
|
8041
|
Discharge summary
|
report
|
Admission Date: [**2129-7-14**] Discharge Date: [**2129-7-19**]
Date of Birth: [**2063-7-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine / Steri-Strip / Adhesive
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent Right pleural Effusion
Major Surgical or Invasive Procedure:
[**2129-7-19**] Right VATS total pulmonary decortication and
parietal pleurectomy.
History of Present Illness:
Mrs. [**Known lastname 28673**] is a 65-year-old woman with a previous history of
Hodgkin lymphoma, who was noted to have dyspnea and found to
have a large, slightly loculated right pleural effusion. This
was incompletely drained. s/p Right video-assisted thoracoscopic
surgery drainage of pleural effusion, pleural biopsy, lysis of
adhesions and removal of clotted hemothorax on [**2129-6-24**]. She
still feels short of breath and using home O2 1 L. She also
complains of night sweat, intermittent cough, no hemoptysis.
Pathology of pleura biopsy no evidence of malignancy. She is
being admitted for right decortication and parietal pleurectomy.
Past Medical History:
Coronary artery disease - MI in [**2122**] s/p stents X3
CABG w/ mitral valve repair in [**2127-3-2**]
Insulin-dependent Type 2 DM
Hypothyroidism
GERD w/ Barrett's esophagitis
Hodgkin's disease s/p XRT
Splenectomy in [**2093**]
Social History:
Lives at home alone - divorced, independent ADLs, works as a
software trainer. Daughter lives nearby
Denies tobacco, alcohol or drugs.
Family History:
Sister with coronary artery dises (MI/CABG) and Type 2 Diabetes
Mellitus
Physical Exam:
VS: T: 98.7 HR: 99 SBP: 108/71 Sats: 95% RA 89-92
w/ambulation
Genera: 65 year-old female in no apparent distress
HEENT: mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: decreased breath sounds throughout
GI: benign
Extre: warm no edema
Incision: Right VATS site clean no drainage
Skin: multiple tape burns
Neuro: non-focal
Pertinent Results:
[**2129-7-19**] WBC-11.2* RBC-3.33* Hgb-8.8* Hct-28.0 Plt Ct-376
[**2129-7-18**] WBC-12.7* RBC-3.19* Hgb-8.7* Hct-27.3 Plt Ct-346
[**2129-7-14**] WBC-15.6*# RBC-4.17* Hgb-11.1* Hct-33.3 Plt Ct-432
[**2129-7-19**] Glucose-176* UreaN-13 Creat-0.7 Na-137 K-4.2 Cl-101
HCO3-31
[**2129-7-14**] Glucose-198* UreaN-19 Creat-0.8 Na-135 K-5.8* Cl-105
HCO3-23
[**2129-7-14**] Glucose-136*
CXR:
[**2129-7-19**] There is no pneumothorax. Unchanged bilateral pleural
effusions
and associated bibasilar atelectasis.
[**2129-7-18**] the right-sided chest tube has been removed. A second
basal right-sided chest tube is in unchanged position. There
might be a minimal right upper air inclusion. The large
pneumothorax is not seen. Unchanged pleural fluid accumulation
in the right hemithorax. The left lung shows a slightly improved
ventilation. The right-sided central venous access line is
unchanged in course and position.
08/16/09The more lateral right-sided chest tube has been
removed. There remains a right apical chest tube. No appreciable
pneumothorax is seen. There remain pleural effusions
bilaterally. There is mild atelectasis within the right mid lung
zone.
[**2129-7-15**] Appearances are stable with remaining small loculated
right pneumothorax and bibasilar pleural effusions.
Brief Hospital Course:
Mrs. [**Known lastname 28673**] was admitted on [**2129-7-14**] for Right VATS total
pulmonary decortication and parietal pleurectomy. She was
transferred to SICU intubated. A bedside echocardiogram
revealed low cardiac output. A central line was placed to
monitor volume status. She was transfused 1 unit of PRBC for
HCT of 26. and administered a fluid challenge with a good
response. On [**2129-7-15**] she was extubated. On [**2129-7-17**] she
transferred to the floor.
Respiratory: Once extubated her oxygen saturations were in the
high 90's on nasal cannula. Aggressive pulmonary toilet & IS
were continued. Her RA oxygen saturations at rest were 94-96%,
on ambulation 89-92%. She was discharged to home on 1 Liter
nasal cannula with ambulation as needed.
Chest tubes; Once the chest tube air-leak resolved the chest
tubes were removed on: [**2129-7-16**] Apical ant chest tube removed,
[**2129-7-18**] Post Apical Chest tube removed. The [**2129-7-19**] the
basilar chest tube was removed. She was followed by serial
chest films. The right pneumothorax resolved. Small bilateral
lower lobe effusion
and atelectasis remain.
Cardiac: She was in sinus rhythm throughout. Her cardiac
medications were restarted immediately. Plavix was restarted on
[**2129-7-17**].
GI: no issues.
Endocrine: She continued on insulin throughout her hospital
stay. The metformin was restarted once her PO intake improved.
FEN: Her lytes were repleted as needed. Tolerated a diabetic
diet.
Pain: An epidural was placed preoperative and managed my the
acute pain service. Immediately postoperatively the epidural was
stopped secondary to hypotension. She converted to a Dilaudid
PCA with good control then to PO pain meds.
Disposition: She was seen by physical therapy who deemed her
safe for home. She was discharged with VNA and home oxygen 1
Liter nasal cannula with ambulation.
Medications on Admission:
Levothyroxine 150 mcg daily, metoprolol succinate 25 mg daily,
clopidogrel 75 mg daily, folic acid 1 mg daily, metformin 1000mg
[**Hospital1 **],niaspan 500mg hs, omeprazole 20 mg [**Hospital1 **], aspirin 81 mg daily,
calcium citrate daily, thiamine 100 mg daily, crestor 40 mg
daily, insulin NPH & SS
Discharge Medications:
1. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
6. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Calcium Citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO
twice a day.
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous twice a day.
13. Insulin
Lispro sliding scale continue
14. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: take with food and water.
Disp:*90 Tablet(s)* Refills:*0*
15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Recurrent Right lower lobe effusion
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased cough, shortness of breath, or chest pain.
-Incision develops drainage
-Chest tube dressing remove tomorrow and cover site with a
bandaid
until healed
-You may shower tomorrow. No tub bathing or swimming for 3 weeks
-No driving while taking narcotics
-Take motrin with food and water for pain.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**8-2**] 9:30 am in the Chest
Disease Center, [**Hospital Ward Name 121**] Building [**Hospital1 **] I.
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
Department for a Chest X-Ray 45 minutes before your appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 9347**]
Completed by:[**2129-7-20**]
|
[
"412",
"201.90",
"244.9",
"998.0",
"V45.81",
"250.00",
"V58.67",
"E878.8",
"518.83",
"511.0",
"511.9",
"530.81",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.52",
"34.04",
"34.59"
] |
icd9pcs
|
[
[
[]
]
] |
6797, 6860
|
3281, 5170
|
331, 417
|
6940, 6949
|
1975, 3258
|
7411, 7862
|
1517, 1591
|
5523, 6774
|
6881, 6919
|
5196, 5500
|
6973, 7388
|
1606, 1956
|
259, 293
|
445, 1096
|
1118, 1348
|
1364, 1501
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,517
| 169,594
|
48365
|
Discharge summary
|
report
|
Admission Date: [**2165-8-27**] Discharge Date: [**2165-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Shortness of breath/hypoxia
Major Surgical or Invasive Procedure:
Right subclavian central line placement.
History of Present Illness:
[**Age over 90 **] year-old male nursing home resident with a history of
coronary artery disease, atonic bladder, left and right hip
fractures with right hip
replacement and colon cancer, who presents with shortness of
breath and hypoxia. At the nursing home, he had cough,
shortness of breath, hypoxia, and cyanosis of lips. His vital
signs were temperature 102.4, oxygen saturation 75% on room air
and 84% on 5 L nasal cannula. It was thought that he had flash
pulmonary edema for which he received lasix 20 mg, 1 inch
nitropaste, oxygen, nebulizers followed by an additional 40 mg
Lasix, 0.5 inch nitropaste and 40 mg Lasix). In the [**Hospital1 18**] ED,
He was febrile and hypotensive with an elevated white count, and
elevated lactate. He was started on the Sepsis protocol and
received ceftriaxone, Vancomycin, and levofloxacin 250 mg.
Past Medical History:
- Dementia.
- Coronary artery disease, status post anterior ST
elevation MI in [**2162-12-25**]. Echocardiogram at the time
showed mild left atrial enlargement, mild left ventricular
hypertrophy, and an ejection fraction of 60%.
Catheterization showed LAD 50% stenosis with a patent stent
(placed in [**2160**]).
- Atonic bladder.
- Status post left hip fracture in [**2154**].
- Status post right hip replacement in [**2161**].
- Colon cancer, status post right hemicolectomy.
- BPH (UTIs, urosepsis in [**2162-4-24**], E. coli).
- Skin cancer.
Social History:
The patient lives in a nursing home. He quit smoking 30 years
ago and does not drink alcohol.
Family History:
Non-contributatory
Physical Exam:
Vitals: T 102, 99/58, 80, 24, 100% NRB
Elderly, responsive to some verbal commands
PERRL, MM dry. No dentition
No JVD or LAD.
Distant HS
Rhonchorous BS, R>L
S/NT/ND
LE w/o edema. Weak pulses. Cold extremities.
Skin with numerous excoriations.
Pertinent Results:
[**Age over 90 **]|103|27/151
4.0|25|2.0\
13.4>42.5<189
N:94.5 B:0 L:2.5 M:2.6 E:0.3 Bas:0.1
PT:13.3 PTT:25.1 INR:1.2
CK:81 MB:not done Trop-T:0.09
Lactate:4.3
CXR: Vague opacity of the right middle lobe, for which a
developing pneumonia cannot be excluded.
EKG: Atrial fibrillation with rate 111.
Brief Hospital Course:
[**Age over 90 **] year-old male nursing home resident admitted for sepsis
secondary to pneumonia.
.
1. Sepsis: The likely source of his sepsis is pneumonia. On
arrival to the ICU, he was hypotensive with a MAP betweem 55-60.
He required 5 liters of normal saline to maintain his CVP >
[**9-4**] in the first 12 hours. His cortisol stimulation test
showed adequate response. His initial venous saturation were
slightly low, indication a cardiogenic component to his
hypotension. He was started on an ionotrope because of the risk
of peripheral vasodilation. His venous saturation improved to
greated than 70 within the first 6-8 hours of admission. After
the first day of hospitalization, he did not require any fluid
boluses to maintain is blood pressure. For his pneumonia, he
was initially started on empiric antibiotic coverage with
vancomycin, zosyn, and azithromycin. Once sputum cultures were
negative for 48 hours and urinary legionella antigen was
negative, he was switched to a less broad regimen of ceftriaxone
and azithromycin to complete a 10 day course. He initially
required non-rebreather to maintain his oxygenation but was
weaned as tolerated to 2 -3 L via NC. He was transferred to the
floor, and there recieved chest physical therapy in addition to
the above until his d/c back to his nursing home on [**2165-9-3**].
.
2. Atrial fibrillation: He does not have history of atrial
fibrillation and it was probably induced by the acute infection.
He returned to [**Location 213**] sinus rhythm during the first
hospilization day. He was not started on anticoagulation given
his fall risk.
.
3. Elevated troponin: His troponin was likely elevated due to
demand ischemia in the setting of hypotension. His CKs remained
flat. He was maintain on aspirin.\
.
4. Dementia/Agitation: Initially, he was not repeatedly
following commands. His mental status improved by hospital day
2 and he was appropriately answering questions and following
commands. At night, he occasionally became agitated requiring
zyprexa.
.
5. FEN: He was initially NPO given his mental status. Once his
mental status improved, he had a bedside speech and swallow and
was cleared for pureed solids and thin liquids with aspiration
precautions. He was maintained on maintenence fluids while he
was NPO. His magnesium, potassium, and calcium were repleted.
Medications on Admission:
PPI
Trazodone 25 qhs
ASA 325
Citalopram
Vit B12
Enulose
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
for SBP<100 or P<65.
7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for agitation, insomnia.
8. Trazodone 50 mg Tablet Sig: one-half Tablet PO at bedtime as
needed for insomnia.
9. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Enulose 10 g/15 mL Solution Sig: One (1) PO three times a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pneumonia
Septic Shock
....
dementia
CAD s/p MI
BPH
Discharge Condition:
stable - satting 93% on 3L NC. tolerating small amounts of PO.
Discharge Instructions:
Please return if you experience shortness of breath, chest pain,
fever> 101.5 or any other worrisome symptoms.
.
Please take all medications as directed. You have been started
on antibiotics; please take the full course, even if you feel
better sooner.
.
You received Pneumovax while hospitalized. Please let Dr.
[**Last Name (STitle) 5351**] know.
Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) 5351**] within the next one week.
Please call [**Telephone/Fax (1) **] to arrange an appointment.
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5992, 6062
|
2535, 4895
|
289, 331
|
6158, 6224
|
2207, 2512
|
6623, 6776
|
1908, 1928
|
5001, 5969
|
6083, 6137
|
4921, 4978
|
6248, 6600
|
1943, 2188
|
222, 251
|
359, 1208
|
1230, 1779
|
1795, 1892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,445
| 183,334
|
51117
|
Discharge summary
|
report
|
Admission Date: [**2184-10-27**] Discharge Date: [**2184-10-30**]
Date of Birth: [**2110-3-15**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This patient is a 74-year-old
man with a history of lung cancer and coronary artery
disease, who underwent an esophagogastroduodenoscopy at an
outside institution to assess chronic abdominal pain. During
that study, the patient developed acute pulmonary edema which
required treatment with Morphine and Lasix. He was admitted,
had an echocardiogram which revealed an interval decrease of
ejection fraction to 15-20% from a previous echocardiogram
showing "preserved ejection fraction."
Subsequently, the patient underwent a stress test showing
apical and inferior perfusion defects. Diagnostic
catheterization was performed which showed multivessel
coronary artery disease including a 45% left main lesion, 70%
mid left anterior descending artery, and 95% proximal right
coronary artery, and 80% mid right coronary artery lesions.
He was then transferred to [**Hospital1 188**] for intervention.
Upon transfer to [**Hospital1 69**], the
patient immediately went to the cardiac catheterization
laboratory. A left ventriculogram revealed a left
ventricular ejection fraction of 30%, coronary angiography
revealed a right dominant system with a 40% left main
coronary artery lesion, 70% proximal left anterior descending
artery lesion, normal circumflex, and a 90% distal right
coronary artery lesion. Patient underwent rotablation and
stenting of the proximal right coronary artery lesion and
stenting of the distal lesion.
Catheterization was complicated by postprocedural
hypertension requiring dopamine for maintenance of pressure.
He was then transferred to the CCU for further management.
Of note, the patient had also recently undergone workup for
hypotension and has been tentatively diagnosed with autonomic
dysfunction being treated with midodrine and Florinef. The
autonomic dysfunction was thought to be secondary to his
diabetes. At the time of admission to the CCU, the patient
was pain free without complaints.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
in [**2177**] with ejection fraction of 15-20%.
2. Hypertension.
3. Type 2 diabetes on insulin.
4. Chronic pancreatitis.
5. Lung cancer Stage III status post right pneumonectomy and
chemotherapy.
6. Patient with negative bone scan in [**10-31**].
7. Monoclonal gammopathy of uncertain significance.
8. Status post cholecystectomy.
SOCIAL HISTORY: The patient is a former engineer at [**Hospital6 14475**]. He is married.
ALLERGIES: Penicillin, cephalosporins, Pravachol, Zestril,
Fosamax.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Creon with meals.
3. Protonix 40 mg q day.
4. NPH insulin 12 units q am, 8 units q pm.
5. Diovan 40 mg q day.
6. Lopressor 25 mg [**Hospital1 **].
7. Florinef 0.1 mg [**Hospital1 **].
8. Flovent 220 mcg three puffs [**Hospital1 **].
9. Lasix 40 mg q day.
EXAMINATION ON ADMISSION TO THE CCU: The patient's heart
rate was in the 120s. Blood pressure 108/60 on 3 mcg of
dopamine. O2 sat was 97% on 3 liters. In general, he was
alert and oriented times three in no acute distress. Jugular
venous pressure was at 8 cm. His lungs revealed decreased
breath sounds on the right status post pneumonectomy. He had
crackles at the base on the left side. His heart examination
was tachycardic with a normal S1, S2. No murmurs were noted.
Abdomen was soft and nontender with a well-healed incision
from a pneumonectomy. Extremities were without peripheral
edema.
HOSPITAL COURSE:
1. Cardiovascular.
A: Coronary artery disease. The patient underwent cardiac
catheterization as described in history of present illness,
and was brought to the Coronary Care Unit. Transient
requiring dopamine for maintenance of blood pressure.
Dopamine was weaned over the first few hours upon arrival to
the CCU. For his coronary artery disease, he was continued
on aspirin and Plavix. His groin site from the
catheterization was stable without any development of
hematoma or bruit.
As his blood pressure tolerated, he was begun on Lopressor
12.5 mg [**Hospital1 **], which was increased to 25 mg in the morning and
12.5 in the evening. On the day of discharge, he was
continued on aspirin and Plavix.
B: Pump. Patient underwent echocardiography to evaluate his
left ventricular function postcatheterization.
Echocardiogram revealed an ejection fraction of 20% with
severely depressed overall left ventricular systolic function
with inferior and septal hypo or akinesis. It was noted that
the RV cavity as well as the right atrium were compressed
likely by the liver, edge of the right lung. This
compression produced 16 mm Hg gradient across the tricuspid
valve. The patient was also noted to have 1+ mitral
regurgitation.
He was diuresed with Lasix prn for heart failure and was
loaded on digoxin with 0.25 mg q6h x4, and begun on a daily
regimen of 0.125 mg. At the time of discharge, he was
increased to 0.25 mg and further diuresis was held to ensure
adequate preload given the compression of the right atrium.
C: Rhythm. Again the patient was begun on Lopressor as
above, and he was in sinus rhythm throughout his
hospitalization.
2. Hypotension: Excluding the initial postcatheterization
hypotension requiring dopamine, the patient's systolic blood
pressures were maintained in the 80s-90s for the first day of
his admission which then came up to the systolics in the 1
teens to 130s. He was continued on his midodrine and
Florinef without any evidence of orthostasis with ambulation.
3. Pulmonary: The patient was on oxygen by nasal cannula and
titrated to keep oxygen saturations greater than 92%. At the
time of discharge, he was requiring no oxygen and was sating
all on room air.
4. Endocrine: The patient is type 2 diabetic on standing
doses of insulin. Once he was taking po, following
catheterization, he was reinstituted on his outpatient doses
of NPH insulin and covered with sliding scale of regular
insulin. He had good glycemic control throughout his
hospitalization.
5. Gastrointestinal: Chronic pancreatitis. The patient was
continued on his pancreatic enzyme replacement of Creon with
meals and was given Protonix.
6. Asthma: The patient was continued on his outpatient
inhalers including Flovent and salmeterol. He tolerated the
beta blocker well with no exacerbations of his asthma during
his hospitalization.
FOLLOWUP: The patient is instructed to followup with Dr.
[**Last Name (STitle) 11679**] this week. He will call to make an appointment,
([**Telephone/Fax (1) 5455**]. After evaluation by physical therapy, the
patient was deemed safe to return to home and he was
discharged to home in stable condition.
DISCHARGE DIAGNOSES:
1. Multivessel coronary artery disease status post stenting
of the right coronary artery with rotablation of the proximal
lesion and stenting of the proximal end distal lesions.
2. Stage III lung cancer status post right pneumonectomy.
3. Orthostatic hypotension.
4. Type 2 diabetes.
5. Chronic pancreatitis.
6. Asthma.
DISCHARGE MEDICATIONS:
1. Digoxin 0.25 mg po q day.
2. Midodrine 10 mg po tid.
3. Florinef 0.1 mg po bid.
4. Salmeterol 1-2 puffs [**Hospital1 **].
5. NPH insulin 12 units q am, 8 units q pm.
6. Lopressor 25 mg q am, 12.5 mg po q pm.
7. Protonix 40 mg q day.
8. Creon two caps po qid with meals.
9. Plavix 75 mg po q day.
10. Aspirin 325 mg po q day.
11. Flovent 220 mcg three puffs [**Hospital1 **].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2184-10-30**] 16:09
T: [**2184-11-3**] 05:32
JOB#: [**Job Number **]
|
[
"428.0",
"427.89",
"250.00",
"493.90",
"273.1",
"414.01",
"458.2",
"424.0",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.55",
"36.06",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6793, 7114
|
7137, 7739
|
2702, 3580
|
3597, 6772
|
163, 2098
|
2120, 2513
|
2530, 2676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,300
| 105,633
|
42846
|
Discharge summary
|
report
|
Admission Date: [**2111-11-25**] Discharge Date: [**2111-12-9**]
Date of Birth: [**2028-5-11**] Sex: F
Service: MEDICINE
Allergies:
aspirin / Lactose
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hypoxia/Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83F history of CAD CHF presenting from a nursing facility with
hypoxia to the 70s. She is baseline dementia and is not
complaining of any pain. She is alert and oriented to self only
but will answer questions.
Overall, history is unclear, since patient is unable to provide
detailed history. Per ED, she was sent from a nursing facility
with hypoxia into 70s.
Her nephew reports that about a week ago she was at [**Hospital 26260**]
hospital with some "discomfort", unclear exactly what it was,
however. He reported that she was going to undergo a cardiac
catherization, but this did not happen for some reason. Since
then she has been living at [**Doctor First Name 4233**] house by herself and not
having any major concerns. She did have a cough that he noted
today only, but not clear how long that this has been going on.
In the ED, initial vs were: Temp of 101.4, Tachycardic into
120s, blood pressure in 80s, a central line was placed into her
groin, given that she was not cooperative with other access
sites, and she was started on norepinephrine for blood pressure
support after getting 2Liters of NS IV. UA was notable for Hazy
urine, with neg Leuk, WBC 10, few Bact, No epis, and negative
for Nitrites. Labs were notable for WBC 18.6, with 82%Neuts, 1
band, 10Lymphs. Troponin <0.01. An EKG showed sinus tachycardia
at HR of 120, QTc of 456, Normal Axis. No concerning ST changes.
Urine culture was sent off. Patient was given Vancomycin, Zosyn
Past Medical History:
Memory impairment
Microcytic anemia
Absolute glaucoma of right eye
Not Taking Medication as Directed
Bullous Keratopathy
PSEUDOPHAKIA
GLAUCOMA - PRIMARY OPEN ANGLE
TOBACCO DEPENDENCE
Social History:
Obtained from Patient, and Atrius OMR)
Grew up in [**Doctor First Name 26692**], moved to MA 20 years ago permanently,
also lived in [**Location 92535**]. Her husband was from MA. Married in the
[**2059**], deceased in [**2089**] (she is not sure of details). No
children of her own but many nieces and nephews. Lives in
apartment with kitchenette, is a senior building, no communal
meals. They bring her meals for lunch and dinner.
Current Everyday Smoker -- 0.2 packs/day for 60 years
ETOH only socially; rarely
Family History:
Sister heart disease, Tuberculosis,
Father - CAD, PVD
Physical Exam:
Admission:
VS: T: 97.3, P: 131, RR: 27, BP: 155/93, 100% on 4L NC
Gen: NAD, comfortable, coughing intermittently
HEENT: OP clear, dry MM
Neck: supple, no LAD
CV: RRR, S1/S2, no MRG appreciated
Lungs: CTAB, no w/r/r
Abd: soft, NT, ND, NABS
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Skin: wound on back
Pertinent Results:
Admission labs:
[**2111-11-24**] 11:00PM BLOOD WBC-18.6* RBC-4.57 Hgb-10.8* Hct-33.0*
MCV-72* MCH-23.7* MCHC-32.7 RDW-13.6 Plt Ct-200
[**2111-11-24**] 11:00PM BLOOD Neuts-82* Bands-1 Lymphs-10* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2111-11-25**] 06:32AM BLOOD PT-14.4* PTT-38.6* INR(PT)-1.3*
[**2111-11-24**] 11:00PM BLOOD Glucose-137* UreaN-17 Creat-1.0 Na-143
K-3.6 Cl-105 HCO3-27 AnGap-15
[**2111-11-24**] 11:00PM BLOOD ALT-14 AST-29 AlkPhos-62 TotBili-0.8
DirBili-0.2 IndBili-0.6
[**2111-11-24**] 11:00PM BLOOD cTropnT-<0.01
[**2111-11-24**] 11:00PM BLOOD proBNP-518
[**2111-11-25**] 06:32AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8
[**2111-11-24**] 11:28PM BLOOD Glucose-134* Lactate-1.6 K-3.5
[**2111-11-25**] CT CHEST
1. No evidence of acute aortic syndrome or acute pulmonary
embolus.
2. Soft tissue density nodal mass surrounding the right lower
lobe bronchus and [**Last Name (LF) 56207**], [**First Name3 (LF) **] be infectious in nature or may
represent a neoplasm. Right lower lobe consolidation is present,
which may represent post-obstructive changes, infection in the
appropriate clinical setting or aspiration.
3. Markedely enlarged thryoid gland with multple hypodense
lesions, consider thyroid unltrasound exam for further
assessment.
4. Prominent centrilobular emphysema involving primarily upper
lobes.
5. A 6-mm endobronchial lesion at the left main bronchus, may
represent an
endobronchial neoplasm, hamartoma and small mucous nodele.
6. Intrahepatic biliary ductal dilatation. Gallbladder is
distended without gallbladder wall thickening or pericholecystic
fluid collection.
7. Left renal cysts.
Brief Hospital Course:
83F history of CAD CHF presenting from a nursing facility with
hypoxia to the 70s, hypotension, fever of 101.4, and
leukocytosis. Initially admitted to the MICU, started on empiric
treatment for HCAP and COPD exacerbation. She showed some signs
of improvement at times throughout her course, but experienced
numerous setbacks, including intermittent tachycardia,
hypotension, guaic positive stool concerning for an acute GI
bleed, and acute encephalopathy. She then had profound
respiratory decompensation on [**2111-12-7**]. This resulted in a
shift in the focus of care to comfort-centered care. She passed
away peacefully at 04:26 am on [**2111-12-9**]. Please [**Last Name 788**] problem
summaries below for further details on the antecedent causes of
her death.
# Acute hypercarbic respiratory failure: found around 11 AM on
[**12-7**] to be unresponsive to sternal rub or nailbed pressure.
She was tachypneic, but actually less so than her baseline, and
O2 sats were also baseline. ABG obtained showing pH 7.03, pCO2
138. Started on BiPAP briefly while we contact[**Name (NI) **] her nephew
[**Name (NI) **], who decided upon arrival to change her care to comfort
measures only (CMO). In terms of the etiology of her
decompensation, this is still not entirely clear. The family
has granted an autopsy, which may help provide some information.
# Pneumonia: Presented with new infiltrates on CXR and CT chest,
consistent with possible post-obstructive type pneumonia in RLL
due to RLL bronchus mass vs. HAP/HCAP. She was started initially
on Vancomycin and Pip/Tazo in the ED, added azithromycin in MICU
for atypical coverage. Urine legionella negative. Infiltrates
improved on CXR and CT chest, however she is still required O2
and was perstently tachypneic. Switched to linezolid [**12-1**] from
vanco, given ?VRE UTI and persistently low vanco troughs. She
was on day 13 of antibiotics when she decompensated (see above).
# Severe COPD exacerbation: Respiratory status worsened by
presumed COPD exacerbation, which left her quite wheezy, "tight"
and tachypneic nearly all the time. She was started on steroids
at 40 mg qday, which we began to taper after 5 days. She was
also given nebulizers around the clock and continued on her
advair.
# Lung mass: soft tissue mass suspicious for lung CA seen on CT
on admission here. Obtained records from [**Location (un) 1121**] with CT
read-- can see the mass encasing the RLL bronchus and the
endobronchial lesion in left bronchus. Repeated non-contrast
chest CT done [**12-1**], no significant changes to the mass or the
degree of bronchus constriction. Her family was originally
interested in pursuing a diagnosis on this mass, but it was felt
that a biopsy would not be worth the risk during her acute
illness, especially given that she was on plavix for a recent
medically-managemed NSTEMI. Futher work up was deferred, but
knowledge of this lesion helped play a role in the family's
decision to ultimately make her CMO.
Medications on Admission:
None Per chart. One note mentions the following medications:
Latanoprost (XALATAN) 0.005 % Ophthalmic Drops 1 drop to both
eyes at bedtime
Brinzolamide (AZOPT) 1 % Ophthalmic Drops, Suspension 1 drop to
both eyes two times daily
Methazolamide 25 mg Oral Tablet 1 tablet daily
Methazolamide 25 mg Oral Tablet TAKE 1 TABLET TWICE A DAY FOR 3
MONTHS
Brimonidine 0.2 % Ophthalmic Drops INSTILL 1 DROP IN THE LEFT
EYE TWICE DAILY
Brinzolamide (AZOPT) 1 % Ophthalmic Drops, Suspension INSTILL 1
DROP TO LEFT EYE TWO TIMES DAILY (AZOPT) [3 MONTH SUPPLY]
Latanoprost (XALATAN) 0.005 % Ophthalmic Drops Instill 1 drop in
left eye at bedtime/ generic
Brimonidine 0.2 % Ophthalmic Drops INSTILL ONE DROP INTO BOTH
EYES TWICE DAILY
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute hypercarbic respiratory failure
Severe COPD exacerbation
Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"276.0",
"570",
"294.20",
"485",
"161.0",
"458.9",
"V09.80",
"707.8",
"578.1",
"584.9",
"518.81",
"491.21",
"V66.7",
"799.4",
"348.31",
"599.0",
"519.19",
"788.20",
"428.30",
"V49.86",
"410.72",
"V49.87",
"041.04",
"428.0",
"401.9",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8508, 8517
|
4709, 7706
|
300, 306
|
8633, 8642
|
3057, 3057
|
8698, 8708
|
2549, 2606
|
8476, 8485
|
8538, 8612
|
7732, 8453
|
8666, 8675
|
2621, 3038
|
240, 262
|
334, 1795
|
3073, 4686
|
1817, 2001
|
2017, 2533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,956
| 104,972
|
41740
|
Discharge summary
|
report
|
Admission Date: [**2158-12-26**] Discharge Date: [**2158-12-30**]
Date of Birth: [**2109-5-21**] Sex: M
Service: MEDICINE
Allergies:
naproxen / penicillin G
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 yo male w/ EtOH cirrhosis with h/o multiple prior upper GI
bleeds from esophageal and gastric ulcers transferred from [**Hospital1 **] with hematemesis. Patient has a history of medication
non-compliance and per notes continues to drink EtOH. He was
transferred From [**Hospital3 **] after an EGD there did not
achieve adequate hemostasis.
Patient tells me got up this morning around 8am, had a vitamin
shake with ensure, that he usually takes three times a day. Then
went to the shower, and after felt a bit "queazy", and thats
when he vomited out the milkshake, but no blood, just food. Then
got dressed, sat down, and 1/2 hour later stared feeling
nauseated, went to the brathroom, and that's when blood came out
- not as much as last time, but about [**1-8**] a pint - bright red
blood. No diarrhea, had a normal bowel movement last night,
muddy dark look to the stool.
Since last admission he had several small episodes of emesis,
but no new bleeding since EGD.
In terms of drinking, had not had a drink in a week in a half.
He had episodes of withdrawal when he was drinking in the past.
But had no withdrawal episodes lately.
He is otherwise complaint-free, thirsty and hungry.
At [**Hospital1 **], he was admitted to the MICU, given D5NS, potassium, at
100cc/hr. He was seen by GI - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was started on
octreotide drip, protonix IV BID, received FFP and vitamin K.
Was deemed hemodynamicallly stable for transfer to [**Hospital1 18**].
Of note, he was recently transferred from [**Hospital1 **] to [**Hospital1 18**] at
beginning of [**Month (only) **] for the same indication. At that time he
was intubated, with active bleeding, thought to be arterial at
GE junction. He had an EGD here. Patient was treated with
octreotide drip for 72 hours and [**Hospital1 **] iv pantoprazole. Pt was
given cipro 500mg [**Hospital1 **], with plan for 1 week course. Pt had
repeat EGD showing 3 grade [**1-8**] esophageal varices. Overlying one
of the varices was a linear ulcer with 3 clips distally. No
active bleeding. Few other smaller ulcers at
GEJ that looked like peptic injury. Stomach filled with food and
old blood which obscured view. No active bleeding. There was
some evidence of protal HTN gastropathy in body/fundus. There
was a 4mm polyp at junction of duodenal sweep. No biopsies taken
because of recent significant GI bleed.
Patient reports that he was doing well since discharge.
Prior to transfer, patient was noted to have some hives on his
chest -for this he was given solumedrol, also given ativan 1mg
for anxiety.
On arrival, the vitals were - afebrile, HR 103, BP 170/85 99% on
Room air.
Past Medical History:
(per OSH chart):
- EtOH and Hep C cirrhosis, c/b varices w/ variceal bleeds,
ascites
- Hypertension
- hyperlipidemia
- Diabetes
- Hemochromatosis
- Anxiety
- EtOH abuse
- ostearthritis
- Depression
- Peripheral vascular disease
Social History:
graduated from [**Last Name (un) 90683**] [**Location (un) **], former financial manager,
but is currently unemployed. Lives with a roommate. Divorced.
Has been to rehab before (Garcenold, [**Doctor Last Name **] Point, [**Hospital1 **])
- Tobacco: No
- Alcohol: Currently denies actively drinking.
- Illicits: None.
Family History:
Has a maternal uncle who was an alcoholic. Paternal uncles were
also alcoholic.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 96.7, P: 101, BP: 170/85, RR: 16, 100% on RA
WD, WN, NAD, mild tremor that gets worse with movement.
HEENT: PERRLA, EOMI
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, mildly bulging flanks
without a fluid wave. Palpable liver tip and splenomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously, nonfocal grossly.
Gross intention tremor in upper extremities and upper body.
.
PHYSICAL EXAM ON DISCHARGE:
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no spider
angiomas
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no asterixis
Neuro: CNs2-12 intact, motor function grossly normal; A+O x3
Pertinent Results:
ADMISSION LABS:
[**2158-12-26**] 10:24PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.4* Hct-28.4*
MCV-90 MCH-29.8 MCHC-33.3 RDW-15.9* Plt Ct-34*#
[**2158-12-26**] 10:24PM BLOOD PT-15.2* PTT-33.8 INR(PT)-1.4*
[**2158-12-26**] 10:24PM BLOOD Glucose-152* UreaN-17 Creat-0.9 Na-137
K-4.2 Cl-97 HCO3-28 AnGap-16
[**2158-12-27**] 02:28AM BLOOD ALT-36 AST-86* AlkPhos-112 TotBili-4.8*
[**2158-12-26**] 10:24PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
DISCHARGE LABS:
[**2158-12-30**] 07:10AM BLOOD WBC-4.2 RBC-3.12* Hgb-9.5* Hct-28.6*
MCV-92 MCH-30.3 MCHC-33.1 RDW-16.6* Plt Ct-60*
[**2158-12-30**] 07:10AM BLOOD PT-17.8* PTT-32.8 INR(PT)-1.7*
[**2158-12-30**] 07:10AM BLOOD Glucose-96 UreaN-22* Creat-1.2 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
[**2158-12-30**] 07:10AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2
[**2158-12-30**] 07:10AM BLOOD ALT-28 AST-72* LD(LDH)-193 AlkPhos-91
TotBili-4.2*
EEC [**2158-12-27**]
Normal EEG in the waking state. There were no focal
abnormalities or epileptiform features.
CT HEAD W/O CONTRAST [**2158-12-27**]
No acute intracranial process. Chronic atrophy and microvascular
disease.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI
bleeds from esophageal varices and gastric ulcers transferred
from [**Hospital3 **] with hematemesis. His Hct was stable and
here he did not require further intervention. His course was
complicated by grand mal seizure (toxic/metabolic vs EtOH w/d).
He was discharged home with Hepatology and PCP [**Last Name (NamePattern4) 702**].
#) Upper GI bleed: due to sequelae of cirrhosis.
Had an episode of Upper GI bleed, was scoped at OSH, which
showed marked telangiectasia of R cardia, portal hypertension
gastropathy, initially increasing bleeding, with spurting of
blood. 5 clips were placed. At the end of procedure no active
bleeding was noted. Here, his hematocrit remained stable and he
had no episodes of further bleeding. H.Pylori was negative. He
was treated with pantoprazole and octreotide gtt. He was also
given ceftriaxone IV (switched to PO Cipro) for 1 week of
post-variceal bleed prophylaxis. Continued on Nadolol and PPI.
He was discharged home and will f/u for repeat EGD.
#) Seizure: Toxic/metabolic vs. EtOH withdrawal.
Patient had a tonic clonic seizure on [**2158-12-28**] at 0200 am. He
was given 2 mg IV ativan which resolved the seizure. Etiology
was thought to be alcohol withdrawal. He was seen by the
neurology service who recommended EEG and CT head which were
unremarkable. It was felt that the etiology was possibly EtOH
w/d (though per his report his last drink was 10 days prior),
vs. electrolyte disturbance (his Mg and K were low). He has no
further seizures and Neurology did not feel that he needed
further workup/follow-up.
#) Cirrhosis: due to EtOH/HCV.
He was followed by the Hepatology team while he was in house.
His diuretics were held in the setting of Cr above baseline. He
had no asterixis ro evidence of ascites at the time of
discharge. He was started on Lactulose and Rifaximin this
admission. He will have electrolytes checked [**Last Name (un) **] after d/c
which will be faxed to his Hepatologist, and he will f/u with
Hepatology [**Last Name (un) **] thereafter.
#) [**Last Name (un) **]: likely prerenal.
Cr at baseline is 0.8 but rose to 1.4. Responded to IV
fluid/albumin so hepatorenal syndrome unlikely. His diuretics
were held. Cr at discharge was 1.2. he will have
electrolytes/Cr checked soon after discharge, which will be
faxed to Hepatology.
#) Alcoholism: ongoing issue.
He does have baseline intentention tremor, without asterixis. He
was monitored on CIWA; did have a seizure this admission 9see
above). He was given daily thiamine/ folate/ multivitamin.
#)Anxiety/Depression: stable.
He was continued on home celexa 20 mg po daily.
#) Transitional issues
-PCP f/u: ten days after d/c (Dr. [**Last Name (STitle) 1693**], [**2158-1-9**])
Instructed to have CHEM10/LFTs/coags checked at that visit and
faxed to Dr. [**Last Name (STitle) **].
-next EGD: [**2158-1-16**]
-Hepatology f/u: [**2158-1-17**] Dr. [**Last Name (STitle) **] (diuretics may be restarted
then)
-pending labs/studies: none
Medications on Admission:
1. Celexa 20mg PO
2. Furosemide 40mg PO daily
3. Magnesium tablet 1 PO daily
4. Nadolol 40mg PO daily
5. Omeprazole 20mg PO BID
6. Trental 400mg PO TID
7. Aldactone 50mg PO BID
8. Sucralfate 1g PO before each meal and at bedtime
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. magnesium Oral
3. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. 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:*2*
5. Trental 400 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO three times a day.
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*1 bottle* Refills:*2*
11. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days: total course of antibiotics is 7
days (last day is [**2159-1-2**]).
Disp:*14 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
[**2158-1-9**]
Please check CBC/diff, CHEM10, PT/INR, AST, ALT, AlkPhos,
T.bili.
Fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (fax [**Telephone/Fax (1) 4400**], phone
[**Telephone/Fax (1) 2422**]).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper gastrointestinal bleed
Alcoholic cirrhosis complicated by varices
Seizure
.
Secondary:
Hypertension
Diabetes
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Name13 (STitle) **],
.
You were transferred to [**Hospital3 **] Medical center from another
hospital because you vomited blood. You had an endoscopy where
a bleeding ulcer was visualized and the bleeding was stopped.
Since admission, your blood counts have been stable and you have
not vomited any more blood.
.
During the hospitalization, you had a seizure. It was due to a
number of things including alcohol withdrawal, sleep deprivation
and some lab abnormalities. The seizure resolved with medicines
and did not happen again. The neurologists evaluated you, and
per, their recommendations, you had an EEG and CAT scan of the
head both of which were normal. You do not need to see a
neurologist as an outpatient.
.
Please seek emergent help for:
-bleeding from te rectum, vomiting blood
-confusion, lethargy
-chest pain, shortness of breath
-fever >100.4, chills
-increased abdominal girth, swelling
.
We also spoke with you about quitting drinking alcohol. You
were not interested in help with enrolling in a treatment
program. We highly encourage you to stop drinking as alcohol
use will cause progression of your liver disease, low blood
counts, more bleeds from your intestinal tract and possibly more
seizures. We know it is difficult, but we think you should
really strongly consider quitting drinking.
.
We have made the following changes to your medications:
-STOP Lasix (this will likely be restarted at your outpatient
appointment)
-STOP Aldactone (this will likely be restarted at your
outpatient appointment)
-INCREASE Omeprazole from 20mg daily to 40mg twice per day
-START Folic acid 1mg daily
-START Thiamine 100mg daily
-START Lactulose 30ml three times per day (you need to be moving
your bowels 2-3 times per day)
-START Rifaximin 550mg twice per day
-START Ciprofloxacin twice a day (an antibiotic; last day is
[**2159-1-2**])
.
On discharge, you will follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1693**].
Please have labs checked at that visit (lab slip has been
provided) and make sure these labs are sent to your Liver
doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Fax [**Telephone/Fax (1) 4400**], phone [**Telephone/Fax (1) 2422**].
You will see Dr. [**Last Name (STitle) **] as an outpatient as well, because you
need to have a repeat EGD (upper endoscopy), see appointment
below.
.
It was a pleasure taking care of you. We wish you all the best
and happy holidays!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Hospital1 **] PHYSICIAN SERVICES
Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appointment: Tuesday [**2159-1-9**] 11:15am
.
[**2159-1-16**] 02:30p [**Doctor Last Name **] [**Doctor Last Name **],EAST PROCEDURES (Endoscopy)
[**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
ENDOSCOPY SUITES
You will be called about more information
.
Department: LIVER CENTER
When: WEDNESDAY [**2159-1-17**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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icd9cm
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188
| 164,735
|
20280
|
Discharge summary
|
report
|
Admission Date: [**2161-7-1**] Discharge Date: [**2161-7-10**]
Date of Birth: [**2105-5-18**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ambien / Shellfish Derived
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Bleeding, anemia
Major Surgical or Invasive Procedure:
Mechanical Intubation and Ventilation
EGD
Sigmoidoscopy
Central Venous Line Placement
Therapuetic Paracentesis
Hemodialysis Catheter Removal
Hemodialysis Catheter Placement
History of Present Illness:
This is a 56-year-old male four years five months status post
liver [**First Name3 (LF) **] for hepatitis C cirrhosis and HCC with
recurrent hepatitis C with cirrhosis decompensated by ascites
and encephalopathy presented with hematochezia and hematemesis.
Friday at dialysis patient noted feeling lethargic and unwell.
Initial thought was that this was related to hypoglycemia to 40
post-dialysis. Friday night extensive teeth removal by Dr. [**Last Name (STitle) 54446**]
pager number [**Telephone/Fax (1) 54447**] with FFP prior.
Discharged from hospital after teeth removal on Saturday.
Sunday mild increased oozing. Monday onset of cherry colored
stoools and general malaise. Tuesday to dialysis with Hct
decrease slightly per sister who is present giving details.
Wednesday continued and to ED today with malaise, mild
confusion, oozing from mouth and hematemesis with clots in
addition to hematochezia. HCT 14.5 at OSH, given three units
PRBC and 1 FFP and transferred urgently to the [**Hospital1 **].
.
Bleeding from mouth and rectum on arrival to the ED. Teeth
pulled given recent gingival infection. NG lavage with
serosanginous then clear. INR at OSH 3.1, now 2.0. Given 1 g
Ceftriaxone, Octreotide bolus and gtt, Pantoprazole bolus and
gtt. Cordis in right femoral vein. Also with 16g x 2, 20g x 2.
VS on transfer 109/63, 126, 26, 99 on unknown level of oxygen.
Mental status improving with blood transfusion. Liver and
surgery consulted in ED. 4 units PRBC upon transfer.
Past Medical History:
- Hepatitis C cirrhosis and hepatocellular carcinoma s/p
radiofrequency ablation x 3, s/p liver transplantation [**1-10**],
recurrent Hep C after transpant, now with decompensated liver
failure with ascites and encephalopathy, listed. Last EGD in
[**2158**] showed 1 cords of grade I varices.
- Recurrent Hep C after Transpant- last viral load 69 on [**2158-7-11**].
- HTN
- Hx of Type II DM
- Adrenal Insufficiency: [**2158-11-6**]. After Cortisol
Stimulation test.
- s/p appendectomy
- s/p tonsillectomy
- s/p cervical laminectomy
- s/p right forearm ORIF
- s/p [**Year (4 digits) 500**] graft from right hip to elbow
- s/p knee surgery
- Urolithiasis, s/p stent placement and removal [**3-18**] by Urology
Social History:
Former fireman and bar owner; positive tobacco history; 2 packs
per day x 30 years, quit prior to liver [**Month/Year (2) **]. He is not
using IV drugs. Lives with his wife.
Family History:
His father has renal failure. His mother has hypothyroidism.
Physical Exam:
Vitals - 74 122/79 16 97/RA
GENERAL: Comfortable, alert. Able to recount history.
HEENT: Mild scleral icteris, o/p with healing gingiva. No
bleeding. Small head bruise.
CARDIAC: Regular rate/rhythm with 2/6 systolic murmur at apex,
not previously docmented.
LUNG: Decreased breath sounds and trace crackles on right.
ABDOMEN: Mildly distended, bowel tones and without TTP
EXT: WWP, trace ankle edema, 2+ PT pulses.
Pertinent Results:
CBCs:
[**2161-7-1**] 07:00PM BLOOD WBC-9.9 RBC-1.11*# Hgb-3.4*# Hct-10.8*#
MCV-98 MCH-31.1 MCHC-31.8 RDW-17.3* Plt Ct-168
[**2161-7-1**] 09:40PM BLOOD WBC-4.4# RBC-2.64*# Hgb-8.0*# Hct-23.6*#
MCV-90# MCH-30.4 MCHC-33.9 RDW-16.5* Plt Ct-86*
[**2161-7-1**] 11:57PM BLOOD Hct-27.0* Plt Ct-93*
[**2161-7-2**] 04:03AM BLOOD WBC-6.5 RBC-2.95* Hgb-9.0* Hct-26.0*
MCV-88 MCH-30.6 MCHC-34.6 RDW-16.6* Plt Ct-82*
[**2161-7-2**] 12:01PM BLOOD WBC-6.8 RBC-2.99* Hgb-9.1* Hct-26.4*
MCV-89 MCH-30.5 MCHC-34.5 RDW-16.9* Plt Ct-98*
[**2161-7-2**] 09:47PM BLOOD WBC-5.8 RBC-2.92* Hgb-9.0* Hct-26.5*
MCV-91 MCH-31.0 MCHC-34.1 RDW-17.2* Plt Ct-73*
[**2161-7-4**] 01:57AM BLOOD WBC-7.3 RBC-3.38* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.7 MCHC-34.1 RDW-17.2* Plt Ct-93*
[**2161-7-6**] 05:35AM BLOOD WBC-9.5 RBC-3.52* Hgb-10.7* Hct-32.8*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.8* Plt Ct-111*
.
COAGS:
[**2161-7-1**] 07:00PM BLOOD PT-21.3* PTT-42.4* INR(PT)-2.0*
[**2161-7-2**] 04:03AM BLOOD PT-19.8* PTT-41.2* INR(PT)-1.8*
[**2161-7-4**] 01:57AM BLOOD PT-18.2* PTT-37.6* INR(PT)-1.6*
[**2161-7-6**] 05:35AM BLOOD PT-18.8* PTT-35.9* INR(PT)-1.7*
.
CHEMISTRIES:
[**2161-7-1**] 07:00PM BLOOD Glucose-35* UreaN-27* Creat-3.2*# Na-140
K-4.0 Cl-100 HCO3-23 AnGap-21*
[**2161-7-3**] 03:45AM BLOOD Glucose-190* UreaN-45* Creat-4.1* Na-138
K-3.8 Cl-102 HCO3-23 AnGap-17
[**2161-7-6**] 05:35AM BLOOD Glucose-165* UreaN-39* Creat-5.1* Na-136
K-3.2* Cl-97 HCO3-26 AnGap-16
.
[**2161-7-3**] 03:45AM BLOOD tacroFK-3.8*
[**2161-7-4**] 02:04AM BLOOD tacroFK-4.0*
.
[**2161-7-3**] 09:52AM BLOOD Cortsol-17.6
.
MICRO:
no growth on any blood, urine, sputum, or peritoneal fluid
cultures
.
IMAGING:
CXR [**7-1**]
ET tube is 5.5 cm above the carina. NG tube tip is out of view
below the
diaphragms. There are low lung volumes. There is
mild-to-moderate
cardiomegaly. There is mild pulmonary edema. Right pleural
effusion is
small-to-moderate in amount. Right central catheter tip is in
the right
atrium. There is evidence of pneumothorax.
.
CXR [**7-2**]
ET tube tip is at the level of the carina and should be
repositioned. NG tube tip is in the stomach. Side port is distal
to the EG junction.
Cardiomediastinal contours are unchanged. Right supraclavicular
catheter
remains in place. No other interval changes.
.
[**7-2**] CXR #2 ET tube tip is 5.6 cm above the carina. NG tube tip
is in the stomach. There are low lung volumes. There is mild
cardiomegaly. Right supraclavicular catheter tip is in the right
atrium. Moderate right pleural effusion has increased from [**7-1**]. Left lower lobe atelectasis has worsened. Pulmonary edema
has almost resolved.
.
[**7-4**] CXR
IMPRESSION:
1. Stable right pleural effusion and right lower lobe
atelectasis.
2. Stable left lower lobe airspace opacity.
3. Stable mild pulmonary vascular congestion and cardiomegaly.
.
[**2161-7-8**]: Rib films:
1. Left anterolateral rib fractures without substantial
displacement.
2. New right lower lobe opacity suggesting either atelectasis or
pneumonia.
3. Mildly prominent small bowel caliber with many air-fluid
levels. The
appearance is not fully characterized here. Although suspected
to represent
an ileus, further clinical and radiographic evaluation may be
helpful with
small bowel obstruction not completely excluded.
.
[**2161-7-10**]: T and L spine
By verbal report, no evidence of acute fracture.
Brief Hospital Course:
This is a 56-year-old man with liver failure and recurrent
admissions for hepatic encephalopathy who returns with
hematochezia and hematemesis.
.
# GI BLEED: Source thought to be form teeth extraction as well
as possible rectal varices/hemorrhoids. Intubated for airway
protection in setting of large volume UGIB. EGD did not show
bleeding esophageal varices. Kept on octreotide and Pantoprazole
gtt until these findings were available. Presented with HCT
10.8, so massive transfusion protocol initiated, received 13U
PRBC between both OSH, ED and ICU, plus plateletes and FFP.
Access was with PIV 16g x 2, femoral Cordis. HCTs stayed stable
without further transfusions. He was weaned off of pressors on
[**7-2**]. Received Ceftriaxone for post-GI bleeding ppx in a
cirrhotic patient. OMFS consulted and had no additional surgical
recommendations for his gums/mouth. Cordis removed [**7-4**]. On
the floor, patient bleeding stopped, and patient's hematocrit
remained stable.
# ENTEROCOCCAL BACTEREMIA: Confirmed with outside dialysis
center that blood cultures positive for enterococci were drawn
through dialysis line. Enterococcos was vancomycin sensitive;
initially on linezolid and then daptomycin, but switched to
vancomycin one final sensitivities were available. Patient was
afebrile and without leukocytosis. A TTE was negative for
vegetations and infectious disease did not feel strongly about
pursuing a TEE. Patient will remain on vancomycin, dosed at
dialysis, through [**7-17**]. His tunneled dialysis line was removed
by IR on [**7-9**] and replaced on [**7-10**] without any complication.
.
VENTILATOR ASSOCIATED PNA: Patient with evidence of VAP after
intubation. He finished an 8 day course of cefepime,
levofloxacin, and vancomycin. His 02 sats remained normal and
he was encouraged to use his incentive spirometer.
.
# LIVER FAILURE: Patient is currently listed for another liver
[**Month/Day (4) **] with kidney. HIs LFTs and coags remained at
baseline. A diagnostic paracentesis showed no evidence of SBP.
He received a therapeutic paracentesis (5L removed) on [**7-7**].
Patient was continued on tacrolimus, bactrim, lactulose, and
rifaxamin. He was confused after extubation, but this was
related to ICU delirium and side-effect of multiple sedating
medications.
.
# ESRD: Patient on hemodialysis as outpatient. Awaiting dual
liver/kidney [**Month/Day (4) **]. Mr. [**Known lastname 54381**] was dialyzed Monday,
Wednesday, and Friday during this admission.
.
# ADRENAL INSUFFICIENCY: Mr. [**Known lastname 54381**] was continued on his home
dose of hydrocortisone.
.
# THROMBOCYTOPENIA: Platelet count at baseline. Likely due to
splenomegaly and decreased thrombopoetin. Patient's platelets
were monitored throughout admission.
.
# DM2: Patient's insulin was initially held while he was NPO.
His NPH was slowly uptitrated, and he was discharged on 40 units
[**Hospital1 **]. This can be uptitrated to his home dose as an outpatient.
.
# CHRONIC BACK PAIN: Patient with long-standing history of back
pain. Mr. [**Known lastname 54381**] reports that he has multiple slipped disks.
Lumbar and thoracic XRAYs showed no evidence of acute fractures.
.
# RIB FRACTURE: Mr. [**Known lastname 54381**] fell out of bed in the ICU in the
setting of delirium and multiple sedating medications. He
complained of left-sided pain, and XRAYs showed: "left
anterolateral rib fractures without substantial displacement."
He was treated symptomatically for pain, and symptoms had
improved at time of discharge.
Medications on Admission:
IPROFLOXACIN 750 mg q sun
HYDROCORTISONE 10 mg am /5 mg pm
PANTOPRAZOLE 40 qd
PROPRANOLOL -10 mg [**Hospital1 **]
RIFAXIMIN 200 mg [**Hospital1 **]
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] -400 3/wk
TACROLIMUS [PROGRAF] - 0.5 mg Capsule -[**Hospital1 **].
PAROXETINE HCL
NPH insulin 55 units [**Hospital1 **]
Discharge Medications:
1. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a
week: Weekly on Sunday.
2. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
3. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. NPH Insulin Human Recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Forty (40) Units Subcutaneous twice a day.
Disp:*1 1* Refills:*2*
13. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1) Units
Subcutaneous four times a day: Per Sliding Scale.
14. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Please draw labs every Tuesday for CBC, PT/INR, Na, Cr, Tbili,
albumin, tacrolimums. Please Fax all labs to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**],
Liver [**Hospital 1326**] Clinic [**Telephone/Fax (1) 697**]
16. Vancomycin in D5W 1.25 gram/250 mL Solution Sig: One (1)
Intravenous Q Hemodialysis for 3 doses: Stop Date [**7-17**].
Discharge Disposition:
Home With Service
Facility:
So shore VNA
Discharge Diagnosis:
Primary:
1. Acute Blood Loss Anemia secondary to bleeding of mouth and
gums
2. Upper Gastrointestinal Bleed
3. Enterococcal Bacteremia
4. HCV Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 54381**],
It was a pleasure taking care of you on this admission. You
came to the hospital because of bleeding in your mouth and from
you rectum. You were initially admitted to the intensive care
unit where you had a breathing tube placed and underwent an
endoscopy. Your bleeding was caused by your recent dental
procedures. You were transfused blood with an improvement in
your blood counts.
.
You were also found to have a blood stream infection caused by a
bacteria called enterococcus. You had your hemodialysis line
replaced as this was believed to be a source of your infection.
You are continuing on a course of an antibiotic called
vancomycin to treat this infection. You will complete your 14
day course of vancomycin on [**2161-7-17**].
.
We did XRAYS of your spine, which showed chronic degenerative
changes. There were no acute fractures seen on these films.
You would benefit from physical therapy as an outpatient. You
also suffered a small rib fracture on the left. Your symptoms
will improve with time, but please call your doctor if you have
worsening pain on your left side.
.
The following changes to your medications have been made:
1. You have STARTED Vancomycin 1250mg IV at hemodialsys for 3
more sessions to complete a 14 day course on [**7-17**].
2. Your medication propranolol has been decreased to 10mg twice
daily.
3. Your NPH has been decreased to 40 units twice daily. Please
continue to check your fingersticks at least twice daily and
call your PCP if you readings remain above 200 for further
adjustment.
.
Please maintain your scheduled follow up listed below.
Followup Instructions:
Please maintain your scheduled follow up listed below:
.
1. Infectious Disease - Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D.
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2161-7-20**] 3:00
.
2. Spine - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 54448**], MD Date/Time:[**2161-7-30**] 10:40
.
3. Please follow up with Dr. [**Last Name (STitle) 497**] in [**2-7**] weeks. Please call the
Liver [**Date Range 1326**] Center at ([**Telephone/Fax (1) 1582**].
|
[
"996.82",
"E884.4",
"285.21",
"585.6",
"997.31",
"285.1",
"E878.8",
"250.00",
"999.31",
"455.2",
"571.5",
"070.54",
"V49.83",
"E849.7",
"807.02",
"455.5",
"790.7",
"E878.0",
"998.11",
"V58.67",
"537.89",
"255.41",
"041.04",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"00.14",
"45.13",
"96.04",
"54.91",
"38.93",
"96.71",
"39.95",
"38.95",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
12430, 12473
|
6828, 10373
|
312, 486
|
12668, 12668
|
3466, 6805
|
14504, 15049
|
2953, 3016
|
10732, 12407
|
12494, 12647
|
10399, 10709
|
12850, 14481
|
3031, 3447
|
256, 274
|
514, 2012
|
12683, 12826
|
2034, 2744
|
2760, 2937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,338
| 103,364
|
29548
|
Discharge summary
|
report
|
Admission Date: [**2146-1-21**] Discharge Date: [**2146-2-7**]
Date of Birth: [**2120-2-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Nausea and vomitting
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
This is a 25 year old female transferred from [**Hospital3 **]
for acute pancreatitis and nausea and vomiting. She presented to
the ED on [**2146-1-17**] with sudden onset of severe epigastric pain and
vomiting (several episodes of non-bloody,non-bilious). She
denied HA, CP, SOB, dizziness, changes in bowel or bladder
habits. At the OSH, she had a CT scan that was consitent with
moderate pancreatitis, without evidence of ductal dilation or
necrosis. A RUQ US showed no evidence of biliary
obstruction/sludge/stones. She developed acute mentl status
changes on the afternoon of [**2146-1-20**], possibly related to EtOH
withdrawl. She was then transferred here.
Past Medical History:
Ankle injury - takes Tylenol with codeine PRN
Social History:
Rare tobacco
1 glass wine daily
Family History:
Unknown
Physical Exam:
VS: 99.7, 127, 153/59, 31, 96% 2L
Gen: NAD
Neuro: A+O x 3
HEENT: PEERL, EOMI intact
CV: reg rhythm, tachy
Chest: CTA bilat
Abd: mod distended, TTP, min BS
Ext: WWP without C,C,E. +2 DP bilat.
Pertinent Results:
[**2146-1-21**] 01:25AM BLOOD WBC-9.8 RBC-3.40* Hgb-11.1* Hct-32.9*
MCV-97 MCH-32.7* MCHC-33.7 RDW-13.9 Plt Ct-88*
[**2146-1-25**] 05:10AM BLOOD WBC-28.4*# RBC-3.31* Hgb-10.7* Hct-31.9*
MCV-96 MCH-32.2* MCHC-33.4 RDW-14.5 Plt Ct-366#
[**2146-1-31**] 04:00PM BLOOD WBC-21.5* RBC-3.13* Hgb-9.8* Hct-29.6*
MCV-95 MCH-31.2 MCHC-33.0 RDW-14.4 Plt Ct-620*
[**2146-2-1**] 06:15AM BLOOD WBC-25.8* RBC-3.42* Hgb-10.5* Hct-32.7*
MCV-96 MCH-30.6 MCHC-32.0 RDW-14.4 Plt Ct-866*
[**2146-1-31**] 04:00PM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-133
K-4.5 Cl-96 HCO3-26 AnGap-16
[**2146-1-21**] 01:25AM BLOOD ALT-20 AST-32 AlkPhos-45 Amylase-90
TotBili-0.6
[**2146-2-1**] 06:15AM BLOOD ALT-36 AST-49* AlkPhos-96 Amylase-35
TotBili-0.4
[**2146-1-21**] 01:25AM BLOOD Lipase-118*
[**2146-1-27**] 11:43AM BLOOD Lipase-132*
[**2146-2-1**] 06:15AM BLOOD Lipase-93*
[**2146-1-21**] 01:25AM BLOOD Albumin-2.8* Calcium-7.6* Phos-1.9*
Mg-1.9 Iron-8*
[**2146-2-1**] 06:15AM BLOOD Albumin-3.3* Calcium-9.5 Phos-5.1* Mg-2.3
[**2146-1-31**] 04:00PM BLOOD calTIBC-183* Ferritn-942* TRF-141*
CT HEAD W/O CONTRAST [**2146-1-21**] 3:07 PM
[**Hospital 93**] MEDICAL CONDITION:
25 year old woman with confusion
REASON FOR THIS EXAMINATION:
unremarkable.
IMPRESSION: No acute intracranial pathology, including no sign
of intracranial hemorrhage. Please note if high suspicion for
intracranial mass, CT examination is not sensitive and an MRI
would be recommended.
.
CHEST (PA & LAT) [**2146-1-25**] 10:29 AM
INDICATION: 25-year-old female with pancreatitis and left
pleural effusion. ? pneumonia.
IMPRESSION:
1. Unchanged moderate left-sided pleural effusion.
2. Left lower lobe consolidation, most likely representing
atelectasis.
3. Small right-sided subpulmonic pleural effusion.
.
CHEST (PORTABLE AP) [**2146-1-27**] 9:11 AM
[**Hospital 93**] MEDICAL CONDITION:
25 year old woman with pancreatitis, fevers, room air sat 87%
REASON FOR THIS EXAMINATION:
Interval change. Assess for effusion/PNA?
IMPRESSION: AP chest compared to [**2146-1-25**]:
There has been no recent interval change. Moderate left pleural
effusion and large area of consolidation at the base of the left
lung and a smaller region of consolidation on the right medially
are unchanged. Small right pleural effusion may also be present.
Upper lungs are clear. The heart is normal size. Tip of the left
PIC catheter projects over the mid SVC. No pneumothorax.
[**2146-2-6**] 05:47AM BLOOD WBC-13.8* RBC-3.08* Hgb-9.5* Hct-29.4*
MCV-95 MCH-30.7 MCHC-32.2 RDW-14.3 Plt Ct-705*
[**2146-2-6**] 05:47AM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-138
K-4.8 Cl-103 HCO3-24 AnGap-16
[**2146-2-6**] 05:47AM BLOOD ALT-31 AST-27 AlkPhos-67 Amylase-31
TotBili-0.2
[**2146-2-6**] 05:47AM BLOOD Lipase-78*
[**2146-2-6**] 05:47AM BLOOD Calcium-9.2 Phos-5.6* Mg-2.1
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IGG 1 [**Telephone/Fax (1) 70863**] MG/DL
IGG 2 181 35-477 MG/DL
IGG 3 46 15-135 MG/DL
IGG 4 36 4-158 MG/DL
IGG 648 L [**Telephone/Fax (1) **] MG/DL
Brief Hospital Course:
She was admitted to the ICU with pancreatitis. She was made NPO,
with IVF.
CV: She was tachycardic to the 130's and hypertensive in the
150's. She was hemodynamically stable. She was treated with
several boluses of fluid for hypovolemia and also placed on
Lopressor. She continued with Lopressor and her HR was WNL.
Resp: A CXR revealed left pleural effusion. Slight improvement
in right infrahilar consolidation. There was a question of
possible pneumonia as a source of her high fevers. She received
Levofloxacin for 3 days until a repeat CXR showed no evidence of
pneumonia. Her lungs cleared over the next few days.
Pancreatitis: She had moderate to severe pancreatitis and
experiencing lots of pain. She had no stone disease by U/S. Her
Lipase was as high as 143 and then decreased to 78 at time of
discharge. The other enzymes were WNL. She had a slow recovery
and was treated conservatively.
Fever + elevated WBC: She had fevers for several days, as high
as 103, and a WBC as high as 28,000. These persisted for several
days. All blood, stool, and urine cultures were negative. She
was treated with Tylenol. This was all likely due to the
pancreatitis. She was not treated with antibiotics, but instead
let the pancreatitis run its course and slowly she recovered.
FEN: She was NPO. a PICC line was placed and she was started on
TPN. She continued on TPN until [**2146-2-4**]. Her PO diet was slowly
advanced, starting with sips on [**2146-2-3**] and advanced to a
regular diet. She did not have a rise in her enzymes and so
continue to take a diet.
Pain: She was having lots of abdominal pain on admission. She
was treated with IV Dilaudid. A PCA Dilaudid was started and she
continued to need high doses of pain medications. A Pain Consult
was obtained and she received Tylenol, Ibuprofen, Amitriptyline.
Anxiety: She was very anxious on admission. She was placed on a
CIWA scale and received Ativan per the scale for possible EtOH
withdrawl. A Head CT was performed and showed No acute
intracranial pathology, including no sign of intracranial
hemorrhage. She reportedly had mental status changes at the OSH
prior to transfer to [**Hospital1 18**]. She received Valium for anxiety and
this was then switched to Ativan.
Pancreatology Consult: Dr. [**Last Name (STitle) 174**] saw and examined this patient.
Fevers were likely related to cytokine mediated inflammation.
Other differential included: increased triglycerides, CFTR
mutation mediated, autoimmune pancreatitis, sphincter of oddi
dysfunction. She will follow-up with Dr. [**Last Name (STitle) 174**] in [**8-26**] weeks.
Medications on Admission:
OCP, tylenol prn
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for 2 weeks.
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain and fever.
Disp:*qs Tablet(s)* Refills:*0*
4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for pain and insomnia for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for 1 months.
Disp:*75 Tablet(s)* Refills:*0*
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Fevers
Tachycardia
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Continue to ambulate several times per day.
.
You should avoid all alcohol consumption.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 70864**] (GI - [**Hospital1 **]
Gastroenterology) in [**2-19**] weeks. Call ([**Telephone/Fax (1) 70865**] to schedule
an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. You were started on
Lopressor for your HR. Discuss whether this needs to be
continued.
Please follow-up with Dr. [**Last Name (STitle) 174**] (Pancreatologist) in 8 weeks.
Call ([**Telephone/Fax (1) 22346**] to schedule an appointment.
Completed by:[**2146-2-7**]
|
[
"785.0",
"401.9",
"577.0",
"305.00",
"276.52",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8259, 8265
|
4667, 7267
|
348, 355
|
8341, 8348
|
1419, 2526
|
8727, 9248
|
1183, 1192
|
7334, 8236
|
3255, 3317
|
8286, 8320
|
7293, 7311
|
8372, 8704
|
1207, 1400
|
273, 310
|
3346, 4644
|
383, 1049
|
1071, 1118
|
1134, 1167
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,467
| 198,042
|
40388
|
Discharge summary
|
report
|
Admission Date: [**2107-11-3**] Discharge Date: [**2107-11-4**]
Date of Birth: [**2047-4-26**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
fistula clogged
Major Surgical or Invasive Procedure:
Chest compression, right IJ, left HD line
History of Present Illness:
60 yo male ESRD on HD, CAD, AVR, ischemic cardiomyopathy, HTN,
HL, PE, DVT, GIB bleed, diverticulosis, hyperkalemia, chronic LE
foot ulcers, and ? h/o acute leukemia who presents to the ED
with hypotension, evletated lactate, clogged left fistula, and
left wrist pain.
Of note the patient had yesterday moved from the Heritage
facility near [**Location (un) 5583**] to Radius in [**Location (un) 669**]. In discussion
with teh Radius facility they stated the pt was refusing care on
arrival the night before (declined EKG, refusing to eat,
refusing are). Onarrival to the facility his SBP was 78/52 then
increased up to 89/56.
At Radius on the day of admission to [**Hospital1 **], they were unable to
access his AV fistula. His SBO was in the 70s. He became
lethargic and refused IV access. He also complained of nausea
and refused antiemetics.
60 yo m transferred from radius rehab due to clotted dialysis
catheter, but was hypotensive to 60s here, lactate 13, minimally
responsive. CHF EF 30%
On arrival to the ED SBPs were 60s with a lactates of 13.1 and
minimally responsive. While in the ED he received a toatl of 1.6
L of IVF including the antibiotics vancomycin and zosyn. His
lactate trended down to 11 while in the ED. Labs were notable
for hyperkalemia to 6.7, elevated calcium to 10.7, and trop 0.34
trending up to 0.85. CXR was done after line was placed with
line terminating in the distal SVC and a possible left lower
lobe opacity on the left may represent infection or contusion.
Blood cx were obtaines (pt does not make urine). A R IJ was
placed and the patient was started on levophed. For his
hyperkalemia he received 1amp calcium gluconate, 10 units of
insulin, amp of D50, and 3 amps off bicarb. The ED was concerned
about possible peaked t wave in lateral leads. Pt refused
kayexelate.
He later looked lethargic, cool, pale, and sweaty. His sugar was
108 when checked and he received another amp of D50. He then was
more awake and interactive.
A discussion occured with his brother [**Name (NI) **] [**Known lastname **] over the phone
and the patient was made DNI but ok to do chest compressions.
The brother said Mr. [**First Name (Titles) **] [**Last Name (Titles) 37653**] in the DNI aspect of the
conversations. He was signed out to the medicine floor. While
awaiting transit up from the ED he developed a wide complex and
bradycardia and likely PEA. He received between 15 sec and 1 min
of chest compressions and regained a pulse and was alert and
interactive.
Repeat labs showed trop of 0.85 and lactate of 11. Pt still
hyperkalemic and received calcium/insulin/glucose again. He was
made DNR/DNI in the ED after discussion with the brother and
[**Name2 (NI) **] to the MICU. Vitals prior to transfer were afeb, T
97.1 HR 98 BP 93/50 RR22 100% NRB whole time while in ED. He was
on levophed of 0.08.
.
On the floor, pt VS were T96 97/53 (on 3 of neo) 92% on NRB. He
was alert and interactive but not able to engage in very indepth
complex conversation. He started passing BRB and melena from
below. He later developed chest pain with lateral ST depression
in the setting of HR to 100s. He had episodes of V tach (like
lasting 20-30 beats) that broke spontaneously. He agreed to
having a dilaysis line placed. We were unable to reach his
brother to get full ICU consent but I had spoken with the
brother [**Name (NI) **] [**Known lastname **] earlier in the night to make the patient
DNR/DNI while the patient was still in the ED.
Past Medical History:
ESRD on HD
CAD
AVR
Ischemic cardiomyopathy EF 30%
DM
PVD
HTN
Anemia
HL
PE
Venous embolism
GIB
Hyperkalemia
Chronic LE foot ulcers
Scrotal hernia
R UE skin CA
Diverticulosis
Gait instability
Adjustment d/o
Depression
Acute leukemia
Scrotal hernia
Social History:
unavailable
Family History:
unavailable
Physical Exam:
General: Alert, oriented
HEENT: Sclera anicteric, mildly dry mm
Neck: supple, no JVD
Lungs: decreased bs anteriorly
CV: tachycardic, RV heave, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cold and clammy, radial pulses +2, DP pulses +1, ulcer on
heel of left foot and belwo third digit, pain to palpation of
left wrist, soft tissue mass on right wrist and right shoulder
Pertinent Results:
[**2107-11-3**] 02:14PM BLOOD Lactate-13.1*
[**2107-11-3**] 04:10PM BLOOD Lactate-11.5*
[**2107-11-3**] 07:34PM BLOOD Lactate-11.6*
[**2107-11-3**] 11:31PM BLOOD Glucose-242* Lactate-11.0* Na-140 K-6.0*
Cl-98* calHCO3-15*
[**2107-11-4**] 01:06AM BLOOD Lactate-8.2*
[**2107-11-3**] 11:31PM BLOOD freeCa-1.56*
[**2107-11-3**] 03:55PM BLOOD Calcium-10.7* Phos-11.5* Mg-2.8*
[**2107-11-3**] 11:21PM BLOOD Calcium-15.8* Phos-10.9* Mg-2.9*
[**2107-11-4**] 12:57AM BLOOD Calcium-11.1* Phos-10.3* Mg-2.7*
[**2107-11-3**] 02:25PM BLOOD Glucose-74 UreaN-104* Creat-808* Na-136
K-6.7* Cl-89* HCO3-14* AnGap-40*
[**2107-11-3**] 03:55PM BLOOD Glucose-73 UreaN-104* Creat-8.8*# Na-140
K-6.2* Cl-92* HCO3-16* AnGap-38*
[**2107-11-3**] 11:21PM BLOOD Glucose-287* UreaN-107* Creat-8.8* Na-138
K-6.1* Cl-93* HCO3-17* AnGap-34*
[**2107-11-4**] 12:57AM BLOOD Glucose-59* UreaN-105* Creat-8.6* Na-140
K-5.3* Cl-95* HCO3-20* AnGap-30*
[**2107-11-3**] 02:25PM BLOOD WBC-9.9 RBC-3.93* Hgb-11.0* Hct-37.9*
MCV-96 MCH-28.0 MCHC-29.1* RDW-18.7* Plt Ct-284
[**2107-11-3**] 03:55PM BLOOD WBC-13.3* RBC-3.51* Hgb-9.8* Hct-33.5*
MCV-96 MCH-27.9 MCHC-29.2* RDW-19.2* Plt Ct-268
[**2107-11-3**] 11:21PM BLOOD WBC-12.9* RBC-3.44* Hgb-9.9* Hct-32.7*
MCV-95 MCH-28.8 MCHC-30.3* RDW-19.0* Plt Ct-224
[**2107-11-4**] 12:57AM BLOOD WBC-14.7* RBC-3.41* Hgb-9.6* Hct-32.4*
MCV-95 MCH-28.1 MCHC-29.6* RDW-19.4* Plt Ct-238
[**2107-11-3**] 02:25PM BLOOD Neuts-88.6* Lymphs-7.3* Monos-3.6 Eos-0.1
Baso-0.4
[**2107-11-3**] 02:25PM BLOOD PT-16.7* PTT-32.8 INR(PT)-1.5*
[**2107-11-3**] 11:21PM BLOOD PT-19.5* PTT-37.6* INR(PT)-1.8*
[**2107-11-3**] 02:25PM BLOOD cTropnT-0.34*
[**2107-11-3**] 03:55PM BLOOD cTropnT-0.36*
[**2107-11-3**] 11:21PM BLOOD cTropnT-0.85*
[**2107-11-4**] 12:57AM BLOOD CK-MB-30* MB Indx-15.4* cTropnT-0.92*
[**2107-11-3**] 04:10PM BLOOD pO2-59* pCO2-39 pH-7.21* calTCO2-16* Base
XS--11
[**2107-11-3**] 04:54PM BLOOD Type-ART pO2-381* pCO2-27* pH-7.31*
calTCO2-14* Base XS--11 Intubat-NOT INTUBA
.
blood cx [**2107-11-3**]- pending
.
CXR [**2107-11-3**]:
The lungs are low in volume and show an unchanged left opacity
with mild
interstitial opacities. The cardiac silhouette is enlarged,
unchanged. The
mediastinal silhouette is widened, unchanged. The hilar contours
and pleural
surfaces are normal. Again noted is significant calcification in
the soft
tissues of the right axilla and right upper cervical region,
which might
represent tumoral calcinosis given patient's renal failure.
Aortic valve
replacement and intact sternal wires are noted. Right IJ line
terminates in
the distal SVC appropriately.
IMPRESSION:
1. Right IJ line terminates in the distal SVC appropriately. No
pneumothorax.
2. Calcified mass in the soft tissues of the right axilla and
cervical region should be further evaluated with either a
shoulder radiograph or CT if clinically necessary. Presumed
tumoral calcinosis.
.
CXR [**2107-11-4**]:
FINDINGS: There has been interval placement of the left internal
jugular
catheter which terminates in the upper SVC without evidence of
pneumothorax.
Right IJ catheter is unchanged in position. There is a linear
lucency along
the right tracheal border. There are unchanged calcifications
projecting over the shoulders bilaterally that likely represent
tumoral calcinosis.
Persistent enlarged cardiac silhouette with low lung volumes and
a stable left opacity. There is slight improvement in the
pulmonary edema.
IMPRESSION:
1. Linear lucency along the right tracheal border that may
represent artifact versus free mediastinal air. Recommend
short-term followup radiograph for further assessment.
2. Interval placement of left internal jugular catheter
terminating in the
upper SVC without evidence of complications including
pneumothorax.
Brief Hospital Course:
Patient was DNR/DNI and while placing an a line he suddenly
developed a wide complex and immediately became bradycardic and
then asystolic.
Shock/Hypotension: The etiology of his shock was unclear. [**Name2 (NI) **]
was on levophed 0.27 on arrival to the ICU which was titrated
up within the first hour of being in the ICU. His mixed venous
sat was 80 suggesting it was not cardiogenic shock. His lactate
was 13.1 on arrival to the hospital and improved to 8.2 on
arrival to the ICU. He was bolused with D5W with 3 amps of
bicarb on arrival to the ICU. Septic shock seemed less likely
once a CVP was checked and returned as 20. However, we do not
know how his heart functioned at baseline and he could have
other cardiac etiologies explaining his elevated CVP and thus
sepsis was not ruled out. He was covered with vancomycin and
zosyn for possible sepsis. Blood cx were done in the ED. He did
not make urine to send for culture. We were concerned about PE
especially given his history of PE. He was never stable enough
to go for CTA and we could not start heparin in the setting of
his active GI bleed.
.
s/p PEA arrest: In the ED the patient bradied down and his QRS
widened and he then was pulseless. We did not have any strips
to review of this event. He received between 15 sec and 1 min
of chest compressions with return of circulation and mental
status. He was given calcium gluconate, insulin, D50, and
bicarb. He was in the thiamine versus placebo study. He did
have several episodes of V tach but never long enough to
administer metoprolol. He later had a similar event in the ICU
and given that he was DNR/DNI he died at that time.
.
GI bleed: He passed bright red blood from his rectum on arrival
to the ICU.unclear Baseline HCT on [**2107-10-3**] was 34.8. His HCT was
32 on arrival to the ICU. He has a history of GI bleed per
records but they do not indicate upper or lower bleed. He was
tranfused 2 units of RBCs and started on protonix IV and an
octreotide gtt.
.
Acidemia with lactic acidosis: His anion gap was 25. His renal
failure and sepsis were his most likely etiology. He was given
D5W with 3 amps of bicarb. An HD line was placed and CVVH was
initiated.
.
ESRD on HD with severe electrolyte imbalance: He arrived with
severe hyperkalemia. His fistula was clogged. An emergent HD
line was placed for CVVH.
.
Chest pain and concern for ACS: He had EKG changes with ST
depression in lateral leads v4-v6 in the setting of tachycardia.
Despite calling several previous facilities where he received
care, we were unable to obtain a baseline EKG. These are likely
rate related changes and he would be too unstable to go for cath
if this was ACS. ASA, morphine, and a statin was given. No
plavix or other agents were given in the setting of his bleed.
He received 2 units of RBCs. His chest discomfort was most
likely secondary to chest compressions.
.
Hypoglycemia: BS was 59 on floor and he was given [**1-1**] amp of
D50.
.
Hypothermia: He was warmed with a bear huger and his temperature
immediately increased so he was no longer hypothermic. He was
warmed despite his cardiac arrest given that he was experiencing
arrythmias while in the ICU.
Medications on Admission:
Aspirin
Lisinopril
Carvedilol
Simvastatin
Renagel
Tramadol HCL
Nexium
Neprhocaps
Fluzone
Silver sulfa
Senna
Miralax
Mycostatin powder
[**Last Name (un) **]
Emla
pneumovax
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2107-11-8**]
|
[
"414.01",
"403.91",
"786.50",
"785.50",
"V45.11",
"V49.86",
"276.7",
"585.6",
"038.9",
"996.73",
"578.1",
"V43.3",
"427.1",
"272.0",
"276.2",
"427.89",
"E878.2",
"995.91",
"E849.9",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
11877, 11886
|
8437, 11623
|
282, 325
|
11938, 11948
|
4677, 8414
|
12005, 12044
|
4128, 4141
|
11844, 11854
|
11907, 11917
|
11649, 11821
|
11972, 11982
|
4156, 4658
|
227, 244
|
353, 3814
|
3836, 4083
|
4099, 4112
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,288
| 129,859
|
3734
|
Discharge summary
|
report
|
Admission Date: [**2167-8-6**] Discharge Date: [**2167-8-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
SOB, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 16832**] is a [**Age over 90 **]M with a h/o 3rd degree heart block s/p dual
chamber PM ([**2154**]), CRI (Cr 1.5-1.8), DM, and CHF (likely
systolic) who initally presented 3 days prior to transfer from
home with progressive SOB, malaise, confusion and worsening LE
edema in setting of bradycardia to the high 40s at home. He had
also been confused the last couple of days, but without
infectious sx: no fevers, cough, dysuria, headache,
lightheadness. Prior to this family states he is clear at
baseline and is not confused. He denied CP, chest pressure but
endorsed orthopnea, LEs edema, DOE, and mild SOB at rest. He
was recently (1mo ago) started on lasix, and despite escalating
doses, had increasing LE edema. Prior to coming to the ED on day
of admission [**2167-8-6**], pt received 40mg IV at home w/o response.
.
In the ED initial vital signs were 98.2 44 113/47 20 94% on RA.
An initial ECG showed demand V pacing and LBBB with inferior ST
elevations unchanged from baseine EKG. Initial labs were
notable for BNP [**Numeric Identifier 16833**], creatinine of 1.8, and TnT of 0.11. A CXR
showed mild pulmonary edema. He was given ASA 325mg PO x1 and
furosimide 40mg IV x1 with no effect. He was started on a NTG
drip and given NTG SL x3 for tachypnea. He was admitted to
Cardiology for further management.
.
On the floor his SOB improved with lasix gtt, however at ~ 3am
[**2167-8-7**], pt was noted to be more somnolent and not following
commands. ABG showed severe hypercarbia 7.34/77/144, he
received 250mg of diamox and was transferred to the MICU.
.
In the MICU, continued to be somnolent, but was able to open
eyes and moving UEs to command non-specifically. VS were
notable for periods of apnea up to 20 seconds. Exam notable for
holosystolic murmur at apex and diastolic m at 4LICS, peripheral
edema. Pt was started on BIPAP 10/5 for over 1 day (last bipap
[**8-7**]); diuresed 5 Liters, spent 12 hours on BIPAP Mask. Repeat
ABG showed 7.31/84/141 and echo showed improved EF of 25% up
from ~15%. No infectious source was found. Pt improved
(although he remained moderately confused) and was transferred
to [**Hospital Ward Name 121**] 3 to finish diuresis.
.
On transfer back to the floor, VS Tc 97 BP 109/56 (94-122/37-63)
HR 64 100% on Neb w/4L NC. Pt's family was present and able to
verify information regarding baseline mental status; at baseline
pt is not confused but currently has to be regularly reminded of
location. He does state repeatedly that he wants to know why he
had fluid accumulation. Family is excellent about reminding and
reorienting pt.
.
At baseline, uses a walker, but just prior to admission needed a
wheelchair.
.
Per NF admission note: "he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative. Cardiac review of systems is
notable for absence of chest pain, palpitations, syncope or
presyncope."
Past Medical History:
Past Medical History:
- DM
- HL
- CRI
- Complete heart block s/p [**Company 1543**] Kappa dual chamber pacer
placed in [**2154**]
- CHF, EF ~ 15%, ECHO 2 mo ago; improved to 25% after diuresis
Social History:
Lives with wife in CT. Active, independent in ADLs up until 1mo
ago.
- Tobacco: distant
- Alcohol: denies
- Illicits: denies
Physical Exam:
Physical Exam on Admission to MICU:
VS - see below
General: somnolent, eyes closed, opens to sternal rub.
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: JVP 10cm, no LAD
Lungs: Mildly decr. breath sounds at bases, no crackles.
CV: Regular rate and rhythm, normal S1 + S2, [**4-11**] holoSM at apex,
? [**2-11**] Diast. m. at 4LICS.
Abdomen: soft, non-tender, non-distended
Ext: warm, 3+ edema to knees b/l.
NEURO: see general for MS. Does not follow commands. reaches
for the face mask, toes down, normal tone, occasional UE
myoclonus.
.
Physical Exam on Discharge:
VS - VS Tc 96.8 BP 134/67 (124-134/65-67) HR 74 93% 2L NC wgt
71kg gluc 197
24hr I/O awaiting
shift I/O awaiting
General: sleeping but easily woken, did not appear aggitated,
family member sleeping in the room w/pt
[**Name (NI) 4459**]: Sclera anicteric, MMM
Neck: JVP did not appear elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
appreciated best at LLSB and apex, did not radiate to axila
Resp: Decreased breath sounds at bases, crackles bilaterally; no
rhonchi or rales. Exam limited by pt sleeping
Abdomen: +BS, soft, non-tender, non-distended
Ext: warm, 0-1+ edema to knees b/l
NEURO: Deferred until pt more awake
Pertinent Results:
Discharge Labs:
[**2167-8-13**] 07:10AM BLOOD WBC-8.3 RBC-3.88* Hgb-11.5* Hct-36.2*
MCV-93 MCH-29.7 MCHC-31.9 RDW-14.3 Plt Ct-217
[**2167-8-13**] 07:10AM BLOOD Neuts-79.5* Lymphs-14.4* Monos-5.0
Eos-0.7 Baso-0.4
[**2167-8-13**] 07:10AM BLOOD Plt Ct-217
[**2167-8-13**] 07:10AM BLOOD PT-12.9 PTT-27.7 INR(PT)-1.1
[**2167-8-14**] 06:00AM BLOOD Glucose-129* UreaN-49* Creat-1.6* Na-142
K-4.0 Cl-103 HCO3-31 AnGap-12
[**2167-8-13**] 12:40PM BLOOD Glucose-260* UreaN-51* Creat-1.7* Na-142
K-4.0 Cl-102 HCO3-31 AnGap-13
[**2167-8-13**] 07:10AM BLOOD Glucose-149* UreaN-50* Creat-1.8* Na-144
K-4.1 Cl-103 HCO3-35* AnGap-10
[**2167-8-14**] 06:00AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.4
[**2167-8-13**] 12:40PM BLOOD Calcium-8.5 Phos-2.7 Mg-2.3
[**2167-8-13**] 07:10AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3
.
Additional lab values:
[**2167-8-10**] 07:05AM BLOOD WBC-12.2*# RBC-3.68* Hgb-11.4* Hct-34.4*
MCV-93 MCH-30.8 MCHC-33.0 RDW-13.8 Plt Ct-174
[**2167-8-9**] 08:28AM BLOOD WBC-6.9 RBC-3.66* Hgb-10.8* Hct-35.0*
MCV-96 MCH-29.6 MCHC-31.0 RDW-14.0 Plt Ct-196
[**2167-8-8**] 03:37AM BLOOD WBC-6.5 RBC-3.55* Hgb-10.8* Hct-33.5*
MCV-94 MCH-30.5 MCHC-32.3 RDW-14.2 Plt Ct-166
[**2167-8-7**] 06:50AM BLOOD WBC-6.9 RBC-3.66* Hgb-10.8* Hct-34.7*
MCV-95 MCH-29.5 MCHC-31.1 RDW-14.0 Plt Ct-212
[**2167-8-6**] 09:00PM BLOOD WBC-8.5 RBC-3.68* Hgb-11.2* Hct-35.5*
MCV-96# MCH-30.3 MCHC-31.5 RDW-14.2 Plt Ct-169
[**2167-8-6**] 09:00PM BLOOD Neuts-80.4* Lymphs-13.6* Monos-4.6
Eos-0.9 Baso-0.4
[**2167-8-10**] 07:05AM BLOOD Plt Ct-174
[**2167-8-9**] 08:28AM BLOOD Plt Ct-196
[**2167-8-8**] 03:37AM BLOOD Plt Ct-166
[**2167-8-7**] 06:50AM BLOOD Plt Ct-212
[**2167-8-6**] 09:00PM BLOOD Plt Ct-169
[**2167-8-6**] 09:00PM BLOOD PT-14.5* PTT-28.0 INR(PT)-1.3*
[**2167-8-10**] 07:05AM BLOOD Glucose-178* UreaN-52* Creat-1.6* Na-145
K-4.0 Cl-100 HCO3-38* AnGap-11
[**2167-8-9**] 05:01PM BLOOD Glucose-404* UreaN-59* Creat-1.9* Na-145
K-4.3 Cl-96 HCO3-40* AnGap-13
[**2167-8-9**] 08:28AM BLOOD Glucose-129* UreaN-55* Creat-1.8* Na-150*
K-4.1 Cl-106 HCO3-38* AnGap-10
[**2167-8-8**] 04:45PM BLOOD Glucose-233* UreaN-59* Creat-2.0* Na-144
K-4.3 Cl-96 HCO3-39* AnGap-13
[**2167-8-8**] 03:37AM BLOOD Glucose-90 UreaN-58* Creat-1.7* Na-145
K-3.9 Cl-99 HCO3-41* AnGap-9
[**2167-8-7**] 03:04PM BLOOD Glucose-145* UreaN-62* Creat-1.6* Na-143
K-4.1 Cl-98 HCO3-41* AnGap-8
[**2167-8-7**] 06:50AM BLOOD Glucose-186* UreaN-65* Creat-1.6* Na-147*
K-3.6 Cl-98 HCO3-41* AnGap-12
[**2167-8-6**] 09:00PM BLOOD Glucose-329* UreaN-67* Creat-1.8* Na-141
K-3.9 Cl-96 HCO3-37* AnGap-12
[**2167-8-7**] 03:04PM BLOOD CK(CPK)-55
[**2167-8-7**] 06:50AM BLOOD CK(CPK)-33*
[**2167-8-7**] 03:04PM BLOOD CK-MB-5 cTropnT-0.12*
[**2167-8-7**] 06:50AM BLOOD CK-MB-4 cTropnT-0.11*
[**2167-8-6**] 09:00PM BLOOD cTropnT-0.11*
[**2167-8-6**] 09:00PM BLOOD proBNP-[**Numeric Identifier 16833**]*
[**2167-8-10**] 07:05AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.2
[**2167-8-9**] 05:01PM BLOOD Calcium-9.6 Phos-4.1 Mg-2.3
[**2167-8-9**] 08:28AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
[**2167-8-8**] 04:45PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.2
[**2167-8-8**] 03:37AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
[**2167-8-7**] 03:04PM BLOOD Mg-2.2
[**2167-8-7**] 06:50AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.3 Cholest-148
[**2167-8-7**] 06:50AM BLOOD %HbA1c-8.2* eAG-189*
[**2167-8-7**] 06:50AM BLOOD Triglyc-65 HDL-51 CHOL/HD-2.9 LDLcalc-84
[**2167-8-7**] 06:50AM BLOOD TSH-2.1
[**2167-8-8**] 05:46AM BLOOD Type-ART pO2-113* pCO2-63* pH-7.41
calTCO2-41* Base XS-12
[**2167-8-8**] 04:06AM BLOOD Type-[**Last Name (un) **] Temp-36.7 O2 Flow-2 pO2-51*
pCO2-70* pH-7.39 calTCO2-44* Base XS-13 Intubat-NOT INTUBA
[**2167-8-7**] 03:46PM BLOOD Type-ART pO2-86 pCO2-68* pH-7.39
calTCO2-43* Base XS-12
[**2167-8-7**] 09:25AM BLOOD Type-ART pO2-99 pCO2-83* pH-7.33*
calTCO2-46* Base XS-13
[**2167-8-7**] 08:33AM BLOOD Type-ART pO2-141* pCO2-84* pH-7.31*
calTCO2-44* Base XS-11
[**2167-8-7**] 06:14AM BLOOD Type-ART pO2-144* pCO2-77* pH-7.34*
calTCO2-43* Base XS-12
[**2167-8-8**] 05:46AM BLOOD Lactate-0.9
[**2167-8-8**] 04:06AM BLOOD K-3.8
[**2167-8-7**] 08:33AM BLOOD Lactate-1.1
[**2167-8-7**] 06:14AM BLOOD Lactate-1.1
[**2167-8-7**] 06:14AM BLOOD O2 Sat-98
[**2167-8-7**] 06:14AM BLOOD freeCa-1.21
.
ECG Study Date of [**2167-8-6**] 8:48:16 PM Atrial sensed and
ventricular paced rhythm and frequent ventricular ectopy.
Left atrial abnormality. Compared to the previous tracing of
[**2155-1-6**] the
A-V interval is longer. There is frequent ventricular ectopy.
Otherwise, no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 0 140 492/493 0 150 -60
.
CHEST (PORTABLE AP) Study Date of [**2167-8-6**] 8:47 PM
FINDINGS: There is an indwelling dual-chamber pacemaker. The
vascular
pedicle is engorged with pulmonary vascular indistinctness.
There is marked aortic tortuosity with calcified plaque seen at
the arch. The cardiac silhouette size is difficult to assess but
is grossly enlarged. There are bilateral pleural effusions. The
hazy opacity is noted at both lung bases, likely in part due to
atelectasis, although early developing infection cannot be
entirely excluded. The right effusion is slightly larger than
the left. Degenerative changes are seen throughout the thoracic
spine. An indwelling dual-chamber pacemaker is in standard
position from a left subclavian approach.
IMPRESSION: Mild volume overload with bilateral pleural
effusions, right
greater than left. There is likely associated atelectasis at the
lung bases, although early developing pneumonia cannot be
excluded.
.
Portable TTE (Complete) Done [**2167-8-7**] at 12:04:31 PM FINAL
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severe regional LV systolic dysfunction. Apical LV
aneurysm. Estimated cardiac index is depressed (<2.0L/min/m2).
No LV mass/thrombus. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**2-7**]+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Echocardiographic results were reviewed by
telephone with the houseofficer caring for the patient.
Bilateral pleural effusions.
Conclusions:
The left and right atria are moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe regional left
ventricular systolic dysfunction with near akinesis of the
distal half of the anterior septum, anterior, anterolateral and
inferior walls and apex. The remaining segments contract well.
The apex is aneurysmal. (LVEF 30%). Left ventricular cardiac
index is depressed (<2.0L/min/m2). No apical left ventricular
thrombus is seen. Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with extensive
regional systolic dysfunction suggestive of multivessel CAD.
Moderate mitral regurgitation. Right ventricular free wall
hypokinesis. Bilateral pleural effusions.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2164**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
CHEST (PORTABLE AP) Study Date of [**2167-8-7**] 6:18 AM
COMPARISON: Portable chest radiograph [**2167-8-6**] at 9:00 p.m.
FINDINGS: There is a left pacemaker in place with leads in
standard position. Stable moderate cardiomegaly. Calcification
at the aortic arch. Bibasilar opacities, likely bilateral small
pleural effusion with adjacent atelectasis, and retrocardiac
opacity likely atelectasis at the left lung base. No
pneumothorax.
IMPRESSION:
1. Stable moderate cardiomegaly.
2. Stable bilateral small pleural effusion with adjacent
atelectasis.
.
CHEST (PORTABLE AP) Study Date of [**2167-8-8**] 8:51 AM
HISTORY: Short of breath, CHF, evaluate fluid status.
CHEST, SINGLE AP PORTABLE VIEW.
There is cardiomegaly, with a calcified unfolded aorta. A
left-sided
pacemaker is present, with lead tips over right atrium and right
ventricle. There is upper zone re-distribution and mild diffuse
vascular blurring. There is slightly more confluent opacity at
the bases, consistent with CHF and pulmonary edema. There are
small bilateral effusions, with underlying collapse and/or
consolidation.
Compared with [**2167-8-7**], the CHF findings are more pronounced.
.
CHEST (PORTABLE AP) Study Date of [**2167-8-9**] 7:30 AM
HISTORY: Hypoxia, to assess for change in effusions.
FINDINGS: In comparison with study of [**8-8**], there is an increased
opacification at the bases silhouetting the hemidiaphragms,
consistent with atelectasis and effusion. This may be increasing
on the left. Respiratory motion greatly degrades the image, so
the degree of pulmonary vascular congestion is difficult to
assess on this study.
Brief Hospital Course:
[**Age over 90 **]M with CHB s/p dual chamber PM ([**2154**]), CRI (Cr 1.5-1.8), DM,
and CHF (likely systolic) presented from home with progressive
SOB, malaise, confusion and worsening LE edema in setting of
bradycardia to the high 40s at home. Per daughter in law
(physician) may have had a "silent MI" ~ 1mo ago, ECHO 6wks ago
showed "EF of 15% and global dysfunction". He has been confused
the last couple of days, but no nfectious sx: no fevers, cough,
dysuria, headache, lightheadness. He denied CP, chest pressure
but endorsed orthopnea, LEs edema, DOE, and mild SOB at rest. He
was recently (1mo ago) started on lasix, and despite escalating
doses, had increasing LE edema. Received 40mg IV at home prior
to coming to the ED w/o response.
.
On the floor his SOB improved with lasix gtt, however at ~ 3am,
was noted to be more somnolent and not following commands. ABG
showed severe hypercarbia 7.34/77/144, he received 250mg of
diamox and was transferred to the MICU.
.
In the MICU, was somnolent, but opening eyes and moving UEs to
command non-specifically. VS were notable for periods of apnea
up to 20 seconds. Exam notable for holosystolic murmur at apex
and diastolic m at 4LICS, peripheral edema. Pt. was started on
BIPAP 10/5. ABG repeated showed 7.31/84/141.
.
MICU course ([**Date range (1) 16834**]):
.
# Respiratory failure: Likely initially with hypoxic failure,
then increasing WOB and impaired lung compliance with subsequent
fatigue with hypercarbic respiratory failure. Metabolic
alkalosis likely also contributed to process. Pt was placed on
BiPAP, given Acetazolamide for elevated bicarbonate, and had
nebulizers available if needed. Pt remained tachypneic on [**8-7**],
likely blowing off CO2. Pt eventually weaned from BiPAP and
maintained on NC. In interim, pt on Lasix drip to help diurese
excess fluid. Pt with good response to Lasix 40mg IV dosing at
a time.
.
# CHF/CAD: Systolic failure, likely due to underlying CAD and a
prior MI ~ 1mo ago with progressive fluid overload. Started
Lasix drip with good urine response. Pt's beta-blocker was held
given bradycardia throughout MICU stay. Home ASA was
administered. Repeat ECHO showed left ventricular ejection
fraction is <40%. Starting ACE-I and statin were deferred until
able to discuss pt with cardiology and PCP. [**Name10 (NameIs) 16835**] with
stable, mild elevation (CKMB wnl), likely because of prior,
recent MI.
.
Pt's condition improved and he was transferred back to the floor
[**8-9**]. On transfer back to the floor, VS Tc 97 BP 109/56
(94-122/37-63) HR 64 100% on Neb w/4L NC. Pt's family was
present and able to verify information regarding baseline mental
status; at baseline pt is not confused but had to be regularly
reminded of location. Over the next few days the pt condition
improved and his mental status returned to baseline. However, on
[**8-12**] pt developed rigors w/a positive UA suggestive of UTI. CXR
on [**8-12**] compared to [**8-10**] CXR showed changes concerning for
possible PNA (?aspiration); given rigors, elevated WBC and
change on CXR, pt was started on broad spectrum IV antibiotics
(CefePIME +MetRONIDAZOLE (FLagyl)+Vancomycin). With antibiotics,
pt's condition improved substantially and he was able to be
discharged home with 24hr nursing care to complete his course of
IV antibiotics and complete his recovery.
.
Pt was full code during this entire admission.
Medications on Admission:
-amaryl 1mg daily
-was on carvedilol for last 2 wks 6.25 [**Hospital1 **]
-lasix (new for him in last 2 wks) 60 qam, 40 QPM
-ASA 162 daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. Glimepiride 1 mg Tablet Sig: Two (2) Tablet PO daily () as
needed for DM II.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once
every late afternoon): Please hold if systolic blood pressure is
< 100.
Disp:*30 Tablet(s)* Refills:*2*
4. [**Hospital 16836**] medical equipment
[**Hospital 16836**] medical equiptment:
Wheelchair with elevated leg rests.
Indication:
Lower extremety edema
5. durable medical equipment
Hospital Bed
Patient Requires frequent change in body position
needs immediate change to body position
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
Please hold if your systolic blood pressure is less than 100 and
if your heart rate is less than 60. .
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Cefepime 1 gram Recon Soln Sig: One (1) gram Intravenous
every twenty-four(24) hours for 4 days: Continue dose through
[**2167-8-17**]. .
Disp:*4 grams* Refills:*0*
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous q48
hrs for 4 days: Continue through [**2167-8-17**]. You may have 1 dose
extra.
Disp:*3 1000 mg* Refills:*0*
9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO qAM: Please
hold if systolic blood pressure is < 100.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern [**State 2748**]
Discharge Diagnosis:
Primary:
CHF exacerbation
Respiratory failure
.
Secondary:
Altered mental status
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because of worsening shortness
of breath, malaise confusion and increased lower leg swelling.
This was likely due to an exacerbation of you existing heart
failure. While in the hospital you required transfer to the
intensive care unit due to worsening breathing due to fluid in
your lungs and respiratory fatigue as well as increasing
confusion and somnulence. You were given medication to help
remove the fluid from your lungs and you were assisted with your
breathing using a special respiratory assist device called a
BiPAP. Your condition improved and you left the ICU in stable
condition on transfer to the cardiac floor where you continued
to receive medication to remove the fluid accumulation. Your
overall condition improved and you were discharged in stable
condition. Unfortunately while on the floor you developed an
infection which required treatment with IV antibiotics. You
improved substantially on IV antibiotics and you were discharged
home with 24hr nursing care on these IV antibiotics in order to
complete full 7 day course.
.
The following changes were made you your medications:
- Please INCREASE Amaryl to 2 mg once daily.
- Please START Metoprolol Succinate 25 mg PO daily.
- Please STOP taking Carvedilol.
- Please CONTINUE taking your IV antibiotics for a total of 7
days with your last doses on [**8-17**]. These antibiotics include
CefePIME 1 g IV Q24H and Vancomycin 1000 mg IV Q48H.
- Please note that you need to take Lasix (furosemide) 60 mg in
the morning and Lasix (furosemide) 40 mg in the late afternoon.
You will need to discuss with your primary care physician for
further adjustment.
- Please continue to take all of your other home medications as
prescribed.
.
Please be sure to take all medication as prescribed.
.
You will need to be evaluated for telemonitoring. This
evaluation for telemonitoring is very imporant gievn that you
need significant assistance with daily activities such as taking
medications, showering and other activities; however, you and
your family strongly prefer care in the home.
.
Please be sure to weigh yourself each day. If you have greater
than a 3 lbs weight gain, please contact your doctor immediately
as this may be indicative of fluid accumulation and worsening
heart function.
.
Please be sure to keep all follow-up appointments with your PCP
and cardiologist.
It was a please taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP
and cardiologist.
Completed by:[**2167-8-14**]
|
[
"428.23",
"799.02",
"276.8",
"250.00",
"518.0",
"564.09",
"276.4",
"486",
"414.01",
"518.81",
"428.0",
"403.90",
"272.4",
"585.9",
"276.0",
"599.0",
"426.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19991, 20058
|
15005, 18408
|
271, 278
|
20183, 20183
|
5095, 5095
|
22837, 22950
|
18597, 19968
|
20079, 20162
|
18434, 18574
|
20368, 22814
|
5111, 12943
|
3824, 4391
|
12966, 14982
|
4419, 5076
|
223, 233
|
306, 3450
|
20198, 20344
|
3494, 3667
|
3683, 3809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,652
| 162,109
|
38369+58216
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-6-30**] Discharge Date: [**2106-7-7**]
Date of Birth: [**2082-2-28**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
Need for surgical repair of left zygomaticomaxillary complex
fracture and left orbital floor blowout fracture.
Major Surgical or Invasive Procedure:
Left ZMC and orbital floor fracture repairs
History of Present Illness:
This is a 24 year old male who was originally admitted to the
Trauma service on [**2106-6-25**] s/p assault with multiple facial
fractures and left subarachnoid hemorrhage (SAH) and a large
left subgaleal hematoma. Patient was recovering well and was
transferred to Plastics service on [**2106-6-29**] for repair of his
facial fractures. He was scheduled for those repairs on [**2106-6-30**]
and NPO for surgery when at approximately 3 a.m. the morning of
[**6-30**], he became agitated and despite efforts to keep in with us
for surgery, he suddenly signed out AMA. He was able to return
directly home to his parent's home in [**Location (un) 246**] where he decided to
eat a cookie. They were able to convince him to return to the
hospital where they brought him to the ER at a little bit before
7am for purposes of keeping with the surgical plan. Due to the
fact that he had eaten a cookie prior to returning to the
hospital, his surgery on [**6-30**] had to be delayed further into the
day.
Past Medical History:
left subarachnoid hemorrhage (SAH) [**2106-6-25**]
Left zygomaticomaxillary complex fracture [**2106-6-25**]
Left orbital floor blowout fracture [**2106-6-25**]
right inferior orbital wall fracture [**2106-6-25**]
Social History:
Self reported abuse of heroin and prescriptive medications over
the past three years or so. Possibly participating in a needle
exchange program (card was found in his pocket but not sure
where this was from). Possible ETOH abuse. Smokes 1 PPD x past
10 years. Parents did have a formal restraining order in the
recent past so he could not come to the house but they did have
that lifted recently. He has been in prison in the past, has
gone through rehab programs and was living in a halfway house in
the past. He has recently been homeless and living on the
streets with a girlfried named 'KiKi' who witnessed the assault,
fled the scene, and then waited 12 hours to call his parents to
let them know what happened.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION
.
Temp:99.1 HR:104 BP:134/91 Resp:18 O(2)Sat:100 normal
.
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, sutured left brow laceration,
bilateral subacute periorbital ecchymoses
Oropharynx within normal limits, nontender, full range of
motion
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent, cranial nerves intact, symmetric
strength/sensation, stable gait
Pertinent Results:
[**2106-6-30**] 10:50PM GLUCOSE-115* UREA N-6 CREAT-0.7 SODIUM-142
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14
[**2106-6-30**] 10:50PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-1.7
[**2106-6-30**] 10:50PM WBC-16.3*# RBC-4.01* HGB-12.3* HCT-35.3*
MCV-88 MCH-30.6 MCHC-34.7 RDW-14.2
[**2106-6-30**] 10:50PM PLT COUNT-370
[**2106-6-30**] 11:16AM PT-11.3 PTT-22.0 INR(PT)-0.9
[**2106-6-30**] 10:05AM URINE HOURS-RANDOM
[**2106-6-30**] 10:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2106-6-30**] 10:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2106-6-30**] 10:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2106-6-30**] 08:50AM GLUCOSE-97 UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-31 ANION GAP-14
[**2106-6-30**] 08:50AM CALCIUM-10.5* PHOSPHATE-3.8 MAGNESIUM-2.2
[**2106-6-30**] 08:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-6-30**] 08:50AM WBC-9.9 RBC-4.81 HGB-14.6 HCT-42.6 MCV-89
MCH-30.3 MCHC-34.2 RDW-14.2
[**2106-6-30**] 08:50AM NEUTS-67.8 LYMPHS-25.6 MONOS-4.5 EOS-1.4
BASOS-0.6
[**2106-6-30**] 08:50AM PLT COUNT-453*
.
RADIOLOGY
[**Known lastname **],[**Known firstname **] [**Age over 90 85451**] M [**2011-3-9**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2106-6-30**]
11:23 AM
[**Hospital 93**] MEDICAL CONDITION:
24 year old man with AMS, agitation and hx of SAH, eval for new
bleeding
REASON FOR THIS EXAMINATION:
blood?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Wet Read: RBLd WED [**2106-6-30**] 1:56 PM
No new intracranial hemorrhage. continued evolution/decrease in
SAH layering along corpus callosum. facial fxs better assess on
prior face CT.
.
Final Report
EXAM: Non-contrast-enhanced CT of the head.
CLINICAL INFORMATION: 24-year-old male with history of altered
mental status and agitation, history of recent subarachnoid
hemorrhage, evaluate for new acute intracranial hemorrhage.
COMPARISON: Multiple priors, including [**2106-6-27**], [**2106-6-25**].
TECHNIQUE: Non-contrast-enhanced CT of the head was performed.
Reformatted
coronal and sagittal images were also obtained.
FINDINGS: Again seen is evolving/resolving subarachnoid
hemorrhage along the corpus callosum, best seen on the coronal
and sagittal images, slightly decreased in amount as compared to
[**2106-6-25**]. No new acute intracranial hemorrhage is seen. There is
no mass effect, midline shift, or hydrocephalus. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. Mucosal thickening is seen
in the ethmoid air cells and maxillary sinuses. Multiple facial
fractures are not fully included or optimally evaluated and are
better assessed on prior maxillofacial CT from [**2106-6-25**]. These
include fractures involving left zygomaticomaxillary complex and
left and possibly right orbit. The maxillary sinuses are not
fully imaged on the current study. Evidence of large left
subgaleal hematoma is again seen. There has been interval
decrease in size in the right subgaleal hematoma as compared to
[**2106-6-25**], without significant change from [**2106-6-27**].
.
IMPRESSION:
1. Resolving/evolving subarachnoid hemorrhage layering along the
corpus
callosum, with interval decrease since [**2106-1-26**]. No new
intracranial hemorrhage seen.
2. Facial and orbital fractures, not fully included and
incompletely
evaluated, better evaluated on recent dedicated maxillofacial
CT. Large left subgaleal hematoma again noted.
Brief Hospital Course:
In the ER, the patient became increasingly agitated despite
multiple conversations and attempts to calm him with Ativan and
Haldol. For his safety and the safety of others, the patient
was then placed in seclusion/restraints due to the imminent
threat of Self Harm. The patient's response to the intervention
was agitated (Combative). It was felt that this behavior was
not typical and may have represented a change in mental status
related to an unstable SAH which had previously been stable. He
was sent for an urgent head CT but was non-compliant with
staying still. Due to the fact that he needed an urgent head CT
and was likely going to go for surgical repair of his facial
fractures, the decision was made to sedate and intubate the
patient for his own safety. This was discussed with the
patient's father and all parties were in agreement. The patient
underwent the head CT which showed a stable left SAH and stable
large left subgaleal hematoma. Neurosurgery saw the patient and
the head CT and gave clearance for facial fracture repair
surgery with plastics. Patient underwent ORIF of left facial
fractures on the afternoon of [**2106-6-30**] and tolerated the
procedure well. He spent the night intubated in in our trauma
ICU. He was extubated and transferred to the floor on [**2106-7-1**]
where he was maintained on sinus precautions and started on
Seroquel PRN for agitation. At this time a 'Psych consult' was
called for help with etiologies of agitated behaviors. They
felt as though confusion/delerium and agitation may be related
to head injury or seizures. On [**7-1**], Psych again met with
patient and found him to have some suicidal ideation. They felt
he lacked the capacity to make informed medical decisions, such
as leaving AMA, and would likely require dual diagnosis
following medical stabilization and resolution of delirium. On
[**2106-7-2**], the Medicine team was also consulted for help with
etiology/management of delerium. They felt medications,
withdrawal and infection could all be causes of delirium. On
[**2106-7-3**], Psych again saw the patient and felt that his mental
status appeared
to be improving quite a bit, with only minimal attentional
deficits. He denied any SI/HI to them, but appeared ambivalent
about what was best for his care. Collateral
info from his family suggested significant safety concerns and
depressive symptoms along with severe substance use disorder
that has been ongoing. Based on the above information, Psych
felt that the patient appeared appropriate for dual-dx level of
care for stabilization and treatment. They also felt he met
section 12 criteria based on risk to self. They recommended
inpatient dual diagnosis admission and BEST was called to assist
with dispo. Patient had 1:1 sitter for safety and a Section 12
was placed in chart. Patient was maintained with 1:1 sitter and
on PRN Seroquel, ativan and haldol. His seroquel was increased
from 25mg po TID PRN, to 50mg po QID PRN to 100mg PO QID PRN.
On Monday, [**2106-7-5**] patient became agitated, refusing meds and
insisting he was going to leave. Psych RN was called and after
assessment she felt that [**Hospital1 18**] security needed to be in
attendance. Patient very upset and saying 'I'd rather be in
jail than here'. Emotional support was provided to patient by
RNs, Psych RN, Psych MD, sitter, Plastics team and [**Hospital1 18**]
Security. Patient eventually settled down and the BEST team is
screening him for placement to a facility which he has currently
agreed to. This patient is medically cleared to be discharged
to a facility that is better able to manage his current
psychosocial needs.
Medications on Admission:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) Left ZMC, left orbital floor, right orbital floor facial
fractures
2) Depression/suicidal ideation
3) substance abuse/addiction
Discharge Condition:
Mental Status: Clear, agitated at times
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on [**2106-6-30**] for repair of a facial fracture.
Please follow these discharge instructions:
.
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
* Take prescription pain medications for pain not relieved by
tylenol.
* Take your antibiotic as prescribed.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
.
Call the office IMMEDIATELY if you have any of the following:
* Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
* A large amount of bleeding from the incision(s).
* Fever greater than 101.5 oF
* Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Activities:
* No strenuous activity
* Exercise should be limited to walking; no lifting, straining,
or excessive bending.
* Unless directed by your physician, [**Name10 (NameIs) **] not take any medicines
such as Motrin, Aspirin, Advil or Ibuprofen etc
.
Comments:
* Please sleep on several pillows and try to keep your head
elevated to help with drainage. Avoid sleeping on the left side
of your face.
* Please maintain SOFT diet until your follow up clinic visit
and you can ask your surgeon whether you can advance your diet
at that time. Avoid soft diet foods with 'little pieces' (ie;
oatmeal) that can get stuck in surgical wounds.
* Please avoid blowing your nose.
* Sneeze with your mouth open
* Try to avoid sipping liquids through a straw
* Avoid smoking
Followup Instructions:
Patient to be followed for psych/substance abuse issues at an
outside facility.
.
Please follow up Friday, [**2106-7-9**], with Dr. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 85452**]
in Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3228**]' abscence.
.
Please Call Dr. [**Last Name (STitle) **] office at [**Telephone/Fax (1) 5343**]
The clinic/office is located on the [**Hospital Ward Name 517**], [**Hospital Unit Name 85453**] on the fifth floor.
Completed by:[**2106-7-5**] Name: [**Known lastname 13568**],[**Known firstname 399**] Unit No: [**Numeric Identifier 13569**]
Admission Date: [**2106-6-30**] Discharge Date: [**2106-7-7**]
Date of Birth: [**2082-2-28**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Addendum:
We were unable to secure an appropriate facility bed (psych/dual
diagnosis) for this patient on the original date of expected
discharge, [**2106-7-5**]. The patient remained with us on CC-6, with
1:1 sitter 24 hrs/day, in seclusion, until the evening of
[**2106-7-7**] when he was offered a bed in our psych unit,
[**Hospital1 **]-4. The patient showed daily improvements in his mood
and affect over the past few days but still not completely
making sense during periods of agitation. His periods of
agitation dwindled down as the days went on to only one outburst
on [**2106-7-7**] which was quickly diffused with offering a
compromised selection for a dinner meal.
.
Patient completed his course of Augmentin while he was an
inpatient on CC6 and he was compliant with Peridex rinses and
with taking the PRN sedatives when he felt he needed them.
Discharge Disposition:
Extended Care
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4029**] MD [**MD Number(2) 4030**]
Completed by:[**2106-7-8**]
|
[
"V60.0",
"E968.9",
"V62.84",
"305.51",
"873.42",
"311",
"293.0",
"300.00",
"802.4",
"802.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.79",
"76.92",
"76.72"
] |
icd9pcs
|
[
[
[]
]
] |
15268, 15439
|
6806, 10474
|
426, 472
|
10719, 10719
|
3196, 4632
|
13483, 15245
|
2493, 2511
|
4669, 4742
|
10565, 10698
|
10500, 10506
|
10989, 13460
|
2526, 3177
|
275, 388
|
4771, 6782
|
500, 1501
|
10734, 10851
|
1523, 1739
|
1755, 2477
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,715
| 125,545
|
53930
|
Discharge summary
|
report
|
Admission Date: [**2157-11-14**] Discharge Date: [**2157-11-19**]
Date of Birth: [**2089-11-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
azithromycin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath with occasional chest pain.
Major Surgical or Invasive Procedure:
Excision of angiosarcoma, reconstruction of right atrium with
bovine pericardial patch [**2157-11-14**]
History of Present Illness:
Ms. [**Known lastname **] is a 67 year old female with a known mediastinal
angiosarcoma. She initially presented in [**2157-2-13**] with
dyspnea, fevers and weight loss. She was hospitalized in [**Month (only) 958**]
[**2157**] at which time chest x-ray identified a mass at the right
heart border. Extensive workup revealed a 10.0 cm mass arising
from the pericardium. Biopsy in [**2157-5-15**] showed intermediate
to high-grade angiosarcoma. She began weekly Paclitaxel on
[**2157-5-27**]. Ms. [**Known lastname **] completed two cycles of Paclitaxel
followed by radiation with concurrent paclitaxel as of [**10-5**], [**2157**]. Radiation and the latter two cycles of
chemotherapy were administered by Dr. [**Last Name (STitle) 110608**] in [**Location (un) 9101**]. The
radiation course was complicated by nausea, vomiting, anorexia,
diarrhea, esophagitis and a 10-pound weight loss. She also
reports ongoing fatigue, dry cough and episodes of
lightheadedness with standing, and diarrhea. She does feel
dyspneic with exertion. She admits to occasional chest pain.
Despite this, she has been able to go sailing, walking each day,
and spend time with her grandchildren.
Following her most recent PET CT, and brain MRI, there are plans
to move forward with surgical exploration and possible resection
on [**2157-11-14**].
Past Medical History:
recent pneumonia [**2-/2157**]
hysterectomy for hemorrhage following childbirth
Social History:
Ms. [**Known lastname **] never smoked and denies drinking alcohol on a
regular basis. She is married and lives with her family.
Family History:
Her mother had coronary artery disease and a myocardial
infarction. Her father had coronary artery disease and
"metastatic cancer".
Physical Exam:
Admission exam:
Pulse: 107 Resp: 18 O2 sat: 96% room air
B/P Right: 93/61 Left: 91/58
Pre-Op Weight:138.23lbs62.7kgs
General: Appeared older than stated age of 67
Skin: Warm [x] Dry [x] intact [x]
HEENT: NCAT [x] PERRL [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] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: None
Discharge exam:
VS: T 98 HR 63 BP 114/63 Rr 18 O2sat 93 % 2L NC RA 86-88
with activity
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
Pulm: scattered rhonchi
CV:RRR, no M/R/G. Sternum-stable, incision-CDI
Abdm: soft, NT/ND/+BS
Ext: trace bilat pedal edema
Pertinent Results:
Admission labs:
[**2157-11-14**] PT-16.1* PTT-33.2 INR(PT)-1.5*
[**2157-11-14**] PLT COUNT-208
[**2157-11-14**] WBC-5.6 RBC-2.78*# HGB-7.9*# HCT-24.8*# MCV-89 MCH-28.5
MCHC-32.0 RDW-15.4
[**2157-11-14**] UREA N-13 CREAT-0.5 SODIUM-138 POTASSIUM-4.2
CHLORIDE-109* TOTAL CO2-24 ANION GAP-9
Discharge Labs:
[**2157-11-19**] WBC-3.1* RBC-2.86* Hgb-8.3* Hct-25.6* MCV-90 MCH-29.0
MCHC-32.3 RDW-15.3 Plt Ct-242
[**2157-11-19**] Glucose-99 UreaN-10 Creat-0.6 Na-135 K-4.3 Cl-98
HCO3-31 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal diameter of aorta
at the sinus, ascending and arch levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Brief RA diastolic collapse.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is normal in size. 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.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
T
he ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors.
The diameters of aorta at the sinus, ascending and arch levels
are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is 10cm x 10cm echodense mass seen adjacent to the right
atrium. It seems to be within the pericardium. The mass seems to
be encroaching the SVC. There is no compression of SVC. There is
right atrial compression. No signs of pericardial tamponade. The
mass does not seem to be entering RA or SVC cavity. There is no
definite space seen between the right atrial wall and the mass
suggesting adherent mass.
Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] was notified in person of the
results before surgical incision.
POSTBYPASS:
Preserved LV systolic function. LVEF 55%. RV has mild global
systolic dysfunction. No new valvular findings. The pericardial
patching of the atrium seems intact. No residual mass seen in
theperciardium.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2157-11-15**] 7:59
AM
Final Report:No pneumothorax or appreciable mediastinal widening
after removal of midline and right pleural drain and
endotracheal tube. Atelectasis in the right middle and lower
lobes has worsened and there is a very small right pleural
effusion. Left lung is clear. Small left pleural effusion is
new. A left internal jugular introducer ends at the thoracic
inlet.
CXR: [**2157-11-19**]:
Compared with [**2157-11-18**] at 17:46 p.m., there has been slight
interval
improvement in the opacity at the right lung base. Otherwise,
no significant change is detected. Again seen are sternotomy
wires. The cardiomediastinal silhouette is stable. No CHF,
other areas of opacity. No significant left-sided effusion. No
pneumothorax detected.
IMPRESSION: Minimal improvement compared with [**2157-11-18**],
otherwise unchanged.
PLEURAL [**2157-11-18**]
PLEURAL ANALYSIS WBC 1246; RBC [**Numeric Identifier 110609**]; Polys 62; Lymphs 12;
Monos 0; Eos 1 NRBC 1 Meso 1 Macro 24
PLEURAL CHEMISTRY TotProt 2.9 Glucose 99 LD(LDH) 447 Amylase
27 Albumin 1.7 Cholest 43 Triglyc 23
Pleural FLUID pH 7.55 [**2157-11-18**]
[**2157-11-18**] PLEURAL FLuid GRAM STAIN (Final [**2157-11-18**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2157-11-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Brief Hospital Course:
The patient was a same day admission. She was brought to the
Operating Room on [**2157-11-14**] by Dr [**Last Name (STitle) 110610**] and [**Doctor Last Name **],
please see operative report for details, in summary she had:
excision of a right atrial angiosarcoma and reconstruction of
her right atrium with bovine pericardial patch. Her bypass time
was 67 minutes with a crossclamp time of 40 minutes. She
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. She remained hemodynamically stable in the
immediate post-op period, woke neurologically intact and was
extubated. On POD 1 the patient was alert and oriented and
breathing comfortably, she remained neurologically intact and
hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. All tubes, lines and wires were discontinued per
cardiac surgery protocol without complication. The right pleural
effusion was tapped for 450 mL. Pleural chemistry revealed an
Exudative effusion pH 7.55, LDH 444. Micro with no organism.
She required 2 L NC supplemental oxygen for saturation of 86-88%
with ambulation. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with [**Hospital3 **] VNA,
on oxygen in good condition. She will follow-up with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 7772**] as an outpatient.
Medications on Admission:
1. Citalopram 20 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Pravastatin 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN pain, fever
5. Aspirin EC 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 0.5-1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
9. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*3
10. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
12. Home oxygen 2L nasal cannula
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
s/p exc tight atrial angiosarcoma/reconstruction right atrium
w/bovine pericardial patch([**11-14**])
PMH: cardiac angiosarcoma s/p chemo/XRT
PSH: TAH
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema trace lower extremity edema
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep a log
No driving for one month or while taking narcotics.
Driving will be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check NURSE: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2157-11-29**] 10:00
at Cardiac Surgery Office in the [**Hospital **] Medical Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Surgeon Dr. [**Last Name (STitle) 7772**] [**2157-12-20**] at 1:00pm in the [**Hospital **] Medical
Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 19944**] [**2157-12-7**] at 2:15pm
Other:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 8770**]
Date/Time:[**2157-12-7**] 2:30
Provider: [**Name10 (NameIs) **] HEM ONC CC9 Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2157-12-7**] 1:45
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone: Date/Time:[**2157-11-29**]
2:00 [**0-0-**] on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x ray
Please call to schedule the following:
Primary Care Dr.[**Name (NI) **],[**Doctor Last Name **] W. [**Telephone/Fax (1) 20997**] in [**5-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2157-11-19**]
|
[
"511.9",
"530.81",
"V87.41",
"786.2",
"E879.2",
"458.29",
"272.4",
"508.0",
"164.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"32.39",
"34.91",
"37.33",
"37.49"
] |
icd9pcs
|
[
[
[]
]
] |
10847, 10908
|
8230, 9955
|
330, 436
|
11103, 11293
|
3164, 3164
|
11944, 13511
|
2058, 2192
|
10094, 10824
|
10929, 11082
|
9981, 10071
|
11317, 11921
|
3469, 7991
|
2207, 2887
|
8207, 8207
|
2903, 3145
|
242, 292
|
464, 1792
|
3180, 3453
|
8075, 8170
|
1814, 1895
|
1911, 2042
|
8023, 8038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,710
| 154,121
|
49573
|
Discharge summary
|
report
|
Admission Date: [**2139-3-27**] Discharge Date:
Date of Birth: Sex: F
Service:
PRINCIPAL DIAGNOSES:
1. Right common carotid artery stenosis.
2. Right brachiocephalic artery occlusion.
3 Right arm ischemia
PRINCIPAL PROCEDURE PERFORMED: Aorto to right common
carotid bypass and right CEA
HISTORY OF PRESENT ILLNESS: The patient was a 64-year-old
female with a past medical history significant for coronary
artery disease as well as extensive peripheral vascular
disease who was admitted to the [**Hospital6 2018**] on [**2139-3-27**] for an elective aortic arch to carotid
bypass surgery.
The patient was admitted because as an outpatient she had
been on Coumadin and the plan for her was to be converted to
a Heparin drip prior to her surgery. Of note, the patient
has undergone a catheterization in [**12/2138**] which demonstrated
that the brachiocephalic artery was occluded just before the
origin of the right common carotid artery.
PAST MEDICAL HISTORY:
1. Coronary artery disease with occlusion of the right
coronary artery.
2. Peripheral vascular disease.
3. Abdominal aortic aneurysm.
4. Renal artery stenosis.
5. Hypercholesterolemia.
6. Paroxysmal atrial fibrillation.
7. Hypertension.
8. Peptic ulcer disease.
9. History of gastrointestinal bleed.
10. Chronic renal insufficiency.
11. History of Methicillin-resistant enterococcal urinary
tract infection.
PAST SURGICAL HISTORY:
1. Left subclavian artery stent.
2. Left carotid artery stent.
3. Left subclavian artery stent.
4. Aortofemoral bypass.
5. Left renal artery stent
MEDICATIONS AT TIME OF ADMISSION:
1. Lasix 40 mg p.o. t.i.d.
2. Amiodarone 200 mg p.o. daily.
3. Lopressor 50 mg p.o. daily.
4. Aspirin 81 mg daily.
5. Lipitor 40 mg daily.
6. Isosorbide dinitrate 30 mg p.o. t.i.d.
7. Norvasc 2.5 mg p.o. daily.
8. Colace 100 mg p.o. daily.
9. Protonix 40 mg p.o. daily.
10. Coumadin 6 mg p.o. q. h.s.
ALLERGIES: Patient had no known drug allergies.
SOCIAL HISTORY: Patient had a 30-pack-year smoking history
and quit three years prior to admission.
PHYSICAL EXAMINATION: She is awake and alert. Temperature
98.3, heart rate 54, blood pressure 120/76, respiratory rate
14, satting 93% on room air. Her HEENT exam demonstrates her
head to be normocephalic and atraumatic with her extraocular
muscles intact and anicteric sclerae and a left carotid
bruit. There is no jugular venous distention. Her lungs are
clear to auscultation bilaterally. Heart sounds are regular
in rate and rhythm with no murmur, rub, or gallop
appreciated. The abdomen is soft, obese, nontender,
nondistended. There is trace edema noted.
LABORATORY EVALUATION AT TIME OF ADMISSION: White blood cell
count of 5.6, hematocrit 34.5, platelets of 170, sodium of
144, potassium of 4.3, chloride of 106, bicarbonate of 28,
BUN of 40, creatinine of 2.7, and glucose of 99.
ASSESSMENT AND PLAN: This is a 64-year-old female with a
history of coronary artery disease, peripheral vascular
disease with a demonstrated brachiocephalic artery occlusion
who is now presenting for elective bypass of this occlusion.
Patient was admitted, placed on a Heparin drip with a
Cardiology evaluation, and preoperative clearance given. She
was taken to the Operating Room on [**2139-3-30**] when the bypass
was performed without incident. Patient had Dopplerable
triphasic brachial, radial, and ulnar pulses postoperatively.
She was in the Cardiothoracic Surgery Intensive Care Unit
postoperatively.
Her postoperative course was initially stable. She was
weaned off of her pressors and continued on antibiotics.
By postoperative day number two she had been extubated and
was neurologically intact and transferred to the Vascular
Intermediate Care Unit. A Physical Therapy consultation was
obtained for postoperative recovery. Patient was resumed on
her Coumadin as well as her preadmission medication regimen.
Of note, the patient developed atrial fibrillation on
[**2139-4-1**] which was rate controlled with Lopressor. Her
Amiodarone dose was increased and this continued to control
her rate.
Patient, on the evening of [**2139-4-4**], developed respiratory
distress and arrest which led to a cardiac arrest. She was
emergently intubated and transferred to the Intensive Care
Unit.
During the code she developed asystole. Cardiopulmonary
resuscitation was initiated and tracings at that time showed
fine ventricular fibrillation. She was successfully
defibrillated and developed an organized rhythm. Her EKG
demonstrated diffuse ST segment ischemic changes. Her blood
pressure returned to 110/68 and she was seen by the
cardiologist.
The patient required Dopamine drip to maintain her blood
pressure which was changed to Levophed. She underwent a
bronchoscopy which demonstrated some areas of atelectasis but
otherwise without acute pathology.
A PA catheter was placed which initially was unable to be
wedged but demonstrated a central venous pressure of 15, PA
pressures of 35/12, and a cardiac output and index of 4.8 and
1.9, respectively. The SVR was 833 at that time and the
Levophed drip was running at 0.02 mcg/kg per minute at that
time.
A TEE was emergently performed which demonstrated normal
biventricular function and no evidence of dissection. A
chest x-ray that had been done at the time of the code
demonstrated left basilar collapse, for which the
bronchoscopy was performed.
The patient was continued on her Heparin with full supportive
Intensive Care Unit care. However, after extensive
discussions with the family members it was decided that the
patient would no longer want to have full supportive care
given her grave prognosis following her cardiopulmonary
arrest. With this in mind the family made a decision to not
have the patient undergo any additional diagnostic testing or
therapeutic interventions. They requested that the level of
support not be escalated or withdrawn, that is, that her
current level of support that was being delivered on
[**2139-4-5**] be continued without change.
Patient remained comfortable and became asystolic on the
morning of / / and was pronounced by the Intensive Care Unit
team at that time. The medical examiner was notified by the
Intensive Care Unit team.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 96566**]
MEDQUIST36
D: [**2139-4-6**] 08:49
T: [**2139-4-6**] 10:22
JOB#: [**Job Number 103685**]
|
[
"435.3",
"570",
"427.5",
"518.0",
"440.21",
"584.9",
"585",
"427.31",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"99.62",
"99.04",
"88.72",
"39.22",
"89.64",
"96.04",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
1438, 1986
|
2111, 6522
|
349, 975
|
997, 1415
|
2003, 2088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,639
| 149,795
|
48732
|
Discharge summary
|
report
|
Admission Date: [**2188-12-2**] [**Month/Day/Year **] Date: [**2188-12-15**]
Service: SURGERY
Allergies:
Penicillins / Amoxicillin / Morphine Sulfate / Erythromycin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall - left hip pain
Major Surgical or Invasive Procedure:
1. IVC filter placement
2. Operative treatment to left intertrochanteric hip fracture
with cephalomedullary nail.
3. Angiogram
History of Present Illness:
87 yo female s/p mechanical fall resulting in left
intratrochanter fracture.
Past Medical History:
Cardiac Risk Factors:
(-)ve Diabetes
(-)ve Dyslipidemia
(-)ve Hypertension
Cardiac History:
CABG: None
Percutaneous coronary intervention: None
Pacemaker/ICD:
29-month-old Guidant Discovery II Model 1284 dual single-chamber
pacemaker
Atrial fibrillation
- with recent RVR
- s/p DDD pacer (for tachy-brady syndrome)
- On coumadin
Other Past History (copied from [**2188-4-16**] DC summary and
confirmed):
1) Stable IV Chronic kidney disease
-Baseline Cr 2.4-2.6
-home diet: low sodium, low potassium
2) GI bleed, most recent [**2-/2188**]
-Colonoscopy [**2185**]: Grade III internal hemorrhoids, multiple
severe diverticuli in sigmoid colon, descending colon.
-Normal EGD [**2185**]
3) Hiatal hernia
4) Chronic back pain (spinal stenosis, facet degeneration,
spondylolisthesis s/p laminectomy, ?osteoporosis)
5) Bilateral cataracts
6) s/p TAH and appendectomy
7) R cerebellar stroke
10) Anemia of chronic disease, ?pernicious anemia
11) ?allergic bronchitis, many years ago
Social History:
The patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. She has help with cooking,
cleaning, and shopping on tuesday through [**Last Name (NamePattern4) **]. Has two
daughters and two grand-daughters. Social history is significant
for the absence of current tobacco use. There is no history of
alcohol abuse, as the patient drinks alcohol only on holidays.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Pertinent Results:
[**2188-12-2**] 07:15PM GLUCOSE-130* UREA N-66* CREAT-2.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2188-12-2**] 07:15PM PT-41.2* PTT-32.4 INR(PT)-4.5*
[**2188-12-2**] 07:15PM PLT COUNT-277
[**2188-12-2**] 07:15PM WBC-9.8# RBC-3.93* HGB-12.0 HCT-36.7 MCV-93
MCH-30.5 MCHC-32.7 RDW-13.2
[**2188-12-2**] 07:15PM CK(CPK)-67
[**2188-12-2**] 07:15PM cTropnT-0.06*
CT Head [**2188-12-2**]
IMPRESSION: No intracranial hemorrhage or fracture. Right
cerebellar
hypodensity likely represents encephalomalacia from remote
infarction.
[**2188-12-2**] CT Chest/Abd/Pelvis
IMPRESSION:
1. Large pelvic hematoma measuring 14.6 x 9.1 x 9.3 and a large
anterior
abdominal wall hematoma secondary to active extravasation from
the left
external iliac branch, most likely external pudendal artery.
2. Free fluid is noted around the liver and spleen and is
tracking into the
mediastinum with no definite evidence of solid organ injury.
3. Comminuted left trochanteric fracture of the femur with mild
surrounding
hematoma. Nondisplaced Fx also of right inferior pubic ramus.
4. Large distended gallbladder which contains gallstones.
Mild-to-moderate
CBD dilatation. MRCP can be obtained for further evaluation.
5. Large hiatal hernia.
6. Bilateral atrophic kidneys.
ECG [**2188-12-2**]
Atrial flutter with 3:1 A-V block
Severe right axis deviation
Right bundle branch block
Low lead voltage
Inferior/lateral ST-T changes are nonspecific
Since previous tracing of [**2188-9-24**], ventricular pacing not seen
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 0 128 408/457 0 -133 -5
CTA Chest & Pancreas [**2188-12-9**]
IMPRESSION:
1. Distended gallbladder with gallstone and mild surrounding
stranding. No
wall thickening. Acute cholecystitis could be considered
according to
clinical symptoms.
2. No pulmonary embolism.
3. Bilateral pleural effusions, right larger than left,
associated with
bibasilar atelectasis.
4. Enlarged pulmonary arteries which are suggestive of pulmonary
hypertension.
5. Large hiatal hernia containing stomach and small bowel.
6. Dilated common bile duct measuring 15 mm.
7. 10-mm metallic density is seen in bowel loops that could
represent a
foreign body.
8. Anasarca.
9. Low-attenuation lesion/structure can be identified in the
inferior images
and could represent bowel loop or fluid pocket or cyst.
ECHO
Conclusions
EF>55%
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is dilated with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. The pulmonic
valve leaflets are thickened. There is a trivial/physiologic
pericardial effusion.
No intracavitary ventricular thrombus seen. Intra-atrial
thrombus cannot be adequately assessed by transthoracic
echocardiography.
Compared with the prior study (images reviewed) of [**2188-1-22**].
Estimated pulmonary artery systolic pressure is now higher and
tricuspid regurgitation is now more prominent. Right ventricular
chamber size is now larger.
Brief Hospital Course:
She was admitted initially admitted to the medical service where
an Orthopedics consult was placed given her left hip fracture.
She was noted with an elevated INR to 4.5 (was on Coumadin at
home for atrial fibrillation) and was given Vitamin K for
reversal upon admission. A little over 24 hours from admission
it was noted upon exam that there was an expanding left groin
mass concerning for retroperitoneal bleed with an INR of 4.7 and
4.3. She was taken to Interventional Radiology for Gelfoam
embolization for active pelvic extravasation arising from branch
of left external pudendal artery. She was taken back to IR the
following day to assess for further bleeding and no new areas of
extravasation were noted. Her Coumadin was withheld (last INR
1.2 on [**12-12**]). She was returned to the SICU post procedure.
She was taken to the operating room on [**12-7**] for repair of her
left hip fracture; her INR on day of surgery was 1.3.
Postoperatively she was taken back to the ICU where she remained
for close monitoring and respiratory care. She did have high
oxygen requirements initially felt likley due to her fluid
status and cardiac history. A CTA of her chest was done to rule
out pulmonary embolus, none was identified. Her oxygen was
weaned but she does still require intermittent nasal cannula.
It was noted on abdominal CT imaging that she had a very large
hiatal hernia containing stomach and small bowel. She underwent
ultrasound of her gallbladder which did show CBD 10mm, +gall
stones with intrahepatic duct dilation. There were discussion
which took place as to whether she would require surgical
intervention because of the size of the hiatal hernia and
concern for it causing her symptoms. The decision to hold on
surgery was made after discussions with patient and family.
It was discussed with her Cardiologist, Dr. [**Last Name (STitle) **] whether to
restart her Coumadin; he would like for her to go back on her
Coumadin as she is very high risk for embolic process given her
history of stroke secondary to her atrial fibrillation. He
suggested [**Last Name (un) 2557**] Lovenox as a bridge until her goal INR of [**2-17**]
is reached. She will be ordered for Coumadin 4.5 mg to be given
tonight; her home regimen was ordered.
She would eventually be transferred the regular nursing unit;
she continued to work with Physical therapy which had been
initiated in the ICU. Recommendations for an LTAC after her
acute hospital stay were made. Case management initiated the
screening process.
Medications on Admission:
Prilosec 20', Coumadin 4.5MWF and 3 T/Th/Sat/Sun, Percocet
5/325'', Diltiazem 180', B12 1000', Calcium+D, Senna, Colace,
Dulcolax, gas-ex
[**Date Range **] Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
5. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as
needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Lidex 0.05 % Cream Sig: One (1) APPL Topical three times a
day: Apply as directed to affected areas on thighs.
11. Ipratropium-Albuterol 0.5-2.5 mg/3 mL Solution for
Nebulization Sig: One (1) NEB Inhalation four times a day as
needed for shortness of breath or wheezing.
12. Hep Flush-10 10 unit/mL Solution Sig: One (1) ML Intravenous
DAILY & PRN: Flush PICC line per hospital protocol.
13. Guaifenesin 50 mg/5 mL Liquid Sig: [**5-24**] ML's PO every [**6-22**]
hours as needed for cough.
14. Lovenox 60 mg/0.6 mL Syringe Sig: 0.5 ML's Subcutaneous
every twelve (12) hours: Continue until INR goal of [**2-17**] reached
and then discontinue use.
15. Coumadin 4 mg Tablet Sig: One (1) Tablet PO every evening:
Every Mon, Wed, Fri.
16. Coumadin 1 mg Tablet Sig: [**1-16**] Tablet PO every evening: Every
Mon, Wed, Fri
to total dose 4.5 mg.
17. Coumadin 3 mg Tablet Sig: One (1) Tablet PO every evening:
Every Tuesday, Thursday, Sat and Sun.
[**Month/Day (2) **] Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care
[**Hospital **] Diagnosis:
s/p Fall
Retroperitoneal bleed
Left hip fracture
Acute blood anemia
[**Hospital **] Condition:
Hemodynamically stable, pain fairly well controlled.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics. Call
[**Telephone/Fax (2) 102443**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
The following appointments were made prior to your hosptial
stay:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2189-1-13**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2189-3-10**] 12:20
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2189-5-7**]
11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2188-12-17**]
|
[
"553.3",
"780.97",
"V12.54",
"403.90",
"511.9",
"287.5",
"574.20",
"458.29",
"585.4",
"E885.9",
"E934.2",
"281.0",
"V45.01",
"724.02",
"715.96",
"790.92",
"493.90",
"427.31",
"820.21",
"576.8",
"428.32",
"285.29",
"428.0",
"285.1",
"427.32",
"902.89",
"518.82",
"808.2",
"733.00",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"38.93",
"88.47",
"38.7",
"34.91",
"99.04",
"79.05",
"99.07",
"38.86",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
5655, 8176
|
304, 435
|
2067, 5632
|
10390, 11264
|
1966, 2048
|
8202, 10367
|
240, 266
|
463, 541
|
563, 1540
|
1556, 1950
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
366
| 134,462
|
10051
|
Discharge summary
|
report
|
Admission Date: [**2164-11-18**] Discharge Date: [**2164-11-22**]
Date of Birth: [**2112-5-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo male with Down's syndrome and NAFLD who presented to ED
with two weeks of intermittent facial rash, BLE petechial rash
and one day of fevers. Pt has been complaining of not feeling
well over the past few weeks and has been c/o of stomach pain.
Sister states that she gave him an OTC [**Doctor Last Name 360**] (can't remember the
name) and he developed a macular rash on his face, transiently.
He saw his PCP ~5 days PTA and was given a prescription for an
anti-spasmodic elixer for his abdominal pain. His sister was
concerned about his facial rash so she took him to the doctor
two days ago and was given a prescription for acular eyedrops
and benadryl. Yesterday he developed a diffuse, confluent red
rash on his trunk, "like sunburn" that was pruritic. He was
treated with sarna lotion and cortisone creams. His rash then
spread to his lower extremities,where it appeared petechial in
nature. His sister notes that he had temps to [**Age over 90 **] yesterday. He
had some nausea but no diarrhea or emesis. She thinks he may
have been c/o a sore throat. He was brought to the ER for
further evaluation.
.
In the ER the patient was initially observed and was apparently
non-compliant with his exam. His WBC returned at 30.6, lactate
4.6 and patient was noted to be afebrile, tachycardic and
normotensive. He had an abdominal CT (non-contrast) that showed
some stranding surrounding the aorta, IVC and left renal
vessels. He was given
ceftazidime, vancomycin and 1 gm ceftriaxone. CXR showed mild
pulm edema but no PNA and UA was negative. he was admitted to
the ICU due to the elevated lactate and leukocytosis.
.
In the MICU, ID and dermatology were consulted. He was given
vanc and ceftriaxone to cover for meningococus and GPCs, doxy to
cover rickettsial dz and flagyl given the abd complaints. Pt
improved symptomatically, defervesced and his rash faded. He was
uncooperative with exams and refused all bld draws.
.
On arrival to the floor, pt has no complaints but is very
difficult to communicate with. pt's sister states he has been
coughing more and when he coughs his heart rate increases. he
started coughing while in the hospital. he likes the atrovent
nebs and wants more. she states his rash has improved
dramatically. no recent travel. sick contacts include a nurse
whoe helps out at home who has been sick with ?flu (but was not
coughing, and no rash). no hx of asthma
Past Medical History:
Down's syndrome
fatty liver
gastritis
Social History:
Lives with his sister and her husband
no ETOH, drugs or tobacco
No recent travel, no known tick exposures
Family History:
- one sister, age 57, developed colon cancer
- father died of colon cancer with polyps at age 70
- mother died of lung cancer
- 10 total siblings and some of them have hypertension, diabetes
and myocardial infarction
Physical Exam:
temp 98.0, BP 107/51 (87-130/38-60), HR 111 (98-120), R 24, O2
94% on RA; LOS +5.6L; today 2.5/2.5
Gen: well appearing with some auditory exp wheezing
HEENT: anicteric sclera, dry MMM, macroglossia
Neck: supple, no LAD
Cardio: tachy with regular rhythm, no m/r/g
Pulm: wheezes heard anterioly; lungs clear posteriorly without
wheezes; no stridor
Abd: soft, distended, hypoactive BS, NT
Ext: 1+ edema in lower ext bilaterally; trace edema in hands; 2+
DP
Skin: erythema across abd and arms but no definite rash; no
petechiae seen on lower ext; no rash on palms or soles
Derm exam on admit:
-On face: greasy scales w mild erythema on sebhorreic
distribution
faint erythema on cheeks
-Diffuse erythematous morbilliform eruption on chest, arms,
legs, with tiny blanchable papules on arms. On b/l shin evidence
of slightly raised erythematous papules and petechiae, no
evidence of the palpable purpura that team described today. Not
able to examine palms and soles [**12-29**] to patient's incooperation.
No evidence of mucosal involvement, no target lesions, bullae,
vesicles.
Pertinent Results:
Abd CT:
1. Mild airspace opacity in left lower lobe which may reflect an
infective process in the correct clinical setting.
2. Slight stranding of the retroperitoneal fat, of uncertain and
doubtful clinical significance.
3. Left renal cyst.
4. Thickened bladder wall which may reflect neurogenic bladder.
.
CXR [**11-18**]: Mild pulmonary vascular congestion, suggesting mild
pulmonary edema
.
Hematology:
[**2164-11-18**] 07:00PM BLOOD WBC-30.6*# RBC-4.35* Hgb-15.7 Hct-45.1
MCV-104* MCH-36.1* MCHC-34.8 RDW-16.5* Plt Ct-217
[**2164-11-18**] 07:00PM BLOOD PT-13.4* PTT-28.6 INR(PT)-1.2*
[**2164-11-18**] 07:00PM BLOOD Plt Smr-NORMAL Plt Ct-217
[**2164-11-18**] 07:00PM BLOOD ESR-51*
.
Chemistry:
[**2164-11-18**] 02:30PM BLOOD Glucose-184* UreaN-17 Creat-1.5* Na-143
K-5.3* Cl-103 HCO3-27 AnGap-18
[**2164-11-18**] 07:00PM BLOOD ALT-71* AST-56* AlkPhos-103 Amylase-90
TotBili-0.8
[**2164-11-18**] 07:00PM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.3* Mg-1.7
[**2164-11-18**] 07:00PM BLOOD CRP-224.1*
[**2164-11-19**] 04:29AM BLOOD RheuFac-12
[**2164-11-19**] 04:29AM BLOOD C3-101 C4-22
[**2164-11-18**] 07:12PM BLOOD Lactate-4.6*
[**2164-11-19**] 05:37AM BLOOD Lactate-2.5*
.
Brief Hospital Course:
.
# Rash: The Ddx for this patient's rash was enormous when
combined with fever/leukocytosis. Rash started on his head and
spread down to his feet. facial and truncal rash was
maculopapular and the LE rash was a palpable purpuric rash. ID
and Derm saw patient and narrowed Ddx to leukoclastic
vasculitis, drug reaction, viral exanthem or HSP (though UA is
without rbc, wbc, casts or protein). Leukoclastic vasculitis
possible though complement levels are normal (usually low in
vasculitis). Cryoglobulins pending (if elevated, suggests type
III cryoglobulinemia seen with autoimmune d/o such as
leukoclastic vasculitis). Drug reaction possible though would
expect serum eos? Rapid improvement with abx suggests bacterial
etiology. The family will provide the patient's immunization
history. Down's patient's have higher incidences of ALL and
leukemic infiltrates are not out of the question given his
elevated WBC count. Rash significantly improved at discharge
with topical steroid creams and antibiotics, will follow-up with
PCP [**Last Name (NamePattern4) **] [**11-28**] weeks.
.
# ID: proposed to finish off a course of 7 days of Levo/Flagyl.
Of note, pts with down's syndrome are at increased risk of skin
infection and other skin disorders.
He was thus treated with levo/flagyl x 7 days (day 1 = [**11-20**]).
He was also treated with NSAIDs, antihistamines, as well as
benadryl q4-6h and/or atarax 25mg qhs for symptoms of pruritus
as well as Sarna liberally.
.
# Elevated lactate/leukocytosis/fevers: Elevated lactate in the
setting of fevers and tachycardia, suggested an early septic
picture. Abd CT had only nonspecific findings thought limited
study due to lack of contrast. CXR showed only pulm edema but
abd CT showed possible LLL opacity which could represent PNA. UA
negative. no wounds visible. when combined with rash, could be a
variety of infections. ?PNA now with this increased cough. These
findigs prompted brief admission to the MICU. Blood and urine
cultures were unrevealing. On HOD #3, lactate and WBC trending
down and the patient was clinically improved. He will complete a
course of levo/flagyl as an outpatient. Despite multiple
attempts prior to discharge additional labs were unable to be
obtained due to patient agitation. Given his marked improvement,
afebrile with stable vitals and no complaints, the patient was
stable for discharge home.
.
# Cough: new since admission. could be pneumonia (aspiration vs
CAP picked up just before admission), no asthma hx. did not
progress and improved with albuterol nebs and tessla perles.
.
# Tachycardia: sinus tach that responds to fluid boluses
suggested hypovolemia. Pt also gets anxious with coughing. By
the time he reached the floor, he was +5.6L for his LOS. As
such, patient was taking PO, and thus we were reluctant to
administer more IVFs.
.
# Renal Insufficiency: Basline cr 1.3. Pt admitted with Cr
elevated at 1.6. Could be [**12-29**] to vasculitis but improved back to
baseline with 2.5L fluids so likely etiology was prerenal
azotemia.
.
# h/o of fatty liver disease: Slightly elevated LFTs. INR 1.2
and pt's MS appears at baseline.
Medications on Admission:
Anti-spasmodic elixer
Acuvar eye drops
Benadryl
Sarna lotion
Cortisone cream
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
3. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Topical twice a
day: Apply to affected areas on face, groin, insides of
elbows/knees.
Disp:*1 tube* Refills:*2*
4. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for rash/purpura: Apply to
trunk and extremities.
Disp:*1 tube* Refills:*0*
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
8. nebulizer
use every 6 hours as needed for shortness of breath/wheezing
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Rash
.
Down's syndrome
NAFLD
Discharge Condition:
Afebrile.
Minimally conversant (baseline)
Discharge Instructions:
You were admitted with a rash and fever. You were seen by the ID
and derm consultants but we are not sure of the cause of your
rash. The rash improved with antibiotics and topical steroids.
.
Please finish off the antibiotics that you were prescribed.
Continue using the topical steroids until you follow up with
your primary care physician or the rash disappears.
Followup Instructions:
Please call your PCPs office to arrange for a follow up
appointment within 1-2 weeks.
If the rash persists or gets worse, you may also schedule an
appointment with the dermatology clinic by calling ([**Telephone/Fax (1) 6306**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"535.50",
"038.9",
"571.8",
"276.52",
"995.91",
"585.9",
"486",
"758.0",
"057.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9761, 9819
|
5431, 8559
|
278, 284
|
9891, 9935
|
4235, 5408
|
10348, 10675
|
2908, 3127
|
8686, 9738
|
9840, 9870
|
8585, 8663
|
9959, 10325
|
3142, 4216
|
234, 240
|
312, 2707
|
2729, 2768
|
2784, 2892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,850
| 119,897
|
54030
|
Discharge summary
|
report
|
Admission Date: [**2195-7-21**] Discharge Date: [**2195-7-28**]
Date of Birth: [**2152-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation
Esophagogastroduodenoscopy
History of Present Illness:
43yoF with h/o ETOH cirrhosis, cocaine abuse, and gastric bypass
who presents with altered mental status. Patient was unable to
provide history. However per report, patient was notable altered
by husband and was having darker stools for 2-3 days. Denies
fevers or chills.
In the ED, initial VS were: 99.6 110 117/63 20 99%RA. On arrival
patient was very combative haldol 5mg x 2. Evaluation was
significant for diffuse abdomen pain and melena on rectal exam.
Labs showed Hct of 17.5. LFTs were above base. Plts were 183
(which is up from baseline) and INR was 1.7. Lactate was 5.3
(previously normal). Patient were started on protonix and
octreotide. She was started on 1unit pRBC. Liver was consulted
who planned for urgent EGD while in ICU. Prior to transfer,
patietn had RUQ ultrasound that was not read. Patient was then
admitted to MICU for further evaluation.
.
On arrival to the MICU, patient was urgently intubated in
preparation for EGD.
Past Medical History:
-EtOH abuse, denies hx of seizures, DT's
-cocaine abuse
-EtOH hepatitis
-depression with history of suicide attempts
-SBO
-PID
-[**Last Name (un) **], s/p pelvic washout and drainage [**2192**]
-recent syncopal episodes, w/u negative thus far, followed by
Neuro
-s/p gastric bypass in [**2181**]
-s/p open CCY
-s/p laparotomy with LOA for SBO
-s/p left hip arthoplasty (as a child)
Social History:
Does not work due to "handicap," which patient reports is
chronic left hip pain from her prior hip replacement. Lives with
her husband. Denies tobacco use. Has long history of EtOH abuse.
Was sober for a few months, but started drinking again 2 weeks
ago, up to 10 drinks daily (vodka). Also endorses cocaine
monthly, most recently 2 days ago. Denies IVDU.
Family History:
Both parents with DM. Father also with Alzheimer's.
Denies any other FH.
2 brothers and 1 sister both healthy.
No children.
Physical Exam:
ADMISSION EXAM
General: intubated/sedated
HEENT: Sclera icteric, dry MM, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic. normal S1 + S2, no murmurs, rubs, gallops
Lungs: bibasilar crackles
Abdomen: soft, non-tender, obese, bowel sounds present, no
organomegaly, no appreciable fluid wave
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: intubated/sedated, R gaze deviation, babinski positive on
R foot
DISCHARGE EXAM
Vitals: 98.7, 105-150/60-88, p105-113, RR20 100RA
GEN: NAD, sitting up comfortably, endorses back pain
HEENT: EOMI, MMM
Neck: JVP Not elevated, no lymphadenopathy
CV: RRR, no m/r/g
RESP: CTA b/l
ABD: Soft, NT, ND, no organomegaly
Pertinent Results:
ADMISSION LABS:
[**2195-7-21**] 02:30PM PT-18.1* PTT-34.9 INR(PT)-1.7*
[**2195-7-21**] 02:30PM PLT COUNT-183#
[**2195-7-21**] 02:30PM NEUTS-82.2* LYMPHS-15.3* MONOS-2.1 EOS-0.1
BASOS-0.3
[**2195-7-21**] 02:30PM WBC-16.2*# RBC-1.79*# HGB-5.6*# HCT-17.5*#
MCV-98# MCH-31.3 MCHC-32.0 RDW-17.1*
[**2195-7-21**] 02:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2195-7-21**] 02:30PM AMMONIA-129*
[**2195-7-21**] 02:30PM ALBUMIN-2.5*
[**2195-7-21**] 02:30PM ALT(SGPT)-74* AST(SGOT)-262* ALK PHOS-147*
TOT BILI-6.9*
[**2195-7-21**] 02:30PM estGFR-Using this
[**2195-7-21**] 02:30PM GLUCOSE-99 UREA N-13 CREAT-0.4 SODIUM-136
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2195-7-21**] 03:09PM LACTATE-5.3*
[**2195-7-21**] 03:18PM URINE MUCOUS-MOD
[**2195-7-21**] 03:18PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-14 TRANS EPI-1
[**2195-7-21**] 03:18PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-MOD UROBILNGN->12 PH-7.5
LEUK-NEG
[**2195-7-21**] 03:18PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2195-7-21**] 03:18PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2195-7-21**] 03:18PM URINE UHOLD-HOLD
[**2195-7-21**] 03:18PM URINE HOURS-RANDOM
[**2195-7-21**] 11:28PM PT-17.8* PTT-40.8* INR(PT)-1.7*
[**2195-7-21**] 11:28PM WBC-14.2* RBC-2.60*# HGB-7.8*# HCT-23.7*#
MCV-91# MCH-29.9 MCHC-32.7 RDW-18.1*
[**2195-7-21**] 11:28PM CALCIUM-6.9* PHOSPHATE-3.5 MAGNESIUM-1.1*
[**2195-7-21**] 11:28PM GLUCOSE-123* UREA N-12 CREAT-0.3* SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
IMAGING:
EGD [**2195-7-21**]: Gastric remnant/pouch was 5 cm in length. Large
marginal ulcer ~ 1.3 cm with small blood clot and vissible
vessel. No signs of active bleeding. The ulcer was injected at
base in 4 quadrant with 1.5cc epinephrine 1:10.000, for a total
of 6cc. 2 resolution hemoclips were deployed on the vissible
vessel. Mild erythema was noted in the gastric pouch GJ
anastomosis was identified along with blind jejunal limb and
efferent jejunal limb. Efferent jejunal limb was traversed till
25 cms were reached
Otherwise normal EGD to second part of the duodenum
CT head: [**7-22**]
CONCLUSION:
1. No evidence of acute intracranial process.
2. Ill-defined small low-attenuation foci, symmetrically
located in the globi
[**Last Name (LF) **], [**First Name3 (LF) **] be the result of a previous toxic or metabolic
insult.
[**7-25**] CXR: IMPRESSION: NG tube in mid esophagus.
DISCHARGE LABS
[**2195-7-25**] 02:10PM BLOOD WBC-10.4 RBC-3.12* Hgb-9.6* Hct-29.7*
MCV-95 MCH-30.9 MCHC-32.5 RDW-17.6* Plt Ct-96*
[**2195-7-28**] 06:00AM BLOOD WBC-4.0 RBC-2.63* Hgb-8.2* Hct-25.3*
MCV-96 MCH-31.3 MCHC-32.5 RDW-16.8* Plt Ct-90*
[**2195-7-25**] 02:10PM BLOOD PT-19.4* PTT-34.4 INR(PT)-1.8*
[**2195-7-28**] 06:00AM BLOOD PT-20.1* INR(PT)-1.9*
[**2195-7-25**] 03:58AM BLOOD Glucose-68* UreaN-7 Creat-0.4 Na-139
K-3.4 Cl-109* HCO3-24 AnGap-9
[**2195-7-26**] 02:46AM BLOOD Glucose-74 UreaN-5* Creat-0.4 Na-140
K-3.7 Cl-110* HCO3-20* AnGap-14
[**2195-7-27**] 05:04AM BLOOD Glucose-85 UreaN-3* Creat-0.5 Na-135
K-3.2* Cl-104 HCO3-22 AnGap-12
[**2195-7-28**] 06:00AM BLOOD Glucose-70 UreaN-2* Creat-0.4 Na-135
K-3.8 Cl-107 HCO3-24 AnGap-8
[**2195-7-28**] 06:00AM BLOOD Glucose-70 UreaN-2* Creat-0.4 Na-135
K-3.8 Cl-107 HCO3-24 AnGap-8
[**2195-7-22**] 03:46AM BLOOD ALT-64* AST-203* AlkPhos-133*
TotBili-6.8*
[**2195-7-24**] 04:40AM BLOOD ALT-50* AST-133* AlkPhos-146*
TotBili-6.6*
[**2195-7-25**] 03:58AM BLOOD ALT-34 AST-81* AlkPhos-110* TotBili-6.6*
[**2195-7-27**] 05:04AM BLOOD ALT-27 AST-76* AlkPhos-102 TotBili-6.4*
[**2195-7-28**] 06:00AM BLOOD ALT-22 AST-73* LD(LDH)-169 AlkPhos-90
TotBili-5.7*
[**2195-7-24**] 04:15PM BLOOD Calcium-8.5 Phos-2.3* Mg-1.6
[**2195-7-25**] 02:10PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
[**2195-7-28**] 06:00AM BLOOD Albumin-3.4* Calcium-8.1* Phos-1.6*
Mg-1.6
[**2195-7-22**] 08:57AM BLOOD Type-[**Last Name (un) **] pH-7.41
[**2195-7-22**] 04:27PM BLOOD Type-MIX pH-7.40
Brief Hospital Course:
43 yo female with active EtOH abuse s/p Gastric bypass, now
admitted with altered mental status and active GI bleed with
associated blood loss anemia. This required sedation and
intubation with EGD showing ulcer with visible vessel and clot
treated with sclerotherapy and clips locally
#GI Bleed- from marginal ulcer at the location of her
anastamosis. She had no varices on exam. She initially did not
have any acute bleeding, however subsequently had a significant
drop in her hematocrit which required transfusion and repeat EGD
which showed a bleeding ulcer which was treated with local
epinephrine injections. Her hematocrits were trended daily and
she had no repeat exacerbations during her hospitalization.
Treated with antibiotics for 5 days post GI bleed.
#Anemia- Following GI bleed, Hct dropped. Appeared to drop on
the floor, but was as she was being rehydrated-> dilusional. She
was not actively bleeding. D/c Hct 25 but stable.
#Oliguria- Patient had significant oliguria throughout her
hospital stay. She was given fluid resuscitation with normal
saline initially, and then transitioned to albumin treatment
with minimal improvement in her urine output. Throughout this
time, she did not have an increase in her serum creatinine.
When moved to the floor, she appeared dry and improved with
fluid resuscitation.
#Transaminitis: Likely related to ETOH cirrhosis. Patient has
long history of EtOH liver disease.
#Altered Mental Status ?????? Patient was agitated on admission and
required intubation/sedation for emergent procedure. While
intubated she had a rightward gaze deviation. once she was
successfully extubated, she no longer had any focal neurologic
deficits, however she continued to be encephalopathic. She was
treated with lactulose for hepatic encephalopathy with moderate
improvement in her mental status.
TRANSITIONAL ISSUES
#GI Bleed: Will need to follow up with GI for liver disease as
well as to ensure not still bleeding and that Hct stable.
#Alcohol abuse: Patient with hx of alcohol abuse. She said she
plans on stopping as an outpatient. She should receive
counseling as an outpatient to help with this goal.
Medications on Admission:
NONE
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Gabapentin 600 mg PO QAM
5. Gabapentin 600 mg PO HS
6. Gabapentin 300 mg PO NOON
7. Lactulose 30 mL PO BID
8. Pantoprazole 40 mg PO Q12H
9. solifenacin *NF* 5 mg Oral daily
10. Spironolactone 25 mg PO BID
11. traZODONE 50 mg PO HS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Thiamine 100 mg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD DAILY
For back pain
RX *Lidoderm 5 % (700 mg/patch) Please apply to back daily Disp
#*7 Transdermal Patch Refills:*0
17. Sucralfate 1 gm PO QID
RX *Carafate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
18. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
Please do not drive, operate heavy machinery, or drink alcohol
while on this medication
RX *Oxecta 5 mg 1 tablet(s) by mouth every eight (8) hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Altered Mental Status
Peptic ulcer with bleed
Thrombocytopenia
Secondary diagnosis:
Alcoholic hepatitis
Depression
Small bowel obstruction
Pelvic inflammatory disease with tubo-ovarian abscess
Status post gastric bypass ([**2181**])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 110746**],
It was a pleasure caring for you at the [**Hospital1 18**]. You came for
further evaluation of a gastrointestinal bleed. Further
evaluation showed that you had a bleeding ulcer that was
stabilized. You are now being discharged home. It is important
that you continue to take all your prescribed medications and
follow up with your appointments listed below.
The following changes have been made to your medications:
We ADDED oxycodone, to treat your pain. Please do not drive,
operate heavy machinery, or drink alcohol while on this
medication.
We ADDED a lidocaine patch, which will also help to treat your
pain
We ADDED sucralfate, which will help your ulcer
Followup Instructions:
Department: LIVER CENTER
When: MONDAY [**2195-8-3**] at 8:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: BIDHC [**Location (un) **]
When: WEDNESDAY [**2195-8-5**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
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icd9cm
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[
[
[]
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icd9pcs
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10574, 10574
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10316, 10380
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,307
| 103,751
|
44351
|
Discharge summary
|
report
|
Admission Date: [**2188-5-10**] Discharge Date: [**2188-5-12**]
Date of Birth: [**2129-2-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 59 yo male with liver mets (?colon primary) s/p
Xeloda/Oxaliplatin/Avastin started [**2188-4-24**], who presents with
diarrhea.
He began treatment [**4-24**] with oxaliplatin and Xeloda 1500 mg
b.i.d. for two out of three weeks and Avastin 15 mg/kg every
three weeks. He had diarrhea the first 2 days which improved. At
a routine follow up visit, the patient was noted to be
hyperkalemic. This was felt to be [**3-12**] to aldactone so it was
stopped [**5-6**]. He was also given IVFs in the office and sent home
with one dose of kayexylate. After the kayexylate, the patient
developed diarrhea - small volumes every 30 minutes -1 hour. He
describes the stool as brown, but mixed with blood (chronically
mixed with blood [**3-12**] hemorrhoids). He took Immodium as directed
without relief, then changed to lomotil He continues to have
frequent episodes of diarrhea. He has had decreased fluid
intake, despite being thirsty. His wife also notes that he has
been breathing fast. He denies fevers/chills/sweats. He denies
nausea /vomiting and notes stable RUQ pain [**5-18**] without
radiation. He also notes stable chronic shortness of breath but
denies chest pain/palpations/diaphoresis/lightheadedness. He
denies lower extemity edema.
ROS: no melena/hematochezia. no new ecchymoses/gingival
bleeding. no dysuria. no new numbness/tingling.
Past Medical History:
Past Onc History:
Mr. [**Known lastname **] is a 59-year-old gentleman with recently discovered
liver masses. He had an EGD ~2 months ago for right sided
abdominal pain which was notable for Barrett's esophagus. Biopsy
of this showedmild active esophagitis. He then underwent an MRI
on [**2188-3-13**] that demonstrated multiple masses throughout
the liver, largest being about 8 cm with some central necrosis.
Periportal, pancreatic and periceliac node were also enlarged.
Biopsy was performed on [**2188-3-17**], and this showed poorly
differentiated carcinoma with focal squamous differentiation.
The cells were CK20+, CK7-. An endoscopic ultrasound and an
upper GI showed no evidence of any tumor. On [**4-24**], he started
treatment with oxaliplatin 135 mg per meters squared every three
weeks along with Xeloda 1500 mg b.i.d. for two out of three
weeks and Avastin 15 mg/kg every three weeks. He had diarrhea
the first 2 days which improved.
Past Medical History:
Hypercholesterolemia
Hemorroids
Social History:
He is married. He lives with his wife in [**Name (NI) 701**].
He Drinks one glass of wine a week. He has no history of tobacco
use.
Family History:
Sister - breast cancer-age 40
Physical Exam:
GENERAL: jaundiced, thin, NAD
VITAL SIGNS: blood pressure 110/70, pulse 105, O2 sat 98% RA,
RR 24 and
temperature 97.
HEENT: PERRL, EOMI. (+) scleral icterus. Oropharynx
without lesions or erythema. (+)dry mucus membranes
LYMPHATICS: No cervical, supraclavicular, axillary, or inguinal
adenopathy.
NECK: Supple, flat neck veins, no thyromegaly.
LUNGS: Clear to auscultation bilaterally.
BACK: No spinal tenderness.
CV: Regular rate and rhythm. Nl S1, S2. (+) 3-4/6 holosystolic
murmur -loudest at apex. PMI nondisplaced.
ABDOMEN: Soft, nontender, nondistended. liver edge palpable ~10
cm below the
costal margin. No rebound/guarding.
EXTREMITIES: No clubbing/cyanosis/ edema. Bottoms of feet dry,
red. Left lateral foot, (+)hypopigmented lesions with brown
rings.
SKIN: jaundiced.
Pertinent Results:
[**2188-5-10**] 06:45AM WBC-8.8# RBC-4.22* HGB-11.7* HCT-37.3* MCV-88
MCH-27.6 MCHC-31.3 RDW-25.8*
[**2188-5-10**] 06:45AM NEUTS-40* BANDS-30* LYMPHS-16* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-1* NUC RBCS-3*
[**2188-5-10**] 06:45AM PLT COUNT-527*
[**2188-5-10**] 06:45AM PT-19.6* PTT-39.0* INR(PT)-2.4
[**2188-5-10**] 06:45AM GLUCOSE-99 UREA N-76* CREAT-1.5* SODIUM-133
POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-12* ANION GAP-34*
[**2188-5-10**] 06:45AM ALBUMIN-2.8* CALCIUM-11.2* PHOSPHATE-4.6*
MAGNESIUM-2.9*
[**2188-5-10**] 06:45AM ALT(SGPT)-49* AST(SGOT)-81* LD(LDH)-230
CK(CPK)-106 ALK PHOS-571* AMYLASE-33 TOT BILI-26.4*
[**2188-5-10**] 06:45AM CK-MB-24* MB INDX-22.6*
[**2188-5-10**] 06:45AM cTropnT-<0.01
[**2188-5-10**] 03:00PM CK(CPK)-93 TOT BILI-22.1* DIR BILI-17.0*
INDIR BIL-5.1
[**2188-5-10**] 03:00PM CK-MB-20* MB INDX-21.5* cTropnT-<0.01
[**2189-5-10**]:
Abdominal US:
1) No evidence of intra or extrahepatic biliary ductal
dilatation.
2) Slight possible gallbladder wall thickening, which is
nonspecific, but contracted gallbladder.
3) Major hepatic arteries and veins and main portal vein and its
major branches, with appropriate directional flow.
4) Extensive involvement of the liver with metastases
Brief Hospital Course:
59 yo M with newly diagnosed liver masses (primary vs mets from
unknown primary (?colon)) s/p xeloda, avastin, oxaliplatin who
present with diarrhea, hyperkalemia, hypercalcemia, and an anion
gap acidosis.
#Diarrhea - etiology includes c.diff (recent course of augmentin
for elevated wbc), infectious diarrhea, malabsorptive diarrhea,
chemo related. The patient was started on flagyl empirically for
c. diff. He was also started on octreotide/cholestyramine for a
question of malabsorptive/chemo related diarrhea that was
resistant to immodium. His diarrhea improved with these
interventions.
#Anion Gap Acidosis - On admission the patient was found to have
a primary gap acidosis with an insignificant delta-delta. His
lactate on admission was 10.7 and did not improve despite
aggressive IVF hydration. He was started on IVFs with bicarb for
his bicarb of 13 and shortness of breath associated with the
acidosis. His lactic acidosis was thought to be secondary to
infection vs extensive tumor burden vs possible bowel ischemia.
He was continued on IVFs and treated empirically with vanco,
levo, flagyl. His lactate was stable with these interventions.
#Hypotension - On admission the patient's blood pressure was
110/70. His blood pressures remained stable with IVF hydration
for the first 12 hours. It then transiently decreased to 80/40
but responded to 1 L NS bolus. He continued to be tachycardic
100-120 so he was bolused again. His blood pressures remained
stable for 2-3 hours then decreased to 84/60 again. This time
his blood pressures did not improve with IVF bolus so he was
transferred to the ICU for closer monitoring. Blood cultures
were sent and he was started on empiric broad spectrum
antibiotics. Vanco/Levo was started for a question of SBE in the
setting of a new holosystolic murmur and flagyl was started for
a question of c. diff. A cortisol was sent which was
appropriate. His blood pressures improved with IVFs and
antibiotics.
#Acute Renal Failure - BUN/Creatinine ratio and history were
consistent with prerenal etiology. UA was notable for granular
casts. It was felt his diarrhea had led to hypovolemia and this
in combination with his hypotension had caused ATN and acute
renal failure. IVFs were instituted for supportive care.
#Liver Failure/Hyperbilirubinemia - The patient had an elevated
INR and low albumin. The rest of his labs were not consistent
with DIC, thus both his coagulopathy and hyperbilirubinemia were
felt to be [**3-12**] extensive tumor burden of his liver.
#Hospital Course - In the setting of his recent diagnosis, the
patient was originally full code on admission. A family meeting
was held on the day of admission and both the patient and his
family agreed that they wanted everything done in the case of a
code. He was transferred to the unit for a central line and
possible pressors in the setting of his repeated hypotension. As
the patient became increasingly short of breath, acidemic, and
uncomfortable, his views on code status changed. On hospital day
2, another family meeting was held and it was decided that the
patient would be treated with best supportive measures and
comfort care. He was seen by social work and palliative care. He
was started on a morphine drip and transferred to the floor. He
expired on [**2188-5-12**] at 23:45.
Medications on Admission:
oxycodone
priolosec
lomotil
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"584.9",
"199.1",
"285.9",
"197.0",
"197.7",
"276.2",
"272.0",
"276.5",
"275.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
8471, 8480
|
5044, 8360
|
324, 330
|
8532, 8542
|
3770, 5021
|
8599, 8610
|
2911, 2943
|
8438, 8448
|
8501, 8511
|
8386, 8415
|
8566, 8576
|
2958, 3751
|
276, 286
|
358, 1718
|
2712, 2745
|
2761, 2895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,481
| 195,410
|
18792
|
Discharge summary
|
report
|
Admission Date: [**2172-12-30**] Discharge Date: [**2173-1-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
inferior STEMI
Major Surgical or Invasive Procedure:
Right and left cardiac catheterization with placement of 2 bare
metal stents in the right coronary artery [**2172-12-30**].
Temporary pacer wire placement; removed on [**2173-1-4**]
PICC line placement on [**2173-1-11**]
History of Present Illness:
82 yo M with no documented cardiac hx; who was in his USOH until
this afternoon at 2:45 while sitting in a car dealership began
having severe L-sided substernal CP associated with n/v,
diaphoresis, weakness, no SOB or light headedness. He went home
and then called an ambulance and arrived at N [**Hospital **] hospital
where he was found to have STE in inferior leads; VS on
presentation HR 80, BP 175/76, 98% RA. He was given heparin,
aggrostat, aspirin, plavix and was life-flighted to [**Hospital1 18**]. He
also received morphine and SL NTG which alleviated but did not
totally resolve his chest pain.
.
In the [**Hospital1 18**] cath lab he was found to have a 99% mid-RCA lesion
with poor-flow which was treated with thrombectomy and 2x BMS
(may have jailed acute marginal branch). There was initially no
reflow, but this improved with IC nifedipine. Elevated Mean RAP
15; mean PCWP 16. CI 2.07.
.
During the procedure he was became bradycardic into the 40's
which resolved spontaneously. After the procedure he was
chest-pain free although he did develop a small R-groin hematoma
with sheath in(2x2cm); the sheath was removed, pressure applied,
and aggronox was discontinued.
.
Mr. [**Known lastname 51459**] currently feels well, denying any chest pain, SOB,
nausea, vomiting. Prior to this event he was able to walk and
play golf w/o chest pain or SOB; although his movement is
limited by chronic lower back pain.
Past Medical History:
Lower back pain s/p 2 back surgeries
GIB? PUD
denies HTN, hyperlipidemia, diabetes
Social History:
lives with wife; retired from computer assembly plant; no EtOH;
no toboacco; enjoys golf; former runner
Family History:
no h/o heart problems
Physical Exam:
T AF HR 74, BP 140/83, RR 16, 98% RA
Gen: well-appearing AA male in NAD; appears younger than stated
age
CV: RRR no m/r/g
Lungs: CTAB
Abd: s/nd/nt + BS
groin: no bruits; pressure dressing to R groin
Extremities: trace pulses, cool
Pertinent Results:
Admission Labs:
GLUCOSE-131* UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-4.3
CHLORIDE-102 TOTAL CO2-28 ANION GAP-11
ALT(SGPT)-22 AST(SGOT)-70* CK(CPK)-754* ALK PHOS-133* TOT
BILI-0.2
WBC-10.8 RBC-4.12* HGB-9.8* HCT-31.1* MCV-75* MCH-23.9*
MCHC-31.7 RDW-18.1*
.
CK peak: 1240
.
Sputum + staph aureus + GNR
.
Bld Cx [**1-10**] + staph aureus
.
RLE doppler negative for DVT
.
Cath report
cath: mild LMCA da; 20% ostial LAD; 90% distal LCx; 99% stenosis
mid-RCA with TIMI 1 flow
RHC: RA 19/17/15
RV 39/17
PA 39/25/20
PCWP 20/18/16
PA sat 61
CI 2.07
.
EKG:
OSH: sinus with PVC; LVH, 2mm STE III, 1mm STE II, STE V4R
.
post cath: NSR, rate 77, normal axis, normal intervals, LVH,
?2mm STE V2-3; ?1mm STE in lead III; no Q waves.
.
Echo
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. LV systolic function appears depressed
secondary to
inferior posterior hypokinesis (LVEF 40%). The right ventricular
cavity is dilated. There is severe global right ventricular free
wall hypokinesis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is no pericardial
effusion. Compared with the findings of the prior study (images
reviewed) of [**2172-12-31**], the right ventricle may be more
hypokinetic; the mitral regurgitation is increased.
Brief Hospital Course:
#)Cardiac
a. Ischemia/Rhythm: Mr [**Known lastname 51459**] presented with an inferior STEMI;
he was taken urgently to the cath lab where he was found to have
a proximal RCA lesion which was treated with thrombectomy + 2
BMS. He was transferred to the CCU in stable condition on
integrillin drip, aspirin, plavix. He had a small groin
hematoma so his integrellin was d/c'd shortly after transfer.
His hct dropped from 34 to 27.7 prompting blood transfusion and
CT abdomen/pelvis which showed some diffuse hemorrhage in the
left thigh. this stabilized with pressure. He was started on
lipitor, ACE and BB; approximately 36 hrs post transfer he went
into complete heart block with jx escape rhythm of 60 with
associated hypotension that did not respond to multiple IVF
bolus. He was vomiting and visibly aspirated and was therefore
intubated for airway protection. EP was consulted and placed an
emergent temporary pacing wire and he was begun on dopamine and
dobutamine drips. These were weaned off within 24 hours.
Temporary pacer wires placed but then discontinued due to MRSA
bacteremia. Upon discontinuation, patient reverted to sinus
rhythm and did not revert back into heart block in the week that
he was monitored on telemetry. His electrical functioning was
thus deemed to have recovered and he did not need an implanted
pacer. He was started on a low-dose beta blocker once in sinus.
.
b. Pump: Echo showed LVEF of 40% with RV hypokinesis and 3+ MR.
Hypotension resolved s/p 1d on dopa/dobuta. Captopril titrated
up for afterload reduction. As rhythm normalized, tolerated
gentle titration of beta blocker.
.
#) Bacteremia: Mr [**Known lastname 51459**] became febrile post-intubateion/line
placement. 2 of 4 initial blood cultures were positive for
MRSA. He was started on vancomycin and his lines and pacing
wires were removed; once these were removed his cultures became
negative and he remained afebrile. A PICC line was placed under
fluoro on [**2173-1-11**] and he will finish a 14-day course starting
from the date of his last positive blood culture.
.
#) Respiratory: intubated for airway protection during
hypotensive/vomiting episode. He was extubated within 24 hours.
Diuresis was initially held to maintain his preload in the
setting of RV infarction. As his heart block resolved
(indicating recovering electrical and RV function), he was
diuresed with prn Lasix boluses and was euvolemic upon
discharge.
.
#) Hematoma: D1 s/p cath had small groin hematoma but increasing
thigh pain and falling hct; Hct was trended and subsequently
remained stable. CT showed no RPB but possible hematoma
diffusely in thigh. RLE US showed no DVT
.
#) h/o GIB
- pt has endorsed melena at home; no gross GI bleed while
in-house
- consider GI scope as outpatient
- cont protonix
.
#) FEN/GI: low-salt, heart-healthy diet
.
#) Dispo: will go to [**Hospital 3058**] rehab for PT and to finish
course of vancomycin
Medications on Admission:
prilosec
percocet
prn ibuprofen
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
6. Naphazoline 0.1 % Drops Sig: 1-2 Drops Ophthalmic Q6H (every
6 hours) as needed.
7. 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*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-15**]
MLs PO Q6H (every 6 hours) as needed for cough.
Disp:*QS ML(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*90 Tablet(s)* Refills:*0*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous Q 12H (Every 12 Hours) for 4 days.
14. Outpatient Lab Work
Please check vancomycin trough prior to evening dose on [**2173-1-13**].
Hold next dose if trough >20.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
S-T Elevation Myocardial Infarction
Gastrointestinal bleeding
Transient complete heart block
Methicillin Resistant Staph Aureus Bacteremia
Secondary:
Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You had a major heart attack.
.
You were started on new medications.
.
Please keep all follow-up appointments. Please take all
medications as prescribed.
.
Please seek medical attention if you have chest pain, shortness
of breath, swelling in you legs, lightheadedness or any other
symptoms that are concerning to you.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 16518**] [**Last Name (NamePattern1) 174**], ([**Telephone/Fax (1) 51460**] to schedule
follow-up within the next 1-2 weeks after discharge.
.
Please call ([**Telephone/Fax (1) 12468**] to schedule follow-up with Dr.
[**First Name (STitle) **] [**Name (STitle) 1911**] of cardiology within 1-2 weeks after
discharge.
|
[
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"426.0",
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"998.12",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
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"36.06",
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"96.71",
"88.56",
"37.78",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
8612, 8683
|
3879, 6811
|
278, 500
|
8893, 8903
|
2488, 2488
|
9270, 9636
|
2198, 2221
|
6894, 8589
|
8704, 8872
|
6837, 6871
|
8927, 9247
|
2236, 2469
|
224, 240
|
528, 1954
|
2505, 3856
|
1976, 2061
|
2077, 2182
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,532
| 124,500
|
42845
|
Discharge summary
|
report
|
Admission Date: [**2194-12-23**] Discharge Date: [**2195-3-3**]
Date of Birth: [**2147-1-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
OSH transfer for evaluation of HRS
Major Surgical or Invasive Procedure:
[**2194-12-31**] Diagnostic Paracentesis
[**2195-1-2**]: Therapeutic paracentesis
[**2195-1-9**]: Diagnostic paracentesis
[**2195-1-13**]: Feeding tube placement
[**2195-1-23**]: Therapeutic paracentesis
[**2195-1-29**]: PLacement of tunneled Left IJ hemodialysis catheter
[**2195-2-5**]: Combined Liver/kidney transplant
History of Present Illness:
47 yo M with EtOH/hep C cirrhosis, HTN, DM who was transferred
from [**Hospital3 **] for liver transplant evaluation and
management of Hepatorenal syndrome.
Patient has a 10yrs of HCV (never tx and no bx, genotype 3a) and
EtOH hepatitis and cirrhosis. His initial decompensation
appears to have occured in [**2194-1-25**] with ascites, edema and
deconditioning. Reportedly he quit EtOH use at that time. He
was seen at the [**Doctor Last Name **] state Liver transplant center in may with
w/up including EGD with Grade 1 varices and portal gastropathy,
CT abd/pelvis ([**10-6**]) with hepatosplenomgealy w/o lesions, RML
nodule in the lung and large ascites. He has never had a
variceal bleed. He has been undergoing biweekly paracenteses
since spring [**2194**], however there is no documentation of diuretic
refractory ascites. He did have grade 2 HE and had no hx of
HRS, HPS or HCC. His labs at time of that evaluation were
notable for Cr of 0.9, INR 1.1 and Bili of 0.9. Fe studies
were notabel for ferritin of 621, FeSat 49% and Fe 86. MELD was
7 and CPS 10. He was initially seen at [**Doctor Last Name **] state in [**Month (only) 116**] and
then in [**Month (only) **], when majority of the work up was initiated.
Of note he did not complete further evaluation as he moved to MA
to be with his son 1 mo ago.
.
Patient was in USOH with recurrent ascites, non-encephalopathic
until ~ 2 wks ago when he developed increasing abdominal
distension and pain.
.
per NF note: "The patient initially presented to [**Hospital3 **]
on [**2194-12-21**] with 2 weeks of malaise, body aches, chills, poor PO
intake, non-bloody diarrhea, nausea/vomiting, abdominal
discomfort, dysuria, and jaundice. No sick contacts. Traveled to
[**Male First Name (un) 1056**] 3 months ago.
.
At [**Hospital3 **], exam was notable for jaundice and ascites.
Admission labs showed WBC 8.8 (8% bands), Hct 33.7, Plt 136, Na
126, Cr 2.1 (up from normal on [**2194-12-2**]), albumin 2.0, ALT 53,
AST 61, alkphos 314, Tbili 18.9 (up from 1.9 on [**2194-12-2**]), Dbili
14.3, lipase 249, INR 1.5. Urine sodium was 23. FENA 0.3%.
Abdominal ultrasound showed normal portal and hepatic venous
flow, moderate ascites, splenomegaly, no biliary dilatation, no
stones or hydronephrosis."
.
His UA was positive with nitrates, but Cx was negative. He
received ketorolac for pain at [**Hospital3 **] ED.
.
"Diagnostic and therapeutic paracentesis was performed, with WBC
50, 4% polyps. A total of 7.5 L of fluid was removed. The
admission (written prior to the paracentesis) suggests empiric
ertapenem for SBP, but it is unclear from the available records
if this was given. Quinapril was stopped. and the patient was
challenged with fluids and albumin. Midodrine and octeotide were
started. Renal was consulted and recommend transfer to [**Location (un) 86**]
for transplant evaluation.
.
On transfer, BUN was 35, creatinine 3.1, tbili 22.3, dbili 16.8,
INR 1.6. Urine output during the 24 hours prior to transfer was
200 cc."
.
On the floor, patient appeared to be encephalopathic and had no
complaints other then pain at the site of the foley catheter.
Above history was also confirmed with his son, [**Name (NI) **].
.
.
REVIEW OF SYSTEMS: as per HPI.
Past Medical History:
-HCV/EtOH cirrhosis (see above).
-HTN
-RLL calcified granuloma
-chronic low back pain
-brittle diabetes mellitus (last A1C 10%)
-s/p tonsillectomy
-s/p hernia repair
Social History:
Recently moved to Massachusetss to be near his son. Previously
living in [**State 5887**] being taken care of by his daughter, who
no longer is able to care for him and moved to CT. He worked as
a carpenter, and was incarcerated for 9 years with discharge in
[**2183**].
Tobacco: Smokes 1 pack every 3-4 days
EtOH: Last drink 10-11 months ago
Drugs: Former heroin and cocaine, IVDU, with last use [**11-5**]
months ago
Family History:
Denies family history of liver disease
Physical Exam:
VS Temp 98.2F, BP 110/68, HR 70, R 18, O2-sat 96% RA
GENERAL - somnolent, opens eyes and follows verbal commands,
jaundiced, chronically ill-appearing, NAD
HEENT - NC/AT, sclerae icteric, dMM, OP clear
NECK - supple, JV flat
LUNGS - Trace crackles b/l.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - distended, shifting dullness, NT/ND, no
rebound/guarding, cound not palpate spleen/liver. no bruit over
the liver.
EXTREMITIES - WWP, no c/c/e
SKIN - excoriations on upper chest, multiple tatoos, 7 spiders,
palmar erythema.
.
NEURO: somnolent, opens eyes and follows verbal commands. DOWb
took 3 minutes with multiple errors. Repeats, reads and
encodes, but 0/3 recall. VFF, EOMi, smooth, face symmetric and
tongue is midline. SHoulder shrug symmetric. Moving all 4
extremities AG. DTRs not tested, but seems to have normal tone.
There is asterixis.
Pertinent Results:
[**10-6**] [**Doctor Last Name **] state labs:
HCV VL [**Numeric Identifier 92531**]
AFP 16 (nl < 6)
Cr 0.6 on [**9-/2194**]
Na 140
AST/ALT 46/33
Bili 0.7
EGD [**6-/2194**] - grade 1 varices.
Ceruloplasmin 35H
HAB-ab pos
HB sAb, cAb - negative
HCV ab - positive
Genotype 3a
[**Doctor First Name **] positive 320:1 speckled
Antismooth - 29H
AntiMitoab - 37H
Alpha1antitrypsine - MM
CMV IgM and IgG - negative
HSV 1 and 2 ab - positive
HSV igM - positive
RPR - NR
VZV igG -equivocal
HIV - neg
Labs on [**Hospital1 18**] Admission: [**2194-12-24**]
WBC-6.8 RBC-3.19* Hgb-10.5* Hct-30.2* MCV-95 MCH-32.8* MCHC-34.6
RDW-14.7 Plt Ct-95*
PT-18.2* PTT-40.5* INR(PT)-1.7*
Glucose-226* UreaN-33* Creat-2.4* Na-130* K-4.1 Cl-103 HCO3-18*
AnGap-13
ALT-32 AST-64* AlkPhos-138* TotBili-27.4*
Albumin-3.0* Calcium-8.8 Phos-2.7 Mg-1.7 Iron-73 Cholest-63
%HbA1c-11.0* eAG-269*
Triglyc-128 HDL-4 CHOL/HD-15.8 LDLcalc-33
Brief Hospital Course:
47 y.o. male with h/o EtOH abuse/hep C cirrhosis (see above for
detailed history), HTN, poorly controlled DM who was transferred
from [**Hospital3 **] for transplant evaluation in the setting of
markedly worsening hepatic and renal function, and concern for
hepatorenal syndrome. Meld was 34. Admission labs revealed VRE
UTI.
He completed a course of Linezolid. Liver function worsened with
sequelae. Meld score increased to 40s. Lactulose and Rifaximin
were started for hepatic encephalopathy. Frequent therapeutic
paracentesis were needed for refractory ascites. Liver
transplantation was pursued with subsequent workup. He agreed
to participate in substance abuse relapse programs and his son
agreed to be his advocate and care giver. Pre transplant workup
was completed and approved.
As an outpatient he was given diagnosis of HRS as renal function
worsened in setting of receiving Toradol,and volume depletion
post large volume paracentesis. Renal US was unrevealing for
abnormalities. Nephrology was consulted. Etiology for [**Last Name (un) **] was
likely pre-renal and some component of ATN in the setting of
worsening liver failure. Octreotide/midodrine were started, but
were discontinued as there was no improvement. Hemodialysis was
initiated. Nephrology deemed him a suitable candidate for
combined liver kidney transplant.
He had a lower GI bleed requiring blood products and transfer to
SICU. EGD on [**1-7**] showing severe gastropathy, previously banded
varices were not actively bleeding. Colonoscopy showed 4 cords
of small rectal varices that were not bleeding. Ulceration,
friability, erythema and mosaic appearance from 50 cms until
Cecum were compatible with portal colonopathy which seemed to be
bleeding spontaneously from low platelets and elevated INR.
Patient had been transferred to the ICU for continued
management, was on CVVHD and receiving transfusions PRN. Once
stable, he transferred out of the ICU and went on intermittent
HD. However, BRBPR recurred and he was transferred back to the
SICU for management.
He experienced diarrhea. Stool cultures isolated C. diff. PO
vanco and flagyl were started on [**1-20**].
On [**2195-2-5**] he received an offer for combined liver and kidney
transplant. On [**2195-2-5**], he underwent combined liver/kidney
transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Postop, he was sent
intubated to SICU for management. He was extubated on postop day
1. LFTs decreased and liver duplex demonstrated normal
vasculature. Renal duplex also demonstrated normal vasculature
with appropriate waveforms. Creatinine decreased to normal.
Urine output was excellent. JP outputs were non-bilious. Tube
feeds were started. PO Vanco continued indefinitely for C.diff
and IV Flagyl was stopped after a 24 day course.
He did well until [**2-16**] when he spiked to 101.4. He was pan
cultured and started on Linezolid on [**2-15**]. Pseudomonas was
isolated on urine culture from [**2-13**]. Linezolid was stopped on
[**2-17**] and switched to IV Meropenem as blood cultures as well as
urine isolated Pseudomonas sensitive to Meropenem. On [**2-17**] blood
culture isolated budding yeast. This was speciated out on [**2-18**]
as [**Female First Name (un) 564**] Torulopsis. IV tip was negative. Micafungin was
started on [**2-18**]. IV Flagyl was resumed for diarrhea. Repeat
stool cultures were were C.diff negative. ID recommended a slow
PO Vanco taper other IV antibiotic course. Surveillance blood
cultures remained negative.
ID was consulted and recommended TTE. TTE was done [**2-19**] showing
systolic anterior motion of the mitral valve chordae
(appreciated previously), but the suggestion of torn mitral
chordae, and a possible mitral valve vegetation was new. A TEE
was attempted but TEE probe could not be passed into the
esophagus due to resistance and the patient's inability to
cooperate despite adequate sedation and analgesia. The plan was
to treat with Micafungin for one month and repeat the TTE to
determine whether course should extend. TTE will be scheduled as
an outpatient.
He was doing well until [**2-16**] when creatinine started to increase
from 0.9. This was initially attributed to supra therapeutic
Prograf level of 17.9 (goal of 10). Doses were held and repeat
levels decreased. Creatinine continued to increase daily up to
3.6. Renal duplex was done on [**2-21**] noting no arterial flow seen
in the transplant kidney and findings concerning for gas in the
renal sinuses/collecting system. On [**2-23**], he was taken to the OR
for transplant nephrectomy. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A JP
drain was placed. JP outputs were high (likely from a small tear
in the peritoneum). The plan was to leave the JP in place until
f/u in the [**Hospital 18**] [**Hospital 1326**] Clinic. Postop, intermittent HD was
resumed via a tunnelled HD line. Last HD was [**3-3**]. Two liters
were removed. Vein mapping was done to assess vasculature. Need
for HD access will be reassessed in f/u with outpatient clinic
visit.
He was very depressed after nephrectomy and psychiatry was
consulted. Remeron was recommended and started with some
improvement. He continued to c/o of RLQ pain over nephrectomy
site, R shoulder pain, LUE picc line site pain and chronic back
pain(xrays of shoulder [**3-3**] were notable for slight subluxation
and no fracture). Dilaudid (po)with break thru iv Dilaudid were
given with only fair relief. Methadone 2.5mg [**Hospital1 **] was started on
pm of [**3-2**]. Po Dilaudid was decreased from prn 6mg to 4mg. Plan
was to further taper Dilaudid after 1-2 days of methadone.
Dietary intake was insufficient therefore tube feedings
continued via a post pyloric feeding tube. He experienced
diarrhea. Stool cultures were negative for C. Diff. Imodium was
started. Diarrhea/frequent stools persisted. Cellcept was
stopped on [**3-2**] as this was thought to be possible cause of GI
symptoms. Vancomycin oral was to continue on slow taper as
outlined per ID.
Immunosuppression: Cellcept stopped [**3-2**] for diarrhea. Prednisone
taper per protocol (decreased to 17.5mg on [**2-26**] then decrease by
2.5mg every 10 days)and Prograf per trough levels. Trough level
was 6.0 on [**3-3**]. Dose increased from 4mg [**Hospital1 **] to 5mg [**Hospital1 **] on [**3-3**]. A
trough level should be repeated on [**3-4**] with stat results faxed
to [**Hospital 18**] [**Hospital 1326**] Clinic [**Telephone/Fax (1) 92532**]. Doses should only be
adjusted by [**Hospital1 18**] Transplant Center [**Telephone/Fax (1) 673**]
Physical therapy worked with him and recommended rehab. A bed
was available at [**Hospital 5503**] Rehab on [**3-3**]. He will transfer
there today. He is now ambulating with supervision.
Of note, explant liver path report noted punctate necrotic areas
within the ex planted liver parenchyma corresponding to
Adenovirus infection. ID reviewed. No change in antibiotic
regimen.
DM II- This was poorly controlled as an out pt and presented to
the hospital with an A1C of 11%. His blood sugars were difficult
to control and [**Last Name (un) **] was consulted for assistance with glucose
management. Patient was maintained on glargine and ISS which
was adjusted several times to maintain adequate control. He was
also followed by [**Last Name (un) **] following transplant. Post transplant
improved glycemic control was achieved with Lantus and sliding
scale regular insulin accounting for dietary intake and
continuous tube feeding.
Medications on Admission:
Albuterol 0.083% Neb q6h prn, MVI', omeprazole 20',
rifaximin 550'', tylenol 500 q6h prn, lidocaine patchy', vit d
50,000u qwk, miralax 17g', simethicone 40-80 qid prn,
tramadol'''
prn, insulin, mirtazapine 15'
Allergies: NKDA
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not exceed 2 g in 24 hours.
3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritis.
4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
5. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow printed taper.
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): continue until [**3-12**] then decrease to 125mg [**Hospital1 **] x 2
weeks then 125mg qd x2 weeks then 125mg every 48 hours x2 weeks
then d/c.
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP < 100, HR < 60.
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 1 days: then taper to 2mg prn
every 4 hours.
12. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
13. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
15. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): continue until [**3-21**].
16. tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO Q12H (every
12 hours).
17. epoetin alfa 2,000 unit/mL Solution Sig: One (1) Injection
3x per week: at Hemodialysis.
18. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): For Pain. monitor for sedation/respiratory depression.
started [**3-2**].
19. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) dose
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
20. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
21. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
22. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
23. Outpatient Lab Work
Stat labs Wednesday [**3-4**] then every Monday and Thursday for cbc,
chem 10, ast, alt, alk phos, t.bili, albumin and trough prograf
level
-fax results to [**Hospital1 18**] Transplant, [**Telephone/Fax (1) 697**] attention RN
coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary: Acute kidney injury, hepatic encephalopathy
Secondary: Liver cirrhosis, Hepatitis C, EtOH abuse history,
Diabetes Mellitus, HRS
s/p liver and kidney transplant
s/p transplant nephrectomy for thrombosis
malnutrition
Pseudomonas UTI/bacteremia
[**Female First Name (un) 564**] Torulopsis bacteremia
VRE UTI
C.diff
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:
Please call the transplant clinic at [**Telephone/Fax (1) 673**]
Please follow transplant clinic schedule for lab draws every
Monday and Thursday with results to the transplant clinic at
[**Telephone/Fax (1) 697**]
Patient should not lift items greater than 10 pounds
Please continue tube feeds as ordered
Drain care as ordered
Dialysis will continue on Mon-Wed-Fri schedule at rehab
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-3-5**] 3:00
TTE to be schedule as f/u by [**Hospital1 18**] to assess for vegetations
(may need to extend Micafungin course beyond 1 month based on
repeat TTE)
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-3-12**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-3-19**] 3:00
Completed by:[**2195-3-3**]
|
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"585.6",
"038.43",
"998.59",
"518.4",
"276.4",
"276.1",
"276.7",
"593.81",
"537.89",
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"578.9",
"403.91",
"486",
"599.0",
"250.42",
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"38.95",
"38.97",
"00.93",
"55.53",
"45.23",
"38.91",
"39.95",
"42.33",
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"00.14",
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] |
icd9pcs
|
[
[
[]
]
] |
16957, 17055
|
6410, 13965
|
337, 661
|
17420, 17420
|
5483, 6387
|
18011, 18643
|
4561, 4601
|
14245, 16934
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17076, 17399
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13991, 14222
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17603, 17988
|
4616, 5464
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3907, 3920
|
263, 299
|
689, 3887
|
17435, 17579
|
3942, 4109
|
4125, 4545
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,786
| 177,710
|
40875
|
Discharge summary
|
report
|
Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-9**]
Date of Birth: [**2021-11-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2106-4-7**]
Cardiac catheterization with placement of drug-eluting stent
[**2106-4-8**]
History of Present Illness:
Mr. [**Known lastname 89277**] is an 84yo male with history of CAD s/p CABG in [**2098**]
(LIMA-LAD and SVG-Ramus), hypertension, hyperlipidemia, CRI,
unilateral vocal cord paralysis after CABG in [**2098**], and
sarcoidosis who presents now with exertional dyspnea and chest
pain concerning for unstable angina.
Mr. [**Known lastname 89277**] did well s/p CABG in [**2098**], though had recurrent chest
pain four years later. Exercise thallium test [**2103-6-21**] showed
mild anteroapical ischemia, but given patient did not want to
procede with repeat cath, he was continued on medical management
of CAD. However, over the past several months he has had
increasing exertional dyspnea, prompting repeat exercise
thallium stess test on [**2105-12-4**]. This study showed no ischemia,
but did show evidence of a borderline increase in LV filling
pressure during exercise. Had echo [**2106-3-26**], which showed mild
concentric LVH, decreased LV diastolic compliance, and
borderline pulmonary hypertension. LVEF was preserved.
Patient had been started on furosemide 20mg daily by his
cardiologist in late [**Month (only) 958**], given concern that exertional
dyspnea may be secondary to dCHF. Patient's symptoms did not
improve, and he also began to develop exertional chest pain. He
describes the pain as a pressure-like sensation across his chest
which is non-radiating and comes on after walking a short
distance. The pressure is associated with mild dyspnea, but no
dizziness, nausea, or diaphoresis. The pain resolves within one
minute if he stops to rest. Over the past 2-3 days, he has also
had similar chest pressure with minimal activity such as washing
dishes. He saw his cardiologist for follow-up in clinic
yesterday, who was concerned that his symptoms are due to
recurrent ischemia. Cardiologist recommended right and left
heart cath for further evaluation, and patient is admitted now
for pre-cath hydration given CRI, with plans for cath early
tomorrow morning.
On arrival to the floor, patient is comfortable and denies any
dyspnea or chest pain. Denies any HA, dizziness/lightheadedness.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. Does report chronic
non-productive cough, chronic right-sided leg cramps at night.
All of the other review of systems were negative.
Cardiac review of systems is notable for absence of PND,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Patient does report [**2-26**] pound weight gain over past several
months.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: [**2098**], LIMA-LAD and SVG-Ramus
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
CAD s/p CABG [**2099-6-4**] at [**Hospital1 112**]
Diastolic CHF
Hypertension
Hyperlipidemia
CRI, recent baseline Cr 1.9
DJD
Unilateral vocal cord paralysis after CABG in [**2098**]
Sarcoidosis
s/p cholecyctectomy [**2094**]
s/p left inguinal hernia repair [**2088**]
s/p hydrocolectomy [**2073**]
s/p TURP [**2094**]
s/p left total knee [**2100**]
Social History:
Widowed. Lives alone, but son is 2 miles away. Retired plumber.
Rare smoking history in past ~ 60 years ago, but no recent use.
Rare EtOH use. No illicit drug us.
Family History:
Father deceased from MI, brother deceased from MI in his 40s,
uncle with MI in his 50s.
Physical Exam:
ADMISSION EXAM:
VS: T= 98.8 BP= 193/88 HR= 62 RR= 16 O2 sat= 96% RA
Weight: 83.5 kg
GENERAL: elderly male, comfortable appearing, pleasant, alert,
oriented, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva mildly injected
bilaterally. MMM.
NECK: Supple, JVP of 10cm
CARDIAC: RRR, normal S1/S2, no r/m/g, S4 present
LUNGS: Respirations unlabored, no accessory muscle use.
Bibasilar rales, no wheezing or rhonchi
ABDOMEN: Bowel sounds present, soft, NTND. No
hepatosplenomegaly.
EXTREMITIES: Warm, well-perfused, 1+ edema to mid-shins
bilaterally, no clubbing or cyanosis
SKIN: No stasis dermatitis, rashes or lesions
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
PSYCH: Calm, appropriate
DISCHARGE EXAM:
VS: 97.9 168/75 59 16 94% RA
GENERAL: elderly male, alert, oriented, NAD
HEENT: sclera anicteric, MMM
NECK: supple, no appreciable JVD
CARDIAC: RRR, normal S1/S2, S4, no r/m/g
LUNGS: bibasilar rales, no wheezing or rhonchi
ABDOMEN: soft, NTND
EXTREMITIES: warm, well-perfused, 1+ edema to mid-shins
bilaterally
GROIN: bilateral faint femoral bruits, no evidence of hematoma
bilaterally at cardiac cath sites
PULSES: femoral/DP/PT 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
[**2106-4-6**] 05:34PM BLOOD WBC-5.8 RBC-4.13* Hgb-14.4 Hct-40.1
MCV-97 MCH-34.8* MCHC-35.8* RDW-13.1 Plt Ct-124*
[**2106-4-6**] 05:34PM BLOOD PT-12.4 PTT-31.6 INR(PT)-1.0
[**2106-4-6**] 05:34PM BLOOD Glucose-86 UreaN-53* Creat-2.2* Na-135
K-4.9 Cl-101 HCO3-27 AnGap-12
[**2106-4-6**] 05:34PM BLOOD proBNP-449
[**2106-4-6**] 05:34PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
OTHER PERTINENT LABS:
[**2106-4-8**] 05:44AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.1 Mg-2.0
[**2106-4-7**] 01:57PM BLOOD CK-MB-4 cTropnT-<0.01
[**2106-4-7**] 10:20PM BLOOD CK-MB-4 cTropnT-0.11*
[**2106-4-8**] 05:44AM BLOOD CK-MB-3 cTropnT-0.08*
[**2106-4-7**] 01:57PM BLOOD CK(CPK)-55
[**2106-4-7**] 10:20PM BLOOD CK(CPK)-60
[**2106-4-8**] 05:44AM BLOOD ALT-57* AST-50* LD(LDH)-215 CK(CPK)-58
AlkPhos-90 TotBili-1.2
DISCHARGE LABS:
[**2106-4-9**] 07:25AM BLOOD Glucose-89 UreaN-37* Creat-2.2* Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2106-4-9**] 07:25AM BLOOD WBC-7.8 RBC-3.79* Hgb-13.2* Hct-36.6*
MCV-97 MCH-34.8* MCHC-36.0* RDW-13.1 Plt Ct-114*
IMAGING:
ECG [**2106-4-6**]: Normal sinus rhythm. Left atrial abnormality.
Otherwise, tracing is within normal limits. No previous tracing
available for comparison.
CXR [**2106-4-6**]:
1. Scattered interstitial and alveolar opacities. Differential
diagnosis
includes pulmonary sarcoidois, however, basilar changes suggest
an additional interstial lung disease or superimposed pulmonary
edema.
2. Pleural irregularity, possible asbestos exposure.
TTE [**2106-4-7**]: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
No thoracic aortic dissection is seen. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
CTA Chest [**2106-4-7**]:
1. No aortic dissection.
2. Extensive moderately severe atherosclerosis of the aorta and
its branches, including thoracic aortic arch ulcers as
described, and ulcerated mixed plaque in the proximal left
subclavian artery, of undetermined age. There is no periaortic
bleeding.
3. Occlusion of the left vertebral artery from its origin, of
undetermined
age.
4. Extensive scarring in both apices and lung bases consistent
with the given history of sarcoidosis, comparison with prior
imaging is suggested to determine disease activity.
5. Very mild pulmonary edema.
6. Solid left renal lesion, possible renal cell carcinoma.
7. Chronic mild scarring and traction bronchiectasis, right
lower lobe.
CARDIAC CATH [**2106-4-7**] (Prelim):
Right dominant
LMCA 30% tapering distally
LAD 90% ostial stenosis
LCX 70% ostial stenosis
RCA 95% proximal stenosis
SVG-OM1 patent
LIMA-LAD unable to engage for selective injection because of
tortuosity of left subclavian
Ascending aorta and arch - no obvious dissection
CARDIAC CATH [**2106-4-8**]: report pending
Brief Hospital Course:
84yo male with history of CAD s/p CABG, HTN, HL, CRI and
sarcoidosis who presented for cardiac catheterization in setting
of progressive dyspnea on exertion and new onset exertional
chest pain, concerning for unstable angina.
# Exertional Dyspnea/Chest Pain/CAD: Exertional dyspnea and
chest pain prior to admission were concerning for unstable
angina. Patient underwent right and left heart cath on [**2106-4-7**],
which revealed patent SVG-OM1 graft, presumed patent LIMA-LAD
graft, and new proximal 95% RCA stenosis. Patient developed
severe, non-pleuritic pain across his chest during the procedure
and had vagal response, requiring administration of atropine and
increased IVF. He did not have any acute ST changes on ECG, and
CTA chest was negative for dissection or PE. Had slight
troponin bump, which was felt to be secondary to demand ischemia
in setting of hypotension from vagal response. Patient was
transferred to CCU for close BP monitoring, and later became
hypertensive requiring nitro gtt. Went back to cath lab on
[**2106-4-8**] for repeat cath with DES placed to RCA. Patient
tolerated procedure well and did not have further CP during the
admission. He remained hemodynamically stable, and was weaned
off nitro gtt. Was discharged on regimen of aspirin 325mg
daily, plavix 75mg daily, simvastatin, and metoprolol. ACE
inhibitor was not started given Cr slightly elevated above
baseline, though patient would likely benefit from addition of
ACEi if Cr remains stable in outpatient setting. Patient will
follow-up with his cardiologist within 1 week of discharge.
# Acute dCHF: Recent echo [**2106-3-26**] showed preserved LVEF but
evidence of diastolic dysfunction, and diastolic dysfunction
also present on recent exercise thallium test. TTE [**2106-4-7**]
showed EF >55%. Cardiac cath revealed mildly increased right
and left heart filling pressures, again consistent with
diastolic dysfunction. Patient's exam was suggestive of volume
overload, and HTN was likely contributing to acute exacerbation
of dCHF. Patient's home furosemide dose increased from 20mg
daily to 40mg daily on discharge. He was continued on a beta
blocker, though atenolol changed to metoprolol given underlying
CKD. Patient will likely benefit from an ACE inhibitor, though
this was deferred to outpatient setting given Cr slightly above
baseline during this admission.
# Hypertension: Patient hypertensive on admission, and of note
briefly required nitro gtt during his hospital course for
management of hypertension. His nifedipine dose was increased
from 30mg daily to 60mg daily, and atenolol was changed to
metoprolol given underlying CKD. Patient will need BP monitored
in follow-up, and may need further adjustment to
anti-hypertensive regimen. [**Month (only) 116**] benefit from ACE inhibitor,
though this was deferred to outpatient provider given Cr
elevated above baseline this admission.
# CKD: Baseline Cr 1.9, and Cr ranged 1.9-2.2 this admission.
Patient received pre-cath hydration, as he is at higher risk for
contrast-induced nephropathy given low GFR. His Cr was stable
during the admission, but should be rechecked in follow-up the
week of [**2106-4-12**]. As above, if Cr stable, patient will likely
benefit from ACE inhibitor.
# Hyperlipidemia: Continued simvastatin 20mg daily.
# Sarcoidosis: CXR this admission revealed scattered
interstitial and alveolar opacities, which could represent
pulmonary sarcoidosis. Patient will follow-up with his PCP.
# Left renal mass: CTA chest revealed incidental finding of 38 x
37mm peripherally enhancing solid left renal lesion, concerning
for a renal cell carcinoma. Patient will follow-up with PCP
within one week of discharge, and will likely need MRI for
further evaluation based on radiology recommendations. Pending
MRI results, patient may require biopsy or resection, as well as
referral to heme/onc if mass determined to be malignant.
PENDING AT TIME OF DISCHARGE:
-final cardiac catheterization report from [**2106-4-7**], [**2106-4-8**]
TRANSITIONAL CARE ISSUES:
-Patient's code status was DNR/DNI this admission
-Patient will likely need outpatient MRI for further evaluation
of left renal mass, and may eventually need biopsy or resection
of mass as well as referral to hematology/oncology if mass
determined to be malignant
-Patient will need renal function checked at follow-up
appointment week of [**2106-4-12**]
-Patient will need to be on aspirin 325mg daily, plavix 75mg
daily x12 months
Medications on Admission:
Furosemide 20 mg daily (stopped yesterday)
Atenolol 50 mg daily
Simvastatin 20 mg daily
Nifedipine 30 mg ER tablet daily
Aspirin 325mg daily (dose increased [**2106-4-5**])
MVI daily
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CAD: RCA DES.
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Coronary artery disease
Hypertension
Acute on chronic diastolic heart failure
Seconary Diagnoses:
Dyslipidemia
Chronic kidney disease
Sarcoidosis
Renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 89277**],
You were admitted to the hospital for a cardiac catheterization,
for further evaluation of your shortness of breath and chest
pressure. During your catheterization on [**2106-4-7**], you developed
the sudden onset of chest pain. This was likely caused by
having decreased blood flow to the heart because your blood
pressure was low.
You were briefly admitted to the ICU for close monitoring of
your blood pressure, which improved. You had a repeat cardiac
catheterization on [**2106-4-8**], and had a stent placed into one of
the coronary arteries. You will need to continue taking
aspirin, and will also need to take a new medication called
clopidogrel (plavix) daily for the next 12 months. It is very
important that you take this medication daily, and that you
speak with Dr. [**First Name (STitle) **] before stopping it for any reason.
Your CT scan revealed that there is a mass on your left kidney,
which could represent a cancer. We will let Dr. [**First Name (STitle) **] know about
this lesion. You may need to have an MRI to look more closely
at the kidney, and ultimately they may decide to either biopsy
the lesion or remove it.
We made the following changes to your medications while you were
here:
1. STARTED clopidogrel (plavix) 75mg daily
2. STOPPED atenolol
3. STARTED metoprolol tartrate 25mg twice daily
4. INCREASED furosemide to 40mg daily
5. INCREASED nifedipine to 60mg daily
Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **]
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
When: Thursday, [**4-15**], 1:45PM
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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13749, 13755
|
8328, 12367
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302, 419
|
13976, 13976
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5288, 5288
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3992, 4081
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3221, 3289
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3810, 3976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,228
| 192,382
|
33260
|
Discharge summary
|
report
|
Admission Date: [**2188-9-8**] Discharge Date: [**2188-9-22**]
Date of Birth: [**2111-3-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
78M s/p unwitnessed fall, unresponsive, with multiple L rib
fractures and pneumothorax
Major Surgical or Invasive Procedure:
[**2188-9-8**]: Intubated in the ED secondary to agitation and emesis
with aspiration
[**2188-9-8**]: Placement L chest tube in ED, later removed as it was
found to be in subcutaneous space.
[**2188-9-9**]: Arterial line placed
[**2188-9-9**]: Insertion left-sided 3-lumen subclavian CVL
[**2188-9-16**]: Percutaneous tracheostomy at ICU bedside for failure to
wean from vent
History of Present Illness:
Pt is a 78M with a hx of alcohol dependence who was found down
and unresposive by his wife after apparently [**Last Name (un) 27194**] down 8
concrete steps. The pt was initially oriented x1 with a GCS of
4 on the scene, however his GCS was 15 in the ED. He became
agitated in the ED, vomited, and desaturated and was therefore
intubated for airway protection. CT in the ED showed left sixth
through ninth rib fractures and a small left-sided pneumothorax.
Past Medical History:
PMH: CAD, peripheral neuropathy, depression, gout, EtOH
dependence, asbestosis/lung scar
PSH: CABG, aortic valve (tissue) replacement [**2184**]
Social History:
Pt is married, lives in his own home with his wife. A daughter
lives on next street and a son lives in [**Name (NI) 108**]. He is a
retired fire fighter. He has been independent in his ADLs. He
has a history of tobacco and EtOH dependence, on arrival was
+ETOH with BAL=206
Family History:
Non-contributory
Physical Exam:
HR:75 BP:118/62 Resp:22 O(2)Sat:93 nrb low
Constitutional: Moaning, uncomfortable, confused
HEENT: Pupils equal, round and reactive to light, Extraocular
muscles intact, C-collar, no crepitus
Chest: Clear to auscultation, + L chest wall ttp
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, diffuse ttp, R inguinal hernia easily
reducible, FAST negative, stable pelvis
Extr/Back: c/o diffuse pain with vertebral palpation
Skin: R lateral thigh ecchymosis, R knee laceration, L arm
abrasion
Neuro: Confused, follows commands, MAE, equal strength
bilaterally, decreased sensation to l.t. in bilateral feet(which
patient states is old)
Pertinent Results:
[**9-8**] CT A/P: Mildly displaced multilevel left-sided rib
fractures. At the site of rib fractures there is a chest tube,
which does not enter into the thoracic cavity. There is
subcutaneous emphysema with a small amount of hematoma at this
site. Small left basilar and apical pneumothorax. Bibasilar
atelectasis. Pleural calcifications may reflect asbestos
exposure, correlate clinically.
[**9-8**] CT C-Spine: No fracture of the cervical spine. Compression
deformity at T2 age-indeterminate but may relate to degenerative
changes. Degenerative changes at C3-4 and C4-5 cause mild degree
of central canal
narrowing may predispose to cord injury in the setting of
trauma. If there is concern for cord injury, MRI would be
recommended. Left apical pneumothorax, seen on concurrent CT
Torso. Patient is intubated. Nasogastric tube in the esophagus.
[**9-8**] CT Head: . No acute intracranial findings. Parenchymal
atrophy and small vessel disease.
[**9-11**] TLS-Spine MRI: No evidence of acute fractures. Compression
fractures involving T2, T5 and L1 are likely chronic given
absence of marrow edema. Mild multilevel degenerative changes
as described above with multiple
areas of mild to moderate foraminal stenosis and mild cord
indentation at
T5-T6 without cord signal intensity abnormality.
Well-circumscribed 2-cm upper back subcutaneous lesion, most
consistent with an epidermal inclusion cyst or a sebaceous cyst.
Minimal marrow edema L2 and L3 and L5-S1 facets and C1-2 lateral
mass joints , pattern most compatible with degenertive changes
without secondary features to indicate acute trauma. Multilevel
degenerative changes as described above.
[**9-12**] CXR: Asymmetric lucency of the left lung suggests an
anterior pneumothorax in this supine patient. Right lower lobe
opacity likely reflects new right pleural effusion (moderate)
and right lower lobe consolidation. New moderately severe
pulmonary edema.
[**9-14**] CT Chest: Bilateral moderate-sized simple pleural effusions
and associated compressive atelectasis of the lower lobes, new
since the prior study. Multifocal ground-glass opacities in the
right lung may represent
infection or aspiration. Extensive subcutaneous emphysema in the
left anterior chest wall, has increased since the prior study.
Interval resolution of a left-sided pneumothorax. Multiple left
recent rib fractures and non-acute right rib fractures.
[**9-16**] CXR: The Dobbhoff catheter is in the left main bronchus
and should be removed. Stable severe right lower lobe pneumonia,
bilateral pleural effusions and left lower lobe atelectasis.
[**9-17**] CXR: The Dobbhoff tube is coiled in the stomach. The tip
projects over the middle parts of the stomach. Normal
tracheostomy tube. No evidence of complications. Unchanged left
subclavian vein catheter. Mild retrocardiac atelectasis.
Unchanged size of the cardiac silhouette. The study and the
report were reviewed by the staff radiologist.
[**9-19**] CXR: Improved ventilation at both lung bases with small
remnant areas of atelectasis. No newly-occurred focal
parenchymal opacities. Mild
cardiomegaly without pulmonary edema.
[**9-20**] CXR: As compared to the previous radiograph, the Dobbhoff
tube has been advanced. The tip of the tube now projects over
the middle parts of the stomach. No evidence of complications.
Otherwise, the radiograph is
unchanged.
[**2188-9-8**] 09:50PM BLOOD WBC-8.4 RBC-4.40* Hgb-13.8* Hct-40.1
MCV-91 MCH-31.4 MCHC-34.4 RDW-16.2* Plt Ct-343
[**2188-9-8**] 09:50PM BLOOD Plt Ct-343
[**2188-9-8**] 09:50PM BLOOD Fibrino-382
[**2188-9-9**] 04:32AM BLOOD Glucose-53* UreaN-13 Creat-0.8 Na-131*
K-4.5 Cl-102 HCO3-19* AnGap-15
[**2188-9-8**] 09:50PM BLOOD CK(CPK)-109
[**2188-9-9**] 04:32AM BLOOD ALT-12 AST-27 CK(CPK)-304 AlkPhos-76
TotBili-0.3
[**2188-9-9**] 04:32AM BLOOD CK-MB-12* MB Indx-3.9 cTropnT-0.02*
[**2188-9-10**] 12:54AM BLOOD CK-MB-6 cTropnT-<0.01
[**2188-9-9**] 04:32AM BLOOD Albumin-3.2* Calcium-7.6* Phos-3.5 Mg-1.8
[**2188-9-8**] 09:50PM BLOOD ASA-NEG Ethanol-206* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-9-8**] 11:09PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100
pO2-501* pCO2-52* pH-7.20* calTCO2-21 Base XS--7 AADO2-182 REQ
O2-38 -ASSIST/CON Intubat-INTUBATED
[**2188-9-17**] 02:32AM BLOOD Type-ART Temp-38.8 PEEP-10 pO2-116*
pCO2-43 pH-7.41 calTCO2-28 Base XS-1 Intubat-INTUBATED
Brief Hospital Course:
Neuro: The patient requires medication for agitation, and
should continue oxycodone and Tylenol prn pain, as well as
clonidine, seroquel QHS, q16:00 and prn. Zyprexa Zydis was used
prn as well. For his history of EtOH dependence and previous
episodes of complicated withdrawal he was maintained on CIWA
protocol with thiamine, folate & multivitamin for
neuroprotection. Benzodiazepines were stopped [**9-14**]. He has been
in restraints intermittently for agitation and pulling at lines.
CV: The pt was initally in septic shock from his pneumonia and
required pressors to mainatin hemodynamic stability. These were
discontinued on [**9-11**]. The pt has been maintained on metoprolol
25 mg [**Hospital1 **]
Pulm: The pt was initially intubated in the Emergency Department
for agitation, emesis and concern for aspiration. He was found
to have a leftsided pneumothorax and a chest tube was placed in
the ED. This was found to enter the subcutaneous space and was
removed. The pneumothorax did resolve on serial films. The pt
did develop a likely aspiration pneumonia and was treated
empirically with Vancomycin and Zosyn, and completed a 10-day
course on [**9-18**]. The pt was unable to wean from the vent and was
very agitated by the ETT tube, a bedside percutaneous
tracheostomy was performed in the ICU [**9-16**] with a #8 Portex. He
has been able to wean to CPAP and, on the day of discharge did
have a trial with trach mask.
FEN/GI: Pt had dobhoff tube placed x3 for tube feeds. He pulled
out the first two and the third was carefully secured with tape.
Tube feeds were initiated per Nutrition recommendations and, at
time of discharge, were running at goal (55cc/hr).
ID: The pt was initially septic from his pnemonia and completed
a 10-day course of Vanc/Zosyn on [**9-18**], pressors d/c'ed [**9-11**].
GU: The pt has been diuresed with Lasix 20mg IV BID. He has a
Foley catheter.
Musculoskeletal: Pt has lateral L rib fractures of [**5-28**]. He also
has old compression deformities of T2, T5, L1. He came off
logroll precautions and had his C-Spine cleared [**9-13**].
Heme: Heparin SC and venodyne boots for DVT Prophylaxis, PPI for
ulcer prophylaxis
Medications on Admission:
zocor, ASA, omeprazole, allopurinol, ativan, neurontin, atenolol
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-10 Puffs Inhalation Q4H (every 4 hours) as needed for
wheezing.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: 10 (ten) mL PO BID (2
times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Recon Soln Sig: 40 (forty) mg Intravenous
Q24H (every 24 hours).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): at
16:00.
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
10. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID PRN () as
needed for agitation.
11. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever.
12. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every
4 hours) as needed for pain.
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold SBP<90, HR<50.
16. Furosemide 20 mg IV BID
17. HydrALAzine 10 mg IV Q6H:PRN SBP > 140
18. Metoclopramide 5 mg IV Q6H:PRN residuals
19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
20. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
23. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) mg
Injection Q15MIN () as needed for hypoglycemia protocol.
24. Regular Insulin Sliding Scale
FSBS Q6H
Glucose Regular Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-100mg/dL 0 Units
101-150mg/dL 2 Units
151-200mg/dL 4 Units
201-250mg/dL 6 Units
251-300mg/dL 8 Units
301-350mg/dL 10 Units
351-400mg/dL 12 Units
> 400mg/dL Notify M.D.
Instructons for NPO Patients: Evening Prior to
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 100% usual dose. Morning of
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 50% of usual dose; If on premix insulin
(e.g. 70/30, 75/25): take total number of AM units ordered,
divide by 3, and give that many units as NPH; If on sliding
scale of short acting insulin: administer according to HS
schedule. Hold all oral antidiabetic medications, and consider
sliding scale coverage; If appropriate, give IVF with dextrose
to prevent hypoglycemia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
-Displaced 6-9th left-sided rib fractures & small pneumothorax
s/p unwitnessed fall
-Alcohol dependence
-Aspiration Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair has ambulated in ICU with assist
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2537**] to schedule a follow-up appointment
in the Acute Care Surgery clinic in [**1-23**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2188-9-22**]
|
[
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"860.0",
"995.92",
"V45.82",
"V42.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"33.21",
"96.72",
"96.04",
"96.6",
"31.1",
"34.04",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
12014, 12085
|
6814, 9002
|
400, 777
|
12255, 12255
|
2439, 3302
|
14436, 14727
|
1744, 1762
|
9117, 11991
|
12106, 12234
|
9028, 9094
|
12465, 13910
|
13925, 14413
|
1777, 2420
|
274, 362
|
805, 1266
|
3311, 6791
|
12270, 12441
|
1288, 1435
|
1451, 1728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,673
| 154,642
|
36164
|
Discharge summary
|
report
|
Admission Date: [**2121-10-21**] Discharge Date: [**2121-10-26**]
Date of Birth: [**2050-3-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
hypoglycemia and cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo F w/ DMII on insulin, HTN p/w confusion found to be
hypoglycemic. Pt. has had multiple episodes of hypothermia
occuring early in the morning and thinks that her nighttime
insulin dose is too large, her granddaughter regularly checks on
her early in the am and this morning found her unresponsive at
0400, they checked her FS and was 46 and she was unable to take
PO juice. She was given IM glucagon in the field and brought
into the ED where she still appeared confused and lethargic w/ a
FS of 71. She was also noted to be hypothermic to 95.4. She was
given an amp of D50 and her FS came up to 300s. She was started
on bear hugger and her temperatures started to trend up. She was
noted to cough up green phlegm in the ED and was started on
Vanc/levo/flagyl.
Past Medical History:
- T2DM (HbA1C 12.3%, [**2120-1-3**], dxed app 10 yrs ago)
- HTN
- Hyperlipidemia
- Cataracts, corneal opacities, OD macular pigment changes
([**2120-1-11**])
- Lower back pain
- Inpt treatment approx 10 yrs ago for lung infection, ? TB
.
PSH:
Hysterectomy (for "uterus infection" in [**Country 3587**], c. [**2107**])
Social History:
From [**Country 3587**], immigrated to the USA 12/[**2119**]. Lives in family
house in [**Location (un) 686**]. Widowed. Smoked pipe (tobacco) for >30 yrs,
no cigarettes, quit two years ago. Denies h/o alcohol or illicit
drugs. Three adult children.
Family History:
Son with T2DM. [**Name2 (NI) **] known history of HTN, CAD, cancer.
Physical Exam:
Vitals: T: 96.2 BP: 124/57 P: 94 R: 29 O2: 96% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to 8cm above clavicle
Lungs: Crackles in Left lung base no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2121-10-21**] 05:45AM URINE RBC-0-2 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0 RENAL EPI-0-2
[**2121-10-21**] 05:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-10-21**] 05:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2121-10-21**] 06:00AM PT-12.8 PTT-25.5 INR(PT)-1.1
[**2121-10-21**] 06:00AM PLT COUNT-345
[**2121-10-21**] 06:00AM NEUTS-80.3* LYMPHS-16.1* MONOS-1.9* EOS-1.2
BASOS-0.5
[**2121-10-21**] 06:00AM WBC-6.7 RBC-3.51* HGB-9.0* HCT-27.2* MCV-78*
MCH-25.6* MCHC-32.9 RDW-13.8
[**2121-10-21**] 06:00AM TSH-0.98
[**2121-10-21**] 06:00AM proBNP-86
[**2121-10-21**] 06:00AM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-70 TOT
BILI-0.2
[**2121-10-21**] 06:00AM estGFR-Using this
[**2121-10-21**] 06:00AM estGFR-Using this
[**2121-10-21**] 06:00AM GLUCOSE-312* UREA N-34* CREAT-1.2* SODIUM-136
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
[**2121-10-21**] 06:04AM LACTATE-0.9
.
CXR ([**10-21**]): New right middle and right lower lobe pneumonia.
Unchanged
volume loss and peribronchial opacities particularly noticeable
in left upper lobe and better evaluated on prior CT.
.
.
[**2121-10-23**] INPATIENT SPUTUM
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
[**2121-10-21**] URINE Legionella Urinary Antigen -FINAL INPATIENT
Brief Hospital Course:
In brief this is a 71 yo F w/ DM II, bronchiectasis, HTN p/w
hypoglycemia, hypothermia and hypoxia.
.
#)Hypoxia: Patient was admitted to the ICU with hypoglycemia and
hypothermia. CXR was concerning for pneumonia and patient was
started on Ceftriaxone and levofloxacin for CAP. Patient
continued to have cough and wheezing so antibiotics was then
changed to vanc/zosyn for history of pseudomonal/proteus
PNEUMONIA. She was stable in the unit for the day and on the
evening of [**10-22**] she was transferred to the floor where her ABX
coverage was broadened to include azithromycin. She had one
episode of increased wheezing on the morning of [**10-23**] that
resolved with nebulizer treatments. She was started on chest
physiotherapy, and deep suctioning to aid in clearance of
secretions. Further history revealed that she had no respiratory
symptoms prior to her hypoglycemic episode. This fact in
conjunction with sputum cultures positive for mixed flora
suggested aspiration pneumonia and her azithromycin was held.
Her vancomycin was continued until discharge int he setting of
one sputum culture positive for GPCs in cultures to cover for
possible MRSA. On the day of discharge the likelihood of a MRSA
pneumonia was thought to be low and the patient was sent home
with a 5 day course of Augmentin and Guaifenesin and told to
follow up with her PCP.
.
.
# Hypoglycemia: Home 70/30 Insulin dose was stopped on admission
given hypoglycemic episode. HISS was started to cover patient
for day of admission. On transfer to the floor her insulin was
changed to 30U Lantus QHS to avoid hypoglycemia. Her sugars were
relatively well controlled on this regimen. Prior to discharge a
[**Location 7972**] speaking nurse [**First Name (Titles) 20554**] [**Last Name (Titles) **]. [**Known lastname 49957**] training on her new
insulin regimen. She was discharged home on 35U Lantus QHS and
her home dose of metformin.
.
.
Hypertension: Patient's hypertension was well controlled on home
doses of calcium amlodipine, lisinopril and metoprolol. Her HCTZ
was also restarted on discharge.
Medications on Admission:
Albuterol
Amlodipine 5mg daily
Cyclobenzaprine 5mg QHS
HCTZ 25mg daily
Ibuprofen 400mg TID
Lisinopril 40mg daily
Metoprolol 50mg daily
Metformin 1000 mg [**Hospital1 **]
Omeprazole 20mg daily
Simvastatin 40mg daily
Triamcinolone
ASA
CA+D
Insulin 70/30 36 units Qam and 16 units QPM
MVI
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation PRN as needed for shortness of breath or
wheezing.
11. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous once a day.
Disp:*5 vials* Refills:*2*
15. Guaifenesin-DM NR 10-100 mg/5 mL Liquid Sig: [**6-2**] mL PO four
times a day as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Aspiration pneumonia
Hypoglycemia
Bronchiectasis
Diabetes type II
Hypertension
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 [**Hospital1 18**] with low blood sugar that caused you
to be less alert and possibly aspirate, leading to pneumonia.
This infection was partially treated with antibiotics. Please
continue to take the antibiotics as prescribed. We recommended a
change to your insulin regimen to help prevent low blood sugar.
.
Please continue to check your blood sugar at meals and at
bedtime, and record the values. Contact your doctor if your
blood sugar is less than 80 or higher than 300.
Please have a follow-up chest x-ray in [**4-29**] weeks to ensure that
your pneumonia has resolved.
The following medication changes were recommended:
1) STOP Insulin (humulin) 70/30.
2) START Insulin glargine (lantus) 35 units at bedtime
3) START Augmentin (Amoxicillin-Clavulanic Acid) 875 mg TWICE
daily.
4) START Guafenisin as needed for cough.
Followup Instructions:
Department: [**Hospital1 7975**] ST. HLTH CTR-KCSS
When: WEDNESDAY [**2121-11-12**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7980**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"V58.67",
"494.0",
"414.01",
"585.3",
"250.40",
"403.90",
"507.0",
"272.0",
"250.80",
"991.6",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7788, 7845
|
3920, 6001
|
339, 346
|
7968, 7968
|
2374, 3897
|
9025, 9375
|
1767, 1837
|
6337, 7765
|
7866, 7947
|
6027, 6314
|
8151, 9002
|
1852, 2355
|
277, 301
|
374, 1142
|
7983, 8127
|
1164, 1483
|
1499, 1751
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,848
| 103,662
|
47516
|
Discharge summary
|
report
|
Admission Date: [**2127-12-15**] Discharge Date: [**2128-1-8**]
Service: MEDICINE
Allergies:
Ampicillin / Codeine / Tetracyclines
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cough, fever
Major Surgical or Invasive Procedure:
Bronchoscopy x 2
Intubation/extubation, mechanical ventilation
History of Present Illness:
The pt is an 85-yo woman w/ hypertension, hyperchol,
hypothyroid, GERD, anemia, and stage IV CKD (bl Cr 3.2-3.5) who
presents with 1.5 weeks of left side pain and cough. She notes
constant left side and back pain, and feeling weak. She has had
chest congestion with an intermittent cough, productive of a
white sputum. Denies SOB, or chest or abdominal pain. She has
not been eating well, [**12-30**] no appetite. No LH, dizziness, N/V,
diarrhea, or dysuria. She has been taking [**Doctor Last Name 1819**] Aspirin 325mg x2
three times daily for pain. Additionally, she has not gotten out
of bed because of the weakness, and has not been able to care
for herself, needing help getting to the bathroom.
.
In the ED, VS - Temp 99.2F, HR 76, BP 151/80, R 24, SaO2 96% 4L
NC. Labs significant for WBC 10.2 (85.6% PMNs), Cr elevation to
4.5, trop 0.05, and negative UA. ECG was unremarkable. CXR
showed RLL atelectasis and LLL consolidation vs effusion; CT-A/P
confirmed LLL pulm consolidation and RLL atelectasis, as well as
diverticulosis w/o diverticulitis, and stable atrophic kidneys.
She got 1L NS IVF, and Ceftriaxone 1gram IV + Azithromycin 500mg
PO for pneumonia.
.
Prior to transfer to the ICU, patient was treated for CAP with 5
days azithromycin and 14 days ceftriaxone. On [**12-19**] she was
transferred to the MICU and bronched for mucus plugging and
another bronch on [**12-22**] for same reason. She was called out to
the floor on [**12-24**] and had been doing well from a respiratory
standpoint until this morning when she desaturated. Currently,
the patient's breathing is much more comfortable. She was
transitioned to nasal cannula and Venturi mask. She states her
dyspnea is stable. She denies any chest pain, nausea, vomiting,
abdominal pain, or diarrhea.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Hypertension
AAA s/p intravascular repair in [**2119-2-26**]
s/p CVA in [**2120-1-26**], lacunar infart with no residual deficits
Hypercholesterolemia
Chronic back pain
Hypothyroidism
Osteoarthritis
GERD
Bilateral parotid gland masses
Diverticulitis
Chronic bronchitis
Anemia with baseline hematocrit 31 to 34 (likely secondary to
renal disease)
Stage IV Chronic Kidney Disease with baseline creatinine 3.2-3.5
Social History:
Widowed since [**2111**]. Has three grown sons. Lives with one of her
sons. Continues to smoke [**11-29**] pack per day x 70 years. No alcohol
or recreational drugs.
Family History:
No family history of gastrointestinal bleeding
Physical Exam:
Physical Exam:
VS: Temp 97.3F, BP 159/77, HR 75, R 22, SaO2 92% 2L NC
General: frail elderly woman in mild respiratory distress
HEENT: NC/AT, sclera anicteric, dry MM
Neck: supple, no LAD, no JVD
Lungs: diffuse rhonchi, occasional wheeze, no crackles
Heart: RRR, nl S1-S2, +[**1-3**] HSM @ LLSB w/o radiation
Abdomen: +BS, soft/NT, mild upper abd distension, no r/g, no HSM
Extrem: WWP, no c/c/e, 1+ pedal pulses
Neuro: awake, A&Ox3, CNs [**2-6**] grossly intact, muscle strength
full and sensation to light touch grossly intact throughout
Pertinent Results:
ADMISSION LABS
[**2127-12-15**] 04:15PM BLOOD WBC-10.2 RBC-4.02* Hgb-10.7* Hct-33.5*
MCV-83 MCH-26.6* MCHC-31.9 RDW-17.4* Plt Ct-390
[**2127-12-15**] 04:15PM BLOOD Neuts-85.6* Lymphs-10.8* Monos-2.8
Eos-0.3 Baso-0.5
[**2127-12-15**] 04:15PM BLOOD PT-11.3 PTT-24.8 INR(PT)-0.9
[**2127-12-15**] 04:15PM BLOOD Glucose-101* UreaN-58* Creat-4.5* Na-138
K-3.9 Cl-108 HCO3-16* AnGap-18
[**2127-12-15**] 04:15PM BLOOD cTropnT-0.05*
[**2127-12-16**] 07:00AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1
[**2127-12-16**] 08:21AM BLOOD Type-ART pO2-66* pCO2-28* pH-7.35
calTCO2-16* Base XS--8
[**2127-12-15**] 04:28PM BLOOD Lactate-1.2 K-3.5
[**2127-12-16**] 08:21AM BLOOD freeCa-1.11*
MICROBIOLOGY
BLOOD CULTURE: (1//18/[**2127**]) NO GROWTH
URINE CULTURE (Final [**2127-12-16**]): BETA STREPTOCOCCUS GROUP B.
10,000-100,000 ORGANISMS/ML..
SPUTUM
GRAM STAIN (Final [**2127-12-17**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2127-12-19**]):
RARE GROWTH Commensal Respiratory Flora.
BRONCHOALVEOLAR LAVAGE
[**2127-12-22**] 5:41 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final [**2127-12-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
CT ABDOMEN:
IMPRESSION:
1. Left lower lobe pulmonary consolidation, concerning for
pneumonia.
Additional right lower lobe patchy opacities could reflect
atelectasis.
2. Bilateral renal hypodensities, which are incompletely
characterized, but stable, and may reflect cysts.
3. Aortoiliac stent, incompletely assessed without IV contrast.
4. Severe diverticulosis without evidence of diverticulitis.
5. Stable retroperitoneal lymphadenopathy.
CHEST X-RAY ([**2127-12-15**])
Left lower lobe consolidation, better assessed on the
subsequently performed CT abdomen and pelvis.
CHEST X-RAY ([**2127-12-20**])
There is complete consolidation and opacification of the left
lung with mild mediastinal shift to the left. The right lung is
relatively [**Name (NI) **], and there is minimal atelectasis at
the right lung base. There is a stent in the upper abdomen.
.
[**2127-12-19**] CXR:
new opacification of the LEFT hemithorax. mediastinal shift
indicates left lung collapse. truncation of left main bronchus -
likely due to mucus plug or aspiration. d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] 8:45am
[**2127-12-19**].
.
ECHO: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. Mild to
moderate ([**11-29**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2125-1-19**], the aortic stenosis may be slightly worse
(but still only mild).
.
CT chest: 1. Partial atelectasis of the lingula and complete
collapse of left lowerlobe is likely due to mucous impaction,
but a mass cannot be excluded due to absence of contrast
administration.
2. Several pulmonary nodules are predominantly stable. Several
new right
lung lobe nodules are likely inflammatory and can followed by CT
to ensure
stability in 6 months if warranted clinically.
3. Findings suggestive of pulmonary artery hypertension.
4. Enlarged mediastinal lymph nodes are similar to [**2121-10-30**].
.
Chest Xray ([**2128-1-6**]): As compared to the previous examination,
there is a complete
collapse of the left lung. As a consequence, there is an
extensive shift of
the mediastinum and the heart to the left. In the right lung,
the parenchyma
shows minimally improved ventilation. No evidence of interval
occurrence of
focal parenchymal opacities on the right.
Brief Hospital Course:
85 yo female with HTN, HLP, CKD stage 4, admitted with cough and
pleuritic CP, found to have LLL pneumonia,
.
# Hypoxia/respiratory distress/ Community acquired pneumonia:
Patient initially admitted with CAP involving the left lower
lobe and with 3-4L Oxygen requirement (PORT Score 135, Risk
class V, 26.7% Mortality). Patient was admitted to the medical
floor where she developed acute respiratory distress and
hypoxia, requiring transfer to the MICU. Patient cleared a large
mucous plug with immediate improvement in respiratory status and
underwent urgent bronchoscopy which confirmed large amount of
mucous. Patient required repeat bronchoscopy which was
successful in removal of a large mucous plug. She became
progressively more dyspneic and hypoxemic in the MICU and
required intubation with mechanical ventilation. Repeat
bronchoscopy at that time showed complete collapse of her left
lower lungs with thick mucus plugging and secretions that were
very difficult to suction out. Patient was started on Mucomyst,
aggressive chest PT and frequent deep suctioning. Her collapsed
left lung slowly re-expanded on mechanical ventilation. There
was difficulty weaning patient off the ventilator; when propofol
was turned off, she would wake up minimally. CT head showed no
acute processes, however, and ultimately, patient self-extubated
one morning with family at her bedside. She made it explicitly
clear that she did not wish to be intubated again. In
discussions with her and her sons, the patient was made DNR/DNI.
In the following two days, patient became progressively anxious
and delirious, as well as refusing chest PT, deep suctioning and
face mask. She would intermittently desaturate to the 70-80s.
Palliative Care was consulted and in further discussions with
her family, the goal was for comfort measures. Patient was
started on Morphine 1-3mg every hour for symptomatic relief of
air hunger. No more labs were drawn, lines were pulled. Final
chest xray two days prior to expiration showed recollapse of her
entire left lung, which the family understood could not be
reinflated with bronchoscopy with likely re-intubation, which
was not in keeping with patient's desires. Patient was
ultimately transferred to the regular Medicine floor where she
passed away on [**1-8**] in the early morning.
.
Pneumonia was treated with Ceftriaxone x 7 days and 5 day course
of azithromycin. Agressive chest physical therapy, flutter
valve, decongestants and nebulizer treatments were given.
#. Acute on Chronic renal insufficiency: Patient with Stage IV
CKD at baseline, at time of admission with Cr up to 4.5, with
muddy brown casts suggestive of ATN, most likely ischemic from
prerenal failure vs NSAID induced ischemia. ASA, NSAIDs,
nephrotoxins avoided, patient volume resuscitated and creatinine
improved to 3.2 by day of expiration.
.
# Metabolic Acidosis: During acute decompensation, likely due to
Acute Kidney Injury. Delta/delta was suggestive of combination
of anion-gap and nonanion-gap metabolic acidosis. This however
resolved during hospitalization.
.
#. Hypertension - Somewhat better controlled. Patient was
continued on Diltiazem 60mg PO four times daily.
.
#. Weakness -Elderly female with acute illness now in addition
to baseline deconditioning. Patient was evaluated by Physical
Therapy who recommended rehabilitation facility.
#. Hypothyroidism - Continued home levothyroxine
.
#. Hyperlipidemia - Continued home statin
.
#. Anemia - Likely anemia of chronic disease. Given patient's
resistance to hemodialysis, it was never initiated and she was
never started on Epogen.
Medications on Admission:
Diltiazem SR 120mg daily
Doxercalciferol 0.5 mcg daily
Levothyroxine 150 mcg daily
Oxybutynin 5 mg daily -- pt denies
Simvastatin 40 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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"E849.8",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
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[
[
[]
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256, 320
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|
204, 218
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348, 2378
|
2400, 2815
|
2831, 2999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,123
| 182,813
|
7939
|
Discharge summary
|
report
|
Admission Date: [**2189-8-18**] Discharge Date: [**2189-8-29**]
Date of Birth: [**2118-11-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine / Fluorescein / IV Dye, Iodine Containing
Contrast Media
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
[**2189-8-24**] heart catheterization with bare metal stent to SVG-OM2
graft
History of Present Illness:
70 y/o M with ESRD [**1-15**] DM, s/p transplant [**2180**] on double
immunosuppressive therapy, CHF, CAD, afib on coumadin,
hypertension, who presented to the ED today with 1 episode
nausea, 3 days dry heaving. Had URI three weeks ago, did not
take prescribed zpack since resolving. Over last two weeks has
appreciated 14 pound weight gain. Went to daughter's wedding on
[**Hospital3 4298**], denies liberalizing diet, stuck to <2g Na
daily. Notes with weight gain now having SOB on climbing 1
flight of stairs, no orthopnea.
ROS Denies chest pain, pressure, palpitations, cough, fevers, or
chills. He has been gaining some weight. He does urinate, but is
unclear as to whether or not the amount of urine he produces has
changed. He has a diabetic right foot ulcer, which was recently
debrided by Dr [**Last Name (STitle) 3407**], vascular surgery recommended but deferred
by patient given history dye alllergy (kidney failure).
Of note, the patient was admitted to [**Hospital1 18**] in [**Month (only) **]-[**2189-6-14**] for
acute kidney injury and volume overload. His presenting
creatinine was 3.5, and he required two dialysis sessions to
stabilize his renal function and volume overload. His renal
failure was ultimately felt to be multifactorial, including
issues with volume and medication effect. This hospitalization
was also notable for GI bleeding in the setting of a
supratherapeutic INR; anticoagulation was held then eventually
restarted prior to discharge.
Full 10-system review otherwise negative except as noted above
In the ED intial VS were T 02: 95%RA BP: 80/60 transiently to
140/78 without intervention. T:97
Labs notable for BNP 60 689, k+ 5.8, Cr: 4.6 INR 5.8.
Past Medical History:
- End-stage renal disease [**1-15**] diabetic nephropathy s/p cadaveric
renal transplant [**2180**], complicated by CMV and delayed graft
function on Tacrolimus and Prednisone followed by Dr. [**Last Name (STitle) **]
- Coronary Artery Disease, s/p Non-ST Elevation Myocardial
Infarction
-- s/p atherectomy LAD in [**2176**], s/p Cypher DES to mid LAD
[**6-/2180**], s/p Taxus DES for ISR in [**5-/2181**], s/p POBA for ISR
[**1-/2186**], s/p CABG
- Congestive heart failure -EF 20% on TTE [**2188**]
- Chronic afib on Coumadin
- Hyperparathyroidism
- Diabetes-type II
- Hypertension
- Hyperlipidemia
- Gout
- HSV meningitis in [**2184**]
- Spinal stenosis
- Sciatica chronic back pain and left hip pain
- s/p AV fistula for HD in the past
- Scalp seborrhea
Social History:
Lives in [**Location 2312**] with wife.
[**Name (NI) **] not been very active for the past 8 months due to his leg
ulcers.
He has 4 children.
Used to run a yacht charter company.
No smoking.
No significant alcohol use.
Family History:
Father died of MI in early 60s, brother died of MI age 53.
Mother with diabetes.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.8 48 127/37 14 97% RA
General: awake, alert, oriented, mildly nauseous
HEENT: no conjunctival icterus or pallor, MMM, OP clear, no
exudate; left eye mildly adducted
Neck: supple, no JVD or LAD
Lungs: decreased BS at bases, no crackles wheeze or rhonchi
CV: bradycardic, normal S1/S2, no S3/S4/M/R
Abdomen: soft, NT/ND, +BS throughout, no rebound/guarding. no
tenderness over RLQ renal graft, no bruits
Ext: symmetric 1+ bilateral LE edema; right foot with ulcer
dressing C/D/I, multiple toes with erythema and abrasions
Access: left forearm AVF with audible bruit, palpable thrill
DISCHARGE EXAM:
Vitals: T 97.5, BP 162/80 (78-162/33-126), HR 54 (54-63), RR 18,
POx 97%RA
24H in: 120cc (inaccurately recorded)
24H out: 3L
weight: 73kg
(was 84kg on admission)
General: awake, alert, NAD, lying in bed, pleasant
HEENT: no conjunctival icterus or pallor, MMM, OP clear, no
exudate, mild tenderness bilateral temples; left eye mildly
adducted
Neck: supple, no JVD or LAD
SKIN: Multiple large ecchymoses all over skin.
PULM: decreased BS at bases, no crackles/wheezes/rhonchi
CV: normal S1/S2, no murmur no rub, HR regular
ABD: soft, NT/ND, +BS throughout, no rebound/guarding. no
tenderness over RLQ renal graft, no bruits
EXTREM: symmetric 1+ bilateral LE edema; discoloration which
looks chronic in nature, right foot with ulcer dressing C/D/I,
multiple right toes with erythema and abrasions.
ACCESS: left arm AVF with audible bruit, palpable thrill, R
upper arm w/ PICC in place, bandaged
NEUROLOGIC EXAM, PER NEUROLOGY CoNSULT NOTE:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**2-14**] at 5
minutes. The pt. had good
knowledge of current events. There was no evidence of apraxia
or neglect.
-CN:II-XII are intact except for a small left palpebral fissure
& subtle flattening of the left NLF. PERRl. There is slight
adduction of left eye at rest, but EOMI. Cover-Uncover test is
unrevealing
VII: No facial 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: Atrophic muscle lower ext more than upper ext. No
pronator drift right side, he is under HD via L AVF (can not
move the No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 4- 5- 5 5 5 5 5 4- 4+ 4 4- 4- 3+
R 4- 5- 5 5 5 5 5 4- 4+ 4 4- 4- 3+
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was extensor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
Pertinent Results:
ADMISSION LABS
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] WBC-8.6# RBC-3.53* Hgb-10.1* Hct-32.5*
MCV-92 MCH-28.5 MCHC-31.0 RDW-20.0* Plt Ct-114*
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] Neuts-80.7* Lymphs-13.2* Monos-5.4
Eos-0.6 Baso-0.1
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] PT-57.9* PTT-42.9* INR(PT)-5.8*
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] Glucose-133* UreaN-171* Creat-4.6*#
Na-132* K-5.8* Cl-96 HCO3-21* AnGap-21*
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] ALT-15 AST-21 AlkPhos-154* TotBili-0.7
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] proBNP-[**Numeric Identifier 28497**]*
[**2189-8-18**] 10:00PM [**Month/Day/Year 3143**] cTropnT-0.34*
[**2189-8-19**] 04:21AM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-0.30*
[**2189-8-18**] 12:45PM [**Month/Day/Year 3143**] Albumin-3.7 Calcium-8.8 Phos-8.2*# Mg-2.5
[**2189-8-18**] 12:57PM [**Month/Day/Year 3143**] Lactate-2.4*
DISCHARGE LABS
[**2189-8-29**] 04:28AM [**Month/Day/Year 3143**] WBC-5.0 RBC-3.15* Hgb-8.9* Hct-29.1*
MCV-92 MCH-28.3 MCHC-30.6* RDW-19.5* Plt Ct-81*
[**2189-8-29**] 04:28AM [**Month/Day/Year 3143**] Glucose-111* UreaN-32* Creat-2.3* Na-136
K-4.2 Cl-98 HCO3-30 AnGap-12
[**2189-8-29**] 04:28AM [**Month/Day/Year 3143**] Calcium-8.1* Phos-3.2 Mg-1.9
[**2189-8-29**] 04:28AM [**Month/Day/Year 3143**] PT-30.2* INR(PT)-2.9*
URINE STUDIES
[**2189-8-19**] 06:24AM URINE Hours-RANDOM UreaN-563 Creat-62 Na-11
K-29 Cl-11
[**2189-8-19**] 06:24AM URINE Osmolal-334
MICRO DATA
[**2189-8-18**] 12:30 pm [**Month/Day/Year 3143**] CULTURE
[**Month/Day/Year **] Culture, Routine (Final [**2189-8-24**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2189-8-19**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2189-8-18**] 12:45 pm [**Month/Day/Year 3143**] CULTURE
**FINAL REPORT [**2189-8-24**]**
[**Month/Day/Year **] Culture, Routine (Final [**2189-8-24**]): NO GROWTH.
[**2189-8-20**] 2:00 pm [**Month/Day/Year 3143**] CULTURE Source: Line-HD #1.
**FINAL REPORT [**2189-8-26**]**
[**Month/Day/Year **] Culture, Routine (Final [**2189-8-26**]): NO GROWTH.
[**2189-8-20**] 3:26 pm [**Month/Day/Year 3143**] CULTURE Source: Line-HD fistula #2.
**FINAL REPORT [**2189-8-26**]**
[**Month/Day/Year **] Culture, Routine (Final [**2189-8-26**]): NO GROWTH.
TACROLIMUS TROUGHS
[**2189-8-24**] 08:57AM [**Month/Day/Year 3143**] tacroFK-9.5
[**2189-8-25**] 06:03AM [**Month/Day/Year 3143**] tacroFK-8.2
[**2189-8-25**] 06:24AM [**Month/Day/Year 3143**] tacroFK-8.4
[**2189-8-26**] 06:30AM [**Month/Day/Year 3143**] tacroFK-5.8
[**2189-8-28**] 06:26AM [**Month/Day/Year 3143**] tacroFK-4.8*
ECG [**2189-8-18**] 12:34:16 PM
Baseline artifact. Sinus bradycardia. First degree A-V block.
Left axis deviation. Intraventricular conduction defect. Cannot
rule out inferior wall myocardial infarction of indeterminate
age. Diffuse non-specific ST-T wave abnormalities. Compared to
the previous tracing of [**2189-7-1**] small R waves in leads III and
aVF are less prominent raising possibility of prior inferior
wall myocardial infarction. Clinical correlation is suggested.
Otherwise, no diagnostic change.
CXR PA/LAT [**2189-8-18**]
Indistinct pulmonary vasculature and small pleural effusions are
consistent with worsening of mild CHF since [**Month (only) 216**].
TRANSTHORACIC ECHO [**2189-8-19**]
The left atrium is moderately dilated. The left atrium is
markedly dilated. The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. Overall left ventricular systolic function is
severely depressed secondary to akinesis of the apex, mid-distal
anterior septum, anterior, antero-lateral walls, and severe
hypokinesis of the mid-distal infero-lateral wall (LVEF= 20 %).
No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION
Compared with the prior study (images reviewed) of [**2189-2-25**],
the mid-distal infero-lateral wall involvement is new. Overall
left ventricular systolic function is similar (slightly
underestimated on the prior study).
CARDIAC CATH [**2189-8-24**]
Coronary angiography: right dominant
LMCA: Diffuse calcific disease with distal 40% into 90% LAD
origin lesion.
LAD: Total occlusion proximally
LCX: Occluded after diffuse calcific disease in the mid vessel.
RCA: Known occluded
SVG-OM3: Widely patent
SVG-OM2: Origin 80% ulcerated. Jump graft occluded.
LIMA-LAD: Widely patent. LAD has 40% eccentric stenosis after
touchdown.
FLUORO GUIDED ADVANCEMENT OF PICC [**2189-8-24**] 9:07 AM
Successful replacement of a double-lumen Power PICC with the new
PICC length measuring 44 cm. The tip of the PICC is in the
distal SVC. The line is ready to use.
CT HEAD W/O CONTRAST [**2189-8-27**] 12:45 PM
No acute intracranial abnormality.
Brief Hospital Course:
Mr. [**Known lastname **] is a 70y/o gentleman with AFib on Warfarin, HTN, DM2
c/b neuropathy & RLE ulcers, as well as DM2-related ESRD s/p
DDRT [**2180**] on Tacro/Prednisone, and CAD s/p PCIs and CABG x5 with
systolic heart failure (LVEF 20%) who presented with
nausea/uremia & hypervolemia from [**Last Name (un) **] (acute-on-chronic renal
failure). He had a brief MICU stay for concern of worsening
dyspnea, but he was able to be transferred to Cardiology given a
new wall motion abnormality on echo. He underwent cardiac
catheterization with stent to one of his bypass grafts. In
addition, he was re-initiated on dialysis this admission. He
was discharged to [**Hospital3 2558**] for rehab.
ACTIVE ISSUES
#. CAD: s/p PCI's & CABG x5, with new WMA on echo. Now s/p BMS
to SVG-OM2 graft.
New mid-distal infero-lateral wall hypokinesis; overall his echo
appeared to show a significant decrease in pump function
compared to prior, with new mid-distal infero-lateral wall
hypokinesis. Troponins this admission were ~0.3 which could
imply NSTEMI, though this was also in the setting of renal
failure. Curious that he had a relatively normal dobutamine
[**Hospital3 **] echo in 5/[**2188**]. Given that this new WMA might have
represented stunned myocardium, he underwent cardiac
catheterization [**2189-8-24**] which showed diffuse calcific disease
but also an 80% lesion of his SVG-OM2 graft with jump graft
occluded. He received a bare metal stent.
-He will continue on ASA 81mg daily
-Started on Plavix (to be continued for at least 1 month
uninterrupted).
-He was continued on a beta blocker (Metoprolol dose was
decreased due to bradycardia to the 50's)
-He was continued on Simvastatin (LDL is at goal)
-He was started on an ACE inhibitor (low-dose Lisinopril 5mg
daily)
Mr. [**Known lastname **] will follow up with his Cardiologist after discharge.
#. Ischemic cardiomyopathy with LVEF of 20%: now euvolemic
(weight 160 lbs).
He presented with significant hypervolemia and was diuresed with
Torsemide as well as having volume control via ultrafiltration
at HD. His dry weight had reportedly been 163 lbs, he was
admitted at 185 lbs, and on discharge he is 160 lbs. He is
being discharged on his home dose of Torsemide (60mg daily) and
also can receive ultrafiltration as needed for volume control.
He continues on a BB and an ACE. He will follow up with
Cardiology as an outpatient. Might consider discussion as an
outpatient regarding possible ICD placement.
#. [**Last Name (un) **] in transplant patient: likely from prerenal
state/cardiorenal syndrome.
Likely etiology of injury is poor forward flow (patient with low
EF at baseline and now worsened EF). Per Nephrology, he is
unlikely to regain enough renal function to be able to be off HD
for a meaningful amount of time, but it is possible that he
might be able to be weaned off HD in the future.
(a) HD planning
-re-initiated dialysis via his LUE AVF (HD was started on [**8-19**],
new schedule M/W/F)
-cervical arch stenosis: he should have a fistulogram as an
outpatient in [**12-15**] weeks
(b) volume - appears euvolemic now (dry weight ~160 lbs)
-should check daily weights
-continue Torsemide
(c) electrolytes - now stable on HD
He was initially hyperkalemic with peaked T waves on EKG, but
since being initiated on dialysis this resolved.
(d) minerals/bone health
He has elevated PTH. Elevated phos.
-continue cholecalciferol daily
-started Sevelamer, which he will continue
-patient had been on calcitriol as outpatient but this was
stopped; will have a follow-up PTH checked at dialysis
(e) anemia
See below.
-on Epo at dialysis (started [**8-26**])
-might consider [**Month/Year (2) **] transfusion if Hct <~27
-did receive 1u pRBC this admission and Hct remained stable
(f) s/p transplant
-continue Prednisone/Tacrolimus
-continue Bactrim prophylaxis
-check AM Tacrolimus trough next on [**2189-8-31**] PRIOR to getting
tacro that morning. (will be followed up by Transplant
Nephrology at his next appointment on [**2189-9-1**])
Mr. [**Known lastname **] will be followed by his Nephrologist (Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1366**]) after discharge, and will also be seen in clinic by his
Transplant Nephrologist (Dr. [**First Name (STitle) **] [**Name (STitle) **]).
#. Positive [**Name (STitle) **] culture: likely a contaminant, off
antibiotics.
One of his initial [**Name (STitle) **] cultures from [**8-18**] returned with GPCs so
he was started on empiric Vancomycin but this was discontinued
[**8-21**] when it grew coag-negative Staph. This was most likely a
contaminant and no further antibiotics were received.
Subsequent [**Month/Day (4) **] cultures were all negative.
#. Coagulopathy: INR should be monitored closely.
Pre-hospital Warfarin dose was 3mg on Wednesdays and 2mg six
days. On admission, INR was 5.8. Possibly secondary to renal
failure and vitamin K deficiency. Warfarin was held on
admission and INR trended. INR is 2.9 on discharge and he is
being discharged on Warfarin 1mg daily. Given that he is on ASA
and Plavix as well, care should be taken to ensure he does not
become supratherapeutic as his risk of bleeding is already high.
Next INR should be checked on day after discharge.
#. Atrial fibrillation: currently in NSR.
He is anticoagulated on Warfarin (goal INR [**1-16**]). He is
rate-controlled with Metoprolol. Has been in sinus rhythm this
admission with rate 55-65.
#. Low BP when measured noninvasively: likely inaccurate.
Patient is on Metoprolol and Lisinopril. On [**8-23**] he had SBP
70-80, asymptomatic and not tachycardic. Though he had
impressive ecchymosis and bleeding at his PICC site, his Hct was
stable so hemorrhage was less likely. Team considered
overdiuresis as an etiology, considering that he had been
receiving ultrafiltration, so his diuretics were held
temporarily. However, in the cardiac cath lab on [**8-24**] his
invasive [**Month/Year (2) **] pressures were 120-130/60-70. His noninvasive
peripheral BP measurements were inaccurate, especially because
he could not have them checked in left arm due to fistula, and
right upper arm due to PICC. During this hospitalization, the
most reasonable measurements were via pediatric BP cuff on his
right forearm. However, PICC was removed prior to discharge, so
should use right arm for BP measurements.
#. Blurry/doube vision: not acute, no concern for ocular
emergency.
Patient had an episode of blurry vision on [**8-25**] that lasted <1
hour and resolved. Then on [**8-27**] this returned and lasted the
duration of the day. On exam, he had baseline mild abduction of
left eye, and this was unchanged. He reported diplopia (double
vision) but neuro exam was normal. Still, he was bothered by
the double vision, reporting eye strain and mild headache so
Ophthalmology and Neurology were consulted. CT head was
negative for bleed. It was felt that this did not represent
stroke so no further imaging was pursued. He does have known
diabetic retinopathy bilaterally for which he should follow up
with Dr. [**Last Name (STitle) **] at [**Last Name (un) **]. In addition, he has a cataract
(right eye) and is s/p PCIOL (left eye) for which he should
follow up with Dr. [**Last Name (STitle) **] as an outpatient.
INACTIVE ISSUES
#. DM2: stable.
HbA1c was 7.6% in 6/[**2188**]. He continues with insulin sliding
scale.
#. Diabetic ulcers: right toe ulcers.
Podiatry was consulted and per their note, he has: "stable
superficial ulcer right sub 5th met head right, felt to foam in
place. Wound looks stable, no deep
tracking or localized SOI. Felt to foam in good condition, does
not need to be replaced. Apply wet to dry to this wound and
Santyl to the heel eschar." He will follow up with Podiatry
(Dr. [**Last Name (STitle) **] after discharge. Also has follow-up with Vascular
Surgery. He is on a Fentanyl patch for pain.
#. Anemia: chronic anemia, likely anemia of CKD.
Hct ~26-30 which is baseline. Had been iron deficient in the
past, and also has anemia of CKD. Has been transfused as an
outpatient. He was started on iron supplements this admission
as he has been iron deficiency on prior testing, but per
Nephrology Transplant team this was stopped and he can receive
IV iron as needed as an outpatient. In addition, was started on
Epo on [**8-26**]. Received one unit pRBC on [**8-28**] with very stable
Hct.
#. Thrombocytopenia: chronic.
Plt 80-100 this admission.
#. Gout: stable.
He continues on Allopurinol.
TRANSITIONAL ISSUES
#. Code status: Full code
#. Emergency Contact: [**Name (NI) **] [**Name (NI) **] (wife/HCP) [**Telephone/Fax (1) 28498**]
#. Follow-up: Cardiology (in clinic), Nephrology (at HD),
Transplant Nephrology (in clinic), Podiatry (in clinic),
Vascular Surgery (in clinic)
#. Appointments that still require scheduling:
-Fistula care: Due to cervical arch stenosis, needs fistulogram
in ~2 weeks. Please call ([**Telephone/Fax (1) 28499**] to schedule.
-[**Last Name (un) **] Ophthalmology: Please call ([**Telephone/Fax (1) 28500**] to schedule an
eye appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for within 1-2 weeks.
#. Plavix duration: Started [**8-24**], should continue daily at least
1 month uninterrupted (to be determined by Cardiology)
#. Labs/studies pending at discharge: None.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Allopurinol 100 mg PO DAILY
2. Collagenase Ointment 1 Appl TP [**Hospital1 **]
apply to affected area of Right foot
3. Fentanyl Patch 25 mcg/hr TP Q72H pain
4. Insulin SC
Insulin SC Sliding Scale using HUM Insulin
5. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
6. PredniSONE 5 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Torsemide 80 mg PO DAILY
9. Calcitriol 0.25 mcg PO DAILY
1 tablet on ODD days and 2 tablets on EVEN days.
10. Warfarin 2-6 mg PO DAILY16
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Tacrolimus 0.5 mg PO Q12H
13. Sulfameth/Trimethoprim DS 1 TAB PO MWF
14. Aspirin 81 mg PO DAILY
15. Docusate Sodium 100 mg PO DAILY:PRN constipation
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Collagenase Ointment 1 Appl TP [**Hospital1 **]
apply to affected area of Right foot
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Fentanyl Patch 25 mcg/hr TP Q72H pain
please hold for RR<12 or oversedation
RX *fentanyl 25 mcg/hour remove old patch and apply a new patch
every 72 hours Disp #*1 Unit Refills:*0
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. PredniSONE 5 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Tacrolimus 0.5 mg PO Q12H
9. Vitamin D 1000 UNIT PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
hold for RR <12 or oversedation
11. Calcitriol 0.25 mcg PO DAILY
1 tablet on ODD days and 2 tablets on EVEN days.
12. Allopurinol 100 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
[**Last Name (un) **] hold for SBP<100 or HR<55.
14. Torsemide 60 mg PO DAILY
please hold for SBP<95
15. Warfarin 1 mg PO DAILY16
16. Clopidogrel 75 mg PO DAILY
17. Lisinopril 5 mg PO DAILY
18. sevelamer CARBONATE 800 mg PO TID W/MEALS
19. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (MO,WE,FR)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
acute on chronic kidney failure
congestive heart failure
anemia
diabetic retinopathy
right eye cataract
SECONDARY:
coronary artery disease
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
Thank you for choosing your health care at [**Hospital1 827**]! You were admitted here because of nausea. You
were found to have decreased kidney function, as well as
decreased heart pump function. You underwent dialysis to improve
your fluid status and electrolytes, and you will continue with
this after discharge. You also underwent a cardiac
catheterization at which time a bare metal stent was placed to
open a blockage in one of your bypass grafts.
Please note that after placement of this kind of stent, you must
continue Plavix (a [**Hospital1 **] thinner) for AT LEAST one month
uninterrupted, until told to stop by your cardiologist. Also
you should continue with Aspirin daily.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
We made the following changes to your medications:
-START Plavix
-START Lisinopril
-START Sevelamer
-START Iron
-CHANGE Metoprolol
-CHANGE Warfarin
Followup Instructions:
TRANSPLANT NEPHROLOGY
When: TUESDAY [**2189-9-1**] at 3:20 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
PODIATRY
Department: PODIATRY
When: FRIDAY [**2189-9-4**] at 3:50 PM
With: [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
VASCULAR SURGERY
When: TUESDAY [**2189-9-8**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
CARDIOLOGY
When: WEDNESDAY [**2189-9-9**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NEPHROLOGY
Since you have been restarted on dialysis, you will be followed
by your Nephrologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**], after discharge.
FISTULA CARE
You have cervical arch stenosis and require an outpatient
fistulogram in ~2 weeks. Please call ([**Telephone/Fax (1) 28499**] to schedule
this.
OPHTHALMOLOGY - [**Hospital **] CLINIC
Please call ([**Telephone/Fax (1) 28500**] to schedule an eye appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for within 1-2 weeks.
PRIMARY CARE & [**Hospital3 **]
You should follow up at [**Hospital 18**] [**Hospital3 **] to see your
Primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as well as being seen
in [**Hospital3 **] [**Hospital3 271**] after you are
discharged from rehab.
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4,976
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10583
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Discharge summary
|
report
|
Admission Date: [**2179-11-19**] Discharge Date: [**2179-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
[**Age over 90 **] yo female with PMH HTN, Afib s/p pacer now being evaluated
s/p presumed Vfib arrest. History limited but per daughter, pt
report USOH with exception of mild increased fatigue, dizziness
x several weeks. Apparently, pacer battery was changed on [**11-10**]
[**1-25**] low battery. Today, the pt drove from home in [**Location (un) 13040**] to
[**Location (un) **] to visit daughter-in-law. Apparently pt was sitting
with daughter after lunch when she became unresponsive with
"eyes rolled behind" head. Episode began at 1315. Daughter
called 911 and started CPR; no pulse initially. Pt was
unresponsive for 3-4 minutes. [**Location (un) **] fire department arrived
and monitor reported WCT (reported to be Vfib), shockable
rhythm, and pt defibrillated x 1 with reported return to sinus
tachy with palpable pulse. EMS arrived shortly thereafter and
found pt with perfusing rhythm. Pt had a couple episodes of VT.
Pt was bolused with lidocaine and started on drip. Intubated was
attempted x 3 for airway protection, but failed.
.
Pt was transferred to [**Hospital1 18**]. Had traumatic intubation in ED,
after multiple attempts finally intubated. She was
hemodynamically stable with O2sat 99%. ABG of 7.22/70/97. K of
4.0. Started on amio drip preceded by bolus. Stat bedside echo
showed no focal wall motion abnormalities, reported preserved LV
function with moderate MR/AI and pulmonary hypertension.
Interrogation of pacer showed Afib with rapid ventricular rate,
but unable to locate clear VT/VF episode with the exception of
an episode with a rate in 300s. Intermittent with Afib were
bursts of pacing to 120s-130s. There was a concern for
subcutaneous emphysema in the neck given traumatic intubation.
Chest/neck CT showed perforation of trachea with marked
subcutaneous emphysema and pneumomediastinum.
.
Per daughter, no recent CP/SOB/n/v/abd pain
Past Medical History:
HTN
AF s/p pacer (tachy-brady; syncope)
Hypothyroid
Hypercholesterolemia
Arthritis
Social History:
Lives alone; very independent and functional
Family History:
Non-contributory
Physical Exam:
VS: t97.8, p97, 148/59, 99% AC 20/550/5/1.00
Gen: elderly female, lying flat on back, occasional posturing
type movements of bilateral upper/lower extremities
HEENT: blood oozing from trach, pupils constricted and
non-reactive, no corneal reflex, 2+ carotid, no clear bruit
CVS: irreg irreg, nl s1 s2,
Lungs: CTAB anteriorly
Abd: RUQ surgical scar, vertical midline scar, +BS, distended
Ext: 2+DP, no edema, posturing
Neuro: upgoing toes, no corneal reflex, eyes midline, no pupil
reaction, hyper-reflexive DTRs
Pertinent Results:
CBC:
[**2179-11-26**] 04:54AM BLOOD WBC-45.5* RBC-4.54 Hgb-13.5 Hct-44.0
MCV-97 MCH-29.7 MCHC-30.7* RDW-18.2* Plt Ct-973*
[**2179-11-26**] 01:00AM BLOOD WBC-40.7* RBC-4.57 Hgb-13.5 Hct-44.0
MCV-96 MCH-29.6 MCHC-30.8* RDW-17.9* Plt Ct-927*
[**2179-11-19**] 02:30PM BLOOD WBC-19.5*# RBC-4.84 Hgb-14.8 Hct-46.1
MCV-95 MCH-30.5 MCHC-32.1 RDW-17.4* Plt Ct-367
[**2179-11-25**] 06:27PM BLOOD Neuts-68 Bands-12* Lymphs-2* Monos-0
Eos-0 Baso-0 Atyps-1* Metas-9* Myelos-5* NRBC-16* Other-3*
[**2179-11-19**] 02:30PM BLOOD Neuts-60 Bands-2 Lymphs-29 Monos-1* Eos-0
Baso-0 Atyps-4* Metas-2* Myelos-0 NRBC-2* Other-2*
[**2179-11-25**] 06:27PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL
[**2179-11-19**] 02:30PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL
[**2179-11-26**] 04:54AM BLOOD Plt Smr-VERY HIGH Plt Ct-973*
[**2179-11-26**] 04:54AM BLOOD PT-23.4* PTT-60.9* INR(PT)-3.5
[**2179-11-19**] 02:30PM BLOOD PT-17.7* PTT-35.1* INR(PT)-2.0
[**2179-11-19**] 02:30PM BLOOD Plt Smr-NORMAL Plt Ct-367
[**2179-11-26**] 04:54AM BLOOD Fibrino-445*#
Electrolytes:
[**2179-11-26**] 04:54AM BLOOD Glucose-162* UreaN-78* Creat-2.6* Na-143
K-5.8* Cl-111* HCO3-10* AnGap-28*
[**2179-11-19**] 02:30PM BLOOD Glucose-184* UreaN-32* Creat-1.3* Na-143
K-4.2 Cl-105 HCO3-24 AnGap-18
LFTs:
[**2179-11-26**] 04:54AM BLOOD ALT-[**2149**]* AST-3278* CK(CPK)-82
AlkPhos-145* Amylase-56 TotBili-1.6*
[**2179-11-19**] 02:30PM BLOOD ALT-35 AST-52* CK(CPK)-55 AlkPhos-111
Amylase-71 TotBili-1.1
Cardiac enzymes:
[**2179-11-26**] 04:54AM BLOOD CK-MB-4 cTropnT-0.21*
[**2179-11-25**] 01:40PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2179-11-26**] 04:54AM BLOOD Calcium-8.5 Phos-8.8* Mg-2.2
[**2179-11-19**] 02:30PM BLOOD Calcium-9.6 Phos-3.8 Mg-1.8 Cholest-160
[**2179-11-23**] 04:34AM BLOOD Triglyc-100
[**2179-11-19**] 02:30PM BLOOD Triglyc-132 HDL-87 CHOL/HD-1.8 LDLcalc-47
LDLmeas-65
Blood gas:
[**2179-11-26**] 05:20AM BLOOD Type-MIX
[**2179-11-26**] 05:17AM BLOOD Type-ART pO2-75* pCO2-32* pH-7.16*
calHCO3-12* Base XS--16
[**2179-11-19**] 02:37PM BLOOD Type-[**Last Name (un) **] pO2-97 pCO2-70* pH-7.22*
calHCO3-30 Base XS-0
[**2179-11-26**] 01:40AM BLOOD Lactate-5.6*
[**2179-11-19**] 02:37PM BLOOD Glucose-183* Lactate-2.4* Na-143 K-4.0
Cl-105
[**2179-11-26**] 05:20AM BLOOD O2 Sat-48
[**2179-11-19**] 02:37PM BLOOD Hgb-15.6 calcHCT-47
[**2179-11-26**] 01:40AM BLOOD freeCa-1.13
[**2179-11-19**] 02:37PM BLOOD freeCa-1.22
Brief Hospital Course:
Assessment and Plan: [**Age over 90 **] yo female with PMH HTN, Afib s/p pacer
adm wtih episode of unresponsiveness/syncope thought to be
secondary to cardiac arrest.
.
1. ?Posturing/syncopal episode: Unclear if secondary to VFA,
rapid afib, or brainstem stroke. Per neuro, findings on neuro
exam were worrisome for brainstem injury secondary to
hypotensive stroke. Other possibility is diffuse anoxic brain
injury. EEG performed indicated encephalopathy. Repeat head CT
showed no evidence of bleed or mass effect.
.
Regarding cardiogenic causes of syncope, arrythmia is very
likely. Interrogation of pacer shows several episodes of Vtach,
which could be etiology of syncope; however, the timing of Vtach
does not correlate with time of syncope. Rapid afib is also a
possibility since pt seems to have had episodes of rapid afib
around time of syncope. Pt has valvular abnormalities on echo.
Ischemia unlikely given negative cardiac enzymes. Pt was taken
off sedation to follow neuro exam. On HD2, pt became aggitated
and was given propofol. Pt also began to respond to voice and
some commands. She was slowly weaned off of all sedating
medications and began to respond to basic commands.
.
She was extubated when her RSVI was less than 100. However her
respiratory status and mental status worsened over the course of
the day and following night. The following day she was
re-intubated for respiratory support. She was fighting the vent
and sedated with Propofol. She required Neo, Levo, and Dopa to
maintain her blood pressure. Overnight her creatinine continued
to increased, her Lactate trended upward, her LFTs were
elevated. The following morning her family decided to withdraw
care as she was doing worse and they felt that she would not
have wanted the level of care being performed. She expired
shortly after.
.
2. Rhythm: Question of Vfib arrest per EMT report. Vtach and
rapid afib seen on pacer. Vtach may be potential cause of
cardiac arrest. Pt was continued on IV amio. Digoxin was
discontinued. On HD2, pt was noted to be tachycardic in the
setting of hypotension immediately after being given propofol
for agitation. Pt was restarted on beta-blocker: metoprolol 5mg
IV q6h for rate control. She was continued on Amiodarone and
beta blocker (briefly on an Esmolol drip) however her rate was
difficult to control with continued afib with RVR.
.
3. ?CHF: Pt had preserved EF by initial echo. Pt is most likely
volume overloaded from chest x-ray. She was given small dose of
lasix for diuresis. On hospital day 4 she was febrile with
decreased urine output she was given IV fluids.
.
4. Hypotension: On HD2, pt developed hypotension and tachycardia
immediately after being given propofol for aggitation. Pressures
returned to [**Location 213**] after fluid bolus. Unlikely to be septic or
in cardiogenic shock. She later had recurrence of hypotension
requiring three pressors for support.
.
5. CAD: No hx of CAD. Cardiac enyzmes have been flat. Ischemia
is unlikely to be cause of cardiac arrest.
.
6. Tracheal perforation: Intubation on the field for airway
protection was attempted but failed. Pt was intubated in the ED,
but suffered traumatic intubation. Trachea was perforated with
resulting subcutaneous emphysema and pneumonmediastinum. CT
surgery was consulted who recommended conservative management.
At the time of extubation interventional pulmonary was around in
case of needed re-intubation. At the time of re-intubation
interventional pulmonary performed the proceedure with a
bronchoscope.
7. ?cervical spine injury: Cervical spine CT showed subluxation
C3 vertebral body on Cr and subluxation of C5 on C6. Pt was put
on C-spine collar until she is able to be cleared. On HD2, pt's
family stated that they felt the subluxations were old. They
stated that they wanted to switch to soft collar and that they
would assume responsibility for any injuries. She eventually had
a neck CT and denied any further pain so that she was cleared
from the soft collar.
.
8. ?Aspiration pneumonia: Given traumatic intubation, pt most
likely aspirated gastric contents. Respiratory therapist
suctioned gastric contents from airway. Pt was started on
empiric Flagyl and Levo for potential development of aspiration
pneumonitis.
.
9. Leukocytosis: Pt had elevated WBC of unclear etiology. Has
only had few low grade temps. We are following blood and urine
cultures which are no growth to date.
.
10. GI: Pt has abdominal distension since admission. Several
attempts were made to pass OGT without success. NGT was also
unable to be passed by CT surgery. Finally interventional
pulmonary passed an NGT under bronchoscopic guidance.
Medications on Admission:
Digoxin 0.125mg (4 days a week for rate control)
Dyazide 37.5/25 qd for HTN
Coumadin 3mg qd
Synthroid 125 mcg qd
Lipitor 10mg qd
Argyrophil 0.5mg tid for thrombocytopenia
Verapamil SR 180mg qd
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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56,243
| 195,815
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50698
|
Discharge summary
|
report
|
Admission Date: [**2159-12-20**] Discharge Date: [**2159-12-24**]
Date of Birth: [**2097-7-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
reaccumulation of pericardial fluid found on follow-up echo
Major Surgical or Invasive Procedure:
balloon pericardiotomy [**2159-12-21**]
History of Present Illness:
This is a 62 year old female with a PMH notable for CML in
remission for 15 years on hydroxyurea with recent relapse, s/p
recent admission from [**Date range (1) 105483**]/11 with complicated medical
course necessitating ICU care following fall, pericardial
effusion, acute stress induced cardiomyopathy and volume
overload, who underwent pericardiocentesis on [**2159-10-22**] and
represented to [**Hospital1 18**] on [**2159-12-20**] with recurrent pericardial
effusion.
.
Patient with complicated recent hospital course. On [**2159-10-22**],
patient presented s/p fall and was admitted to the ICU due to
hypoxic respiratory failure requiring intubation in the setting
of acute stress induced cardiomyopathy with an EF of 25-30% and
bilateral pleural effusions. Patient underwent
pericardiocentesis with drainage of 700 cc of straw colored
fluid. Cytology was negative. A repeat TTE at the time of
discharge did not demonstrate reaccumulation of her effusion,
which was thought to be secondary to her dasatinib. Patient was
diuresed and underwent bilateral thoracentesis (700cc and
1500cc). Hospital course complicated by strep pneumo septicemia
and patient was treated with broad spectrum antibiotics. Of
note, following her fall, OSH CT was suggestive of SAH/SDH, and
brain MRI demonstrated findings consistent with PRES vs.
evolving infarcts, for which she has been followed by neurology
as an outpatient.
.
Since her discharge, patient has been doing fairly well, and
denies any signficant chest pain, dyspnea, fevers, chills,
palpitations, PND, or orthopnea. She has been fatigued since
her prior hospitalization and can only travel around the house
without developing significant dyspnea. Patient was started on
gleevec 6 days prior, and was evaluated by her cardiologist on
[**2158-12-19**] as an outpatient follow up visit and surveillance TTE
demonstrated a moderate pericardial effusion with early signs of
tamponade physiology. Patient was admitted to [**Hospital1 1516**] for
consideration of a pericardial window. Today, patient was taken
to the cath lab and underwent ballon pericardiotomy with removal
of 450 cc of serosanguinous fluid.
.
On the floor, patient reports that she is without acute
complaints. Of note, patient is also s/p bilateral
thoracentesis during her prior hospitalization.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Chronic myelogenous leukemia
Social History:
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None
2 daughters very involved.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Alive at 85
- Father: Father MI 60s
Physical Exam:
ON ADMISSION:
VS: 96.4, 101/48, 72, 18, 99%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Elderly
appearing lady.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP at 4cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Drain
located over the left chest, draining serosanguinous fluid. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
Groin: Right sided cath acccess site c/d/i with no bruits,
hematomas.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
AT DISCHARGE:
AF, VSS. JVP not present. Drain over left chest has been
removed. lungs clear. no peripheral edema. exam otherwise
unchanged.
Pertinent Results:
CBC:
[**2159-12-20**] 07:16PM BLOOD WBC-5.4# RBC-3.59*# Hgb-9.7*# Hct-30.7*#
MCV-86 MCH-27.1 MCHC-31.7 RDW-15.9* Plt Ct-218#
[**2159-12-21**] 07:03PM BLOOD WBC-7.3# RBC-3.52* Hgb-9.7* Hct-29.9*
MCV-85 MCH-27.5 MCHC-32.4 RDW-15.6* Plt Ct-199
[**2159-12-22**] 03:20AM BLOOD WBC-15.1*# RBC-3.52* Hgb-9.7* Hct-29.5*
MCV-84 MCH-27.5 MCHC-32.8 RDW-15.8* Plt Ct-230
[**2159-12-23**] 04:37AM BLOOD WBC-4.1# RBC-2.95* Hgb-8.2* Hct-25.2*
MCV-85 MCH-27.7 MCHC-32.5 RDW-15.8* Plt Ct-138*
[**2159-12-20**] 07:16PM BLOOD Neuts-64 Bands-0 Lymphs-18 Monos-5
Eos-11* Baso-0 Atyps-0 Metas-2* Myelos-0
[**2159-12-22**] 03:20AM BLOOD Neuts-78.6* Lymphs-13.2* Monos-7.5
Eos-0.4 Baso-0.3
COAGS:
[**2159-12-20**] 07:16PM BLOOD PT-10.8 PTT-30.6 INR(PT)-1.0
ELECTROLYTES:
[**2159-12-20**] 07:16PM BLOOD Glucose-91 UreaN-22* Creat-0.8 Na-141
K-4.5 Cl-107 HCO3-27 AnGap-12
[**2159-12-23**] 04:37AM BLOOD Glucose-87 UreaN-21* Creat-1.0 Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2159-12-22**] 03:20AM BLOOD CK-MB-2
[**2159-12-20**] 07:16PM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
[**2159-12-22**] 03:20AM BLOOD Calcium-8.8 Phos-5.6* Mg-1.9
OTHER:
[**2159-12-21**] 07:55AM BLOOD TSH-3.7
URINE:
[**2159-12-22**] 11:58AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2159-12-22**] 11:58AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2159-12-22**] 11:58AM URINE RBC-19* WBC-12* Bacteri-NONE Yeast-NONE
Epi-<1
[**2159-12-22**] 11:58AM URINE CastHy-25*
MICROBIOLOGY:
URINE CULTURE (Final [**2159-12-23**]): NO GROWTH.
STUDIES/IMAGING:
Pericardial Fluid Cytology ([**2159-10-22**]):
-NEGATIVE FOR MALIGNANT CELLS.
Pericardial Fluid Analysis ([**2159-10-22**])
WBC 311 hct 8.5 polys51 bands2 lymphs43 monos3 eos1 total
protein4.1 glu92 LDH305 amylase29 albumin2.9
.
[**2159-10-22**] 3:40 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2159-10-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2159-10-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2159-10-28**]): NO GROWTH.
ACID FAST SMEAR (Final [**2159-10-23**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2159-11-5**]): NO FUNGUS ISOLATED.
- ECG: [**2159-12-20**]: 75 bpm, borderline left axis deviation, RBBB, no
evidence of active ischemia
.
- ECHO: [**2159-12-19**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is a moderate sized pericardial effusion. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows (respiratory variation 25-30%),
consistent with impaired ventricular filling.
IMPRESSION: Moderate pericardial effusion with early signs of
tamponade physiology. Normal biventricular function. No
signifcant valvular disease. Borderline pulmonary hypertension.
Compared with the findings of the prior study (images reviewed)
of [**2159-11-9**], the pericardial effusion is now moderate with signs
of early tamponade physiology. Dr. [**Last Name (STitle) **] aware and reviewed
current echo findings.
.
- ECHO: [**2159-12-21**]: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is a small to moderate sized pericardial effusion. The
effusion is circumferential, with predominance of fluid
posterior to the heart. With the patient sitting at 30 degrees,
there is an approximately 0.5 cm of fluid anterior to the RV.
IMPRESSION: Small to moderate pericardial effusion. No definite
signs of tamponade physiology. Findings reviewed in person with
Dr. [**Last Name (STitle) **] at 1440 hours on the day of the study.
.
Cardiac Cath report [**2159-12-21**]
COMMENTS:
1. Pericardiocentesis and balloon pericardiotomy was performed
under local anesthesia and moderate sedation via sub-xiphoid
approach. Right femoral artery and vein were also accessed with
placement of a 4 Fr and a 5 Fr sheath respectively. This was
performed to maintain arterio-venous access to deal with any
complications during the procedure, and also for hemodynamic
monitoring during the procedure. The effusion was mostly
loculated posteriorly. Using an alligator clip connected to the
pericardial needle, as well as a pressure tube to directly
transmit pressure from the needle tip, thus providing multiple
layers of safety for the procedure, the needle was advanced to
the pericardial sac, and a guidewire was placed. A dilator was
advanced over the wire and a .038 J-wire was then placed in the
pericardial sac. A drainage catheter was then advanced
posteriorly in the area of loculation and about 450 ml
serosanguinous fluid was drained and sent to lab for analysis.
Then an 8 Fr [**Last Name (un) **] tip sheath was advanced to the sac over an
Amplatz superstiff wire for optimum support. A Tyshak II 5 cm x
22 mm balloon catheter was then advanced astride the parietal
pericardium, the sheath withdrawn, position of the balloon
verified by contrast injection through the sheath, and the
balloon inflated 3 times to perform balloon pericardiotomy. The
balloon was then withdrawn and a pericardial drainage catheter
was placed posteriorly in the pericardial sac and sutured to
skin. The entire procedure was performed under repeated echo
guidance, position of catheters in the pericardial sac being
verified by agitated saline injection through the catheters.
Patient had a brief vasovagal episode during the procedure that
was treated with atropine and IV fluids. Final echo images
showed near complete resolution of the effusion. The arterial
and venous sheaths from the right groin were removed in the cath
lab and manual pressure held for hemostasis. Patient tolerated
the procedure well and left the cath lab in a stable condition
without any complaints.
FINAL DIAGNOSIS:
1. Large recurrent loculated pericardial effusion with late
diastolic
right atrial collapse.
2. Pericardial effusion successfully treated with
pericardiocentesis and
balloon pericardiotomy
3. Pericardial drain to be removed when drainage/24 hours <75
ml.
.
ECHO [**2159-12-22**]
This study was compared to the prior study of [**2159-12-22**].
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: No AS. Significant AR, but cannot be quantified.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. Effusion echo dense, c/w blood, inflammation or
other cellular elements.
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is no aortic
valve stenosis. Significant aortic regurgitation is present, but
cannot be quantified. The mitral valve leaflets are mildly
thickened. There is a small pericardial effusion. The effusion
appears circumferential. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements.
Compared with the prior study (images reviewed) of [**2159-12-22**],
findings are similar.
.
CXR [**2159-12-22**]
AP radiograph of the chest was compared to [**2159-12-20**].
There is new right lower lobe consolidation highly concerning
for infectious process. Pericardial drain is in place. There is
interval decrease in the cardiac silhouette consistent with
known pericardial drainage. Right upper lobe opacity is also
noted, and concerning for infectious process as well. Followup
of the patient after antibiotic treatment is highly recommended.
Brief Hospital Course:
62 year old female with a PMH notable for CML in remission for
15 years on hydroxyurea with recent relapse, s/p recent
admission from [**Date range (1) 105483**]/11 with complicated medical course
necessitating ICU care following fall, pericardial effusion,
acute stress induced cardiomyopathy and volume overload, who
underwent pericardiocentesis with drainage of 700 cc straw
colored effusion on [**2159-10-22**] and represented to [**Hospital1 18**] on [**2159-12-20**]
with recurrent pericardial effusion. Now s/p pericardiotomy and
hemodynamically stable.
.
# Pericardial Effusion: Differential for pericardial effusion is
broad and includes idiopathic (most commonly), iatrogenic,
trauma, malignancy, post MI, uremia, thyroid disease, viral,
medication related or collagen vascular disease. Patient's
prior pericardial effusion was thought to be secondary to
dasatinib, which has subsequently been discontinued. More
recently, patient was started on gleevec, which has been
associated with pericardial effusion, ascites, pleural effusion,
CHF, LV dysfunction. Gleevac was held. Pt will follow up with
cardiology for repeat echo in roughly 2 weeks and also follow up
with her oncologist. Pt underwent cardiac cath with balloon
pericardiotomy [**2159-12-21**]. Post cath check that evening was
unremarkable. Gram stain of pericardial fluid was unrevealing
and cultures showed no growth. Cell count also unrevealing. Pt
had roughly 700 ccs of pericardial fluid removed. S/P
pericardiotomy pt remained hemodynamically stable without
elevated pulsus. Drain was pulled on [**2159-12-22**] without issues after
repeat TTE showed no further reaccumulation of pericardial
fluid. Pt was called out to the floor. Localized pain at drain
site significantly improved. TSH was in normal range. hematocrit
and CBC stable. Pt was [**Doctor First Name **] negative but would suggest additional
rheumatologic workup going forward.
.
# leukocytosis - on [**2159-12-22**] pt had WBC of 15. This dropped to 4.1
on [**2159-12-23**]. It was felt to be secondary to cardiac manipulation
and stress response. However, there did appear to be possible
infiltrates in the right upper and lower lobes on cxr (although
very subtle). Pt did state that in the past week prior to
admission she had several fevers at home with the highest up to
101. She did not seek therapy or medical attention for those at
that time. Accordingly, she was treated for community acquired
pneumonia and sent home to complete a 5 day course of
levofloxacin. UA showed pyuria but no bacteria, and culture was
without growth. Blood cultures also showed no growth.
.
# CML: Recently relapsed. pt was being treated with Gleevac at
the time of admission, which was held as it was felt to be a
likely etiology for pericardial effusion re-accumulation. Pt's
outpatient oncologist was contact[**Name (NI) **] who agreed to stop gleevac
for now (Dr. [**Last Name (STitle) **] at [**Hospital3 3765**]).
.
#pain - from pericardial drain site - managed with
tylenol/oxycodone prn.
.
#pt was maintained as FULL CODE throughout the course of this
hospitalization.
.
EMERGENCY CONTACT: Daughter/HCP [**Name (NI) **] [**Telephone/Fax (1) 105480**]
.
TRANSITIONAL ISSUES:
would suggest rheumatologic workup for investigation of etiology
of recurrent pericardial effusions.
Pt found to have evidence of right upper and right lower lobe
consolidation, given 5d course of levofloxacin for CAP. Please
follow up with PCP regarding symptoms to ensure resolution.
Medications on Admission:
HOME MEDICATIONS: Per [**Hospital1 1516**] note:
-Lactobacillus acidophilus 4 tab po q12h
-Lansoprazole 30 mg po qday
-Levothyroxine 50 mcg po qday
-Potassium chloride 20 mEq po qday
-Multivitamin 1 tab po qday
-Lorazepam 2 mg po q6h prn anxiety
-Gleevac 400 mg po qday
-acetaminophen 650 mg po q6h prn pain
-Carboxymethylcellulose sodium 2 drops q3h left eye discomfort
-Zolpidem tartrate 5 mg po qhs prn insomnia
-Eucerin cream prn q8h
-Stool softeners as needed.
.
MEDICATIONS AT THE TIME OF TRANSFER:
- Lorazepam 2 mg PO/NG Q6H:PRN anxiety
- Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
- Multivitamins 1 TAB PO/NG DAILY
- Docusate Sodium 100 mg PO BID:PRN constipation
- Heparin 5000 UNIT SC TID
- Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
- Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
- Levothyroxine Sodium 50 mcg PO/NG DAILY
- Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Medications:
1. lactobacillus acidophilus Capsule [**Hospital1 **]: One (1) Capsule PO
once a day: pre-admission med.
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
4. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. lorazepam 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6
hours) as needed for anxiety.
6. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-17**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
8. zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. polyethylene glycol 3350 17 gram/dose Powder [**Month/Day (2) **]: One (1)
PO DAILY (Daily) as needed for constipation.
12. oxycodone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 4 days.
Disp:*15 Tablet(s)* Refills:*0*
13. levofloxacin 750 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please check Chem-7 and CBC on Thursday [**2159-12-27**] with results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 62**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (5) 105484**].89
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
PRIMARY
pericardial effusion
SECONDARY
- History of ? Stress induced cardiomyopathy in the setting of
septicemia
- Prior history of pericardial effusion thought to be secondary
to dasatinib
- Chronic Myelogenous Leukemia
- History of c. diff infection
- Legally blind due to retinal detachment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were found on a follow-up echocardiogram to
have re-accumulation of the fluid around your heart which was
starting to effect the heart's ability to pump blood
effectively. You underwent a procedure called ballon
pericardiotomy - fluid was removed from around the heart and a
small window was created in the casing around the heart so that
fluid would not accumulate in that space again. You improved
after the procedure and we felt comfortable sending you home. We
had some concern that your gleevac might be contributing to the
re-accumulation of fluid, so this was stopped. You will follow
up with your oncologist to discuss this further. We also found
you had evidence of a possible pneumonia on chest xray so we
started antibiotics. You will go home with 2 more days of
levofloxacin.
We made the following CHANGES to your medications:
STARTED levofloxacin for pneumonia
STARTED oxycodone for pain
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2515**]
Location: [**Location (un) **] INTERNAL MEDICINE
Address: [**Location (un) 39681**], [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 22235**]
Appt: [**12-27**] at 2pm
.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2160-1-15**] at 2:00 PM
With: VISUAL FIELD SCREENING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2160-1-15**] at 2:30 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2160-1-30**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 18267**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) 37561**],[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD
Location: [**Doctor Last Name **] [**Doctor Last Name **] BLDG, [**Apartment Address(1) **]
Address: 131 ORNAC, [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 61873**]
***Dr [**Last Name (STitle) **] is now affiliated with [**Hospital3 2576**] and you will
need to register with their main registry service before you can
book another appt with him. Please call [**Hospital3 2576**] at
[**Telephone/Fax (1) 66939**] to generate a Medical Record Number with them and
then call Dr [**Last Name (STitle) **] office asap to book a follow up appt. This
was per Dr [**Last Name (STitle) **] office. Any ?s please call the office
directly.
|
[
"696.1",
"361.9",
"423.9",
"205.12",
"486",
"369.4",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
19574, 19621
|
13257, 16449
|
365, 407
|
19960, 19960
|
4778, 6951
|
21236, 23175
|
3448, 3611
|
17707, 19551
|
19642, 19939
|
16783, 16783
|
11425, 13234
|
20111, 21000
|
3626, 3626
|
16801, 17684
|
6984, 11408
|
4632, 4759
|
16470, 16757
|
21029, 21213
|
266, 327
|
435, 3273
|
3640, 4618
|
19975, 20087
|
3295, 3326
|
3342, 3432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,325
| 181,777
|
13057
|
Discharge summary
|
report
|
Admission Date: [**2189-5-3**] Discharge Date: [**2189-5-6**]
Date of Birth: [**2122-8-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent placement
History of Present Illness:
66f with HTN and Crohn's disease, no known DM, prior CAD or
prior sx thereof presented to [**Hospital3 4107**] on [**5-2**] at 10pm
with one hour's worth of sudden onset chest pain that began at
rest and was felt to have an anterior STEMI. She'd never had sx
like that before, with no previous rest or exertional chest
discomfort; she'd otherwise been feeling well the last few days.
At [**Hospital1 **], she was treated with asa, clopidogrel load,
atorvastatin, metoprolol, heparin, and integrilin and was
transferred to [**Hospital1 18**] for cath. In the cath lab, she was found
to have a proximal LAD lesion present at the bifurcation of a
high [**Hospital1 **] (D1); the LAD was sucessfully stented with a DES, but
a stent was not able to be placed in the [**Last Name (LF) **], [**First Name3 (LF) **] POBA was
performed. A good result was not obtainable from POBA in the
D1, with persistentence of decreased flow and dissection of the
vessel. PCWP was 18-20, and her CI was 1.9. She continued to
have chest pain and similar ECG changes following the procedure,
felt to be due to unstentable and partially dissected D1 branch.
Bleeding occured at the sheath, which was pulled, as well as a
hematoma, so heparin was stopped, eptifibatide continued.
At the time of interview in the CCU, she said her pain persisted
but had improved with morphine. She denied recent illness, f/c,
dyspnea, Crohn's symptoms, or other sx.
.
Denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
-HTN
-Crohns: S/p partial colectomy with colostomy (reversed after ?
infection)
-Chronic LBP
-Osteoporosis
Social History:
Significant for the absence of current tobacco use; she smoked a
bit as a kid, never consistently, "sneaking cigarettes behind
her mother's back." There is no history of alcohol abuse. She
lives with her husband.
Family History:
There is no family history of premature coronary artery disease
or sudden death. No major fhx.
Physical Exam:
VS: t 95.8, bp 116/78, hr 86, rr 14, spo2 97% 3l NC
Gen: pleasant, somewhat sleepy female, looks age, non-tox, doesn
not appear to be in any obvious distress
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no JVD, LAD, or thyromegaly.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2 and positive s4. No m/r/g. No thrills, lifts.
No S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Moves air well, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP dopplerable PT dop
Left: Carotid 2+ Femoral 2+ DP dopplerable PT dop
Pertinent Results:
EKG demonstrated NSR, nl axis, nl intervals (mod prolonged PR),
near LAA, 1-2mm ST elevation in v1-v3 (also in I and aVl on
[**Hospital1 39933**] ECG)
.
CARDIAC CATH performed on [**2189-5-3**] demonstrated: Proximal LAD
occlusion at bifurcation of high [**Year (4 digits) **], s/p DES to LAD and POBA
to D1, with persistent D1 obstruction and dissection
HEMODYNAMICS: PCWP 18-20, CI 1.9
.
LABORATORY DATA (see attached): WBC 17.1, hct 33.1, plt 618, mcv
101; BUN 6, Cr 0.6.
[**2189-5-3**] 02:00AM CK-MB-26* MB INDX-14.7*
[**2189-5-3**] 02:00AM CK(CPK)-177*
[**2189-5-3**] 02:57AM CK-MB-28* MB INDX-15.1*
[**2189-5-3**] 02:57AM CK(CPK)-185*
Brief Hospital Course:
Pt is a 66f with HTN and hypercholesterolemia who presented to
[**Hospital3 4107**] on [**2189-5-2**] at 10pm with her first episode of
chest pain and was found to have anterior STEMI, now s/p stent
to LAD and POBA to D1, with persistent poor flow and dissection
in D1. She was chest pain free on discharge.
.
1) CAD: S/p STEMI, stenting to LAD and POBA to D1, with ongoing
symptoms and ECG changes. Ongoing symptoms may have been due to
difficult-to-intervene-on D1 branch. She continued to have
chest pain for 2 days after her cath. These were not accompanied
by EKG changes. The pain was relieved with morphine/ percocet/
ativan. Nitro drip was weaned to off. Her cardiac enzymes peaked
and trended down 2 days after cath. She was chest pain free for
the remainder of her stay. She was continued on aspirin,
clopidogrel, maximum dose atorvastatin, metoprolol. On discharge
her lopressor was transition to toproll xl 150 qday and she was
started on lisinopril 5mg qday.
.
2) Pump: PCWP elevated and CI somewhat depressed on right-heart
cath. This was probably diastolic dysfunction in the setting of
ischemia. An echo showed a EF of 20-25% with moderate regional
left ventricular systolic dysfunction c/w CAD. She also had
moderate pulmonary artery systolic hypertension and mild mitral
regurgitation. She was started on coumadin with a lovenox
bridge for apical akinesis.
.
3) Hematoma: Moderate sized after cath. This resolved during her
stay.
.
4) HTN: She was maintained on lopressor, which was transitioned
to toprol xl. She was started on lisinopril 5 qday. She will
follow up with [**Hospital1 18**] cardiology for further tailoring of her
medications.
.
5) Anemia: The patient had a macrocytic anemia consistent with
B12 deficiency. She received supplemental B12 and will continue
as an outpatient. She may need further workup for pernicous
anemia as an outpatient.
6) Leukocytosis: No focal symptoms of infection, no fever.
Likely acute phase response to MI, stress. Cultures remained
negative throughout her stay.
.
7) Osteoporosis: continue calcitonin
.
8) Crohn's: inactive. Continue mesalamine, flexeril prn,
percocet prn
.
9) FEN: Cardiac diet.
.
#) Code: Full
Medications on Admission:
-Enalapril 20mg [**Hospital1 **]
-Miacalcin nasal spray
-Asacol 2tabs tid
-Loperamide
-Ranitidine
-Percocet prn (low back pain)
-Fexofenadine
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day). Tablet,
Delayed Release (E.C.)(s)
7. 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*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 3 days.
Disp:*6 syringes* Refills:*0*
12. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
13. Outpatient Lab Work
INR check on [**2189-5-8**] on coumadin
14. Toprol XL 100 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
1. CAD/STEMI, s/p stent placement
2. HTN
3. Chrominc Anemia
.
Secondary diagnosis:
1. Crohn's disease
2. Osteoporosis
Discharge Condition:
Hemodynamically stable, tolerating POs, ambulating, afebrile.
Discharge Instructions:
You have been treated for a heart attack. A stent has been
placed in one of your heart supplying vessels. You have been
started on several new medications:
Toprol xl 150mg once a day
lisinopril 5mg once a day
lovenox injections
coumadin 5mg
atorvastatin 80mg
Aspirin 81mg
.
Please call your PCP for any Chest pain, shortness of breath,
dizziness, palpitations, fevers or any other concerning
symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 171**] (phone: [**Telephone/Fax (1) 1989**]) at [**Hospital1 18**]
on [**2189-6-22**] at 10am.
.
Please also follow up with your PCP as needed. Please also go to
your PCP's office two days after discharge in order to have your
INR checked. Your INR should be in the 2-3 range on coumadin
(the blood thinner that was started during this admission).
Completed by:[**2189-5-6**]
|
[
"724.2",
"998.12",
"V45.3",
"410.71",
"555.9",
"733.00",
"414.01",
"272.4",
"401.9",
"V44.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.45",
"37.23",
"99.20",
"36.07",
"00.66",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
8347, 8404
|
4404, 6590
|
302, 361
|
8585, 8649
|
3730, 4381
|
9100, 9526
|
2686, 2783
|
6783, 8324
|
8425, 8425
|
6616, 6760
|
8673, 9077
|
2798, 3711
|
252, 264
|
389, 2307
|
8527, 8564
|
8444, 8506
|
2329, 2438
|
2454, 2670
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,194
| 193,817
|
47862
|
Discharge summary
|
report
|
Admission Date: [**2140-7-14**] Discharge Date: [**2140-7-20**]
Date of Birth: [**2082-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Melena x 3 weeks and massive amounts of maroon stool
Major Surgical or Invasive Procedure:
EGD on [**7-15**] and [**7-18**]
C-scope on [**7-18**]
Blood transfusions
LUE dopplers
Echocardiogram
History of Present Illness:
The patient is a 57y/o M with a PMH of DM, CAD s/p CABG,and ESRD
on HD presenting with a 3 week history of melena since starting
hemodialysis. Pt thought dark stools related to HD medications.
Beginning last night he had BRBPR with 15-20 bowel movements,
with associated light headedness and SOB. Went for dialysis this
am, noted to have hypotension, per pt's report down to 97/57,
did not mention bloodly stools. Received chicken soup with
improvement bp. Continued to have bloody stools, worse
lightheadedness, presented to ER.
ROS negative for NSAID use, chest/abdominal pain,recent travel,
sick contacts, [**Name (NI) 621**] use, n/v/fever/chills/reflux, iron
supplementation, excessive beet intake. Of note pt had AVF
placed 2 days ago with heparin given during procedure.
On arrival to the ER, Vitals: T 97.9, HR 106, BP 137/71, RR 18,
O2 98% RA. NG lavage of 120cc was negative for blood. He was
given 40mg IV pantoprazole. 2 PIV placed.
.
On arrival to the MICU pt noted to be hemodynamically stable
with bp 109/57, HR 97. PT complained of mid sternal chest pain
and SOB when lying down, asymptomatic when sitting up. No stool
since arrival to MICU.
Past Medical History:
minor stroke with loss temp sensation R hand
HTN
Diabetes mellitus
Coronary artery disease status post CABG
End-stage renal disease on HD (2nd to DM/HTN)
Gout
Colonoscopy 4yrs ago normal per pt report.
Social History:
works as plumber, no ETOH/drug/tobacco use
Family History:
signif for HTN and DM, father with [**Name2 (NI) 499**] cancer
Physical Exam:
Admission physical exam:
VS 98.9 120s/70s 80s 18 96% RA
gen: pleasant, sitting up in bed, NAD
heent: MMM, normal JV pressure
cv: RRR no mrg
chest wall: LIJ tunneled catheter site c/d/i
lungs: clear b/l, no rales/wheezes
abd: soft, nt, nd, nabs, no sacral edema
ext: no c/c/e, normal skin turgor
Pertinent Results:
Admission laboratories:
[**2140-7-14**] WBC-8.2# RBC-1.72*# Hgb-5.3*# Hct-16.2*# MCV-94
MCH-30.8 MCHC-32.7 RDW-19.6* Plt Ct-334
[**2140-7-14**] Neuts-77.6* Lymphs-18.1 Monos-3.4 Eos-0.5 Baso-0.4
[**2140-7-14**] PT-13.8* PTT-23.1 INR(PT)-1.2*
[**2140-7-14**] Glucose-180* UreaN-69* Creat-6.0*# Na-137 K-3.8 Cl-101
HCO3-21* AnGap-19 Calcium-7.7* Phos-7.2* Mg-1.7
Discharge Hct:
[**2140-7-20**] 05:50PM BLOOD Hct-33.4*
Cardiac enzymes:
[**2140-7-14**] 04:15PM BLOOD CK(CPK)-114 CK-MB-9 cTropnT-0.14*
[**2140-7-14**] 11:20PM BLOOD CK(CPK)-118 CK-MB-9 cTropnT-0.15*
[**2140-7-15**] 08:38AM BLOOD CK(CPK)-187* CK-MB-19* MB Indx-10.2*
cTropnT-0.30*
[**2140-7-15**] 10:43PM BLOOD CK(CPK)-257* CK-MB-22* MB Indx-8.6*
cTropnT-1.12*
[**2140-7-16**] 05:05AM BLOOD CK(CPK)-209* CK-MB-14* MB Indx-6.7*
cTropnT-1.23*
[**2140-7-16**] 05:00PM BLOOD CK(CPK)-170 CK-MB-7 cTropnT-1.72*
[**2140-7-17**] 06:50AM BLOOD CK(CPK)-135 CK-MB-5 cTropnT-1.82*
H. pylori antibody test ([**7-18**]): Positive by EIA
EKG: Sinus rhythm. Mild Q-T interval prolongation. Probable left
atrial
abnormality. Cannot exclude prior anteroseptal myocardial
infarction.
Anterolateral ST-T wave changes. Clinical correlation is
suggested.
Compared to the previous tracing of [**2140-7-8**] ST segment
depressions are more
prominent in the high lateral leads and the rate is faster.
Rate PR QRS QT/QTc P QRS T
97 166 100 380/444 52 6 133
Pertinent imaging:
Echo ([**2140-7-18**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild to moderate regional left ventricular
systolic dysfunction with hypokinesis of the distal half of the
septum and anterior walls and apex. The remaining segments
contract normally (LVEF = 40 %). No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (mid-LAD distribution).
Upper extremity doppler ([**7-20**]): official result pending
Brief Hospital Course:
57 y/o male with hx ESRD with melanotic stools since starting
dialysis. On plavix for hx CAD, and given timing of symptoms
with dialysis possible that combination of being on plavix and
heparin flushes from dialysis +uremic platelets revealed a
lesion in his GI tract susceptible to bleeding.
.
GI bleed: Initially, the etiology was unclear but a differential
included ulcer, gastritis, esophageal varices (no alcohol
hx),esophageal Ca(no dysphagia), AVM, diverticulosis,
diverticulitis (llq pain), [**Month/Year (2) 499**] polyp, [**Month/Year (2) 499**] ca. The patient
had a hct of 16.2 on admission and was transfused to a goal Hct
of 30 due to CAD history. An IV PPI and desmopressin were
started in the MICU. An initial EGD showed multiple ulcers in
antrum and pylorus without clear signs of bleeding. Biopsy was
not performed since patient was on plavix. He was transferred to
the floor on [**7-18**] after his HCT remained stable X24hours. He
underwent repeat EGD and c-scope on [**7-18**]. EGD once again showed
antral ulcers and duodenitis (biopsy pending at time of
discharge) and Cscope showed 3 sessile polyps that were resected
(biopsy pending at time of discharge). He was also started on
sucralafate QID X6weeks. He will need [**Hospital1 **] PPI for 6weeks at
least with GI follow-up for possible repeat scope to ensure
resolution since he will need lifelong plavix +/-ASA. By time
of discharge, he was having brown stools. He did recieve his
last unit prbc on day of discharge to keep HCT near 30. He is
started on daily Fe supp along with bowel regimen. Of note, at
time of discharge, it was noted that his H.pylori serology that
was previously negative had turned postiive by EIA, thus he was
contact[**Name (NI) **] and Rx for clarithro and amox X2weeks was added
(already on PPI [**Hospital1 **]) for triple therapy.
.
CAD s/p bypass: In the setting of his severe anemia/GIB, he had
an NSTEMI while
in ICU. The patient was seen by cardiology who agreed this was
not ACS and more likely demand related. He was kept on optimal
medical management with coreg and statin but his plavix was
held. He underwent an Echo with showed anteroseptal WMA (mid LAD
distribution) and it is unclear whether this is new/old
(reversible or fixed). We recommend that he have a outpt stress
test to assess reversibility, esp since his EF is depressed to
40% and he may be candidate for revascularisation. He is
scheduled for a cardiology appointment at [**Hospital1 18**] where he will
get a stress echo. Per cardiology and GI, we will resume plavix
10days after discharge. He stated that he only took his coreg
25mg daily due to low BP, but we reccommended he change
this to 12.5mg [**Hospital1 **]. His cozaar was resumed and statin/tricor
kept at maximal doses.
.
H. pylori infection: The patient was found to have a positive H.
pylori serology in the setting of gastric ulcers. The patient
was placed on a PPI for his GI bleed and started on two weeks of
amoxicillin 1g [**Hospital1 **] and clarithromycin 500 mg [**Hospital1 **].
Left hand thrombophlebitis: He had a transient fever on [**7-16**] and
was started on Vanco. He had an infectious w/u which had
negative cultures and subsequently Vancomycin was stopped. The
superficial thrombophlebitis on his left doral hand resolved
prior to discharge and the patient was afebrile >24 hours.
.
Left arm thrombosis: two days prior to discharge, he complained
of left arm swelling. He had left arm swelling in the past. He
underwent a doppler which showed OLD/Chronic nonocclusive DVTs
of brachial and basillic veins and a NEW occlusive DVT of
axillary vein which is likely reason for the new swelling. Of
note, his SC vein and IJ were fine and his HD catheter is
functional. Given his GIB, He is not a candidate for
anticoagulation. With time, his clot might recanalize like the
others have in the past. Repeat dopplers in 2weeks are
recommended to rule out extension of the clot. He is advised to
seek immediate attention if he develops worsening/severe
swelling of L arm for concern for compartment syndrome, which
would be an indication for catheter directed thrombolysis.
ESRD with complications of anemia and secondary
hyperparathyroidism: The patient tolerated hemodialysis on
Tu/Th/Sat while in house. Of note, he has secondary hyperpara
and severe hyperphos. He is on PhosLo at home and we added
renagel as well. He [**Last Name (un) **] get VitD with HD per renal. He was
asked to follow a low P/low K diet. If the patient has not been
receiving Epogen shots, one might consider starting them.
Recommended followup:
1. Patient should be started back on Plavix on [**7-31**].
2. CAD: Patient will need stress echo. Cardiology appointment
scheduled.
3. Consider changing Coreg to 12.5 [**Hospital1 **] instead of 25 mg daily.
4. GI: Followup on biopsies of the gastric ulcers and sessile
polyps, appt. scheduled
5. Left arm swelling: left upper extremity doppler in 2 weeks
(not scheduled)
6. Consider Epogen shots for ESRD
7. Check phosphate as an outpatient since high while in the
hospital. Currently taking PhosLo and Renagel.
Medications on Admission:
Allopurinol 100 mg Tablet 1 Tablet(s) by mouth prn
Atorvastatin 80 mg Tablet 1 Tablet(s) by mouth daily
B Complex-Vitamin C-Folic Acid [Nephrocaps] 1 mg Capsule daily
Calcium Acetate [PhosLo] 667 mg Capsule 2 Capsule(s) TID
Carvedilol 25 mg Tablet [**Hospital1 **]
Clopidogrel [Plavix] 75 mg Tablet daily
Colchicine 0.6 mg Tablet 1 Tablet(s) by mouth prn
Fenofibrate Nanocrystallized [Tricor] 145 mg Tablet daily
nr Hydrocodone-Acetaminophen 5 mg-500 mg Tablet [**12-4**] Tablet(s) by
mouth every six (6) hours as needed for pain
Rosiglitazone [Avandia] 4 mg Tablet 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. Carvedilol 25 mg Tablet Sig: [**12-4**] Tablet PO twice a day.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Calcium Acetate 667 mg Tablet Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID with
meals.
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours:
take twice a day for atleast 6weeks, then daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: RESUME
after [**7-30**]. .
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day:
take daily to prevent gout, NOT only when gout happens.
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for gout flare.
11. Cozaar 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation: take with iron pills for constipation.
Disp:*qs Tablet(s)* Refills:*0*
15. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
16. Epogen Injection
17. and 18. Clarithro and Amox were added after discharge for
triple therapy for H.pylori
Discharge Disposition:
Home
Discharge Diagnosis:
UGIB [**1-4**] PUD (melena/hematochezia)
Acute blood loss anemia s/p 9U prbc
NSTEMI [**1-4**] demand (anemia, bleed)
ESRD on HD
2ndary HyperPara->severe hyperphos
CAD s/p CABG, current Echo with WMA (mid-LAD), need outpt stress
Discharge Condition:
STABLE
Discharge Instructions:
***Please bring this discharge instruction sheet to your primary
doctor!
.
You were admitted for 3 weeks of black stools and 1 day of
marroon stool secondary to bleeding from you gastrointestinal
tract (likely ulcers).
You recieved total of 9 Units of blood while here.
You will need to be in Protonix (or similar medication) twice a
day for at least 6weeks (then daily forever) until the GI
doctors say it is okay to decrease to daily. You are also on
sucralafate four times a day for 6weeks (then can stop).
You are started on daily Iron pills (which can get you
constipated and turn your stools dark, but not black like tar).
You will finish 2 week course of amoxicilin and clarithromycin
for H.pylori infection in your stomach that may have caused the
ulcers.
Please return to ER if you have recurrance of black/marroon
stools or chest pain, lightheadedness.
Your plavix was held here but can be resumed in 10days per the
cardiologist.
You will need to follow up wtih the GI doctors to [**Name5 (PTitle) 788**] if you
need repeat EGD (scope)
Also, the biopsy results from the ulcers in your stomach and
polyps in your [**Name5 (PTitle) 499**] are pending at time of discharge and this
needs to be followed up by your Primary doctor.
......
Due to your severe anemia and stress, your heart also was stress
out. For this, you will need to have a stress test after
discharge and close follow up with cardiology. Please do not do
too much exertion until you have this completed. Please resume
plavix in 10days after discharge. Stay on your coreg twice a day
(have decreased dose to 12.5 so your blood pressure can handle)
and lipitor 80mg daily and cozaar 100mg daily. Come to ER if
you develop chest discomfort, shortness of breath,
lightheadedness.
.
.
You were also found to have old and new blood clot of your Left
arm near armpit. This is causing your swelling. Ideally we would
you on blood thinner for this but cant because of the bleeding.
Thus we will follow this closely clinically. You need a repeat
ultrasound in 2weeks to see if the new clot has opened up like
the old ones. So far, the clot is not near your dialysis
cathetor, but if your arm swelling gets worse, this may be
happening, so please see your doctor right away. They may need
to go in through the veins to break the clot up.
.
.
You can resume your dialysis per schedule. Your doctor will tell
you when your fistula is mature to use. Ask your dialysis
doctor to start you on anemia shots (like epogen) weekly. Also
you may need other dialysis meds for your high phosphorus. For
now, continue your dialysis vitamins, phosLo with meals. We have
also added renagel to take with meals to bring down your
phosphorous. please follow low potassium and low phosphorus
diet.
.
Do not take any more NSAIDs.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13959**]
Specialty: PCP
Date and time: [**8-1**] at 10:40PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) 895**]
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable:
Appointment #2
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Gastroenterology
Date and time: Wednesday, [**8-10**] at 2:00PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 452**] Bldg [**Location (un) **]
Phone number: [**Telephone/Fax (1) 463**]
Special instructions if applicable:
Appointment #3
MD: Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**]
Specialty: Nephrology
Date and time: Tuesday, [**8-30**] at 10:30AM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 721**]
Special instructions if applicable:
Appointment #4
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: [**8-15**] at 2:00PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
|
[
"588.81",
"428.0",
"211.3",
"285.1",
"531.40",
"403.91",
"532.90",
"410.71",
"451.82",
"414.8",
"585.6",
"453.8",
"250.40",
"535.60",
"V45.81",
"V45.11",
"428.22",
"V12.54",
"278.00",
"211.4",
"274.0",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95",
"45.16",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
12130, 12136
|
4757, 9856
|
368, 472
|
12408, 12417
|
2356, 2776
|
15243, 16580
|
1961, 2025
|
10505, 12107
|
12157, 12387
|
9882, 10482
|
12441, 15220
|
2065, 2337
|
2793, 4734
|
276, 330
|
500, 1660
|
1682, 1885
|
1901, 1945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,644
| 170,124
|
10554
|
Discharge summary
|
report
|
Admission Date: [**2117-11-12**] Discharge Date: [**2117-11-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Stroke
Major Surgical or Invasive Procedure:
Echo
PEG by IR
History of Present Illness:
[**Age over 90 **]M with hypertension, hyperlipidemia, coronary disease, atrial
fibrillation (although in sinus now) admitted [**11-12**] /06 to
Neurology Service for new L MCA CVA.
Per Neurologist patient was doing better overall for the last 3
days and was ready to be discharged to rehab today. He was awake
until yesterday and although not able to talk, he was able to
slurry speak. For the last 24 h he became more somnolent and
with difficulty breathing. He had speech and swallow study
yesterday which he did not pass. For this reason a GY tube was
placed today.
Called today by Neurologist stating his respiratory status had
worsened over the last 24 h. There is no clear history of
pulmonary disease . Upon evaluation he was breathing at 35 bpm ,
SPO2 was 95 % on NRB mask ABGs c pH 7.16 pCO2 59 pO2 62 HCO3 22
. Of note patient had a GJ tube placed yesterday and tube feeds
were started last night.
Patient's code status was discussed with the family . His health
care proxy stated clearly he is DNI/DNR , but expressed her
wishes to try non invasive measures. He was transferred to MICU
for eventual non invasive mechanical ventilation.
.
The pt's wife stated that he has recently been treated with
antibiotics (azithromyci for pneumonia as an outpatient) . He
seemed to have been improving over the past week, but has
complained of generalized fatigue. There is no further history
of antecedent illness prior to the event leading to
presentation.
Past Medical History:
-atrial fibrillation, not on anticoagulation
-hyperlipidemia
-hypertension
-CAD with three-vessel disease
-mitral regurgitation
-metastatic prostate cancer
-iron deficiency anemia
-chronic renal insufficiency, with baseline creatinine 1.7-2.4
-gout
-depression
-osteoarthritis
Social History:
Lives at home with his wife. [**Name (NI) **] history of tobacco, alcohol, or
illicit drug use.
Family History:
Not elicited.
Physical Exam:
Vitals: T: 97.1F P: 60 R: 16 BP: 155/76 SaO2: 92% 3L FSBS 126
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no JVD or carotid bruits appreciated.
Pulmonary: Lungs with rhonchi bilaterally and transmitted upper
airway sounds
Cardiac: RRR, nl. S1S2, III/VI crescendo-decrescendo HSM at left
sternal border radiating into axilla
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, regards examiner. He is able to state his
name and the month of the year. He repeats words only, but
nothing more complex such as two word phrases. He closes eyes
and
shows tongue briefly to command, but does not follow more
complex
commands or appendicular commands. When he speaks, his words
are
dysarthric.
-Cranial Nerves: Olfaction not tested. PERRL 2.5 to 2mm. He
does
not appear to blink to threat on the right. Funduscopic exam
was
technically impossible due to pt cooperation. His extraocular
movements are full, but he prefers to look to the left. Right
facial droop. He prefers to keep head to left, suggesting
dysfunction of left sternocleidomastoid. Tongue protrudes in
midline.
-Motor: Somewhat atrophic musculature throughout. Tone is
flaccid
on the right. He will not cooperate with formal strength
testing,
but he is plegic on the right and briskly withdraws to noxious
stimuli on the left. No adventitious movements noted.
-Sensory: Brisk withdrawal to noxious stimuli on left, no
response on right.
-Coordination: Could not test due to pt cooperation.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 0 0 0 0 0
Plantar response was extensor on the right, flexor on the left.
-Gait: Deferred.
Pertinent Results:
[**2117-11-12**] 02:05AM PT-13.7* PTT-25.2 INR(PT)-1.2*
[**2117-11-12**] 02:05AM PLT COUNT-249
[**2117-11-12**] 02:05AM NEUTS-80.6* LYMPHS-15.0* MONOS-3.0 EOS-1.1
BASOS-0.4
[**2117-11-12**] 02:05AM WBC-8.0 RBC-3.36* HGB-10.5* HCT-31.3* MCV-93#
MCH-31.4 MCHC-33.7 RDW-14.4
[**2117-11-12**] 02:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-11-12**] 02:05AM TRIGLYCER-152* HDL CHOL-48 CHOL/HDL-2.8
LDL(CALC)-55
[**2117-11-12**] 02:05AM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2117-11-12**] 02:05AM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-4.0
MAGNESIUM-2.8* CHOLEST-133
CT: Moderate to large left middle cerebral artery early subacute
infarct. There is no evidence of herniation.
Carotid Echo: Bilateral less than 40% carotid stenosis.
CXR: Mild improvement but persistent left retrocardiac opacity
consistent with improving left lower lobe pneumonia with small
adjacent effusion.
Brief Hospital Course:
[**Age over 90 **] yo M c Afib , new L sided MCA , CAD admitted for respiratory
failure and acidosis. Most likely cause of respiratory failure
is aspiration considering the abrupt onset and that he was
recently started on tube feeds. He also has a new infiltrate on
CxR . Worseing mental status can also be contributing to
acidosis and hypoventilation. Pt met criteria for intubation
although DNR/DNI. After evaluation of the patient with the team
and discussing his case with the family , it was decided to make
the patient CMO . This taking into consideration the patient's
poor prognosis and his wishes prior to having a CVA.
Case was discussed extensively between Dr [**Last Name (STitle) **] , the
patient's family and health care proxy [**Name (NI) **] [**Name (NI) 34742**] and myself.
Patient expired after a few minutes of his ICU admission.
.
Medications on Admission:
ASA 81mg po daily
Atenolol 25mg po daily
Colchicine prn gout flare
Fluoxetine 10mg po daily
Imdur 30mg po daily
Lasix 40mg po daily
Lipitor 10mg po daily
Lupron Depot 30 mg injection q4 months
Nabumetone 500mg po bid pain
Omeprazole 20mg po daily
Discharge Disposition:
Expired
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left MCA stroke
GJ tube placement
Hypertension
Hyperlipidemia
Coronary artery disease
Atrial fibrillation
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications and follow up with your
doctors.
** in [**8-2**] days (ie. [**11-23**]) he will need the T fastners removed
from the gj tube; ie. cut under the cotton balls **
Followup Instructions:
Provider: [**Name10 (NameIs) 34743**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 34744**] Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2118-1-20**] 11:30
NEUROLOGY F/U: Provider: [**Name Initial (NameIs) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2118-2-1**] 4:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2118-3-10**] 3:30
Please see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Fri [**12-24**] 9am.
Completed by:[**2118-7-28**]
|
[
"199.1",
"414.01",
"486",
"787.2",
"434.91",
"507.0",
"784.3",
"427.31",
"342.91",
"585.9",
"403.90",
"280.9",
"276.2",
"272.4",
"274.9",
"311",
"V66.7",
"716.90",
"V10.46",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
6259, 6323
|
5102, 5962
|
272, 289
|
6484, 6493
|
4149, 5079
|
6736, 7391
|
2213, 2229
|
6344, 6463
|
5988, 6236
|
6517, 6713
|
3185, 4130
|
2244, 2833
|
225, 234
|
317, 1780
|
2848, 3168
|
1802, 2081
|
2097, 2196
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,545
| 153,064
|
10467
|
Discharge summary
|
report
|
Admission Date: [**2176-8-1**] Discharge Date: [**2176-8-3**]
Date of Birth: [**2123-8-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
CC:[**CC Contact Info 34566**]
Major Surgical or Invasive Procedure:
[**8-1**]-Bilateral Burr hole evacuation
History of Present Illness:
HPI: Mrs. [**Known lastname 34567**] is known to the neurosurgery service.
Briefly, she is a 52 year-old female who initially presented in
[**5-16**] with headaches without findings on CT scans. She was
eventually diagnosed with migraines after a neurology evaluation
and placed on amitriptyline. She reports that she had continued
to have headaches since that time. She presented to [**Hospital 1725**]
Hospital today per report confused with difficulty walking. A
CT scan of her head there revealed symmetrical bilateral
subdural hematomas with approximately 1 cm thickness in the
frontal and parietal regions, sparing the vertex, with
effacement of sulci and slight compression of the lateral
ventricles and possible evidence of subtentorial herniation. At
this time, she was transferred to [**Hospital1 18**] for further management.
Currently, she reports to have a continued headache bilaterally
located behind her eyes. She has never had nausea or vomiting
and denies any trauma in the past. She denies chest pain,
shortness-of-breath, fevers, or chills.
Past Medical History:
1. Recent hospitalization ([**2176-4-23**], for RUQ pain. Starting in
[**2175-12-9**], patient reports "squeezing" pain in abdomen, which
increased in intensity up to [**11-16**] prior to the admission. No
specific diagnosis was made, and the pain significantly subsided
prior to discharge.)
2. Obesity
3. GERD (diagnosed)
4. Ventral hernia (s/p surgical repair)
.
PAST SURGICAL HISTORY:
1. Open roux-en-Y gastric bypass ([**2168**])
2. Panniculectomy, brachioplasty
3. Repair of ventral hernia
4. Excision of 4 cm right knee lymphocele([**2171**])
5. Cholecystectomy ([**2154**])
Social History:
Patient lives at home with her son. She works as a business
manager at a group home for kids, and manages the financing and
staff. Smoking: Hx 1.5 ppd x 10 yrs (patient quit smoking 30
years ago). EtOH: Patient drinks 2 glasses of wine every other
night. Recreational drugs: Denies.
Family History:
[**Name (NI) **] mother: CAD, HTN
[**Name (NI) **] father: Diabetes (type II)
[**Name (NI) **] 2 sisters: Diabetes (type II)
Physical Exam:
On admission:PHYSICAL EXAM:
O: T: BP:111/66 HR:86 RR:20 O2Sats:98% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRLA, EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date. Does not know
why she is in the hospital. Mile word finding difficulty.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-11**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On the day of discharge:
She was AVSS, A&Ox3, full motor, no drift and no neurological
deficits.
Pertinent Results:
[**2176-8-1**] 03:44AM PT-11.1 PTT-24.5 INR(PT)-0.9
[**2176-8-1**] 03:44AM PLT COUNT-271
[**2176-8-1**] 03:44AM NEUTS-59.2 LYMPHS-32.2 MONOS-6.3 EOS-1.7
BASOS-0.7
[**2176-8-1**] 03:44AM WBC-6.1 RBC-4.13* HGB-13.0 HCT-38.4 MCV-93
MCH-31.4 MCHC-33.8 RDW-13.6
[**2176-8-1**] 03:44AM CALCIUM-9.3 PHOSPHATE-4.6* MAGNESIUM-2.0
[**2176-8-1**] 03:44AM estGFR-Using this
[**2176-8-1**] 03:44AM GLUCOSE-99 UREA N-30* CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2176-8-1**] 04:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2176-8-1**] 04:56AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.029
[**2176-8-1**] 04:56AM URINE GR HOLD-HOLD
[**2176-8-1**] 04:56AM URINE HOURS-RANDOM
[**2176-8-1**] 09:13AM CK(CPK)-35
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2176-8-1**]
4:53 AM
1. Bilateral subacute subdural hematomas and diffuse cerebral
edema with
resultant effacement of the sulci, fissures and basal cisterns
and slightly low lying cerebellar tonsils. In the setting of
multiple prior LPs, these findings may be secondary to
intracranial hypotension. MRI could be considered for further
evaluation, including dural venous sinuses.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2176-8-1**] 5:05
AM
Final Report
Portable AP chest radiograph was compared to [**2176-5-14**].
Cardiomediastinal silhouette is stable. Lungs are essentially
clear except
for the left cardiophrenic angle that was not included in the
field of view. There is no appreciable pleural effusion. There
is no pneumothorax.
Head CT [**8-1**] 1016
1. Bifrontal hypodensities may represet artifact, but infarct
cannot be
excluded. Findings are otherwise in the spectrum of post-
surgical change.
There is minimal residual subdural hematoma.
2. The brain parenchyma remains separated from the inner table,
which
suggests the subdural hematoma was chronic.
Brief Hospital Course:
This is a 52 year-old female who initially presented in [**5-16**]
with headaches without findings on CT scans. She was eventually
diagnosed with migraines after a neurology evaluation and placed
on amitriptyline. She reports that she had continued to have
headaches since that time. She presented to [**Hospital 1725**] Hospital
today per report confused with difficulty walking. A CT scan of
her head there revealed symmetrical bilateral subdural hematomas
and she was transferred to [**Hospital1 18**] for further management on
[**2176-8-1**]. She was admitted to the ICU and pre-operaticvely was
reportaed to have short term memory loss X 1 week per her
family's reports. On exam, she exhibited a slight right sided
drift. Consent for the procedure was signed by the patient and
her son as the patient has had recent memory issues. She
underwent bilateral burr holes post op CT showed good expansion
of the brain. On [**8-2**] she was transferred to the floor and was
neurologically intact. While on the floor she tolerated a
regular diet was seen by PT who determined she was safe to go
home.
Medications on Admission:
Protonix40 mg [**Hospital1 **], Allegra180 mg qd,Diovan
160mg qd, amitriptyline 10 mg qd, Lunesta qd, Retin-A,
Veramyst, lorazepam 0.5qd, hydrocodone PRN
headache, Bentyl 10 mg qd, Vitamin B12.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*100 Capsule(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QD ().
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Tretinoin 0.025 % Cream Sig: One (1) Appl Topical QHS (once a
day (at bedtime)).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*1*
11. Lunesta 3 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subacute Subdural Hematomas
Discharge Condition:
Neurologically Stable.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-16**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2176-8-3**]
|
[
"852.21",
"401.9",
"V15.82",
"E879.4",
"997.02",
"530.81",
"348.4",
"346.90",
"V45.86",
"V10.82",
"780.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
8487, 8493
|
6123, 7229
|
348, 391
|
8575, 8600
|
4123, 6100
|
10181, 10796
|
2419, 2546
|
7474, 8464
|
8514, 8554
|
7255, 7451
|
8624, 10158
|
1903, 2098
|
2589, 2826
|
278, 310
|
419, 1491
|
3152, 4104
|
2574, 2574
|
2841, 3136
|
1513, 1880
|
2114, 2403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,200
| 118,313
|
6743
|
Discharge summary
|
report
|
Admission Date: [**2193-10-6**] Discharge Date: [**2193-10-21**]
Date of Birth: [**2131-12-25**] Sex: M
Service: [**Last Name (un) **]
CLINICAL HISTORY: Mr. [**Name13 (STitle) 12101**] is a 61 year old gentleman who
is status post a segment 5 liver resection in [**2193-3-11**] by
Dr. [**Last Name (STitle) **] for cholangiocarcinoma. On [**2193-10-6**] he presented
via the emergency room with a three week history of
increasing abdominal pain, a 72 hour history of intense
nausea and vomiting and inability tolerate P.O.'s. Since his
original surgery he had been quite well and denies any
similar events. He denies any prior abdominal surgery, has
had a negative colonoscopy in [**2191-3-11**].
PRIOR MEDICAL HISTORY:
1. Cholangiocarcinoma, status post resection [**2193-3-11**].
2. Tonsillectomy.
3. Colonoscopy in [**2191-3-11**] which was negative.
MEDICATIONS: Aspirin 81 mg P.O. q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies smoking. He is an
occasional alcohol drinker. Denies intravenous or other
recreational drug use. He is a retired [**Company 2318**] worker who is
divorced but does spend time with his son.
FAMILY HISTORY: Mother died at 85 of unknown cause and
father died at 92 of cancer.
LABORATORIES ON PRESENTATION: White blood cell count of
13.4, hematocrit of 45, platelets of 309. Sodium 135,
potassium 4.3, chloride 92, CO2 32, BUN 31, creatinine 1.0
and glucose 111. Lactate noted to be 1.5. AST 35, ALT 26,
alkaline phosphatase 168, total bilirubin 2.0. PT 13.0, PTT
23.8, INR of 1.1. CT scan with both P.O. and intravenous
contrast performed in the emergency department shows several
dilated loops of small bowel. There is a high grade
obsturction in the mid small bowel in an area proximal to
that obstruction which was concerning for pneumatosis.
PHYSICAL EXAMINATION: In the emergency department Mr.
[**Name13 (STitle) 12101**] was described as a frail appearing male clearly
uncomfortable. He is alert and oriented times three but
easily distracted. He has a maximum temperature of 96.4,
pulse of 114, blood pressure of 140/80, respirations 18,
satting 19 percent. In general his conjunctiva and mucosa
both seem to be dry. Cranial nerves 2 through 12 are grossly
intact. Pupils are equal and reactive to light with sclera
nonicteric. Trachea is midline. Lungs are clear to
auscultation bilaterally. Nose is likewise noted to be
nontender, noninflamed. Cardiac examination is regular rate
and rhythm, no evidence of any murmurs, rubs or gallops.
Abdomen shows a well healed midline incision without any
evidence of any herniation. Auscultation shows highly
pitched hypoactive bowel sounds. Abdomen is otherwise soft,
diffusely tender, nondistended. No evidence of any
organomegaly. Rectal examination shows no evidence of masses
and is guaiac negative.
CLINICAL COURSE: Based on his presentation to the emergency
department and CT scan findings examination by Dr. [**First Name (STitle) **] in
the emergency department felt that the patient would be best
served by an emergent exploratory laparotomy. In the
emergency department a Foley catheter was placed and less
than 100 cc of urine was seen with this. The patient was
immediately bolused 4 liters of Crystalloid and urine output
gradually began to increase. Shortly thereafter the patient
was taken to the operating room. During operation diffuse
carcinomatosis was seen. There was a high grade obstruction
and mat of cancer tethering down a considerable portion of
the bowel. A diverting enterostomy was placed. A
decompression gastric tube was placed. Please refer to
operative note for full details.
Following surgery the patient was extubated and transferred
to the post anesthesia care unit. He continued to be very
hypotensive and oliguric and ultimately required several
liters of Crystalloid boluses. Postoperative laboratories
included a white count of 7.7, hematocrit of 36.5, platelets
of 320. Sodium was 138, potassium 4.1, chloride 103, CO2 26,
BUN 21, creatinine 0.8, glucose 139.
On the first postoperative night patient was again
persistently oliguric and was dosed several times for this.
He was started empirically on Zosyn and his gastric tube was
left to drainage. From the post anesthesia care unit the
patient was transferred to the Intensive Care Unit. Pain
control was provided by p.r.n. analgesia. On the morning of
postoperative day three patient was transferred to the normal
surgical floor. At that time diuresis was started.
Initially patient had a brisk diuresis but intermittently
required doses of 20 to 40 mg intravenous of Lasix. Also at
that time surgical teams began engaging both the social work
resources and palliative cancer resources in discussing the
poor prognosis of this patient with him and his family.
Through several meetings the treatment and long term
prognosis of this patient were discussed at length with the
patient.
By postoperative day four there was an attempt to cap the
patient's gastrostomy tube. This ultimately had to be opened
shortly after for distention and for passage of flatus. On
postoperative day five patient was initiated on total
parenteral nutrition. On the evening of hospital day six the
patient had a spontaneous desaturation event. By report he
attempted to get out of bed on his own and became vasovagal.
Once placed back in bed his oxygen saturations were shown to
go down approximately 60 percent on room but quickly returned
to [**Location 213**] when placed on nasal cannula. Initial arterial
blood gas on room was 7.46, 44, 36, 26 and 1. On 6 liters of
oxygen. This was 7.48, 38, 78 and 283. Of note, the CBC at
that time showed a rising white count of 15.8. Full work up
for possible pulmonary embolism was started at that time
including a VQ scan and ultimately a CTA. Both of these were
shown to be negative for pulmonary embolism. Patient was
transferred back to the Intensive Care Unit where he
continued to stabilize. He was started empirically on Zosyn
for suspected pneumonia and consolidation which was seen by
CT scan. On hospital day 8 patient was placed with a PICC
line. He clinically responded well to Zosyn and ultimately
was transferred out of the Intensive Care Unit. On
subsequent days his gastrointestinal tract likewise opened up
and his diet was slowly advanced from n.p.o. to regular
although this total parenteral nutritions continued to be
run. On [**2193-10-17**], postoperative day 11, patient was
actually felt to be a good candidate for discharge to
rehabilitation. However, he had an episode of abdominal pain
and distention and is deemed appropriate to keep hem over the
weekend with his gastrostomy tube unclamped. Over the next
48 hours his gastrostomy tube was reclamped. He tolerated
this well and tolerated a regular diet. Again total
parenteral nutrition was left in place. On the morning of
[**2193-10-21**] after evaluation by the attending surgeon and the
entire surgical team it was deemed that the patient was an
appropriate candidate for discharge.
MEDICATIONS ON DISCHARGE:
1. Patient will continue total parenteral nutrition until
weaned off.
2. Albuterol MDI 1 to 2 q 6 hours p.r.n.
3. Ipratropium bromide MDI q 4 hours p.r.n.
4. Sliding scale insulin as needed for total parenteral
nutrition.
5. Amitriptyline 25 mg 1 P.O. q h. s.
6. Lopressor 100 mg P.O. B.I.D
7. Alprazolam 0.25 mg P.O. t.i.d.
8. Alprazolam 0.25 mg P.O. q 8 as needed for agitation.
9. Morphine 15 mg tablets 1 to 2 P.O. q 3 hours p.r.n. as
needed for pain.
10. Finally Zosyn 4.5 grams intravenous q 8 hours for
three days.
FOLLOW UP: The patient is scheduled to follow with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr.[**Name (NI) 1369**] office will likewise contact him to
set up a follow up appointment.
In addition, the patient has been actively involved with the
palliative care team and they are working with him on the
best long term options.
DISCHARGE DIAGNOSES:
1. Include all prior diagnoses and add carcinomatosis.
2. Recurrent cholangiocarcinoma.
3. Status post enteral diversion and placement of gastrostomy
tube.
DISPOSITION: The patient is discharged on total parenteral
nutrition while tolerating early stage regular diet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2193-10-21**] 09:39:10
T: [**2193-10-21**] 10:45:22
Job#: [**Job Number 25650**]
|
[
"486",
"197.4",
"263.9",
"V10.09",
"560.9",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"38.91",
"54.11",
"99.15",
"54.23",
"38.93",
"45.91"
] |
icd9pcs
|
[
[
[]
]
] |
1207, 1854
|
8047, 8592
|
7122, 7663
|
7675, 8026
|
1877, 7096
|
978, 1190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,784
| 148,747
|
26727
|
Discharge summary
|
report
|
Admission Date: [**2173-9-14**] Discharge Date: [**2173-9-23**]
Date of Birth: [**2104-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
acute SOB at rehab, arrested, intubated and transferred to [**Hospital1 18**]
Major Surgical or Invasive Procedure:
flex bronch
History of Present Illness:
HPI: 69yo Cambodian woman with history of metastatic papillary
thyroid cancer s/p subtotal thyroidectomy and tracheostomy,
presenting from OSH after respiratory and cardiac arrest. Her
history dates back to [**2173-4-9**] when she presented unresponsive
requiring intubation. She had been diagnosed with papillary
thyroid cancer in [**3-/2173**] and underwent subtotal thyroidectomy on
[**2173-4-12**]. She subsequently developed upper airway compromise due
to subglottal edema. She underwent tracheostomy [**2173-4-16**] and PEG
placement [**2173-5-3**]. She was hospitalized at [**Hospital1 18**] from
[**Date range (3) 65848**]. Hospital course was complicated by acinetobacter
and enterobacter pneumonias, newly diagnosed diabetes mellitus,
sepsis, sinusitis, and atrial flutter. She was eventually
discharged to rehab. She continued to have problems with
tracheal stenosis, and was admitted to [**Hospital1 18**] [**2173-8-20**]. She
underwent rigid and flexible bronchoscopy revealing
tracheomalacia, subglottic stenosis, and infra and superior
glottic swelling. She had a swallow study which showed
aspiration. She was transferred to rehab not on ventilator.
At rehab on [**2173-9-2**] pseudomonas, stenotrophomonas, MRSA, and
enterococcus were cultured from the trach site, and she was
treated with levofloxacin and linezolid. Today she was noted to
be having difficulty breathing through the trach and was brought
to [**Hospital6 5016**] ED. She was intubated with 6ETT through
trach stoma. She arrested requiring CPR, epinephrine, and
atropine, and was revived. Thick secretions were suctioned. A
6.0trach tube was reinserted by anesthesia at the OSH prior to
transfer. On presentation now she is alert. She responds "no" to
question of speaking English.
Past Medical History:
thyroid cancer dx in [**3-/2173**]- Papillary cancer with positive
nodes
status post sternotomy and partial right and total left
thyroidectomy on [**2173-4-12**].
IDDM
HTN
papillary ca - thyroid, DM2, HTN, Hiatal hernia, B12 defic, B
cell lymphoma-s/p chemo
PSH: thyroidectomy w/ sternotomy, trach, PEG [**4-12**]
Social History:
Social: The pt has six children living in the area, 2 children
living in [**Country 5737**]. She is from [**Country **] and speaks Catnonese.
She understands some English. Apparently she was independent
with mobility and basic ADL prior to her last hospitalization.
Her functional capacity recently has been the need for maximal
assistance to total dependency in most areas
Family History:
not known
Physical Exam:
PE: T 97.3 HR 99 BP 110/50 RR 18 100%
PS 10x5 FiO2 0.50
Gen: comfortable, alert, NAD
HEENT: PERRL, anicteric, MM dry, OP clear
Neck: supple, vertical scar to chest, t-tube
CV: tachy, regular, no mrg
Resp: CTA anteriorly
Abd: +BS, soft, NT, ND, PEG
Ext: no edema, 1+ DPs B
Neuro: alert, follows command to open mouth, MAEW. Portugese
speaking
Pertinent Results:
[**2173-9-14**] 04:34PM GLUCOSE-297* UREA N-28* CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal
swallowing video fluoroscopy was performed today in
collaboration with the speech and language pathology division.
Various consistencies of barium including thin liquid, nectar
thickened liquid, puree, and a half cookie coated with barium
were administered.
FINDINGS: The oral phase was unremarkable for pathology. Mild
valleculae residue was noted, cleared with frequent swallowing.
Mild spillover was noted before each swallow. With thin liquids,
mild aspiration was noted without cough reflex initiated. _____
laryngeal excursion was normal. Palatal elevation and, laryngeal
valve closure, and epiglottic deflection were within functional
limits.
IMPRESSION: Before swallowing patient develops mild spillover
into the valleculae cleared with frequent swallows. No
aspiration noted with thick liquids but mild aspiration upon
thin liquids without initiating cough reflex.
Echo: GENERAL COMMENTS: Frequent ventricular premature beats.
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. Right ventricular systolic function is
normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is
moderate pulmonary artery systolic hypertension. There is no
pericardial
effusion.
Compared with the prior study (images reviewed) of [**2173-4-13**], the
LVEF is no
longer hyperdynamic, but remains normal. Otherwise, no change.
CXR:
INDICATION: Tracheostomy and shortness of breath.
A tracheostomy tube remains in place. There is narrowing of the
airway proximal to the level of the tube without change. Heart
size is normal. The aorta is tortuous. The lungs are clear, and
there are no pleural effusions.
IMPRESSION:
Airway narrowing proximal to tracheostomy entry site without
change.
No evidence of pneumonia.
Brief Hospital Course:
Pt was admitted to MICU intubated after resp arrest at Rehab
facility. Thought to be r/t plugging from granulation tissue.
Flex bronch showed patent T-tube w/o granulation tissue above or
below the T-tube. Etiology of resp arrest then thought to be
from secretion plugging. Rec'd supporttive pulmonary/cardiac
care in MICU w/ good recovery. Intubation via stoma w/ ETT was
converted back to trach as prior to event.
On HD #3 pt transferred from ICU to floor for ongoing pul rahab.
Noted to be having runs of non-sustained, asymptomatic bigeminy
and trigeminy. Cardiology was consulted and echo was performed
(see report section )w/o etiology of ectopy; thought to be
related to CPR given during arrest. Currently on betablocker and
can be titrated up for HR control if BP allows.
Treated w/ linezolid and levoflox for MRSA PNA which will stop
on [**2173-9-27**]. Rec'ing bactrim for UTI until [**2173-9-28**]. On steriod
taper for edmea noted on bronch.
glucoses controlled w/ [**Hospital1 **] NPH and SSRI.
Kept NPO w/ tube feeds via J-tube until able to perform video
swallow study.
Swallow study done on HD#7 and pt passed for ground diet and
nectar thick liquids; no thin liquids.
capping trial initiated on HD#7-[**Last Name (un) 1815**] capping x 4 hrs but became
anxious. Sats were mid-high 90's however, pt was uncapped d/t
anxiety. Remained uncapped over noc w/ hunidified oxygen.
Communication: daughter: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 65849**]
Medications on Admission:
levofloxacin 500', linezolid 600", procrit, metoprolol 25",
levothyroxine 100', colace 100", lansoprazole 30',
albuterol/atrovent nebs, NaCl 1g''', calcium carbonate 1.25",
Vit D 800', FeSO4 300", Lactinex 2tabs''', lovenox 40', insulin
15am, 25pm, mag hydroxide q4hr
Discharge Medications:
1. Levothyroxine 100 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 150 mg/15 mL Liquid [**Telephone/Fax (1) **]: Seven (7) ml PO BID
(2 times a day).
3. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Telephone/Fax (1) **]: One
(1) PO DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2) Puff
Inhalation Q6H (every 6 hours).
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2)
Puff Inhalation QID (4 times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: 2.5 Tablet,
Chewables PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Telephone/Fax (1) **]: Two (2)
Tablet PO DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
DAILY (Daily).
9. Linezolid 600 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q12H (every 12
hours): last dose [**2173-9-27**].
10. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Zolpidem 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO HS (at bedtime).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection [**Hospital1 **] (2 times a day).
13. Guaifenesin 600 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO BID (2 times a day) as needed for
secretions.
14. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day).
15. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Three (3) ml
Miscell. [**Hospital1 **] (2 times a day).
16. Levofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours): last dose [**2173-9-27**].
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO BID (2 times a day) for 5 days: last dose [**2173-9-28**].
18. regular insulin
per sliding scale finger sticks.
19. T-Tube cap
cap T-Tube during day and uncap at noc and provide humidified
oxygen
20. NPH insulin
20 units NPH Sq qam and 17 units NPH Sq qpm
21. Decadron 0.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO twice a day
for 7 days: then decrease to 0.5mg x 7days then d/c.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
papillary ca - thyroid, DM2, HTN, Hiatal hernia, B12 defic, B
cell lymphoma-s/p chemo
PSH: thyroidectomy w/ sternotomy, trach, PEG [**4-12**], T -Tube d/t
tracheomalacia
Discharge Condition:
requires ongoing capping trials of T-tube and family teaching as
well as assessing tolerance of po's. Repeat swallow in the
future ~1 month to assess for ability to [**Last Name (un) 1815**] clear liquids
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Name (STitle) **] office [**Telephone/Fax (1) 3020**] for any questions.
Followup Instructions:
call Dr[**Doctor Last Name **] office [**Telephone/Fax (1) 3020**] for a follow up appointment
upon leaving rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2173-9-23**]
|
[
"427.32",
"599.0",
"266.2",
"458.8",
"519.02",
"276.0",
"416.8",
"V10.87",
"250.00",
"401.9",
"V58.67",
"553.3",
"041.4",
"196.0",
"V10.79",
"285.9",
"428.30",
"V44.1",
"276.2",
"426.89",
"519.01",
"428.0",
"478.6",
"427.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.42",
"31.5",
"31.41",
"97.23",
"31.48",
"38.93",
"33.21",
"96.71",
"31.99"
] |
icd9pcs
|
[
[
[]
]
] |
9787, 9866
|
5720, 7203
|
398, 412
|
10080, 10287
|
3345, 5697
|
10447, 10684
|
2956, 2967
|
7523, 9764
|
9887, 10059
|
7229, 7500
|
10311, 10424
|
2982, 3326
|
281, 360
|
440, 2208
|
2230, 2546
|
2562, 2940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,582
| 151,772
|
44534
|
Discharge summary
|
report
|
Admission Date: [**2169-1-28**] Discharge Date: [**2169-2-8**]
Date of Birth: [**2102-1-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Fvers, admitted from rehab
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 67 yoM trached, h/o
Pseudomonas/Acineterbacter MDR PNA who is admitted from [**Hospital 100**]
Rehab with T 102.4 and altered MS. Of note, he was recently
admitted at [**Hospital1 18**] MICU green from [**Date range (1) 95399**]/09 for similar system
of complaints; he was followed closely by ID and has been on a
course of amikacin/inhaled colistin for MDR PNA. His course was
complicated by ARF thought to be [**2-6**] colistin side effect and
persistent fevers, for which no cause other than the PNA was
ever identified (numerous BCx were negative).
.
His wife reports that he was doing well this week at rehab with
improving MS. It is unclear whether he was still having
intermittent fevers throughout the week, but this morning he
spiked and became less arousable. He was noted to have thick
secretions. ABG from 3:45 this afternoon showed 7.41/53/101 on
50% trach collar. He had a set of BCx from [**1-26**] that are NGTD.
In the ED on arrival, VS were T, HR 108, BP 120/60, RR 24, RA
100%. Head CT was negative for acute hemorrhage/edema, though
there is some question of mastoiditis b/l on the prelim read.
The ED staff touched base with ID who said to leave him on
amikacin/colistin. He got a dose of amikacin 750 mg IV x 1.
Past Medical History:
- [**8-/2168**] fall + subdural hematoma c/by S. bovis endocarditis. Tx
6 weeks ceftriaxone. Course c/by MRSA, Enterococcal thought to
be line-related bacteremia.
- [**11/2168**] PCN/Vanc sensitive Enterococcal aortic valve
endocarditis. Tx 6 weeks vancomycin (pcn allergic) - completed 6
weeks tx [**2168-12-21**].
- [**11/2168**] admit c/by Acinetobacter in sputum (? colonization
versus VAP), treated with tobramycin and unasyn (plan was to d/c
on [**12-1**]).
- [**Date range (3) 95358**], one day after discharge, resp failure,
re-intubated. ESBL Klebsiella pna: treated with Meropenem x 12
days. Tracheostomy. Sputum later grew Acinetobacter on [**2168-12-10**]
-> unasyn and tobramycin as above. [**Date range (3) 95400**]. DC [**12-16**] on
trach mask.
- Morbid obesity
- DM type 2 poorly controlled with complications
- Chronic renal insufficiency (new baseline as of [**12-12**] - Cr
1.6-2)
- HTN
- reactive airways disease
- h/o asbestos exposure with pleural plaques
- GERD
- Parkinson's disease
- detrusor instability
- gout
- hypothyroidism
- aortic stenosis, valve area 0.9cm2, peak gradient 24, median
gradient 48
- Anemia
- h/o nephrolithiasis
Social History:
-- has wife, [**Name (NI) **], who is HCP; also with two daughters
-- no alcohol or tobacco use
-- currently resides at [**Hospital 100**] Rehab
-- formerly owned pizzaria restuarants
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
VS on arival to MICU: T 100.2, HR 102, BP 143/91, RR 21, 96% on
35% trach collar
General: apears comfortable but ill; obese
HEENT: PERRL; trached
LUNGS: crackles at bases b/l anteriorly; does not cooperate for
full exam; some referred upper airway breath sounds
CARDIO: RRR, no m/r/g appreciated
ABD: + BS, obese, soft, no rebound/guarding, difficult to assess
whether TTP
EXTREMITIES: 1+ [**Location (un) **], WWP, no rashes; left arm PICC
NEURO: somnolent, does not arouse to voice for me (but do so for
wife [**Doctor First Name **]; stimulates with pain. reflexes 2+ throughout;
down-going Babinksi's
Pertinent Results:
[**2169-1-28**] 06:09PM BLOOD WBC-8.3 RBC-3.50* Hgb-10.0* Hct-30.1*
MCV-86 MCH-28.7 MCHC-33.3 RDW-17.2* Plt Ct-294
[**2169-2-7**] 06:04AM BLOOD WBC-11.0 RBC-3.02* Hgb-8.5* Hct-25.7*
MCV-85 MCH-28.0 MCHC-32.9 RDW-17.4* Plt Ct-191
[**2169-1-28**] 06:09PM BLOOD PT-14.7* PTT-44.3* INR(PT)-1.3*
[**2169-2-3**] 04:28AM BLOOD PT-16.2* PTT-44.5* INR(PT)-1.5*
[**2169-1-28**] 06:09PM BLOOD Glucose-146* UreaN-74* Creat-2.1* Na-145
K-3.6 Cl-105 HCO3-32 AnGap-12
[**2169-2-7**] 06:04AM BLOOD Glucose-131* UreaN-49* Creat-1.8* Na-146*
K-3.8 Cl-105 HCO3-31 AnGap-14
[**2169-1-28**] 06:09PM BLOOD ALT-23 AST-42* CK(CPK)-49 AlkPhos-64
TotBili-0.4
[**2169-1-28**] 06:09PM BLOOD Lipase-111*
[**2169-1-28**] 06:09PM BLOOD Albumin-3.6 Phos-3.3 Mg-2.1
[**2169-2-7**] 06:04AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
[**2169-1-29**] 03:23AM BLOOD calTIBC-273 Ferritn-495* TRF-210
[**2169-1-28**] 10:07PM BLOOD Type-ART FiO2-100 pO2-91 pCO2-47* pH-7.40
calTCO2-30 Base XS-2 AADO2-591 REQ O2-95 Intubat-NOT INTUBA
[**2169-1-30**] 05:31PM BLOOD Type-ART Temp-38.3 PEEP-5 FiO2-30 pO2-98
pCO2-54* pH-7.38 calTCO2-33* Base XS-4
[**2169-1-28**] 10:07PM BLOOD Lactate-0.8
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-2-8**] 03:38AM 162* 52* 1.8* 143 3.8 104 31 12
Source: Line-picc
[**2169-2-7**] 06:04AM 131* 49* 1.8* 146* 3.8 105 31 14
Source: Line-Rsc
[**2169-2-6**] 04:32AM 139* 43* 1.7* 144 3.4 106 30 11
CXR [**2169-1-28**]:
IMPRESSION: 1. Retrocardiac opacity may reflect atelectasis.
2. Extensive pleural and parenchymal scarring with pleural
calcifications,
unchanged.
CT Head w/o contrast [**2169-1-28**]:
IMPRESSION:
1. No intracranial hemorrhage or edema.
2. Bilateral opacification of mastoid air cells without osseous
destruction.
3. Small amount of fluid in the sphenoid and right maxillary
sinus
ECG [**2169-1-28**]:
Sinus tachycardia. Possible left ventricular hypertrophy (lead
aVL).
Non-specific inferolateral T wave flattening. Non-specific
intraventricular conduction delay. Compared to the previous
tracing of [**2169-1-11**] the ventricular premature beat is absent and
there is increased QRS voltage. Sinus tachycardia and T wave
flattening are new.
ECHO [**2168-2-1**]:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the mid to distal septum. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
severely thickened/deformed. There is a probable vegetation on
the aortic valve. There is moderate aortic valve stenosis (area
1.0cm2). Significant aortic regurgitation is present, but cannot
be quantified. The mitral valve leaflets are structurally
normal. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2169-1-4**],
the severity of aortic stenosis is similar. There seems to be a
calcified leaflet that is more mobile than seen in the prior
echo, possible vegetation. A transesophageal echocardiographic
examination is recommended to further evaluate the aortic valve.
CT Chest/ABD/Pelvis [**2169-2-3**]:
IMPRESSION:
1. No definite cause for persistent fevers is noted aside from
atelectasis/pleural plaques/scarring within the lungs,
particularly at the
dependent bases. These may in part be secondary to changes
related to prior asbestos exposure. Overall, the appearance of
the lungs is actually improved when compared to prior imaging
from [**2168-11-5**].
2. No evidence of abscess or infection within the abdomen or
pelvis, although assessment is somewhat limited without IV
contrast and due to streak artifact from patient's arm
positioning.
MICRO:
Sputum Culture [**2169-1-29**]:
RESPIRATORY CULTURE (Final [**2169-2-5**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
WORKUP PER DR.[**Last Name (STitle) 95401**],[**First Name3 (LF) **] B#[**Serial Number 14013**] [**2169-2-4**].
STAPH AUREUS COAG +. HEAVY GROWTH.
Please contact the Microbiology Laboratory ([**7-/2466**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ACINETOBACTER BAUMANNII
COMPLEX
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- =>64 R 32 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R 2 I
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R 8 I
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 4 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ <=1 S
Sputum Culture [**2169-1-31**]:
GRAM STAIN (Final [**2169-1-31**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2169-2-6**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
VANCOMYCIN Sensitivity testing performed by Sensititre.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2466**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
67 year-old male with Parkinsons?????? disease, complicated medical
course since [**8-/2168**] after fall and SDH including endocarditis
and MDR PNA with Acinetobacter/Pseudomonas admitted with fever
and altered mental status; found to have MRSA PNA.
# Multi-drug resistant Pneumonia: Patient has history of MDR
Pneumonia and was found to have lung consolidation on admission
and sputum positive for MRSA. Patient then had continuous
fevers despite antibiotic coverage with Vanco/Colistin/Amikacin.
Blood cultures and urine cultures remained negative. Sputum
culture grew MRSA. CT Torso was done which was negative for
occult source of infection. C.diff also negative. ID was
consulted for assistance with continued fevers. Patient has now
defervesced. ID now recommending vancomycin for a 14-day
course for MRSA coverage. Amikacin and colistin were started on
admission for treatment of previous Amikacin/Klebsiella
Pneumonia. However, this was discontinued based on culture
data. Patient is to continue on Vancomycin for a 14 day course,
last day [**2168-2-12**]. PICC placed on [**2168-2-7**] for Vancomycin
administration.
# Respiratory failure: Patient was on intermittent trach mask as
an outpatient. Patient had respiratory distress on and off
during admission requiring intermittent ventilation, likely due
to PNA, fluid overload, and component of ICU myopathy. Patient
will be discharged to rehab with goal of weaning off ventilator,
currently has been on trach mask during the day for the past two
days and then he has been rested at night on the Ventilator on
Pressure Support with a Pressure Support of 5 and PEEP of 5.
# Altered mental status: Improved, patient now has PMV in place
and answering questions appropriately. Likely toxic/metabolic
encephalopathy in the setting of infection. Head CT was
negative for acute processes.
# CoNS + blood cx bacteremia: ?????? OSH blood cultures positive from
PICC line placed last admission ?????? coagulase negative Staph and
presumed contaminant. PICC line was discontinued. TTE this
admission with likely aortic valve vegetation, similar to prior
TTE ?????? believed unlikely to represent new endocarditis.
Remaining blood cultures should be followed up as an outpatient.
# Acute renal failure: Creatinine now stable; improved from 2.8
last discharge [**1-24**]. Thought to be AIN from colistin from last
admission, however, improvement on continued colistin. Likely
component of dehydration in the setting of infection but now
stable.
# Hypernatremia: Likely dehydration in the setting of infection
which has now resolved with free water repletion. He should
continue free water flushes in his Tube feeds.
# Parkinson??????s disease: No active issues. Patient to continue on
Sinemet and Ropinirole
# Hypothyroidism: No acute issues. - Continue Levothyroxine 88
mcg
# Diabetes: No acute issues. Continue Glargine 34 units QHS +
Sliding Scale Insulin
# Code Status: DNR discussed with family
Medications on Admission:
MEDICATIONS ([**Hospital 100**] Rehab list):
Combivent Q8 hours std
Acetazolamide 250 mg [**Hospital1 **]
Amikacin 750 mg QOD
ASA 81 mg QD
Carbidopa/levodopa 25/250 Q4 hours ?
colistin 75 mg nebs Q8 hours
Senna
Colace
Fondaparinux 2.5 mg QOD
Lantus 34 units QHS
SSI
syntrhoid 88 mcg QD
Omeprazole 40mg QD
Ropinirole 3 mg QID
Simvastatin 20 mg QD
Miconazole powder PRN
Tylenol PRN
Morphine PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carbidopa-Levodopa 25-250 mg Tablet [**Hospital1 **]: One (1) Tablet PO
every four (4) hours.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed.
5. Fondaparinux 2.5 mg/0.5 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
Q48H (every 48 hours).
6. Levothyroxine 88 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Ropinirole 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO QID (4 times
a day).
9. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed.
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed for fever, pain.
12. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day): Use if patient is on
mechanical ventilation.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for when on vent.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for when on
vent.
15. Vancomycin 500 mg Recon Soln [**Hospital1 **]: 1.5 Recon Solns
Intravenous Q 24H (Every 24 Hours): for total of 750mg daily.
16. Lantus 100 unit/mL Solution [**Hospital1 **]: Thirty Four (34) Units
Subcutaneous at bedtime.
17. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) Unit
Subcutaneous four times a day: Per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
MRSA Pneumonia
Respiratory Failure
Discharge Condition:
Patient afebrile, now on intermittent tracheal mask. Patient is
very weak and will require intensive physical therapy and
occupational therapy
Discharge Instructions:
You were admitted into the hospital for respiratory distress due
to a new Pneumonia. You are being treated for a MRSA Pneumonia
and you are to complete a 2 week course of Vancomycin.
If you experience worsening chest pain, shortness of breath,
fevers > 101 or any other concerning symptoms please notify your
doctor immediately or report to the nearest emergency room
Followup Instructions:
Please follow up with your Primary Care Physician 1-2 weeks from
your discharge from rehab.
Please follow up as directed by your rehab facility
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,960
| 168,915
|
24045
|
Discharge summary
|
report
|
Admission Date: [**2154-1-1**] Discharge Date: [**2154-1-8**]
Date of Birth: [**2097-6-25**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Levaquin / Dextromethorphan / Adhesive Tape /
Actigall / Zithromax
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter placement; removed
[**2154-1-8**]
History of Present Illness:
56M s/p open RNY gastric bypass (without cholecystectomy) in
[**2152-4-9**] and 150 pound weight loss presents with abdominal
distension and RUQ pain x 12 hours. The pain was acute in onset
at 2AM on [**1-1**], severe ([**10-19**] out of 10), sharp, and was
associated with back pain. Pain was worse when drinking shakes
this morning. Patient also endorsed lightheadedness, chills, and
nausea without vomiting starting at 11AM. He denies fevers,
constipation, diarrhea; he has been passing flatus.
Past Medical History:
Hypertension
Diabetes, type 2
Hyperlipidemia
Gastroesophageal reflux
Ostructive sleep apnea on CPAP
History of kidney stones
Osteoarthritis of the hips, knees and thumbs
Fatty liver
Colonic polyps (benign)
History of iron deficiency anemia
Social History:
Tobacco: none
ETOH: occasional wine
Married, lives with wife
Family History:
Non-contributory
Physical Exam:
Vital signs: temperature 97, heart rate 64, blood pressure
108/68, respiratory rate 18, oxygen 100% room air
Constitutional: No acute distress
Neuro: Alert and oriented to person, place and time; gait steady
Cardiac: Regular rate and rhythm, no murmurs/rubs/gallops,
normal S1,S2
Lungs: Clear to auscultation, bilaterally, no wheezes/ rales/
rhonchi
Abdomen: soft, mild epigastric tenderness to palpation, no
rebound/ guarding
Wounds: well healed abominal incisions
Pertinent Results:
CT [**2154-1-1**] -
1. Findings consistent with uncomplicated acute pancreatitis.
2. Cholelithiasis without definite evidence of cholecystitis or
choledocholithiasis.
3. Large ventral hernia containing loops of collapsed small and
large bowel
loops as well as a portion of the excluded stomach without
evidence of
obstruction.
4. Unremarkable post-gastric bypass anatomy with patent Roux
limb and no
evidence of gastro-gastric fistula.
MRCP [**2154-1-3**] -
1. Findings of acute pancreatitis with small areas of
hypoenhancement within the head and uncinate process consistent
with areas of necrosis.
2. No intra- or extra-hepatic biliary dilatation. Cholelithiasis
but no
evidence of choledocholithiasis.
3. Diffuse fatty infiltration of the liver.
4. Small bilateral pleural effusions, new since prior study of
[**2154-1-1**].
5. Large ventral hernia containing portions of the excluded
stomach, small
bowel and large bowel.
Brief Hospital Course:
The patient was admitted to the West 2b service on [**2154-1-1**].
Initially patient was managed in the ICU and kept NPO/IVF and
pain was treated. On [**1-4**], patient was deemed stable to come to
the floor after pancreatic labs and bilirubin began to trend
down.
Neuro: The patient was alert and oriented throughout his
hospitalization; In the ED, patient was given IV Dilaudid for
pain with good effect. Upon transfer to the unit, fentanyl was
started due to rash from Dilaudid. This seemed to control the
patient's pain well. When patient transferred to floor, Pain
service was consulted to control pain. They recommended Roxicet,
which provided good relief for the patient.
CV: The patient remained stable from a cardiovascular
standpoint. Vital signs were routinely monitored. BP was
slightly low in the ED with SBP in the high 90, however this
improved substantially with adequate hydration.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient was kept nothing by mouth with intravenous
fluid upon admission to the hospital, but was advanced to stage
3 upon transfer to the general surgical [**Hospital1 **], which he tolerated
without increased pain or nausea. CT scan was performed in the
ED which showed acute uncomplicated pancreatitis and
cholelithiasis, but no signs of cholecystitis. Large ventral
hernia was also seen on CT scan. Labs were trended throughout
hospital course, which showed continuous drop in pancreatic
enzymes. However bilirubin continued to rise with a peak total
bilirubin of 4.4 on HD. ERCP was consulted, but they were unable
to perform the procedure due to patient's altered anatomy from
bypass surgery. MRCP on [**1-3**] showed no intra or extrahepatic
dilation, and no stone was seen. Bilirubin and other labs
continued to trend down and patient was transferred to the floor
on [**1-4**]. Labs continued to trend downward throughout the
remainder of her hospitalization;
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Patient was not started on
any antibiotics upon admission to the hospital.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; he was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He will return for an open
cholecystectomy and hernia repair on [**2154-1-14**].
Medications on Admission:
- Lisinopril 10 mg daily
- Metformin 1000 mg [**Hospital1 **]
- Pioglitazone 15 mg daily
- Sertraline 50 mg daily
- Vitamin supplements
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every four (4) hours as needed for pain.
Disp:*500 ML(s)* Refills:*0*
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
Disp:*250 ml* Refills:*0*
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Please crush.
4. lisinopril Oral
5. sertraline Oral
6. Lipitor Oral
7. Actos Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Acute gallstone pancreatitis
Incisional hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Please refrain
from drinking any alcohol at this time.
Please stay on a Stage 3 diet until returning for surgery.
Please ensure that you are drinking adequate fluids and meeting
your protein goals. Please call Dr. [**Last Name (STitle) **] if you experience
worsening abdominal pain associated with eating.
Please check your blood sugars four times per day at home and
contact your primary care provider if your glucose levels are
consistently elevated above 180.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2154-1-10**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2154-1-10**] 4:00
You have surgery scheduled for [**2154-1-14**] at 2:00 with Dr.
[**Last Name (STitle) **].
Completed by:[**2154-1-8**]
|
[
"E935.2",
"577.0",
"280.9",
"278.01",
"715.89",
"574.20",
"571.8",
"250.00",
"530.81",
"272.4",
"693.0",
"553.21",
"327.23",
"401.9",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
6288, 6294
|
2789, 5665
|
353, 428
|
6385, 6385
|
1837, 2766
|
8310, 8766
|
1316, 1334
|
5852, 6265
|
6315, 6364
|
5691, 5829
|
6536, 8287
|
1349, 1818
|
299, 315
|
456, 957
|
6400, 6512
|
979, 1221
|
1237, 1300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,515
| 153,311
|
7065
|
Discharge summary
|
report
|
Admission Date: [**2171-8-25**] Discharge Date: [**2171-8-29**]
Date of Birth: [**2109-2-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Tetanus / Latex / Fluzone
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
cardiac catheterization x2 with drug eluting stent to left
circumflex artery.
History of Present Illness:
62 year old female with PMH significant for DM 2, HTN,
hyperlipedemia and recent CABG [**2171-7-22**] (for anatomy see
studies). Patient presented to ED with vomiting and nausea since
friday. In ED EKG initially demonstrated ST elevation III, awF
and ST depression V5. Patient then developed new left bundle
branch block and was taken to cath lab. Patient became chest
pain free when started on Heparin and Integrillin. Cath
demonstrated OM3 occlusion (full report see below). No
intervention was done and patient was admitted to the CCU for
medical management.
.
On history patient describes nausea and vomiting since friday.
She subsequently developed epigastric [**5-15**] pain and midline back
pain. Additionally developed shortness of breath when lying
flat. Patient actively vomiting during interview. Prior patient
felt her usual state of health.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia,
Hypothyroidism
Depression
Osteopenia
Squampous cell cancer s/p excision
Renal tumor with renal calculi
Bronchitis
Anxiety
s/p Cholecystectomy
s/p appendectomy
s/p polypectomy.
Social History:
Occupation: Retired hairstylist
Lives with her husband, daughter and grandson.
Tobacco: 1 pack per day
ETOH Only rare alcohol use, no recreational drug use.
Family History:
Mother passed away age 78 from MS, Father 68 from cancer. No
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
VS: T= 98.4 BP=134/78 HR=86 RR=22 O2 sat=96%
GENERAL: Patient actively vomiting. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anterior.
ABDOMEN: Soft, non-distended, tender mid-epigastric region. No
HSM or tenderness. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2171-8-25**] 06:05AM BLOOD WBC-12.5* RBC-4.51# Hgb-13.1# Hct-38.6#
MCV-86 MCH-29.0 MCHC-33.8 RDW-14.4 Plt Ct-352#
[**2171-8-25**] 06:44PM BLOOD Hct-35.9*
[**2171-8-26**] 03:08AM BLOOD WBC-13.7* RBC-4.13* Hgb-11.8* Hct-35.1*
MCV-85 MCH-28.7 MCHC-33.7 RDW-14.5 Plt Ct-332
[**2171-8-27**] 06:15AM BLOOD WBC-14.4* RBC-4.98 Hgb-14.3 Hct-42.6
MCV-86 MCH-28.6 MCHC-33.5 RDW-14.4 Plt Ct-388
[**2171-8-28**] 06:05AM BLOOD WBC-12.8* RBC-4.81 Hgb-13.8 Hct-40.6
MCV-84 MCH-28.6 MCHC-33.9 RDW-14.3 Plt Ct-404
[**2171-8-29**] 06:40AM BLOOD WBC-11.9* RBC-4.85 Hgb-13.9 Hct-41.5
MCV-86 MCH-28.7 MCHC-33.5 RDW-14.3 Plt Ct-396
[**2171-8-25**] 06:05AM BLOOD Neuts-83.6* Lymphs-12.4* Monos-2.9
Eos-0.8 Baso-0.4
[**2171-8-29**] 06:40AM BLOOD Neuts-65.3 Lymphs-25.4 Monos-6.2 Eos-1.8
Baso-1.3
[**2171-8-25**] 06:05AM BLOOD PT-11.6 PTT-25.4 INR(PT)-1.0
[**2171-8-27**] 06:15AM BLOOD PT-12.9 PTT-28.7 INR(PT)-1.1
[**2171-8-28**] 06:05AM BLOOD PT-13.4 PTT-28.7 INR(PT)-1.1
[**2171-8-25**] 06:05AM BLOOD Glucose-229* UreaN-14 Creat-0.6 Na-139
K-3.4 Cl-105 HCO3-20* AnGap-17
[**2171-8-25**] 01:09PM BLOOD Glucose-165* UreaN-12 Creat-0.5 Na-142
K-3.5 Cl-105 HCO3-21* AnGap-20
[**2171-8-26**] 03:08AM BLOOD Glucose-184* UreaN-12 Creat-0.6 Na-137
K-3.2* Cl-101 HCO3-22 AnGap-17
[**2171-8-27**] 06:15AM BLOOD Glucose-198* UreaN-17 Creat-0.6 Na-135
K-3.2* Cl-101 HCO3-20* AnGap-17
[**2171-8-28**] 06:05AM BLOOD Glucose-198* UreaN-17 Creat-0.5 Na-132*
K-3.6 Cl-101 HCO3-19* AnGap-16
[**2171-8-29**] 06:40AM BLOOD Glucose-212* UreaN-16 Creat-0.5 Na-136
K-3.1* Cl-105 HCO3-18* AnGap-16
[**2171-8-25**] 06:05AM BLOOD ALT-23 AST-64* CK(CPK)-349* AlkPhos-126*
TotBili-0.3
[**2171-8-25**] 01:09PM BLOOD CK(CPK)-255*
[**2171-8-25**] 06:44PM BLOOD CK(CPK)-184*
[**2171-8-27**] 06:15AM BLOOD CK(CPK)-55
[**2171-8-27**] 11:49AM BLOOD CK(CPK)-58
[**2171-8-27**] 10:09PM BLOOD CK(CPK)-48
[**2171-8-28**] 06:05AM BLOOD CK(CPK)-43
[**2171-8-25**] 06:05AM BLOOD CK-MB-50* MB Indx-14.3*
[**2171-8-25**] 06:05AM BLOOD cTropnT-0.74*
[**2171-8-25**] 01:09PM BLOOD CK-MB-26* MB Indx-10.2* cTropnT-0.64*
[**2171-8-25**] 06:44PM BLOOD CK-MB-18* MB Indx-9.8* cTropnT-0.75*
[**2171-8-27**] 06:15AM BLOOD CK-MB-5 cTropnT-0.54*
[**2171-8-27**] 11:49AM BLOOD cTropnT-0.68*
[**2171-8-25**] 01:09PM BLOOD Calcium-9.7 Phos-4.1 Mg-1.7
[**2171-8-26**] 03:08AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.7
[**2171-8-27**] 06:15AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2
[**2171-8-28**] 06:05AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.9
[**2171-8-29**] 06:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8
.
[**8-28**] fecal Cx:
FECAL CULTURE (Final [**2171-8-31**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2171-8-30**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2171-8-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Cardiac Cath [**8-25**]:
COMMENTS:
1. Selective coronary angiography in this left dominant system
demonstrated single and branch vessel disease. The LMCA had a
40%
stenosis. The LAD had mild disease. The Cx had a 60% stenosis in
the
mid-portion and a 70% stenosis in OM1. OM3 was occluded. The RCA
was
small and non-dominant.
2. Graft angiography demonstrated a patent LIMA-LAD. The SVG-OM1
was
patent. The SVG-OM3 was occluded.
FINAL DIAGNOSIS:
1. Single and branch vessel coronary artery disease.
2. Patent LIMA and SVG-OM1. Occluded SVG-OM3.
.
CHEST, AP PORTABLE UPRIGHT VIEW [**8-25**]: The lungs are clear on
this single frontal view. There is no evidence for pulmonary
edema, consolidation or large effusion. The cardiac silhouette
is normal in size. Sternal closure wires are intact. Clips
overlying the mediastinum are unchanged. Surgical clips in the
right upper quadrant are noted.
IMPRESSION: No acute cardiopulmonary process.
.
TTE [**2171-8-26**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the basal half of the inferior wall and mid
anterior septum. The remaining segments contract normally (LVEF
= 40 %). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-7-12**], the
basal inferior wall dysfunction is new and the severity of
mitral regurgitation is increased. Apical function is improved.
.
Cardiac Cath [**2171-8-27**]:
COMMENTS:
1. Limited coronary angiography in this left dominant system
demonstrated a 40% stenosis in the LMCA. The LAD had no
angiographically
apparent disease. The LCx had a 70% stenosis mid vessel at the
level of
OM1. The OM3 was patent with evidence of thrombus likely from
the vein
graft. The RCA was not injected. The LIMA was not injected. The
vein
grafts were not injected.
2. Limited resting hemodynamics demonstrated mild systemic
hypertension
with a blood pressure of 148/80, mean 106.
3. [**Name (NI) 26367**] PTCA and stenting of the mid LCx with a 3.0 x
15mm Promus
drug eluting stent which was postdilated to 3.25mm. Final
angiography
revealed no residual stenosis, no angiographically apparent
dissection,
and TIMI 3 flow. (see PTCA comments for details)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PTCA and stenting of the LCx.
Brief Hospital Course:
62 year old female with multiple medical problems including
diabetes type 2, dyslipidemia, hypertension and recent CABG
[**2171-7-22**] (see HPI for anatomy) who presented to ED with nausea
and found to have ST changes in lead III, avF and new left
bundle branch block.
.
# CAD s/p NSTEMI: Due to ST elevation in inferior leads and new
left bundle branch block, the patient was evaluated by cardiac
catheterization, which demonstrated occlusion of the OM 3 vein
graft. No intervention was done. The patient continued to have
nausea, vomiting and epigastric pain for the next several days,
felt to be consistent with ongoing ACS and completion of
infarct. She was followed with serial cardiac enzymes, which
peaked at Troponin 0.75, CK 349, CK-MB 50, MBIndex 14.3. She
was treated with integrillin and heparin post-cath, as well as
ASA, Plavix and statin. In addition, she was treated with
morphine, ativan and antiemetics prn for symptom control. The
patient's nausea, vomiting and epigastric pain, which were felt
to be an anginal equivalent, did not improve and she again
underwent cardiac cath on [**8-27**], with PTCA and drug-eluting stent
to the mid Left circumflex artery. Post procedure, nausea and
vomiting improved significantly.
.
#Acute Systolic Dysfunction: TTE showed new basal inferior wall
hypokinesis and LVEF 40 % (decreased from 50% at prior ECHO
[**7-14**]). No signs of fluid overload on physical exam; no O2
requirement or peripheral edema. She was started on ACEI and
long-acting beta blocker, to be continued as outpatient.
.
#HTN: Known history of hypertension. Blood pressure control was
initially difficult to obtain and the patient was transiently
maintained on a nitro drip after catheterization. During course
of stay, metoprolol was titrated up with a goal BP of 120/70.
She was discharged on long acting metoprolol and lisinpril.
.
# RHYTHM: Patient remained in sinus rhythm throughout admission,
with new left bundle branch block likely due to ischemia. See
treatment of ACS as above.
.
#Vomiting: Felt to be due to ongoing ischemia. Resolved after
second cardiac cath with DES to LCX. C diff negative. Stool Cx
pending. Nausea and vomiting completely resolved at discharge
with patient able to tolerate PO intake.
.
# Diabetes type 2: Metformin was held due to contrast
administration at cardiac cath. Pt was continued on outpatient
glipizide with humalog sliding scale.
.
# Dyslipidemia: Switched outpatient Simvastatin 80 mg qd to
Lipitor 80 mg during ACS. Patient to resume outpatient regimen
at discharge.
.
# Hypothyroidism: Continued home dose Synthroid.
Medications on Admission:
MEDICATIONS: reviewed with patient
GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth twice a day
LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet - 1 Tablet(s) by
mouth
once a day - No Substitution
LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth q hs prn
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a
day
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day
.
Medications - OTC
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC, DISC [ASCENSIA AUTODISC TEST] - Strip -
as directed twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
NICOTINE - 7 mg/24 hour Patch 24 hr - apply in am, remove hs
once
a day
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Start taking on [**8-30**] am.
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day: apply in am, remove at hs.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual for chest pain or nausea, take 5 minutes apart: If
you still have severe nausea or vomiting after 2 [**Month/Year (2) 4319**], call Dr. [**Name (NI) 11723**].
Disp:*1 bottle* Refills:*2*
11. Outpatient Lab Work
Please check Chem-7 on Monday [**2171-9-2**] and call results to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26368**]
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Non ST Elevation Myocardiac Infarction
Hypertension
Hyperlipidemia
Discharge Condition:
stable. Able to tolerate PO's.
Discharge Instructions:
You had a small heart attack and a drug eluting stent to your
left circumflex artery. We believe that your nausea is related
to your heart and should resolve with time. A stool sample was
sent which showed no signs of infection, a final report is
pending.
Medication changes:
1. Your Metoprolol was increased to 200mg long acting
2. START Lisinopril to lower your blood pressure and help your
heart pump better.
3. Increase aspirin to 325 mg daily for at least 2 months.
4. START Plavix to prevent the stent from clotting off. Do not
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr.[**Doctor Last Name 3733**] tells
you to.
5. START Reglan to treat your nausea. You [**Doctor First Name **] stop taking this
in a few days to see if your nausea is better without this
medicine.
6. Nitroglycerin: to take if your nausea or chest pressure
returns. See information sheet on how to take this.
.
Please look at your right and left groin sites and notify Dr. [**Name (NI) 11723**] if you see any bleeding, increasing pain or swelling,
or redness.
Also call Dr.[**Name (NI) 3733**] if you notice more nausea, vomiting,
chest pain, trouble breathing, sweating. Call your Ms [**First Name (Titles) **] [**Last Name (Titles) **]
for any abdominal pain, diarrhea, fevers, chills, or any other
unusual symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 1240**]: [**Telephone/Fax (1) 7976**] Date/Time: Monday
[**9-2**] at 5:15pm.
.
Cardiology:
Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2171-9-17**] 9:20
|
[
"733.90",
"414.02",
"250.00",
"426.3",
"305.1",
"V45.79",
"272.4",
"276.1",
"401.9",
"311",
"410.71",
"244.9",
"564.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.45",
"00.66",
"88.57",
"37.22",
"36.07",
"88.56",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
14054, 14112
|
8980, 11590
|
331, 411
|
14223, 14256
|
3272, 6542
|
15784, 16114
|
2254, 2426
|
12441, 14031
|
14133, 14202
|
11616, 12418
|
8873, 8957
|
14280, 14536
|
2441, 3253
|
14556, 15761
|
272, 293
|
439, 1808
|
1830, 2062
|
2078, 2238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,050
| 182,968
|
53996
|
Discharge summary
|
report
|
Admission Date: [**2189-3-28**] Discharge Date: [**2189-3-29**]
Date of Birth: [**2127-5-31**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Variceal Bleed
Major Surgical or Invasive Procedure:
TIPS
[**State **] Tube Placement
Arterial Line Placement
History of Present Illness:
Patient is a 60 year old male with a history HCVand alcoholic
cirrhosis complicated by known varices, with right renal to
portal vein thrombosis, hypertension, hyperlipidemia and
significant smoking history who initially presented to [**Hospital 40576**] this morning with hematemesis and hematochezia.
Prior to presentation per his family he had been complaining of
nausea. At [**Hospital3 **] he underwent an EGD that was initially
done without intubation but when they saw the amount of blood he
was intubated for airway protection. Per the gastroenterologist
at [**Hospital3 **] all that could be seen on the EGD were varices and
that the esophagus/stomach were both full of blood, as a result
7 bands were placed blindly. He had five PIV's placed (4x18g
and 1x16g in his EJ), he received a 7 units of PRBC's, 4 of FFP
and 2 of platelets, was started on octreotide and pantoprazole
drips and transferred to [**Hospital1 18**] for further evaluation.
In the ED, initial VS were: 70, 114/76, 17, 100%. He arrived
intubated and sedated, his blood pressures dropped into the 90's
systolic so he was given a total of 4LNS. He was given his 8th
and 9th units of blood, and then the massive transfusion
protocol was initiated. After discussion with hepatology since
he was continuing to bleed, the plan was for the patient to go
to IR for an emergent TIPS, despite his history renal vein and
right portal vein thrombosis IR felt that the procedure would be
successful. Additionally, he only made about 100cc's of urine
since his transfer from [**Hospital6 302**]. His labs were
notable for a HCT of 22.5, plt of 132, INR of 2.0, K of 7.8, Ca
of 5.8, Cr of 2.0 (unknown baseline), HCO3 of 13 and lactate of
6.0. He was given 1g of calcium gluconate, 10units of IV
insulin and an amp of D50 to treat the hyperkalemia, 1g of
ceftriaxone for SBP prophylaxis and transferred to the IR suite
for his procedure. VS on transfer: 70, 114/76, 14, 100% on PSV
[**7-12**], 100% FiO2.
.
In IR he continued to receive blood products, he received a
total of 10 units of PRBC's, 6 units of FFP, 1 pack of platelets
and 1 unit of cryo. A femoral a-line was placed for monitoring,
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] was placed in IR with the gastric balloon inflated
due to continued bleeding. The TIPS was eventually successfully
completed along with embolization of one large caliber gastric
varix, with reported good radiographic appearance. Also during
his IR course he became progressively more acidemic and
difficult to ventilate with rising PCO2 from the 50's up into
the 70's.
.
On arrival to the MICU, he was hemodynamically unstable on three
pressors, and then began to have large volume output of bright
red blood from his nose and mouth.
.
Review of systems: unable to obtain, patient is intubated and
sedated
Past Medical History:
- Hepatitis C and Alcoholic Cirrhosis
- Known varices seen on prior EGD
- H/O Encephalopathy
- Right Portal Vein Thrombosis
- Hypertension
- Hyperlipidemia
- Significant Smoking History
Social History:
Married, two daughters, 1 son, per family report significant
smoking history, remainder unknown
Family History:
unknown
Physical Exam:
Gen: intubated, sedated, nonresponsive
HEENT: football helmet in place, +[**Last Name (un) **], +ETT, large amount
of bright red blood in mouth, coming out of his nose and down
his face
Lungs: coarse breath sounds throughout
CV: regular, difficult to hear over the lung sounds
Abd: distended, firm
Ext: warm (was warmed during TIPS as he became hypothermic), +1
edema
Pertinent Results:
Chest X-ray: IMPRESSION:
1) ET tube approximately 2.9 cm above the carina.
2) Low inspiratory volumes with bibasilar atelectasis. If there
is concern for an infectious infiltrate, then a lateral view may
help for further assessment.
3) Possible enlargement of the superior mediastinum. Clinicial
correlation requested. PA upright chest or alternatively cross
sectional imaging could help for further assessment
.
CT A/P [**2189-3-28**] (OSH): Wet Read by [**Hospital1 18**] radiology-> gastric and
small bowel distension. Small bowel measures ~3.0cm. Nodular
liver + ascites. No pneumatosis. Right portal vein thrombosis
with extension into main portal vein.
Brief Hospital Course:
60yo man with a h/o HCV / EtOH cirrhosis who presented with an
acute variceal GI bleed, intubated for airway protection and
acute respiratory failure.
1) Variceal bleed: In the setting of known underlying cirrhosis
and his clinical presentation, a variceal bleed was found to be
the source of his bleed. He was on octreotide and PPI gtts,
underwent an emergent TIPS, while undergoing massive
transfusion. Despite successful TIPS with lower pressures post
procedure he continued to have large volume upper GI bleeding.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] was placed with both balloons inflated, still with
no hemostasis. He was supported with transfusions but continued
to bleed, surgery was also involved given the volume of his
bleed and progressive abdominal hypertension, but it was felt
that a surgical intervention was not indicated and would not be
helpful. His shock continued to worsen and he was requiring
increasing amounts of vasopressors, and developed worsening
renal dysfunction with acidemia and hyperkalemia. Despite
aggressive resuscitative efforts his condition worsened, after
discussions with the ICU and hepatology teams his family decided
to make him comfort measures only and he passed away shortly
after withdrawal of supports.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"V66.7",
"456.0",
"070.54",
"571.5",
"530.81",
"452"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6062, 6071
|
4682, 5975
|
308, 366
|
6126, 6139
|
3998, 4659
|
6198, 6348
|
3585, 3594
|
6033, 6039
|
6092, 6105
|
6001, 6010
|
6163, 6175
|
3609, 3979
|
3192, 3245
|
254, 270
|
395, 3173
|
3267, 3455
|
3471, 3569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,843
| 194,493
|
2815+55412
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-9-24**] Discharge Date: [**2159-9-30**]
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
pneumonia, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known firstname 1806**] [**Known lastname **] is a [**Age over 90 **] year old male with a history of
paroxysmal afib, type 2b heart block s/p [**Age over 90 4448**], PE s/p IVC
filter, and Parkinson's disease who presents from home with
pneumonia. Per the patient's wife he has not been himself and
was not giving good answers to questions. He has not played the
piano in two days and has been ignoring their dogs which is
unusual for him. Two days prior to presentation he reportedly
had a fever at home that resolved with agressive PO fluids and
ice on his forehead. He slept in and was more himself on
waking, but then became increasingly lethargic over the course
of the afternoon. He spiked a temperature of 101.4 at home and
his wife noticed a rattling sound in his chest. He was not
coughing and he was not short of breath. She called 911 per
advice of a family member who is a gerontologist.
.
In the ED, initial vs were: HR 84, BP 79/54, RR 34, O2 sat 88%.
Patient was noted to be audibly wheezing with diffuse rhonchi on
exam. He spiked a fever to 102.8. CXR showed a left lingular
pneumonia. EKG showed an old RBBB. Patient was given cefepime
2 g IV, vancomycin 1 g IV, acetaminophen 650 mg PR x 2 and 4L
NS. Vital signs on sign-out were BP 121/60, HR 69, RR 27, O2
sat 97% on 2L. He is being admitted to the ICU for "soft blood
pressures" and potential need for further IVF/pressors. Urine
output was 525 cc.
.
On arrival to the ICU, the patient denied any symptoms
whatsoever. Mental status was improved per the wife.
.
Review of systems:
(+) Per HPI
(-) Denies headache, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. 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:
Paroxysmal atrial fibrillation
Type IIb heart block: s/p dual chamber PM [**2155-1-29**]
PE in [**12-5**] with placement of IVC filter.
Parkinson disease diagnosed [**2156-7-29**]
GERD/hiatal hernia
h/o pancreatitis (etiology unknown) and SBO in [**8-7**]
Osteoarthritis
Chronic LBP - likely sciatica
Varicose veins s/p stripping in RLE
GI Bleed [**1-8**] ? Gastritis
.
Past Surgical History:
Repair of hiatal hernia
Open cholecystectomy,
Gastrojejunostomy tube
Gastropexy - for gastric volvulus (Dr.[**Last Name (STitle) **] 08)
Social History:
Patient lives with his wife at home and uses a walker to get
around. He is a retired jazz painist. He quit smoking in the
[**2108**]. No ETOH.
Family History:
not relevant to this admission.
Physical Exam:
Vitals: T: 96.5 BP: 113/57 P: 78 R: 27 O2: 95% on 2L NC
General: Elderly male in no acute distress. Alert. Oriented to
person, month, and year, but not to place (thought he was at
[**Hospital1 **])
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear on the right side. Decreased BS on the left side
half way up. Now wheezes or ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Pertinent Results:
[**2159-9-24**] 01:00AM BLOOD WBC-16.7*# RBC-4.13* Hgb-11.7* Hct-35.3*
MCV-86 MCH-28.3 MCHC-33.1 RDW-15.1
[**2159-9-28**] 09:30AM BLOOD WBC-7.7 RBC-3.93* Hgb-10.7* Hct-33.5*
MCV-85 MCH-27.1 MCHC-31.8 RDW-14.6 Plt Ct-305#
[**2159-9-25**] 03:00AM BLOOD PT-19.7* PTT-142.7* INR(PT)-1.8*
[**2159-9-26**] 06:10AM BLOOD PT-18.8* INR(PT)-1.7*
[**2159-9-28**] 09:30AM BLOOD PT-21.5* INR(PT)-2.0*
[**2159-9-24**] 01:00AM BLOOD Glucose-208* UreaN-35* Creat-1.8* Na-150*
K-4.4 Cl-119* HCO3-19* AnGap-16
[**2159-9-28**] 09:30AM BLOOD Glucose-84 UreaN-5* Creat-0.8 Na-141
K-3.7 Cl-111* HCO3-22 AnGap-12
[**2159-9-26**] 06:10AM BLOOD Calcium-8.9 Mg-1.9
Initial U/A
[**2159-9-24**] 01:15AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.014
[**2159-9-24**] 01:15AM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2159-9-24**] 01:15AM URINE RBC-[**2-2**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-<1
Follow up U/A
[**2159-9-28**] 08:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2159-9-28**] 08:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2159-9-28**] 08:25PM URINE RBC-2 WBC-5 Bacteri-NONE Yeast-NONE Epi-0
CHEST (PORTABLE AP) FINDINGS: In comparison with the study of
[**9-24**], there has been substantial increase in opacification at
the left base with silhouetting of the hemidiaphragm. This is
consistent with lower lobe pneumonia and possible pleural
effusion. Opacification at the right base could reflect
pneumonia involving the right lower lobe with possible effusion
as well. [**Month/Year (2) **] device remains in place. Some indistinctness
of pulmonary markings raises the possibility of elevated
pulmonary venous pressure. Esophageal distention due to
achalasia.
RENAL U.S. IMPRESSION:
1. Normal-appearing kidneys without evidence of abscess.
2. Highly irregular appearance of the urinary bladder wall with
nodular
thickening. While this could represent changes related to
obstructive
uropathy, due to enlarged prostate, and/or chronic cystitis,
further
evaluation by cystoscopy is recommended.
VIDEO OROPHARYNGEAL SWALLOW:
FINDINGS: There is severe swallow delay. No penetration or
aspiration is
visualized during the study. For further details, please refer
to the speech and swallow division note in OMR.
IMPRESSION: No penetration or aspiration on today's exam.
Microbiology:
[**2159-9-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-Negative
[**2159-9-24**] URINE Legionella Urinary Antigen -Negative
[**2159-9-24**] MRSA SCREEN MRSA SCREEN-{POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
[**2159-9-24**] URINE CULTURE-STAPH AUREUS COAG +
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Pending:
[**2159-9-24**] Blood Culture, Routine-PENDING
[**2159-9-24**] Blood Culture, Routine-PENDING
Brief Hospital Course:
[**Age over 90 **] M with a medical history notable for Parkinson's Disease. He
was admitted on [**9-24**] to the [**Hospital Unit Name 153**] with fever, lethargy and
hypotension (SBP 80s); he was found to have a pneumonia (likely
aspiration), and UTI (MRSA).
.
While in the [**Hospital Unit Name 153**] he received levofloxacin, ceftriaxone,
linezolid. His low SBPs were responsive to IV fluids. He did not
require intubation and did not require pressors for blood
pressure support.
.
.
# Pneumonia, likely aspiration
He received Ceftriaxone and Levfloxacin in the ICU, which was
narrowed to Levfloxacin 750 mg. He completed a 5 day course, and
his breathing remained comfortable without evidence of ongoing
infection after completion of the course.
.
# Chronic aspiration
Pt is well known to the Speech+Swallow service, and is known to
have hx of aspiration.
Pt passed video swallow, however, he is still at intermittent
risk for aspiration. He is recommended to eat pureed solids,
nectar thick liquids. Wife understands and accepts risk of
aspiration with po intake.
.
# UTI, MRSA
Pt was found to have a MRSA UTI during this admission, which is
currently being treated with Linezolid due to a vancomycin
allergy. He will complete a 2 week course of linezolid, which
will finish [**10-8**]. A renal ultrasound was obtained to rule out
renal abscess, which was negative, but there was noted to be
abnormalities on the bladder wall (see U.S. report), for which
cystoscopy was recommended. Pt will follow up with Urology as
an outpatient.
.
# Parkinson's Disease
- continued carbidopa-levodopa. Pt is on low dose, as he has a
history of being sedated with larger doses. He was continued on
his home dose without changes.
- PT consult
.
# Paroxysmal atrial fibrillation and history of DVT/PE s/p IVC
filter
Discussed with wife, and they are not opposed to continuing
warfarin and having INR followed.
- continued warfarin 3.5 mg.
.
# BPH, with urinary obstruction
Pt was noted to have significant retention throughout the
hospitalization. His bladder scans were followed closely on the
floor, and he was started on flomax in addition to his proscar
to aid in voiding. He continued to have retention at the time
of discharge, so a foley was placed. He should follow up with
Urology as an outpatient for his obstruction, as well as the
incidentally noted bladder nodularity for consideration of
cystoscopy.
- continued finasteride
- started flomax
.
DNR/DNI
DISP: [**Doctor First Name **] [**Telephone/Fax (1) 13774**] [**Location (un) 86**] VNA. Pt and family want him to
go home with 24 hour supervision.
Medications on Admission:
calcium carbonate [Calcium Carbonate] 500 mg daily
carbidopa-levodopa [Carbidopa-Levodopa]25-100 mg Tablet
0.5 tablet [**Hospital1 **]
cholecalciferol (vitamin D3) 800 units daily
finasteride [Finasteride] 5 mg daily
multivitamin [Multivitamin] daily
tamsulosin [Tamsulosin] 0.4 mg daily - not taking, gets nauseous
tiotropium bromide [Tiotropium Bromide] 18 mcg INH daily
warfarin [Warfarin] 3.5 mg daily
Discharge Medications:
1. cholecalciferol (vitamin D3) 1,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO once a day.
2. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. carbidopa-levodopa 25-100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3
times a day).
5. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM: for total dose 3.5 mg.
Please follow up with [**Hospital 197**] clinic for INR monitoring and
dose titration.
7. warfarin 1 mg Tablet [**Hospital **]: One (1) Tablet PO daily at 4 pm:
for total dose 3.5 mg.
Please follow up with [**Hospital 197**] clinic for INR monitoring and
dose titration.
8. linezolid 600 mg Tablet [**Hospital **]: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital **]:
One (1) INH Inhalation once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
# Pneumonia, likely aspiration
# Urinary tract infection, MRSA
# Chronic aspiration
# Parkinson's disease
# BPH, with urinary obstruction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with fevers and low blood pressure, and you
were found to have a pneumonia and a urinary tract infection
with MRSA. You are being treated with antibiotics.
Unfortunately, you have not been able to adequately urinate, and
you will be discharged with a foley catheter. Please follow up
with Urology as an outpatient to consider having the foley
removed in the future.
Followup Instructions:
Please call your primary care physician's office to schedule a
follow up appointment for approximately 1 week from discharge.
Name: [**Last Name (LF) 5533**],[**First Name3 (LF) **] M.
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Description: Urology Department: Surgery Location: E/CCE-3
Organization: [**Hospital1 18**] Phone: ([**Telephone/Fax (1) 772**]
Please call to schedule an appointment for approx 2-3 weeks from
discharge for evaluation of foley catheter and consideration of
removal. Please also consider cystoscopy, considering findings
on bladder ultrasound. Please refer to report.
Department: SURGICAL SPECIALTIES
When: [**Telephone/Fax (1) **] [**2160-1-18**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 2723**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 808**],[**Known firstname 2107**] Unit No: [**Numeric Identifier 2108**]
Admission Date: [**2159-9-24**] Discharge Date: [**2159-9-30**]
Date of Birth: [**2066-2-8**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 128**]
Addendum:
Patient was discharged on Oxygen 2-4 Liters NC. Patient with
new oxygen requirement due to pneumonia and aspiration.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]
Completed by:[**2159-9-30**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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|
6720, 9333
|
233, 239
|
11197, 11197
|
3662, 6697
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267, 1824
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11212, 11350
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2217, 2587
|
2764, 2911
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,439
| 179,687
|
7442
|
Discharge summary
|
report
|
Admission Date: [**2160-6-3**] Discharge Date: [**2160-6-8**]
Date of Birth: [**2093-8-5**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Bactrim / Bactroban
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory failure s/p airway fire
Major Surgical or Invasive Procedure:
rigid bronchoscopy
bronchoscopy
placement of arterial line
placement of right IJ central venous line
History of Present Illness:
67yo woman with h/o tobacco use, breast CA, who presented to [**Hospital 2586**] Hosp on [**2160-4-22**] with dyspnea, cough and
blood-streaked sputum x 4d, found to have R main stem bronchus
(RMSB) near obstruction, underwent laser resection [**4-24**]
complicated by intraoperative airway fire and extensive
endobronchial burn, now in resp failure s/p trach, transferred
for trach revision and second opinion.
.
Patient's CT scan at OSH showed a near obstructing RUL lung
mass, which on subsequent biopsy turned out to be a squamous
cell CA. She also had a breast biopsy recently which returned as
infiltrating ductal CA. On [**4-24**], she underwent a laser resection
of her lung mass in a palliative attempt to open up her RLL, RML
and RUL. They were able to open her RLL and RML, though upon
trying to open the RUL and while at 22% oxygen concentration an
airway fire occurred. The IP MD put his mouth on the ETT and
blew out the fire, though it lasted [**6-28**] secs in his opinion. She
suffered an extensive endobronchial burn injury. Subsequent to
that, she developed a large R pleural effusion, underwent
CT-guided drainage with pigtail cath placement, which itself was
complicated by a tension PTX, leading to eventual chest tube
placement. She was later felt to have a L PTX from barotrauma,
and underwent a L chest tube placement. A tracheostomy was
performed.
.
On [**5-8**], on a repeat bronch, it was noted that the patient had
narrowing of the R main stem bronchus again, severely limiting
her airflow. They dilated the RMSB and placed an uncovered 8mm x
30mm metal stent in the RMSB, expecting to occlude the RUL but
maintain the patency of the RLL and RML. Subsequent bronch
showed tumor starting to grow in the distal trachea, distorting
the opening of the R main bronchus. She then underwent [**2-23**]
treatments to this area with external beam XRT. Despite this,
her resp status worsened, with increasing tachypnea and air
hunger, which they felt was from near obstruction of the distal
trachea as visualized by another bronch.
A meeting was held with the patient's friend [**Name (NI) 27272**] [**Name (NI) **], who
felt that the pt would not want further measures taken, and so
the patient was made DNR/DNI. However, the patient's previously
estranged daughter [**Name (NI) **] [**Name (NI) 27273**] was [**Name (NI) 653**], and she stated that
she wanted the patient to continue to receive maximal care
except for electric shocks and CPR. Furthermore, she wanted the
pt transferred to [**Hospital1 18**] for a second opinion and possible
therapeutic measures. As [**Doctor First Name 27272**] was not officially the HCP, and
the daughter the next-of-[**Doctor First Name **], the patient was transferred to
[**Hospital1 18**]. Dr. [**First Name (STitle) **] [**Name (STitle) **] is the accepting physician.
Past Medical History:
1. Single episode of seizure of unclear etiology 20 years ago
with negative workup.
2. Supraventricular tachycardia.
3. Depression.
4. Arthritis.
5. Breast CA
6. Lung CA
Social History:
The patient smoked one to two packs a day for more than 40 years
(100+ packyears), quit [**2-25**]. No history of alcohol. Lives with
friend of five years, [**Name (NI) 27272**] [**Name (NI) **] [**Telephone/Fax (1) 27274**], who by the
pt's will should be the pt's HCP, though no HCP form was signed
by patient. Patient's daughter (previously estranged), [**Name (NI) **]
[**Name (NI) 27273**] [**Telephone/Fax (2) 27275**]w, [**Telephone/Fax (1) 27276**], lives in CT but recently
became involved again in her mother's care and is the NOK
(default HCP), wants aggressive measures taken.
Family History:
Notable for diabetes and cancer. Brother has multiple
sclerosis. Father died of a CVA.
Physical Exam:
T 96.7, HR 135, BP 111/56 (NI), 97/58 (a-line), AC 350 (300 obs)
x 30, 10 PEEP, Sat 94% on 100% FiO2
Gen: elderly ill-appearing woman, lying flat in bed, intub, sed,
paralyzed
HEENT: eyes closed, dry MM, neck bullous, trach in place with no
discharge
CV: difficult to appreciate any heart sounds [**1-24**] loud breathing
Lungs: from anterior exam -- loud coarse BS with rhonchi
throughout
Abd: obese, ND, decreased BS, no masses
Ext: 2+ pitting UE edema bilaterally, 1+ LE edema bilaterally
Skin: warm, diaphoretic
Neuro: sedated and paralyzed
Pertinent Results:
[**2160-5-8**] St. E BCX CNS
[**2160-5-26**]: St. E sputum cx: pseudomonas, pan sensitive and
stenotrophomonas [**First Name9 (NamePattern2) 27277**] [**Last Name (un) 36**] to gent, amikacin and bactrim.
[**2160-6-4**] Bcx negative
[**2160-6-4**]: Ucx yeast
[**2160-6-5**] Ucx pending
[**2160-6-5**] Bcx pending
[**2160-6-5**] cath tip pending
[**2160-6-5**] BAL 4+ PMN no organisms.
[**2160-6-6**] Stool c diff negative
.
CT Chest St. E [**6-2**]: complex stellate nodule in right lung apex,
azygous node 2.4 cm in diameter, perihilar mass 3.7 cm in
diameter. No mets in adrenal or liver.
.
[**2160-6-5**] LENI negative
[**2160-6-5**] CXR: partial reexpansion of RUL extensive perihilar
opacification in the absence of cardiomegly. fullness in right
hila.
.
[**2160-6-3**] 11:03PM TYPE-ART TEMP-35.9 RATES-30/0 TIDAL VOL-332
PEEP-8 O2-80 PO2-101 PCO2-56* PH-7.29* TOTAL CO2-28 BASE XS-0
AADO2-426 REQ O2-72 INTUBATED-INTUBATED VENT-CONTROLLED
[**2160-6-3**] 09:23PM TYPE-ART TEMP-35.9 RATES-27/0 TIDAL VOL-400
PEEP-10 O2-80 PO2-88 PCO2-60* PH-7.26* TOTAL CO2-28 BASE XS--1
AADO2-435 REQ O2-73 -ASSIST/CON INTUBATED-INTUBATED
[**2160-6-3**] 08:23PM TYPE-ART TEMP-36.6 RATES-24/0 TIDAL VOL-400
PEEP-10 O2-100 PO2-136* PCO2-68* PH-7.21* TOTAL CO2-29 BASE
XS--2 AADO2-525 REQ O2-86 -ASSIST/CON INTUBATED-INTUBATED
[**2160-6-3**] 08:23PM freeCa-1.31
[**2160-6-3**] 08:04PM GLUCOSE-144* UREA N-54* CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2160-6-3**] 08:04PM ALT(SGPT)-99* AST(SGOT)-41* LD(LDH)-230
CK(CPK)-31 ALK PHOS-470* TOT BILI-0.5
[**2160-6-3**] 08:04PM CK-MB-NotDone cTropnT-0.05*
[**2160-6-3**] 08:04PM DIGOXIN-2.4*
[**2160-6-3**] 08:04PM WBC-19.5*# RBC-3.37*# HGB-10.0*# HCT-30.3*#
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.2
[**2160-6-3**] 08:04PM NEUTS-86* BANDS-1 LYMPHS-3* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-6* MYELOS-0
[**2160-6-3**] 08:04PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
TEARDROP-OCCASIONAL
[**2160-6-3**] 08:04PM PLT COUNT-341
[**2160-6-3**] 08:04PM PT-14.6* PTT-23.0 INR(PT)-1.3*
[**2160-6-3**] 08:04PM RET AUT-1.3
Brief Hospital Course:
67yo woman with lung CA, extensive endobronchial burn from
airway fire with resultant resp failure, admitted for rigid
bronchoscopy. During her hospitalization the following issues
were addressed:
.
#Hypoxemic and hypercarbic respiratory failure: This was felt
to be due to combination of lung injury from smoke inhalation
with capillary leak, bilateral pneumonia, volume overload and
airway disease secondary to lobar collapse with lung cancer.
She underwent rigid bronchoscopy in the OR [**2160-6-4**] with
debridement of eschar, removal of RMS stent in pieces and
replacement of tracheostomy. Extensive pseudomembranes were seen
mid-trachea down to distal LLL. Lingula was obstructed with
pseudomembranes. She required pressure control ventilation with
maximum pressure and oxygenation support. Repeat bronchoscopy
[**2160-6-4**] showed diffuse eschar with with sluffing mucosa, lingula
obstructed by pseudomembrane, no bleeding. She was diuresed as
blood pressure tolerated, but by day three became hypotensive
requiring pressor support. LENIs were performed to evaluate for
PE and were negative. She was too unstable to go to the CT
scanner as she desaturated on FiO2 of 80% with any movement.
She was treated with vancomycin, cefepime for pneumonia. This
was changed to vancomycin and meropenem on day three. She
underwent a third bronchoscopy [**2160-6-5**]. An esophageal balloon
was placed [**2160-6-6**] which showed exp transpulmonary pressure 2,
insp transpulmonary pressure 15, exp intrathoracic pressure 16,
insp intrathoracic pressure 19, exp total pressure 18, insp
total pressure 34. She continued ot be difficult to oxygenate,
and required sedation and paralysis to maintain respiratory
support. She underwent two further bronchoscopies [**2160-6-7**].
.
#Hypotension: Thought to be pre-sepsis/SIRS. Blood pressure was
supported with normal saline iv fluid boluses and levophed.
Cortisol stimulation test was negative indicating no adrenal
insufficiency.
.
#Sedation: Patient was transfered from OSH intubated, sedated,
paralyzed; on Fentanyl drip, 300mcg/hr; Versed drip, 22mg/hr;
Nimbex drip, 4.2mcg/kg/min. Nibmex was changed to vecuronium as
nibmex was maxed and she was still responding. She was weaned
off vecuronium twice, but both times responded with hypoxemia,
PaO2 50s. When the decision was made to withdraw ventilatory
support, the vecuronium was discontintued five hours prior to
ventilatory weaning.
.
#Elevated wbc/fever: Patient was noted to have bilateral
infilatrates on chest x-ray and urinalysis consistent with
infection. Sputum and BAL cultures grew pseudomonas.
Additionally there was a report of stenotrophomonus infection at
the OSH that was not seen on BAL or sputum culture at [**Hospital1 18**].
She was treated initially with cefepime and vancomycin.
Cefepime was switched to meropenem to broaden gram-negative
coverage.
.
#CV
a) Supraventricular tachycardia ofunclear etiology, though
longstanding per the notes (was admitted to [**Hospital1 18**] in [**2152**] for
this problem). Started amiodarone at osh on [**2160-6-1**] in response
to SVT with HR in 160s. She was continued on Digoxin 0.125 qday,
and amiodarone was change to po dosing. She was in rapid afib
[**2160-6-6**], but otherwise remained in sinus, sinus tachycardia.
b) Coronaries: no h/o CAD
c) Pump: no prior history of CHF. volume overloaded with
continued urine output.
.
#DM: patient was kept on insulin gtt for tight glucose control.
.
# Anemia: stools were guiaic negative. anemia was thought to be
due to chronic inflammation.
.
#Buttocks: Decubitus ulcer was treated with accuzyme and dressed
daily
.
#FEN: patient continued ot have high residuals while on
paralytics. She received tubefeeds. electrolytes were repleted
as needed.
.
#Code status: the patient expired [**2160-6-8**] after family meeting
was held and decision made to withdraw care with focus on
comfort measures. The patient's daughter, [**Name (NI) **] [**Name (NI) 27273**], was
present. The patient's son had visited the day prior.
Medications on Admission:
Peridex [**Hospital1 **]
Digoxin 0.125 qd
Combivent MDI 4 puffs TID
Flovent MDI 110mcg 4 puffs [**Hospital1 **]
Pepcid 20mg qd
Heparin 5000 units SC TID
Accuzyme to coccyx/buttocks qd
Betadine to chest tube site daily
Fentanyl drip, 300mcg/hr
Versed drip, 22mg/hr
Nimbex drip, 4.2mcg/kg/min
Cefepime 2mg IV q12h
Perolube both eyes q6h
Insulin gtt 2 units per hour
Vancomycin 1gm IV q12h
Flagyl 500mg IV q8h
Amiodarone gtt, 0.5mg/min
Mucumyst 2cc with 2cc saline, nebulized, TID
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
lung cancer
breast cancer
airway burn
hypoxic and hypercapneic respiratory failure
pneumonia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"948.00",
"995.92",
"947.1",
"518.89",
"998.89",
"285.9",
"162.8",
"E879.8",
"996.59",
"038.43",
"V44.0",
"427.89",
"E878.6",
"482.1",
"707.03",
"E849.8",
"E876.8",
"518.81",
"V10.3",
"E849.7",
"427.31",
"799.02",
"250.00",
"V15.82",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"97.23",
"33.22",
"31.99",
"38.93",
"32.28",
"38.91",
"33.21",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11582, 11591
|
6971, 11022
|
341, 443
|
11727, 11736
|
4796, 6948
|
11792, 11928
|
4126, 4216
|
11550, 11559
|
11612, 11706
|
11048, 11527
|
11760, 11769
|
4231, 4777
|
266, 303
|
471, 3309
|
3331, 3502
|
3518, 4110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,427
| 148,232
|
51530
|
Discharge summary
|
report
|
Admission Date: [**2140-6-28**] Discharge Date:
Date of Birth: [**2078-1-10**] Sex: M
Service: VSU
CHIEF COMPLAINT: Ischemic right hand.
HISTORY OF PRESENT ILLNESS: The patient was initially
evaluated in the Emergency Room. He is a 63-year-old male
with blue index finger for three days. He reports onset of
pain without changes in his index finger and right hand. The
patient denies chest pain.
PAST MEDICAL HISTORY: Coronary artery disease status post
angioplasty ten years ago, hypercholesterolemia. Denies
diabetes, hypertension or stroke.
FAMILY HISTORY: There is a strong family history of
myocardial disease. Father with a myocardial infarction
after the age of 50.
ALLERGIES: Denied.
MEDICATIONS: None.
SOCIAL HISTORY: He is divorced. He has four grown children.
He admits to two drinks per day and has smoked for 40 pack
years.
PHYSICAL EXAMINATION: In the Emergency Room, 97.7, 88, 16,
149/96. Oxygen saturation 96 percent on room air. General
appearance: Elderly white male in no acute distress. HEENT
examination was unremarkable. Neck supple. Heart was a
regular rate and rhythm without murmur, rub or gallop. Chest
with occasional wheeze with bronchial sounds in the left mid
lung fields. Abdominal examination is benign. Rectal
examination is guaiac negative. Peripheral vascular
examination: No edema. Right hand with blue index finger.
Palpable radial pulse.
LABORATORY: CBC 9.5, hematocrit 48.3, platelet count
231,000. BUN 12, creatinine 0.8. CK 87, troponin-I 0.01.
RADIOLOGY: Chest x-ray: Possible hazy opacity in the right
lower lobe likely represents early pneumonia.
ELECTROCARDIOGRAM: Normal sinus rhythm without acute
ischemic changes.
HOSPITAL COURSE: Patient's pulse examination showed a
palpable radial and palpable upper atrial pulse bilaterally
with sensation and motor intact. Strength was [**5-25**]. Distal
pulses: Femorals were 2 plus bilaterally with palpable
dorsalis pedis pulses bilaterally. The right index finger
was bluish and tender on palpation. Intravenous
heparinization was instituted which was negative for
intracardiac mass or thrombus. The patient's left
ventricular cavity was normal in size and systolic function.
He underwent arteriogram with a right femoral approach. A
thoracic aortogram demonstrated non-visualized right
vertebral artery. The left vertebral artery was dominant and
enlarged. Otherwise, the aortic arch had a normal
appearance, specifically without evidence for atherosclerotic
disease involving the right subclavian or innominate
arteries. Attempts were made to access the innominate artery
and this was unsuccessful. Eventually using a 5 French SOS
cath, access was obtained. A guide wire was placed in the
axillary artery which catheter was advanced over the guide
wire which was removed. The upper extremity arteriogram
demonstrated normal appearance of the subclavian and proximal
axillary artery. The catheter was then advanced to the
axillary artery. The remainder of the upper extremity was
interrogated which demonstrated two arteriovenous shunts at
about the site of the elbow, one involving the cephalic vein
and the other involving the brachial vein. The remainder of
the upper extremity run-off demonstrated abrupt occlusion 11
cm before the radiocarpal joint. This had an appearance of
an involved occlusion in the palmar arch field via the ulnar
artery which was without significant disease. There was no
aneurysm or atherosclerotic disease identified to suggest a
source of embolus.
After reviewing these findings with Dr. [**Last Name (STitle) 1391**], it was
decided that a TPA infusion would be beneficial; therefore,
infusion was instituted. The patient was transferred to the
Medical Intensive Care Unit for continued monitoring and care
while receiving his TPA infusion. During the first 24 hours
of TPA therapy the groin wire was displaced and TPA was
stopped. This showed improvement in the index finger. The
patient continued to show improvement in the wound. He was
continued on intravenous heparin. Coumadization was
instituted on [**2140-6-30**], and he was transferred to the
regular nursing floor. The patient was discharged to home in
stable condition when INR was therapeutic. The patient was
discharged on post procedure five. His heparin was
discontinued. His INR was at 1.8. He was discharged on a
Coumadin dose of 7.5 mg q. day. He will follow up as
directed for continuing monitoring of his coags and
adjustment of his anticoagulation.
DISCHARGE MEDICATIONS:
1. Pentamidine 20 mg b.i.d.
2. Atorvastatin 10 mg q. day.
3. Metoprolol 25 mg b.i.d.
4. Coumadin 7.5 mg q. day.
DISCHARGE DIAGNOSES: Ischemic right index finger secondary
to embolus, source not identified.
Status post radial artery lysis and angiogram.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1391**] in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2140-7-4**] 12:53:25
T: [**2140-7-4**] 13:43:08
Job#: [**Job Number **]
|
[
"486",
"414.01",
"272.0",
"V45.82",
"444.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"88.49",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
592, 749
|
4701, 4823
|
4565, 4679
|
1744, 4542
|
4835, 5163
|
901, 1726
|
138, 160
|
189, 424
|
447, 575
|
766, 878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,990
| 128,290
|
54374+54375+59598
|
Discharge summary
|
report+report+addendum
|
Unit No: [**Numeric Identifier 111318**]
Admission Date: [**2132-7-17**]
Discharge Date: [**2132-7-22**]
Date of Birth: [**2061-5-11**]
Sex: M
Service: MED
This is an off-service note which covers the patient's
admission from [**7-17**] through [**2132-7-21**].
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man
with past medical history significant for type 2 diabetes,
cirrhosis, alcohol abuse and hypertension who was in his
usual state of health until two days prior to admission when
he developed increasing fatigue, nonproductive cough and
decreased p.o. intake. The patient also noted some neck
stiffness. In addition, he had some baseline pain secondary
to vocal cord surgery approximately one week prior to
admission. For his neck stiffness and his vocal cord pain he
was taking mainly Tylenol but also Aleve. In addition his
home is not air conditioned and he was dehydrated. Also of
note is that the patient had several episodes of hypoglycemia
over the past three days.
At approximately 12:30 p.m. on the day of admission he was
found by his daughter short of breath at home with a
complaint of left-sided chest pain and left arm pain. At
this time he was noted to be taking rapid shallow breaths.
She called his primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**], who
recommended that the patient be taken to [**Hospital1 346**] for further evaluation. When EMS
arrived the patient's heart rate was in the 180's. He was
given 25 mg of IV diltiazem and became hypotensive.
Upon arrival at the [**Hospital1 69**] his
vital signs were checked and his heart rate was found to be
in the 140's. The patient was again treated with 25 mg of IV
diltiazem and his systolic blood pressure dropped to the
60's. He was treated with six liters of normal saline.
Chest x-ray showed a left upper lobe pneumonia for which he
received a dose of Levaquin and was eventually intubated for
worsening ABG's. The patient remained hypotensive with maps
less than 60 and a heart rate in the 140's. He was started
on _______, dopamine and vasopressin. He received an
additional four liters of intravenous fluids, vancomycin and
stress dose steroids. Due to persistently low maps and being
unresponsive to intravenous fluids on three pressors, the
patient was cardioverted with 200 joules. This temporarily
improved his hemodynamics. A groin line was placed for
better access.
The patient denied history of cardiac disease. At baseline
he can climb two flights of stairs without difficulty.
REVIEW OF SYMPTOMS: Significant for worsening cough. He
denied fevers, chills, nausea or vomiting. He denied history
of gastrointestinal bleed. He did have some chest pain when
his daughter initially found him.
PAST MEDICAL HISTORY: Cirrhosis secondary to alcohol abuse.
Diabetes.
Hypertension.
Vocal cord polyp removal.
Drop foot.
Abdominal hernia.
Pseudothrombocytopenia.
Bilateral cataract surgery.
Zoster six months ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metformin 500 mg b.i.d.
2. Lexapro 40 mg b.i.d.
3. Hydrochlorothiazide 25 mg q. day.
4. Doxazosin 4 mg q. hs.
5. Spectravite q. day.
6. Vitamin B1.
7. Lactulose 15 mL q. day.
FAMILY HISTORY: Mother with diabetes. No family history of
liver or kidney disease.
SOCIAL HISTORY: The patient lives with his wife who is house-
bound in a wheelchair. He has three daughters and two sons.
His daughter, [**Name (NI) **] [**Name (NI) 17**], is his health care proxy. [**Name (NI) **] has a
remote 50 pack year history of smoking. He has a significant
alcohol history.
PHYSICAL EXAMINATION: Temperature 98, heart rate 110, blood
pressure 110/70, respiratory rate 25, vented on assist
control of 700 x 25 satting at 100 percent. General:
Intubated sedated male nonresponsive. HEENT: Sclerae
anicteric. Pupils equal, round and reactive to light.
Cardiovascular: Regular, tachycardia, no murmurs, rubs or
gallops. Lungs: Rhonchi on the left. Clear on the right.
Abdomen soft, non-distended, non-tender, normoactive bowel
sounds, large ventral reducible hernia, obese. Extremities:
No clubbing, cyanosis or edema, 1 plus dorsalis pedis and
posterior tibialis pulses. Neurological: The patient
withdraws to pain.
HOSPITAL COURSE: Pneumonia: Upon admission the patient's
chest x-ray was significant for a left upper field pneumonia.
Upon hydration the radiographic findings were markedly worse.
The patient was started on vancomycin, levofloxacin and
Flagyl. Respiratory cultures were sent. These grew out
Strep pneumoniae. At this time the patient was switched to
ceftriaxone. The following day's sensitivities revealed that
this bacteria was sensitive to penicillin. Ceftriaxone was
then discontinued and the patient's antibiotic therapy was
then switched to penicillin.
INCOMPLETE DICTATION
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 39096**]
Dictated By:[**Doctor Last Name 2020**]
MEDQUIST36
D: [**2132-7-22**] 12:58:32
T: [**2132-7-22**] 13:23:57
Job#: [**Job Number 111319**]
Unit No: [**Numeric Identifier 111318**]
Admission Date: [**2132-7-17**]
Discharge Date: [**2132-7-22**]
Date of Birth: [**2061-5-11**]
Sex: M
Service: MED
Continuation of previous report:
Pneumonia: Upon admission patient's chest x-ray showed a
left upper lobe consolidation. Upon hydration his
radiographic findings worsened. Initially the patient's
pneumonia was treated with Flagyl, levofloxacin and
vancomycin. However, when an endotracheal sample grew out
Strep pneumoniae his antibiotic regimen was switched to
ceftriaxone. The following day the sensitivities for this
organism were complete and it was found that the Strep
pneumoniae was sensitive to penicillin. At this time the
patient's antibiotic regimen was again switched to penicillin
alone and the antibiotics were discontinued. A CT scan of
the patient's chest was obtained. This showed a left upper
and left lower lobe consolidation with patchy infiltrates
consistent with pneumoniae, bilateral pleural effusions, left
greater than right, cirrhosis and findings consistent with
portal hypertension. With the severity of the patient's
pneumonia, ceftriaxone was again added to the patient's
antibiotic regimen to ensure broader coverage. Initially the
patient required 18 PEEP to maintain good oxygenation. At
the time of this dictation his PEEP was weaned down to 14-16
and his FiO2 down to 50 percent. On these settings he was
satting 100 percent.
Acute renal failure: The patient on presentation had acute
renal failure with a creatinine of 3.8. His renal failure
was felt to be secondary to his long-standing diabetes and
hypertension in the setting of NSAID use, decreased p.o.
intake, dehydration and persistent hydrochlorothiazide and
ACE inhibitor use and low blood pressure in the setting of
pneumonia/sepsis. It was believed that the patient was in
ATN. He was initially started on a bicarb drip which was
discontinued in the Medical Intensive Care Unit as the
patient's bicarb on his Chem-7 was greater than 20.
Initially the patient became oliguric making only
approximately 5 cc/hour of urine. However, at the time of
this dictation the patient was entering a polyuric phase of
ATN with increased urine output. In addition, his creatinine
began to improve closer to baseline and was 2.1 at the time
of this dictation.
Acidosis: The patient had a combination of respiratory and
metabolic acidosis at presentation to the Medical Intensive
Care Unit. His metabolic acidosis was likely secondary to
sepsis as evidenced by his elevated lactate greater than 10.
The patient's respiratory acidosis was secondary to
hypoventilation in the setting of mild chronic obstructive
pulmonary disease given his significant tobacco history.
Lastly, the patient received multiple liters of normal saline
infusion and does likely have a non anion gap acidosis from
this. His last tape was closely monitored and this resolved
quickly. The patient was also hyperventilated on the vent
which also helped improve his acidosis. At the time of this
dictation his acidosis had completely resolved, his anion gap
had closed and his lactate levels were normal.
Hypotension: The patient was hypotensive upon admission to
the Emergency Room. He was started on vasopressin, Neo-
Synephrine and dopamine. Upon arrival to the floor he was
switched to Levophed, dopamine and vasopressin. His maps
were kept greater than 60. He had a central line placed for
CVP measurement. He was weaned off of dopamine and continued
on Levophed and vasopressin. Because the patient had
persistent bradycardia, these two medications were stopped
and he was started on dopamine at the time of this dictation.
The patient's requirement for pressors was also significantly
reduced at the time of this dictation.
Thrombocytopenia: The patient had a diagnosis of
pseudothrombocytopenia at the time of dictation. His blood
was sent in a special tube for platelet analysis. This
revealed that he did, indeed, have thrombocytopenia with a
platelet count of 33,000. The thrombocytopenia was thought
to be secondary to hypersplenism as evidenced on his CT scan.
In addition, some element of bone marrow suppression was
thought to be contributing to his thrombocytopenia.
Atrial fibrillation: At presentation to the Emergency Room
the patient was in rapid atrial fibrillation with a rapid
ventricular response. This was felt to be secondary to
increased cardiac output demand in the setting of infection.
The patient was cardioverted in the Emergency Room and
remained in normal sinus rhythm throughout his hospital
course. He was not anticoagulated given his increased
bleeding risk secondary to likely esophageal varices. In
addition, this was his first episode of atrial fibrillation
and it was felt that the factors contributing to this event
were resolving. Specifically, the patient's septic
physiology was improving.
Coagulopathy: The patient had an elevated INR at the time of
presentation. This was thought to be secondary to his liver
disease. A DIC panel was relatively unremarkable with FDP of
10-40 and a fibrinogen greater than 400. His INR's were
monitored. In the setting of broad spectrum antibiotic use,
his INR increased to 3.1. At this time he received vitamin
K.
Thrombosis/hepatoma: Upon presentation the patient was
evaluated for _____________. Given his liver disease an
abdominal ultrasound was obtained. This revealed moderate
degree of ascites. Signs of portal hypertension with a
markedly enlarged spleen containing a small cyst. Occluded
and expanded portal vein, right portal vein and anterior and
posterior right portal vein with thrombus extending down the
SMV. An 8 cm thrombus within the SMV was noted. The patient
was also found to have a distended gallbladder containing a
large stone but no definite evidence of acute cholecystitis.
Lastly, there was a very abnormal liver with focal areas of
mass light configuration particularly evident within the left
lobe lateral segment where there was a five times 5 cm
apparent mass. With these radiographic findings,
anticoagulation was again considered. The Liver team was
consulted who felt that this could represent a stable clot
from portal congestion. The plan was made to get a repeat
abdominal ultrasound to see whether or not this clot had
extended after a few days. If the clot appeared unstable or
larger, the plan was to inform the family of the bleeding
risk of starting anticoagulation and to anticoagulate the
patient. As for his apparent liver mass, the [**Last Name (un) **] and AFP
tumor markers were sent. These were just minimally elevated
above normal. The long term plan was to obtain an MRI when
the patient was more stable to further evaluate this mass.
Bradycardia: The patient had initially presented to the
Medical Intensive Care Unit with tachycardia. However, over
the course of several days his heart rate persistently
slowed. This was thought to be multifactorial. Possible
etiologies included sedation, tachybrady syndrome given his
recent history of atrial fibrillation, slow heart rate
secondary to sepsis, some [**Last Name **] problem with his conduction
system such as endocarditis or abscess. At the time of this
dictation the plan was to wean his sedation and to start the
patient back on dopamine as this may help his heart rate.
INCOMPLETE DICTATION
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 12-981
Dictated By:[**Doctor Last Name 2020**]
MEDQUIST36
D: [**2132-7-22**] 13:22:58
T: [**2132-7-22**] 14:21:34
Job#: [**Job Number 111320**]
Name: [**Last Name (LF) 18267**],[**Known firstname **] Unit No: [**Numeric Identifier 18268**]
Admission Date: [**2132-7-17**] Discharge Date: [**2132-8-20**]
Date of Birth: [**2061-5-11**] Sex: M
Service: MED
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 10790**]
Chief Complaint:
Sepsis Protocol admit
Pneumonia
Hypotension
Major Surgical or Invasive Procedure:
endotracheal intubation & mechanical ventilation
History of Present Illness:
71 year-old man with a PMH significant for type II diabetes,
cirrhosis, alcohol abuse and HTN who was in his usual state of
health until 2 days prior to admission when he developed URI
symptoms. Patient also reported increased fatigue,
non-productive cough, neck stiffness, decreased PO intake and
increased NSAID use in the setting of recent vocal cord surgery.
In addition his home is not airconditioned and he has been
dehydrated. Also of note is that the patient has had several
episodes of hypoglycemia over the past 3 days.
At approximatley 12:30PM on the day of admission he was found by
his daughter short of breath at home with complaint of
left-sided chest and arm pain. At this time he was noted to be
taking rapid shallow breaths. She called his primary care
[**Last Name (LF) 18269**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18270**], who recommended the patient be taken to
[**Hospital1 8**] for further evaluation. When EMS arrrived the patient's
HR was in the 180s. He was given 25mg IV Dilt and became
hypotensive.
ED EVENTS
In ED his HR was 140s. Patient was again treated with 20mg IV
dilt and SBP dropped again again to the 60s. Hypotension in ER
was treated with 6L NS. CXR showed LLL pneumonia for which he
received a dose of levaquin and was eventually intubated with
worsening ABGs. Patient remained hypotensive with MAPs <60 and
HR 140's. He was started on Neo dopa and vasopressin. He
received an additional 4L IVF, vancomycin, and stress dose
steroids. Due to persistently low MAPs unresponsive to IVF
while on 3 pressors the patient was cardioverted with 200J.
This temporary improvement his hemodynamics. Upon transfer to
MICU the patient's groin line was lost and right subclavian
placed.
Past Medical History:
PAST MEDICAL HISTORY: Cirrhosis secondary to alcohol abuse.
Diabetes.
Hypertension.
Vocal cord polyp removal.
Drop foot.
Abdominal hernia.
Pseudothrombocytopenia.
Bilateral cataract surgery.
Zoster six months ago.
Social History:
h/o EtOH use --> cirrhosis, still w/ periodic EtOH use
60+ pk/yr tobacco use, quit [**2123**]
Family History:
Father - diabetes
Physical Exam:
ON ADMISSION:
T=98 HR 110 BP 110/70 RR 25 vented on AC 700x25
Gen: intubated, sedated
HEENT: anicteric sclera, PERRLA
CV: reg, tachy, no r/m/g
lungs: ronchi on left
ABD: soft, mod distension, NABS, ventral hernia reducible
EXT: no c/c/r
Neuro: withdraws to pain
Pertinent Results:
[**2132-7-17**] 11:53PM TYPE-ART PO2-103 PCO2-41 PH-7.22* TOTAL
CO2-18* BASE XS--10
[**2132-7-17**] 09:47PM LACTATE-6.4*
[**2132-7-17**] 07:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2132-7-17**] 07:00PM WBC-7.6 RBC-3.52* HGB-11.5* HCT-34.1* MCV-97
MCH-32.6* MCHC-33.7 RDW-14.7
[**2132-7-17**] 07:00PM NEUTS-85.5* BANDS-0 LYMPHS-10.6* MONOS-3.0
EOS-0.7 BASOS-0.2
[**2132-7-17**] 07:00PM PT-17.9* PTT-40.8* INR(PT)-2.1
[**2132-7-17**] 02:30PM ALT(SGPT)-47* AST(SGOT)-67* LD(LDH)-182
CK(CPK)-166 ALK PHOS-41 TOT BILI-1.7*
Brief Hospital Course:
Pneumonia/Respiratory failure: Upon admission patient's chest
x-ray showed a left upper lobe consolidation. Upon hydration
his radiographic findings worsened. Initially the patient's
pneumonia was treated with Flagyl, levofloxacin and vancomycin.
However, when an endotracheal sample grew out Strep pneumoniae
his antibiotic regimen was switched to ceftriaxone. The
following day the sensitivities for this organism were complete
and it was found that the Strep pneumoniae was sensitive to
penicillin. At this time the patient's antibiotic regimen was
again switched to penicillin alone and the antibiotics were
discontinued. A CT scan of the patient's chest was obtained.
This showed a left upper and left lower lobe consolidation with
patchy infiltrates consistent with pneumoniae, bilateral pleural
effusions, left greater than right, cirrhosis and findings
consistent with portal hypertension. With the severity of the
patient's pneumonia, ceftriaxone was again added to the
patient's antibiotic regimen to ensure broader coverage.
Initially the patient required 18 PEEP to maintain good
oxygenation. On [**7-23**] he was on only PCN and was satting well &
was normotensive. On [**7-24**] he became hypotensive with inc WBC &
inc temp. He was started on zosyn, flagyl & vancomycin. His
sputum eventually grew out MRSA, presumed to be ventilator
associated PNA. He completed a 21 day course of vanc on [**8-13**].
Since the d/c of antibiotics he remained afebrile and
hemodynamically stable. He was extubated on [**8-17**], and he did
very well with minimal supplemental oxygen. He was weaned to
room air on [**8-19**] and reported no dyspnea.
Acute renal failure: The patient on presentation had acute
renal failure with a creatinine of 3.8. His renal failure was
felt to be secondary to his long-standing diabetes and
hypertension in the setting of NSAID use, decreased p.o. intake,
dehydration and persistent hydrochlorothiazide and ACE inhibitor
use and low blood pressure in the setting of pneumonia/sepsis.
It was believed that the patient was in ATN. He was initially
started on a bicarb drip which was discontinued in the MICU as
the patient's bicarb on his Chem-7 was greater than 20.
Initially the patient became oliguric making only approximately
5 cc/hour of urine. However, he eventually entered a polyuric
phase of ATN with increased urine output. In addition, his
creatinine began to improve and returned to [**Location 1867**] at the time
of discharge. Due to his septic shock and hypotension, he
received many fluid boluses and was net + over 30 liters. He was
fairly aggressively diuresed with Lasix and required dopamine to
maintain his BP & UOP. At the time of extubation, he was approx
10 L +, he demonstrated no evidence of pulmonary edema.
Acidosis: The patient had a combination of respiratory and
metabolic acidosis at presentation to the MICU. His metabolic
acidosis was likely secondary to sepsis as evidenced by his
elevated lactate greater than 10. The patient's respiratory
acidosis was secondary to hypoventilation in the setting of mild
chronic obstructive pulmonary disease given his significant
tobacco history. Lastly, the patient received multiple liters of
normal saline infusion and does likely have a non anion gap
acidosis from this. His last tape was closely monitored and
this resolved quickly. The patient was also hyperventilated on
the vent which also helped improve his acidosis. At the time of
this dictation his acidosis had completely resolved, his anion
gap had closed and his lactate levels were normal.
Hypotension/septic shock: The patient was hypotensive upon
admission to the Emergency Room. He was started on vasopressin,
Neo-Synephrine and dopamine. Upon arrival to the floor he was
switched to Levophed, dopamine and vasopressin. His MAPS were
kept greater than 60. He had a central line placed for CVP
measurement. He was weaned off of dopamine and continued on
Levophed and vasopressin. Because the patient had persistent
bradycardia, these two medications were stopped and he was
started on dopamine at the time of this dictation. On [**7-24**], when
he became hypotensive, he was restarted on pressors, eventually
requiring dopamine to maintain adequate MAPS & urinary output.
This was slowly weaned & at the time of extubation, he was off
of pressors, and maintaining adequate MAPs.
[**Month (only) **] platelets/WBC: The patient had a diagnosis of
pseudothrombocytopenia at the time of dictation. His blood was
sent in a special tube for platelet analysis. This revealed
that he did, indeed, have thrombocytopenia with a platelet count
of 33,000. The thrombocytopenia was thought to be secondary to
hypersplenism as evidenced on his CT scan. In addition, some
element of bone marrow suppression was
thought to be contributing to his thrombocytopenia. Hematology
was consulted and followed for several days. It was thought that
his decreased platelets & WBC were secondary to hypersplenism
and decreased thrombopoietin production, combined with his
sepsis, and possibly low WBC secondary to cirrhosis. He also
developed a worsening of his thrombocytopenia in the setting of
receiving heparin. Concern was for heparin induced
thrombocytopenia. Heme was consulted as above. He was thought to
have adequate marrow response. Further evaluation is deferred to
his outpatient PMD.
Atrial fibrillation: At presentation to the Emergency Room the
patient was in rapid atrial fibrillation with a rapid
ventricular response. This was felt to be secondary to
increased cardiac output demand in the setting of infection. The
patient was cardioverted in the Emergency Room and remained in
normal sinus rhythm throughout his hospital course. He was not
anticoagulated given his increased bleeding risk secondary to
likely esophageal varices. In addition, this was his first
episode of atrial fibrillation and it was felt that the factors
contributing to this event were resolving. Specifically, the
patient's septic physiology was improving.
Diabetes: The pt required close management of his blood sugars
throughout his stay, and was on an insulin drip for most of the
time he was intubated. Once extubated, he was evaluated by
speech & swallow. He was cleared to start liquid diet and was
quickly transitioned to a regular diet which he tolerated well.
Coagulopathy: The patient had an elevated INR at the time of
presentation. This was thought to be secondary to his liver
disease. A DIC panel was relatively unremarkable with FDP of
10-40 and a fibrinogen greater than 400. His INR's were
monitored. In the setting of broad spectrum antibiotic use, his
INR increased to 3.1. At this time he received vitamin K.
Initial HIT panel showed HIT+, another cause of his
thrombocytopenia. There was discussion about starting argatroban
or lepirudin for anticoagulation, but it was decided, in concert
with heme, that the risks outweighed the benfits, and no further
anticoagulation was started.
Thrombosis/hepatoma: Given his liver disease an abdominal
ultrasound was obtained. This revealed moderate degree of
ascites. Signs of portal hypertension with a markedly enlarged
spleen containing a small cyst. Occluded and expanded portal
vein, right portal vein and anterior and posterior right portal
vein with thrombus extending down the SMV. An 8 cm thrombus
within the SMV was noted. The patient was also found to have a
distended gallbladder containing a large stone but no definite
evidence of acute cholecystitis. Lastly, there was a very
abnormal liver with focal areas of mass light configuration
particularly evident within the left lobe lateral segment where
there was a five times 5 cm apparent mass. With these
radiographic findings, anticoagulation was again considered.
The Liver team was consulted who felt that this could represent
a stable clot from portal congestion. Repeat u/s did not show
extension of the clot. As for his apparent liver mass, the [**Last Name (un) **]
and AFP tumor markers were sent. These were just minimally
elevated above normal. The long term plan was to obtain an MRI
when the patient was more stable to further evaluate this mass.
Bradycardia: The patient had initially presented to the MICU
with tachycardia. However, over the course of several days his
heart rate persistently slowed. This was thought to be
multifactorial. Possible etiologies included sedation,
tachybrady syndrome given his recent history of atrial
fibrillation, slow heart rate secondary to sepsis, some [**Last Name **]
problem with his conduction system such as endocarditis or
abscess. Once off pressors, and his septic shock resolved, his
bradycardia resolved, and he remained in NSR with no ectopy the
remainder of his stay.
Medications on Admission:
1. Metformin 500 mg b.i.d.
2. Lexapro 40 mg b.i.d.
3. Hydrochlorothiazide 25 mg q. day.
4. Doxazosin 4 mg q. hs.
5. Spectravite q. day.
6. Vitamin B1.
7. Lactulose 15 mL q. day.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Lactulose 10 g/15 mL Syrup Sig: One (1) PO once a day.
4. Insulin 70/30 70-30 unit/mL Suspension Sig: Eighty Five (85)
Units Subcutaneous QAM (every morning).
5. Insulin 70/30 70-30 unit/mL Suspension Sig: Seventy Five (75)
units Subcutaneous QPM (every evening).
6. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
pneumonia
respiratory failure
heparin induced thrombocytopenia
cirrhosis
septic shock - resolved
Discharge Condition:
good
Discharge Instructions:
1. Rehab at extended care facility to regain your strength.
2. Follow up with your primary care doctor, Dr. [**Last Name (STitle) 18270**], as soon as
possible.
Followup Instructions:
1. Extended care facility for rehab
2. with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18270**] as soon as possible
[**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**]
Completed by:[**2132-8-20**]
|
[
"287.4",
"482.41",
"995.92",
"785.52",
"038.2",
"518.81",
"584.5",
"427.31",
"481"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.61",
"96.6",
"99.15",
"34.91",
"96.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
25972, 26053
|
16356, 25119
|
13201, 13252
|
26193, 26199
|
15731, 16333
|
26409, 26720
|
15407, 15426
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25145, 25325
|
4307, 13100
|
26223, 26386
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15441, 15441
|
3660, 4289
|
13117, 13163
|
13280, 15041
|
15455, 15712
|
15086, 15280
|
15296, 15391
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,424
| 188,476
|
27794
|
Discharge summary
|
report
|
Admission Date: [**2125-1-24**] Discharge Date: [**2125-2-27**]
Date of Birth: [**2080-4-16**] Sex: M
Service: MEDICINE
Allergies:
Tegaderm / Codeine / Penicillins / Neurontin / Lorazepam / Latex
Attending:[**First Name3 (LF) 10644**]
Chief Complaint:
Worsening pain
Major Surgical or Invasive Procedure:
PICC placement
Chemotherapy
History of Present Illness:
44 y/o male w/ metastatic renal cell carcinoma (extensive
metastases to bone)who presented to clinic with worsening pain,
particularly in his sacrum. After his last hospitalization (d/c
on [**2125-1-8**]), he was able to ambulate with a walker and had
achieved modest pain control with methadone (dose was increased
to 60 mg PO TID) to the point where he was not using much
dilaudid for breakthrough. However, since then, he has called
the clinic multiple times for worsening pain not covered by
medications at home. He's increased the use of dilaudid to
approximately 24 mg PO daily and had also started using MS
Contin 30 mg PO BID. Despite these medications, he has been
essentially bed bound, to the point where he is not even able to
stand and self cath. Since starting MS Contin, he has had nausea
and emesis (brown, nonbloody, nonbilious). He has not eaten any
PO solids in 2 days. He came to clinic today for a regularly
scheduled appointment, during which he was supposed to get
gemzaar and zometa. However, treatment was deferred and the pt
was admitted to 7F for better pain control and possible [**Hospital1 1501**]
placement. Discussions have been had during previous
hospitalizations around hospice and what services are available
at home. Other than his girlfriend, the patient does not have
many supports and has come to the point where he needs more care
at home than outpatient services can provide.
Past Medical History:
ROS:
+ "feeling warm", w/ temp of 99; however taking RTC tylenol at
home
+ chills, but denies night sweats
~30# wt loss since [**11-27**]
denies CP, palp, SOB
denies URI sx other than mild ear pain
denies LH, headaches, dizziness
denies abd pain
+ mild odynophagia, but able to take PO liquids OK
+ n/v (none since yesterday)
normal BM, nonbloody, no melena
+ numbness and tingling in genitals/buttocks since [**2125**]
denies leg swelling
+ urinary retenion but no dysuria or hematuria
.
PMH:
Metastatic renal cell carcinoma (see below)
Recent ? UGIB (felt to be due to esophagitis)
Thoracotomy, ex lap after stab wound
Herniorrhaphy
Bilateral ankle injuries
.
ONC HX:
In [**2124-5-22**], he was diagnosed with metastatic renal cell
carcinoma following a pathological fracture of his left femur.
His leg was stabilized at [**Hospital1 336**], and a biopsy of the left thigh
mass was positive for clear cell carcinoma. His postoperative
course was complicated by a PE and treated with Lovenox. A bone
scan also revealed metastasis to the left distal femur and right
acetabulum. From [**2124-5-29**] to [**2124-6-16**] he received palliative
radiation to these areas. Subsequently, in a staging work-up, a
torso CT also indicated two lung lesions, and a lesion in his
right kidney. The patient transferred his oncological care to
[**Hospital1 69**] in [**2124-8-22**] and started
on Zometa and Sutent. Later that month, an MRI of the brain
indicated a solitary enhancing mass in the right occipital lobe.
The lesion was treated with Cyberknife radiosurgery on [**2124-9-18**]
to 2,220 cGy in one fraction. On [**2124-10-9**] the patient presented
to the ED with urinary retention, numbness of his perineal area,
and leg pain. An MRI of the thoracic/lumbar spine indicated
lesions in the sacrum and T5 vertebrae. Subsequently, he had
external beam radiation to these areas from [**2124-10-10**] to [**2124-10-16**].
He has been intermittently on Sutent since [**8-27**]. During his last
admission in [**11-27**], the Sutent was stopped as it was thought it
was contributing to his neutropenia and esophagitis. The Sutent
was restarted on [**2124-12-18**]. He had an MRI of his Lspine on
[**2124-12-23**], which showed stable involvement of L3-L4 but increased
involvement of the sacrum. His MRI head showed unchanged size of
the right occipital and left temporal lesions compared with the
previous MRI.
Social History:
Lives w/ girlfriend [**Name (NI) 1258**] who is very involved in his care.
Used to work in telecommunications, has been out of work since
diagnosis 8 mo ago. No tob, occ EtOH.
Family History:
M died of embolus to brain post surgery; F died of MI/CAD. Has
several brothers/sisters, all of whom are healthy. No fam hx of
DM, CAD, HTN or lung disease. Positive for renal cell carcinoma.
Physical Exam:
VS - T 97.6, BP 128/90, HR 75, RR 20, sats 95% on RA, 5'[**28**]",
170#
Gen: WDWN middle aged male, cooperative and awake, in NAD.
HEENT: Sclera anicteric, PERRL, EOMI. OP w/ small, millimeter
size white lesions on roof of mouth, none under tongue/along
sides of mouth. Conjunctival pallor. No LAD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA on left, but decreased BS at base on right. No
crackles or wheezes.
Abd: Soft, mildly distended, tender in suprapubic region. No
masses. + BS.
Ext: No c/c/e. 2+ PT, radial pulses bilaterally. No rashes.
Neuro: CN II-XII grossly intact. Strength 5/5 in UE - triceps,
biceps, adductors bilaterally. Grip strong and symmetric. In LE,
[**4-26**] plantarflexion bilaterally, dorsiflexion 4-/5 bilaterally
and symmetric; knee flexion/extension [**4-26**] on R, [**3-26**] on L but
limited by pain. Can not lift legs off of bed due to pain, can
not hold legs in air on own due to pain thus could not assess
iliopsoas. Sensation intact to light touch, proprioception, pain
bilaterally in LE to knees. Hyperreflexic at patella bilaterally
3+, symmetric. No clonus at ankles. Equivocal toes. Gait
deferred [**2-23**] pain.
Pertinent Results:
AXR [**2125-1-29**]: Unremarkable abdominal radiograph with no evidence
of free air.
.
Ultrasound [**2125-1-30**]: 1) Limited study especially in distal
superficial femoral vein and greater saphenous vein, however, no
evidence of DVT.
2) Somewhat flattened waveform of common femoral vein. Please
perform abdominal and pelvic CT for the assessment of
compression of IVC which can be a cause of symptoms and the
change in waveform.
.
CXR [**2125-1-31**]: No evidence of active cardiopulmonary process.
.
CTA chest/CT abd/pelvis [**2125-2-1**]: 1. No evidence of pulmonary
embolism. Persistently dilated esophagus with new focal filling
defect, probably representing residual food material. 2. Mostly
resolved multiple nodules seen previously, with increased
peribronchial patchy nodular opacities and thickening in lower
lobes with moderate effusion, worrisome for aspiration or
aspiration pneumonia in this patient with fever. Clinical
correlation is recommended. 3. Unchanged enhancing right renal
mass measuring 3 cm.
4. Unchanged 3-cm ill-defined hypodense lesion abutting the
duodenum, which can be partially in the intramural location,
worrisome for metastasis. 5. Unchanged 1-cm left adrenal nodule.
6. Numerous osseous metastases with soft tissue with bony
destruction as described above, overall not significantly
changed since prior study. 7. Increased fat stranding in
bilateral lower pelvis seen in extraperitoneal area with small
amount of fluid with increased anasarca. 8. 1 cm hyperdense
material in the right renal pelvis. No hydronephrosis. This may
represent stone or residual contrast material if there was any
recent intervention. Please correlate clinically.
.
Tib/Fib XRay [**2125-2-7**]: The portion of the intramedullary rod
within the distal femur is visualized with the two distal
interlocking screws. No evidence of hardware complication is
seen. There is a healed fracture involving the mid shaft of the
left fibula with mature callus. The left tibia is within normal
limits without acute fractures.
.
Ultrasound LLE [**2125-2-8**]: No DVT in the left lower extremity.
.
Head MRI [**2125-2-11**]: Interval decrease in enhancement and FLAIR
signal abnormality of the right occipital lesion. The left
temporal lobe lesion is nearly non- discernable on the FLAIR and
T1-weighted post-contrast images.
.
Spine MRI [**2125-2-11**]: PENDING
.
CXR [**2125-2-13**]: A right-sided PICC line terminates in the distal
portion of the superior vena cava. There is no pneumothorax.
Heart size normal. Heterogenous opacities in both lungs are
stable and may represent multifocal pneumonia and are unchanged.
.
CXR [**2125-2-13**]: Lateral aspect of the right lower chest is excluded
from the examination. Lungs are low in volume today on [**2-9**]. Some engorgement of mediastinal and pulmonary vasculature
may be due to supine positioning. There is heterogeneous
opacification in the right mid and both lower lungs zones.
Whether this is atelectasis or changes due to aspiration is
radiographically indeterminate. There is no pneumothorax or
pleural effusion seen along the imaged pleural surfaces. Heart
is normal size. Right subclavian line tip projects over the SVC.
.
CTA [**2125-2-13**]: 1. No pulmonary embolism. 2. Multifocal opacities
concerning for multifocal pneumonia. 3. Osseous metastases with
surrounding soft tissue and bone destruction, not significantly
changed from [**2125-2-1**].
.
CXR [**2125-2-19**]
Lungs clear, no evidence of failure.
.
CXR [**2125-2-22**]
New opacity in the right mid zone concerning for pneumonia.
.
MRI [**2125-2-25**]
No evidence for metastatic disease seen involving the cervical
spine.
.
Stable metastatic foci involving T5 and T11 vertebra without
extrinsic cord compression seen. There is no MRI evidence for
discitis or fluid collection. No cord compression is present.
.
Stable metastatic disease involving the lower lumbar spine and
the sacrum with pathologic compression deformity of the sacrum
as noted previously and unchanged in appearance. There is no
compromise of the lumbar canal.
.
CXR [**2125-2-25**]
Bibasilar interstitial abnormality, more pronounced on the left,
has developed since [**2-22**] could represent either an
atypical pneumonia or a pulmonary drug or transfusion related
reaction. Consolidation in question in the right mid lung on
[**2-22**] was either spurious or has resolved. Heart is normal
sized. Minimal mediastinal vascular engorgement has not changed
since [**2-13**], may be a function of supine positioning. The
abnormality in the lungs is slightly more severe in the left
lower lobe, the only finding that suggests this may be
pneumonia. On the other hand, there is mild pulmonary vascular
engorgement and abnormality at the right lung base, suggesting
this may be asymmetric edema, either cardiogenic or related to
reaction to medications or drug products.
Brief Hospital Course:
Mr. [**Known lastname 67759**] is a 44 year old male with metastatic renal cell
carcinoma who was admitted on [**2125-1-24**] for pain management and
rehab placement.
.
His pain is located in his sacrum and left thigh, known sites of
his metastatic disease. His Sutent was initially held, pain
service was consulted, and his pain management was adjusted
according to his needs. At maximum doses, he required 240 mg
OxyContin TID, a Dilaudid PCA set at 1 mg basal with 4 mg q6min,
Lyrica 150 mg [**Hospital1 **], three lidocaine patches, and Tylenol around
the clock. His bowel regimen was maximized with the extreme
doses of narcotics. He maintained regular bowel movements. He
was given a dose of gemcitabine on [**1-31**], and his Sutent was
restarted.
.
The night of [**1-31**], he developed a fever to 103.5 with rigors, as
well as episodes of hypoxia, and was placed on levo/flagyl/vanco
for several days thereafter. Unclear what exactly happened. He
then became neutropenic (secondary to gemcitabine). He was noted
to have an exquisitely tender and tense left thigh (which was
attributed to his known metastatic disease). Ultrasound negative
for DVT. He had a CTA on [**2-1**] which was negative for PE, and a
CT abd/pelvis also done at that time showed no clear source of
the fever. On [**2-7**] he noted calf pain: tib-fib film was negative
for fracture/metastasis and ultrasound was negative again for
DVT.
.
During the admission, he also developed urinary pain (despite
the presence of a foley catheter); this has been controlled with
oxybutynin and Pyridium.
.
A multidisciplinary meeting was held on [**2-9**] (social work, case
management, medicine, anesthesia, nursing all represented) to
determine the plan; the patient was approached regarding the
decision to pursue an intrathecal pump, which he had previously
rejected. On [**2-12**], the patient decided to pursue the pump.
.
On [**2-10**], Mr. [**Known lastname 67759**] noticed that his right foot was tremulous; a
full neuro exam showed clonus and hyperreflexia in his right
lower extremity, a new finding not documented previously. Given
the high enough suspicion for cord compression, an urgent MRI
was obtained and high dose steroids were started. The MRI was
negative for cord compression and the MRI head showed
improvement in his known temporal lesion.
.
Overnight [**Date range (1) 25388**], however, he had an episode of oxygen
desaturation to mid-80's on NRB, and he was subsequently found
to be hypotensive to the mid-70's systolic; he was transferred
to the [**Hospital Unit Name 153**] for better monitoring overnight. With IV antibiotics
(levofloxacin, metronidazole for presumed aspiration pneumonia)
and decrease in pain medications, as well as the addition of
high dose steroids, he improved and was transferred back to the
oncology floor. Since his transfer back on [**2-14**], he has been
stable fairly stable without any further transfers to the ICU.
.
Attempts were made the week of [**2-20**] - [**2125-2-23**] for placement of an
intrathecal (IT) pump. On [**2125-2-22**], pt spiked a temperature of
102.9 and developed a new oxygen requirement. CXR revealed new
RML infiltrate. The etiology was most likely aspiration
pneumonitis or aspiration PNA. Pt was started on vancomycin and
aztreonam was later added. Flagyl was continued and levofloxacin
was D/C. On [**2125-2-23**], pt was clinically improved and pending
transfer to [**Hospital1 112**] for IT pump placement.
.
On [**2125-2-25**], pt spiked a temperature to 103.2 with an oxygen
requirement of 2L NC. CXR was obtained which revealed possible
atypical PNA. Azithromycin was then added for atypical coverage.
He has been afebrile since [**2125-2-25**]. He will be continued on
aztreonam, vancomycin, flagyl, and azithromycin upon transfer to
[**Hospital1 112**]. He will then be transferred back to [**Hospital1 18**] after IT pump
placement. After transfer back to [**Hospital1 **], he will then be discharged
to [**Hospital **] Rehab for further physical therapy.
Medications on Admission:
ambien 10mg PO QHS
colace [**1-23**] tab PO QD
diazepam 4mg PO QHS
dilaudid 4mg PO q prn pain
gelclair daily for mouth ulcers
lidocaine (viscous) 5-10cc prn mouth ulcers
lidoderm 5% 12hrs on/12 hrs off
lomotil prn
MS contin 30mg PO BID
methadone 60mg PO TID
protonix 40mg PO Q12
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Oral Wound Care Products Packet Sig: One (1) ML Mucous
membrane QID (4 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD () as needed for to
leg.
11. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
15. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
16. SUTENT 12.5 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
18. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours).
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
20. Aztreonam 1 g Recon Soln Sig: Two (2) Recon Soln Injection
Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Metastatic Renal Cell Carcinoma
.
Secondary:
Gastritis
Discharge Condition:
The patient was discharged hemodynamically stable afebrile with
appropriate follow up.
Discharge Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67760**] or seek medical attention in the
ED if you experience any chest pain, shortness of breath,
nausea, vomiting, diarrhea, abdominal pain, weakness, inability
to tolerate liquids, or any other concerning symptom.
.
Please keep all follow up appointments. They are listed below.
.
Please take all medications as directed.
.
You will be transferred to the [**Hospital6 1708**] for
your IT pump placement. You will then be transferred back to
[**Hospital3 **].
Followup Instructions:
Your follow up will be arranged when you return to [**Hospital3 **].
Completed by:[**2125-2-27**]
|
[
"198.3",
"V12.51",
"288.03",
"197.0",
"E933.1",
"507.0",
"780.6",
"788.20",
"198.5",
"518.82",
"189.0",
"733.13",
"338.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
16885, 16900
|
10720, 14742
|
341, 371
|
17008, 17097
|
5837, 10697
|
17684, 17784
|
4452, 4645
|
15072, 16862
|
16921, 16987
|
14768, 15049
|
17121, 17661
|
4660, 5818
|
287, 303
|
399, 1818
|
1840, 4243
|
4259, 4436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,231
| 146,103
|
55156
|
Discharge summary
|
report
|
Admission Date: [**2112-7-18**] Discharge Date: [**2112-7-23**]
Date of Birth: [**2032-8-6**] Sex: M
Service: MEDICINE
Allergies:
lisinopril / Sulfa(Sulfonamide Antibiotics) / Quinine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79M w/ hx Hep B & C, metastatic HCC, mets to brain, who
presented with lethargy, decreased PO intake from [**Hospital1 1501**] to [**Hospital1 498**]
on [**7-17**], transferred to [**Hospital1 18**] [**7-18**]. Patient code status had been
CMO at [**Hospital1 1501**], was noted to be increasingly unresponsive, had
increased abdominal girth, and hypoglycemic for 1-2 days. At
baseline, he needs significant aid with ADLs, however could
still follow simple instructions and interact with caregivers.
[**Name (NI) **] was evaluated initially at [**Hospital1 498**], where his family revoked
CMO status. He received a paracentesis draining 500cc straw
colored/blood tinged fluid (sent for G stain, cx, CBC, alb,
protein). His family then requested that for the patient to be
transferred to [**Hospital1 18**] for further evaluation.
In the ED, initial VS were: T 99.9 HR 120 BP 118/82 RR 18 O2 99%
4L NC. He was found to be moderately agitated, and was given
lorazepam 1mg. Labs were significant for FS 60s, Na 155, ALT
218, AST 413, AP 180, lactate 2.9. CXR: RML pneumonia, small
lung volumes. The OSH infiltrated IV line was discontinued, and
he was given D50% and drip through a new IV line. He also
received morphine 5mg, vancomcin 1g, cefepime 3g, and flagyl
500mg.
On arrival to the MICU, patient's VS: T 97.7, HR 110s, BP
100-150s/67-80, RR 15, O2 97% / 2L
Past Medical History:
1. Hepatitis B.
2. Hepatitis C.
3. Hepatocellular carcinoma (left lobe involving vasculature),
advanced.
4. Hypertension.
5. GERD.
6. Subarachnoid hemorrhage.
Social History:
married, a former police officer and sergeant. 13 children
Family History:
No known family history of liver disease or hepatocellular
carcinoma.
Physical Exam:
cachectic, elderly black gentleman. Neither oriented nor
attentive. Does not follow commands, mildly agitated with
movement.
HEENT: Sclerae anicteric, pupils 3 to 2mm, oropharynx dry but
clear, EOMI, PERRL
Neck: supple, JVP 7-8cm but difficult to appreciate given
bounding carotid pulse, no LAD
CV: Regular, tachycardic, S1 + S2, 3/6 systolic murmur, no rubs
/ gallops
Lungs: rales at R middle lobe region, clear otherwise
bilaterally, no wheezes, rales, ronchi
Abdomen: tensely distended, clear dressing on left lower
quadrant, bowel sounds present, no grimace to palpation,
organomegaly difficult to appreciate given dissension.
GU: foley draining dark yellow urine
Ext: 2+ pitting edema bilaterally to the knee, warm, 2+ pulses,
no clubbing, cyanosis
Neuro: Does not follow commands, CNII-XII grossly intact, moves
all four extremities, brisk reflexes 2+ throughout in upper and
lower extremities, clonus in R foot, none in left.
Pertinent Results:
[**2112-7-18**] WBC-10.9 RBC-4.37* HGB-12.1* HCT-37.6* MCV-86 MCH-27.7
MCHC-32.1 RDW-18.8*
[**7-18**] CXR IMPRESSION: Patchy but extensive new right lung
opacity worrisome for pneumonia or aspiration. Although
probably an artifact, repeat radiographs are recommended to
exclude the unlikely possibility of free air associated with a
curvilinear lucency projecting along the right lower hemithorax.
MRI Brain w/ contrast ([**Hospital1 **] [**2112-7-13**]):
1. R post temporal lobe significantly increased hyper intensity
on FLAIR concerning for met.
2. Superimposed resolving SAH in same region
3. Scattered white matter changes c/w microangiopathic disease
EKG: 1mm ST depressions in antero-lateral leads, otherwise
normal.
Brief Hospital Course:
79 yo M h/o Hep B & C, metastatic hepatocellular carcinoma,
subarachnoid hemorrhage who presents with lethargy and
hypoglycemia from nursing home and [**Hospital **] transferred to the [**Hospital Unit Name 153**]
for prominent hypernatremia and higher nursing level care
ACTIVE ISSUES:
====================
#Altered Mental Status: Thought to be multifactorial including
electrolyte abnormalities, infection (RML pneumonia), and HCC
metastastic disease to the R post temporal lobe. His electrolye
abnormalities were corrected as below. His pneumonia was
treated as below with no improvements of his altered mental
status. A family meeting was held and included patient's
priest, family, palliative care, and the ICU team where his
goals of care were addressed. Following extensive discussion of
medical condition, poor prognosis and poor progress, decision
was made to focus care on comfort as priority (consistent with
patients previously expressed wishes).
.
# HYPERNATREMIA: Now corrected, with no real change in mental
status; was likely hypovolemic hypernatremia secondary to
dehydration with Na 155 at admission. His free water deficit
was corrected, but no change in his altered mental status.
.
# RML PNEUMONIA: CXR was concerning for PNA, elevated WBC, and
productive cough were concerning for nursing-home acquired
pneumonia. He was on vancomycin/cefepime, which was continued
until the family decided to make him comfort measures only.
.
# HYPOGLYCEMIA: likely due to impaired gluconeogenesis and
increased tumor burden from his HCC. He was treated with
continuous D12.5 infusion and prn iv boluses of D50W. Once his
hypoglycemia was corrected, his mental status did not improved.
These measures were continued until his family decided to make
him comfort measures only.
.
# HEPATOCELLULAR CARCINOMA: he has locally advanced neoplasm
contributing to his abdominal girth, radiating back pain, and
profound bilateral edema. It may also have a local mass effect
with the stomach and lead to early satiety and postprandial
discomfort. Per GI note [**2112-7-1**], palliative management may be
best. Sorafenib may increase the risk of recurrent ICH, and
local CyberKnife has limited value. Surgical resection,
radiofrequency ablation, chemoembolization and liver transplants
are not being considered. The patient was previously CMO at his
nursing care facility, however his family reversed his status.
Per GI note in [**Month (only) **]/[**2112-7-3**], palliative management may be best
given the extent of his HCC. While hospitalized, radiation
oncology recommended no intervention. Hem/onc and palliative
care were consulted and his goals of care were changed to CMO.
Patient quietly and peacefully expired on [**2112-7-23**].
INACTIVE ISSUES:
====================
# GERD: stable. continue with nexium 40mg [**Hospital1 **] at home
# BPH: stable, continue home medications of doxazosin 1mg daily,
and oxybutynin 100mg daily.
Medications on Admission:
- Dexamethasone 4mg Q8H
- Nexium 40mg [**Hospital1 **]
- Doxazosin 1mg daily
- Oxybutynin 100mg daily
- Hydralazine 50mg Q8H
- Diovan 240mg, 2 tablets daily
- Zofran 4mg Q8H prn
- Ativan 1mg Q8H prn
- Norvasc 5mg
- Cardiezm 45mg Q8H
- Morphine sulphate IR 15mg Q8H prn
- Aldactone 25mg
- Lasix 60mg QAM, 20mg QHS
Discharge Disposition:
Expired
Discharge Diagnosis:
HBV, HCV HCC with metastasis to brain
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"572.2",
"V66.7",
"401.9",
"V12.09",
"530.81",
"486",
"155.0",
"287.5",
"572.3",
"600.00",
"338.3",
"307.9",
"V58.65",
"251.1",
"785.0",
"276.0",
"780.97",
"285.22",
"789.59",
"V49.86",
"V12.54",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7124, 7133
|
3812, 4085
|
335, 341
|
7214, 7223
|
3057, 3789
|
7275, 7407
|
2016, 2088
|
7154, 7193
|
6786, 7101
|
7247, 7252
|
2103, 3038
|
274, 297
|
4100, 4130
|
369, 1735
|
6576, 6760
|
4146, 6559
|
1757, 1924
|
1940, 2000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,898
| 139,803
|
41104
|
Discharge summary
|
report
|
Admission Date: [**2163-8-1**] Discharge Date: [**2163-8-10**]
Date of Birth: [**2098-1-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Shortness of breath, hypoxia.
Major Surgical or Invasive Procedure:
Bronchoscopy x3 ([**8-2**], [**8-3**], [**8-7**])
History of Present Illness:
Mr. [**Known lastname 1924**] is a 65 y/o man with history of AAA repair ([**1-/2163**])
c/b T8 paraplegia, bowel perforation leading to graft infection
with bacteriodes, strep pneumo and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23729**]/fungemia on
chronic suppressive medications (antibiotics and antifungals -
fluconazole, cipro, flagyl), recently admitted and discharged on
[**7-9**] for PNA, who represented to [**Hospital1 18**] on [**8-1**] from [**Hospital 38**]
rehab w/ increasing white count to 39, increased shortness of
breath, increased cough and inability to clear his airway
secretions.
During his previous admission he had CT imaging demonstrating
collapsed lower lobe with concern for chronic infectious process
vs mucus plugging. Given acute deterioration in respiratory
function he underwent bronchoscopy that demonstrated purulent
secretions in the LLL c/w infection. His antibiotics were
broadened from cipro/flagyl/fluconazole (chronic suppressive
meds) to levofloxacin/vancomycin/flagyl/fluconazole. He was
discharged with plan for 14 days on this abx course, with plan
to go back on his chronic suppressive therapy afterwards.
However, after discharge, pt grew resistant Pseudomonas in his
BAL fluid culture. Readmitted on [**8-1**] directly to the MICU for
worsening SOB with sats in the high 70s. In the MICU, ID was
consulted who started patient on meropenem to cover bacteroides
and pseudomonas PNA. Patient was bronched multiple time since
admission to remove mucus plugs which imporves patient's
repiratory symptoms.
.
Currently, he feels better from a respiratory standpoint.
Reports occasional SOB which improves with suctioning.
.
ROS: Otherwise positive for occasional pleuritic CP, chest
heaviness, occasional pain from his abdominal surgical area with
tenderness though unchanged. Denies fever, chills, sweats.
Denies nausea, vomiting, diarrhea, change in stool from ostomy,
no melena or BRB from ostomy. He has no feeling from his penis
so would not know if he had burning, and chronically has a
foley.
Past Medical History:
- AAA repair ([**1-/2163**]) c/b T8 paraplegia, bowel perforation with
graft infection and bacteremia/fungemia (bacteriodes, strep
pneumo and [**Female First Name (un) **]). On chronic suppressive medications with
suppressive antibiotics with ciprofloxacin, Flagyl and
fluconazole.
- complete heart block, now status post pacemaker placement
- Hypertension
- Hyperlipidemia
- COPD
- Osteoarthritis
- Increased PSA for which the patient underwent a biopsy prior
to [**2163-1-29**], which was complicated by an E. coli bacteremia
- s/p Trach for inability to clear secretions
Social History:
Has 50 pack-year smoking history who stopped smoking prior to
his admission in [**Month (only) 404**]. He has a pet dog. He is married with a
very supportive wife and children. He works as a wine
distributor but is currently on disability and also retired a
year ago.
Family History:
Non-contributory.
Physical Exam:
ON ADMISSION:
VS: Temp: 99.6 BP: 126/63 HR: 81 RR: 21 O2sat 99% on 50% trach
mask
GEN: pleasant, chronically ill appearing male, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, trach collar in
place, no jvd
CV: RRR, S1 and S2 wnl, no m/r/g
RESP: decreased BS at right and left bases with crackles at
right base, no wheezes, no use of access mm but tachypneic to
high 20s
ABD: large graft, healing skin, +BS, right-sided ostomy with
brown stool, +BS, soft, non-tender, no masses or
hepatosplenomegaly
EXT: warm, waffle boots in place, extreme mm wasting
bilaterally, erythema over left upper thigh with scabbing, but
no open wounds
GU: foley in place, light yellow urine
SKIN: no jaundice, no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength in upper
extremities, paraplegic in lower extremities, no sensation in
bilateral lower extremities, 2+ DTR's in biceps &
brachioradialis
GU: wound vac in place, though not completely covering sacral
area, several more superficial sacral wounds, no [**Month (only) **] purulence
.
On Discharge:
GEN: pleasant, chronically ill appearing male, NAD
HEENT: MMM, op without lesions, no supraclavicular or cervical
lymphadenopathy, trach collar in place,
CV: RRR, S1 and S2 wnl, no m/r/g
RESP: Decreased breath sounds in the lung bases with crackles in
the right lung bases as well. No wheezes
ABD: large graft, healing skin, right-sided ostomy with brown
stool, soft, non-tender
EXT: Warm and well perfused, no edema
GU: foley in place, light yellow urine
SKIN: no jaundice, no splinters, no rashes
NEURO: AAOx3. Cn II-XII intact. 5/5 strength in upper
extremities, paraplegic in lower extremities, no sensation in
bilateral lower extremities
GU: wound vac in place, though not completely covering sacral
area, several more superficial sacral wounds, no [**Month (only) **] purulence
Pertinent Results:
ADMISSION LABS:
[**2163-8-1**] 10:20AM BLOOD WBC-28.9*# RBC-3.83* Hgb-10.9* Hct-34.4*
MCV-90 MCH-28.5 MCHC-31.7 RDW-14.5 Plt Ct-512*
[**2163-8-1**] 10:20AM BLOOD Neuts-90.0* Lymphs-4.6* Monos-4.4 Eos-0.4
Baso-0.6
[**2163-8-1**] 10:20AM BLOOD Glucose-102* UreaN-13 Creat-0.6 Na-136
K-4.4 Cl-98 HCO3-27 AnGap-15
[**2163-8-1**] 06:57PM BLOOD Calcium-9.1 Phos-2.7 Mg-1.7
[**2163-8-1**] 10:43AM BLOOD Lactate-3.6*
.
DISCHARGE LABS:
[**2163-8-9**] 08:21AM BLOOD WBC-10.1 RBC-3.59* Hgb-10.2* Hct-30.8*
MCV-86 MCH-28.4 MCHC-33.1 RDW-15.0 Plt Ct-518*
[**2163-8-9**] 05:27AM BLOOD Glucose-133* UreaN-20 Creat-0.5 Na-139
K-4.1 Cl-102 HCO3-30 AnGap-11
[**2163-8-9**] 05:27AM BLOOD ALT-84* AST-81* LD(LDH)-178 AlkPhos-135*
TotBili-0.1
[**2163-8-7**] 02:37AM BLOOD Lactate-1.8
.
MICRO:
URINE CX [**2163-8-1**]:
[**2163-8-1**] 10:45 am URINE Site: CATHETER
**FINAL REPORT [**2163-8-5**]**
URINE CULTURE (Final [**2163-8-5**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
2ND MORPHOLOGY. sensitivity testing performed by
Microscan.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I <=1 S
MEROPENEM------------- 2 S 1 S
PIPERACILLIN/TAZO----- 16 S <=4 S
TOBRAMYCIN------------ 2 S <=1 S
.
Urine Culture [**2163-8-2**] No Growth
.
Blood Cultures 7/4 and [**8-7**]: No growth
.
[**2163-8-2**] 5:42 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2163-8-2**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2163-8-6**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SECOND MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S 2 S
CEFTAZIDIME----------- 2 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 8 I
MEROPENEM------------- 4 S 4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
POTASSIUM HYDROXIDE PREPARATION (Final [**2163-8-2**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary):
YEAST.
STUDIES:
CXR [**2163-8-1**]:
IMPRESSION: Persistent moderate bilateral pleural effusions and
compressive atelectasis. Retrocardiac atelectasis versus less
likely infection.
.
CXR [**2163-8-2**]:
Left lower lobe atelectasis is chronic. Moderate right lower
lobe atelectasis developed after [**7-26**], unchanged. Small
bilateral pleural effusions also unchanged. Heart size normal.
Upper lungs clear of pneumonia. Tracheostomy tube in standard
placement. Left PIC line ends in the mid SVC. Transvenous right
ventricular pacer in standard placement. No pneumothorax.
CXR [**2163-8-4**]:
IMPRESSION: Persisting and unchanged bilateral basal atelectatic
changes and bilateral pleural effusions.
CXR [**2163-8-7**]:
Tracheostomy tube is in place. A right-sided single-lead
pacemaker is present with lead tip over right atrium. Additional
clips overlie lower mediastinum. Left PICC line is present, tip
at confluence of brachiocephalic and proximal SVC. Hazy density
at both lung bases likely reflects presence of bilateral
effusions. Left lower lobe collapse and/or consolidation,
probably slightly worse compared with one day earlier. Probable
atelectasis right base medially. Upper zone re-distribution,
without overt CHF. Compared with [**2163-8-5**], the appearance is
similar.
Brief Hospital Course:
65 y/o man with a history of AAA repair ([**1-/2163**]) c/b T8
paraplegia, bowel perforation leading to graft infection with
bacteriodes, strep pneumo and [**Female First Name (un) **] bacteremia/fungemia on
chronic suppressive medications, recently admitted and
discharged on [**7-9**] for SOB, and treated for a PNA, who
represents to [**Hospital1 18**] from [**Hospital 38**] rehab w/ increasing white
count, increased shortness of breath, hypoxia, and leukocytosis.
He was found to have quinolone resistant pneumonia, and treated
with Meropenem.
# Pseudomonas Pneumonia: Patient presented with worsening
dyspnea, fever, leukocytosis (28), increased sputum production,
and infiltrate seen on CXR suggestive of pneumonia. Was hypoxic
with oxygen saturations in the high 70s and was admitted to the
MICU. Of note, he was recently discharged from [**Hospital1 18**] 2 days
prior and was discharged home at the time on
levofloxacin/vancomycin/flagyl/fluconazole. In the MICU, patient
underwent multiple bronchoscopy due to concern for mucous
plugging with return of thick secretions. ID was consulted and
patient was initiated on meropenem based on prior sensitivities
for pseudomonas from BAL cultures as well as to cover for
bacteriodes. Patient's course of Meropenem will end with last
dose on [**8-14**] after which patient will return to his chronic
suppresive medications with cipro, flagyl, and fluconazole.
Patient will continue to need ongoing monitoring of oxygen
saturations and suction as needed for secretions at LTAC
facility. He would also benefit from a cough assisting device
(coughalator) at LTAC to help clear secretions. Has ID follow up
as an outpatient.
# Hypoxemnia: Likely secondary to mucus plugging and HCAP.
Patient originally had low sat in the high 70s and was directly
admitted to the MICU. Required multiple bronchoscopy to remove
thick secretions, which improved with broad spectrum
antibiotics. Patient also continued on albuterol and atrovent
nebs.
# Bacterial UTI: Patient initially had urine culture which grew
Pseudomonas. Per ID recs, no need to treat given likely
colonization. Repeat urine culture when foley was changed ([**8-4**])
showed no growth.
# Pre-Existing Sacral Decubitus ulcer stage 4: Patient has
chronic sacral stage IV pressure ulcer. Followed by ID for long
term chronic therapy with cipro/flagyl/fluconazole. Eventual
plan for potential intervention once patient has completed
rehab. He was treated with meropenem and fluconazole.
Cipro/Flagyl (his chronic suppressive regimen) was held and will
be restarted once he finishes his course of Meropenem on [**8-15**].
.
# Pruritis: Patient complained of itchying over his body. ID did
not think that Meropenem was causing the itchying and wants
patient to complete his course. Patient did not have any rashes
and did not complain of SOB or throat closing and symptoms
relieved with benadryl. Will continue Benadylr and Sarna lotion
to help with itching.
.
# H/O Graft Infection: Abx modified/continued as above.
.
# Anemia: Unclear etiology. HCT stable during this admission.
Patient hemodynamically stable. No change in stool color in the
colostomy.
.
# HTN: on lisinopril as home med. This was held in the ICU given
infection and concern for developing hypotension.
# Depression/Anxiety: Continued paroxetine, trazodone, ativan
prn.
# GERD: Continued home PPI.
# Chronic Immobilization secondary to Paraplegia: Continued
fondaparinux.
Transition of Care:
- Patient does not have good cough reflex and would benefit from
a Coughalator at LTAC to help clear thick secretions.
- Patient will finish his course of Meropenem with last dose to
be taken on [**8-14**]. Patient will go back to his chronic
suppressive regimen of Cipro/Flagyl/Fluconazole to be started on
[**2163-8-15**].
- Patient will follow up with ID for chronic antibiotic
management. Patient will also follow up with PCP for anemia and
resolution of pneumonia.
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-30**] Inhalation Q6H (every 6 hours) as needed
for shortness of breath.
2. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY 3. fluticasone-salmeterol 500-50 mcg/dose Disk
with Device Sig: [**1-30**] Disk with Devices Inhalation [**Hospital1 **] (2 times a
day).
4. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous
once a day.
5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. metronidazole 250 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One(1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): please give at 22:00.
14. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. sorbitol 70 % Solution Sig: One (1) ML Miscellaneous DAILY
(Daily) as needed for constipation.
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet,Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea.
17. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
18. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
20. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours
21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous every twelve (12) hours for 10 days.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation Inhalation once a day.
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily).
12. fluconazole 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
14. ferrous gluconate 325 mg (36 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
15. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
16. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
17. sorbitol 70 % Solution Sig: One (1) Miscellaneous once a
day as needed for constipation.
18. Advair Diskus 500-50 mcg/dose Disk with Device Sig: [**1-30**]
Inhalation Inhalation twice a day.
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-30**] Inhalation Inhalation every six (6) hours
as needed for wheezing, SOB.
20. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day) as needed for constipation.
21. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours): Last Dose to be taken on [**8-14**].
22. Flagyl 250 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours: Please start taking on [**8-15**] after finishing course of
Meropenem. Avoid any alcohol products.
23. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: Please Start taking on [**8-15**], after
finishing course of Meropenem.
24. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every 6-8 hours as needed for itching.
25. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: Apply as needed
Topical once a day as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Health Care Associated Pneumonia
Sacral Decubitus Ulcer Stage IV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 1924**], it was a pleasure taking care of you during
your hospitalization at [**Hospital1 18**]. You were admitted because you
were complaining of shortness of breath, unable to cough up
secretions from your airways, and found to have lower oxygen
levels. You had multiple bronchoscopy procedures which
demonstrated thick secretions and you were found to have a
pneumonia. Your prior long term antibiotics regimen was changed
and you were started on Meropenem to be taken until [**8-14**].
Then you should resume your chronic antibiotic therapy with
ciprofloxacin, flagyl, and fluconazole. Your symptoms improved
with antibiotics and with repeated suctioning. On discharge you
were still feeling congested with secretions therefore you would
benefit from a cough assisting device (Coughalator) at your LTAC
facility to help your cough reflex.
.
We have made the following medication changes for you.
-CONTINUE Meropenem to be taken until [**2163-8-14**]. on [**8-15**], you will then resume with your outpatient chronic antibiotic
therapy of ciprofloxacin, flagyl, and fluconazole.
-STOPPED Vancomycin
-STOPPED Levofloxacin
-STARTED Benadryl to be used only as needed for itching
-STARTED Sarna lotion to be used only as needed for itching
.
Once you start taking your Flagyl again, please aviod any
alcohol containing products which can interact with Flagyl and
cause severe reaction.
.
Please follow up with Infectious disease doctors (as scheduled
below) for any further decision on your future antibiotics
course. Please also follow up with your Primary care physician
(as scheduled below) for evaluation of anemia and to monitor
resolution of pneumonia.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2163-8-23**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], 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: TRANSPLANT CENTER
When: THURSDAY [**2163-8-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2163-10-5**] at 10:30 AM
With: [**Last Name (NamePattern5) 14644**], MD, PHD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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20,731
| 150,328
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22433
|
Discharge summary
|
report
|
Admission Date: [**2108-10-12**] Discharge Date: [**2108-10-15**]
Date of Birth: [**2074-1-31**] Sex: M
Service: MED
Allergies:
Prednisone
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
transfer from OSH
Major Surgical or Invasive Procedure:
1. Intubation and ventilator use
History of Present Illness:
34 yo male with bipolar affective disorder who was admitted on
[**2108-10-10**] to OSH for 4th pneumonia since [**2106-3-19**]. Pt
initially presented to OSH with 3day history of weakness,
productive cough (yellow sputum), SOB, and pleuritic chest
discomfort. In [**Name (NI) **], pt was afebrile, WBC 26, O2 sat 76% on RA,
pO2 39 on RA, with diffuse bilateral interstitial infiltrates on
CXR. Pt was given cefuroxime and IV bactrim in ED and admitted
to the ICU on 100% non-rebreather. Pt developed increasing
respiratory distress requiring intubation ([**10-11**]). He also became
hypotensive requiring neo-synephrtine. Blood cultures at OSH
have been negative and pt has been treated with cefriaxone,
levaquin, and vancomycin since admission. Of note, pt is s/p
bronch and BAL at OSH; he was found to be PCP negative,
viral/fungal/bacterial cultures were pending.
*
Per patient's wife, pt recently started new psych med
(strattera). Depression has not been well-controlled, thus
increase in meds in the last year. Wife reports that pt
occasionally awakens from sleep with coughing and sometimes
nausea/vomiting. She wonders if this may be related to psych
meds.
*
ROS per wife significant only for DOE at baseline, which may
have worsened in the last week. Pt has gained weight recently.
Otherwise has felt well since [**12-19**]. Pt was transferred to [**Hospital1 18**]
for further management.
Past Medical History:
Bipolar disorder
hx of elbow surgery [**5-20**]
hx kidney stones
recurrent pneumonias ([**3-19**], [**6-18**], [**12-19**])
crohn's disease
Social History:
married with 2 children
works as a house painter (wears respirator)
no recent travel
smokes [**4-19**] pack/day
denies alcohol
denies IVDU
abused ephedrine four months ago
Family History:
non-contributory
Physical Exam:
VS: t98.7, p85, 116/63, rr17, 100% on AC 70% 500/10, rate set 15
Gen: sedated, intubated, unresponsive
HEENT: PERRL, ETT in place, NGT in place, MMM
neck: supple, large, no lymphadenopathy
Chest: decreased breath sounds at bases, crackes at L base and
anteriorly, no wheezes
CVS: RRR, no m/g/r
Abd: obese, distended, hypoactive bowel sounds
Ext: right fem line in place. warm. 2+ pedal pulses
Pertinent Results:
[**2108-10-12**] 08:48PM WBC-12.3* RBC-3.65* HGB-11.0* HCT-33.9*
MCV-93 MCH-30.0 MCHC-32.3 RDW-15.0
[**2108-10-12**] 08:48PM PLT COUNT-274
[**2108-10-12**] 08:48PM NEUTS-78.8* LYMPHS-15.6* MONOS-2.5 EOS-2.9
BASOS-0.3
[**2108-10-12**] 08:48PM PT-12.7 PTT-24.7 INR(PT)-1.0
*
[**2108-10-12**] 08:48PM GLUCOSE-92 UREA N-8 CREAT-0.6 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-13
[**2108-10-12**] 08:48PM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-2.2
*
[**2108-10-12**] 08:48PM ALT(SGPT)-29 AST(SGOT)-21 LD(LDH)-363* ALK
PHOS-96 AMYLASE-33 TOT BILI-0.3
[**2108-10-12**] 08:48PM LIPASE-14
*
[**2108-10-12**] 08:48PM CORTISOL-10.9
[**2108-10-12**] 08:48PM LITHIUM-0.3
*
[**2108-10-12**] 08:48PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2108-10-12**] 08:48PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2108-10-12**] 08:48PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2108-10-12**] 09:35PM LACTATE-0.5
*
[**2108-10-12**] 09:35PM TYPE-ART TEMP-36.9 RATES-15/3 TIDAL VOL-500
PEEP-10 O2-70 PO2-149* PCO2-48* PH-7.34* TOTAL CO2-27 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
*
[**2108-10-12**] 09:35PM freeCa-1.22
*
[**2108-10-14**] 04:06AM BLOOD PEP-NO SPECIFI IgG-695* IgA-194 IgM-122
IFE-NO MONOCLO
*
[**2108-10-12**] portable CXR:
PORTABLE AP CHEST: An ET tube is identified, with its tip 4.8 cm
above the carina. An NG tube is also seen. The tip courses below
the diaphragm. The heart size is normal allowing for position.
There is diffuse wide spread air space consolidation in both
lungs, consistent with prior history of pneumonia. The
mediastinum cannot be assessed due to the patient's
consolidation and because this is a supine film.
Impression:Widespread airspace consolidation consistent with
pneumonia.
*
[**2108-10-13**] portable CXR:
FINDINGS: Compared to the film from the prior day, the ET tube
has been removed. There is an NG tube in the stomach. The
bilateral lower lobe infiltrates are still present but are less
confluent. Overall, there is improved aeration compared to the
prior film but infiltrates are still present. There is hazy
bilateral vasculature which suggests that there may be an
element of fluid overload as well.
*
Brief Hospital Course:
ICU course: Pt was thought to have aspiration pneumonia
especially since he has a history of awakening at night with
cough/nausea/vomiting in setting of multiple psychiatric
medications. His respiratory failure was thought to be from
ARDS. His sputum culture grew out gram negative rods.
Ceftriaxone and vancomycin were discontinued after one day. He
was maintained on levofloxacin. Pt remained afebrile. Pt was
weaned from the ventilator and extubated on [**10-14**].
*
Floor course ([**Date range (1) 49940**])
1. Pneumonia/ARDS/Respiratory failure: On transfer, pt was
stable from respiratory standpoint. He denied SOB or cough. He
had an O2sat of 94% on RA. Lungs were clear with minimal
crackles at the left base. Pt was continued on Levofloxacin,
with which he was discharged to complete a 7 day course. Pt was
kept on aspiration precautions. Pt was seen by speech and
swallow who found no signs of aspiration on bedside swallowing
evaluation. Ambulatory sat was noted to be in mid-90's. Pt was
discharged on floor day 2 in stable condition with instructions
to follow-up with pulmonary as an outpatient regarding etiology
of recurrent pneumonia.
*
2. Ileus: Pt had decreased stool while in the ICU, but had BM on
the floor. Likely resolved ileus.
*
3. GERD: Pt has history of GERD symptoms, likely resulting in
aspiration. He was continued on Protonix. He was instructed to
consider outpatient pH manometry.
*
4. Bipolar: Mood was stable. Pt was continued on outpatient
psych meds. He was instructed to follow-up with outpatient
psychiatrist to review psych medications for increased risk of
GERD/decreased lower esophageal sphinctor tone.
*
5. FEN: He was continued on aspiration precautions
*
6. Prophylaxis: He was continued on PPI, heparin sc tid.
Medications on Admission:
Effexor 150mg qam, 225mg qhs
Zoloft 100mg qam
Neurontin 800mg [**Hospital1 **]
Abilify 75mg qpm
Risperdal 4mg [**Hospital1 **]
Straterra 15mg qam
Lithium 300mg [**Hospital1 **]
Protonix 40mg qd
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
2. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Venlafaxine HCl 75 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
4. Venlafaxine HCl 75 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
Disp:*90 Tablet(s)* Refills:*2*
5. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
6. Aripiprazole 30 mg Tablet Sig: 2 1/2 tabs Tablets PO at
bedtime.
Disp:*90 Tablet(s)* Refills:*2*
7. Strattera 10 mg Capsule Sig: 1 [**2-17**] tab Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*2*
8. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Take for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Elevate head of the bed to at least 30 degress by putting a
brick or bed raiser on the two legs at the head of the bed.
follow up with psychiatrist and primary care physician as stated
below
Followup Instructions:
follow up with PCP on [**11-7**] as scheduled. Follow up on
following issues: 1. further work-up of recurrent pneumonias 2.
follow-up chest X-ray 3. consider pH manometry study 4.
coordinate with psych doc on altering psych medications
follow up with psychiatrist to consider the possible effects of
psych medications on reflux symptoms. have psych doc and PCP
coordinate any possible medication changes.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"507.0",
"305.1",
"V13.01",
"555.9",
"530.81",
"599.7",
"296.7",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8140, 8146
|
4890, 6650
|
286, 321
|
8211, 8219
|
2566, 4867
|
8459, 8999
|
2119, 2137
|
6894, 8117
|
8167, 8190
|
6676, 6871
|
8243, 8436
|
2152, 2547
|
229, 248
|
349, 1749
|
1771, 1913
|
1929, 2103
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,680
| 185,704
|
54303
|
Discharge summary
|
report
|
Admission Date: [**2189-1-21**] Discharge Date: [**2189-1-23**]
Date of Birth: [**2142-5-4**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Antihistamines / Cipro
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr [**Name13 (STitle) **] is a 46 yo man c hx of alcohol dependence, depression
, ADHD.Multiple suicide attempts including Phenobarb overdose.
Pt recently transferred from [**Hospital 42339**] Hosp .Has been there
since [**1-16**] for detox from alcohol. Pt had been c/o being unable
to sleep over the last 72 hours.Pt was given trazodone and
Seroquel after which he was found on the floor at the lobby of
the institution, obtunded.
In ED: pinpoint pupils, responding only to pain. BP 130/70 HR
70.SpO2 99% RR 10. Given 2 mg IV Narcan with no response. Pt
was intubated for airway protection. Started on propofol drip.
Urine was (+) for Benzos. CT of head with craniotomy on the
left, no acute bleeding. CT c-spine negative for fracture, kept
in c-collar until able to clinically clear. Charcoal through NG
tube was started.
Past Medical History:
Delirium tremens
Bipolar Disorder
[**7-4**] suicide attempts
Traumatic brain injury [**2176**] s/p assault
Secondary seizure disorder (d/2 trauma?)
Cerebellar Ataxia (seizure meds?)
Hep B
[**Known firstname 15532**]'s esophagus
Hx Delirium Tremens
Social History:
Lives in a shelter in [**Location (un) 47**]
Unemployed
No source of income
Alcohol use since age 22
Drinks 1 and [**11-24**] gallons of vodka every day
Hx of many detoxes (one note reported >100)
Denies use of any other illicit drugs/street pills/IVDA
Family History:
Non-contributory.
Physical Exam:
VS BP 116/82 HR 78 T 98.8
-Gen: caucasian man, intubated , sedated, no response to pain
-HEENT: pinpoint pupils
-Neck: no JVP
-Chest: cta bl
-CV: RRR no m/g/r
-Abd: nt, nd
-Ext: no edema
Pertinent Results:
[**2189-1-21**] 03:57PM TYPE-ART O2-20 PO2-138* PCO2-40 PH-7.39 TOTAL
CO2-25 BASE XS-0
[**2189-1-21**] 09:16AM TYPE-ART PO2-64* PCO2-48* PH-7.36 TOTAL
CO2-28 BASE XS-0
[**2189-1-21**] 05:40AM TYPE-ART TEMP-37.0 RATES-[**11-7**] TIDAL VOL-600
PEEP-5 O2-100 PO2-347* PCO2-53* PH-7.36 TOTAL CO2-31* BASE XS-3
AADO2-312 REQ O2-58 -ASSIST/CON INTUBATED-INTUBATED
[**2189-1-21**] 05:24AM GLUCOSE-131* UREA N-6 CREAT-0.6 SODIUM-142
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2189-1-21**] 05:24AM ALT(SGPT)-30 AST(SGOT)-18 LD(LDH)-145
CK(CPK)-68 ALK PHOS-58 TOT BILI-0.3
[**2189-1-21**] 05:24AM CK-MB-3 cTropnT-<0.01
[**2189-1-21**] 05:24AM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-4.2
MAGNESIUM-1.6
[**2189-1-21**] 05:24AM VALPROATE-65
[**2189-1-21**] 05:24AM WBC-6.3 RBC-4.02* HGB-12.5* HCT-35.9* MCV-89
MCH-31.0 MCHC-34.8 RDW-13.8
[**2189-1-21**] 05:24AM NEUTS-51.7 LYMPHS-40.7 MONOS-4.4 EOS-2.2
BASOS-1.0
[**2189-1-21**] 05:24AM PLT COUNT-401
[**2189-1-21**] 05:24AM PT-12.3 PTT-24.2 INR(PT)-1.1
[**2189-1-21**] 02:50AM URINE HOURS-RANDOM
[**2189-1-21**] 02:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2189-1-21**] 02:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2189-1-21**] 02:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2189-1-21**] 02:28AM COMMENTS-GREEN TOP
[**2189-1-21**] 02:28AM GLUCOSE-158* LACTATE-1.6 NA+-143 K+-3.4*
CL--101 TCO2-29
[**2189-1-21**] 02:23AM UREA N-8 CREAT-0.7
[**2189-1-21**] 02:23AM CK(CPK)-68 AMYLASE-32
[**2189-1-21**] 02:23AM CK-MB-NotDone cTropnT-<0.01
[**2189-1-21**] 02:23AM PHENYTOIN-<0.6*
[**2189-1-21**] 02:23AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2189-1-21**] 02:23AM WBC-5.2 RBC-4.38* HGB-13.7* HCT-38.9* MCV-89
MCH-31.4 MCHC-35.3* RDW-13.9
[**2189-1-21**] 02:23AM PT-12.4 PTT-24.9 INR(PT)-1.1
[**2189-1-21**] 02:23AM PLT COUNT-425
[**2189-1-21**] 02:23AM FIBRINOGE-266
.
CT c-spine: There is anterior cervical spine fusion seen at
C4-C5. Degenerative changes are seen at this level and at C3-4
and C4-5, as well as moderate to severe spinal stenosis. No
fractures are identified. There is mild kyphosis at C3-4
probably related to degenerative changes and fusion. The patient
is intubated and has a nasogastric tube; prevertebral soft
tissue swelling cannot be assessed. There appears to be some
posterior pleural thickening at the right pulmonary apex.
IMPRESSION: Degenerative changes of the spine, spinal stenosis,
with cervical spine fusion at C4-5; no acute fracture is
identified.
.
CT head: No acute intracranial hemorrhage. Previous left
craniotomy and encephalomalacia of left frontal lobe.
.
CXR: 1. Successful intubation. Successful placement of
nasogastric tube.
2. Retrocardiac opacity with air bronchograms suggesting
consolidation.
.
EKG: Sinus rhythm
Inferior/lateral ST-T changes
Since previous tracing, no significant change
.
Brief Hospital Course:
The patient was admitted to the medical ICU, intubated and
sedated. He was extubated on hospital day #1 without
complication, and quickly weaned to room air by HD [**12-26**]. He
remained somewhat sleepy but arousable to voice. A psychiatry
consult was obtained and the patient was deemed not suicidal and
the exact etiology of his obtundation/respiratory depression
remained unclear.
.
Unresponsive episode:
The pt was found down after being given Seroquel at an outside
detoxification facility. The pt was noted to be unresponsive and
was intubated for respiratory depression. The pt also underwent
a CT head which ruled out a mass effect or bleed. The pt also
underwent an MRI neck which showed the pt to be status post
fusion at C4-5. There was no evidence of a fracture involving
the posterior aspects of the vertebral bodies or acute
encroachment on the spinal canal. There was hyperintensity in
the cervical spinal cord at C4-5 which likely represents malacia
from prior compression. There was some evidence of a narrowing
of the spinal canal at the C4-5 and [**3-28**] levels but the spinal
cord was also noted to be atrophic through these levels and did
not appear compressed. There was no evidence of ligamentous
injury posteriorly (of note, the hardware prevented evaluation
of the possibility of anterior longitudinal ligament
disruption). To date, the etiology of the pt's unresponsive
episode was unclear but it was thought to be most likely toxic/
metabolic. The pt was evaluated by psychiatry and they
recommended a toxic-metabolic workup. On the first day on the
[**Hospital1 **], the pt requested to leave against medical advise. The pt
was evaluated urgently by the psychiatry service and was deemed
to be capable of making a decision. Pt was deemed safe for
discharge, and appeared to have good understanding the of
medical concerns and risks of premature discharge. The
psychiatry service felt that the pt was not suicidal, psychotic
or confused. Their primary concern was that pt will resume
alcohol abuse on discharge. He was also subsequently evaluated
by the Medicine Attending, Dr. [**Name (NI) **] and was deemed
medically stable for discharge home. The following studies:
TSH, RPR and B12 were pending at the time of discharge and will
need to be followed up as an outpatient by the patient's primary
care provider.
.
ETOH abuse
The pt was noted to be slightly tremulous on admission to the
[**Hospital1 **]. It is likely that he is out of the window period for
alcohol withdrawal. The pt was continued on thiamine, folate
and multivitamins. The pt was encouraged to participate in a
more intensive addictions treatment, including inpatient
rehabilitation. The pt reported that he is on a "waiting list"
at [**Hospital **] Hosp and does not want us to pursue this further.
.
Seizure disorder
The pt was continued on anti-epileptics and there was evidence
of active seizure activity.The pt was offered complete workup of
possible underlying seizures, including an EEG, but he refused.
The pt was made aware of the possibility of recurrent seizures
with the possibility of harm to himself or someone else. The pt
acknowledged and accepted these risks. He was instructed to not
drive until he was cleared to do so by a neurologist. The pt may
benefit from an EEG as an outpatient in the event of recurrent
seizures.
.
Neck pain
The pt was noted to complain of neck pain. There was no evidence
of fracture or misalignment on CT. The pt also underwent an MRI
that showed no evidence of a cord compression or a ligamentous
injury. He was given a soft collar by the orthopedics service
which he agreed to wear until there was improvement of neck
pain.
.
?Ascites
The pt was noted to have a mild shifting dullness on clinical
exam. However, there is no current evidence of synthetic
dysfunction. The pt would benefit from an out-patient evaluation
of underlying ascites and possible cirrhosis with an abdominal
ultrasound.
.
Prophylaxis:
The pt was maintained on pantoprazole and was encouraged to
ambulate.
.
Code: Full code
Medications on Admission:
Depakote 500mg tid
Neurontin 600mg tid
Ritalin 54mg qam
Campral 666mg tid
Thiamine 100mg daily
seroquel 100mg qhs
Effexor 225mg qd
.
All: Dilantin, Tegretol, Antihistamines, cipro
Discharge Medications:
1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day) for 7
days.
Disp:*21 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. CONCERTA 54 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO once a day for 7 days.
Disp:*7 Tab, Sust Release Osmotic Push(s)* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
-unresponsive episode: likely adverse effect of medication
-Substance abuse with h/o DTs
-Bipolar disorder
-Multiple suicide attempts
-s/p subdural hematoma in '[**76**] following trauma w/ evacuation and
cranitomy
-Secondary seizure disorder
-Cerbellar ataxia
-HBV
-[**Known firstname 15532**]'s esophagus
-?c-spine surgery several years ago
-s/p appy
Discharge Condition:
Stable, in no respiratory distress and has no confusion.
Discharge Instructions:
Please report to the nearest emergency room if you have
lighheadedness, loss of consciousness, worsening neck pain,
nausea, vomiting, confusion, weakness or loss of sensation.
.
There has been a change in your medications. Please take all
medications as directed. Please ask your primary care provider
for refills of your home medications.
.
Please call your PCP and schedule an appointment to see her
within the next week. You will need to ask your PCP to [**Name9 (PRE) 702**]
on the final results of your MRI head and neck.
.
Please continue to attend your AAA meetings and see your
psychiatrist within one week of discharge.
Followup Instructions:
Please call your PCP after discharge and schedule an appointment
to see her within the next week.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2189-1-26**]
|
[
"518.81",
"303.91",
"296.7",
"E854.0",
"E853.8",
"070.30",
"314.01",
"780.39",
"969.0",
"V60.0",
"571.5",
"311",
"789.5",
"969.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10298, 10304
|
5030, 9079
|
313, 325
|
10701, 10760
|
1983, 4649
|
11437, 11687
|
1741, 1760
|
9310, 10275
|
10325, 10680
|
9105, 9287
|
10784, 11414
|
1775, 1964
|
254, 275
|
353, 1182
|
4658, 5007
|
1204, 1454
|
1470, 1725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,370
| 160,150
|
9763+9764
|
Discharge summary
|
report+report
|
Admission Date: [**2107-9-22**] Discharge Date: [**2107-10-13**]
(anticipated)
Date of Birth: [**2034-4-10**] Sex: M
Service: SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 18473**] is a 73-year-old man
with a history of hypertension, diverticulitis, status post
sigmoid colectomy and adenocarcinoma of the distal esophagus,
status post chemotherapy, radiation therapy and
esophagectomy, who presented following an anastomotic leak.
He was diagnosed with esophageal adenocarcinoma in [**2107-4-24**]. His workup demonstrated that his cancer was not
metastatic. He did receive both chemotherapy with 5-FU and
carboplatin and radiation therapy.
On [**2107-8-30**], the patient had an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **]
esophagectomy at [**Hospital6 7472**]. His
postoperative course was reportedly unremarkable and he was
discharged home on [**2107-9-8**]. However, on [**2107-9-15**] the patient awoke suddenly with right sided pleuritic
chest pain associated with tachypnea and was subsequently
admitted back to [**Hospital6 7472**], where a chest
x-ray revealed a large right pleural effusion.
The patient underwent a gastrografin swallowing study that
revealed a leak from the proximal esophagogastric anastomosis
posteriorly with extension to the right pleural space. He
then underwent a right pleuracentesis which returned 600 cc
of green-tinged fluid. A chest tube was placed, which again
returned several hundred cubic centimeters more of this green
and blood-tinged fluid. Blood cultures revealed Enterococcus
faecalis and pleural fluid culture yielded [**Female First Name (un) 564**]. The
patient was started on Levaquin, Flagyl, ampicillin and
fluconazole and was transferred to [**Hospital1 190**] for definitive care.
PAST MEDICAL HISTORY: The past medical history was notable
for hypertension.
PAST SURGICAL HISTORY:
1. Status post left knee arthroscopy.
2. Status post sigmoid colectomy.
SOCIAL HISTORY: The patient had a positive tobacco history,
but quit 13 years ago. He drank occasional alcoholic
beverages.
ALLERGIES: The patient was allergic to latex by report.
MEDICATIONS ON ADMISSION:
1. Verapamil SR 240 mg p.o. q.d.
2. Verapamil 5 mg p.o. q.d.
3. Amitriptyline 50 mg p.o. q.d.
4. Percocet p.r.n.
MEDICATIONS AT TRANSFER:
1. Vasotec 1.25 mg intravenous every eight hours.
2. Levaquin 500 mg intravenous q.d.
3. Flagyl 500 mg intravenous every eight hours.
4. Pepcid 20 mg intravenous every 12 hours.
5. Lopressor 5 mg intravenous every six hours.
6. Heparin 5000 units subcutaneous every 12 hours.
7. Ampicillin 2 gm intravenous every six hours.
8. Fluconazole 400 mg intravenous q.d.
PHYSICAL EXAMINATION: Physical examination on admission
revealed a temperature of 100.8??????F, a pulse of 116, a blood
pressure of 156/68, a respiratory rate of 23 and an oxygen
saturation of 96% on four liters of oxygen. Neurologically,
the patient was awake and alert, but oriented to self only.
On head, eyes, ears, nose and throat examination, the pupils
were equal, round and reactive to light. The extraocular
movements were intact.
The chest examination was notable for a right thoracotomy
scar with erythema at the site of the incision. A chest tube
was in place in a posterior location with no air leak. There
were approximately [**2056**] cc of dark green fluid in the
Pleur-evac. The patient had diminished breath sounds on the
right. He was clear to auscultation on the left. On cardiac
examination, the patient had an S1 and S2 with a regular
rhythm, tachycardic. The abdomen was noted to be soft,
nontender and nondistended with a midline incision that was
healing. The extremities were warm.
LABORATORY DATA: Laboratory studies from [**Hospital6 32916**] included a white blood cell count of 17,000 with 47%
neutrophils and 32% bands, a hematocrit of 28.9, a platelet
count of 549,000. Chem 7 was relatively unremarkable, as
were liver function tests.
RADIOLOGY DATA: The patient did have a CT scan at [**Hospital6 5168**], which demonstrated a large right pleural
effusion with a right chest tube anterior to the effusion.
HOSPITAL COURSE: The patient was transferred from [**Hospital6 5168**] to [**Hospital1 69**]
and was admitted to the surgical intensive care unit. On the
second day of the patient's hospitalization at [**Hospital1 346**], he was taken to the CT scanner,
where the interventional radiology team placed a catheter in
the fluid collection in the right hemithorax under CT guided
localization and CT fluoroscopic guidance. This catheter did
drain approximately 60 cc of purulent fluid that was sent for
culture. During this time, his white blood cell count
increased to approximately 20,000 and the patient remained
confused.
It was unclear whether or not the CT guided drain would be
adequate for draining his fluid; however, drainage did appear
to be adequate at the time of placement and it was not felt
that the patient needed to go to the operating room for
surgical drainage of his empyema. Instead, he was managed
conservatively and observed with his pigtail catheter in
place. In addition, the patient had a nasogastric tube
placed under fluoroscopic guidance. He was also started on
total parenteral nutrition through his left chest
Port-A-Cath.
Over the ensuing days, the patient was kept in the surgical
intensive care unit for intensive monitoring, one-on-one
care, multiple intravenous antibiotics and observation to
prevent him from manipulating his nasogastric tube in his
delirious state. His microbiology cultures started to return
during this time and he was found to have coagulase-negative
Staphylococcus that was sensitive to oxacillin but resistant
to both penicillin and Levaquin. He was also found to be
growing [**Female First Name (un) 564**] albicans and Lactobacillus in his pleural
fluid cultures. For this reason, his antibiotic regimen was
altered. His ampicillin was discontinued and he was started
on intravenous vancomycin. His vancomycin peak and trough
levels were found to be therapeutic and non-nephrotoxic at
multiple points during his hospitalization.
On [**2107-9-28**], the seventh day of the patient's
hospitalization, he was taken back to the CT scanner to
evaluate his right posterior hemithorax abscess following
drainage on [**2107-9-23**]. The abscess was found to have
markedly decreased with the 16-French drainage tube in good
position. However, it was also noted that his nasogastric
tube had penetrated the wall of the gastric pull-through and
the distal 2 cm of the tube terminated in the subcutaneous
tissues of the posterior back. There was noted to be a
minimal leak of oral contrast through the tube, suggesting
that the perforation of the gastric pull-through might be
tamponaded by the nasogastric tube.
After discussing this in some detail with both the attending
surgeon and the radiologist, the decision was made to
redirect his nasogastric tube under fluoroscopic guidance.
The tube was withdrawn and repositioned proximally with the
tip within the gastric pouch. After injection with
Gastrografin, this demonstrated no leak or extravasation of
contrast from the pouch.
On [**2107-9-29**], the patient's eighth hospital day, he
was transferred from the surgical intensive care unit to a
regular hospital floor, where his broad spectrum antibiotics
were continued. His nasogastric tube was kept to low
continuous wall suction. His cardiovascular system was
controlled with intravenous Lopressor and intravenous
Vasotec. In addition, his total parenteral nutrition was
continued. During this time, he did require a one-on-one
sitter to ensure his safety and to ensure that he did not
manipulate his nasogastric tube.
Over the ensuing hospital days, the patient's mentation
improved dramatically and, by the 12th hospital day, he was
noted to be mentating clearly. At this point, he had been on
a two week course of Levaquin, Flagyl and fluconazole and an
eight day course of vancomycin with an intended goal of
having a four week course of each.
A few days later, the patient was noted to have a nine beat
run of ectopy that was concerning for nonsustained
ventricular tachycardia. The electrophysiology cardiology
team was consulted. They noted that his electrolytes were
normal and that his electrocardiogram demonstrated no
ischemia and had a normal Q-T interval. In addition, an
echocardiogram was obtained that demonstrated no areas of
hypokinesis or other suggestion of arrhythmogenic focus. The
electrophysiology team recommended that we continue
monitoring the patient on telemetry and continue his
Lopressor for both hypertension and arrhythmia suppression.
They did not feel that the patient needed an internal
defibrillator to be implanted before his discharge.
On the 15th day of the patient's hospitalization, his
nasogastric tube was injected with 60 cc of activated
charcoal. There was no charcoal observed in his pigtail
catheter subsequently. During all of this time, the patient
had only small output from his pigtail catheter, varying
between 5 and 95 cc per day, depending on the patient's
amount of activity and movement. Following his activated
charcoal injection, his pigtail catheter had scant output for
the remainder of his hospitalization.
The patient was started on sips of water, which were quickly
advanced to sips of clear liquids. He did frequently
complain of reflux-type symptoms and, for this reason, was
started on Milk of Magnesia and Protonix. As the patient's
diet was attempted to be advanced, he complained for multiple
days of retching and he was also started on 10 mg of Reglan
t.i.d. During all of this time, the patient was maintained
on total parenteral nutrition.
By the 20th day of the patient's hospitalization, the patient
was taking in some food and liquid, but not enough to
maintain his total nutritional needs. A lower dose of total
parenteral nutrition was continued, in which he received 1250
cc of volume, 75 gm of amino acids, 313 gm of dextrose and 25
gm of fat, to provide 1250 kcal in a day. In addition, he
had 35 units of insulin, 12 mg of zinc and 6000 units of
heparin added to his total parenteral nutrition. On this
same day of hospitalization, it was felt that his pleural
infection had cleared and his Levaquin, vancomycin and Flagyl
were all discontinued. His fluconazole was continued as a
200 mg regimen to continue for another four days, at which
time it could be discontinued. The patient was started on 50
mg per day of Zoloft with the intention of improving his
depressed affect, as that might be impacting his appetite.
By the following day, the patient was making a more concerted
effort toward eating. On Thursday, [**2107-10-13**], the
patient was transferred to an acute rehabilitation facility
for further recovery and care.
DISCHARGE MEDICATIONS:
1. Fluconazole 200 mg p.o. q.d. times three days.
2. Reglan 10 mg p.o. t.i.d. before meals.
3. Protonix 40 mg p.o. q.d.
4. Lopressor 50 mg p.o. b.i.d. (hold for systolic blood
pressure of less than 110 or heart rate of less than 60).
5. Zoloft 50 mg p.o. q.d.
6. Maalox 30 cc p.o. every four hours p.r.n.
7. Vasotec 10 mg p.o. q.d. (hold for systolic blood pressure
of less than 110).
DISCHARGE DIET: The patient is to take six small meals per
day. In addition, in his rehabilitation care, he may require
additional parenteral nutritional support until he [**Last Name (un) 5798**] his
nutritional goals.
DISCHARGE INSTRUCTIONS: We asked that the rehabilitation
staff observe his right chest pigtail catheter for any
further output. This catheter is to remain in place until
the patient follows up with Dr. [**Last Name (STitle) **].
FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) **]
in approximately three weeks, at which time we will most
likely repeat a CT scan of his chest to determine whether the
pigtail catheter can be discontinued.
DISPOSITION: The patient was transferred to acute
rehabilitation in stable condition. He expressed
understanding of all of his discharge instructions. In
addition, his discharge instructions were reviewed with his
son, [**Name (NI) **].
DISCHARGE DIAGNOSES:
Right pleural anastomotic leak, status post [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **]
esophagectomy resulting in polymicrobial and fungal
infection, now resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2107-10-12**] 21:48
T: [**2107-10-13**] 07:16
JOB#: [**Job Number 32917**]
Admission Date: [**2107-9-22**] Discharge Date: [**2107-10-15**]
Date of Birth: [**2034-4-10**] Sex: M
Service:
ADDENDUM: The patient's chest tube was discontinued on the
[**9-28**] following his CT scan that demonstrated that
his abscess had markedly diminished in size. During this
time his 16 French pigtail catheter was left in place. We
are asking that the rehabilitation facility flush this
catheter with 10 cc of saline once a day and observe it for
any output. In addition, the patient's discharge status is
amended as follows:
The patient was kept on the Acute Surgical Service for
another two days as he awaited rehab placement. The patient
was discharged on [**2107-10-15**] in stable condition to
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] in [**Location (un) **], [**State 350**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2107-10-14**] 09:58
T: [**2107-10-14**] 10:06
JOB#: [**Job Number 32918**]
|
[
"V10.03",
"401.9",
"997.4",
"427.1",
"998.59",
"510.9",
"038.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12290, 13877
|
10946, 11562
|
2237, 2752
|
4227, 10923
|
11587, 11794
|
1951, 2026
|
11806, 12269
|
2775, 4209
|
231, 1849
|
1872, 1928
|
2043, 2211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,006
| 190,152
|
17969+56905
|
Discharge summary
|
report+addendum
|
Admission Date: [**2113-6-19**] Discharge Date: [**2113-7-6**]
Date of Birth: [**2047-11-5**] Sex: F
Service: VSURG
Allergies:
Penicillins / Cephalosporins / Tape
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Altered mental status, hypotension.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 49752**] is a 65 y/o woman with a pmhx. of DM w triopathy and
ESRD who presented [**6-19**] to the [**Hospital1 **] EW from her NH with hx. of
hypotension, decresed temp, and ams "babbling". At EW she had a
temp of 101.4, and was hypotensive in the 80's. She responded
to fluids, and was dosed with vanc and flagyl emperically. A
lt. fem line was placed due to concern over using Lt IJ that was
already in for dialysis for other uses, and due to INR of 5.8
(did not want to attempt a SC line). EKG revealed diffuse ST
segment changes consistent with pericarditis - this was the
opinion of cards consult as well - had recent neg mibi also.
Note: was recently admitted to [**Hospital1 **] for line sepsis - MRSA - from
tunneled cath that was removed (admit [**5-29**] to [**6-9**]) was sent to
NH on IV vanc for line sepsis and for Lt. foot MRSA infection,
and with Flagyl for C Diff colitis. In the ICU here, she did
not require pressors, and is followed by vascular sx. and [**Month/Year (2) 2081**]
(retinal detachment). Of note - in the EW here, she did "perc
up" after fentanyl patch removed and narcan given, so it appears
that she is very opiate sensitive re: mental status.
Past Medical History:
DM2 with retinopathy (L eye blindness, R eye cataract)
S/P left eye victrectomy in [**October 2112**]
Neuropathy
ESRD on HD
PVD s/p R AKA [**2110**]
paroxysmal A flutter on coumadin
Dry gangrene of L foot
HTN
Depression on zoloft
s/p cholecystectomy
s/p appendectomy
atrial flutter
R groin graft infection s/p debridement, MRSA+
Social History:
come from nursing home
Family History:
Unknown
Physical Exam:
96.7 60 146/91 16 100 3 lpm nc
Obese female in NAD
Blind, many opth meds in place
OP clear, neck supple, Lt.tunneled IJ in place
[**Last Name (un) **], no mrg
bibasilar rales anteriorly
abd s/nt/nd/bs+, obese
trace edema, Lt. groin fem. line
no rashes
Pertinent Results:
[**2113-6-19**] 02:15PM GLUCOSE-135* UREA N-54* CREAT-10.4*
SODIUM-148* POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-29 ANION
GAP-21*
[**2113-6-19**] 02:15PM ALT(SGPT)-17 AST(SGOT)-28 LD(LDH)-151 ALK
PHOS-118* TOT BILI-0.4
[**2113-6-19**] 02:15PM ALBUMIN-2.9*
[**2113-6-19**] 12:55PM WBC-14.8* RBC-3.57* HGB-10.5* HCT-35.2*
MCV-99* MCH-29.5 MCHC-30.0* RDW-16.6*
[**2113-6-19**] 12:55PM PLT COUNT-458*
[**2113-6-19**] 12:55PM CALCIUM-10.6* PHOSPHATE-4.4 MAGNESIUM-2.8*
[**2113-7-5**] 08:15AM BLOOD WBC-8.2 RBC-3.73* Hgb-11.2* Hct-34.5*
MCV-93 MCH-29.9 MCHC-32.3 RDW-16.9* Plt Ct-320
[**2113-7-6**] 06:05AM BLOOD PT-24.1* PTT-71.6* INR(PT)-3.7
[**2113-7-6**] 06:05AM BLOOD Glucose-70 UreaN-16 Creat-3.6*# Na-140
K-3.7 Cl-100 HCO3-27 AnGap-17
[**2113-7-5**] 08:15AM BLOOD Calcium-12.5* Mg-3.4*
[**2113-7-3**] 01:43PM BLOOD TSH-5.2*
[**2113-7-5**] 08:15AM BLOOD PTH-59
[**2113-7-5**] 12:04PM BLOOD Vanco-17.7*
Brief Hospital Course:
65 y/o admitted from NH with hypotension and ams. Responded
well to fluids and abx.
1. Hypotension - responded well to IVF - no need for pressors.
2. Sepsis - treating emperically for MRSA given hx., and flagyl
for CDiff colitis, as this was also in history of recent
admission here ending [**6-9**]. Cx. pending. Also on Levo for ?
PNA/UTI. Gangrene of foot less likely as source per vascular.
3. ams - head CT neg. Will continue to treat possible
infectious etiologies and maintain fluid and electrolyte
balance.
4. Coagulopathy - treating with Vit K, and FFP given night of
admission. Coumadin held. Will restart once stable.
5. Dry Gangrene Lt. foot - s/p AKA on [**6-26**]. stable wound.
staples to be d/c'd in 1 month.
6. ESRD on HD. Stable protocol per renal - cont.
7. [**Month/Day (2) **] - retinal detachment - followed by [**Last Name (LF) 2081**], [**First Name3 (LF) **] continue
ggt's per [**First Name3 (LF) 2081**] and attempt to limit virious hemorrhage via
controlling coagulopathy.
8. ECG changes - likely pericarditis per cards, will get serial
ECGs. Enzymes neg. Cont ASA, B blocker as BP tolerates.
9. BG - NPH/RISS/FSQID
10. Code - DNR/DNI
11. PPx - PPI, has supratherapeutic INR.
12. FEN - Diabetic diet.
Medications on Admission:
Gabapentin
protonix
metoprolol
phoslo
bimatoprost
NPH/RISS
loratadine
albuterol
dulcolax
vicodin
coumadin
atropine
vanco
prednosolone
dorzdamide
asa
Discharge Medications:
1. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic qhs ().
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
6. Atropine Sulfate 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous twice a day: Qam dose : NPH 4units
QHS dose: NPH 2units.
16. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection four times a day: AC/HS;
glucoses < 150/ no insulin
glucoses 151-200/2u
glucoses 201-250/4u
glucoses 251-300/6u
glucoses 301-350/8u
glucoses 351-400/10u
glucoses > 400 [**Name8 (MD) 138**] MD.
17. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 3 weeks: then 200mg po qd.
18. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous QHD (each hemodialysis) for 1 weeks.
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
left foot gangrene s/p AKA
urosepsis
a-fibrillation
ESRD/HD
diabetes type 2 with triopathy
MRSA
depression
glaucoma
Discharge Condition:
stable.
Discharge Instructions:
L aka site - open to air
PT as tolerated
Please call back if develop wound erythema, discharge
Followup Instructions:
1 month with Dr. [**Last Name (STitle) **], to remove staples then. call for
appointment. [**Telephone/Fax (1) 1241**].
Cardiology Dr. [**Last Name (STitle) 73**]. [**Telephone/Fax (1) 902**]. Dr. [**Last Name (STitle) 73**] will call
pt for appt in [**11-25**] weeks.
Hemodialysis.
PT/INR checks, dose coumadin accordingly for target INR 2.0-3.0.
Name: [**Known lastname 9214**],[**Known firstname **] Unit No: [**Numeric Identifier 9215**]
Admission Date: [**2113-6-19**] Discharge Date: [**2113-7-6**]
Date of Birth: [**2047-11-5**] Sex: F
Service: VSURG
Allergies:
Penicillins / Cephalosporins / Tape
Attending:[**First Name3 (LF) 270**]
Chief Complaint:
transferred from OSH for sepsis.
Major Surgical or Invasive Procedure:
Left Above Knee Amputation
Past Medical History:
DM2 with retinopathy (L eye blindness, R eye cataract)
S/P left eye victrectomy in [**October 2112**]
Neuropathy
ESRD on HD
PVD s/p R AKA [**2110**]
paroxysmal A flutter on coumadin
Dry gangrene of L foot
HTN
Depression on zoloft
s/p cholecystectomy
s/p appendectomy
atrial flutter
R groin graft infection s/p debridement, MRSA+
Social History:
come from nursing home
Family History:
Unknown
Brief Hospital Course:
Pt had paroxysmal episodes of AFib. Given lopressor, IV
amiodarone, cardiology consult obtained. serial cardiac enzymes
obtained, minor troponin leak. d/c'd amiodarone, recurred AFib
and NSVT of 4 beats duration. cardiology recommendation
followed to begin PO amiodarone. Pt cleared from cardiac
standpoint, telemetry d/c'd, and [**Doctor Last Name **] of Hearts monitor
obtained.
Discharge Medications:
1. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Bimatoprost 0.03 % Drops Sig: One (1) gtt Ophthalmic qhs ().
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
6. Atropine Sulfate 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous twice a day: Qam dose : NPH 4units
QHS dose: NPH 2units.
16. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection four times a day: AC/HS;
glucoses < 150/ no insulin
glucoses 151-200/2u
glucoses 201-250/4u
glucoses 251-300/6u
glucoses 301-350/8u
glucoses 351-400/10u
glucoses > 400 [**Name8 (MD) 233**] MD.
17. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 3 weeks: then 200mg po qd.
18. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous QHD (each hemodialysis) for 1 weeks.
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
left foot gangrene
urosepsis
a-fibrillation
ESRD/HD
diabetes type 2 with triopathy
MRSA
depression
glaucoma
Discharge Condition:
stable.
Discharge Instructions:
L aka site - open to air
PT as tolerated
Please call back if develop wound erythema, discharge
Followup Instructions:
1 month with Dr. [**Last Name (STitle) **], to remove staples then. call for
appointment. [**Telephone/Fax (1) 4749**].
Cardiology Dr. [**Last Name (STitle) **]. [**Telephone/Fax (1) 9223**]. Dr. [**Last Name (STitle) **] will call
pt for appt in [**11-25**] weeks.
Hemodialysis.
PT/INR checks, dose coumadin accordingly for target INR 2.0-3.0.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2113-7-6**]
|
[
"440.24",
"995.91",
"996.62",
"585",
"038.11",
"599.0",
"427.32",
"008.45",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"84.17",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10795, 10876
|
8347, 8734
|
7878, 7907
|
11028, 11037
|
2281, 3192
|
11180, 11681
|
8315, 8324
|
8757, 10772
|
10897, 11007
|
4481, 4632
|
11061, 11157
|
2005, 2262
|
7806, 7840
|
362, 1573
|
7929, 8259
|
8275, 8299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,437
| 145,841
|
15214
|
Discharge summary
|
report
|
Admission Date: [**2131-11-12**] Discharge Date: [**2131-11-26**]
Date of Birth: [**2064-9-22**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
gentleman who has developed a progressive dysphagia and
underwent a workup by Dr. [**Last Name (STitle) **] which included
esophagoscopy by Dr. [**Last Name (STitle) **], which demonstrated distal
esophageal mass extending from 38 cm to 42 cm and was found
to be a T3 N1 adenocarcinoma utilizing biopsy and
intraoperative ultrasound.
A staging chest computed tomography scan, head computed
tomography scan, and bone computed tomography scan were
negative for metastatic disease.
On [**2131-8-17**] Dr. [**Last Name (STitle) 30652**] performed a mini-laparotomy
with placement of a jejunostomy tube and a Port-A-Cath. He
subsequently underwent neuroadjuvant chemoembolization by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 3274**] by Thoracic Oncology and by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44287**]
of Radiology/Oncology.
He has done well from this, having complained therapy and now
presents for his esophagectomy. A repeat chest computed
tomography scan demonstrated no progression of the disease.
He is doing well status post therapy, having lost a
significant amount of weight from therapy. He has regained
some of his weight and is currently about 180 pounds. He has
no other symptoms. He denies neurological or musculoskeletal
complaints. All other systems reviewed were negative.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was a
well-developed male with appropriate weight. He was not
cachectic. He was in no apparent distress. He seemed
comfortable. Vital signs were within normal limits. His
sclerae were anicteric. His neck revealed no supraclavicular
or cervical adenopathy. The lungs were clear to
auscultation. The heart was regular. The abdomen was with no
masses. Thorax demonstrated no asymmetry or masses.
Extremities revealed no clubbing, cyanosis, or edema.
Vascular examination revealed 2+ pulses throughout and
without bruits. Neurologically, he was nonfocal.
HOSPITAL COURSE: The patient was admitted on [**2131-11-12**] on the Cardiothoracic Surgery Service.
On [**2131-11-13**], the patient was brought to the operating
room, at which time an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy was
performed. The patient tolerated the procedure well, and
postoperatively was sent to the Surgical floor to recuperate.
His postoperative course was without complications. The
patient had a good amount of gastric losses from the
nasogastric tube and was started on tube feeds on
postoperative day two. The patient's chest tubes put out a
good amount of serosanguineous material up until
postoperative day six, at which time they were discontinued.
During the postoperative course, the patient's heart rate
climbed into the 130s to 140s, at which time he was started
on Lopressor. Because of the patient's extensive history of
emphysema, the Lopressor was discontinued and replaced with
diltiazem at 360 mg once per day, for which the patient's
heart rate came down to the 100s.
Subsequent chest x-rays each day throughout the patient's
early postoperative course were consistent with normal
postoperative changes without dilatation of the gastric
component of the esophageal reconstruction.
On postoperative day eight, secondary to complaints of the
patient's shortness of breath as well as the resurgence of
the tachycardia, a V/Q scan was performed in order to rule
out pulmonary embolism. The results of the test were low
probability for pulmonary embolism. At that time, the
patient's theophylline was restarted; it had been held
previously secondary to his tachycardia to prevent ectopy.
In addition, the chest x-ray that was done at the time of the
complaints of shortness of breath were consistent with a
significant left pleural effusion. The patient was taken to
Interventional Radiology, at which time the effusion was
tapped for a total of 1400 cc of pleural fluid. The patient
was started Levaquin to cover for pneumonia.
By postoperative eleven, the patient was doing quite well and
was subsequently discharged. During the [**Hospital 228**] hospital
course, a Cardiology consultation was obtained for his
tachycardia as well, and they recommended the course of
diltiazem, and if his tachycardia was refractory to diltiazem
to start the patient on Lopressor; which was not necessary,
as the patient responded nicely to diltiazem.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. T3 N1 esophageal adenocarcinoma.
2. Status post [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy on [**2131-11-13**].
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to see Dr. [**Last Name (STitle) 30652**] in two weeks in the
office.
2. The patient was to see his primary care physician in one
week.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-367
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2131-11-25**] 21:16
T: [**2131-11-26**] 00:05
JOB#: [**Job Number 44288**]
|
[
"486",
"568.0",
"150.5",
"196.1",
"427.89",
"300.01",
"493.92",
"492.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"34.91",
"54.59",
"40.29",
"97.41",
"43.99",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4712, 4864
|
2184, 4602
|
4897, 5288
|
4617, 4691
|
182, 2165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,669
| 174,575
|
38270
|
Discharge summary
|
report
|
Admission Date: [**2175-8-29**] Discharge Date: [**2175-9-8**]
Date of Birth: [**2138-2-2**] Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Neutropenic fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
The patient is a 37 year old female with a history of AML M4-Eo
who initially presented on [**2175-6-30**]. She was treated with 7+3
cytarabine / idarubicin induction from [**2175-7-3**] to [**2175-7-30**].
She began HiDAC on [**2175-8-11**], and is currently on C1D19. She
presented to clinic today for a routine count check and was
found to have a temperature of 99.9 F and labs with WBC-0.9,
HGB-8.8, HCT-25.0, PLT-172, and CR-0.6. She was asymptomatic at
the time, with no new complaints. Blood cultures x2 were sent
and a chest Xray were obtained. Her temperature then rose to a
maximum of 100.4, she was given Cefepime 2 grams once, and she
was admitted to the BMT service.
.
On admission, she reported feeling well, with no recent focal
symptoms suggesting infection. She denied fever prior to the
clinic visit, but did feel feverish in the clinic. She denied
recently increased fatigue, SOB, or DOE. She denied cough, URI
symptoms, congestion, or recent sick contacts. She denied
abdominal pain, nausea, vomiting, diarrhea, constipation,
dysphagia, odynophagia, mouth sores, bloody stool, dark stool,
or other stool changes. She denied any changes in her urine,
dysuria, frequency, urgency, or hematuria. She denied any new
rashes, ecchymoses, or lesions. She denied any joint or muscle
pain, weakness, loss of sensation, or paresthesias. She did
describe a mild headache this morning that was typical for her
and resolved after drinking some coffee.
.
Past Medical History:
# Latent Syphilis -- positive VDRL/FTA-ABS on [**2175-7-3**] admission
-- Treated with Penicillin IV x14 days per ID recs
-- LP performed, with CSF VDRL negative
# HSV -- sacral rash on [**2175-6-30**] admission, responded to acyclovir
# C-Section x3
.
Social History:
Born in [**Country 4194**], moved to United States in [**2161**]. Lives in
[**Location 47**], MA with 3 roommates, no pets. She has 3 children in
[**Country 4194**] (ages 18, 17, and 15). She works full time for a cleaning
company.
Smoking: None
Alcohol: Social
Drugs: None
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
VS: T 100.8, BP 98/58, HR 83, RR 18, SpO2 100% on RA
Gen: Young female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear. No thrush or mouth
lesions.
Neck: Supple, full ROM. No JVD. Several slightly enlarged,
soft, mobile, nontender submandibular nodes. Normal carotid
pulses. No carotid bruits noted.
CV: Slightly hyperdynamic. RRR with normal S1, S2. No M/R/G.
No thrills or lifts. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
with no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, ND. No organomegaly. Abdominal
aorta pulsations prominent and easily palpable. Mild tenderness
in the epigastric region and LUQ. No rebound or guarding.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact, radial 2+, DP 2+, and PT 2+.
Skin: No ulcers, rashes, or other lesions. Tunneled line to
left IJ without tenderness, erythema, or fluctuance. Slight
skin irritation at superior end of tunnel where catheter bends
to enter IJ.
Neuro: CN II-XII grossly intact.
.
.
Physical Exam on ICU Transfer:
Vitals: T:98.7 BP:91/58 P:121 R:29 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardiac, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact
.
.
Physical Exam on Return to Floor:
VS: T 99.2, BP 102/70, HR 92, RR 18, SpO2 98% on RA
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Resting in bed.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No erythema or fluctuance at right central line or left Hickman.
CV: RRR. Normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. Lungs
CTAB. No wheezes, rhonchi, or rales.
Abd: BS present. Soft, ND. No HSM detected. Tender to palpation
in epigastric region and LLQ. No rebound or guarding.
Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Skin: No rashes, ecchymoses, or other lesions noted.
.
.
.
Physical Exam on Discharge:
VS: T 98.2, BP 96/66, HR 68, RR 18, SpO2 96% on RA
Gen: NAD. Alert and oriented x3. Mood and affect cheerful.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No erythema or fluctuance at left IJ Hickman site.
CV: RRR. Normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. Lungs
CTAB. No wheezes, rhonchi, or rales.
Abd: BS present. Soft, NT, ND. No HSM detected.
Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Skin: No rashes, ecchymoses, or other lesions noted.
.
.
Pertinent Results:
[**2175-8-29**] 09:15AM BLOOD WBC-0.9* RBC-2.86* Hgb-8.8* Hct-25.0*
MCV-88 MCH-30.7 MCHC-35.1* RDW-15.6* Plt Ct-172#
[**2175-8-30**] 12:00AM BLOOD WBC-1.1* RBC-2.66* Hgb-8.1* Hct-23.4*
MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-227
[**2175-8-31**] 12:00AM BLOOD WBC-1.8*# RBC-3.07* Hgb-9.4* Hct-26.7*
MCV-87 MCH-30.8 MCHC-35.4* RDW-16.3* Plt Ct-334
[**2175-9-1**] 12:00AM BLOOD WBC-2.0* RBC-3.10* Hgb-9.6* Hct-27.5*
MCV-89 MCH-30.9 MCHC-34.8 RDW-16.9* Plt Ct-419
[**2175-9-2**] 12:00AM BLOOD WBC-3.2*# RBC-3.18* Hgb-9.6* Hct-28.9*
MCV-91 MCH-30.1 MCHC-33.2 RDW-16.4* Plt Ct-479*
[**2175-9-3**] 12:30AM BLOOD WBC-9.7# RBC-2.84* Hgb-8.9* Hct-25.0*
MCV-88 MCH-31.4 MCHC-35.7* RDW-18.1* Plt Ct-385
[**2175-9-3**] 11:30AM BLOOD WBC-16.0*# RBC-2.91* Hgb-9.0* Hct-25.5*
MCV-88 MCH-31.0 MCHC-35.4* RDW-18.3* Plt Ct-442*
[**2175-9-3**] 08:15PM BLOOD WBC-14.6* RBC-2.62* Hgb-8.2* Hct-23.3*
MCV-89 MCH-31.1 MCHC-35.1* RDW-18.2* Plt Ct-323
[**2175-9-4**] 04:00AM BLOOD WBC-16.4* RBC-2.88* Hgb-9.0* Hct-25.4*
MCV-88 MCH-31.2 MCHC-35.4* RDW-18.0* Plt Ct-278
[**2175-9-5**] 12:00AM BLOOD WBC-21.2* RBC-2.88* Hgb-8.9* Hct-26.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-17.9* Plt Ct-302
[**2175-9-5**] 12:48PM BLOOD WBC-18.7* RBC-3.05* Hgb-9.6* Hct-27.4*
MCV-90 MCH-31.3 MCHC-34.8 RDW-17.3* Plt Ct-262
[**2175-9-6**] 12:00AM BLOOD WBC-14.9* RBC-2.91* Hgb-9.1* Hct-26.1*
MCV-90 MCH-31.4 MCHC-34.9 RDW-17.9* Plt Ct-278
[**2175-9-7**] 12:00AM BLOOD WBC-14.4* RBC-3.10* Hgb-9.7* Hct-28.0*
MCV-90 MCH-31.1 MCHC-34.6 RDW-17.7* Plt Ct-266
[**2175-9-8**] 12:00AM BLOOD WBC-13.7* RBC-3.21* Hgb-10.1* Hct-28.9*
MCV-90 MCH-31.6 MCHC-35.1* RDW-16.9* Plt Ct-258
.
[**2175-8-29**] 09:15AM BLOOD Neuts-2* Bands-0 Lymphs-73* Monos-15*
Eos-2 Baso-1 Atyps-6* Metas-0 Myelos-0 Plasma-1*
[**2175-8-30**] 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-78* Monos-17*
Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2175-8-31**] 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-74* Monos-23*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-2*
[**2175-9-1**] 12:00AM BLOOD Neuts-2* Bands-0 Lymphs-52* Monos-41*
Eos-2 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2175-9-2**] 12:00AM BLOOD Neuts-2* Bands-3 Lymphs-23 Monos-56*
Eos-0 Baso-0 Atyps-0 Metas-8* Myelos-6* Other-2*
[**2175-9-3**] 12:30AM BLOOD Neuts-51 Bands-14* Lymphs-4* Monos-29*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2175-9-3**] 11:30AM BLOOD Neuts-54 Bands-14* Lymphs-7* Monos-21*
Eos-0 Baso-1 Atyps-0 Metas-2* Myelos-0 Promyel-1*
[**2175-9-3**] 08:15PM BLOOD Neuts-53 Bands-21* Lymphs-3* Monos-23*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-9-4**] 04:00AM BLOOD Neuts-72* Bands-7* Lymphs-7* Monos-14*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-9-5**] 12:00AM BLOOD Neuts-76* Bands-13* Lymphs-3* Monos-4
Eos-0 Baso-1 Atyps-0 Metas-3* Myelos-0
[**2175-9-6**] 12:00AM BLOOD Neuts-77* Bands-4 Lymphs-8* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2175-9-7**] 12:00AM BLOOD Neuts-60 Bands-2 Lymphs-9* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-10* Myelos-9* Promyel-1*
[**2175-9-8**] 12:00AM BLOOD Neuts-61 Bands-2 Lymphs-21 Monos-11 Eos-0
Baso-1 Atyps-1* Metas-1* Myelos-2*
.
[**2175-8-29**] 09:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2175-8-30**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL
[**2175-8-31**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2175-9-1**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2175-9-2**] 12:00AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+
Tear Dr[**Last Name (STitle) 833**]
[**2175-9-3**] 12:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-NORMAL
[**2175-9-3**] 08:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Ovalocy-1+
[**2175-9-5**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL
[**2175-9-6**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2175-9-7**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2175-9-8**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
.
[**2175-8-29**] 09:15AM BLOOD Gran Ct-30*
[**2175-8-30**] 12:00AM BLOOD Gran Ct-0*
[**2175-8-31**] 12:00AM BLOOD Gran Ct-0*
[**2175-9-1**] 12:00AM BLOOD Gran Ct-102*
[**2175-9-2**] 12:00AM BLOOD Gran Ct-606*
.
[**2175-8-30**] 12:43AM BLOOD PT-14.1* PTT-28.9 INR(PT)-1.2*
[**2175-8-31**] 12:00AM BLOOD PT-14.5* PTT-33.9 INR(PT)-1.3*
[**2175-9-1**] 12:00AM BLOOD PT-13.6* PTT-27.8 INR(PT)-1.2*
[**2175-9-2**] 12:00AM BLOOD PT-13.8* PTT-25.2 INR(PT)-1.2*
[**2175-9-3**] 12:30AM BLOOD PT-19.6* PTT-36.0* INR(PT)-1.8*
[**2175-9-3**] 11:30AM BLOOD PT-19.9* PTT-46.5* INR(PT)-1.8*
[**2175-9-5**] 12:00AM BLOOD PT-14.6* PTT-30.4 INR(PT)-1.3*
[**2175-9-6**] 12:00AM BLOOD PT-14.2* PTT-32.3 INR(PT)-1.2*
[**2175-9-7**] 12:00AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1
[**2175-9-8**] 12:00AM BLOOD PT-13.2 PTT-28.0 INR(PT)-1.1
.
[**2175-9-3**] 12:30AM BLOOD Fibrino-394
[**2175-9-3**] 11:30AM BLOOD Fibrino-443*
[**2175-9-4**] 04:00AM BLOOD Fibrino-441*
.
[**2175-8-29**] 09:15AM BLOOD UreaN-11 Creat-0.6 Na-135 K-4.0 Cl-101
HCO3-28 AnGap-10
[**2175-8-30**] 12:00AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-136
K-3.8 Cl-103 HCO3-26 AnGap-11
[**2175-8-31**] 12:00AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2175-9-1**] 12:00AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-136
K-4.1 Cl-101 HCO3-26 AnGap-13
[**2175-9-2**] 12:00AM BLOOD Glucose-119* UreaN-7 Creat-0.5 Na-137
K-4.2 Cl-101 HCO3-28 AnGap-12
[**2175-9-3**] 12:30AM BLOOD Glucose-134* UreaN-12 Creat-0.6 Na-133
K-3.2* Cl-101 HCO3-20* AnGap-15
[**2175-9-3**] 11:30AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-142 K-4.4
Cl-113* HCO3-23 AnGap-10
[**2175-9-3**] 08:15PM BLOOD Glucose-108* UreaN-6 Creat-0.4 Na-141
K-3.7 Cl-114* HCO3-22 AnGap-9
[**2175-9-4**] 04:00AM BLOOD Glucose-98 UreaN-8 Creat-0.4 Na-137 K-3.4
Cl-109* HCO3-24 AnGap-7*
[**2175-9-5**] 12:00AM BLOOD Glucose-83 UreaN-5* Creat-0.4 Na-141
K-3.6 Cl-109* HCO3-25 AnGap-11
[**2175-9-6**] 12:00AM BLOOD Glucose-105* UreaN-5* Creat-0.5 Na-142
K-3.8 Cl-107 HCO3-28 AnGap-11
[**2175-9-7**] 12:00AM BLOOD Glucose-109* UreaN-6 Creat-0.5 Na-142
K-4.0 Cl-106 HCO3-29 AnGap-11
[**2175-9-8**] 12:00AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-140 K-4.1
Cl-104 HCO3-30 AnGap-10
.
[**2175-8-29**] 09:15AM BLOOD ALT-71* AST-28 LD(LDH)-106 AlkPhos-91
TotBili-0.5
[**2175-8-30**] 12:00AM BLOOD ALT-60* AST-26 LD(LDH)-110 AlkPhos-82
TotBili-0.3
[**2175-8-31**] 12:00AM BLOOD ALT-54* AST-22 LD(LDH)-121 AlkPhos-84
TotBili-0.5
[**2175-9-1**] 12:00AM BLOOD ALT-47* AST-23 LD(LDH)-160 AlkPhos-80
TotBili-0.3
.
[**2175-9-1**] 12:57AM BLOOD CK(CPK)-14* CK-MB-1 cTropnT-<0.01
[**2175-9-1**] 09:04AM BLOOD CK(CPK)-12* CK-MB-1
[**2175-9-1**] 04:30PM BLOOD CK(CPK)-12* CK-MB-1 cTropnT-<0.01
[**2175-9-3**] 12:30AM BLOOD CK(CPK)-12* CK-MB-1 cTropnT-<0.01
[**2175-9-3**] 11:30AM BLOOD CK(CPK)-11* CK-MB-2 cTropnT-<0.01
[**2175-9-3**] 08:15PM BLOOD CK(CPK)-23* CK-MB-2 cTropnT-<0.01
[**2175-9-6**] 12:00AM BLOOD CK(CPK)-13* CK-MB-1
.
[**2175-9-2**] 12:00AM BLOOD ALT-42* AST-21 LD(LDH)-129 AlkPhos-78
TotBili-0.3
[**2175-9-3**] 12:30AM BLOOD ALT-28 AST-18 LD(LDH)-126 AlkPhos-58
TotBili-1.3
[**2175-9-3**] 08:15PM BLOOD LD(LDH)-169
[**2175-9-4**] 04:00AM BLOOD LD(LDH)-174
[**2175-9-5**] 12:00AM BLOOD ALT-66* AST-44* LD(LDH)-203 AlkPhos-62
TotBili-0.5
[**2175-9-6**] 12:00AM BLOOD ALT-52* AST-27 LD(LDH)-202 AlkPhos-62
TotBili-0.4
[**2175-9-7**] 12:00AM BLOOD ALT-48* AST-38 LD(LDH)-233 AlkPhos-59
TotBili-0.3
[**2175-9-8**] 12:00AM BLOOD ALT-78* AST-100* LD(LDH)-269* AlkPhos-57
TotBili-0.3
.
[**2175-8-29**] 09:15AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.8
[**2175-8-30**] 12:00AM BLOOD Albumin-4.0 Calcium-8.7 Phos-5.5* Mg-1.9
UricAcd-4.3
[**2175-8-31**] 12:00AM BLOOD Albumin-3.8 Calcium-8.9 Phos-5.3* Mg-2.0
UricAcd-4.3
[**2175-9-1**] 12:00AM BLOOD Albumin-4.1 Calcium-9.3 Phos-5.2* Mg-1.9
UricAcd-3.8
[**2175-9-2**] 12:00AM BLOOD Albumin-4.1 Calcium-8.9 Phos-5.0* Mg-1.9
UricAcd-4.4
[**2175-9-3**] 12:30AM BLOOD Albumin-3.2* Calcium-7.6* Phos-3.5
Mg-1.1* UricAcd-3.9
[**2175-9-3**] 11:30AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.0
[**2175-9-3**] 08:15PM BLOOD Calcium-8.4 Phos-1.6* Mg-1.7 UricAcd-3.0
[**2175-9-4**] 04:00AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1 UricAcd-3.1
[**2175-9-5**] 12:00AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.7 Mg-1.7
[**2175-9-6**] 12:00AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.7 Mg-1.8
[**2175-9-7**] 12:00AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.0 Mg-1.8
[**2175-9-8**] 12:00AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.6* Mg-1.8
.
[**2175-9-3**] 12:30AM BLOOD Hapto-79
.
[**2175-8-29**] 09:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2175-8-29**] 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
.
CHEST (PA & LAT) Study Date of [**2175-8-29**] 11:42 AM
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: Comparison is made to prior radiograph from [**2175-8-12**].
FINDINGS: The lungs are clear without any new focal opacities.
The cardiomediastinal silhouette, hilar silhouette, and pleural
surfaces remain unchanged. No pleural effusions or
pneumothoraces. Central venous catheter remains with the
catheter tip at the superior cavoatrial junction.
IMPRESSION: Normal chest radiograph. However, given the history
of neutropenic fever, if the patient has any clinical symptoms,
a CT should be
obtained for further evaluation given the increased sensitivity.
These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**] of the
patient's primary clinical team at approximately 2 p.m. on
[**2175-8-29**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 251**] [**Name (STitle) 8580**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2175-8-30**] 12:16 AM
.
.
CHEST (PORTABLE AP) Study Date of [**2175-9-1**] 1:19 AM
REASON FOR EXAMINATION: Acute onset of chest pain for three
hours.
Portable AP chest radiograph was compared to [**2175-8-29**].
The Hickman catheter tip is at the level of low SVC. The
cardiomediastinal silhouette is stable. Lungs are clear. There
is no pleural effusion or pneumothorax.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2175-9-1**] 12:30 PM
.
.
CHEST (PORTABLE AP) Study Date of [**2175-9-2**] 4:24 PM
HISTORY: AML, fever, evaluate for infection.
One portable view. Comparison with [**2175-9-1**]. The lungs remain
clear. The heart and mediastinal structures are unremarkable.
The bony thorax is grossly intact. A left internal jugular
catheter remains in place.
IMPRESSION: No active pulmonary disease.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SUN [**2175-9-3**] 7:31 AM
.
.
CHEST (PORTABLE AP) Study Date of [**2175-9-2**] 11:07 PM
HISTORY: Line placement.
One view. Comparison with [**2175-9-2**]. The lungs remain clear. The
heart and mediastinal structures are unremarkable. The bony
thorax is grossly intact. A left IJ line remains in place,
terminating in the region of the cavoatrial junction.
IMPRESSION: No active pulmonary disease.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SUN [**2175-9-3**] 9:33 AM
.
.
CHEST (PORTABLE AP) Study Date of [**2175-9-3**] 5:51 AM
HISTORY: New IJ line.
One view. Comparison with [**2175-9-2**]. The lungs remain clear.
Mediastinal structures are unchanged. A left internal jugular
line remains in place. A right internal jugular catheter has
been inserted and terminates at the level of the right atrium or
junction of the right atrium and inferior vena cava. There is no
other significant change.
IMPRESSION: Line placement as described. Result called to floor.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SUN [**2175-9-3**] 9:33 AM
.
.
CHEST PORT. LINE PLACEMENT Study Date of [**2175-9-3**] 10:34 AM
HISTORY: Central line placement.
ONE VIEW: Comparison with the previous study done earlier the
same day. The right chest is not entirely included. The lungs
remain clear. A left internal jugular catheter remains in place.
A right internal jugular catheter has been pulled back and now
terminates at the level of the cavoatrial junction.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: SUN [**2175-9-3**] 3:39 PM
.
.
Cardiology Report ECG Study Date of [**2175-9-1**] 12:22:40 AM
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2175-7-3**] no diagnostic interim change. The slight ST segment
elevation in the inferior and lateral leads is early
repolarization and not likely to represent ischemia in this
patient's age group.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 138 86 384/413 -7 55 38
.
.
CT ABDOMEN/PELVIS W/CONTRAST Study Date of [**2175-9-1**] 5:40 PM
COMPARISON: CT scan dated [**2175-7-11**].
FINDINGS: Within the lung bases, no concerning lesions or
pleural effusions are seen. A central venous line terminates
just within the right atrium. Within the abdomen, the previously
seen colitis has essentially resolved on this examination.
Several loops of collapsed bowel in the left upper quadrant are
incompletely assessed; however, no surrounding inflammation is
seen. A 1.7 cm hypodensity in segment VII of the liver is
incompletely characterized; however, unchanged. On review of the
previous imaging, this is thought to represent a hemangioma. The
spleen and pancreas are normal. A hypodensity in the left kidney
is incompletely characterized; however, likely represents a
simple cyst. The right kidney appears normal. Retroaortic left
renal vein, accessory right renal artery noted. The bilateral
adrenal glands are unremarkable. There is cholelithiasis,
similar to the prior examination in appearance. No evidence of
cholecystitis on this study. The bladder, distal ureters, and
uterus appear normal. No free air is seen. A small amount of
free fluid is present within the pelvis. A calcification in the
right lower quadrant is not clearly localized and may be related
to the right adnexa, particularly on the coronal reformats. No
lymphadenopathy is identified. No concerning osseous lesion is
seen. Incidental note is made of advanced degenerative changes
in the left hip joint. The configuration of the femoral head
suggests a previous slipped capital femoral epiphysis.
IMPRESSION:
1. Resolution of previously seen colitis.
2. Cholelithiasis without evidence of cholecystitis.
3. Central line with tip in right atrium.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 12562**] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] NI MHUIRCHEARTAIGH
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: SAT [**2175-9-2**] 5:28 PM
.
.
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2175-9-6**]
9:49 AM
TECHNIQUE: Helical CT acquisition from top of the lungs to upper
abdomen without intravenous contrast with multiplanar
reformations.
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is a left
chest wall Port-A-Cath with the tip of the catheter terminating
at the cavoatrial junction. Small amount of residual thymic
tissue is present. There is no mediastinal, axillary adenopathy.
Evaluation of hilar adenopathy is limited in the absence of IV
contrast. Limited non-contrast evaluation of heart and
pericardium is unremarkable. The superior segment of the right
lower lobe demonstrates a new broad based subpleural nodular
opacity measuring 1.4 X 0.7 cm (4:76), this could represent
focal atelectasis, however in the right clinical infection is
not excluded. There are several unchanged non-calcified
pulmonary nodules measuring upto 3 mm, (4:72, 106, 149). There
is new diffuse septal thickening, small bilateral pleural
effusions, right greater than left with bibasilar compressive
atelectasis. The tracheobronchial tree is patent to subsegmental
levels. Spleeen is partially imaged and appears prominent.
Limited non-contrast evaluation of the imaged upper abdomen is
within normal limits. Osseous structures are unremarkable.
IMPRESSION:
1. New diffuse septal thickening likely due to hydrostatic edema
in the setting of new pleura effusions.
2. New dependent right lower lobe opacity, likely focal nodular
atelectasis and less likely an early focus of pneumonia.
3. Unchanged small pulmonary nodules.
4. No specific findings to explain left chest wall pain. Please
note given non-contrast nature of this study, vascular etiology
for pain cannot be evaluated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: WED [**2175-9-6**] 2:33 PM
.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2175-9-8**]
4:13 PM
FINDINGS: The liver demonstrates normal echotexture. There is a
1.7 x 1.5 x 2.5 cm hemangioma in the right lobe of the liver. No
other lesions are identified. There is normal hepatopetal flow
within the patent portal vein. There is no intrahepatic or
extrahepatic biliary dilatation. The common bile duct measures 2
mm. The gallbladder contains a 0.7-cm calcified gallstone.
There is no gallbladder wall thickening or pericholecystic
fluid. The spleen measures 10.9 cm. The pancreas is
unremarkable. The tail is obscured by overlying bowel gas. There
is no evidence of free fluid.
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis.
2. 2.5-cm hemangioma in the right lobe of the liver. This
corresponds to the CT finding dated [**2175-9-1**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2175-9-8**] 11:53 PM
.
.
Brief Hospital Course:
The patient is a 37 year old female with AML M4-Eo diagnosed
[**2175-6-30**], s/p 7+3 cytarabine / idarubicin induction, and currently
undergoing HiDAC started [**2175-8-11**]. She presented to clinic on
C1D19 for a routine cell count check and was found to be febrile
to 100.4 F. She was started on Cefepime and admitted to the
floor. She remained afebrile and asymptomatic for several days
before spiking a fever to 104.5 and becoming hypotensive while
on multiple antibiotics. She was transfered to the ICU briefly
on [**2175-9-3**] and returned to the floor on [**2175-9-4**].
.
# Neutropenic Fever: She had a fever to 100.4 in clinic the day
of admission without any clear symptoms pointing to focus of
infection. Physical exam was unremarkable except for mild
tenderness to palpation in epigastric region and LUQ without
rebound or guarding to suggest an acute abdomen. She had a
previous episode of febrile neutropenia during induction that
was thought secondary to colitis and resolved after treatment
with Vancomycin, Cefepime, Flagyl, and Micafungin. Cefepime was
started in clinic and continued on admission. She remained
afebrile for several days until [**2175-9-2**], when she spiked a fever
overnight. She was started on Flagyl and Vancomycin. Later
that day, her fever increased to 104.5 despite Tylenol. She was
given several liters of IV fluid and her BP remained stable.
Her counts had started to improve by [**2175-9-2**], but she was still
neutropenic at this time.
.
She continued to have fevers on [**2175-9-3**], and Micfungin was added.
She became hypotensive despite fluids and was sent to the ICU,
where she received IV fluids, blood, and pressors for a brief
period. Her condition improved after switching from Cefepime to
Meropenem and starting Vancomycin PO for a positive C diff assay
sent on [**2175-9-2**]. She was transfered back to the floor on [**2175-9-4**]
and remained afebrile until discharge. She was no longer
neutropenic on transfer. Her WBC count was elevated to 21.2,
but slowly decreased over the next few days. Multiple urine and
blood cultures sent during her stay did not show any growth. No
clear infectious etiology was identified except for C diff. Her
Vancomycin IV, Flagyl, and Micafungin were discontinued on
[**2175-9-6**]. Meropenem was discontinued the afternoon of [**2175-9-7**].
She was discharged on Vancomycin 125 mg PO Q6H for continued
treatment of her C diff infection.
.
# Hypotension: She became hypotensive on [**2175-9-3**] and was
initially managed with fluid boluses on the floor. She was
later transfered to the ICU, a central line was placed and she
was started on pressors. She was volume resusicated and weaned
off Levophed. She also received a unit of PRBCs during this
time for likely dilutional anemia.
.
# Coagulopathy: Her INR increased from 1.2 to 1.8 during her
episode of high fever and hypotension. Her fibrinogen and
platelets remained normal during this time. She was treated
with Vitamin K, and her coags had returned to [**Location 213**] by [**2175-9-7**].
.
# Chest Pain: She complained of an episode of chest pain
overnight from [**2175-8-31**] to [**2175-9-1**]. An EKG was obtained which
showed no evidence of ischemia. A CXR was unremarkable.
Cardiac enzymes were sent and were also negative. Another set
of cardiac enzymes was sent on [**2175-9-3**] during her fever episode.
These were also negative. She complained of mild vague chest
pain at several other points during her stay without a clear
etiology identified, but likely muskuloskeletal or GI.
.
# Transaminitis: On the day of discharge, her labs showed a mild
increase in her transaminases with ALT 78 and AST 100. She had
a slight increase in LDH from 233 to 269 and her AlkPhos and
Bilirubin were unchanged. Her Acyclovir and Bactrim were
discontinued pending followup after discharge. She had an
ultrasound of her liver and gallbladder which showed
cholelithiasis without evidence of acute cholecystitis, and a
2.5 cm hemangioma in the right lobe of the liver, unchanged from
a previous ultrasound.
.
# AML M4-Eo: Diagnosed [**2175-6-30**] after presenting to ED with sore
throat, dysphagia, and neck swelling. Bone marrow showed AML
M4-Eo, and she was started on 7+3 induction. No residual
disease seen on BMB from [**2175-8-2**]. On admission, she was on HiDAC
C1D19 with recent nadir. Her granulocyte count was 30 on
admission, and she was placed on neutropenic precautions. Her
WBC and platelet counts improved during her stay. She remained
anemic, but Hct was trending up for several days by the time of
discharge.
.
# Pancytopenia: Her Hct on admission was 25.0 with the patient
asymptomatic from anemia. She had Platelets 172 and Granulocyte
count 30 on admission. During her stay, she received PRBCs on
[**2175-8-30**] and [**2175-9-3**]. She did not require platelets. Her ANC
began to increase on [**2175-9-1**] and she was no longer neutropenic by
[**2175-9-3**]. Her anemia was improving without additional
transfusions by the time of discharge.
.
# Infection Prophylaxis: Prior to admission, she was taking
Bactrim, Acyclovir, and Fluconazole for infection prophylaxis.
She has a history of a sacral HSV rash during induction that
resolved with Acyclovir treatment. Her prophylactic meds were
continued on admission. Her Fluconazole was later held on
[**2175-9-2**] when Micafungin was started. Her Bactrim and Acyclovir
were held on discharge due to an increase in her transaminases
on the day of discharge.
.
# Latent Syphilis: She has a history of latent syphilis that was
previously evaluated and treated with Penicillin IV x14 days at
a prior admission. She showed no evidence of active infection
during this admission.
.
Medications on Admission:
Acyclovir 400 mg PO Q8H
Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
Levofloxacin 500 mg PO DAILY
Fluconazole 200 mg PO Q24H
Lorazepam 0.5-1 mg PO Q4H PRN nausea
Ondansetron HCl 8 mg PO Q8H PRN nausea
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID PRN constipation
Senna 1 TAB PO QHS PRN constipation
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*120 Capsule(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO four times a day as
needed for pain for 4 days: Do not drive or operate heavy
machinery while on this medication as it may make you sleepy.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
Neutropenic fevers
Clostridium difficile infection
Secondary Diagnoses:
Acute Myelogenous Leukemia
Discharge Condition:
All vital signs stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for neutropenic fevers. When
you were admitted, your immune system had not yet recovered from
your recent chemotherapy, and your white blood cells were low.
Since these cells help fight bacteria and viruses, infections
during this time can be very dangerous and life threatening.
You were started on a number of powerful antibiotics to help
your body fight off these organisms that cause infections.
During your stay, you briefly developed high fevers and low
blood pressure due to an infection, and had a brief stay in the
Intensive Care Unit. Your condition improved with the
antibiotics courses, and your blood counts started returning to
normal. The antibiotics were stopped slowly, and you did not
develop any new fevers or concerning symptoms.
During your stay, you were also diagnosed with an infection in
your intestines called Clostridium difficile (C. diff). This
infection was probably the cause of the abdominal pain you had.
This type of infection is common in patients who have been
hospitalized for long periods of time and who have received many
antibiotics.
You were started on an oral antibiotic called Vancomycin to
treat the C. diff infection. You should continue taking this
antibiotic during your upcoming lymphoma treatments to prevent
it from happening again.
START: Vancomycin Oral Liquid 125 mg by mouth every 6 hours
You were started on a medication called Omeprazole to help with
some of the abdominal discomfort you have been having.
START: Omeprazole 20 mg daily
Several of your liver enzymes were elevated slightly today.
Since this can sometimes be related to a medication side effect,
you should stop taking Acyclovir, Bactrim, and Fluconazole at
discharge. Your primary oncologist may restart them at a later
date.
STOP: Acyclovir 400 mg three times daily
STOP: Bactrim SS one tab daily
STOP: Fluconazole 200 mg daily
Several changes were made to your medications during your
admission. You should only take the medications indicated on
your discharge medication sheet.
You should meet with your primary oncologist, Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], after discharge to discuss your upcoming lymphoma
treatments. An appointment has been scheduled for you as
indicated below.
Followup Instructions:
You have an appointment scheduled in the [**Hospital Ward Name 1826**] 7 outpatient
area on Sunday, [**2175-9-10**] at 11:30am to have your blood drawn for
lab work.
[**Provider Number 38601**] [**Hospital Ward Name **] OUTPATIENT CLINIC
Date/Time:[**2175-9-10**] 11:30
You are scheduled for [**Month/Day/Year **] the next day on Monday, [**2175-9-11**]
as shown below.
Provider: [**Name10 (NameIs) 1248**],BED ONE [**Name10 (NameIs) 1248**] ROOMS
Date/Time:[**2175-9-11**] 7:15
Provider: [**Name10 (NameIs) 6122**] EAST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2175-9-11**] 10:00
An appointment has also been scheduled with Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on Thursday, [**2175-9-14**] to discuss your treatment plan.
|
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23,811
| 148,086
|
44713
|
Discharge summary
|
report
|
Admission Date: [**2145-7-14**] Discharge Date: [**2145-9-15**]
Date of Birth: [**2085-3-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old man
with a history of right-sided congestive heart failure with
an ejection fraction of 45 percent, atrial fibrillation,
pulmonary hypertension and cardiomyopathy, who presented with
progressive shortness of breath, abdominal distention,
increasing cough with intermittent fevers up to 100.2. The
patient states that his dyspnea has been getting worse over
the past two to three weeks and he became increasingly
concerned when he noticed abdominal swelling. The patient
has been complaining of shaking chills and fever times two
days. He denies any chest pain, headache, nausea, vomiting,
diarrhea, dysuria, rash, myalgia, arthralgia. The patient
had a recent [**Hospital1 69**] admission
for hypotension and congestive heart failure in [**2144-12-20**].
PAST MEDICAL HISTORY: Atrial septal defect repair in [**2102**].
Cardiomyopathy.
Right-sided congestive heart failure.
Pulmonary hypertension.
Atrial fibrillation and flutter.
Mild cirrhotic changes of the liver.
Chronic hepatic congestion.
History of prostate cancer, status post brachytherapy.
History of rectal bleeding.
Obstructive sleep apnea on continuous positive airway
pressure at home.
ALLERGIES: ACE inhibitor, possible allergy to barium.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.25 mg daily.
2. Toprol 25 mg daily.
3. Amiodarone 200 mg daily.
4. Warfarin 2.5 mg daily.
5. Lasix 20 mg daily.
6. Pravachol 20 mg daily.
7. Trazodone 50 mg q.h.s.
8. Lexapro 10 mg daily.
9. Flovent 110 daily.
10. Atrovent twice a day.
11. Diovan 120 daily.
SOCIAL HISTORY: Remote tobacco use, occasional alcohol use.
He is a retired firefighter.
PHYSICAL EXAMINATION: At the time of admission, temperature
98.1, heart rate 66, blood pressure 108/88, respiratory rate
24, oxygen saturation 95 percent in room air. Head, eyes,
ears, nose and throat - Jugular venous distention to ten
centimeters. Respiratory - Bibasilar crackles, right greater
than left. Cardiovascular - II/VI systolic murmur heard best
at the apex. The abdomen is soft, no costovertebral angle
tenderness. Extremities are warm, no lower extremity edema.
Neurologically, alert and oriented times four, speaking in
full sentences.
HOSPITAL COURSE: The patient was admitted to the medical
service. He was worked up for congestive heart failure,
probable left lower lobe pneumonia, anemia, and chronic renal
insufficiency. Initial workup included echocardiogram as
well as heart failure consult. Over the next several weeks,
the patient was followed closely by the medicine service as
well as the heart failure service. Additionally, pulmonary
medicine and cardiology consulted on the patient's case.
Ultimately the patient went for cardiac magnetic resonance
imaging that showed moderate to severe mitral regurgitation
with preserved left ventricular function and increased left
ventricular size. Echocardiogram done shortly after
admission showed an ejection fraction of 55 percent with a
left atrium that is mildly dilated, right ventricle that was
markedly dilated with severe global right ventricular free
wall hypokinesis, two plus mitral regurgitation and four plus
tricuspid regurgitation and severe pulmonary artery
hypertension. Ultimately the patient's condition
deteriorated.
He was transferred to the Coronary Care Unit and, on
[**2145-7-27**], he underwent cardiac catheterization that showed
severe pulmonary arterial hypertension unresponsive to
nitrate and clean coronaries following which cardiothoracic
surgery was consulted. The patient was felt to be have
multiple medical problems and continued to be followed by the
medical and cardiology service while optimizing his medical
condition. Ultimately on [**2145-8-16**], the patient was brought
to the operating room at which time he underwent a redo
sternotomy, tricuspid valve annuloplasty with a thirty
millimeter [**Doctor First Name 7624**] ring and a mitral valve replacement with
a number twenty-seven [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve.
Please see the operating room report for full details.
In summary, the patient's bypass time was 112 minutes with a
cross clamp time of 80 minutes. He tolerated the operation
and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At the time of transfer,
the patient had Levophed at 0.1 mcg/kg/minute, Milrinone at
0.25 mcg/kg/minute and Propofol at 50 mcg/kg/minute. He had
a mean arterial pressure of 53 and he was V paced at a rate
of 80 with a PAD of 21. Additionally, the patient had
Epinephrine infusion of 0.3 mcg/kg/minute. The patient did
well in the immediate postoperative period. His intravenous
medications were weaned as tolerated. His ventilatory status
was adequate, and on postoperative day one, he was weaned
from the ventilator and successfully extubated. On
postoperative day three, the patient returned to the Cardiac
Catheterization Laboratory at which time a permanent
pacemaker was implanted due to the patient's bradycardic
episodes during his preoperative course.
By postoperative day seven, the patient was complaining of
dyspnea. His chest x-ray showed worsening congestive heart
failure. Additionally, the patient began to complain that he
felt like he had a kidney stone with lower abdominal pain.
He became increasingly acidotic and his white blood cell
count went to 27.4. He was seen by general surgery as well
as by the infectious disease service. Abdominal ultrasound
showed dilated gallbladder and the patient was brought to the
operating room for an open cholecystectomy. The patient's
recovery from this open cholecystectomy was slow but, by
postoperative day four from his cholecystectomy, he had been
weaned back to ventilator settings of continuous positive
airway pressure five and five. On postoperative day six from
his cholecystectomy, he was extubated. Extubation was short
lived and within several hours the patient needed to be
reintubated. From that point forward, the patient's recovery
from ventilatory status was extremely slow. On postoperative
day twenty-one from his MVR/TVR, the patient was scheduled
for tracheostomy. A percutaneous tracheostomy was done at
the bedside following which the patient was noted to be in
respiratory distress. A bronchoscopy done after the
tracheostomy showed bright red blood within the trachea and
the patient was brought to the operating room where they
found bleeding from the thyroid isthmus. Open tracheostomy
was performed. The bleeding was controlled and the patient
returned to the Cardiothoracic Intensive Care Unit following
the exploration.
Over the next week, attempts were made to wean the patient
from his full ventilation with limited success and screening
process was begun to place the patient in a pulmonary
rehabilitation center. On postoperative day twenty-nine, the
patient was noted to have some rectal bleeding. At that
time, the patient was receiving both Coumadin and Heparin.
Gastroenterology service was consulted and they felt that he
had radiation proctitis. His Heparin was held. The bleeding
resolved and on the following day the patient was restarted
on Heparin and Coumadin. At that time, the patient was also
accepted to rehabilitation at [**Hospital1 **] in [**Hospital1 1559**].
The patient's physical examination is as follows:
Temperature 100, heart rate 70, V paced, blood pressure
120/50, respiratory rate 29, oxygen saturation 95 percent on
assist control, tidal volume of 550, respiratory rate of 24,
FIO2 60 percent with 10 of PEEP. Blood gas 7.48, 39, 91.
White blood cell count 10.9, hematocrit 29.8, platelet count
324,000. Prothrombin time 14.0, partial thromboplastin time
29.3, INR 1.2. Sodium 136, potassium 4.1, chloride 102, CO2
28, blood urea nitrogen 23, creatinine 1.1, glucose 101.
Neurologic - Alert, responsive, in no acute distress.
Pulmonary - Coarse breath sounds bilaterally. Cardiovascular
- Regular rate and rhythm. Sternal incision is clean, dry
and intact. Abdomen is soft and somewhat distended with
positive bowel sounds. Extremities are warm with one plus
edema bilaterally.
MEDICATIONS ON DISCHARGE:
1. Acetaminophen 325 mg to 650 mg q4hours p.r.n. for
temperature greater than 38.
2. Atrovent two puffs four times a day.
3. Albuterol one to two puffs q6hours.
4. Escitalopram Oxalate 10 mg daily.
5. Colace 15 cc twice a day.
6. Aspirin 325 mg daily.
7. ________ Powder four times a day p.r.n.
8. Percocet 5/325 one to two tablets q4-6hours p.r.n.
9. Flovent two puffs twice a day.
10. Digoxin 0.125 mg daily.
11. Amiodarone 200 mg daily.
12. Valsartan 40 mg twice a day.
13. Nystatin swish and swallow four times a day p.r.n.
14. Bisacodyl suppository one PR q.h.s. p.r.n.
15. Lasix 20 mg twice a day.
16. Pantoprazole 40 mg daily.
17. Morphine 1 to 4 mg q4hours p.r.n.
18. Lorazepam 0.5 to 1 mg q4hours p.r.n.
19. Heparin 800 units per hour.
20. Warfarin 2 mg as directed to maintain a goal INR of
1.5 to 2.0. The patient received 2 mg on [**2145-9-13**], and
was held on [**2145-9-14**].
DISCHARGE STATUS: The patient is to be discharged to
[**Hospital3 **] Center. He is to have his partial
thromboplastin time INR checked daily with Heparin and
Warfarin doses adjusted accordingly to maintain a partial
thromboplastin time of 40 and an INR of 1.5 to 2.0. He has
tube feeds that are Respalor with the goal rate being 60
cc/hour.
FOLLOW UP: He is to have follow-up with Dr. [**Last Name (STitle) **] in one
month. He is to have follow-up with Dr. [**Last Name (STitle) 73**] and the EP
Device Clinic as scheduled. The patient is to call.
DISCHARGE DIAGNOSES: Status post mitral valve replacement
with a number twenty-seven [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve as
well as tricuspid valve repair with a number thirty
annuloplasty band.
Status post permanent pacemaker.
Status post open cholecystectomy.
Status post tracheostomy.
Atrial fibrillation.
Status post atrial septal defect repair.
Pulmonary hypertension.
Prostate cancer, status post radiation therapy and
brachytherapy.
Radiation proctitis.
Chronic obstructive pulmonary disease.
Hypercholesterolemia.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2145-9-15**] 13:29:30
T: [**2145-9-15**] 14:43:28
Job#: [**Job Number 95665**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
177
| 143,120
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47249+58991
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-11-9**] Discharge Date: [**2125-12-12**]
Date of Birth: [**2048-4-20**] Sex: M
Service: ICU
HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with
complex cardiac history including coronary artery disease,
status post coronary artery bypass graft in [**2104**] with
multiple percutaneous interventions, Instent stenosis as well
as brachytherapy, congestive heart failure, ejection fraction
of 42%, hypertension, hyperlipidemia, gastrointestinal bleed,
CVA, weakness, dementia. The patient originally presented to
the hospital on [**2125-11-9**] with complaints of slow
onset of left shoulder pain, about [**4-1**] that radiated to the
back associated with shortness of breath, but without nausea,
vomiting or palpitations; somewhat similar to his past
angina. Patient was given aspirin at home and brought to the
Emergency Room by EMS.
In the Emergency Room, he received nitropaste, Lopressor,
morphine, tramadol and had some improvement in his symptoms.
REVIEW OF SYSTEMS: Significant for a lack of fevers and
chills, non-productive cough with a head cold without
shortness of breath. Positive peripheral burning neuropathy,
no dysuria, no hematuria, no sick exposures, no lower
extremity edema, no orthopnea.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2104**] (graft right saphenous vein graft to
left anterior descending, saphenous vein graft to ramus to
OM and saphenous vein graft to posterior descending
artery), complicated by Instent restenoses of the
saphenous vein graft to left anterior descending in [**2117**],
saphenous vein graft to ramus and OM in [**2121-10-22**]
with subsequent stent placement which was then further
complicated by Instent stenoses treated by percutaneous
transluminal coronary angioplasty and brachytherapy in
[**2120**]. Last cardiac catheterization was [**2122-12-4**]
which revealed significant native three vessel disease,
with patent saphenous vein graft to left anterior
descending with 40-50% Instent restenoses, saphenous vein
graft to ramus to OM with ostial 70% Instent restenoses
and 80% Instent restenoses and proximal stent, as well as
50% stenoses distally in the saphenous vein graft,
saphenous vein graft to posterior descending artery
totally occluded. Patient underwent brachytherapy of
Instent restenoses and saphenous vein graft to ramus to
OM, as well as atherectomy and percutaneous transluminal
coronary angioplasty of Instent restenoses of saphenous
vein graft ramus to OM.
2. Congestive heart failure. Last echocardiogram during
this admission, [**2125-10-22**], ejection fraction 40-45%
with anterolateral akinesis, posterior hypokinesis.
3. 1+ AI.
4. Mitral regurgitation.
5. Hypertension.
6. Hyperlipidemia.
7. Question of CVA in [**2121**].
8. Right internal carotid disease.
9. History of gastrointestinal bleed with duodenal ulcer and
esophageal erosion in [**2124-11-22**], treated with
embolization.
10. Benign prostatic hypertrophy.
11. Spastic bladder.
12. Gait disorder, multifactorial, wheelchair bound status
with progressive functional decline over the past one
year.
13. Urinary tract infection.
14. Esophagitis.
15. Question of buccal facial apraxia. New on this
admission.
16. Frontotemporal dementia, not Parkinson's per Neurology.
17. History of strangulated abdominal hernia and repair.
18. Atrial fibrillation and atrial flutter during this
admission.
ALLERGIES: Statin which causes hepatitis.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Zoloft 25 mg po q.d.
2. Lopressor 25 mg po b.i.d.
3. Prilosec 20 mg po q.d.
4. Tramadol 50 mg po q.d.
5. Oxycodone 1 tablet, po b.i.d.
6. Aspirin 81 mg po q.d.
PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Vital signs:
Pulse 75. Blood pressure 149/63. Respiratory rate 25.
Oxygen saturation 3 liters nasal cannula with 95% oxygen
saturation. General: Chronically ill-appearing elderly
male. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light. Extraocular movements intact.
No conjunctival injection. Oropharynx with thick white
secretions posteriorly. Mucous membranes are dry. Neck: No
lymphadenopathy, no jugular venous distention, no
hepatojugular reflux, no carotid bruits. Cardiovascular: No
heave, no thrills, point of maximal impulses laterally
displaced and diffuse, regular rate and rhythm with
occasional premature ventricular contractions, 3+
holosystolic murmur at left upper sternal border. Pulmonary:
Expiratory wheezes half way down bilaterally. Crackles one
third of the way up on the right, decreased breath sounds
half way up on the left. Abdomen: Positive distention,
positive bowel sounds, guaiac negative, nontender, no
hepatosplenomegaly. Extremities: 1+ edema bilateral lower
extremities. Neurological: 2+ reflexes throughout.
LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell
count 9.2, hematocrit 37.2, platelets 185,000. Differential:
Neutrophils 84%, lymphocytes 11%, monocytes 4%, eosinophils
.3%, basophils .2%. Sodium 131, potassium 4.8, chloride 97,
bicarbonate 29, BUN 26, creatinine 0.6, CK 86, troponin of
.02.
Chest x-ray: Mild cardiomegaly compared to prior films,
perihilar haziness, elevated left hemidiaphragmatic (old),
small left pleural effusion consistent with mild congestive
heart failure.
Electrocardiogram: Normal sinus rhythm, left axis deviation,
left ventricular hypertrophy, left anterior fascicular block,
left atrial enlargement, down sloping ST segments 1 mm in I,
aVL, V2, V3 with small ST depressions in V5 and V6 less than
a mm, T wave inversions in I, aVL, biphasic T wave in II. In
comparison with an electrocardiogram dated [**2124-12-7**],
the patient's electrocardiogram at the time of admission
appeared to be improved in terms of the ST segment, T wave
inversion were normalizing V2 to V6. In relation with an
electrocardiogram done in [**2124-10-22**], the ST
depressions are new.
HOSPITAL COURSE: By system:
1. Cardiovascular:
Ischemia: The patient ruled out for myocardial infarction at
the start of his admission. It was thought that his initial
shoulder pain was more related to a pulmonary process versus
a cardiac process. He subsequently was maintained on
aspirin, beta-blocker and ACE inhibitor, doses of which were
variable throughout his hospital course based on his blood
pressure and other ongoing medical issues. It was told to us
that patient does not tolerate statins or Plavix and he was
not maintained on these medications.
Pump: Patient had an echocardiogram on this admission that
showed an ejection fraction of 40-45% consistent with
systolic congestive heart failure. His hospital course was
notable for increasing blood pressures 200/100s soon after
his admission with associated shortness of breath and oxygen
desaturations to 92% on a nonrebreather. This was thought to
be consistent with flash pulmonary edema. Patient was
diuresed subsequently hypotensive requiring a dopamine drip
and was transferred to the Intensive Care Unit for closer
monitoring, as well as a question aspiration event. Patient
was treated with a nitroglycerin drip and Lasix and did have
an electrocardiogram that showed ST depressions in the
anterior lateral leads thought to be secondary to demand
ischemia. He was subsequently in the Coronary Care Unit,
however, his course was then complicated by persistent
hypoxia from pneumonia and his blood cultures grew out 3-4
bottles of Methicillin sensitive staph aureus. Patient
required intubation on [**2124-11-22**] and was subsequently
transferred to the Medical Intensive Care Unit Service after
an episode of hypotension with systolic blood pressures down
to the 60s. He was subsequently started on a neo drip, given
fluid boluses, extubated on [**11-29**] and transferred to the
floor and then re-intubated on [**12-2**] in the setting of
an aspiration event, desaturations, when he was found
unresponsive with a weak cough. At that time, the patient
was then transferred to the [**Hospital Ward Name 332**] Intensive Care Unit.
Subsequent details will be elaborated in the various
problems.
Rhythm: The patient remained in normal sinus rhythm with
relative bradycardia during his [**Name (NI) 332**] Intensive Care Unit
stay which dates [**2125-12-2**] until the time of discharge
anticipated to be during the week of [**2125-12-10**].
Patient received amiodarone load and then followed by op
amiodarone while he was in the Coronary Care Unit and has
subsequently remained out of atrial fibrillation and atrial
flutter. The issue of anticoagulation was raised, however,
given patient's multiple ongoing medical problems, bloody
sputum and history of CVA, as well as history of
gastrointestinal bleed, which was severe, patient was not
anticoagulated on this admission and that will need to be
re-addressed when the patient is more stable.
2. Pulmonary: Patient has had multiple complex problems
with his pulmonary status during this admission but to
summarize, he initially had hypoxia secondary to congestive
heart failure. Subsequently, he was found to have difficulty
with swallowing and probable persistent aspiration with a
failed swallow evaluation on [**2125-11-14**] with
subsequent positive blood cultures for Methicillin Sensitive
Staph Aureus. He was on several antibiotic courses including
initial levofloxacin and Flagyl for aspiration pneumonia
which was started on [**2125-11-12**] and discontinued on
[**2125-11-21**]. Subsequently he was empirically started
on Zosyn for potential pseudomonal nosocomial pneumonia, as
well as vancomycin on the [**11-16**] for gram positive
cocci, however, when he had neck gene analysis for the
Infectious Disease Service and was found to have
methicillin-sensitive Staphylococcus aureus, he was changed
to a course of four weeks of Oxicillin and 14 days of
levofloxacin per Infectious Disease recommendations. His
course of Oxicillin is due to end on [**2125-12-12**]. He
will complete his levofloxacin at the same time.
Patient had multiple intubations and extubations during this
admission. It is unclear what the precipitants of his
worsening hypoxia were during all the various events,
although, aspiration seemed to play a large role, as well as
congestive heart failure and these are the two main issues
for which he was treated while he was here. Patient
underwent bronchoscopy on [**2125-11-23**] where he was found
to have a lingula with sputum plug. He had a repeat
bronchoscopy on [**2125-12-6**] at which time he was found
to have very thick secretions mixed with blood in the ET
tube. It was thought that the patient likely had a mucous
plug and some aspiration which then led to pulmonary edema
and congestive heart failure with bloody secretions.
Patient had difficulty weaning from the ventilator and
ultimately had a trachea on [**2125-12-7**]. Subsequently
he was able to come off of the ventilator and is currently
doing well from a respiratory prospective, however, he does
require at least q. 4 hour suctioning of his thick bloody
secretions which are thought to be due to congestive heart
failure, as well as his pneumonia.
Patient also had a thoracentesis of about 800 cc of straw
colored fluid on [**2125-12-3**] which improved his
breathing parameters and culture data from that fluid was
negative.
3. Neurological: Patient has had a chronic neurological
condition over the past six months to one year over which
time he has had a function decline and is wheelchair bound at
home. He was seen and followed by Neurology multiple times
during this hospitalization. It is thought that he may have
some sort of neurological degenerative disorder at baseline.
He definitely has a sensory polyneuropathy and he had an EMG
during this hospitalization on [**2125-12-5**] consistent
with ICU polyneuropathy, as well as a mild myopathy. Patient
will need a Neurology follow-up as an outpatient for further
evaluation. There was some talk of myasthenia [**Last Name (un) 2902**],
however, this was then thought to be unlikely and further
diagnostic work-up was not pursued along these lines.
4. Gastrointestinal: Patient did have an ileus during this
hospital course and has been continued on an aggressive bowel
regimen. He had no subsequent problems with this issue. He
also had a G tube placed by Gastrointestinal on [**2125-11-26**] and tolerates his tube feeds at goal at this point.
5. Anemia: Patient has a history of anemia, as well as a
history of gastrointestinal bleed. He was transfused to
maintain his hematocrit above 30 during his hospital course.
6. IV access: Patient had multiple central lines and A
lines during this hospitalization. He currently has a PICC
line in place that was placed on [**2125-12-7**] by
Interventional Radiology.
7. Prophylaxis: Patient was maintained on subcutaneous
heparin prophylaxis, Protonix and a bowel regimen during his
hospital course.
8. Code: Patient's code status is full code.
9. Disposition: Patient is being screened for
rehabilitation at this time.
DR [**Last Name (STitle) **], NAIMESH 12.ACV
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2125-12-11**] 03:57
T: [**2125-12-11**] 16:42
JOB#: [**Job Number 100038**]
Name: [**Known lastname **], [**Known firstname 4572**] Unit No: [**Numeric Identifier 16068**]
Admission Date: [**2125-11-9**] Discharge Date: [**2125-12-12**]
Date of Birth: [**2048-4-20**] Sex: M
Service: [**Hospital Ward Name **] ICU
DISCHARGE MEDICATIONS:
1. Colace 100 mg one po b.i.d.
2. Aspirin 81 mg po q day.
3. Robitussin syrup 5 mls po q 6 hours prn.
4. Zoloft 25 mg po q day.
5. Heparin flush for PICC 100 units per ml give 2 ml
intravenously q day prn with 10 ml of normal saline
followed by 2 ml of heparin each lumen q day and prn.
Site is to be inspected each shift.
6. Senna one tablet b.i.d. prn.
7. Maalox 30 cc po q 6 hours prn.
8. Neurontin 300 mg po q day.
9. Captopril 12.5 mg po t.i.d. hold for systolic blood
pressure less then 100.
10. Ativan .5 to 2 mg intravenously q 4 hours prn.
11. Amiodarone 200 mg po q day.
12. Insulin sliding scale subcutaneous as directed.
13. Atrovent meter dose inhaler six puffs q 6 hours.
14. Metoprolol tartrate 12.5 mg po b.i.d. hold for systolic
blood pressure less then 100 and for a pulse less then 60.
15. Albuterol meter dose inhaler six puffs q six hours.
16. Dulcolax suppository 10 mg q day.
17. Lansoprazole 30 mg po q day (via G tube).
18. Polyvinyl alcohol 1.4% drops one to two drops ophthalmic
prn.
19. Artificial tears .1% ointment prn.
20. Heparin 5000 units subq q 8 hours.
21. Percocet 5/325 mg in 5 ml solution give 5 ml po q 4 to 6
hours prn for peripheral neuropathy.
22. Miconazole powder one application miscellaneous b.i.d.
prn.
23. Oxacillin 2 grams intravenously q 4 hours, this
antibiotic should be given for the full day of [**2125-12-12**].
24. Lasix 40 mg intravenously q day. The dose of this
medication may be adjusted according to the patient's
urine output. Goal diuresis is for a negative 500 to 1000
cc for the next several days. The patient does respond to
the dose of 40 mg intravenously, however, this may need to
be decreased or changed to po depending on rate of
diuresis.
TREATMENTS AND FREQUENCY: The patient will need q four hour
suctioning for thick bloody secretions that continue to
improve in the management of his congestive heart failure.
However, he does need to have suctioning every four hours
regularly. His diet will be tube feeds. He will need
physical therapy. You may refer the physical therapy
recommendations for weight bearing status, however, the
patient was wheel chair bound at baseline prior to hospital
admission and now has multiple medical comorbidities in
addition to ICU polyneuropathy.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(2) 10844**]
Dictated By:[**Name8 (MD) 4791**]
MEDQUIST36
D: [**2125-12-12**] 11:35
T: [**2125-12-12**] 11:38
JOB#: [**Job Number 16073**]
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65,404
| 102,742
|
18639
|
Discharge summary
|
report
|
Admission Date: [**2151-5-11**] Discharge Date: [**2151-5-12**]
Date of Birth: [**2084-10-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
s/p PVI for refractory atrial fibrillation with hypotension and
bradycardia
Major Surgical or Invasive Procedure:
Pulmonary vein isolation for atrial fibrillation ([**2151-5-11**])
History of Present Illness:
66 year old male with hx of paroxysmal atrial fibrillation since
[**2148**] s/p numerous failed chemical and electrical cardioversions
presents with fatigue. He has been cardioverted a total of 3
times, last on [**3-12**], and he has been on amiodarone since [**8-25**]
(previously on sotalol and dronedarone). He presented for PVI
today and was found to be bradycardic to 40s-50s with junctional
escape beats and hypotensive to SBPs 80-90s in the PACU,
requiring dopamine. Attempts to wean off dopamine were
unsuccessful. His INRs are generally followed by his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 14522**], and his last dose on [**5-10**] was held prior to the
procedure.
He normally takes 5mg of Coumadin on Mondays, 2.5mg all
other days of the week.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2147**] cardiac
catheterization (NEBH): mild CAD, Normal LVEF
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation diagnosed initially in [**2148**] s/p
cardioversion in [**2148-12-16**], treated with sotalol with
subsequent recurrence. s/p 2nd cardioversion ([**2150-8-16**])
after the initiation dronedarone. Recent DCCV in [**2151-2-16**]
unsuccessful.
- Prostate cancer s/p brachytherapy ([**2143-8-16**])
- ? Sleep apnea (has not had sleep study yet)
- Kidney stone
- Resection of basal skin cancers
- Appendectomy
Social History:
Patient is married with three children. He is
retired as airline pilot for Delta.
-Tobacco: Denies
-ETOH: 2 drinks per day
Family History:
Father with heart disease and siblings with atrial fibrillation.
Physical Exam:
On admission:
VS: T=98.0, BP=118/59, HR=74, RR=15, O2 sat=94% on RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB over anterior and
lateral lung fields (cannot lean forward [**2-17**] femoral cath
sites), no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c. Trace edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Vitiligo over hands and neck
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
On discharge: unchanged, vital signs stable
Pertinent Results:
On admission:
[**2151-5-11**] 07:10AM BLOOD WBC-6.5 RBC-4.50* Hgb-16.1 Hct-45.1
MCV-100* MCH-35.7* MCHC-35.6* RDW-13.1 Plt Ct-215
[**2151-5-11**] 07:10AM BLOOD PT-30.0* INR(PT)-2.9*
[**2151-5-11**] 07:10AM BLOOD Glucose-128* UreaN-22* Creat-1.0 Na-141
K-4.2 Cl-102 HCO3-27 AnGap-16
MICROBIOLOGY: none
IMAGING: none
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname 11312**] underwent pulmonary vein isolation,
electrical cardioversion, and right atrial flutter ablation
yesterday. He was hypotensive upon anesthesia induction and
required mild pressor support with dopamine during the
procedure. After cardioversion his sinus rate was slow (30-40)
with junctional escape rhythm associated with hypotension. Upon
extubation his sinus rate improved to 60, but needed continued
pressor support. In the CCU, he was weaned off dopamine and his
systolic blood pressures were steady off dopamine.
.
ACTIVE ISSUES
.
# Hypotension s/p PVI: After PVI procedure, patient became
bradycardic and hypotensive in the PACU, requiring pressor
support with dopamine. This hypotension may have been secondary
to the anesthesia medications, which may needed time to wear
off, or related to the bradycardia [**2-17**] to the procedure itself.
He was transferred to the CCU on dopamine, but completely
asymptomatic and feeling quite well. He was weaned from
3mcg/kg/min to off prior to discharge. Upon discharge, his
B-blocker and [**Last Name (un) **]/thiazide were held. He will restart his
Diovan 1 day after discharge and will follow up with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in Dr.[**Name (NI) 1565**] office.
.
# RHYTHM / bradycardia s/p PVI for atrial fibrillation: The
patient had bradycardia to the 50s-60s, with some junctional
escapes. Bradycardia is not a common occurrence s/p PVI, as we
are generally more concerned about more mechanical consequences
such as tamponade or pulmonary vein stenosis, rather than
electrical disturbances that may cause a bradyarrythmia. Though
is some debate and a paucity of data about chronic
anticoagulation s/p PVI, most agree to continue anticoagulation
based on CHADS2 score (=1). Upon discharge, we have cut his
amiodarone is half to 100mg daily and he will follow-up in
Zimetbaum's office as above. He was also discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts holter monitor. He will continue on warfarin + ASA
for anticoagulation, long-term course to be decided as
outpatient possibly with argatoban, to be discussed with PCP.
[**Name10 (NameIs) **] will have his INR followed up in [**2-18**] days as an outpatient.
.
# PUMP: Mildly depressed EF of 50% on recent cardiac MR (done
prior to PVI). Current medication regimen is actually quite
appropriate for systolic HF, even though this is a recent
finding. We will defer medical management of this to his PCP
and cardiologist.
.
INACTIVE ISSUES
.
# Hyperlipidemia: Last lipid panel checked about 6 months ago,
per patient. He has a scheduled appointment with his PCP, [**Name10 (NameIs) **]
he will get it rechecked. He has been on a statin for control
of his hyperlipidemia and was continued on this during his
hospitalization.
.
TRANSITIONAL ISSUES
.
Communication: [**Name (NI) 7346**] [**Name (NI) 11312**] (wife - [**Telephone/Fax (1) 51159**] cell)
Medications on Admission:
AMIODARONE 200 mg daily
METOPROLOL SUCCINATE 100 mg daily
SIMVASTATIN 40 mg daily
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] 320 mg-25 mg daily
WARFARIN 5 mg on Mondays, 2.5 all other days qPM
ASPIRIN 81 mg daily
MULTIVITAMIN daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO every Monday.
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: on
Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday .
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atrial fibrillation, hypotension
Secondary: hypertension, dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 11312**], it was a pleaure taking care of you in the hospital.
You were admitted for pulmonary vein isolation for your atrial
fibrillation. Your blood pressure was noticed to be low, and you
were monitored in the cardiac care unit overnight.
It is important to follow-up with your primary care doctor and
have your INR (warfarin level) checked in the next **[**2-18**]** days.
Please read the post-procedure information sheet for activity
restrictions and danger signs.
You will also be wearing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor to monitor
your heart rhythm.
Medications:
STOP metoprolol succinate 100 mg by mouth daily
STOP valsartan-hydroclorothiazine (Diovan)
CHANGE amiodarone from 200 mg by mouth daily TO 100 mg by mouth
daily
CHANGE aspirin 81 to 325 mg by mouth daily
Followup Instructions:
** Please visit Dr.[**Name (NI) 51160**] office to get your INR checked
within the next 2-3 days.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-5-14**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Location (un) **] CARDIOVASCULAR ASSOCIATES
[**Hospital6 **]
Address: [**Apartment Address(1) 14524**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 14525**]
Appt: We are working on an appt for you within the next week.
THe office will call you at home with an appt. If you dont hear
from them by tomorrow, please call them directly to book one.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2151-5-26**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"401.9",
"427.31",
"272.4",
"185",
"458.29",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
7844, 7850
|
4065, 7068
|
382, 451
|
7974, 7974
|
3723, 3723
|
8999, 10146
|
2620, 2687
|
7350, 7821
|
7871, 7953
|
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|
8125, 8976
|
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|
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|
3673, 3704
|
267, 344
|
479, 1781
|
3738, 4042
|
7989, 8101
|
2034, 2464
|
1803, 1859
|
2480, 2604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 177,162
|
5113
|
Discharge summary
|
report
|
Admission Date: [**2127-12-16**] Discharge Date: [**2128-2-5**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
unresponsive, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation for unresponsiveness
History of Present Illness:
Mr. [**Known lastname **] is a 56 year-old man with DM1, ESRD, PVD, dCHF, and
recurrent admissions for hypoglycemia presents with hypoglycemia
requiring intubation for unresponsiveness and is transferred to
the MICU for further management.
.
He was recently discharged on [**2127-12-13**] after presenting with
lethargy and hypoglycemia. His course was complicated by left
sided subdural hematoma found in the setting of AMS evaluation,
and AV fistula clot requiring thrombectomy. He was due for
dialysis today but missed his session and per report was found
at home unresponsive. He was brought be EMS to the ED.
.
In the ED, vital signs were initially: 29C rectal 45 150/palp 20
95%nrb. He had an undetectable glucose level and was intubated
for agonal breathing with etomidate 20 mg iv and roc 10 mg iv
and was also given 1 amp calcium gluconate, 1 amp d50,
vanc/zosyn empirically, levothyroxine 37.5 mcg iv x 1,
solumedrol 125 mg iv x 1, and started on glucose drip. A right
femoral groin line ws placed semi-sterily. A bear hugger was
placed and temp rose to 29.7 after 1.5 hours. His ETT was pulled
back after a CXR demonstrated partial right main stem intubation
and he was transferred to the MICU for further evaluation.
.
In the MICU, the patient was extubated and his blood sugars were
controlled [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Pt was warmed to good
effect. Vanc and zosyn was discontinued on [**2127-12-17**]. He was found
to have gram positive rods grow on [**2127-12-18**] 0500 in 1 anaerobic
bottle dated from [**2127-12-16**]. Speciation is pending. He also had
low grade temperatures (99.5) persistently. He was started on
Ampicillin 2 g IV Q12H, Ciprofloxacin 400 mg IV Q24H, and
Clindamycin 600 mg IV Q8H.
Past Medical History:
1. Type 1 diabetes with insulin autoantibody receptor syndrome
-since age 16 on insulin, followed by Dr. [**Last Name (STitle) 10088**]
[**Name (STitle) 21002**] hypoglycemic episodes, has required intubation for
altered MS in the past
-high level of anti-insulin Ab
-complicated by nephropathy
-complicated by retinopathy (s/p right eye laser surgery,
repeated [**8-2**])
-on immunosuppression ?? no records at [**Hospital1 18**]
2. End-stage renal disease on dialysis
3. Diastolic heart failure
4. Hypertension,
5. Hyperlipidemia
6. Peripheral vascular disease
7. Hypothyroidism
8. Anemia
9. Recent burn on his left upper extremity, now s/p skin graft
10. S/p left first toe distal phalangectomy in [**2127-9-28**]
11. Pancreatic lesions seen on an abdominal CT done in [**2127-5-28**]
Social History:
He states that he currently lives with his parents. Several
other relatives also live there at different times. He worked in
construction but was laid off. He denied alcohol tobacco, or
illicit drug use.
Family History:
Per OMR, history of DM (Type 1 and 2), RA and HTN.
Mother - Type 2 Diabetes [**Year (4 digits) **], Rheumatoid Arthritis
Maternal Aunt - Type 2 Diabetes [**Name (NI) **]
Nephew - Type 1 Diabetes [**Name (NI) **]
Physical Exam:
VS: 97.2 141/86 75 20 100%RA
General: Pleasant middle aged man in NAD. AOx3. Can say all days
of the week backwards.
HEENT: PERRL, EOMI, ETT
Neck: supple
Heart: RRR, no m/r/g
Lungs: CTAB, no rales, moderately reduced air-movement.
Abd: +BS, NTND, no rebound or guarding
Ext: no edema, no calf TTP
Neuro: CN 2-12 intact. moves all extremities, no pronator drift,
light touch sensation intact throughout
MSK: R toe s/p amputation, mild TTP, poor wound healing,
fibrinous exudate, foul smelling
Pertinent Results:
LABS ON ADMISSION:
[**2127-12-16**] 08:00AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.3* Hct-32.3*
MCV-90 MCH-28.7 MCHC-32.1 RDW-15.0 Plt Ct-212
[**2127-12-16**] 11:40AM BLOOD Neuts-93.4* Lymphs-4.2* Monos-1.9*
Eos-0.3 Baso-0.1
[**2127-12-16**] 08:00AM BLOOD Plt Ct-212
[**2127-12-16**] 08:00AM BLOOD UreaN-28* Creat-5.9*#
[**2127-12-16**] 08:00AM BLOOD Lipase-44
[**2127-12-16**] 08:00AM BLOOD ALT-10 AST-21 LD(LDH)-226 AlkPhos-56
TotBili-0.2
[**2127-12-16**] 08:00AM BLOOD Albumin-3.6
[**2127-12-16**] 08:00AM BLOOD TSH-20*
[**2127-12-16**] 08:00AM BLOOD Free T4-1.3
[**2127-12-19**] 06:40AM BLOOD Cortsol-17.7
[**2127-12-16**] 08:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-12-16**] 11:40AM BLOOD Ethanol-NEG
.
LABS ON DISCHARGE:
.
STUDIES:
EKG [**2127-12-17**]: Sinus tachycardia, LAD, poor R-wave progression,
low voltage. Non-specific ST-T changes. When compared to prior
on [**2127-12-16**], QTc prolongation has improved to normal.
NCHCT ([**2127-12-16**]): Interval decrease in thin left subdural fluid
collection
overlying the left cerebral convexity posteriorly as well as an
improvement in
the local mass effect on subjacent sulci. No new acute
intracranial
hemorrhage, edema, or mass effect.
.
NCHCT ([**2127-12-19**]): Overall further improvement, with
near-complete resolution of the thin subdural fluid collection
layering over the posterior left cerebral convexity, and no new
acute intracranial process.
.
CXR [**12-16**] FINDINGS: In comparison with the study of earlier in
this date, the endotracheal tube has been pulled back so that
the tip now lies approximately 6 cm above the carina. There is
poor definition of the medial aspect of the left hemidiaphragm
with increased opacification in the retrocardiac region. This is
consistent with volume loss in the left lower lobe, related to
the prior low position of the endotracheal tube.
There is a suggestion of some patchy opacification in the right
mid lung zone, raising the possibility of aspiration pneumonia.
.
MICRO
Blood cultures ([**2127-12-16**]): CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS) 1/2 bottles.
Blood culture ([**2127-12-18**]): No growth
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year-old man with DM1, ESRD, PVD, dCHF, and
recurrent admissions for hypoglycemia who presents with
hypoglycemia and unresponsiveness, called out from the MICU for
further management.
.
# Competency: Given the large number of life-threatening
hypoglycemic episodes, pt was evaluated by psychiatry, social
work, the medical team and was deemed to be incompetent in
managing his medical illness. The patient's family also satted
that they were unable to provide 24 hour supervision for the
patient and were no longer able to care for him. Therefore, the
process of guardianship was pursued. temporary limited
guardianship for the purposes of transfer to extended care
facility was assigned to the patient's son [**Name (NI) **] [**Name (NI) **]. The
patient's sister [**Name (NI) 1022**] [**Name (NI) 21004**] remains his health care proxy.
.
# Unresponsiveness: Has had these episodes last admission
thought to be related to interruption of consciousness syndrome
secondary to cerebral edema and frontal lobe dysfunction. This
edema was thought to be related to the chronic SDH. Seizure was
questioned but routine EEG negative. Differential diagnosis
included cerebral edema/fronal dysfx vs seizure, vs relative
hypoglycemia (given drop from 400s overnight to 130). CT head
and labs were ordered, neuro was consulted, EEG was scheduled,
however, pt refused any further work up, was made aware of risks
including death, and still refused. The patient had no further
episodes of unresponsivess the rest of this admission.
.
# Recurrent hypoglycemia: Thought to be multifactorial etiology
with combination of poor medication adherance, including
confusing levemer with short-acting, poor PO intake. Insulin
Antibody less likely to be a factor as the patient only had
several mild hypoglycemic episodes as an inpatient with blood
sugars in the 50s range, during which the patient remained
asymptomatic. The patient was followed by [**Last Name (un) **] consult
thorughout this admission and long-acting insulin and sliding
scale doses were adjusted. The patient still exhibited a wide
range of blood sugars ranging from 50s to 400s, but remained
asymptomatic throughout. [**Last Name (un) **] purposely used conservative
insulin scale to avoid hypoglycemic episodes.
.
# History of SDH: Found on head CT in [**11-4**] for evaluation for
agitation/AMS, thought to be secondary to a fall. Seen by
neurosurg and thought to be chronic, not intervened upon. Held
heparin. Ambulation was used for DVT prophylaxis. The patient
remained asymptomatic throughout the rest of his
hospitalization.
.
# Diabetes I: History of recurrent episodes of hypoglycemia. The
patient was continued on prednisone for insulin antibody
syndrome. Dose of prednisone decreased to 15mg daily. [**Last Name (un) **]
consulted and followed the patient throughout this admission.
We continued QID fingerticks and sliding scale. Continued
lantus (dose increased to 10 units QAM and 6 units QPM) as well
as humalog sliding scale. The patient will follow up at [**Last Name (un) **]
upon discharge.
.
# ESRD on HD: The patient received dialysis while inpatient on
his outpatient schedule every Tuesday, Thusday, Saturday. We
continued nephrocaps, calcitriol, and TID calcium carbonate.
The patient's medications were adjusted based on his renal
function. The patient will resume his outpatient dialysis upon
discharge at [**Location (un) **] [**Location (un) **] Dialysis Center, [**State 21005**], [**Location (un) **], [**Numeric Identifier 1415**]. He will continue to be followed by
his outpatient nephrologist Dr. [**First Name (STitle) **] [**Name (STitle) 4090**]. His next
outpatient HD session is on Saturday, [**2128-2-7**]. If the
patient is not able to receive HD at [**Last Name (un) 4029**] on Saturday, please
page Dr. [**Last Name (STitle) 4090**] by calling [**Telephone/Fax (1) 2756**] and arrange for HD at
[**Hospital1 18**].
.
# Left hallux amputation: The patient had a prior amputation of
left toe on prior admission and underwent closure pf left hallux
during this admissiojn by Podiatry. Betadine dressing were
changed daily and should continue to be changed upon discharge.
Sutures remain in place upon discharge. The patient may
continue to ambulate in his post-surgical shoe essential
distances. He will follow up with podiatry upon discharge.
.
# HTN: Pt was hypertensive on the floor because all his BP meds
were discontinued in the MICU. After restarting his home meds,
his pressures returned to normotensive.
We continued Metoprolol 50mg PO TID, diltiazem SR 180mg PO BID,
doxazosin 4mg PO HS
and minoxidil 5mg PO BID
.
# [**Doctor Last Name 933**] disease: we continued synthroid
.
# Hyperuricemia: we continued allopurinol
.
# Hyperlipidemia: we continued statin
Medications on Admission:
MEDICATIONS AT HOME (per [**2127-12-13**] d/c summary):
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
9. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn
11. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
capsule, Sustained Release PO BID (2 times a day).
12. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
qhs
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
daily
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1)capsule, Delayed Release(E.C.) PO twice a day.
17. Insulin: Please resume you outpatient diabetes therapy.
Please
administer 3 units levemir under the skin, twice daily. Please
administer humalog according to the attached sliding scale.
18. Levemir 100 unit/mL Solution Sig: Three (3) units
Subcutaneous twice a day for 2 weeks.
19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
prn
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for n/v.
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
15. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
17. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Ten (10)
Subcutaneous QAM.
18. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6)
Subcutaneous QPM.
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
21. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for toe pain.
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
24. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous four times a day: Please check fingersticks QID and
administer insulin based on the attached sliding scale. .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Ctr
Discharge Diagnosis:
PRIMARY:
1. unresponsiveness, likely secondary to hypoglycemic coma
2. hypoglycemia
.
SECONDARY:
1. Chronic kidney disease, stage V
2. Type I diabetes, with neuropathy and retinopathy and insulin
autoantibodies
3. Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Ambulates without assistance
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] for an
episode of unresponsiveness felt to be from low blood sugars.
Your insulin medications were adjusted with assistance from the
[**Last Name (un) **] doctors. You also had an episode of unresponsiveness with
some shaking in the hospital, for which neurology input was
requested, but this was not felt to be seizure or other
neurologic disease.
.
While you were here, you continued to receive dialysis per your
usual schedule. After discharge, you will continue to receive
dialysis at [**Location (un) **] [**Location (un) **], your usual dialysis site.
.
Your son was chosen to be your legal guardian while you were in
the hospital. This is to make sure that you are able to go to
the appropriate rehab setting.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- We adjusted your dose of Insulin (Lantus and sliding scale).
- We started you on Simethicone QID: PRN for gas/bloating
- We decreased your doses of Prednisone to 15mg daily,
Prochlorperazine to 5mg every 6 hours as needed for
nausea/vomiting, Omeprazole to 20mg daily.
- We started you on Ulltram 50mg every 12 hours as needed for
toe pain
.
Please continue your other medications as prescribed.
.
Please keep your appointments below.
.
Please seek medical attention for lightheadedness, dizziness,
shaking, low blood sugars with symptoms, chest pain, abdominal
pain, shortness of breath, nausea/vomiting, or any other
concerning symptoms. Please also weigh yourself every morning,
and notify your primary care physician if your weight goes up
more than 3 lbs.
Followup Instructions:
You have the following appointments:
.
Department: PODIATRY
When: FRIDAY [**2128-2-20**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Name: [**Last Name (LF) 10088**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: Wednesday, [**3-3**], 8am
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Please call the above number and ask for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21006**] if the
you need an appointment sooner because of poor blood sugar
control.
.
Completed by:[**2128-2-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
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icd9pcs
|
[
[
[]
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|
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355, 2123
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3942, 4669
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15221, 15317
|
2145, 2935
|
2951, 3157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,039
| 110,712
|
5661
|
Discharge summary
|
report
|
Admission Date: [**2206-1-17**] Discharge Date: [**2206-1-20**]
Date of Birth: [**2143-8-20**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Thoracentesis
Hemodialysis
History of Present Illness:
62 year old male with a history of DM1, ESRD on HD, and
bilateral chylothoraces without clear etiology who was referred
to the ED after his VNA checked his sat at home and found it to
be 84%. Patient was completely asymptomatic.
.
In the ED, CXR showed large L sided effusion. He underwent
left-sided thoracentesis in the ED, with 2.1L were removed. He
was then satting mid 90's on 2L NC. 90 minutes later he was
noted to have persistently low saturations to 70%s on RA and
systolic BP of 210. Responded to 100% on NRB, titrated down to
5L NC with sat of 93%. BP responded to home dose of labetalol.
Repeat CXR showed re-expansion pulmonary edema, and he was
admitted to the ICU for monitoring.
.
In the ICU, he used Bipap overnight. Oxygen requirement
improved to 92% on RA, 95% on 2L. BP has been well controlled
with outpatient antihypertensive regimen. Patient continued to
feel well, and tolerated HD well this AM. On transfer, patient
has no complaints. Denies SOB, CP, HA, cough, abdominal pain, or
diarrhea.
.
ROS: Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia.
Past Medical History:
1. DM I for 45 yrs, complicated by triopathy
2. ESRD on HD T/Th/Sa
3. h/o Tunneled cath infections
4. UGIB [**2-17**] PUD
5. VSE septic shoulder
6. Osteomyelitis
7. Left BKA
8. HTN w/ visual changes and AMS when SBP <150, must run
150-170/80s
9. Gastroparesis
10. Depression
11. Right femoral dorsalis pedis graft - [**2198-3-15**]
12. H/o gangrenous cholecystitis
13. H/O R pleural effusion
14. h/o frequent episodes of delerium while hospitalized and
infected, always negative work-up
15. Non-specific right and left exudative pleural effusion
(?chylothorax) status post right pleuroscopy, pleural biopsy,
pleurodesis and Pleurex catheter placement (removed on [**2205-10-18**]).
No
16. Hx of recurrent C.diff
Social History:
Lives in [**Location 701**] with wife [**Name (NI) **] [**Name (NI) 10653**] (Home:
[**Telephone/Fax (1) 22469**], cell: [**Telephone/Fax (1) 22470**]). No EtOH. Former remote
smoker. Used to work in retail 14 yrs ago.
Family History:
Noncontributory.
Physical Exam:
T: 97.6 BP: 120/57 HR: 75 RR: 18 02 sat: 95% on 2L
GENERAL: middle aged male, no respiratory distress
HEENT: NC/AT MMM
CARDIAC: RRR no m/r/g. HD tunneled cath R chest
LUNG: inspiratory crackles on L anteriorly and posteriorly, with
decreased BS at both bases. Expiratory wheezes on R side.
ABDOMEN: S/NT/ND + BS
EXT: L BKA. WWP, no c/c/e
NEURO: non-focal
.
Pertinent Results:
[**1-18**] CXR: IMPRESSION: Persistent and increased left effusion with
increased compressive atelectasis.
[**1-19**] CXR: IMPRESSION: Allowing for differences in projection, no
probable change in size of left effusion.
[**1-20**] CXR:
Consolidation in the left lung, now largely restricted to
lingula and medial lung base continues to clear. The earlier
component of upper lobe
consolidation on [**1-18**] was probably asymmetric pulmonary
edema. The
components in the lower lungs could be pneumonia or resolving
hemorrhage.
Interstitial pulmonary edema is new, and a small right pleural
effusion has increased slightly. Heart is partially obscured but
size is probably top normal unchanged. Dual channel right
supraclavicular central venous line ends in the right atrium, as
before. No pneumothorax.
1/2 Blood cultures x2 pending
[**1-17**] pleural cx: 2+ PMNs
[**1-19**] Blood cultures x2 pending
[**1-19**] C diff negative
[**2206-1-17**] 12:15PM BLOOD WBC-7.4 RBC-3.86* Hgb-11.4* Hct-35.0*
MCV-91 MCH-29.5 MCHC-32.6 RDW-14.8 Plt Ct-313
[**2206-1-19**] 08:20AM BLOOD WBC-6.1 RBC-3.67* Hgb-11.1* Hct-33.7*
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.6 Plt Ct-248
[**2206-1-17**] 12:15PM BLOOD Neuts-81.8* Lymphs-7.2* Monos-5.1
Eos-4.3* Baso-1.5
[**2206-1-17**] 12:15PM BLOOD Glucose-315* UreaN-31* Creat-5.1* Na-141
K-4.1 Cl-95* HCO3-33* AnGap-17
[**2206-1-19**] 08:20AM BLOOD Glucose-107* UreaN-16 Creat-3.9*# Na-147*
K-4.4 Cl-108 HCO3-30 AnGap-13
Brief Hospital Course:
62M with history of nonspecific exudative pleural effusions,
called out from MICU [**2205-1-17**] with hypoxia and re-expansion
pulmonary edema after thoracentesis.
.
1. Hypoxia: Secondary to chronic accumulation of pleural
effusion with subsequent re-expansion pulmonary edema. Patient
has infiltrates on LLL. Per IP, expect to resolve within 72
hours. No antibiotics were started, given that patient was
afebrile, without a leukocytosis. Pleural studies were
consistent with an exudate. Pleural culture were unremarkable
on discharge, though not finailized. Patient at high risk of C
diff given prior history. He was kept on supplemental oxygen to
keep saturations above 92%. Serial chest x-rays showed
pulmonary edema, with improving infiltrates. Interventional
pulmonology evaluated the patient daily, and recommended
ultrafiltration. They will see him as an outpatient in [**2-18**]
weeks.
-Please follow up final pleural fluid culture and gram stain.
.
2. End stage renal disease on Hemodialysis: Patient was
evaluated by Nephrology daily as an inpatient. He received
ultrafiltration, and was continued on outpatient regimen of
nephrocaps and phoslo.
.
3. History of C. diff: Patient at high risk for recurrent C.
diff. Had 2 episodes of diarrhea as an inpatient, that were not
foul smelling. Stool C diff negative x1.
.
4. Type 1 diabetes: Complicated by retinopathy, nephropathy, and
neuropathy. Patient has a history of labile blood sugars.
Patient was continued on outpatient regimen of NPH and sliding
scale insulin only for sugars > 300.
.
5. Hypertension: History of labile blood pressures. Per medical
record, patient has visual changes and altered mental status
when SBP < 150. History of labile BPs. SBP of 210 in ED.
Overnight BPS from (119-219)/(55-90). He was continued on
outpatient regimen of Nifedipine, Minoxidil, Labetalol, and
Lisinopril, with goal SBP 150-170s.
.
Medications on Admission:
# Labetalol 200 mg PO daily
# Minoxidil 2.5 mg PO DAILY
# Nifedipine SR 60 mg PO DAILY
# Sertraline 150 mg PO DAILY
# Lisinopril 80 mg PO DAILY
# PhosLo 3 caps po tid with meals
# nephrocaps 1 cap daily
# insulin NPH 8 units in the AM, 4 units at bedtime
# vancomycin 250mg po started today when decided to come to
hospital
# Florastor 250 mg PO BID as needed for replacement of
intestinal flora.
Discharge Medications:
1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed.
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
10. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule
PO bid ().
11. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: as directed units Subcutaneous see below: 8 units in AM, 4
units in PM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary diagnosis:
1. Left sided pleural effusion
2. Reexpansion pulmonary edema
3. Hypertension
4. Type 1 Diabetes Mellitus
Secondary diagnosis:
End stage renal disease on hemodialysis
Discharge Condition:
Hemodynamically stable. Hypertensive. Stable Left sided pleural
effusion.
Discharge Instructions:
You were admitted with a pleural effusion. This was drained, but
you developed pulmonary edema thereafter. Interventional
pulmonology evaluated and recommended ultrafiltration to remove
some of the fluid. You were kept on supplemental oxygen, but no
longer required this prior to discharge. Nephrology evaluated
you and you received dialysis. Your blood pressure was poorly
controlled. We continued you on your home regimen of blood
pressure medications.
We did not change any of your medications.
If you have shortness of breath, cough, fevers, chills, chest
pain, or any other symptoms that concern you, please call your
primary care doctor or go to the emergency room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on [**1-31**] at 10am.
The clinic phone number is [**Telephone/Fax (1) 17398**] or [**Telephone/Fax (1) 22635**].
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2206-1-31**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2206-1-31**]
11:00
Completed by:[**2206-1-21**]
|
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"799.02",
"V49.75",
"250.51",
"250.41",
"518.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91",
"88.73"
] |
icd9pcs
|
[
[
[]
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] |
7907, 7970
|
4482, 6388
|
324, 353
|
8200, 8276
|
3015, 4459
|
8998, 9483
|
2605, 2623
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6836, 7884
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7991, 7991
|
6414, 6813
|
8300, 8975
|
2638, 2996
|
277, 286
|
381, 1618
|
8137, 8179
|
8010, 8116
|
1640, 2353
|
2369, 2589
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,359
| 190,155
|
16010+16011+16012+56721+56724
|
Discharge summary
|
report+report+report+addendum+addendum
|
Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-14**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 2470**] is an 84 year-old
gentleman with an unknown past medical history as he has
never seen a physician in the past who, on the day of
admission, developed sudden onset of chest pain at rest. He
described the pain as substernal chest pain radiating across
his chest and between his shoulder blades. The patient
denied associated shortness of breath, nausea, vomiting,
lightheadedness, or dizziness. He states he has been in his
usual state of health prior to the onset of chest pain.
He denied fevers or chills, congestion, cough, no GI
symptoms. He denies prior history of chest pain as well.
The patient also denied paroxysmal nocturnal dyspnea,
orthopnea, dyspnea on exertion, or lower extremity edema. He
states he walks three to four miles every day without
symptoms.
The patient arrived at an outside hospital Emergency
Department approximately forty minutes after his chest pain
began. The chest pain continued to radiate across his chest
to his back. His pulse on admission was 92 with a blood
pressure of 106/80. A CTA was done at the outside hospital
that was negative for aortic injury, but the
electrocardiogram showed anterior ST elevations, Qs in V1 and
V2, right bundle branch block and left anterior vesicular
block. The patient was given nitro drip, heparin
intravenous, intravenous beta blocker and transferred to [**Hospital1 1444**] for cardiac catheterization.
Electrocardiograms at the outside hospital involved to
include ST elevation and both the anterior and lateral leads
with peak ST elevations of 6 mm in leads V2 and V3. Initial
cardiac enzymes were negative at the outside hospital. Of
note, the patient's glucose is in the 400s when he was
admitted.
In the cardiac catheterization laboratory the patient was
shown to have the following results on angiography. He had a
right dominant system and left anterior descending coronary
artery with a 95% thrombotic proximal and mid lesion
involving the first diagonal and first septal branch. His
left circumflex had an 80% mid lesion and his right coronary
artery had a 40% mid and 60% posterolateral lesions.
For intervention the patient had Angioject and stent to the
left anterior descending coronary artery without
complications. Hemodynamics in the cardiac laboratory showed
a cardiac output suppressed at 3.10, a low index of 1.67, PA
pressure of 31/18 with a wedge pressure of 22, the A wave
being 23 and the V wave being 28, and a right ventricular
pressure of 32/8.
PAST MEDICAL HISTORY: As previously stated the patient
denies.
MEDICATIONS: The patient states he only takes one
multivitamin every day at home.
ALLERGIES: No known drug allergies.
PAST SURGICAL HISTORY: The patient denies.
SOCIAL HISTORY: The patient lives by himself. His wife
suffers from dementia and lives in a nursing home. He visits
her every day. The patient has remote smoking history
describing that he smoked during World War II basically a
pack per month. He denies ETOH use.
PHYSICAL EXAMINATION: On admission the patient's temperature
was 97.4. His heart rate was 92 and sinus. His blood
pressure was 150/90. Sat 98% on a nonrebreather and then
subsequently 93% on 8 liters nasal cannula. Respiratory rate
17. In general, he was anxious. He was alert, but not
oriented. Per report the patient had been very anxious in
the catheterization laboratory requiring heavy sedation with
morphine and Haldol. Heart regular rate and rhythm. S1 and
S2. Difficulty to hear over diffuse lung, rhonchi and
crackles. Lungs diffuse crackles bilaterally. Abdomen soft,
nontender, nondistended. Positive bowel sounds. No
hepatosplenomegaly. Extremities no clubbing, cyanosis or
edema. Good distal pulses with 2+ dorsalis pedis pulses
bilaterally and 2+ posterior tibial pulses bilaterally.
Neurological examination not oriented to time or place.
Cranial nerves II through XII grossly intact. Strength
grossly normal bilaterally, although examination limited as
the patient has sheath in place.
LABORATORY DATA: The patient's data from the outside
hospital included a hematocrit of 47.4, white blood cell
count 15.6, platelets 249.
The CKs at the outside hospital included a CK of 143 with an
MB of 3.8, MB index of 2.7 and an troponin I of 0.22. At
[**Hospital1 69**] the patient's second CK
came back at 6433 with an MB of 465 and MB index of 7.2 and a
troponin greater then 50.
The patient's chem 7 included sodium 134, K 4.8, chloride 98,
bicarb 20, BUN 21, creatinine 1.1 and glucose of 412.
HOSPITAL COURSE:
1. Cardiovascular: The patient had a very large anterior ST
elevation myocardial infarction. He is status post stenting
of his left anterior descending coronary artery. For
management of his coronary artery disease he was started on
aspirin, Plavix and he was placed on Integrilin for a total
of 18 hours. He was empirically started on a statin. He was
also started on a beta blocker and an ace inhibitor and his
cardiac enzymes were cycled. The patient was started on
Captopril 12.5 t.i.d. This was titrated up to 25 t.i.d.,
however, the patient had problems with hypotension and
orthostasis, therefore this was decreased to 12.5 t.i.d. The
patient tolerated Lopressor 25 b.i.d. He is also placed on
Atorvastatin 20 q.h.s., Plavix 75 q.h.s. and aspirin 325 q.d.
Post cardiac catheterization the patient's anterior and
lateral ST elevations did resolve with flattening of the ST
segment. After the CK peak of 6433 the patient's CK
decreased to 2963 with an MB of 214. The next CK on [**2104-12-12**]
was down to 1269.
Pump function: The patient was noted on bed side
echocardiogram after his cardiac catheterization to have
severe increase in his ejection fraction with a estimated EF
of 20% The patient had a formal echocardiogram on the [**5-10**] that showed an ejection fraction between 20 and 30%.
The left ventricular wall thickness was seen to be normal.
Left ventricular cavity size normal, overall left ventricular
systolic function was said to be severely depressed. Right
ventricular free wall is hypertrophied. Right ventricular
chamber size normal. Focal hypokinesis of the apical free
wall. Left ventricular cavity size was said to be normal with
severely depressed severe hypokinesis of the anterior septum
and anterior free wall, moderate hypokinesis of the inferior
septum and lateral wall and akinesis of the apex.
Based on these results the patient was started on intravenous
heparin for the risk of left ventricular thrombus with such
an akinetic ventricle including the apex. However, as it was
discovered that the patient had baseline dementia per family
report and he subsequently suffered from an episode of
delirium it was felt that the atrial fibrillation did not
outweigh the risk the patient had of falling. Therefore the
intravenous heparin was stopped and the patient was placed on
prophylactic subQ heparin. The patient was diuresed with 20
intravenous Lasix prn and responded nicely within the first
24 hours. His chest x-ray, which had initially showed
failure cleared after diuresis and the patient required no
further dosing of Lasix.
Rhythm: With the patient's low EF and guard ventricular EP
consult was considered for risk stratification. However, it
was felt that with the patient's underlying medical
conditions including delirium on top of dementia an EP
consult would not benefit the patient at this time.
Cardiac follow up: The patient was to be set up with a
cardiologist in his area prior to discharge and to be set up
with cardiac rehabilitation.
2. Diabetes: The patient presented with blood sugars in the
400s. His urine and serum were negative for ketones. The
hemoglobin A1C was checked that came back at 12.7 indicating
the patient had diabetes undiagnosed for quite some time.
The patient was initially controlled with an intravenous
insulin drip according to the [**Last Name (un) **] protocol and was then
converted over to a sliding scale of regular insulin along
with Glucophage 500 b.i.d. and NPH fixed doses.
3. Neurological: As stated previously the patient was noted
to be severely agitated during cardiac catheterization and
subsequently in the Coronary Care Unit and on the floor. He
was initially managed with Haldol, which seemed to help with
the patient's agitation and was therefore discontinued. A
geriatric consult was obtained and they recommended that the
patient be given Risperidone .5 mg b.i.d. on a prn basis only
and this was done with control of the patient's agitation.
To rule out causes of delirium the patient had blood cultures
times two, urine cultures and analysis and a chest x-ray.
All infectious workup was negative.
The patient also had a TSH checked, which was within normal
limits and a B-12 level checked. B-12 was within normal
limits at 773. His TSH was within normal limits at 0.32.
The patient's mental status cleared during his hospital
course and was significantly cleared on [**2104-12-14**] at which time
the patient was alert and oriented times three and was
appropriate and cooperative. The patient had required a one
to one sitter from the 9th until the 12th. The sitter was
then discontinued on the [**5-14**]. It was concluded
that the most likely cause of the patient's delirium on top
of his baseline dementia were hypotension and hyperglycemia.
Therefore as stated under Cardiovascular the patient's
Captopril dose was decreased to prevent orthostasis and he
was put on a tight glucose control regimen including
Glucophage, NPH and regular insulin sliding scale.
This is the end of the [**Hospital 228**] hospital course as of
[**2104-12-14**]. The rest of the dictation will be completed by the
intern taking over this service.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 45275**]
MEDQUIST36
D: [**2104-12-14**] 14:25
T: [**2104-12-16**] 11:26
JOB#: [**Job Number 45826**]
Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-14**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 2470**] is an 84 year-old
gentleman with an unknown past medical history as he has
never seen a physician in the past who, on the day of
admission, developed sudden onset of chest pain at rest. He
described the pain as substernal chest pain radiating across
his chest and between his shoulder blades. The patient
denied associated shortness of breath, nausea, vomiting,
lightheadedness, or dizziness. He states he has been in his
usual state of health prior to the onset of chest pain.
He denied fevers or chills, congestion, cough, no GI
symptoms. He denies prior history of chest pain as well.
The patient also denied paroxysmal nocturnal dyspnea,
orthopnea, dyspnea on exertion, or lower extremity edema. He
states he walks three to four miles every day without
symptoms.
The patient arrived at an outside hospital Emergency
Department approximately forty minutes after his chest pain
began. The chest pain continued to radiate across his chest
to his back. His pulse on admission was 92 with a blood
pressure of 106/80. A CTA was done at the outside hospital
that was negative for aortic injury, but the
electrocardiogram showed anterior ST elevations, Qs in V1 and
V2, right bundle branch block and left anterior vesicular
block. The patient was given nitro drip, heparin
intravenous, intravenous beta blocker and transferred to [**Hospital1 1444**] for cardiac catheterization.
Electrocardiograms at the outside hospital involved to
include ST elevation and both the anterior and lateral leads
with peak ST elevations of 6 mm in leads V2 and V3. Initial
cardiac enzymes were negative at the outside hospital. Of
note, the patient's glucose is in the 400s when he was
admitted.
In the cardiac catheterization laboratory the patient was
shown to have the following results on angiography. He had a
right dominant system and left anterior descending coronary
artery with a 95% thrombotic proximal and mid lesion
involving the first diagonal and first septal branch. His
left circumflex had an 80% mid lesion and his right coronary
artery had a 40% mid and 60% posterolateral lesions.
For intervention the patient had Angioject and stent to the
left anterior descending coronary artery without
complications. Hemodynamics in the cardiac laboratory showed
a cardiac output suppressed at 3.10, a low index of 1.67, PA
pressure of 31/18 with a wedge pressure of 22, the A wave
being 23 and the V wave being 28, and a right ventricular
pressure of 32/8.
PAST MEDICAL HISTORY: As previously stated the patient
denies.
MEDICATIONS: The patient states he only takes one
multivitamin every day at home.
ALLERGIES: No known drug allergies.
PAST SURGICAL HISTORY: The patient denies.
SOCIAL HISTORY: The patient lives by himself. His wife
suffers from dementia and lives in a nursing home. He visits
her every day. The patient has remote smoking history
describing that he smoked during World War II basically a
pack per month. He denies ETOH use.
PHYSICAL EXAMINATION: On admission the patient's temperature
was 97.4. His heart rate was 92 and sinus. His blood
pressure was 150/90. Sat 98% on a nonrebreather and then
subsequently 93% on 8 liters nasal cannula. Respiratory rate
17. In general, he was anxious. He was alert, but not
oriented. Per report the patient had been very anxious in
the catheterization laboratory requiring heavy sedation with
morphine and Haldol. Heart regular rate and rhythm. S1 and
S2. Difficulty to hear over diffuse lung, rhonchi and
crackles. Lungs diffuse crackles bilaterally. Abdomen soft,
nontender, nondistended. Positive bowel sounds. No
hepatosplenomegaly. Extremities no clubbing, cyanosis or
edema. Good distal pulses with 2+ dorsalis pedis pulses
bilaterally and 2+ posterior tibial pulses bilaterally.
Neurological examination not oriented to time or place.
Cranial nerves II through XII grossly intact. Strength
grossly normal bilaterally, although examination limited as
the patient has sheath in place.
LABORATORY DATA: The patient's data from the outside
hospital included a hematocrit of 47.4, white blood cell
count 15.6, platelets 249.
The CKs at the outside hospital included a CK of 143 with an
MB of 3.8, MB index of 2.7 and an troponin I of 0.22. At
[**Hospital1 69**] the patient's second CK
came back at 6433 with an MB of 465 and MB index of 7.2 and a
troponin greater then 50.
The patient's chem 7 included sodium 134, K 4.8, chloride 98,
bicarb 20, BUN 21, creatinine 1.1 and glucose of 412.
HOSPITAL COURSE:
1. Cardiovascular: The patient had a very large anterior ST
elevation myocardial infarction. He is status post stenting
of his left anterior descending coronary artery. For
management of his coronary artery disease he was started on
aspirin, Plavix and he was placed on Integrilin for a total
of 18 hours. He was empirically started on a statin. He was
also started on a beta blocker and an ace inhibitor and his
cardiac enzymes were cycled. The patient was started on
Captopril 12.5 t.i.d. This was titrated up to 25 t.i.d.,
however, the patient had problems with hypotension and
orthostasis, therefore this was decreased to 12.5 t.i.d. The
patient tolerated Lopressor 25 b.i.d. He is also placed on
Atorvastatin 20 q.h.s., Plavix 75 q.h.s. and aspirin 325 q.d.
Post cardiac catheterization the patient's anterior and
lateral ST elevations did resolve with flattening of the ST
segment. After the CK peak of 6433 the patient's CK
decreased to 2963 with an MB of 214. The next CK on [**2104-12-12**]
was down to 1269.
Pump function: The patient was noted on bed side
echocardiogram after his cardiac catheterization to have
severe increase in his ejection fraction with a estimated EF
of 20% The patient had a formal echocardiogram on the [**5-10**] that showed an ejection fraction between 20 and 30%.
The left ventricular wall thickness was seen to be normal.
Left ventricular cavity size normal, overall left ventricular
systolic function was said to be severely depressed. Right
ventricular free wall is hypertrophied. Right ventricular
chamber size normal. Focal hypokinesis of the apical free
wall. Left ventricular cavity size was said to be normal with
severely depressed severe hypokinesis of the anterior septum
and anterior free wall, moderate hypokinesis of the inferior
septum and lateral wall and akinesis of the apex.
Based on these results the patient was started on intravenous
heparin for the risk of left ventricular thrombus with such
an akinetic ventricle including the apex. However, as it was
discovered that the patient had baseline dementia per family
report and he subsequently suffered from an episode of
delirium it was felt that the atrial fibrillation did not
outweigh the risk the patient had of falling. Therefore the
intravenous heparin was stopped and the patient was placed on
prophylactic subQ heparin. The patient was diuresed with 20
intravenous Lasix prn and responded nicely within the first
24 hours. His chest x-ray, which had initially showed
failure cleared after diuresis and the patient required no
further dosing of Lasix.
Rhythm: With the patient's low EF and guard ventricular EP
consult was considered for risk stratification. However, it
was felt that with the patient's underlying medical
conditions including delirium on top of dementia an EP
consult would not benefit the patient at this time.
Cardiac follow up: The patient was to be set up with a
cardiologist in his area prior to discharge and to be set up
with cardiac rehabilitation.
2. Diabetes: The patient presented with blood sugars in the
400s. His urine and serum were negative for ketones. The
hemoglobin A1C was checked that came back at 12.7 indicating
the patient had diabetes undiagnosed for quite some time.
The patient was initially controlled with an intravenous
insulin drip according to the [**Last Name (un) **] protocol and was then
converted over to a sliding scale of regular insulin along
with Glucophage 500 b.i.d. and NPH fixed doses.
3. Neurological: As stated previously the patient was noted
to be severely agitated during cardiac catheterization and
subsequently in the Coronary Care Unit and on the floor. He
was initially managed with Haldol, which seemed to help with
the patient's agitation and was therefore discontinued. A
geriatric consult was obtained and they recommended that the
patient be given Risperidone .5 mg b.i.d. on a prn basis only
and this was done with control of the patient's agitation.
To rule out causes of delirium the patient had blood cultures
times two, urine cultures and analysis and a chest x-ray.
All infectious workup was negative.
The patient also had a TSH checked, which was within normal
limits and a B-12 level checked. B-12 was within normal
limits at 773. His TSH was within normal limits at 0.32.
The patient's mental status cleared during his hospital
course and was significantly cleared on [**2104-12-14**] at which time
the patient was alert and oriented times three and was
appropriate and cooperative. The patient had required a one
to one sitter from the 9th until the 12th. The sitter was
then discontinued on the [**5-14**]. It was concluded
that the most likely cause of the patient's delirium on top
of his baseline dementia were hypotension and hyperglycemia.
Therefore as stated under Cardiovascular the patient's
Captopril dose was decreased to prevent orthostasis and he
was put on a tight glucose control regimen including
Glucophage, NPH and regular insulin sliding scale.
This is the end of the [**Hospital 228**] hospital course as of
[**2104-12-14**]. The rest of the dictation will be completed by the
intern taking over this service.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 45275**]
MEDQUIST36
D: [**2104-12-14**] 14:25
T: [**2104-12-16**] 11:26
JOB#: [**Job Number 45826**]
Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-16**]
Service: CCU
THIS DISCHARGE ADDENDUM COVERS THE HOSPITAL COURSE FOR DATES
[**12-15**] TO [**2104-12-16**]:
This is an 84-year-old male without prior medical care
presenting with anterior ST segment elevation myocardial
infarction, now status post left anterior descending stent
this hospitalization. Decreased ejection fraction to 20%,
new diagnosis diabetes mellitus and hospital course
complicated by delirium on top of baseline dementia which is
now resolved.
1. Cardiovascular:
A. Coronary artery disease: Continued Plavix times nine
months, aspirin, Toprol XL was started in exchange for
Lopressor, statin was continued.
B. Pump: Ejection fraction 20%, status post myocardial
infarction. Continue the ACE. Lisinopril was started in
exchange for Captopril.
C. Electrophysiologic: Patient with a right bundle branch
block in sinus tachycardia likely secondary to his depressed
ejection fraction to maintain cardiac output.
D. Blood pressure: Blood pressure 90-120 systolic on his
ACE and beta-blocker. This is the desired range.
2. Psychiatry: Delirium now resolved. Does not require a
sitter times 48 hours. Risperidone 0.5 mg prn can be given
if acutely confused, though, this patient did not require
this medication over the past three days.
3. Diabetes: Blood sugar is 180-280 on Lantus 16 units
q.h.s. and metformin 500 b.i.d. and insulin sliding scale.
Metformin increased to 1000 b.i.d. today. Patient's family
should have diabetic teaching.
4. Fluid, electrolytes and nutrition: Diabetic diet.
Electrolytes are stable.
5. Hematology: Hematocrit stable at 37. No anticoagulation
for a depressed ejection fraction in this patient at risk for
falls besides his aspirin and Plavix.
DISPOSITION: To [**Hospital 3058**] rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Toprol XL 50 mg po q.d.
2. Lisinopril 5 mg po q.d.
3. Aspirin 325 mg po q.d.
4. Plavix 75 mg po q.d.
5. Metformin 1000 mg po q.d.
6. Lantus 16 units subcutaneous q.h.s.
7. Insulin sliding scale.
8. Atorvastatin 20 mg po q.d.
9. Colace 100 mg po b.i.d.
10. Pantoprazole 40 mg po q.d.
DISCHARGE DIAGNOSES:
1. ST elevation myocardial infarction.
2. Diabetes mellitus.
3. Dementia.
DISCHARGE FOLLOW-UP: Follow-up appointment Wednesday,
[**2104-12-31**] at 2:45 p.m. with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
Cardiology [**Hospital 45827**] Medical Associates, [**Street Address(2) 45828**], [**Location (un) 1475**], [**Numeric Identifier 45829**]. Phone
number [**Telephone/Fax (1) 3183**]. Follow-up with primary care physician
in two weeks.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**First Name3 (LF) 15581**]
MEDQUIST36
D: [**2104-12-16**] 01:35
T: [**2104-12-16**] 13:39
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 45830**] Name: [**Known lastname 8428**], [**Known firstname **] Unit No: [**Numeric Identifier 8429**]
Admission Date: [**2104-12-17**] Discharge Date: [**2104-12-20**]
Date of Birth: [**2020-4-9**] Sex: M
Service:
ADDENDUM: From [**2104-12-17**] to [**2104-12-20**].
Mr. [**Known lastname **] was to be discharged on [**2104-12-16**] to a
[**Hospital 6777**] rehabilitation facility. That morning, he
experienced 10/10 chest pain and was found to have anterior
ST elevations on his EKG. He was taken to the
Catheterization Laboratory within 30 minutes of the onset of
his chest pain and was found to have a thrombosed LAD stent.
This was reopened with suction of the clot and PTCA
angioplasty of the stent.
Mr. [**Known lastname **] [**Last Name (Titles) 8430**] did not bump his cardiac enzymes from
this event. He remained stable status post this LAD stent
rethrombosis.
He was started on Lovenox 30 mg subcutaneously b.i.d. for two
weeks which will end on [**2105-1-1**] to help prevent
in-stent rethrombosis. His Lipitor was also discontinued and
changed to pravastatin 40 mg p.o. q.d. which is not
associated with decreasing the active levels of Plavix.
2. INFECTIOUS DISEASE: Mr. [**Known lastname **] was found to have a mild
right upper lobe pneumonia which was found on chest x-ray
after he spiked a fever to 101. He was begun on Levaquin 500
mg p.o. q.d. on [**2104-12-19**] and will complete a ten day
course of this. Otherwise, his medications will be unchanged
from the previous discharge summary addendum.
[**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D. [**MD Number(2) 579**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2104-12-20**] 02:58
T: [**2104-12-21**] 08:25
JOB#: [**Job Number 8431**]
Name: [**Known lastname 8428**], [**Known firstname **] Unit No: [**Numeric Identifier 8429**]
Admission Date: [**2104-12-10**] Discharge Date: [**2104-12-24**]
Date of Birth: [**2020-4-9**] Sex: M
Service:
The patient was discharged to short term rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Toprol XL 50 mg p.o. once daily.
2. Lisinopril 5 mg p.o. once daily.
3. Aspirin 325 mg p.o. once daily.
4. Plavix 75 mg p.o. once daily.
5. Metformin 1000 mg p.o. once daily.
6. Lantus 16 subcutaneously q.h.s.
7. Insulin sliding scale.
8. Atorvastatin 20 mg p.o. once daily.
9. Colace 100 mg p.o. twice a day.
10. Pantoprazole 20 mg p.o. once daily.
11. Lovenox 30 mg subcutaneous twice a day will be continued
for two weeks.
12. Levaquin 500 mg p.o. once daily for ten days.
Lipitor was discontinued and changed to Pravastatin.
FOLLOW-UP: As per previous discharge summary, the patient
will follow-up Wednesday, Wednesday, [**2104-12-31**], with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital 8439**] Medical Associates and
follow-up with his primary care physician two weeks after
discharge.
DISCHARGE DIAGNOSES:
1. ST elevation myocardial infarction.
2. Congestive heart failure.
3. Dementia.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: As above.
[**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D. [**MD Number(2) 579**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2105-3-7**] 20:50
T: [**2105-3-8**] 08:59
JOB#: [**Job Number 8440**]
|
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icd9cm
|
[
[
[]
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[
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"88.56",
"99.20",
"37.23",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
26270, 26355
|
25403, 26249
|
14776, 17660
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12940, 12961
|
17672, 22091
|
13254, 14759
|
10237, 12729
|
12752, 12916
|
12978, 13231
|
26380, 26671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,729
| 120,698
|
33274
|
Discharge summary
|
report
|
Admission Date: [**2115-3-24**] Discharge Date: [**2115-3-28**]
Service: MEDICINE
Allergies:
Haldol / Penicillins / Augmentin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 77261**] is an 87 yo male s/p CVA, nonverbal at baseline, who
presents from rehab with fevers and hyperglycemia. He is
non-verbal so unable to obtain further history. Family feels
mental status and level of alertness has declined over the last
week.
In the ED, intial vitals were T 106, HR 115, BP 105/70, RR 20,
99% on NRB. He was noted to have abdominal tenderness, so
underwent CT abd/pelvis which was unremarkable. He was noted to
have RLE cellulitis. He He was given vancomycin and levaquin for
?infiltrate on CXR. He was given regular insulin IV for
hyperglycemia, though he did not have urine ketones or an anion
gap. A bedside echo was performed given low voltages on EKG
which showed moderate pericardial effusion though CT abd/pelvis
showed only small effusion.
On the floor, patient is nonverbal so unable to obtain further
history.
Review of sytems: Unable to obtain
Past Medical History:
s/p CVA left frontoparietal and temporooccipital [**2110**],
nonverbal, s/p PEG placement
Traumatic subdural hematoma x 2
HTN
Type II DM
Dementia
Atrial flutter: off warfarin due to traumatic subdural x 2
Social History:
Lives in [**Hospital **] Health center. Supportive daughters and wife.
[**Name (NI) 3003**] Chinese Restauranteur. No tobb or etoh
Family History:
NC
Physical Exam:
Vitals: T: 100.6 axillary BP: 94/68 P:98 R: 18 O2: 99% on AC
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MM dry, oropharynx w/ oral airway in
place, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds bilaterally with loud upper airway
sounds, no appreciable wheezes or rales
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, distended but soft, bowel sounds present, unable
to assess for tenderness to palpation
Ext: 1+ RLE edema, trace LLE edema
Pertinent Results:
CT HEAD W/O CONTRAST [**2115-3-24**]:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Encephalomalacic changes involving the left cerebral
hemisphere secondary to remote stroke again demonstrated.
3. Unchanged scalp lipoma.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2115-3-24**]:
IMPRESSION:
1. Moderate stool within the rectum without evidence of bowel
obstruction.
2. Atelectasis in the left lung base.
3. Degenerative changes and spinal stenosis in the lower lumbar
spine.
CHEST (PORTABLE AP) [**2115-3-24**]:
IMPRESSION:
Retrocardiac opacity likely atelectasis. No other acute
abnormality.
CHEST (PORTABLE AP) [**2115-3-25**]:
FINDINGS: As compared to the previous radiograph, a central
venous access
line has been introduced over the right internal jugular vein.
The tip of the line projects over the inflow tract of the right
atrium. There is no evidence of complications such as
pneumothorax. Minimally increasing retrocardiac atelectasis,
unchanged cardiac enlargement. Otherwise, no radiographic
changes.
UNILAT (RIGHT) LOWER EXT VEINS [**2115-3-25**]:
IMPRESSION: No evidence of right lower extremity DVT.
CHEST (PORTABLE AP) [**2115-3-26**]:
HEMATOLOGY:
[**2115-3-24**] 12:30PM BLOOD WBC-14.9*# RBC-3.93* Hgb-12.9* Hct-38.8*
MCV-99*# MCH-33.0* MCHC-33.4 RDW-15.2 Plt Ct-124*
[**2115-3-24**] 12:30PM BLOOD Neuts-88* Bands-0 Lymphs-8* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-3-25**] 04:09AM BLOOD WBC-10.9 RBC-3.30* Hgb-10.6* Hct-31.4*
MCV-95 MCH-32.1* MCHC-33.7 RDW-15.0 Plt Ct-93*
[**2115-3-25**] 04:09AM BLOOD Neuts-83.5* Lymphs-11.4* Monos-2.9
Eos-1.9 Baso-0.2
COAGS:
[**2115-3-24**] 12:30PM BLOOD PT-14.7* PTT-30.6 INR(PT)-1.3*
[**2115-3-25**] 04:09AM BLOOD PT-15.6* PTT-45.5* INR(PT)-1.4*
CHEMISTRY
[**2115-3-24**] 12:30PM BLOOD Glucose-415* UreaN-43* Creat-1.1 Na-157*
K-3.8 Cl-134* HCO3-13* AnGap-14
[**2115-3-25**] 04:09AM BLOOD Glucose-166* UreaN-42* Creat-1.2 Na-161*
K-3.4 Cl-136* HCO3-20* AnGap-8
[**2115-3-25**] 04:09AM BLOOD Calcium-6.6* Phos-1.6* Mg-2.5 Iron-40*
[**2115-3-25**] 09:02AM BLOOD Glucose-333* UreaN-38* Creat-1.1 Na-155*
K-4.1 Cl-129* HCO3-21* AnGap-9
[**2115-3-25**] 09:02AM BLOOD Calcium-6.3* Phos-1.9* Mg-2.3
[**2115-3-25**] 02:47PM BLOOD Glucose-263* UreaN-35* Creat-1.1 Na-155*
K-3.7 Cl-130* HCO3-22 AnGap-7*
[**2115-3-25**] 02:47PM BLOOD Calcium-7.0* Phos-2.0* Mg-2.4
CARDIAC ENZYMES:
[**2115-3-24**] 12:30PM BLOOD CK(CPK)-450*
[**2115-3-24**] 12:30PM BLOOD cTropnT-0.06*
[**2115-3-24**] 05:45PM BLOOD CK(CPK)-857*
[**2115-3-24**] 05:45PM BLOOD CK-MB-2 cTropnT-0.07*
[**2115-3-25**] 04:09AM BLOOD LD(LDH)-248 CK(CPK)-939*
[**2115-3-25**] 04:09AM BLOOD CK-MB-6 cTropnT-0.05*
[**2115-3-25**] 02:47PM BLOOD CK(CPK)-771*
[**2115-3-25**] 02:47PM BLOOD CK-MB-7 cTropnT-0.04*
[**2115-3-25**] 06:34PM BLOOD CK(CPK)-715*
[**2115-3-25**] 06:34PM BLOOD CK-MB-7 cTropnT-0.03*
[**2115-3-26**] 03:28AM BLOOD CK(CPK)-574*
[**2115-3-26**] 03:28AM BLOOD CK-MB-5 cTropnT-0.03*
IRON STUDIES:
[**2115-3-25**] 04:09AM BLOOD Iron-40*
[**2115-3-25**] 04:09AM BLOOD calTIBC-90* Hapto-253* Ferritn-1478*
TRF-69*
LACTATE TREND:
[**2115-3-24**] 12:33PM BLOOD Lactate-2.2* K-4.3
[**2115-3-24**] 06:05PM BLOOD Lactate-1.7
[**2115-3-25**] 01:11AM BLOOD Lactate-1.1
Brief Hospital Course:
Mr [**Known lastname 77261**] is an 87 yo M with a history of stroke, nonverbal, with
hypertension, type 2 diabetes mellitus, who presented [**2115-3-24**]
with fever to 106, likely secondary to extensive lower extremity
cellulitis. At the time of admission the pt also had
hypernatremia and acute renal failure likely secondary to
dehydration.
# Fever / Leukocytosis/ sepsis:
The pt's fever was attributed to a right lower extremity
cellulitis. There was significant warmth and and erythema over
right lower extremity at presentation. After intitiation of
antibiotics the pt's WBC decreased from 14 to 10.9 and he was
afebrile for the duration of the admission. The pt had a right
lower extremity ultrasound that was negative for deep vein
thrombosis. The pt was initially on Vancomycin and cefepime,
and given low suspicion of pneumonia or PEG site infection,
cefepime was eventually stopped and the pt was discharged to
complete a 10 day course of vancomycin for resolving cellulitis.
.
# Hypotension:
The pt's initial hypotension was likely secondary to poor PO
intake over several weeks in addition to sepsis from infection
(likely cellulitis). It resolved during the admission and the pt
was discharged on his home antihypertensives.
.
# Ventricular tachycardia code:
On [**3-25**] the pt had an episode of pulseless/unresponsive VT and a
code BLUE was called. CPR was initiated but stopped immediately
after initiation due to the pt's spontaneous recovery of pulse.
The pt was not defibrillated during this event. The pt was awake
and responsive afterward, and a post-code EKG was without ST
elevations, and per cardiology the pt had not had ventricular
tachycardia, but had intermittent atrial tachycardia with
baseline bradycardia. The pt's troponins trended down during
this admission. Electrophysiology and cardiology were asked to
see the pt and determined that a pacemaker would not be
appropriate given the pt's advanced age, nonverbal status and
the fact that there was no evidence that the pt was symptomatic
from his rhythm abnormalities.
# Hypernatremia:
The pt initially received normal saline for rehydration. After
the pt's hypotension resolved the pt was treated with free water
boluses via the PEG tube. The pt's sodium improved with q3h 250
cc free water boluses.
.
# Acute renal failure:
The pt's creatinine returned to [**Location 213**] during this
hospitalization with intravenous fluids.
.
# Hyperglycemia:
The pt is a type 2 diabetic. On this admission there was no
evidence of DKA. The pt's blood glucose was likely elevated in
setting of infection. The pt was initially on an insulin drip
and then transitioned to qid sliding scale without
complications.
.
# AMS:
The pt's daughter on discharge stated that the pt was at his
baseline mental status (responds to voice but hard of hearing,
speaking in jibberish). Head CT showed no acute process.
Donepezil was continued.
.
Medications on Admission:
Docusate Sodium 50 mg [**Hospital1 **]
Baclofen 2.5 mg TID
Tamsulosin 0.4 mg qhs
Trazodone 7.5 mg PO HS
Paroxetine HCl 15 mg daily
Ascorbic Acid 90 mg daily
Thiamine HCl 100 mg daily
Amlodipine 5 mg daily
Aspirin 81 mg daily
Lansoprazole 30 mg daily
Levetiracetam 500 mg/mL [**Hospital1 **]
Donepezil 5 mg qhs
Magnesium Hydroxide 400 mg/5 mL 30 ml po Q6H prn
Bisacodyl 10 mg daily prn
Lantus 14 QHS with HISS
Morphine IV 1-2 mg IV every 4-6 hours PRN
Calcium Carbonate 1,250 mg/5 mL(500 mg) TID
Cholecalciferol (Vitamin D3) 400 unit daily
Acetaminophen 1000 mg Tablet TID prn pain
Morphine 15 mg PO Q4H PRN
Lisinopril 2.5 mg daily
Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) g
Intravenous Q 24H (Every 24 Hours) for 5 days: Finish on [**2115-4-2**].
2. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2
times a day).
3. Baclofen Oral
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Date Range **]: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
5. Trazodone Oral
6. Paroxetine HCl 10 mg Tablet [**Date Range **]: 1.5 Tablets PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
8. Donepezil 5 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime).
9. Thiamine HCl 100 mg Tablet [**Date Range **]: One (1) Tablet PO once a day:
Per g tube.
10. Amlodipine 5 mg Tablet [**Date Range **]: One (1) Tablet PO once a day:
Per g tube. .
11. Aspirin 81 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: Per
g tube. .
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: Per g tube. .
13. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five (5) PO BID (2
times a day).
14. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) PO
every six (6) hours as needed for constipation: Per g tube. .
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: Per g
tube. .
16. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Fourteen (14) u
Subcutaneous at bedtime: With humalog sliding scale.
17. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO three times a day: Per g tube. .
18. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO once a day.
19. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO three
times a day: Per g tube. .
20. Lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Per g tube. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
sepsis due to RLE cellulitis
acute renal failure
Secondary:
diabetes mellitus type II, uncontrolled with complications
Hypertension
hx CVA
Discharge Condition:
Stable, breathing comfortably on room air, all intake is via g
tube including medications.
Discharge Instructions:
Mr [**Known lastname 77261**]: You were admitted with fever, high blood sugar and high
sodium. You were treated with insulin, fluids and antibiotics
and your fever, high blood sugar and high sodium improved. An
area on your leg was noted to be hot and red, and we suspect
that this skin infection was the cause of your fever.
.
Your home medications are the same.
The medication Vancomycin has been ADDED. You will take this
medication for 5 more days to complete a 10 day course.
Your morphine has been STOPPED. You have not required this
medication during this admission.
.
If you develop chest pain, shortness of breath, or any other
concerning symptoms, please return to the emergency room.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 6924**], in
your nursing home.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,265
| 177,823
|
34492
|
Discharge summary
|
report
|
Admission Date: [**2120-12-18**] Discharge Date: [**2120-12-22**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product
Derivatives
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
History of Present Illness:
87 yo female with PMH Atrial fibrillation on coumadin, HTN on
lisinopril , HL, eczema, recent drermatologic rashes, and recent
facial/lip swelling presenting with new tongue swelling this AM.
Pt called daughter around 10:45 am and speech sounded garbled
and pt complained of new swollen tongue. She took 1 tab of
benedryl this AM and called her PCP who referred her to the ED.
Of note per her family pt had episodes of ichy skin this summer
and was seen by Dr. [**Last Name (STitle) 22342**] in dermatology. Family also reports
facial and periorbital swelling on and off since [**Month (only) **] of
unknown etiology. Some family members report voice sounding
funny on and off. Also 2 wks ago had significant swelling of the
lips that was thought to be associated with eating pineapple.
She took benadryl for several days with improvement and had
appointment with allergist for later this month.
.
PT took benedryl 25mg po at home and received 50mg IV in the
ambulance. In the emergency department on arrival vitals were
T98.2 HR73 BP139/65 RR16 98% RA. The patient had significant
tongue swelling and was difficult to understand. The decision
was made to intubate the patient due to difficulty speaking. EKG
was done and reported to have mild depressions in inferior
leads. In the ED he received solumedrol 125mg IV x1, pepcid 20mg
IV x1, versed 2mg IV prn sedation. VSS stable on transfer.
.
Unable to obtain ROS given pt intubated. Family reported pt
recently feeling well except for HPI.
Past Medical History:
Atrial fibrillation
Hypertension
Hyperlipidemia
Osteoporosis
Osteoarthritis
s/p right hip replacement
eczema
Hayfever as a child
Social History:
Lives at an independent living facility. Walks with walker and
is very active and does exercise program. Never smoker. 1 glass
wine per week. No illicits.
Family History:
-1st cousin with peanut allergy developed in his 80s.
-No FH of asthma or eczema
Physical Exam:
Physical Exam on Admission:
T 97/8 BP 147/61 HR 78 RR 20 O2 100% RA
GENERAL: sedated, arousable, able to open eyes on command but no
squeeze hands
HEENT: Markedly swollen tongue unable to visualize back of
throat. No facial or periorbital swelling. Normocephalic,
atraumatic. No conjunctival pallor. No scleral icterus. PERRLA.
MMM.
CARDIAC: irregular rhythm. No murmurs, rubs or [**Last Name (un) 549**]. No JVD.
LUNGS: CTAB, good air movement bilaterally anteriorly.
ABDOMEN: +BS. Soft, NT, ND. No HSM
EXTREMITIES: No edema, 2+ dorsalis pedis and radial pulses.
SKIN: + macular papular rash with excoriations on right back and
hip.
NEURO: sedated, arousable, able to open eyes on command but no
squeeze hands
Pertinent Results:
Labs on Admission:
.
[**2120-12-18**] 12:30PM BLOOD WBC-11.6* RBC-4.10* Hgb-12.4 Hct-37.1
MCV-91 MCH-30.2 MCHC-33.4 RDW-12.9 Plt Ct-266
[**2120-12-18**] 12:30PM BLOOD Neuts-69.0 Lymphs-24.5 Monos-4.6 Eos-1.6
Baso-0.4
[**2120-12-18**] 12:30PM BLOOD Plt Ct-266
[**2120-12-18**] 05:45PM BLOOD PT-27.3* PTT-30.3 INR(PT)-2.7*
[**2120-12-18**] 12:30PM BLOOD Glucose-118* UreaN-28* Creat-1.0 Na-143
K-5.4* Cl-109* HCO3-21* AnGap-18
[**2120-12-18**] 12:30PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
.
Labs during admission
[**2120-12-21**] 04:55AM BLOOD PT-38.8* PTT-30.9 INR(PT)-4.0*
[**2120-12-21**] 04:55AM BLOOD ESR-28*
[**2120-12-21**] 04:55AM BLOOD ALT-32 AST-48*
[**2120-12-21**] 04:55AM BLOOD TSH-0.096*
[**2120-12-21**] 04:55AM BLOOD T3-PND Free T4-1.4
[**2120-12-21**] 04:55AM BLOOD Anti-Tg-PND antiTPO-PND
[**2120-12-18**] 05:45PM BLOOD C4-43*
.
Cardiac Enzymes:
[**2120-12-18**] 12:30PM BLOOD CK(CPK)-92
[**2120-12-18**] 05:45PM BLOOD CK(CPK)-57
[**2120-12-19**] 04:00AM BLOOD CK(CPK)-43
[**2120-12-18**] 12:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2120-12-18**] 05:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2120-12-19**] 04:00AM BLOOD CK-MB-2 cTropnT-<0.01
.
EKG ([**2120-12-18**]): Atrial fibrillation, average ventricular rate
81. Right bundle-branch block. Diffuse non-diagnostic
repolarization abnormalities. No previous tracing available for
comparison.
.
CXR ([**2120-12-18**]): Endotracheal tube as above. For optimal
placement, consider retraction by approximately 1 cm. A tortuous
aorta with cardiomegaly and no signs of failure.
.
[**2120-12-22**] 07:20AM BLOOD WBC-11.8* RBC-4.42 Hgb-13.6 Hct-39.5
MCV-89 MCH-30.7 MCHC-34.4 RDW-12.2 Plt Ct-258
[**2120-12-22**] 07:20AM BLOOD PT-25.8* INR(PT)-2.5*
[**2120-12-22**] 07:20AM BLOOD Glucose-125* UreaN-23* Creat-0.9 Na-138
K-3.5 Cl-98 HCO3-27 AnGap-17
[**2120-12-21**] 04:55AM BLOOD ALT-32 AST-48*
[**2120-12-21**] 04:55AM BLOOD TSH-0.096*
[**2120-12-21**] 04:55AM BLOOD T3-PND Free T4-1.4
[**2120-12-21**] 04:55AM BLOOD Anti-Tg-PND antiTPO-PND
[**2120-12-18**] 05:45PM BLOOD C4-43*
[**2120-12-21**] 04:55AM BLOOD CU INDEX (ANTI-FCER1 ANTIBODY)-PND
[**2120-12-18**] 05:45PM BLOOD C1 INHIBITOR-PND
Brief Hospital Course:
87 yo female with PMH Atrial fibrillation on coumadin, HTN on
lisinopril , HL, eczema, recent drermatologic rashes, and recent
facial/lip swelling, who presented with new tongue swelling and
s/p intubation in the ED. Each of the problems addressed during
this hospitalization are described in detail below:
.
Angioedema: The patient was intubated in the ED as was having
trouble talking secondary to tongue swelling and was tranferred
to ICU for further care. Although pt with recent facial and lip
swelling on and off since end of [**Month (only) **], this was first
episode of tongue swelling. The patient also noted to have had
hay fever as child. Allergies to fish and sulfa but no exposure
recently. Of note, the patient was also recently followed by
dermatologist for rash. Because of the high degree of suspicion
that this was caused by Lisinopril, this medication was
dicontinued and added to the list of allergies. The patient was
continued on Benadryl 50mg IV q6hrs, IV Methylprednisolone 80mg
q8hrs, pepcid 20mg IV BID, fexofenadine. The morning after
admission, the patient was successfully extubated as the
swelling had significantly improved. The patient had no further
episodes of facial or tongue swelling, difficulty breathing
while in the ICU. The patient was seen by Allergy service, who
will follow up the patient as outpatient. As part of workup for
allergy, C4 levels were normal, C1 inhibitor levels, TSH,
Thyroglobulin antibody, CU Index (Anti-FCer1 Antibody), Anti-TPO
Antibody, SED RATE, RAST, and RAST for pineapple, flounder, cod,
haddock, salmon. The TSH was 0.096 and free T4 was 1.4. The
T3 was pending. The patient was switched to PO Prednisone, H2
blocker, and antihistamine. She will continue Prednisone 40mg
daily, as well as her H2 Blocker and antihistamine until follow
up with allergy to decide a taper.
.
Low TSH: TSH was 0.096 with free T4 of 1.4. T3, antiTPO, antiTg
pending at discharge. By review of systems and exam, there was
no evidence of thyroid dysfunction. The case was discussed with
endocrinology, who felt her low TSH was a result of her recent
high dose steroids, vs sick euthyroid syndrome, unlikely
contributing to her angioedema in the setting of her lisinopril.
Her TFTs should be rechecked in [**4-10**] weeks, and her pending
results followed up.
.
EKG changes: On admission, the patient was noted to have ST
depression in inferior leads from EKG in ED. No EKG was
available for comparison. No Aspirin as given on admission
given angioedema. The patient had 3 sets of negative cardiac
enzymes. She had no symptoms concerning for ACS. We continued
home Metoprolol and Zocor.
.
Hypertension: Lisinopril was discontinued due to angioedema. We
continued home Amlodipine and Metoprolol. She was started on
hydralazine for a third hypertension [**Doctor Last Name 360**]. Her BP stabilized
and she was discharged on higher dose metoprolol (50mg [**Hospital1 **]) as
well as her amlodipine.
.
Eczema: We continued outpatient Triamcinolone topical 0.1% 1 app
QID
.
Hyperlipidemia: We continued Zocor.
.
Atrial fibrillation: INR was theraputic an arrival. Coumadin was
re-started on the morning of extubation. INR then became
supertherapeutic to 4 and coumadin was held. On the day of
discharge her INR was 2.5. Her home warfarin was resumed and
her INR should be rechecked on [**2120-12-24**] and adjusted
accordingly.
.
Osteoporosis: Home calcium and vitamin D were re-started in the
morning after extubation. Patient receives Fosamax q Wednesday.
.
Medications on Admission:
Coumadin 2.5 mg 1 tab MWF;1/2tab all other days
metoprolol 50 mg [**2-9**] tab am; 1 tab pm
Claritin 10 mg 1 tab(s) once a day
triamcinolone topical 0.1% 1 app QID
Norvasc 10 mg 1 tab(s) once a day
calcium and vitamin D combination 600 mg-200 units 1 tab(s) TID
Fosamax 70 mg 1 tab(s) 1X/W
lisinopril 10 mg 1 tab(s) once a day
Zocor 20 mg 1 tab(s) once a day (at bedtime)
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
to continue until your allergist appointment. DO NOT stop this
medication abruptly.
Disp:*60 Tablet(s)* Refills:*0*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for itchiness: apply to
affected area.
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every
Wednesday).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please resume your normal coumadin dosing and check your INR on
[**2120-12-24**].
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema secondary to ACE inhibitor
Atrial Fibrillation
Hypertension, benign
Sublcinical Hyperthyroidism
Eczema
Discharge Condition:
Good
Discharge Instructions:
You were admitted with swelling of the tongue (angioedema), and
were briefly intubated to protect your airway. With steroids
and anti-inflammatory medication, you condition improved. This
was most likely caused by your Lisinopril. Please DO NOT take
this medication or similar medications (ACE inhibitors) in the
future. You ill be prescribed anti-inflammatory medications to
treat your condition.
.
It is very important that you follow up with the Allergist on
[**2120-12-24**], to decide a taper of your prednisone and to identify a
cause.
.
Your thyroid test was abnormal, which may be a false value. You
will need your thyroid tests checked in [**4-10**] weeks to further
assess this value.
.
Resume all medications as prescribed. Your metoprolol has been
increased to 50mg twice daily. Please resume your coumadin and
recheck your INR on [**2120-12-24**]
.
Return to the hospital with recurrent lip/tongue swelling,
shortness of breath, or any other concerning symptoms.
Followup Instructions:
Allergist appointment
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9703**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 9316**]
Date/Time:[**2120-12-24**] 2:00
.
Please follow up with PCP: [**First Name8 (NamePattern2) 3296**] [**Last Name (NamePattern1) 3297**],[**Name12 (NameIs) 3295**] I. [**Telephone/Fax (1) 608**],
in [**3-13**] weeks
|
[
"E942.9",
"242.80",
"692.9",
"715.90",
"995.1",
"272.4",
"733.00",
"427.31",
"V58.61",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10323, 10329
|
5193, 8718
|
297, 334
|
10487, 10494
|
3029, 3034
|
11525, 11906
|
2197, 2280
|
9142, 10300
|
10350, 10466
|
8744, 9119
|
10518, 11502
|
2295, 2309
|
3888, 5170
|
247, 259
|
362, 1856
|
3048, 3871
|
1878, 2009
|
2025, 2181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,878
| 133,247
|
39242
|
Discharge summary
|
report
|
Admission Date: [**2181-2-15**] Discharge Date: [**2181-2-19**]
Service: SURGERY
Allergies:
Tetanus
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89yo Female with MDS and now AML, baseline dementia suffered a
mechanical fall at nursing home resulting in a right
frontotemporal SAH. Pt could not recall the details of the
fall. She was transported to [**Hospital1 18**] for further treatment.
Past Medical History:
MDS, no AML treated with regular transfusions
s/p cataract surgery
Hypertension
Dementia
Chronic Kidney Disease
Atrial Fibrillation
Gout
Social History:
Currently living in a skilled/extended nursing facility. Support
from brother and nephew.
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM At presentation:
O: T: 96.8 BP: 136/56 HR:60 R:18 O2Sats:98 RA
Gen: WD/WN, comfortable, NAD.
HEENT: R occipital scalp lac, dry MM
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place. thought it was
"patriot's
day" today (it's St. [**Doctor Last Name **]). Unclear of month.
UNable to name DOW backwards.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: pupils miotic, equal, 2mm minimally reactive. 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: generalized wasting. tone limited d/t pain. No abnormal
movements, tremors. No pronator drift. Unable to lift L leg due
to pain. dorsiflexes L ankle (TA [**4-4**]).
Sensation: Intact to light touch, cool throughout.
Reflexes: B T Br Pa
Right 1 1 1 1
Left 1 1 1 1
L toe upgoing, R toe downgoing.
Coordination: slowed bilaterally with hand [**Doctor First Name 6361**].
IMAGING:
Head CT: R frontal-temporal SAH, L frontal SAH.
Pertinent Results:
[**2181-2-19**] 06:55AM BLOOD WBC-2.2*# RBC-2.67* Hgb-8.2* Hct-24.2*
MCV-91 MCH-30.6 MCHC-33.8 RDW-16.3* Plt Ct-45*
[**2181-2-16**] 11:50AM BLOOD Neuts-18* Bands-0 Lymphs-48* Monos-31*
Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2181-2-19**] 06:55AM BLOOD Glucose-117* UreaN-27* Creat-1.3* Na-134
K-4.4 Cl-100 HCO3-24 AnGap-14
[**2181-2-19**] 06:55AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.3
[**2181-2-19**] 06:55AM BLOOD Digoxin-2.3*
Coagulation:
[**2181-2-19**] 06:55AM BLOOD Plt Ct-45*
[**2181-2-18**] 09:50PM BLOOD Plt Ct-62*#
[**2181-2-18**] 07:20AM BLOOD Plt Ct-40*#
[**2181-2-17**] 06:25AM BLOOD Plt Ct-91*#
[**2181-2-17**] 03:55AM BLOOD Plt Ct-48*
[**2181-2-16**] 09:45PM BLOOD Plt Ct-59*
[**2181-2-16**] 05:30PM BLOOD Plt Ct-68*#
[**2181-2-16**] 11:50AM BLOOD Plt Smr-VERY LOW Plt Ct-35*
[**2181-2-16**] 12:47AM BLOOD Plt Smr-VERY LOW Plt Ct-52*
[**2181-2-15**] 06:02PM BLOOD Plt Ct-88*
[**2181-2-15**] 01:49PM BLOOD Plt Smr-LOW Plt Ct-99*
[**2181-2-15**] 08:47AM BLOOD Plt Ct-109*
[**2181-2-15**] 05:37AM BLOOD Plt Ct-132*#
[**2181-2-15**] 05:37AM BLOOD PT-13.1 PTT-26.9 INR(PT)-1.1
[**2181-2-14**] 11:29PM BLOOD Plt Smr-VERY LOW Plt Ct-22*
[**2181-2-14**] 11:29PM BLOOD PT-13.1 PTT-24.3 INR(PT)-1.1
IMAGING:
[**2-14**] Head CT: unchanged multifocal SAH in comparison to 3 hrs
prior. no shift of midline structures, no uncal or
transtentorial herniation.
[**2181-2-15**] Repeat CT head Right syl fissure/temp lobe stable and
L frontal
[**2-15**] Imaging:
CT Cspine: DJD no fx
XR Left hip: no fx, no dislocation
XR b/l knee: no fx, no dislocation
Brief Hospital Course:
Patient presented to the emergency department after a fall at
nursing home resulting in a right frontotemporal SAH in the
setting of thrombocytopenia related to acute myeloid leukemia.
She received platelets in the emergency room and was then
admitted to the TSICU for monitoring and followed by trauma
surgery with neurosurgery for consultation. The patient was also
found to be neutropenic; precautions were observed. Her
platelet count as of [**2-19**] is 45K with a HCT of 24.2. At this
time the patient was also found to have a urinary tract
infection, was started on a 3 Day course of ciprofloxacin 500mg.
On day of discharge the patients Foley catheter was removed and
she is due to void by 8pm on the evening of [**2181-1-30**].
She was transferred from the TSICU to the floor [**2181-2-16**]. Her
neurologic exam was followed closely and presently at baseline;
serial head CT imaging was stable. No further neurosurgical
intervention warranted at this time. The patients CBC was
watched closely during her hospital stay. She received 5 units
of platelets and also received 1 unit of packed red blood cells
during her hospitalization.
Medications on Admission:
Allopurinol 100mg PO BID
Prednisone 10mg daily
Neupogen 300mcg SC daily
Epogen 40,000unit SC q wednesday
Protonix 40mg daily
Metoprolol 200mg PO daily
Digoxin 0.125mg daily
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000
Injection Every Wednesday.
2. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache.
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Expired
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]
Discharge Diagnosis:
s/p Fall
Right frontotemporal subarachnoid hemorrahge
Urinary tract infection
Secondary diagnosis: acute myeloid leukemia
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You suffered a fall at your current place of resident which
caused a collection of blood in your brain. The injury to your
brain is slightly complicated by your current blood disorder,
acute myeloid leukemia which causes you to have less ability to
stop bleeding than normal. You recieved blood components during
your hospital stay to help your blood to clot and at this time,
it has been determined that the collection of blood in the brain
is stable and it is safe for you return to your extended care
facilty. If you feel as though you are confused, sleepy, or have
a severe headache please notify those who are taking care of you
and they can get you to the emergency room.
During your hospital stay, you were also found to have a urinary
tract infection which was treated with antiobiotics for 3 days.
You have finished treatment. During your hospital stay you had a
foley catheter placed in your bladder, this was removed prior to
your discharge. It is important that you void at least 6 hours
after this was removed which would be 8-10pm tonight [**2181-2-19**]. If
you have not voided by this time please inform your caregivers
and they will seek medical attention for you. If you find that
you have abdominal pain, lower back pain, the frequent need to
urinate, buring during urination, new urinary incontinence, or
blood in your urine please notify your care givers and see your
health care provider.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 739**], Neurosurgery in [**3-6**] weeks
with a non contrast Head CT. Extended care facility can call
[**Telephone/Fax (1) 1669**] for an appointment.
Follow up with your oncologist Dr. [**Last Name (STitle) 55834**] within the next week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2181-6-6**]
|
[
"E849.7",
"V58.65",
"284.1",
"414.01",
"599.0",
"V15.82",
"403.90",
"873.0",
"294.8",
"852.06",
"238.75",
"V13.01",
"E888.9",
"585.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5977, 6058
|
3930, 5079
|
223, 230
|
6225, 6225
|
2352, 3577
|
7839, 8256
|
790, 807
|
5305, 5954
|
6079, 6158
|
5105, 5280
|
6402, 7816
|
822, 1086
|
174, 185
|
258, 507
|
1449, 2283
|
6179, 6204
|
3586, 3907
|
6240, 6378
|
529, 667
|
683, 774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,743
| 177,427
|
46909
|
Discharge summary
|
report
|
Admission Date: [**2152-1-17**] Discharge Date: [**2152-2-5**]
Date of Birth: [**2092-8-23**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with abdominal pain.
Major Surgical or Invasive Procedure:
Status Post Ex Laparotomy for Small Bowel Resection for internal
hernia.
History of Present Illness:
Patient presented with 2 days of abdominal pain. Accompanied
with nausea and vomiting. OR for Closed loop obstruction with
concern
for strangulated bowel.
Past Medical History:
PMH: Depression
PSH: C-section
[**Last Name (un) 1724**]: Paxil 40
Social History:
Lives with husband and son.
Family History:
Non applicable
Physical Exam:
On discharge:
Afebrile, VSS
Gen: NAD A+Ox3
CVS: Reg
Pulm: no resp distress
Abd: Soft/approp tender/non-distended. Staples intact from
surgical incision except for middle portion there is 2-3cm
opening of skin packed.
LE: no lower limb edema
Pertinent Results:
[**2152-1-18**] 12:15AM BLOOD WBC-6.5 RBC-3.54* Hgb-11.0* Hct-32.5*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.2 Plt Ct-202
[**2152-1-18**] 06:25AM BLOOD WBC-8.9 RBC-3.15* Hgb-9.8* Hct-29.0*
MCV-92 MCH-31.1 MCHC-33.7 RDW-13.3 Plt Ct-202
[**2152-1-19**] 06:50AM BLOOD WBC-9.0 RBC-2.96* Hgb-9.3* Hct-27.5*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.3 Plt Ct-192
[**2152-1-21**] 03:45PM BLOOD WBC-7.0 RBC-3.12* Hgb-9.7* Hct-28.4*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.6 Plt Ct-326#
[**2152-1-22**] 07:20AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.4* Hct-25.0*
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-344
[**2152-1-22**] 09:55AM BLOOD WBC-4.8 RBC-2.69* Hgb-8.3* Hct-24.0*
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-292
[**2152-1-25**] 06:40AM BLOOD WBC-8.7# RBC-3.69*# Hgb-10.9*# Hct-32.7*#
MCV-88 MCH-29.5 MCHC-33.4 RDW-14.4 Plt Ct-443*
[**2152-1-25**] 10:05PM BLOOD Hct-27.1*
[**2152-1-25**] 11:35PM BLOOD WBC-8.2 RBC-2.88* Hgb-9.0* Hct-25.6*
MCV-89 MCH-31.2 MCHC-35.0 RDW-14.7 Plt Ct-365
[**2152-1-26**] 06:34AM BLOOD WBC-8.3 RBC-3.42* Hgb-10.3* Hct-30.1*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.8 Plt Ct-342
[**2152-1-26**] 09:34AM BLOOD Hct-28.8*
[**2152-1-26**] 02:27PM BLOOD Hct-29.1*
[**2152-1-26**] 05:18PM BLOOD Hct-28.4*
[**2152-1-26**] 09:15PM BLOOD WBC-5.5 RBC-4.56# Hgb-13.6# Hct-39.2#
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.9 Plt Ct-223
[**2152-1-27**] 03:48AM BLOOD WBC-11.4*# RBC-4.81 Hgb-14.1 Hct-40.6
MCV-84 MCH-29.4 MCHC-34.9 RDW-15.2 Plt Ct-247
[**2152-1-27**] 10:07AM BLOOD Hct-38.7
[**2152-1-27**] 08:09PM BLOOD Hct-32.4*
[**2152-1-28**] 01:05AM BLOOD Hct-32.7*
[**2152-1-28**] 10:34AM BLOOD Hct-29.9*
[**2152-1-28**] 08:49PM BLOOD Hct-32.0*
[**2152-1-29**] 04:06AM BLOOD WBC-9.4 RBC-4.14* Hgb-12.4 Hct-36.4
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.0 Plt Ct-247
[**2152-1-30**] 04:50AM BLOOD WBC-7.8 RBC-4.19* Hgb-12.9 Hct-37.2
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.8 Plt Ct-310
[**2152-2-1**] 10:28AM BLOOD WBC-8.8 RBC-4.43 Hgb-13.0 Hct-39.3 MCV-89
MCH-29.2 MCHC-33.0 RDW-14.1 Plt Ct-452*
[**2152-2-2**] 04:48AM BLOOD WBC-7.9 RBC-4.21 Hgb-12.3 Hct-37.5 MCV-89
MCH-29.2 MCHC-32.8 RDW-13.9 Plt Ct-489*
[**2152-2-4**] 10:19AM BLOOD WBC-7.7 RBC-4.03* Hgb-12.3 Hct-36.4
MCV-90 MCH-30.5 MCHC-33.7 RDW-13.5 Plt Ct-516*
[**2152-1-18**] 12:15AM BLOOD Glucose-190* UreaN-14 Creat-0.7 Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
[**2152-1-25**] 06:40AM BLOOD Glucose-129* UreaN-8 Creat-0.6 Na-135
K-3.8 Cl-100 HCO3-25 AnGap-14
[**2152-2-4**] 10:19AM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-137
K-4.3 Cl-100 HCO3-29 AnGap-12
[**2152-1-26**] 06:34AM BLOOD ALT-134* AST-87* AlkPhos-106*
Amylase-107* TotBili-0.6
[**2152-1-26**] 09:15PM BLOOD ALT-82* AST-72* LD(LDH)-160 AlkPhos-89
Amylase-117* TotBili-0.8
[**2152-1-28**] 03:44AM BLOOD ALT-108* AST-104* AlkPhos-68 TotBili-0.5
[**2152-1-30**] 04:50AM BLOOD ALT-68* AST-45* AlkPhos-155* TotBili-0.6
[**2152-1-26**] 06:34AM BLOOD Lipase-214*
[**2152-1-26**] 09:15PM BLOOD Lipase-112*
[**2152-1-18**] 12:15AM BLOOD Calcium-7.2* Phos-3.9 Mg-1.4*
[**2152-1-18**] 06:25AM BLOOD Calcium-7.4* Phos-3.3 Mg-2.6
[**2152-1-19**] 06:50AM BLOOD Calcium-8.1* Phos-1.6*# Mg-2.0
[**2152-1-22**] 07:20AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9
[**2152-1-22**] 09:55AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
[**2152-1-25**] 06:40AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
[**2152-1-25**] 11:35PM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9
[**2152-1-26**] 06:34AM BLOOD Albumin-2.6* Calcium-7.5* Phos-3.2 Mg-1.9
Iron-33 Cholest-106
[**2152-1-26**] 09:15PM BLOOD Albumin-1.7* Calcium-7.3* Phos-3.0
Mg-1.3*
[**2152-1-27**] 03:48AM BLOOD Calcium-6.9* Phos-3.4 Mg-1.2*
[**2152-1-27**] 05:35PM BLOOD Calcium-7.4* Phos-3.9 Mg-1.7
[**2152-1-28**] 03:44AM BLOOD Calcium-7.1* Phos-2.7 Mg-1.6
[**2152-1-29**] 04:06AM BLOOD Albumin-2.2* Calcium-7.0* Phos-2.9 Mg-1.8
[**2152-1-30**] 04:50AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.0
[**2152-1-31**] 05:58AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9
[**2152-2-1**] 07:03AM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.5 Mg-2.0
Iron-29*
[**2152-2-2**] 04:48AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.9
[**2152-2-4**] 10:19AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.8
[**2152-1-26**] 07:42PM BLOOD Type-ART pO2-190* pCO2-33* pH-7.44
calTCO2-23 Base XS-0 Intubat-INTUBATED
[**2152-1-26**] 09:24PM BLOOD Type-ART pO2-362* pCO2-37 pH-7.39
calTCO2-23 Base XS--1
[**2152-1-27**] 04:00AM BLOOD Type-ART pO2-154* pCO2-33* pH-7.46*
calTCO2-24 Base XS-1
[**2152-1-28**] 10:52AM BLOOD Type-ART pO2-72* pCO2-40 pH-7.47*
calTCO2-30 Base XS-4 Intubat-NOT INTUBA
[**2152-1-26**] 07:42PM BLOOD Hgb-12.3 calcHCT-37
Brief Hospital Course:
Patient taken to OR for with closed loop obstruction with
concern
for strangulated bowel for exploratory laparotomy on [**1-16**].
Intraoperatively patient found to have: Meckel diverticulum
with volvulus and gangrene of the distal ileum. Patient
underwent:
PROCEDURE:
1. Exploratory laparotomy.
2. Adhesiolysis.
3. Ileocolic resection and ileocolonic anastomosis.
Post operatively the patient the patients course was complicated
by a fever on [**2152-1-24**] to 101.4 and she was pancultured. Blood
cultures showed no growth and urine culture grew ENTEROBACTER
AEROGENES. CXR showed atelectasis however PNA could not be
ruled out.
[**1-25**] Patient had nausea and poor PO intake, KUB showed ?ileus vs
small bowel obstruction and was very distended. NG was placed
but patient self-dc'ed the NG and refused another tube. She
also had large melanotic stool and HCT was checked:27.1->25.6,
patient agreed to have NG placed, and after being transfused 2
units Hct went to 30.1 however continued melena her Hct
continued to drop as low as 24. 2 large bore iv's were placed
and she was fluid resuscitated in addition to recieving PRBC's.
She underwent colonoscopy on [**1-26**] which showed blood in rectal
vault and patient was taken to OR as it was believed this was
most likely a bleed from the anastamotic site.
Patient was found intraoperatively to have SBO and underwent LOA
and had revision of ileocolic anastomosis in hopes to resolve
her bleeding. Post operatively she was transferred to the ICU
and remained intubated overnight. In the ICU she was weaned to
extubation and nutrition support was given via TPN. She was also
given IV abx. On [**1-28**] CXR showed no PNA and improvement in
dilation of bowels. When the patient was stable she was
transferred out of the ICU to the floor and continued to
improve. Once she had bowel function her NG was removed and her
diet was advanced slowly and she was continued on TPN. Her
abdomen was softer and she tolerated her diet. Her abdominal
staples were removed, and it was noticed that she did have some
drainage from the middle portion of her surgical site and this
was opened and packed. By time of discharge patient had been
off TPN and tolerating regular diet, pain was controlled on PO
meds. She was ambulating and feeling much stronger. She will
have VNA for dressing changes and will follow up in clinic.
Medications on Admission:
Paxil 40
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis: SBO, post operative bleeding
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-3**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower 48 hours after surgery, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) 470**] - Please call
[**Telephone/Fax (1) 2723**] to make an appointment two weeks after discharge.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12293**], MD (Psychiatry) Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2152-2-29**] 9:40. Location: [**Hospital Ward Name 452**], [**Location (un) 551**], [**Hospital Ward Name 516**].
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,934
| 121,073
|
41008
|
Discharge summary
|
report
|
Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-10**]
Date of Birth: [**2136-7-23**] Sex: F
Service: SURGERY
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Colovesicular fistula
Major Surgical or Invasive Procedure:
Placement of left-sided ureteral stent, sigmoid colectomy,
takedown of colovesicular fistula, mobilization of splenic
flexure and diverting loop ileostomy.
History of Present Illness:
The patient is a 59-year-old woman, with COPD on steroids with
enlarging thoracic aortic aneurysm, colovesicular fistula from
diverticulitis, as well as lung lesion, who presented for
management of diverticulitis. Cystoscopy revealed a small
bladder mass that seemed external on the left side. CT and
MRI and also confirmed that there is diverticulitis in the left
colon with involvement of the bladder.
Past Medical History:
Thoracic aortic aneurysm
Hypertension
Hyperlipidemia
Asthma/COPD
Mild renal insufficiency, proteinuria
[**2191**] Hx of CVA (transient visual disturbance)
Right lung nodule
Hypothyroidism
Glucose intolerance, ? due to prednisone use
Polymyalgia rheumatica/ giant cell arteritis (currently on
steroid taper)
[**4-/2195**]: total abdominal Hysterectomy for uterine cancer
+ PPD
s/p removal of colon polyps
Presumed UTI, s/p course of Cipro (completed on [**2196-3-9**])
Tonsillectomy
s/p C-section
Arthritis involving neck and spine
Social History:
Patient is divorced with a 24 year old son. She lives alone. She
is employed as a clinical social worker.
ETOH: None recently
Tobacco: Patient has smoked 35-40 years, half a pack to 1ppd.
She quit in [**2195-12-9**]
Recreational Drug Use: Denies
Family History:
Mother with abdominal aortic aneurysm
No history of colorectal cancer
Physical Exam:
On discharge:
98.9 69 133/66 16 98% RA
General: Appears well, NAD
CV: RRR
Resp: CTAB, no distress
Abd: Soft, nontender, nondistended, incisions c/d/i, stoma pink
with liquid stool
Ext: No peripheral edema
Pertinent Results:
[**2196-5-7**] 05:35AM BLOOD WBC-10.1 RBC-3.55* Hgb-11.1* Hct-32.9*
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.9 Plt Ct-339
[**2196-5-9**] 05:30AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-28 AnGap-12
Echo ([**2196-4-29**]):
The left atrium is mildly dilated LVEF 70%. Focal wall motion
abnormality cannot be fully excluded. The abdominal aorta is
markedly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present.
Renal US ([**2196-4-29**]):
No evidence of hydronephrosis
KUB ([**2196-5-3**] & [**2196-5-4**]):
Multiple dilated loops of small bowel with air-fluid levels
likely suggestive of a postoperative ileus; however, obstruction
cannot be
ruled out.
CT abd/pelvis ([**2196-5-6**]):
1. Dilated fluid-filled loops of small bowel up to 5 cm with
multiple
air-fluid levels and a gradual transition point in the proximal
ileum but
without any upstream fecalization. This appearance is likely
related to an
underlying ileus with the decompressed distal ileum related to
lack of
contrast progression at the time of exam.
2. Streaky opacities in the right middle lobe with some more
peripheral
centrilobular nodules likely reflect a combination of
atelectasis and mild
infectious bronchiolitis.
3. No findings of abscess within the abdomen or pelvis. Normal
appearance to the loop ileostomy and colocolonic anastomosis
site. Submucosal fatty
deposition within the ascending colon is nonspecific and may
reflect chronic inflammation or secondary to patient body
habitus and steroid use.
Brief Hospital Course:
Ms. [**Known lastname 52903**] was admitted on [**2196-4-27**] after undergoing sigmoid
colectomy with coloproctostomy and diverting loop ileostomy for
colovesicular fistula and diverticulitis without complications.
Due to the length of her case and low urine output in PACU,
patient was transferred to the ICU extubated for volume
resuscitation and monitoring. Her course is detailed below by
system:
1. Neuro: Patient was neurologically at baseline throughout her
stay. Her pain was initially controlled with an epidural
catheter which was dced on POD#4. Patient was then transitioned
from IV to po pain meds as she was tolerated po intake.
2. CV: While in ICU, patient was fluid resuscitated for low
urine output, however SBP was normal throughout. Patient
developed an increasing O2 requirement on POD#2 and an echo was
performed to assess for CHF secondary to resuscitation. ECHO
showed a normal EF and no signs of fluid overload. She was
maintained on home medications when taking po.
3. Resp: Patient was extubated in the OR and had increased O2
requirement on POD#2. CXR performed at that time showed mild
atelectasis b/l but no signs of pneumonia. O2 was gradually
weaned and patient's O2 sats were >95% on room air at the time
of discharge. She was given nebulizer treatments for her COPD.
4. GI: Patient's ostomy was pink and protubertant throughout
stay. Her diet was advanced from clears to regular when passing
flatus. However, on POD5, patient had an episode of bilious
emesis. She was made NPO and started on IV fluids. KUB was
performed revealing an ileus. Due to continued nausea, abdominal
distension, and emesis, an NG tube was placed on POD#8 with 900
cc of bilious return. Patient was encourage to ambulate and
minimize narcotics and reglan was started. Due to prolonged NPO
status, a PICC line was placed and TPN started. A CT abdomen was
performed to investigate prolonged ileus and revealed ileus with
no clear SBO or fluid collections. Once distension had resolved,
patient's NGT was clamped for 6 hours with no nausea or
distension. NGT was removed and she was started on clear
liquids. She was advanced to regular diet when ostomy had good
output and gas, which she was tolerating at the time of
discharge.
4. Renal/GU: Patient had low urine output perioperatively and
was fluid resuscitated in ICU. Her Cr peaked at 2 on POD#1 with
FeNa of 1%. Renal US was performed with no evidence of
hydronephrosis. With continued resuscitation, Cr trended
downward. Once transferred to the floor (POD#4), patient was
diuresed with IV lasix back to baseline weight. Cr at discharge
was 0.9
5. Heme/ID: Patient was on heparin SC and venodyne boots for DVT
prophylaxis. She was given 24 hours of periop antibiotics.
6. Endo: Patient was given stress dose steroids perioperatively
and then resumed on home dose when taking po. She was kept on an
insuline sliding scale and her levothyroxine was continued.
Dispo: Patient was evaluated by physical therapy with
recommendations for discharge home. She worked with the
inpatient stoma nurse and received education.
Medications on Admission:
albuterol prn
fluticasone 110 2 puffs [**Hospital1 **]
Spiriva 18 daily
Atenolol 50mg daily
HCTZ 25mg
Irbesartan 300mg daily
Wellbutrin ER 150mg daily
Prozac 40mg daily
Levothyroxine 250mg daily
Prednisone 5mg daily
Aspirin 325mg daily
B vitamins
Calcium
Vitamin D
Augmentin 875mg twice daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
6. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. irbesartan 150 mg Tablet Sig: Two (2) Tablet PO daily ().
10. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain for 5 days: Do not drink alcohol or
drive a car while taking this medication. .
Disp:*30 Tablet(s)* Refills:*0*
12. Vitamin B Complex Oral
13. Calcium 500 Oral
14. Vitamin D Oral
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Diverticulitis with colovesicular fistula.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a Sigmoid Colectomy for
surgical management of your Diverticulitis. You have recovered
from this procedure well and you are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonges loose stool, or
constipation.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc.
Please record the output of your ileostomy on the flow sheet
provided to you by the nursing staff. If you find that your
output has become too much or too little, please call the office
for advice. The office nurse or nurse practitioner can recommend
medications to increase or slow the ileostomy output. Keep
yourself well hydrated, if you notice your ileostomy output
increasing, take in more electrolyte drink such as gatoraide.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If you notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. You may eat a mosified regular
diet with your new ileostomy. However it is a good idea to avoid
spicy foods.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for buldging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery, You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own. Currently your ileostomy is allowing the
surgery in your large intestine to heal, which does take some
time. You will come back to the hospital for reversal of this
ileostomy at a time decided on Dr. [**Last Name (STitle) 1120**] or [**Doctor Last Name **] that is safe
to do so. You will follow-up in the clinic, and the surgeon will
decide when will be the best time for your second surgery. Until
this time there is healthy intestine that is still functioning
as it normally would and it will produce mucus and some may leak
or you may feel as though you need to have a bowel movment and
you may sit on the toilet and empty this mucus, it is normal.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) **]. You may gradually increase
your activity as tolerated but clear heavy excersise with Dr.
[**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
hydromorphone. Please take this medication exactly as
prescribed. You may take Tylenol as recommended for pain. Please
do not take more than 4000mg of Tylenol daily. Do not drink
alcohol while taking narcotic pain medication or Tylenol. Please
do not drive a car while taking narcotic pain medication.
You have an appointment with thoracic surgery as listed below to
evaluate your lung, please keep this appointment.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Call and schedule appointment with Dr. [**Last Name (STitle) **] in [**7-21**] days. Call
[**Telephone/Fax (1) 160**] with questions, concerns and to make this
appointment.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2196-5-19**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**].
Completed by:[**2196-5-10**]
|
[
"585.9",
"569.5",
"780.62",
"493.20",
"596.1",
"441.2",
"560.1",
"272.4",
"518.89",
"403.90",
"562.11",
"244.9",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.01",
"99.15",
"87.74",
"59.8",
"45.76",
"57.83",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8116, 8168
|
3592, 6677
|
290, 448
|
8255, 8255
|
2028, 3569
|
13842, 14267
|
1717, 1788
|
7020, 8093
|
8189, 8234
|
6703, 6997
|
8406, 13819
|
1803, 1803
|
1817, 2009
|
229, 252
|
476, 882
|
8270, 8382
|
904, 1436
|
1452, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,011
| 119,132
|
34507
|
Discharge summary
|
report
|
Admission Date: [**2182-2-26**] Discharge Date: [**2182-2-28**]
Date of Birth: [**2125-10-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line placement
History of Present Illness:
56 y/o M PMH patient presented to [**Hospital 4199**] Hospital for altered
mental status and severe diaphoresis. Pt found to be hypoxic
(per record sat 70s) and intubated. BP recorded as 76-90/35-51,
P 70. Central line placed. Patient given narcan, versed, ativan
and ceftriaxone. ABG 7.21/76.40/210/31 following intubation.
Patient unable to fit in CT scan so was transferred to [**Hospital1 18**].
.
Per wife patient was watching TV in his bed (normal actvity) and
intermittently was less responsive with slurred speech and
diaphoritic. No headache. Calling name and would be "sleepy". No
weakness. No recent trauma. Increased work of breathing - would
improve NEB for the past 2 days. No fever, chills. No chest
pain. No abdominal pain or back pain.
.
In the ED, initial vs were: T 96.7 P 65 BP 131-170/78-83 R 28 O2
sat 100% vent. Patient was given vancomycin and midazolam drip.
.
Review of systems: Unable to obtain due to intubation
Past Medical History:
DM, with neuropathy
HTN
Hyperlipidemia
BPH
Depression
Morbid Obesity (487lbs)
Severe Osteoarthritis
OSA on CPAP 17cm H20 with 2L O2
Nephrolithiasis
GERD
Social History:
No tobacco. Previous EtOH abuse but none since [**2156**]. Occasional
marijuana. No other illicits. Disabled, uses scooter to get
around out of house but does ambulate at home
Family History:
father had first MI at age 50, required 4v CABG; three paternal
uncles all died of MI in their 60s.
Physical Exam:
Tmax: 36.9 ??????C (98.5 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 52 (52 - 74) bpm
BP: 114/52(68) {100/43(59) - 160/74(100)} mmHg
RR: 18 (11 - 24) insp/min
SpO2: 96%
Heart rhythm: SB (Sinus Bradycardia
General: Sedated. Squeezes hands to name. Malodorous.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2182-2-26**] 12:20AM BLOOD WBC-8.8 RBC-4.19* Hgb-11.4* Hct-36.2*
MCV-86 MCH-27.2 MCHC-31.5 RDW-15.7* Plt Ct-236
[**2182-2-26**] 12:20AM BLOOD Neuts-84.4* Lymphs-11.7* Monos-2.9
Eos-0.5 Baso-0.4
[**2182-2-26**] 12:20AM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0
[**2182-2-26**] 12:20AM BLOOD UreaN-28* Creat-1.1 Na-142 K-5.2* Cl-106
HCO3-32 AnGap-9
[**2182-2-26**] 12:20AM BLOOD ALT-119* AST-101* LD(LDH)-260*
CK(CPK)-114 AlkPhos-86 TotBili-0.1
[**2182-2-26**] 05:56AM BLOOD Lipase-60
[**2182-2-26**] 12:20AM BLOOD cTropnT-<0.01
[**2182-2-26**] 12:20AM BLOOD CK-MB-3
[**2182-2-26**] 05:56AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
[**2182-2-26**] 12:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-2-26**] 12:25AM BLOOD Type-CENTRAL VE pO2-59* pCO2-81* pH-7.18*
calTCO2-32* Base XS-0
[**2182-2-26**] 03:19AM BLOOD Lactate-1.4
[**2182-2-26**] 03:19AM BLOOD O2 Sat-98
[**2182-2-26**] 10:58PM BLOOD freeCa-1.18
[**2182-2-26**] 12:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2182-2-26**] 12:20AM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-2-26**] 12:20AM URINE RBC-[**3-8**]* WBC-[**3-8**] Bacteri-NONE Yeast-NONE
Epi-0
[**2182-2-26**] 05:56AM URINE Mucous-RARE
[**2182-2-26**] 12:20AM URINE Hours-RANDOM
[**2182-2-26**] 12:20AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MICRO:
[**2-26**] BCx: No growth to date
[**2-26**] UCx: Negative
[**2-26**] Sputum: GRAM STAIN (Final [**2182-2-26**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS
AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2182-2-28**]): SPARSE GROWTH Commensal
Respiratory Flora.
STUDIES
[**2-26**] TTE: No thrombus/mass is seen in the body of the left
atrium. Right atrial appendage ejection velocity is good (>20
cm/s). No atrial septal defect is seen by 2D or color Doppler.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is probably normal (LVEF>55%). Right ventricle
is not well-visualized. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. There are
simple atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. No thoracic aortic dissection is
seen. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. No mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly dilated ascending
aorta. No thoracic aortic dissection. Probably preserved left
ventricular systolic function without significant valvular
regurgitation.
[**2-26**] ECG: Sinus rhythm with slight A-V conduction delay.
Consider left atrial abnormality. Delayed R wave progression.
Modest T wave inversion in lead V2. Findings are non-specific
but clinical correlation is suggested. No previous tracing
available for comparison.
[**2-26**] CXR: 1. Massive cardiomegaly. Small left pleural effusion.
2. Mediastinal widening could represent adenopathy, pulmonary
arterial
enlargement. 2. ET tube 5.8 cm above the carina. NG tube tip is
not identified.
[**2-26**] LENIS: Limited exam without evidence of DVT.
[**2-27**] CXR: FINDINGS: As compared to the previous radiograph, the
endotracheal tube, the nasogastric tube and the right-sided
central venous access line are unchanged. There is minimal
increase in extent of the pre-existing left-sided pleural
effusion and the subsequent retrocardiac atelectasis. In the
well-ventilated areas of the lung parenchyma, no focal
parenchymal opacities have newly occurred. Overall, the diffuse
widening of the mediastinum is unchanged.
[**2-28**]: Single bedside AP examination labeled "semi-supine at
0850" is compared with the limited bedside views (labeled "line
placement") obtained the previous day, as well as a study of
[**2182-2-26**]. Once again, the study is limited due to patient habitus
and radiographic technique; however, allowing for this, there
has been marked improvement in both cardiomegaly and apparent
superior mediastinal widening since the initial study. There is
now only smooth prominence of the right paratracheal soft
tissues, borderline LV enlargement and no pulmonary vascular
congestion or significant pleural effusion. No focal airspace
process is seen.
Labs on discharge:
[**2182-2-28**] 06:14AM
White Blood Cells 9.1 K/uL 4.0 - 11.0
Red Blood Cells 4.06* m/uL 4.6 - 6.2
Hemoglobin 10.4* g/dL 14.0 - 18.0
Hematocrit 33.3* % 40 - 52
MCV 82 fL 82 - 98
MCH 25.6* pg 27 - 32
MCHC 31.2 % 31 - 35
RDW 15.4 % 10.5 - 15.5
Platelet Count 218 K/uL 150 - 440
[**2182-2-28**] 06:14AM
RENAL & GLUCOSE
Glucose 202* mg/dL 70 - 100
Urea Nitrogen 11 mg/dL 6 - 20
Creatinine 0.8 mg/dL 0.5 - 1.2
Sodium 140 mEq/L 133 - 145
Potassium 3.8 mEq/L 3.3 - 5.1
Chloride 96 mEq/L 96 - 108
Bicarbonate 35* mEq/L 22 - 32
Anion Gap 13 mEq/L 8 - 20
Alanine Aminotransferase (ALT) 55* IU/L 0 - 40
Asparate Aminotransferase (AST) 20 IU/L 0 - 40
Alkaline Phosphatase 74 IU/L 40 - 130
Bilirubin, Total 0.4 mg/dL 0 - 1.5
CHEMISTRY
Calcium, Total 8.2* mg/dL 8.4 - 10.3
Phosphate 3.7 mg/dL 2.7 - 4.5
Magnesium 1.7 mg/dL 1.6 - 2.6
ANTIBIOTICS
Vancomycin 6.5* ug/mL 10 - 20
Brief Hospital Course:
556 y/o M PMH diabetes, HTN, hyperlipidemia who presents with
altered mental status and hypoxia.
.
# Altered mental status/respiratory distress: The patient was
initially diaphoretic with slurred speech. Toxicology screen was
positive for benzos. Head CT was not obtained given patient's
habitus. He was hypercarbic with CO2 76 after intubation,
potentially due to obstructive apnea in the setting of oxycodone
or cannibis use. Cultures were sent, and antibiotics were
started (ceftriaxone, azithromycin, vancomycin). Sputum
eventually came back positive for GPCs in pairs and clusters,
with culture showing respiratory flora. The central venous lines
from the outside hospital were removed. He was intubated and
placed on mechanical ventilation. Heparin gtt was not started
due to inability to rule out intracranial hemorrhage (given
habitus). EKG and cardiac biomarkers were negative for MI. LENIs
were negative for DVT. Neurology was consulted and felt the
patient's mental status was due to infectious or toxic/metabolic
abnormalities. The patient was stable for extubation on [**2-27**],
and did well immediately afterwards. He wore CPAP the following
night. He was called out from the MICU on the morning of [**2-28**]
and transferred to the floor without incident. He continued to
do well on O2 by nasal cannula and even room air. He did not
have significant coughing or difficulty breathing. He was able
to walk with nursing after transfer to the floor. He was
transitioned to PO Levaquin and felt ready for discharge. The
patient should undergo an outpatient sleep study to evaluate for
obstructive sleep apnea, and he said that he had an appointment
at a facility in late [**Month (only) 547**]. Per his family he does wear CPAP at
night.
.
# Widened mediastinium: Given patient's inability to fit in CT
scanner, a TEE was performed and was negative for esophageal
rupture or aortic dissection. Of note, serial CXR's eventually
revealed a remarkably significant improvement in mediastinal
widening, for unclear reasons.
.
# Arrhythmia The patient had an isolated eight beat run of
ventricular tachycardia on [**2-27**], captured on telemetry. As he
was intubated at the time, it was not discernible if the patient
was symptomatic from this. He had no further events.
.
# Asthma: The patient was treated with nebulizers and MDI
treatments.
.
# Diabetes: sliding scale
.
# Hypertension: The patient was quite hypertensive following
extubation and was transiently on a nitro gtt. Otherweise,
metoprolol, HCTZ, and lisinopril were restarted after the
patient's home medications were confirmed with his pharmacy.
.
# Hyperlipidemia: The patient's statin was eventually restarted,
after being confirmed by his pharmacy.
.
# GERD: Convert omeprazole to IV pantoprazole. He was discharged
on his home omeprazole.
.
# Pain: The patient was restarted on his home pain medications
after extubation/discussion with his pharmacy.
.
# Code: The patient was full code for the duration of his
admission to the MICU.
Medications on Admission:
Confirmed with pharmacy by MICU team
Flomax 0.4 qd
Gapapentin 800mg TID
Oxycodone-tylenol 7.5mg-325 TID
Mirapex 0.25mg [**Hospital1 **]
ProAir HFA q6hour
Atrovent HFA 2 puffs QID
Humalin 70/30 100 units morning and dinner
KCL 10 meq TID
Ibuprofen 800mg q8hrs prn
Omeprazole 20 mg qd
Lipitor 80 mg qhs
HCTZ 25 mg qd
Metoprolol tartate 25 mg [**Hospital1 **]
Lisinopril 20 mg qd
Sertaline 100 mg [**Hospital1 **]
Fluticasone nasal spray
Aspirin 81 mg qd
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-5**]
puffs Inhalation every six (6) hours.
6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
7. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: One Hundred
(100) units Subcutaneous at breakfast and dinner.
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO three times a day.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
15. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
16. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia, mental status change
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with a concern for your mental
status. Originally, you were transferred to [**Hospital1 18**] because your
doctors were worried [**Name5 (PTitle) **] might have had a stroke. Unfortunately,
we could not do a CT scan on you. We had the neurologists
evaluate you, and they felt that you did not have a stroke. You
had been intubated at [**Hospital 4199**] hospital because you were also not
breathing well. Your respiratory status improved, and once the
breathing tube was removed you did very well breathing on your
own. Your mental status also improved so that you were at your
normal level of function by discharge. Please use your oxygen at
home as usual and your CPAP machine at night.
.
You were evaluated and thought to have community-acquired
pneumonia. Treatment was started with IV antibiotics, and you
were transitioned to oral antibiotics. You will need to continue
these for one week.
.
You should re-start all of your home medications. The only
medication that has been added is the Levaquin, which is an
antibiotic.
.
You should have your liver function enzymes re-checked as an
outpatient, as they were slightly elevated in the hospital.
.
It is important that you stop using marijuana.
.
It is also important that you keep your appointment for a sleep
study in [**Month (only) 547**].
Followup Instructions:
We have made you an appointment with your primary care doctor,
Dr. [**Last Name (STitle) **], on [**3-7**] at 12:20. Please call her office with any
questions; ([**Telephone/Fax (1) 62298**].
.
You have an appointment for a sleep study in [**Month (only) 547**]. Please call
the place where this is scheduled to confirm this appointment.
Completed by:[**2182-3-3**]
|
[
"278.01",
"493.90",
"338.29",
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"530.81",
"250.00",
"305.1",
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"272.4",
"401.9",
"V58.67",
"782.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
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icd9pcs
|
[
[
[]
]
] |
13316, 13322
|
8321, 11332
|
304, 359
|
13406, 13406
|
2535, 2535
|
14912, 15280
|
1716, 1818
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11835, 13293
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13343, 13385
|
11358, 11812
|
13554, 14889
|
1833, 2516
|
1293, 1329
|
234, 266
|
7359, 8298
|
387, 1274
|
2551, 7340
|
13421, 13530
|
1351, 1506
|
1522, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,259
| 163,565
|
49310
|
Discharge summary
|
report
|
Admission Date: [**2156-12-28**] Discharge Date: [**2156-12-31**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Right sided chest pain.
Major Surgical or Invasive Procedure:
Chest Tube.
History of Present Illness:
[**Age over 90 **]yo female nursing home patient transferred from [**Hospital 100**] rehab
after fall from standing. Patient poor historian, history
obtained from EMS and charts. After fall, patient began
complaining of right sided chest pain, no other complaints. CXR
showed small right pneumothorax and rib factures.
Hemodynamically stable in ED.
Past Medical History:
1. Dementia NOS
2. Osteoarthritis
3. Poor vision.
5. Poor hearing.
6. Status post appendectomy.
7. Cellulitis.
8. Gait instability.
Social History:
SOCIAL HISTORY: The patient lives in nursing home. Denies any
tobacco, alcohol or intravenous drug abuse. Has a graduate
degree.
Family History:
Non contributory.
Physical Exam:
T 98.0 P 96 BP 177/55 RR 20 O2sat 98%on RA
Neuro: A&Ox2, NCAT
Chest: Right sided tenderness to palpation w/? decreased breath
sounds
Heart: Reg rate and rhythm
Abd: Soft NT/ND
Back: No stepoffs/ Nontender
Rectal: Guaic neg per ED staff
Ext: Bilateral palp femoral 2+ pulses. No deformity.
ADMIT STUDIES:
Labs WNL
CT Head/Cspine/Abdomen/Pelvis: read as negative
Chest: large right pneumothorax w/6/7/8/9 rib fractures.
Pertinent Results:
[**2156-12-27**] 09:15PM PT-12.7 PTT-23.8 INR(PT)-1.0
[**2156-12-27**] 09:15PM PLT SMR-LOW PLT COUNT-91*#
[**2156-12-27**] 09:15PM HYPOCHROM-1+
[**2156-12-27**] 09:15PM NEUTS-75.9* LYMPHS-17.3* MONOS-5.1 EOS-1.4
BASOS-0.3
[**2156-12-27**] 09:15PM WBC-7.0 RBC-3.63* HGB-10.5* HCT-32.7* MCV-90
MCH-28.8 MCHC-32.0 RDW-15.3
[**2156-12-27**] 09:15PM GLUCOSE-136* UREA N-42* CREAT-1.0 SODIUM-144
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-30* ANION GAP-14
[**2156-12-28**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2156-12-28**] 02:00AM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005*
[**2156-12-28**] 02:00AM URINE GR HOLD-HOLD
[**2156-12-28**] 02:00AM URINE HOURS-RANDOM
[**2156-12-27**] 09:15PM BLOOD WBC-7.0 RBC-3.63* Hgb-10.5* Hct-32.7*
MCV-90 MCH-28.8 MCHC-32.0 RDW-15.3 Plt Ct-91*#
[**2156-12-29**] 03:03AM BLOOD WBC-6.0 RBC-3.02* Hgb-8.7* Hct-27.3*
MCV-90 MCH-28.8 MCHC-31.9 RDW-15.0 Plt Ct-96*
[**2156-12-30**] 05:10AM BLOOD WBC-5.4 RBC-3.04* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.7 MCHC-31.4 RDW-15.0 Plt Ct-107*
[**2156-12-27**] 09:15PM BLOOD Neuts-75.9* Lymphs-17.3* Monos-5.1
Eos-1.4 Baso-0.3
[**2156-12-27**] 09:15PM BLOOD PT-12.7 PTT-23.8 INR(PT)-1.0
[**2156-12-27**] 09:15PM BLOOD Plt Smr-LOW Plt Ct-91*#
[**2156-12-29**] 03:03AM BLOOD Plt Ct-96*
[**2156-12-30**] 05:10AM BLOOD Plt Ct-107*
[**2156-12-27**] 09:15PM BLOOD Glucose-136* UreaN-42* Creat-1.0 Na-144
K-4.3 Cl-104 HCO3-30* AnGap-14
[**2156-12-29**] 03:03AM BLOOD Glucose-86 UreaN-28* Creat-0.6 Na-142
K-4.1 Cl-105 HCO3-31*
AnGap-10
[**2156-12-30**] 05:10AM BLOOD Glucose-97 UreaN-30* Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-32* AnGap-8
[**2156-12-29**] 03:03AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.6
[**2156-12-30**] 05:10AM BLOOD Mg-1.6
[**2156-12-30**] 05:13AM BLOOD freeCa-1.16
[**2156-12-30**] 05:13AM BLOOD pH-7.39 Comment-GREEN TOP
CT RECONSTRUCTION [**2156-12-27**] 11:09 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval rib fractures, degree of pneumothorax
Field of view: 30 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall 2 d. ago, now with rib fx, ptx
REASON FOR THIS EXAMINATION:
eval rib fractures, degree of pneumothorax
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: [**Age over 90 **] year old female with fall.
TECHNIQUE: Multidetector CT images were obtained from the
thoracic inlet through the symphysis pubis following the
administration of 100 cc of Optiray. Nonionic contrast was used
per the trauma protocol.
Sagittal and coronal reformatted images of the thoracic and
lumbosacral spine were created.
CT OF THE CHEST WITH IV CONTRAST: There are atherosclerotic
changes of the thoracic aorta, with multifocal calcifications,
but there is no evidence of aortic injury. Pulmonary arteries,
heart, and pericardium appear grossly normal. There is a
moderate sized right hemopneumothorax with associated
subcutaneous emphysema tracking along the right chest wall and
right neck. There are associated atelectatic changes of the
right lower lobe. The left lung demonstrates patchy dependent
atelectatic changes.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
spleen, and adrenal glands are normal in appearance. There are
two cystic lesions arising posterior to the pancreatic head, the
larger measuring 1.8 x 1.2 cm The pancreas is grossly normal in
appearance. There is a 2.7 x 1.8 cm cyst arising from the lower
pole of the right kidney as well as a smaller low attenuation
focus which cannot be characterized further on this study. There
is a 1.9 x 2.2 cm cystic lesion arising from the lower pole of
the left kidney. Both kidneys enhance and excrete contrast
symmetrically. There are atherosclerotic changes of the thoracic
aorta, with evidence of calcification at the origins of the
celiac and SMA. However, the distal branches appear patent. The
stomach and unopacified loops of bowel appear grossly normal.
There are several prominent benign pathologically enlarged
celiac and retroperitoneal lymph nodes. There is no free fluid
or air.
CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, distal
ureters and pelvic loops of bowel appear grossly normal. Note is
made of a calcified uterine fibroid. There is no free fluid
within the pelvis.
BONE WINDOWS: There are fractures of the right 6th, 7th, 8th,
and 9th right posterior ribs. Extensive degenerative changes of
the lumbosacral spine are present. In addition, there is loss of
height of the L4 vertebral body, likely representing compression
deformity of uncertain age.
CT RECONSTRUCTIONS: Multiplanar reformatted images were reviewed
and confirm the above findings.
IMPRESSION:
1. Fractures of the right posterior 6th, 7th, 8th, and 9th ribs
associated with a moderate hemopneumothorax and subcutaneous
emphysema.
2. Extensive atherosclerotic changes of the aorta, but no
evidence of intrinsic aortic injury.
3. Nonspecific cystic lesions posterior to the head of the
pancreas.
4. Compression deformity of the L4 vertebral body of
undetermined age as above
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: eval c-spine - r/o fracture
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall 2 d. ago, now with rib fx, ptx
REASON FOR THIS EXAMINATION:
eval c-spine - r/o fracture
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: [**Age over 90 **] year old female with recent fall.
TECHNIQUE: Contiguous axial images of the cervical spine were
obtained without IV contrast. Sagittal and coronal reformatted
images were created.
FINDINGS: There is no evidence of acute fracture or
mal-alignment. There are multilevel degenerative changes, most
severe at C4/5, with evidence of intravertebral disc space
narrowing and a disc osteophyte complex resulting in moderate
spinal stenosis. Less severe changes are evident at C5/6, C6/7
and C7/T1. The prevertebral soft tissues are within normal
limits. Subcutaneous gas is visualized within the right neck.
Known large right pneumothorax is again identified.
IMPRESSION:
1) Multilevel degenerative changes. No evidence of acute
fracture.
2) Large right pneumothorax and subcutaneous emphysema within
the right neck.
CT HEAD W/O CONTRAST
Reason: eval for bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman s/p fall 2 d. ago
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: [**Age over 90 **] year old female with a history of fall two
days prior.
TECHNIQUE: CT of the brain without intravenous contrast.
COMPARISON: [**2156-9-2**].
FINDINGS: There is no acute intracranial hemorrhage, mass
effect, or shift of the normally midline structures. The
ventricles and sulci are prominent but stable and symmetric,
compatible with involutional change. There is a stable left
cerebellar infarct. [**Doctor Last Name **]/white matter differentiation is grossly
preserved. Osseous structures demonstrate no evidence of
fracture. There is near-complete opacification of the left
frontal and left maxillary sinuses, as well as mucosal
thickening of the ethmoid air cells, unchanged from prior study.
There is sclerosis and thickening of the left maxillary wall,
consistent with chronicity. Note is made of subcutaneous air
tracking along the posterior right neck.
IMPRESSION: No acute intracranial hemorrhage, mass effect, or
edema.
RIGHT WRIST.
CLINICAL INDICATION: Right wrist trauma.
AP, lateral and oblique views of the right wrist are compared to
a prior examination dated [**2156-7-7**]. As on the prior
examination there is a fracture of the distal radius. On the
current examination the fracture fragment demonstrates a volar
angulation as opposed to the prior dorsal angulation. It
measures approximately 34 degrees volar angulation.
Additionally, the distal fragment demonstrates increased
sclerosis and loss of volume suggesting resorption. No new
fractures are identified. Degenerative changes of the first CMC
joint are unchanged in appearance.
IMPRESSION:
Distal radial fracture with volar angulation. These findings
were discussed with Dr. [**Last Name (STitle) 103325**] on the date of examination.
PELVIS (AP ONLY) [**2156-12-29**] 11:03 AM
PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS RIGHT
Reason: assess for fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with
REASON FOR THIS EXAMINATION:
assess for fx
INDICATION: Assess for fracture.
AP PELVIS AND TWO VIEWS RIGHT HIP: Mild lumbosacral degenerative
changes. The L4 vertebral body appears sclerotic and short in
height, consistent with known old transverse fracture.
Otherwise, no acute fractures or dislocations identified.
Diffuse enthesopathy. SI joints and head joints are unremarkable
without significant degenerative change. No soft tissue
calcifications noted.
IMPRESSION: No acute fracture or dislocation. Old L4 transverse
vertebral body fracture. Mild lumbar spondylosis.
CHEST (PORTABLE AP)
Reason: please take in early am of [**12-30**] for eval of pneumo/hemo
on
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] yo s/p fall with pneumothorax
REASON FOR THIS EXAMINATION:
eval RUL PTX
HISTORY: [**Age over 90 **] year old status post fall and pneumothorax. Evaluate
the right upper lobe pneumothorax.
Comparison is made to the prior study of a day earlier. Tissue
emphysema along the right lateral aspect of the chest with
multiple rib fractures and a small right apical pneumothorax are
again noted. The right apical pneumothorax is smaller at this
time than on the prior study. There is partial atelectasis at
the right lung base. There is an associated right pleural
effusion or hemothorax is suspected. Also noted is a round area
of infiltration in the right upper lobe which is most likely a
pulmonary hematoma. Left lung is clear. A small soft tissue
nodular density is seen in the left midlung field adjacent to
the anterior aspect of the 2nd rib on the left.
IMPRESSION: The right apical pneumothorax is smaller at this
time. Right upper lobe organizing hematoma.
Multiple right rib fractures and soft tissue emphysema along the
right lateral chest wall.
Right hemothorax.
Questionable soft tissue nodule in the left midlung field. A
followup study would be of value for further evaluation of this
finding.
Brief Hospital Course:
[**2156-12-27**]: placed right chest tube, to ICU for close monitoring.
Air leak noted on chest tube exam. Repeat CXR showed
repositioning required.
[**2156-12-28**]: Replaced tube shown to have kink w/questionable
postioning. Determined to remove tube and monitor.
[**2156-12-29**]: Foley d/c. Switched to percocet for pain control. Reg
diet resumed. Repeat wrist films show old right distal radius
fracture/partially corticated. Ortho placed splint. Left eye
chalazion noted. Warm packs applied with good relief. No
evidence of infection. Transfer to floor bed.
[**2156-12-30**]: Some episodes of urinray frequency with small output
noted. UA sent with positive culture, started on Levo. PT and OT
evals seen w/recs made.
[**2156-12-31**]: No events. Patient stable with good vital signs.
Bladder scanned for residuals. D/c to rehab facility.
Medications on Admission:
1. Metamucil
2. ASA qd
3. Calcium 500mg [**Hospital1 **]
4. MVI qd
5. Aledronate Qweek
6. Donepezil 5mg qd
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
5. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO
1X/WEEK (FR).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1. Right pneumothorax-resolving.
2. Right distal radius fracture-stable/splinted.
3. Rib fractures at level 6/7/8/9.-stable.
4. Urinary tract infection w/frequency-under treatment.
5. Osteoperosis
6. Dementia NOS
7. Chronic hearing loss.
Discharge Condition:
Good / Stable.
Discharge Instructions:
Continue taking medications as discussed.
Resume regular diet and activity as tolerated.
Follow up appointments as noted below.
If you experience any of the following, seek medical attention
immediately: fever >101.4F, severe headached, chest pain,
shortness of breath, inability to urinate, severe abdominal
pain, loss of conciousness, seizure, or any other concerning
symptoms.
Followup Instructions:
1. Follow up with the orthopedics department in 2 weeks. Call
[**Telephone/Fax (1) 58200**] to schedule an appointment with Dr. [**Last Name (STitle) **].
2. Follow up with the Trauma service in 2 weeks. Call
[**Telephone/Fax (1) 2359**] to schedule an appointment.
|
[
"E885.9",
"958.7",
"860.0",
"599.0",
"807.04",
"733.00",
"294.8",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13963, 14028
|
11843, 12690
|
287, 300
|
14310, 14326
|
1470, 3549
|
14754, 15024
|
997, 1016
|
12848, 13940
|
10592, 10641
|
14049, 14289
|
12716, 12825
|
14350, 14731
|
1031, 1451
|
224, 249
|
10670, 11820
|
328, 678
|
700, 834
|
866, 981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,596
| 110,730
|
43754
|
Discharge summary
|
report
|
Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-13**]
Date of Birth: [**2100-3-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Septic Shock
Pericarditis
Pericardial effusion
Major Surgical or Invasive Procedure:
Right Heart Catheterization
Left Heart Catheterization
Intubation
Pericardiocentesis
History of Present Illness:
This is a 77 year old woman with a history of ESRD (HD MWF),
diabetic nephropathy, and dementia found at her nursing home to
be more lethargic than baseline since AM when she woke up for
HD. Her temp was 100.2 but no other symptoms of infection per
[**Hospital3 **] report or daughter. [**Name (NI) **] was transfered to
[**Hospital1 18**] for further evaluation. On arrival she was found to be in
altered mental status (but her baseline was poor) and she was
intubated for ? airway protection. Her EKG showed ST elevation
in I, II , aVF, V4-6 with STD in V1. She was taken to the cath
lab. She was started on dopamine 15/min for blood pressure
support. She received [**Hospital1 **] 325 but no plavix given lack of OGT
and no IIb/IIIa inhibitor given renal failure. Cath showed
80-90% LCx lesion and 90% prox RCA and received BMS.
She was transfered to CCU care intubated and on dopamine of
5/min.
Past Medical History:
Past Medical History:
1. End-stage renal disease. Anuric. On HD MWF with new L AV
graft.
2. Diabetic nephropathy.
3. Noninsulin-dependent diabetes mellitus.
4. Hypertension.
5. Cholecystectomy.
6. S/p Nephrectomy.
7. Mixed vascular and alzheimer's dementia.
8. Anemia.
9. Infected AVG LUE, I&D [**2176-12-20**].
Social History:
There is no history of alcohol abuse. Denies drug use,
smoking.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Has lived at [**Hospital3 2558**] since [**12-5**].
Physical Exam:
VS: T 97.1, BP 102/47 , HR 74, RR 17, pO2 293 on 100%,
(difficult to check sats) on 5 of dopamine
Gen: Intubated, in NAD, tracking with eyelids but not following
commands. Exam limited by intubation, mental status/dementia
and post cath position.
HEENT: NCAT. PERRL, EOMI.
Neck: Unable to properly assess JVP.
CV: RR, normal S1, S2. ? S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Soft NTND. No mass.
Ext: No c/c/e. Sheath still in.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2177-9-8**] 07:12AM BLOOD WBC-15.9*# RBC-2.83*# Hgb-8.3*#
Hct-27.1*# MCV-96 MCH-29.4 MCHC-30.7* RDW-15.1 Plt Ct-228#
[**2177-9-8**] 07:26PM BLOOD Hct-28.9*
[**2177-9-8**] 08:00AM BLOOD Glucose-308* UreaN-68* Creat-9.0*#
Na-149* K-5.3* Cl-109* HCO3-19* AnGap-26*
[**2177-9-8**] 07:12AM BLOOD CK-MB-3 cTropnT-0.13*
[**2177-9-8**] 11:10AM BLOOD calTIBC-104* Hapto-411* Ferritn-GREATER
TH TRF-80*
[**2177-9-8**] 04:25PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-112* pCO2-36
pH-7.39 calTCO2-23 Base XS--2 Intubat-INTUBATED
[**2177-9-8**] 12:42PM URINE RBC-21-50* WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2177-9-8**] Blood Culture, Routine (Preliminary):
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
Catheterization [**2177-9-8**]
COMMENTS:
1. Selective coronary angiography of this right-dominant system
revealed two-vessel coronary artery disease. The LMCA was
heavily
calcific but without flow-limiting stenoses. The LAD had mild
diffuse
disease and heavy calcification throughout. The Ramus was
diffusely
diseased. The LCX was non-dominant with an 80-90% hazy lesion
at its
origen with preserved flow. The RCA was dominant and heavily
calcified
and had a 90% lesion at its origin.
2. Limited resting hemodynamics demonstrated high-normal right-
and
left-sided filling pressures with an RVEDP of 10 mmHg and an
PCWP a-wave
of 13 mmHg.
3. Successful PTCA and stenting of the ostial LCX with a 3.5x16
mm
Vision BMS and the ostial RCA with a 4.0x18 mm Vision BMS. Final
angiography of both vessels revealed 0% residual stenosis and
TIMI III
flow without angiographically-apparent dissection or distal
emboli.
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Successful stenting of the ostium LCX and ostium RCA with
bare metal
stents.
ECHO [**2177-9-8**]
The left atrium and right atrium are normal in cavity size.
There is moderate symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function (LVEF
>55%). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The abdominal aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small pericardial effusion.
IMPRESSION: Prominent symmetric left ventricular hypertrophy
with normal cavity size and preserved global/regional
biventricular systolic function. Increased LVEDP. Mild mitral
regurgitation. Dilated aorta.
Compared with her prior study (images reviewed) of [**2174-11-29**], the
estimated pulmonary artery systolic pressure is lower.
Biventricular systolic function is similar.
[**2177-9-9**] U/S R arm
FINDINGS: Limited study of the right jugular and subclavian line
only were
performed. Complete upper extremity study could not be completed
as the
clinical team requested early termination of the study. The
right jugular
vein appears patent demonstrating normal compressibility.
Echogenic thrombus
identified within the right subclavian vein, without evidence of
Doppler flow.
IMPRESSION: Limited study demonstrating thrombus within the
right subclavian
vein.
[**2177-9-10**] TTE
Left ventricular systolic function is hyperdynamic (EF>75%). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. The effusion appears loculated. No
right ventricular diastolic collapse is seen.
Compared to the prior study dated [**2177-9-8**], the pericardial
effusion appears slightly larger (this may be due to differing
imaging angles) with a more echodense effusion.
[**2177-9-10**] CT ABd
Provisional Findings Impression: KNw WED [**2177-9-10**] 5:09 PM
1 No evidence of infection identifed. No colitis or
intra-abdominal abcess.
Brief Hospital Course:
77 lady with ESRD/HD and dementia was admitted with changes in
mental status and STE in EKG. Status post cath and BMS to prox
80-90% LCX and 90 % prox RCA.
.
# CAD/Ischemia: Admission EKG was concerning for STEMI and she
underwent catheterization w/placement of 2 BMS to the LCx and
RCA. However, given the diffuse nature of the STE, pericarditis
remained on the differential, although the lack of preceding
infectious sx, lack of fever and ST depressions on V1 made that
dx less likely. She was loaded with Plavix and maintained on
that along with [**Year (4 digits) **] and high dose lipitor. Repeat CE showed
stable CE. EKGs continued to show diffuse STE concerning for
bacterial pericarditis given positive BlCx for MSSA.
.
# Pump: The patient appeared euvolemic but her BP was in the low
80s, requiring a dopamine drip of 5mcg/kg/min. Given the
relatively good function of the heart seen on RHC, the
possibility of sepsis was entertained, especially since her
temperature dropped to 95 and her WBC was 20 and a NL SVR in the
setting of using a pressor. We gave her 1500cc bolus and 1 unit
of RBC for a low Hct and we were then able to stop the dopamine
and her BPs remained in the 110s. TTE showed an EF of 65% w/NL
LV systolic function and symmetric LVH. Antihypertensives were
held initially. CXR showed no pulmonary edema.
.
# Rhythm: She remained on telemetry and was NSR initially. On
[**2177-9-9**], had episode of AF w/RVR Tx with diltiazem drip and
return to NSR; BP dropped to 90s (from 110s) and dilt stopped at
this point. Remained on and off of AF w/o changes in BP due to
RVR.
.
# Respiratory: Pt was initially quickly weaned from CMV to PS of
[**10-5**] on 40% FIO2 and she maintained paO2 greater than 100; we
were unable to maintain sat monitor on her. Given the potential
for sepsis, we kept her intubated. Her BP didn't tolerate
sedation well and she became apneic; she was switched back to
CMV on 40% FIO2. ABGs c/w good oxygenation. She remained
intubated throughout her stay until her Code (read below).
.
# Anemia and drop in HCT: Pt was admitted with a Hct of 27.9 and
s/p cath, repeat Hct was 23.9; guiaic was negative and hemolysis
labs were unremarkable. There were no clear signs of bleed and
iron studies were c/w anemia of chronic dz. She was given 1 Unit
of RBCs which maintained her Hct at 28.9. Of note, the cath was
uncomplicated and w/o significant blood loss.
.
# HTN: Initially, we held of antihypertensive as she was
requiring dopamine and eventually levophed given her sepsis.
.
# DM: Her initial glucose levels were in the 300s which then
leveled b/n 190 and 240. She was maintained on RISS and NPH 4U
[**Hospital1 **].
# ID: Pt reportedly had a temp to 100.2 and initially, had a WBC
of 20. This became more concerning when her temp dropped to 95
and her RHC showed an SVR of 800 although in the setting of a
high pressor requirement. The possibility of sepsis was
entertained and she was pan-Cx and empirically started on
renally dosed Cefepime and Vancomycin. BlCx grew coag positive
staph and UCx alpha hemolytic strep and lactobacillus; she was
maintained on vanco and added PO vanc/IV flagyl as her WBC rose
to 31 for potential C.diff. All her access lines were changed
and a new L femoral vein was placed for HD; central access in
RIJ/SC failed [**2-1**] venous thrombus and failure to advance the
guide wire. Abd CT sent and showed no abscess. TTE re-sent which
showed echodense, loculated effusion. BlCx grew MSSA and
switched to Nafcillin on [**9-11**]; she was C.diff negative.
.
# ESRD/HD: Renal was notified of her admission and HD was
deferred on Day 1 given her HoTN and stable potassium level. She
was maintained on her baseline ESRD Rx. CVVH was started on
[**2177-9-11**] given concern for rising lytes.
# FEN: Tube Feeds were started on [**9-11**].
.
# Prophylaxis: SC heparin, PPI
.
# Code: We had a discussion with her daughter, who is the
health care proxy, on [**9-11**] and she wished to continue with the
full code status. We explained that although her WBC count and
fever were decreasing, her direction was unclear. On the morning
of [**9-13**] she developed agonal respirations and went into PEA
arrest. A code was called. She received multiple doses of
epinephrine and electrical shocks during the code which lasted
over one hour. Pericardiocentesis was performed during the code
as her arrest was believed due to tamponade; serosanguinous
fluid was removed. She eventually returned into VT for which she
was shocked and cardioverted into NSR. By this time the family
had arrived at the hospital. After discussion with her daughter
and family, she was made DNR/DNI; her pressors were
discontinued. Her BP and HR slowly dropped and she passed away
shortly thereafter, moments after being extubated.
Medications on Admission:
[**Date Range **] 81 mg daily
Losartan 50 [**Hospital1 **]
Amlodipine 10 daily
Hydralazine 75 [**Hospital1 **] (hold on dialysis day)
Humulin R SS
Glipizide 5 mg (3 tabs PO QAM)
Renegel 800 mg TID
[**Hospital1 **] 30 mg daily
Calcium carbonate 500 mg (2 tabs TID)
Ativan 0.5 mg PRN up to 3x/day
Ranitidine 150 mg daily
Colace
Nephrocaps 1 capsule QD
Fluoxetine 10mg QD
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Completed by:[**2177-9-15**]
|
[
"999.31",
"403.91",
"294.10",
"331.0",
"427.5",
"250.40",
"420.90",
"038.11",
"995.92",
"585.6",
"285.21",
"785.52",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"38.91",
"36.06",
"99.60",
"38.95",
"99.04",
"00.66",
"37.22",
"96.04",
"96.72",
"00.46",
"88.55",
"37.0",
"88.52",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12307, 12316
|
7072, 11854
|
361, 447
|
12369, 12409
|
2583, 3196
|
1827, 1961
|
12273, 12284
|
12337, 12348
|
11880, 12250
|
4464, 7049
|
1976, 2564
|
3234, 4447
|
275, 323
|
475, 1383
|
1427, 1728
|
1744, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,478
| 103,885
|
33131
|
Discharge summary
|
report
|
Admission Date: [**2174-2-23**] Discharge Date: [**2174-3-4**]
Service: CARDIOTHORACIC
Allergies:
Protamine Sulfate / Gluten / Milk / Wheat Flour
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath, atrial fibrillation s/p MVR ( 25 Mosaic
procine), Maze, ligation of left atrial appendage [**2174-2-8**]
Major Surgical or Invasive Procedure:
Re-do sternotomy, evacuation of pericardial and pleural
effusions [**2174-2-24**]
MVR (25 Mosaic, porcine), MAZE, Ligation of left atrial
appendage
History of Present Illness:
85 year old female s/p MVR (25 Mosaic porcine),Maze, ligation of
left atrial appendage [**2174-2-8**]. Readmitted from rehab with
shortness of breath, atrial fibrillation.
Past Medical History:
Paroxysmal atrial fibrillation
Rheumatic heart disease
Moderate-to-severe mitral stenosis
Hypertension
Hypothyroidism
Glaucoma
Osteoporosis
Social History:
She currently lives alone but has a daughter
Retired
[**Name2 (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
admit history and physical
vs: 99.2, 94/55, 66, 18, 96% on 2 liters
neuro: alert and oriented x3, non-focal
resp: lings CTA bilat,-decreased at the bases, no rhonchi or
wheezing.
cardiac RRR S1, S2, no murmur
GI: soft, tender bilat lower quadrants, non-distended, +BS
Extrem: upper extremities: warm, pulses +2, no edema. lower
extremities: Cool, Pulses +1, +1 edema.
Skin: Sternal incision- healing, no erythema, no drainage,
stable
Pertinent Results:
[**3-4**]: WBC 7.9 *Hgb 11.4* HCT 35.0* Plt 319
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77013**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77015**]Portable TTE
(Complete) Done [**2174-2-23**] at 4:37:43 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2088-7-7**]
Age (years): 85 F Hgt (in): 64
BP (mm Hg): / Wgt (lb): 119
HR (bpm): 66 BSA (m2): 1.57 m2
Indication: H/O cardiac surgery. Pericardial effusion.
ICD-9 Codes: 423.3, V42.2
Test Information
Date/Time: [**2174-2-23**] at 16:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W0-0:00 Machine: Vivid [**6-6**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 1.0 m/s
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.9 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Left Ventricle - Ejection Fraction: 65% to 75% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 91 ms
Mitral Valve - MVA (P [**12-3**] T): 2.4 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.56
Mitral Valve - E Wave deceleration time: *270 ms 140-250 ms
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 2.2 cm
Findings
Left pleural effusion
This study was compared to the prior study of [**2174-2-11**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients. No MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Mild PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Stranding is visualized within the pericardial
space c/w organization. No echocardiographic signs of tamponade.
No RV diastolic collapse.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. with borderline normal free wall
function. 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. A
bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. No mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a large
pericardial effusion. The effusion appears circumferential.
Stranding is visualized within the pericardial space c/w
organization. No right ventricular diastolic collapse is seen,
however there are indirect signs of elevated intrapericardial
pressure (RV free wall diastolic flattening)
Compared with the prior study (images reviewed) of [**2174-2-11**],
the large pericardial effuison is new.
IMPRESSION: Large circumfirential pericardial effusion with
early organization. No overt tamponade.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-2-23**] 17:04
Brief Hospital Course:
Pt was admitted to intially to the cardiac surgical floor then
had an ECHO which revealed pericardial effusion and was
transferred to the cardiac ICU to monitor for tamponade. Of
note, Ms. [**Name14 (STitle) 77017**] was c-diff positive at rehab abd was being
treated with flagyl. Her urine was also positive for gram neg
rods and was treated with cipro. Ms. [**First Name (Titles) 77017**] [**Last Name (Titles) 1834**] aggressive
diuresis. On HD #2 Ms. [**Known lastname **] was taken to the OR with Dr.
[**First Name (STitle) **] for pericardial window for drainage of pericardial
effusion and bilat pleural effsuions (left 1 liter and right
500cc). She was treated with periop vanco. She was readmitted to
the ICU post operatively intubated and on neosynephrine. She
weaned from the vent and pressors and was extubated. She was
seen by electrophysiology and her dofetilide was maintained and
VERY LOW DOSE COUMADIN was recommended when stable. She was
transferred from the ICU to the floor. Bilateral chest tubes
remained in place to suction for drainge. when chest tubes were
placed to water seal, she developed pneumothoracies and was
placed back to suction. Chest tubes were later removed and Ms.
[**Name14 (STitle) 77018**] CXR showed stable bilateral 20% pneumothoracies. She
was evaluated by physical therapy and reab was recommended.
On POD#8 she was discharged to rehab.
SHE WILL NEED HER INR CHECKED DAILY AND RECIEVE ONLY LOW DOSE
COUMADIN- 1MG DAILY. SHE WILL ALSO NEED HER RENAL AND LIVER
FUNCTION MONITORED CLOSELY WHILE ON DOFETILIDE. SHE WILL HAVE
CLOSE FOLLOW UP WITH DR. [**Last Name (STitle) **]- APPOINTMENT IS SCHEDULED.
Medications on Admission:
Coumadin held since [**2-21**], ASA, Levoxyl 75/D, Effexor XR 75/D,
Vanco po for cdiff
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
17. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 months.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
19. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
pericardial and pleural effusion after MVR (25 Mosaic, porcine),
MAZE, Left atrial appendage ligation
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, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
DAILY INR CHECKS- VERY LOW COUMADIN FOR AFIB.
CLOSE MONITORING OF LIVER FUNCTION AND RENAL TESTS WHILE ON
DOFETILIDE.
Followup Instructions:
Make the following appointments:
Dr. [**Last Name (STitle) 17863**] (primary care)UPON DISCHRAGE FROM REHAB
You have the following appointments:
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-10**]
11:40
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2174-3-14**]
1:00
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-5-19**]
10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-3-4**]
|
[
"429.4",
"733.00",
"E878.8",
"512.1",
"511.9",
"423.9",
"427.31",
"244.9",
"V42.2",
"997.39",
"398.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.41",
"37.12",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
10186, 10216
|
6553, 8200
|
385, 535
|
10362, 10369
|
1515, 6530
|
11028, 11767
|
1027, 1045
|
8337, 10163
|
10237, 10341
|
8226, 8314
|
10393, 11005
|
1060, 1496
|
220, 347
|
563, 736
|
758, 899
|
915, 1011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,325
| 126,194
|
23928
|
Discharge summary
|
report
|
Admission Date: [**2134-3-24**] Discharge Date: [**2134-4-6**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
found slumped over
Major Surgical or Invasive Procedure:
cardiac catheterization
intubation
History of Present Illness:
81F resident of [**Hospital3 **], with history of CAD, COPD,
diabetes mellitus type 2, Breast Cancer, pulmonary embolism 6
months ago, who was sent here from rehab on [**3-24**] after being
found hypoxic (O2 sat 70%), tachypneic, and cyanotic. She was
intubated in the ED, and found to have ST elevations in V3-V4,
as well as positive Trop of 0.49, CK 218. Cath revealed decrease
ejection fraction at ~25% and diffuse hypokinesis consistent
with "critical illness cardiomyopathy," with distal anterior,
apical and distal inferior akinesis, but clean coronaries;
hemodynamics revealed elevated filling pressures with near
equalization of diastolic pressures (RV 32/13/15; PA 35/25/28;
PCWP 13 mean; LV 110/17/31) C.O. 5.64 CI 3.33. This cardiac
morphology was consistent with Takatsubo's cardiomyopathy, and
is new compared to Echo she had 1 year ago when she was also
admitted for COPD exacerbation.
Past Medical History:
COPD
Diabetes mellitus
CAD
mastectomy for Breast Ca
DVT on coumadin
Social History:
Family History:
non-contributory
Physical Exam:
on transfer to med service [**4-1**]:
Vitals: Tm/c 98.9/94.2 BP 98-149/53-60 HR 85-100 R 20-24 Sat
93-99% RA
BG: 238(7:30am), 214(11:40am)
*
WT: 59.9kg
*
PE: G: Elderly female, appears chronically ill/facial cachexia,
+NGT in place, NAD
HEENT: PERRL, sclearae anicteric, MMM, NGT in place, neck supple
Neck: No JVD appreciated
Lungs: Crackles BL, with occ rhonchi/ exp wheezes throughout
CV: Distant S1S2. No M/R/G appreciated
Abd: Soft, NT, ND, BS+
Ext: 2+ edema of LE, upper extremtities with b/l dermal
edema/erythema R>L; warm/dry; still with diffuse ecchymosis on
arms/back
Pertinent Results:
Echo: Ejection Fraction: 25% to 30%, mid to distal septal,
anterior and apical akinesis. No left ventricular thrombus seen
(cannot exclude). The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis.
Cath: 1. LMCA had mild disease. The LAD had serial 30% stenoses.
The LCX had mild disease. The RCA had proximal 30% stenosis.
2. Left ventriculography demonstrated global hypokinesis with
akinesis
of the distal anterior, apex, and distal inferior walls.
ejection fraction 30%. 3. Resting hemodynamics demonstrated
elevated right sided filling pressures with mRA pressure of 18
mmHg. The left sided filling pressures were markedly elevated
with mPCWP of 25 mmHg and LVEDP of 31 mmHg. There was no
significant pulmonary hypertension with PASP of 32 mmHg. The
cardiac output and cardiac index were preserved at 5.6 L/min and
3.3 L/min/M2, respectively. There was no gradient across the
aortic valve.
[**2134-3-24**] 10:47PM CK(CPK)-218*
[**2134-3-24**] 10:47PM CK-MB-8
[**2134-3-24**] 03:22PM CK-MB-12* MB INDX-4.5 cTropnT-0.26*
[**2134-3-24**] 10:47PM WBC-7.8 RBC-3.26* HGB-10.1* HCT-29.4* MCV-90
MCH-31.0 MCHC-34.3 RDW-14.0
[**2134-3-24**] 10:47PM GLUCOSE-276* UREA N-34* CREAT-1.4* SODIUM-139
POTASSIUM-3.0* CHLORIDE-104 TOTAL CO2-28 ANION GAP-10
[**2134-3-24**] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-SM
[**2134-3-24**] 08:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
Brief Hospital Course:
Ms. [**Known lastname 953**] is an 81 year old woman with an ejection fraction of
25%, whose catheterization showed minimal disease. She had no
intervention done in the cath lab for her Takatsubo type
cardiomyopathy.
Ms. [**Known lastname 953**] initially appeared overloaded and was diuresed on
day 1 of her intubation. This resulted in low pressures post
diuresis of 900 cc, so the patient was then repleted with normal
saline and started on pressors. Once she received a unit of
blood, her pressor requirement diminished. She remained in
normal sinus rhythm.
From the pulmonary standpoint, the patient was intubated for
respiratory arrest. She was treated for a COPD flare and treated
with IV steroids, nebulilzers, and levofloxacin, aztreonam, and
vancomycin for possible exacerbation. Her chest x ray appeared
clear but showed large volumes-c/w emphysematous changes. She
was extubated and briefly required bipap. Thereafter, she did
well on nasal cannula.
For her DM II, Ms. [**Known lastname 953**] was controlled with fingersticks and
an insulin drip. She was then transitioned to a sliding scale.
Ms. [**Known lastname 953**] had a hematocrit drop from 36 to 23 on [**3-25**]
periprocedurally. She was transfused 2 units PRBC. Her blood
loss was thought to be secondary to an RP bleed, but she did
have coffee grounds in her emesis and OB positive blood in her
stool. She was started on a PPI [**Hospital1 **] and a gastroenterology
consult was called. As she was unstable, no intervention was
made, however, it was thought that her small GI blood losses
should be followed up as an outpatient.
Ms. [**Known lastname 953**] initially required tube feeds when she was intubated
and afterwards as well as she failed her speech and swallow
evaluation and was at risk for aspiration. She also briefly
developed hypernatremia which was controlled with free water
boluses.
She was admitted to the CCU, where she was initially
aggressively diuresed with dopamine. She became hypotensive and
was place on levophed, with eventual restoration of blood
pressure to the point of becoming hypertensive and was started
on anti-HTN medication. Course was complicated by decrease in
Hct (34 ->23), with guaiac positive stools and negative NG
lavage. Hct stabilized and pt was continued on PPI. Pt was
weaned off of the ventilator, and continued on nebs, steroids,
and 7 day course of levo/vanc, and BIPAP. She was also noted to
have thrombocytopenia, but was HIT ab negative. She failed a
Speech and swallow study, and had a FEES (flexible endoscopic
examination of swallowing) study [**3-31**], which showed
moderate-severe pharyngeal dysphagia with difficulty clearing
secretions, poor airway closure, and weakened bolus propulsion,
all putting her at risk for aspiration. Per S&S, she should
remain NPO with NGT TFs for nutrition, pending repeat evaluation
in [**3-13**] days. On [**4-1**] being transfer from [**Hospital Unit Name 196**] to MED for
further management of dysphagia/COPD exacerbation.
On the medicine service, she was continued on all her cardiac
medications which included aspirin, metoprolol and lisinopril.
She was also started on low dose lasix given her low ejection
fraction. She should have a repeat echocardiogram in 4 weeks as
outpatient to evaluate for any improvement in cardiac function.
Her coumadin was held for high INR, thought to be from
nutritional deficiency. SHe would have her INR followed up in
rehab and coumadin restarted when INR<2.Her goal INR is between
[**2-11**] for PE and also atrial fibrillation. SHe was also started on
prednisone taper for COPD exacerbation. Her respiratory status
remained stable throughout her hospital stay. She also completed
10 days course of levofloxacin and vancomycin. She was also
continued on albuterol standing and switched from ipratropium to
tiotropium. Her hematocrit stabilzed on the floor and she was
guiac negative even when her INR was high. Her blood glucose was
closely watched and her insulin sliding scale tightened while
she was on steroid.
SHe initially failed speech and swallow study secondary to
edema post intubation. She was thus placed on tubefeeds for
awhile with promote with fiber. She eventually passed the
swallow study and was put on pureed diet prior to discharge.
Medications on Admission:
coumadin, lasix, imdur, tamoxifen
Discharge Medications:
1. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): HOLD coumadin until INR<2.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Betaxolol HCl 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) [**Doctor First Name **]
Inhalation Q6H (every 6 hours).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO ASDIR for 9
days: [**Date range (1) 15037**]:3 tablets
[**Date range (1) 15038**]:2 tablets
[**Date range (1) 3683**]:1tablet
then stop.
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. Glyset 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
17. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
cardiomyopathy
diabetes mellitus
chronic obstructive pulmonary disease flare
dysphagia post intubation
BLeeding from the gut in the setting of anticoagulation
C diff positive
Discharge Condition:
fair
Discharge Instructions:
Please take all medications as listed on the next page.
Call your doctor for chest pain, shortness of breath,
lighheadedness, swelling feet, palpitations, nausea and
vomitting or if there are any concerns at all.
Restrict your fluid intake to 1500 cc and weigh yourself every
day. If you gain more than 3 lbs, call your doctor. Stick to a
low salt diet.
Followup Instructions:
Please call ([**Telephone/Fax (1) 1921**] to set up an appointment with a new
PCP at [**Name9 (PRE) 191**] clinic within 1 weeks of your discharge. If you would
prefer your own PCP, [**Name10 (NameIs) 138**] your PCP and set up an appointment in
1 week. You will need outpatient follow up of the GI bleed that
you have while you were anticoagulated. Your diabetes
medication might need titration as well
Please call ([**Telephone/Fax (1) 2037**] to set up an appointment with the
next available cardiologist, preferably within one month of your
discharge. You will need to have an echocardiogram soon to have
a relook at your heart function.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2134-4-6**]
|
[
"250.00",
"263.9",
"427.31",
"458.29",
"518.81",
"410.71",
"276.0",
"496",
"787.2",
"785.59",
"008.45",
"535.51",
"425.4",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"42.23",
"96.72",
"88.53",
"37.22",
"96.6",
"38.93",
"93.90",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9473, 9543
|
3482, 7758
|
237, 273
|
9762, 9768
|
1963, 3459
|
10172, 10972
|
1327, 1345
|
7842, 9450
|
9564, 9741
|
7784, 7819
|
9792, 10149
|
1360, 1944
|
179, 199
|
301, 1203
|
1225, 1294
|
1311, 1311
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,756
| 152,644
|
1642
|
Discharge summary
|
report
|
Admission Date: [**2143-12-8**] Discharge Date: [**2143-12-9**]
Date of Birth: [**2067-12-13**] Sex: F
Service: MEDICINE
Allergies:
Tetanus&Diphtheria Toxoid / Ceftazidime / Cefazolin /
Penicillins / levofloxacin in D5W
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 75-year-old woman with dCHF (EF 65%) and ESRD on HD
MWF p/w SOB beginning ~8 hrs prior to arrival to ED. Patient
reports increased fluid and salt intake over the holidays as
well as bananas and tangerines, especially on day prior to
admission. She knew she was fluid-overloaded but wanted to wait
until HD tomorrow. Unfortunately, symptoms progressed throughout
the day and she called EMS. She reports orthopnea but also c/o
DOE. She also noted facial edema which she gets with CHF
exacerbations but denies PND. She also denies chest pain at rest
or with exertion, palpitations, LE edema, fevers, chills, N/V,
diaphoresis, change in chronic morning cough, change in weight.
En route EMS administered 0.8 nitro spray x 1 and she cannot
recall if she experienced relief.
.
In the ED, initial VS: 98.4 78 134/66 24-28 100%2L. Exam was
notable for a woman in respiratory distress with tachypnea as
well as bibasilar rales and elevated JVD. She was placed on a
NRB and her breathing improved. EKG: SR 79, LAD, TWI III, aVF-
old, c/w prior. CXR revealed increased vascular congestion and
bilateral pleural effusions. She was started on nitro gtt
titrated to symptoms. K was also 6.7 so she was given 1 g
calcium gluconate, 10 regular insulin, 2 amps D50 and 30g
kayexalate for hyperkalemia. She was seen by the renal fellow
who plans to initiate HD overnight in ICU.
.
On arrival to the floor patient reports mild relief in symptoms.
She denies chest pain and states SOb mildly improved with
oxygen.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She states she urinates "a few drops" per day which is
stable. Denies dysuria. All of the other review of systems were
negative.
Past Medical History:
- Dyslipidemia
- Hypertension
- CAD s/p BMS to LCx in [**2140**] with improvement in lateral wall
hypokinesis on TTE. Also has fixed inferior wall defect (due to
a chronic RCA occlusion that is collateralized).
- Severe MR seen on cardiac cath in [**2140**] slightly better on TTE
in [**5-/2143**]
- End-stage renal disease of unclear etiology, [**2126**]. She was
originally on hemodialysis from [**2126**] to [**2129**] and switched to
peritoneal dialysis in [**2129**] but suffered from recurrent
peritonitis. She now has HD on three times weekly for the past 9
years. She does not have good venous conduits and is currently
undergoing dialysis through a right subclavian access. Her dry
weight is approximately 129 pounds.
- Diabetes mellitus, Type 2 since [**2131**] currently diet
controlled.
- Depression, currently on Zoloft
- Gastroesophageal reflux disease
- s/p parathyroidectomy for tertiary hyperparathyroidism.
- Osteoarthritis right hand and wrist
- Anemia, epogen responsive at dialysis
- Spinal osteomyelitis: treated
- s/p cataract removal
Social History:
Lives alone, ambulates with a cane
-Tobacco history: Quit >30 years ago
-ETOH: Denies
-Illicit drugs: Denies
Family History:
F: CAD, Aneurysm/MI passed @ 79
M: CVAx3
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric with mild conjuctival injection.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP of approx 10 cm to jawline. Midline
thyroidectomy scar
CARDIAC: PMI laterally displaced. RR, normal S1, S2 with 3/6
holosystolic blowing murmur heard best at the apex. No r/g. No
thrills, lifts. No S3 or S4 appreciated. R tunnelled IJ dsg
C/D/I. No purulent drainage or erythema.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use at rest but uses
accessory muscles with speaking. Speaks in full sentences but
becomes dyspneic after 1-2 minutes. Decreased BS in bases with
bibasilar crackles.
ABDOMEN: Soft, NTND. Midline well healed scar. No HSM or
tenderness.
EXTREMITIES: No c/c/e. 2+ DP/PT
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3. CN 2-12 intact. MAE.
Pertinent Results:
[**2143-12-8**] 08:05PM GLUCOSE-86 UREA N-86* CREAT-9.0*# SODIUM-141
POTASSIUM-6.7* CHLORIDE-99 TOTAL CO2-25 ANION GAP-24*
[**2143-12-8**] 08:05PM estGFR-Using this
[**2143-12-8**] 08:05PM cTropnT-0.04*
[**2143-12-8**] 08:05PM proBNP-5044*
[**2143-12-8**] 08:05PM CALCIUM-8.6 PHOSPHATE-6.3*# MAGNESIUM-2.2
[**2143-12-8**] 08:05PM WBC-7.4 RBC-3.73* HGB-11.2* HCT-33.9* MCV-91
MCH-29.9 MCHC-32.9 RDW-19.6*
[**2143-12-8**] 08:05PM NEUTS-71.4* LYMPHS-20.6 MONOS-5.0 EOS-2.5
BASOS-0.6
[**2143-12-8**] 08:05PM PLT COUNT-188
CXR [**2143-12-8**]
Increased atelectasis in the setting of low lung volumes. There
is minimal interstitial edema.
Brief Hospital Course:
Ms. [**Known lastname 732**] is a 75-year-old woman with dCHF, ESRD on HD, and CAD
admitted with acute diastolic CHF exacerbation, volume overload,
and hyperkalemia after dietary non-compliance over the holidays.
.
# Shortness of breath: Patient presented with acute onset
shortness of breath in the setting of dietary indiscretion over
the holidays. She was in mild distress on initial presentation,
requiring 4L NC. Nitroglycerin gtt was started for sypmtom
control. Physical exam, CXR and history were all consistent
with volume overload and acute diastolic heart failure
exacerbation. Lack of leukocytosis, fever, cough, CP, or
consolidation argued against another process such as PNA or PE.
Patient is HD dependent for fluid status, and nephrology was
called for urgent HD overnight. Her I's and O's were strictly
monitored. Patient was given information about heart healhty
eating. She was restarted on cozaar for afterload reduction
after herpotassium improved. Her carvedilol was continued.
.
# Hyperkalemia/ESRD on HD: On initial presentation, patient met
criteria for emergent HD given fluid overload and hyperkalemia.
Her ECG was without evidence of hyperkalemia. She was started
on calcium, insulin, D50 and kayexalate for hyperkalemia.
.
# CAD: With fixed defect in RCA territory and BMS to LCx in [**2140**]
with resultant improved cardiac function. Troponin mildly
elevated in setting of renal failure and CHF exacerbation but
this is non-specific. No acute EKG changes and very low
suspicion for ACS as cause of CHF exacerbation given admittance
to dietary non-compliance over the holiday. Her ASA,
beta-blocker, and [**Last Name (un) **] were held until after HD. She was ruled
out for a myocardial infarction via enzymes.
.
# Severe MR: Last TTE in [**Month (only) **] of this year (6 months ago) with
slightly improved valvular function and decreased pulmonary
pressures. Followed by Dr. [**Last Name (STitle) **] in cardiology clinic and may
need replacement at some point in the future. Her heart failure
regimen was continued.
.
#. ESRD on HD: HD MWF at [**Location (un) **]. Outpatient nephrologist is Dr.
[**Last Name (STitle) 1366**]. Currently c/b volume overload and hyperkalemia as above.
Dialysis as above. Patient was continued on sevelamer,
sensipar and nephrocaps.
.
# HTN: Carvedilol was continued and Cozaar was restarted after
.
# HLD : Simvastatin was continued.
.
# Diabetes Mellitus Type 2: Questionable history. Patient was
placed on insulin sliding scale during admission.
.
#. Depression: Zoloft was continued throughout admission.
.
#. Anemia: Likely [**1-15**] ESRD on HD. Currently at baseline.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by
Other Provider) - 1 mg Capsule - 1XD Capsule(s) by mouth
CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
CINACALCET [SENSIPAR] - (Prescribed by Other Provider) - 60 mg
Tablet - 1 Tablet(s) by mouth twice a day
LOSARTAN [COZAAR] - 100 mg Tablet - 1 Tablet(s) by mouth daily
PHYSICAL THERAPY - - for right lower extremity arthritis and
gait deficits three times per week
SEVELAMER HCL [RENAGEL] - 800 mg Tablet - 1 Tablet(s) by mouth
three times a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily
ZOLOFT - 50 mg Tablet - One (1) Tablet PO once a day.
ASPIRIN - (OTC) - 325 mg Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis: Volume overload; Acute on Chronic Diastolic
Heart failure; Hyperkalemia
Secondary Diagnosis: ESRD on HD, Hypertension
Discharge Condition:
Hemodynamically stable, afebrile, O2 sats mid 90s on room air
Discharge Instructions:
You were admitted to the hospital with elevated potassium and
shortness of breath. This was most likely related to your
dietary intake of lots of fluids and high potassium foods on
[**Holiday **] day. Please avoid these foods as you have been
previously instructed.
You were treated with dialysis and your symptoms of shortness of
breath as well as your potassium levels improved.
Please resume your usual MWF dialysis schedule; you received HD
before leaving the hospital on Monday.
We did not make any changes to your medications.
Followup Instructions:
Please resume your regular Monday, Wednesday, Friday schedule
for dialysis.
Please call [**Company 191**] at [**Telephone/Fax (1) 250**] to follow up with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], this week.
Department: RADIOLOGY
When: THURSDAY [**2144-1-2**] at 9:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 9511**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2144-2-26**] at 3:40 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.21",
"428.33",
"403.91",
"428.0",
"276.7",
"424.0",
"272.4",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9374, 9431
|
5245, 7903
|
370, 378
|
9611, 9674
|
4571, 5222
|
10258, 10998
|
3525, 3567
|
8710, 9351
|
9452, 9452
|
7929, 8687
|
9698, 10235
|
3582, 4552
|
310, 332
|
406, 2300
|
9564, 9590
|
9471, 9543
|
2322, 3382
|
3398, 3509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,379
| 116,732
|
34459
|
Discharge summary
|
report
|
Admission Date: [**2114-7-25**] Discharge Date: [**2114-8-1**]
Date of Birth: [**2051-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2114-7-28**] - CABGx3 (Left internal mammary artery->Left anterior
descending artery, Saphenous vein graft(SVG)->Obtuse marginal
artery, SVG->Posterior descending artery).
History of Present Illness:
Mr [**Known lastname 12130**] is a 63-year-old male with angina, positive stress
test. Catheterization showed severe left main disease and right
coronary stenosis. He is known to have peripheral vascular
disease and has had bilateral carotid
endarterectomies and has occlusion of both internal carotid
arteries. He understands the necessity for the operation and the
high-risk involved.
Past Medical History:
s/p frontal-parietal CVA [**2107**]
Neurogenic Claudication
s/p Bilateral CEA's in [**2091**] and [**2092**]
s/p Aorto-bifem bypass [**2101**]
Hypertension
Hyperlipidemia
s/p Right toe amputation
Social History:
Unemployed currently. Quit smoking [**2113-8-5**], but had a
90 pack year history prior. Has 2 alcoholic beverages per
night.
Family History:
Both parents with CAD s/p MI.
Physical Exam:
Vitals- T 98.4 , HR 55 , BP 150/96 , RR 18 , O2sat
Gen- NAD, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, diastolic murmur
Lungs- CTAB
Abd- s, nt, nd
Ext- warm, well-perfused, no edema
1+ palp pulses fem/[**Doctor Last Name **]/dp/pt bilaterally
Pertinent Results:
[**2114-7-25**] 09:45PM WBC-6.0 RBC-4.61 HGB-13.7* HCT-40.3 MCV-88
MCH-29.6 MCHC-33.9 RDW-13.9
[**2114-7-25**] 09:45PM ALT(SGPT)-23 AST(SGOT)-19 CK(CPK)-68 ALK
PHOS-54 AMYLASE-60 TOT BILI-0.3
[**2114-7-25**] 09:45PM GLUCOSE-112* UREA N-12 CREAT-1.0 SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10
[**2114-7-26**] Carotid Duplex Ultrasound
Right ICA occlusion. Left ICA, CCA, and ECA occlusion. Right
vertebral occlusion.
[**2114-7-28**] ECHO
Pre-CPB:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. No left ventricular aneurysm
is seen. Regional left ventricular wall motion is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the ascending aorta. The
aortic arch is mildly dilated. There are complex (>4mm) atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are moderately thickened. No mitral regurgitation
is seen.
There is no pericardial effusion.
Post-CPB:
Patient is AV-Paced, on no infusion.
Normal biventricular systolic fxn.
Aorta intact. No AI, no MR.
[**2114-7-26**] Vein Mapping
Patent bilateral greater and lesser saphenous veins with
diameters as noted.
Brief Hospital Course:
Mr. [**Known lastname 12130**] was admitted to the [**Hospital1 18**] on [**2114-7-25**] via transfer
from [**Hospital6 5016**] for surgical management of his severe
coronary artery disease. He was worked-up in the usual
preoperative manner. A carotid duplex ultrasound showed
occlusion of both his internal carotid arteries and a right
vertebral artery occlusion. The vascular surgery service was
consulted who found indication for surgical intervention at this
time. The neurology service was consulted for assistance in his
care given his severe cerebral vascular disease. An opthalmology
consult was obtained who diagnosed him with occular ischemic
syndrome and recommended a higher perfusion pressure during
bypass. On [**2114-7-28**], Mr. [**Known lastname 12130**] was taken to th eoperating room
where he underwent coronary artery bypass grafting to three
vessels. Postoperatively he was taken to the cardiac surgical
intensive care unit. Within 24 hours, Mr. [**Known lastname 12130**] had awoke
neurologically intact and was extubated. He required
neosynephrine for blood pressure support until postoperative day
two. He was then transferred to the step down unit for further
recovery. Beta blockade, aspirin and a statin were resumed. He
was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. By post-operative day four
he was ready for discharge to home on his home dose of coumadin
for his CVA history.
Medications on Admission:
Wellbutrin, Zetia, Lipitor, Norvasc, Aspirin and coumadin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. 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*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
INR to be checked on Friday [**2114-8-3**] and sent to the office of
Dr. [**Last Name (STitle) **]. Fax ([**Telephone/Fax (1) 79204**]. Plan confirmed with [**Location (un) 7049**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p CABG x3 (LIMA-LAD, SVG-OMI, SVG-PDA)
CVA [**2107**]
Hyperlipidemia
HTN
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.
6) No driving for 1 month.
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) 4783**] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-7**] weeks. [**Telephone/Fax (1) 41901**]
INR to be checked on Friday [**2114-8-3**] and sent to the office of
Dr. [**Last Name (STitle) **]. Fax ([**Telephone/Fax (1) 79204**]. Plan confirmed with [**Location (un) 7049**].
Completed by:[**2114-8-1**]
|
[
"413.9",
"V12.54",
"433.10",
"272.4",
"414.01",
"401.9",
"443.9",
"378.81",
"V58.61",
"721.3",
"433.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6380, 6429
|
3307, 4827
|
330, 507
|
6548, 6555
|
1636, 3284
|
7298, 7776
|
1303, 1334
|
4935, 6357
|
6450, 6527
|
4853, 4912
|
6579, 7275
|
1349, 1617
|
280, 292
|
535, 924
|
946, 1143
|
1159, 1287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,427
| 178,731
|
8458
|
Discharge summary
|
report
|
Admission Date: [**2161-12-8**] Discharge Date: [**2162-1-21**]
Date of Birth: [**2084-1-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
bilateral lower extremity disabling claudication
Major Surgical or Invasive Procedure:
[**2161-12-8**]-B/l femoral endarterectomies and patch
profundoplasties, removal R ileofemoral bypass, B/l common and
external ileac stenting, R EIA to distal CFA dacron bypass
[**2161-12-9**]- ileocecectomy and 15 cm distal small bowel resection,
left open, mesenteric angiogram, thrombectomy with patch
angioplasty SMA with stenting
[**12-10**]-ex lap, resection proximal R colon, cholecystectomy,
resection distal ileum, liver biopsy
[**2161-12-11**]-abdominal exploration, washout, ileocecostomy
[**12-13**]-ex lap, abdominal washout, gastrojejunostomy tube, LLE
fasciotomies
[**12-28**]-permcath
History of Present Illness:
77 yF with disabling claudication s/p R ileofemoral bypass in
[**2153**]. She was having progressive difficulty ambulating over the
past 5 years. Non invasives done at an OSH suggest severe
aortoiliac and superficial femoral disease.
Past Medical History:
HTN
MVP
osteoporosis
PVD
DJD
gout
Social History:
quit smoking 10 years ago
Physical Exam:
HR 72, BP 150/80
Gen-NAD
HEENT-soft b/l cervical bruits
Cor-RRR
Lungs-CTA
Abd-soft nt/nd
R femoral pulse diminished compared to left, all distal pulses
are nonpalpable
Brief Hospital Course:
Patient underwent B/l femoral endarterectomies and patch
profundoplasties, removal R ileofemoral bypass, B/l common and
external ileac stenting, R EIA to distal CFA dacron bypass on
[**12-8**]. Postoperatively she remained hypotensive, had a rising
lactate and worsening abdominal pain. Dr. [**First Name (STitle) **] from the
hepatobiliary service took the patient to the OR and performed
an ileocectomy and temporary abdominal closure. At the same
time, the SMA was stented and a patch angioplasty was performed
for severe stenosis and mesenteric ischemia. Postoperatively,
the patient was critically ill in the surgical ICU. She was
taken back to the OR on [**12-10**] for ex lap, resection proximal R
colon, cholecystectomy, resection distal ileum, liver biopsy due
to worsening hepatic function. She was brought back to the OR
for ileocecostomy and washout on [**12-11**] and had LLE fasciotomies.
She was on significant vent support and pressor support as well
as on broad spectrum antibiotics. A gastrojejunostomy tube was
place on [**12-12**] and a vicryl mesh abdominal closure was performed
- a vac type dressing was placed. The patient was initiated on
CVVHD in consultation with the renal service. TPN was
initiated. She was eventually extubated on [**12-23**]. Tube feeds
was initiated and the patient no longer required CVVH or
hemodialysis. A vac type dressing was placed on the fasciotomy
wounds. She then began to have LGIB for which the GI service
was consulted. A colonoscopy was performed -showed anastomotic
ulcers. She continued to having maroon stools (about 200-300
cc/day)for about 2 weeks with continued PRBC requirement. A CT
angiogram revealed patent SMA and hypogastrics with an occluded
celiac. A tagged red cell scan revealed no source for bleeding.
In early [**Month (only) 404**] her pulmonary status began to decline with
worsening pleural effusions for which thoracentesis was
performed. The patient was unable to tolerate TF due to
abdominal pain. On [**1-19**] she developed an SVT for which adenosine
was required;during this time she was hypotensive and
re-intubated for respiratory distress. A meeting with the
family and surgical attendings was performed and it was decided
to withdraw care. The patient expired on [**2161-1-21**].
Medications on Admission:
lisinopril
ASA
Zocor
Discharge Disposition:
Expired
Discharge Diagnosis:
[**2161-12-8**]-B/l femoral endarterectomies and patch
profundoplasties, removal R ileofemoral bypass, B/l common and
external ileac stenting, R EIA to distal CFA dacron bypass
[**2161-12-9**]- ileocecectomy and 15 cm distal small bowel resection,
left open, mesenteric angiogram, thrombectomy with patch
angioplasty SMA with stenting
[**12-10**]-ex lap, resection proximal R colon, cholecystectomy,
resection distal ileum, liver biopsy
[**2161-12-11**]-abdominal exploration, washout, ileocecostomy
[**12-13**]-ex lap, abdominal washout, gastrojejunostomy tube, LLE
fasciotomies
Patient expired
Discharge Condition:
patient expired
|
[
"274.9",
"557.0",
"511.9",
"401.9",
"997.2",
"444.22",
"276.2",
"518.5",
"997.71",
"584.5",
"286.9",
"996.74",
"570",
"427.1",
"440.21",
"729.72",
"733.00",
"998.2",
"997.4",
"998.59",
"719.7",
"578.9",
"255.4",
"728.88",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"00.17",
"00.48",
"83.09",
"99.04",
"38.18",
"39.29",
"38.93",
"99.06",
"96.04",
"45.93",
"50.11",
"45.13",
"00.45",
"45.23",
"99.07",
"96.72",
"39.95",
"00.40",
"99.05",
"00.43",
"38.95",
"38.06",
"00.44",
"51.22",
"39.25",
"34.91",
"44.32",
"39.90",
"99.15",
"39.50",
"96.6",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
3859, 3868
|
1494, 3788
|
320, 922
|
4507, 4525
|
3889, 4486
|
3814, 3836
|
1302, 1471
|
232, 282
|
950, 1187
|
1209, 1244
|
1260, 1287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,990
| 130,523
|
52547
|
Discharge summary
|
report
|
Admission Date: [**2145-2-19**] Discharge Date: [**2145-2-25**]
Date of Birth: [**2086-3-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 58-year-old gentleman with
known aortic stenosis for several years had been followed
with repeat echocardiogram for his increasing shortness of
breath with ambulation. He had no chest pain and no
peripheral edema at the time that he was seen in preoperative
testing.
His cardiac catheterization on [**1-29**] demonstrated no
significant coronary artery disease, severe aortic stenosis,
moderate systolic ventricular dysfunction, and severe
diastolic ventricular dysfunction.
His echocardiogram on [**1-14**] showed left ventricular
hypertrophy with systolic function depressed with moderate
global hypokinesis, and aortic root and ascending aorta were
mildly dilated.
PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Benign prostatic hypertrophy.
3. Status post pilonidal cyst.
4. Status post removal of pituitary tumor from a
transphenoidal approach in [**2143-6-27**]; tumor of unknown
type (per chart).
5. Hypercholesterolemia.
6. Obesity.
7. Hypertension.
8. Glucose intolerance.
9. Sleep apnea, in BiPAP.
MEDICATIONS ON ADMISSION: Medications prior to admission
were Lasix 40 mg p.o. b.i.d., Flomax weekly, terazosin 5 mg
p.o. q.d., and Lipitor 10 mg p.o. q.d.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, he was
in no apparent distress. His lungs were clear. He had a
grade 3/6 systolic ejection murmur. His heart was regular in
rate and rhythm. He had no adenopathy and no masses in his
neck. His extremities had 1 to 2+ pitting edema. His
neurologic examination was grossly intact. He had good
distal pulses with the exception of a Doppler signal on the
right dorsalis pedis.
RADIOLOGY/IMAGING: Preoperatively, his chest x-ray showed
stable cardiomegaly with no evidence of pulmonary edema or
pneumonia.
PERTINENT LABORATORY DATA ON PRESENTATION: His preoperative
laboratory work showed a white blood cell count of 8.4,
hematocrit of 34, platelet count of 293. PT of 12, PTT of
28.9, INR of 1. Blood urea nitrogen of 17, creatinine of 1,
sodium of 141, potassium of 4.1, chloride of 102, bicarbonate
of 27, anion gap of 16. ALT of 22, LDH of 206.
HOSPITAL COURSE: He was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
for aortic valve replacement.
On [**2-19**], he underwent aortic valve replacement with a
#23 St. [**Male First Name (un) 923**] mechanical valve. He was transferred to the
Cardiothoracic Intensive Care Unit with an intra-aortic
balloon pump in place. Please refer to his Operative Note.
He was on a vasopressin drip at 6, Levophed at 0.2, and
milrinone at 0.5.
On postoperative day one, he was seen by the Endocrine
Service for continuing problems with hypotension. They were
concerned about his history of pituitary surgery for
apoplexy.
His postoperative laboratories were sodium of 137, potassium
of 4.8, glucose of 143, blood urea nitrogen 16, creatinine 1.
A hemoglobin of 9.
The patient received hydrocortisone therapy and was followed
by the Endocrine Service as additional laboratory work was
pursued. At that point, his blood pressure was
hemodynamically stable. He was weaned from the balloon on
postoperative day one, and off of the ventilator, and
extubated, and up in the chair.
On postoperative day two, he had his Foley removed, his
cordis removed, and his chest tubes pulled, and he was
transferred out to the floor, being followed for possible
dysfunction of his pituitary gland. He was in sinus rhythm
with a blood pressure of 122/65. His steroid taper was
continued. He was started on his aspirin and Lopressor
therapy, as well as receiving his first dose of Coumadin for
his mechanical valve. His incision was clean, dry, and
intact. He was also seen by Physical Therapy for evaluation.
On postoperative day three, he was afebrile with a heart rate
in the 90s, a blood pressure of 116/55. His blood urea
nitrogen was 22, creatinine of 0.8, with an INR of 1.2. His
heart was regular in rate and rhythm. His lungs were clear.
His sternum was stable with no drainage, and he continued his
ambulation. His pacing wires were also discontinued. He was
seen the Rehabilitation Service and again followed by
Endocrine through Endocrine's taper, and they recommended
additional study could be done as long as the patient was
hemodynamically stable as an outpatient.
On postoperative day four, the patient was afebrile with a
hematocrit of 21, a blood urea nitrogen of 29, a creatinine
of 0.8, and INR of 1.1. He received 2 units of packed red
blood cells. He continued Lasix diuresis. His Coumadin dose
was 7.5 mg, and he was hemodynamically stable, satting 90% on
room air, with a blood pressure of 129/56.
On postoperative day five, he had no complaints and did a
level III ambulation. He was hemodynamically stable with a
heart rate in the 80s, satting 92% on room air, with a
hematocrit of 19.9. He received an ACTH stress test. He was
seen again by Endocrine, and his steroids were held. His
sternum was stable with no drainage. His lungs were clear.
On[**Last Name (STitle) 14810**]perative day six, on the day of discharge, his lungs
were clear. His heart was regular in rate and rhythm. His
sternum was stable with no drainage. He was instructed to
see his cardiologist or primary care physician in three weeks
with instructions to speak to Dr. [**Last Name (STitle) 9346**] for his INR checks
(with a goal for his INR of 2.5 to 3). He was also
instructed to see Dr. [**Last Name (Prefixes) **] postoperatively in four
weeks. Endocrinology stated they would call the patient for
followup.
MEDICATIONS ON DISCHARGE: (Discharge medications were as
follows)
1. Lopressor 50 mg p.o. b.i.d.
2. Captopril 6.25 mg p.o. t.i.d.
3. Lasix 20 mg p.o. b.i.d.
4. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d.
5. Aspirin 325 mg p.o. q.d.
6. Hydrocortisone 15 mg p.o. q.a.m. and 5 mg p.o. q.p.m.
7. Flomax 0.5 mg p.o. q.d.
8. Percocet 5/325 one to two tablets p.o. p.r.n. q.4-6h.
9. Colace 100 mg p.o. b.i.d.
10. Coumadin 7.5 mg p.o. q.d. (with instructions for an INR
check with Dr. [**Last Name (STitle) 9346**], the primary care physician).
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with mechanical
St. Judge prosthesis.
2. Hypertension.
3. Obesity.
4. Benign prostatic hypertrophy.
5. Status post pituitary tumor removal.
6. Increased cholesterol.
7. Sleep apnea, with BiPAP.
DISCHARGE STATUS: The patient was discharged to home on
[**2145-2-25**].
CONDITION AT DISCHARGE: In stable condition
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2145-4-29**] 15:11
T: [**2145-4-30**] 07:46
JOB#: [**Job Number **]
|
[
"401.9",
"424.1",
"458.2",
"780.57",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
6369, 6696
|
5769, 6348
|
1208, 2298
|
2317, 5742
|
6711, 6988
|
156, 833
|
855, 1181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,865
| 111,501
|
45271+58799
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-9-12**] Discharge Date: [**2192-9-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Diaphoresis, Hypotension, Tachycardia
Major Surgical or Invasive Procedure:
RIJ central line placed on [**2192-9-12**]
History of Present Illness:
88M with h/o HOCM and GI bleed [**2-4**] AVMS who was tramsferred from
[**Hospital3 2558**] with hypotension, tachycardia and diaphoresis
overnight. Pt states that he awoke at 2am drnched in sweat. He
reports nausea, diaphoresis, positional dizziness and heart
palpitations. Earlier in the evening, he had had indigestion
and stomach discomfort for which he had taken Mylanta and Tums
with symptomatic relief. Pt states that he had been free water
restricted for his hyponatremia for the last several days and
had also noted limited appetite.
.
In the ED, vitals 100.4 99/60 102 20 99% on RA. Per ED, BPs
were labile ranging from high 70s to 100s. Patient received a
total of 4 liters fluid resuscitation with some reduction in
heart rate. CXR showed no acute cardiopulmonary process. Urine
and blood cultures were sent. Pt was guaiac negative. Cardiac
enzymes were negative x1. EKG sinus tachycardia, otherwise
unchanged from baseline. Labs were significant for a Na of 129
and INR 2.7. CBC showed elevation of WBC and HCT which are
unchanged from prior admission. Pt has been seen in
consultation by heme-onc at time of last admission who felt that
relative [**Name (NI) 47038**] was due to volume depletion and
over-[**Name (NI) **] during last admission.
Past Medical History:
1)Colon cancer ([**Location (un) **] A) s/p R hemicolectomy in [**2176**]
2)Multiple AVMs with 15 year history of recurrent GIB
3)CAD s/p stent to LAD in [**10-8**]
4)Hypertrophic cardiomyopathy
5)HOCM
6)GERD
7)h/o jejunal lipoma in [**2176**]
8)Hypertension
9)Hyperlipidemia
10) Spinal Stenosis
.
Past Surgical History:
1)s/p cholecystectomy in [**2178**]
2)s/p prostatectomy
3)L inguinal hernia repair [**2179**]
4)s/p hemicolectomy in [**2176**]
Social History:
Lives in [**Location **] with his wife. Originally from [**Country 3399**]. Has 2
sons, one of who lives in same apartment building. Remote
history of minimal social smoking, no alcohol.
Family History:
His father died elderly of lung cancer; his mother had
hypertension, and died at age 67 of a CVA.
Pertinent Results:
On Admission:
[**2192-9-12**] 03:00PM WBC-12.5* RBC-5.18 HGB-16.1 HCT-46.2 MCV-89
MCH-31.1 MCHC-34.8 RDW-16.3*
[**2192-9-12**] 03:00PM NEUTS-83.6* LYMPHS-11.6* MONOS-3.6 EOS-0.8
BASOS-0.4
[**2192-9-12**] 03:00PM PLT COUNT-301
[**2192-9-12**] 03:00PM PT-27.4* PTT-19.4* INR(PT)-2.7*
[**2192-9-12**] 03:00PM GLUCOSE-116* UREA N-24* CREAT-1.0 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2192-9-12**] 04:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2192-9-12**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-9-12**] 04:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2 TRANS EPI-<1
[**2192-9-12**] 05:20PM LACTATE-2.1*
[**2192-9-12**] 11:02PM FIBRINOGE-303
[**2192-9-12**] 11:02PM TSH-3.1
[**2192-9-12**] 11:02PM HAPTOGLOB-LESS THAN
[**2192-9-12**] 11:02PM CALCIUM-7.0* PHOSPHATE-2.1* MAGNESIUM-1.4*
[**2192-9-12**] 11:02PM CK-MB-4 cTropnT-<0.01
[**2192-9-12**] 11:02PM LD(LDH)-224 CK(CPK)-31*
[**9-12**] CXR
The lungs are of low volume likely due to poor inspiratory
effort. The
previously seen atelectasis at the left lung base has now
resolved.
Cardiomediastinal contour is unremarkable. There are no focal
consolidations.
[**9-14**]
Na 134
K 4.0
Cl 101
HCO3 26
BUN 17
Cr 0.9
Hgb 13.2
HCT 38.7
WBC 10.6
Plt 234
Brief Hospital Course:
MICU Course: Patient was admitted to the [**Hospital Unit Name 153**] overnight for
hypotension and tachycardia. While in the ICU he received IVFs
with improvement in his blood pressure. His metoprolol was
cautiously restarted given his HOCM with subsequent improvement
in his heart rate and blood pressure. His hydrochlorothiazide
was discontinued. He is transferred to the [**Hospital1 1516**] service for
further management.
Hypotension/Tachycardia: Most likely secondary to dehydration in
setting of free water restriction, especially in the context of
a patient with HOCM who is pre-load depent. On transfer to the
floor, patient was hemodynamically stable.
Hyponatremia: resolved with IV normal saline. Na 134 on
discharge.
.
Tingling - Patient reports that he has been having tingling of
his hands, thigh. face and mouth since his last admission.
Heme-onc attributed this to his relative polycythemia. Ionized
calcium was normal.
.
Medications on Admission:
Sucralfate 1 gram PO QID
Simvastatin 10 mg daily
Tylenol PRN
Maalox PRN
Spironolactone 25 mg daily
Atenolol 50 mg daily
Simethicone 120 mg QID:PRN
Detrol LA 2 mg daily
Clonazepam 0.5 mg PO BID:PRN
Hydrochlorothiazide 12.5 mg daily
Omeprazole 20 mg [**Hospital1 **]
Polyvinyl Alcohol drops
Ferrex 150 Oral
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
4. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO QID (4 times a day) as needed.
5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis: hypotension and tachycardia secondary to
hypovolemia
Secondary diagnosis:
Hyperobstructive cardiomyopathy
Aortic stenosis
Coronary artery disease
Hypertension
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with low blood pressure and high heart rate.
You were treated with IV fluids in the intensive care unit.
Your blood pressure and heart rate came back to normal. We
monitored you closely on telemetry.
We stopped your diurectics (HCTZ and aldactone) and have started
you on Lisinopril. Otherwise, continue your medications as you
were taking them.
Please see your primary care doctor or go the emergency room if
you feel light headed, palpitations, chest pain, or short of
breath.
Followup Instructions:
You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] NP on [**10-8**]
2:50pm, on the [**Location (un) **] of [**Hospital Ward Name 23**] building.
You have an appointment with Dr. [**Last Name (STitle) 120**] on [**10-24**] at
noon.
Completed by:[**2192-9-14**] Name: [**Known lastname 15357**],[**Known firstname **] S Unit No: [**Numeric Identifier 15358**]
Admission Date: [**2192-9-12**] Discharge Date: [**2192-9-14**]
Date of Birth: [**2104-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6568**]
Addendum:
Please check electrolytes, as patient has recently started ACE
inhibitor, and stopped diuretics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**]
Completed by:[**2192-9-14**]
|
[
"276.52",
"V10.05",
"V45.82",
"414.01",
"401.9",
"424.1",
"425.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7626, 7855
|
3861, 4809
|
299, 343
|
6251, 6260
|
2458, 2458
|
6808, 7603
|
2340, 2439
|
5166, 5921
|
6035, 6035
|
4835, 5143
|
6284, 6785
|
1988, 2117
|
222, 261
|
371, 1645
|
6128, 6230
|
6054, 6107
|
2472, 3838
|
1667, 1965
|
2133, 2324
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,178
| 132,598
|
16370
|
Discharge summary
|
report
|
Admission Date: [**2200-4-6**] Discharge Date: [**2200-4-17**]
Date of Birth: [**2133-2-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
sepsis, PNA
Major Surgical or Invasive Procedure:
CVVH line placement, Left femoral vein
Intubation
History of Present Illness:
Pt is a 67 yo m with ESRD (on HD MWF), ESLD [**2-8**] polycystic liver
disease who presented to [**Location (un) **] after 3 days of myalgias,
cough, SOB, and not able to get out of bed. He had been in his
USOH prior to this. At OSH, T 101.3, he was noted to have CXR
with LLL pna and received levaquin and 250cc IVF. At that time,
SBP 70-90's with normal BP 100's.
.
He was transferred to [**Hospital1 18**] due to bed shortages at OSH. In [**Hospital1 **]
ED, T98.7; HR 120-130's; BP 63-77/50's; RR89% RA and 100% NRB.
Lactate 1.3. Given low BP, a CVL was sterilely placed and he was
started on levophed. CVP was 15 once levophed on board. EKG with
afib and lateral ST depressions. He also received a dose of
clindamycin in ED.
.
Upon arrival to ICU, he is currently feeling comfortable in no
distress. he denies any chest pain, SOB, pleuritic pain,
abdominal pain, or any other symptoms. He does note that for
past few days he had orthopnea, which is new for him. Per his
wife, last week he also had one episode of severe lower
abdominal pain. he went to HD at that time and there was some
concern for a ruptured liver cyst; however, his wife does not
think he had any imaging at that time. This pain has since
resolved.
Past Medical History:
- atrial fibrillation
- ESRD: on HD, MWF
- ESLD: never had paracentesis
- s/p colectomy and ileostomy in place
- s/p parathyroidectomy
- hx of ? MI and arrhythmia requiring defibrillation (per wife)
Social History:
Married, retired printer
Smoking: quit 15 yrs ago, but prior has 80 pack year (5ppd since
age 8 until 50's)
EtOH: none for many years
Illicits: none
Family History:
Mother: d. pancreatic ca
Father: d. MI age 65
Brother: brain tumor
Sisters: DM
Physical Exam:
PE: 96.7 115-140's 101/72 25 97% NRB
Gen: NAD, in very mild resp distress, but otherwise fairly
comfortable
HEENT: PERRL, Clear OP, MMM
NECK: Supple, No LAD, JVP difficult to assess as RIJ in place
CV: tachy, irreg, irreg; difficult to auscultate murmurs
LUNGS: CTA ant and laterally
ABD: Soft, area of hard, cystic masses on R
EXT: No edema. 2+ DP pulses BL. fistula in left with palp thrill
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Normal coordination.
Pertinent Results:
[**2200-4-6**] 11:25AM BLOOD WBC-10.4# RBC-3.55* Hgb-11.1* Hct-35.0*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.5 Plt Ct-158
[**2200-4-6**] 11:25AM BLOOD Neuts-93.8* Bands-0 Lymphs-3.5* Monos-2.3
Eos-0.2 Baso-0.1
[**2200-4-6**] 11:25AM BLOOD PT-27.1* PTT-43.3* INR(PT)-2.7*
[**2200-4-7**] 12:32AM BLOOD Fibrino-366
[**2200-4-6**] 11:25AM BLOOD Glucose-74 UreaN-41* Creat-6.5*# Na-135
K-5.6* Cl-97 HCO3-24 AnGap-20
[**2200-4-6**] 11:25AM BLOOD ALT-8 AST-10 CK(CPK)-158 AlkPhos-82
Amylase-57 TotBili-1.8*
[**2200-4-8**] 12:00AM BLOOD ALT-1710* AST-3118* LD(LDH)-2352*
AlkPhos-88 TotBili-2.8*
[**2200-4-9**] 04:04AM BLOOD ALT-1311* AST-1089* LD(LDH)-588*
AlkPhos-100 TotBili-3.2*
[**2200-4-10**] 09:52AM BLOOD ALT-859* AST-547* LD(LDH)-400*
AlkPhos-102 TotBili-3.4*
.
RADS
TTE [**4-6**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function appears mildly depressed (LVEF= 50%), but
could not be fully evaluated because of technical limitations.
The right ventricular cavity is moderately dilated with severe
global free wall hypokinesis. There is abnormal septal
motion/position. The number of aortic valve leaflets cannot be
determined. The mitral valve leaflets are mildly thickened.
Tricuspid regurgitation is present but cannot be quantified.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction. Probable mild left ventricular systolic
dysfunction. Heavily calcified valves.
If clinically indicated, a full transthoracic study with Doppler
is recommended.
.
TTE [**4-7**]
The left ventricle is not well seen. The left ventricular cavity
is unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%). The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2200-4-6**],
the image quality is no better. The estimated pulmonary artery
systolic pressure is slightly lower but is probably unreliable
given poor image quality. The other findings are similar.
.
CTA [**4-7**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Cardiomegaly with prominence of the right heart and
enlargement of the
main pulmonary artery suggestive of pulmonary hypertension.
3. Right lower lobe consolidation/volume loss. Left lower lobe
with
consolidation or volume loss and occluded left lower bronchus.
4. Diffuse emphysematous changes.
5. Small bilateral pleural effusions. Ascites. Anasarca.
6. Massively enlarged multicystic liver. Status post bilateral
nephrectomy.
7. Cystic changes in both femoral heads and acetabula.
Differential includes
changes secondary to secondary hyperparathyroidism. Comparison
is recommended
with old studies if available.
8. Mediastinal nodes, largest measuring 16mm.
9. Sigmoid diverticulosis without definite evidence of
diverticulitis.
10. Cholelithiasis without definite evidence of cholecystitis.
11. Right lower quadrant diverting ileostomy. No evidence of
obstruction.
12. NG tube and ET tube in proper placement.
Brief Hospital Course:
The patient is a 67 y/o M hx of ESRD on HD and ESLD [**2-8**]
polycystic liver/kindey disease who presented after 3 days of
myalgians, fever, cough, new infiltrate on CXR and hypotension
requiring pressors.
Brief Course:
He was transferred here on [**2200-4-6**] [**2-8**] bed shortages at OSH. He
arrived and was
stable but developed A fib to 140s and decompensated requiring
intubation, his AF was eventually controlled with amiodarone
bolus and drip as well as esmolol. Pt was found with influenza
A, c/b VAP. He was successfully extubated, but had persistent
oxygen requirement. He was continued on broad spectrum
antibiotics for possible VAP. He was found to have severe RV
dilation and hypokinesis. He was initiated on CVVH for fluid
overload which resulted initially in improved blood pressures.
He tolerated weaning from three pressors to one.
Throughout his hospitalization he had persistent pressor
requirement despite negative blood and sputum cultures.
In setting of patients grim overall prognosis a palliative care
consult was initiated to assist the family with end of life care
and transition to CMO status. The patient was made CMO on [**4-17**],
pressors and CVVH were discontinued and expired shortly
thereafter.
Medications on Admission:
Warfarin 5 mg M/W/F/Sun; 4mg T/Th/Sat
Digoxin 0.125 daily
lomotil 0.25 daily prn
nephrocaps 2 daily
colchicine 0.6 daily
tums
folic acid
oxycodone QHS
neurontin 200 mg QHS
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"427.31",
"995.92",
"416.8",
"570",
"518.0",
"V44.2",
"496",
"038.41",
"287.5",
"327.23",
"574.20",
"572.8",
"459.81",
"562.10",
"585.6",
"751.62",
"482.2",
"518.81",
"276.2",
"785.52",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.95",
"99.15",
"38.91",
"38.93",
"96.07",
"96.72",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7840, 7849
|
6348, 7586
|
302, 353
|
7900, 7909
|
2702, 6325
|
7965, 7975
|
2011, 2091
|
7808, 7817
|
7870, 7879
|
7612, 7785
|
7933, 7942
|
2106, 2683
|
251, 264
|
381, 1607
|
1629, 1829
|
1845, 1995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,375
| 177,945
|
34236
|
Discharge summary
|
report
|
Admission Date: [**2135-7-7**] Discharge Date: [**2135-7-9**]
Date of Birth: [**2053-8-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Mobic / Cyclobenzaprine / Clonidine / Prednisone
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Name14 (STitle) 78849**] is an 81 y/o female s/p ground level fall. She was
transferred to an outside hospital where a head CT revealed a 7
mm right temporal-parietal subdural hematoma. She had no focal
neurological deficits. She was transferred to [**Hospital1 18**] for
neurosurgical care.
Past Medical History:
pancreatic cancer
Social History:
denies tobacco, EtOH, or IVDU
Family History:
noncontributory
Physical Exam:
PERRLA
EOMI
FC all 4 extremities
sensation to LT intact all around
A & O x 3
gait unsteady, uses walker to ambulate
no evidence of dysmetria
cranial nerves II - XII grossly intact
no clonus
negative babinski
Pertinent Results:
Click "Import Result" to add to discharge summary.
Results from [**2135-7-6**] to
Note: For Cytogenetics results see Clinical Information System
Blood Urine CSF Other Fluid Microbiology
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2135-7-9**] 07:40AM 10.1 4.18* 12.4 35.0* 84 29.8 35.5* 14.1
300 Import Result
[**2135-7-8**] 06:24AM 10.2 3.76* 11.1* 31.9* 85 29.6 34.9 14.2
283 Import Result
[**2135-7-7**] 12:52PM 15.9*# 3.91* 11.6* 33.0* 84 29.6 35.1*
14.1 272 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2135-7-7**] 12:52PM 93* 0 4.0* 3 0 0 Import Result
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2135-7-9**] 07:40AM 300 Import Result
[**2135-7-8**] 06:24AM 283 Import Result
[**2135-7-7**] 12:52PM 272 Import Result
[**2135-7-7**] 12:52PM 11.6 21.0* 1.0 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2135-7-9**] 07:40AM 78 23* 0.7 134 4.4 102 24 12 Import
Result
[**2135-7-8**] 06:24AM 125* 31* 0.7 133 4.2 102 24 11 Import
Result
[**2135-7-7**] 12:52PM 233* 58* 1.1 134 4.2 102 25 11 Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2135-7-7**] 12:52PM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2135-7-7**] 12:52PM 126 Import Result
CPK ISOENZYMES CK-MB cTropnT
[**2135-7-7**] 12:52PM 0.03* Import Result
[**2135-7-7**] 12:52PM 7 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2135-7-8**] 06:24AM 3.4 8.6 2.3* 2.2 Import Result
NEUROPSYCHIATRIC Phenyto
[**2135-7-8**] 06:24AM 1.6* Import Result
LAB USE ONLY GreenHd
[**2135-7-7**] 12:52PM HOLD Import Result
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to [**Hospital1 18**] on [**2135-7-7**] for
neurosurgical evaluation and observation. She was followed up
with a repeat head CT which revealed the subdural hematoma to be
stable. She did not require surgical intervention. PT was
consulted to evaluate her gait. They recommended on [**2135-7-9**] that
she is stable for discharge to home with services.
Medications on Admission:
ambien
ASA
cozaar
diltiazem
os-cal
percocet
premarin
synthroid
fentanyl
morphine
lexapro
lidoderm patch
motrin
decadron
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 3 weeks.
Disp:*63 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
subdural hematoma
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **].
Followup Instructions:
schedule appointment with Dr. [**Last Name (STitle) **]; call [**Telephone/Fax (1) 1669**]
Completed by:[**2135-7-9**]
|
[
"401.9",
"E888.1",
"157.9",
"852.20",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3629, 3678
|
2901, 3300
|
320, 327
|
3740, 3764
|
1032, 2878
|
4962, 5083
|
762, 779
|
3470, 3606
|
3699, 3719
|
3326, 3447
|
3788, 4939
|
794, 1010
|
271, 282
|
355, 658
|
680, 699
|
715, 746
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,107
| 139,288
|
29289
|
Discharge summary
|
report
|
Admission Date: [**2186-12-27**] Discharge Date: [**2186-12-31**]
Date of Birth: [**2124-3-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 YO M with pmhx of CAD s/p CABG, tracheomalacia, CHF, HTN
underwent OP bronchoscopy with BAL today for tracheomalacia
evaluation , and developed progressive chills, neck stiffness,
shortness of breath later in the day while at radiology for a
routine scheduled CT scan for tracheomalacia (no contrast). His
VS were stable except for hypoxia of 89% on a NRB, he was
administered 1 amp d50 and transferred to the ED.
.
In ED, initial VS T99 HR 95 165/53 26 95% on 15L proBNP: 2864,
lactate 2.1 given, albuterol levo, flagyl, and vanco, lasix
with 800cc output. Was 97.1. 73 154/77 97% on 4L on admission
request to ICU.
.
Of note, he has recently had 2 episodes of PNA in [**8-25**] and
[**10-25**], which required inpatient therapy at [**Hospital3 **] with
antibiotics but no intubation. He has been on 6 weeks of
antibiotics most recently for PNA with productive cough,
initially with levaquin, then 2 cycles of amoxicillin, although
records suggest Bactrim, finished yesterday. He has also noted
increased DOE over the past few weeks, also associated with
increased swelling in the legs bilaterally, and wt gain of 20lbs
since [**Month (only) **], no clear affirmation of dietary indiscretion.
This required increasing use of his baseline 2L oxygen at night
with CPAP to use during the day.
.
MICU course:
[**12-28**]: admitted, resumed diet, goal I/O even, started steroids,
call out
echo, start prednisone 40 qday x 5days
.
Abx:
[**2186-12-27**] started on levo, flagyl, vanc
[**12-28**] vanco stopped
.
ROS: No HA, blurry vision, chest pain, palpitations, nausea
vomitting, + Cough 6 weeks with greenish sputum, + SOB, no
diarrhea constipation, no dysuria, frequency, no abd pain, +
chills, no photophobia, mild neck stiffness, no rash
Past Medical History:
PMHX:
CAD s/p CABG [**2177**]
Emphysema 2L home O2
DM
HTN
Hypothyroidism
Gout
Social History:
married retired, lives with wife, was a state worker retired in
95, has chemical exposure in airplane, rubber factory. Social
drinker, + smoking quit 30 yrs ago, although with 60+ pk=yr
history, no illicit drugs
Family History:
mother died 75, Father died 58 from stroke
Physical Exam:
VS 99 110/60 72 24 96%4L
GEN: NAD, Obese, speaking in full sentences
HEENT: PERRL, EOMI, OP Clear, dry MM, thick neck, elevated JVP
10cm
CV : distant HS, no mrg
CHEST: coarse bs throughout, exp wheezes, mild crackles at bases
ABD: +BS obese, NT/ND,
EXT: No C/C/ 2+ pitting edema to knees
SKIN: No rashes, lesions
NEURO: AAOx3, CNII-CNXII intact, no focal deficits, motor [**3-24**]
throughout
Pertinent Results:
PATIENT/TEST INFORMATION:
Indication: H/O cardiac surgery. Left ventricular function.
Shortness of breath.
Height: (in) 65
Weight (lb): 375
BSA (m2): 2.59 m2
BP (mm Hg): 145/67
HR (bpm): 65
Status: Outpatient
Date/Time: [**2186-12-28**] at 09:50
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007E002-0:34
Test Location: East Echo Lab
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *2.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.1 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 1.22
Mitral Valve - E Wave Deceleration Time: 177 msec
TR Gradient (+ RA = PASP): *>= 37 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Severe symmetric LVH. Mildly depressed LVEF. TDI
E/e' >15,
suggesting PCWP>18mmHg.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferolateral - akinetic; mid inferolateral - akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion. No echocardiographic signs
of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
There is severe symmetric left ventricular hypertrophy. Overall
left
ventricular systolic function is mildly depressed with thinned
and akinetic
inferolateral wall. Tissue Doppler imaging suggests an increased
left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and
free wall motion are normal. There may be right ventricular
hypertrophy. 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 mildly thickened. Trivial mitral regurgitation is
seen. There is
at least moderate pulmonary hypertension. There is a partially
echo dense
pericardial region (particularly posterior to the left
ventricle) consistent
with a small somewhat organized pericardial effusion . There is
no
echocardiographic evidence of tamponade.
Final Report
CT TRACHEA, [**2186-12-27**]
COMPARISON: CT trachea [**2186-11-8**].
INDICATION: Tracheobronchomalacia.
Multidetector CT of the chest was performed using the CT trachea
protocol,
which includes a standard-dose end inspiratory CT of the chest
followed by
[**Last Name (un) **]-dose dynamic expiratory CT of the chest to assess for
tracheomalacia.
At end inspiration, there is no evidence of fixed tracheal or
bronchial
stenosis, and there are no suspicious endoluminal lesions.
During dynamic expiration, there is severe diffuse
tracheobronchomalacia,
involving the entirety of the intrathoracic trachea and
extending into the
main, proximal lobar, and segmental bronchi. There is
near-complete collapse
at the level of the trachea, main bronchi, and lower lobe
subsegmental
bronchi. Multifocal air trapping is present, a finding that
frequently
accompanies tracheobronchomalacia.
As compared to the previous scan, the degree of airway malacia
is similar, but
the prior scan did not evaluate the distal airways due to
differences in
images acquisition.
Within the lungs, there are new multifocal areas of
consolidation and ground
glass attenuation, which involve all lobes of both lungs and are
accompanied
by peribronchiolar nodular opacities. However, the dependent
portions of the
lower lobes and the right middle lobe are most severely
affected. Previously
reported poorly defined opacity adjacent to the right
hemidiaphragm is
difficult to compare due to coexisting adjacent new areas of
consolidation.
Previously present scattered peribronchiolar opacities are
difficult to
compare due to the new diffuse areas of abnormality, but some of
these have
resolved in the interval.
Within the imaged portion of the neck, a small air collection
lateral to the
airway in the region of the thyroid cartilage was present
previously but
incompletely imaged due to differences in acquisition areas
between the two
studies. This is possibly due to asymmetric left piriform
sinus, but an
extraluminal air collection is not excluded on this limited
exam.
Mediastinal lymph nodes have slightly increased in size,
including a right
paratracheal node, now measuring 11 mm and previously measuring
8 mm as well
as additional lymph nodes in multiple nodal stations. These are
probably
reactive in the setting of presumed diffuse pulmonary infection.
Main
pulmonary artery remains enlarged. Diffuse coronary artery
calcifications are
present in this patient status post prior coronary bypass
surgery, and focal
pericardial calcifications along the right heart border are
again
demonstrated. No pericardial or pleural effusion is seen.
In the imaged portion of the upper abdomen, the adrenal glands
are normal.
Nonspecific stranding is present in the mesentery and in the
perinephric
regions. Note is made of previous cholecystectomy procedure.
Degenerative changes are present in the spine, and
post-sternotomy changes are
noted.
Finally, bilateral mild gynecomastia is present.
MULTIPLANAR AND 3D IMAGES: These images confirm diffuse severe
tracheobronchomalacia.
IMPRESSION:
1. Diffuse severe tracheobronchomalacia.
2. New multifocal areas of consolidation, ground glass opacity,
and
peribronchiolar nodules, which may be due to either a diffuse
infectious
pneumonia or a massive aspiration event. These findings were
communicated to
Dr. [**Last Name (STitle) 70397**] by telephone [**2186-12-27**], while the patient was
still on the
CT scanner.
3. Small air collection in upper left cervical region, possibly
due to
asymmetric appearance of left pyriform sinus. Correlation with
bronchoscopic
findings recommended to exclude a small contained laceration
injury which is
less likely.
Brief Hospital Course:
1. Multifocal Aspiration Pneumonia: In the setting of
bronchoscopy, intially covered with broad spectrum antibiotics,
but when BAL returned without specific organisms, he was
transition to augmentin with continued clincal improvement. Will
complete outpatient therapy.
.
2. Acute Exacerbation of COPD: Treated with brief course of
steroids, continued inhalors, and improved. Steroids
discontinued at discharge, but will give patient a prescription
in case of relapse - instructed him to contact PCP if this
occurs.
.
3. Acute Renal Failure: Consistent with pre-renal azotemia
secondary to diuresis. Given systolic heart failure and
nephrotic range proteinuria, would benefit from initiation of
ACE inhibitor at outpatient follow-up.
.
4. Systolic Heart Failure: Patient was changed to Toprol XL,
continued on aspirin and plavix, and started on Simvistatin for
secondary prevention. Recommend lipid testing and goal LDL <
100.
.
5. Iron Deficiency Anemia: Patient with normocytic anemia, TSAT
< 10% and Ferritin < 100 in the setting of acute inflammation.
Empiric iron replacement started and recommend outpatient
gastroenterology consultation to rule out occult GI blood loss.
6. Diabetes Mellitus Type II: Uncontrolled secondary to
steroids, expect that it will normalize on oral hypoglycemics as
an outpatient.
Medications on Admission:
Doxazosin Mesylate 2mg QHS
Advair 500/50 [**Hospital1 **]
Spiriva 18mcg QD
Levoxyl ?
Prilosec 20mg QD
Torsemide 40mg QD
Colchicine 1.2 mg QD
Glipizide 10mg qam, 5mg qpm
Atenolol 12.5 [**Hospital1 **]
Plavix 75 QD
Singulair 10mg QD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Multifocal Aspiration Pneumonia.
2. Acute Exacerbation of COPD.
3. Acute Renal Failure.
4. Chronic Kidney Disease with Nephrotic Range Proteinuria.
4. Iron Deficiency Anemia
Secondary:
1. Emphysema.
2. Tracheobronchomalacia.
3. CAD s/p IMI and CABG.
4. Systolic Heart Failure.
5. Diabetes Mellitus Type II.
6. Hypothyroidism.
7. Gout.
8. Obesity.
9. Hypertension.
10. Hyperlipidemia.
Discharge Condition:
good
Discharge Instructions:
- [**Hospital1 **] PPI for GERD
Followup Instructions:
1. Interventional Pulmonary for stent for trachiomalacia
2. Outpatient GI evaluation for Iron Defiency.
|
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icd9cm
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[
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[]
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54,205
| 177,558
|
52504
|
Discharge summary
|
report
|
Admission Date: [**2129-5-13**] Discharge Date: [**2129-5-28**]
Date of Birth: [**2078-9-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Cyclobenzaprine / Norvasc
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Hypertensive crisis, Acute kidney injury
Major Surgical or Invasive Procedure:
Kidney biopsy
Initiation of hemodialysis
AV fistula placement in L arm
History of Present Illness:
50 yo F with h/o anxiety, panic disorder, HTN, and other medical
issues presents today with persistent headache and HTN. Patient
is transferred from [**Hospital1 **]-[**Location (un) 620**]. She was sent to [**Hospital **] from PCP's office because of markedly elevated BP.
Patient states that she has not been herself for several months.
She describes intermittent headache/migraine preceeding it, but
noticed visual changes a few months ago. She thought she was
starting to have migraine with aura. She described her vision
changes as having scintillating scotomata (zig-zag lines with
multiple colors that move). She states that she was on
lisinopril many years ago but developed cough. She was
prescribed HCTZ around [**2129-3-18**] for her BP and had significant
dizziness with it. She was subsequently switched to amlodipine
but had similar symptoms. Finally, she was switched to Cozaar
12.5 mg daily ([**2129-4-11**]). She reports persistent change in her
vision and it evolved to triangular shaped shadow in her left
eye (left lower visual field). The number of triangles
increased over time despite trials of antihypertensives, and she
thought it was the medications that was giving her the vision
changes. The triangles then spread to her right eyes too. They
then became "swiss cheese" like with holes. She also describes
being able to see these triangles with her eyes closed. She
states that her vision seems to be sharper when she focuses on
the gap between the triangles, which is unusual. She states
that she wears corrective lenses. She finally stopped her
Cozaar about 1 week ago.
Patient has had a headache 4 days prior to admission. It
started after a stressful episode dealing with a friend. It was
frontal and temporal, throbbing in nature. The intensity
increased over the course of the days. She was also
experiencing some lightheadedness, nausea, and blurry vision,
[**First Name8 (NamePattern2) **] [**Location (un) 620**] report. She thought it was a sinus infection and
went to the PCP first, but was sent to [**Location (un) 620**] given elevated
BP. She denies rhinorrhea, fever, photophobia, SOB, cough,
chest pain. Her VS at [**Location (un) 620**] were Temp: 98.2 HR: 100 BP:
208/141 Resp: 20 O(2)Sat: 99%. Neurological exam there was
reported to be unremarkable other than significant anxiety.
Labs were notable for WBC 10.9, Hgb 12, Hct 34.2, Plt 116, 85%
neutraphils, Na 132, K 3.2, Cl 90, Bicarb 28, BUN 65, Crt 5.37,
Ca 8.9, trop T 0.018. UA had 100 protein, and large blood with
[**4-7**] RBC, no WBC, and few bacteria. EKG showed NSR, < 1 mm STD
in II/aVF/V4-V6, no q waves, LVH. CT head showed subtle
hypodensities in the posterior white matter, most c/w probable
PRES syndrome and no evidence of hemorrhage. CXR was negative
for acute cardiopulmonary process. She was given 20 mg IV
labetolol x 2, then labetolol gtt (1 mg/min, 60 cc/hr), zofran 4
mg IV, and morphine 5mg IV.
In the [**Hospital1 18**] ED, initial VS were 97.3 77 164/95 18 95%.
Labetolol gtt was discontinued given stable BP. No additional
labs were drawn. Neurological exam was reported to be normal.
Patient was transferred to ICU for frequent neurological exams
and BP monitoring. Her transfer VS were 167/94, 83
On arrival to the MICU, patient's VS 98.2, 83, 151/87, 22, 99%
RA. She states that she also noticed that she is more easily
bruised lately. Her husband told nursing that he felt patient
was not herself for a couple of months but did not specify.
Review of systems:
(+) Per HPI. + constipation, thirst.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies shortness of
breath, cough, dyspnea or wheezing. Denies chest pain, chest
pressure, palpitations. Denies abdominal pain, diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes.
Past Medical History:
- HTN
- ADD
- Anxiety
- Post-partum panic disorder
- Fibromyalgia
- Chronic fatigue syndrome
- Asthma as a child
- seasonal allergy
- Migraine headache +/- aura
- history of cervical disc herniation
Social History:
- denies any history of tobacco use
- + marijuana use, but not any other illicit drugs
- occasional EtOH
- has 2 teenage children
- married
Family History:
- mother: migraine with aura, CAD, stroke
- father: had floaters, HTN, overweight
Physical Exam:
ADMISSION EXAM
Vitals: 98.2, 83, 151/87, 22, 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear,
EOMI, PERRLA
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-distended, bowel sounds present, no
organomegaly, mild tenderness to the RUQ, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
normal sensation, 2+ reflexes bilaterally, gait deferred. +
diplopia with upward gaze. No obvious defect in visual fields.
alert and oriented x 3.
Psych: talkative, easily overwhelmed, somewhat of
circumferential
Skin: a couple small ecchymosis in various stage of healing over
her extremities
DISCHARGE EXAM
VS: Temp 98.3 F, BP 147/76, HR 72, R 16, O2-sat 94% (94-99%) RA
General: Alert, oriented, anxious, AO3x.
HEENT: Sclera anicteric, mucous membrane moist, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no increased work of breathing
Abdomen: soft, ND, bowel sounds present, no organomegaly, no
rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left arm antecubitus- bandage in place over fistula,
palpable thrill over fistula site.
Neuro: CNII-XII intact, normal gait
Pertinent Results:
ADMISSION LABS
[**2129-5-14**] 12:29AM BLOOD WBC-9.6 RBC-3.44* Hgb-9.7* Hct-26.7*
MCV-78* MCH-28.2 MCHC-36.3* RDW-14.7 Plt Ct-116*
[**2129-5-14**] 12:29AM BLOOD PT-10.4 PTT-28.9 INR(PT)-1.0
[**2129-5-14**] 12:29AM BLOOD Glucose-135* UreaN-66* Creat-5.3* Na-134
K-3.6 Cl-95* HCO3-24 AnGap-19
[**2129-5-14**] 12:29AM BLOOD ALT-16 AST-21 AlkPhos-49 TotBili-0.8
[**2129-5-14**] 12:29AM BLOOD Albumin-3.9 Calcium-8.1* Phos-5.4* Mg-2.1
Iron-50
[**2129-5-14**] 12:29AM BLOOD calTIBC-350 Ferritn-211* TRF-269
[**2129-5-14**] 06:50AM BLOOD CRP-15.4*
.
[**2129-5-27**] 09:32AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Schisto-OCCASIONAL
[**2129-5-27**] 07:29AM BLOOD LD(LDH)-238
[**2129-5-27**] 07:29AM BLOOD Hapto-155
[**2129-5-25**] 01:10PM BLOOD HBsAb-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HCV Ab-NEGATIVE
[**2129-5-14**] 06:50AM BLOOD HCV Ab-NEGATIVE
[**2129-5-14**] 03:17PM BLOOD ANCA-NEGATIVE B
[**2129-5-18**] 12:06PM BLOOD [**Doctor First Name **]-NEGATIVE Cntromr-NEGATIVE
[**2129-5-18**] 12:06PM BLOOD RheuFac-12
[**2129-5-14**] 03:17PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40
[**2129-5-14**] 06:50AM BLOOD PEP-HYPOGAMMAG IgG-401* IgA-34* IgM-26*
IFE-NO MONOCLO
[**2129-5-14**] 06:50AM BLOOD C3-90 C4-40
[**2129-5-19**] 06:21PM BLOOD Metanephrines (Plasma)- Negative
[**2129-5-18**] 12:06PM BLOOD ADAMTS13 EVALUATION-98% (wnl)
[**2129-5-18**] 12:06PM BLOOD SCLERODERMA ANTIBODY-Negative
[**2129-5-18**] 12:06PM BLOOD ANTI-GBM-Negative
.
DISCHARGE LABS
[**2129-5-28**] 07:50AM BLOOD WBC-8.0 RBC-3.17* Hgb-9.0* Hct-26.4*
MCV-83 MCH-28.3 MCHC-34.0 RDW-15.1 Plt Ct-265
[**2129-5-28**] 07:50AM BLOOD Glucose-132* UreaN-36* Creat-6.1*# Na-135
K-4.3 Cl-95* HCO3-28 AnGap-16
[**2129-5-28**] 07:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
.
URINE STUDIES
[**2129-5-14**] 05:02AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2129-5-14**] 05:02AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2129-5-14**] 05:02AM URINE RBC-5* WBC-77* Bacteri-FEW Yeast-NONE
Epi-15
[**2129-5-14**] 05:02AM URINE Hours-RANDOM Creat-84 Na-49 K-29 Cl-45
TotProt-208 Prot/Cr-2.5* Albumin-PND
.
IMAGING
[**5-13**]
- CXR: PA and lateral views. Heart size is normal. Mediastinal
and hilar contours are unremarkable. There is no pulmonary
edema or pleural effusion. No evidence of a pulmonary
consolidation is seen. The imaged bones are unremarkable.
- CT head without contrast: There are subtle hypodensities in
the white matter of the posterior occipital lobes and posterior
periventricular regions. These findings can be seen in the
setting of PRES syndrome. There is no evidence of hemorrhage,
edema, mass, mass effect, or large vascular territory
infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns are patent. No fracture is
identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
1. SUBTLE HYPODENSITIES IN THE POSTERIOR WHITE MATTER MOST
CONSISTENT WITH PROBABLE PRES SYNDROME. MRI CAN BE OBTAINED FOR
FURTHER EVALUATION IF CLINICALLY INDICATED.
2. NO EVIDENCE OF HEMORRHAGE.
EKG:
[**5-13**] EKG showed NSR, < 1 mm STD in II/aVF/V4-V6, no q waves,
LVH
RUS [**2129-5-15**]
IMPRESSION:
1. No evidence of renal artery stenosis with normal wave forms.
Slightly
greater right sided RI measurements likely reflect technically
more limited left sided assessment.
2. Focal area of hypoechogenicity seen in the upper pole of the
right kidney can be reassessed during US guided renal biopsy
planned for [**5-16**]. If not, non-contrast MRI can be considered.
3. Diffusely echogenic kidneys suggest medical renal disease.
.
TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade.
Brief Hospital Course:
50 yo F with a history of HTN, anxiety, panic disorder who
presented with persistent headache with visual changes and
elevated BP to 210s/140s.
#Malignant Hypertension: On admission the patient's blood
pressure was significantly elevated to SBP>210 and DBP>140. She
had evidence of PRES (posterior reversible encephalopathy
syndrome) (see below), retinopathy (see below), and acute renal
failure (see below). She was initially started on labetolol gtt
in the ICU to bring down her blood pressure and was eventually
stabilized on labetolol 300 mg TID, with SBP ranging 110s-140s
and DBP 50s-70s on discharge. The etiology of the malignant HTN
is most likely poorly controlled primary HTN, worsened by OCP,
Neurontin, and Adderall use; OCPs, Adderall, and Neurontin were
held. Work up of secondary causes is thus far negative, with
negative serum metanephrines, no evidence of RAS. [**Male First Name (un) **]/renin is
still pending. Work up for causes of primary renal failure were
negative (see below).
.
#Acute Renal Failure: The patient developed acute renal failure
with Cr reaching 9.2; the patient was hypoxic with significant
SOB and had emergent HD. A tunneled line was placed and she was
stabilized on a MWF dialysis schedule which will be continued
outpatient, with significant improvement in hypoxia and SOB.
Lung exam clear on discharge. AV fistula was placed for chronic
HD, and a nutrition consult was obtained for ESRD dietary
counseling. Significant work up for causes of renal failure were
negative. Note initial labs showed low haptoglobin and elevated
LDH, raising concern for TTP; however, smear showed no schistos,
and repeat LDH and haptglobin were wnl the day prior to
discharge. Negative work up includes: negative hepatitis
virologies (HBV/HCV negative), normal complements, [**Doctor First Name **] neg
(originally [**Doctor First Name **] 1:40), negative ANCA, negative anti-centromere,
smear w/o schisto's, negative SPEP/UPEP, renal US w/o RAS,
ADAMTS13 wnl, negative anti-Scl, negative anti-GBM, negative
cryocrit. Kidney biopsy was consistent with thrombotic
microangiopathy likely in the setting of malignant hypertension.
.
#PRES: Head CT was concerning for PRES, MRI was consistent with
mild PRES. Treatment is BP control. The patient's neuro exam was
stable throughout admission, with persistent visual field
deficits but otherwise unremarkable.
.
#Retinopathy: The patient had bilateral papilledema and cotton
wool spots, likely [**12-30**] malignant HTN; ophthalmology was
consulted. Ophthalmology recommended that blood pressure control
was the only therapy, with plans for formal outpatient visual
field testing on discharge. The patient continued to have visual
field deficits, somewhat waxing and [**Doctor Last Name 688**], throughout her
hospital stay and on discharge.
.
# Anemia: Likely multifactorial with some contribution of her
renal failure, chronic inflammation. There was initial concern
for hemolysis due to low haptoglobin and milidly elevated LDH;
however, she had normal tbili and no schistos on smear.
Vasculitis work up was also done, with ANCA returning negative.
Iron panel without evidence of iron deficiency. The day prior to
discharge, her Hct dropped to 22 and she was symptomatic with
feelings of lightheadedness on walking. Repeat LDH, hapto, and
smear were within normal limits. She was given one unit of PRBC,
with Hct of 26 the morning of discharge and improvement in
symptoms.
.
# ADHD: Home Adderall was held given HTN. Stable throughout
admission.
# Anxiety: She was continued on her home clonazepam. Note
anxiety appeared to contribute to feelings of shortness of
breath.
.
# Hyponatremia: Low Na on admission, most likely hypervolemic
hyponatremia. Improved with HD to 135 on discharge.
.
#Transitions:
1) Follow up [**Male First Name (un) 2083**]/renin, pending
2) Hemodialysis MWF indefinitely
3) Follow up appointments scheduled with Nephrology, Transplant,
Neurology, Ophthalmology
4) OCPs, Adderall, and Neurontin discontinued; will need to
avoid medications that may exacerbate HTN in the future.
Medications on Admission:
- Adderall 20 mg [**Hospital1 **]
- clonazepam 0.5 mg daily
- flonase prn
- neurontin 300 mg QD
- Zovia 1/35 daily
- Cozaar 12.5 mg, stopped for about 1 week
Discharge Medications:
1. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 Capsule(s) by mouth TID with meals
Disp #*90 Tablet Refills:*0
2. Clonazepam 0.5 mg PO DAILY
hold for sedation, RR<10
3. Labetalol 300 mg PO TID
hold for sbp < 110, hr<60
RX *labetalol 300 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
4. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid 400 mcg 1 Tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
5. Lorazepam 0.5-1 mg PO WITH DIALYSIS anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth with dialysis
Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Hypertension with end organ damage
Anemia
Thrombocytopenia (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4334**],
It was a pleasure participating in your care here at [**Hospital1 18**]. You
were admitted because of very high blood pressure, kidney
failure, retinopathy, and headaches. You were seen by Neurology,
Hematology, Nephrology, and Ophthalmology services. You were
retaining fluid due to your impaired kidney function and
developed fluid in your lungs and shortness of breath. For this
reason, you started hemodialysis, with improvement in your
breathing. You have been set up on a MWF dialysis schedule. A
fistula was placed while you were here for future outpatient
dialysis.
You had a kidney biopsy which showed damage likely due to high
blood pressure. Many lab tests were checked to determine if
there was a cause of kidney damage other than high blood
pressure, and these tests were all negative. Several tests were
done to determine if there was a cause for your high blood
pressure, and these tests were all negative as well. One test
is still pending (aldosterone/renin) and you should follow up
with your outpatient doctors about this [**Name5 (PTitle) **].
You were also noted to have low blood counts, called anemia. You
received one unit of blood. They will recheck your blood counts
at dialysis.
Please make the following changes to your medications:
# START labetalol 300 mg three times a day
# START ativan as needed with dialysis
# START calcium acetate 667 mg three times a day with meals
# START vitamin complex daily
Followup Instructions:
Department: Ophthalmology
With: Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]
When: Please call the office number below to schedule a follow
up appointment for 9-15 days after your hospital discharge.
Building: [**Hospital1 69**]-[**Hospital Ward Name 23**] Bldg [**Location (un) 6332**]
Address: [**Location (un) **]., [**Location (un) 86**], MA
Phone: ([**Telephone/Fax (1) 5120**]
Department: Nephrology
Name: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
When: You will be followed by your nephrologist, Dr. [**First Name (STitle) 805**]
during your upcoming dialysis appointment.
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: TRANSPLANT CENTER
When: THURSDAY [**2129-6-9**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2129-7-20**] at 4:30 PM
With: DRS. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] & [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2129-5-30**]
|
[
"362.11",
"403.01",
"799.02",
"584.9",
"585.6",
"729.1",
"287.5",
"276.69",
"285.21",
"348.39",
"593.81",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"55.23",
"39.27",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16062, 16068
|
11152, 15234
|
398, 471
|
16202, 16202
|
6460, 11129
|
17857, 19430
|
4815, 4899
|
15443, 16039
|
16089, 16181
|
15260, 15420
|
16353, 17632
|
4914, 6441
|
17661, 17834
|
4030, 4418
|
318, 360
|
499, 4011
|
16217, 16329
|
4440, 4641
|
4657, 4799
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,740
| 102,712
|
46616
|
Discharge summary
|
report
|
Admission Date: [**2127-7-1**] Discharge Date: [**2127-7-14**]
Date of Birth: [**2054-3-5**] Sex: F
Service: MEDICINE
Allergies:
Levaquin / Neurontin / Neomycin / Ciprofloxacin / Percocet /
Perfume Ht52 / Shellfish Derived / Statins-Hmg-Coa Reductase
Inhibitors
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
abdominal pain, diarrhea, nausea
Major Surgical or Invasive Procedure:
ICU stay with central venous line placement [**7-1**]
Cardiac catheterization [**7-10**]
History of Present Illness:
73 year-old female with CAD, hypertension, CRI (baseline
1.3-1.4), SMA partial stenosis, chronic diarrhea admitted with
weakness x2-3 days in context of abdominal pain, diarrhea,
nausea. Cramping began three days prior to admission.
Periumbilical, without radiation, and not associated with PO
intake. Also with diarrhea, similar to baseline chronic
diarrhea; no noticeable blood in stools. Nausea without
vomiting. Decreased PO intake, although reports drinking plenty
of water. Denies fevers; reports chills at night for which she
used a heating pad on her abdomen. Denies sick contacts. Denies
dysuria. Reports decreased urine production. She feels her
symptoms are secondary to stress; her sister recently had a
stroke. Reports taking Tylenol 1 tablet approximately 4-5 days
ago for low back pain, and Vicodin x1 tablet today and
yesterday. Reports spending time in garden in heat recently.
.
In the ED, 112/41 80% RA. Physical examination notable for
abdominal distension, guaiac positive stool. Laboratory
evaluation significant for leukocytosis with bandemia,
thrombocytopenia (65), transaminitis, elevated lipase,
creatinine 8.1 with anion gap 39, normal coag panel, serum osm
341, lactate 3.8. Opiate positive; Tylenol 16.8. VBG prior to
transfer with 7.15 26 61. Blood cultures sent. EKG reportedly
unremarkable. CXR 2V reportedly unremarkable. CT abdomen/pelvis
without contrast with "diffuse distension of stomach and small
bowel and large bowel loops extending into rectum is mostly
suggestive of gastroenteritis." Surgery consulted; feel
consistent with severe gastroenteritis; no acute surgical issue,
but will continue to follow. Case discussed with renal; no acute
indication for dialysis, will continue to follow. Received
vancomycin, Zosyn, Flagyl; received 150mEq HCO3 in D5W, 2L total
@ 150cc/hr.
On transfer to MICU, 98.9 71 113/45 26 98% NRB.
.
On the floor, she reports discomfort with Foley catheter. Also
with persistent abdominal cramping, need to take BM. Also
reports feeling very thirsty.
.
Review of systems:
(+) Per HPI. Reports weight loss over past 1 week, unable to
quantify amount. Reports chronic low back pain.
(-) Denies fever, night sweats. Denies headache, rhinorrhea.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies rashes.
Past Medical History:
CAD 1VD s/p BMS to D1 ([**2124**])
CRI
Hypertension
Hyperlipidemia
SMA stenosis with chronic abdominal pain with eating
Chronic intermittent diarrhea
Stable, bilateral 60-69% ICA stenosis
Severe scoliosis
Lumbar spondylosis
Postherpetic neuralgia
Nocturnal leg cramps
Chronic anemia
Osteoporosis
Arthritis
s/p left rotator cuff repair
s/p bilateral cataract surgery
s/p right breast lumpectomy
Social History:
Lives with husband in [**Name (NI) 745**]. Reports 1 alcohol drink per
evening, none recently. Stopped tobacco use 45 years ago. Denies
illicit drug use.
Family History:
non-contributory
Physical Exam:
96.4, 61, 93/57, 14, 100% 2L NC
General: In mild distress
HEENT: Sclera anicteric; dry mucous membranes; OP clear
Neck: JVP to angle of mandible at 30 degreess
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
CV: Decreased heart sounds; regular rate and rhythm; normal
S1/S2; no murmurs appreciated
Abdomen: Hypoactive bowel sounds; mildly distended; diffusely
tender to palpation; no rebound or guarding; no appreciable
hepatomegaly.
GU: Foley
Ext: Cool upper extremities; radial pulses 1+ and symmetric;
warm lower extremities, DP pulses 1+ and equal bilaterally; no
edema
Skin: Tanned; no jaundice
Pertinent Results:
Labs at admission:
[**2127-7-1**] 01:00PM BLOOD WBC-16.2*# RBC-4.22 Hgb-13.5 Hct-40.3
MCV-95 MCH-31.9 MCHC-33.4 RDW-13.7 Plt Ct-65*#
[**2127-7-1**] 01:00PM BLOOD Neuts-63 Bands-12* Lymphs-16* Monos-7
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2127-7-1**] 01:00PM BLOOD PT-10.9 PTT-28.7 INR(PT)-0.9
[**2127-7-2**] 02:56PM BLOOD Fibrino-388
[**2127-7-6**] 09:50AM BLOOD Parst S-NEG
[**2127-7-3**] 05:51AM BLOOD Ret Aut-0.4*
[**2127-7-1**] 01:00PM BLOOD Glucose-200* UreaN-137* Creat-8.1*#
Na-135 K-5.3* Cl-87* HCO3-9* AnGap-44*
[**2127-7-1**] 01:00PM BLOOD ALT-227* AST-642* AlkPhos-166*
TotBili-0.5
[**2127-7-1**] 08:27PM BLOOD ALT-169* AST-502* LD(LDH)-950*
CK(CPK)-[**Numeric Identifier 98991**]* TotBili-0.4
[**2127-7-1**] 01:00PM BLOOD Lipase-525*
[**2127-7-1**] 01:00PM BLOOD cTropnT-<0.01
[**2127-7-1**] 08:27PM BLOOD Calcium-5.0* Phos-9.6*# Mg-2.0
[**2127-7-1**] 08:27PM BLOOD Hapto-57
[**2127-7-5**] 07:15PM BLOOD calTIBC-126* Folate-17.7 Ferritn-1608*
TRF-97*
[**2127-7-3**] 05:51AM BLOOD VitB12-GREATER TH
[**2127-7-1**] 08:27PM BLOOD TSH-1.8
[**2127-7-6**] 07:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-7-1**] 01:00PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-16.8
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-7-1**] 08:27PM BLOOD Acetmnp-11.4
[**2127-7-2**] 04:15AM BLOOD Acetmnp-NEG
[**2127-7-6**] 09:50AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM-PND
)
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY 5.43 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider a Parvovirus
B19 DNA, PCR test.
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Liver/GB U/S [**7-7**]
FINDINGS: The gallbladder is normal with no gallstones, no wall
thickening, and no pericholecystic fluid identified. There is no
biliary dilatation and the common duct measures 0.2 cm. No focal
liver lesion is identified. The pancreas is unremarkable, but is
only partially visualized due to overlying bowel. The spleen is
unremarkable and measures 7.7 cm. A scant trace of ascites is
seen in the perihepatic space. Small bilateral pleural effusions
are noted.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. The main, right and left portal veins are patent with
hepatopetal flow. Appropriate arterial waveforms are seen in the
main, right and left hepatic arteries. Appropriate flow is seen
in the IVC, the hepatic veins, the SMV, and the splenic vein.
IMPRESSION:
1. No gallstones and no evidence of cholecystitis.
2. Patent hepatic vasculature.
3. Scant trace of ascites in the perihepatic space. Bilateral
pleural
effusions.
LUE U/S [**7-7**]
FINDINGS: Grayscale, color and Doppler images were obtained of
the left IJ, subclavian, axillary, brachial, basilic, and
cephalic veins. There is normal flow, compression and
augmentation seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
CXR [**7-3**]
REASON FOR EXAM: CAD, hypertension, abdominal complaint, and
chronic renal
failure.
Comparison is made with prior study performed a day earlier.
Small-to-moderate bilateral pleural effusions are new. Cardiac
size is
normal. There are bibasilar atelectases. There is mild pulmonary
edema.
Biapical pleural thickening is unchanged. There is no
pneumothorax.
[**7-3**] TTE
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Large
pleural effusion.
[**7-1**] CT abd/pelvis
FINDINGS: The study is moderately limited as no IV or oral
contrast has been administered, however no definite bowel wall
thickening is noted. Moderate fluid-filled distention of the
stomach, small bowel, large bowel loops and rectum are noted. No
free fluid is noted. No pathologically enlarged nodes are
visualized. Small hiatal hernia is noted. The liver, spleen,
adrenal glands, kidneys appear unremarkable. Tiny punctate foci
of calcification noted within the right renal pelvis may be
vascular or within the collecting system. The urinary bladder
contains a Foley catheter. The uterus and adnexa appear
unremarkable.
BONE WINDOWS: Severe levoconvex scoliosis of the lumbar spine
with associated degenerative changes are noted.
IMPRESSION: Moderate fluid-filled distention of the stomach,
small bowel and large bowel loops to the level of the rectum are
most likely suggestive of infectious enteritis. As no IV and
oral contrast was administered, evaluation for ischemic bowel is
limited, however no signs of bowel ischemia such as wall
thickening was noted.
[**7-1**]/ CXR
FINDINGS: Hyperexpansion is again evident, similar to prior
exam. Stable
calcified pleural plaques predominantly over the lung apices are
again noted. The mediastinum is grossly stable but difficult to
assess due to the profound dextroconcave scoliosis involving the
lower thoracic spine. No large effusion or pneumothorax is seen.
IMPRESSION: Severe but stable scoliosis as detailed above. No
definite
superimposed acute process. Relatively stable chest x-ray
examination.
TTE [**7-9**]
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with akinesis of the distal LV and apex. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**2-1**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-7-3**],
regioanl LV systolic dysfunction is new.
ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA [**Doctor Last Name **])
IGG/IGM
Test Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG 1:1024 <1:64
A. PHAGOCYTOPHILUM IGM 1:80 <1:20
Anaplasma phagocytophilum is the tick-borne [**Doctor Last Name 360**]
causing Human Granulocytic Ehrlichiosis (HGE).
HGE is distinct and separate from Human Moncytic
Ehrlichiosis (HME), caused by Ehrlichia chaffeensis.
Serologic crossreactivity between A. phagocyto-
philum and E. Chaffeensis is minimal (5-15%).
This test was developed and its performance
characteristics have been determined by [**Company 30232**] [**Doctor Last Name **] Institute, Chantilly, VA.
It has not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined
that such clearance or approval is not necessary.
Performance characteristics refer to the analytical
performance of the test.
Test Result Reference
Range/Units
INTERPRETATION see note
Recent/Current Infection
Labs at discharge:
Brief Hospital Course:
Ms. [**Known lastname 17437**] is a 73 year old female with a history of CAD,
hypertension, CRI, SMA partial stenosis, chronic diarrhea and
abdominal pain admitted with abdominal cramping, nausea, and
diarrhea and found to have acute on chronic renal failure,
transaminitis, and thrombocytopenia.
.
# Acute systolic heart failure: EF 35%. Akinesis at the distal
LV and apex on ECHO; catheterization [**7-10**] showed dilation at the
apex, no flow limitations requiring intervention. Differential
includes ischemia (less likely given cath results), infectious
myocarditis (more likely given positive Anaplasma titers,
below), or Takotsubo's. Is currently tachycardic, thought to be
compensatory for systolic dysfunction. She was continued on
aspirin and atenolol, with diuresis with lasix. She will need a
repeat TTE in 3 weeks in Dr.[**Name (NI) 5452**] office.
.
# Human granulocytic ehrlichiosis (aka anaplasmosis): Positive
IgG and IgM serologies for anaplasma phagocytophilum returned
from [**2127-7-6**]; may have been the inciting cause of her
hypotensive shock and presenting symptoms, though her
presentation was atypical in being afebrile. Though ID
unimpressed, as you cannot always seen organsims on smear, given
+IgM and unknown cause of illness, elected to treat with
Doxycycline 100mg [**Hospital1 **] X 10 days. She should have repeat titers
in one month by PCP.
.
# Anemia: Continued slow decline. Tbili and haptoglobin were
normal, so concern for occult bleeding (vs. hemolysis). Rectal
guiaic [**7-9**] positive. Trended Hcts. Follow up with GI as
outpatient unless has transfusion needs then will contact here.
.
# Abdominal pain/diarrhea: Chronic abdominal cramping and loose
stools; thought to have exacerbation on admission. Symptoms
improved with codeine. RUQ ultrasound was normal. Outpatient
workup recommended by GI. Appointment scheduled with Dr.
[**Last Name (STitle) 1940**].
.
# Transaminitis: Enzymes are continuing to trend down.
Elevations on admission thought to be due to shock liver from
hypotension, possibly from infection, though she was only
documented to be severely hypotensive after admission. Has been
noted to have partial SMA stenosis, so may have had transient
ischemia at some point. RUQ ultrasound did not show signs of
infiltrative or cholestatic processes.
.
# Thrombocytopenia: Baseline platelet count 200+, was 63 on
admission; now above baseline in 300s. Possible etiologies are
anaplasmosis or other infection, ITP (less likely because of
resolution without steroids), or toxic insult/drug reaction.
.
# Acute on chronic renal failure: Resolved. Thought to be due to
ATN from rhabdomyolysis given CK and UA on admission.
.
# CAD: 2 bare metal stents placed [**2123**] and [**2124**]. Aspirin 81 mg
started and atenolol restarted. Held [**Year (4 digits) **] due to
thrombocytopenia and risk of bleeding and no absolute indication
for [**Year (4 digits) **] given remote history of bare metal stents.
# Hypertension: SBP has been 100s-120s. Increased atenolol to 50
mg as patient was tachycardic, decreased lisinopril to 5 mg and
stopped HCTZ, nifedipine.
.
# Hypercholesterolemia: Discontinued statin due to elevated
CK/suspected rhabdomyolysis. Held Zetia. Consider alternate
anti-cholesterol [**Doctor Last Name 360**], such as niacin as an outpatient.
.
# Osteoporosis: Held Actonel.
.
# Communication: [**Name (NI) **] (husband), ([**Telephone/Fax (1) 98992**]
# Code status: FULL CODE, confirmed with patient in ICU
Medications on Admission:
Medications: (Per PCP [**Name Initial (PRE) 626**], [**2127-6-18**])
ATARAX - 25MG Tablet - ONE TID, AS NEEDED
ATENOLOL - 25MG Tablet - ONE EVERY DAY
ATORVASTATIN [LIPITOR] - (Dose adjustment - no new Rx) - 80 mg
Tablet - 1 Tablet(s) by mouth
CELEBREX - 200MG Capsule - ONE EVERY DAY
CLOPIDOGREL [[**Month/Day/Year **]] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day pt to stop 7 days prior
to procedures
FLUOROURACIL [EFUDEX] - (Prescribed by Other Provider) - 5 %
Cream - take as directed as needed
HCTZ - 25 MG - ONE EVERY MORNING
LISINOPRIL - 10MG Tablet - ONE EVERY DAY
NITROQUICK - 0.4MG Tablet, Sublingual - AS DIRECTED
OMEPRAZOLE - (Prescribed by Other Provider) - Dosage uncertain
PROCARDIA XL - 60MG Tablet Extended Rel 24 hr - ONE EVERY DAY
RISEDRONATE [ACTONEL] - (Dose adjustment - no new Rx) - 35 mg
Tablet - 1 Tablet(s) by mouth weekly
TYLENOL/CODEINE NO.3 - 30-300MG Tablet - ONE TABLET BY MOUTH Q 6
HOURS AS NEEDED FOR PAIN
ZETIA - 10MG Tablet - TAKE ONE TABLET DAILY.
COMPRESSION STOCKINGS - Misc - WEAR AS DIRECTED
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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain.
5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 6 days.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Lorazepam 0.5 mg Tablet Sig: 0.25-0.5 mg PO Q8H (every 8
hours) as needed for anxiety .
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): to be given until patient
ambulates.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
-acute renal failure
-thrombocytopenia
-viral gastroenteritis
-acute MI
Secondary
-CAD
Discharge Condition:
alert, oriented X3
ambulating with assistance
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of abdominal pain, nausea and diarrhea. While you were
here you were found to have severe kidney injury. This greatly
improved and was normal at discharge. You also had low
platelets, which also improved and were normal at discharge.
You had liver injury and muscle breakdown which may have been
due to your Lipitor. You should not take statins, which lower
cholesterol, in the future.
Your liver injury also improved.
While you were here you were found to have had mild damage to
your heart muscle. You were restarted on some of your
medications.
You were seen by the hematology, gastroenterology, and kidney
doctors.
You required a stay in the intensive care unit.
Be sure to follow-up with your primary care doctor within [**2-1**]
weeks after discharge.
While you were here, some of your medications were changed.
You should STOP taking:
ATARAX
ATORVASTATIN [LIPITOR]
CELEBREX
CLOPIDOGREL [[**Month/Day (2) **]]
FLUOROURACIL [EFUDEX]
HYDROCHLORTHIAZIDE
NITROQUICK
PROCARDIA XL
RISEDRONATE [ACTONEL]
ZETIA
You should CONTINUE:
COMPRESSION STOCKINGS "
ATENOLOL
You should CHANGE:
INSTEAD of TYLENOL/CODEINE NO.3, take CODEINE alone
DECREASE LISINOPRIL to 5mg daily
INSTEAD of OMEPRAZOLE, take PANTOPRAZOLE
You should START:
ASPIRIN
You will need to have your hematocrit (blood level) checked
every 3 days to determine if it is decreasing.
Followup Instructions:
Department: [**State **] SQ
When: [**Last Name (LF) 766**], [**7-21**] at 3:40 pm
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: PAIN MANAGEMENT CENTER
When: [**Location (un) **] [**2127-7-21**] at 7:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2127-7-25**] at 7:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: GASTROENTEROLOGY
When: THURSDAY [**2127-7-24**] at 12:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Cardiology
When: Wednesday, [**7-30**] at 4:00 (you will also have an echo
the same day)
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Apartment Address(1) 98993**]
[**Location (un) 86**], [**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,706
| 154,002
|
33468
|
Discharge summary
|
report
|
Admission Date: [**2153-2-5**] Discharge Date: [**2153-2-12**]
Date of Birth: [**2112-10-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/pCABGx1(SVG-OM)
History of Present Illness:
pt with known coronary desease presents for bypass graft
Past Medical History:
PMH:anxiety
Social History:
social drinker
no alcohol
Family History:
n/c
Physical Exam:
a/o
nad
grossly intact
cta
rrr
benign abdomen
palp pulses
sternal inc c/d/i
Pertinent Results:
[**2153-2-11**] 01:05PM BLOOD
WBC-9.2 RBC-2.81* Hgb-9.0* Hct-25.3* MCV-90 MCH-32.0 MCHC-35.4*
RDW-13.0 Plt Ct-279
[**2153-2-10**] 08:55AM BLOOD
Glucose-142* UreaN-7 Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-26
AnGap-12
[**2153-2-6**] 01:10AM BLOOD
ALT-21 AST-26 LD(LDH)-147 AlkPhos-43 Amylase-60 TotBili-0.3
[**2153-2-10**] 08:55AM BLOOD
Calcium-8.1* Phos-3.9 Mg-1.8
[**2153-2-7**] 10:28PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
URINE RBC-0-2 WBC-21-50* Bacteri-MANY Yeast-NONE Epi-[**6-5**]
[**2153-2-7**] 10:28 pm URINE Source: CVS.
URINE CULTURE (Final [**2153-2-9**]):
PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000 ORGANISMS/ML..
Brief Hospital Course:
pt admitted
found to UTI - treated with flagyl - see urine cx
underwent cabg - no sequele
cvicu - weaned from preesure support / extubated
ct out post op day 2 / foley out post op day 2
low hct 22
pw out post op day 3
pt transfused after increase HR low BP with ambulation
post hct 25
pt / clears for home
Medications on Admission:
[**Last Name (un) 1724**]:ASA 325', lopressor 25", tylenol 650 protonix 40', colace
100'
Discharge Medications:
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
CAD
low hct secondary to OR procedure - requirunf trransfusion
UTI
anxiety
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. 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.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
[**Last Name (LF) **],[**First Name3 (LF) **] H [**Telephone/Fax (1) 29920**], should follow up ion 1-2 weeks
Completed by:[**2153-2-12**]
|
[
"V17.3",
"414.01",
"285.9",
"599.0",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"99.04",
"99.20",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1920, 1979
|
1441, 1757
|
330, 350
|
2099, 2108
|
646, 1418
|
2823, 3127
|
530, 535
|
1897, 1897
|
2000, 2078
|
1783, 1873
|
2132, 2800
|
550, 627
|
280, 292
|
378, 436
|
458, 471
|
487, 514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 189,387
|
50314
|
Discharge summary
|
report
|
Admission Date: [**2148-7-27**] Discharge Date: [**2148-8-6**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Peripherally Inserted Central Catheter
Central Line Placement (R IJ)
History of Present Illness:
The pt is a 51-yo woman with T1-T2 paraplegia, COPD, and
multiple recent admissions for pneumonia, who comes in from home
with hypoxia, somnolence, and cough productive of green sputum.
The pt and husband confirm that she had been feeling very well
until the morning of admission. On the morning of admission, the
husband found her to be more difficult to arouse. He checked her
oxygen saturation and found her to be 92-93% on 2L NC, but over
the next few hours continued to be somnolent and with
progressively worsening hypoxia to the low 80s on 2L NC and
still less than 90% on 4L NC, so she was brought in to the ED.
Her husband also reports that she has had increased cough today,
with green liquid/watery secretions, and feeling cold, but notes
that she was warm to touch. He found her temperature to be 99F.
She denies any chest pain, palpitations, shortness of breath, or
wheeze.
.
On arrival to the ED, VS - Temp 101.8F, BP 144/102, HR 110, R
24, SaO2 81%. She was placed on NRB with improvement to 100%.
CXR showed worsening RLL process, and ECG was unremarkable.
Right IJ CVL was placed due to difficulty gaining access, and
blood Cx were sent. She received 1L NS IVF, Zosyn 4.5g IV, and
Vancomycin 1g IV. She is admitted to the MICU for further care
given her hypoxia requiring NRB. Lactate was 1.5 and all other
labs were pending at time of transfer.
.
Of note, the pt was admitted for pneumonia from [**2148-6-11**] -
[**2148-6-15**] with RLL consolidations, treated with Vancomycin and
Cefepime, with a brief admission to the MICU for hypotension and
fever that improved without intubation or pressors, transferred
to the floor and ultimately discharged on a 7-day course of
antibiotics. She was again admitted to [**Hospital1 18**] from [**2148-7-19**] -
[**2148-7-21**] with fever and hypoxia, which was thought to be related
to a possible exacerbation of viral bronchitis with atelectasis.
She was discharged with acappella for chest PT to aid in lung
expansion and decrease oxygen dependence. She was feeling
significantly improved on discharge and was doing very well at
home until the day of admission.
.
ROS: As per HPI. Otherwise, she denies any headache, dizziness,
lightheadedness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, dysuria, arthralgias, or
myalgias.
.
Past Medical History:
1. T1-T2 paraplegia following MVC [**1-4**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]
Social History:
- Lives at home with her husband and 2 adolescent children
- Tobacco: 35 pack years, quit smoking several months ago, but
relapsed recently (last cigarette was week of presentation).
- etOH: Denies
- Illicits: Denies
Family History:
No history of lung disease.
Physical Exam:
VS: Temp 99.8F, BP 103/49, HR 101, R 21, SaO2 93% NRB
Gen: ill appearing. On 4L NC. Mild respiratory distress
HEENT: pale conjunctiva. Dry mm. poor dentition. no cervical
LAD. neck supple. R IJ in place.
CV: Difficult to auscultate [**3-5**] to coarse BS. RRR. No MRG
appreciated. NL S1,S2
Pulm: Course breath sounds, rhonchorous throughout bilaterally
R>L. Exp wheezes present. Wet craclkes in LLF's B'L.
Abd: Protuberant. NBS. NT. No HSM appreciated.
GU: Foley. Chronic [**3-5**] T1/T2 paraplegia.
Ext: 2+ pitting edema B/L up to the knee
Neuro: Oriented to person, place, and time. Pt. appears midly
lethargic. CN II-XII grossliy intact. SNo sensation to touch
below L2 dermatome BL. Can twist abdomen and move arms. 5+
strength in UE B/L.
Skin: clammy, pale. 3x3 macule on R. Foremarm.
Pertinent Results:
[**2148-7-27**] 05:05PM URINE Blood-NEG Nitrite-POS Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
.
[**2148-7-29**]
.
WBC 10.4 (93.3% PMNs), Hgb 9.8, Hct 30.4, Plt 210
Na 139, K 3.6, Cl 100, HCO3 32, BUN 13, Cr 0.3, Gluc 124
Lactate 1.5
UA: clear yellow, pH 6.5, SG 1.024, trace leuks, positive
nitrite, 25 protein, trace ketone; negative blood / glucose /
bilirubin / urobilinogen; 0-2 RBCs, 11-20 WBCs, many bacteria,
no yeast, 0-2 epithelial cells, 0-2 transitional epithelial
cells, 0-2 fine granular casts, occasional WBC clumps
.
[**2148-8-1**] 08:55PM BLOOD Type-ART pO2-64* pCO2-69* pH-7.40
calTCO2-44* Base XS-13
.
[**2148-8-2**] 05:41AM BLOOD calTIBC-190* Hapto-332* Ferritn-265*
TRF-146*
.
[**2148-8-6**]
BLOOD WBC-6.4 RBC-3.58* Hgb-9.5* Hct-30.7* MCV-86 MCH-26.6*
MCHC-31.1 RDW-15.4 Plt Ct-327
Glucose-89 UreaN-4* Creat-0.3* Na-146* K-3.7 Cl-100 HCO3-42*
AnGap-8
.
.
.
.
MICROBIOLOGY
.
URINE CULTURES **FINAL REPORT [**2148-7-30**]**
.
URINE CULTURE (Final [**2148-7-30**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
([**Month/Day/Year 40097**]) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
[**Month/Day/Year 40097**]-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- 2 S
SPUTUM CULTURES **FINAL REPORT [**2148-7-31**]**
.
GRAM STAIN (Final [**2148-7-28**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2148-7-31**]):
SPARSE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
51-yo woman with T1-T2 paraplegia, COPD, multiple recent
admissions for pneumonia, now admitted with hypoxia and fever,
altered mental status.
.
#. Hypotension: The patient was admitted with relative
hypotension compared to home blood pressures. A right IJ CVL was
placed in the ED and the patient's pressures did not respond
sufficiently to aggressive fluid resuscitation. On admission to
the MICU unit, a Levophed drip was started, more NS was
administered and her MAP and CVP responded. On [**7-28**]/[**Numeric Identifier **], the
patient was weaned off levophed. She remained relatively
normotensive throughout the remainder of her MICU stay, and was
eventually transferred to the general medical floors on [**2148-8-5**].
The pt. had one episode of severe hypotension to 60mmHg SBP
accompanied by altered mental status several days after being
transferred to the general medical floor. This occurred after
delivering 20 mg of Lasix the day prior for severe shortness of
breath secondary to pulmonary edema. Additionally, the pt's O2
sats dropped to the mid 80's and ABG's were performed which
showed CO2 retention. The pt. was stabilized with fluid boluses
and O2 nonrebreather. At this time, her medication list was
re-evaluated as it contained multiple centrally acting sedating
medications (medication addendum listed below). The pt. was
normotensive for the remainder of her stay.
.
#. Hypoxia: Pt was admitted with significant hypoxia. Right
lower lung exam and CXR findings concerning for pneumonia.
Fever, leukocytosis with neutrophilic predominance, and
increased sputum production supportive as well of a pneumonia.
Sputum notably pink and mucoid in appearance. Per recent chest
CT, the patient also had some atelectasis and mucoid impaction
which likely contributed to her presenting hypoxia. Broad
spectrum antibiotics, vancomycin and zosyn, were initiated to
treat hospital acquired pneumona. On [**2148-7-28**], after
persistent hypotension despite treatment, ciprofloxacin was
briefly initiated to provide double coverage for pseudomonas.
Ciprofloxacin was discontinued on the same day after infectious
disease consult advised low probablity of success with cipro
after zosyn resistance identified. On [**2148-7-29**], Zosyn was
discontinued as cultures were vancomycin sensitive. Chest
physical therapy was performed throughout her stay and the
patient required oxygen supplementation (4 liter nasal canula)at
the time of transfer from the MICU. The patient was given 10mg
IV lasix on [**7-30**] and [**2148-7-31**] to diurese the patient after CXR
demonstrated evidence of fluid overload. On transfer to the
floor, the pt. had oxygen saturations persistently in the low
90's. Sputum cultures were MRSA positive, and the pt. was
continued on Vancomycin. She had an episode of severe
respiratory distress several days after transferring to the
general medical floors. The pt. had crackles on exam, and she
was given 20 mg of Lasix to relieve her pulmonary edema.
Additionally, she was put on O2 NRB, then weaned to 4-5 L NC.
The following day, the pt's blood pressure dropped and she
experienced aother episode of hypoxia (as outlined above). She
was bolused fluids, put on NRB, and weaned to 4L NC. At this
time, her medication list was also reevaluated (as above) as her
MS/pulmonary performance was waxing and [**Doctor Last Name 688**] since her return
from the MICU. After her medication adjustments, the pt's O2
demands slowly improved until discharge where she was doing well
breathing room air.
.
#. Altered mental status: Patient initially presented with
altered mental status thought to be likely toxic-metabolic given
infection, hypoxia and hypotension. An ABG taken on [**7-27**]/201
showed CO2 of 56 suggesting carbon dioxide retention and mental
status changes secondary to hypercarbia. However, review of
records demonstrated chronic hypercarbia with pCO2s in 50s-60s.
Altered mental status largely resolved throughout her stay in
the MICU. On the general medical floors, the pt. had several
issues with waxing/[**Doctor Last Name 688**] mental status thought to be a
combination of poor ventilation/over sedation with centrally
acting medications. Adjustments were made to her medication
list, and the pt's mental status improved to a consistently
interactive state. Changes in medications are outlined below:
.
Addendum: Pt has been waxing and [**Doctor Last Name 688**] with her mental status,
and has been fluctuating in her ability to maintian oxygen
saturations in the 90-92 range, dipping as far as 80%. Her
medications were reviewed, and with the help of the on-call
pharmacist, several changes have been made. Her attending Dr.
[**Last Name (STitle) 665**] is aware and agrees with the medication changes.
.
PREVIOUS MEDICATION DOSE..........NEW MEDICATION DOSE
Oxybutynin- 10 mg TID ........... DISCONTINUED
Pregabalin- 150 mg TID........... Titrated down- New dose 100 mg
TID
Methadone- 5 mg TID .........changed to 5mg [**Hospital1 **]-- back to TID
[**2148-8-6**]
Baclofen-20mg,10mg,10mg.............10 mg TID
.
#. UTI: Patient admitted with a urinalysis concerning for a UTI.
The patient has a history of [**Month/Day/Year 40097**] urinary tract infections.
Meropenem was initially withheld as colonization of her urinary
tract was presumed and prior [**Month/Day/Year 40097**] infections were Zosyn
sensitive. While no urinary cultures were positive, Meropenem
treatment was initiated on [**2148-7-31**] as the patient's mental
status had some-what worsened despite treatment for pneumonia.
The pt. was continued on Meropenem throught the duration of her
hospitalization, and was discharged on Ertapenem to finish her
treatment cycle.
.
#. COPD: Past medical records demonstrate that the patient may
have some component of hypercarbia in setting of COPD, with
pCO2s in the 50s-60s. Sedating medications were held as
tolerated during the day and the patient was continued on home
albuterol and ipratropium. She was counselled on smoking
cessation and reports that she has stopped several months prior.
During her stay on the general medical floors, the pt had
several issues with chronic CO2 retention and exaing/[**Doctor Last Name 688**]
mental status as outlined above. Upon discharge, the importance
of not smoking was emphasized to the pt.
.
#. Depression: Reportedly increased from baseline despite home
Celexa. Patient previously amenable to seeing a psychologist as
an outpatient. She was continued on her Celexa and social work
was consulted and has been following the patient. The patient
was continued on her home Klonapin dose for anxiety and
Trazadone was added on [**2148-7-31**] as a sleep aid. The pt. was
continued on these medications during the rest of her hospital
stay.
.
#. T1-T2 paraplegia with chronic pain: Patient maintained on
multiple medications at home including baclofen, lidocaine
patch, methadone, oxybutynin, pregabalin, trazodone, oxycodone.
Due to waxing/[**Doctor Last Name 688**] mental status, several of her medications
were changed (see above addnedum).
.
#. Hypothyroidism - the patient was contined on home
levothyroxine.
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia
2. Albuterol-Ipratropium [**2-3**] PUFF IH TID
3. Baclofen 10 mg PO/NG HS
4. Baclofen 10 mg PO/NG NOON
5. Baclofen 20 mg PO/NG BREAKFAST
6. Citalopram Hydrobromide 40 mg PO/NG DAILY
7. Clonazepam 1 mg PO/NG [**Hospital1 **]
8. Docusate Sodium 100 mg PO BID
9. Levothyroxine Sodium 75 mcg PO/NG DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Methadone 5 mg PO/NG TID
12. Oxybutynin 5 mg PO NOON
13. Oxybutynin 10 mg PO BREAKFAST
14. Oxybutynin 10 mg PO HS
15. Polyethylene Glycol 17 g PO/NG DAILY
16. Pregabalin 150 mg PO/NG TID
17. Sucralfate 1 gm PO/NG QID
18. traZODONE 100 mg PO/NG HS
19. OxycoDONE (Immediate Release) 5 mg PO TID pain
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous
every twelve (12) hours for 3 days.
Disp:*QS * Refills:*0*
2. Ertapenem 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous
once a day for 3 days.
Disp:*QS * Refills:*0*
3. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
4. Pregabalin 75 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times
a day).
5. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
7. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily).
10. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
11. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO NOON (At Noon).
12. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours).
15. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
16. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety / sleep.
17. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
18. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BREAKFAST
(Breakfast).
19. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Inhalation every 4-6 hours as needed for SOB.
21. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puffs
Inhalation TID PRN as needed for shortness of breath or
wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
Pneumonia (organism: Methicillin Resistant Staph Aureus)
Urinary Tract Infection - (organism: Extended spectrum
betalactamase resistant Klebsiella)
Sepsis (organisms per above)
.
Secondary Diagnosis
Chronic obstructive pulmonary disease
Paraplegia (lower extremity)
Chronic Pain
Hypothyroidism
Anxiety
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were hospitalized with a severe Pneumonia and Urinary Tract
Infection. You developed a condition known as sepsis, and
required intensive care in the medical intensive care unit for
several days. Once you were stable in the intensive care unit,
you were sent to the general medical floors to receive continued
care as you regained your strength and your infections resolved.
You were treated with very strong antibiotics, which you will
continue to take outside the hosptial. These drugs are called
VANCOMYCIN and ERTAPENEM.
While you were on the general medical floors, you had issues
with your breathing, requiring increased oxygen to breath. In
agreement with your primary care doctor, we changed several of
your medications that were causing you to be overly sedated,
preventing you from breathing well. After the change in
medications was made, your clinical status continued to improve.
You had installation of a peripherally inserted central
catheter (PICC LINE) to allow you to receive antibiotics IV
outside the hospital.
.
SEVERAL OF YOUR HOME MEDICATIONS HAVE BEEN CHANGED!
.
PREVIOUS MEDICATION DOSE..........NEW MEDICATION DOSE
Oxybutynin- 10 mg 3x day........... DISCONTINUED
Pregabalin- 150 mg 3x day......... Titrated down- New dose 75mg
3x day
Methadone- 5 mg TID .........changed to 5mg [**Hospital1 **]-- back to TID
[**2148-8-6**]
Baclofen-20mg,10mg,10mg.............10 mg TID
.
You will continue to take antibiotics outside the hospital:
VANCOMCYIN:
ERTAPENEM:
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2148-8-13**] at 10:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2148-8-20**] at 12:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2148-8-29**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"070.54",
"038.12",
"995.91",
"535.50",
"496",
"599.0",
"428.0",
"V12.51",
"518.83",
"285.29",
"344.1",
"482.42",
"038.49",
"428.33",
"244.9",
"338.29",
"311",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17950, 18005
|
7878, 11432
|
324, 395
|
18361, 18361
|
4324, 7855
|
20059, 20945
|
3469, 3498
|
15779, 17927
|
18026, 18340
|
15050, 15756
|
18539, 20036
|
3513, 4305
|
276, 286
|
423, 2745
|
18376, 18515
|
2767, 3218
|
3234, 3453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
376
| 197,503
|
45066+45067
|
Discharge summary
|
report+report
|
Admission Date: [**2140-5-16**] Discharge Date: [**2140-5-21**]
Date of Birth: [**2068-1-22**] Sex: F
Service: MED
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is a 72-year-old female
with history of hypertension, diabetes type 2, and
diverticulosis by colonoscopy in [**7-10**], who presents with
large volume of BRBPR x2 this a.m. The patient was unclear
about amount of bleeding, but quantifies it as cupfuls. She
had 2 more episodes in the ED with 1 episode about 200 cc [**Name8 (MD) **]
RN. In the ED, her hematocrit was noted to be 37.2 (baseline
36 to 37) and hemodynamically stable with blood pressure
129/88 and pulse 95. Unfortunately, she failed NG lavage.
She has never had prior GI bleeding and denied chest pain,
shortness of breath, lightheadedness, abdominal pain,
nausea/vomiting, palpitations, recent fevers and chills,
recent NSAID use, GERD, anticoagulation, ETOH. She received
1.5 liters of normal saline following resuscitation in ED and
was transferred to the floor.
PAST MEDICAL HISTORY: Hypertension.
NIDDM.
Diverticulosis with no history of GI bleed (colonoscopy,
[**7-10**], showing diverticula of sigmoid and descending colon
and grade 1 internal hemorrhoids, otherwise normal to cecum).
Seborrheic keratosis.
MEDICATIONS: On admission,
1. Hydrochlorothiazide 50 mg p.o. q.d.
2. KCl 20 mEq p.o. q.d.
3. Glyburide 5 mg p.o. q.d.
4. Prazosin 1 mg p.o. b.i.d.
5. Moexipril 15 mg p.o. q.d.
6. MDI.
7. Calcium carbonate.
ALLERGIES: PENICILLIN WITH UNCLEAR REACTION.
SOCIAL HISTORY: The patient lives in [**Location 96323**] with husband
(who is currently hospitalized in Rehab Center with CVA), no
tobacco or ETOH.
PHYSICAL EXAMINATION: On admission, vital signs, blood
pressure 124/79, pulse 74, respirations 18, 97 percent on
room air with blood pressure and pulse changing to 99/58 with
pulse of 81 during course of examination. General: NAD,
resting on the stretcher, alert and oriented x3. HEENT:
PERRLA, EOMI, MMM, clear oropharynx, anicteric sclerae.
Neck: Supple, no JVD, no lymphadenopathy. Cardiovascular:
Regular rate and rhythm, normal S1 and S2; no murmurs, rubs,
or gallop. Lungs: Clear to auscultation bilaterally.
Abdomen: Normoactive bowel sounds, soft, nontender,
nondistended. No hepatosplenomegaly. Extremities: No
clubbing, cyanosis, or edema, 2 plus PT pulses. Rectal:
Skin tag at anus with bright red blood noted, good sphincter
tone.
LABORATORY DATA: On admission, significant for white count
of 4.3 with 16 neutrophils, 33 lymphocytes, 4 monocytes, 4
eosinophils. Hematocrit 37.2, platelets 311. Chemistry is
notable for BUN 26, creatinine 0.9.
On [**2140-5-16**], ECG, normal sinus rhythm at 79 beats per minute,
normal axis and intervals, left atrial enlargement, frequent
PACs, no ST-T wave changes from prior ECG.
HOSPITAL COURSE: Bright red blood per rectum. Patient was
typed and crossed for several units of packed red cells and
was ensured adequate peripheral IV access and given normal
saline for volume resuscitation. Over the course of the
evening, she had several more episodes of hematochezia while
attempting to prep for colonoscopy for the following day.
Her hematocrit dropped to 24 over the next several hours and
the patient was sent for packed red blood cell scan given the
active bleeding. This localized the area of bleeding to the
distal transverse colon just proximal to the splenic flexure.
She was then immediately sent to angiography, which
unfortunately was unable to localize the bleed. She was
monitored in the MICU for the next several days and
transfused several units of packed red cells for continually
decreasing hematocrit. She had a colonoscopy on [**2140-5-17**]
showing extensive diverticulosis in the entire colon, though
more concentrated in the left colon, and fresh blood in the
rectosigmoid colon to about 50 cm from the anal verge, but
most concentrated from about 40 to 50 cm and no bleeding
proximally. While fresh blood was continually seen, no
specific bleeding diverticulum was identified. She
stabilized over the next few days and continued on IV
Protonix, though the most likely source of bleeding was from
the sigmoid or descending colon, secondary to diverticulosis.
After her hematocrit stabilized with no further episodes of
hematochezia, the patient was transferred to the floor and
prepared for discharge. Surgery had evaluated the patient
earlier, but did not wish to operate at this time. However,
we discussed with the patient that these episodes were likely
to recur and should they recur surgery may be indicated in
the future.
Anemia. The patient was transfused a total of 8 units of
packed red blood cells during this admission. She was
started on iron supplements on discharge.
NIDDM. She was on sliding scale insulin, but will restart
her p.o. hypoglycemics on discharge.
Prophylaxis. The patient will not need to continue PPI at
home as unlikely to have upper GI lesions.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Diverticulosis.
Lower gastrointestinal bleed.
Hypertension.
Diabetes, non-insulin dependent.
Internal hemorrhoids.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 50 mg p.o. q.d.
2. KCl 20 mEq p.o. q.d.
3. Glyburide 5 mg p.o. q.d.
4. Prazosin 1 mg p.o. b.i.d.
5. Moexipril 15 mg p.o. q.d.
6. MDI.
7. Calcium carbonate.
8. Iron 325 mg 1 tablet p.o. t.i.d.
9. Colace 100 mg p.o. b.i.d.
FOLLOW-UP PLANS: The patient was advised to follow up with
her primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**], in the next few days.
She was advised from the GI team to eat a high-fiber diet,
but that these episodes may recur. She was instructed to
return to the Emergency Department immediately should she
experience any further bright red blood per rectum.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], [**MD Number(1) 93373**]
Dictated By:[**Last Name (NamePattern1) 7193**]
MEDQUIST36
D: [**2140-6-1**] 11:00:25
T: [**2140-6-1**] 12:47:56
Job#: [**Job Number **]
Admission Date: [**2140-5-22**] Discharge Date: [**2140-5-25**]
Date of Birth: [**2068-1-22**] Sex: F
Service: MED
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
female with recent discharge after diverticular bleed
presents with repeated bright red blood per rectum. During
the last admission, the patient had colonoscopy on [**2140-5-17**]
showing fresh blood in the left colon up to 50 cm with
extensive diverticulosis. She had packed red blood cells
again on [**2140-5-16**] showing active bleeding at the distal
transverse colon proximal to the splenic flexure and then in
angio, which was unable to visualize active bleeding. On the
morning of admission, the patient had 3 episodes of passing
clots (greater than size of a quarter). She denies
dizziness, lightheadedness, nausea, vomiting, diarrhea,
fevers, chills, chest pain, or shortness of breath. She does
report hearing a rapid heartbeat. In the ED, vital signs
stable and hematocrit noted to be 24 down from 28 on
discharge. She was given 2 units of packed red cells.
PAST MEDICAL HISTORY: Diverticulosis, status post recent GI
bleed.
Diabetes type II.
Hypertension.
MEDICATIONS:
1. Protonix 40 mg by mouth every day.
2. Minipress 1 mg by mouth every day.
3. Moexipril 15 mg by mouth every day.
4. Hydrochlorothiazide 50 mg by mouth every day.
5. Glyburide 5 mg by mouth every day.
6. Iron supplements 3 times a day.
7. Potassium 20 mEq by mouth every day.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Husband in hospital in [**Location (un) 38**] status post
stroke, 6 children.
PHYSICAL EXAMINATION: Temperature 97 degrees, blood pressure
122/72, pulse 75, respirations 14, and O2 saturation 100
percent on 2 liters. In general, a well-appearing female in
no acute distress. HEENT: PERRL, anicteric. Moist mucous
membranes. Throat without erythema. Cardiovascular:
Regular rate and rhythm. Normal S1 and S2. Chest: Clear to
auscultation bilaterally. Abdomen: Normoactive bowel
sounds, soft, nontender, and nondistended. Extremities:
Pitting edema [**12-11**] plus bilaterally, 2 plus DPs. Rectal:
Bright red blood seen at anus.
LABORATORY DATA: Laboratory data on admission is significant
for white count 4.6 with 76 percent neutrophils, 19 percent
lymphocytes, 3 percent monocytes, hematocrit 24.7, and
platelets 269. Chemistry is notable for potassium of 3.7,
BUN 17, creatinine 0.8, glucose 119, CK 389, MB of 7, and
troponin less than 0.01.
RADIOGRAPHIC STUDIES: EKG, no ST- or T-wave changes. Sinus
tachycardia at 96 beats per minute.
HOSPITAL COURSE: Bright red blood per rectum. The patient
was prepped for repeat colonoscopy, which showed multiple
diverticula with large openings in the sigmoid and descending
colon, but no blood seen anywhere, as well as a single
sessile 6 mm non-bleeding polyp of benign appearance in the
descending colon, which was excised. No intervention was
performed at that time and the patient did not have any
further bleeding. Her hematocrit remained stable at 32 on
discharge. Again, she was recommended to eat a very high-
fiber diet and take Colace. A left hemicolectomy was
discussed with her in case of re-bleed and the patient is
aware that she may have to have this done in the future as it
is very likely that she will re-bleed.
Hypertension. Her blood pressure medications were held, and
she was advised to not take them until she follows up with
her primary care doctor in the next week.
Type II diabetes. Oral hypoglycemics were held while n.p.o.,
but she will resume her normal medications on discharge.
Diet. Repleted electrolytes and the patient was tolerating
solids by discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Lower gastrointestinal bleed likely
secondary to diverticulosis.
Diabetes.
Hypertension.
Blood loss anemia.
DISCHARGE MEDICATIONS: As per admission medications with the
addition of Colace 100 mg by mouth 2 times a day.
FOLLOW-UP PLANS: The patient was advised to call PCP for
[**Name9 (PRE) 702**] in the next week to monitor hematocrit and blood
pressure.
[**First Name11 (Name Pattern1) 1528**] [**Last Name (NamePattern4) **], [**MD Number(1) 93373**]
Dictated By:[**Last Name (NamePattern1) 7193**]
MEDQUIST36
D: [**2140-5-27**] 16:19:48
T: [**2140-5-28**] 06:31:23
Job#: [**Job Number 96324**]
|
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icd9cm
|
[
[
[]
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[
"45.23",
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icd9pcs
|
[
[
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9901, 9939
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,015
| 102,584
|
27681
|
Discharge summary
|
report
|
Admission Date: [**2194-12-1**] Discharge Date: [**2194-12-5**]
Date of Birth: [**2157-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
overdose
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
He presented to the ED reported that he was s/p ingestion (right
prior to coming into the ED) of 12 400mg seroquels and 11 900mg
pills of trileptals. However the patient only had 600mg
trileptal pills available to him and none on his person despite
bringing in a bag of his meds.
.
In the ED, vital signs on arrival were 96.0 116 149/94 16 98%.
In the ED the patient was originally asking questions
appropriately but became increasingly somnolent. The patient was
vomiting large amounts in the ED. He was given etomidate 20mg
and succ 120mg and intubated. He received was then put on
propofol. CXR showed low lung volume, ET tube terminates at 4.9
cm above carina, NG tube terminating at appropriate location,
mild pulm vasc congestion, bibasilar opacities likely infection
vs aspiration. He received 2.5L of NS and zofran 4mg IV x1 in
the ED.
.
The pt's exam was notable for mydriasis with pupils dilated to
5mm, roving eye movements, diaphoretic, slurred speech, [**5-6**]
beats of clonus, psychomotor depression, wheezy after
intubation, mottling of the hands, poor cap refill. There was no
evidence rigidity or fevers. His EKG at 18:20 was notable for
sinus tachycardia to 117 and Qtc of 387 with QRS of 80 and then
repeat EKG at 18:50 was sinus tachycardia to 104 and Qtc of 331
with QRS 86. FS was normal at 134. CBC was unremarkable.
Electrolytes were normal. Serum tox screen was pending at the
time of transfer. Unable to place foley to get urine tox. Vitals
prior to transfer were Hr 93, BP 135/84 RR 15 100%.
.
On arrival to the ICU were 100% on AC TV 550 RR14 PEEP 5 Fio2
100%, HR 94 BP 154/96. He was awake on 60mcg/kg/min and
responding to commands. EKG was concerning for 1mm ST elevations
in v5, v6, old ST elevation in II, old j point elevation in
v2/v3. His QRS remained narrow and his QTC was 383.
Past Medical History:
Past Psych Hx:
- dx of bipolar II with psychotic features in the past- symptoms
unclear that led to that diagnosis at this time.
- cognitive d/o NOS by neuropsychological testing [**12-9**] (prior
to
TBI)
- h/o prior psychiatric hospitalizations, with "8 or 9" suicide
attempts by overdose
- h/o assaultive behavior: stabbed a friend with a penknife many
years ago (in secondary school)
PMH:
Klinefelter's, Raynaud's, Systemic sclerosis (extent uncertain,
recent dx), hypercholesterolemia, s/p pedestrian vs. car
accident in [**1-8**] with TBI
Social History:
Per OMR: Mr. [**Known lastname 67595**] reported in previous psych notes that he has
h/o etoh abiue. Between the ages of 19 and 21 he reported
drinking 2 pints of scotch or vodka per day. [**2193-10-1**] 3 to 6
times per week, drinking a six pack of beer at each use." He
also reported a history of marijuana use. The period of
heaviest usage was between the ages of 19 and 21. He stopped
using marijuana because of its side effects such as paranoia.
[**Year (4 digits) **] h/o of IVDU and cocain in past notes but urine and serum
tox positive for methadone in [**11-9**]. H/o stabbing friend with
[**Name2 (NI) **]. After graduating high school, he worked for one year as a
prep cook, he then works at a farm, and later at [**Company 25282**]
pharmacy.
.
Family History:
His father and two aunts (paternal and maternal) have a history
of depression. This maternal aunt also has a history of alcohol
abuse.
Physical Exam:
On admission:
VS: T96.4 BP 154/96 RR18 95% on AC TV 550 RR14 PEEP 5 Fio2 100%
GEN: awake and arousable, able to squeeze hands and follow
commands
HEENT: Pupils dilated to 5 and reactive to 3, EOMI grossly,
anicteric, MMM, op, intubated
RESP: CTA b/l with good air movement throughout anteriorly
CV: RRR nl s1/s2 no m/r/g
ABD: +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: + poor cap refill in right hand and doppler but not
palpable right radial pulse, left radial pulse +1
NEURO: Pupils responsive to light bilaterally 5mm -> 3mm. Able
to squeeze hands when initially awake. 10+ beats of clonus
bilaterally in feet.
On discharge:
VS: 96.0 140/P 79 16 94% RA
GEN: NAD, AOx3, awake and alert
HEENT: anicteric, MMM, op clear, CN II-XII grossly intact
RESP: CTAB, no crackles or wheezes
CV: RRR nl s1/s2 no m/r/g
ABD: +b/s, soft, nt, nd, no hsm
EXT: wwp, no c/c/e, + poor cap refill in right hand and doppler
but not palpable right radial pulse, left radial pulse +1
Pertinent Results:
[**2194-12-1**] 10:42PM GLUCOSE-153* UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
[**2194-12-1**] 10:42PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2194-12-1**] 10:09PM TYPE-ART PO2-250* PCO2-53* PH-7.33* TOTAL
CO2-29 BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED
[**2194-12-1**] 06:35PM GLUCOSE-127* UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
CXR [**12-1**]:
IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Low lung volumes. Possible mild pulmonary vascular
congestion. Bibasilar opacities could be due to pneumonia and/or
aspiration
Tib/fib xray [**12-4**]:
Patient is status post internal fixation of the right tibia.
There is no
evidence of hardware fracture or loosening. Again identified is
an oblique
fracture of the mid shaft of the tibia with mature bridging bone
along the
lateral aspect of the tibial fracture and no significant callus
formation
along the medial aspect of the tibial fracture, unchanged. The
proximal
fibular fracture line is still seen, unchanged. There is diffuse
osteopenia.
No new fractures are identified.
IMPRESSION:
No significant change when compared to prior exam.
Brief Hospital Course:
P: 37 yo male with h/o raynauds, HL, suicide attempt, and etoh
abuse who presents with suicide attempt likely with trileptal
and seroquel but also the potential for other medications being
involved given was incorrect about doses when speaking with ED
doctors. EKG also notable for new 1mm ST elevation in v5 and v6.
.
Overdose: Pt reported over dose with seroquel and trileptal on
arrival to the ED although he was incorrect about the doses of
the medications and brought a seroquel bottle but not a
trilpetal bottle with him to the ED. The additional medications
he brought with him included: sertraline, lexapro, abilify,
trazodone, nifedipine, naltrexone, and lipitor. Tox screen was
notably negative for ASA, EtOH, Acetminophen, Benzo,
Barbituates, and Tricyclics. Both Seroquel and Trileptal can
cause CNS depression and are unlikely to cause aggitation. QRS
and QTc were normal.
Toxicology saw the patient and on the basis of possible
trileptal and seroquel overdose recommended to avoid
antipsychotics for acute aggitation and instead using benzos,
serial EKGs q4-6 hours to monitor for prolonged QTc, and
monitoring electrolytes as Tripelptal can cause mild
hyponatremia. All EKGs and electrolytes remained normal.
.
Respiratory acidosis and ? Aspiration PNA: Pt intubated for
airway protection in the setting of decreased mental status and
in the setting of large volume emesis and likely aspiration. ABG
with respiratory acidosis 7.33/53/250 with component of acute on
chronic co2 retention. Bicarb was 28. She was started on ARDS
net ventilation, and FiO2 was quickly decreased. CXR on the
second hospital day showed L consolidation and effusion,
consistent with aspiration.
.
Depression with suicidality: All psychiatric medications were
held given concern for overdose while in MICU. On awakening,
patient wrote that he wanted to kill himself. Psychiatry was
consulted. Patient was transferred to medical floor after being
extubated for observation and then was deemed medically clear
for transfer to inpatient psych floor.
.
ST elevations: 1mm in II (old) and 1mm in v5 and v6, old j point
elevation in v2 and v3. There is no reason that the meds he took
should cause ST elevations unless cocaine involved. Cocaine
screen was negative. Cardiac ischemia was thought very
unlikely.
.
Etoh abuse history: He was initially on a midazolam gtt and CIWA
after extubation, showed no signs or symptoms of withdrawal, was
taken off CIWA on medical floor. He was given thiamine, folate,
MVI.
.
Mottling on arms in ED and delayed cap refill: Pt with baseline
Raynaud's disease. On admission he had palpable radial pulse on
left and a dopplerable pulse with delayed cap refill on the
right.
.
HL: Lipitor continued
.
Bipolar II: Held home psych meds until transfer to medical
floor. Restarted seroquel, trazodone and sertraline at
outpatient doses, restarted trileptal at 300 mg [**Hospital1 **] per psych
recs. Patient will be transferred to an inpatient psych unit for
further management.
.
Urinary obstruction, unable to place foley: Pt with 800 cc
urinary retention and difficult foley placement. Urology was
consulted, found a stricture, and placed foley. They recommended
instilling 400 cc into the bladder prior, which was done and he
was able to void.
.
S/p tib/fib fracture: Stable since [**Month (only) 1096**] of last year, got
inpatient Xray which was initially scheduled as outpatient,
showed no significant change in fibula fracture. Per ortho, he
should be non weight bearing on the R leg and will follow up as
needed.
Medications on Admission:
Sertraline 100mg 2.5 tabs qam
lexapro 20 mg daily
abilify 5mg [**Hospital1 **]
trazodone 100mg qhs
nifedipine 60mg daily
naltrexone 50mg daily
lisinopril 20mg daily
lipitor 10mg daily
seroqeul 25mg 1 tab TID prn agitation
seroquel 300mg qhs
protonix 40mg daily
ducosate 100mg [**Hospital1 **]
calcium + vit D
-trileptal (had in med list but no bottle here)
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily). Tablet(s)
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. quetiapine 100 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
6. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Bipolar disorder II
Secondary:
hyperlipidemia
Raynaud's disease
systemic sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for an overdose of your
medications, for this you were in the intensive care unit and
intubated, but your breathing function recovered. After
discharge, you will be transferred to an inpatient psychiatry
unit for further management of your bipolar disorder and your
medications.
Changes to your medications:
Start taking trileptal 300 mg twice a day (decreased dose)
Followup Instructions:
You will be transferred to an inpatient psychiatry unit for
further management of your bipolar disorder.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2194-12-5**]
|
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323, 335
|
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28,805
| 133,947
|
46569
|
Discharge summary
|
report
|
Admission Date: [**2111-8-11**] Discharge Date: [**2111-8-14**]
Service: UROLOGY
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
bladder cystoscopy
History of Present Illness:
88 year old gentleman with a diagnosis of CAD, CKD, metastatic
prostate cancer, bladder cancer s/p pelvic XRT with recent
hematuria requiring PRBC's. He underwent a palliative
transurethral bladder procedure for palliation given he was
having hematuria. Cystoscopy and bladder fulgaration procedure
done earlier today. In the PACU post-procedure he developed
chest pain [**3-16**] and had TWI in the lateral leads in the setting
of being hypertensive to systolic >200. He was given SL
Nitroglycerin and CP resolved per anesthesiology report. Patient
has poor recollection of event. Given his history of CAD the
urology team called Dr. [**Last Name (STitle) 1147**], his outpatient cardiologist
who recommended beta blockade and trending cardiac enzymes. The
patient was started on Lopressor 12.5 mg PO BID this evening.
Also of note, patient has pertinent cardiac history of CAD, MI
[**2095**], coronary stents, reports occasional self-resolving chest
pain at home, and as aforementioned he also has CKD (baseline Cr
2.0-3.0).
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
bladder cancer
diabetes mellitus type 2
hypertension
Peptic ulcer disease
CAD: MIs in [**2091**] and again in [**2104**] with stents in place
perforated diverticulum with a colostomy x30 yers now s/p
reanastomosis.
Social History:
Retired, married and lives in [**Location 2199**] with wife. [**Name (NI) **] quit
smoking 35 years ago, and drinks alcohol rarely. Worked on real
estate development. Prior to that he was a musician.
Physical Exam:
Physical exam on ICU admission was as follows:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
At Discharge:
NAD
RRR
CTAB
soft, NT, ND, palpable firm R SP nodule
Foley: clear urine
Pertinent Results:
[**2111-8-11**] 06:20PM GLUCOSE-113* UREA N-24* CREAT-1.6* SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2111-8-11**] 06:20PM CK-MB-3 cTropnT-0.03*
[**2111-8-11**] 06:20PM CK-MB-3 cTropnT-0.03*
[**2111-8-11**] 06:20PM WBC-8.8 RBC-4.08* HGB-10.9* HCT-34.2* MCV-84
MCH-26.7* MCHC-31.8 RDW-14.5
[**2111-8-11**] 06:20PM PLT COUNT-359
------------------
[**8-12**] : wbc 7.3, Hct 27.8, Hgb 8.7, Plts 247
[**8-12**]: PT 14.5, PTT 33, INR 1.3
[**8-12**]: Ca 9, Mg 1.9, Phos 4
[**8-12**]: Troponin 2am .05, CK 27, MB 3
[**8-11**] : ECG 7pm Rate 83, Sinus rhythm, LAD, prolonged PR with 1st
degree AV block noted (same as prior EKGs), no ST elevations,
TWI in lateral leads, QRS WNL, QT interval WNL
Brief Hospital Course:
Assessment:
The patient is an 88yo male with a history of CAD, CKD,
metastatic prostate cancer, and bladder cancer who experienced
chest pain and hypertension following a bladder
fulgaration/cystoscopy as part of a follow-up for recent
hematuria.
Plan:
# Chest pain - History of CAD, given poor prognosis it seems
patient would be managed medically.
- trend cardiac enzymes: will con??????t trend Trops and CK q8hours ,
first 2 troponins were .03, .05 respectively
- f/up ECG this morning, last EKG with new T wave inversions in
lateral leads likely [**2-7**] mild ischemia in post-operative setting
and in conjunction with HTN episode
- Hold ASA for now given post-op status per surgery
- beta blockade with Lopressor 12.5mg PO BID
- nitro SL prn for any additional CP
# CKD - patient has baseline Cr 2.0-3.0 and was note to have Cr
1.6 on last set of labs this morning. Will continue to give
gentle IVFs for hydration post-operatively.
-will follow daily BUN/Cr
-avoid any nephrotoxic medications
#s/p bladder fulgaration/cystoscopy - patient to continue with
local irrigation of bladder overnight.
-con't Ampicillin and Gentamicin antibiotics empirically to
protect against post-op infections
-f/up with Urology on additional recs in a.m.
#DM- 2 - will place patient on SSI coverage, check qid
fingersticks
# FEN: Patient to have sips overnight, consider starting cardiac
diet PO tomorrow , and will replete electrolyes PRN. 1/2 NS IVF
now at 60cc/hr for gentle hydration
# Access: Right PIV
# PPx: Holding anticoagulation given recent surgery, no
indication for PPI at this time
# Code: FULL
# Dispo: rule out ACS with last set cycled enzymes, will
observe in ICU and consider call out later today if stable
# Comm: with patient, wife [**Name (NI) 4317**] [**Telephone/Fax (1) 98874**], son [**Name (NI) **]
[**Telephone/Fax (1) 98875**]
Floor Course: Pt transferred to the floor from ICU in stable
condition POD1. The CBI was clamped, atenolol started per
cardiology rec, Pt tolerated house diet. In AM POD2 Pt developed
small clots in Foley which were hadn irrigated clear. Hematuria
recurred following irrigation, CBI resumed O/N. POD3 CBI
clamped, no clots developed, pt otherwise stable and D/C'd home
with VNA care to resume.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day): To tip of penis while Foley catheter is in
place.
Disp:*1 tube* Refills:*4*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Follow up with your Cardiologist about your new medication.
Disp:*30 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO once a day for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
15 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice [**Location (un) 270**] East
Discharge Diagnosis:
Bladder CA
Discharge Condition:
Stable
Discharge Instructions:
-You may shower any time after surgery, but do not tub bathe,
swim, soak.
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
chest pain or shortness of breath.
-Follow up in [**1-7**] weeks for evaluation.
Followup Instructions:
Follow up in clinic with Dr. [**Last Name (STitle) 770**] in [**1-7**] weeks, or as
directed by Dr. [**Last Name (STitle) 770**]. Call [**Telephone/Fax (1) 164**] for an appointment.
Completed by:[**2111-8-14**]
|
[
"585.9",
"V44.3",
"V45.89",
"250.00",
"V58.67",
"414.01",
"403.90",
"780.4",
"599.7",
"V45.82",
"V10.46",
"412",
"413.9",
"188.5",
"533.90",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"57.49"
] |
icd9pcs
|
[
[
[]
]
] |
6692, 6778
|
3737, 4099
|
230, 250
|
6833, 6842
|
2985, 3714
|
7183, 7397
|
6014, 6669
|
6799, 6812
|
6866, 7160
|
2138, 2878
|
2892, 2966
|
4116, 5991
|
180, 192
|
278, 1665
|
1688, 1905
|
1921, 2123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,789
| 171,922
|
12319
|
Discharge summary
|
report
|
Admission Date: [**2194-2-25**] Discharge Date:
Date of Birth: [**2146-9-17**] Sex: M
Service: [**Company 191**]
DATE OF DEATH: [**2194-3-1**].
HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old
male with HIV disease who is admitted with increasing
shortness of breath and increasing oxygen requirement. The
patient was admitted [**2194-2-7**] until [**2194-2-14**] with
presumed PCP [**Name Initial (PRE) 1064**]. He was initially treated with
Levofloxacin and Bactrim. The Levofloxacin was discontinued
on hospital day four. Of note his sputum was negative for
PCP on that admission and he had no infiltrate on chest
x-ray. He was discharged home on prednisone taper and
Bactrim as well as Zithromax, Mycelex and oxygen.
At home he felt tired and weak but he only needed to use his
oxygen immediately after exertion. His temperature was
consistently around 100 F. Two days ago his temperature
increased to 101 F and he felt increasingly short of breath
and needed his oxygen at rest. He also reports night sweats
when febrile. He denies urinary symptoms, nausea, vomiting,
diarrhea or cough. He states he has been taking all his
medications as prescribed.
On the date of admission VNA came to check and found that his
oxygen saturation was in the low 80s. The patient was
brought to the ER for further evaluation.
In the ER he was found to have a room air saturation in the
high 80s and on chest x-ray a new left sided infiltrate.
PAST MEDICAL HISTORY:
1. HIV since [**2178**], no opportunistic infections until [**2194-1-24**]. He stopped his antiretroviral medications around
[**Month (only) 1096**] because of a move and insurance issues.
MEDICATIONS:
1. Zithromax 1200 milligrams po q week.
2. Dapsone 100 milligrams po q day.
3. Mycelex po five times a day.
4. Prednisone 20 milligrams po q day.
5. Bactrim double strength two tablets po tid day 11 on 14
day course.
ALLERGIES: Rash to Bactrim.
SOCIAL HISTORY: Smoked one packs a day for 19 years. He
quite three weeks ago. Alcohol one ounce of vodka a day. He
denies binges. No other drugs. Not currently sexually active.
Former American Airlines pilot. Recently moved here from [**Last Name (un) 38424**]. He lives with his mother.
FAMILY HISTORY: Brain cancer in his father. [**Name (NI) **] aneurysm
in his brother. [**Name (NI) 3495**] disease in his mother.
PHYSICAL EXAMINATION: Temperature 98.3 F, heart rate 92,
blood pressure 116/70, respiratory rate 18. Saturation 87% on
room air, 93% on four liters. HEENT - pupils are equal,
round and reactive to light. Extraocular muscles are intact.
Oropharynx is clear, no thrush. Respiratory - decreased
breath sounds at right lung. Crackles at the left base. No
wheezes. Heart - regular rate and rhythm, no murmurs. Abdomen
- soft, nondistended, nontender. Extremities - well
perfused, no clubbing or cyanosis. Skin - dry flaking
especially in the lower extremities. He has a red macular
blanching rash on his face in a malar distribution. Neuro -
alert and oriented times three. Cranial nerves are intact.
Sensation intact, 5/5 strength throughout.
LABORATORY DATA: Sodium 129, potassium 4.4, chloride 94,
bicarb 25, BUN 18, creatinine 0.5, glucose 113. White blood
cell 8.1, hematocrit 44.8, platelet count 247,000.
Chest x-ray showed a new diffuse, reticular nodular opacities
in the left lung throughout in the right upper lobe.
HOSPITAL COURSE: The patient was admitted and placed in
respiratory isolation for a concern about possible TB. He
was continued to be treated empirically with Bactrim which
was changed to IV. The Levofloxacin was continued. The
patient did well overnight on four liters of nasal cannula
oxygen.
On the second hospital day the patient underwent
bronchoalveolar lavage by the pulmonary team. They found no
sputum and a pretty normal lavage. The patient initially did
well but about one hour post procedure desaturated acutely
into the 60s and was transferred to the Intensive Care Unit.
Due to his wish not to be intubated the patient was treated
with noninvasive pressure ventilation to which he responded
very well.
Other possibilities were considered including PE, viral
infection, bacterial superinfection and fungal infection.
The patient was continued on Levofloxacin and IV Bactrim. He
was changed to IV Solu-Medrol secondary to concern for poor
absorption.
The patient was transferred out of the Intensive Care Unit on
the third hospital day after he did very well over night and
was comfortable with saturation in the 90s on nasal cannula
oxygen. The patient continued to do well throughout the day
and his Bactrim and Solu-Medrol were continued.
Of note the BAL results include negative cultures for any
viral infection, negative acid fast smear but positive for
PCP.
On the morning of [**2194-3-1**] the patient acutely desaturated
to the 70s on 100% nonrebreather. MICU team was called to
evaluate and a trial of BiPAP was done. However the patient
did not tolerate this and iterated again that he did not want
to be intubated. The patient was treated with 100% face
mask. As he became more uncomfortable and began to rigor and
after discussion with him the patient was given Morphine to
make his breathing more comfortable. The patient continued
to be hypoxic. His blood gas showed pH 7.44, Po2 of 38, Pco2
of 34.
The patient expired [**2194-3-1**] at 1:05. Family agreed to
limited autopsy of the thorax and abdomen.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2194-3-1**] 13:52
T: [**2194-3-3**] 11:32
JOB#: [**Job Number 38425**]
|
[
"136.3",
"042",
"786.06",
"276.5",
"V15.81",
"427.89",
"692.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
2263, 2378
|
3433, 5739
|
2401, 3415
|
191, 1472
|
1494, 1952
|
1970, 2246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,629
| 134,971
|
32864
|
Discharge summary
|
report
|
Admission Date: [**2119-1-2**] Discharge Date: [**2119-1-8**]
Date of Birth: [**2042-3-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 76 y.o. man with a history of CAD and
prostate cancer who presented to an OSH ER with hematemesis and
BRBPR on the day before [**Hospital1 18**] admission. He underwent EGD which
showed only gastritis and some "trauma" to the esophagus but no
ulcers, MWT or Dieulafoy.
Subsequent colonoscopy was notable for a dusky appearing colon
to
the hepatic flexure. There were no ICU beds at the OSH and he
was
transferred to [**Hospital1 18**] for further work-up. 3 months prior the
patient had a
single episode of upper abdominal cramping that radiated to the
lower abdomen with associated vomiting of bilious material. The
pain was relieved by multiple bowel movements about 30
minutes later which were initially formed thenloose. He had a
similar episode last month which again subsided after he passed
a loose but non-bloody stool. About 8 days ago he developed low
back pain radiating down his left leg which his PCP diagnosed as
sciatica. He was prescribed Flexeril, OxyContin and
Ibuprofen which he has been taking at least 3 times a day for
the last 3 days. Yesterday, he developed the same upper
abdominal pain for the third time and proceeded to vomit 9 times
followed by 3 episodes of small volume hematemesis.
Past Medical History:
CAD s/p MI
History of TIA
HTN
Prostate cancer
Pertinent Results:
CT PELVIS W/CONTRAST [**2119-1-2**] 5:16 AM
1. Acute colitis spanning from the mid transverse colon to the
proximal sigmoid. Given this distribution, ischemic colitic is
the most likely etiology though the mesenteric vasculature is
patent. Recommend clinical correlation.
2. Emphysema.
3. Right adrenal adenoma.
4. Cystic lesion in the subcutaneous tissues of the mid-back,
likely a a sebacious cyst.
Echo:[**2119-1-3**] at 09:54
IMPRESSION: Symmetric LVH with mild regional left ventricular
systolic dysfunction, c/w CAD.
ABDOMEN (SUPINE & ERECT) [**2119-1-5**] 11:18 AM
No evidence of small-bowel obstruction.
CHEST (PA & LAT) [**2119-1-7**] 11:34 AM
FINDINGS: There are bilateral pleural effusions, best seen on
the lateral film. These are probably increased compared to the
film from the prior day. The PICC line is unchanged. There is
increased opacity at the right base that could represent an
early infiltrate versus volume loss
[**2119-1-2**] 10:14PM CK(CPK)-61
[**2119-1-2**] 10:14PM CK-MB-NotDone cTropnT-0.01
[**2119-1-2**] 10:13PM HCT-41.8
[**2119-1-2**] 03:42PM HCT-41.1
[**2119-1-2**] 10:04AM HCT-40.4
[**2119-1-2**] 06:43AM LACTATE-3.0*
[**2119-1-2**] 04:25AM POTASSIUM-4.1
[**2119-1-2**] 03:00AM GLUCOSE-180* UREA N-20 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-113* TOTAL CO2-18* ANION GAP-16
[**2119-1-2**] 03:00AM ALT(SGPT)-30 AST(SGOT)-30 LD(LDH)-193
CK(CPK)-65 ALK PHOS-66 TOT BILI-0.8
[**2119-1-2**] 03:00AM LIPASE-21
[**2119-1-2**] 03:00AM CK-MB-7 cTropnT-0.06*
[**2119-1-2**] 03:00AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-2.0
[**2119-1-2**] 03:00AM WBC-14.3* RBC-4.91 HGB-15.9 HCT-44.8 MCV-91
MCH-32.4* MCHC-35.5* RDW-13.2
[**2119-1-2**] 03:00AM PT-15.5* PTT-28.5 INR(PT)-1.4*
Brief Hospital Course:
The patient was admitted to the gold surgery service on [**2119-1-2**]
with abdominal pain, hematemesis and BRBPR. On admission he was
started on antibiotics, IVF and pain controlThe patient was
initially admitted to the ICU, and was transferred to a surgical
floor on HD2 when stabilized.
Ischemic Colitis:
HCT trend:
[**2046-1-4**].6*
[**2045-1-3**].3*
[**2046-1-3**].8*
[**2046-1-3**].5*
[**2048-1-3**].6*
[**2050-1-2**].0*
[**2052-1-2**].8
[**2052-1-2**].1
[**2051-1-1**].4
[**2055-1-1**].8
Serial abdominal exams showed gradual improvement and the
patient reported gradually decreasing pain. Shortly after
leaving the ICU he did report a bloody bowel movement and his
HCT did show a mild drop, but soon stabilized and the patient
did not require transfusion.
GI: A GI consult was obtained on [**1-2**], and recommended
conservative treatment with antibiotics, IVF, and pain control.
Nutrition:
The patient was NPO on admission and was advanced to sips of
liquids on HD1. He was advanced to clear liquids ad lib on [**1-5**]
and to a regular diet on [**1-6**]. He gradually increased his PO
intake and was discharged tolerating a regular diet.
The patient required no intervention. He was discharged on
[**2119-1-8**] tolerating a regular diet and with pain well controlled
on oral medication.
Medications on Admission:
Oxycodone
Ativan
Cipro
Flexeril
Diazepam
Plavix
Citracal plus D
Lisinopril
Simvastatin
Flomax
Imdur
Prilosec
Aspirin 81mg
Lipitor
Advil
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not take more than 4g
of tylenol in 24 hours.
Disp:*40 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Ischemic Colitis
Discharge Condition:
Good. Tolerating a regular diet. Pain controlled on oral
medication.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily and work towards daily
ambulation.
* No heavy lifting (>[**9-20**] lbs) until your follow up
appointment.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in 2 weeks. Call ([**Telephone/Fax (1) 55864**]
for an appointment.
Please follow up with your Urologist, Dr. [**First Name (STitle) 2405**] in 1 week.
Please also schedule an appointment to follow up with your
primary care physician
|
[
"412",
"578.0",
"788.20",
"227.0",
"V10.46",
"401.9",
"557.0",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6228, 6290
|
3452, 4758
|
327, 333
|
6351, 6422
|
1681, 3429
|
7934, 8227
|
4944, 6205
|
6311, 6330
|
4784, 4921
|
6446, 7911
|
273, 289
|
361, 1593
|
1615, 1662
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,986
| 102,352
|
19504
|
Discharge summary
|
report
|
Admission Date: [**2180-10-6**] Discharge Date: [**2180-11-8**]
Date of Birth: [**2104-2-15**] Sex: F
Service: MEDICINE
Allergies:
Naproxen
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
urosepsis; metabolic acidosis
Major Surgical or Invasive Procedure:
endotracheal intubation
placement of PICC
placement of tunneled catheter for hemodialysis
removal of tunneled catheter
History of Present Illness:
76 y/o F with DM, HTN, PVD, afib not on coumadin due to hx of
SDH, CRI who was taken to [**Hospital 6687**] Hosp today for worsening
mental status. +N/V x3 days, + diarrhea on questioning. Initial
VS at scene nml. Here denies any CP, SOB, dyspnea, orthopnea.
Denies any abd pain, CP, HA, visual changes. Not able to relate
any further hx. Denies any new meds, but does not have accurate
history of her meds.
.
On transfer to our ED, her VS were 97.9, HR 93, Bp 143/63, RR
22, 94% on 4L NC. Her RR increased progressively to the 30s, and
she was placed on a NRB for hypoxia. She was given 2 amps
bicarb, 1gram of tylenol and admitted to the MICU in the setting
of her profound acidosis.
Past Medical History:
1. DM II with neuropathy
2. PVD
3. Hypertension
4. Dyslipidemia
5. Atrial fibrillation
6. h/o TB s/p LUL resection [**2129**]
7. h/o Diverticulosis s/p bowel resection [**2169**]
8. Osteoarthritis
9. h/o arrythmia s/p AV node ablation
[**82**]. s/p TAH, s/p c-section
11. s/p spinal surgery
[**84**]. s/p rt. hip surgery
[**85**]. s/p rt. EIA endartectomy with patch angioplasty w dacron
14. s/p b/l foot surgeries
15. SDH s/p mechanical fall
16. Suspected diastolic dysfunction
17. CRI likely due to HTN/DM; baseline 1.6-1.8
18. COPD on home oxygen (no PFTs in OMR)
Social History:
Married and lives with spouse of 26 years; has 2 kids. Reports
smoking (quit 20 years ago), admits to drinking [**12-7**] glasses of
wine with dinner daily.
Family History:
non-contributory
Physical Exam:
Admission exam:
VS: Temp:97.1 BP:111/53 HR:75 RR:16 O2sat: 97% 2L NC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: No jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl. IV/VI systolic murmur at RUSB that
radiates to carotids
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: +LE chronic ulcers with some granulation tissue; some areas
of pus formation. +charcot joints bilaterally. Wrist joints with
arthritis.
NEURO: AAOx2. Moves all ext spont.
discharge exam:
Neuro: LUE 4/5 strength at proximal and distal muscles, [**4-8**]
strength at RUE, 1-2/5 strength in LLE, 3/5 strength in RLE.
Pertinent Results:
labs on admission:
[**2180-10-6**] 05:01PM BLOOD WBC-11.3* RBC-3.46* Hgb-9.8* Hct-31.7*
MCV-92 MCH-28.3 MCHC-30.9* RDW-18.0* Plt Ct-115*#
[**2180-10-6**] 05:01PM BLOOD Neuts-85.8* Lymphs-5.2* Monos-3.7
Eos-5.2* Baso-0.1
[**2180-10-6**] 05:01PM BLOOD PT-13.8* PTT-42.1* INR(PT)-1.2*
[**2180-10-6**] 05:01PM BLOOD Glucose-84 UreaN-86* Creat-6.4*# Na-143
K-3.7 Cl-115* HCO3-7* AnGap-25*
[**2180-10-7**] 05:30PM BLOOD ALT-8 AST-15 LD(LDH)-368* CK(CPK)-363*
AlkPhos-103 TotBili-0.7
[**2180-10-7**] 05:30PM BLOOD CK-MB-12* MB Indx-3.3 cTropnT-0.15*
[**2180-10-7**] 10:59PM BLOOD CK-MB-11* MB Indx-3.7 cTropnT-0.15*
[**2180-10-8**] 05:44AM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.16*
[**2180-10-6**] 05:01PM BLOOD Albumin-3.2* Calcium-7.7* Phos-9.2*#
Mg-1.8
[**2180-10-7**] 05:13AM BLOOD calTIBC-156* Ferritn-721* TRF-120*
[**2180-10-6**] 05:01PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
labs on discharge:
[**2180-11-8**]: Na: 142 K: 4.8 Cl: 113 CO2: 18 BUN: 53 Cr: 2.4 glu: 78
Ca: 8.8 Mg: 2.2 P: 5.0
[**2180-11-8**]: WBC: 6.1 Hct: 33.8 Plt: 147
[**2180-11-8**]: PT: 14.8 PTT: 53.1 INR: 1.3
.
CT Head without contrast [**2180-11-4**]: IMPRESSION: No acute
intracranial pathology. Please note that MRI is more sensitive
for the detection of early CVA. If clinically indicated, MRI
with diffusion images could be performed.
.
CT abdomen/pelvis [**2180-10-25**]: IMPRESSION:
1. Large left retroperitoneal hematoma involving the iliopsoas
extends down into the left groin.
2. Unchanged nodular enlargement of the left adrenal gland is
incompletely characterized on this non-contrast CT.
3. Interstitial thickening of the dependent lung bases suggest
volume overload.
.
Portable Abdomen [**2180-10-24**]:IMPRESSION: Right-sided 7 mm renal
stone located overlying the right transverse process of the L4
vertebral body corresponding closely to the right renal stone
identified in the [**2180-6-30**] CT.
.
MRI Brain/Head/Neck [**2180-10-14**]:
FINDINGS: BRAIN MRI:
There are several areas of slow diffusion identified in both
cerebral hemispheres. In the right cerebral hemisphere,
prominent approximately 1-cm area of slow diffusion seen in the
right basal ganglia periventricular region. In addition, several
small subcortical areas of hyperintensity seen, one in the right
periatrial region and the second in right parietal subcortical
region. In addition, small areas of slow diffusion are seen in
the left basal ganglia periventricular region and left parietal
subcortical region. Findings are indicative of multiple acute
infarct, probably from embolic source. There is no midline
shift, mass effect or hydrocephalus. Moderate brain atrophy and
mild-to-moderate changes of small vessel disease are identified.
The suprasellar and craniocervical regions are normal.
.
IMPRESSION: Multiple small acute infarcts in the subcortical
region as described above. Moderate brain atrophy and mild
changes of small vessel disease.
.
MRA OF THE NECK:
Neck MRA somewhat limited by motion demonstrates mild
atherosclerotic disease at both internal carotid origin. No
evidence of high-grade stenosis seen in the internal carotid
carotids. Stenosis is also seen at the origin of the right
external carotid. Both vertebral arteries demonstrate
tortuosity, which could be secondary to cervical spondylosis.
.
IMPRESSION: Mild atherosclerotic at the origin of both internal
carotid arteries. The evaluation is somewhat limited by motion.
.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal in the arteries of
anterior and posterior circulation. Both middle cerebral artery
bifurcation regions are not visualized on projection images. In
addition, both posterior cerebral arteries are not well
visualized on projection images. However, these vessels are well
visualized on the source images.
IMPRESSION: No significant abnormalities on MRA of the head.
.
Bilateral Duplex LE [**2180-10-14**]: IMPRESSION: No evidence of DVT
involving the right or left lower extremities.
.
CT Head [**2180-10-13**]: IMPRESSION: Evidemce of sinusitis invloving
bilateral sphenoid, left ethmoid sinuses. Opacification of right
mastoid air cells. No acute intracranial pathology, hemorrhage
or masses.
.
ECHO [**2180-10-9**]: The left atrium is dilated. The right 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>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (area <0.8cm2). The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2180-1-21**],
the ejection fraction now appears normal. Moderate symmetric
LVH, severe AS and moderate pulmonary artery systolic
hypertension are similar to prior.
.
CT without contrast [**2180-10-8**]:
IMPRESSION:
1. Severe upper lobe predominant interstitial and ground-glass
opacities, with a small simple right pleural effusion and
scattered pathologically enlarged mediastinal lymph nodes.
Differential considerations include hemorrhage, interstitial
pneumonia (either infectious or acute, idiopathic) and
noncardiac edema.
2. Probable calcific aortic stenosis. Severe coronary, aortic
and branch atherosclerosis.
3. Nodular enlargement of the left adrenal gland, which cannot
be further characterized on this study. If clinically indicated,
an MRI or adrenal protocol CT may be considered.
4. Subcentimeter splenic hypodensity, which is also incompletely
characterized.
5. Nasogastric tube terminating in the distal esophagus.
.
Renal U/S [**10-6**]: No hydronephrosis
.
CXR [**10-6**]: Upright AP and lateral views of the chest are
obtained. There is persistent cardiomegaly. Improved aeration at
the left lung base is noted. Mild interstitial prominence is
again noted, which may represent interstitial edema. Mediastinal
contour is unremarkable. Atherosclerotic calcification of the
aortic knob is again noted. No large effusions are present.
Visualized osseous structures are intact. Clips are noted in the
left upper quadrant.
Brief Hospital Course:
76 y/o F with DM, HTN, PVD, afib, hx of SDH, CRI who was taken
to [**Hospital 6687**] Hosp for worsening mental status found to be in ARF
with severe acidosis. Transferred to [**Hospital1 18**] MICU for management.
Hosp course by problem:
.
# Acute respiratory distress: She initially was tachypneic to
compensate for her metabolic acidosis. She then developed
hypoxia and increased work of breathing. She was intubated for
hypoxic respiratory failure. CT chest without contrast showed
bilat infiltrates. Initially, concerning for infectious vs CHF
vs interstitial lung disease. She was started on vanco,
ceftriaxone (also for UTI), and azithro to cover broadly for
infectious causes. She briefly was treated with steroids given
possibility of interstitial pneumonitis however bronch only
showed 1 eosinophil thus this was stopped. She then was
aggressively diuresed and improved dramatically. Thus, much of
her distress was thought secondary to fluid overload given 1)
aggressive IVF resusc in OSH and 2) likely CHF. However, her
sputum grew GNR and ceftriaxone was switched to Zosyn and vanc
was started on [**10-12**] for VAP. Pt was also diuresed with lasix
gtt and iv lasix for pulmonary edema. Vanc was stopped after 8
days as sputum only grew pseudomonas. Zosyn was switched to
Cefepime on [**10-18**] when GNR was identified as pseudomonas (Later,
sensitivities returned sensitive to Zosyn and Cefepime/[**Last Name (un) 2830**]).
Pt was extubated on [**10-17**] and did well. Pt is to have 14 day
course of abx for pseudomonas and last day of Cefepime is [**10-25**].
Pt continued to diurese intermittently with IV lasix which was
switched to po lasix to keep her I/O even. Lasix was temporarily
discontinued when the patient began dialysis, but she was
restarted on lasix when dialysis was stopped. Her oxygen
saturations remained in the mid-90s on room air.
.
# Severe acidosis and acute on chronic renal failure: Acute
onset not entirely clear. She had had poor PO intake, N/V for
several days prior to admit. Her Cr though increased
dramatically from baseline. She also had pH of 7.03 on
presentation. Delta-delta suggested AG (renal failure) and
nonAG (? IVF) acidosis. She received HCO3 in ED and gradually
stabilized. Her Creatinine peaked at 6.8 and trended down once
she diuresed. Acidosis resolved as creatinine improved. The
patient had a tunnelled catheter placed for hemodialysis by
Interventional Radiology and hemodialysis was started for
uremia. She was followed by the renal service, and the decision
was made to stop dialysis, given a return of her creatinine to a
new baseline of 2.5. Her hemodialysis catheter was removed on
[**11-7**] without incident. Following discontinuation of her
hemodialysis, she was started on renagel 1600 tid, and sodium
bicarb 600 mg tid. She has an appointment scheduled with Dr.
[**Last Name (STitle) 4883**] on [**12-28**] at 10:00 AM. Her creatinine remained
stable off dialysis.
.
# Atrial fibrillation: Pt was in sinus at admission and while
intubated. However, post-extubation, pt went into atrial
fibrillation with rapid ventricular response to 140-150s. Pt
was continued on home dose amiodarone which was intermittently
held for ?pulmonary fibrosis and a couple of bradycardia
episodes but was started when AF with RVR occurred. Pt
initially responded to IV/po metoprolol, but later there wasn't
a good rate response. Thus, diltiazem drip and po dilt was
started with HR in 90-100s. EP was consulted and recommended
increasing amiodarone to 400mg [**Hospital1 **] and switching to metoprolol.
Pt was not anticoagulated at home and anticoagulation was not
continued until she suffered a stroke (see below for details)
and then anticoagulation was started.Her amiodarone was
decreased back to 400 mg qd and her diltiazem was titrated up to
60 mg qid. Her heart rate was better controlled on this regimen
in the 60s-80s, with occasional return to sinus rhythm; however,
she continued to have bursts up to the 120s. Anticoagulation is
discussed below regarding her retroperitoneal bleed. Her
amiodarone will have to be reduced to 200 mg qd in 1 week.
.
# Embolic stroke: On [**10-13**], pt was noted to have L sided weakness
with L facial droop. Stat head CT was obtained and neuro was
consulted. CT did not reveal acute processes, but MRI later
recommended by neuro whose suspicious was high for R MCA stroke
showed R caudate stroke. Pt was started on Argatroban initially
as there was a concern for HIT as plts were trending down and
with new stroke in the setting of NSR. HIT came back negative,
and argatroban was switched to heparin and plts continued to
rise. Patient's strength continued to improve during her
hospital stay. Neuro exam on discharge revealed 4/5 strength in
the LUE, 5/5 strength in the RUE, 2/5 strength in LLE, [**2-7**]
strength in RLE.
.
#. Retroperitoneal bleed: Patient had acute RP bleed, with a Hct
drop of 15 points, while on heparin gtt for acute embolic stroke
during her course in the ICU. Since RP bleed, the patient had
been off of anticoagulation. She was monitored closely for back
and flank pain, and her hematocrit was monitored closely,
without subsequent drops. Heparin gtt was restarted on [**11-3**],
with a goal PTT of 40-60, until patient proved stable (had
retroperitoneal bleed as below) her PTT goal was then increased
to 60-80. She was started on coumadin 2.5 on [**11-7**]. Her INR on
day of discharge was 1.3, and she will need to continue on the
heparin gtt until her INR is therapeutic. She will need INR
levels closely monitored. She will need to be monitored for
back/flank pain and hematocrit drop to watch for recurrence of
her RP bleed. Also, patient has been transiently guaiac positive
with brown stools, now resolved. Also, anemia due to chronic
renal insufficiency treated with procrit.
.
# Thrombocytopenia: Likely due to marrow suppression in setting
of ARF and UTI. When pt suffered a stroke, HIT was sent and
argatroban was started. Later, HIT came back negative. Her
platelets were closely monitored.
.
# Cards CHF: Echo showed no diastolic or systolic function.
However, she was thought profoundly fluid overloaded. She
responded to diurel and lasix 80 then was placed on lasix gtt
for 1 day. Good UOP then auto-diuresed well. The patient was
restarted on lasix 40 qd after her hemodialysis was
discontinued.
.
# Cards vessels: trop leak thought [**1-7**] demand ischemia. No new
wall motion abnl. Pt was started on lipitor when stroke was
found. The patient wsa maintained on telemetry, and denied chest
pain.
.
# UTI: [**Last Name (un) 36**] to ceftriaxone. received 7 d course. Yeast was
found in her urine and she completed a 14 day course of
fluconazole.
.
# LE Ulcers: The patient has bilateral lower extremity ulcers on
her feet.
Unclear etiology; per old notes has ? hx of paraproteinuria vs
diabetic neuropathy, Wound care was consulted, and dressed her
ulcers. Podiatry also came to see her ulcer, and indicated that
no new acute surgery was necessary. Nutrition was encouraged to
promote wound healing. She will need qod dressing changes on
her feet, and her ulcers should be considered if she an increase
in her temperature.
.
#. Urinary yeast infection: many yeast on UA. UCx [**10-21**] no
growth. Fluconazole was completed with a 14 day course.
.
#. s/p Pseudomonas pneumonia: Patient afebrile, leukocytosis
resolving, good sat on room air, no dyspnea. s/p 2 week course
of cefepime. Follow up chest x-ray shows pulmonary vascular
congestion without obvious infiltrate.
.
#. DM: Her diabetes mellitus was managed with a sliding scale
insulin regimen with fingersticks 4 times daily.
.
#. Hypernatremia: The patient was found to be hypernatremic and
fluid boluses were initiated. With the start of hemodialysis,
hypernatremia resolved and fluid boluses were stopped; however,
when hemodialysis was discontinued, fluid was gently restarted.
.
FEN: TF started [**10-9**]. When it was felt that the patient could
take adequate PO, tube feeds were stopped andd she was seen by
the speech and swallow team. Her diet was slowly advanced to
thin liquids and soft foods. Pt's intake towards the end of her
hospital course was improved, however not entirely adequate. She
refused an NG tube or PEG tube.
.
Access: PICC
.
Prophylaxis: The patient was started on subcutaneous heparin for
prophylaxis initially, then, heparin gtt was started when it was
felt that her retroperitoneal bleed was stable. She was started
on a proton pump inhibitor for ulcer prophylaxis.
.
Code: Full Code confirmed on multiple occasions during the
[**Hospital 228**] hospital stay.
Medications on Admission:
Amio 200 qD
Calcitriol 0.25
Zoloft 100
Senna [**Hospital1 **]
Synthroid 25mcg
Zyprexa 2.5 qD
Folic Acid/Thiamine/MVI
Ambien qhs
Percocet prn
Toprol XL 50
Norvasc 5
PPI 40
Humalog SS
Coumadin 5
Lasix 20 qOD
.
Allergies: Naproxen --> renal toxicity
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
2. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) insulin per
sliding scale Subcutaneous ASDIR (AS DIRECTED).
3. Sertraline 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
10. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulizer
inhalation Inhalation Q6H (every 6 hours) as needed.
13. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
14. Olanzapine 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
15. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Sevelamer 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
17. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QID
(4 times a day): hold for sbp <90 or HR <55.
18. Amiodarone 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
19. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
20. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): hold for sbp <100 .
21. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
22. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: One (1) injection
4000 units/mL Injection QMOWEFR (Monday -Wednesday-Friday).
23. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
24. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
25. Sodium Bicarbonate 650 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID
(2 times a day).
26. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
27. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
28. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
[**Last Name (STitle) **]: One (1) sliding scale asdir Intravenous ASDIR (AS
DIRECTED): until INR therapeutic. please titrate ptt to target
60-80.
29. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands
Discharge Diagnosis:
Primary diagnoses:
Ventilator associated pneumonia
Acute on chronic renal failure
Metabolic acidosis
Atrial fibrillation with rapid ventricular response
Valvular and acute diastolic heart failure
Cardioembolic right basal ganglia stroke - left hemiparesis.
Retroperitoneal bleed
Blood loss anemia
Anemia of chronic kidney disease
[**Female First Name (un) 564**] UTI
Rectal bleeding
Secondary diagnoses:
Chronic kidney disease stage IV
COPD on home oxygen
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Atrial fibrillation
SDH s/p mechanical fall
Mod/Severe aortic stenosis
Osteoarthritis
AV node ablation
s/p TAH, s/p c-section
s/p spinal surgery
s/p right hip surgery
s/p b/l foot surgeries
h/o TB s/p LUL resection [**2129**]
h/o Diverticulosis s/p bowel resection [**2169**]
Right CFA below-knee popliteal artery bypass graft
Endarterectomy of right internal iliac artery and Dacron patch
Severe peripheral neuropathy and PVD s/p bilateral foot
reconstruction
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital and had a long hospital stay.
You were initially placed in the ICU. You had a stroke, and
blood thinners were started initially, but after developing a
bleed, the blood thinners wre temporarily stopped. They were
restarted when it was felt that it was stable. You also had a
pneumonia and you were given antibiotics. Furthermore, your
kidneys had failure, and you were followed by the renal team and
started on hemodialysis, which was discontinued when your renal
function remained stable. Your medications were monitored
carefully and you will need assistance with your medications.
You will remain on the heparin drip until you are appropriately
anticoagulated. Then, you will only have to take warfarin
(coumadin) for anticoagulation.
.
You should call your primary care doctor, or return to the
emergency room with any new symptoms of chest pain, shortness of
breath, fever >101.4 F, any new weakness, or any other symptoms
which are concerning to yuo.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 4883**] (renal). Provider:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2180-12-27**] 10:00.
Please call if you are unable to keep this appointment.
Completed by:[**2180-11-8**]
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[
[
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[
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[
[
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21130, 21215
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2643, 2648
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2495, 2624
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228, 259
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3575, 6089
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446, 1134
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6106, 9059
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2662, 3556
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1156, 1725
|
1741, 1899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,494
| 171,794
|
49620
|
Discharge summary
|
report
|
Admission Date: [**2108-10-5**] Discharge Date: [**2108-10-16**]
Date of Birth: [**2031-7-29**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Iodine
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 77 year old male who complains of ABD
PAIN after accidental dislodgement of of perc chole tube.
Patient complains of pain mostly in the right upper quadrant
but also diffusely
Timing: Sudden Onset
Severity: Moderate
Duration: Hours
Location: abdomen
Context/Circumstances: above
Mod.Factors: Worse with time
Past Medical History:
Type II DM
HTN
CKD - bl Cr 2.5
Gout
Gastritis/ulcer/GERD -> last EGD in [**2105**] with gastritis
presumed CAD
Dyslipidemia
LE DVT in [**2095**]
NSTEMI in [**2104**]
Social History:
His social history is significant for the absence of current
tobacco use, was former smoker. No EtOH abuse. Wife takes care
of him.
Family History:
Mother with CAD s/p CABG
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2108-10-4**]
Temp: 98.0 HR: 48 BP: 120/46 Resp: 16 O(2)Sat: 97
Constitutional: Comfortable
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: tender mostly in the right upper quadrant; soft
Physical examination upon discharge: [**2108-10-16**]:
Vital signs: t=99.3, bp= 152-175/60-80, hr=71, resp. rate 20,
99% room air
General: NAD
Neuro: alert and oriented x 3, speech clear, no tremors
CV: Ns1, -s2, -s3, -s4
Lungs: Clear, no adventitious bil.
ABDOMEN: steri-strips to umbilical port site and right upper
quadrant port site, no erythema, mild tenderness right upper
quadrant, no rebound, no guarding
EXTREMITES: weak DP bil., feet warm, no ankle edema, +1 upper
foot edema bil., no calf tenderness bil.
SKIN: Ecchymotic areas lateral aspect of right arm
Pertinent Results:
[**2108-10-14**] 05:50AM BLOOD WBC-7.1 RBC-2.76* Hgb-7.8* Hct-24.3*
MCV-88 MCH-28.2 MCHC-32.1 RDW-16.6* Plt Ct-201
[**2108-10-13**] 03:35PM BLOOD Hct-25.4*
[**2108-10-4**] 04:12PM BLOOD WBC-7.0 RBC-2.74* Hgb-8.0* Hct-23.7*
MCV-87 MCH-29.4 MCHC-33.9 RDW-17.1* Plt Ct-225
[**2108-10-14**] 05:50AM BLOOD Neuts-69.1 Lymphs-21.3 Monos-5.0 Eos-4.4*
Baso-0.2
[**2108-10-5**] 07:15AM BLOOD Neuts-68.5 Lymphs-20.7 Monos-5.4 Eos-5.1*
Baso-0.3
[**2108-10-4**] 04:12PM BLOOD PT-14.4* PTT-24.4 INR(PT)-1.2*
[**2108-10-14**] 04:10PM BLOOD Glucose-125* UreaN-25* Creat-3.2* Na-139
K-4.3 Cl-108 HCO3-24 AnGap-11
[**2108-10-14**] 05:50AM BLOOD Glucose-110* UreaN-26* Creat-3.6* Na-140
K-4.2 Cl-108 HCO3-24 AnGap-12
[**2108-10-13**] 03:35PM BLOOD Glucose-141* UreaN-26* Creat-3.8* Na-139
K-4.4 Cl-107 HCO3-23 AnGap-13
[**2108-10-11**] 09:54PM BLOOD CK(CPK)-41*
[**2108-10-8**] 06:30AM BLOOD ALT-12 AST-13 AlkPhos-88 TotBili-0.5
[**2108-10-7**] 05:35AM BLOOD ALT-16 AST-13 AlkPhos-91 TotBili-0.5
[**2108-10-5**] 07:15AM BLOOD Lipase-23
[**2108-10-4**] 04:12PM BLOOD Lipase-63*
[**2108-10-11**] 09:54PM BLOOD CK-MB-1 cTropnT-0.02*
[**2108-10-11**] 01:21PM BLOOD CK-MB-1 cTropnT-0.02*
[**2108-10-5**] 01:03AM BLOOD cTropnT-0.02*
[**2108-10-14**] 05:50AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
[**2108-10-12**] 03:16AM BLOOD Type-ART pO2-108* pCO2-37 pH-7.42
calTCO2-25 Base XS-0
[**2108-10-4**] 04:27PM BLOOD Lactate-1.5
[**2108-10-12**] 03:16AM BLOOD freeCa-1.19
Current labs:
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-10-15**] 08:45 121*1 24* 2.7* 141 4.9 111* 21* 14
[**2108-10-4**]: EKG:
Sinus bradycardia. One ventricular premature beat noted.
Inferior and
lateral non-specific T wave flattening. Prominent U waves.
Compared to the
previous tracing of [**2108-9-20**] the described ST-T wave abnormality
is new.
Possible metabolic abnormality suggested.
[**2108-10-4**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. No evidence of bile leak with trace stranding along the site
of the prior cholecystostomy tube.
2. Nondistended gallbladder with diffuse mural thickening and
adjacent
stranding/pericholecystic fluid. This could reflect smouldering
infectious
process, be related to recent tube decompression or reflective
of third
spacing with heart disease given the presence of bilateral
pleural effusions.
[**2108-10-5**]: Gallbladder scan:
IMPRESSION: The cystic duct remains obstructed, putting this
patient at risk for acute cholecystitis in the absence of a
cholecystostomy drain.
[**2108-10-6**]: Ultrasound of abdomen:
IMPRESSION:
1. Limited right upper quadrant ultrasound performed in
preparation for
replacement of percutaneous cholecystostomy tube. Given the
above findings
and lack of patient's symptoms, a percutaneous cholecystostomy
tube was not placed at this time. It was recommended that if the
patient's symptoms return or laboratory values worsen, a repeat
ultrasound be performed to determine feasibility of percutaneous
cholecystostomy tube placement.
2. String from prior percutaneous cholecystostomy tube is
partially left
within the patient. Attempted removal was unsuccessful.
[**2108-10-8**]: ECHO:
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Pulmonary artery
hypertension
[**2108-10-11**]: EKG:
Artifact is present. Sinus bradycardia. Non-specific ST-T wave
changes.
The Q-T interval is prolonged. Compared to the previous tracing
of [**2108-10-4**] the Q-T interval is longer.
[**2108-10-11**]: chest x-ray:
IMPRESSION: AP chest compared to [**10-11**] at 12:24 and 4:44
p.m.:
Moderately severe pulmonary edema has improved over three hours.
Borderline cardiomegaly unchanged. Small bilateral pleural
effusions are presumed. No pneumothorax. ET tube and right
subclavian line are in standard placements respectively and an
orogastric tube passes into the stomach and out of view.
[**2108-10-12**]: cat scan of the head:
IMPRESSION: No acute intracranial process.
[**2108-10-11**] 3:55 pm BLOOD CULTURE Source: Line-central line.
Blood Culture, Routine (Pending):
[**2108-10-11**] 5:03 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2108-10-14**]**
MRSA SCREEN (Final [**2108-10-14**]): No MRSA isolated.
[**2108-10-15**]: chest x-ray:
IMPRESSION:
1. Standard position of a right-sided central line in the upper
SVC. No
pneumothorax.
2. Stable chronic pleural thickening.
3. Mild pulmonary vascular congestion without overt edema.
Brief Hospital Course:
77 year old gentleman admitted to the acute care service after
dislodgement of his percutaneous cholecystotomy tube. He also
reported fatigue and weakness which was attributed to mild
exacerbation of congestive heart failure. He was evaluated by
cardiology because of his findings on presentation and
recommendations for his daily care were addressed. After
evaluation, he was cleared for his cholecystectomy. Prior to his
surgery, he was taken to IR for attempted removal of a single
wire from the percutaneous cholecystostomy site. They were
unsuccessful at removing it and the wire fell out without any
intervention.
On [**10-11**], the patient went to the OR for uncomplicated
laparoscopic cholecystectomy. His operative course was stable.
He was extubated after the procedure and monitored in the
recovery room where he desaturated requiring re-intubation for
concern of persistent neuromuscular blockade. He was admitted
to the ICU for further management. Chest x-ray was performed
that showed significant pulmonary edema, so diuresis was
performed with lasix. The vent was weaned overnight, and on
[**10-12**], the patient extubated without problem. [**Name (NI) **] had persistent
confusion on POD1, and head CT was obtained that was normal. His
confusion improved later in the day and patient remained
hemodynamically stable and was transferred to the surgical floor
POD #1.
He completed his course of meropenum for enterobacter and
klebeiella in the urine. He was weaned off his intravenous
analgesia and started on oral agents. He has been followed by
the renal service for his history of CRI. He did receive 1 u
PRBC on PPOD #2 to 21 to help improve renal perfusion. His
current hematocrit is 24. He has had his electrolytes monitored
and his creatinine has decreased to baseline of 2.7. He has been
cleared by Renal to resume his valsarten. He reports localized
right rib pain after falling. Nursing staff made aware of this
and are following-up on it. No visible signs of hematomas or
localized right hip pain. Ecchymotic areas visible right lower
arm. Chest x-ray done [**10-15**] shows stable chronic pleural
thickening and mild pulmonary vascular congestion without overt
edema. His oxygenation saturation on room air has been
maintained at 99% room air.
His vital signs are stable and he is afebrile. He is
tolearting a regular diet with assistance in setting up his
meal. He continues to have episodes of mild confusion, but
re-orients easily. He has been evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility where he can further regain his strength and mobility.
Right subclavian central line d/c [**10-16**], DSD applied
He will follow up with the acute care service on [**10-30**].
Medications on Admission:
[**Last Name (un) 1724**]: Tylenol 1000''', atorvastatin 40', calcitriol 0.25 qod,
plavix 75', cyclobenzaprine 10''', fluticasone 50'', folic acid
1', lactulose, ranitidine 150', tamsulosin 0.4', timolol maleate
0.5 %', valsartan 160', colace 100'', senna 8.6'',torsemide 5',
labetalol 200''', amlodipine 10'
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
4. torsemide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for heart rate <60, systolic blood pressure <100.
6. hydralazine 10 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
7. labetalol 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): hold hr <50, systolic blood pressure <100.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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) neb Inhalation Q6H (every 6 hours) as
needed for wheezing, sob.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasms.
14. valsarten Sig: One [**Age over 90 881**]y (160) mg once a day.
15. insulin SC ( per sliding scale)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
chlolecystitis
pulmonary edema (post-op)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive ( hard of hearing)
Activity Status: Ambulatory - needs assistance with ambulation,
walker use
Discharge Instructions:
You were admitted to the hospital after your cholecystostomy
tube fell out. Your electrolytes and liver studies were
monitored. Once you stabilized, you were taken to the operating
room where you had your gallbladder removed. You did well
during the operation and you are now preparing for dishcharge
back to the rehabilitation facility.
Followup Instructions:
Please follow up with the acute care service in 2 weeks. Your
appointment is scheduled on [**10-30**], 2:30pm in the acute care
clinic, [**Location (un) 470**] [**Hospital Unit Name **], room 3A. The telephone number
is #[**Telephone/Fax (1) 600**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2108-10-16**]
|
[
"585.4",
"530.81",
"274.9",
"584.9",
"428.33",
"412",
"041.3",
"599.0",
"272.4",
"583.81",
"403.90",
"575.0",
"518.52",
"600.00",
"414.01",
"041.85",
"V12.51",
"250.40",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11273, 11358
|
6745, 9515
|
292, 323
|
11443, 11443
|
2118, 6261
|
12009, 12399
|
1178, 1204
|
9878, 11250
|
11379, 11422
|
9541, 9855
|
11644, 11986
|
1219, 1242
|
6296, 6722
|
237, 254
|
1557, 2099
|
351, 823
|
1256, 1540
|
11458, 11620
|
845, 1012
|
1028, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,045
| 192,498
|
45590
|
Discharge summary
|
report
|
Admission Date: [**2161-3-27**] Discharge Date: [**2161-4-5**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 87 year old male with a history of COPD,
recent pneumonia, and recent admission s/p fall with complex
tibial plateau and non-displaced fibular head fractures. He was
recently admitted to [**Hospital6 5016**] from [**2161-2-24**] to [**2161-3-4**]
for COPD exacerbation and pneumonia. Several days after
discharge, he fell and sustained complex tibial plateau and
non-displaced fibular head fractures. He was admitted to [**Hospital 28941**] and then transfered to [**Hospital1 18**] due to his comorbidities and
concern about whether he would be a good surgical candidate. He
was admitted at [**Hospital1 18**] from [**2161-3-12**] to [**2161-3-14**] and evaluated by
Orthopedics, with a decision made to pursue nonsurgical
management with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] hinge knee brace and rehabilitation.
Enoxaparin was continued during his stay and at discharge. He
had a followup appointment with Orthopedics today.
.
After his Orthopedics appointment, he developed acute shortness
of breath while waiting for his ride back to rehab, which he
attributed to his oxygen tank running out. Prior to his recent
pneumonia admission, he had not been on home oxygen, nebulizers,
or systemic steroids. His SpO2 was initially reported in the
80s, but there was difficulty getting good pulse oximetry
readings. He remained alert and conversant, and was sent to the
ED by EMS.
.
In the ED, initial VS were T 96.6, BP 105/61, HR 110, RR 32,
SpO2 100% on NRB. His labs were notable for WBC 14.0, Hct 31.0,
Na 130, and K 7.0 (hemolyzed). He had Troponin elevation to
0.10 (<0.01 on [**2161-3-12**]) and proBNP 1188. UA and coags were
unremarkable. His initial lactate in the ED was 5.2, decreasing
to 4.2 one hour later. His CXR was grossly unremarkable with no
definite acute pulmonary process. He became hypotensive to
79/58 and was given 3 L NS, with improvement in his pressure to
105/71 and UO 400 ml. He was given Cefepime 2 grams IV,
Levofloxacin 500 mg IV, and Vancomycin 1 gram IV. Subsequent
CTA showed bilateral lobar and segmental pulmonary emboli, right
lower lobe consolidation, and enlarged right heart likely due to
right heart strain. He was placed on a Heparin drip and NRB.
His lactate decreased to 2.0 prior to reaching the ICU. Vital
signs on transfer to the ICU were HR 96, BP 100/57, RR 24, and
SpO2 98% on NRB.
.
On reaching the ICU, the patient reported mild SOB improved from
earlier in the day and a chronic cough, also improved. He
reported having looser stools than usual at rehab, but had been
started on stool softeners, and mild periumbilical tenderness in
his abdomen. He was generally comfortable but tired. He denied
any pain in his leg at the fracture site or in his calves.
Past Medical History:
recent bilateral pneumonia and influenza A&B & RSV Rx at OSH
[**Date range (1) 97230**]/11 - Rx by nebs, O2, stable on prednisone taper and
outpatient antibiotics - doxycycline
HTN
CVA
CAD s/p 2 vessel bypass [**2135**]
AAA 2.7 cm
COPD
nephrolithiasis
h/o bladder and prostate ca
OA
osteoporosis
spinal stenosis with h/o L2 vertebral #
h/o B12 def, on monthly injection
gout
hard of hearing
Social History:
He has recently been at rehab ([**Location (un) 582**] at [**Location (un) 7658**]) since his
admission for knee fracture. He previously lived at home
despite his multiple medical issues with help from daughter. [**Name (NI) **]
had previously refused placement into rehab or a nursing home.
Occasionally uses cane while walking.
# Tobacco: Smokes ~1 PPD currently.
# Alcohol: None
# Drugs: None
Family History:
No family history of abnormal bleeding or blood clots.
Otherwise noncontributory.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: BP 115/79, HR 94, RR 16, SpO2 96% on NRB
Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate.
Appears tired.
HEENT: NCAT. Sclera anicteric. PERRL. Left pupil slightly
irregular in contour. EOMI. Somewhat dry MMs, OP benign.
Neck: Supple, full ROM. JVP to mid neck lying at 30 degree
angle. No cervical lymphadenopathy.
CV: Mild tachycardia with regular rhythm. No M/R/G.
Chest: Respiration unlabored. Good air movement. Coarse breath
sounds and rhonchi throughout.
Abd: Normal bowel sounds. Soft, mildly tender in epigastric
area, ND. No organomegaly or masses.
Ext: WWP. Digital cap refill <2 sec. No C/C. LE edema [**1-25**]+ with
R>L. Distal pulses intact radial 2+, DP 2+, PT 2+. Right leg
wrapped.
Skin: Ecchymosis on right knee. No rashes, ulcers, or other
lesions noted.
Neuro: CN II-XII grossly intact. Moving all four limbs.
Pertinent Results:
[**2161-3-27**] 02:15PM BLOOD WBC-14.0*# RBC-3.14* Hgb-10.2* Hct-31.0*#
MCV-99* MCH-32.4* MCHC-32.9 RDW-14.3 Plt Ct-345#
[**2161-3-31**] 05:55AM BLOOD WBC-8.4 RBC-2.90* Hgb-9.5* Hct-29.6*
MCV-102* MCH-32.8* MCHC-32.2 RDW-15.5 Plt Ct-188
[**2161-3-27**] 03:15PM BLOOD PT-12.1 PTT-25.4 INR(PT)-1.0
[**2161-3-31**] 05:55AM BLOOD PT-15.3* PTT-85.8* INR(PT)-1.3*
[**2161-3-27**] 02:15PM BLOOD Glucose-225* UreaN-31* Creat-0.9 Na-130*
K-7.0* Cl-97 HCO3-22 AnGap-18
[**2161-3-31**] 05:55AM BLOOD Glucose-102* UreaN-18 Creat-0.6 Na-138
K-3.7 Cl-104 HCO3-25 AnGap-13
[**2161-3-27**] 03:15PM BLOOD cTropnT-0.10* proBNP-1188*
[**2161-3-28**] 07:32PM BLOOD CK-MB-4 cTropnT-0.21*
[**2161-3-28**] 01:37AM BLOOD CK(CPK)-45*
[**2161-3-28**] 07:32PM BLOOD CK(CPK)-30*
[**2161-3-28**] 01:30PM BLOOD Calcium-7.4* Phos-4.9* Mg-2.1
[**2161-3-27**] 09:59PM BLOOD Lactate-2.0
[**2161-3-27**] 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
[**2161-3-28**] 11:10AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
[**2161-4-5**]: INR 3.3
.
Blood culture [**2161-3-27**]: No growth to date.
Urine culture [**2161-3-28**]: No growth.
Sputum culture [**2161-3-29**]: Respiratory flora.
.
EKG Sinus tachycardia with ventricular premature beats and
atrial premature beats. Right bundle-branch block. Compared to
the previous tracing of [**2161-3-12**] right bundle-branch block and
ventricular premature beats are seen on the current tracing.
.
Knee x-ray: 1. Comminuted tibial plateau fractures in unchanged
alignment with approximately 11 mm of depression of the lateral
tibial plateau articular surface. 2. Nondisplaced proximal
fibular fracture.
.
CXR: Limited study, but otherwise grossly unremarkable with no
definite acute pulmonary process.
.
CTA: 1. Bilateral lobar and segmental pulmonary emboli. 2. Right
lower lobe consolidation might represent infarct or less likely
pneumonia/aspiration. 3. Enlarged right heart likely due to
right heart strain. Correlate with echocardiogram.
.
TTE: Suboptimal image quality. The left atrium is mildly
dilated. No atrial septal defect is seen by 2D or color Doppler.
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 (LVEF 50-60%). There is no ventricular septal defect. RV
systolic function appears mildly depressed (RV not well seen).
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
CXR: New right pleural effusion and right lower lobe opacity,
which may represent atelectasis, but aspiration or pneumonia
cannot be excluded.
Brief Hospital Course:
The patient is an 87 year old male with a history of COPD, CAD,
and recent complex right knee fracture who developed SOB after
an Ortho followup appointment and was found to have bilateral
PEs on CTA with hypotension and evidence of right heart strain,
hospital course was complicated by an aspiration pneumonia.
.
# Pulmonary Embolism: He presented with SOB and was found to
have bilateral lobar and segmental pulmonary emboli on CTA, with
evidence of right heart enlargement. He was started on a heparin
drip and monitored in the ICU without event. TTE showed mild
right heart dysfunction. He was transferred to the floor the
evening of [**3-28**]. He continued to be stable on the floor and was
transitioned to a lovenox bridge until coumadin was therapeutic.
His coumadin was somewhat difficult to titrate - initially
minimally responsive to 5mg daily of coumadin then
supratherapeutic rapidly to >4 on 6-7mg daily. He requires INR
measurement every day for now with coumadin dosing changes as
needed based upon the results. The night of transfer to rehab he
should receive 3mg of coumadin. The duration of anticoagulation
will be a minimum of 6 months and maybe 9-12 months or longer.
This must be followed-up on with his outpatient primary care
doctor.
.
# Aspiration pneumonia and encephalopathy. The patient had an
episode of desaturation to high 80's% on RA improved to 90's%
with nasal cannula oxygen with some associated altered mental
status on [**2161-3-31**]. He had a chest x-ray with new right sided
effusion and increased RLL opacification consistent with an
aspiration pneumonia. He was started on Vanc/Cefepime/Flagyl and
with sputum culture growing MRSA, this was weaned to Vanco
monotherapy for an expected 10 day course. He described some
difficulty swallowing though speech and swallow eval cleared him
for a ground solid, thin liquid diet. The patient also received
chest PT with good effect, allowing him to clear secretions
better than he can independently. The patient will complete an
10 day course of antibiotics. He requires 3 times daily chest
PT. He should also observe basic aspiration prevention measures
- sitting upright with meals, chewing fully, swallowing multiple
times and stopping eating if coughing occurs. He may require
repeat swallow eval if his symptoms persist
.
# Frequent premature APB's and tachycardia. On telemetry on the
medical floor, the patient had asymptomatic tachycardia to
110-130 with frequent APB's and possible changing p wave
morphology consistent with an atrial tachycardia. Given his
history of CAD and therefore known indication for beta-blocker,
he was started on metoprolol for rate control, blood pressure
control and to reduce atrial ectopy.
.
# COPD: He has a history of COPD and continued smoking. We
continued ipratropium nebs Q6H and albuterol nebs Q4H PRN.
.
# Hyponatremia: His Na was 130 on admission, similar to a prior
value 132 on his last admission. He received IV fluids and his
Na normalized. His urine lytes and Cr trend suggest a mixed
picture with possible intrinsic renal component.
.
# Knee Fractures: He was seen in [**Hospital 1957**] clinic immediately prior
to admission, and evaluation of his fracture showed maintained
reduction. He must continue in the [**Doctor Last Name **] brace with full
range of motion, 0-90 degrees in the brace. He should be
non-weight bearing on that side until he follows-up as scheduled
with his orthopedist. We controlled pt's pain with oxycodone
2.5mg Q4H PRN and acetaminophen 650mg Q6 PRN.
.
# [**Doctor Last Name **]: Probable [**Doctor Last Name **] of chronic disease, this appears
stable.
.
# CAD. The patient continues on aspirin and new beta-blocker
therapy.
.
# GERD. He continues on omeprazole.
.
# Stage 2 sacral decubitus ulcer. The patient has a sacral
decubitus ulcer which was present from prior to this
hospitalization. He requires ongoing wound care and frequent
turning. He should get out of bed to chair three times daily
with meals. He had some pain in his left heel and had early
signs of a pressure blister in that area. He should wear
multipodus boots to relieve heel pressure bilaterally when in
bed.
.
# Code status: FULL CODE, needs to be further discussed with the
patient and his daughter. They are considering a change in code
status.
# Contacts: Daughter, [**First Name4 (NamePattern1) 24606**] [**Last Name (NamePattern1) **] (phone: [**Telephone/Fax (1) 97233**])
Medications on Admission:
(per recent discharge)
Aspirin 81 mg PO DAILY
Verapamil 80 mg PO Q8H
Enoxaparin 30 mg/0.3 mL SC DAILY
Ipratropium bromide (0.02%) 1 neb IH Q6H
Albuterol sulfate (0.083 %) 1 neb IH Q4H
Albuterol sulfate (0.083 %) 1 neb IH Q2H PRN SOB
Guaifenesin (100 mg/5 mL) [**6-2**] mL PO Q6H PRN cough
Omeprazole 40 mg PO DAILY
Acetaminophen 650 mg PO TID
Oxycodone 2.5 mg PO Q4H PRN pain
Docusate 100 mg PO BID
Senna 8.6 mg PO QHS
Calcium 500 mg (1,250 mg) 1 Tablet PO BID
Vitamin D 1,000 units PO DAILY
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2h as needed for wheeze.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours.
5. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for Cough.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 8 days.
16. Lab test
Obtain INR measurement daily and dose coumadin based upon level
for goal INR [**2-26**].
17. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Change dose based upon daily INR monitoring.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 7658**]
Discharge Diagnosis:
Acute pulmonary embolism
Aspiration pneumonia
Tachycardia, NOS with frequent APB's
Hyponatremia
Tibial plateau fracture
[**Location (un) **]
CAD
GERD
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted because of a blood clot to the lungs called
pulmonary embolism. This was a complication of your recent leg
fracture and associated immobilization. Take coumadin as
prescribed with INR blood testing every day. Obtain dosage
changes of the coumadin from a doctor based upon the blood test
results.
In addition, you were noted to have frequent premature heart
beats. Please take metoprolol for blood pressure and heart rate
control.
You had an aspiration pneumonia which you must treat with the
antibiotic Vancomycin as prescribed for 8 more days. At the end
of your Vancomycin course you must have the PICC line removed.
You will also receive 3 times daily chest PT.
You have a pressure sore on your sacrum. Please continue to have
wound care and get out of bed 3 times a day to a chair with
meals. Please wear multipodus boots when in bed to reduce
pressure on your heels as you are showing some early signs of
pressure damage to your left heel. This skin area should be
checked daily.
Continue to wear the [**Doctor Last Name **] brace. You must not bear weight on
the right leg until you are seen again in the orthopedic clinics
as scheduled.
Followup Instructions:
Follow-up with your primary care doctor within 1 week of
discharge from rehab.
Department: ORTHOPEDICS
When: WEDNESDAY [**2161-4-29**] at 12:55 PM
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: WEDNESDAY [**2161-4-29**] at 1:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"482.42",
"276.2",
"276.1",
"305.1",
"585.9",
"721.3",
"458.8",
"V45.81",
"415.19",
"V54.16",
"707.07",
"414.00",
"348.39",
"285.29",
"530.81",
"786.09",
"403.90",
"V58.61",
"496",
"507.0",
"389.9",
"707.22",
"V12.54",
"707.03",
"427.61",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14857, 14935
|
8162, 12590
|
269, 275
|
15129, 15139
|
4925, 8139
|
16353, 17019
|
3923, 4006
|
13132, 14834
|
14956, 15108
|
12616, 13109
|
15163, 16330
|
4021, 4035
|
210, 231
|
303, 3077
|
4049, 4906
|
3099, 3492
|
3508, 3907
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,427
| 149,390
|
8240
|
Discharge summary
|
report
|
Admission Date: [**2121-4-7**] Discharge Date: [**2121-4-23**]
Date of Birth: [**2050-5-24**] Sex: F
Service: MEDICINE
Allergies:
Augmentin / Gluten
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
back pain/groin pain
Major Surgical or Invasive Procedure:
PICC line placement
CT-guided left paraspinal muscle biopsy
right knee arthrocentesis
History of Present Illness:
70 year old female with celiac disease, osteoporosis, B12
deficiency, L4 compression fracture initially presented with to
PCP [**4-1**] with right groin/hip pain X 2 weeks; U/S was without
DVT. She was seen in [**Hospital **] clinic [**4-3**] and underwent an pelvic
MRI, later read as a right sacral insufficiency fracture. She
presented to the ED [**4-7**] complaining of continued right groin
pain, associated with difficulty starting her urine stream and
constipation. In the ED, she had a temp to 101.6, and was noted
to be hypotensive sbp 80s (baseline 90s-100s)in the setting of a
HCT 24 (baseline 34-36). She received fluid and 1 unit of PRBC
and was admitted to the ICU for further evaluation. In the ICU,
she received 1 unit of PRBC. Given she remained hemodynamically
stable, she was kept off antibiotics and transferred to the
general medical floor [**4-8**] p.m. Currently, she notes mild low
back pain. No groin pain at rest, but pain occurs, "gnawing" in
character, when she moves her right leg. She notes that the back
pain is in a band across her back, worse on the left, occasional
shooting pain around her back, but not down her leg. She also
notes bilateral leg weakness R>L, although it is difficult for
her to determine whether this is due to true weakness or pain.
She notes fever and chills X 1 week. She has noted difficulty
initiating urinary stream X 6 mos, denies urinary/bowel
incontinence
ROS: She denies shortness of breath or cough. No sore throat, no
dysuria, no diarrhea. She is constipated, no black stool or
rectal bleeding
Past Medical History:
Celiac sprue: chronic diarrhea, improved recently on a
gluten-free diet.
osteoporosis- L4 compression fx (~[**2116**])
vitamin B12 deficiency
hyperhomocysteinemia
lactose intolerance
actinic keratosis
blepharitis
sciatica
Multiple miscarriages
Social History:
She does do some part-time work writing. No tobacco, quite [**2103**],
1 glass of wine daily. Does yoga
Family History:
Mother with osteoporosis and diabetes.
Physical Exam:
Physical Exam on Transfer to General Medical Floor
Tc 100.1, bpc 112/55, resp 18, 99% RA
Gen: elderly female, A&OX3, NAD
HEENT: anicteric, pale conjunctiva, OMMM, OP clear, neck supple
Cardiac: RRR, no M/R/G appreciated
Pulm: (+) crackles at bases bilaterally L>R, no wheezes
Abd: NABS, mildly distended, soft, NT/ND
Ext: No cyanosis, clubbing. (+) mild edema right lower
extremity. (+) right groin tenderness over hamstring tendon.
Neuro: CN II-XII grossly intact and symmetric bilaterally. 4+/5
strength left plantar/dorsiflexors, 2+/5 strength hip flexors
and extensors, 5/5 strength left lower extremity, 5/5 strength
upper extremities bilaterally. 2+ DTR throughout except right
lower extremity which is 1+. Toes equivocal on left, downgoing
on right. Sensation intact to light touch proximally and
distally in upper and lower extremities bilaterally
Psychiatric: appropriate, pleasant
GU: normal external genitalia
Heme/Lymph: No cervical or supraclavicular lymphadenopathy
Back: (+) point tenderness L4, L5, S1. (+) paraspinal muscle
spasm at L5. (+) pain at hip flexion to 60 degrees, but pain is
in groin, not back/leg.
Pertinent Results:
Laboratory studies on admission:
[**2121-4-7**]
WBC-14.5 HGB-8.2 HCT-24.8 MCV-87 RDW-12.6 PLT COUNT-823
NEUTS-83.1* LYMPHS-10.6* MONOS-5.9 EOS-0.2 BASOS-0.2
IRON-8 calTIBC-213 VIT B12- >[**2113**] FOLATE-19.1 HAPTOGLOB-369
FERRITIN-219
LD(LDH)-124 TOT BILI-0.2 FIBRINOGE-671
GLUCOSE-95 UREA N-7 CREAT-0.4 SODIUM-128* POTASSIUM-4.0
CHLORIDE-90* TOTAL CO2-30
LACTATE-0.8
U/A: URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG
Laboratory studies on discharge:
[**2121-4-23**]
WBC 5.9 RBC Hgb 9.1* Hct 28 plt 318
Glucose 89 UreaN 11 Creat 0.5 Na 137 K 3.8 Cl 101 HCO3 28
[**4-7**] EKG: Sinus tachycardia. Left atrial abnormality. RSR'
pattern in leads VI-V2 represents a normal variant. No previous
tracing available for comparison.
Radiology
[**4-18**] Torso CT: No pulmonary nodules, parenchymal consolidations,
or pleural effusions are noted within the lungs. There is a
calcific focus/surgical clip in the calcification in the left
lung apex which is associated with fibrotic change most likely
secondary to the patient's prior granulomatous disease. Shotty
mediastinal and hilar lymph nodes are not pathologically
enlarged by CT criteria. The liver has decreased attenuation
consistent with fatty change. No pathologically enlarged
retroperitoneal mesenteric lymph nodes are seen. Right ischial
bursitis. Fluid collections are noted within both hip joints
most likely secondary to an underlying arthritis. There are
areas of sclerosis within the sacral bones which are consistent
with the patient's history of sacral insufficiency fracture. The
previously mentioned hypodensity in the left paraspinal area at
the level of L4 and T11 are unchanged.
[**4-16**] MRI L-spine: No significant interval change in the
enhancement of the left paraspinal muscle tissues compared to
[**2121-4-9**]. Differential diagnosis would include both infection
versus inflammation.
[**4-14**] right upper extremity ultrasound: Thrombosis of the right
cephalic vein. No evidence of extension to other veins of the
upper arm.
[**4-11**] TTE: The left atrium is normal in size. The estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion
[**4-10**] right shoulder X-ray: No fracture is seen. The glenohumeral
and AC joints appear normal. The visualized portions of the
lungs are clear. No prior shoulder studies available
[**4-9**] C/T/L spine MRI with contrast: Cervical spine: No disc,
vertebral or paraspinal pathology is seen. There is no spinal
stenosis or suluxation of the component vertebrae. The
visualized spinal cord, foramen magnum and its contents are
unremarkable. Thoracic spine: No significant interval changes
are seen in the thoracic spine images when compared to a prior
study. Folowing gadolinium adiminstration, no abnormal
enhancement is seen. Lumbar spine: Sagital and axial images of
the lumbar spine after gadolinium administration demonstrate
enhancement of the left paraspinal muscles from L2 to L5
extending into the subcutaneous soft tissues. No other areas of
abnormal enhancement are noted. The intervertebral disks as well
ad the vertebral bodies show normal signal intensity.
IMPRESSION: L2 to L5 left paraspinal muscle enhancement
extending into the subcutaneous tissues. In view of negative
history of recent trauma, these findings most likely represent
infection.
[**4-8**] MRI T spine without contrast: There is mild compression of
the superior endplate of T11 identified without increased signal
on inversion recovery images indicating chronic compression.
Mild degenerative changes are seen in the thoracic region. No
evidence of acute compression fracture identified. There is no
evidence of cord compression. There is no evidence of
intraspinal fluid collection.
[**4-8**] MRI L spine without contrast: Insufficiency fracture
involving the right ala of sacrum. Fluid within the left facet
joint of L4-5 with soft tissue increased signal in the adjacent
areas could be secondary to degenerative change and soft tissue
edema but early septic arthritis of the facet joint could not be
excluded. Gadolinium-enhanced images with fat suppression of the
lumbar spine are recommended.
[**4-7**] CT Abd/pelvis w/o contrast: No retroperitoneal bleed or
intra-abdominal collections. Tiny perihepatic air bubbles of
unknown significance. Bowel loops are unremarkable.
[**4-4**] MRI hip: bilateral sacral insufficiency fractures R>L,
bilateral hip effusions, extensive SC edema, small amt of
intraperitoneal free fluid
[**4-4**] Lumbar spine plain films: unchanged L4 compression
fracture, mild degnerative arthritis, narrowing of L4-5 disc
space
[**4-3**] LENI: tubular hypoechogenic strcuture in right groin area
adjacent to tendinous structures that could represent hematoma
Pathology
[**4-18**] Left paraspinal muscle biopsy: Nodular fibroblastic
proliferation with associated dense fibrosis and focal chronic
inflammation; adjacent skeleton muscle with atrophic and
reactive changes; no active inflammation present.
[**4-22**] left temporal artery biopsy: No arteritis seen. Focal
calcifications of internal elastic band.
Brief Hospital Course:
70 year old female with celiac disease, osteoporosis, and spinal
compression fractures admitted with groin/back pain in the
setting of recently diagnosed sacral insufficiency fractures,
found to be anemic with fever and elevated inflammatory markers.
1) Fevers/myositis/elevated systemic inflammation markers: Given
fever, back pain, and lower extremity weakness, there was an
initial concern for epidural/spinal infection. The patient
underwent C/T/L spine MRIs with and without contrast (see
results section), which were significant for fluid within the
left facet joint of L4-5 with soft tissue increased signal in
the adjacent areas that could be secondary to degenerative
change and soft tissue edema but early septic arthritis of the
facet joint could not be excluded. The infectious disease
service was consulted, and the patient was treated empirically
with vancomycin for suspected facet infection/myositis. A repeat
MRI of the L-spine was obtained on [**4-16**] which showed no
significant interval change in the enhancement of the left
paraspinal muscle tissues compared to [**2121-4-9**]. The MRIs were
reviewed with the radiologists, ID team, and primary team who
decided that the probability of facet infection/infectious
myositis was unlikely; antibiotics were therefore discontinued
(received 7 days of vancomycin). She underwent a CT-guided
biopsy of the left paraspinal muscle on [**4-18**], the cultures of
which were negative. The biopsy showed nodular fibroblastic
proliferation with associated dense fibrosis and focal chronic
inflammation; adjacent skeleton muscle with atrophic and
reactive changes; no active inflammation was present. In terms
of other infectious work-up, blood cultures had no growth to
date, TTE was without evidence of endocarditis, and urine
culture was negative. Lyme antibody was pending at time of
discharge. Given elevated ESR (max 103) and CRP (max >300) a
rheumatology consult was obtained. [**Doctor First Name **] was negative and RF was
not elevated; SPEP and UPEP were without monoclonal bands. The
patient underwent an arthrocentesis of her right knee on [**4-15**]
with 5250 wbc and only a few intra/extracellular monosodium
urate crystals, not felt be significant. She has a torso CT
which showed left apical lung calcific focus, shotty,
non-pathologically enlarged mediastinal/hilar LAD, fatty liver,
right ischial bursitis, and bilateral hip effusions, but no
evidence of malignancy. Orthopedics were consulted for possible
hip arthrocentesis, but given good range of movement of hips
without significant pain, these were not felt to be infected
(rheumatology and infectious disease services agreed). The
patient underwent a temporal artery biopsy to evaluate for giant
cell arteritis on [**4-22**], which was without evidence of arteritis.
She remained afebrile and, at time of discharge, her ESR and CRP
were trending down (85 and 119.7, respectively). Her platelets
were also trending down, 318 on discharge from a maximum of
1069. She will follow-up with rheumatology as an outpatient. She
should also follow-up with her gastroenterologist for
EGD/colonoscopy (given risk of lymphoma with celiac sprue) and
have age-appropriate outpatient cancer screening (mammogram -
last [**2118**] BIRADS 1, pap smear).
2) Bilateral sacral insufficiency fractures: The orthopedic
service (Dr. [**Last Name (STitle) **] was consulted, who recommended weight
bearing as tolerated and follow-up with orthopedics as an
outpatient.
3) Anemia of chronic disease: The patient's HCT was 24 on admit
from 36 on 11/[**2119**]. She has a history of celiac sprue, but her
symptoms have improved on low-gluten diet. Iron studies were
consistent with anemia of chronic disease (due to celiac sprue
vs above inflammatory process), vitamin B12 was elevated, folate
wnl, and UPEP/SPEP without monoclonal bands (has had abnormal
tests in the past). Fibrinogen was elevated, not consistent with
DIC, and haptoglobin was elevated, not consistent with
hemolysis. Her hematocrit remained stable at 28 following 2
units of PRBC. The gastroenterology service was consulted, and
recommended outpatient follow-up with Dr. [**Known lastname 1356**].
6) Hyponatremia: The patient was gently hydrated following
admission, given she appeared intravascularly dry, but her
sodium continued to trend down to 128. The nephrology team was
consulted, who felt this was secondary to SIADH (possibly
related to pain, chest CT/head CT without abnormalities) and
recommended fluid restriction (2L/day) and salt tabs. Her sodium
improved to 137 on discharge.
8) Osteoporosis/spinal Compression fx: The patient was continued
on calcium, vitamin D, and Fosamax
9) Right arm cephalic vein thrombosis: Following a right PICC
line placement, the placement developed right arm swelling. An
ultrasound revealed a catheter-associated right cephalic vein
clot. The catheter was removed and the patient's arm swelling
resolved.
Full Code
Medications on Admission:
calcium carbonate 1000mg daily
ferrous sulfate 325mg daily
Fosamax 70mg PO Q weekly
Metamucil
Percocet for pain
Ibuprofen 400-1600mg daily since last [**Month (only) 404**]
vitamin B12 1,000mg IM q Monthly
vitamin D 50,000 Units monthly
budesonide - took from [**October 2120**]
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 12H (Every 12 Hours).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO Q 12H (Every 12 Hours).
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Vitamin B-12 1,000 mcg/mL Solution Sig: 1000 (1000) mcg
Injection once a month.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to
6 hours) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: L2-L4 paraspinal myositis
Secondary: bilateral sacral insufficiency fractures, vertebral
compression fractures, anemia of chronic disease, hyponatremia
Discharge Condition:
stable
Discharge Instructions:
1) Please take all medications as prescribed
2) Please follow-up as indicated below.
3) Please see your primary care physician or come to the
emergency room if you develop worsening back pain, weakness,
fevers, chills, or other symptoms that concern you.
Followup Instructions:
1. You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
rheumatology clinic ([**Hospital **] Medical Building) on Tuesday, [**2121-4-29**]
at 9:30 a.m. [**Telephone/Fax (1) 2226**]. This is to follow-up the results of
your biopsy.
2. You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
the orthopedic clinic ([**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 1385**]) on [**2121-5-22**] at 9:30. [**Telephone/Fax (1) 1228**]
3. You have an appointment scheduled with a physician who works
in Dr.[**Name (NI) 29254**] office: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9974**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2121-5-8**] 4:00 p.m.
4. You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) 6665**] [**Known lastname 1356**] (GI)
on [**2121-6-9**] at 11:40. [**Telephone/Fax (1) 463**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2121-4-23**]
|
[
"266.2",
"733.13",
"733.00",
"444.21",
"276.1",
"285.9",
"458.9",
"729.1",
"996.74",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.21",
"81.91",
"83.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15235, 15320
|
9211, 14159
|
299, 387
|
15525, 15534
|
3586, 3605
|
15837, 17010
|
2381, 2421
|
14488, 15212
|
15341, 15504
|
14185, 14465
|
15558, 15814
|
2436, 3567
|
4101, 9188
|
239, 261
|
415, 1977
|
3619, 4087
|
1999, 2244
|
2260, 2365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,623
| 170,514
|
39085
|
Discharge summary
|
report
|
Admission Date: [**2189-3-19**] Discharge Date: [**2189-3-24**]
Date of Birth: [**2145-6-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
rapid heartbeat and chest discomfort
Major Surgical or Invasive Procedure:
[**2189-3-19**]
OPERATION:
1. Emergency redo sternotomy.
2. Mini left anterior thoracotomy and drainage of
pericardial fluid secondary to cardiac tamponade.
3. Pericardial window.
History of Present Illness:
This 43 male is s/p Bental procedure
and MAZE on [**2189-2-13**] and was discharged to home on [**2-21**]. He was
doing well and had been put on Amoxicillin for a question of a
wound infection. He was sitting at the computer last PM and had
a rapid heart rate and chest discomfort. He presented to the
[**Hospital 5279**] Hospital ED and was in A flutter. He received IV
Lopressor and became hypotensive. He had an echo this morning
which revealed a pericardial effusion and cardiac tamponade.
His
INR was 7.7. He was med-flighted to [**Hospital1 18**] for further
treatment.
Past Medical History:
Hypertension
Hyperlipidemia
Morbid obesity
non insulin dependent Diabetes Mellitus
chronic Atrial Fibrillation
Obstructive sleep apnea
Hypothyroidism
Depression
s/p Laparoscopic Cholecystectomy
s/p Tonsillectomy
s/p Bilateral carpal tunnel surgery
s/p left foot surgery
Social History:
Lives with: wife
Occupation: [**Name2 (NI) **]
Tobacco: remote, quit 20 yrs ago
ETOH: denies use since [**96**] yrs ago
Family History:
non contributory
Physical Exam:
Pulse: 120 a flutter Resp: O2 sat:
B/P 140/100 Right: Left:
Height: 72" Weight: 145 kg
General:
Skin: Dry [x]intact [x] Sternal wound healing well, sternum
stable
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2189-3-23**] 04:25AM BLOOD WBC-6.1 RBC-2.77* Hgb-8.4* Hct-25.2*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.8 Plt Ct-283
[**2189-3-24**] 04:43AM BLOOD PT-18.7* INR(PT)-1.7*
[**2189-3-23**] 04:25AM BLOOD PT-22.1* PTT-28.8 INR(PT)-2.1*
[**2189-3-22**] 04:43AM BLOOD PT-32.2* INR(PT)-3.2*
[**2189-3-21**] 08:41AM BLOOD PT-36.9* PTT-38.5* INR(PT)-3.8*
[**2189-3-20**] 03:17AM BLOOD PT-26.9* PTT-27.5 INR(PT)-2.6*
[**2189-3-19**] 05:36PM BLOOD PT-22.9* PTT-31.3 INR(PT)-2.2*
[**2189-3-19**] 04:08PM BLOOD PT-24.2* PTT-32.0 INR(PT)-2.3*
[**2189-3-19**] 02:13PM BLOOD PT-31.1* PTT-33.2 INR(PT)-3.1*
[**2189-3-19**] 01:00PM BLOOD PT-31.5* PTT-33.9 INR(PT)-3.2*
[**2189-3-22**] 04:43AM BLOOD Glucose-96 UreaN-15 Creat-0.6 Na-137
K-3.6 Cl-100 HCO3-31 AnGap-10
[**2189-3-24**] 04:43AM BLOOD K-4.3
[**2189-3-23**] echo
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve is not
well seen. The mitral valve leaflets are mildly thickened. There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. No pathologic valvular abnormality
seen. Small pericardial effusion located near right atrium
without evidence of tamponade.
Brief Hospital Course:
The patient was taken to the operating room for surgical
management of his pericardial effusion. He underwent a
mediastinal exploration and pericardial window via sternotomy
and small left thoracotomy. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. *****
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 no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. He remained in atrial
fibrillation and he was started on digoxin as well as amiodarone
in addition to the atenolol. Coumadin was resumed at low dose
for goal INR [**12-24**]. Chest tubes were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5, the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Amiodorone 200 mg PO BID
Augmentin 1 PO BID
ASA 81 mg PO daily
Atenolol 50 mg PO daily
Enalapril 10 mg PO daily
Fluoxetine 20 mg PO daily
Synthroid 75 mcg PO daily
Metformin 500 mg PO BID
Zantac 150 mg PO BID
Coumadin 4 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 7 days then 200 mg daily until further
instructed.
Disp:*60 Tablet(s)* Refills:*2*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal [**Hospital1 **] (2 times a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
Disp:*60 Tablet(s)* Refills:*2*
13. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
15. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose
will change daily for goal INR [**12-24**]. Dr. [**First Name (STitle) 4553**] to manage.
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
serial PT/INR
dx: atrial fibrillation
goal INR [**12-24**]
Results to Dr. [**First Name (STitle) 4553**] (FAX [**Telephone/Fax (1) 86629**])
Discharge Disposition:
Home with Service
Discharge Diagnosis:
pericardial effusion and cardiac tamponade
s/p pericardial window this admission
PMH:
Hypertension
Hyperlipidemia
Morbid obesity
non insulin dependent Diabetes Mellitus
chronic Atrial Fibrillation
Obstructive sleep apnea
Hypothyroidism
Depression
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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**]
**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:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2189-4-7**] 2:15
Please call to schedule appointments
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 86628**] in [**11-22**] weeks
Cardiologist Dr. [**Last Name (STitle) 39975**] in [**11-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
**Dr. [**First Name (STitle) 4553**] will resume management of coumadin/INR, confirmed
with [**Month (only) 547**]**
Completed by:[**2189-3-24**]
|
[
"420.90",
"V58.61",
"785.51",
"250.00",
"272.4",
"423.3",
"244.9",
"278.01",
"401.9",
"327.23",
"427.31",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
7236, 7255
|
3806, 5142
|
357, 543
|
7546, 7702
|
2315, 3783
|
8403, 9088
|
1602, 1620
|
5425, 7213
|
7276, 7525
|
5168, 5402
|
7726, 8380
|
1635, 2296
|
281, 319
|
571, 1154
|
1176, 1448
|
1464, 1586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,879
| 185,287
|
46378
|
Discharge summary
|
report
|
Admission Date: [**2145-4-4**] Discharge Date: [**2145-4-9**]
Date of Birth: [**2086-5-30**] Sex: F
Service: MEDICINE
Allergies:
Azathioprine
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Anuria
Major Surgical or Invasive Procedure:
renal biopsy
History of Present Illness:
58f with htn, dm, hypothyroidism, psoriasis and polymyositis on
prednisone and cyclosporine who presents with urinary retention.
She reports that she was not able to urinate since last night.
She reports that until that time, she was urinating normally.
She has had 1 month of nausea, anorexia and occassionally
vomitting. She has chronic diarrhea. She reports a 45 lb
weight loss over the last 3 months. She reports that it was
unintentional, but thinks it is due to eating less. She has
been taking cyclosporine x 1 year and it has been helping with
her polymyositis and psoriasis. She has recently started on
celexa ([**3-28**]).
.
The renal fellow was able to access her [**Hospital1 112**] records (with
permission) and prior values were Cr: 0.9 1 year ago [**2145-3-29**]
1.8, [**3-29**] 228 3pm (likely not trough).
.
In the ED VS were 96.0 90 174/82 16 100%. Serum K was 7.4.
EKG had peaked t waves. She was given calcium, insulin, glucose,
sodium bicarb, kayexalate. Foley was placed. UA had WBC, + bact,
+ leuks, - nit and she was given 400mg IV cipro.
.
When she arrived to the floor she had ~1 hour of profuse watery
diarrhea.
.
ROS: + chills, weight loss. negative for fever, URI sxs
Past Medical History:
Polymyositis LE predominent
DM (metformin)
HTN
hypothyroid
psoriasis
s/p appy
Social History:
lives with son and twin grandkids, working on getting
disability, quit smoking 8 years ago, very occassional etoh.
Family History:
FHx: father with psoriasis, no known kidney disease. 4 healthy
siblings
Physical Exam:
MICU Admission PE:
PE: middle aged NAD
VS: 97.4 112 73/45 (improved to 90s with 250cc NS), 15 98% RA
HEENT: PERRL, EOMI no nystagmus, OP clear, MM dry
Neck: no LAD, no thyromegaly
Chest: CTAB
Cardiac: RRR 2/6 holosystolic murmur
Abd: + BS, soft, NTND, no HSM
ext: no edema, 1+ pulses, fine tremor in hands
neuro: Alert and oriented x 3, CN 2-12 intact, ?hyperreflexia in
biceps, [**5-8**] bilateral strength in hip extension, but [**6-7**]
everywhere else.
.........
Transfer to floor PE:
Vitals: 81 118/58 18 96%ra
GEN: WD, ND, NAD
HEENT: PERRL, EOMI no nystagmus, OP clear, MM dry
Neck: no LAD, no thyromegaly
Chest: CTAB, no w/c/r
Cardiac: RRR 2/6 holosystolic murmur
Abd: + BS, soft, NTND, no HSM
ext: no edema, 1+ pulses, fine tremor in hands
neuro: Alert and oriented x 3, CN 2-12 intact
Pertinent Results:
RADIOLOGY Final Report
RENAL U.S. [**2145-4-3**] 11:18 PM
FINDINGS: The right kidney measures 11.5 cm and the left kidney
measures 12.2 cm. The corticomedullary differentiation is
preserved. There are no perinephric fluid collections. There is
no hydronephrosis, renal masses or stones noted. Incidental note
is made of a mildly distended gallbladder filled with sludge and
multiple shadowing foci consistent in appearance with
gallstones.There is also probably a mildly fatty liver which is
non - specific.It is unchanged sicnce [**2139**] as essentially are
the gallbladder changes.
IMPRESSION:
1. No hydronephrosis.
2. Mildly distended gallbladder containing multiple gallstones
and sludge.
[**2145-4-9**] 06:30AM BLOOD WBC-8.1 RBC-3.55* Hgb-10.2* Hct-31.7*
MCV-90 MCH-28.8 MCHC-32.2 RDW-13.7 Plt Ct-323
[**2145-4-8**] 06:35AM BLOOD WBC-7.7 RBC-3.63* Hgb-10.6* Hct-32.4*
MCV-89 MCH-29.1 MCHC-32.7 RDW-13.7 Plt Ct-329
[**2145-4-7**] 07:15AM BLOOD WBC-9.0 RBC-3.62* Hgb-10.6* Hct-32.1*
MCV-89 MCH-29.3 MCHC-33.1 RDW-13.5 Plt Ct-323
[**2145-4-6**] 05:35AM BLOOD WBC-8.7 RBC-3.24* Hgb-9.4* Hct-28.1*
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.6 Plt Ct-285
[**2145-4-6**] 01:40AM BLOOD Hct-27.8*
[**2145-4-5**] 02:47PM BLOOD WBC-8.5 RBC-3.62* Hgb-11.1* Hct-31.5*
MCV-87 MCH-30.6 MCHC-35.1* RDW-13.5 Plt Ct-293
[**2145-4-5**] 04:50AM BLOOD WBC-9.2 RBC-3.53* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.4 Plt Ct-289
[**2145-4-4**] 08:16AM BLOOD WBC-12.5* RBC-3.96* Hgb-11.8* Hct-35.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.6 Plt Ct-327
[**2145-4-4**] 02:40AM BLOOD WBC-16.4* RBC-4.62 Hgb-13.3 Hct-41.1
MCV-89 MCH-28.8 MCHC-32.4 RDW-13.4 Plt Ct-419
[**2145-4-4**] 02:40AM BLOOD WBC-16.4* RBC-4.62 Hgb-13.3 Hct-41.1
MCV-89 MCH-28.8 MCHC-32.4 RDW-13.4 Plt Ct-419
[**2145-4-4**] 08:16AM BLOOD Neuts-77.2* Lymphs-15.1* Monos-6.3
Eos-1.2 Baso-0.3
[**2145-4-6**] 05:35AM BLOOD PT-11.4 PTT-21.7* INR(PT)-0.9
[**2145-4-9**] 06:30AM BLOOD Plt Ct-323
[**2145-4-9**] 06:30AM BLOOD Glucose-110* UreaN-53* Creat-2.9*# Na-145
K-3.5 Cl-106 HCO3-28 AnGap-15
[**2145-4-8**] 06:35AM BLOOD Glucose-141* UreaN-61* Creat-4.0* Na-143
K-3.5 Cl-103 HCO3-29 AnGap-15
[**2145-4-7**] 11:42AM BLOOD Glucose-550* UreaN-73* Creat-5.0* Na-137
K-4.1 Cl-98 HCO3-25 AnGap-18
[**2145-4-7**] 07:15AM BLOOD Glucose-141* UreaN-77* Creat-5.5*# Na-143
K-3.9 Cl-101 HCO3-27 AnGap-19
[**2145-4-6**] 05:35AM BLOOD Glucose-127* UreaN-88* Creat-6.7* Na-141
K-3.6 Cl-100 HCO3-26 AnGap-19
[**2145-4-3**] 09:50PM BLOOD Glucose-117* UreaN-103* Creat-6.4*#
Na-135 K-7.4* Cl-99 HCO3-15* AnGap-28*
[**2145-4-4**] 02:40AM BLOOD CK(CPK)-778*
[**2145-4-3**] 09:50PM BLOOD ALT-43* AST-30 LD(LDH)-337* CK(CPK)-708*
AlkPhos-64 Amylase-87 TotBili-0.3
[**2145-4-3**] 09:50PM BLOOD Lipase-58
[**2145-4-9**] 06:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2145-4-4**] 02:40AM BLOOD TSH-3.8
[**2145-4-4**] 02:40AM BLOOD T4-7.5
[**2145-4-4**] 10:04AM BLOOD ANCA-NEGATIVE B
[**2145-4-4**] 10:04AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2145-4-4**] 08:16AM BLOOD dsDNA-NEGATIVE
[**2145-4-4**] 02:29PM BLOOD C3-122 C4-40
[**2145-4-3**] 09:50PM BLOOD C3-159 C4-50*
[**2145-4-4**] 08:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2145-4-4**] 01:08AM BLOOD Cyclspr-45*
[**2145-4-4**] 02:50PM BLOOD Lactate-4.0*
Brief Hospital Course:
# Acute Renal Failure
# DM-2 with Hyperglycemia
The patient was admitted to the ICU. There she was monitored
for her elevated potassium, anuria, and monitored closely. On
HD 2 the patient's lab values had much improved, she had been
evaluated by the renal team - cyclosporin, metformin, and ace
inhibitor were stopped, and was transferred to the floor. For
the next 5 days the patient slowly improved. She continued
therapy for her urinary tract infection. Daily labs were done
and her creatinine slowly improved, she began making urine, and
was doing well overall. Only partial results of the renal
biopsy were back at the time of discharge so a final diagnosis
was still pending. She had normal complement studies. The most
likely cause of her renal failure was ATN.
.
On HD 3 the patient's blood sugar began to rise - mostly in the
afternoon. This persisted and on HD 4 the patient was seen by
the [**Last Name (un) **] team for help in controling her diabetes - as she
currently could not take oral medications. They adjusted here
evening and sliding scales of insulin. The patient underwent
much teaching regarding how and when to dose insulin. She was
quite comfortable with this prior to her discharge.
.
On HD 6 the patient's Cr had continued to decline, she was
tolerating a regular diet, was ambulating without difficulty,
urinating without difficulty, and ready for discharge. She was
discharged with VNA services as she was new to insulin. A
follow-up appointment with the [**Hospital **] clinic had been arranged
for the patient this coming [**Hospital 766**]. She was instructed not to
take her metformin, lisinopril, or cyclosporin until she
followed up with the renal team. She continued the cipro for
the urinary tract infection. If the cyclosporin will need to be
restarted, this should be discussed between rheumatology and
nephrology.
.
# Gap Metabolic acidosis, hypercalcemia, hypophosphatemia:
Secondary to ARF. Subsequently improved.
.
# Polymyositis:
Will need f/u w/rheum as outpatient. Cyclosporine held.
Continued on prednisone.
.
# hypothyroidism:
Continued on home meds.
Medications on Admission:
Medications:
metformin 1g, 500mg, 1g
levoxyl 100 mcg daily
lisinopril (dosage unknown Dr. [**Last Name (STitle) **] at [**Hospital1 **]?)
prednisone 20mg Daily
cyclosporine 4 tabs daily
citalopram (dosage unknown Dr. [**Last Name (STitle) **] at [**Hospital1 **]?)
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
Disp:*5 Tablet(s)* Refills:*0*
4. Humalog 100 unit/mL Solution Sig: One (1) mls Subcutaneous
four times a day: as directed per sliding scale.
Disp:*qs * Refills:*0*
5. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime: - pharmacy: please pre-fill 3 syringes
for patient then give her the rest of the bottle.
Disp:*qs * Refills:*0*
6. Insulin Syringe 1 mL 28 x [**2-3**] Syringe Sig: One (1) syringe
Miscellaneous four times a day.
Disp:*120 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- acute renal failure
- diabetes
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital and treated for acute
decompensation of your kidney function. You underwent a variety
of procedures to determine why this happened. You were seen by
the nephrology team as well. You were also seen by the [**Last Name (un) **]
doctors who have helped to adjust your insulin regimen as you
have been taken off of oral diabetes medications for now. You
have improved a great deal since your admission.
You will need to take all medications as instructed.
Do not take your lisinopril, cyclosporin, or metformin.
Continue taking your home dose of citalopram.
You will need to check your blood sugars 4 times a day - 30 min
before breakfast, lunch, dinner, and just before bed. You will
need to give yourself insulin at this time as well. The amount
you give will be according to the sliding scale the [**Last Name (un) **] team
has made for you. You will also need to give yourself an
evening dose of the long acting insulin.
It is very important that you record all of your blood sugars
and bring this log to your appointment with Dr. [**Last Name (STitle) **] on
[**Last Name (STitle) 766**].
You will need to keep all of your follow-up appointments.
Please call your primary doctor or return to the ED if you
experience any of the following:
T>101.5, chills, nausea, vomiting, chest pain, shortness of
breath, abdominal pain, lack of urination, extremely elevated
blood sugars, change in mental status, or any other concern.
Followup Instructions:
- you need to follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**]
for post-hospitalization visit and lab work -> need to have
electrolytes checked
- you need to follow-up with your rheumatologist in the next
week for adjustments in your medications as the cyclosporin has
been stopped.
***Very important that you keep the following appointments***
- Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2145-4-20**] 1:30
- You have an appointment scheduled with Dr. [**Last Name (STitle) **] at [**Last Name (un) **]
on [**Last Name (un) 766**] - [**4-12**]. You need to arrive at 12:20 for your
1:00pm appointment -> this will be followed by a 2:00pm
appointment for your eyes.
|
[
"041.4",
"401.9",
"V58.67",
"788.20",
"710.4",
"584.5",
"244.9",
"250.02",
"V58.65",
"275.42",
"276.7",
"696.1",
"276.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
9159, 9230
|
5983, 8104
|
277, 291
|
9307, 9314
|
2687, 5960
|
10831, 11643
|
1777, 1850
|
8419, 9136
|
9251, 9286
|
8130, 8396
|
9338, 10808
|
1865, 2668
|
231, 239
|
319, 1527
|
1549, 1628
|
1644, 1761
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,788
| 126,313
|
45682
|
Discharge summary
|
report
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Admission Date: [**2119-8-19**] Discharge Date: [**2119-9-1**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Incision and drainage of R gluteus.
Peripherally-inserted central venous catheter.
History of Present Illness:
87 yo male fell out of bed, now presenting with lower back pain.
The patient was [**Location (un) 1131**] a book in bed when the book fell and
apparently reached over to grab it. He fell out of bed and
landed on his back and was found after being down for an unclear
amount of time. His daughter [**Name (NI) **] reports "at least a few
hours." On presentation he reports bilateral pain in his arms,
legs, ankles, and back. The parts that hurt him the most are his
right elbow, right hip, lower back, and left calf. He has a
history of lower back pain but reports that this is worse than
prior. He denies any current changes in his speech or vision.
Denies headaches, CP, SOB, fever, cough, abdominal pain, N/V/D,
dysuria. He reports occasional diarrhea. He notes normal UOP and
PO intake recently at home. Of note, he reports taking ibuprofen
at home for his chronic low back pain.
In the ED, initial vitals were: afeb 76 111/56 21 100% on RA.
Highlights of initial studies and interventions include:
- Multiple plain films and CTs revealing: irregularity along L
navicular, could be avulsion or enthesopathy, old rib fractures,
no c-spine or hip fracture, no head bleeds
- CK elevated to 10,287 IU/L
- Lactate of 3.9
- 3L IVF and 2L PO given
- Given tylenol 1000mg PO once for fever
- Given vancomycin/cefepime for coverage
- EKG: SR with STE in V2, no CP, neg troponin
MICU Admission Vitals: HR 76, BP 105/45, Sat 95% RA
On arrival to the MICU, he reports low back pain, right upper
arm pain, and right sided pain.
Past Medical History:
Hyperlipidemia
HTN
BPH, awaiting laser surgery
s/p cataracts surgery bilaterally
CAD
DJD with lower back pain and bulging disc
mod left foraminal stenosis at L2-L3
macular degeneration
BCC
Bilateral inguinal hernia repair
Social History:
Lives with wife and son. Wife with advanced Alzheimer's disease,
son and daughter take care of her. He eats at Panera. He bathes
himself and walks independently. Prior pipe smoker 40 years ago,
occaisional glass of white wine. He reads during the day. Takes
all of his medications by himself and goes to appointments. Goes
on the T by himself, does not drive. Daughter believes that he
may have hired commercial sex workers within the past year.
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T 102 HR 73 RR 20 BP 106/49 SaO2 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, pupils
not reactive, left pupil 2mm, right pupil 6mm
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g, no pain
when palpating chest wall
Lungs: bibasilar crackles
Abdomen: +BS, soft, non-tender, distended, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ distal pulses throughout, no
clubbing, cyanosis or edema, bilateral calf tenderness L>R,
bilateral +[**Last Name (un) 5813**] sign, dependent erythema of bilateral
extermities with blisters over posterior right hip, extremities
are extremely tender and swollen, with pain out of proportion to
exam
Rectal: no tone, intact saddle sensation, no saddle anesthesia
Back: tenderness L3-L5 spinous processes
Neuro: CNII-XII intact, 5/5 strength in UE, strength limited by
pain in the lower extremities, grossly normal sensation
DISCHARGE PHYSICAL EXAMINATION:
VITALS: T 98.0 HR 66 RR 18 BP 139/59 SaO2 96% on RA.
GENERAL: Elderly gentleman is awake and in NAD.
CARDIOVASCULAR: RRR, no m/r/g. Moderate tenderness to palpation
over the left chest wall.
PULMONARY: CTAB other than bibasilar crackles.
SKIN/EXTREMITIES: Petechiae on calf have diminished. Erythema
on left calf in dependent areas. Pneumoboots present.
WOUND: Clean, dry and intact. Mild tenderness to palpation.
NEUROLOGICAL: Alert & oriented x 3. Examination limited by
pain. Strength and sensation exam unchanged.
Pertinent Results:
Labs:
[**2119-8-19**] 05:50PM BLOOD WBC-4.5 RBC-4.39* Hgb-14.4 Hct-41.2
MCV-94 MCH-32.8* MCHC-34.9 RDW-13.4 Plt Ct-131*
[**2119-8-20**] 06:42AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2119-8-20**] 01:58AM BLOOD PT-20.2* PTT-28.7 INR(PT)-1.9*
[**2119-8-20**] 12:11PM BLOOD Fibrino-583*
[**2119-8-20**] 06:42AM BLOOD ESR-49*
[**2119-8-19**] 05:50PM BLOOD UreaN-38* Creat-1.7*
[**2119-8-20**] 01:58AM BLOOD Glucose-105* UreaN-38* Creat-1.6* Na-141
K-3.3 Cl-107 HCO3-22 AnGap-15
[**2119-8-19**] 05:50PM BLOOD CK(CPK)-[**Numeric Identifier 97363**]*
[**2119-8-20**] 01:58AM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2119-8-20**] 06:42AM BLOOD ALT-92* AST-370* LD(LDH)-540*
CK(CPK)-[**Numeric Identifier 97364**]* AlkPhos-24* TotBili-1.4
[**2119-8-19**] 05:50PM BLOOD CK-MB-52* MB Indx-0.5 cTropnT-<0.01
[**2119-8-20**] 01:58AM BLOOD CK-MB-38* MB Indx-0.3 cTropnT-0.03*
[**2119-8-20**] 12:11PM BLOOD CK-MB-27* MB Indx-0.2 cTropnT-0.03*
[**2119-8-20**] 12:11PM BLOOD Albumin-2.4* Calcium-6.4* Phos-3.3 Mg-2.4
[**2119-8-20**] 06:42AM BLOOD TSH-0.86
[**2119-8-20**] 12:11PM BLOOD PTH-111*
[**2119-8-20**] 12:11PM BLOOD 25VitD-23*
[**2119-8-20**] 01:58AM BLOOD CRP-GREATER TH
[**2119-8-20**] 12:11PM BLOOD HIV Ab-NEGATIVE
[**2119-8-19**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-8-19**] 05:53PM BLOOD Glucose-128* Lactate-3.9* Na-139 K-3.9
Cl-108 calHCO3-23
[**2119-8-19**] 08:21PM BLOOD Lactate-4.0*
[**2119-8-20**] 02:12AM BLOOD Lactate-4.1*
[**2119-8-20**] 06:50AM BLOOD Lactate-2.4*
[**2119-8-21**] 12:28AM BLOOD Lactate-1.4
CK Trend
On admission: [**Numeric Identifier 97363**]
Peaked on HD#3: [**Numeric Identifier 97364**]
Downtrended to normal by HD#14: 267.
Creatinine Trend:
On admission: 1.7
Downtrended and normalized by HD#5 to 1.2 and continued to trend
to 0.8-0.9 range.
ON DISCHARGE:
[**2119-9-1**] 06:25AM BLOOD WBC-8.0 RBC-3.23* Hgb-10.1* Hct-30.8*
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.1 Plt Ct-732*
[**2119-9-1**] 06:25AM BLOOD Glucose-145* UreaN-17 Creat-0.8 Na-135
K-4.5 Cl-98 HCO3-30 AnGap-12
[**2119-9-1**] 06:25AM BLOOD ALT-33 AST-33 LD(LDH)-426* CK(CPK)-152
AlkPhos-64 TotBili-0.4
[**2119-8-20**] 06:42AM BLOOD TSH-0.86
[**2119-8-20**] 12:11PM BLOOD 25VitD-23*
MICROBIOLOGY:
[**2119-8-22**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH.
[**2119-8-21**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH.
[**2119-8-20**] URINE Chlamydia trachomatis, Nucleic Acid Probe, with
Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID
PROBE, WITH AMPLIFICATION-FINAL
[**2119-8-20**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
[**2119-8-20**] MRSA SCREEN MRSA SCREEN-FINAL
[**2119-8-19**] BLOOD CULTURE Blood Culture, Routine-FINAL {BETA
STREPTOCOCCUS GROUP B}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
[**2119-8-19**] BLOOD CULTURE Blood Culture, Routine-FINAL {BETA
STREPTOCOCCUS GROUP B}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL
[**2119-8-19**] URINE URINE CULTURE-FINAL
IMAGING:
[**2119-8-19**] CT cspine: Moderate cervical spondylosis. No evidence
for fracture or dislocation. Findings suggesting mild pulmonary
vascular congestion.
[**2119-8-19**] CXR: Rib fractures, without displacement, but of
uncertain acuity. No evidence of acute cardiopulmonary disease
[**2119-8-19**] CT head: 1. No evidence of acute intracranial process.
2. Small vessel ischemic disease. 3. Ventricles are enlarged,
slightly out of proportion of the sulcal enlargement, which may
reflect central atrophy; less likely, however, normal pressure
hydrocephalus could be considered in the appropriate clinical
setting.
[**2119-8-19**] CT torso: 1. Findings suggesting more remote prior
injury involving the right hemipelvis. 2. Fluid in the right
trochanteric bursa. 3. Coronary artery calcifications. 4.
Findings suggesting mild vascular congestion. 5. Small
fat-containing umbilical hernia.
[**8-19**] Ankle films: Findings concerning for non-displaced avulsion
fracture along the proximal superior navicular on the left.
Correlation with physical findings is suggested. If physical
findings do not support the likelihood of acute injury at the
site, then degenerative enthesopathy could be considered as an
alternative etiology.
[**8-19**] elbow films: No evidence of recent injury.
[**8-20**] BLE LENIs: No DVT.
[**8-20**] MRI T/L spine:
1. Multilevel, multifactorial degenerative changes in the lower
cervical,
thoracic, and the lumbar spine as described above. Degenerative
changes are noted at C5 and C6 levels with moderate canal
stenosis, with disc osteophyte complexes indenting the thecal
sac and the cord along with ligamentum flavum changes.
2. No abnormal enhancement to suggest epidural abscess.
3. At L5-S1: Increased signal intensity in the disc with
minimal edema in the adjacent endplates likely degenerative.
Correlate clinically and with labs to exclude any associated
inflammatory/infectious component.
4. Small protrusions in thoracic spine. Bil. small pleural
effusions.
[**8-20**] CT RLE:
1. Nonspecific areas of low attenuation within the right
gluteal muscles
could represent edema from trauma, inflammation, or infection.
Muscle
necrosis and muscle tear would be in the differential. Deep and
superficial fascial edema. Moderate subcutaneous edema. Further
evaluation with MRI of the pelvis may be obtained if clinically
warranted.
2. Focal subcutaneous cystic lesion/fluid collection overlying
the right
buttocks,likely representing a small inflammed subcutaneous
cyst. Clinically correlate to ensure resolution.
3. Evaluation of the deep venous structures shows no evidence
of thrombosis.
[**8-21**] TTE: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Moderate
pulmonary artery hypertension. No valvular pathology or
pathologic flow identified.
[**8-21**] MRI Pelvis:
1. Asymmetric increase in edema predominantly in the gluteal
muscles as well as in the adductor musculature and tracking
along the sciatic nerve into the pelvis. This is a nonspecific
finding, but could be accounted for by changes related to
contusion from recent fall and to reported rhabdomyolysis. The
possibility of superimposed infection cannot be excluded and
could also account for or contribute to this appearance. Of
note, edema is seen tracking from this area through the sciatic
notch into the pelvis. No large fluid collection is seen, but
intravenous contrast would be required to identify smaller fluid
collections.
2. Right ischial bursitis. Again the presence or absence of
infection cannot be assessed by imaging. IV contrast would be
required to distinguish fluid from thickened, hyperemic
synovium.
3. No joint effusion or marrow edema detected about the hips or
pelvic girdle. No gross gluteal tear, but the distalmost
insertion of the gluteus maximus onto the femoral shaft is not
included on these images.
4. Complex fatty mass between the right gluteus medius and
maximus muscles, likely a lipoma with superimposed edema,
however, the differential includes a small liposarcoma.
Therefore, non-acute follow up examination is recommended once
the patient's clinical symptoms have resolved to further assess
this lesion.
MRI WITH AND WITHOUT CONTRAST (7/13,[**8-26**])
========================================
1. Ill-defined low-signal intensity rim-enhancing collection
within the gluteus medius muscle with extension to the gluteus
maximus muscle, felt to represent necrotic tissue versus focal
fluid collection. The presence or absence of infeciton within
this area cannot be evaluated by imaging. Further evaluation
with ultrasound may be obtained.
2. Large area of low signal intensity involving the entire
gluteus maximus muscle, felt to represent developing muscle
necrosis. The ddx could include fluid, but this is considered
less likely.
3. Focal hemorrhage anterior to the gluteus maximus muscle.
4. Diffuse body wall anasarca, and large bilateral
hydroroceles.
LE DOPPLER U/S ([**8-23**]): No right lower extremity DVT.
R SHOULDER XR ([**8-23**]): Probable old healed fracture of the right
proximal humerus. Otherwise, no acute fracture or dislocation.
If clinical suspicion for acute right humeral fracture remains
high, then further assessment is recommended.
ULTRASOUND R GLUTEUS ([**8-28**]): A tiny fluid collection was seen on
a recent MRI performed two days previously. Despite numerous
attempts, the same tiny fluid collection could not be identified
with ultrasound largely due to its location posted to the right
hip joint.
Brief Hospital Course:
==================================
87 year old male with history of CAD and hyperlipidemia who
presents after fall found to have rhabdomyolysis and [**Last Name (un) **],
elevated lactate, sepsis with group B beta hemolytic
streptococcus and extensive right buttocks soft tissue injury.
#) FALL: Unclear inciting event. Unwitnessed. Orthostatics
negative. Patient denied any cardiac prodrome, convulsions,
incontinence, or post-ictal symptoms. Focal weakness in
admission was likely secondary to pain and CT head negative for
ischemic changes. EKGs without arrhythmia. Given later finding
of [**Last Name (un) 97365**] sepsis, fall could have been due to delirium/confusion
from bloodstream infection.
#) MUSCULOSKELETAL INJURY: S/p fall and muscle breakdown leading
to rhabdomyolysis. Back pain in ICU in setting of initial
coagulopathy concerning for epidural hematoma vs. abscess. MRI
thoracic and lumbar spine ruled out epidural mass, showing only
degenerative changes, but could not rule out discitis.
Neurosurgery consulted for poor rectal tone and profound
weakness on admission, but tone improved on their exam and felt
L5/S1 possible discitis seen on MRI more likely to represent
chronic changes.
Pain was controlled in ICU with tylenol and fentanyl boluses for
turns. Pain control upon transfer to the floor initially with
IV dilaudid and PO oxycodone. Initially pain was very poorly
controlled. Pain Service was consulted. Mr. [**Known lastname 97366**] was either
in significant pain or overmedicated. Transitioned to PO
oxycodone monotherapy as pain improved.
Extensive imaging revealed:
* Large area of low signal intensity involving the entire
gluteus maximus muscle, felt to represent developing muscle
necrosis. (However surgery explored this region in the OR and no
muscle necrosis was seen. Fat necrosis was seen.)
* No acute C-spine injury.
* No intracranial bleed.
* Left navicular avulsion.
* Old healed fracture of the right proximal humerus.
* Old rib fractures.
* Old injury to right hemipelvis.
Went to OR on [**8-31**] for exploration of right buttock with
incision and drainage, digital debridement of fat necrosis and
draining fluid thought to represent a hematoma. No muscle
necrosis was seen.
#) SEPSIS ([**Month/Year (2) 97365**]): Initially febrile to 104 F without
leukocytosis in the ICU. Lactate peak at 4. Concerned for
necrotizing fasciitis, so started on vancomycin, cefepime, and
clindamycin. HIV, GC/chlamydia and RPR negative after report of
patient hiring sex workers. Also concerned for possible
infectious endocarditis; TTE showed no evidence of this. Blood
cultures grew group B beta hemolytic streptococcus sensitive to
ceftriaxone, so therapy narrowed to ceftriaxone with ID
consultation. PICC placed for long term antibiotics. Final
course of antibiotics is 3 weeks from last negative blood
cultures ([**8-21**]) so will complete course on [**9-11**]. Source of [**Name (NI) 97365**]
unclear, but evidence of skin breakdown on back on presentation.
Urine culture clean and no evidence of pneumonia or other
infectious nidus.
#) RHABDOMYOLYSIS: Muscle breakdwon with extreme tenderness out
of proportion to exam. CKs peaked in 10,000s. Treated with
aggressive hydration with IVF. CKs continued to rise after
admission and initiation of IVF until HD#2 at 14,948 and
downtrended subsequently until normalization by HD#14.
Initially concerned for compartment syndrome but surgery
consultation and imaging deemed this was unlikely. Home statin
held. Also initially concerned for myositis, TSH WNL, but felt
that trauma and compression injury the more likely culprit,
although etiology of diffuse BLE petechiae anf purpura by HD#10
was unclear and raised the possibility of an evolving
vasculitis. These lesions resolved over a few days.
#) LEFT NAVICULAR AVULSION/ENTHESOPAHTY: Causing minimal pain
during this admission. Per ortho, needs only supportive care.
No activity limitation. Supportive boot only if patient
desires.
#) HEEL ULCERS: Secondary to being bedbound while in hospital.
#) ACUTE KIDNEY INJURY: Admitted with creatinine at 1.7 in
setting of muscle breakdown due to rhabdomyolysis. Home NSDAIDs
and HCTZ held. With IVF, creatinine downtrended to 0.8-0.9
range.
#) HYPOPHOSPHATEMIA: On initial presentation. Unclear etiology.
Vit D low, PTH high.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient [**Name (NI) 2025**] PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45544**].
1. Niacin 400 mg PO QID
2. Aspirin 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Ibuprofen 200 mg PO BID:PRN pain
5. Cyanocobalamin Dose is Unknown PO DAILY
6. Glucosamine *NF* (glucosamine sulfate) unknown Oral daily
7. Fish Oil (Omega 3) 6 tabs PO TID
8. Vitamin D 1000 UNIT PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Tamsulosin 0.4 mg PO HS
Take 30 minutes after the same meal each day.
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. CeftriaXONE 2 gm IV Q24H
4. Hydrochlorothiazide 25 mg PO DAILY
5. Cyanocobalamin 25 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Niacin 400 mg PO QID
8. Pyridoxine 50 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
Take 30 minutes after the same meal each day.
10. Acetaminophen 1000 mg PO Q6H:PRN Pain
Do NOT exceed 4g daily
11. Fish Oil (Omega 3) 6 tabs PO TID
12. Glucosamine *NF* (glucosamine sulfate) 1 tab ORAL DAILY
13. Ibuprofen 200 mg PO BID:PRN pain
14. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain
Hold for oversedation, RR < 12. Please alternate with standing
oxycodone dosing. Thank you.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*120 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary-
Rhabdomyolysis
right gluteal injury with fat necrosis
Acute kidney injury
Sepsis with group B beta-hemolytic streptococci
metabolic encephalopathy
NSTEMI
Secondary-
L2-L3 moderate spinal stenosis
Hypertension
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Patient previously able to ambulate without
difficulty. Out of Bed with assistance to chair or wheelchair.
Discharge Instructions:
Dr. [**Last Name (STitle) **]. [**Known lastname 97366**],
It was a pleasure taking part in your care during your stay at
[**Hospital1 69**]. You were admitted after a
fall and found to have extensive muscle damage. This released
proteins into your blood (called rhabdomyolysis) and caused
acute kidney injury which we treated with intravenous fluids and
your kidney injury resolved. You were also found to have
bacteria growing in your blood (sepsis) which we treated with
antibiotics. Part of the fat in your right buttock was found to
be dead after your fall and needed surgical intervention. This
was completed without complication.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45544**]
at [**Hospital1 2025**]. We recommend trying to see him within 1-2 weeks
following you discharge from rehab. We will send him all of the
records from this hospitalization.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,915
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55034
|
Discharge summary
|
report
|
Admission Date: [**2103-4-10**] Discharge Date: [**2103-4-13**]
Date of Birth: [**2075-4-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fever
endocarditis
Major Surgical or Invasive Procedure:
Redo sternotomy, mitral valve replacement [**2103-4-13**]
History of Present Illness:
27M with a history of IVDA and endocarditis in [**2098**] and [**2100**].
He
is s/p mechanical AVR and MVR in [**2100**]. He presented to [**Hospital6 **] on [**2103-4-6**] with fever, malaise, weakness, vomiting
and diarrhea. He developed diplopia and strabismus in the ED.
He does have a history of intracranial hemorrhage, however CT
was
negative for acute pathology at this time. He is
anti-coagulated
for his mechanical valves, and INR became supra-therapeutic at
8.
He was treated with FFP and Vitamin K. ID was consulted and he
was empirically given Vancomycin, Gentamicin and Zosyn. Per
report his blood cultures have grown methicillin sensitive staph
aureus. Gentamicin has since been discontinued due to elevated
level of 4.7. Trans-thoracic Echo revealed a peri-valvular leak
of the prosthetic mitral. Prosthetic Aortic Valve is well
seated
without AI.
The patient was transferred to the ICU and subsequently became
increasingly tachypneic, tachycardic and agitated. He was
intubated and transiently required levophed for hypotension but
was able to be weaned off with fluid recussitation but has been
progressively more oliguric with rising creatinine. Initial
blood cultures grew methicillin sensitive Staph Aureus and his
antibiotics were changed to nafcillin/rifampin/gentamycin. Of
note, creatinine rose from 0.6 to 1.3 to 2.9 on [**4-10**]. He is
turned down for Redo Sternotomy, AVR/MVR at [**Hospital1 **] due to his
continued IV drug abuse and transferred to [**Hospital1 18**] for further
evaluation. At the time of transfer he is hemodynamically
stable, without pressor support.
Past Medical History:
Past Medical History
Endocarditis [**2098**], [**2100**]
h/o CVA [**2098**] related to endocarditis without deficit
IVDA-patient denied current use on admission but OSH felt he was
continuing to use
s/p AVR, MVR [**2100**]
Intracranial hemorrhage and cavernous malformation
Seizures-currently off medications
Morbid Obesity
Hypertension
Hepatitis C treated w Interferon
Septic Emboli secondary to Endocarditis
Past Surgical History:
AVR(St. [**Male First Name (un) 923**] mechanical), MVR(St. [**Male First Name (un) 923**] mechanical) [**2100**]
Past Cardiac Procedures
Surgery:AVR/MVR Date: [**2100**]
Type of valve:St. [**Male First Name (un) 923**] mechanical size: Company:
Social History:
-Pt currently lives at home with his [**Male First Name (un) **]
-IVDU (active per family).
-Tobacco: 1ppd x 10 yrs
-Denies EtOH
Family History:
Mother: HTN
h/o aneurysm in family
Physical Exam:
T on admission 102.4
Pulse:110 ST Resp:30s-40s, labored O2 sat: 98%
B/P Right:115/48 Left: 112/44
Height:188 cm Weight:176.5
General:sedated on propofol, tachypnic, not folllowing commands
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
Neck: Supple [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] heard at R sternal
border and apex, only 1 valve click heard on second heart sound
Abdomen: Soft [x] obese, non-distended [x] absent bowel sounds
Extremities: Warm [], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact []
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:1+
Carotid Bruit Right:unable to assess d/t RIJ Left:none
extremities: areas of necrosis/?septic emboli on R 1, 2 and 3rd
digits. ? areas of emboli on soles of feet. Petechiae on R
upper arm medial surface
chest with miltiple fawn colored oval patches with slightly
scaly
appearance, larger on area over abdomen and smaller patches over
shoulders.
area under panus with erythema/excoriations, scrotum edematous
and excoriate
Pertinent Results:
Cardiac Echocardiogram:
TTE [**2103-4-8**]
EF 50%
Mechanical Mitral Valve- perivalvular leak
PASP 50-55mmHg
Mechanical Aortic Valve- mean gradient 32mmHg, no AI
TEE [**4-10**]
LVEF 65%, hyperdynamic LV
aortic valve with vegetations on both the LVOT and the aortic
side. The area posterior to the aortic root appears to be
edematous and with lucent areas whic is suspicious for absess
formation, no obvious fistula. AV mean gradiant 70mmHg. The
mechanical mitral valve has moderate paravalvular regurgitation
in the lateral and anterolateral annulus with dehiscense.
Therre
are multiple vegetations on the valve towards the atrial side.
The gradients across the mitral valve are significantly
elevated.
MV mean gradient 12mmHg.
Brief Hospital Course:
After transfer to [**Hospital1 18**] the patient remained sedated and
intubated. He was tachypneic and failed SBT. He underwent MRI
brain which showed several new infarcts (likely septic) and
neurology was consulted. He was also in renal failure on
admission with rising creatinine, acidosis and hyperkalemia.
Renal was consulted and he was started on CVVH. Given his
history of ICH with previous episodes of
endocarditis, he underwent MRI-brain which showed several new
infarcts (likely from septic emboli). He was seen by ID and they
are recommending continuing the same antibiotics. It was agreed
that he would need surgical intervention, but given the risk of
the procedure extensive discussions were had between the
surgical team, CVICU team and the family. An ethics consult
was also obtained. A family meeting was held with the pt.'s
brother and [**Name2 (NI) **] and they would like him to have surgery and
understand the extreme high risk of the procedure.
On [**2103-4-14**] the he was taken to the OR. The family understood
the high risk of surgery.
Unfortunately in the OR he remained profoundly acidotic. During
the case Acute Care Surgery was consulted intra-operatively to
explore the abdomen for possible ischemic GI contents given the
persistent acidosis and elevated lactate. There was no obvious
source for this and the abdomen was closed. Another discussion
was had with the family and the attending cardiac surgeon and it
was decided that he would be taken off cardiopulmonary bypass
despite his acidosis. He had no heart function after being
taken off bypass and expired thereafter. Time of death 1719.
Medications on Admission:
[**Last Name (un) 1724**]:Metoprolol 50 [**Hospital1 **], Coumadin 15mg daily, Methadone 55mg daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Endocarditis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
|
[
"421.0",
"996.02",
"V12.51",
"V12.09",
"275.41",
"305.1",
"276.2",
"428.0",
"584.5",
"304.01",
"518.81",
"434.11",
"785.52",
"E878.1",
"070.54",
"345.90",
"276.7",
"V85.42",
"278.01",
"995.92",
"431",
"V12.54",
"038.11",
"449",
"996.61",
"401.9",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.71",
"54.11",
"50.11",
"35.24",
"38.95",
"39.95",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
6765, 6774
|
4939, 6582
|
328, 388
|
6831, 6841
|
4183, 4916
|
6894, 6993
|
2931, 2968
|
6733, 6742
|
6795, 6810
|
6608, 6710
|
6865, 6871
|
2487, 2768
|
2983, 4164
|
270, 290
|
416, 2032
|
2054, 2464
|
2784, 2915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
634
| 165,899
|
15631
|
Discharge summary
|
report
|
Admission Date: [**2116-8-23**] Discharge Date: [**2116-10-12**]
Date of Birth: [**2053-12-21**] Sex: M
Service: HEPATOBILIARY SURGERY
HISTORY OF PRESENT ILLNESS: The patient is well known to the
Hepatobiliary Surgery Service of Dr. [**Last Name (STitle) **].
He recently underwent a Roux-en-Y hepaticojejunostomy for
Mirizzi syndrome and bile duct stricture. He subsequently
was discharged to home.
At home prior to this admission, he had passed some tarry
stool, had some bloody vomitus and syncope. This developed
into a very severe upper GI bleed, requiring admission with
aggressive volume resuscitation, aggressive administration of
blood products, including more than 40 U of packed red blood
cells, along with multiple units of fresh frozen plasma,
cryoprecipitate and platelets.
He was scoped by the Gastroenterologist on [**8-24**] for the
first time during this hospitalization in which they noted an
ulcer on the gastric side of the GE junction with some
bleeding but was minimal.
On the following day as he was watched in the Intensive Care
Unit, this blossomed to ongoing hemorrhage, and on [**8-25**],
they noted possibly some esophageal varices; however, with
such a significant amount of blood, they could not really
make a very good study out of it, and they placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
tube for all of the active bleeding.
Three days later, he had another endoscopy which did not show
any active bleeding but showed blood in the fundus. At the
same time, as the ongoing volume resuscitation and blood
product resuscitation continued, he was noted to have a
significant amount of portal hypertension and TIPS on [**2116-8-25**]. In addition on the same day, an Interventional
Radiology angiogram was performed, and coiling of a right
hepatic artery, posterior branch, pseudoaneurysm, as well as
coiling of the left gastric artery, which was done on [**2116-9-1**].
The patient had very complicated Intensive Care Unit and
hospital stay.
Neurologic: The patient was intubated, and upon being
awakened from the vent after a significant amount of time, he
was noted to be not following commands had a change in mental
status.
As a Neurology consult was obtained, CT of his head was
obtained, and there was no organic intracranial reason to
have these symptoms which were attributed just to the trauma
and insult that he had been through, as well as the hepatic
encephalopathy.
He was treated with Lactulose through an NG tube in an effort
to clear off the encephalopathy which was successful, and he
was gradually weaned off.
Pulmonary: The patient had a required ventilatory
dependence; however, he was successfully weaned and extubated
from the ventilator. He has no sequelae from this long-term
ventilation.
Cardiovascular: The patient was in hemodynamic hemorrhagic
shock with significant blood loss anemia. Once
resuscitation was completed, he was resumed on beta-blockers.
On [**10-6**], the patient had a cardiac echocardiogram
which had an ejection fraction estimated at 40-45%, moderate
dilation of the left atrium, with trivial mitral
regurgitation. The left ventricular cavity was also mildly
dilated and somewhat depressed in its systolic function, and
they noted posterior and akinesis and distal septal
hypokinesis.
Gastrointestinal: In addition to the already discussed above
facts regarding his history of Roux-en-Y hepaticojejunostomy
and various Interventional Radiology procedures, after the
coilings of the right hepatic artery pseudoaneurysm and the
left gastri artery, there was no further note of new onset GI
bleeding. His hematocrit stabilized, and gradually the
patient was started on tube feedings, and he was continued on
TPN.
The tube feedings were done via a nasojejunal tube which was
placed at endoscopy on [**9-14**]. This was the only way he
could maintain his calories, given his changes in mental
status around this event and obviously the prolonged
resuscitation and ventilation in the Intensive Care Unit.
The patient had percutaneous transhepatic cholangial tubes,
both in the left and right sides. These were eventually
capped. He had hyperbilirubinemia, which did eventually
trend downward. He had hypoalbuminemia which continues, and
at the very least is trending in the proper direction.
On [**2116-9-28**], the patient had an ultrasound which
showed patency of the TIPS and no further hematemesis. He
did have some guaiac positive stools but gradually developed
guaiac negative stools.
At one point, his nasoduodenal tube was pulled out, and he
was able to achieve his goal calories and protein with a lot
of encouragement and education, and currently is being
sustained solely on his own p.o. intake.
GU: During the process of the hypovolemic shock, the patient
went into acute renal failure. This gradually returned to
baseline function with an excellent urine output on his own.
In trying to get all of the volume off him, he was being
diuresed with Lasix and Spironolactone; however, after he was
returning very close to his normal baseline body weight,
these were discontinued.
In the process of numerous volume shifts that the patient
experienced, he experienced some hyponatremia, and this
improved with minimizing the amount of free-water ingested,
educating him, as well as adjusting TPN when he was being
given TPN.
Infectious disease: The patient had multiple intravenous
lines which carried him through the resuscitation in the
Intensive Care Unit. His positive cultures were that of MRSA
in sputum, and he was diagnosed with a MRSA pneumonia and had
an adequate treatment with Vancomycin.
He also had cultures from bile, some of which grew out
bacteria, including MRSA, VRE, VSE, those last two being
Vancomycin resistant Enterococcus and Vancomycin sensitive
Enterococcus.
After the patient was finished with antibiotics and was
transferred to the floor finally, he was doing well and then
developed high fever, and of his lines were removed at that
time, and he was started on Vancomycin. However, given that
he had previous problems with Vancomycin resistant
Enterococcus, he was started on intravenous Linezolid and
transitioned to p.o. Linezolid. He has currently been
afebrile for quite some time.
Hematologic: He remains anemia but without a lot of changes
in his hematocrit. He is being treated with Folate and a
healthy diet to try to improve his bone marrow stores of
vitamins and favor hematopoiesis.
He has accumulated or formulated a significant amount of
antibodies from the multiple blood transfusions, and our
pathology and blood bank has made it quite clear that he is
very difficult to cross-match for blood transfusions.
Endocrine: He has had some Insulin requirements during the
hospitalization. He is not on his oral hypoglycemics. He
has been having his blood sugars checked regularly. At this
point, he will go home and need to contact his primary care
physician to decide on his outpatient regimen. He is not
requiring Insulin regularly on the regular diet. He had been
requiring Insulin when he was on TPN, but since then, this is
just an intermittent blood sugar requirement, in association
with frequent blood sugar checks.
He knows, as on his discharge summary, to document three
times a day his fingersticks and to give them to his primary
care physician upon their [**Name9 (PRE) 702**] visit. He is not going
home on Insulin, and he is not going home on oral agents.
Musculoskeletal: He has suffered a severe amount of diffuse
atrophy of his muscles and has required aggressive physical
therapy and assistance with ADLs, with which he is gradually
improving on and doing significantly better; however, he will
require physical therapy as an outpatient.
DISPOSITION: Home with VNA services for tube checks,
cardiopulmonary checks and wound checks. Home physical
therapy.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery stents. Diabetes mellitus type II.
Hypertension. Common bile duct strictures. Chronic renal
failure. Roux-en-Y hepaticojejunostomy as explained above.
T12 compression fracture. Ascites.
DISCHARGE MEDICATIONS: Linezolid 600 mg p.o. b.i.d. x 2
weeks, Protonix 40 mg p.o. b.i.d., Lopressor 25 mg p.o.
b.i.d., Folate 3 mg p.o. q.d., Silver Sulfadiazine 1% creme
to be applied to his ears for the pressure ulcerations twice
a day
DISCHARGE INSTRUCTIONS: Call or return for problems with
nausea, vomiting, high fevers, any signs of bleeding from the
gastrointestinal tract, any type of syncope. Check
fingersticks regularly and record them. See his primary care
physician. [**Name10 (NameIs) **] Dr. [**Last Name (STitle) **] in follow-up. Call with problems
with oral intake, weight loss. The patient should be seen
within one week or within ten days of discharge. He is aware
that he needs to call to schedule an appointment.
DISCHARGE DIAGNOSIS:
1. Long complicated Intensive Care Unit stay.
2. Methicillin resistant Staphylococcus aureus pneumonia.
3. Enterococcus and Methicillin resistant Staphylococcus
aureus in bile, including both Vancomycin resistant
Enterococcus and VSE strains.
4. Long-term antibiotic treatment.
5. Total parenteral nutrition and tube feeds for nutrition,
eventually discontinued.
6. Prolonged ventilatory dependence.
7. Hemodynamic instability.
8. Hypovolemic shock secondary to ongoing severe upper
gastrointestinal bleed.
9. Status post right hepatic posterior branch pseudoaneurysm
coiling.
10. Coiling of the left gastric artery.
11. Encephalopathy, now resolved.
12. [**Last Name (un) **] tube placement for upper gastrointestinal
bleeding.
13. Multiple cholangiograms.
14. Gastric ulcer, question of mild esophageal varices.
15. PTC tube times two.
16. TIPF.
17. T12 compression fracture.
18. Ascites.
19. Chronic renal failure.
20. Hypertension.
21. Hypoalbuminemia.
22. Hyperbilirubinemia.
23. Status post liver biopsies.
24. Type 2 diabetes.
25. Bile duct strictures status post surgical repair.
26. Blood loss anemia necessitating aggressive transfusions.
27. Echocardiogram showing ejection fraction of 40-45% with
some wall motion abnormalities.
28. Coronary artery disease status post coronary stents.
29. History of 15 pack-year smoking, quitting several years
ago.
30. Severe deconditioning requiring aggressive physical
therapy and rehabilitation.
31. ....................Orthopedically for his T12
compression fracture for at least six weeks, which will need
to be evaluated at some point in the future, and he can
arrange to be seen as an outpatient.
32. History of portal hypertension.
33. History of multiple endoscopies, cholangiograms,
including requirement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube for severe
hemorrhage.
34. Blood requirements for greater than 49 U of packed cells,
33 U FFP, 23 platelets, 5 cryoprecipitate, now with multiple
antibodies to blood products.
34. Status post multiple PICCs and central lines, all of
which are removed.
35. Baseline creatinine between 1.6-2.0; currently he is at
1.5. Hematocrit on discharge 32.
DISCHARGE DIET: Regular diet without added salt.
DISPOSITION: To home with VNA and physical therapy services.
Percutaneous drains are capped currently.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.,Ph.D. 02-366
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2116-10-12**] 14:12
T: [**2116-10-12**] 14:22
JOB#: [**Job Number 45154**]
|
[
"999.8",
"572.3",
"789.5",
"285.1",
"482.41",
"518.5",
"785.59",
"531.00",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"97.05",
"96.06",
"45.13",
"39.1",
"99.15",
"96.6",
"96.72",
"44.43",
"87.54",
"99.29",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
8193, 8410
|
8936, 11530
|
8435, 8915
|
185, 7902
|
7925, 8169
|
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